Aesthetic Dermatology

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

LISBON – The tower technique is a novel method of injecting hyaluronic acid fillers that is particularly well suited for anatomic locations where underlying structural support for soft tissue has been lost because of aging.

The tower technique creates a deep base of scaffolding that extends through the entire subcutis. It reintroduces lost structural support for the overlying facial soft tissue rather than simply filling lines, Dr. C. William Hanke explained in a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"The Big Three with facial aging are skin quality, facial volume, and laxity. Volume trumps the other two. ... You can improve skin quality and laxity with volume alone," said Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

Areas particularly amenable to the tower technique include the nasolabial folds, marionette lines, the brow region, the chin compartment, and the prejowl sulcus. The best areas in which to employ the tower technique have underlying bony structural support, a thick subcutis, or an overlying thick dermis.

The technique is easily mastered, he said. "You take your syringe of hyaluronic acid and point it straight down at the bone, perpendicular, and then you inject as you withdraw. You deposit decreasing amounts of the filler as you withdraw the needle, creating a pyramid-like tower," he explained. "This is really an amazing thing in that it props up the skin right before your eyes. It’s minimally painful, there are a minimum number of injections, and the complications – such as bruising – are very minimal as well."

Dr. Hanke generally utilizes 30-gauge half-inch needles for the injections. For a nasolabial fold or superior marionette line he creates two or three towers, injecting 0.1-0.2 mL of filler into each. Inferior marionette lines get one or two towers, with 0.1-0.3 mL of product placed in each. The lateral brow lift entails two or three towers, each with 0.1 mL of filler.

Restoring support of the mental area requires one to three towers, each constructed of 0.2-0.3 mL of filler placed from the periosteum to the deep dermis. The prejowl sulcus can be shored up with one or two towers, each containing 0.2-0.3 mL of filler.

The tower technique is for use with hyaluronic acid fillers. It’s not appropriate for poly-L-lactic acid or calcium hydroxyapatite fillers, which need to be placed deeper or in a single plane.

Dr. Hanke noted that he didn’t come up with the tower technique.

"I first heard about it in Germany. I think other people were using it, too. I’ve [also] heard about this technique from the Canadians. They call it the tent pole technique," he said.

Dr. Hanke and his colleagues recently wrote a detailed how-to guide to the tower technique (J. Drugs Dermatol. 2011;10:1277-80).

He reported having no relevant financial interests.

ORLANDO – One number keeps coming up with the new autologous fibroblast biologic product that enhances a patient’s nasolabial wrinkles: three.

"There are a lot of threes: three biopsies 3 mm in size, a 3 month’s wait, and three treatment sessions," Dr. Robert Weiss said at the annual meeting of the Florida Society of Dermatology Surgeons.

The Food and Drug Administration cleared the marketing of Fibrocell Science’s azficel-T (LaVív) in June 2011, and the product is now reaching the market. "It’s very exciting to be right at the launch of this," said Dr .Weiss, a dermatologist in private practice in Hunt Valley, Md., and with the dermatology department at Johns Hopkins University, Baltimore. "I’ve been working on this for close to a decade, so it was a personal triumph to see this finally cleared by the FDA."

The FDA based its clearance on two identically designed, multicenter, double-blind, vehicle-controlled studies. A total of 421 patients with moderate to severe nasolabial fold wrinkles were assessed, with 210 being randomized to azficel-T and 211 to vehicle injections. The average age was 55 years, and 90% were women.

A 2-point improvement in the appearance of the nasolabial fold wrinkles was the primary outcome. Physicians at the study sites who were not injectors blindly rated results.

At the 6-month follow-up, doctors observed the 2-point improvement in 33% of the azficel-T group, compared with 7% of controls in the first study. In the second study, 19% of the azficel-T group had at least a 2-point improvement, compared with 7% of controls. These differences were on the borderline of statistical significance, Dr. Weiss said.

"The FDA was convinced that this was effective. We were certainly very convinced by what we observed with the patients," Dr. Weiss said.

Patient reported outcomes were more statistically significant, with 57% reporting a 2-point improvement, compared with 30% in the vehicle group in an intent-to-treat analysis of the first study. In the second study, 45% of the treated patients reported this outcome, compared with 18% of the vehicle group.

The most common adverse effects were injection site reactions lasting approximately 2 hours, Dr. Weiss said. These events included erythema, bruising, and swelling. Facial or eyelid edema, hypersensitivity or decreased skin sensation at the injection site, and postprocedural discomfort were among the adverse events reported by 1% of patients or fewer.

"One of the first questions patients ask me is: ‘How are you going to make sure I’m getting my own cells?’ " Dr. Weiss explained there are strict controls. Each patient is assigned a lot number. Vials for injection are labeled with each patient’s initials, date of birth, and a unique identification number. "All the critical steps are verified twice."

The treatment protocol involves extraction, purification, culturing, and injection. Dr. Weiss said he injects 1 cc to 2 cc of lidocaine in the postauricular area before taking the biopsies. The tissue is sent to Fibrocell for purification and culturing of the fibroblasts.

After 3 months, a vial containing 15 million to 20 million fibroblasts is shipped back to arrive just prior to the patient appointment. "Advise your patients that advance notice of at least 2 business days is required to reschedule treatment. By the FDA guidelines, you cannot inject the cells the next day because the viability count goes down." Treatment at 3- to 6-week intervals is recommended.

Because the product is a biologic, the FDA requires physician certification prior to use of azficel-T. "If you are interested in offering this to your patients, the company will train your staff. There are webinars," Dr. Weiss said. Staff training reinforces proper packing, handling, and shipping.

