by Cap Lesesne
It’s also around age forty-five when the neck begins its descent, followed by the jawline. Of course, for those who’ve spent much time in the sun, all this decay, I’m sorry to say, happens sooner.
You can’t talk about aging without talking about skin.
I’d long believed that exfoliation, if done periodically and gently, would not only remove superficial growths but also improve the texture of the skin and improve the homogeneity of pigmentation. I’d been performing dermabrasion with small, custom-made diamond burs, and my patients would come every year to have skin treatments.
But I was still largely ignorant of, and skeptical about, the importance of skin care. Sure, I knew a lot about skin. Surgeons understand skin differently from other physicians because we have extensive experience with its texture, depth, and fat consistency. We understand the course the muscles and nerves take, and how that interacts with skin to create wrinkles. I knew that older, thinner, “atrophic” skin heals better – the wound closes cleaner and the scar is thinner – because a particular type of collagen changes over time. I knew that drier skin heals better than oily skin. That the forehead and nose are naturally more oily, the cheeks and lower lip drier, the upper lip drier still. I knew that patients with larger pores (oilier skin) tended to heal worse. That the skin of the eyelids heals beautifully; the skin in front of the ear, very well; the areola, badly; the skin on the back, terribly. That any skin that covers a joint heals poorly, because it stretches.
But for all this knowledge, I did not come to realize the importance of skin care until several years ago, when a sixty-year-old Frenchwoman with magnificent skin came to my office seeking a necklift. I asked her why her skin was so good. “I go to this lady in Paris,” she said, and mentioned the woman’s name. (The woman in my office wanted a face-lift because she was quite jowly.)
Six weeks later, another Frenchwoman, sixty-five, came in for a consult, and she, too, had spectacular skin. I asked her why her skin was so good.
“I go to this lady in Paris,” she said, and she mentioned the same woman the previous consult had mentioned.
I decided to see for myself. I flew to Paris and tracked down the woman, Odile Lecoin. Her office was routinely filled with magazine editors who swore by her. I asked her about her methods. She had started doing microdermabrasion before anyone else. Twenty years earlier, she told me, she had started facial sanding, using small crystals and an air-blowing machine she’d found in Italy. My microdermabrasion treatments could leave the skin red for a day; Mme. Lecoin’s did not. I was mightily impressed with her results and invited her to bring her knowledge of skin care to my office, so that I might expand the skin-care treatments I offered my patients.
She accepted. She worked in my office for five years, incorporating her extensive knowledge of microdermabrasion into the skin-care regimen I had established, and teaching me her secrets. When Mme. Lecoin retired two years ago, I decided to expand our offerings. I developed a technique that, using a new kind of crystal, not only allowed smoothing of the skin, but also the prevention and treatment of skin infections. This was of particular advantage for acne, which is notoriously difficult to treat. Moreover, it did not require the use of antibiotics.
While I was doing this on my own, I was asked by one of the Estée Lauder companies to be a consultant on developing a skin-care line. Why they chose me, I wasn’t sure; but I know they’d researched hundreds of plastic surgeons, and I’d heard that some of the Estée Lauder executives had noticed the skin-care results out of my office. At the same time, the CEO of Saks encouraged me to develop a skin-care line. This began a three-year search for me to find chemists to help develop an effective, completely noncosmetic form of skin therapy.
In the meantime, I started collecting, anecdotally and from my own research, thoughts about skin care.
1. It amazes me how many women apply (and overapply) oils and creams to their face – especially women with adult acne or oily skin. If your skin is oily or if you have acne, DO NOT USE moisturizer, day creams, or extra oil on that part of your skin. Doing so only makes it worse. I realize that certain soaps and frequent use of soaps dries the skin. But soap comes in different types and strengths, from the extreme of Dial to that of an olive-oil soap. Some of the best skin I’ve ever seen belongs to women who cleanse with cold water and soap, then apply a mild moisturizer on the dry spots.
2. Ultraviolet light breaks down the collagen bonds in the dermis layer of the skin and can alter the DNA of cells in the base layer. This not only ages the skin but may also give rise to skin cancers such as basal cell cancer, squamous cell cancer, and melanoma. Skin creams with low SPF factors (4–20) are ineffective; use a factor greater than 20. But that’s not enough: If you’re sweating, the salt degrades SPF factors after two hours or less. For it to be effective, you need to reapply it.
3. As I mentioned above, exfoliaton works. Both microdermabrasion – a spraying of fine crystals at the skin to loosen dead tissue – and its forebear, dermabrasion, work. They make your skin smoother and help to remove brown spots. Everyone should incorporate them into their regimen. How frequently you need it depends on your skin. If you have lots of little bumps and growths on your skin or your skin is blotchy, you need more frequent treatments. If you’re younger and your skin is smoother, you need fewer treatments.
