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Treating Post Inflammatory Hyperpigmentation (PIH)

Melanocytes are the cells responsible for the pigmentation in the skin. Their activity can be increased in response to inflammation. When skin becomes hyperpigmented from an injury, it is called “post inflammatory hyperpigmentation” or PIH. This is particularly prevalent in darker skin individuals, where there is more melanocytic activity, but can occur in lighter skin individuals as well.

The widely accepted scale for skin pigmentation types is the Fitzpatrick Scale. The Fitzpatrick Skin Type 1 are extremely light skinned, have blue eyes, and burn extremely rapidly with sun exposure. Type 6 individuals have very dark skin, dark eyes, and tolerate prolonged sun exposure without burning. In general, the type 4-6 skin types are the ones at risk for PIH.

PIH is possible after the following:

  1. Laser procedures (mainly laser resurfacing)
  2. Acne
  3. Surgical incisions
  4. Chemical peels
  5. Burns
  6. Infections
  7. Radiofrequency (Infini is low risk)

The best way to treat PIH is prevention, if possible. Prevention consists of calming down the melanocyte metabolism. The standard recommendations are Retin A and hydroquinones. If there is a procedure a darker skin individual is planning that has risks of PIH, this regime should be started at 3 weeks prior to the procedure. It should be continued at least a month and up to 3 months afterwards. These 2 topicals are also standard therapy for patients with PIH.

Prolonged inflammation after a procedure (more than a week) in a darker skin individual, is a risk for PIH. The practitioner needs to recognize this and treat the inflammation appropriately. If there is prolonged redness of the skin, steroids and/or vascular lasers are needed to reduce this. If infection suspected, antibiotics are needed. Calming the skin is essential to prevent PIH.

The timing of PIH is very predictable. It almost always occurs about 3 weeks after a “at risk” procedure is performed.

If there is already PIH, treatments which can be used are:

  1. Topicals such as Retin A, hydroquinone, and steroids; Triluma contains all 3
  2. Chemical Peels
  3. Gentle laser treatments with a 1064 laser (nanosecond or picosecond)
  4. Possibly PRP with microneedling (experimental but minimal risk)
  5. Antibiotics for ongoing infections
  6. Laser hair removal for PIH associated with folliculitis

In general, PIH is best prevented then trying to treat after it occurs. Recognizing risk factors with certain procedures is the key to success. Treating prolonged redness is often overlooked and must be treated aggressively rather than taking a “wait and see” approach.

Dr. Weiner’s “Superficial Skin Block” to Numb The Face for Aesthetic Procedures – Infini and Laser Resurfacing

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Some of the fastest growing and most popular procedures in the Aesthetic Industry are radiofrequency and laser procedures. The most sighted obstacle for patients doing these procedures is pain. Dr. Weiner has develop and perfected a method to numb the face fairly thoroughly that is fairly quick and simple. The “Superficial Skin Block” takes about 3 minutes to administer for the entire face. It requires no knowledge of neural anatomy and is less invasive/more comfortable than nerve blocks. The anesthesia kicks in within minutes and will last at least a couple hours. It is ideal for improving comfort when undergoing the Infini, CO2, Erbium, or Fraxel laser resurfacing. Dr. Weiner’s mixture for injection is:

  1. Lidocaine 1% with 1:100,000 Epinephrine (Standard premixed from most medical suppliers)- 5cc
  2. Bacteriostatic 0.9% Sodium Chloride with Preservative – 5cc
  3. 8.4% Sodium Bicarbonate – 1cc
  4. All this is drawn up in a 10cc syringe

The “Superficial Skin Block” starts with placement of topical numbing cream. Dr. Weiner uses “Lipothene” from Central Avenue Pharmacy which contains 23% Lidocaine and 7% Tetracaine. It is left on the face for at least 1 hour. Do not place on face and neck simultaneously. This is too large a surface area for the topical. The neck doesn’t require this strong a topical in Dr. Weiner’s experience.

