Aesthetic Dermatology

MIAMI BEACH – More men are seeking cosmetic dermatologic procedures and products, and successfully engaging and treating this segment of the population require recognition of a number of gender-specific differences with respect to skin biology, skin aging, behaviors, and rejuvenation goals, according to Dr. Ivan Camacho.

"We need to be able to understand all of these the differences in order to be able to provide tailored treatments for our patients, so they can get the best results possible," Dr. Camacho said during a focus session on men’s aesthetics at the annual meeting of the American Academy of Dermatology.

Skin biology

When it comes to skin biology, men and women share a number of characteristics, but there are important differences driven by genetic or hormonal specificity that can affect treatment outcomes, Dr. Camacho said. For example, although the number of cell layers and thickness of the stratum corneum is similar in men and women, the dermis is about 20% thicker in men than in women, across the age spectrum and in all anatomic locations, he noted.

Men also have higher collagen density early in life, but they experience skin thinning at a younger age than women. For women, skin thickness generally remains constant until menopause, and then the skin begins to thin rapidly. This difference is most likely because of the role of testosterone in maintaining collagen content, said Dr. Camacho of the University of Miami.

Men also have less subcutaneous fat, greater distribution of body fat in the abdomen and trunk, and higher facial bone density mass than women, Dr. Camacho explained. In addition, men tend to have higher transepidermal water loss because of the lack of estrogen, which has positive effects in the stratum corneum, he said.

Dr. Camacho described other functional differences in men’s skin compared with women’s skin, including:

• A fourfold increase in sebum generation.

• A 30% overall increase in sweating.

• Different hair distribution as determined by androgens, but also by genetics.

• Stronger skin tone.

• Greater sensitivity to ultraviolet radiation, and thus a lower minimal erythema dose threshold and increased rate of skin cancers.

• Greater susceptibility to bacterial and viral infections and slower healing rates as a result of the inhibitory effects of testosterone and hydrotestosterone with respect to wound healing.

• Greater susceptibility to stress-induced immunosuppression, which may explain the higher skin cancer rates and delayed wound healing.

Skin aging

As for the aging process, men age differently from women in that their higher collagen density leads to better maintenance of elasticity, and their higher facial bone density provides better overall support, said Dr. Camacho.

However, thicker skin and stronger muscles make men more prone to develop deeper expression lines, as opposed to the "superficial wrinkles that women complain about," Dr. Camacho noted.

Also, the reduced level of subcutaneous fat in men can lead to more dramatic volume loss.

"Men are ‘sinkers.’ We sink more than wrinklers or saggers, because we have good elasticity, but we actually tend to lose quite a bit of subcutaneous fat," Dr. Camacho explained.

As a result of other differences related to skin aging, he said, men’s skin may be:

• More prone to acne and enlarged pores due to the higher sebaceous gland count.

• More prone to darker and/or redder complexions because of the increased tone and vascularity.

• More likely to have dull areas due to the epidermal water loss.

• Less prone to perioral lines and wrinkles due to facial hair distribution, which acts as a structural support.

• More likely to have unwanted fat in the abdominal and trunk region.

• More likely to develop both melanoma and nonmelanoma skin cancers and to experience photoaging because of greater sensitivity to ultraviolet radiation.

Behavior

In Dr. Camacho’s experience, men tend to be very goal oriented, and that carries over to cosmetic procedures.

"Men are very results-oriented, so we want to have a very clear purpose of what we want to achieve with a given treatment or product," he added, noting that male patients often prefer a lot of detail about procedures and processes.

Providing the extra details requires a greater educational effort on the part of the physician, he said, but "that’s a great thing, because they are going to be well informed about the pros and cons of a given treatment."

Male patients also want fast results. For these reasons, injectables and laser therapies are probably a good fit, he noted.

Men also tend to prefer simplicity, minimal discomfort, and minimal downtime, making noninvasive procedures and multifunctional skin care products ideal, he added.

Rejuvenation goals

Men often have rejuvenation goals that are different from those of women, Dr. Camacho said.

The most common reason that men seek cosmetic treatment is for a "tired, sinking face"; they want to look refreshed and confident, but they want subtle, natural-looking results, he said.

And, of course, there’s hair.

"Hair, hair, hair. Hair is a huge concern for men," Dr. Camacho said.

