Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

Dr. Richard K. Scher discussed the dangers of gel nail polish, and also gave tips to share with patients on how to have a safe experience at the nail salon at the American Academy of Dermatology's Summer Academy meeting in New York.

Patients undergoing gel nail polish application at salons expose their hands to several minutes of UV light to harden the layers of polish, said Dr. Scher of Columbia University, New York. Their hands are also soaked in acetone for up to 10 minutes to dissolve the hard to remove shellac during polish changes.

In the video below, Dr. Scher offers advice and tips for patients that frequent nail salons.

SAN DIEGO – A chief goal during cutaneous surgery in the facial region should be to avoid disturbing or crossing contour lines such as the alar fold, the junction of the eyebrow and forehead, and the eyelid margin, according to Dr. Jenny Kim.

"Alterations in these aesthetic lines will have a profound impact on an individual’s appearance," Dr. Kim said at the meeting sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. "Functional complications may also result from crossing these lines."

If the defect involves one or more cosmetic units, such as the cheek and nose, "repair each unit separately," advised Dr. Kim, associate professor of medicine and dermatology at the University of California, Los Angeles. "This allows for incisions to be hidden along contour lines and will provide you with a better aesthetic appearance."

She also recommends marking contour lines prior to challenging repairs, such as those in the vermilion border of the lip or in the nasolabial fold.

Skin tension lines, she said, follow the direction of the greatest intrinsic tension in the skin. Also known as maximal skin tension lines, relaxed skin tension lines, and Langer’s lines, skin tension lines "are less well defined compared with contour lines, and incisions placed parallel to these lines heal with a finer, more cosmetically pleasing scar," Dr. Kim said.

Unlike contour lines, skin tension lines vary widely among individuals due to various intrinsic and extrinsic factors "One of the most important intrinsic factors is the collagen in our dermis," she said. "Type I and type III collagen provide 70%-80% of wound volume in the dermis as well as tensile properties of the skin. It resists extensibility under tension and elongates with prolonged tension."

On the other hand, she continued, elastic tissue "will easily be extensible under minimal tension. It has the capacity to resume its original shape after tension is released. Elastic fibers maintain static tension of the skin and provide tensile strength."

Elastic tissue has an increased tension vector parallel to skin tension lines and a decreased tension vector perpendicular to skin tension lines. "These are some of the reasons why you want your wound to be parallel to your skin tension lines," said Dr. Kim, who is also a codirector of the medical school’s Procedural Dermatology Fellowship.

Extrinsic factors that play a role in skin tension lines include the muscles of facial expression, sun damage, aging, and smoking. Aging, for example, leads to fragmentation and loss of elastic fiber, "which is why there’s more variability in skin tension lines as you age," she said.

In order to best determine skin tension lines prior to surgery, have the patient sit upright. "This is because the lines can appear different when a person is lying down versus sitting due to gravity," Dr. Kim said. "Creases and folds secondary to muscle movement can be determined by having patients move facial muscles."

She makes it a point to mark skin tension lines before using anesthesia, "as the swelling from anesthesia makes these lines visible and a patient may not be able to contract muscles later. Draw in the skin tension lines before beginning the surgery. You want to make sure that you maintain function [of the lines], especially around the eyes and the mouth. Evaluate each patient individually, because there are always exceptions to our rules."

Dr. Kim said that she had no relevant financial conflicts to disclose.

SAN DIEGO – A chief goal during cutaneous surgery in the facial region should be to avoid disturbing or crossing contour lines such as the alar fold, the junction of the eyebrow and forehead, and the eyelid margin, according to Dr. Jenny Kim.

"Alterations in these aesthetic lines will have a profound impact on an individual’s appearance," Dr. Kim said at the meeting sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. "Functional complications may also result from crossing these lines."

If the defect involves one or more cosmetic units, such as the cheek and nose, "repair each unit separately," advised Dr. Kim, associate professor of medicine and dermatology at the University of California, Los Angeles. "This allows for incisions to be hidden along contour lines and will provide you with a better aesthetic appearance."

She also recommends marking contour lines prior to challenging repairs, such as those in the vermilion border of the lip or in the nasolabial fold.

Skin tension lines, she said, follow the direction of the greatest intrinsic tension in the skin. Also known as maximal skin tension lines, relaxed skin tension lines, and Langer’s lines, skin tension lines "are less well defined compared with contour lines, and incisions placed parallel to these lines heal with a finer, more cosmetically pleasing scar," Dr. Kim said.

Unlike contour lines, skin tension lines vary widely among individuals due to various intrinsic and extrinsic factors "One of the most important intrinsic factors is the collagen in our dermis," she said. "Type I and type III collagen provide 70%-80% of wound volume in the dermis as well as tensile properties of the skin. It resists extensibility under tension and elongates with prolonged tension."

On the other hand, she continued, elastic tissue "will easily be extensible under minimal tension. It has the capacity to resume its original shape after tension is released. Elastic fibers maintain static tension of the skin and provide tensile strength."

Elastic tissue has an increased tension vector parallel to skin tension lines and a decreased tension vector perpendicular to skin tension lines. "These are some of the reasons why you want your wound to be parallel to your skin tension lines," said Dr. Kim, who is also a codirector of the medical school’s Procedural Dermatology Fellowship.

Extrinsic factors that play a role in skin tension lines include the muscles of facial expression, sun damage, aging, and smoking. Aging, for example, leads to fragmentation and loss of elastic fiber, "which is why there’s more variability in skin tension lines as you age," she said.

In order to best determine skin tension lines prior to surgery, have the patient sit upright. "This is because the lines can appear different when a person is lying down versus sitting due to gravity," Dr. Kim said. "Creases and folds secondary to muscle movement can be determined by having patients move facial muscles."

She makes it a point to mark skin tension lines before using anesthesia, "as the swelling from anesthesia makes these lines visible and a patient may not be able to contract muscles later. Draw in the skin tension lines before beginning the surgery. You want to make sure that you maintain function [of the lines], especially around the eyes and the mouth. Evaluate each patient individually, because there are always exceptions to our rules."

Dr. Kim said that she had no relevant financial conflicts to disclose.

SAN DIEGO – A chief goal during cutaneous surgery in the facial region should be to avoid disturbing or crossing contour lines such as the alar fold, the junction of the eyebrow and forehead, and the eyelid margin, according to Dr. Jenny Kim.

"Alterations in these aesthetic lines will have a profound impact on an individual’s appearance," Dr. Kim said at the meeting sponsored by the University of California, San Diego School of Medicine and the Scripps Clinic. "Functional complications may also result from crossing these lines."

If the defect involves one or more cosmetic units, such as the cheek and nose, "repair each unit separately," advised Dr. Kim, associate professor of medicine and dermatology at the University of California, Los Angeles. "This allows for incisions to be hidden along contour lines and will provide you with a better aesthetic appearance."

She also recommends marking contour lines prior to challenging repairs, such as those in the vermilion border of the lip or in the nasolabial fold.

Skin tension lines, she said, follow the direction of the greatest intrinsic tension in the skin. Also known as maximal skin tension lines, relaxed skin tension lines, and Langer’s lines, skin tension lines "are less well defined compared with contour lines, and incisions placed parallel to these lines heal with a finer, more cosmetically pleasing scar," Dr. Kim said.

Unlike contour lines, skin tension lines vary widely among individuals due to various intrinsic and extrinsic factors "One of the most important intrinsic factors is the collagen in our dermis," she said. "Type I and type III collagen provide 70%-80% of wound volume in the dermis as well as tensile properties of the skin. It resists extensibility under tension and elongates with prolonged tension."

On the other hand, she continued, elastic tissue "will easily be extensible under minimal tension. It has the capacity to resume its original shape after tension is released. Elastic fibers maintain static tension of the skin and provide tensile strength."

Elastic tissue has an increased tension vector parallel to skin tension lines and a decreased tension vector perpendicular to skin tension lines. "These are some of the reasons why you want your wound to be parallel to your skin tension lines," said Dr. Kim, who is also a codirector of the medical school’s Procedural Dermatology Fellowship.

Extrinsic factors that play a role in skin tension lines include the muscles of facial expression, sun damage, aging, and smoking. Aging, for example, leads to fragmentation and loss of elastic fiber, "which is why there’s more variability in skin tension lines as you age," she said.

In order to best determine skin tension lines prior to surgery, have the patient sit upright. "This is because the lines can appear different when a person is lying down versus sitting due to gravity," Dr. Kim said. "Creases and folds secondary to muscle movement can be determined by having patients move facial muscles."

She makes it a point to mark skin tension lines before using anesthesia, "as the swelling from anesthesia makes these lines visible and a patient may not be able to contract muscles later. Draw in the skin tension lines before beginning the surgery. You want to make sure that you maintain function [of the lines], especially around the eyes and the mouth. Evaluate each patient individually, because there are always exceptions to our rules."

Dr. Kim said that she had no relevant financial conflicts to disclose.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

SEOUL, SOUTH KOREA – The nonablative fractionated thulium laser at 1,927-nm wavelength is a promising new noninvasive therapy for actinic keratoses.

The laser was actually developed for superficial skin resurfacing, an application for which it is particularly well suited because the 1,927-nm wavelength minimizes patient discomfort. But while investigating the device for improvement of pigmentation, Dr. Roy G. Geronemus noted incidentally that patients were also achieving "a rather dramatic resolution" of multiple facial actinic keratoses (AKs). So he decided to conduct a formal examination of the laser’s performance for this purpose, he said at the World Congress of Dermatology

To date, in 15 patients followed for 1-6 months after the last of several thulium laser treatment sessions for multiple facial AKs, the mean clearance of the lesions was 84%-91%.

"This compares very favorably to other modalities that are out there, including the topical chemotherapies, immunomodulatory agents, and photodynamic therapy. The advantage of this is not only do you improve the AKs, but you’re also getting the cosmetic benefit simultaneously," said Dr. Geronemus, medical director of the Laser and Skin Surgery Center of New York.

Patients received up to four treatments at 2- to 6-week intervals. The laser setting was 5-20 mJ, with 30%-70% coverage per session. Topical anesthetic was utilized for 1 hour, supplemented as needed by intramuscular ketorolac.

After a single treatment a mean of 63% of AKs were cleared. After two, 84%, and after three, 85%.

The laser therapy was well tolerated. The average pain score during treatment was 2.7 on a 0-9 scale. No scarring or infections have occurred. Mild redness and peeling typically lasted 4-5 days.

Dr. Geronemus said he and his colleagues have also found that the 1,927-nm fractionated thulium laser brings about "dramatic improvement" in actinic cheilitis, and is also highly effective for the thorny problem of enlarged facial pore size.

Dr. Geronemus is a shareholder in Solta Medical, which markets the 1,927-nm fractionated thulium laser. He also is on the advisory boards of numerous dermatologic laser manufacturers.

Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.

Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.

Jay Mallin/Elsevier Global Medical News

"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."

Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.

"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."

Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.

All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.

"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."

A Jack of All Trades

Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.

She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.

"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."

Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.

"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."

She doesn't shy away from discussing the financial benefits of cosmetic work.

"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."

She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "

For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."

As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "

Taking on New Roles

Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."

When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.

"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.

At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."

Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.

"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."

"We Treat Cosmetic Issues, Not Health Issues"

Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.

"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."

Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.

Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."

Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.

"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."

He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.

Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.

"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."

Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.

His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.

"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."

Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.

Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.

Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.

Jay Mallin/Elsevier Global Medical News

"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."

Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.

"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."

Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.

All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.

"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."

A Jack of All Trades

Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.

She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.

"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."

Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.

"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."

She doesn't shy away from discussing the financial benefits of cosmetic work.

"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."

She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "

For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."

As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "

Taking on New Roles

Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."

When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.

"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.

At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."

Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.

"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."

"We Treat Cosmetic Issues, Not Health Issues"

Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.

"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."

Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.

Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."

Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.

"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."

He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.

Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.

"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."

Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.

His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.

"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."

Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.

Medical and cosmetic dermatologists may bring different views to the discussion of skin care, but they do agree on one thing – health should always come before beauty.

Basic dermatologic health procedures, like total body skin checks, mole assessment, and sun exposure advice, should be the foundation of any cosmetic dermatologist's work. No amount of wrinkle reduction, laser resurfacing, or complexion correction can ever make up for a missed skin cancer, according to cosmetic dermatologists.

Jay Mallin/Elsevier Global Medical News

"I take this responsibility very seriously," said Dr. Elizabeth Tanzi, a Washington, D.C. dermatologist who specializes in laser surgery. "All our patients, whether new or returning, get a full head-to-toe exam for skin cancer. It would be tragic to be talking about wrinkles and crepey skin when there’s a skin cancer."

Dr. Tanzi said that health should be center of any dermatologic procedure – and that cosmetic procedures are no exception.

"We have to look at it like this: Number one, make sure your skin is healthy. Number two: beautify it."

Dermatologic practices are split into three categories: all cosmetic, all medical, or a combination of the two. Purely medical dermatologists tend to cluster in academic institutions, while purely cosmetic dermatologists are most often seen in large cities. Dual-therapy dermatologists are the workhorses who serve most communities.

All dermatologists need to know when to proceed and when to say "no," Dr. Tanzi said. Referral to a medical dermatologist may cost a patient in the short term, but will serve everyone well in the long term.

"If a patient comes to me with an issue in my area of expertise and I know I can do a great job, I’ll take it," said Dr. Tanzi, codirector of the Washington Institute of Dermatologic Laser Surgery. "If they come in with something where I’m not up on the latest, or something I haven't seen in years and feel I won’t be best for the job, I refer. An urban setting really allows this to happen. In D.C. we have the luxury of saying that there is someone nearby who is an expert in any field. It is a different story in communities where you need to be a jack of all trades."

A Jack of All Trades

Dr. Margaret "Peggy" Fitch fills that bill. "I’m a surgical and cosmetic dermatologist in the morning and a medical dermatologist in the afternoon," said Dr. Fitch, founder of Aiken Dermatology, Aiken, S.C.

She didn't always split her time between the disciplines, however. When she began practicing 30 years ago, she focused on medical and surgical dermatology. Then things began to change.

"Over time, peels, fillers, Botox, and sclerotherapy came along. They were on the front page of Cosmopolitan. Patients were asking about them. And I was seeing the results of bad outcomes – procedures done by physicians who shouldn’t have been doing them."

Taking a weekend course in a cosmetic procedure does not make an expert, Dr. Fitch said.

"Let’s be honest – there are lots of doctors out there who do this just to make a quick buck, and I was seeing the results of that. So I thought, 'I'm a dermatologist. I know skin and the anatomic structure of the face. I should be doing this.' So gradually I learned and added to my practice."

She doesn't shy away from discussing the financial benefits of cosmetic work.

"Sure, it's a revenue builder. But I let patients decide what they want. If someone comes to me for a medical issue, I will never, ever bring up a cosmetic issue. I think that is foraging in the forest for a buck. If a patient asks about Botox while we're talking, that's another issue. But as a doctor, I would never bring up someone’s wrinkles."

She isn’t afraid to say "no" either. "I say no all the time. I’m not above saying, 'Look you don’t need this.' "

For example, she said, a 27-year-old bride-to-be asked her for filler for her lips. Dr. Fitch refused, telling her the lines were too fine to be treated, and that she was too young to be looking at the procedure. "I could have made $500 for that. But I think I'm the exception to the rule here. Most people would have gone and done it."

As a surgical dermatologist, she concentrates on skin cancers, using her own in-office pathology lab to assess the specimens. "I do flaps and grafts, but I would never attempt a full Mohs. That’s all part of knowing when you must say to a patient, 'I'm a good doctor and a good surgeon, but I'm not the best person for this.' "

Taking on New Roles

Dr. Sue Ellen Cox is another dermatologist who enjoys mixing it up. While 80% of her practice is cosmetic, the rest of her patients have medical issues. "If a patient comes to me and doesn't already have a general dermatologist, I'll take on that role without a problem. I really enjoy doing that – it gives me some variety and keeps me sharp."

When she began her 16-year-old practice in Chapel Hill, N.C., she did outreach to local dermatologists. With several years of specialized training in collagen, lasers, and liposuction, and a research study on chemical peels, Dr. Cox felt like she could bring something new and valuable to the medical community.

"I went to all the dermatologists in the area and told them about my specialized training and asked them to send me any cosmetic cases they weren't comfortable with. My practice just took off from there," she said.

At the same time, she never bites the hand that feeds her. "If someone is referred to me for laser and I see a basal cell carcinoma, for example, I'll tell them to talk to their referring physician before I do anything. Referrals are a lifeline, and I don't want to cut that."

Dermatologists who combine both medical and cosmetic work need to be scrupulous in their billing, she warned.

"If I'm doing a laser treatment for rosacea, that's a fee for service procedure. If I'm diagnosing rosacea for the first time, I bill insurance. If I diagnose lentigoes and precancerous lesions and treat them, I bill insurance. But if the main benefit is cosmetic, it's self pay. The same with moles – removal of a benign mole for cosmetic reasons is one thing, removal and biopsy of a suspicious mole is another."

"We Treat Cosmetic Issues, Not Health Issues"

Dr. Eliot Battle has no issues with insurance billing. As a completely cosmetic dermatologist, his business is all self pay. And his patients know that from the beginning.

"There is no confusion about what we do. We treat cosmetic issues – not health issues. I don't take insurance, and our advertising and website are very clear about this. If we see someone with medical issues, we push them to a medical dermatologist – that saves them money, and we know that medical derms are better for these things than we would ever be."

Dr. Battle has built his practice on four areas – laser hair removal, complexion blending, textural rejuvenation, and antiaging procedures. About 100 patients, primarily women, come through his office every day, 6 days a week. Dr. Battle specializes in treating darker skin, which is much more prone to the scarring and pigmentation changes that can result from inexpert cosmetic treatment.

Dr. Battle does few of the procedures. He conducts all of the consultations and designs the treatment plans, but registered nurses perform the procedures. "I work with six full-time nurses, who undergo a strict internal training program and participate in ongoing medical education. I send them to every possible meeting that could be of help, and I support all this education financially."

Dr. Battle brings a unique set of business skills to his medical practice. After working as a marketing director for a large computer firm, he decided to enroll in medical school.

"I took my first science course at age 33 and was a dermatology resident at age 41," he said. "When I finally finished, my passion was cosmetic dermatology. At that point lasers were still in their infancy, and I worked for 3 years in research about laser safety – especially for skin of color."

He designed his cosmetic work as not only a practice but as a business, with his children's future in mind. "I wanted to make sure they could inherit my own success," he said. "Children cannot inherit a physician's practice, but they can inherit a business." Dr. Battle does not treat patients himself, so the Cultura Cosmetic Dermatology and Laser Center in Washington, is considered a business rather than a practice.

Because he offers limited procedures, his staff has become expert in performing them, he said. But when he encounters anything beyond what he is prepared to offer, Dr. Battle refers to a medical dermatologist.

"My medical oath says to do no harm, and that rules all that I do. We are always looking out for the patient's best interest. If I see a suspicious mole or a concerning flare of lupus, I refer. I am not geared to help that person."

Dr. Battle hasn't completely foresworn either medical or academic work, however. He conducts research at Howard University, Washington, and teaches residents who are interested in cosmetic dermatology.

His business background puts him in a position to offer business advice, and his age, he said, allows him to give personal counsel as well.

"One thing I tell residents is that just because they might generate a lot of revenue with a cosmetic practice doesn't necessarily mean they'll generate a lot of profit. It's also important for people to be true to themselves. I encourage them to look deeply into this and not be blinded by the idea that they'll make tons of money doing cosmetic work. A lot of residents really enjoy the academic side of medicine, and cosmetic dermatology will not bring them that. If academics are your passion, you should not forego that for the temporary dollar."

Dr. Tanzi is on the medical advisory board for Zeltiq. Dr. Cox is a consultant for Medisys and Allergan. Dr. Battle and Dr. Fitch reported having no conflicts of interest.

On July 21, the Food and Drug Administration approved incobotulinumtoxinA for the temporary improvement in appearance of moderate to severe glabellar lines in adult patients.

Manufactured by Merz Aesthetics and marketed as Xeomin, incobotulinumtoxinA is the third botulinum toxin type A to enter the marketplace, following Botox and Dysport, respectively. It is expected to be available to physicians in the United States in the spring of 2012.

IncobotulinumtoxinA's approval is based on results from two clinical trials conducted at 16 sites in the United States that included 547 healthy adult patients. According to Merz, in both studies, the product significantly improved the appearance of glabellar lines 30 days after the first injection, compared with placebo.

IncobotulinumtoxinA is classified as a pregnancy category C agent and is the only botulinum toxin currently approved in the United States that does not require refrigeration prior to reconstitution.

In an interview, Dr. Joel L. Cohen, one of the trial investigators and director of AboutSkin Dermatology in Denver called incobotulinumtoxinA "more similar than it is different to other products that are on the market, particularly Botox. It’s exciting for botulinum toxin to be in the news again for something very positive in the approval of another product. I think that we should feel comfortable using Xeomin as something that has demonstrated safety and efficacy."

Dr. Christopher Zachary, professor and chair of the department of dermatology at the University of California, Irvine, predicted that Xeomin "is going to give Allergan a run for its money. The introduction of this product is likely to be more easily adopted than rival Dysport because one vial of Xeomin contains 100 units of botulinum toxin and can be diluted similarly. Dose for dose, this direct comparison with Botox is going to make staff feel quite comfortable from the get-go. Requiring staff to use different dilutions and maintain correct labeling just adds another element of confusion and might increase the potential for incorrect dosing. Having said this, Dysport remains a premier and very equivalent product and will have its devotees."

