Aesthetic Dermatology

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

Dermatosis papulosa nigra, also known as DPN, are small, soft brown papules that may occur on the face and neck of patients of African, Latin, Indian, or Asian descent. While they may not reach the size of their histologically similar seborrheic keratosis counterparts, the lesions do represent a sign of aging in darker skinned patients. However, the lesions can be safely, easily, and effectively removed.

Electrodesiccation with a hyfrecator or destruction with the KTP (532 nm) laser are my favorite methods for DPN removal. I prefer not to use curettage or cryotherapy because of the risk for dyspigmentation in darker skinned patients. Case reports of success with fractional photothermolyis (1,550 nm) and Nd:YAG lasers (1,064 nm) have been published.

2009/Elsevier

If electrodesiccation is performed, the application of topical anesthetic prior to the procedure helps make the patient more comfortable. For larger lesions, injection of 1% lidocaine with 1:100,000 epinephrine may be used.

Also, with electrodesiccation, conservative settings (0.6-2.0 W on the low setting) should be used; the lesions are desiccated using a blunt tip for a few seconds until they turn grayish.

Care is taken not to touch the surrounding skin. A sharp tip may be used with very small (less than 1 mm) lesions for more accurate precision. I wipe the tip from time to time with gauze to avoid char accumulation.

Larger or pedunculated lesions may be treated with electrodesiccation or snipped off with gradle scissors.

With the KTP laser, topical anesthesia is usually not required. I use a smaller spot size than the lesion itself to avoid targeting and potentially causing dyspigmentation of the surrounding skin.

A spot size of 1 mm is typically used, with 6-10 ms and 10-15 j/cm2. The laser tip is held approximately 1 cm away from the skin at a 90 degree angle. I start off with the lowest fluence and adjust it higher until the lesions turn grayish and a light popping sound is heard with the laser pulse.

A split-face study published in the American Journal of Dermatologic Surgery in 2009 showed that both electrodesiccation and KTP have comparable efficacy in removal of DPN. Without use of anesthetics, the KTP laser was preferred for patient comfort.

Immediately after treatment, patients can expect the treated lesions to become red and swollen - similar to insect bite reactions - for about an hour. Antibiotic ointment or aquaphor is applied to soothe the skin.

Patients are then told to leave the lesions alone, to avoid picking, and to avoid sun exposure. Patients are also advised to avoid alpha-hydroxy acids and other "anti-aging" products until healed. If the cheeks were treated, make-up (foundation, blush) may be applied in 3 to 4 days. Lesions typically fall off within a week.

If needed, repeat treatment may be performed in 2 to 4 weeks.

If you have any DPN removal tips, please feel free to share!

-Naissan Wesley, M.D.

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

LAS VEGAS – Dermatologists who provide cosmetic services are well positioned to build and maintain a steady-stream of cash-paying patients, according to marketing strategist Catherine Maley.

"You are in an enviable position," she told attendees at the annual meeting of the American Academy of Cosmetic Surgery. "Your audience is an aging baby boomer group, people with all sorts of needs and wants. ... As the years go on the needs and wants just keep piling up. You have a good target market."

Ms. Maley of Sausalito, Calif., shared "must-haves" for a successful cosmetic practice:

• Focus on targeting mature, "preferred" patients. "Go after the patient who has the income and the age," she advised. The mature patient "has more needs, more wants, and more financial wherewithal than younger people," said Ms. Maley. "Go after the ones in your own zip code; you can’t be everything to everybody. The riches are in the niches."

• Have an A team. Receptionists, patient coordinators, and other staff members "have to offer awesome customer service," Ms. Maley said. "The patient has to be happy, or they’re not going to come back, and they’re certainly not going to refer their friends." She went on to note that a receptionist "is easily worth a quarter of a million dollars to you if you have her scripted correctly and she’s the right person on the phone. She has to have a warm voice that makes it inviting for callers. You also have to have the right patient care coordinator, a buffer between the physician and the patient. That patient has to have a bond with somebody in your office."

Another key for optimizing cosmetic surgery practice is to have the checkout staff book another appointment for patients before they leave the office. "Always book a patient when they’re standing smack in front of you," Ms. Maley said. If a patient says, " ‘I don’t know what my schedule is; I’ll have to call you later,’ you can reply, ‘It’s okay. Let’s go ahead and schedule you for the same day and time 4 months from now, and if we have to change the appointment, we’ll change it later.’ You have to get them on the books. It’s too easy for people to wander off nowadays."

She advised practices to carry certain retail products such as antiaging creams to offer patients upon checkout, as well as gift certificates, since they are perfect add-ons for the day’s purchase. The goal is to ensure that "every patient leaves your office smiling," she said.

• Build ways to retain patients so they return. "What’s the only difference between you and your competitors? The relationship you have with your patients," Ms. Maley said. "Hang on to that. It’s golden. You want to retain them so they’ll return and refer."

You can nurture patient relationships with personal e-mails, greeting cards, invitations to special events or lectures, patient letters, and social media. Optimal times to reach out, she said, include birthdays, Mother’s Day, New Year’s, and during changing seasons.

One "prop" to help spread the word about a practice is a photo note card that contains a before and after photo of the patient, with a message that says, "Thank you for your trust!" she said. "Don’t forget to include your name, website, and phone number right next to those photos so when they open up the card to show their friend, there you are."

Another effective way to build retention is to offer current patients a $50 gift card good toward their next treatment or procedure for referring new patients who book an appointment. "Your No. 1 asset is not just your patient – it’s your patient’s friends, coworkers, family members, hair stylists, and business partners," she said.

• Form strong alliances with potential referrals. Strong referral sources include hair salon owners, noncompeting aestheticians, retail shops, women’s clubs, health clubs, personal trainers, and other noncompeting clinicians. Ms. Maley spoke of one hair stylist who referred 250 of his clients per year to a dermatologist and plastic surgeon right down the street. "That guy alone was a goldmine," she said.

She recommended forming a "VIP club" for customers of alliance referrals. This might include no waiting for appointments, last-minute appointments, a free monthly peel, valet parking (if applicable), 15% off retail products, and a free surprise gift each quarter. "There’s some great psychology in this, because the hair salon owner or other referral source looks like a queen, because she got a deal for her customers through you, and then you got new patients out of it."

Ms. Maley said that she had no relevant financial disclosures.

LAS VEGAS – Dermatologists who provide cosmetic services are well positioned to build and maintain a steady-stream of cash-paying patients, according to marketing strategist Catherine Maley.

"You are in an enviable position," she told attendees at the annual meeting of the American Academy of Cosmetic Surgery. "Your audience is an aging baby boomer group, people with all sorts of needs and wants. ... As the years go on the needs and wants just keep piling up. You have a good target market."

Ms. Maley of Sausalito, Calif., shared "must-haves" for a successful cosmetic practice:

• Focus on targeting mature, "preferred" patients. "Go after the patient who has the income and the age," she advised. The mature patient "has more needs, more wants, and more financial wherewithal than younger people," said Ms. Maley. "Go after the ones in your own zip code; you can’t be everything to everybody. The riches are in the niches."

• Have an A team. Receptionists, patient coordinators, and other staff members "have to offer awesome customer service," Ms. Maley said. "The patient has to be happy, or they’re not going to come back, and they’re certainly not going to refer their friends." She went on to note that a receptionist "is easily worth a quarter of a million dollars to you if you have her scripted correctly and she’s the right person on the phone. She has to have a warm voice that makes it inviting for callers. You also have to have the right patient care coordinator, a buffer between the physician and the patient. That patient has to have a bond with somebody in your office."

Another key for optimizing cosmetic surgery practice is to have the checkout staff book another appointment for patients before they leave the office. "Always book a patient when they’re standing smack in front of you," Ms. Maley said. If a patient says, " ‘I don’t know what my schedule is; I’ll have to call you later,’ you can reply, ‘It’s okay. Let’s go ahead and schedule you for the same day and time 4 months from now, and if we have to change the appointment, we’ll change it later.’ You have to get them on the books. It’s too easy for people to wander off nowadays."

She advised practices to carry certain retail products such as antiaging creams to offer patients upon checkout, as well as gift certificates, since they are perfect add-ons for the day’s purchase. The goal is to ensure that "every patient leaves your office smiling," she said.

