Naissan O. Wesley, MD

Do you ask your acne patients about which hair products they use? This common question has recently brought our attention to popular hair products that are causing an acne epidemic. Have we forgotten about “Pomade acne”? Well, it’s making a comeback. Originally described in ethnic women, new frizz-fighting hair products have resurged and so has pomade acne in all skin types and in both men and women.

Smoothing serums, heat styling sprays, leave-in products popularly known as “It’s-a-10,” “Biosilk,” “anti-frizz serums,” “heat-protectants,” “thermal setting sprays,” and “shine sprays,” contain silicone-derived ingredients and oils to control frizz, add shine, and detangle the hair. They work by smoothing the hair cuticle, and for women with difficult-to-manage hair, they have become an essential part of the daily beauty regimen.

Men are not in the clear either. Hair waxes and pomades used to style men’s hair contain greasy wax-based ingredients that also clog pores, trap bacteria, and cause inflammatory breakouts.

As a general rule in skin and body care, most products work well for what they are made to do, but when misused, they can cause mishaps. You wouldn’t moisturize your face with your hair serum would you? It seems obvious that this could cause some skin issues; however, most people will not think to correlate their acne breakouts with their hair products until we mention it. These products rub off on the face or on the pillow at night. In addition, the less we wash our hair, the more we are going to bed and getting the daytime products all over our pillowcases. Our faces are rolling around in oily, waxy, hair products all night.

Makeup is known to cause acne, and some of the makeups that are well known culprits contain the same ingredients as in hair products. Foundations, primers, and popular “BB” creams often contain cyclopentasiloxane and dimethicone. They serve a similar purpose: smoothing the skin and smoothing the hair. Both should be avoided in acne-prone patients.

Common culprits in hair products include PVP/DMAPA acrylates, cyclopentasiloxane, panthenol, dimethicone, silicone, Quaternium-70, oils, and petrolatum.

The only way to eliminate acne caused by hair products is to completely eliminate the hair product from the daily routine. However, if your patients can’t live without their hair products, here are some tips to share with them to reduce breakouts:

• Choose a hairstyle that keeps the hair away from the face, or wear hair up to avoid prolonged contact with the face, particularly while sleeping.

• Change pillowcase often (every day if possible), especially for side sleepers. Regardless of the fabric, pillowcases trap oil, dirt, and bacteria.

• Shower at night and sleep with clean hair and clean skin.

• Style hair before applying makeup. Wash hands thoroughly to remove all hair products before touching the skin.

• Cover the face prior to applying any hair sprays.

• Cover the hair at bedtime; however, tight head coverings can stimulate sweat and cause scalp breakouts.

As a general rule, any patient with difficult-to-control acne, recalcitrant acne, or acne in areas on the cheeks or hairline should eliminate these hair products in their daily routine or avoid skin contact with these products.

References

1. J Clin Aesthet Dermatol. 2010 Apr;3(4):24-38.

2. Arch Dermatol. 1972;106 (6):843-50.

3. J Am Acad Dermatol. 2003; 48:S127-33.

4. Arch Dermatol. 1970;101(5):580-584.

5. “Cosmetics in Dermatology,” Second Edition, by Zoe Diana Draelos (New York: Churchill Livingstone, 1995).

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Do you ask your acne patients about which hair products they use? This common question has recently brought our attention to popular hair products that are causing an acne epidemic. Have we forgotten about “Pomade acne”? Well, it’s making a comeback. Originally described in ethnic women, new frizz-fighting hair products have resurged and so has pomade acne in all skin types and in both men and women.

Smoothing serums, heat styling sprays, leave-in products popularly known as “It’s-a-10,” “Biosilk,” “anti-frizz serums,” “heat-protectants,” “thermal setting sprays,” and “shine sprays,” contain silicone-derived ingredients and oils to control frizz, add shine, and detangle the hair. They work by smoothing the hair cuticle, and for women with difficult-to-manage hair, they have become an essential part of the daily beauty regimen.

Men are not in the clear either. Hair waxes and pomades used to style men’s hair contain greasy wax-based ingredients that also clog pores, trap bacteria, and cause inflammatory breakouts.

As a general rule in skin and body care, most products work well for what they are made to do, but when misused, they can cause mishaps. You wouldn’t moisturize your face with your hair serum would you? It seems obvious that this could cause some skin issues; however, most people will not think to correlate their acne breakouts with their hair products until we mention it. These products rub off on the face or on the pillow at night. In addition, the less we wash our hair, the more we are going to bed and getting the daytime products all over our pillowcases. Our faces are rolling around in oily, waxy, hair products all night.

