Questions for Dr. Diaz

[Warren]

Please list any questions that you would like to ask Dr Diaz.

My name is Gus Diaz, MD. I am a Facial Plastic Surgeon based in Gulf Shores, Alabama. I would like to thank you for the extraordinary work you are doing in helping patients with rosacea. Currently I have about 3-4 patients that were referred form your board to my practice.

I currently have a Lumenis One since Sep 2004. I currently treat 4 to 5 patients a day. All IPL treatments are preformed by me. I am also currently a teacher for Lumenis for the Lumenis One, ClearLight, LightSheer, and in the near future for 2 new modules that are going to be available for the Lumenis One.

I will like to help you and the group in any way that is possible. My consultations are free, and I think that the prices of my treatments are reasonable. Please, let me know that you received this e-mail.

You question may or may not be used and could be modified so do not be dissapointed if your question does not get asked.

[Tamara]

Dr Diaz,

Thanks so much for your generosity and willingness to share your knowledge with our Rosacea Forum. We are eager to hear your thoughts about rosacea. Would you be willing to share how you generally treat rosacea patients with your Lumenis One? In your opinion, how does the Lumenis One compare with what you were previously using to treat your patients and do you find it to be a significant improvement?

Thanks so much,

Tamara

[Spav]

Do you advocate the use of multiple passes of varying wave lengths during a single treatment session?

[Bob Bear]

Dr Diaz,

First of all, thank you for contributing to our group. We all greatly appreciate you taking to time to talk with us.

Id like to ask you about your opinion of the future of IPL treatment for rosacea and flushing. With the promise new of interesting topical and oral drugs on the horizon, do you think there will be a place for lasers in 5 - 10 years time?

If so, how do you think lasers will develop along side said medications?

Many thanks,

Bob Bear

[drnase]

Hi Group,

The questions so far are great. I learned a lot from our long talk about what he does and does not know. So, in an effort to continue to focus the questions to what he knows (which is what he wants), I will tell you some tnings. Like you, I would like for him to go out on a limb a little bit to make educated guesses about some things that he might not directly know, but may deduce as a physician. However, this concerns him....... thus our big disclaimer. My thoughts so far and take them for what you want:

1. He has only used the Lumenis One to my knowledge. His main specialty is facial plastic surgery (which we should definitely take advantge of -- operations, where the blood vessels are, nerves that he anesthetizes and turns the face white by accident, etc.). Rhinophyma cases are great questions, what he does for enlarged pores or fibroplasia AND NOSE SWELLING.

2. He started out with one pass, now is using two passes and considering three passes. Spav, you may want to dig some specifics out of him.

3. Bob, he does not know about the current or newest drugs available for rosacea. He made that clear to me. It is a great question and we should probably keep it in here, but he stressed that he was not a dermatologist and would probably not go down that road of questioning for his liablity.

[celticgirlie]

How many treatments do your patients, on average need. What about touch-ups?

Do you have any"resistant" or especially difficult cases i.e. patients who have had previous unsuccessful treatments or treatments that could be improved upon.

What kind of doctors do you train? How many do you train per month? How long is the training session? How much experience do you think a laser specialist needs in order to feel confident of his abilities and trust your face to him/her?

Dr. Nase, in this case, what would your hopes be for this doctor learning about macrolides post treatment and the pre-flush?

Elizabeth

[drnase]

Elizabeth,

The reason I liked him so much is that he is an absolute open book who wants to learn, not judge......learn. He does not dismiss things and is willing to safely up the anty.

Open book, open mind and cares about rosacea sufferers.

[alecashley]

Hello dr diaz. If you would get slight or no improvement from ipl alone. would you or could you ues 1064 yag head, small spot size on full flush zone, high fluency to achieve better results.. may be 1064 scatter proof laser light is a better way to treat feeder vessels

[alecashley]

dr would you be willing to keep up with the ever-changing tecnology for rosacea? laser manufactures are always upgrading..would you be willing to add proven and future rosacea lasers and ipl systems such as cutera laser(genesis laser) or new sciton bbl with super yag? :arrow:

[celticgirlie]

Dr. Nase, I really think that if this doctor is willing to learn anything about treatment then you are the one best able to get the facts across. Also, you know the most pertinent questions to ask.

All I would like to know from this doctor is his opinion on the best method of spreading the word to the medical community about up-to-date laser treatments for rosacea including the pre-flush and macrolides.

Has he read your book?

Elizabeth

[Library Lady]

OK, I'll asks the large pore question -

Thanks Dr Diaz for participating here! This is a great thing.

so here goes -

Is there anything you do to specifically treat large pores? does this help oily skin as well? (they seem to go hand in hand)

Also, do you use the YAG 1064 along with IPL?