According to Merz, use of the product is contraindicated "in patients with a known hypersensitivity to the active substance botulinum toxin type A or to any of the components in the formulation and in the presence of infection at the proposed injection site(s)." The company also noted that the potency units of incobotulinumtoxinA are not interchangeable with other preparations of botulinum toxin products. "Therefore, units of biological activity of Xeomin cannot be compared to or converted into units of any other botulinum toxin products."

The most common adverse reaction was headache, which was reported by 5.4% of patients in the trials.

Xeomin is approved for the temporary improvement in the appearance of glabellar lines in 14 countries in the European Union, including Germany, the United Kingdom, France, Italy and Spain, under the brand name Bocouture.

Dr. Cohen disclosed that he has been a consultant and clinical trial investigator for Merz, Allergan, and Medicis.

Dr. Zachary disclosed that he has received support and honoraria from Merz, Allergan, and Medicis for various educational courses in recent years.

On July 21, the Food and Drug Administration approved incobotulinumtoxinA for the temporary improvement in appearance of moderate to severe glabellar lines in adult patients.

Manufactured by Merz Aesthetics and marketed as Xeomin, incobotulinumtoxinA is the third botulinum toxin type A to enter the marketplace, following Botox and Dysport, respectively. It is expected to be available to physicians in the United States in the spring of 2012.

IncobotulinumtoxinA's approval is based on results from two clinical trials conducted at 16 sites in the United States that included 547 healthy adult patients. According to Merz, in both studies, the product significantly improved the appearance of glabellar lines 30 days after the first injection, compared with placebo.

IncobotulinumtoxinA is classified as a pregnancy category C agent and is the only botulinum toxin currently approved in the United States that does not require refrigeration prior to reconstitution.

In an interview, Dr. Joel L. Cohen, one of the trial investigators and director of AboutSkin Dermatology in Denver called incobotulinumtoxinA "more similar than it is different to other products that are on the market, particularly Botox. It’s exciting for botulinum toxin to be in the news again for something very positive in the approval of another product. I think that we should feel comfortable using Xeomin as something that has demonstrated safety and efficacy."

Dr. Christopher Zachary, professor and chair of the department of dermatology at the University of California, Irvine, predicted that Xeomin "is going to give Allergan a run for its money. The introduction of this product is likely to be more easily adopted than rival Dysport because one vial of Xeomin contains 100 units of botulinum toxin and can be diluted similarly. Dose for dose, this direct comparison with Botox is going to make staff feel quite comfortable from the get-go. Requiring staff to use different dilutions and maintain correct labeling just adds another element of confusion and might increase the potential for incorrect dosing. Having said this, Dysport remains a premier and very equivalent product and will have its devotees."

According to Merz, use of the product is contraindicated "in patients with a known hypersensitivity to the active substance botulinum toxin type A or to any of the components in the formulation and in the presence of infection at the proposed injection site(s)." The company also noted that the potency units of incobotulinumtoxinA are not interchangeable with other preparations of botulinum toxin products. "Therefore, units of biological activity of Xeomin cannot be compared to or converted into units of any other botulinum toxin products."

The most common adverse reaction was headache, which was reported by 5.4% of patients in the trials.

Xeomin is approved for the temporary improvement in the appearance of glabellar lines in 14 countries in the European Union, including Germany, the United Kingdom, France, Italy and Spain, under the brand name Bocouture.

Dr. Cohen disclosed that he has been a consultant and clinical trial investigator for Merz, Allergan, and Medicis.

Dr. Zachary disclosed that he has received support and honoraria from Merz, Allergan, and Medicis for various educational courses in recent years.

On July 21, the Food and Drug Administration approved incobotulinumtoxinA for the temporary improvement in appearance of moderate to severe glabellar lines in adult patients.

Manufactured by Merz Aesthetics and marketed as Xeomin, incobotulinumtoxinA is the third botulinum toxin type A to enter the marketplace, following Botox and Dysport, respectively. It is expected to be available to physicians in the United States in the spring of 2012.

IncobotulinumtoxinA's approval is based on results from two clinical trials conducted at 16 sites in the United States that included 547 healthy adult patients. According to Merz, in both studies, the product significantly improved the appearance of glabellar lines 30 days after the first injection, compared with placebo.

IncobotulinumtoxinA is classified as a pregnancy category C agent and is the only botulinum toxin currently approved in the United States that does not require refrigeration prior to reconstitution.

In an interview, Dr. Joel L. Cohen, one of the trial investigators and director of AboutSkin Dermatology in Denver called incobotulinumtoxinA "more similar than it is different to other products that are on the market, particularly Botox. It’s exciting for botulinum toxin to be in the news again for something very positive in the approval of another product. I think that we should feel comfortable using Xeomin as something that has demonstrated safety and efficacy."

Dr. Christopher Zachary, professor and chair of the department of dermatology at the University of California, Irvine, predicted that Xeomin "is going to give Allergan a run for its money. The introduction of this product is likely to be more easily adopted than rival Dysport because one vial of Xeomin contains 100 units of botulinum toxin and can be diluted similarly. Dose for dose, this direct comparison with Botox is going to make staff feel quite comfortable from the get-go. Requiring staff to use different dilutions and maintain correct labeling just adds another element of confusion and might increase the potential for incorrect dosing. Having said this, Dysport remains a premier and very equivalent product and will have its devotees."

According to Merz, use of the product is contraindicated "in patients with a known hypersensitivity to the active substance botulinum toxin type A or to any of the components in the formulation and in the presence of infection at the proposed injection site(s)." The company also noted that the potency units of incobotulinumtoxinA are not interchangeable with other preparations of botulinum toxin products. "Therefore, units of biological activity of Xeomin cannot be compared to or converted into units of any other botulinum toxin products."

The most common adverse reaction was headache, which was reported by 5.4% of patients in the trials.

Xeomin is approved for the temporary improvement in the appearance of glabellar lines in 14 countries in the European Union, including Germany, the United Kingdom, France, Italy and Spain, under the brand name Bocouture.

Dr. Cohen disclosed that he has been a consultant and clinical trial investigator for Merz, Allergan, and Medicis.

Dr. Zachary disclosed that he has received support and honoraria from Merz, Allergan, and Medicis for various educational courses in recent years.

BOSTON - The density of facial bone seems to decrease significantly with age, a finding that suggests that the maxilla and mandible are subject to the same metabolic factors that cause osteoporosis in the axial skeleton, according to Dr. Robert B. Shaw Jr.

In a study designed to quantify age-related changes to facial bone density and compare them with age-related bone density decreases in the axial skeleton, Dr. Shaw, of the University of Rochester (N.Y.) Medical Center and his colleagues obtained dual-emission x-ray absorptiometry (DXA) scans of the facial bones and lumbar spine from 30 female and 30 male patients. The study included 10 patients of each gender in each of three age categories: 20-40 years, 41-60 years, and older than 60 years. Patients with osteoporosis were excluded from the study.

For each subject, the investigators recorded maxillary bone density (mean density of the left and right maxilla), mandibular ramus bone density (mean density of the left and right mandibular ramus), and lumbar spine bone density (mean density of L1-L4 vertebrae), Dr. Shaw said at the annual  meeting of the American Society for Aesthetic Plastic Surgery.

The investigators observed significant decreases with age for both genders between the middle- and old-age groups for lumbar spine density and between the young and middle-age groups for the maxillary and mandibular ramus bone density, Dr. Shaw reported.

Specifically, the respective mean lumbar spine densities for the young, middle-age, and older-age groups of men were 1.29, 1.29, and 1.15 g/cm², and for the women were 1.23, 1.24, and 1.08 g/cm². For the maxillary bone density, the respective measures across the age groups for the men were 1.90, 1.58, and 1.56 g/cm², and for the women they were 1.75, 1.55, and 1.50 g/cm². For the mandibular bone density, the respective measures for the male subjects were 1.52, 1.33, and 1.35 g/cm², and for the female subjects they were 1.52, 1.32, and 1.18 g/cm².

Within each age group, "lumbar spine and maxilla bone density decreases were more pronounced in female vs. male subjects," he said.

The study findings are consistent with those of an investigation published earlier this year in which Dr. Shaw and his colleagues compared three-dimensional reconstructions of CT scans of the facial bones in 120 men and women in young, middle-age, and older-age groups. The investigators observed recession of the eye socket bones and volume loss to midface bones, including the brow bone, nose, and upper jaw. The bone-loss patterns observed in the study differed by gender, with men experiencing the most pronounced decrease in bone volume beginning in the oldest age category, while the process starts in earnest for women in the middle age group, he said (Plast. Reconstr. Surg. 2011;127:374-83).

The results of the current study suggest that "facial bone aging may be linked to the same metabolic factors that cause osteoporosis in the axial skeleton," said Dr. Shaw. They also offer insight into why certain facial rejuvenation strategies may not meet patients' expectations, he said, noting, for example, that although skin tightening alone may effectively minimize wrinkles and improve skin texture, it won't compensate for the underlying structural changes that alter the three-dimensional contour of the face.

Skeletal augmentation via dermal fillers or facial implants, together with skin tightening, can potentially improve outcomes by making up for some of the lost volume, he said, "but it will not make a 60-year-old look 20 years old again." Gaining a better understanding of facial bone strength, however, may lead to new possibilities for facial rejuvenation, he said.

Dr. Shaw reported having no financial conflicts of interest with respect to his presentation.

BOSTON - The density of facial bone seems to decrease significantly with age, a finding that suggests that the maxilla and mandible are subject to the same metabolic factors that cause osteoporosis in the axial skeleton, according to Dr. Robert B. Shaw Jr.

In a study designed to quantify age-related changes to facial bone density and compare them with age-related bone density decreases in the axial skeleton, Dr. Shaw, of the University of Rochester (N.Y.) Medical Center and his colleagues obtained dual-emission x-ray absorptiometry (DXA) scans of the facial bones and lumbar spine from 30 female and 30 male patients. The study included 10 patients of each gender in each of three age categories: 20-40 years, 41-60 years, and older than 60 years. Patients with osteoporosis were excluded from the study.

For each subject, the investigators recorded maxillary bone density (mean density of the left and right maxilla), mandibular ramus bone density (mean density of the left and right mandibular ramus), and lumbar spine bone density (mean density of L1-L4 vertebrae), Dr. Shaw said at the annual  meeting of the American Society for Aesthetic Plastic Surgery.

The investigators observed significant decreases with age for both genders between the middle- and old-age groups for lumbar spine density and between the young and middle-age groups for the maxillary and mandibular ramus bone density, Dr. Shaw reported.

Specifically, the respective mean lumbar spine densities for the young, middle-age, and older-age groups of men were 1.29, 1.29, and 1.15 g/cm², and for the women were 1.23, 1.24, and 1.08 g/cm². For the maxillary bone density, the respective measures across the age groups for the men were 1.90, 1.58, and 1.56 g/cm², and for the women they were 1.75, 1.55, and 1.50 g/cm². For the mandibular bone density, the respective measures for the male subjects were 1.52, 1.33, and 1.35 g/cm², and for the female subjects they were 1.52, 1.32, and 1.18 g/cm².

Within each age group, "lumbar spine and maxilla bone density decreases were more pronounced in female vs. male subjects," he said.