4. To treat wrinkles, brown spots, and blotchy skin, get the real thing – not a cosmetic but something that has medicine in it to correct hyperpigmentation. The state-of-the-art skin lightener is a drug called hydroquinone. The maximum strength allowed for over-the-counter medicines is 2 percent. In my office, I custom-make a skin lightener with 5 percent hydroquinone and add a small amount of cortisone to increase its ability to penetrate the skin. Because of the higher percentage of hydroquinone, this custom blend can only be distributed by my office, since a prescription is required. It’s because of my frustration with the limitations of cosmetics that I’d worked to develop my own skin-care line, which includes a set of proteins that allows medicines to penetrate the skin better, to make skin pigment more homogeneous, and to plump up the lips.
There have been reports that hydroquinone is possibly carcinogenic. When I looked into these reports, I saw that they were few, and that the mice were bathed for weeks in hydroquinone. So I’m skeptical of hydroquinone’s potential for causing cancer. Nonetheless, I will incorporate some newer proteins into my skin-care line that have the same effect as hydroquinone but with no potential carcinogenic issues.
5. Lots of money is spent on products that claim they can eliminate or reduce stretch marks. I’ve never seen them work. I doubt they could ever work because stretch marks are caused by a loss of elastin proteins in the thickness of the dermis. To work, then, these products would have to penetrate the skin deeply so that they could change the skin’s actual protein composition. And if that were the case, these products would be required to undergo testing by the Food and Drug Administration; if they passed those tests, they would be prescription medicines.
Most skin-care products don’t work. Some do, to an extent. Moisturizers form a thin barrier of oil that prevents one’s own moisture from evaporating, thus leaving the skin plump. Glycolic acids and peels can change the natural collagen and make it more “organized” in its appearance – that is, tighten the skin. For the most part, though, skin-care products are just cosmetics that mask what’s actually going on in the skin. A cosmetic does not actually protect or change the skin.
As I became more aware of my patients’ skin conditions and desires, after working with multiple chemists, and after spending years doing research at Cornell and New York University, I was ready to start my own skin-care line, which would offer products that were medicinal, and which would make no exaggerated claims. I call my products anticosmetics. Every cream or lotion I develop must have medicinal qualities, must have a delivery system that enables deep penetration, and must do so without irritating the skin or reducing the skin’s natural barrier to i
nfection. I demanded from my chemists that we avoid the stock lotions that are the basis for almost all the cosmetics currently on the market. Every ingredient would have a function. All fragrances and colorations would be removed. And unlike other products, mine would include pharmaceutically pure substances whenever possible. These substances would probably cost more, but they would be unique and effective.
Despite the time I spent researching and developing a skin-care line, I kept my focus on plastic surgery. My sense of medical discipline made me follow the same pre-op routine with every procedure. The routines were drilled into me in medical school and during my residencies, and they could not be circumvented. I reviewed a checklist to minimize the chance that something could go wrong, then reviewed a checklist for how to handle those moments if something did go wrong. Before the operation, my staff and I together went over everything. Then, even though we’d checked everything once, when the patient was wheeled in for surgery, we checked it all again.
The monitors.
The oxygen tanks.
Were all the necessary drugs and medications within arm’s reach?
If the power failed, did everyone know what to do?
If the patient went into cardiac arrest, did everyone know what to do?
It was like a fire drill, or a pilot going through his sequence. And just as the pilot had a ground crew to check instruments for him preflight, when he got to the plane, it was up to him to check everything again.
As to the particular procedure, I reviewed it in the days leading up to, then again right before, the operation.
My OR environment had its unbreakable rules, too. No pipedin music. No chitchat. No food or drink. No pictures on the wall. No singing. No phone calls.
My office was in a perfect spot, on Park and Sixty-fifth. I played classical music in the waiting room. Across the street was Daniel, the popular French restaurant. Central Park was blocks away. This was the alpha and omega of a Park Avenue practice. I had a Westchester practice, too. Good results were all I wanted. Being in the OR – gowned, gloved, in my mask, instruments ready, operating, transforming – became my sanctuary, my temple.
I was in a zone.
Women of the World
The more my practice grew, and the more diverse my clientele became, the more I was able to say, from my own fund of experiences, that people of different ethnicities, nationalities, and races had particular tendencies. Plastic surgery had come a long way and expanded into every one of these different groups. It became clear that now everyone, regardless of background, had something that bothered him or her. For some, it was groupthink; for others, physical expediency.
For example, when Scandinavian women come in for breast surgery, many more ask for reductions than augmentations. Fortunately for them, the genetics of their skin make them heal the best of pretty much any ethnic or racial group; the scars are finer, flatter, smoother.
Italians often come in for rhinoplasties, to reduce and straighten that famous “Roman nose.” Once, at a medical conference, I was presenting photographs of some large noses I’d operated on. A doctor from Turin stood. “I bet I’ve worked on bigger ones,” he boasted, holding up photos of his own nasal subjects. (He was right.) Italian women also love flat bottoms. Southern Italians have naturally oily, olive skin that heals poorly, yielding wider scars and more pigment around the scars than northern-European skin. The surgeon must be more aware of where he puts his incisions.