Makeup is known to cause acne, and some of the makeups that are well known culprits contain the same ingredients as in hair products. Foundations, primers, and popular “BB” creams often contain cyclopentasiloxane and dimethicone. They serve a similar purpose: smoothing the skin and smoothing the hair. Both should be avoided in acne-prone patients.

Common culprits in hair products include PVP/DMAPA acrylates, cyclopentasiloxane, panthenol, dimethicone, silicone, Quaternium-70, oils, and petrolatum.

The only way to eliminate acne caused by hair products is to completely eliminate the hair product from the daily routine. However, if your patients can’t live without their hair products, here are some tips to share with them to reduce breakouts:

• Choose a hairstyle that keeps the hair away from the face, or wear hair up to avoid prolonged contact with the face, particularly while sleeping.

• Change pillowcase often (every day if possible), especially for side sleepers. Regardless of the fabric, pillowcases trap oil, dirt, and bacteria.

• Shower at night and sleep with clean hair and clean skin.

• Style hair before applying makeup. Wash hands thoroughly to remove all hair products before touching the skin.

• Cover the face prior to applying any hair sprays.

• Cover the hair at bedtime; however, tight head coverings can stimulate sweat and cause scalp breakouts.

As a general rule, any patient with difficult-to-control acne, recalcitrant acne, or acne in areas on the cheeks or hairline should eliminate these hair products in their daily routine or avoid skin contact with these products.

References

1. J Clin Aesthet Dermatol. 2010 Apr;3(4):24-38.

2. Arch Dermatol. 1972;106 (6):843-50.

3. J Am Acad Dermatol. 2003; 48:S127-33.

4. Arch Dermatol. 1970;101(5):580-584.

5. “Cosmetics in Dermatology,” Second Edition, by Zoe Diana Draelos (New York: Churchill Livingstone, 1995).

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Do you ask your acne patients about which hair products they use? This common question has recently brought our attention to popular hair products that are causing an acne epidemic. Have we forgotten about “Pomade acne”? Well, it’s making a comeback. Originally described in ethnic women, new frizz-fighting hair products have resurged and so has pomade acne in all skin types and in both men and women.

Smoothing serums, heat styling sprays, leave-in products popularly known as “It’s-a-10,” “Biosilk,” “anti-frizz serums,” “heat-protectants,” “thermal setting sprays,” and “shine sprays,” contain silicone-derived ingredients and oils to control frizz, add shine, and detangle the hair. They work by smoothing the hair cuticle, and for women with difficult-to-manage hair, they have become an essential part of the daily beauty regimen.

Men are not in the clear either. Hair waxes and pomades used to style men’s hair contain greasy wax-based ingredients that also clog pores, trap bacteria, and cause inflammatory breakouts.

As a general rule in skin and body care, most products work well for what they are made to do, but when misused, they can cause mishaps. You wouldn’t moisturize your face with your hair serum would you? It seems obvious that this could cause some skin issues; however, most people will not think to correlate their acne breakouts with their hair products until we mention it. These products rub off on the face or on the pillow at night. In addition, the less we wash our hair, the more we are going to bed and getting the daytime products all over our pillowcases. Our faces are rolling around in oily, waxy, hair products all night.

Makeup is known to cause acne, and some of the makeups that are well known culprits contain the same ingredients as in hair products. Foundations, primers, and popular “BB” creams often contain cyclopentasiloxane and dimethicone. They serve a similar purpose: smoothing the skin and smoothing the hair. Both should be avoided in acne-prone patients.

Common culprits in hair products include PVP/DMAPA acrylates, cyclopentasiloxane, panthenol, dimethicone, silicone, Quaternium-70, oils, and petrolatum.

The only way to eliminate acne caused by hair products is to completely eliminate the hair product from the daily routine. However, if your patients can’t live without their hair products, here are some tips to share with them to reduce breakouts:

• Choose a hairstyle that keeps the hair away from the face, or wear hair up to avoid prolonged contact with the face, particularly while sleeping.

• Change pillowcase often (every day if possible), especially for side sleepers. Regardless of the fabric, pillowcases trap oil, dirt, and bacteria.