The study findings are consistent with those of an investigation published earlier this year in which Dr. Shaw and his colleagues compared three-dimensional reconstructions of CT scans of the facial bones in 120 men and women in young, middle-age, and older-age groups. The investigators observed recession of the eye socket bones and volume loss to midface bones, including the brow bone, nose, and upper jaw. The bone-loss patterns observed in the study differed by gender, with men experiencing the most pronounced decrease in bone volume beginning in the oldest age category, while the process starts in earnest for women in the middle age group, he said (Plast. Reconstr. Surg. 2011;127:374-83).

The results of the current study suggest that "facial bone aging may be linked to the same metabolic factors that cause osteoporosis in the axial skeleton," said Dr. Shaw. They also offer insight into why certain facial rejuvenation strategies may not meet patients' expectations, he said, noting, for example, that although skin tightening alone may effectively minimize wrinkles and improve skin texture, it won't compensate for the underlying structural changes that alter the three-dimensional contour of the face.

Skeletal augmentation via dermal fillers or facial implants, together with skin tightening, can potentially improve outcomes by making up for some of the lost volume, he said, "but it will not make a 60-year-old look 20 years old again." Gaining a better understanding of facial bone strength, however, may lead to new possibilities for facial rejuvenation, he said.

Dr. Shaw reported having no financial conflicts of interest with respect to his presentation.

BOSTON - The density of facial bone seems to decrease significantly with age, a finding that suggests that the maxilla and mandible are subject to the same metabolic factors that cause osteoporosis in the axial skeleton, according to Dr. Robert B. Shaw Jr.

In a study designed to quantify age-related changes to facial bone density and compare them with age-related bone density decreases in the axial skeleton, Dr. Shaw, of the University of Rochester (N.Y.) Medical Center and his colleagues obtained dual-emission x-ray absorptiometry (DXA) scans of the facial bones and lumbar spine from 30 female and 30 male patients. The study included 10 patients of each gender in each of three age categories: 20-40 years, 41-60 years, and older than 60 years. Patients with osteoporosis were excluded from the study.

For each subject, the investigators recorded maxillary bone density (mean density of the left and right maxilla), mandibular ramus bone density (mean density of the left and right mandibular ramus), and lumbar spine bone density (mean density of L1-L4 vertebrae), Dr. Shaw said at the annual  meeting of the American Society for Aesthetic Plastic Surgery.

The investigators observed significant decreases with age for both genders between the middle- and old-age groups for lumbar spine density and between the young and middle-age groups for the maxillary and mandibular ramus bone density, Dr. Shaw reported.

Specifically, the respective mean lumbar spine densities for the young, middle-age, and older-age groups of men were 1.29, 1.29, and 1.15 g/cm², and for the women were 1.23, 1.24, and 1.08 g/cm². For the maxillary bone density, the respective measures across the age groups for the men were 1.90, 1.58, and 1.56 g/cm², and for the women they were 1.75, 1.55, and 1.50 g/cm². For the mandibular bone density, the respective measures for the male subjects were 1.52, 1.33, and 1.35 g/cm², and for the female subjects they were 1.52, 1.32, and 1.18 g/cm².

Within each age group, "lumbar spine and maxilla bone density decreases were more pronounced in female vs. male subjects," he said.

The study findings are consistent with those of an investigation published earlier this year in which Dr. Shaw and his colleagues compared three-dimensional reconstructions of CT scans of the facial bones in 120 men and women in young, middle-age, and older-age groups. The investigators observed recession of the eye socket bones and volume loss to midface bones, including the brow bone, nose, and upper jaw. The bone-loss patterns observed in the study differed by gender, with men experiencing the most pronounced decrease in bone volume beginning in the oldest age category, while the process starts in earnest for women in the middle age group, he said (Plast. Reconstr. Surg. 2011;127:374-83).

The results of the current study suggest that "facial bone aging may be linked to the same metabolic factors that cause osteoporosis in the axial skeleton," said Dr. Shaw. They also offer insight into why certain facial rejuvenation strategies may not meet patients' expectations, he said, noting, for example, that although skin tightening alone may effectively minimize wrinkles and improve skin texture, it won't compensate for the underlying structural changes that alter the three-dimensional contour of the face.

Skeletal augmentation via dermal fillers or facial implants, together with skin tightening, can potentially improve outcomes by making up for some of the lost volume, he said, "but it will not make a 60-year-old look 20 years old again." Gaining a better understanding of facial bone strength, however, may lead to new possibilities for facial rejuvenation, he said.

Dr. Shaw reported having no financial conflicts of interest with respect to his presentation.

SEOUL, SOUTH KOREA – Low-dose oral isotretinoin and alternate-day tretinoin proved similarly effective for treatment of photoaging in a prospective randomized trial.

Treatment of photoaged skin is an off-label application for isotretinoin, but there have been a number of published favorable case series (J. Eur. Acad. Dermatol. Venereol. 2009;23:115-23).

Some dermatologists are prescribing it in more severe cases where teratogenicity is a nonissue. So Dr. Edileia Bagatin decided to put the potent oral retinoid to the test in a randomized comparison with tretinoin (Renova), a topical retinoid that does have a regulatory indication for photoaging.

The result of the 12-month study was a draw in terms of efficacy. The two treatment groups showed similar improvements in photoaging based upon blinded dermatologic evaluations, patient self-ratings, quality of life scores, and histologic findings.

And because the topical retinoid doesn't come with the baggage for which isotretinoin is notorious – including dyslipidemia, birth defects, liver dysfunction, depression, and inflammatory bowel disease – tretinoin has the clear advantage in most situations, said Dr. Bagatin at the World Congress of Dermatology.

The trial involved 22 patients, aged 50-75 years, with moderate to advanced photoaging. Nine of 11 subjects in each treatment arm were smokers.

Patients were assigned to either 20 mg/day of isotretinoin for 6 months followed by 0.05% tretinoin cream applied every other day for 6 months, or to alternate-day tretinoin for the full 12 months. All patients were instructed to use a moisturizing sunscreen twice daily.

The number of actinic keratoses on the face was reduced to a similar extent via both therapies: by an average of 74% after 6 months and 54% after 12 months. The number of AKs on the forearms dropped by an average of 42% with either therapy after 6 months, and by 61% after 12 months, according to Dr. Bagatin, of the Federal University of Sao Paulo (Brazil).

The patients themselves rated their wrinkles, skin elasticity, actinic keratoses, and freckles as significantly improved at both 6 and 12 months, with no significant difference between treatment arms. Median Dermatology Life Quality Index scores showed significant improvement over time, again with no difference between the two groups.

On histology, both groups displayed reductions in corneal layer thickness and elastosis, along with increased epidermal thickness; these changes were greater with time. There was also a significant reduction in p53 expression and an increase in collagen I, with both changes being greater at 12 months than 6 months.

The study was funded by the Sao Paulo State Research Foundation. Dr. Bagatin reported having no financial conflicts.

SEOUL, SOUTH KOREA – Low-dose oral isotretinoin and alternate-day tretinoin proved similarly effective for treatment of photoaging in a prospective randomized trial.

Treatment of photoaged skin is an off-label application for isotretinoin, but there have been a number of published favorable case series (J. Eur. Acad. Dermatol. Venereol. 2009;23:115-23).

Some dermatologists are prescribing it in more severe cases where teratogenicity is a nonissue. So Dr. Edileia Bagatin decided to put the potent oral retinoid to the test in a randomized comparison with tretinoin (Renova), a topical retinoid that does have a regulatory indication for photoaging.

The result of the 12-month study was a draw in terms of efficacy. The two treatment groups showed similar improvements in photoaging based upon blinded dermatologic evaluations, patient self-ratings, quality of life scores, and histologic findings.

And because the topical retinoid doesn't come with the baggage for which isotretinoin is notorious – including dyslipidemia, birth defects, liver dysfunction, depression, and inflammatory bowel disease – tretinoin has the clear advantage in most situations, said Dr. Bagatin at the World Congress of Dermatology.

The trial involved 22 patients, aged 50-75 years, with moderate to advanced photoaging. Nine of 11 subjects in each treatment arm were smokers.

Patients were assigned to either 20 mg/day of isotretinoin for 6 months followed by 0.05% tretinoin cream applied every other day for 6 months, or to alternate-day tretinoin for the full 12 months. All patients were instructed to use a moisturizing sunscreen twice daily.

The number of actinic keratoses on the face was reduced to a similar extent via both therapies: by an average of 74% after 6 months and 54% after 12 months. The number of AKs on the forearms dropped by an average of 42% with either therapy after 6 months, and by 61% after 12 months, according to Dr. Bagatin, of the Federal University of Sao Paulo (Brazil).

The patients themselves rated their wrinkles, skin elasticity, actinic keratoses, and freckles as significantly improved at both 6 and 12 months, with no significant difference between treatment arms. Median Dermatology Life Quality Index scores showed significant improvement over time, again with no difference between the two groups.

On histology, both groups displayed reductions in corneal layer thickness and elastosis, along with increased epidermal thickness; these changes were greater with time. There was also a significant reduction in p53 expression and an increase in collagen I, with both changes being greater at 12 months than 6 months.

The study was funded by the Sao Paulo State Research Foundation. Dr. Bagatin reported having no financial conflicts.

SEOUL, SOUTH KOREA – Low-dose oral isotretinoin and alternate-day tretinoin proved similarly effective for treatment of photoaging in a prospective randomized trial.

Treatment of photoaged skin is an off-label application for isotretinoin, but there have been a number of published favorable case series (J. Eur. Acad. Dermatol. Venereol. 2009;23:115-23).

Some dermatologists are prescribing it in more severe cases where teratogenicity is a nonissue. So Dr. Edileia Bagatin decided to put the potent oral retinoid to the test in a randomized comparison with tretinoin (Renova), a topical retinoid that does have a regulatory indication for photoaging.

The result of the 12-month study was a draw in terms of efficacy. The two treatment groups showed similar improvements in photoaging based upon blinded dermatologic evaluations, patient self-ratings, quality of life scores, and histologic findings.

And because the topical retinoid doesn't come with the baggage for which isotretinoin is notorious – including dyslipidemia, birth defects, liver dysfunction, depression, and inflammatory bowel disease – tretinoin has the clear advantage in most situations, said Dr. Bagatin at the World Congress of Dermatology.

The trial involved 22 patients, aged 50-75 years, with moderate to advanced photoaging. Nine of 11 subjects in each treatment arm were smokers.

Patients were assigned to either 20 mg/day of isotretinoin for 6 months followed by 0.05% tretinoin cream applied every other day for 6 months, or to alternate-day tretinoin for the full 12 months. All patients were instructed to use a moisturizing sunscreen twice daily.

The number of actinic keratoses on the face was reduced to a similar extent via both therapies: by an average of 74% after 6 months and 54% after 12 months. The number of AKs on the forearms dropped by an average of 42% with either therapy after 6 months, and by 61% after 12 months, according to Dr. Bagatin, of the Federal University of Sao Paulo (Brazil).

