Global Academy for Medical Education (GAME): Summit in Aesthetic Medicine

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

[email protected]

On Twitter @karioakes

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

[email protected]

On Twitter @karioakes

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

[email protected]

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

[email protected]

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

[email protected]

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

[email protected]

On Twitter @karioakes