Sometimes men think they have too much hair, sometimes they have too little. Men drive the market for hair loss treatments, and also are increasingly seeking hair removal treatments, Dr. Camacho noted. Since traditional methods for hair removal, such as waxing, shaving, and epilation, are temporary and can cause irritation, laser hair removal is increasing in popularity among men. In fact, according to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2011, Dr. Camacho said.

Other useful cosmetic procedures

One of the most popular noninvasive cosmetic interventions for both men and women is neuromodulation injections, for softening of expression lines and treating areas including the glabella, forehead, and periocular area, that can contribute to an angry-, tired-, or sad-looking face, Dr. Camacho said.

In 2011, men accounted for 9.1% of botulinum toxin treatment patients, and this represented a 258% increase from the year 2000, he noted.

Skin resurfacing treatments are increasing in popularity among men as well. In 2011, men accounted for 7.3% of skin resurfacing treatments, making skin resurfacing the fourth most common nonsurgical cosmetic intervention in men, Dr. Camacho said.

Other treatments for skin issues of concern to men include laser and light therapies to improve the complexion, and skin-tightening procedures, such as radiofrequency and ultrasound, to help improve skin laxity

In addition, data from 2011 showed that men accounted for about 20% of patients undergoing CoolSculpting, which is both effective and appealing to men seeking treatment for abdominal and trunk fat deposits, Dr. Camacho said.

Treatment pearls

When providing facial treatments for men, preservation of a masculine appearance is essential, Dr. Camacho said.

"The last thing we want to do is have a man’s face looking like a woman’s face; we need to be able to preserve the masculine appearance," Dr. Camacho said, noting that in his experience, a combination of neurotoxins and dermal fillers is excellent for achieving desired results.

For neurotoxins, remember that men require doses at about 1.5 to 2 times as much as women, he said

"But also remember that men want to preserve some animation, so it’s always important to keep a balance between being effective with our treatment, but also keeping the patient happy with what they want," he said.

In Dr. Camacho’s experience, most men are less concerned with periocular lines, but some are, so be sure to ask them exactly what they want at a treatment session.

"You can’t assume they want three areas treated at a time as we usually do with women," he said.

Be sure to preserve the masculine position of the brow, which in men is very subtle, located right at the supraorbital rim, and has no major arching, said Dr. Camacho.

By avoiding injecting at the superior portion of the orbicularis ocular muscle, the subtle arch at the supraorbital rim can be maintained, and feminization of the brow avoided, he said.

"Also, when treating the frontalis major make sure to go all the way lateral, because you don’t want a little bit of frontalis pulling and giving some arching to the eyebrows," he added.

As for fillers, keep in mind that men probably will require higher volumes, which is an important consideration when discussing finances during the initial consultation.

Fillers are particularly useful in the tear trough area for men seeking treatment of tired-looking sunken eyes.

"Very easily, we can create a smooth transition between the lower eyelid and cheek. We can also use (fillers) for prominent nasolabial folds," Dr. Camacho explained.

Before filling the lines, however, consider restoring the cheek to correct for the midfacial fat loss common in men, he noted.

Also, if treatment involves the lip area, avoid overfilling the vermilion border – this will feminize the lips, he said.

Breaking into the men’s market

Consider developing a marketing strategy that shows your practice’s appeal to both genders – by launching a website and developing marketing materials that feature both male and female models and patients, and by offering cosmeceutical product lines developed for men, Dr. Camacho suggested.

"The modern man is here, and the modern man is actively looking for advice on cosmetic procedures and recommendations for skin care. Dermatologists will have a very important role in male aesthetics," he said, noting that a dermatologist’s role can include enhancing awareness and cultural acceptance of cosmetic interventions for men.

"We have every day in our practices, an opportunity to educate our male patients on the multiple treatment options available for them. We also have a responsibility for being knowledgeable about the specificities of male skin ... to be able to formulate tailored treatments, and to be able to, therefore, obtain the best results for our male patients," he said.

Dr. Camacho reported having no disclosures.

MIAMI BEACH – More men are seeking cosmetic dermatologic procedures and products, and successfully engaging and treating this segment of the population require recognition of a number of gender-specific differences with respect to skin biology, skin aging, behaviors, and rejuvenation goals, according to Dr. Ivan Camacho.