The injection requires a mesotherapy apparatus from Mesoram.com. The exact device used is found at: Dr. Weiner’s Preferred Mesoram Needles .  The needles are 4mm, 30g and the plate is circular with 7 needle connectors. Plates can also be purchased without needles and 32g needles can be purchased from the site and attached manually.

The topical is wiped off and the face is cleaned with alcohol and hibiclens. The injection is started on the cheeks with 0.5 ml aliquots placed in each injection. The areas injected are slightly overlapped. A small amount of the mixture is placed above the upper lip with a needle that is removed from the device. A few minutes are allowed before starting the procedure to allow for the small blebs to diffuse into the skin tissues. You will notice areas injected become pale and this is the epinephrine effect. This helps in controlling bleeding and bruising.

Dr. Weiner’s Superficial Skin Block has been used by multiple practitioners with great success. It’s effectiveness, ease of use, and limited downside make it perfect for many aesthetic procedures, particularly Infini and laser resurfacing.

Off Label Uses of the Infini – A Plethora of Potential Treatment Options – Scars, Sweat, Cellulite, Acne, Fat, Breast Lift, Knees, Tattoos

Sweat reduction with the Infini

Dr. Weiner Infini Hyperhidrosis treatment

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The Infini is quickly being recognized by the aesthetic physicians as a very powerful tool to tighten facial and neck skin with very little downtime (less than 36 hours).  It has also proven to have an extremely low risk profile, with very few long term side effects noted, even in tan or dark skinned individuals.  For those unfamiliar with the Infini, please read this blog.  In a nutshell, the Infini is a microneedling fraction radiofrequency (MFR) device that coagulates the dermis at various depths (o.25mm – 3.5mm) leading to tissue contraction, new collagen and elastin formation, and overall skin tightening and wrinkle improvement.  Dr. Weiner has been using the Infini soon after it was FDA approved and has become the largest user of the device in the US.  There have been several off label (non FDA approved) uses of the Infini that Dr. Weiner has been studying that will be discussed below.

  1. Scar Improvement – The Infini causes disruption of the abnormal/pathologic collagen deposition and stimulates new and more organized collagen that more closely resembles the body’s normal collagen.  Acne scars have been treated, even in darker skin individuals, with improvements noted.  A physician in Korea has a large series of acne scarring patients who have been treated with the Infini showing dramatic improvements.  Other scars being studied are stria (stretch marks) and surgical scars (such as tummy tuck and skin cancers).
  2. Hyperhidrosis (Excessive sweating) – The sweat glands lay in the lower part of the dermis and just below it.  By heating these areas up to a certain temperature, they can be destroyed permanently.  This has been proven by the Miradry device, which uses microwaves to heat up the tissue.  There is a very high long term satisfaction rate using this device after undergoing 2 treatments.  It’s drawback has been discomfort (requiring blocks with injections) and cost ($3000 for 2 treatments).  The Infini can be set to a depth that targets the area of the sweat glands and heat this area up to a point of coagulation (gland destruction).  In preliminary studies in axillary (underarm) sweating, Dr. Weiner’s patients have seen improvements with the Infini with less discomfort, no downtime, and at a fraction of the cost.  Dr. Weiner’s Press Release about using Infini for Hyperhidrosis.
  3. Acne – Dr. Weiner had been noting that patients whom were undergoing Infini for skin tightening/wrinkles were also noting improvement with their acne.  It was postulated that the sebaceous glands, the glands responsible for sebum production (the root cause of acne) were being injured with the Infini treatment.  An acne flair is not uncommon after an Infini treatment, and this is caused by inflammation of the sebaceous gland temporarily.  Over time, the glands will involute (becomes smaller with less secretions) and lead to the acne improvements noted.  Eventually sebaceous glands can enlarge again (unlike sweat glands with don’t have the ability to regrow), so the treatment with Infini turns out to be a potential long term but not permanent solution for acne.
  4. Body Skin Tightening – Areas such as knees and arms are a concern for many patients.  Other than surgical correction, which leaves large undesirous scars, there hasn’t been a good solution.  Perhaps the Infini can create similar skin contraction and thickening in these areas as it does on the face. Dr. Weiner is studying this on a few select patients.
  5. Fat Reduction – The depth of 3.5 mm is below the dermis in most areas of the body.  Using this depth with the Infini, it is possible to target fat, particularly in the submental (below the chin) area and along the jaw line.  Many patients have seen improvements in these areas with their Infini treatments for wrinkles on the face and neck.  Dr. Weiner purposely will go deep in these areas to coagulate and destroy fat and then go more superficial to tighten the dermis.  Slimming the mid and lower face for patients with excessive fat tissue can be manage with the deep depth Infini treatment.
  6. Cellulite Improvement – Using the same rationale as targeting fat, it seems logical that destroying the fat that is herniating would improve the appearance of cellulite.  This is still an area of treatment that is more speculation and research is being conducted by Dr. Weiner on a few select patients.
  7. Tattoo Removal – There is evidence that combining fractional ablative lasers with the Q-Switched laser has benefit in removing tattoos.  If this is merely causing more of an inflammatory response to enhance the ink removal, then Infini can cause a similar tissue coagulation, but with less risk and downtime than the lasers do.
  8. Breast Lifting – If the Infini can cause tissue contraction in the area of the breast, is it enough to see a noticeable improvement in the position of the breast?  A no scar breast lift sounds extremely appealing.  Studies will need to be done to see if the Infini can work for this and if so, how many treatments are needed, are touch ups required, and is it’s price justified.