The product has to be handled gingerly and injected superficially in the papillary dermis, he said. "This is for superficial rhytids; this is not a deep volume filler." The needle will be visible under the skin if you are injecting in the right plane.

Resuspend the cells by inverting the vial slowly a few times. Be careful putting the vial on the tray because it can fall over. Apply light pressure to the plunger and inject slowly along the wrinkle line.

Instruct the patient not to wash the site for 24 hours and not to scrub, rub, massage, or apply any pressure for 72 hours. An NSAID can be taken for pain.

Also, instruct patients to call if they experience any adverse reactions. Fibrocell plans to launch a patient registry in July 2012 that will track hypersensitivity reactions.

Dr. Weiss participated in one of the clinical trials as early as 2003. "What we’ve noted on long-term follow-up is that patients maintain this improvement, often for many, many years, which is interesting."

"I’ve seen some phenomenal results, particularly in studies of acne scars, which is another potential application the company is applying for," he added.

Dr. Weiss has been an investigator for Fibrocell Science, which sponsored his presentation.

ORLANDO – One number keeps coming up with the new autologous fibroblast biologic product that enhances a patient’s nasolabial wrinkles: three.

"There are a lot of threes: three biopsies 3 mm in size, a 3 month’s wait, and three treatment sessions," Dr. Robert Weiss said at the annual meeting of the Florida Society of Dermatology Surgeons.

The Food and Drug Administration cleared the marketing of Fibrocell Science’s azficel-T (LaVív) in June 2011, and the product is now reaching the market. "It’s very exciting to be right at the launch of this," said Dr .Weiss, a dermatologist in private practice in Hunt Valley, Md., and with the dermatology department at Johns Hopkins University, Baltimore. "I’ve been working on this for close to a decade, so it was a personal triumph to see this finally cleared by the FDA."

The FDA based its clearance on two identically designed, multicenter, double-blind, vehicle-controlled studies. A total of 421 patients with moderate to severe nasolabial fold wrinkles were assessed, with 210 being randomized to azficel-T and 211 to vehicle injections. The average age was 55 years, and 90% were women.

A 2-point improvement in the appearance of the nasolabial fold wrinkles was the primary outcome. Physicians at the study sites who were not injectors blindly rated results.

At the 6-month follow-up, doctors observed the 2-point improvement in 33% of the azficel-T group, compared with 7% of controls in the first study. In the second study, 19% of the azficel-T group had at least a 2-point improvement, compared with 7% of controls. These differences were on the borderline of statistical significance, Dr. Weiss said.

"The FDA was convinced that this was effective. We were certainly very convinced by what we observed with the patients," Dr. Weiss said.

Patient reported outcomes were more statistically significant, with 57% reporting a 2-point improvement, compared with 30% in the vehicle group in an intent-to-treat analysis of the first study. In the second study, 45% of the treated patients reported this outcome, compared with 18% of the vehicle group.

The most common adverse effects were injection site reactions lasting approximately 2 hours, Dr. Weiss said. These events included erythema, bruising, and swelling. Facial or eyelid edema, hypersensitivity or decreased skin sensation at the injection site, and postprocedural discomfort were among the adverse events reported by 1% of patients or fewer.

"One of the first questions patients ask me is: ‘How are you going to make sure I’m getting my own cells?’ " Dr. Weiss explained there are strict controls. Each patient is assigned a lot number. Vials for injection are labeled with each patient’s initials, date of birth, and a unique identification number. "All the critical steps are verified twice."

The treatment protocol involves extraction, purification, culturing, and injection. Dr. Weiss said he injects 1 cc to 2 cc of lidocaine in the postauricular area before taking the biopsies. The tissue is sent to Fibrocell for purification and culturing of the fibroblasts.

After 3 months, a vial containing 15 million to 20 million fibroblasts is shipped back to arrive just prior to the patient appointment. "Advise your patients that advance notice of at least 2 business days is required to reschedule treatment. By the FDA guidelines, you cannot inject the cells the next day because the viability count goes down." Treatment at 3- to 6-week intervals is recommended.

Because the product is a biologic, the FDA requires physician certification prior to use of azficel-T. "If you are interested in offering this to your patients, the company will train your staff. There are webinars," Dr. Weiss said. Staff training reinforces proper packing, handling, and shipping.

The product has to be handled gingerly and injected superficially in the papillary dermis, he said. "This is for superficial rhytids; this is not a deep volume filler." The needle will be visible under the skin if you are injecting in the right plane.

Resuspend the cells by inverting the vial slowly a few times. Be careful putting the vial on the tray because it can fall over. Apply light pressure to the plunger and inject slowly along the wrinkle line.

Instruct the patient not to wash the site for 24 hours and not to scrub, rub, massage, or apply any pressure for 72 hours. An NSAID can be taken for pain.

Also, instruct patients to call if they experience any adverse reactions. Fibrocell plans to launch a patient registry in July 2012 that will track hypersensitivity reactions.

Dr. Weiss participated in one of the clinical trials as early as 2003. "What we’ve noted on long-term follow-up is that patients maintain this improvement, often for many, many years, which is interesting."

"I’ve seen some phenomenal results, particularly in studies of acne scars, which is another potential application the company is applying for," he added.

Dr. Weiss has been an investigator for Fibrocell Science, which sponsored his presentation.

ORLANDO – One number keeps coming up with the new autologous fibroblast biologic product that enhances a patient’s nasolabial wrinkles: three.

"There are a lot of threes: three biopsies 3 mm in size, a 3 month’s wait, and three treatment sessions," Dr. Robert Weiss said at the annual meeting of the Florida Society of Dermatology Surgeons.

