Aesthetic Dermatology

LAS VEGAS – Treatment for cellulite is a multibillion dollar industry of unproved therapies, according to Dr. Mathew M. Avram.

Some treatments that claim to lessen cellulite may have produced minor, temporary improvements in flawed studies, but none has been proven to be truly effective, said Dr. Avram of Harvard University and director of Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center, Boston.

There is no medical reason to treat cellulite, which is normal in the female dermis and is not associated with morbidity or mortality. Many women care about it anyway "because every tabloid likes to show celebrities and their cellulite running around in Hawaii," he said at the seminar sponsored by Skin Disease Education Foundation (SDEF).

(c) photoCD/Fotolia.com

Many physicians and patients misunderstand cellulite, which is simply gender-related differences in the structure of subcutaneous fat lobules and the connective tissue septae that divide them, usually in the thigh area, Dr. Avram said. The treatment industry capitalizes on this ignorance.

"We need to educate our patients that cellulite is a totally normal condition" and treatments are at best mildly helpful for a short period of time, he said. "We need to be skeptical as well. There is a consistent history of inflated and unsubstantiated claims of success."

Fat removal technologies have no effect on cellulite because fat and cellulite are distinct. Weight and cellulite are unrelated. Cellulite is nearly universal in postpubertal females even if they are lean, but most obese males do not have cellulite unless they have androgen deficiency. "Exercise doesn’t really help it," he explained.

There is no good evidence for invasive treatments such as liposuction, subcision, mesotherapy, or carboxytherapy. Most data on noninvasive treatments measure results by body circumference, "which isn’t relevant to cellulite, so it’s hard to know whether or not there is improvement," he noted.

Flawed studies of treatments such as noninvasive Endermologie (mechanical cell stimulation), unipolar and bipolar radiofrequency, devices combining lasers and light sources, and topical treatments show modest, temporary benefit, he said.

Nearly 2 decades ago, a study of topical retinoids for cellulite showed some improvements, but this may have just been temporary improvements in inflammation, Dr. Avram said. Multiple expensive topical formulations have shown no significant efficacy, including xanthines, lactic acid, and aminophylline.

At least three laser devices that are cleared by the Food and Drug Administration are used to treat cellulite, but these devices only needed to prove safety, not efficacy, to achieve clearance, noted Dr. Avram, who is a lawyer as well as a physician. Studies of two of the laser devices suggested that they may produce temporary and limited decreases in limb circumference, which is a poor measure of cellulite.

A study of the third device treated 17 patients twice weekly for 4 weeks with a dual wavelength laser system with vacuum suction and mechanical massage (Plast. Reconstr. Surg. 2010;125:1788-96). The study suggested that 14 patients (82%) showed "improvement" at 1 month as measured by VECTRA 3-D photographs, but initial cellulite irregularities and any possible improvements were more difficult to see by conventional digital photography. The study did not define "improvement" and included no control sites or histology to assess improvement, noted Dr. Avram.

"This is really a flawed study," he said.

A separate study of a unipolar radiofrequency device for treating cellulite in 30 patients reported a mean 2.45-cm improvement in thigh circumference in 27 patients at 6 months with changes in upper dermis fibrosis on histology (Dermatol. Surg. 2008;34:204-9). However, circumference is an inherently imprecise measure that is irrelevant to cellulite, Dr. Avram noted.

"We need a set of criteria by which we can assess the efficacy of these technologies," he said. Photography is difficult and easily manipulated to exaggerate results. Ultrasound is imprecise and user dependent. MRI is expensive and requires specific coils for fat and 3-D imaging systems.

"At a minimum we need to have untreated controls, weight maintenance during studies, and laboratory data to confirm safety," Dr. Avram said. "We must hold our industry and our colleagues to high standards" and demand proof of scientifically important efficacy.

Physicians also should question whether the postulated mechanisms of action for these new technologies make sense with regard to cellulite. Any study without a histology report, for example, has no basis for a claim of efficacy in treating cellulite, he said.

Dr. Avram holds stock options in Zeltiq Aesthetics. SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Treatment for cellulite is a multibillion dollar industry of unproved therapies, according to Dr. Mathew M. Avram.

Some treatments that claim to lessen cellulite may have produced minor, temporary improvements in flawed studies, but none has been proven to be truly effective, said Dr. Avram of Harvard University and director of Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center, Boston.

There is no medical reason to treat cellulite, which is normal in the female dermis and is not associated with morbidity or mortality. Many women care about it anyway "because every tabloid likes to show celebrities and their cellulite running around in Hawaii," he said at the seminar sponsored by Skin Disease Education Foundation (SDEF).

(c) photoCD/Fotolia.com

Many physicians and patients misunderstand cellulite, which is simply gender-related differences in the structure of subcutaneous fat lobules and the connective tissue septae that divide them, usually in the thigh area, Dr. Avram said. The treatment industry capitalizes on this ignorance.

"We need to educate our patients that cellulite is a totally normal condition" and treatments are at best mildly helpful for a short period of time, he said. "We need to be skeptical as well. There is a consistent history of inflated and unsubstantiated claims of success."