• Build ways to retain patients so they return. "What’s the only difference between you and your competitors? The relationship you have with your patients," Ms. Maley said. "Hang on to that. It’s golden. You want to retain them so they’ll return and refer."

You can nurture patient relationships with personal e-mails, greeting cards, invitations to special events or lectures, patient letters, and social media. Optimal times to reach out, she said, include birthdays, Mother’s Day, New Year’s, and during changing seasons.

One "prop" to help spread the word about a practice is a photo note card that contains a before and after photo of the patient, with a message that says, "Thank you for your trust!" she said. "Don’t forget to include your name, website, and phone number right next to those photos so when they open up the card to show their friend, there you are."

Another effective way to build retention is to offer current patients a $50 gift card good toward their next treatment or procedure for referring new patients who book an appointment. "Your No. 1 asset is not just your patient – it’s your patient’s friends, coworkers, family members, hair stylists, and business partners," she said.

• Form strong alliances with potential referrals. Strong referral sources include hair salon owners, noncompeting aestheticians, retail shops, women’s clubs, health clubs, personal trainers, and other noncompeting clinicians. Ms. Maley spoke of one hair stylist who referred 250 of his clients per year to a dermatologist and plastic surgeon right down the street. "That guy alone was a goldmine," she said.

She recommended forming a "VIP club" for customers of alliance referrals. This might include no waiting for appointments, last-minute appointments, a free monthly peel, valet parking (if applicable), 15% off retail products, and a free surprise gift each quarter. "There’s some great psychology in this, because the hair salon owner or other referral source looks like a queen, because she got a deal for her customers through you, and then you got new patients out of it."

Ms. Maley said that she had no relevant financial disclosures.

LAS VEGAS – Dermatologists who provide cosmetic services are well positioned to build and maintain a steady-stream of cash-paying patients, according to marketing strategist Catherine Maley.

"You are in an enviable position," she told attendees at the annual meeting of the American Academy of Cosmetic Surgery. "Your audience is an aging baby boomer group, people with all sorts of needs and wants. ... As the years go on the needs and wants just keep piling up. You have a good target market."

Ms. Maley of Sausalito, Calif., shared "must-haves" for a successful cosmetic practice:

• Focus on targeting mature, "preferred" patients. "Go after the patient who has the income and the age," she advised. The mature patient "has more needs, more wants, and more financial wherewithal than younger people," said Ms. Maley. "Go after the ones in your own zip code; you can’t be everything to everybody. The riches are in the niches."

• Have an A team. Receptionists, patient coordinators, and other staff members "have to offer awesome customer service," Ms. Maley said. "The patient has to be happy, or they’re not going to come back, and they’re certainly not going to refer their friends." She went on to note that a receptionist "is easily worth a quarter of a million dollars to you if you have her scripted correctly and she’s the right person on the phone. She has to have a warm voice that makes it inviting for callers. You also have to have the right patient care coordinator, a buffer between the physician and the patient. That patient has to have a bond with somebody in your office."

Another key for optimizing cosmetic surgery practice is to have the checkout staff book another appointment for patients before they leave the office. "Always book a patient when they’re standing smack in front of you," Ms. Maley said. If a patient says, " ‘I don’t know what my schedule is; I’ll have to call you later,’ you can reply, ‘It’s okay. Let’s go ahead and schedule you for the same day and time 4 months from now, and if we have to change the appointment, we’ll change it later.’ You have to get them on the books. It’s too easy for people to wander off nowadays."

She advised practices to carry certain retail products such as antiaging creams to offer patients upon checkout, as well as gift certificates, since they are perfect add-ons for the day’s purchase. The goal is to ensure that "every patient leaves your office smiling," she said.

• Build ways to retain patients so they return. "What’s the only difference between you and your competitors? The relationship you have with your patients," Ms. Maley said. "Hang on to that. It’s golden. You want to retain them so they’ll return and refer."

You can nurture patient relationships with personal e-mails, greeting cards, invitations to special events or lectures, patient letters, and social media. Optimal times to reach out, she said, include birthdays, Mother’s Day, New Year’s, and during changing seasons.

One "prop" to help spread the word about a practice is a photo note card that contains a before and after photo of the patient, with a message that says, "Thank you for your trust!" she said. "Don’t forget to include your name, website, and phone number right next to those photos so when they open up the card to show their friend, there you are."

Another effective way to build retention is to offer current patients a $50 gift card good toward their next treatment or procedure for referring new patients who book an appointment. "Your No. 1 asset is not just your patient – it’s your patient’s friends, coworkers, family members, hair stylists, and business partners," she said.

• Form strong alliances with potential referrals. Strong referral sources include hair salon owners, noncompeting aestheticians, retail shops, women’s clubs, health clubs, personal trainers, and other noncompeting clinicians. Ms. Maley spoke of one hair stylist who referred 250 of his clients per year to a dermatologist and plastic surgeon right down the street. "That guy alone was a goldmine," she said.

She recommended forming a "VIP club" for customers of alliance referrals. This might include no waiting for appointments, last-minute appointments, a free monthly peel, valet parking (if applicable), 15% off retail products, and a free surprise gift each quarter. "There’s some great psychology in this, because the hair salon owner or other referral source looks like a queen, because she got a deal for her customers through you, and then you got new patients out of it."

Ms. Maley said that she had no relevant financial disclosures.

LAS VEGAS – Taking time to prescreen men and women who inquire about cosmetic surgery procedures can help maximize their chances of choosing your practice over others, and can help you weed out those who aren’t suitable candidates.

"There is no chance in securing a patient without having a consultation," Tracie Lance, director of finance for Southern Surgical Arts, said at the annual meeting of the American Academy of Cosmetic Surgery. "In order to avoid wasting the patient’s time, the physician’s time, and the staff’s time, we do some prescreening."

Courtesy Southern Surgical Arts

The first step, she said, is to find a time on the schedule that is most appropriate for the consultation. If someone inquires about breast augmentation, "you probably want to get them in as quickly as possible, to reduce the chances of their going to another practice," said Ms. Lance, also a patient care coordinator for the practice, which has locations in Chattanooga, Tenn., and Calhoun, Ga. If they inquire about a facelift, there’s less of an urgency to get them in right away, she said, because "they’ve probably thought about it a long time before they picked up the phone to call your office. If you respond, ‘We can get you in this afternoon,’ you may not give the best first impression of your office."

A second component of prescreening is gauging the person’s ability to pay for or finance the procedure. "This is nonnegotiable," Ms. Lance said. "In our experience, we have found that it can be unfair to set unrealistic expectations that all patients will qualify for financing. The frustration can be avoided by having patients apply before they come to the consultation." Consider options such as, "We have someone on staff that can help you with financing. Is that something you’re interested in?" and document the reply for the in-person consultation. "Being able to assist our patient in successful financing is a skill that has set our practice above others," she said.

A third component of the prescreening is asking people to complete a health history questionnaire before the in-person consultation. "There might be something like body mass index that [precludes them from] surgery," she noted.

Consultation appointments are complimentary at Southern Surgical Arts, yet a credit card is required to hold the appointment. "We have a 5% no-show rate, which is pretty low compared to the industry standard," Ms. Lance said.

To maximize the patient experience, physicians should be mindful of the appearance of their waiting room and reception area. "People pay attention to detail, so the office should be clean, with minimal clutter," she said. "In terms of patient flow, after our patients check in we try to get them into an exam room as quickly as possible with an iPad that contains before and after photos and patient testimonials."

After candidate patients at Southern Surgical Arts meet with the cosmetic surgeon in the exam room, they move to a dedicated postconsultation room, where the patient coordinator will review the estimated cost of the procedure and answer questions. Establishing a dedicated postconsultation room "is one of the best things we’ve ever done," Ms. Lance said. She described the room as a "warm environment," equipped with "a round table, MacBook Air, a wireless printer, and a phone."