Dr. Weiner is carefully studying the Infini for these off label uses and trying to develop standardized protocols for the medical community.  It seems like the Infini’s potential is just starting to be recognized and its future is very promising.

The Top 14 Trends in Cosmetic Procedures (Plastic Surgery) for 2014 as Predicted by Dr. Steven Weiner

This coming year is an exciting one with a couple new FDA approvals expected.  It’s also going to see several procedures fade away and new approaches with the “gold standards”.

  1. Kythera’s ATX-101 will be approved for reducing the double chin fat using only an injection.  The procedure will need to be repeated 3-5 times in most people, but there will be no incisions and minimal risks.  Side effects will be swelling and discomfort that will last maybe up to a week.  Off label, it could be used for fat in the belly, love handles, or thighs.
  2. Longer acting dermal fillers for total facial volumization will catch on.  Fillers such as Voluma, Sculptra, and Artefill can be used to add volume to the temples, cheeks, midface, jawline, and preauricular area.  Even earlobes can use a little volume in most people.  Very little side effects other than swelling and bruising are noted with these “Liquid Facelifts”, particularly when blunt cannulas are used.  Results are instant with Voluma and Artefill, and gradual with the Sculptra.  Duration of improvement is about 2 years with Voluma, 2-3 years or longer with Sculptra, and over 5 years (some doctors may say permanent) with the Artefill.
  3. Botox administration will be “lighter” to give a more natural look.  No more frozen faces leaving people expressionless.  Particularly in the forehead, less Botox using a “micro injection” technique, means more movement and less risk of dropping the brows.  The downside to this lighter dosing is that its duration will be slightly less.
  4. A new topical neuromodulator, Revance’s RT001, will be FDA approved in 2014.  Unfortunately, this won’t eliminate all the injections.  It will be great for the crows feet area and possible for reducing underarm sweat though.  It still will be administered in the doctor’s office (not for in home use).
  5. Tattoo removal will become easier with less trips to the doctors office.  With new protocols like the R20 and R0, several treatments (up to 4) can be combined into one office visit.  It looks like the side effects and risks are the same as doing only one treatment per visit.  The Picosure laser seems to also lead to faster ink removal but it is still too expensive to be widely available.
  6. RF (radiofrequency) skin tightening will become even more popular, spurred on by  microneedling devices which are more effective than transcutaneous ones.  Being able to drive the RF energy to deeper levels both safely and reliably, as with the Infini, will lead to better and more predictable results.  The other RF devices such as Thermage, Exilis, Pelleve and Tripolar will become less and less relevant as consumers are disappointed by their results.
  7. There will be even more interest in noninvasive fat removal.  Lead by Coolsculpting, people will find that having no downtime, minimal risks, and getting real observable fat loss is better than getting liposuction.  Certain areas such as outer thighs have been difficult to treat noninvasively but new attachments with Coolsculpting and/or new devices using high frequency ultrasound (HIFU) might be developed to treat all the areas that liposuction traditionally treats.  RF fat reduction will also become more popular because they will be more effective than prior versions.  Zerona will lose all relevance due to its lack of sustained results.