The patients themselves rated their wrinkles, skin elasticity, actinic keratoses, and freckles as significantly improved at both 6 and 12 months, with no significant difference between treatment arms. Median Dermatology Life Quality Index scores showed significant improvement over time, again with no difference between the two groups.

On histology, both groups displayed reductions in corneal layer thickness and elastosis, along with increased epidermal thickness; these changes were greater with time. There was also a significant reduction in p53 expression and an increase in collagen I, with both changes being greater at 12 months than 6 months.

The study was funded by the Sao Paulo State Research Foundation. Dr. Bagatin reported having no financial conflicts.

There is more to Rosa damascena than its gorgeous flowers and lovely scent. Research on this cultivar is finding some intriguing properties that have potential for topical dermatologic products.

Rosa damascena, also known as the Damask Rose and Rose of Castile, is a rose hybrid the flowers of which have been used for rose oil in perfume and for rosewater.

It originates in the Middle East (the name is based on Damascus, Syria), but it is now only a cultivated plant and no longer found in the wild.

Bulgaria, Turkey, France, and India are the largest producers of rose oil. Rosewater has been used for centuries in religious rites and for physical, emotional, and spiritual purposes or healing. Thriving rosewater industries are found in Bulgaria and France.

In addition to its uses in the perfumery industry, R. damascena is also used for culinary purposes in several global cuisines. Geraniol, which exhibits potent antiseptic activity (seven times that of phenol), is the main constituent of several essential oils and is found in R. damascena (Hoffmann D., Medical Herbalism: The Science and Practice of Herbal Medicine. Rochester, Vt.: Healing Arts Press, 2003, p. 64).

Photo: Courtesy Wikimedia Commons/Kurt Stüber/Creative Commons License

Some of the earliest work to indicate the potential health and dermatologic benefits of R. damascena dates to the late 1970s.

Investigators isolated a strain of cultured cells of the plant that displayed strong resistance to UV radiation (254 nm) and generated a greater amount of polyphenols (primarily flavonoids) during the latter stages of culture growth. They found that this UV resistance was associated with increased polyphenolic production (Plant Physiol. 1979;64:936-41).

Flavonoids are the most prevalent and frequently studied polyphenols, which are the most abundant source of antioxidants in the human diet (Biomed. Pap. Med. Fac. Univ. Palacky Olomouc Czech Repub. 2003;147:137-45; J. Nutr. 2000;130 (8S Suppl):2073S-85S; Annu. Rev. Nutr. 2002;22:19-34; Pharmacol. Ther. 2001;90:157-77; Free Radic. Biol. Med. 2001;30:1213-22).

Antimicrobial Properties

In 2002, R. damascena was among eight essential oils studied for composition and antimicrobial characteristics. The antibacterial activities of the aromatic extracts were ascertained by disk diffusion testing. Among the standard test bacterial strains Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa, R. damascena showed antimicrobial activity against S. aureus (Arch. Pharm. Res. 2002;25:860-4).

Recent work has provided additional evidence of its antibacterial activity. In 2010, investigators tested 10 essential oils for antibacterial activity against Propionibacterium acnes as well as in vitro toxicology against three human cancer cell lines. Among the essential oils tested (which included mint, ginger, lemon, grapefruit, jasmine, lavender, chamomile, thyme, rose, and cinnamon) thyme, cinnamon, and rose were found to display the greatest antibacterial potency against P. acnes. Overall, the cytotoxicity of the essential oils was strongest against human prostate carcinoma cells (PC-3), as opposed to human lung carcinoma (A549) and human breast cancer (MCF-7) cells. Thyme was found to be the most cytotoxic to the cancer cell lines (Molecules 2010;15:3200-10).

UV Protection

In 2003, investigators assessed various extracts of R. damascena for its capacity as an antisolar agent in absorbing UV. The presence of flavonoids as the primary constituents of the extracts was verified before investigators identified the UV absorption spectra, with all three extracts found to be effective in absorbing UV in the 200- to 400-nm range. Next, the team incorporated the extracts into oil-in-water creams at 5% and 8% concentrations. The hydroalcoholic extract provided the highest sun protection factor (SPF), but the cream containing 5% ether extract rendered the most satisfactory appearance and stability. The authors ascribed the UV absorption ability of the extracts to the flavonoid constituents and noted that other synthetic antisolar compounds might be added to R. damascena extracts to enhance overall product efficacy (Int. J. Cosmet. Sci. 2003;25:259-65).

Antioxidant Properties

In 2005, Schiber et al. extracted and characterized flavonol glycosides from R. damascena petals following industrial distillation for essential oil recovery. After analyzing 22 constituents, kaempferol and quercetin were the only flavonoids (specifically, flavonols) detected, with kaempferol compounds accounting for 80% of the compounds measured. In noting the high flavonol content (approximately 16 g/kg in dry weight), the researchers concluded that R. damascena represents a promising source of natural antioxidants (Z. Naturforsch. C. 2005;60:379-84).

In a late 2010 study using a reversed-phase high-performance liquid chromatographic (RP-HPLC) method to simultaneously measure the flavonols, flavones, and phenolic acids as important constituents in various fruits, vegetables, and medicinal plants, R. damascena was identified as one of the species, along with Solidago virgaurea, Ginkgo biloba, and Camellia sinensis (the source of green tea), as having the highest flavonoid content (J. Agric. Food. Chem. 2010 Oct 4. [Epub ahead of print]).

Notably, G. biloba contains quercetin, one of the most abundant natural flavonoids, as well as other flavonoids such as kaempferol, sciadopitysin, ginkgetin, and isoginkgetin with demonstrated antioxidant and anti-inflammatory activity (Clin. Exp. Dermatol. 2001;26:536-9; Radic. Biol. Med. 1998;25:196-200).

Also in late 2010, investigators assessed the antioxidant activity of plants typically used in Unani medicine, of which the 10 displaying the most promising effects, including R. damascena, were identified for additional analysis. The total phenolic, flavonoid, and ascorbic acid contents were ascertained from methanol (50%) extract preparations of all 10 species and researchers also evaluated the in vitro scavenging of reactive oxygen and nitrogen species and the ability of the plant extracts to prevent oxidative DNA harm. R. damascena was among seven of the 10 extracts to exhibit moderate antioxidant activity and one of three species found to potentially have significant preventive activity against oxidative DNA damage as well as antioxidant activity. The investigators concluded that R. damascena, C. icosandra, and C. scariosus, all of which are commonly used in Unani medicine (practiced in South Asia and founded on traditional Graeco-Arabic medicine) and reportedly deliver substantial benefits in the treatment of various human disorders, are potentially useful as natural antioxidants in pharmaceutical products (BMC Complement. Altern. Med. 2010;16:10-77).

A year earlier, investigators examined the phenolic content as well as the antioxidant and antibacterial activities of R. damascena flower extracts absolute, essential oil, and hydrosol. The major constituents of rose essential oil and hydrosol (great than 55%) were found to be citrenellol and geraniol, with phenylethyl alcohol (78.83%) identified as the primary component of rose absolute. The levels of key antioxidants (i.e, beta carotene, tocopherol, and gamma tocopherol) were found to be higher in rose absolute as compared to hydrosol and rose oil. High levels of phenolics were noted in rose absolute and the essential oil, which exhibited potent antibacterial activity against E. coli, P. aeruginosa, Bacillus subtilis, S. aureus, Chromobacterium violaceum, and Erwinia carotovora (Curr. Microbiol. 2009;59:554-8). Of note, hydrosols, also referred to as floral waters, flower waters, hydroflorates, or distillates, are derived from steam distilling plant materials.

Relaxing Properties

In a recent study on the relaxing effects of rose oil administered by transdermal absorption, 40 healthy volunteers were assessed based on autonomic parameters (i.e., blood pressure, breathing rate, blood oxygen saturation, pulse rate, and skin temperature) as well as self-report after receiving rose oil or placebo. Olfactory stimulation was prevented through the use of breathing masks. Significant reductions in systolic blood pressure, breathing rate, and blood saturation were observed, compared to placebo. The rose oil group also self-reported as calmer, more relaxed, and less alert. The author suggested that this small study lends support for the use of rose oil in aromatherapy for the relief of stress and depression (Nat. Prod. Commun. 2009;4:291-6).

Conclusion

The data that exist on R. damascena are interesting but hardly overwhelming. Much more research is necessary to determine the potential efficacy of this botanical in dermatologic products. The current evidence does offer promise though, and further investigation is clearly warranted to determine the full range of activity offered by R. damascena and how well the antioxidant and antibacterial activities of this herb can be harnessed in topical products.

There is more to Rosa damascena than its gorgeous flowers and lovely scent. Research on this cultivar is finding some intriguing properties that have potential for topical dermatologic products.

Rosa damascena, also known as the Damask Rose and Rose of Castile, is a rose hybrid the flowers of which have been used for rose oil in perfume and for rosewater.

It originates in the Middle East (the name is based on Damascus, Syria), but it is now only a cultivated plant and no longer found in the wild.

Bulgaria, Turkey, France, and India are the largest producers of rose oil. Rosewater has been used for centuries in religious rites and for physical, emotional, and spiritual purposes or healing. Thriving rosewater industries are found in Bulgaria and France.

In addition to its uses in the perfumery industry, R. damascena is also used for culinary purposes in several global cuisines. Geraniol, which exhibits potent antiseptic activity (seven times that of phenol), is the main constituent of several essential oils and is found in R. damascena (Hoffmann D., Medical Herbalism: The Science and Practice of Herbal Medicine. Rochester, Vt.: Healing Arts Press, 2003, p. 64).

Photo: Courtesy Wikimedia Commons/Kurt Stüber/Creative Commons License

Some of the earliest work to indicate the potential health and dermatologic benefits of R. damascena dates to the late 1970s.

Investigators isolated a strain of cultured cells of the plant that displayed strong resistance to UV radiation (254 nm) and generated a greater amount of polyphenols (primarily flavonoids) during the latter stages of culture growth. They found that this UV resistance was associated with increased polyphenolic production (Plant Physiol. 1979;64:936-41).

Flavonoids are the most prevalent and frequently studied polyphenols, which are the most abundant source of antioxidants in the human diet (Biomed. Pap. Med. Fac. Univ. Palacky Olomouc Czech Repub. 2003;147:137-45; J. Nutr. 2000;130 (8S Suppl):2073S-85S; Annu. Rev. Nutr. 2002;22:19-34; Pharmacol. Ther. 2001;90:157-77; Free Radic. Biol. Med. 2001;30:1213-22).

Antimicrobial Properties

In 2002, R. damascena was among eight essential oils studied for composition and antimicrobial characteristics. The antibacterial activities of the aromatic extracts were ascertained by disk diffusion testing. Among the standard test bacterial strains Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa, R. damascena showed antimicrobial activity against S. aureus (Arch. Pharm. Res. 2002;25:860-4).