Patients commonly cite fear, financing, timing, and multiple consultations as objections to cosmetic surgery procedures, Ms. Lance said, noting that financing is the biggest obstacle. "If you have a facelift patient, sometimes it’s easier to offer a no-interest plan, as the bill can be around $16,000," she said. "That’s up to each office, but in my experience, the no-interest plan has been extremely successful. Some patients do not use no-interest financing, but I hear facelift patients tell me all the time, ‘Oh my husband will love this,’ because they don’t feel like they’re taking all this money out of savings at once. Payments of $1,100 or $1,200 per month seem easier."

In her experience, patients considering cosmetic surgery for the first time "are nervous and they tell you they’re going to multiple consultations," Ms. Lance added. "I’m not sure that’s always the case. I think that they’re just nervous. It helps to say, ‘we understand that you’re nervous. If you get home and you have questions, don’t hesitate to call us.’ Sometimes it helps for them to hear about another patient’s experience with surgery. We have patients who will do that for us, which is wonderful."

She concluded her remarks by advising patient care coordinators and office staff to offer candidate patients a certain amount of grace and space as they make their decision. "I do not believe in being pushy in a consultation," she said. "I’ve seen that backfire many times; 65% of our patients will give me a deposit on the day that they come in, which is remarkable. But at the same time you have to know when to give someone space. You want to provide the benefits of the surgeons, the benefits of the facility, but not in a pushy way. You want a patient who is just as committed as you are. You want them to be compliant in their care and you want them to follow the rules."

Ms. Lance reported having no relevant financial disclosures.

LAS VEGAS – Taking time to prescreen men and women who inquire about cosmetic surgery procedures can help maximize their chances of choosing your practice over others, and can help you weed out those who aren’t suitable candidates.

"There is no chance in securing a patient without having a consultation," Tracie Lance, director of finance for Southern Surgical Arts, said at the annual meeting of the American Academy of Cosmetic Surgery. "In order to avoid wasting the patient’s time, the physician’s time, and the staff’s time, we do some prescreening."

Courtesy Southern Surgical Arts

The first step, she said, is to find a time on the schedule that is most appropriate for the consultation. If someone inquires about breast augmentation, "you probably want to get them in as quickly as possible, to reduce the chances of their going to another practice," said Ms. Lance, also a patient care coordinator for the practice, which has locations in Chattanooga, Tenn., and Calhoun, Ga. If they inquire about a facelift, there’s less of an urgency to get them in right away, she said, because "they’ve probably thought about it a long time before they picked up the phone to call your office. If you respond, ‘We can get you in this afternoon,’ you may not give the best first impression of your office."

A second component of prescreening is gauging the person’s ability to pay for or finance the procedure. "This is nonnegotiable," Ms. Lance said. "In our experience, we have found that it can be unfair to set unrealistic expectations that all patients will qualify for financing. The frustration can be avoided by having patients apply before they come to the consultation." Consider options such as, "We have someone on staff that can help you with financing. Is that something you’re interested in?" and document the reply for the in-person consultation. "Being able to assist our patient in successful financing is a skill that has set our practice above others," she said.

A third component of the prescreening is asking people to complete a health history questionnaire before the in-person consultation. "There might be something like body mass index that [precludes them from] surgery," she noted.

Consultation appointments are complimentary at Southern Surgical Arts, yet a credit card is required to hold the appointment. "We have a 5% no-show rate, which is pretty low compared to the industry standard," Ms. Lance said.

To maximize the patient experience, physicians should be mindful of the appearance of their waiting room and reception area. "People pay attention to detail, so the office should be clean, with minimal clutter," she said. "In terms of patient flow, after our patients check in we try to get them into an exam room as quickly as possible with an iPad that contains before and after photos and patient testimonials."

After candidate patients at Southern Surgical Arts meet with the cosmetic surgeon in the exam room, they move to a dedicated postconsultation room, where the patient coordinator will review the estimated cost of the procedure and answer questions. Establishing a dedicated postconsultation room "is one of the best things we’ve ever done," Ms. Lance said. She described the room as a "warm environment," equipped with "a round table, MacBook Air, a wireless printer, and a phone."

Patients commonly cite fear, financing, timing, and multiple consultations as objections to cosmetic surgery procedures, Ms. Lance said, noting that financing is the biggest obstacle. "If you have a facelift patient, sometimes it’s easier to offer a no-interest plan, as the bill can be around $16,000," she said. "That’s up to each office, but in my experience, the no-interest plan has been extremely successful. Some patients do not use no-interest financing, but I hear facelift patients tell me all the time, ‘Oh my husband will love this,’ because they don’t feel like they’re taking all this money out of savings at once. Payments of $1,100 or $1,200 per month seem easier."

In her experience, patients considering cosmetic surgery for the first time "are nervous and they tell you they’re going to multiple consultations," Ms. Lance added. "I’m not sure that’s always the case. I think that they’re just nervous. It helps to say, ‘we understand that you’re nervous. If you get home and you have questions, don’t hesitate to call us.’ Sometimes it helps for them to hear about another patient’s experience with surgery. We have patients who will do that for us, which is wonderful."

She concluded her remarks by advising patient care coordinators and office staff to offer candidate patients a certain amount of grace and space as they make their decision. "I do not believe in being pushy in a consultation," she said. "I’ve seen that backfire many times; 65% of our patients will give me a deposit on the day that they come in, which is remarkable. But at the same time you have to know when to give someone space. You want to provide the benefits of the surgeons, the benefits of the facility, but not in a pushy way. You want a patient who is just as committed as you are. You want them to be compliant in their care and you want them to follow the rules."

Ms. Lance reported having no relevant financial disclosures.

LAS VEGAS – Taking time to prescreen men and women who inquire about cosmetic surgery procedures can help maximize their chances of choosing your practice over others, and can help you weed out those who aren’t suitable candidates.

"There is no chance in securing a patient without having a consultation," Tracie Lance, director of finance for Southern Surgical Arts, said at the annual meeting of the American Academy of Cosmetic Surgery. "In order to avoid wasting the patient’s time, the physician’s time, and the staff’s time, we do some prescreening."

Courtesy Southern Surgical Arts

The first step, she said, is to find a time on the schedule that is most appropriate for the consultation. If someone inquires about breast augmentation, "you probably want to get them in as quickly as possible, to reduce the chances of their going to another practice," said Ms. Lance, also a patient care coordinator for the practice, which has locations in Chattanooga, Tenn., and Calhoun, Ga. If they inquire about a facelift, there’s less of an urgency to get them in right away, she said, because "they’ve probably thought about it a long time before they picked up the phone to call your office. If you respond, ‘We can get you in this afternoon,’ you may not give the best first impression of your office."

A second component of prescreening is gauging the person’s ability to pay for or finance the procedure. "This is nonnegotiable," Ms. Lance said. "In our experience, we have found that it can be unfair to set unrealistic expectations that all patients will qualify for financing. The frustration can be avoided by having patients apply before they come to the consultation." Consider options such as, "We have someone on staff that can help you with financing. Is that something you’re interested in?" and document the reply for the in-person consultation. "Being able to assist our patient in successful financing is a skill that has set our practice above others," she said.

A third component of the prescreening is asking people to complete a health history questionnaire before the in-person consultation. "There might be something like body mass index that [precludes them from] surgery," she noted.

Consultation appointments are complimentary at Southern Surgical Arts, yet a credit card is required to hold the appointment. "We have a 5% no-show rate, which is pretty low compared to the industry standard," Ms. Lance said.

To maximize the patient experience, physicians should be mindful of the appearance of their waiting room and reception area. "People pay attention to detail, so the office should be clean, with minimal clutter," she said. "In terms of patient flow, after our patients check in we try to get them into an exam room as quickly as possible with an iPad that contains before and after photos and patient testimonials."

After candidate patients at Southern Surgical Arts meet with the cosmetic surgeon in the exam room, they move to a dedicated postconsultation room, where the patient coordinator will review the estimated cost of the procedure and answer questions. Establishing a dedicated postconsultation room "is one of the best things we’ve ever done," Ms. Lance said. She described the room as a "warm environment," equipped with "a round table, MacBook Air, a wireless printer, and a phone."

