Monthly Archives: February 2016

Hand Rejuvenation

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* Individual results may vary. Refer to disclaimer below.

While make-up can disguise tell-tale signs of aging on the face, it’s more difficult with hands – which is why it’s often said that hands are the best indicator of age. he
skin on the back of your hands is much thinner than on your face and actually ages faster than your face.

Even if you have taken steps to keep your face and neck looking youthful, sun-damaged, veiny, wrinkled hands can make you look older than you are. As we age our hands lose volume, fat and elasticity. The fatty layer of the hand disappears, so the skin is more translucent and shriveled, and you see underlying structures like bones, tendons and veins. There are a number of effective techniques to rejuvenate your hands, improving the quality and texture of your skin, while decreasing the wrinkling and prominent veins. A number of options are available to restore the youthful appearance of the hands.

Age Spots
Treatment – Lighter more diffuse brown spots are most responsive with prescription grade skin care product containing hydroquinone. Hydroquinone contains a bleaching agent which blocks melanin. This medical skincare will help quickly lighten those brown spots on your hands. If the brown spots are dark and larger this usually indicates it is deeper in the dermis of the skin. This type needs to be treated with a laser or IPL (intense pulsed light) machine where the pigment is destroyed.
Prominent veins and tendons

Treatment- This is due to volume loss as we age. Volume replacement is used to treat protruding bones, tendons or veins. Your plastic surgeon can take fat extracted during liposuction, concentrate it, and re-inject it into the back your hands. Soft tissue fillers, including Juvederm, Perlane, Restylane and Radiesse, can add volume to thinning hands. Another option is sclerotherapy where solution is injected collapsing the prominent vein.

Wrinkled and thin skin
Treatment – Laser skin resurfacing is an excellent way to improve skin tone and texture, while reducing the signs of aging on the hands. Laser resurfacing removes the outermost layer of skin on the hands, leaving only the healthy cells underneath. These can then regenerate a new layer of skin, reducing the signs of fine lines, wrinkles, age spots and other age-related blemishes. Radiofrequency skin tightening devices, such as INFINI are also very useful in improving wrinkled skin on the hands.
Homecare will include daily use of Retin-A, which builds collagen and makes skin look firmer and smoother.
Skin tone and color

Treatment – Chemical peels, IPL, or laser skin resurfacing may be used for skin discoloration, sun damage or soften the appearance of brown sun spots on the hands. Treatment may involve a series of chemical peels or three 10-minute IPL treatments.

While there are many treatments available for aging hands, prevention is always the best bet. Remember that our hands get as much sun as our face so be sure to use sunscreen daily on your hands!

Will my insurance cover this procedure

As a plastic surgeon, this is a question my office gets every week. Will my insurance cover a certain procedure? It seems like it should be a very straightforward question, but as you might suspect, nothing is straightforward when it comes to health insurance. Before I endeavor to make some sense out of this topic, allow me to say that the health insurance industry’s only goal is to make money, not to ensure your healthcare. It makes money by charging premiums and then not paying doctors and hospitals when you want a procedure covered. So when it comes to plastic surgery, it will do everything it can do to say a certain procedure is not medically necessary, and therefore, not covered. In the past few years, getting previously covered procedures approved has become harder and harder. It used to be that doctors would get authorization or pre-approval from insurance companies and that would guarantee that the procedure would get covered. Now many companies are saying “pre-authorization not required”. While this seems great at first, doctors, patients, and facilities have found out the hard way that this really means “proceed at your own risk”. For example, I’ve had multiple patients have a procedure performed only to get a bill from the hospital saying the insurance company has refused payment when they said “pre-authorization not needed”. This has become such a problem that many hospitals and centers are making patients pay ahead of time for certain procedures that are not getting covered routinely. All of this has led some plastic surgeons to stop accepting insurance all together.

