Aesthetic Dermatology

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

When resurfacing the skin with nonablative, midinfrared fractional lasers, "don’t think you’re just going to set these devices to the highest [density] setting, and get the best results," Dr. Mathew Avram said at the SDEF Las Vegas Dermatology Seminar.

The percentage of skin in the treatment area that receives microscopic thermal wounds doesn’t necessarily translate to better results, said Dr. Avram, director of the dermatology laser and cosmetic center at Massachusetts General Hospital in Boston.

One study randomized 20 patients with hypertrophic scars to either 26% or 14% scar coverage with 40 mJ. Patients in the 14% group rated the results better at 3 months’ follow-up. "Low-density treatment is at least as effective as high-density treatment and [has] fewer side effects," the authors wrote (Lasers Surg. Med. 2011;43:265-72).

"If you did a lower-density [treatment]," Dr. Avram explained, "you got the same improvement as you did with a higher density, which is counterintuitive. You’d think the more damage you do the better, but basically all you get is more side effects" like pain, peeling, and inflammation. "Density is the key in terms of side effects and risk of hyperpigmentation."

Depth of treatment, which is determined by pulse energy, is another major consideration. "The pulse energy should reflect the pathology of the condition being treated," he said. With superficial pathology, photoaging, for instance,"you use a low pulse energy." With deeper pathology, such as deeper rhytides or traumatic scars, "you use higher pulse energy to penetrate more deeply. Adjust the depth of treatment and density for the pathology you are treating," Dr. Avram advised.

"You want to tell patients about procedural discomfort, side effects, and real expectations. It’s going to take multiple treatments, and these treatments will only partially improve fine to moderate wrinkles, pigmentation, and scars about 3 months after the time of treatment," he said.

Cold-air cooling is an option for anesthesia, as are topical lidocaine/tetracaine and locally injected anesthesia. The anesthetized area should be allowed to settle down a bit before the procedure to reduce the risk of ulceration, he said.

To prevent treatment-induced flares, Dr. Avram said he gives patients with histories of herpes labialis 500 mg of valacyclovir twice daily on the day before the procedure and continues this for about a week. Patients should also have been off isotretinoin for at least 6 months before treatment, he noted.

"I treat through skin type 6, but I’m very cautious doing it. I’m not so much worried about how deeply I’m treating, but I really dial back the density to avoid hyperpigmentation, and pretreat with hydroquinone, as well," he said.

For poikiloderma of Civatte, fractional lasers are more effective for pigment than erythema. Pulsed dye lasers are more effective for erythema. "You can do [the pulsed dye treatment] first, and then do the fractional resurfacing," he said.

Dr. Avram is a paid consultant to Zeltiq Aesthetics, Unilever, and Living Proof.

SDEF and this news organization are owned by Frontline Medical Communications.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

ATLANTA – Noninvasive body contouring is the "new frontier" in dermatologic surgery, according to Dr. Michael S. Kaminer.

Last year in the United States, noninvasive contouring was performed more often than liposuction, and while the competition between devices is getting fierce, not all are created equal, said Dr. Kaminer, a dermatologist in private practice in Chestnut Hill, Mass.

In fact, only four devices are approved by the Food and Drug Administration for noninvasive fat removal. Of those, Dr. Kaminer discussed three for which the data – and his own experience – are most compelling: CoolSculpting, which destroys fat through cryolipolysis; Liposonix, which destroys fat using high-intensity focused ultrasound; and the Zerona laser, which destroys fat using LED light.

The CoolSculpting device from Zeltiq made its debut about 7 years ago and was approved in 2012 for fat reduction. Cryolipolysis induces apoptosis in the adipocyte, and then the body clears the dead fat cells.

Case reports suggest that CoolSculpting reduces fat by about 21%, on average, with a single procedure, Dr. Kaminer said at the annual meeting of the American Society for Dermatologic Surgery.

In some cases, 50% fat reduction can be achieved within 90 days. The effects, which include skin tightening, seem to be durable based on 4-year follow-up studies, he said.

In a small pilot study in his practice, Dr. Kaminer found that 80% of patients were happy (rating their improvement as at least a 7 on a scale of 1-10) after a single procedure. The remaining 20% reached that level of satisfaction after a second treatment.

CoolSculpting is particularly useful for treating fat at the bra line and at the waist, with these areas typically requiring two or three treatments in his office, he said.

The CoolCurve+, a new applicator developed by Zeltiq to expand the capabilities of the CoolSculpting device, allows for treatment in more areas.