Patients commonly cite fear, financing, timing, and multiple consultations as objections to cosmetic surgery procedures, Ms. Lance said, noting that financing is the biggest obstacle. "If you have a facelift patient, sometimes it’s easier to offer a no-interest plan, as the bill can be around $16,000," she said. "That’s up to each office, but in my experience, the no-interest plan has been extremely successful. Some patients do not use no-interest financing, but I hear facelift patients tell me all the time, ‘Oh my husband will love this,’ because they don’t feel like they’re taking all this money out of savings at once. Payments of $1,100 or $1,200 per month seem easier."

In her experience, patients considering cosmetic surgery for the first time "are nervous and they tell you they’re going to multiple consultations," Ms. Lance added. "I’m not sure that’s always the case. I think that they’re just nervous. It helps to say, ‘we understand that you’re nervous. If you get home and you have questions, don’t hesitate to call us.’ Sometimes it helps for them to hear about another patient’s experience with surgery. We have patients who will do that for us, which is wonderful."

She concluded her remarks by advising patient care coordinators and office staff to offer candidate patients a certain amount of grace and space as they make their decision. "I do not believe in being pushy in a consultation," she said. "I’ve seen that backfire many times; 65% of our patients will give me a deposit on the day that they come in, which is remarkable. But at the same time you have to know when to give someone space. You want to provide the benefits of the surgeons, the benefits of the facility, but not in a pushy way. You want a patient who is just as committed as you are. You want them to be compliant in their care and you want them to follow the rules."

Ms. Lance reported having no relevant financial disclosures.

LAS VEGAS – Even though transplantation of fat harvested by cannulas has been performed for almost 3 decades, its precise mechanism of action remains elusive.

"One must admit that so far lipostructuring still has to do more with art than with science," Dr. Giovanni Botti said at the annual meeting of the American Academy of Cosmetic Surgery. In many respects, "we haven’t yet come out of the Middle Ages of subjective and empirical opinions."

Despite the relative lack of objective data to support its use, Dr. Botti, a plastic surgeon based in Lake Garda, Italy, has been performing fat transplantation for 25 years. In his opinion, the procedure "can certainly be considered a therapy of first choice in the treatment of soft tissue hypotrophy, as well as for the correction of tropism disorders such as radionecrosis and burns. It is not clear, though, how to obtain consistently positive and long-lasting results."

This begs the question, he continued: If you were to biopsy the area where fat had been injected 1 year earlier, would you be looking at the same fat that was injected, or is it a brand new pad "rebuilt" by the stem cells and modulated by the growing factors present in the grafted material? If the latter hypothesis is true, "how can the stem cells in the grafted fat promote the growth of exactly the wished for amount of fat?" Dr. Botti said. "Why should it take the desired shape? Could the mass on injected tissue serve as a temporary matrix, used by stem cells as a pattern to form their ‘fat net’?"

He speculated that the fat found after 1 year could be composed of fat that was originally injected, as well as stem cells. The stem cells "promote angiogenesis, which would help adipocytes to survive. We can nowadays only make hypotheses that need to be confirmed by further research."

In the meantime, what really matters is achieving the maximum taking rate during fat transplantation, he said. "Very satisfying" results can be achieved in volume restoration and soft tissue regeneration.

The best treatment for the harvested fat prior to injection remains a matter of debate. Recent research suggests that adding stem cells, insulin, the coenzyme Q-10, and platelet rich plasma may favor survival rates, "though no one has yet been able to provide any evidence," he said. "For sure, stem cells can enhance the local blood supply and release growth factors to help the healing process. Thus, theoretically, the graft survival rate is improved. For this reason nowadays regenerative cell enriched fat is increasingly used within various indications."

Beginning in 1985, Dr. Botti treated aspirated fat by "washing," decantation, and strainer filtration. Fifteen years later he switched to using a centrifuge, but after about 1 year of using it, "I realized I wasn’t getting any better results than by means of filtration," he said. "I therefore went back to my previous technique."

In 2007, Dr. Botti and his associates carried out a study of 32 patients undergoing fat transplantation in the face. They injected one side of the face with centrifuged fat, and the other side with filtrate fat. The patients were observed at postoperative day 10 and after 2 and 6 months. "We didn’t notice any difference between the side into which filtered fat was injected and [the side] treated with centrifuged fat," he said. "Therefore, we came to the conclusion that the way fat is treated does not affect the taking rate, assuming that the ‘cleaning’ was in all cases delicate and complete. And I am deeply sorry for those, like me, who have spent a few thousand euros to buy a centrifuge."

He noted that Cytori Therapeutics’ PureGraft sterile plastic bag is a promising new tool for preparing fat prior to transplantation. It is a closed system which allows clinicians to manually separate fat tissue from blood, saline, and other materials. "We will be able to judge its effectiveness in a couple of years," he said.

Dr. Botti said that he had no relevant financial disclosures to make.

LAS VEGAS – Even though transplantation of fat harvested by cannulas has been performed for almost 3 decades, its precise mechanism of action remains elusive.

"One must admit that so far lipostructuring still has to do more with art than with science," Dr. Giovanni Botti said at the annual meeting of the American Academy of Cosmetic Surgery. In many respects, "we haven’t yet come out of the Middle Ages of subjective and empirical opinions."

Despite the relative lack of objective data to support its use, Dr. Botti, a plastic surgeon based in Lake Garda, Italy, has been performing fat transplantation for 25 years. In his opinion, the procedure "can certainly be considered a therapy of first choice in the treatment of soft tissue hypotrophy, as well as for the correction of tropism disorders such as radionecrosis and burns. It is not clear, though, how to obtain consistently positive and long-lasting results."

This begs the question, he continued: If you were to biopsy the area where fat had been injected 1 year earlier, would you be looking at the same fat that was injected, or is it a brand new pad "rebuilt" by the stem cells and modulated by the growing factors present in the grafted material? If the latter hypothesis is true, "how can the stem cells in the grafted fat promote the growth of exactly the wished for amount of fat?" Dr. Botti said. "Why should it take the desired shape? Could the mass on injected tissue serve as a temporary matrix, used by stem cells as a pattern to form their ‘fat net’?"

He speculated that the fat found after 1 year could be composed of fat that was originally injected, as well as stem cells. The stem cells "promote angiogenesis, which would help adipocytes to survive. We can nowadays only make hypotheses that need to be confirmed by further research."

In the meantime, what really matters is achieving the maximum taking rate during fat transplantation, he said. "Very satisfying" results can be achieved in volume restoration and soft tissue regeneration.

The best treatment for the harvested fat prior to injection remains a matter of debate. Recent research suggests that adding stem cells, insulin, the coenzyme Q-10, and platelet rich plasma may favor survival rates, "though no one has yet been able to provide any evidence," he said. "For sure, stem cells can enhance the local blood supply and release growth factors to help the healing process. Thus, theoretically, the graft survival rate is improved. For this reason nowadays regenerative cell enriched fat is increasingly used within various indications."

Beginning in 1985, Dr. Botti treated aspirated fat by "washing," decantation, and strainer filtration. Fifteen years later he switched to using a centrifuge, but after about 1 year of using it, "I realized I wasn’t getting any better results than by means of filtration," he said. "I therefore went back to my previous technique."

In 2007, Dr. Botti and his associates carried out a study of 32 patients undergoing fat transplantation in the face. They injected one side of the face with centrifuged fat, and the other side with filtrate fat. The patients were observed at postoperative day 10 and after 2 and 6 months. "We didn’t notice any difference between the side into which filtered fat was injected and [the side] treated with centrifuged fat," he said. "Therefore, we came to the conclusion that the way fat is treated does not affect the taking rate, assuming that the ‘cleaning’ was in all cases delicate and complete. And I am deeply sorry for those, like me, who have spent a few thousand euros to buy a centrifuge."

He noted that Cytori Therapeutics’ PureGraft sterile plastic bag is a promising new tool for preparing fat prior to transplantation. It is a closed system which allows clinicians to manually separate fat tissue from blood, saline, and other materials. "We will be able to judge its effectiveness in a couple of years," he said.

Dr. Botti said that he had no relevant financial disclosures to make.

LAS VEGAS – Even though transplantation of fat harvested by cannulas has been performed for almost 3 decades, its precise mechanism of action remains elusive.

"One must admit that so far lipostructuring still has to do more with art than with science," Dr. Giovanni Botti said at the annual meeting of the American Academy of Cosmetic Surgery. In many respects, "we haven’t yet come out of the Middle Ages of subjective and empirical opinions."