"We need to be able to understand all of these the differences in order to be able to provide tailored treatments for our patients, so they can get the best results possible," Dr. Camacho said during a focus session on men’s aesthetics at the annual meeting of the American Academy of Dermatology.

Skin biology

When it comes to skin biology, men and women share a number of characteristics, but there are important differences driven by genetic or hormonal specificity that can affect treatment outcomes, Dr. Camacho said. For example, although the number of cell layers and thickness of the stratum corneum is similar in men and women, the dermis is about 20% thicker in men than in women, across the age spectrum and in all anatomic locations, he noted.

Men also have higher collagen density early in life, but they experience skin thinning at a younger age than women. For women, skin thickness generally remains constant until menopause, and then the skin begins to thin rapidly. This difference is most likely because of the role of testosterone in maintaining collagen content, said Dr. Camacho of the University of Miami.

Men also have less subcutaneous fat, greater distribution of body fat in the abdomen and trunk, and higher facial bone density mass than women, Dr. Camacho explained. In addition, men tend to have higher transepidermal water loss because of the lack of estrogen, which has positive effects in the stratum corneum, he said.

Dr. Camacho described other functional differences in men’s skin compared with women’s skin, including:

• A fourfold increase in sebum generation.

• A 30% overall increase in sweating.

• Different hair distribution as determined by androgens, but also by genetics.

• Stronger skin tone.

• Greater sensitivity to ultraviolet radiation, and thus a lower minimal erythema dose threshold and increased rate of skin cancers.

• Greater susceptibility to bacterial and viral infections and slower healing rates as a result of the inhibitory effects of testosterone and hydrotestosterone with respect to wound healing.

• Greater susceptibility to stress-induced immunosuppression, which may explain the higher skin cancer rates and delayed wound healing.

Skin aging

As for the aging process, men age differently from women in that their higher collagen density leads to better maintenance of elasticity, and their higher facial bone density provides better overall support, said Dr. Camacho.

However, thicker skin and stronger muscles make men more prone to develop deeper expression lines, as opposed to the "superficial wrinkles that women complain about," Dr. Camacho noted.

Also, the reduced level of subcutaneous fat in men can lead to more dramatic volume loss.

"Men are ‘sinkers.’ We sink more than wrinklers or saggers, because we have good elasticity, but we actually tend to lose quite a bit of subcutaneous fat," Dr. Camacho explained.

As a result of other differences related to skin aging, he said, men’s skin may be:

• More prone to acne and enlarged pores due to the higher sebaceous gland count.

• More prone to darker and/or redder complexions because of the increased tone and vascularity.

• More likely to have dull areas due to the epidermal water loss.

• Less prone to perioral lines and wrinkles due to facial hair distribution, which acts as a structural support.

• More likely to have unwanted fat in the abdominal and trunk region.

• More likely to develop both melanoma and nonmelanoma skin cancers and to experience photoaging because of greater sensitivity to ultraviolet radiation.

Behavior

In Dr. Camacho’s experience, men tend to be very goal oriented, and that carries over to cosmetic procedures.

"Men are very results-oriented, so we want to have a very clear purpose of what we want to achieve with a given treatment or product," he added, noting that male patients often prefer a lot of detail about procedures and processes.

Providing the extra details requires a greater educational effort on the part of the physician, he said, but "that’s a great thing, because they are going to be well informed about the pros and cons of a given treatment."

Male patients also want fast results. For these reasons, injectables and laser therapies are probably a good fit, he noted.

Men also tend to prefer simplicity, minimal discomfort, and minimal downtime, making noninvasive procedures and multifunctional skin care products ideal, he added.

Rejuvenation goals

Men often have rejuvenation goals that are different from those of women, Dr. Camacho said.

The most common reason that men seek cosmetic treatment is for a "tired, sinking face"; they want to look refreshed and confident, but they want subtle, natural-looking results, he said.

And, of course, there’s hair.

"Hair, hair, hair. Hair is a huge concern for men," Dr. Camacho said.

Sometimes men think they have too much hair, sometimes they have too little. Men drive the market for hair loss treatments, and also are increasingly seeking hair removal treatments, Dr. Camacho noted. Since traditional methods for hair removal, such as waxing, shaving, and epilation, are temporary and can cause irritation, laser hair removal is increasing in popularity among men. In fact, according to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2011, Dr. Camacho said.

