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

NEWPORT BEACH, CALIF. – It’s unclear how well deoxycholic acid (Kybella) will work in the clinic because doctors and patients are generally opting for fewer injections and fewer treatment sessions than were evaluated in phase III studies, according to Lawrence Bass, MD.

The fat cytolytic was approved in 2015 for shrinking double chins, with up to six 50-injection sessions. In trials, patients tended to get more than 40 shots in their first two sessions and more than 30 in subsequent sessions. At that dosing, 40.5% of patients in one trial and 46% in another lost at least 10% of their submental volume on MRI, according to Food and Drug Administration review documents.

However, at the Summit in Aesthetic Medicine, Dr. Bass, a plastic surgeon in New York City, said that, in clinical practice, patients are typically being treated with 20 injections for two or three sessions – partly because of cost. “This product costs $300 for each 2 mL vial, which means in a typical 20-injection treatment, you use $600 of material,” he noted. An average treatment session in Manhattan costs patients about $1,500. In other parts of the country, sessions are probably around $1,200 each, he added.

Also, the necks of patients enrolled in trials “had to be pretty big, but the necks we are probably going to treat with this are the smaller and medium ones. The big ones are just going to do liposuction or something else,” he said. Given all the variables, “we don’t know how well the study experience is going to match clinical experience.”

Dr. Bass treated his first postapproval patient, a 52-year-old woman, with two 20-injection treatment sessions 2 months apart. “The fat definitely cleaned out” and her skin looked a bit tighter, but it’s tough to know if her skin truly tightened or simply draped flatter, he said.

FDA labeling notes that “the safe and effective use of Kybella for the treatment of subcutaneous fat outside the submental region has not been established and is not recommended,” but this advice is unlikely to keep doctors from trying it in off-label areas.

One issue is that “almost every other area is a whole lot bigger” than a double chin, Dr. Bass said. Treating a tummy with 50 injections six to eight times, for example, would cost patients $12,000-$15,000, which is “a whole lot more than lipo,” he added.

Also, administering more than 50 injections at a time for a larger area is not possible because of toxicity. Trying to get around that limit and cut costs by diluting deoxycholic acid or spacing the injections farther apart doesn’t seem to be an option, since phase II testing showed a loss of efficacy with that approach.

Dr. Bass tried deoxycholic acid on a woman with leftover tummy bulges following liposuction. After two 40-injection sessions, “there was still a little shape there, so I don’t think I’ll be doing that again,” he said at the meeting, which is held by Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

Gynecomastia, meanwhile, would probably require too many shots, and the jowl, another potential target, is too close to the marginal mandibular branch of the facial nerve, “so you are not supposed to inject there,” Dr. Bass said. Diluted deoxycholic acid might be an option for bulging periorbital fat, “but I am going to let somebody who is braver than me try that for a while before I go there.”

Dr. Bass is an investigator and speaker for Cynosure, an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. He participated in phase III testing of deoxycholic acid.

The indication approved for deoxycholic acid is “for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat in adults.”

[email protected]

NEWPORT BEACH, CALIF. – It’s unclear how well deoxycholic acid (Kybella) will work in the clinic because doctors and patients are generally opting for fewer injections and fewer treatment sessions than were evaluated in phase III studies, according to Lawrence Bass, MD.

The fat cytolytic was approved in 2015 for shrinking double chins, with up to six 50-injection sessions. In trials, patients tended to get more than 40 shots in their first two sessions and more than 30 in subsequent sessions. At that dosing, 40.5% of patients in one trial and 46% in another lost at least 10% of their submental volume on MRI, according to Food and Drug Administration review documents.

However, at the Summit in Aesthetic Medicine, Dr. Bass, a plastic surgeon in New York City, said that, in clinical practice, patients are typically being treated with 20 injections for two or three sessions – partly because of cost. “This product costs $300 for each 2 mL vial, which means in a typical 20-injection treatment, you use $600 of material,” he noted. An average treatment session in Manhattan costs patients about $1,500. In other parts of the country, sessions are probably around $1,200 each, he added.

Also, the necks of patients enrolled in trials “had to be pretty big, but the necks we are probably going to treat with this are the smaller and medium ones. The big ones are just going to do liposuction or something else,” he said. Given all the variables, “we don’t know how well the study experience is going to match clinical experience.”

Dr. Bass treated his first postapproval patient, a 52-year-old woman, with two 20-injection treatment sessions 2 months apart. “The fat definitely cleaned out” and her skin looked a bit tighter, but it’s tough to know if her skin truly tightened or simply draped flatter, he said.

FDA labeling notes that “the safe and effective use of Kybella for the treatment of subcutaneous fat outside the submental region has not been established and is not recommended,” but this advice is unlikely to keep doctors from trying it in off-label areas.

One issue is that “almost every other area is a whole lot bigger” than a double chin, Dr. Bass said. Treating a tummy with 50 injections six to eight times, for example, would cost patients $12,000-$15,000, which is “a whole lot more than lipo,” he added.