Recent work has provided additional evidence of its antibacterial activity. In 2010, investigators tested 10 essential oils for antibacterial activity against Propionibacterium acnes as well as in vitro toxicology against three human cancer cell lines. Among the essential oils tested (which included mint, ginger, lemon, grapefruit, jasmine, lavender, chamomile, thyme, rose, and cinnamon) thyme, cinnamon, and rose were found to display the greatest antibacterial potency against P. acnes. Overall, the cytotoxicity of the essential oils was strongest against human prostate carcinoma cells (PC-3), as opposed to human lung carcinoma (A549) and human breast cancer (MCF-7) cells. Thyme was found to be the most cytotoxic to the cancer cell lines (Molecules 2010;15:3200-10).

UV Protection

In 2003, investigators assessed various extracts of R. damascena for its capacity as an antisolar agent in absorbing UV. The presence of flavonoids as the primary constituents of the extracts was verified before investigators identified the UV absorption spectra, with all three extracts found to be effective in absorbing UV in the 200- to 400-nm range. Next, the team incorporated the extracts into oil-in-water creams at 5% and 8% concentrations. The hydroalcoholic extract provided the highest sun protection factor (SPF), but the cream containing 5% ether extract rendered the most satisfactory appearance and stability. The authors ascribed the UV absorption ability of the extracts to the flavonoid constituents and noted that other synthetic antisolar compounds might be added to R. damascena extracts to enhance overall product efficacy (Int. J. Cosmet. Sci. 2003;25:259-65).

Antioxidant Properties

In 2005, Schiber et al. extracted and characterized flavonol glycosides from R. damascena petals following industrial distillation for essential oil recovery. After analyzing 22 constituents, kaempferol and quercetin were the only flavonoids (specifically, flavonols) detected, with kaempferol compounds accounting for 80% of the compounds measured. In noting the high flavonol content (approximately 16 g/kg in dry weight), the researchers concluded that R. damascena represents a promising source of natural antioxidants (Z. Naturforsch. C. 2005;60:379-84).

In a late 2010 study using a reversed-phase high-performance liquid chromatographic (RP-HPLC) method to simultaneously measure the flavonols, flavones, and phenolic acids as important constituents in various fruits, vegetables, and medicinal plants, R. damascena was identified as one of the species, along with Solidago virgaurea, Ginkgo biloba, and Camellia sinensis (the source of green tea), as having the highest flavonoid content (J. Agric. Food. Chem. 2010 Oct 4. [Epub ahead of print]).

Notably, G. biloba contains quercetin, one of the most abundant natural flavonoids, as well as other flavonoids such as kaempferol, sciadopitysin, ginkgetin, and isoginkgetin with demonstrated antioxidant and anti-inflammatory activity (Clin. Exp. Dermatol. 2001;26:536-9; Radic. Biol. Med. 1998;25:196-200).

Also in late 2010, investigators assessed the antioxidant activity of plants typically used in Unani medicine, of which the 10 displaying the most promising effects, including R. damascena, were identified for additional analysis. The total phenolic, flavonoid, and ascorbic acid contents were ascertained from methanol (50%) extract preparations of all 10 species and researchers also evaluated the in vitro scavenging of reactive oxygen and nitrogen species and the ability of the plant extracts to prevent oxidative DNA harm. R. damascena was among seven of the 10 extracts to exhibit moderate antioxidant activity and one of three species found to potentially have significant preventive activity against oxidative DNA damage as well as antioxidant activity. The investigators concluded that R. damascena, C. icosandra, and C. scariosus, all of which are commonly used in Unani medicine (practiced in South Asia and founded on traditional Graeco-Arabic medicine) and reportedly deliver substantial benefits in the treatment of various human disorders, are potentially useful as natural antioxidants in pharmaceutical products (BMC Complement. Altern. Med. 2010;16:10-77).

A year earlier, investigators examined the phenolic content as well as the antioxidant and antibacterial activities of R. damascena flower extracts absolute, essential oil, and hydrosol. The major constituents of rose essential oil and hydrosol (great than 55%) were found to be citrenellol and geraniol, with phenylethyl alcohol (78.83%) identified as the primary component of rose absolute. The levels of key antioxidants (i.e, beta carotene, tocopherol, and gamma tocopherol) were found to be higher in rose absolute as compared to hydrosol and rose oil. High levels of phenolics were noted in rose absolute and the essential oil, which exhibited potent antibacterial activity against E. coli, P. aeruginosa, Bacillus subtilis, S. aureus, Chromobacterium violaceum, and Erwinia carotovora (Curr. Microbiol. 2009;59:554-8). Of note, hydrosols, also referred to as floral waters, flower waters, hydroflorates, or distillates, are derived from steam distilling plant materials.

Relaxing Properties

In a recent study on the relaxing effects of rose oil administered by transdermal absorption, 40 healthy volunteers were assessed based on autonomic parameters (i.e., blood pressure, breathing rate, blood oxygen saturation, pulse rate, and skin temperature) as well as self-report after receiving rose oil or placebo. Olfactory stimulation was prevented through the use of breathing masks. Significant reductions in systolic blood pressure, breathing rate, and blood saturation were observed, compared to placebo. The rose oil group also self-reported as calmer, more relaxed, and less alert. The author suggested that this small study lends support for the use of rose oil in aromatherapy for the relief of stress and depression (Nat. Prod. Commun. 2009;4:291-6).

Conclusion

The data that exist on R. damascena are interesting but hardly overwhelming. Much more research is necessary to determine the potential efficacy of this botanical in dermatologic products. The current evidence does offer promise though, and further investigation is clearly warranted to determine the full range of activity offered by R. damascena and how well the antioxidant and antibacterial activities of this herb can be harnessed in topical products.

There is more to Rosa damascena than its gorgeous flowers and lovely scent. Research on this cultivar is finding some intriguing properties that have potential for topical dermatologic products.

Rosa damascena, also known as the Damask Rose and Rose of Castile, is a rose hybrid the flowers of which have been used for rose oil in perfume and for rosewater.

It originates in the Middle East (the name is based on Damascus, Syria), but it is now only a cultivated plant and no longer found in the wild.

Bulgaria, Turkey, France, and India are the largest producers of rose oil. Rosewater has been used for centuries in religious rites and for physical, emotional, and spiritual purposes or healing. Thriving rosewater industries are found in Bulgaria and France.

In addition to its uses in the perfumery industry, R. damascena is also used for culinary purposes in several global cuisines. Geraniol, which exhibits potent antiseptic activity (seven times that of phenol), is the main constituent of several essential oils and is found in R. damascena (Hoffmann D., Medical Herbalism: The Science and Practice of Herbal Medicine. Rochester, Vt.: Healing Arts Press, 2003, p. 64).

Photo: Courtesy Wikimedia Commons/Kurt Stüber/Creative Commons License

Some of the earliest work to indicate the potential health and dermatologic benefits of R. damascena dates to the late 1970s.

Investigators isolated a strain of cultured cells of the plant that displayed strong resistance to UV radiation (254 nm) and generated a greater amount of polyphenols (primarily flavonoids) during the latter stages of culture growth. They found that this UV resistance was associated with increased polyphenolic production (Plant Physiol. 1979;64:936-41).

Flavonoids are the most prevalent and frequently studied polyphenols, which are the most abundant source of antioxidants in the human diet (Biomed. Pap. Med. Fac. Univ. Palacky Olomouc Czech Repub. 2003;147:137-45; J. Nutr. 2000;130 (8S Suppl):2073S-85S; Annu. Rev. Nutr. 2002;22:19-34; Pharmacol. Ther. 2001;90:157-77; Free Radic. Biol. Med. 2001;30:1213-22).

Antimicrobial Properties

In 2002, R. damascena was among eight essential oils studied for composition and antimicrobial characteristics. The antibacterial activities of the aromatic extracts were ascertained by disk diffusion testing. Among the standard test bacterial strains Escherichia coli, Staphylococcus aureus, and Pseudomonas aeruginosa, R. damascena showed antimicrobial activity against S. aureus (Arch. Pharm. Res. 2002;25:860-4).

Recent work has provided additional evidence of its antibacterial activity. In 2010, investigators tested 10 essential oils for antibacterial activity against Propionibacterium acnes as well as in vitro toxicology against three human cancer cell lines. Among the essential oils tested (which included mint, ginger, lemon, grapefruit, jasmine, lavender, chamomile, thyme, rose, and cinnamon) thyme, cinnamon, and rose were found to display the greatest antibacterial potency against P. acnes. Overall, the cytotoxicity of the essential oils was strongest against human prostate carcinoma cells (PC-3), as opposed to human lung carcinoma (A549) and human breast cancer (MCF-7) cells. Thyme was found to be the most cytotoxic to the cancer cell lines (Molecules 2010;15:3200-10).

UV Protection

In 2003, investigators assessed various extracts of R. damascena for its capacity as an antisolar agent in absorbing UV. The presence of flavonoids as the primary constituents of the extracts was verified before investigators identified the UV absorption spectra, with all three extracts found to be effective in absorbing UV in the 200- to 400-nm range. Next, the team incorporated the extracts into oil-in-water creams at 5% and 8% concentrations. The hydroalcoholic extract provided the highest sun protection factor (SPF), but the cream containing 5% ether extract rendered the most satisfactory appearance and stability. The authors ascribed the UV absorption ability of the extracts to the flavonoid constituents and noted that other synthetic antisolar compounds might be added to R. damascena extracts to enhance overall product efficacy (Int. J. Cosmet. Sci. 2003;25:259-65).

Antioxidant Properties

In 2005, Schiber et al. extracted and characterized flavonol glycosides from R. damascena petals following industrial distillation for essential oil recovery. After analyzing 22 constituents, kaempferol and quercetin were the only flavonoids (specifically, flavonols) detected, with kaempferol compounds accounting for 80% of the compounds measured. In noting the high flavonol content (approximately 16 g/kg in dry weight), the researchers concluded that R. damascena represents a promising source of natural antioxidants (Z. Naturforsch. C. 2005;60:379-84).

In a late 2010 study using a reversed-phase high-performance liquid chromatographic (RP-HPLC) method to simultaneously measure the flavonols, flavones, and phenolic acids as important constituents in various fruits, vegetables, and medicinal plants, R. damascena was identified as one of the species, along with Solidago virgaurea, Ginkgo biloba, and Camellia sinensis (the source of green tea), as having the highest flavonoid content (J. Agric. Food. Chem. 2010 Oct 4. [Epub ahead of print]).

Notably, G. biloba contains quercetin, one of the most abundant natural flavonoids, as well as other flavonoids such as kaempferol, sciadopitysin, ginkgetin, and isoginkgetin with demonstrated antioxidant and anti-inflammatory activity (Clin. Exp. Dermatol. 2001;26:536-9; Radic. Biol. Med. 1998;25:196-200).