Other useful cosmetic procedures

One of the most popular noninvasive cosmetic interventions for both men and women is neuromodulation injections, for softening of expression lines and treating areas including the glabella, forehead, and periocular area, that can contribute to an angry-, tired-, or sad-looking face, Dr. Camacho said.

In 2011, men accounted for 9.1% of botulinum toxin treatment patients, and this represented a 258% increase from the year 2000, he noted.

Skin resurfacing treatments are increasing in popularity among men as well. In 2011, men accounted for 7.3% of skin resurfacing treatments, making skin resurfacing the fourth most common nonsurgical cosmetic intervention in men, Dr. Camacho said.

Other treatments for skin issues of concern to men include laser and light therapies to improve the complexion, and skin-tightening procedures, such as radiofrequency and ultrasound, to help improve skin laxity

In addition, data from 2011 showed that men accounted for about 20% of patients undergoing CoolSculpting, which is both effective and appealing to men seeking treatment for abdominal and trunk fat deposits, Dr. Camacho said.

Treatment pearls

When providing facial treatments for men, preservation of a masculine appearance is essential, Dr. Camacho said.

"The last thing we want to do is have a man’s face looking like a woman’s face; we need to be able to preserve the masculine appearance," Dr. Camacho said, noting that in his experience, a combination of neurotoxins and dermal fillers is excellent for achieving desired results.

For neurotoxins, remember that men require doses at about 1.5 to 2 times as much as women, he said

"But also remember that men want to preserve some animation, so it’s always important to keep a balance between being effective with our treatment, but also keeping the patient happy with what they want," he said.

In Dr. Camacho’s experience, most men are less concerned with periocular lines, but some are, so be sure to ask them exactly what they want at a treatment session.

"You can’t assume they want three areas treated at a time as we usually do with women," he said.

Be sure to preserve the masculine position of the brow, which in men is very subtle, located right at the supraorbital rim, and has no major arching, said Dr. Camacho.

By avoiding injecting at the superior portion of the orbicularis ocular muscle, the subtle arch at the supraorbital rim can be maintained, and feminization of the brow avoided, he said.

"Also, when treating the frontalis major make sure to go all the way lateral, because you don’t want a little bit of frontalis pulling and giving some arching to the eyebrows," he added.

As for fillers, keep in mind that men probably will require higher volumes, which is an important consideration when discussing finances during the initial consultation.

Fillers are particularly useful in the tear trough area for men seeking treatment of tired-looking sunken eyes.

"Very easily, we can create a smooth transition between the lower eyelid and cheek. We can also use (fillers) for prominent nasolabial folds," Dr. Camacho explained.

Before filling the lines, however, consider restoring the cheek to correct for the midfacial fat loss common in men, he noted.

Also, if treatment involves the lip area, avoid overfilling the vermilion border – this will feminize the lips, he said.

Breaking into the men’s market

Consider developing a marketing strategy that shows your practice’s appeal to both genders – by launching a website and developing marketing materials that feature both male and female models and patients, and by offering cosmeceutical product lines developed for men, Dr. Camacho suggested.

"The modern man is here, and the modern man is actively looking for advice on cosmetic procedures and recommendations for skin care. Dermatologists will have a very important role in male aesthetics," he said, noting that a dermatologist’s role can include enhancing awareness and cultural acceptance of cosmetic interventions for men.

"We have every day in our practices, an opportunity to educate our male patients on the multiple treatment options available for them. We also have a responsibility for being knowledgeable about the specificities of male skin ... to be able to formulate tailored treatments, and to be able to, therefore, obtain the best results for our male patients," he said.

Dr. Camacho reported having no disclosures.

MIAMI BEACH – More men are seeking cosmetic dermatologic procedures and products, and successfully engaging and treating this segment of the population require recognition of a number of gender-specific differences with respect to skin biology, skin aging, behaviors, and rejuvenation goals, according to Dr. Ivan Camacho.

"We need to be able to understand all of these the differences in order to be able to provide tailored treatments for our patients, so they can get the best results possible," Dr. Camacho said during a focus session on men’s aesthetics at the annual meeting of the American Academy of Dermatology.