The Food and Drug Administration cleared the marketing of Fibrocell Science’s azficel-T (LaVív) in June 2011, and the product is now reaching the market. "It’s very exciting to be right at the launch of this," said Dr .Weiss, a dermatologist in private practice in Hunt Valley, Md., and with the dermatology department at Johns Hopkins University, Baltimore. "I’ve been working on this for close to a decade, so it was a personal triumph to see this finally cleared by the FDA."

The FDA based its clearance on two identically designed, multicenter, double-blind, vehicle-controlled studies. A total of 421 patients with moderate to severe nasolabial fold wrinkles were assessed, with 210 being randomized to azficel-T and 211 to vehicle injections. The average age was 55 years, and 90% were women.

A 2-point improvement in the appearance of the nasolabial fold wrinkles was the primary outcome. Physicians at the study sites who were not injectors blindly rated results.

At the 6-month follow-up, doctors observed the 2-point improvement in 33% of the azficel-T group, compared with 7% of controls in the first study. In the second study, 19% of the azficel-T group had at least a 2-point improvement, compared with 7% of controls. These differences were on the borderline of statistical significance, Dr. Weiss said.

"The FDA was convinced that this was effective. We were certainly very convinced by what we observed with the patients," Dr. Weiss said.

Patient reported outcomes were more statistically significant, with 57% reporting a 2-point improvement, compared with 30% in the vehicle group in an intent-to-treat analysis of the first study. In the second study, 45% of the treated patients reported this outcome, compared with 18% of the vehicle group.

The most common adverse effects were injection site reactions lasting approximately 2 hours, Dr. Weiss said. These events included erythema, bruising, and swelling. Facial or eyelid edema, hypersensitivity or decreased skin sensation at the injection site, and postprocedural discomfort were among the adverse events reported by 1% of patients or fewer.

"One of the first questions patients ask me is: ‘How are you going to make sure I’m getting my own cells?’ " Dr. Weiss explained there are strict controls. Each patient is assigned a lot number. Vials for injection are labeled with each patient’s initials, date of birth, and a unique identification number. "All the critical steps are verified twice."

The treatment protocol involves extraction, purification, culturing, and injection. Dr. Weiss said he injects 1 cc to 2 cc of lidocaine in the postauricular area before taking the biopsies. The tissue is sent to Fibrocell for purification and culturing of the fibroblasts.

After 3 months, a vial containing 15 million to 20 million fibroblasts is shipped back to arrive just prior to the patient appointment. "Advise your patients that advance notice of at least 2 business days is required to reschedule treatment. By the FDA guidelines, you cannot inject the cells the next day because the viability count goes down." Treatment at 3- to 6-week intervals is recommended.

Because the product is a biologic, the FDA requires physician certification prior to use of azficel-T. "If you are interested in offering this to your patients, the company will train your staff. There are webinars," Dr. Weiss said. Staff training reinforces proper packing, handling, and shipping.

The product has to be handled gingerly and injected superficially in the papillary dermis, he said. "This is for superficial rhytids; this is not a deep volume filler." The needle will be visible under the skin if you are injecting in the right plane.

Resuspend the cells by inverting the vial slowly a few times. Be careful putting the vial on the tray because it can fall over. Apply light pressure to the plunger and inject slowly along the wrinkle line.

Instruct the patient not to wash the site for 24 hours and not to scrub, rub, massage, or apply any pressure for 72 hours. An NSAID can be taken for pain.

Also, instruct patients to call if they experience any adverse reactions. Fibrocell plans to launch a patient registry in July 2012 that will track hypersensitivity reactions.

Dr. Weiss participated in one of the clinical trials as early as 2003. "What we’ve noted on long-term follow-up is that patients maintain this improvement, often for many, many years, which is interesting."

"I’ve seen some phenomenal results, particularly in studies of acne scars, which is another potential application the company is applying for," he added.

Dr. Weiss has been an investigator for Fibrocell Science, which sponsored his presentation.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

LISBON – Neck liposuction using tumescent local anesthesia is the cosmetic dermatology procedure having the optimal combination of high patient satisfaction, minimal complications, and a short learning curve.

"What I consider to be the No. 1, home-run procedure in all of dermatosurgery is liposuction of the neck," Dr. C. William Hanke, a dermatologic surgeon, said during a plenary lecture at the annual congress of the European Academy of Dermatology and Venereology.

"A long, youthful neck is felt to be a sign of beauty. When patients lose that – when their neck fills in with fat, and when the face and the neck become one – it’s not felt to be a sign of beauty. And that’s when liposuction of the neck comes in," explained Dr. Hanke of the Laser and Skin Surgery Center of Indiana, Carmel.

It is important to understand, however, that liposuction is no substitute for weight loss. The ideal candidate for neck liposuction is a young patient with good skin elasticity who has excess submandibular fat resulting in lost definition of the mandibular border.

Using liposuction to remove adipose tissue lying superficial to the platysmal muscle in such a patient, and redraping the skin to reduce the cervicomental angle to a well-defined 105-120 degrees with sharp mandibular demarcation, brings stellar cosmetic results.

In contrast, an elderly patient who is overweight or obese and has poor skin quality and redundant neck skin may need additional procedures, such as platysmal plication and laser resurfacing, he said.

Basically, neck liposuction entails filling the neck with tumescent anesthesia. "Any dermatologist can learn this," Dr. Hanke said. The fat is then suctioned using a combination of 1- to 3-mm cannulas with spatula tips placed through a primary entry point located in the mental crease. Additional holes can be placed for suctioning the lateral neck. The patient is entirely awake for the procedure, which can be performed in an office surgical suite, an ambulatory surgery center, or a hospital operating room.