Also, administering more than 50 injections at a time for a larger area is not possible because of toxicity. Trying to get around that limit and cut costs by diluting deoxycholic acid or spacing the injections farther apart doesn’t seem to be an option, since phase II testing showed a loss of efficacy with that approach.

Dr. Bass tried deoxycholic acid on a woman with leftover tummy bulges following liposuction. After two 40-injection sessions, “there was still a little shape there, so I don’t think I’ll be doing that again,” he said at the meeting, which is held by Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

Gynecomastia, meanwhile, would probably require too many shots, and the jowl, another potential target, is too close to the marginal mandibular branch of the facial nerve, “so you are not supposed to inject there,” Dr. Bass said. Diluted deoxycholic acid might be an option for bulging periorbital fat, “but I am going to let somebody who is braver than me try that for a while before I go there.”

Dr. Bass is an investigator and speaker for Cynosure, an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. He participated in phase III testing of deoxycholic acid.

The indication approved for deoxycholic acid is “for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat in adults.”

[email protected]

NEWPORT BEACH, CALIF. – It’s unclear how well deoxycholic acid (Kybella) will work in the clinic because doctors and patients are generally opting for fewer injections and fewer treatment sessions than were evaluated in phase III studies, according to Lawrence Bass, MD.

The fat cytolytic was approved in 2015 for shrinking double chins, with up to six 50-injection sessions. In trials, patients tended to get more than 40 shots in their first two sessions and more than 30 in subsequent sessions. At that dosing, 40.5% of patients in one trial and 46% in another lost at least 10% of their submental volume on MRI, according to Food and Drug Administration review documents.

However, at the Summit in Aesthetic Medicine, Dr. Bass, a plastic surgeon in New York City, said that, in clinical practice, patients are typically being treated with 20 injections for two or three sessions – partly because of cost. “This product costs $300 for each 2 mL vial, which means in a typical 20-injection treatment, you use $600 of material,” he noted. An average treatment session in Manhattan costs patients about $1,500. In other parts of the country, sessions are probably around $1,200 each, he added.

Also, the necks of patients enrolled in trials “had to be pretty big, but the necks we are probably going to treat with this are the smaller and medium ones. The big ones are just going to do liposuction or something else,” he said. Given all the variables, “we don’t know how well the study experience is going to match clinical experience.”

Dr. Bass treated his first postapproval patient, a 52-year-old woman, with two 20-injection treatment sessions 2 months apart. “The fat definitely cleaned out” and her skin looked a bit tighter, but it’s tough to know if her skin truly tightened or simply draped flatter, he said.

FDA labeling notes that “the safe and effective use of Kybella for the treatment of subcutaneous fat outside the submental region has not been established and is not recommended,” but this advice is unlikely to keep doctors from trying it in off-label areas.

One issue is that “almost every other area is a whole lot bigger” than a double chin, Dr. Bass said. Treating a tummy with 50 injections six to eight times, for example, would cost patients $12,000-$15,000, which is “a whole lot more than lipo,” he added.

Also, administering more than 50 injections at a time for a larger area is not possible because of toxicity. Trying to get around that limit and cut costs by diluting deoxycholic acid or spacing the injections farther apart doesn’t seem to be an option, since phase II testing showed a loss of efficacy with that approach.

Dr. Bass tried deoxycholic acid on a woman with leftover tummy bulges following liposuction. After two 40-injection sessions, “there was still a little shape there, so I don’t think I’ll be doing that again,” he said at the meeting, which is held by Global Academy for Medical Education. Global Academy and this news organization are owned the same company.

Gynecomastia, meanwhile, would probably require too many shots, and the jowl, another potential target, is too close to the marginal mandibular branch of the facial nerve, “so you are not supposed to inject there,” Dr. Bass said. Diluted deoxycholic acid might be an option for bulging periorbital fat, “but I am going to let somebody who is braver than me try that for a while before I go there.”

Dr. Bass is an investigator and speaker for Cynosure, an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. He participated in phase III testing of deoxycholic acid.

The indication approved for deoxycholic acid is “for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat in adults.”

[email protected]

NEWPORT BEACH, CALIF. – Facial CO₂ laser resurfacing deserves a comeback, according to Victor Ross, MD, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego.

The practice fell out of favor in the late 1990s because of long recovery times, hypopigmentation, and the risk of keloid scars, among other issues. Physicians were just being too aggressive, doing multiple full-field passes in one session, he said at the Summit in Aesthetic Medicine, held by Global Academy for Medical Education.

It turns out that doing one pass very conservatively – with maybe a second pass around the mouth for deeper wrinkles – delivers a lot of the benefits with none of the downsides. It takes maybe 45 minutes, and “we get very nice results, I think better than fractional [laser] results,” Dr. Ross said. The wrinkle-smoothing effect may not be as potent or durable as the old-school approach, “but it’s a more natural look and [there’s] much faster recovery. Patients go pink instead of red,” and can wear makeup sooner. “You don’t get delayed hypopigmentation.”