I live near you, so is there a charge for the initial consultation?

Thanks bunches and hope to be seeing you someday!

[drnase]

Group,

These are all great questions. Great response.

However, we will have plenty of laser experts, so lets mix it up. He is a facial plastic surgeon primarily. Lets use that a little bit more. You guys and gals always ask what can be done for facial this and that -- hes the guy. Can rosacea sufferers have blepharoplasty, can you reshape a swollen nose without making it worse, can you remove the fibrotic pads of skin in my cheeks, etc. Get outside the box. While he is willing to listen and learn, the purpose of this is for us to listen and learn. We will educate later. Creative juices flowing (except for Bob Bear).

[bethanne]

Dr. Diaz,

Thank you for agreeing to field questions from the
group. Your time and consideration are very appreciated.


In your experience and knowledge with Rosacea patients,
would it be contraindicated to have procedures such as
restalin injections to approve the appearance of aging
faces? Or are there any other of that type of treatment
that would be more recommendable for someone with
Rosacea?

Kind Regards,
Beth

[celticgirlie]

Have you used JetPeel or something similar? (does a plastic surgeon use that or just a derm.?)

Is plastic surgery an option for rosaceans? To what extent? How about facial implants? What about fat injections?

I have officially watched too many extreme makeovers.

Elizabeth

[Bob Bear]

Thats a great thought Celticgirle.

I wonder if there are any treatments that Dr Diaz would be particularly relucant to perform on a rosacea sufferer?

[IowaDavid]

Hello Dr. Diaz, I'd like to thank you very much for agreeing to participate with this forum.

A question I have asked many laser specialists over the phone, in trying to decide if I should see that doctor, is, "How effective are the treatments at reducing flushing?" Oftentimes, and especially a few years ago when there were alot of aesthetic facial clinics popping up, I would hear that a given clinic treated rosacea. But, more often than not, "treating" rosacea meant clearing telangiectasia, redness, and reducing acneform lesions. Unfortunately, one could come away with pinker-looking skin, but the flushing was still present, and sometimes not affected at all.

With the newer generations of lasers and protocols, do you feel that physicians are more able to treat the vessels which are responsible for flushing, which is the heart of our disorder? What do you consider to be the best protocol for treating flushing with laser?

Thank you very much for your time.

David

[drnase]

Thank you for taking the time out of your schedule to help educate rosacea sufferers. We also find it exciting to be able to ask questions to a physician that has extensive knowledge of the facial skin, vasculature and cartilage, as well as laser treatments.


1. If you are able to divulge the information, what two specific advancements will be made to the Lumenis One Platform in the near future and what theoretical effect could that have on rosacea treatment?


2. For 'nose flushers' or centrofacial flushing that starts with the nose and is propagated via conducted dilation, do you ever envision being able to microcauterize a few key collateral branches from the facial artery, especially the angular artery that gives us so much trouble on the side and tips of the nose? Can you do this without telangiectatic matting?

3. A common question asked by rosacea sufferers is directed at the centrofacial pores. I have a few questions about this topic: (1) Do facial pores mostly widen as you go deeper, does the canal shrink as you go deeper, or is there a combination of both forms, (2) Do you think mild fibrosis, swelling and chronic dilation of vessels surrounding the glands/lobules are the main cause for pore enlargement or is it mostly hormonal?, (3) There are some dyes being made that are very selective for immature sebacytes within sebaceous glands. These dyes are taken up by these cells with high metabolic rates and only react to a very narrow range on lasers. In theory, they should be able to seal shut the sebaceous glands and all the lobules safely with few treatments. Do you plan on testing these dyes or do you have any thoughts on possible negative reactions to this procedure?

4. Concerning treatment of the red ears. A rare, but frustrating side effect is damage to the cartilage. As a facial plastic surgeon, how would you recommend a physician approach ear treatments safely?

5. Rosacea seems to be classified as a Neuro-Vascular disorder at its heart. Using your experience with facial plastic surgery, have you made any deductions as to what nerves might play primary roles in the face after performing various nerve blocks and correlating that with whitening of the skin (e.g. decreased blood flow)?

Thank you very much.

[coquilos1]

Thank you Dr. Diaz for your time. I was curious how often you perform laser treatment on rosacea sufferers with darker skin tones (skin types 3, 4, & 5) and what results you see with these patients? If you do, how does your protocol change? What approaches to treating these patients do you take?

