Older Skull Image

Orbits more “droopy” at the outside lower edge

Cheekbones lower and flatter

Younger Skull Diagram

Orbits more round

Cheekbones higher and more prominent at the upper edge

As  we mature, our facial bones change with time. Specifically, our orbits  (eye sockets) become larger and more trapezoid in shape, with more  pronounced thinning of the bone in the outer lower and inner upper  edges. In addition, if you look at the skull from the side you will  notice that the mature skull becomes flatter in the area at the top of  the lower edge of the eye sockets.

Image 1 is a photo of a skull  that has aged. While this is not an overtly elderly specimen, you can  still compare the orbits (eye sockets) with those in image 2 below. The  most obvious difference is that in the diagram the orbits are rounder  than in the photograph of the skull above.

I believe the first  step in mitigating age-related facial structural change is to inject a  long lasting filler against the bone just below the orbits on the outer  area and directly onto the cheek bone. This serves to provide a basis  for a youthful appearance. If you think of the face like a bed – this  repairs the structure of the box-spring. My philosophy is to level box  spring first, then even out the mattress before smoothing the sheets!

By  injecting against the bone of the orbit, the lower orbital rim is  enhanced, the cheek bone is made more prominent, and the angle of the  facial structure becomes less flat and more youthful. This will also  blunt the folds of skin on the sides of the nose (nasolabial folds) and  efface some wrinkles. In addition, when a series of injections are made  against the zygoma (cheek bone) at about a 45 degree angle upward and  outward, this can lead to a young appearing classically feminine facial  appearance. For males we typically inject in this area on a more  transverse line rather than an such an upward 45 degree angle.  We  prefer Juvéderm Voluma™ for this application in our practice for its  stiffness and long duration.  A softer, more pliable product can then be  injected in the more superficial areas and lines. To refine the  appearance skin resurfacing or peels may be used to give the skin a  youthful glow and treat fine wrinkles. For pigment irregularities such  as brown or red spots, IPL is ideal but can only be used in certain skin  types.


Many people refer to all light therapy for the skin as LASER treatment. In reality though, all light treatments for the skin are not true LASERs. In this segment, I’m going to get a little technical, but I hope it leaves you with a better understanding of the differences between IPL, LED, and LASER skin treatments. For a summary, see the last two paragraphs.

There are many forms of light therapy. They all work by targeting light sensitive pigments in the skin called chromophores. A chromophore is simply a molecule or group of molecules that absorb light of specific wavelengths. Examples of these light-absorbing molecules are blood, (think pink or vascular spots on the skin), melanin (think dark spots on the skin), or hair follicles (think hair removal).

Let’s start with a definition, and move on to some cool history that involves Einstein and Martians. What is a LASER? LASER is an acronym for “light amplification by stimulated emission of radiation.” It’s a mouthful, but basically it is a device that magnifies (amplifies) light, generally of a single wavelength in a narrow, or concentrated beam. The author HG Wells first described the concept in his 1898 science fiction literary classic, War of the Worlds. In this book, he described a “fiery ray” that was used by the invading Martians as a weapon. The energy “ray” he described is uncannily like the modern LASER. The picture I attached is in the public domain and is from his book. We’ve hit Martians, now on to Einstein.

In 1917, Albert Einstein developed the concept of photons and stimulated emission of light, but it wasn’t until 1960 that Thomas Maiman developed the first ruby LASER, and later that same year Dr. Ali Javan produced the first continuous helium-neon LASER. It was only two years after this, in 1962, that Dr. Leon Goldman, commonly known as the “Father of Laser Medicine & Surgery,” first described the clinical use of LASERs in medical practice.

Let’s back up a moment to Einstein’s theory, and the concept of LASERs. Cool physics here: An atom moves from one energy state to another when it absorbes or releases energy. If a specific atom or molecule is stimulated by energy, it can emit light energy (radiation) by changing state. This light energy can be amplified by bouncing the light beam back and forth in a chamber with reflecting mirrors and finally to an output beam, hence, “light amplification by stimulated emission of radiation.”  This LASER light can then be directed in short bursts at an area of skin and its energy will be absorbed by components of the skin depending on that component’s color. This energizes the particles in the skin that are of the color (chromophore) that is sensitive the light energy specific to that wavelength or group of wavelengths.