"We sweep across the neck, suctioning the fat and transecting the septae that run through the fat. We can march into the jowls as well," he said.

Neuropraxia of the marginal mandibular nerve occurs in roughly 5% of cases of neck liposuction. The interruption of motor function typically lasts 4-6 weeks and is never permanent. The marginal mandibular nerve lies deep to the platysma, and the muscle would actually have to be punctured by the cannula to cause permanent nerve injury, Dr. Hanke said.

Immediately after the procedure he has patients wear a compression garment 24 hours a day for the first 1-2 days except while showering, then for 2-4 hours daily for 1-2 weeks. The compression garment helps in redraping the skin, prevents hematomas, speeds absorption of tumescent fluid, and prevents skin wrinkling.

Serious complications are exceedingly rare. In fact, in an early national survey of more than 15,000 patients treated with liposuction using tumescent local anesthesia, Dr. Hanke and coworkers reported no deaths or complications requiring hospital transfer (Dermatol. Surg. 1995;21:459-62).

The finding was confirmed in another national survey, this one involving nearly 67,000 liposuction procedures performed by dermatologic surgeons from 1994 to 2000 (Dermatol. Surg. 2002;28:971-8).

Occasionally, the platysmal bands are unmasked by neck liposuction. This is an unwelcome event, but marked improvement can be achieved through injection of small doses of botulinum toxin.

Dr. Hanke noted that he and Dr. William G. Stebbins recently performed an in-depth review of neck rejuvenation via liposuction, including proper patient selection, technical aspects of the procedure, postop care, and ancillary techniques (Dermatol. Ther. 2011;24:28-40).

Dr. Hanke reported having no financial conflicts of interest.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

NEW ORLEANS – The American Medical Association’s House of Delegates has passed a resolution urging physician organizations to push for stricter state regulation of medical spas. The vote came at the Delegates’ interim meeting, held in New Orleans.

The resolution seeks to ensure that cosmetic medical procedures have the same safeguards as do medically necessary procedures. That includes appropriate training, supervision, and oversight.

The resolution also stated that cosmetic procedures, including botulinum toxin injections, dermal filler injections, and laser and intense pulsed-light procedures, should be considered the practice of medicine.

The Medical Student Section of the House brought the resolution forward, stating that patient safety was a growing concern. The resolution also urged the AMA to increase public awareness about potential dangers presented by unregulated spas and to work to help create a formal complaint procedure for patients.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

WASHINGTON – When it comes to news coverage of dermatology, aesthetic issues get much more attention than oncologic, surgical, or medical topics, according to a recent analysis of the nation’s top newspapers.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," Dr. Kristina Collins, a fellow in dermatologic surgery in the department of dermatology at Harvard Medical School, Boston, and Lahey Clinic, Burlington, Mass., said in an interview. "I think that many dermatologists find that patients or even colleagues in other specialties are not aware of the important medical diseases that the field of dermatology encompasses, and many people are under the false impression that most of a typical dermatologist’s time is dedicated to cosmetics."

In fact, according to Dr. Collins, national practice data shows that the average dermatologist spends only about 10% of his or her time on cosmetic procedures.

To conduct the study, Dr. Collins and her colleagues analyzed the contents of 1,669 dermatology-related articles gathered from the top 10 most widely circulated newspapers over a 10-year period ending on Jan. 1, 2011.

"I found it surprising that cosmetic procedures were so strongly emphasized, with Botox by far the most commonly covered dermatology topic," said Dr. Kristina Collins.

Cosmetic procedures received 32% of the coverage, followed by skin diseases and disorders at 24%, skin cancer/tanning/sun protection at 22%, skin care at 12%, and acne and hair loss at 5% each.

Comparing the percentage of cosmetic vs. noncosmetic articles, the New York Post took the top spot with 72% cosmetic articles. It was followed by the New York Daily News (57%) and USA Today (55%). The Philadelphia Inquirer and the Denver Post had the lowest percentage of cosmetic articles at 37% and 29%, respectively.

Botox topped the chart when the articles were analyzed by topic (105 articles), followed by lasers (64), popularity of procedures (63), and sun protection tips (61). Botox for hyperhidrosis, smallpox/vaccine complications, epidermolysis bullosa, and tanning laws and restrictions took the bottom spots with 15 articles each.

A handful of other studies have also arrived at the same conclusion, with one focusing on the iconic TV sitcom Seinfeld and its reference to dermatologists. "Selecting satire to portray an already misunderstood and unknown subject matter may perpetuate incorrect public beliefs and stereotypes about those with skin diseases and diminish cultural sensitivity towards people who have dermatologic conditions and their caregivers," the authors wrote. (Dermatol. Online J. 2010;16:1).

Dr. Collins said that, with the aging population and the cultural shift in beauty norms, "people are genuinely interested in some of the cosmetic procedures that are available and that interest, in turn, drives the news media." But, "Somehow as a profession, we need to find ways to make important skin health information compelling both to the media and their target audiences.

"All of the aspects of our field have a place in the news, whether we are talking about Botox or basal cell carcinoma. We owe it to our patients to try to get them vital health information any way we are able," she said in an interview.

Dr. Collins had no disclosures.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

In the November issue of Journal of Drugs in Dermatology (2011;10:1235-9), Dr. Eliot F. Battle Jr., gives an excellent review of "Advances in Laser Hair Removal in Skin of Color."

Dr. Battle summarizes that "Laser hair removal, previously contraindicated in patients with ethnically dark (phototypes IV-VI) or sun-tanned skin, is now recognized as a safe and effective method of permanent hair reduction in all patients. Longer wavelengths, conservative fluences, longer pulse durations and appropriate cooling methods are necessary to minimize untoward side effects and maximize efficacy. The longer wavelength Nd:YAG laser is considered safest in treating darker skin of color. An added benefit of laser epilation is that side effects of conventional hair removal such as pseudo-folliculitis barbae and post inflammatory dyspigmentation, more commonly seen in skin of color, may also respond favorably to the laser, thus increasing the potential for patient satisfaction."