The general trend in cosmetic dermatology is to do multiple procedures in one office visit instead of spacing them out over several appointments. For instance, lentigines on the hand could be targeted with intense pulsed light and then hand crepiness could be treated with a fractional laser. You “can get a lot done and a very nice result in one” session, but it makes sense to dial settings back maybe 15%-20% when different devices are used on the same area, he said.

I keep several lasers in one room” and sometimes “go back and forth, back and forth like a mad chef,” he said.

Companies are helping further the approach. One company, for instance, has added a nonablative fractional laser to its intense pulsed light platform. Others are combining ablative and nonablative fractional lasers. It’s all about “allowing you to have more flexibility in how you deliver energy,” Dr. Ross said.

Meanwhile, another newer kid on the block, the picosecond laser, has helped a bit with tattoo removal, but “we are still not really hitting a home run. There’s no doubt that picosecond lasers are more efficient than nanosecond lasers, but they’re maybe 20%-30% better,” he said. The problem is that most commercially available picosecond lasers have pulse durations on the order of 500-800 picoseconds, which is not optimal for the smallest pigment particles. If pulse durations are too short and energies too high, “you get this kind of white plasma in the skin, which doesn’t” help.

Industry hasn’t solved the problem yet; for now “I would give us a C-plus on tattoos,” he said.

Dr. Ross had some advice for dermatologists looking to outfit a new cosmetic practice. Right off the bat, “you will need something for red and brown spots, because you are going to see a lot of that.” An intense pulsed light device or a large-spot potassium titanyl phosphate (KTP) laser fills the bill, he said.

He added that he would have a device for resurfacing, and as the third device, “I would get maybe a Q-switch laser for tattoos,” he said.

So armed, a dermatologist could handle much of what’s likely to come through the door.

Dr. Ross works with a number of companies, including Lutronic, Cynosure, and Ellipse. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – Facial CO₂ laser resurfacing deserves a comeback, according to Victor Ross, MD, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego.

The practice fell out of favor in the late 1990s because of long recovery times, hypopigmentation, and the risk of keloid scars, among other issues. Physicians were just being too aggressive, doing multiple full-field passes in one session, he said at the Summit in Aesthetic Medicine, held by Global Academy for Medical Education.

It turns out that doing one pass very conservatively – with maybe a second pass around the mouth for deeper wrinkles – delivers a lot of the benefits with none of the downsides. It takes maybe 45 minutes, and “we get very nice results, I think better than fractional [laser] results,” Dr. Ross said. The wrinkle-smoothing effect may not be as potent or durable as the old-school approach, “but it’s a more natural look and [there’s] much faster recovery. Patients go pink instead of red,” and can wear makeup sooner. “You don’t get delayed hypopigmentation.”

The general trend in cosmetic dermatology is to do multiple procedures in one office visit instead of spacing them out over several appointments. For instance, lentigines on the hand could be targeted with intense pulsed light and then hand crepiness could be treated with a fractional laser. You “can get a lot done and a very nice result in one” session, but it makes sense to dial settings back maybe 15%-20% when different devices are used on the same area, he said.

I keep several lasers in one room” and sometimes “go back and forth, back and forth like a mad chef,” he said.

Companies are helping further the approach. One company, for instance, has added a nonablative fractional laser to its intense pulsed light platform. Others are combining ablative and nonablative fractional lasers. It’s all about “allowing you to have more flexibility in how you deliver energy,” Dr. Ross said.

Meanwhile, another newer kid on the block, the picosecond laser, has helped a bit with tattoo removal, but “we are still not really hitting a home run. There’s no doubt that picosecond lasers are more efficient than nanosecond lasers, but they’re maybe 20%-30% better,” he said. The problem is that most commercially available picosecond lasers have pulse durations on the order of 500-800 picoseconds, which is not optimal for the smallest pigment particles. If pulse durations are too short and energies too high, “you get this kind of white plasma in the skin, which doesn’t” help.

Industry hasn’t solved the problem yet; for now “I would give us a C-plus on tattoos,” he said.

Dr. Ross had some advice for dermatologists looking to outfit a new cosmetic practice. Right off the bat, “you will need something for red and brown spots, because you are going to see a lot of that.” An intense pulsed light device or a large-spot potassium titanyl phosphate (KTP) laser fills the bill, he said.

He added that he would have a device for resurfacing, and as the third device, “I would get maybe a Q-switch laser for tattoos,” he said.

So armed, a dermatologist could handle much of what’s likely to come through the door.

Dr. Ross works with a number of companies, including Lutronic, Cynosure, and Ellipse. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – Facial CO₂ laser resurfacing deserves a comeback, according to Victor Ross, MD, director of laser and cosmetic dermatology at the Scripps Clinic in San Diego.

The practice fell out of favor in the late 1990s because of long recovery times, hypopigmentation, and the risk of keloid scars, among other issues. Physicians were just being too aggressive, doing multiple full-field passes in one session, he said at the Summit in Aesthetic Medicine, held by Global Academy for Medical Education.

