Dr. Garcia - plastic surgeon

Q: Do you consider plastic surgery more of an art or a science?
A: For me, plastic surgery in particular tends to be artistic, we (plastic / cosmetic surgeons) are commissioned artists, like in the renaissance. Patients should choose their surgeons based on the look they want - aggressive or natural. We (doctors) are all scientists and need to advise the patient about the good, the bad, and the ugly.

Q: Why did you become a physician?
A: My father was an orthopedic surgeon and my grandfather was in radiology. I spent time growing up with my father’s best friend who was a plastic surgeon and got exposed to the field and saw it as an avenue that appealed to me because plastic surgery has a wide variety of treatment modalities.

Q: If someone has acne scarring, what doctor should they go t0 a dermatologist or a plastic surgeon?
A: Either one. It varies from city to city. In some cities the dermatologists stay strictly medical and in some cities the dermatologists have gotten into the cosmetic aspect. Now it seems that most dermatologists are doing a lot of surgical procedures. But with acne scarring the technologies are more commonly utilized in the cosmetic fields. I was a personal sufferer of acne in the 1960s and treatments were limited. It affected me deeply. As a personal sufferer and now as a physician and as a sufferer I try to be very honest with patients. What happens is emotional scars go hand in hand with the physical scars - I totally get it. We as humans are seeking solutions, and oftentimes patients are disappointed that there is no fast or clear-cut solution. I am the first to admit we can only improve acne scars and not remove them–it is the nature of the beast. Prevention is so important. There are many things that I have not performed on myself that are out there because I look at the risk/reward outcome and with my olive skin tone it is hard to treat. I think as we get a little older, and as we mature, we realize that we all have scars, emotionally or physically. Do I still have acne scars? Yes, I do what I can to minimize it the best I can. People want the facts, the realistic facts, and I treat my patients from a deep understanding of the physical and emotional scars. I think one of the values of Acne.org is that it allows people to realize they are not alone.

Q: What can people do for acne scars?
A: We do not have the technology to eliminate scarring but we are working towards it. Acne scarring is deep in the skin. Acne scars are depressed because the scars are so deep and that is the challenge. Some companies in Europe are coming out with new fillers that may minimize scars - I look forward to this development. I am a huge believer in dietary modification. There is truth in this–not necessarily in chocolate causing acne et cetera but there is some truth in non-inflammatory diets. Omega-3 and Omega-6 in our diets have a big effect. Studies on acne in way out there places such as New Guinea showed that teenagers had very little acne and as soon as the Western diet moved there the teenagers broke out. We will see a lot more of this as time goes on throughout the world. Acne scaring in patients is only going to grow because of the Western diet. What we see now is just a fraction.

Q: Have you see people with long term results with dietary changes?
A: Human nature is that we do not stay on it. The key to success is to stay on a diet long term, especially a non-inflammatory diet such as the glycemic index diet. You are only as bad as your last meal and only as good as your next one. Just get on target. Even if you cannot do it exactly, at least try to get closer to a non-inflammatory diet and understand that the closer you are the less damage the potential can be.

Q: Are vitamins / supplements a source good for anti-inflammation?
A: Some great supplements include things like red wine extract, pine bark extract, the Omegas, and vitamin E as a mixed tocopherol, and zinc gluconate. The issue is our genes are set up so that we have nutritional triggers. If you do not have this susceptibility to respond to supplements it won’t work. Nutritional supplements are safe and not that expensive. It has to be trial and error. There is no silver bullet.
Q: Dan recommends Omega-3’s and zinc.
A: Yes, this is solid science. Omega-3 and zinc helps over 80% of people. Topical things like skin toners actually dry the skin and create a bigger problem. It is a matter of balance. It is better to get what you need from food sources if possible. So much of the fish is toxic so I would go with the pills for the Omegas. Stay with a good brand / company but my preference is to get it through food. And I treat acne as a diseased state so you need to take more than the minimal requirement on the label. 1000mg of DHA and EPA is a good idea. Acne patients need to take bigger doses.
Q: How do you treat active acne? If a patient comes into your office,
what is the experience like?
A: Typically the patient will be treated by medication which will make your acne out of control for a little while. The purpose of that with Tazorac and Retin-A is to purge the skin as much as you can to clean it.
Q: What if a patient comes to you with acne scarring?.
A: We will meet and see if the patient will benefit from punch excision, subcision, or resurfacing. I would also create a maintenance program often including cleaning facials and microdermabrasion to maintain the skin’s health. Surgical options exist but as a surgeon we are very seriously limited. As we age the skin loosens and the acne scars tend to look worse. As you age it may look like the scars came back because the skin’s tightness is gone. Acne scar maintenance is a lifetime commitment. This is something people need to know.

Q: Are a combination of procedures necessary?
A: I’d say 50% of the time. Ice- pick scars will not be improved by resurfacing. We excise those. I will do subcisions if there are deep scars. Lasers can help too depending on the case. One good thing about resurfacing is that an acne patient heals faster then a wrinkle patient because by definition we have more oil in the skin.
Q: What about microdermabrasion?
A: It is minimally effective because it is very superficial but it is very good for maintaining skin health.

Q: And dermabrasion?
A: I’ve used it but I think there is more control with a laser. Dermabrasion has too many variables with the spinning diamonds, et cetera. There could be operator error. The face is curved. If it were flat it would work better. Lasers create heat which creates collagen contraction.

Q: Fillers?
A: I use fillers sometimes. It is an option. Long term fillers can have long term good and long term bad results. Long term bad could include lumps. Sometimes the patient may need to have the material cut out. Also understand injecting acne scars is difficult because the area itself is hard. What is more effective is subcision with a filler. However, all treatments have to be customized.