Despite the relative lack of objective data to support its use, Dr. Botti, a plastic surgeon based in Lake Garda, Italy, has been performing fat transplantation for 25 years. In his opinion, the procedure "can certainly be considered a therapy of first choice in the treatment of soft tissue hypotrophy, as well as for the correction of tropism disorders such as radionecrosis and burns. It is not clear, though, how to obtain consistently positive and long-lasting results."

This begs the question, he continued: If you were to biopsy the area where fat had been injected 1 year earlier, would you be looking at the same fat that was injected, or is it a brand new pad "rebuilt" by the stem cells and modulated by the growing factors present in the grafted material? If the latter hypothesis is true, "how can the stem cells in the grafted fat promote the growth of exactly the wished for amount of fat?" Dr. Botti said. "Why should it take the desired shape? Could the mass on injected tissue serve as a temporary matrix, used by stem cells as a pattern to form their ‘fat net’?"

He speculated that the fat found after 1 year could be composed of fat that was originally injected, as well as stem cells. The stem cells "promote angiogenesis, which would help adipocytes to survive. We can nowadays only make hypotheses that need to be confirmed by further research."

In the meantime, what really matters is achieving the maximum taking rate during fat transplantation, he said. "Very satisfying" results can be achieved in volume restoration and soft tissue regeneration.

The best treatment for the harvested fat prior to injection remains a matter of debate. Recent research suggests that adding stem cells, insulin, the coenzyme Q-10, and platelet rich plasma may favor survival rates, "though no one has yet been able to provide any evidence," he said. "For sure, stem cells can enhance the local blood supply and release growth factors to help the healing process. Thus, theoretically, the graft survival rate is improved. For this reason nowadays regenerative cell enriched fat is increasingly used within various indications."

Beginning in 1985, Dr. Botti treated aspirated fat by "washing," decantation, and strainer filtration. Fifteen years later he switched to using a centrifuge, but after about 1 year of using it, "I realized I wasn’t getting any better results than by means of filtration," he said. "I therefore went back to my previous technique."

In 2007, Dr. Botti and his associates carried out a study of 32 patients undergoing fat transplantation in the face. They injected one side of the face with centrifuged fat, and the other side with filtrate fat. The patients were observed at postoperative day 10 and after 2 and 6 months. "We didn’t notice any difference between the side into which filtered fat was injected and [the side] treated with centrifuged fat," he said. "Therefore, we came to the conclusion that the way fat is treated does not affect the taking rate, assuming that the ‘cleaning’ was in all cases delicate and complete. And I am deeply sorry for those, like me, who have spent a few thousand euros to buy a centrifuge."

He noted that Cytori Therapeutics’ PureGraft sterile plastic bag is a promising new tool for preparing fat prior to transplantation. It is a closed system which allows clinicians to manually separate fat tissue from blood, saline, and other materials. "We will be able to judge its effectiveness in a couple of years," he said.

Dr. Botti said that he had no relevant financial disclosures to make.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Psychological distress from dyspigmentation in skin of color is highly prevalent. Disorders of pigmentation such as vitiligo have a significant impact on a patient’s quality of life. Similarly, in skin of color patients, melasma, acne scars, and post-inflammatory hypo- and hyperpigmentation are often hard to treat.

Skin camouflage is a great way to help patients overcome the distress of their pigmentary disorders. However, I have found in my practice that patients under use these masking products.

Once they are on board, remind patients that there is a big difference between over-the-counter corrective makeup and skin camouflage products. For instance, skin camouflage products are designed to last 8-16 hours and are significantly water resistant. They are also more durable, blend better with natural skin tone, and last longer than OTC corrective makeup.

The products are applied by blending a fine layer of camouflage cream followed by a setting powder.Standard makeup and sunscreen can then be applied over the camouflage products.

Choosing the right brand can be confusing to patients. Several lines of products can be bought at department stores and through mail order. And each brand varies in texture, durability, coverage, sun protection, and color.

In the U.S. many department stores carry skin camouflage brands. Although these products reside in the "cosmetic" section, they are not referred to as makeup, so as not to create distress for patients who do not normally wear cosmetics.

In my experience Dermablend, Covermark, and Dermacolor work well. However, there are several other brands available to experiment with.

I encourage my patients with dyspigmentation to look into these well-developed camouflage products. Often times I encourage testing of the product on their skin by an experienced company representative.

Understanding the art of skin camouflage can help many of our patients cover their skin imperfections and regain their self-confidence.

-Lily Talakoub, M.D.

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

Patients who don’t like the vertical lines that form above the lips when they pucker up may benefit from botulinum toxin injections.

"Many patients look at themselves in the morning and they’re not concerned about lip volume, but they’re concerned about these radiating lines that go around their mouth. We call this the ‘bar code,’ " Dr. Joel L. Cohen said.

These patients may complain of radiating lines when the mouth is animated, of lipstick bleeding out from the lips, or of a hollowed look around the mouth. The injection of botulinum toxin into the orbicularis oris muscles can "soften" the columns that appear when the mouth moves, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery in Las Vegas.

He and his associates compared two doses of onabotulinumtoxinA (Botox) to treat the bar code in a recent study of 60 patients. To make the comparison, the investigators first developed three photographic scales for classifying aesthetic features of the perioral area; they presented the scales in a poster at the 2011 meeting of the American Society for Dermatologic Surgery. The scale used in this study assigns a severity grade of none, mild, moderate, or severe vertical lip-line attributes when the lips are at maximum contraction.

All patients had moderate or severe vertical perioral lines at maximum lip contraction before being randomized to receive either 7.5 U or 12 U of Botox in a blinded fashion. Results were assessed for 53 patients at 4 weeks and for 51 patients at 12 weeks. In the 7.5-U group, moderate or severe perioral lines were seen in 15 of 28 patients who had 4 weeks of follow-up (54%) and in 21 of 25 patients who had 12 weeks of follow-up (84%). In the 12-U group, 9 of 25 patients with 4 weeks of follow-up had moderate to severe perioral lines (36%), as did 11 of 26 patients with 12 weeks of follow-up (42%).

Results in either group tended to dissipate by 12-16 weeks of follow-up. As expected, the rate and duration of adverse events were higher in the group that got 12 U of Botox.

"It really convinced us that low-dose botulinum toxin – in this case, it was Botox at 7.5 U – can have a durable response for about 12-16 weeks," said Dr. Cohen, who practices dermatology and dermatologic surgery in Englewood and Lone Tree, Colo.

The safety assessment included 59 patients who had at least one follow-up visit or reported an adverse event. Treatment-related adverse events were seen in 13 of 30 patients in the 7.5-U group (43%) and 18 of 29 patients in the 12-U group (62%). The treatment-related adverse events tended to resolve faster in the 7.5-U group, he said. Five patients in the 12-U group who had mild or moderate adverse events required follow-up, compared with no patients in the 7.5-U group.

In regular daily clinical practice, Dr. Cohen tends to use a total of 6-10 U around the mouth, treating both the upper- and lower-lip regions because patients say they feel "a little bit funny" if only the upper lip area is treated. He injects using BD Medical’s 31-gauge, short-hub needle, inserting it about a third of the way into the skin to stay superficial, he said.

In addition to affecting perioral lines, the injections produce what appears to be a pseudoaugmentation of the upper lip in some patients, although he is unable to predict which patients will have that reaction. "I don’t think we have a great understanding of that," he said.

When they get informed consent for Botox injections to treat vertical lip lines, dermatologists should warn patients that the treatment may affect their ability to whistle, drink from a straw, purse their lips, or enunciate the letters "P" and "B," he said. Dr. Cohen avoids this treatment in patients for whom these effects may be important, such as singers, woodwind instrument players, broadcast journalists, and scuba divers.

Some dermatologists have shied away from using onabotulinumtoxinA in the lower face after having had unsatisfactory experiences in some cases. "Understanding the anatomy is absolutely critical to success," Dr. Cohen said. "I hope that with this type of precise [anatomical] knowledge, people will give lower-face [onabotulinumtoxinA] another try."