It turns out that doing one pass very conservatively – with maybe a second pass around the mouth for deeper wrinkles – delivers a lot of the benefits with none of the downsides. It takes maybe 45 minutes, and “we get very nice results, I think better than fractional [laser] results,” Dr. Ross said. The wrinkle-smoothing effect may not be as potent or durable as the old-school approach, “but it’s a more natural look and [there’s] much faster recovery. Patients go pink instead of red,” and can wear makeup sooner. “You don’t get delayed hypopigmentation.”

The general trend in cosmetic dermatology is to do multiple procedures in one office visit instead of spacing them out over several appointments. For instance, lentigines on the hand could be targeted with intense pulsed light and then hand crepiness could be treated with a fractional laser. You “can get a lot done and a very nice result in one” session, but it makes sense to dial settings back maybe 15%-20% when different devices are used on the same area, he said.

I keep several lasers in one room” and sometimes “go back and forth, back and forth like a mad chef,” he said.

Companies are helping further the approach. One company, for instance, has added a nonablative fractional laser to its intense pulsed light platform. Others are combining ablative and nonablative fractional lasers. It’s all about “allowing you to have more flexibility in how you deliver energy,” Dr. Ross said.

Meanwhile, another newer kid on the block, the picosecond laser, has helped a bit with tattoo removal, but “we are still not really hitting a home run. There’s no doubt that picosecond lasers are more efficient than nanosecond lasers, but they’re maybe 20%-30% better,” he said. The problem is that most commercially available picosecond lasers have pulse durations on the order of 500-800 picoseconds, which is not optimal for the smallest pigment particles. If pulse durations are too short and energies too high, “you get this kind of white plasma in the skin, which doesn’t” help.

Industry hasn’t solved the problem yet; for now “I would give us a C-plus on tattoos,” he said.

Dr. Ross had some advice for dermatologists looking to outfit a new cosmetic practice. Right off the bat, “you will need something for red and brown spots, because you are going to see a lot of that.” An intense pulsed light device or a large-spot potassium titanyl phosphate (KTP) laser fills the bill, he said.

He added that he would have a device for resurfacing, and as the third device, “I would get maybe a Q-switch laser for tattoos,” he said.

So armed, a dermatologist could handle much of what’s likely to come through the door.

Dr. Ross works with a number of companies, including Lutronic, Cynosure, and Ellipse. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – If you inject fillers, Manhattan plastic surgeon Lawrence Bass, MD, recommends that you keep hyaluronidase handy.

It’s the go-to for intravascular injections and helpful for nodules and granulomas, the main filler worries, but some offices don’t stock it. “Complications are rare, but they can be devastating. You have to be prepared.”

Massage, aspiration, transdermal nitroglycerin, and other options might help when, for example, a patient’s lip turns purple after a nasolabial fold injection, but “really, it’s all about hyaluronidase,” whether the filler is hyaluronic acid or not. The enzyme digests hyaluronic acid – both the injected kind and what patients have naturally – and loosens and disperses other fillers.

A patient who says that the injection hurt more than usual is an indication that the vessel may have been injected, Dr. Bass said. In such cases, “you have to deal with it immediately,” and repeat dosing if skin color doesn’t improve within an hour, he noted. “If you manage patients correctly, you can usually settle it with little or no deformity.”

There are two hyaluronidase options in the United States: Vitrase, an ovine formulation, and Hylenex, a recombinant human formulation. It probably doesn’t matter which one is used, he said. Soft tissue vascular compromise generally requires 200 units, and retinal artery occlusion, 500 units or more. Restylane is the easiest filler to digest because it’s the least cross-linked; Juvederm is more difficult; and Belotero is the most difficult, Dr. Bass noted.

Nodules and granulomas from filler injections have a slower onset than vascular compromise. Infected nodules can appear months after injection, and granulomas – red or purplish hypersensitivity reactions with indistinct borders, often with all injection sites involved at once – can appear years afterwards, set off by the flu or some other inflammatory trigger, according to Miles Graivier, MD, a plastic surgeon in Roswell, Ga., who shared the podium with Dr. Bass at the meeting.

Dr. Graivier described his approach to granulomas as “very aggressive.” Patients with granulomas receive oral steroids plus intralesional triamcinolone/fluorouracil/lidocaine injections every 2 weeks or more frequently. Hyaluronidase is used to disperse the filler. Resistant patients also get oral allopurinol. Laser liquefaction can help with both granulomas and infected nodules, he added.

Retinal artery occlusion is probably the most feared filler complication. It’s most likely with glabellar or periorbital injections but possible with any facial injection. “It’s a real horror show when it happens. The bottom line is you must restore circulation within 60-90 minutes” with retrobulbar hyaluronidase injections “or patients will lose vision permanently,” Dr. Bass said. People might not feel comfortable with retrobulbar injections, “but when the alternative is blindness, maybe you want to give them a try,” he added.

A 25 gauge, 1.5 inch needle is introduced to the lateral limbus at the orbital rim. “You pass the needle along the orbital floor to the equator of the globe,” – about 13-14 mm – “angle it up to enter the muscular conus, and inject 500 units or more.” Injecting at the orbital floor is less risky, but probably less effective, he said.