In general, LASERS penetrate the tissue deeper than IPL or LED light, but the treatment pattern is, for most treatments (except for treatments like tattoo removal), a pattern of LASER dots. To review, medical dermatology lasers usually do not treat the whole area of skin in the treatment field, but rather a matrix of dots within the treatment area. Because LASERS target a specific wavelength and are high energy, they are ideal for tattoo removal (the dyes used in tattoos are often absorbed and broken up [ablated] by a specific narrow band of wavelengths). Medically, LASER resurfacing is often called “traumatic ablative” in contrast to IPL rejuvenation, which is often referred to as “non-ablative” therapy.

An IPL is an intense, brief pulse of light that can be filtered to a specific group of wavelengths to impart light-energy to the color-specific component (chromophore) of the skin that that group of wavelengths target. It has been shown that the action spectra for tissue regeneration and repair consist of more than one wavelength; therefore, polychromatic spectrum IPL that covers a broader spectral region of light has advantages for skin rejuvenation and skin repair over either LASER or LED. The other advantage of IPL over LASER or LED is that IPL treats a complete area of skin rather than a usual LASER treatment area that consists of a matrix of dots.

An LED or “light emitting diode” releases light energy that is created by a semiconductor as an electric current passes through it. Light created by an LED is usually monochromatic (one wavelength) like a laser. LED also employs a matrix of LED dots, and is low-level energy that doesn’t penetrate as deeply as either IPL or LASER. Altering cellular function using low-level, non-thermal LED light is called photobiomodulation (PBM), or low-level light therapy (LLLT). PBM bypasses the initial destructive (ablative) step of LASERS and non-ablative higher energy of IPL by directly stimulating regenerative processes in the skin. It is undergoing study as a regenerative modality over wide areas of the skin without inciting as much inflammation. The disadvantage is that it is only one wavelength and that the inflammation caused by IPL or LASER actually incites more rapid repair or regeneration. An example of use of LED is for hair growth stimulation.

So why isn’t there some kind of a scientific study to tell us what the best form of light energy to use for medical applications? There are several reasons. First, each individual has a specific skin type with a specific makeup of melanin, hair color and reactivity to light. Think of it this way: Some people get burned with minutes of exposure to sun, while others virtually never burn. Also, because of progression of instruments approved for medical use it is difficult to study them head to head (a comparison of IPL and LASER devices available in 2014 for example is difficult because devices available in 2018 are quite different than those in use today). For its wide variety of uses and non dot-matrix treatment area, IPL has clear advantages and is most versatile. For hair removal it can be less painful for certain skin types, is less expensive, although it may take a few more treatments (more gentle).

Summary: IPL, LASER and LED are all forms of light energy that can be used in treatment of the skin. They all target pigments in skin to absorb light energy for their result. LASER resurfacing is often medically referred to as traumatic ablative, IPL rejuvenation is often called non-ablative, and LED is referred to as photobiomodulation (PBM).

At our clinic we use the Venus Versa™ machine, an IPL device with additional radiofrequency heads. We were among the first clinic in the San Diego area to have this advanced FDA-approved device, and we have all ten treatment heads including IPL photo facial heads, in various wavelengths, IPL hair removal heads in various wavelengths and differing sizes, the IPL dual-band acne treatment head, and the radiofrequency heads that do skin and tissue resurfacing that is safe for all skin types, and also does deeper tissue tightening that LASERs and LEDs simply cannot do. #BeAllureous, #LASER, #LED, #IPL, #VenusVersa

Further reading:

Thorac Cardiovasc Surg. 1988 Jun;36 Suppl 2:114-7 and Photomed Laser Surg. 2014 Feb 1; 32(2): 93–100.

I recently watched a video clip of a comedy routine, and it began like this: “You know the joke; a guy walks in to a doctor’s office and says to the doctor, ‘When I move my arm like this, it hurts.’ And the doctor says, ‘Well, don’t do that.’ The comedian follows with; ‘Well, I walked into my doctor’s office and I told the doctor my arm hurts, and the doctor said, “You have to lose some weight.”’’ The comedian then launched into a diatribe shaming doctors and various other health care providers for bringing up weight in healthcare interactions.