The mechanism of laser hair reduction (LHR) is based on the theory of selective photothermolysis, whereby thermal injury to a desired chromophore can be achieved with the appropriate wavelength, pulse duration, and fluence.

In LHR, the target chromophore is the pigment in the hair follicle and bulb. However, Dr. Battle notes that destruction of the non-pigmented progenitor stem cells is also required to achieve permanent hair reduction. Therefore, a modified theory of selective photothermolysis has been proposed for the mechanism of LHR where appropriate wavelengths, as well as longer pulse durations, must be used to allow heat to effectively destroy the melanocytic hair follicle and bulb, as well as the amelanotic hair follicle and stem cell. 

In darker skin types, longer wavelength lasers must be used to bypass absorption of epidermal pigment to prevent untoward side effects of dyspigmentation.

Currently the 810-nm diode and 1064-nm Nd:YAG lasers are Food and Drug Administration approved for skin types IV-VI. The Nd:YAG is inherently the safer of the two devices because of the longer wavelength; however,  long pulse durations with the diode laser with appropriate cooling have been shown to increase its safety profile.

Epidermal damage from lasers occurs when the epidermal temperature equals or exceeds 45 degrees Celsius, thus appropriate cooling mechanisms are essential for safe and effective LHR. Excessive cooling, however, can lead to dyspigmentation in darker skin.

Initiating LHR in darker skin should be done conservatively with longer wavelengths, lower fluences, and longer pulse durations. If test spots are performed, it is recommended to wait 48 hours before proceeding with therapy as patients with darker skin may manifest delayed dyspigmentation.

Patients with skin types IV-VI may also be at increased risk for paradoxical hypertrichosis. While it has been reported in most ethnic origins, those of Mediterranean and Pacific Asian descent may be particularly affected. Paradoxical hypertrichosis mainly occurs on the face and neck, and has been reported both within and outside the treatment area. While the exact cause is unknown, possible causes include the effect of inflammatory mediators and subtherapeutic thermal injury causing induction of the hair cycle. Current treatment for paradoxical hypertrichosis is laser therapy of the affected area.

The only contraindications for LHR are gold therapy and St. John’s Wort, which should be discontinued for 3 months prior to therapy. While not contraindicated, LHR is not recommended in pregnant women. 

There is no evidence supporting increased LHR side effects in patients recently receiving Accutane; however, until there is more data, it is recommended to wait 3 months after discontinuing Accutane before initiating LHR. Anti-viral prophylaxis may be taken 2-3 days prior to LHR and for 5-7 days after treatment for patients with a history of recurrent herpetic infections in the treatment area.

With each treatment, patients may expect a 10%-20% decrease in hair count, color, and diameter of the hair. In patients of darker color, a minimum of eight treatments may be required to achieve results, with treatments typically scheduled 4-8 weeks apart. 

Dr. Battle also noted that LHR not only treats unwanted hair, but also effectively diminishes inflammation and dyspigmentation from pseudofolliculitis barbae and acne keloidalis nuchae, as these conditions are due to ingrown and/or tufted coarse curled hairs in darker skin types.

Malcolm Gladwell wrote in "Outliers" that 10,000 hours of practice is the magic number to become an expert at a trade, which is why Dr. Derek Jones gets a little nervous about physician extenders performing dermatologic surgery procedures.

At the annual meeting of the American Society for Dermatologic Surgery in Washington, Dr. Jones reported that RNs receive 500 hours of clinical training, nurse practitioners receive 500-1,500 hours, physician assistants receive 2,800 hours, and dermatologists receive 18,720 hours.

Taking this into consideration, one can understand why Dr. Jones, who is in private practice in Los Angeles, seemed to be disturbed by the syndicated television program "Pretty Hurts," a soap opera-like reality show that documents Rand Rush, RN, (yes, you read that right: RN) as he injects wanna-be celebrity patients in his Beverly Hills office.

"Pretty Hurts is your insider OMFG view into the ridiculous, painful and ugly truth behind maintaining beauty in Hollywood," according to the show's summary. "Once you experience the extreme stop-at-nothing obsession with youth that has become standard in Beverly Hills, you'll never look at 'pretty' the same way again."

According to Rand's website, he is under the supervision (as required by California law) of Dr. Norman Leaf, a plastic surgeon. But, on the show, he appears to be performing with little to no physician supervision.

So who is to blame for non-physicians performing these aesthetic services? "We are," said Dr. Jones. Dermatologists are organizing and teaching at courses geared towards physician extenders.

While he does not believe that it is inappropriate to teach extenders, he said, "What we need here is a rigorous post-training residency program for physician extenders that levels the playing field. We are not going to see physician extenders go away. The genie is out of the bottle." But, he added, more rigorous training would help protect ourselves, our patients, and the specialty.

Dr. Jones disclosed conflicts of interest with Allergan, Galderma, and Merz.

What do you think? Should physician extenders be allowed to perform cosmetic services, such as laser hair removal and cosmetic injections?

-- Amy Pfeiffer

Malcolm Gladwell wrote in "Outliers" that 10,000 hours of practice is the magic number to become an expert at a trade, which is why Dr. Derek Jones gets a little nervous about physician extenders performing dermatologic surgery procedures.