Hard nodules, meanwhile, present early after injection and are usually a result of too much filler or poor technique, Dr. Graivier said. For hard nodules, “hyaluronidase is the number one treatment,” although cracking, massage, and saline injection might help.

Infected nodules look like abscesses, but usually grow nothing on culture. Hyaluronidase is also first line for infected nodules, along with drainage and broad spectrum oral antibiotics for at least 6 weeks, and, if they don’t work, intravenous antibiotics, he added.

Dr. Bass is an investigator and speaker for Cynosure; an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. Dr. Graivier is an advisor for Merz, and an investigator for Merz, Galderma, Evolus, Ideal Implants, Exilis, and Cynosure. The Graivier Center for Plastic Surgery is a training center for Cynosure.

The Summit in Aesthetic Medicine is held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – If you inject fillers, Manhattan plastic surgeon Lawrence Bass, MD, recommends that you keep hyaluronidase handy.

It’s the go-to for intravascular injections and helpful for nodules and granulomas, the main filler worries, but some offices don’t stock it. “Complications are rare, but they can be devastating. You have to be prepared.”

Massage, aspiration, transdermal nitroglycerin, and other options might help when, for example, a patient’s lip turns purple after a nasolabial fold injection, but “really, it’s all about hyaluronidase,” whether the filler is hyaluronic acid or not. The enzyme digests hyaluronic acid – both the injected kind and what patients have naturally – and loosens and disperses other fillers.

A patient who says that the injection hurt more than usual is an indication that the vessel may have been injected, Dr. Bass said. In such cases, “you have to deal with it immediately,” and repeat dosing if skin color doesn’t improve within an hour, he noted. “If you manage patients correctly, you can usually settle it with little or no deformity.”

There are two hyaluronidase options in the United States: Vitrase, an ovine formulation, and Hylenex, a recombinant human formulation. It probably doesn’t matter which one is used, he said. Soft tissue vascular compromise generally requires 200 units, and retinal artery occlusion, 500 units or more. Restylane is the easiest filler to digest because it’s the least cross-linked; Juvederm is more difficult; and Belotero is the most difficult, Dr. Bass noted.

Nodules and granulomas from filler injections have a slower onset than vascular compromise. Infected nodules can appear months after injection, and granulomas – red or purplish hypersensitivity reactions with indistinct borders, often with all injection sites involved at once – can appear years afterwards, set off by the flu or some other inflammatory trigger, according to Miles Graivier, MD, a plastic surgeon in Roswell, Ga., who shared the podium with Dr. Bass at the meeting.

Dr. Graivier described his approach to granulomas as “very aggressive.” Patients with granulomas receive oral steroids plus intralesional triamcinolone/fluorouracil/lidocaine injections every 2 weeks or more frequently. Hyaluronidase is used to disperse the filler. Resistant patients also get oral allopurinol. Laser liquefaction can help with both granulomas and infected nodules, he added.

Retinal artery occlusion is probably the most feared filler complication. It’s most likely with glabellar or periorbital injections but possible with any facial injection. “It’s a real horror show when it happens. The bottom line is you must restore circulation within 60-90 minutes” with retrobulbar hyaluronidase injections “or patients will lose vision permanently,” Dr. Bass said. People might not feel comfortable with retrobulbar injections, “but when the alternative is blindness, maybe you want to give them a try,” he added.

A 25 gauge, 1.5 inch needle is introduced to the lateral limbus at the orbital rim. “You pass the needle along the orbital floor to the equator of the globe,” – about 13-14 mm – “angle it up to enter the muscular conus, and inject 500 units or more.” Injecting at the orbital floor is less risky, but probably less effective, he said.

Hard nodules, meanwhile, present early after injection and are usually a result of too much filler or poor technique, Dr. Graivier said. For hard nodules, “hyaluronidase is the number one treatment,” although cracking, massage, and saline injection might help.

Infected nodules look like abscesses, but usually grow nothing on culture. Hyaluronidase is also first line for infected nodules, along with drainage and broad spectrum oral antibiotics for at least 6 weeks, and, if they don’t work, intravenous antibiotics, he added.

Dr. Bass is an investigator and speaker for Cynosure; an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. Dr. Graivier is an advisor for Merz, and an investigator for Merz, Galderma, Evolus, Ideal Implants, Exilis, and Cynosure. The Graivier Center for Plastic Surgery is a training center for Cynosure.

The Summit in Aesthetic Medicine is held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – If you inject fillers, Manhattan plastic surgeon Lawrence Bass, MD, recommends that you keep hyaluronidase handy.

It’s the go-to for intravascular injections and helpful for nodules and granulomas, the main filler worries, but some offices don’t stock it. “Complications are rare, but they can be devastating. You have to be prepared.”

Massage, aspiration, transdermal nitroglycerin, and other options might help when, for example, a patient’s lip turns purple after a nasolabial fold injection, but “really, it’s all about hyaluronidase,” whether the filler is hyaluronic acid or not. The enzyme digests hyaluronic acid – both the injected kind and what patients have naturally – and loosens and disperses other fillers.