The elephants have multiplied! The unseen elephant in the room that we have to worry about is the pachyderm of politics. We, as health care providers, (Doctors, NP’s PA’s Nurses etc.) are somehow beholden to political correctness at all times. Right? Wrong!

The other elephant that we have to talk about is the elephant himself, (let’s leave gender political correctness out of this conversation).  And that elephant has multiplied as well: According to the National Center for Health Statistics, in the United States, among people aged 20 years old or older, the prevalence of obesity rose from 19.4% in 1997 to 31.4% in 2017. And yes this is related to a myriad of healthcare problems that can maim or kill us early. If I can borrow a phrase from Bernie Sanders, “that’s UUUUGE.”

In medicine, we have to tell it like it is. Weight must to be talked about and health care providers are the ones to do it. Furthermore, we need to talk about it without fear of insults, anger, or doctor-shaming comedians. Keep in mind that weight-relatedness of many conditions may not be immediately evident to some, and like smoking, health care providers must keep hounding until the elephant gets under control.

Now that we’ve identified the herd it’s up to us to do something about it. I submit that doctors, nurse practitioners, nurses and PA’s simply can’t always be politically correct when it comes to our patient’s health. We have to tell it like it is. I’ve had to tell people their family members have died countless times. There are few effective ways to sugar coat it. I’ve also had countless interactions in the emergency department when I have a chat about something that seems tangential to the visit itself – yet may save the patient’s life: helmet use, smoking or drug use, and yes–weight, to name a few.

Sometimes these frank discussions have been met with anger. “Why are you talking with me about smoking when I came for an ear infection?” I have to respond: “Well, actually, upper respiratory infections are associated with smoking.” But it seems that there’s nothing like the PC rage these days than that which seems to be ignited by broaching the subject of a patient’s weight.

Now that I’ve got that weight off of my chest – what can we do about the herd? First, if you are a patient, be receptive to that health care provider who is talking to you about the weight, even if you’ve come in for arm pain, and even if you’ve heard it before. The doctor isn’t interested in shaming anyone. She (excuse the pronoun, I’m still not going to be PC on that one for now either) just wants to save your life.

People often ask what to do to lose some pounds. I am not, nor do I claim to be a weight loss specialist. As a physician who’s been in the business three decades, I can identify some things that will get you on your way: Portion control – buy some smaller plates. Yes, studies have shown that smaller plates are associated with smaller portion size, and smaller portion size helps. And here’s some basic (not common-core) mathematics: decrease caloric input and increase your caloric use or activity. It works. Count those calories; identify the areas where you can effectively cut them. Dump sugar-containing drinks. Drink coffee? Cut out the cream, eliminate the sugar and downsize your cup. Eat a diet that’s primarily plant-based and use fish, nuts and legumes as your major protein source. And, don’t fly in the fog without instruments. Get a scale and use it every morning. Start an exercise program after you visit your health care provider and determine what’s safe and realistic for you. Even if you start with ten minutes a day working with tiny barbells in bed and work up to an hour a day in the gym. Do something active every day and stay on a program.

Finally, as you trim the pounds away there are ways to tighten up and look great in that bathing suit you haven’t worn in a couple of summers. Venus Versa Diamondpolar and Octipolar treatments can safely and effectively tighten loose tissue on your neck, abdomen and other areas, and can help eliminate cellulite. Have that pocket of fat under your chin? Kybella is a wonderful way to loose it for good!

I got in trouble at Stanford Medical School with the dean over nurses once in the dean’s office while in medical school. But the reason isn’t as important as National Nurses Week.

I love National Nurses Week! First of all, as an ER doctor it was always a selfish pleasure to enjoy all the treats in the lounge that were brought in to celebrate the hard work that nurses do day in and day out all year long.

Doctors really owe a lot to nurses. They are the ones that bring your attention to patients that really need help now. Not just now, but right now. Do you know that patient who is about to go into cardiac arrest? Maybe, and maybe not, but the nurse usually does! She’s (or he’s) at the bedside watching the patient minute by minute. What about that patient who you’re sending to the ward from the ER who’s just taken a turn for the worse and who’s about to crump? The nurse does! And they are the ones that bring your attention to that indecipherable order you wrote. But to me there is much more to nursing … I owe my life to a nurse, quite literally.