Liposonix from Solta Medical destroys unwanted subcutaneous adipose tissue and fat using high-intensity focused ultrasound. This device "made a big splash" when it was approved specifically for noninvasive waist circumference reduction in 2011, Dr. Kaminer said.

Most of the end effects are based on heat, although there is some mechanical or acoustical component that disrupts and "basically kills" the fat cells. Some evidence also suggests that this device promotes contraction and thickening of collagen, thereby tightening the skin.

"I think the jury may still be out on that one ... I don’t know if it is a skin-tightening device, but I haven’t seen any proof that would say that it definitely is," he said.

One particular benefit of this device is its customizability. The transducer can be used more heavily in areas where there is more fat and lighter in areas where there is less fat, and it can be worked around the umbilicus in those with an umbilical hernia, so it can be used more as a sculpting device than a "bulk fat remover," he said.

Patient comfort can be an issue with this device. "This hurts, so what we’ve started to do is use a low fluence, multiple-pass protocol," he said. When low fluencies are used, no pain medicine is needed. The exception is treatment of the sensitive inner thighs.

The Zerona laser from Erchonia Medical is approved for general body contouring and basically uses low-level laser therapy to deliver light to the skin. "The key effect of Zerona – and this is sort of the concept that I think we are all going to have to start to think about and decide if we buy it – is the concept of a transitory pore, which is basically a hole that’s poked into a fat cell by exposing it to 635-nm red light," he said. The fat leaks out of the adipocytes, causing long-lasting and perhaps permanent change.

Dr. Kaminer said that he uses CoolSculpting as his "go-to device" for love handles, bra line, and abdomen treatments. The workflow is easy: A nurse can put the applicator on and the patient can read a book for an hour or watch television. This treatment – like any treatment that uses suction – can be problematic in patients with an umbilical hernia, however, he added.

The Liposonix device also can do a nice job on the abdomen and love handles, and perhaps the bra line, and it is really the only device that can be used on the arms and the outer and inner thighs, which "respond really nicely to Liposonix," he said. Treatment can be painful, however, and this can be limiting in some practices.

Dr. Kaminer has been a consultant to Thermage, Sciton, and Zeltiq and has stock ownership or options in Cabochon, Miramar Labs, and Thermage.

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

[email protected]

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

[email protected]

LAS VEGAS – Do your receptionists, patient coordinators, and other staff members represent you and your practice well? If not, it might be time for you to remind them that their role comes down to supporting you.

"Not knowing who’s on your team is a common marketing mistake," Catherine Maley said at the annual meeting of the American Academy of Cosmetic Surgery. "Nothing is more important in a cosmetic dermatology practice than having the right team in place. Your team is going to make or break your practice, because they are going to spend more time with your patients than you are."

Your staff must represent and promote you as the best choice, Ms. Maley said. "They have to embrace aesthetics," she emphasized. "I’ve been in offices where I’ve heard the receptionist say, ‘I would never get Botox.’ I have also heard a patient care coordinator say, ‘Just so you know, that’s not his best procedure. I would probably go somewhere else for that.’ "

Ms. Maley, a marketing strategist with Sausalito, Calif.–based Cosmetic Image Marketing, said that clinicians can find out which of their staff are true team players by staging a "refer a friend" contest in January or September, which are traditionally slow months for cosmetic dermatology practices. For the contest, employees have 30 days to distribute referral cards to family, friends, and other people in their social network. "At the end of 30 days, have a party and the employee who brings in the most referrals wins a prize – maybe an iPad or cash," Ms. Maley said. "Those who gave you the most referrals you know are on your team. Those who never participated aren’t."

Ms. Maley noted several other common mistakes clinicians make in marketing their practices, including:

• Ignoring your patients. Indifference "costs you, and it allows the gate to be open for your competitors," said Ms. Maley, who is also author of the book "Your Aesthetic Practice: What Your Patients Are Saying" (Sausalito: Cosmetic Imaging Marketing, 2011). "You have a captive market of aging baby boomers, so you want to keep them," she said. "For example, let’s say a patient shows up for a simple peel procedure or to buy a product. If they like what they got, they’re likely to start working their way up to injectables, laser procedures, or skin-tightening procedures. Keep them coming with messages by direct mail, e-mail, and social media," she said.

Although the Internet is fast and easy, don’t put all your eggs in that basket, Ms. Maley added. "You are missing out on half the patients who aren’t reading their e-mail and who can’t get past a computer firewall at work." Direct mail, she continued, offers an opportunity for one-on-one communication with the patient, "which is golden." Face time also builds trust. "The more face time you have with patients, the more they feel like they know you," she said.