The use of onabotulinumtoxinA in the lower face, in combination with fillers or with laser- or light-based treatments, "may be very, very helpful," he added. Botox alone would not be the primary treatment, for example, in a patient who has significant vertical lines above the upper lip when the mouth is at rest.

A small trial by South American investigators evaluated 12 women and suggested that injecting the orbicularis oris muscle with onabotulinumtoxinA 1 week before treating upper-lip vertical rhytides with trichloroacetic acid and dermasanding improved results (Dermatol. Surg. 2007;33:1066-72).

Dr. Cohen has been a consultant or researcher for Allergan, Medicis, Johnson & Johnson/Mentor, and Merz.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.

ORLANDO – Dose is the most important consideration when injecting botulinum toxin in the lower face – even more important than during treatment of the upper face, according to Dr. Doris Hexsel.

"You should always use the lowest effective dose in the lower face," said Dr. Hexsel. This strategy reduces the risk for asymmetry, muscle dysfunction, and temporary oral paralysis. "These are dose-related and technique-related side effects."

Botulinum toxin can treat perioral wrinkles and marionette lines, as well as improve the appearance of a patient’s chin or gummy smile. However, only treat one or two areas in the lower face during the same session to minimize the risk of "sum of effect," she said. In other words, the effects of multiple, simultaneous injections around the mouth can be cumulative.

Also consider a combination of the botulinum toxin and filler injections, Dr. Hexsel said at the annual meeting of the Florida Society of Dermatologic Surgeons.

Dr. Hexsel shared her expertise with botulinum toxin for the following indications:

• Perioral wrinkles. Injections should be superficial and at least 1.5 cm from the corners of the mouth. Any closer and you increase the risk of undesirable relaxation of the depressor anguli oris muscle, the zygomaticus major muscle, and the risorius muscle, said Dr. Hexsel of the department of dermatology at Pontificia Universidade Católica do Rio Grande do Sul, Brazil.

She said that she typically injects 1.25 U-2.5 U abobotulinumtoxinA (Dysport, Ipsen/Medicis) per point, or 0.5 U-1.0 U onabotulinumtoxinA (Botox, Allergan). With two to six injection points, the total dose varies from 4 U-18 U for abobotulinum toxin or 4 U-10 U for onabotulinumtoxinA.

As a bonus, she said, "We observe a slight increase in the volume of the lips due to just the relaxation."

• "Cellulitic chin." Loss of collagen and subcutaneous fat, along with action of the jaw muscles, can cause a chin to have a cellulitic or "peau d’orange" appearance. Botulinum toxin can treat this area as well, said Dr. Hexsel. "I prefer two point injections – bilaterally at the most distal point of the mentalis muscle.

Again, keep the injections superficial and avoid high doses to minimize undesirable relaxation of the depressor labii inferioris muscle, she said. The total dose for a dimpled chin ranges from 15 U to 20 U of abobotulinumtoxinA and from 5 U to 10 U of onabotulinumtoxinA.

"I touch up patients 15 to 30 days later, if necessary," she added.

• Marionette lines. Botulinum toxin can improve the appearance of patients when the corners of their mouth appear permanently turned down. Better results may be obtained by combining toxin with fillers, she said.

For mild presentations, treat the mentalis muscle first, she advised. Treatment of this muscle also recruits the depressor anguli oris (DAO) muscle less (the mentalis is the agonist muscle to the DAO). Dr. Hexsel said she generally uses a total dose of 10 U-20 U of abobotulinumtoxinA or 3 U-6 U of onabotulinumtoxinA for this indication.

• Gummy smile. Consider botulinum toxin when a patient complains of a gummy smile. To foster a more natural look, also treat any natural asymmetries or posterior gummy smile, Dr. Hexsel said.

To treat posterior gingival exposure, inject two points on either side of the malar region. Inject in the nasolabial fold at the point of greatest lateral contraction during a smile.

Total doses vary from 5 U to 15 U of abobotulinumtoxinA or from 4 U to 10 U of onabotulinumtoxinA.

A final tip is to take before and after clinical photos, both during movement and at rest, when injecting the lower face.

Dr. Hexsel reported receiving grants and research support from Allergan, Galderma, and Ipsen. She also is a consultant for Allergan and Ipsen.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

LAS VEGAS – Manufacturers of the approved botulinum toxins may claim that their product is superior, but there is likely little difference between them for cosmetic dermatology purposes, according to Dr. Michael H. Gold.

"The reality is, they all work about the same," said Dr. Gold at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Unfortunately, there are hundreds of other botulinum toxin products available on the Internet that have not been tested or approved. "This is where it gets scary," added Dr. Gold, a dermatologist in private practice in Nashville, Tenn.

There is little difference between the three botulinum toxins approved by the Food and Drug Administration – Botox (onabotulinumtoxinA, Allergan), Dysport (abobotulinumtoxinA, Medicis/Ipsen), and Xeomin (incobotulinumtoxinA, Merz) – and a fourth that is likely to be approved, he said. Phase III clinical data for PurTox (Mentor), are being reviewed by the FDA.

"It’s going to get approved eventually, and will have the same approval as all the others," Dr. Gold predicted. He said that his office was the first in the United States to have done research on all four neurotoxins. All are approved in Europe, where they sell under different names.

There are well-known dosing differences between Botox and Dysport. Dosing charts are easily available on the Internet. "If you use both of these, you should have these charts in your office," he said.

Some company-sponsored studies claim differences in efficacy between the neurotoxins, but the industry-sponsored trials should be read skeptically, he said.

A 20-patient study, sponsored by Medicis, showed that Dysport reached full effect faster than Botox when injected into the frontalis muscle, which was already known from the pivotal clinical trials, Dr. Gold said (J. Drugs Dermatol. 2011;10:1148-57).

A separate Medicis-sponsored study of 90 patients treated for lateral orbital rhytids reported that Dysport worked better than Botox (Arch. Facial Plast. Surg. 2011;13:380-6[doi:10.1001/archfacial.2011.37]). On average, the full effect was achieved in 1-2 days with Dysport, compared with 3 days for Botox. "But again, this is a sponsored study," not an independent evaluation, he noted.

Noninferiority studies comparing Xeomin (approved by the FDA in August 2011) and Botox showed that "they work exactly the same," Dr. Gold said. Xeomin’s approval is nearly identical to the approvals of the other botulinum toxins, and its duration is equivalent – "about 3 months," he said.

Xeomin does not contain hemagglutinin and, therefore, should have a lower risk for an antigen effect than Botox and Dysport. Whether or not this is significant is unclear, because there have been no antigen effects reported from the use of Botox or Dysport, he said.

PurTox also is a pure neurotoxin, "which means no resistance," but again it’s not clear if containing hemagglutinin is a risk, he said.

Another difference between the approved toxins is that the FDA required a two-point satisfaction grading scale in the Xeomin clinical studies, compared with a one-point satisfaction grading scale in the studies of Botox and Dysport. To show an effect from Xeomin, the satisfaction rating had to change from 3 to 1 or from 2 to 0.

In comparing the products, "the numbers and how you put them together are hard," Dr. Gold said. "Both Allergan and Medicis are going to tell us how great their product is, and the poor folks from Merz are going to have to tell us the difference between a one-point and two-point satisfaction" rating change.

Data for botulinum toxins that have not been FDA approved, however, are even harder to find.

Makers of neurotoxins available in other parts of the world have their own sponsored studies claiming equivalence to Botox. In China, for example, the search engine Alibaba turns up hundreds of botulinum toxin products for sale from at least 24 suppliers, said Dr. Gold. Most of them have no data to back them up, are sold illegally, and put the buyer at risk of a jail sentence.

An Allergan researcher analyzed a product from Nanfeng, China, and found that it contained 240 times the dose of botulinum toxin available in a vial of Botox. It killed every animal on which it was tested until it was diluted in a 1:240 ratio (J. Am. Acad. Dermatol. 2009;61:149-50).

Several well-manufactured neurotoxins are available in China that have gone through extensive Chinese regulatory processes, but caution is needed even with these, Dr. Gold said. In one open-label study comparing ChinaTox with Botox for the treatment of spasms and dystonia, five patients developed rash, even though the neurotoxin is less powerful than Botox.

"You’ve got to be careful what you do," he said, and suggested that dermatologists stick with branded and approved neurotoxins.