• Shower at night and sleep with clean hair and clean skin.

• Style hair before applying makeup. Wash hands thoroughly to remove all hair products before touching the skin.

• Cover the face prior to applying any hair sprays.

• Cover the hair at bedtime; however, tight head coverings can stimulate sweat and cause scalp breakouts.

As a general rule, any patient with difficult-to-control acne, recalcitrant acne, or acne in areas on the cheeks or hairline should eliminate these hair products in their daily routine or avoid skin contact with these products.

References

1. J Clin Aesthet Dermatol. 2010 Apr;3(4):24-38.

2. Arch Dermatol. 1972;106 (6):843-50.

3. J Am Acad Dermatol. 2003; 48:S127-33.

4. Arch Dermatol. 1970;101(5):580-584.

5. “Cosmetics in Dermatology,” Second Edition, by Zoe Diana Draelos (New York: Churchill Livingstone, 1995).

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The obsession with longer, fuller, darker eyelashes has become a mainstay in our culture – initially with the ever growing options of mascaras and glue on eyelashes, and now with options that are longer lasting, including eyelash extensions (semipermanent eyelashes) and topical eyelash growth enhancers (such as bimatoprost).

Eyelash extensions are not the same as glue-on strip or individual lashes bought at the drug store or makeup counter that last 1-2 days. These are silk, mink, or poly nylon synthetic lashes that typically last for approximately four weeks, with refills often required at 2-4 week intervals as the natural eyelash sheds. They are adhered to the person’s natural eyelash via an adhesive bonding process that can take 1-2 hours for initial application. Generally, a single lash is applied to each natural lash.

When applied properly, neither the extension eyelash nor the glue should touch the eyelid. The bond is designed to last until the lashes naturally fall out, although the extensions may fall out faster if one uses oil-based eye makeup remover or rubs the eyes regularly, as oil weakens the bond between the glue and the lash. Eyelash extensions are waterproof and give the appearance of having mascara on without wearing it. In the United States, eyelash extension services can range from $100 to $500 for the initial application, with decreased cost for refills. Lash extensions are waterproof and popular for special occasions and vacations, and even more so now for every day.

Potential adverse effects of eyelash extensions include ocular hyperemia, keratoconjunctivitis, allergic blepharitis, and allergic contact dermatitis in the patient. Keratoconjunctivitis is thought to be due to formaldehyde contained in some of the glues used for application.¹ Eyelash extensions have also been associated with occupational allergic contact dermatitis, allergic rhinitis, and occupational asthma in the practitioner applying the eyelash extensions, particularly with the cyanoacrylate-based glues.^2,3

In a national survey of eyelash extensions and their health-related problems in Japan, 10% (205) of the respondents had experience with eyelash extensions. Of those women, 27% (55) experienced problems that included ocular hyperemia, pain, and itchy swollen eyelids.⁴ Conjunctival erosion from the eyelid fixing tape used during application and subconjunctival hemorrhage from compression during removal of the extensions has been also reported.¹ Hair breakage and even traction alopecia may occur, especially in patients who accidentally or intentionally pull the extensions off.

If permanent eyelash damage occurs, eyelash transplantation may be required to replace the eyelash, as eyelash growth medications such as bimatoprost may not be effective if the follicle is missing or severely damaged. Eyelash transplants often grow long enough where they require trimming, especially if donor sites are taken from the scalp.⁵

Eyelash extensions offer a nice alternative to daily use of mascara, temporary glue-on eyelashes, and daily application of topical eyelash growth products. As this procedure has increased in number, the dermatologist may be consulted for recommendations and treatment of any potential adverse events associated with it.

References

1. Cornea. 2012 Feb;31(2):121-5.

2. Contact Dermatitis. 2012 Nov;67(5):307-8.

3. Occup Med (Lond). 2013 Jun;63(4):294-7.

4. Nihon Eiseigaku Zasshi. 2013;68(3):168-74.

5. Plast Reconstr Surg Glob Open. 2015 Apr 7;3(3):e324.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

We’re always working toward medical breakthroughs so we can provide the most effective treatments for our patients with cutting-edge technology; however, there is a lot to be said about the techniques that have paved the way for new medical devices.

For certain conditions, the efficacy of classic procedures often cannot be matched by their modern successors. Subcision for treatment of deep depressed scars, for example, is often a more effective option than microneedling and can produce results with less healing time and fewer treatments, and at a more cost-effective price.