• Assuming your patients will refer. Ms. Maley estimated that almost everyone knows about 150 people in their general geographic area, including service providers, family, friends, colleagues, and neighbors. "What if each patient referred one person to you?" she asked. "That could double your patient database. It’s worth asking patients who know you, like you, and trust you to refer at least one person to you."

While asking for referrals may seem awkward for some, she recommended displaying a sign in your waiting room that reads: "We love you as a patient. We would love to have more patients just like you." Another positive gesture is to hand patients before and after photos on a card following their treatment sessions, along with a handwritten note from you that says, "Thank you for your trust."

Patient surveys also can help you gauge how you’re doing, but keep them short, such as, "What’s one thing we could have done to improve your experience today?"

• Taking a "one-size-fits-all" approach. Gone are the days when an advertisement in your local newspaper with a menu of services is considered sufficient. Instead, "create one message to a specific market using the one media channel they are most likely in," Ms. Maley said. "For example, a woman in her 60s who is considering a facelift is more likely to respond to a one-on-one phone call or direct mail. Her daughter who is considering blepharoplasty is likely to research the procedure on the Internet."

• Having no marketing plan. Ms. Maley recommended carving out dedicated time with staff and perhaps a marketing consultant to devise a strategy for attracting high-value patients. "First, you have to attract them," she said. "Then, you have to qualify them to make sure they have the financial and emotional wherewithal to want what you offer. Then, you have to convert them to procedures, retain them for a lifetime, obtain testimonials and reviews, and encourage referrals. If you can set up a system that works just like protocols for surgery, it becomes an automatic system," she noted.

Ms. Maley said she had no relevant financial disclosures.

[email protected]

A marine protein–based oral food supplement was safe and associated with significant hair growth in women with self-perceived thinning hair, according to findings from a small randomized controlled, double-blind study.

The mean number of terminal hairs in a 4 cm² area at the junction of the frontal and lateral hairlines was measured. In 10 women randomized to receive the supplement, terminal hairs increased from 271 at baseline to 571 after 90 days of treatment and 610 after 180 days of treatment. The mean number of terminal hairs in five women randomized to receive placebo was 256 at baseline, 245 after 90 days, and 242 after 180 days, Dr. Glynis Ablon reported in a poster at the annual meeting of the American Society for Dermatologic Surgery.

The mean number of vellus hairs in the treatment group was 46.5 at baseline and did not appreciably change over 180 days; the mean number of vellus hairs in the placebo group was 57 at baseline, 68 at 90 days, and 66 at 180 days, said Dr. Ablon, a Manhattan Beach, Calif.–based dermatologist.

Treated subjects were significantly more likely to report improvements in overall hair volume, scalp coverage, and hair body thickness after 90 days. Improved hair shine, skin moisture retention, and skin smoothness were reported after 180 days, she noted.

Study participants were women aged 21-75 years (mean age, 50 in the treatment group and 48 in the control group) with Fitzpatrick I-IV skin types. All were in generally good health but had perceived hair thinning. All study participants agreed to maintain their baseline diet, medications, and exercise level during the study period, and to maintain consistent hair care throughout the study period.

Treatment group subjects were instructed to take one tablet of the proprietary supplement (Viviscal) each morning and evening with water after a meal.

The study was supported by Lifes2good Inc., the maker of Viviscal. Dr. Ablon received a research grant from Lifes2good.

A marine protein–based oral food supplement was safe and associated with significant hair growth in women with self-perceived thinning hair, according to findings from a small randomized controlled, double-blind study.

The mean number of terminal hairs in a 4 cm² area at the junction of the frontal and lateral hairlines was measured. In 10 women randomized to receive the supplement, terminal hairs increased from 271 at baseline to 571 after 90 days of treatment and 610 after 180 days of treatment. The mean number of terminal hairs in five women randomized to receive placebo was 256 at baseline, 245 after 90 days, and 242 after 180 days, Dr. Glynis Ablon reported in a poster at the annual meeting of the American Society for Dermatologic Surgery.

The mean number of vellus hairs in the treatment group was 46.5 at baseline and did not appreciably change over 180 days; the mean number of vellus hairs in the placebo group was 57 at baseline, 68 at 90 days, and 66 at 180 days, said Dr. Ablon, a Manhattan Beach, Calif.–based dermatologist.

Treated subjects were significantly more likely to report improvements in overall hair volume, scalp coverage, and hair body thickness after 90 days. Improved hair shine, skin moisture retention, and skin smoothness were reported after 180 days, she noted.