Skin biology

When it comes to skin biology, men and women share a number of characteristics, but there are important differences driven by genetic or hormonal specificity that can affect treatment outcomes, Dr. Camacho said. For example, although the number of cell layers and thickness of the stratum corneum is similar in men and women, the dermis is about 20% thicker in men than in women, across the age spectrum and in all anatomic locations, he noted.

Men also have higher collagen density early in life, but they experience skin thinning at a younger age than women. For women, skin thickness generally remains constant until menopause, and then the skin begins to thin rapidly. This difference is most likely because of the role of testosterone in maintaining collagen content, said Dr. Camacho of the University of Miami.

Men also have less subcutaneous fat, greater distribution of body fat in the abdomen and trunk, and higher facial bone density mass than women, Dr. Camacho explained. In addition, men tend to have higher transepidermal water loss because of the lack of estrogen, which has positive effects in the stratum corneum, he said.

Dr. Camacho described other functional differences in men’s skin compared with women’s skin, including:

• A fourfold increase in sebum generation.

• A 30% overall increase in sweating.

• Different hair distribution as determined by androgens, but also by genetics.

• Stronger skin tone.

• Greater sensitivity to ultraviolet radiation, and thus a lower minimal erythema dose threshold and increased rate of skin cancers.

• Greater susceptibility to bacterial and viral infections and slower healing rates as a result of the inhibitory effects of testosterone and hydrotestosterone with respect to wound healing.

• Greater susceptibility to stress-induced immunosuppression, which may explain the higher skin cancer rates and delayed wound healing.

Skin aging

As for the aging process, men age differently from women in that their higher collagen density leads to better maintenance of elasticity, and their higher facial bone density provides better overall support, said Dr. Camacho.

However, thicker skin and stronger muscles make men more prone to develop deeper expression lines, as opposed to the "superficial wrinkles that women complain about," Dr. Camacho noted.

Also, the reduced level of subcutaneous fat in men can lead to more dramatic volume loss.

"Men are ‘sinkers.’ We sink more than wrinklers or saggers, because we have good elasticity, but we actually tend to lose quite a bit of subcutaneous fat," Dr. Camacho explained.

As a result of other differences related to skin aging, he said, men’s skin may be:

• More prone to acne and enlarged pores due to the higher sebaceous gland count.

• More prone to darker and/or redder complexions because of the increased tone and vascularity.

• More likely to have dull areas due to the epidermal water loss.

• Less prone to perioral lines and wrinkles due to facial hair distribution, which acts as a structural support.

• More likely to have unwanted fat in the abdominal and trunk region.

• More likely to develop both melanoma and nonmelanoma skin cancers and to experience photoaging because of greater sensitivity to ultraviolet radiation.

Behavior

In Dr. Camacho’s experience, men tend to be very goal oriented, and that carries over to cosmetic procedures.

"Men are very results-oriented, so we want to have a very clear purpose of what we want to achieve with a given treatment or product," he added, noting that male patients often prefer a lot of detail about procedures and processes.

Providing the extra details requires a greater educational effort on the part of the physician, he said, but "that’s a great thing, because they are going to be well informed about the pros and cons of a given treatment."

Male patients also want fast results. For these reasons, injectables and laser therapies are probably a good fit, he noted.

Men also tend to prefer simplicity, minimal discomfort, and minimal downtime, making noninvasive procedures and multifunctional skin care products ideal, he added.

Rejuvenation goals

Men often have rejuvenation goals that are different from those of women, Dr. Camacho said.

The most common reason that men seek cosmetic treatment is for a "tired, sinking face"; they want to look refreshed and confident, but they want subtle, natural-looking results, he said.

And, of course, there’s hair.

"Hair, hair, hair. Hair is a huge concern for men," Dr. Camacho said.

Sometimes men think they have too much hair, sometimes they have too little. Men drive the market for hair loss treatments, and also are increasingly seeking hair removal treatments, Dr. Camacho noted. Since traditional methods for hair removal, such as waxing, shaving, and epilation, are temporary and can cause irritation, laser hair removal is increasing in popularity among men. In fact, according to the American Society of Aesthetic Plastic Surgery, it was the second most common nonsurgical cosmetic intervention for men in 2011, Dr. Camacho said.