Both subcision and microneedling improve the appearance of scars by creating wounds in an effort to break up scar tissue and trigger collagen regrowth. Microneedling involves the use of a microneedling pen with several small needles that glide across the skin at different depths and speeds. Subcision is achieved with one larger gauge needle that is injected into scars at different angles and depths to break up scar tissue. Microneedling needles yield more epidermal damage than does subcision, causing more bleeding and ultimately lengthening the healing time.

The mechanism of subcising deeper scar tissue also seems to be more effective than that of microneedling. It often takes fewer subcision treatments than microneedling treatments to achieve comparable improvement of depressed scars. Microneedling needles are limited to penetrating at best 2.5 mm beneath the skin surface, while subcision allows the freedom to penetrate deeper into the dermis to reach deeper dermal scars. Subcising also creates larger channels within the scar tissue, which create more space for collagen regrowth, while microneedling does not.

A technique that has shown to improve treatment outcomes is the use of a 26- or 30-gauge needle, moving back and forth in a fanning pattern under the scar tissue while simultaneously injecting lidocaine or saline in those channels. The injection of a fluid component, particularly that of lidocaine, can both decrease the pain as well as inflate the scar in question, allowing more collagen regrowth and wound growth factors to fill the “gaps” created.

Unless scars have a significant epidermal component in addition to their dermal component, subcising the scar is a more effective and has faster healing times. Both procedures can cause bruising , edema, and erythema. However, the epidermal damage that can occur in microneedling has significantly more downtime.

In addition, subcision is a more cost-effective treatment than microneedling. The required materials for subcision are limited to materials that are readily used within practices: needles, syringes, saline, and lidocaine. Microneedling, on the other hand, requires purchase of expensive tools, including microneedling pens, sterile single-use microneedling tips, and protective sleeves for the device, in addition to topical skin care products to apply after the treatment to promote safe healing.

While microneedling is remarkably effective for treatment of superficial scars, fine lines, and hypopigmentation, subcision tends to be more effective for the treatment of deeper scars such as box-car acne scars.

We love new technology in our practices; however, sometimes our tried and true procedures may prove to be a better option in the appropriate patient.

Dr. Wesley and Dr. Talakoub are co-contributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Pretreatment of skin prior to nonablative or ablative laser resurfacing is common practice, particularly in darker skin types. Treatment regimens include using hydroquinone 4% (and other hydroquinone-containing combinations) once to twice daily for 1-2 weeks prior to the laser procedure. The rationale makes sense. Quieting melanin production by inhibiting tyrosinase would seem to decrease the incidence of postinflammatory hyperpigmentation after laser resurfacing procedures. But is this common practice effective?

For ablative CO₂ resurfacing in 100 patients Fitzpatrick Skin Types (FST) I-III, there was no significant difference in the incidence of hyperpigmentation in those randomized to be pretreated with either hydroquinone, glycolic acid, tretinoin, or to no treatment.¹ The thought was that the follicular melanocytes involved in re-epithelialization were not affected by the pretreatment. This is the only published laser resurfacing today to date examining various pretreatment protocols with hyperpigmentation as a primary study outcome. From this study, it seems as though pretreatment before laser resurfacing is not helpful, but what about for nonablative resurfacing in darker skin types (FST IV-VI)?

In darker skin types (FST IV-VI), the risk of postinflammatory hyperpigmentation (PIH) is inherently higher and the incidence after laser resurfacing is greater. While the incidence of PIH is lower with nonablative fractional resurfacing, compared with ablative resurfacing, PIH can still occur whether pretreatment hydroquinone is used or not.^2,3,4 To date, there are no published studies looking at the incidence of PIH when comparing pretreatment antipigment agents versus no pretreatment for laser resurfacing for acne scars in darker skin types. A split-face study comparing pretreatment on one side and no pretreatment on the other could help delineate whether this practice is evidence based.

For nonablative fractional laser resurfacing of acne scars, lower densities in darker skin types are recommended and may help reduce PIH risk. There is no statistically significant difference in improvement of acne scars in using low versus high densities using the same fluences. However, some studies note that higher densities clinically resulted in a mild improvement of acne scars over lower densities (not statistically significant); thus, if lower densities are used, it is possible that more treatments may be needed.^4,5

Vigorous sun protection before and after treatment is prudent, with sun avoidance and physical sunscreens reducing the risk of PIH in darker skin from irritant or allergic contact dermatitis, compared with chemical sunscreens. If PIH occurs, it is often self limited (up to 1-2 months). Sun protection and posttreatment regimens of hydroquinone (or other lightening agent) aid in hastening improvement.