Study participants were women aged 21-75 years (mean age, 50 in the treatment group and 48 in the control group) with Fitzpatrick I-IV skin types. All were in generally good health but had perceived hair thinning. All study participants agreed to maintain their baseline diet, medications, and exercise level during the study period, and to maintain consistent hair care throughout the study period.

Treatment group subjects were instructed to take one tablet of the proprietary supplement (Viviscal) each morning and evening with water after a meal.

The study was supported by Lifes2good Inc., the maker of Viviscal. Dr. Ablon received a research grant from Lifes2good.

A marine protein–based oral food supplement was safe and associated with significant hair growth in women with self-perceived thinning hair, according to findings from a small randomized controlled, double-blind study.

The mean number of terminal hairs in a 4 cm² area at the junction of the frontal and lateral hairlines was measured. In 10 women randomized to receive the supplement, terminal hairs increased from 271 at baseline to 571 after 90 days of treatment and 610 after 180 days of treatment. The mean number of terminal hairs in five women randomized to receive placebo was 256 at baseline, 245 after 90 days, and 242 after 180 days, Dr. Glynis Ablon reported in a poster at the annual meeting of the American Society for Dermatologic Surgery.

The mean number of vellus hairs in the treatment group was 46.5 at baseline and did not appreciably change over 180 days; the mean number of vellus hairs in the placebo group was 57 at baseline, 68 at 90 days, and 66 at 180 days, said Dr. Ablon, a Manhattan Beach, Calif.–based dermatologist.

Treated subjects were significantly more likely to report improvements in overall hair volume, scalp coverage, and hair body thickness after 90 days. Improved hair shine, skin moisture retention, and skin smoothness were reported after 180 days, she noted.

Study participants were women aged 21-75 years (mean age, 50 in the treatment group and 48 in the control group) with Fitzpatrick I-IV skin types. All were in generally good health but had perceived hair thinning. All study participants agreed to maintain their baseline diet, medications, and exercise level during the study period, and to maintain consistent hair care throughout the study period.

Treatment group subjects were instructed to take one tablet of the proprietary supplement (Viviscal) each morning and evening with water after a meal.

The study was supported by Lifes2good Inc., the maker of Viviscal. Dr. Ablon received a research grant from Lifes2good.

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

[email protected]

LAS VEGAS – A technique that involves injecting tiny, closely placed amounts of botulinum toxin A to balance the actions of the muscles around the eyebrows yielded natural-looking outcomes without forehead paralysis, based on data from a 5-year study.

"Doctors have mistakenly adopted maximal forehead paralysis as a desirable treatment endpoint," Dr. Kenneth D. Steinsapir said at the annual meeting of the American Academy of Cosmetic Surgery. "Forehead paralysis as a result of cosmetic botulinum toxin is feared by the public and lampooned by the media."

Courtesy Dr. Kenneth D. Steinsapir

Over the years, onabotulinumtoxinA treatments have evolved to create maximal frontalis brow lifts while minimizing the risk of eyelid ptosis. As a result, "the forehead is smooth, but the central forehead is also ptotic," said Dr. Steinsapir of the department of ophthalmology at the University of California, Los Angeles. "There can be recruitment lines on the side of the forehead, which can make for an undesirable treatment effect."

In 2006, Dr. Steinsapir first described the microdroplet botulinum toxin forehead lift, a technique he developed for treating eyebrow depressors that leaves the brow elevator untreated. "I hypothesized that very small quantities of botulinum toxic can be injected and effectively trapped between the skin and the underlying orbicularis oculi muscle in the brow, and in the crow’s feet area as well," said Dr. Steinsapir, who also maintains a private cosmetic surgery practice in Beverly Hills, Calif. "This weakens the eyebrow depressors, allowing the frontalis muscle to lift unopposed, lifting the brows. Forehead movement is preserved and unwanted diffusion responsible for eyelid ptosis is prevented."

Between August 2006 and July 2011, Dr. Steinsapir performed 574 consecutive microdroplet botulinum toxin forehead lift treatments on 175 women and 53 men with a mean age of 45 years. A typical treatment involves 10 mcL of injectable saline containing 0.33 U of botulinum toxin A using the product formulation of Botox or Xeomin. About 100 microinjections are needed to complete the pattern, and all patients in the study received 33 units of Botox exclusively.

Dr. Steinsapir reported that there were no cases of treatment-induced upper eyelid or eyebrow ptosis or cases of diplopia, "which established that this treatment can be safely performed." Of the 574 patients, 49 returned for follow-up appointments between 10 and 45 days after treatment. Before and after images were used to assess the effect of treatment on the upper eyelid margin reflex distance, the tarsal platform show, and the brow position central to the cornea. Dr. Steinsapir used National Institutes of Health imaging software to perform quantitative image analysis and validated facial scales to assess the brow and forehead before and after treatment.