The first nurse that I want to call out was is Sister Elizabeth Kenny.  Sister Kenny was an Australian nurse who served in World War I. She also saved my mother’s life by standing up for her and arguing with the doctors who wanted to put her in an iron lung when she had polio and was deteriorating to the point that she had quadriparesis and bulbar polio. It’s a long story and the reason that I’m alive today; it contributed to me going into medicine, and is the reason my mother developed deep faith and created the Noah’s Ark Ministry. Mom’s story is too long for a blog, but you can read about it in her book, From Paralysis to Praise.

So thank you Nurse Kenny for saving my mother’s life. For staying up all night with her and packing her in hot packs, and for taking her out to breakfast on your dime when she got well!

The second nurse, I want to call out is Jenilyn Peros, DNP, MSN, FNP-C. She’s a nurse but has a Doctorate in Nursing Practice, so we get to celebrate her on both National Nurses Week and Doctor’s Day. This year she already won two well-deserved awards, Nurse Practitioner of the Year, and Advanced Practice Nurse of the year.  Most importantly won the award of my heart, as she is my life partner as well as my business partner.

And the trouble I had with nurses in the Dean’s Office way back when? Well, I was always the guy with an idea; so, as per my usual I went into the Dean’s Office with my idea of the week… I felt that Stanford University School of Medicine should add a required clerkship to the required clinical grid. So I told the dean about it.

The idea of making more required work for medical students was bad enough I suppose, but the clerkship idea itself was enough to get me tarred and feathered by the House of Medicine. You see, I wanted Stanford Medical Students to add the requirement to serve as a nurse for at least two weeks. Here was my twisted logic: Nurses have to follow doctors’ orders. They have to read them, mark them off and do them. What better way to learn how to work collaboratively with nurses than to walk in their shoes? What better way to learn to write better orders than actually take them? Well, my idea floated with the dean like a bullet in a swimming pool. But I still think it was a good one. If you’re reading this Dean Minor …

Here’s to National Nurses Week, to Nurse Kenny of yesteryear and to Dr. Jen, this year’s Nurse Practitioner of the Year, Advanced Practice Nurse of the Year, and my Personal Nurse of the Year (She nursed ME back to health after my foot and ankle surgery).  And, lastly here’s to nurses everywhere who all year are both saving patients and their doctors