Surgical procedures are covered if they are deemed medically necessary. Some plastic surgery is routinely covered, such as trauma, cancer, burns, and wounds. Some plastic surgery is always considered cosmetic and therefore never covered: for example, tummy tucks, liposuction, and injectable fillers. To complicate things, now many policies have small print “exclusions” for common procedures like breast reduction, meaning they are never covered under any circumstance, even if medically necessary. Here are a list of the common procedures that fall in the grey area of medical necessity:

Breast reduction- Most insurance companies will cover this procedure if the patient has symptoms related to overly large breasts and a certain amount of breast tissue by weight needs to be removed. The higher your body weight, the more needs to be removed. Of course, this amount is different for every woman. But in general, going from a DD to a C cup is not going to be covered. Going from a G to a C would be. Typically at least 500 grams (Slightly over one pound) needs to be removed from each breast from a woman who weighs under 175 pounds. Each insurance company has their own formula and your doctor can help you understand if the procedure would be covered.

Rhinoplasty- Rhinoplasty is covered only if there is breathing impairment, such as a severely deviated septum. Oftentimes, insurance companies will requre CT scans to validate this finding.

Upper eyelids- Upper blepharoplasty may be covered when the excess skin impairs vision. This must be verified through a visual field exam done by an independent optometrist. Even when visual field defects are verified, the procedure often doesn’t get paid by the insurance company. Ask me how I know.

Removal of excess skin following weight loss- With the recent increase in weight loss surgery, we are seeing more patients who have lost 100 or more pounds coming in with the desire to have the excess skin removed from their trunks, arms, and legs. The only procedure which we can sometimes get covered is a panniculectomy. A panniculectomy is surgical removal of the overhanging skin of the lower abdomen. But there must be documentation of severe skin infections and/ or open wounds. Even when these conditions are met, many insurance companies treat this like a tummy tuck and simply refuse to pay.

Botox- We all know about the cosmetic benefits of Botox, but there are some medical indications as well including migraine treatment. But this requires extensive documentation from the doctor managing your migraines and IF the doctor injecting Botox gets paid, it can take months. So most doctors, myself included, do not accept insurance for medically indicated Botox.

Breast cancer reconstruction- The good news here is that so far all procedures relating to breast cancer reconstruction are covered. This includes treatment of the opposite, non-cancerous breast to maintain symmetry. So in the case of breast cancer, breast implants, lifts, and reductions may all be covered.

If you have any more questions regarding the insurance coverage of plastic surgery procedures contact my office at 301-829-4110. I accept most insurances. For now….


What is the best moisturizer to use during the winter months?
Moisturizing is an essential part of every daily skincare routine. Most people tend to have dryer skin during the winter months due to the combination of the outdoor elements and indoor heating. In the winter months the dryer the air the more moisture it will pull from your skin. A moisturizer will prevent, protect and hydrate to ensure your skin stays healthy in the cold weather.

There are three types of moisturizing agents and knowing how to use such agents will help keep your skin looking young and supple. Moisturizers work in one of two main ways: they either trap moisture in your skin to keep it from escaping as a temporary barrier, or they restore moisture in the outer layer of skin that’s already been lost.

1. Emollient Moisturizing Agents:
An emollient is an ingredient that smoothes the skin’s surface by creating a barrier over the skin, trapping water in the skin’s layers and stopping evaporation but aren’t usually long lasting. This class of moisturizer, which exists in the form of creams, ointments, lotions, and gels, are generally preferred over occlusives because they feel less sticky.

2. Occlusive Agents:
These ingredients form a film on the skin and prevent water loss. They can be very effective but can end up feeling waxy or greasy on the skin, and may cause acne or blackheads. Occlusive agents increase moisture levels in the skin by actually providing a physical barrier.

3. Humectants Agents:
Humectants acts like a sponge, attracting moisture to the skin and keeping it there. This is basically the opposite of occlusives and emollients, which don’t like water. Hyaluronic acid is one such ingredient that attracts and holds water, which is what plumps your skin so that wrinkles and lines are less visible.