Thank you,

Carlos

[Spav]

Hi Dr Diaz,

(My First question revised)
I hear you are currently using two passes to treat rosacea with the Lumenis One. What wave lengths and energy settings do you use for each pass? Do you think there is room for improvement by extending this protocol?

When using the Lumenis One, do you advocate treating the whole flushing zone of the rosacea sufferer? If the flushing zone is too large to be treated in one session does this adversely effect the success of the treatment?

[ian]

My question for Dr. Diaz:

Even though I don't suffer from severe rhinophyma (or even moderate for that matter), I'd be interested and very curious as to wether Dr. Diaz has treated/treats severe rhinophyma patients. As outlined by Dr. Nase before, it's quite the combo of treatments for repairing/reversing severe rhinophyma - and goes beyond just laser treatments. Being that Dr. Diaz is a plastic surgeon, perhaps he's had experience in this. That may be especially comforting as it would be an option for those that need this sort of specialized treatment to have someone with experience to go to. If not - does he know anyone who does have the experience and expertise to treat it?

I've attached re-copied/re-pasted an article that's been posted by Dr. Nase before that sort-of touches on this I think:
Aesthetic Plast Surg. 2004 Dec 23; [Epub ahead of print]

The Gold Standard for Decortication of Rhinophyma: Combined Erbium-
YAG/CO(2) Laser.

Goon PK, Dalal M, Peart FC.

Department of Plastic Surgery, University Hospital Birmingham, Selly
Oak, West Midlands, Birmingham, United Kingdom, pat...@yahoo.co.uk.

Rhinophyma is a benign condition of the nose that often is severely
disfiguring and occasionally causes functional problems. A
considerable proportion of the patients, with rhinophyma are elderly
with chronic medical problems. Electrocautery, heated scalpel,
carbon dioxide (CO(2)) laser, argon laser, Weck blade, dermabrasion,
cryotherapy, radiotherapy, full-thickness excision, skin graft, flap
reconstruction, and cold scalpel have been used either alone or in
combination. All these techniques have disadvantages that are
resolved by using the combined erbium:yttrium-aluminum-garnet
(YAG)/CO(2) laser. The authors present their technique and the
results from decortication of rhinophyma using a combined
erbium:YAG/CO(2) laser. The technique requires only local anesthesia
with a vasoconstrictor. The combination of an efficient vaporization
tool consisting of the erbium:YAG laser and the CO(2) coagulation
laser provides a nearly bloodless field for accurate sculpting of
the nose and produces cosmetically pleasing results.

[flushnomore]

4. Concerning treatment of the red ears. A rare, but frustrating side effect is damage to the cartilage. As a facial plastic surgeon, how would you recommend a physician approach ear treatments safely?


Dr. Nase what type of damage are you referring to? Is it immediate damage or seen as time progresses? Damage caused by what...IPL? I thought it was safe to IPL the ears?


Dr. Diaz are there any potential side effects for rosaceans who have restalyne injections into the smile lines?

Thanks, Karen :)

[irishgenes]

Dr. Diaz, what machine do you use for rosaceans with papules/pustules who would also like rejuvenating effects (the 50+ crowd)? I have head that the RF machines like Thermage are dangerous for us, causing melting of fat cells and waffling of the skin.

[nova]

Dr. Diaz, I would like to echo the thanks that others have offered for your willingness to participate in our forum.

I'm wondering, along with those who have already expressed this, about facial procedures you would NOT recommend for rosacea sufferers. I have read that microdermabrasion as well as dermabrasion are not suitable for rosacea sufferers. Is this correct? If so, what do you recommend for rosacea sufferers who would like to get rid of deepening lines near the lips (not the nasolabials but the tiny vertical "cracks" that form on and near the lips as a person ages).

What about rhinoplasty? Would this be something contraindicated in a rosacea patient?

Also, I have been looking for some time now for a doctor who can perform the specific treatment Dr. Nase recommends using a YAG 1064 for purposes of reducing facial sensitivity. Is this something you do?

Thanks again for your help.

Nova

[drnase]

Great questions folks. Keep them coming.


Some more possible ones:

1. In patients with a familial history of rhinophyma and in the moderate to severe stages, can you reshape their nose without making it permanently red (sort of like Ians question)?

2. Would you be able to remove a couple collateral vessels permanently if while you were working on the rhinophymatous nose.

3. Very Important Question: The red nose was a huge problem for me as it is many males and some females. Can you ever non-invasively go through the nasal mucosa and sear shut some of the vessels tha loop around to the outside of the nose to decrease total overall blood volume that the nose seems to love being drenched with? I have had two anecdotal reports from alllergists who microcauterized nasal mucosa vessles -- one patient said it made a 75% difference in nose flushing (and maintained this over a year after surgery during one follow up) and the other said it had no effect.