At the annual meeting of the American Society for Dermatologic Surgery in Washington, Dr. Jones reported that RNs receive 500 hours of clinical training, nurse practitioners receive 500-1,500 hours, physician assistants receive 2,800 hours, and dermatologists receive 18,720 hours.

Taking this into consideration, one can understand why Dr. Jones, who is in private practice in Los Angeles, seemed to be disturbed by the syndicated television program "Pretty Hurts," a soap opera-like reality show that documents Rand Rush, RN, (yes, you read that right: RN) as he injects wanna-be celebrity patients in his Beverly Hills office.

"Pretty Hurts is your insider OMFG view into the ridiculous, painful and ugly truth behind maintaining beauty in Hollywood," according to the show's summary. "Once you experience the extreme stop-at-nothing obsession with youth that has become standard in Beverly Hills, you'll never look at 'pretty' the same way again."

According to Rand's website, he is under the supervision (as required by California law) of Dr. Norman Leaf, a plastic surgeon. But, on the show, he appears to be performing with little to no physician supervision.

So who is to blame for non-physicians performing these aesthetic services? "We are," said Dr. Jones. Dermatologists are organizing and teaching at courses geared towards physician extenders.

While he does not believe that it is inappropriate to teach extenders, he said, "What we need here is a rigorous post-training residency program for physician extenders that levels the playing field. We are not going to see physician extenders go away. The genie is out of the bottle." But, he added, more rigorous training would help protect ourselves, our patients, and the specialty.

Dr. Jones disclosed conflicts of interest with Allergan, Galderma, and Merz.

What do you think? Should physician extenders be allowed to perform cosmetic services, such as laser hair removal and cosmetic injections?

-- Amy Pfeiffer

Malcolm Gladwell wrote in "Outliers" that 10,000 hours of practice is the magic number to become an expert at a trade, which is why Dr. Derek Jones gets a little nervous about physician extenders performing dermatologic surgery procedures.

At the annual meeting of the American Society for Dermatologic Surgery in Washington, Dr. Jones reported that RNs receive 500 hours of clinical training, nurse practitioners receive 500-1,500 hours, physician assistants receive 2,800 hours, and dermatologists receive 18,720 hours.

Taking this into consideration, one can understand why Dr. Jones, who is in private practice in Los Angeles, seemed to be disturbed by the syndicated television program "Pretty Hurts," a soap opera-like reality show that documents Rand Rush, RN, (yes, you read that right: RN) as he injects wanna-be celebrity patients in his Beverly Hills office.

"Pretty Hurts is your insider OMFG view into the ridiculous, painful and ugly truth behind maintaining beauty in Hollywood," according to the show's summary. "Once you experience the extreme stop-at-nothing obsession with youth that has become standard in Beverly Hills, you'll never look at 'pretty' the same way again."

According to Rand's website, he is under the supervision (as required by California law) of Dr. Norman Leaf, a plastic surgeon. But, on the show, he appears to be performing with little to no physician supervision.

So who is to blame for non-physicians performing these aesthetic services? "We are," said Dr. Jones. Dermatologists are organizing and teaching at courses geared towards physician extenders.

While he does not believe that it is inappropriate to teach extenders, he said, "What we need here is a rigorous post-training residency program for physician extenders that levels the playing field. We are not going to see physician extenders go away. The genie is out of the bottle." But, he added, more rigorous training would help protect ourselves, our patients, and the specialty.

Dr. Jones disclosed conflicts of interest with Allergan, Galderma, and Merz.

What do you think? Should physician extenders be allowed to perform cosmetic services, such as laser hair removal and cosmetic injections?

-- Amy Pfeiffer

WASHINGTON – The autologous cellular product azficel-T produced significant improvement in acne scarring compared with placebo, according to new study results reported at the annual meeting of the American Society for Dermatologic Surgery.

The product, Laviv (Fibrocell Science), was recently approved by the Food and Drug Administration for the treatment of moderate to severe nasolabial folds. It is the first FDA-approved personalized cell therapy for aesthetic use, according to Dr. Girish Munavalli of the dermatology department at Wake Forest University, Winston-Salem, N.C.

In the multicenter, randomized, double-blind, placebo-controlled study, skin biopsies were collected from 119 patients with moderate-to-severe depressed acne scarring of at least 9 cm² for at least 3 years. The biopsies were used to produce individual fibroblasts for each patient. Up to three injections of 2 mL of autologous fibroblasts (10-20 million cells/mL) were given on one cheek and placebo on the other at 14-day intervals in 99 of the patients. Treatment was administered at a dose of 0.1 mL/cm² into areas of acne scarring. Adverse events were recorded for each cheek.

At 4 months after completion of the treatment, a statistically significant higher percentage of patients had responded to treatment with azficel-T than to treatment with placebo, as rated by both the study investigators (58.7% vs. 42.2%, respectively) and patients (43.1% vs. 18.3%). Patient and evaluator assessments at earlier time points during the study also showed a significantly higher proportion of responses with azficel-T than with placebo at all but one assessment, reported Dr. Munavalli.

The study successfully met its two prospectively defined end points: a 2-point or greater improvement on a 5-point Subject Live Acne Scarring assessment scale, and a 1-point or greater reduction in cheek acne severity on a physician-assessed, validated 5-point Evaluator Live Acne Scar assessment scale.

All reported adverse events were mild or moderate in severity. No subjects experienced serious adverse events, discontinued treatment, or withdrew from the study. The incidence of adverse events occurring in the treatment areas was comparable between azficel-T and placebo. The most commonly reported adverse events were treatment-area erythema (occurring in 11.1%) and swelling (10.1%). In the azficel-T-treated area, erythema was moderate in 5 of the 12 subjects who reported it, and swelling was moderate in 5 of the 11 who reported it. In contrast, all treatment-related adverse events in the placebo-treated areas were mild.