Q: What is recovery like?
A: Most patients with a deep acne treatment who elect laser resurfacing are looking at a 2 week downtime with pinkness up to 4-6 weeks. They often need to repeat this about once per year. Lighter treatments (nonablative) have less downtime but require more frequent procedures.

Q: In your opinion which is the best ablative laser.
A: C02.

Q: And the best nonablative?
A: I don’t think they work.

Q: What about silicon microdroplets?
A: They are illegal in many states. I think they’re dangerous. They can migrate and can be hard to get in the right place. They can sometimes all become a big ball.

Q: What about topical?
A: Nothing works for acne scars.

Q: Do peels work for scars?
A: They’re good for controlling the skin but not even a TCA peel will do much for scarring. Chemical peels do not have a great safety margin.
Q: What about Fraxel?
A: The problem is that it is ablative, painful, and if you think about it you are only treating a fraction of the problem. If Fraxel is so good, then why did they come out with a newer version?

Q: What is the typical cost for procedure?
A: You can expect $25-75 per subscision, $25-100 for each punch excision, $3500-4500 for aggressive resurfacing (once a year). Then there is the cost of the products and ongoing maintenance. I would say someone would need to budget $500-750 per month long term.

Member questions:

Q: What is his opinion on fillers and what type of scars will they work on best?
A: I often perform subcision first so the scar is not tethered. I usually use Juvederm Ultra and/or Perlane.

Q: What exactly are redmarks? I heard they were hyperpigmentation or they are damaged blood vessels. So which is it? I also have had the same redmarks for about a year and there is no sign of fading. Is this normal? What is the best treatment for the red marks.
A: Redness is from broken blood vessels, and thin skin. Try to let the body do its magic and heal on its own. I would perhaps add squalane oil, and Omega-3s to the diet. Also when you’re handling your skin make sure to pat dry and not use irritating products.

Q: how come the mark up for scar treatments is so dear?
A: (We didn’t ask. I think what this person is asking is, “why are scar treatments so hella expensive dude?)

Q: question, about fraxel: 1st: it works better on what kind of scars?
2nd: so far, how much improvement have they noticed between
fraxel 1 to the fraxel 2? 3rd: on average, how much improvement do doctors see with fraxel
2 on the patients? 4th: is fraxel the best treatment for acne scars on the market now?

thanks, as i will be considering this treatment when i am done with accutane.
A: Fraxel is best for shallow rolling soft shoulder scars. (see full interview for more on Fraxel)

Q: Dear Dr Garcia. I am trying to schedule treatments. How long would you recommend waiting after Fraxel before doing Sculptra injections in specific scars (ie to let swelling go down for accurate injection)? Thanks
Answer: well I think most of the swelling from a Fraxel is gone in about 5 days so maybe a week or so should do. JG 5.17.07
A: (I don’t think we asked him this one) Maybe we can say “For more on Fraxel see Dr. Garcia’s full interview)

Q: I’d like to hear Dr. Garcia’s opinion on Needling for rolling scars. And more specifically, if he’s heard of Frank from Transitions, I’d like to hear his thoughts on him and his technique.
A: (I don’t think we asked this either. Maybe we need to have a follow up with Dr. Garcia for a couple of these missed questions.)

Q: 1) Why is it that TCA cross is not a common procedure for scar treatments among doctors today?

2) What is the longest lasting filler on the market; any news on the potential fillers in the future?
A: The TCA cross does not work very well. The longest filler on the market is probably radius right now. A new filler coming out is called artifill. But be cautioned that depressed scars will need to be released first before filler is injected.

Q: My red marks arent going away. Its been over a year, and it doesnt want to fade at all. When in the morning when my skin is calm it looks ok, the red marks dont look very deep, but as the day goes on, gets warmer, and i have to go out in the sun, the red marks intensify 5 times. What can I do about this? What is the best treatment for these marks, and can they even be eliminated?
A: (see previous question on red marks)(or maybe just place same answer here)

Q: I’d like to ask him if sea water is any effective on red marks?
A: I don’t think you’ll notice a huge difference. Some things that may help a bit are squalane, topicals that contain copper, and vitamin C orally.

Q: is the co2 ultrapulsed laser the best treatment for acne scars?
A: The pixilated CO2 is good. However, other CO2s are comparable. This is not the only one. Pulsed computerized is probably the standard of care as of now. Keep in mind that I don’t think any laser is perfect.

Q: Is there any deep research being done on controlling/slowing down/curing hyperactive sebaceous glands? I’m talking for those of us who become an oil slick minutes after a thorough washing, even with so called oil control cleansers.

Perhaps the medical industry has something now available I’m not aware of
A: Blue light and IPL may help to a mild extent. Accutane obviously can shrink oil glands significantly and permanently. Jojoba and emu oil can also help control oil.

Q: Do you see potential for substantially better treatment of scars in any current developing science / technology (stem cell, recell, laser etc) ? Which appears most promising and how soon do you think it will be available?
A: Hopefully within the next two years we’ll see some strides. I do think we’ll see a huge difference in the future. For instance, tumor necrosis factor is interesting.

Q: A lot of questions here are for serious problems. I am curious what Dr. Garcia recommends for mild acne and how to treat/maintain this with over the counter products.

Also, when having used to much of a topical, skin can flare up with red spots and irritation. are there some recommendations on how to repair your skin before using the topical again? I ask this because I think irritation may be something that sustains my acne….on the other hand, completely stopping with medication is also not acceptable.
A: For mild acne I would recommend a mild facial cleanser, Omega-3s, a low glycemic diet, retinols, microdermabrasion for some people, IPLs. Eliminate aggravating factors if and when possible.

Q: What OTC product is best for little red marks?
A: Squalane oil, emu oil, jojoba oil, and even just regular extra virgin olive oil can help a bit.