[celticgirlie]

Is there any way to cauterize some of the vessels in the eyelids that are involved in ocular rosacea?

[drnase]

Dr. Diaz, 7/08/05

One major complaint made by both male and female rosacea sufferers regards the large bags that they have under their eyes. This is not the normal small puffy bag under the eye, but is a chronic mass of swollen tissue and fibrosis. This often happens after years of flushing over-runs the lymphatic system or the lymphatic system becomes damaged and cannot remove fluid and proteins from the delicate under-eye area.

In some cases, the 1064 YAG seems to help, but that is more for the blue veins and bluish tint. For those sufferers with longstanding lymphedema that will never resolve by itself or with standard treatments, would you ever surgically go into this area, remove the fluid & fibrosis, and work on some parts of the vasculature in order to try to resolve this? Or is this a guesing game on who will respond and who will get worse?

Last part. I have also been informed by some physicians that a couple treatments with diluted norepinephrine injected into those areas sometimes relieves this syndrome or at least brings it back to normal for long periods of time. Even with major dilutions to norepinephrine, does this sound theoretically possible or does it sound like we have some live human guinea pigs?

Thank you.

[todmiller]

A few question for Dr. Diaz:

1) Can rosacea sufferers benefit from ablative laser resurfacing of the periorbital skin, beneath the eyes? In addition to talengiectasia, I also have wrinkles that I might one day consider getting removed with laser resurfacing. Can people with rosacea heal in the same manner as those without?

2) What is the downtime of laser resurfacing? Is it still around 5 weeks? Is the pain tolerable by most?

3) Where do you see the future of plastic surgery heading?

4) What is a good age to consider laser resurfacing? My assumptions: The younger you are, the quicker your skin will heal. But get in done too early on the "aging curve", and you may have wrinkles all over again in a couple of years. Hope this made sense.

Thank you very much for contributing, doctor.

[GJ]

Qand A

Given the level of knowledge here there is slight danger that some of the physicians may feel that they are being repeatedly slapped about the face; chided for their ignorance.

I think a few easy, hittable balls should be thrown their way.

Dr Diaz

I imagine that many enter your office red-faced and unhappy. You will meet with a sufferer on perhaps 6 or 7 occasions over as many months. A number will experience significant reduction in their symptoms. Tell me about their changes in body language, in outlook and in mood over that time.

Thanks

[drnase]

Hello Group,

Are there any more questions for Dr. Diaz? This is a time whn you can ask a personal question to a facial plastic surgeon and laser specialist. Take advantage of that please.

[Winnie M]

Hi Dr. Diaz,

Welcome you to this forum and thanks a lot for helping us!!

Dr. Soldo said no laser treats seborrheic dermatitis, is it true? Laser can treat rosacea, cancer... I wish there is hope for seb derm sufferers. Winnie

----------------------------------------------------------------------




From : Laura <laura@email.skyrunner.net>
Sent : Friday, June 24, 2005 7:29 PM
To : "Winnie M" <luckywin777@hotmail.com>
Subject : Re: Can Dr. Soldo treat SD?

| | | folder | Inbox




----------
From: "Nicholas Soldo" <nicholas@arizonaveininstitute.com>
Date: Fri, 24 Jun 2005 17:26:12 -0700
To: "Laura Thomas" <laura@email.skyrunner.net>
Subject: RE: a post directed at you

No laser that I am aware of treats seb derm

________________________________

From: Laura Thomas [mailto:laura@email.skyrunner.net]
Sent: Fri 6/24/2005 4:53 PM
To: Nicholas Soldo
Subject: a post directed at you



74508?
From: "Winnie M" <luckywin777@...>
To: rosacea-support@yahoogroups.com
Date: Fri Jun 24, 2005 7:37pm
Subject: Can Dr. Soldo treat SD??? luckywin777@...
Send Email
??
Hi group,

Seems like laser mania here, haha. Can Dr. Soldo treat seb
derm with the
laser machines he has? Would you ask this question for me if
you are his
patient or going to see him in the near future. Thanks a lot,
Winnie

[Mermaid]

Welcome Dr Diaz and hello again Dr Nase,

I was wondering if you could tell me if the following has any merit and exactly what does it mean for us with rosacea.

A neurologist told me the following. In describing rosacea he said: 'Rosacea is a multifactorial inflammatory neuro vascular disorder where the basic defect is the function and the structure of the sophisticated dermal micro neuro-vascular network. There is A-V shunt sphincter malfunction which creates one way A-V shunt, causing 'trapped blood' resulting in a pathological condition known as rosacea'.