A patient who says that the injection hurt more than usual is an indication that the vessel may have been injected, Dr. Bass said. In such cases, “you have to deal with it immediately,” and repeat dosing if skin color doesn’t improve within an hour, he noted. “If you manage patients correctly, you can usually settle it with little or no deformity.”

There are two hyaluronidase options in the United States: Vitrase, an ovine formulation, and Hylenex, a recombinant human formulation. It probably doesn’t matter which one is used, he said. Soft tissue vascular compromise generally requires 200 units, and retinal artery occlusion, 500 units or more. Restylane is the easiest filler to digest because it’s the least cross-linked; Juvederm is more difficult; and Belotero is the most difficult, Dr. Bass noted.

Nodules and granulomas from filler injections have a slower onset than vascular compromise. Infected nodules can appear months after injection, and granulomas – red or purplish hypersensitivity reactions with indistinct borders, often with all injection sites involved at once – can appear years afterwards, set off by the flu or some other inflammatory trigger, according to Miles Graivier, MD, a plastic surgeon in Roswell, Ga., who shared the podium with Dr. Bass at the meeting.

Dr. Graivier described his approach to granulomas as “very aggressive.” Patients with granulomas receive oral steroids plus intralesional triamcinolone/fluorouracil/lidocaine injections every 2 weeks or more frequently. Hyaluronidase is used to disperse the filler. Resistant patients also get oral allopurinol. Laser liquefaction can help with both granulomas and infected nodules, he added.

Retinal artery occlusion is probably the most feared filler complication. It’s most likely with glabellar or periorbital injections but possible with any facial injection. “It’s a real horror show when it happens. The bottom line is you must restore circulation within 60-90 minutes” with retrobulbar hyaluronidase injections “or patients will lose vision permanently,” Dr. Bass said. People might not feel comfortable with retrobulbar injections, “but when the alternative is blindness, maybe you want to give them a try,” he added.

A 25 gauge, 1.5 inch needle is introduced to the lateral limbus at the orbital rim. “You pass the needle along the orbital floor to the equator of the globe,” – about 13-14 mm – “angle it up to enter the muscular conus, and inject 500 units or more.” Injecting at the orbital floor is less risky, but probably less effective, he said.

Hard nodules, meanwhile, present early after injection and are usually a result of too much filler or poor technique, Dr. Graivier said. For hard nodules, “hyaluronidase is the number one treatment,” although cracking, massage, and saline injection might help.

Infected nodules look like abscesses, but usually grow nothing on culture. Hyaluronidase is also first line for infected nodules, along with drainage and broad spectrum oral antibiotics for at least 6 weeks, and, if they don’t work, intravenous antibiotics, he added.

Dr. Bass is an investigator and speaker for Cynosure; an investigator for Endo Pharmaceuticals and Neothetics, and an advisor to Merz. Dr. Graivier is an advisor for Merz, and an investigator for Merz, Galderma, Evolus, Ideal Implants, Exilis, and Cynosure. The Graivier Center for Plastic Surgery is a training center for Cynosure.

The Summit in Aesthetic Medicine is held by Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – Despite all the technical advances in aesthetic medicine, there’s still a place for treating fine facial lines with thin hyaluronic acid fillers, according to Dr. Mark G. Rubin, a dermatologist at the Lasky Skin Center in Beverly Hills, Calif.

“In the last couple of years, with all the volumizing products, a lot of people say they don’t treat wrinkles anymore. The idea is if you just put some volume in [a patient’s] nasojugal groove, you inflate the cheek, pull the skin tight, and the nasolabial fold will miraculously disappear. I don’t think that’s really true,” he said at the meeting held by Global Academy for Medical Education.

When patients don’t have good skin elasticity and tightness – and most older patients worried about fine lines don’t – volumizing will improve skin contour but not do much for atrophic lines.

That’s a good time to turn to fillers. “Basically, you are putting putty into a dent. Different wrinkles need different depths of material. We have fillers that are thin like sand, medium like pebbles, or thick like boulders.” Shallow lines need thinner material; deeper folds need volumizing boulders for lift. In some patients, “you need to layer them, boulders first then more superficial fillers to smooth out the surface,” Dr. Rubin said. “There are a lot of medium and deep fillers, but for really fine lines and superficial filling, there’s only Restylane Silk and Belotero.”

However, even superficial fillers need to be diluted sometimes with saline or lidocaine. “There isn’t a perfect filler; you need to create the one that works by changing its characteristics,” he said.

“With Restylane, if you dilute it too much, it turns into water, and you get no lift at all. You can dilute Juvederm down pretty well, but in some patients it still leaves ridges. You can dilute Belotero a lot without losing its ability to create lift, but I think in a lot of patients, Restylane Silk has a little better persistence than Belotero,” he said.

Staying in the dermis is important for superficial lines. “You need to come in at a very acute angle, and you have to see drug coming back at you through the pores. If you are not seeing that, you are definitely too deep. You also need to overcorrect, and see the area blanch a little bit,” he said.