Because Frenchwomen smoke a lot, they tend not to heal well. They like face-lifts but they’re insistent that the look be natural, subtle; in twenty years, I’ve never had a Frenchwoman (or one from Madrid) who wanted a face-lift that looked even remotely pulled. They like big lips. For some reason I can’t explain, Parisian women, contrary to expectation, rarely use makeup well – or maybe, to my eye, they wear too much. They’re as stylish as any group of women in the world and understand the use of color for their face. However, their application of eyelid makeup and lipstick can be excessive. (I would not venture this opinion if I were the only plastic surgeon who has noted it.)
Thanks to the liberal French medical system, women and men tend to use far more injectables – vitamins and misotherapy – to treat wrinkles than elsewhere in Europe and the United States. Unfortunately, there is much mystery about what’s in some of these injectables. Sometimes they’re mixed with silicone or other foreign materials, which frequently leads to reactions and infections. (In my experience, only South Americans and Mexicans get infected more than the French; they, too, are often injected with silicone contaminated with bacteria.) These infections can be nasty. Because silicone is a foreign material, it rarely clears from the system with just antibiotics, and the infection persists until the material is surgically removed.
Spanish women – perhaps the most elegant international group I deal with – come in for lipos, face-lifts, lip augmentations, and pretty much everything else, and they come back for multiple procedures. I’ve tended to develop a rapport with them, perhaps because my first-ever Spanish patient – a member of the royal family – turned out so well (she was thrilled with the result) that I received numerous referrals. Around Christmastime, I frequently receive phone calls from Malaga, Seville, or Madrid saying, “Cap, how are you? … May I come in January for a quick fix?”
I have not developed such a rapport with German women. They break appointments, frequently change their mind about what operation they want done, and can be fairly demanding. Like Scandinavian women, they also get lots of breast reductions. They like liposuction, particularly for the outer leg.
British women also have body sculpting procedures, but with a different twist. In my experience it is breast implants that prove the most popular amongst British men and women – you only need to look at the back of British magazines to confirm that. I have, on several occasions, recommended to women from the UK that they might consider a smaller implant size than the one they initially requested.
That being said, I think that when it comes to facial surgery, British women have got it right. Like the French, they want to appear younger, like themselves, and without the obvious signs of plastic surgery. I’ve never had an English woman request for her face to be extremely tight. One would initially think that that would require less surgery, but this is not the case. To get subtle results requires a myriad of small procedures addressing each area of the face. It is therefore much more detailed and, for many surgeons, much more complicated. I’ve consulted with several women, particularly from the Midlands and the North of England, who’ve had failed plastic surgery of the facial area and have been left with completely unacceptable scarring. When consulting in London, I frequently have to address that issue first before moving on to the actual facial improvement.
The other advantage of English women is their intelligence. When I explain the risks and complication and the options they face, they understand them immediately, and to date have never challenged me as to why this or that is so.
But in my opinion it is Australian women who rank amongst some of the most beautiful women in the world. Because of the climate they are predominantly interested in body sculpting but do not tend to go to such extremes as the British when it comes to breast implants. Unfortunately, later in life reconstruction after skin cancers is also common because of the lifestyle in the sun that gives them such athletic physiques in their youth. Kudos to Nicole Kidman for growing up in Aussie and having such beautiful skin.
In contrast, Hispanic women come for lipo on every body part but the rear, which they prefer to look like Jennifer Lopez’s. (In fact, sometimes they ask for buttock implants or fat grafts to the buttocks.)
Brazilians don’t care so much about scarring, which can in their case be hard to disguise because of their generally dark pigmentation, given the large Indian influence in their genetic pool. Dr. Ivo Pitanguy made Brazil the center of cosmetic surgery in the 1970s by getting Brazilian surgeons to publish in Western medical journals and by masterfully mark
eting himself. Because of this, and because Brazilians love the outdoors and curvy bodies, they have an extraordinary amount of breast augmentation. Billboards on freeways advertise breast implants. This is a somewhat recent development; the Brazilian ideal – “the girl from Ipanema” – used to be svelte, almost flat-chested. Girls in Brazil get breast implants way too young, younger even than American girls (though ours are catching up).
Argentinians – not as body-conscious as Brazilians, and on average a little heavier – mostly come in for facial work. Their skin quality is mostly of northern Italian and European background, so they heal better than Brazilians.
Venezuelan women are beautiful and showy. For the Miss Venezuela beauty pageant, contestants who’ve had plastic surgery don’t merely refrain from hiding it; they flaunt it. They like large breasts, slim hips, and full lips. They do not like big rears.
Colombians do like big rears. In one unfortunate instance, a lawyer from Bogotá wanted her buttocks built up, so she injected herself with filler, which caused an infection. When she came to see me about it, she had two infected cheeks, each with a bright red dimple. I told her she had two choices: take antibiotics and hope that it killed the infection (unlikely) or have all the subcutaneous tissue cut out of her buttocks. Not surprisingly, she opted first to try the antibiotics. Within a month, fortunately, they worked.
For a small country, Peru is quite chic. I have worked on both the more Indian-inflected Peruvians and the more European ones (who tend to come to me when they’re younger). Peruvians have more facial work than body work. They are unusually worldly, maybe more so than my clients from any other country in South America. They can tell me what plastic surgeons are doing in London, Paris, and Madrid.