He then went on to explain the A-V sphincter dysfunction. 'Arterial Sphincter relaxes erratically (trigger factors), Venous sphincter constricts (initially for a period of time then opens and the blood drains), Eventually there is venous sphincter malfunction (the sphincter is constantly constricted and the blood is trapped resulting in pathology known as rosacea'.

What I'd like to know is whether this is some new discovery or just another way to express what we already know or neither. The doctor in question did not elaborate much further except to give me a script for Neurontin and I have not been back to see him.

Could you please, if you are able to, explain all this in layman's terms and if anything is available to control this malfunction if the above theory holds some truth.

Once again, thank you for giving so generously of your time.

Mermaid

[Bob Bear]

Wow, great question (i think!). Sounds like some really 'nitty gritty' stuff, I hope the good Dr has his Wheetabix when gets these questions. :wink:



Ask for facial plastic surgery, Iv heard talk of clinics actually growing implants to use in patients. I know this must be very 'pie in the sky' at the moment, but Im sure I saw something on a study they did where they actually grew an organic implant inside a sheep (seriously!). I think the idea is that they can grow various implants (kind of like a controlled tumour I suspect) with minimal risc of rejection or other problems relating to foreign materials entering the body.

What are your thoughts on this technology Dr Diaz? Do you think you will be using such techniques within the next ten years?

[celticgirlie]

Dr. Diaz,

We have been encouraged to ask personal questions so here goes:

Personally, I have had 9 unsuccessful IPLs with the 560 filter (when I had very mild rosacea). Now that my rosacea has progressed I have had 8 reasonably successful v-beams. I say "reasonably successful" because the veins/redness on my chin go away straight after the laser but always return after a couple of months. Do you think that the Lumenis One machine might be able to help me eradicate this problem once and for all and what settings would you recommend?

Thank you for all your assistance with any and all of the questions that you answer! And thank you Dr. Nase, as always.

Elizabeth

[drnase]

Welcome Dr Diaz and hello again Dr Nase,

I was wondering if you could tell me if the following has any merit and exactly what does it mean for us with rosacea.

A neurologist told me the following. In describing rosacea he said: 'Rosacea is a multifactorial inflammatory neuro vascular disorder where the basic defect is the function and the structure of the sophisticated dermal micro neuro-vascular network. There is A-V shunt sphincter malfunction which creates one way A-V shunt, causing 'trapped blood' resulting in a pathological condition known as rosacea'.

He then went on to explain the A-V sphincter dysfunction. 'Arterial Sphincter relaxes erratically (trigger factors), Venous sphincter constricts (initially for a period of time then opens and the blood drains), Eventually there is venous sphincter malfunction (the sphincter is constantly constricted and the blood is trapped resulting in pathology known as rosacea'.

What I'd like to know is whether this is some new discovery or just another way to express what we already know or neither. The doctor in question did not elaborate much further except to give me a script for Neurontin and I have not been back to see him.

Could you please, if you are able to, explain all this in layman's terms and if anything is available to control this malfunction if the above theory holds some truth.

Once again, thank you for giving so generously of your time.

Mermaid


Mermaid,

That is a very intriguing question that comes from a physician's description. I am glad you brought this up, but during our voting, I would like to note that facial blood vessels do not have sphincters. None of them do going from the superficial blood vessels back to the largest feed vessels. They do have what is caused spontaneous vasomotion, but this is a totally different thing. So, I guess, if I can put my two cents in to help narrow down important germane questions rather than him scratching his head on this one. Once again, this is what your doctor said and it was such a logical answer that 99% would believe this or actually ask the same question...... but, we know the morphology of these blood vessels and they do not contain a single sphincter. Just my two cents. I wish they did because then we could target them selectively.

[prryjones]

Dr. Nase,
Maybe the neurosurgeon was referring to the precapillary sphincters?
Perry

[drnase]

Dr. Nase,
Maybe the neurosurgeon was referring to the precapillary sphincters?
Perry

Great question Perry. They dont contain precapillary sphincters -- only one line of endothelial cells and a basement membrane before the capilllary, along the capillary and after the capillary.

The neurologist has tremendous experience with syndromes in the brain where blood vessels contain sphincters and in the legs where they contain sphincters and valves

[irishgenes]

I have "seborrheic dermatitis" of the scalp, too, which seems to be just the same as my face symptoms, as I have scalp flushing, papules along the hairline, a swelling on top of the scalp which comes & goes, greasiness, and all-over hair thinning. Is IPL on the scalp impossible due to the danger of destroying hair follicles?