  8. Lip enhancements will be smaller and done using blunt cannulas.  It seems like the trend for having your lips enter the room before you do is waning.  People want to look like they have naturally beautiful lips and not obviously overdone lips.  Using blunt cannulas enables one to have minimal downtime, minimal discomfort, and a naturally enhanced look.
  9. People will become more concerned with anti-aging procedures of the hands and chest.  Volumization using Sculptra in the declotage and Radiesse in the hands will become popular.  Skin tightening using the Infini RF device will help with the wrinkles.  Spots can be improved with the Fraxel Dual or Q-switched laser.
  10. Tear trough injection will be the most popular area treated with dermal fillers.  Blunt cannulas make this procedure both comfortable, safe, and quick.  Restylane is the filler of choice for this area.  By treating the tear trough and upper cheek, the nasolabial folds (smile lines) actually improve as well due to the lifting from above.  Patients will have some swelling in most cases for a couple days which can be reduced by sleeping elevated.  Bruising is minimal or none with the cannulas when compared to the needles which almost always has bruising lasting up to a week or more.
  11. Men will do more cosmetic procedures.  The drivers for this will be the competitive jobs market and the “no downtime” procedures.  Sometimes experience isn’t all that is needed to land a job.  To compete with the younger job seekers, the more “experienced” men are seeking procedures that can improve their looks, yet not keep them out of the public for very long.  Botox, fillers, Ulthera, and Coolsculpting will become even more popular for men.
  12. The number of people getting facelifts will continue to drop.  With the improvements in skin tightening by Ulthera and full face volumization with dermal fillers, particularly collagen stimulators (Artefill and Sculptra) the aging face can be more naturally improved.  There will be a trend for younger patients to start anti-aging treatments earlier leading to “more graceful” aging.  People are not as willing to undergo the knife given the associated risks, downtime, and potential for undesirable results.
  13. Artefill, a permanent filler that stimulates collagen, will gradually replace fat grafting for the face.  As an off the shelf solution, Artefill is much more attractive to the patient than undergoing 2 procedures for fat; fat harvesting and then grafting.  Also, fat is not always predictable with its “take”, and there can be a need for more than one procedure.  Fine tuning with fat is also somewhat difficult and is much easier with Artefill.  The apprehension behind the permanent aspect of Artefill has not been borne out and more of the well known injectors are warming up to Artefill.
  14. Hydroquinones will gradually be replaced by other products to help with pigmentary problems.  This trend started in Europe and South America.  They have banned hydroquinones because of concerns over their potential carcinogenicity (even though there have been no known documented cancers from hydroquinones), ochronosis (pigmentation side effect that is very difficult to treat), and possible rebound hyperpigmentation.  SkinMedica’s Lytera and Neocutis Perle will become acceptable replacements.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Press Release regarding these predictions by Dr. Weiner.

Dr. Steven Weiner of The Aesthetic Clinique Celebrates 25 years of Laser Surgical Experience. Only State-Of-The-Art Lasers are Used in his Practice.