Other adverse events with a possible relationship to study treatment included bruising, rash, irritation, nodules, pain, acne, induration, and headache, Dr. Munavalli reported.

"Our findings show that using a person's own collagen-producing cells in the form of Laviv may provide a promising new alternative to improve acne scarring with minimal downtime and an excellent safety profile," he noted.

Dr. Munavalli received research funding from Fibrocell Science.

WASHINGTON – The autologous cellular product azficel-T produced significant improvement in acne scarring compared with placebo, according to new study results reported at the annual meeting of the American Society for Dermatologic Surgery.

The product, Laviv (Fibrocell Science), was recently approved by the Food and Drug Administration for the treatment of moderate to severe nasolabial folds. It is the first FDA-approved personalized cell therapy for aesthetic use, according to Dr. Girish Munavalli of the dermatology department at Wake Forest University, Winston-Salem, N.C.

In the multicenter, randomized, double-blind, placebo-controlled study, skin biopsies were collected from 119 patients with moderate-to-severe depressed acne scarring of at least 9 cm² for at least 3 years. The biopsies were used to produce individual fibroblasts for each patient. Up to three injections of 2 mL of autologous fibroblasts (10-20 million cells/mL) were given on one cheek and placebo on the other at 14-day intervals in 99 of the patients. Treatment was administered at a dose of 0.1 mL/cm² into areas of acne scarring. Adverse events were recorded for each cheek.

At 4 months after completion of the treatment, a statistically significant higher percentage of patients had responded to treatment with azficel-T than to treatment with placebo, as rated by both the study investigators (58.7% vs. 42.2%, respectively) and patients (43.1% vs. 18.3%). Patient and evaluator assessments at earlier time points during the study also showed a significantly higher proportion of responses with azficel-T than with placebo at all but one assessment, reported Dr. Munavalli.

The study successfully met its two prospectively defined end points: a 2-point or greater improvement on a 5-point Subject Live Acne Scarring assessment scale, and a 1-point or greater reduction in cheek acne severity on a physician-assessed, validated 5-point Evaluator Live Acne Scar assessment scale.

All reported adverse events were mild or moderate in severity. No subjects experienced serious adverse events, discontinued treatment, or withdrew from the study. The incidence of adverse events occurring in the treatment areas was comparable between azficel-T and placebo. The most commonly reported adverse events were treatment-area erythema (occurring in 11.1%) and swelling (10.1%). In the azficel-T-treated area, erythema was moderate in 5 of the 12 subjects who reported it, and swelling was moderate in 5 of the 11 who reported it. In contrast, all treatment-related adverse events in the placebo-treated areas were mild.

Other adverse events with a possible relationship to study treatment included bruising, rash, irritation, nodules, pain, acne, induration, and headache, Dr. Munavalli reported.

"Our findings show that using a person's own collagen-producing cells in the form of Laviv may provide a promising new alternative to improve acne scarring with minimal downtime and an excellent safety profile," he noted.

Dr. Munavalli received research funding from Fibrocell Science.

WASHINGTON – The autologous cellular product azficel-T produced significant improvement in acne scarring compared with placebo, according to new study results reported at the annual meeting of the American Society for Dermatologic Surgery.

The product, Laviv (Fibrocell Science), was recently approved by the Food and Drug Administration for the treatment of moderate to severe nasolabial folds. It is the first FDA-approved personalized cell therapy for aesthetic use, according to Dr. Girish Munavalli of the dermatology department at Wake Forest University, Winston-Salem, N.C.

In the multicenter, randomized, double-blind, placebo-controlled study, skin biopsies were collected from 119 patients with moderate-to-severe depressed acne scarring of at least 9 cm² for at least 3 years. The biopsies were used to produce individual fibroblasts for each patient. Up to three injections of 2 mL of autologous fibroblasts (10-20 million cells/mL) were given on one cheek and placebo on the other at 14-day intervals in 99 of the patients. Treatment was administered at a dose of 0.1 mL/cm² into areas of acne scarring. Adverse events were recorded for each cheek.

At 4 months after completion of the treatment, a statistically significant higher percentage of patients had responded to treatment with azficel-T than to treatment with placebo, as rated by both the study investigators (58.7% vs. 42.2%, respectively) and patients (43.1% vs. 18.3%). Patient and evaluator assessments at earlier time points during the study also showed a significantly higher proportion of responses with azficel-T than with placebo at all but one assessment, reported Dr. Munavalli.

The study successfully met its two prospectively defined end points: a 2-point or greater improvement on a 5-point Subject Live Acne Scarring assessment scale, and a 1-point or greater reduction in cheek acne severity on a physician-assessed, validated 5-point Evaluator Live Acne Scar assessment scale.

All reported adverse events were mild or moderate in severity. No subjects experienced serious adverse events, discontinued treatment, or withdrew from the study. The incidence of adverse events occurring in the treatment areas was comparable between azficel-T and placebo. The most commonly reported adverse events were treatment-area erythema (occurring in 11.1%) and swelling (10.1%). In the azficel-T-treated area, erythema was moderate in 5 of the 12 subjects who reported it, and swelling was moderate in 5 of the 11 who reported it. In contrast, all treatment-related adverse events in the placebo-treated areas were mild.

Other adverse events with a possible relationship to study treatment included bruising, rash, irritation, nodules, pain, acne, induration, and headache, Dr. Munavalli reported.

"Our findings show that using a person's own collagen-producing cells in the form of Laviv may provide a promising new alternative to improve acne scarring with minimal downtime and an excellent safety profile," he noted.

Dr. Munavalli received research funding from Fibrocell Science.