If the patient is undergoing nonablative laser resurfacing to treat pigmentation, such as melasma, then hydroquinone pre- and postlaser is appropriate. In my opinion, laser treatment of melasma should not be first line because of safety and efficacy concerns. However, in these cases, hydroquinone prior to laser has shown benefit.⁶ In addition, hydroquinone after nonablative fractional resurfacing may enhance penetration of the topical and improve efficacy.

In summary, the evidence shows that pretreatment with antipigment agents is not warranted in skin types I-III for ablative laser resurfacing. Pretreatment with antipigment agents for nonablative laser resurfacing for melasma (which should not be considered a first line treatment for melasma) is warranted. However, at this time, it is not clear whether pretreatment with antipigments for nonablative laser resurfacing for acne scars in darker skin types is useful. Lower densities should be used and if PIH does occur, it is usually self limited, and posttreatment hydroquinone or other antipigment agents may be useful.

References

1. Dermatol Surg. 1999 Jan;25(1):15-7.

2. Dermatol Surg. 2010 May;36(5):602-9.

3. Br J Dermatol. 2012 Jun;166(6):1160-9.

4.Lasers Surg Med. 2007 Jun;39(5):381-5.

5. Lasers Surg Med. 2007 Apr;39(4):311-4.

6. Dermatol Surg. 2010 Jun;36(6):909-18.

Dr. Wesley and Dr. Talakoub are co-contributors to the monthly Aesthetic Dermatology column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

One of the most apparent and difficult-to-treat aspects of the aging eye is the descent of the eyebrow. The change in the orbital bone structure as well as fat loss and fat redistribution along the upper and lower eyelids and loss of skin elasticity contribute to the skeletonization of the periorbital area and a “drooping” of the eyebrow. Patients either have loss of volume across the entire brow, or primarily across the lateral and central brow creating what is known as an “a-frame” deformity.

Nonsurgical techniques that help lift the brow include a combination of relaxation of the orbicularis oculi muscle with neurotoxins, in addition to the injection of hyaluronic acid fillers along the brow margin and upper third of the face.

Small amounts of hyaluronic acid fillers injected with a 22- to 25-gauge cannula both above and below the eyebrow along the orbital rim provide an instantaneous lifting effect with long-lasting results. Hyaluronic acid and poly-L-lactic acid in dilute concentrations can also be injected with a cannula in the forehead, which creates a repletion of the volume in the upper face that is often lost with aging to create a lift of the eyebrows. Temple hollows can also be filled with calcium hydroxylapatite, poly-L-lactic acid and less often with hyaluronic acid to revolumize and create a lift of the lateral brow. Care should be taken as fillers used in these areas are off-label and need to be done by trained, expert injectors. The periorbital area is a danger zone with many vessels and nerves, and proper injection technique is crucial to avoid arterial blockage, nerve damage, and long-term complications.

Nonablative skin tightening with radiofrequency energy or ultrasound can be used for achieving a brow-lift. Although these techniques do provide collagen remodeling, multiple procedures are often necessary, and results are not always substantial. In a study of 36 patients undergoing ultrasound tightening of the face and neck, 86% showed a clinically significant brow-lift 90 days after treatment. The average brow elevation in this study was 1.7 mm.

In practice, however, patients are often more satisfied with the brow elevation they achieve with neurotoxins and fillers. Injectables provide a faster onset of results, fewer treatments, and minimal discomfort. Combination treatments provide the best overall results and although injectables in the periorbital area are technically difficult, patients are often very satisfied and return for repeat treatments.

References Aesthet Surg J. 2009;May-Jun;29(3):174-9.

J Am Acad Dermatol. 2010;Feb;62(2):262-9.

Dr. Wesley and Dr. Talakoub are cocontributors to this column. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

The annual American Society for Dermatologic Surgery conference in Chicago Oct. 15-18 was one of the best attended meeting in years. From injectables to lasers to reconstruction, the newest information was distributed among the members.

Here are pearls gained from the ASDS conference that every dermatologist should know:

There are reports of temporary alopecia of the beard area in men after deoxycholic acid (Kybella) injections in the submentum. Patients should be counseled prior to injection. Deeper injections in males, pinching up the skin, and penetrating the needle to the hub are measures that have been suggested to help minimize the risk of this potential side effect.