Dr. Weiner began his training at Johns Hopkins Hospital, the number one rated hospital in the country (for the past 22 of 23 years), in 1988. At that time, he was introduced to the CO2 laser and the Argon laser. In the ensuing years, he has mastered dozens of lasers and has selected the “best of breed” aesthetic lasers for The Aesthetic Clinique. His lasers include:

Fraxel Dual Laser: The Fraxel Dual is a skin resurfacing laser with 2 wavelengths. The nonablative erbium1550nm wavelength has been researched extensively and shown to benefit wrinkles, pigmentation, scars (particularly acne scars), improve sun damage, and help eradicate precancerous skin lesions. The 1927nm wavelength is a Thullium laser which is effective for superficial pigment, melasma, precancerous skin lesions, and superficial fine lines. When used together, they have a synergistic effect on the resurfacing process.

VBeam Laser: The VBeam is a pulsed dye laser with a wavelength of 595nm. It was developed to treat Port Wine Stains. It has long been recognized as the state of the art laser to treat anything red on the skin: rosacea, hemangiomas, telangiectasias, and cherry angiomas. It has also been found to improve acne, acne scars, and surgical scars.

LightSheer Duet Laser: The LightSheer Duet Laser is a modernized version of the long established “king of laser hair removal” laser the LightSheer. It is a diode laser with a wavelength of 800nm. It has been FDA approved for all skin types but Dr. Weiner limits it’s use to skin types 1-4. The Duet’s modification is in the handpiece which has an integrated vacuum. This draws the treated hair closer in to the laser and allows for a safer treatment with less power and potential risks. It also makes treatments significantly faster (2-3x) because the handpiece can treat a much larger surface area at once. Last, but not least, it improves the tolerability by the patient.

Spectra Q-Switched Laser: This laser has 4 different wavelengths, the 2 “work horses” are the 1064nm and 532nm. The laser has a pulse duration that is 1000x shorter than most lasers which makes its peak power significantly higher. This power is what is needed to remove tattoos. It causes shockwaves in the dye of the tattoo, breaking it up into smaller particles, so the body can dispose of it. The spectrum of wavelengths are need for the different colors in the tattoos. Another use for this laser is for any type of pigmented lesion: lentigo, nevus, congenital nevi, and even FDA approved for melasma. A Spectra Laser Peel has been developed as well, which takes a very superficial layer of skin off. The peel leaves the skin with a complexion that is radiant, glowing, and vibrant, with absolutely no downtime or discomfort. This has been called the “Hollywood Peel” because stars do this peel just before their entrance on the red carpet. Lastly, this laser has been shown to be a very effective acne treatment, particular good at treating active acne.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Press release:  http://www.prweb.com/releases/2013/12/prweb11418199.htm

Fastest way to get Tattoo removal – R0 protocol, at The Aesthetic Clinique

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The frustration with typical tattoo removal has been that it can take up to 10-15 treatments to remove that unwanted ink from your skin.  With the recommended 2 month interval between treatments, this can take over a year to get to your final results.

The limiting factor when treating a tattoo has been that white gas bubbles develop under the skin which inhibit the laser from being effective.  Physicians noted though, that after 20 minutes, the bubbles were gone, allowing for another treatment.  This waiting 20 minutes and repeating the treatment is called the R20 protocol, and allows for 4 treatments in one day.  The downside is that it requires over an hour of being in the doctor’s office and can be longer if the laser or doctor is busy when the 20 minutes are up.  It was consistently reported by the patients that the subsequent treatments on the same day after the first one were much more comfortable.

An exciting new protocol, called the RO protocol, now eliminates the 20 minute wait between treatments.  By placing a fluid on the skin, perfluorodecalin, the white gas bubbles are eliminated almost instantly, thereby allowing the 4 treatments to be performed in rapid succession.  A study showed this treatment was safe and that the tattoos were removed faster than with the one treatment per session standard protocol.

So now, tattoo removal is faster with only 2-4 sessions, and more comfortable with the RO protocol.  Please call the Aesthetic Clinique for your tattoo removal evaluation.  We use the Spectra Q switched laser which is, in our opinion, the safest laser for tattoo removal on the market.