The Food and Drug Administration has approved Restylane for lip augmentation, the manufacturer announced Oct. 11.

The hyaluronic acid dermal filler was first approved in 2005 for mid to deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, and has been used off-label for lip augmentation. Restylane (Medicis Aesthetics) is a hyaluronic acid gel generated by Streptococcus bacteria, chemically crosslinked with 1,4 butanediol diglycidyl ether.

At a meeting in April, an FDA advisory panel voted 6-0 with 1 abstention that the benefits of using the filler as a submucosal injection for lip augmentation outweighed its risks, and that the filler was safe and effective for the expanded indication.

At that meeting, the panel reviewed the results of a study of 135 patients who received lip augmentation with Restylane (with a mean filler volume of 2.9 cc per patient, with a range of 0.6-5.6 cc per patient) and 45 patients with no treatment. At 8 weeks, 92% of patients who received Restylane were considered responders; almost all patients (99%) experienced adverse events, which included expected treatment-emergent adverse events such as bruising, redness, swelling, pain, tenderness, itching, and skin exfoliation. Of those who were treated, 40% experienced adverse outcomes that they felt affected their daily activity or were disabling, and 15% experienced adverse events (typically swelling and tenderness) that lasted more than 15 days.

Among the concerns expressed by the panel was the lack of men and people with dark skin in the study.

The Food and Drug Administration has approved Restylane for lip augmentation, the manufacturer announced Oct. 11.

The hyaluronic acid dermal filler was first approved in 2005 for mid to deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, and has been used off-label for lip augmentation. Restylane (Medicis Aesthetics) is a hyaluronic acid gel generated by Streptococcus bacteria, chemically crosslinked with 1,4 butanediol diglycidyl ether.

At a meeting in April, an FDA advisory panel voted 6-0 with 1 abstention that the benefits of using the filler as a submucosal injection for lip augmentation outweighed its risks, and that the filler was safe and effective for the expanded indication.

At that meeting, the panel reviewed the results of a study of 135 patients who received lip augmentation with Restylane (with a mean filler volume of 2.9 cc per patient, with a range of 0.6-5.6 cc per patient) and 45 patients with no treatment. At 8 weeks, 92% of patients who received Restylane were considered responders; almost all patients (99%) experienced adverse events, which included expected treatment-emergent adverse events such as bruising, redness, swelling, pain, tenderness, itching, and skin exfoliation. Of those who were treated, 40% experienced adverse outcomes that they felt affected their daily activity or were disabling, and 15% experienced adverse events (typically swelling and tenderness) that lasted more than 15 days.

Among the concerns expressed by the panel was the lack of men and people with dark skin in the study.

The Food and Drug Administration has approved Restylane for lip augmentation, the manufacturer announced Oct. 11.

The hyaluronic acid dermal filler was first approved in 2005 for mid to deep dermal implantation for the correction of moderate to severe facial wrinkles and folds, and has been used off-label for lip augmentation. Restylane (Medicis Aesthetics) is a hyaluronic acid gel generated by Streptococcus bacteria, chemically crosslinked with 1,4 butanediol diglycidyl ether.

At a meeting in April, an FDA advisory panel voted 6-0 with 1 abstention that the benefits of using the filler as a submucosal injection for lip augmentation outweighed its risks, and that the filler was safe and effective for the expanded indication.

At that meeting, the panel reviewed the results of a study of 135 patients who received lip augmentation with Restylane (with a mean filler volume of 2.9 cc per patient, with a range of 0.6-5.6 cc per patient) and 45 patients with no treatment. At 8 weeks, 92% of patients who received Restylane were considered responders; almost all patients (99%) experienced adverse events, which included expected treatment-emergent adverse events such as bruising, redness, swelling, pain, tenderness, itching, and skin exfoliation. Of those who were treated, 40% experienced adverse outcomes that they felt affected their daily activity or were disabling, and 15% experienced adverse events (typically swelling and tenderness) that lasted more than 15 days.

Among the concerns expressed by the panel was the lack of men and people with dark skin in the study.

When patients ask about fillers for their face, it presents the opportunity to also talk to them about their aging hands, according to Dr. Dee Anna Glaser, a professor and vice-chairman of the department of dermatology at St. Louis University School of Medicine. 

Prepared fillers such as hyaluronic acid can be used to rejuvenate aging hands, she said. The amount used is about two to three syringes for both hands, recovery is quick, and the results can last up a year.

The procedure is also relatively safe, and aside from the initial bruising and lumpiness, the odds of infection are low, said Dr. Glaser. However, she did not advise using permanent fillers.

When patients ask about fillers for their face, it presents the opportunity to also talk to them about their aging hands, according to Dr. Dee Anna Glaser, a professor and vice-chairman of the department of dermatology at St. Louis University School of Medicine. 

Prepared fillers such as hyaluronic acid can be used to rejuvenate aging hands, she said. The amount used is about two to three syringes for both hands, recovery is quick, and the results can last up a year.

The procedure is also relatively safe, and aside from the initial bruising and lumpiness, the odds of infection are low, said Dr. Glaser. However, she did not advise using permanent fillers.

When patients ask about fillers for their face, it presents the opportunity to also talk to them about their aging hands, according to Dr. Dee Anna Glaser, a professor and vice-chairman of the department of dermatology at St. Louis University School of Medicine. 

Prepared fillers such as hyaluronic acid can be used to rejuvenate aging hands, she said. The amount used is about two to three syringes for both hands, recovery is quick, and the results can last up a year.

The procedure is also relatively safe, and aside from the initial bruising and lumpiness, the odds of infection are low, said Dr. Glaser. However, she did not advise using permanent fillers.