More than 60 cases of blindness secondary to filler injections have been reported, but such cases are likely underreported. The majority of reports were from South Korea and most cases were due to autologous fat transfer. High risk areas include the glabella, nasal dorsum, and anteromedial cheek/tear trough due to retrograde flow of a filler embolus to the ophthalmic artery from anastomoses with the angular, dorsal nasal, and supratrochlear arteries. Cannulas are recommended as they are considered safer than needles, particularly when injecting either fat or fillers in the mid face area.

However, even cannulas are not foolproof. There are some areas where periosteal placement of filler is important and therefore the use of needles is required, such as the anterosuperior temple, zygomaticomalar cheek, and central chin. Expert knowledge of the vascular anatomy of the face, including location and depth of important vessels, is a must.

If a vascular occlusion occurs – particularly to the ophthalmic artery that can result in blindness – symptoms may include pain, visual disturbances, vomiting, and blanching/reticulation of blood vessels on the skin surface. Time is of the essence in preventing or reversing vision loss. If a hyaluronic acid filler was used, retrobulbar injection of at least 1,000 units of hyaluronidase and referral to an ophthalmologist should be done within minutes.

For body contouring and skin tightening, cryolipolysis and high-intensity focused ultrasound have shown results over the past several years. However, newer technologies including nonthermal focused ultrasound, multipolar radiofrequency, and fractional radiofrequency with microneedling, and a 1064 nm diode laser also show some promise.

The ablative fractional CO₂ laser was shown to be helpful for hypopigmented scars.

Malpractice lawsuits against cosmetic procedures are highest among physician extenders (physician assistants, nurses, assistants, etc).

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

This article was updated Nov. 16, 2015.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

I recently went to a local salon for a manicure, and when I asked the manicurist not to cut my cuticles, she looked at me as though I was offending her. Shortly thereafter, I took a phone call that swayed my attention, and she secretly dove in and quickly started cutting my cuticles thinking I would not notice. Why is cuticle-cutting a necessary part of nail care ... and almost a rampant ritual?

The cuticle is the protective barrier surrounding the nail plate and nail folds. Biting, pulling, or improper cutting of the cuticle over time can cause long-term damage to the nail plate, such as ridging of the nail, median nail dystrophy, or permanent destruction of the nail plate. Trimming the cuticles can also break the seal that protects the surrounding skin and nails. Not only can the removal of the cuticle introduce infection, but it can also cause deformities in the nail plate itself. Infections to consider around the nail include acute or chronic paronychia, herpetic whitlow, onychomycosis, and warts. These infections can be the direct result of entry from the removal of the cuticle barrier or improperly cleaned and sterilized instruments.

Tools used to remove cuticles can transfer infections. In addition to skin infections, viruses that cause systemic infections, such as hepatitis C, can live in dry blood for up to 3 days and can be transferred on tools that have not been cleaned properly. Sterilized tools must first be cleaned and submerged in antiseptic solutions, then sterilized in an autoclave or a Food and Drug Administration–registered dry-heat sterilizer, not a UV box. UV boxes are commonly used and do not actually sterilize tools; they keep tools clean only if they have been previously sterilized.

The best way to ensure proper sterilization is to check the indicator tape or indicator color on the packaging. Autoclave tape and dry heat sterilizer strips work by changing colors when exposed to a certain temperature (and pressure for the autoclave tape) for a certain amount of time. I routinely check the sterilizing packets and immediately look up the indicator color on the Internet to ensure the color change was correct. I ask about what sterilization techniques the salon uses, and I often require salons to use my own nail care tools (which should be cleaned after every use).

Trimming or cutting cuticles is a bad habit and can be a dangerous salon ritual. Many states, such as New York and Massachusetts, do not allow manicurists to cut the cuticles given blood-borne pathogen risks and improper sanitation; however, this regulation is often loosely enforced. It also creates an endless cycle of cuticle trimming as the growing cuticle can often look frayed – and thus creates the need for them to be cut over and over again. Pushing the cuticle back may be a better option for those who prefer the cosmetic appearance of trimmed cuticles, but it still poses a portal of entry for pathogens.

Let’s educate our patients, the salons, and the regulatory boards to prevent the spread of infection and ensure safe nail care techniques.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.