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

Everything you need to know about Laser Tattoo Removal

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As more and more people are getting tattoos, there is an increasing demand to get them removed.  Whether the tattoo was a mistake from the get go, it didn’t turn out as you expected, or a relationship has changed and you want to remove your “ex” from your skin, the most common way to remove tattoos is with a laser.  The only other option is to surgically excise the tattoo which can realistically be done only for smaller tattoos and it always leaves a scar.

A Q-switched laser is needed to removed tattoos.  What’s unique about this type of laser is that its pulse duration (how long the time is which it fires it energy) is in the nanosecond range.  By making the pulse this short, it makes the energy level of the pulse in the billions of watts.  That huge energy hit to the tattoo causes a shock wave in the tattoo pigment which leads to the pigment breaking up into smaller pieces. Once the particles of the tattoo pigment get pulverized to a certain size, they are small enough for the body to “chew them up” and remove them from the body. Using traditional laser tattoo removal techniques, it takes multiple treatments, 10-15, to get complete tattoo removal.  Often the waiting between treatments is up to 2 months, so it can take a year to 2 to removal a tattoo.

There is a newer technique called the R0 protocol for tattoo removal which will remove tattoos much faster than traditional techniques.  The R0 protocol entails treating the tattoo 4 times in the same day.  There is a liquid placed on the tattoo which removes the frosting which occurs (from heating nitrogen in the skin) so you can immediately proceed to another pass.  Studies show much faster eradication, 1-4 sessions, with no more risks or side effects.

What type of Q-switched laser is the best?  The safest wavelength for treating skin of all colors is the 1064 nm Nd:YAG laser.  There is less pigmentation side effects and less textural changes with the 1064 Q switched laser than with the Alexandrite and Ruby laser.  Sometimes, after treating with this wavelength, residual pigment remains, and that’s when other wavelengths are needed.  You also want to look for a laser that has a “tophat” distribution of its pulse energy.  What this means is that the energy is evenly distributed across the entire spot size to give a uniform treatment.  If this is not the case, the tattoo can be under or over treated in some areas.  The shorter duration of the pulse, the better safety profile, and the better results.  The short pulse allows for less diffusion of the energy to nearby skin so as to leave this skin unaffected.  It also allows for greater energy levels on the treated area.

Top Hat energy distribution of the Spectra laser. Left=others, Right=Spectra

Top Hat energy distribution of the Spectra laser. Left=others, Right=Spectra

Side effects from Laser Tattoo Removal are:  scarring, hypopigmentation, hyperpigmentation, incomplete tattoo removal, and rare allergic reaction to the dyes of the tattoo.  Darker skin individuals are at higher risks of complications than lighter skin individuals.

The Lutronic Spectra Q-Switched Laser seems to be an ideal laser for tattoo removal.

  1. An extremely short pulse duration which leads to high peak energies
  2. Based on 1064nm Nd:YAG platform
  3. Has multiple other wavelengths for difficult pigment (4)
  4. “Tophat” energy pulse profile
  5. Dual energy generators to prevent loss of energy during prolonged laser firing

Energy output showing the high peak energy of the Spectra laser

Energy output showing the high peak energy of the Spectra laser

Using the Kirby-Desai Scale, you can determine how many treatments it should take to improve the tattoo (within 80% accuracy)  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2923953/

For further information about Lutronic Spectra Q-Switched laser tattoo removal, please call our office at 850.622.1214.  

Dr. Steven Weiner is a Board Certified Facial Plastic Surgeon practicing in Santa Rosa Beach, Florida, between Destin and Panama City Beach, Florida. After laying down his scalpel in 2005 he has devoted his practice to Lasers and Injectables.

Blog: http://stevenfweinermd.wordpress.com/

YouTube: http://www.youtube.com/user/StevenFWeinerFacial

Website: http://www.theclinique.net

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2050 West County Highway 30A Suite 114
Santa Rosa Beach, Fl 32459
Phone: 850-622-1214

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