There was no significant change in the margin reflex distance after treatment in the 49 patients who returned for follow-up, Dr. Steinsapir said. "There was a slight trend to minimal brow elevation, and the tarsal platform show was essentially unchanged after treatment," he said. "It’s my clinical impression that the principal effect of the treatment is the softening of the brow pinch that commonly purses the brow and brings an unintentional negative affect to the face."

Dr. Steinsapir acknowledged that the procedure requires a learning curve "and a need to educate patients regarding the effect of treatment. This is more labor intensive than standard treatment methods." Dr. Steinsapir has developed a detailed training video that is available online on his website, and he said that he is working on a treatment atlas.

The microdroplet botulinum toxin forehead lift "presents the first alternative to standard periocular treatments that cause unwarranted forehead paralysis, brow flare, or muscle activation," Dr. Steinsapir said. "By controlling the depth, volume, and dose of agent, very controlled brow shaping and lifting can be performed to create aesthetic improvement with natural results, including preservation of forehead movement," he noted.

Dr. Steinsapir received a United States patent on the microdroplet method. He said that he hopes to license the technique to a drug company for the development of a Food and Drug Administration–approved indication, so the treatment can be directly marketed to consumers. He had no other relevant financial conflicts to disclose.

[email protected]

Lips, like hairstyles, have trends. Bee-stung lips were the thing of 1920s; big hair was the thing of 1980s. And now, while bangs may be the next big thing after the First Lady's new 'do, lips with well-defined philtrum columns are in. 

Lips, like hairstyles, have trends. Bee-stung lips were the thing of 1920s; big hair was the thing of 1980s. And now, while bangs may be the next big thing after the First Lady's new 'do, lips with well-defined philtrum columns are in. 

Lips, like hairstyles, have trends. Bee-stung lips were the thing of 1920s; big hair was the thing of 1980s. And now, while bangs may be the next big thing after the First Lady's new 'do, lips with well-defined philtrum columns are in. 

When using laser resurfacing for patients with skin of color (Fitzpatrick types 4 to 6), use caution, said Dr. Andrew Alexis at the 10th annual meeting of the Orlando Dermatology Aesthetic and Clinical Conference. 

Traditional approaches to laser resurfacing for acne scarring can lead to postinflammatory hyperpigmentation and scarring in patients with darker skin types, said Dr. Alexis. But two main steps can considerably reduce the risk of adverse effects: choosing the appropriate laser and taking pre- and post-treatment precautions. 

In a video interview with Skin & Allergy News, Dr. Alexis shares his laser recommendations, tips on technique, and treatment suggestions for before and after the procedure. 

Dr. Alexis is the director of the Skin of Color Center at St. Luke's-Roosevelt Hospital Center, and associate professor of clinical dermatology at Columbia University in New York.

When using laser resurfacing for patients with skin of color (Fitzpatrick types 4 to 6), use caution, said Dr. Andrew Alexis at the 10th annual meeting of the Orlando Dermatology Aesthetic and Clinical Conference. 

Traditional approaches to laser resurfacing for acne scarring can lead to postinflammatory hyperpigmentation and scarring in patients with darker skin types, said Dr. Alexis. But two main steps can considerably reduce the risk of adverse effects: choosing the appropriate laser and taking pre- and post-treatment precautions. 

In a video interview with Skin & Allergy News, Dr. Alexis shares his laser recommendations, tips on technique, and treatment suggestions for before and after the procedure. 

Dr. Alexis is the director of the Skin of Color Center at St. Luke's-Roosevelt Hospital Center, and associate professor of clinical dermatology at Columbia University in New York.

When using laser resurfacing for patients with skin of color (Fitzpatrick types 4 to 6), use caution, said Dr. Andrew Alexis at the 10th annual meeting of the Orlando Dermatology Aesthetic and Clinical Conference. 

Traditional approaches to laser resurfacing for acne scarring can lead to postinflammatory hyperpigmentation and scarring in patients with darker skin types, said Dr. Alexis. But two main steps can considerably reduce the risk of adverse effects: choosing the appropriate laser and taking pre- and post-treatment precautions. 

In a video interview with Skin & Allergy News, Dr. Alexis shares his laser recommendations, tips on technique, and treatment suggestions for before and after the procedure. 

Dr. Alexis is the director of the Skin of Color Center at St. Luke's-Roosevelt Hospital Center, and associate professor of clinical dermatology at Columbia University in New York.