It’s Memorial Day Weekend! Time to reflect on those who served to make our country what it is today. To all those who served and sacrificed, thank you! For those who spend the weekend in the sun, watch out!
Time to break out cold drinks and spread some mustard on hotdogs, and sunscreen on hot bods. But hold on; let’s take a look at our sunscreen for a moment. Your sunscreen has an SPF on the label, what does it mean? Let’s sort it out by reviewing ultraviolet rays:
Get on the spectrum: When we think of rays north of the visible spectrum we often think of UVA and UVB. Visible light is that light we can see. It lies between 700 and 400nm. On the ultraviolet end of the spectrum, we designate UVA as between 400-320 nm, and UVB between 320 and 290 nm. The importance of this is that UVA makes up 95% of the ultraviolet light reaching the earth, and its rays penetrate deeper into the dermis, the skin’s thickest layer. Think of it like this: unprotected UVA exposure causes premature aging and wrinkling, and UVB is implicated in sunburn and we think of it as causing many skin cancers (though UVA is implicated in some too).
SPF or Sun Protection Factor is a measure of how well sunscreen protects you from sunburn, or UVB. An SPF of 10 means that if you burn at 10 minutes without the product, you have a theoretical 100 minutes before you burn with the product (assuming good reapplication).
Another way of thinking about it is like this: SPF 15 blocks 93%, SPF30 97% and SPF 50, 98% of the rays. So if you’re a physicist, SPF 15 (93% protection) allows 7 out of 100 photons through to your skin and SPF 30 (97% protection) allows 3 out of 100 photons through to cause havoc.
That’s a nice review of physics, probably of more interest to my son who does research at at MIT than anyone else, but you ask, how does that help me choose a sunscreen? My recommendation is to choose a sunscreen with a minimum SPF of 30 (the difference between 97% protection and 98% protection is a pretty thin margin). I also feel that for UVA photoprotection, the sunscreen should meet a minimal 370 nm wavelength test (UVA is between 400 and 320 nm so at a minimal wavelength of 370 nm, it protects you against 90% of UVA rays).
What’s in a word? In the United States, “Broad Spectrum” means both UVA and UVB protection. Nice. The term “Water Resistant” means that SPF is maintained for up to 40 minutes during water exposure. The term “Very Water Resistant” means that SPF is maintained for 80 minutes. If any of you find a product that doesn’t burn your eyes when you wear a mask, I want to know about it.
Types of sunscreen:
Organic: Typically absorbs UV radiation and converts it to heat.
Inorganic: Reflects and scatters UV radiation. (Typically these are a little more comfortable).
Creams: Think moisturizing. So if you have dry skin you’ll probably like a cream.
Lotions: Think thinner solution, its better for covering large areas rapidly.
Gels: Ideal for hairy areas. Are you balding? Or a Sasquatch?
Stick: Ideal for areas around the eyes. I have to remember this when SCUBA diving.
Spray: Ideal for fast application (a moving child), or reapplication.
Rules to Live by:
Apply early: Apply the sauce 15 – 30 minutes before you bake.
Do Shots! To ensure that you get the full SPF of a sunscreen, you need to apply 1 oz – about a shot glass full. Cool.
Factor X: There are other factors to think about. Scars and wounds take up pigment from the skin differently than skin around them for about a year. Medications: Some medications are photo-sensitizing and can predispose to burns. Sulfa drugs and tetracyclines are especially notorious, but not the only ones. Read the label if you’re taking medications. Procedures: If you’re having a treatment like an IPL or Photo Facial, don’t sun for a few days before or after.
Know your Fitzpatrick Skin type: Fitzpatrick I and II’s have to be especially careful of sun exposure, if you’re a Fitzpatrick V or VI though, beware, you’re still at risk!
Cook this:
When are UV rays strongest? 10a – 2p
What Season? Summer (you knew that one already)
What other factors contribute?
Surfaces that reflect – like water, cement, snow.
Elevation – the higher you go the stronger the UV rays
Latitude – Equator = higher risk
1) If it’s cloudy I don’t need sunscreen. Wrong: Up to 40% of the suns radiation still hits the earth’s surface through clouds.
2) I’m black, or from Southeast Asia so I don’t have to worry. Wrong. You can still get skin cancer and age from sun exposure. This is also true: Blacks that get malignant melanoma have worse outcomes than people of Caucasian origin. And in the United States, most of us are mixed, whatever ethnic origin we think we are. So use sunscreen whatever your skin tone!
3) Maybe sun exposure isn’t good, but sunscreen doesn’t really prevent aging skin does it? Wrong! Scientific studies have demonstrated that aging can be prevented by sunscreen!
4) I shouldn’t wear it to save coral reefs. There is evidence that sunscreens could be implicated in coral reef damage. I’m still waiting for evidence to indicate which sunscreens are safe for the reef. Use sunscreen like you use a seat belt. Every time. Best way to save reefs? Minimize your carbon footprint and don’t kick them with your fins.
Some Useful References:
Skin Cancer Foundation:
Mayo Clinic on Sunscreen:
Annals of Internal Medicine on sunscreen preventing aging:
Critical wavelength for UVA protection, 370 nm:
Skin Cancer Foundation Seal of Recommendation: A symbol of safe and effective sun protection
Take Home Messages:
Apply early. A minimum of 15 minutes before you go out.
Do shots. Think of an application as a shot glass full. That’s the right amount.
Apply often. A minimum of each 2 hours. Set your alarm!
Type matters! Minimum SPF 30, Broad spectrum UVA and B with a minimum UVA wavelength of 370 nm.
And if you are a darker skin type – don’t think the sun is your friend. Use sunscreen.
Think of the time of the day, time of the year and other factors (medications, treatments, scars and skin type).
Sun protection with regular maintenance at an aesthetic clinic is the best way to have wonderful looking skin, so wear that sunscreen and get that maintenance! And don’t forget those annual exams with the cancer screening dermatologist!