What is the best moisturizer for your skin?
One of the first mistakes people make when using products on their skin is using a product that doesn’t necessarily fit their skin type. Skin types generally fall into one of five categories: normal, oily, dry, combination, or sensitive.

Normal Skin:
Characterized by healthy skin with an even skin tone and small pores. Clients typically have not complaints about their skin.
– Use a water-based moisturizer that has a light, non-greasy feel.

Oily Skin:
Characterized by skin that has large pores and have visible oil on the skin. The skin is thicker and more prone to breakouts.
-Use lotions instead of creams such as lactic glycolic and salicylic acids. Choose a water-based product that’s non-comedogenic” if your skin is acne prone.

Dry Skin:
Characterized by skin that is often itchy, red, flaky, or generally tight. Thinner skin with visible fine lines and wrinkles and skin is rough to the touch.
-To restore moisture to dry skin, choose a heavier, oil-based moisturizer that contains ingredients that help keep your skin hydrated.

Combination Skin:
Characterized by skin that has an oily T-zone (that’s your forehead, nose, and chin) alongside drier patches on the cheeks.
– This is the hardest skin type to find products to meet your need. Try a heavier cream on cheeks and a lighter, oil-free formula on the T-zone

Sensitive Skin:
Characterized by visible capillaries, skin is dehydrated, prone to acne and inflames easily. Skin is warm to the touch, flaky and often red.
– Look for a moisturizer that contains soothing ingredients, such as green tea or aloe. Avoid fragrances, dyes and products containing acids.

Seeking the professional advice from an esthetician or dermatologist even once is a good investment. Such a specialist can analyze your skin type, troubleshoot your current skin care regimen, and give you advice on your skin care routine.

INFNI for skin tightening

Advancements in skin tightening

Patients often ask me if there are any good treatments for wrinkles that don’t involve surgery. Fortunately, the options for non-surgical skin tightening are growing. Most everyone is familiar with Botox and other neurotoxins that relax facial wrinkles. But for most people, those treatments are limited to the forehead and upper face. Dermal fillers also help with deeper wrinkles. Several energy based skin tightening devices exist. But these treatments for skin tightening have been sub-optimal in my opinion, until now.

In 2015 a new skin tightening technology was unveiled that has me really excited. It’s called Infini. This unique device is specially developed for wrinkle reduction through 3-D volumization; it maximizes results while minimizing patient discomfort. Patients looking to fight the ravages of time now have a new alternative treatment that is comfortable and won’t keep them hidden at home during recovery while still providing outstanding results. Infini is proven worldwide, with over 10,000 treatments performed and sound clinical proof.

How Infini Works
Infini applies radiofrequency energy through microneedles, allowing precise treatment depths for different areas of the body with varying skin thickness. Infini works in the deeper skin layers (dermis), where wrinkles originate, to rebuild collagen without causing unwanted damage to the top layer of skin (epidermis). The collagen continues to build over several weeks after each treatment; the skin becomes more youthful as wrinkles become less and less visible. Because Infini applies energy below the surface of the skin the Infini can treat dark and tanned skin patients, providing wrinkle solutions for patients who had few,if any, other options.

Three treatments are needed, each about one month apart. Downtime is usually limited to less than 24 hours of redness. Most patients go to work the next day looking completely normal. Infini can treat wrinkles of the entire face, neck, chest, arms, hands, thighs, or anywhere with unwanted laxity. Infini is also highly effective for the treatment of acne scars. The beneficial effects are long lasting. It’s best to think that the treatment will turn the clock back 5-10 years on your skin, and then the aging process will continue from there.

I chose this technology, because of its combined benefits; excellent wrinkle reduction outcomes, extremely short downtimes, and greater comfort than other traditional energy based treatments, such as Ultherapy. My patients really appreciate that the short down times get them back to their daily routine fast and they LOVE their results.

To learn more about Infini, contact Board Certified Plastic Surgeon, Dr. Guy Cappuccino, in Mt. Airy at 301-829-4110. For more information on Infini visit