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

ATLANTA – Low-level laser therapy produced a significant and durable reduction in upper arm circumference in a randomized, double-blind, sham-controlled study of 62 patients.

An overall reduction in upper arm circumference of at least 1.25 cm was achieved in 58% of 31 patients randomized to receive three, 20-minute treatments each week for 2 weeks, compared with 3% of 31 patients randomized to receive sham treatments, Dr. Mark S. Nestor reported at the annual meeting of the American Society for Dermatologic Surgery.

The mean combined reductions in arm circumference were 2.0 cm after three treatments and 3.7 cm after six active treatments in the intervention group patients, compared with a gain of 0.1 cm and a reduction of 0.3 cm after 3 and 6 treatments, respectively, in the sham-treated control group, said Dr. Nestor, a dermatologist in private practice in Aventura, Fla.

The differences between the intervention and control group were statistically significant, he said.

The results were unchanged at the 2-week follow up. In 14 intervention group patients available for follow-up at 5-10 months post treatment, the decrease in upper arm circumference persisted at 3.25 cm, which was "essentially unchanged from the 4-week result," he noted.

The low-level laser therapy device used for this study (Zerona) consists of five independent diodes emitting 17 mW of red 635-nm laser light in overlapping patterns. A total of 3.94 J/cm² of energy was delivered during each treatment.

The device has been cleared as a noninvasive body contouring therapy for reducing hip, waist, and thigh circumference, but potential effects of confounding variables when it comes to measuring results have created confusion about the extent of the effects, Dr. Nestor said.

For example, abdominal measures from one day to the next can easily be affected by diet and other factors, he explained.

Upper arm circumference provides a more objective measure.

"I think that this model for body contouring is really wonderful, because [with the upper arm] you don’t see a lot of change from exercise or diet in the short term," he said.

Subjects in this study, who agreed to abstain from changes in diet or exercise during the study period, were treated at one of three participating centers. Arm circumference was measured at three equidistant points between the elbow and shoulder.

There were no reports of pain or discomfort, and no adverse events occurred.

Patient satisfaction was high, Dr. Nestor said. More subjects in the treatment group than in the control group reported satisfaction with the results (65% vs. 22%), improved appearance (81% vs. 26%), and results that exceeded expectations (45% vs. 17%).

Dr. Nestor reported that he has served as a consultant for and received research funding from Erchonia, maker of the Zerona laser therapy device used in this study.

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

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

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

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

Cosmetic tattooing, also known as micropigmentation or permanent makeup, is a technique in which tattooing is performed to address cosmetic skin imperfections. It is often used to create eyeliner or lip liner, but it can also be used to camouflage stable patches of vitiligo, to create eyebrows on those who have lost them due to alopecia areata or chemotherapy, to create areolas for women who have had mastectomies, or to correct the shape of a reconstructed cleft lip. Cosmetic tattooing is also useful in women who want to wear makeup, but who have trouble applying it due to visual deficits, tremor, stroke, multiple sclerosis, or Parkinson’s disease.

In Asian cultures, cosmetic tattooing is not uncommon. Many women have cosmetic tattooing procedures to create permanent eyeliner and eyebrows, since many Asian women have sparse brows at baseline that often become thinner with aging. Cosmetic tattooing of eyeliner also enhances the natural almond shape of the eyes.

In darker ethnic skin types, where vitiligo is more visible, stable patches can be effectively camouflaged by cosmetic tattooing. However, cosmetic tattooing is not recommended unless these patches have been stable for several years and the patient has failed other therapies. The best candidate would be the darker-skinned patient with long-standing segmental vitiligo, for whom pigment grafting would also be highly considered.

Individuals who wish to perform cosmetic tattooing can receive training and certification in micropigmentology. Many also undergo apprenticeships to receive more hands-on training. I have firsthand knowledge of this process because my mother received this training and performed cosmetic tattooing on her clients when I was growing up. Good training is key, as not every tattoo ink will have the same result in every skin tone. For example, brown eyeliner might eventually turn pink on skin that has a red undertone. On someone with yellow undertones or olive skin, black pigment liner might turn greenish. So the experienced practitioner will often use different color hues depending on the person’s underlying skin color and tone to prevent this discoloration. The best results of cosmetic tattooing are achieved when others can’t tell that the work has been done.

Pitfalls with cosmetic tattooing, as with tattooing in general, include infection, allergic reaction to the tattoo ink, scarring, photocytotoxicity, and cosmetic disfigurement if the tattoo is placed improperly. Delayed granulomatous response has also been reported in cases of permanent eyebrow tattooing. In addition to typical skin infections caused by staphylococcus or streptococcus, cases of mycobacterium infection with tattooing have been reported (although such infections have been reported more often with traditional tattooing than with permanent makeup).