Dr. Gold has been a consultant or researcher for Allergan, Galderma, Medicis, Mentor (Johnson & Johnson), and Merz Aesthetics.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.

LAS VEGAS – A large array of home laser and light devices can be purchased on the Internet, with sellers touting their cosmetic benefits in treating acne, age spots, large pores, wrinkles, sagging skin, puffy eyes, rosacea, cold sores, and many other skin conditions.

However, few of the devices have been studied or approved by the Food and Drug Administration, and "some of them sound sort of scary," said Dr. Anne M. Chapas. "There are a lot of junk devices that, at the very least, are a waste of money and, at worst, could be harmful to consumers."

Sales of home cosmetic devices totaled $500 million last year, and are expected to nearly double to $950 million in 2015, according to Dr. Chapas.

"At this time, it’s a buyer-beware market," she said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "As dermatologists, we really need to jump on this" and educate patients and consumers about what the best devices really are.

Extensive Internet listings include devices using blue, yellow, and red light laser ultrasonic therapy. "I know that if I’m confused about it, my patients are certainly going to have a lot of questions," said Dr. Chapas of the department of dermatology at New York University.

Some home devices may serve a purpose for maintenance therapy between office treatments, a strategy that Dr. Chapas employs for some patients with acne. A helpful home device also can generate a patient’s interest in getting office-based laser treatments.

These new home devices tend to fall into four categories, she said: Diode or intense pulsed light devices that target hair removal, light-emitting diode (LED) or heat devices that claim benefits for acne treatment, devices to treat wrinkles using infrared light, and a home phototherapy device that provides UVB.

Hair Removal

Professionals use a variety of laser devices for hair removal – Dr. Chapas said she prefers the long-pulsed alexandrite or long-pulsed Nd:YAG lasers – while home devices tend to use diode, intense pulsed light, or heat technology.

Home devices use lower fluences and longer pulse widths, compared with office-based treatments. To be effective, energy must be absorbed by the hair shaft, penetrate deep enough to affect the follicle, and be administered in a pulse duration that is less than the thermal relaxation time of the hair follicle.

One of the first home laser devices to be studied, the Tria diode laser, showed mean hair reductions of 60% at 1 month, 41% at 6 months, and 33% at 12 months after three home treatments in 77 appropriate users (Lasers Surg. Med. 2007;39:476-93). A skin color sensor blocks the device on darker skin colors that could easily blister. The FDA approved the device for off-face use; it costs approximately $395.

The Silk’n SensEpil by Sephora uses intense pulsed light at low energy and short pulse durations. Approved for use on skin on or below the cheeks, it costs approximately $499 plus the price of disposable parts. Three studies in 34, 20, and 10 females, respectively, found it works best for thin hair on the legs and arms, and is less effective for hair on the axilla or inguinal areas, Dr. Chapas said (J. Cosmet. Laser Ther. 2009;11:106-9; Dermatol. Surg. 2009;35:483-9; and Lasers Surg. Med. 2010;42:287-91).

The No! No! device uses patented Thermicon technology employing a thermal filament to deliver heat to the hair shaft. In a study of 12 patients, twice-weekly treatment for 6 weeks with the low-energy device removed 44% of hair on the legs and 15% of hair in the bikini area at the 12-week follow-up (J. Drugs Dermatol. 2007;6:788-92).

"I think you would have to spend a lot of your time" to get results even on the legs, Dr. Chapas said. The No! No! costs approximately $270.

Acne

Home devices tend to use LED, intense pulsed light, and heat technology. Eight studies since 1999 have shown that office treatments with blue light are effective in eliminating Propionibacterium acnes bacteria, and four home devices now offer self-application of blue light, she noted.

In her office treatments, Dr. Chapas said she usually treats patients for 11-20 minutes twice a week for 4-8 weeks. "For a lot of patients, it’s just a pain to come into the office twice a week for 8 weeks, so there really is a need for a home device," she said. "I think these devices can help, and I now use them in between my PDT [photodynamic therapy] treatments."

The power density of the various devices makes a difference. Lower power density requires twice-weekly, 20-minute applications on each side of the face, which can be difficult for patients to do. Higher-density blue light devices, such as the Tria skin clarifying system, require less than 3 minutes twice a day, she said.

A company-sponsored study of the Tria device in 33 adults showed significant reductions in inflammatory acne lesions after 3 weeks of treatments (J. Drugs Dermatol. 2011;6:596-602).

"Just clearing P. acnes isn’t enough a lot of time because the antigens are still there," Dr. Chapas said. The Tria system comes with washes and topical creams, or patients can use the device with whatever prescription regimen they are on.

Several devices use heat shock proteins to reduce P. acnes, but these too are not enough when used alone because they do not reduce inflammation or comedones. "They do seem to work, but you have to do it frequently and you have to put it on every single acne spot," she said. Heat devices by ThermaClear, Zeno, and No! No! cost approximately $149-$180.

The Claro home device by Sephora combines heat and blue and red light to clear P. acnes and costs approximately $195.

Rejuvenation

The PaloVia fractionated laser (Palomar Medical Technologies) is approved for home treatment of periorbital rhytids. A blinded study of 34 subjects presented at the 2010 meeting of the American Society for Laser Medicine and Surgery reported a 1-point improvement on the 9-point Fitzpatrick wrinkle scale in 90% of patients after 4 weeks of daily use and in 79% after 4 weeks of twice-weekly maintenance treatments, Dr. Chapas said.

Phototherapy

The Levia UVB device (Lerner Medical Devices) is approved for home use to treat psoriasis, vitiligo, and atopic dermatitis. Dr. Chapas said she likes to prescribe it for children with vitiligo who have to travel a significant distance to her office and find it difficult to get time off from school for in-office excimer laser treatments.

"It’s something you can write a prescription for and you can program" to the desired settings, she said. Multiple studies have shown that home UVB therapy is as effective as office treatments.

Dr. Chapas said she has been a consultant for Tria, Phillips, and Solta.

LISBON – A novel, intradermally-injected, monophasic hyaluronic acid filler known as Belotero Intense outperformed Perlane for the treatment of moderate to deep nasolabial folds in a 12-month, double-blind, randomized trial, according to Dr. Martina Kerscher.

Merz Pharmaceuticals’ Belotero Intense is manufactured using a proprietary Cohesive Polydensified Matrix technology. The resultant product, a monophasic, polydensified hyaluronic acid filler, was designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than achievable with biphasic hyaluronic acid fillers, said Dr. Kerscher at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients aged 35-65 years, with nasolabial folds (NLFs) that were grades 3-4 on a 5-point scale, meaning the defects were either moderately deep or very long and deep. Participants were randomized double-blindly to a single intradermal injection on one side of the face with Belotero Intense, while the NLFs on the other side of the face were treated with Medicis Aesthetics’ Perlane, a biphasic hyaluronic acid filler. Both products are gels of nonanimal origin. No touch-ups were permitted during the 12 months of follow-up.

Physician- and patient-rated scores on the Wrinkle Severity Rating Scale improved with both products; however, the degree of improvement was significantly greater through 24 weeks with the monophasic hyaluronic acid filler.

Belotero Intense is designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than is achievable with biphasic hyaluronic acid fillers, said Dr. Martina Kerscher.

Mean scores on the 0-4 scale went from a baseline of 4.0 to 2.4 with the biphasic filler and to 2.1 with the monophasic filler at week 2; at week 24, mean scores were 2.7 for the biphasic filler, compared with 2.4 for the monophasic filler. At week 48, however, both products showed similar effects.

Investigators and patients gave the monophasic hyaluronic acid gel higher marks on the Global Aesthetic Improvement Scale through 24 weeks. After week 24, scores for the two products merged, reported Dr. Kerscher of the University of Hamburg (Germany) division of cosmetic science.

Standardized measurements of wrinkle depth for the Belotero Intense-treated NLFs went from a baseline of 271 mm to 172 mm at week 2, 194 mm at week 24, and 213 mm at week 48. Depth of the Perlane-treated NLFs improved from 222 mm at baseline to 152 mm at week 2, 177 mm at week 24, and 184 mm at week 48. This translated to a 28% reduction in wrinkle depth at week 24 in the monophasic filler-treated lesions, compared with a 20% decrease in the biphasic filler-treated folds. The week 48 improvement was 21% in the monophasic- and 17% in the biphasic-treated NLFs.