Dr. Rubin warns patients that they might have what looks like a string of pearls under their skin after injection. “We massage [the beads] down with a Q-tip,” rolling it back and forth over the bulges, and they melt over time. A part of the reaction is histamine-related, so antihistamines like loratadine (Claritin) can help.

There can be more serious swelling as well, especially after perioral injections, and “it’s more common with Silk than with regular Restylane. Some patients have erythema that stays a long time, and some have a burning sensation. If it’s not horrific, you wait and see. If it’s still there in 10 days or 2 weeks, my inclination is to dissolve it out and switch drugs,” he said.

Dr. Rubin is a consultant for Merz, maker of Belotero, Radiesse, and other products. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – Despite all the technical advances in aesthetic medicine, there’s still a place for treating fine facial lines with thin hyaluronic acid fillers, according to Dr. Mark G. Rubin, a dermatologist at the Lasky Skin Center in Beverly Hills, Calif.

“In the last couple of years, with all the volumizing products, a lot of people say they don’t treat wrinkles anymore. The idea is if you just put some volume in [a patient’s] nasojugal groove, you inflate the cheek, pull the skin tight, and the nasolabial fold will miraculously disappear. I don’t think that’s really true,” he said at the meeting held by Global Academy for Medical Education.

When patients don’t have good skin elasticity and tightness – and most older patients worried about fine lines don’t – volumizing will improve skin contour but not do much for atrophic lines.

That’s a good time to turn to fillers. “Basically, you are putting putty into a dent. Different wrinkles need different depths of material. We have fillers that are thin like sand, medium like pebbles, or thick like boulders.” Shallow lines need thinner material; deeper folds need volumizing boulders for lift. In some patients, “you need to layer them, boulders first then more superficial fillers to smooth out the surface,” Dr. Rubin said. “There are a lot of medium and deep fillers, but for really fine lines and superficial filling, there’s only Restylane Silk and Belotero.”

However, even superficial fillers need to be diluted sometimes with saline or lidocaine. “There isn’t a perfect filler; you need to create the one that works by changing its characteristics,” he said.

“With Restylane, if you dilute it too much, it turns into water, and you get no lift at all. You can dilute Juvederm down pretty well, but in some patients it still leaves ridges. You can dilute Belotero a lot without losing its ability to create lift, but I think in a lot of patients, Restylane Silk has a little better persistence than Belotero,” he said.

Staying in the dermis is important for superficial lines. “You need to come in at a very acute angle, and you have to see drug coming back at you through the pores. If you are not seeing that, you are definitely too deep. You also need to overcorrect, and see the area blanch a little bit,” he said.

Dr. Rubin warns patients that they might have what looks like a string of pearls under their skin after injection. “We massage [the beads] down with a Q-tip,” rolling it back and forth over the bulges, and they melt over time. A part of the reaction is histamine-related, so antihistamines like loratadine (Claritin) can help.

There can be more serious swelling as well, especially after perioral injections, and “it’s more common with Silk than with regular Restylane. Some patients have erythema that stays a long time, and some have a burning sensation. If it’s not horrific, you wait and see. If it’s still there in 10 days or 2 weeks, my inclination is to dissolve it out and switch drugs,” he said.

Dr. Rubin is a consultant for Merz, maker of Belotero, Radiesse, and other products. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – Despite all the technical advances in aesthetic medicine, there’s still a place for treating fine facial lines with thin hyaluronic acid fillers, according to Dr. Mark G. Rubin, a dermatologist at the Lasky Skin Center in Beverly Hills, Calif.

“In the last couple of years, with all the volumizing products, a lot of people say they don’t treat wrinkles anymore. The idea is if you just put some volume in [a patient’s] nasojugal groove, you inflate the cheek, pull the skin tight, and the nasolabial fold will miraculously disappear. I don’t think that’s really true,” he said at the meeting held by Global Academy for Medical Education.

When patients don’t have good skin elasticity and tightness – and most older patients worried about fine lines don’t – volumizing will improve skin contour but not do much for atrophic lines.

That’s a good time to turn to fillers. “Basically, you are putting putty into a dent. Different wrinkles need different depths of material. We have fillers that are thin like sand, medium like pebbles, or thick like boulders.” Shallow lines need thinner material; deeper folds need volumizing boulders for lift. In some patients, “you need to layer them, boulders first then more superficial fillers to smooth out the surface,” Dr. Rubin said. “There are a lot of medium and deep fillers, but for really fine lines and superficial filling, there’s only Restylane Silk and Belotero.”

However, even superficial fillers need to be diluted sometimes with saline or lidocaine. “There isn’t a perfect filler; you need to create the one that works by changing its characteristics,” he said.

“With Restylane, if you dilute it too much, it turns into water, and you get no lift at all. You can dilute Juvederm down pretty well, but in some patients it still leaves ridges. You can dilute Belotero a lot without losing its ability to create lift, but I think in a lot of patients, Restylane Silk has a little better persistence than Belotero,” he said.