Red ink is the more commonly reported allergen. Titanium dioxide (TiO₂) is widely used in tattoo inks to achieve certain colors. When TiO₂ is exposed to certain wavelengths of light, including UV light and certain lasers, hydroxyl radicals can form, leading to photocytotoxicity (also called paradoxical darkening), which often results in a change or darkening of the pigment color. This condition is more common with pink, peach, or white tattoo colors where TiO₂ is used in the color. Q-switched lasers are the most effective at removing tattoos.

If performed correctly by a properly trained person, cosmetic tattooing can be a useful aesthetic solution to various cosmetic and medical skin concerns.

This column, "Skin of Color," regularly appears in Dermatology News, a publication of Frontline Medical Communications. Dr. Wesley practices dermatology in Beverly Hills, Calif.

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

LAS VEGAS – It’s probably best to treat one area during an initial cryolipolysis session and wait "2-3 months to see what clinical benefits you have" before the next treatment, according to Dr. Mathew Avram.

"If patients are going to get another treatment, I want them to be happy with the first one," he said. Cryolipolysis is expensive, and "there are definitely patients who do not respond."

Also, "you’ll get down a little deeper to cells that weren’t reached" during the first treatment if inflammation and dead fat cells are given a chance to dissipate before the next treatment. "If you wait 2 or 3 months, I think you’ll get a better end-result," said Dr. Avram, director of the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital in Boston.

Most patients can expect a small but noticeable difference with the procedure. "It’s not a home run," but it’s helpful for areas "that you can’t really get rid of with diet and exercise," he said at the SDEF Las Vegas Dermatology Seminar.

The study that earned cryolipolysis (CoolSculpting – Zeltiq Aesthetics Inc.) Food and Drug Administration clearance found that one session decreased love-handle fat layer thickness by 22.7% in 32 patients. One side was treated in each patient, with the other side used as a control. Results were assessed by high-resolution ultrasound and histology at 4 months.

"Most people come in for a little bit of protrusion in the lower abdomen. Two to three months later, they’ll see a small but noticeable decrease," said Dr. Avram, who’s also treated gynecomastia, the upper back, and other areas over the past 3 years.

But "this does not compare to liposuction. This is a much more modest amount of fat removal," he said.

CoolSculpting takes about 1-3 hours and does not require close supervision once the cooling device is placed. The procedure is thought to crystalize lipids in subcutaneous fat cells at near-freezing temperatures, causing their death without damaging the skin. Fat "feels like slush underneath the skin" after treatment, and patients can expect some redness, numbness, and bruising where the device was applied.

Overall, it’s "typically very mild – not a very painful treatment." Postprocedure massage may improve clinical results [although] "there are no hard data to show that," Dr. Avram said.

The areas that respond best are "grabbable areas of fat" because the cooling applicator is not contoured to curved areas like the buttocks, though Zeltiq is working to address the problem, he said.

"The posterior upper arms don’t do as well either. Typically both laxity and fat are involved, and sometimes you can get a little problem with the nerve root there," he said.

The procedure does not change skin pigmentation, but rarely patients can experience significant pain 3-7 days following treatment that resolves with no sequelae. Even more rarely, there can be a paradoxical fat increase in the treated area 3-5 months later, Dr. Avram said.

Cold-air urticaria, cryoglobulinemia, and hernia are all contraindications.

SDEF and this news organization are owned by Frontline Medical Communications. Dr. Avram is on the scientific advisory board of Zeltiq and is a paid consultant to the company.

LAS VEGAS – It’s probably best to treat one area during an initial cryolipolysis session and wait "2-3 months to see what clinical benefits you have" before the next treatment, according to Dr. Mathew Avram.

"If patients are going to get another treatment, I want them to be happy with the first one," he said. Cryolipolysis is expensive, and "there are definitely patients who do not respond."

Also, "you’ll get down a little deeper to cells that weren’t reached" during the first treatment if inflammation and dead fat cells are given a chance to dissipate before the next treatment. "If you wait 2 or 3 months, I think you’ll get a better end-result," said Dr. Avram, director of the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital in Boston.

Most patients can expect a small but noticeable difference with the procedure. "It’s not a home run," but it’s helpful for areas "that you can’t really get rid of with diet and exercise," he said at the SDEF Las Vegas Dermatology Seminar.