Also in late 2010, investigators assessed the antioxidant activity of plants typically used in Unani medicine, of which the 10 displaying the most promising effects, including R. damascena, were identified for additional analysis. The total phenolic, flavonoid, and ascorbic acid contents were ascertained from methanol (50%) extract preparations of all 10 species and researchers also evaluated the in vitro scavenging of reactive oxygen and nitrogen species and the ability of the plant extracts to prevent oxidative DNA harm. R. damascena was among seven of the 10 extracts to exhibit moderate antioxidant activity and one of three species found to potentially have significant preventive activity against oxidative DNA damage as well as antioxidant activity. The investigators concluded that R. damascena, C. icosandra, and C. scariosus, all of which are commonly used in Unani medicine (practiced in South Asia and founded on traditional Graeco-Arabic medicine) and reportedly deliver substantial benefits in the treatment of various human disorders, are potentially useful as natural antioxidants in pharmaceutical products (BMC Complement. Altern. Med. 2010;16:10-77).

A year earlier, investigators examined the phenolic content as well as the antioxidant and antibacterial activities of R. damascena flower extracts absolute, essential oil, and hydrosol. The major constituents of rose essential oil and hydrosol (great than 55%) were found to be citrenellol and geraniol, with phenylethyl alcohol (78.83%) identified as the primary component of rose absolute. The levels of key antioxidants (i.e, beta carotene, tocopherol, and gamma tocopherol) were found to be higher in rose absolute as compared to hydrosol and rose oil. High levels of phenolics were noted in rose absolute and the essential oil, which exhibited potent antibacterial activity against E. coli, P. aeruginosa, Bacillus subtilis, S. aureus, Chromobacterium violaceum, and Erwinia carotovora (Curr. Microbiol. 2009;59:554-8). Of note, hydrosols, also referred to as floral waters, flower waters, hydroflorates, or distillates, are derived from steam distilling plant materials.

Relaxing Properties

In a recent study on the relaxing effects of rose oil administered by transdermal absorption, 40 healthy volunteers were assessed based on autonomic parameters (i.e., blood pressure, breathing rate, blood oxygen saturation, pulse rate, and skin temperature) as well as self-report after receiving rose oil or placebo. Olfactory stimulation was prevented through the use of breathing masks. Significant reductions in systolic blood pressure, breathing rate, and blood saturation were observed, compared to placebo. The rose oil group also self-reported as calmer, more relaxed, and less alert. The author suggested that this small study lends support for the use of rose oil in aromatherapy for the relief of stress and depression (Nat. Prod. Commun. 2009;4:291-6).

Conclusion

The data that exist on R. damascena are interesting but hardly overwhelming. Much more research is necessary to determine the potential efficacy of this botanical in dermatologic products. The current evidence does offer promise though, and further investigation is clearly warranted to determine the full range of activity offered by R. damascena and how well the antioxidant and antibacterial activities of this herb can be harnessed in topical products.

DANA POINT, CALIF. – Scar formation and fibrosis can be reduced by altering the mechanical environment of wounds, results from a phase I study found.

At the Summit in Aesthetic Medicine, sponsored by Skin Disease Education Foundation (SDEF), Dr. Geoffrey C. Gurtner presented findings from a study in which nine patients undergoing elective abdominal surgery were treated postoperatively with a stress-shielding polymer on one side while the other side was treated with standard wound care.

©Neodyne Biosciences, Inc

The device, manufactured by Neodyne Biosciences, looks like a Band-Aid strip and is stretched over the incision after sutures are removed. It conforms to the wound and adheres to skin, creating "a compressive region that has no level of mechanical stimulation or distractive strain," said Dr. Gurtner, professor of surgery at Stanford (Calif.) University. "Essentially, you create stress risers in the unwounded skin and a mechanically privileged environment in the wounded skin."

A panel of three independent plastic surgeons reviewed 18 photos of the scars (nine treated, nine control) taken 6-12 months after surgery (Ann. Surg. 2011 May 19 [doi: 10.1097/SLA.0b013e318220b159]). They used a visual analog scale (VAS) that ranged from 0 (very good scar) to 100 (very poor hypertrophic scar).

Dr. Gurtner reported that the average VAS score in the treated group was 18.6, while the average VAS score in the control group was 50.5, a difference that was statistically significant (P = .0039). "In none of the cases was the treated scar worse than the control scar, which I think is different than some of the biologic agents we’ve seen over the last few years," he said.*

A panel of lay persons who reviewed the photos reported similar results that favored the treated group (P = .004).

In earlier mouse studies of wound environment manipulation, Dr. Gurtner and his associates found that focal adhesion kinase (FAK) is a critical regulator in the formation of hypertrophic scars. He described FAK as "a molecule that exists on the inner surface of cell membranes and transmits forces that are set in the external extracellular matrix to the inside of the cell. FAK transmits those forces into biological or biochemical cues that then turn on genes in the nucleus and make the cells do different things. This seems to be a very important molecule in the ability of us to produce hypertrophic scars in mice. If you take out FAK, you can prevent hypertrophic scar formation."

FAK is a target that has been examined extensively in cancer, Dr. Gurtner said, suggesting that in the next few years, "We should have products that will not only be able to treat incision wounds but will also be able to treat large burn injuries. You need to fool the cells into thinking they’re in a different mechanical environment, either by using small molecule or pharmacologic blocking therapies such as fat inhibitors, or by using biomaterials that provide cues in a controlled way that minimize the amount of mechanical stimulation that the fibroblasts feel in the healing wound so as to mitigate the inflammation and subsequent fibrosis."

The study was supported by a Wallace H. Coulter Translational Partners Grant; the Armed Forces Institute of Regenerative Medicine; the Hagey Family Endowed Fund in Stem Cell Research and Regenerative Medicine; and the Oak Foundation. Neodyne Biosciences supplied the surgical dressings used in the study. Dr. Gurtner disclosed that he holds an equity interest in Neodyne.

SDEF and this news organization are owned by Elsevier.

*Correction 8/22/11: An earlier version of this story misstated the VAS scores for the two groups of patients.

DANA POINT, CALIF. – Scar formation and fibrosis can be reduced by altering the mechanical environment of wounds, results from a phase I study found.

At the Summit in Aesthetic Medicine, sponsored by Skin Disease Education Foundation (SDEF), Dr. Geoffrey C. Gurtner presented findings from a study in which nine patients undergoing elective abdominal surgery were treated postoperatively with a stress-shielding polymer on one side while the other side was treated with standard wound care.

©Neodyne Biosciences, Inc

The device, manufactured by Neodyne Biosciences, looks like a Band-Aid strip and is stretched over the incision after sutures are removed. It conforms to the wound and adheres to skin, creating "a compressive region that has no level of mechanical stimulation or distractive strain," said Dr. Gurtner, professor of surgery at Stanford (Calif.) University. "Essentially, you create stress risers in the unwounded skin and a mechanically privileged environment in the wounded skin."

A panel of three independent plastic surgeons reviewed 18 photos of the scars (nine treated, nine control) taken 6-12 months after surgery (Ann. Surg. 2011 May 19 [doi: 10.1097/SLA.0b013e318220b159]). They used a visual analog scale (VAS) that ranged from 0 (very good scar) to 100 (very poor hypertrophic scar).

Dr. Gurtner reported that the average VAS score in the treated group was 18.6, while the average VAS score in the control group was 50.5, a difference that was statistically significant (P = .0039). "In none of the cases was the treated scar worse than the control scar, which I think is different than some of the biologic agents we’ve seen over the last few years," he said.*

A panel of lay persons who reviewed the photos reported similar results that favored the treated group (P = .004).

In earlier mouse studies of wound environment manipulation, Dr. Gurtner and his associates found that focal adhesion kinase (FAK) is a critical regulator in the formation of hypertrophic scars. He described FAK as "a molecule that exists on the inner surface of cell membranes and transmits forces that are set in the external extracellular matrix to the inside of the cell. FAK transmits those forces into biological or biochemical cues that then turn on genes in the nucleus and make the cells do different things. This seems to be a very important molecule in the ability of us to produce hypertrophic scars in mice. If you take out FAK, you can prevent hypertrophic scar formation."

FAK is a target that has been examined extensively in cancer, Dr. Gurtner said, suggesting that in the next few years, "We should have products that will not only be able to treat incision wounds but will also be able to treat large burn injuries. You need to fool the cells into thinking they’re in a different mechanical environment, either by using small molecule or pharmacologic blocking therapies such as fat inhibitors, or by using biomaterials that provide cues in a controlled way that minimize the amount of mechanical stimulation that the fibroblasts feel in the healing wound so as to mitigate the inflammation and subsequent fibrosis."

The study was supported by a Wallace H. Coulter Translational Partners Grant; the Armed Forces Institute of Regenerative Medicine; the Hagey Family Endowed Fund in Stem Cell Research and Regenerative Medicine; and the Oak Foundation. Neodyne Biosciences supplied the surgical dressings used in the study. Dr. Gurtner disclosed that he holds an equity interest in Neodyne.

SDEF and this news organization are owned by Elsevier.

*Correction 8/22/11: An earlier version of this story misstated the VAS scores for the two groups of patients.

DANA POINT, CALIF. – Scar formation and fibrosis can be reduced by altering the mechanical environment of wounds, results from a phase I study found.

At the Summit in Aesthetic Medicine, sponsored by Skin Disease Education Foundation (SDEF), Dr. Geoffrey C. Gurtner presented findings from a study in which nine patients undergoing elective abdominal surgery were treated postoperatively with a stress-shielding polymer on one side while the other side was treated with standard wound care.

©Neodyne Biosciences, Inc

The device, manufactured by Neodyne Biosciences, looks like a Band-Aid strip and is stretched over the incision after sutures are removed. It conforms to the wound and adheres to skin, creating "a compressive region that has no level of mechanical stimulation or distractive strain," said Dr. Gurtner, professor of surgery at Stanford (Calif.) University. "Essentially, you create stress risers in the unwounded skin and a mechanically privileged environment in the wounded skin."

A panel of three independent plastic surgeons reviewed 18 photos of the scars (nine treated, nine control) taken 6-12 months after surgery (Ann. Surg. 2011 May 19 [doi: 10.1097/SLA.0b013e318220b159]). They used a visual analog scale (VAS) that ranged from 0 (very good scar) to 100 (very poor hypertrophic scar).

Dr. Gurtner reported that the average VAS score in the treated group was 18.6, while the average VAS score in the control group was 50.5, a difference that was statistically significant (P = .0039). "In none of the cases was the treated scar worse than the control scar, which I think is different than some of the biologic agents we’ve seen over the last few years," he said.*

A panel of lay persons who reviewed the photos reported similar results that favored the treated group (P = .004).

In earlier mouse studies of wound environment manipulation, Dr. Gurtner and his associates found that focal adhesion kinase (FAK) is a critical regulator in the formation of hypertrophic scars. He described FAK as "a molecule that exists on the inner surface of cell membranes and transmits forces that are set in the external extracellular matrix to the inside of the cell. FAK transmits those forces into biological or biochemical cues that then turn on genes in the nucleus and make the cells do different things. This seems to be a very important molecule in the ability of us to produce hypertrophic scars in mice. If you take out FAK, you can prevent hypertrophic scar formation."