Other useful cosmetic procedures

One of the most popular noninvasive cosmetic interventions for both men and women is neuromodulation injections, for softening of expression lines and treating areas including the glabella, forehead, and periocular area, that can contribute to an angry-, tired-, or sad-looking face, Dr. Camacho said.

In 2011, men accounted for 9.1% of botulinum toxin treatment patients, and this represented a 258% increase from the year 2000, he noted.

Skin resurfacing treatments are increasing in popularity among men as well. In 2011, men accounted for 7.3% of skin resurfacing treatments, making skin resurfacing the fourth most common nonsurgical cosmetic intervention in men, Dr. Camacho said.

Other treatments for skin issues of concern to men include laser and light therapies to improve the complexion, and skin-tightening procedures, such as radiofrequency and ultrasound, to help improve skin laxity

In addition, data from 2011 showed that men accounted for about 20% of patients undergoing CoolSculpting, which is both effective and appealing to men seeking treatment for abdominal and trunk fat deposits, Dr. Camacho said.

Treatment pearls

When providing facial treatments for men, preservation of a masculine appearance is essential, Dr. Camacho said.

"The last thing we want to do is have a man’s face looking like a woman’s face; we need to be able to preserve the masculine appearance," Dr. Camacho said, noting that in his experience, a combination of neurotoxins and dermal fillers is excellent for achieving desired results.

For neurotoxins, remember that men require doses at about 1.5 to 2 times as much as women, he said

"But also remember that men want to preserve some animation, so it’s always important to keep a balance between being effective with our treatment, but also keeping the patient happy with what they want," he said.

In Dr. Camacho’s experience, most men are less concerned with periocular lines, but some are, so be sure to ask them exactly what they want at a treatment session.

"You can’t assume they want three areas treated at a time as we usually do with women," he said.

Be sure to preserve the masculine position of the brow, which in men is very subtle, located right at the supraorbital rim, and has no major arching, said Dr. Camacho.

By avoiding injecting at the superior portion of the orbicularis ocular muscle, the subtle arch at the supraorbital rim can be maintained, and feminization of the brow avoided, he said.

"Also, when treating the frontalis major make sure to go all the way lateral, because you don’t want a little bit of frontalis pulling and giving some arching to the eyebrows," he added.

As for fillers, keep in mind that men probably will require higher volumes, which is an important consideration when discussing finances during the initial consultation.

Fillers are particularly useful in the tear trough area for men seeking treatment of tired-looking sunken eyes.

"Very easily, we can create a smooth transition between the lower eyelid and cheek. We can also use (fillers) for prominent nasolabial folds," Dr. Camacho explained.

Before filling the lines, however, consider restoring the cheek to correct for the midfacial fat loss common in men, he noted.

Also, if treatment involves the lip area, avoid overfilling the vermilion border – this will feminize the lips, he said.

Breaking into the men’s market

Consider developing a marketing strategy that shows your practice’s appeal to both genders – by launching a website and developing marketing materials that feature both male and female models and patients, and by offering cosmeceutical product lines developed for men, Dr. Camacho suggested.

"The modern man is here, and the modern man is actively looking for advice on cosmetic procedures and recommendations for skin care. Dermatologists will have a very important role in male aesthetics," he said, noting that a dermatologist’s role can include enhancing awareness and cultural acceptance of cosmetic interventions for men.

"We have every day in our practices, an opportunity to educate our male patients on the multiple treatment options available for them. We also have a responsibility for being knowledgeable about the specificities of male skin ... to be able to formulate tailored treatments, and to be able to, therefore, obtain the best results for our male patients," he said.

Dr. Camacho reported having no disclosures.

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].

In an effort to improve sun protection and curb skin cancer, dermatologists are doing a better job of educating patients of all skin types about the consequences of UV damage. Sunscreen manufacturers also continue to develop more elegant formulations of both chemical and physical blockers that do not leave a whitish hue on darker skin.

But what about some other, lesser-known innovative ways we can protect ourselves without looking chalky?

Just in time for summer, here’s some food for thought.