Staying in the dermis is important for superficial lines. “You need to come in at a very acute angle, and you have to see drug coming back at you through the pores. If you are not seeing that, you are definitely too deep. You also need to overcorrect, and see the area blanch a little bit,” he said.

Dr. Rubin warns patients that they might have what looks like a string of pearls under their skin after injection. “We massage [the beads] down with a Q-tip,” rolling it back and forth over the bulges, and they melt over time. A part of the reaction is histamine-related, so antihistamines like loratadine (Claritin) can help.

There can be more serious swelling as well, especially after perioral injections, and “it’s more common with Silk than with regular Restylane. Some patients have erythema that stays a long time, and some have a burning sensation. If it’s not horrific, you wait and see. If it’s still there in 10 days or 2 weeks, my inclination is to dissolve it out and switch drugs,” he said.

Dr. Rubin is a consultant for Merz, maker of Belotero, Radiesse, and other products. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – The promise of Janus kinase (JAK) inhibitors for alopecia seems to be holding up in the practice of Dr. Natasha Mesinkovska, a dermatologist at the University of California, Irvine.

There’s been much excitement about JAK inhibitors since Yale researchers reported in 2014 that tofacitinib (Xeljanz), a JAK inhibitor approved in the United States for rheumatoid arthritis, appeared to grow a full head of hair, plus body hair, in an essentially hairless 25-year-old man with plaque psoriasis. JAK inhibitors have been under investigation for alopecia ever since. Meanwhile, they are being used off label for hair loss around the country.

In her own practice, Dr. Mesinkovska estimates that about two-thirds of patients have some degree of hair regrowth, with particularly satisfying results in men. About 40 of her alopecia patients have opted for JAK inhibitors so far.

In an interview at the Summit in Aesthetic Medicine, Dr. Mesinkovska shared her insights and tips, as well as promising alopecia results for the psoriasis biologic ustekinumab (Stelara), an interleukin-12 and -23 antagonist. “This is a very exciting time for alopecia areata,” she said.

The Summit in Aesthetic Medicine is held by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – The promise of Janus kinase (JAK) inhibitors for alopecia seems to be holding up in the practice of Dr. Natasha Mesinkovska, a dermatologist at the University of California, Irvine.

There’s been much excitement about JAK inhibitors since Yale researchers reported in 2014 that tofacitinib (Xeljanz), a JAK inhibitor approved in the United States for rheumatoid arthritis, appeared to grow a full head of hair, plus body hair, in an essentially hairless 25-year-old man with plaque psoriasis. JAK inhibitors have been under investigation for alopecia ever since. Meanwhile, they are being used off label for hair loss around the country.

In her own practice, Dr. Mesinkovska estimates that about two-thirds of patients have some degree of hair regrowth, with particularly satisfying results in men. About 40 of her alopecia patients have opted for JAK inhibitors so far.

In an interview at the Summit in Aesthetic Medicine, Dr. Mesinkovska shared her insights and tips, as well as promising alopecia results for the psoriasis biologic ustekinumab (Stelara), an interleukin-12 and -23 antagonist. “This is a very exciting time for alopecia areata,” she said.

The Summit in Aesthetic Medicine is held by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – The promise of Janus kinase (JAK) inhibitors for alopecia seems to be holding up in the practice of Dr. Natasha Mesinkovska, a dermatologist at the University of California, Irvine.

There’s been much excitement about JAK inhibitors since Yale researchers reported in 2014 that tofacitinib (Xeljanz), a JAK inhibitor approved in the United States for rheumatoid arthritis, appeared to grow a full head of hair, plus body hair, in an essentially hairless 25-year-old man with plaque psoriasis. JAK inhibitors have been under investigation for alopecia ever since. Meanwhile, they are being used off label for hair loss around the country.

In her own practice, Dr. Mesinkovska estimates that about two-thirds of patients have some degree of hair regrowth, with particularly satisfying results in men. About 40 of her alopecia patients have opted for JAK inhibitors so far.

In an interview at the Summit in Aesthetic Medicine, Dr. Mesinkovska shared her insights and tips, as well as promising alopecia results for the psoriasis biologic ustekinumab (Stelara), an interleukin-12 and -23 antagonist. “This is a very exciting time for alopecia areata,” she said.

The Summit in Aesthetic Medicine is held by the Global Academy for Medical Education. Global Academy and this news organization are owned by the same company.

[email protected]

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]

NEWPORT BEACH, CALIF. – A combination of propranolol and laser is more effective than propranolol alone for infantile hemangiomas, and rapamycin can improve pulse die laser results for port wine stains.

Meanwhile, lasers hurt, so general anesthesia is in order for children as long as they’re older than 6 months.

Those are just a few of the pearls Dr. Kristen Kelly, a University of California, Irvine, professor of dermatology and surgery, shared at the Summit in Aesthetic Medicine. Dr. Kelly explained the latest developments in an interview at the conference, held by Global Academy for Medical Education.

Global Academy and this news organization are owned the same company.

[email protected]