FAK is a target that has been examined extensively in cancer, Dr. Gurtner said, suggesting that in the next few years, "We should have products that will not only be able to treat incision wounds but will also be able to treat large burn injuries. You need to fool the cells into thinking they’re in a different mechanical environment, either by using small molecule or pharmacologic blocking therapies such as fat inhibitors, or by using biomaterials that provide cues in a controlled way that minimize the amount of mechanical stimulation that the fibroblasts feel in the healing wound so as to mitigate the inflammation and subsequent fibrosis."

The study was supported by a Wallace H. Coulter Translational Partners Grant; the Armed Forces Institute of Regenerative Medicine; the Hagey Family Endowed Fund in Stem Cell Research and Regenerative Medicine; and the Oak Foundation. Neodyne Biosciences supplied the surgical dressings used in the study. Dr. Gurtner disclosed that he holds an equity interest in Neodyne.

SDEF and this news organization are owned by Elsevier.

*Correction 8/22/11: An earlier version of this story misstated the VAS scores for the two groups of patients.

BOSTON – The only polymethylmethacrylate dermal filler approved by the Food and Drug Administration may be a safe and effective option for malar augmentation in patients seeking to reverse age-related volume loss to the outer upper cheek region, according to interim results from a multicenter study.

The synthetic, nonresorbable agent, Artefill, produced significant improvements in malar volume in 24 patients enrolled in a 5-year prospective study and received high patient satisfaction and physician-assessed aesthetic improvement scores at 6 and 12 months, reported Dr. Daniel C. Mills of the plastic surgery department at Loma Linda (Calif.) University at the annual meeting of the American Society for Aesthetic Plastic Surgery. "And so far, with 1.5 years of follow-up under our belt, there have been no safety issues."

To assess the safety and efficacy of the polymethylmethacrylate (PMMA)/bovine collagen filler as a malar implant, Dr. Mills and his colleagues from multiple sites across the country enrolled 24 patients seeking malar augmentation into the open-label investigation.

"Each patient received up to three injections supraperiosteally: a first injection of no more than 6 cc, followed by one or two touch-ups after a month until full correction was achieved, with no patient getting more than 8 cc of the filler," he said. "The mean total volume injected was 5.5 cc." The reason for the serial injections, he noted, was because "this is close to a permanent filler, so we start low to make sure we have the right amount, then go back and add more if necessary."

The study outcomes include baseline and post-treatment assessments (weeks 8, 26, 52, 104, and 260) of malar volume on a 5-point scale: investigator and patient global aesthetic improvement, safety data, patient satisfaction, and patient likelihood to recommend the procedure.

Of the 24 patients in the study, all but one reported being satisfied with the procedure at 8 weeks and 1 year post-injection, "and all of my patients said they had more volume fill as time went by," said Dr. Mills. "It’s worth noting that the [global aesthetic improvement] scores of the one patient who was not satisfied with the outcome did improve."

Overall, malar volume improved significantly. "We saw the lipoatrophy go up one grade across the board, and the physician-assessed aesthetic score improved 96%," Dr. Mills reported. Of the 23 patients who reported being satisfied with the outcome, "the satisfaction rating was uniformly very high and all of them said they would recommend the procedure to other patients."

To date, with close to 1.5 half years of follow-up data, no device-related adverse events or serious adverse events have been reported, said Dr. Mills. He stressed, however, that the agent being investigated is "totally different" than the black market PMMA that is available in other parts of the world.

"The compounded PMMA being used in some countries, such as Brazil and Venezuela, has caused a wide range of complications and resulted in a lot of bad press," he said. "The FDA-approved product that we’re investigating is ultrapure and very uniform."

Artefill was approved by the FDA in 2006 for the treatment of nasolabial folds around the mouth, and is the only FDA-approved filler with a documented durability over a 5-year period, said Dr. Mills.

The product is composed of PMMA microspheres and a water-based carrier gel containing bovine collagen, buffered isotonic water, lidocaine, phosphate buffer, and sodium chloride.

Unlike most of the soft-tissue dermal fillers on the market, the PMMA-based implant provides a permanent support structure for wrinkle correction. "As the bovine collagen degrades over the course of a few weeks postinjection, the PMMA is encapsulated by the patient’s own collagen to stabilize the implant, resulting in continued [aesthetic] improvement over time," he said.

The study was sponsored by Suneva Medical. Dr. Mills disclosed a financial relationship with Allergan.

BOSTON – The only polymethylmethacrylate dermal filler approved by the Food and Drug Administration may be a safe and effective option for malar augmentation in patients seeking to reverse age-related volume loss to the outer upper cheek region, according to interim results from a multicenter study.

The synthetic, nonresorbable agent, Artefill, produced significant improvements in malar volume in 24 patients enrolled in a 5-year prospective study and received high patient satisfaction and physician-assessed aesthetic improvement scores at 6 and 12 months, reported Dr. Daniel C. Mills of the plastic surgery department at Loma Linda (Calif.) University at the annual meeting of the American Society for Aesthetic Plastic Surgery. "And so far, with 1.5 years of follow-up under our belt, there have been no safety issues."

To assess the safety and efficacy of the polymethylmethacrylate (PMMA)/bovine collagen filler as a malar implant, Dr. Mills and his colleagues from multiple sites across the country enrolled 24 patients seeking malar augmentation into the open-label investigation.

"Each patient received up to three injections supraperiosteally: a first injection of no more than 6 cc, followed by one or two touch-ups after a month until full correction was achieved, with no patient getting more than 8 cc of the filler," he said. "The mean total volume injected was 5.5 cc." The reason for the serial injections, he noted, was because "this is close to a permanent filler, so we start low to make sure we have the right amount, then go back and add more if necessary."

The study outcomes include baseline and post-treatment assessments (weeks 8, 26, 52, 104, and 260) of malar volume on a 5-point scale: investigator and patient global aesthetic improvement, safety data, patient satisfaction, and patient likelihood to recommend the procedure.

Of the 24 patients in the study, all but one reported being satisfied with the procedure at 8 weeks and 1 year post-injection, "and all of my patients said they had more volume fill as time went by," said Dr. Mills. "It’s worth noting that the [global aesthetic improvement] scores of the one patient who was not satisfied with the outcome did improve."

Overall, malar volume improved significantly. "We saw the lipoatrophy go up one grade across the board, and the physician-assessed aesthetic score improved 96%," Dr. Mills reported. Of the 23 patients who reported being satisfied with the outcome, "the satisfaction rating was uniformly very high and all of them said they would recommend the procedure to other patients."

To date, with close to 1.5 half years of follow-up data, no device-related adverse events or serious adverse events have been reported, said Dr. Mills. He stressed, however, that the agent being investigated is "totally different" than the black market PMMA that is available in other parts of the world.

"The compounded PMMA being used in some countries, such as Brazil and Venezuela, has caused a wide range of complications and resulted in a lot of bad press," he said. "The FDA-approved product that we’re investigating is ultrapure and very uniform."

Artefill was approved by the FDA in 2006 for the treatment of nasolabial folds around the mouth, and is the only FDA-approved filler with a documented durability over a 5-year period, said Dr. Mills.

The product is composed of PMMA microspheres and a water-based carrier gel containing bovine collagen, buffered isotonic water, lidocaine, phosphate buffer, and sodium chloride.

Unlike most of the soft-tissue dermal fillers on the market, the PMMA-based implant provides a permanent support structure for wrinkle correction. "As the bovine collagen degrades over the course of a few weeks postinjection, the PMMA is encapsulated by the patient’s own collagen to stabilize the implant, resulting in continued [aesthetic] improvement over time," he said.

The study was sponsored by Suneva Medical. Dr. Mills disclosed a financial relationship with Allergan.

BOSTON – The only polymethylmethacrylate dermal filler approved by the Food and Drug Administration may be a safe and effective option for malar augmentation in patients seeking to reverse age-related volume loss to the outer upper cheek region, according to interim results from a multicenter study.

The synthetic, nonresorbable agent, Artefill, produced significant improvements in malar volume in 24 patients enrolled in a 5-year prospective study and received high patient satisfaction and physician-assessed aesthetic improvement scores at 6 and 12 months, reported Dr. Daniel C. Mills of the plastic surgery department at Loma Linda (Calif.) University at the annual meeting of the American Society for Aesthetic Plastic Surgery. "And so far, with 1.5 years of follow-up under our belt, there have been no safety issues."

To assess the safety and efficacy of the polymethylmethacrylate (PMMA)/bovine collagen filler as a malar implant, Dr. Mills and his colleagues from multiple sites across the country enrolled 24 patients seeking malar augmentation into the open-label investigation.

"Each patient received up to three injections supraperiosteally: a first injection of no more than 6 cc, followed by one or two touch-ups after a month until full correction was achieved, with no patient getting more than 8 cc of the filler," he said. "The mean total volume injected was 5.5 cc." The reason for the serial injections, he noted, was because "this is close to a permanent filler, so we start low to make sure we have the right amount, then go back and add more if necessary."

The study outcomes include baseline and post-treatment assessments (weeks 8, 26, 52, 104, and 260) of malar volume on a 5-point scale: investigator and patient global aesthetic improvement, safety data, patient satisfaction, and patient likelihood to recommend the procedure.

Of the 24 patients in the study, all but one reported being satisfied with the procedure at 8 weeks and 1 year post-injection, "and all of my patients said they had more volume fill as time went by," said Dr. Mills. "It’s worth noting that the [global aesthetic improvement] scores of the one patient who was not satisfied with the outcome did improve."

Overall, malar volume improved significantly. "We saw the lipoatrophy go up one grade across the board, and the physician-assessed aesthetic score improved 96%," Dr. Mills reported. Of the 23 patients who reported being satisfied with the outcome, "the satisfaction rating was uniformly very high and all of them said they would recommend the procedure to other patients."

To date, with close to 1.5 half years of follow-up data, no device-related adverse events or serious adverse events have been reported, said Dr. Mills. He stressed, however, that the agent being investigated is "totally different" than the black market PMMA that is available in other parts of the world.

"The compounded PMMA being used in some countries, such as Brazil and Venezuela, has caused a wide range of complications and resulted in a lot of bad press," he said. "The FDA-approved product that we’re investigating is ultrapure and very uniform."

Artefill was approved by the FDA in 2006 for the treatment of nasolabial folds around the mouth, and is the only FDA-approved filler with a documented durability over a 5-year period, said Dr. Mills.

The product is composed of PMMA microspheres and a water-based carrier gel containing bovine collagen, buffered isotonic water, lidocaine, phosphate buffer, and sodium chloride.

Unlike most of the soft-tissue dermal fillers on the market, the PMMA-based implant provides a permanent support structure for wrinkle correction. "As the bovine collagen degrades over the course of a few weeks postinjection, the PMMA is encapsulated by the patient’s own collagen to stabilize the implant, resulting in continued [aesthetic] improvement over time," he said.

The study was sponsored by Suneva Medical. Dr. Mills disclosed a financial relationship with Allergan.