Strawberries, as well as other darker-colored berries, are known to contain polyphenols that are antioxidants. Researchers in Italy and Spain tested a strawberry extract on cultured human fibroblasts to see whether there was a photoprotective effect. They added strawberry extract in different concentrations (0.05, 0.25, and 0.5 mg/mL) to all but the control group. They then exposed the samples to a dose of UV light "equivalent to 90 minutes of midday summer sun in the French Riviera," said lead investigator Maurizio Battino. Strawberry extract, especially at a concentration of 0.5 mg/mL, provided UVA protection, and not only boosted cell survival and viability, but also minimized DNA damage, compared with the effects on control cells (J. Agric. Food Chem. 2012;60:2322-70). Perhaps there will be topical sunscreens that contain strawberry extract in the future.

Other foods high in antioxidants that have been considered to have potential sun-protective benefits include bell peppers (red, yellow, green) and yellow squash (high in carotenoids); tomatoes and watermelon (high in lycopene); dark berries such as blueberries, acai, blackberries, and cranberries (rich in anthocyanin); turmeric root (curcumin); pomegranate (ellagic acid); green and black tea (catechins); dark cocoa (flavenols); green leafy vegetables such as spinach and kale (xanthophylls, oxygenated carotenoids); and fish such as mackerel, salmon, trout, herring, and sardines (omega-3 fatty acids).

Of course, just because certain foods have protective benefits does not mean we can advise patients to eat some fruits and veggies and then go lie in the sun sans sunscreen. These foods are not a replacement for the more common methods of sun protection, but they certainly contribute to overall health and, by extension, to healthy skin of all types.

This column, "Skin of Color," appears regularly in Skin & Allergy News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif. Scan the QR code to read this column online at edermatologynews.com.

Do you have questions about treating patients with dark skin? If so, send them to [email protected].

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

[email protected]

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

[email protected]

BOSTON – Performing laser hair removal might be hazardous to your health.

Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.

The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.

Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.

The compounds included:

• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.

• 2-Methylpyridine, which can cause headache and nausea.

• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.

• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.

• Various soap and perfume components of unknown toxicity.

The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.

Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.

"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.

Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.

"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.

The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.

[email protected]

GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.

At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.

The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.

This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.

Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.

The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.

Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.

At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.

The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.

Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.

Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.

However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.

A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.

The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.

Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.

The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.

No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.

The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.

The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.

During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.

Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.

[email protected]

GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.

At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.

The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.

This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.

Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.

The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.

Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.

At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.

The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.

Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.

Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.

However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.

A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.

The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.

Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.

The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.

No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.

The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.

The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.

During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.

Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.

[email protected]

GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.

At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.

The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.

This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.

Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.

The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.

Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.

At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.

The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.

Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.

Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.

However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.

A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.

The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.

Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.

The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.

No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.

The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.

The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.

During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.

Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.

[email protected]

MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.

People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.

Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.

"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.

"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."

Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.

Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.

Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).

There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).

Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.

[email protected]

On Twitter @NaseemSMiller

MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.

People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.

Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.

"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.

"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."

Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.

Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.

Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).

There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).

Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.

[email protected]

On Twitter @NaseemSMiller

MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.

People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.

Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.

"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.

"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."

Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.

Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.

Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).

There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).

Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.

[email protected]

On Twitter @NaseemSMiller

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

[email protected]

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

[email protected]

LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.

"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."

As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."

He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53  C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.

"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.

In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.

In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."

Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."

His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."

He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.

Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46  C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."

The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."

The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm², 25 cm², 30 cm², and 40 cm². This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.

Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."

In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m² who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.

Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.

[email protected]

MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.

"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.

The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.

For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.

"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.

Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.

To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.

Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.

"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.

On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.

"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.

The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:

– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."

– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.

– Expect the results to last at least 6 months before beginning to fade.

– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.

– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.

Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.

[email protected]

MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.

"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.

The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.

For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.

"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.

Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.

To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.

Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.

"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.

On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.

"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.

The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:

– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."

– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.

– Expect the results to last at least 6 months before beginning to fade.

– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.

– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.

Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.

[email protected]

MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.

"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.

The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.

For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.

"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.

Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.

To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.

Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.

"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.

On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.

"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.

The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:

– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."

– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.

– Expect the results to last at least 6 months before beginning to fade.

– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.

– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.

Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.

[email protected]

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients with rhinophyma who were treated with a fractional ablative CO₂ laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.

"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.

Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.

Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.

CO₂ laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO₂ lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.

In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.

Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.

"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.

Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.

Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.

In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.

The study was internally funded. Dr. Serowka had no financial conflicts to disclose.

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

[email protected]

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

[email protected]

LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.

"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."

According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.

"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."

Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."

Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."

When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."

When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."

In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."

When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."

Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.

[email protected]