The study that earned cryolipolysis (CoolSculpting – Zeltiq Aesthetics Inc.) Food and Drug Administration clearance found that one session decreased love-handle fat layer thickness by 22.7% in 32 patients. One side was treated in each patient, with the other side used as a control. Results were assessed by high-resolution ultrasound and histology at 4 months.

"Most people come in for a little bit of protrusion in the lower abdomen. Two to three months later, they’ll see a small but noticeable decrease," said Dr. Avram, who’s also treated gynecomastia, the upper back, and other areas over the past 3 years.

But "this does not compare to liposuction. This is a much more modest amount of fat removal," he said.

CoolSculpting takes about 1-3 hours and does not require close supervision once the cooling device is placed. The procedure is thought to crystalize lipids in subcutaneous fat cells at near-freezing temperatures, causing their death without damaging the skin. Fat "feels like slush underneath the skin" after treatment, and patients can expect some redness, numbness, and bruising where the device was applied.

Overall, it’s "typically very mild – not a very painful treatment." Postprocedure massage may improve clinical results [although] "there are no hard data to show that," Dr. Avram said.

The areas that respond best are "grabbable areas of fat" because the cooling applicator is not contoured to curved areas like the buttocks, though Zeltiq is working to address the problem, he said.

"The posterior upper arms don’t do as well either. Typically both laxity and fat are involved, and sometimes you can get a little problem with the nerve root there," he said.

The procedure does not change skin pigmentation, but rarely patients can experience significant pain 3-7 days following treatment that resolves with no sequelae. Even more rarely, there can be a paradoxical fat increase in the treated area 3-5 months later, Dr. Avram said.

Cold-air urticaria, cryoglobulinemia, and hernia are all contraindications.

SDEF and this news organization are owned by Frontline Medical Communications. Dr. Avram is on the scientific advisory board of Zeltiq and is a paid consultant to the company.

LAS VEGAS – It’s probably best to treat one area during an initial cryolipolysis session and wait "2-3 months to see what clinical benefits you have" before the next treatment, according to Dr. Mathew Avram.

"If patients are going to get another treatment, I want them to be happy with the first one," he said. Cryolipolysis is expensive, and "there are definitely patients who do not respond."

Also, "you’ll get down a little deeper to cells that weren’t reached" during the first treatment if inflammation and dead fat cells are given a chance to dissipate before the next treatment. "If you wait 2 or 3 months, I think you’ll get a better end-result," said Dr. Avram, director of the Dermatology Laser and Cosmetic Center at Massachusetts General Hospital in Boston.

Most patients can expect a small but noticeable difference with the procedure. "It’s not a home run," but it’s helpful for areas "that you can’t really get rid of with diet and exercise," he said at the SDEF Las Vegas Dermatology Seminar.

The study that earned cryolipolysis (CoolSculpting – Zeltiq Aesthetics Inc.) Food and Drug Administration clearance found that one session decreased love-handle fat layer thickness by 22.7% in 32 patients. One side was treated in each patient, with the other side used as a control. Results were assessed by high-resolution ultrasound and histology at 4 months.

"Most people come in for a little bit of protrusion in the lower abdomen. Two to three months later, they’ll see a small but noticeable decrease," said Dr. Avram, who’s also treated gynecomastia, the upper back, and other areas over the past 3 years.

But "this does not compare to liposuction. This is a much more modest amount of fat removal," he said.

CoolSculpting takes about 1-3 hours and does not require close supervision once the cooling device is placed. The procedure is thought to crystalize lipids in subcutaneous fat cells at near-freezing temperatures, causing their death without damaging the skin. Fat "feels like slush underneath the skin" after treatment, and patients can expect some redness, numbness, and bruising where the device was applied.

Overall, it’s "typically very mild – not a very painful treatment." Postprocedure massage may improve clinical results [although] "there are no hard data to show that," Dr. Avram said.

The areas that respond best are "grabbable areas of fat" because the cooling applicator is not contoured to curved areas like the buttocks, though Zeltiq is working to address the problem, he said.

"The posterior upper arms don’t do as well either. Typically both laxity and fat are involved, and sometimes you can get a little problem with the nerve root there," he said.

The procedure does not change skin pigmentation, but rarely patients can experience significant pain 3-7 days following treatment that resolves with no sequelae. Even more rarely, there can be a paradoxical fat increase in the treated area 3-5 months later, Dr. Avram said.

Cold-air urticaria, cryoglobulinemia, and hernia are all contraindications.

SDEF and this news organization are owned by Frontline Medical Communications. Dr. Avram is on the scientific advisory board of Zeltiq and is a paid consultant to the company.