Self-rated patient satisfaction was scored on a 0-10 scale, with a lower score showing a higher level of satisfaction. From a baseline of 7.0, scores improved to 2.3 for the biphasic filler and 2.1 for the monophasic filler at week 2, to 4.9 for biphasic and 3.8 for monophasic at week 24, and to 6.7 for biphasic and 5.7 for monophasic at week 48.

Of note, the blinded patients consistently recorded significantly less injection site pain with the monophasic hyaluronic acid filler.

Belotero Intense is licensed in the United Kingdom and several European countries as a medical device for the correction of deep folds and for volume augmentation. A sister product, Belotero Balance, earned marketing approval from the Food and Drug Administration in November 2011 for correction of moderate to severe wrinkles and folds. Belotero Intense is intended for deeper injection and correction of more pronounced defects than is Belotero Balance.

Merz is seeking FDA approval of Belotero Intense.

The study presented by Dr. Kerscher was sponsored by Merz, which markets the Belotero product line. She is a consultant to the company.

LISBON – A novel, intradermally-injected, monophasic hyaluronic acid filler known as Belotero Intense outperformed Perlane for the treatment of moderate to deep nasolabial folds in a 12-month, double-blind, randomized trial, according to Dr. Martina Kerscher.

Merz Pharmaceuticals’ Belotero Intense is manufactured using a proprietary Cohesive Polydensified Matrix technology. The resultant product, a monophasic, polydensified hyaluronic acid filler, was designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than achievable with biphasic hyaluronic acid fillers, said Dr. Kerscher at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients aged 35-65 years, with nasolabial folds (NLFs) that were grades 3-4 on a 5-point scale, meaning the defects were either moderately deep or very long and deep. Participants were randomized double-blindly to a single intradermal injection on one side of the face with Belotero Intense, while the NLFs on the other side of the face were treated with Medicis Aesthetics’ Perlane, a biphasic hyaluronic acid filler. Both products are gels of nonanimal origin. No touch-ups were permitted during the 12 months of follow-up.

Physician- and patient-rated scores on the Wrinkle Severity Rating Scale improved with both products; however, the degree of improvement was significantly greater through 24 weeks with the monophasic hyaluronic acid filler.

Belotero Intense is designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than is achievable with biphasic hyaluronic acid fillers, said Dr. Martina Kerscher.

Mean scores on the 0-4 scale went from a baseline of 4.0 to 2.4 with the biphasic filler and to 2.1 with the monophasic filler at week 2; at week 24, mean scores were 2.7 for the biphasic filler, compared with 2.4 for the monophasic filler. At week 48, however, both products showed similar effects.

Investigators and patients gave the monophasic hyaluronic acid gel higher marks on the Global Aesthetic Improvement Scale through 24 weeks. After week 24, scores for the two products merged, reported Dr. Kerscher of the University of Hamburg (Germany) division of cosmetic science.

Standardized measurements of wrinkle depth for the Belotero Intense-treated NLFs went from a baseline of 271 mm to 172 mm at week 2, 194 mm at week 24, and 213 mm at week 48. Depth of the Perlane-treated NLFs improved from 222 mm at baseline to 152 mm at week 2, 177 mm at week 24, and 184 mm at week 48. This translated to a 28% reduction in wrinkle depth at week 24 in the monophasic filler-treated lesions, compared with a 20% decrease in the biphasic filler-treated folds. The week 48 improvement was 21% in the monophasic- and 17% in the biphasic-treated NLFs.

Self-rated patient satisfaction was scored on a 0-10 scale, with a lower score showing a higher level of satisfaction. From a baseline of 7.0, scores improved to 2.3 for the biphasic filler and 2.1 for the monophasic filler at week 2, to 4.9 for biphasic and 3.8 for monophasic at week 24, and to 6.7 for biphasic and 5.7 for monophasic at week 48.

Of note, the blinded patients consistently recorded significantly less injection site pain with the monophasic hyaluronic acid filler.

Belotero Intense is licensed in the United Kingdom and several European countries as a medical device for the correction of deep folds and for volume augmentation. A sister product, Belotero Balance, earned marketing approval from the Food and Drug Administration in November 2011 for correction of moderate to severe wrinkles and folds. Belotero Intense is intended for deeper injection and correction of more pronounced defects than is Belotero Balance.

Merz is seeking FDA approval of Belotero Intense.

The study presented by Dr. Kerscher was sponsored by Merz, which markets the Belotero product line. She is a consultant to the company.

LISBON – A novel, intradermally-injected, monophasic hyaluronic acid filler known as Belotero Intense outperformed Perlane for the treatment of moderate to deep nasolabial folds in a 12-month, double-blind, randomized trial, according to Dr. Martina Kerscher.

Merz Pharmaceuticals’ Belotero Intense is manufactured using a proprietary Cohesive Polydensified Matrix technology. The resultant product, a monophasic, polydensified hyaluronic acid filler, was designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than achievable with biphasic hyaluronic acid fillers, said Dr. Kerscher at the annual congress of the European Academy of Dermatology and Venereology.

She reported on 20 patients aged 35-65 years, with nasolabial folds (NLFs) that were grades 3-4 on a 5-point scale, meaning the defects were either moderately deep or very long and deep. Participants were randomized double-blindly to a single intradermal injection on one side of the face with Belotero Intense, while the NLFs on the other side of the face were treated with Medicis Aesthetics’ Perlane, a biphasic hyaluronic acid filler. Both products are gels of nonanimal origin. No touch-ups were permitted during the 12 months of follow-up.

Physician- and patient-rated scores on the Wrinkle Severity Rating Scale improved with both products; however, the degree of improvement was significantly greater through 24 weeks with the monophasic hyaluronic acid filler.

Belotero Intense is designed to provide greater elasticity, less risk of lumping, and longer-lasting improvements than is achievable with biphasic hyaluronic acid fillers, said Dr. Martina Kerscher.

Mean scores on the 0-4 scale went from a baseline of 4.0 to 2.4 with the biphasic filler and to 2.1 with the monophasic filler at week 2; at week 24, mean scores were 2.7 for the biphasic filler, compared with 2.4 for the monophasic filler. At week 48, however, both products showed similar effects.

Investigators and patients gave the monophasic hyaluronic acid gel higher marks on the Global Aesthetic Improvement Scale through 24 weeks. After week 24, scores for the two products merged, reported Dr. Kerscher of the University of Hamburg (Germany) division of cosmetic science.

Standardized measurements of wrinkle depth for the Belotero Intense-treated NLFs went from a baseline of 271 mm to 172 mm at week 2, 194 mm at week 24, and 213 mm at week 48. Depth of the Perlane-treated NLFs improved from 222 mm at baseline to 152 mm at week 2, 177 mm at week 24, and 184 mm at week 48. This translated to a 28% reduction in wrinkle depth at week 24 in the monophasic filler-treated lesions, compared with a 20% decrease in the biphasic filler-treated folds. The week 48 improvement was 21% in the monophasic- and 17% in the biphasic-treated NLFs.

Self-rated patient satisfaction was scored on a 0-10 scale, with a lower score showing a higher level of satisfaction. From a baseline of 7.0, scores improved to 2.3 for the biphasic filler and 2.1 for the monophasic filler at week 2, to 4.9 for biphasic and 3.8 for monophasic at week 24, and to 6.7 for biphasic and 5.7 for monophasic at week 48.

Of note, the blinded patients consistently recorded significantly less injection site pain with the monophasic hyaluronic acid filler.

Belotero Intense is licensed in the United Kingdom and several European countries as a medical device for the correction of deep folds and for volume augmentation. A sister product, Belotero Balance, earned marketing approval from the Food and Drug Administration in November 2011 for correction of moderate to severe wrinkles and folds. Belotero Intense is intended for deeper injection and correction of more pronounced defects than is Belotero Balance.

Merz is seeking FDA approval of Belotero Intense.

The study presented by Dr. Kerscher was sponsored by Merz, which markets the Belotero product line. She is a consultant to the company.