Fat removal technologies have no effect on cellulite because fat and cellulite are distinct. Weight and cellulite are unrelated. Cellulite is nearly universal in postpubertal females even if they are lean, but most obese males do not have cellulite unless they have androgen deficiency. "Exercise doesn’t really help it," he explained.

There is no good evidence for invasive treatments such as liposuction, subcision, mesotherapy, or carboxytherapy. Most data on noninvasive treatments measure results by body circumference, "which isn’t relevant to cellulite, so it’s hard to know whether or not there is improvement," he noted.

Flawed studies of treatments such as noninvasive Endermologie (mechanical cell stimulation), unipolar and bipolar radiofrequency, devices combining lasers and light sources, and topical treatments show modest, temporary benefit, he said.

Nearly 2 decades ago, a study of topical retinoids for cellulite showed some improvements, but this may have just been temporary improvements in inflammation, Dr. Avram said. Multiple expensive topical formulations have shown no significant efficacy, including xanthines, lactic acid, and aminophylline.

At least three laser devices that are cleared by the Food and Drug Administration are used to treat cellulite, but these devices only needed to prove safety, not efficacy, to achieve clearance, noted Dr. Avram, who is a lawyer as well as a physician. Studies of two of the laser devices suggested that they may produce temporary and limited decreases in limb circumference, which is a poor measure of cellulite.

A study of the third device treated 17 patients twice weekly for 4 weeks with a dual wavelength laser system with vacuum suction and mechanical massage (Plast. Reconstr. Surg. 2010;125:1788-96). The study suggested that 14 patients (82%) showed "improvement" at 1 month as measured by VECTRA 3-D photographs, but initial cellulite irregularities and any possible improvements were more difficult to see by conventional digital photography. The study did not define "improvement" and included no control sites or histology to assess improvement, noted Dr. Avram.

"This is really a flawed study," he said.

A separate study of a unipolar radiofrequency device for treating cellulite in 30 patients reported a mean 2.45-cm improvement in thigh circumference in 27 patients at 6 months with changes in upper dermis fibrosis on histology (Dermatol. Surg. 2008;34:204-9). However, circumference is an inherently imprecise measure that is irrelevant to cellulite, Dr. Avram noted.

"We need a set of criteria by which we can assess the efficacy of these technologies," he said. Photography is difficult and easily manipulated to exaggerate results. Ultrasound is imprecise and user dependent. MRI is expensive and requires specific coils for fat and 3-D imaging systems.

"At a minimum we need to have untreated controls, weight maintenance during studies, and laboratory data to confirm safety," Dr. Avram said. "We must hold our industry and our colleagues to high standards" and demand proof of scientifically important efficacy.

Physicians also should question whether the postulated mechanisms of action for these new technologies make sense with regard to cellulite. Any study without a histology report, for example, has no basis for a claim of efficacy in treating cellulite, he said.

Dr. Avram holds stock options in Zeltiq Aesthetics. SDEF and this news organization are owned by Elsevier.

LAS VEGAS – Treatment for cellulite is a multibillion dollar industry of unproved therapies, according to Dr. Mathew M. Avram.

Some treatments that claim to lessen cellulite may have produced minor, temporary improvements in flawed studies, but none has been proven to be truly effective, said Dr. Avram of Harvard University and director of Massachusetts General Hospital’s Dermatology Laser and Cosmetic Center, Boston.

There is no medical reason to treat cellulite, which is normal in the female dermis and is not associated with morbidity or mortality. Many women care about it anyway "because every tabloid likes to show celebrities and their cellulite running around in Hawaii," he said at the seminar sponsored by Skin Disease Education Foundation (SDEF).

(c) photoCD/Fotolia.com

Many physicians and patients misunderstand cellulite, which is simply gender-related differences in the structure of subcutaneous fat lobules and the connective tissue septae that divide them, usually in the thigh area, Dr. Avram said. The treatment industry capitalizes on this ignorance.

"We need to educate our patients that cellulite is a totally normal condition" and treatments are at best mildly helpful for a short period of time, he said. "We need to be skeptical as well. There is a consistent history of inflated and unsubstantiated claims of success."

Fat removal technologies have no effect on cellulite because fat and cellulite are distinct. Weight and cellulite are unrelated. Cellulite is nearly universal in postpubertal females even if they are lean, but most obese males do not have cellulite unless they have androgen deficiency. "Exercise doesn’t really help it," he explained.

There is no good evidence for invasive treatments such as liposuction, subcision, mesotherapy, or carboxytherapy. Most data on noninvasive treatments measure results by body circumference, "which isn’t relevant to cellulite, so it’s hard to know whether or not there is improvement," he noted.

Flawed studies of treatments such as noninvasive Endermologie (mechanical cell stimulation), unipolar and bipolar radiofrequency, devices combining lasers and light sources, and topical treatments show modest, temporary benefit, he said.

Nearly 2 decades ago, a study of topical retinoids for cellulite showed some improvements, but this may have just been temporary improvements in inflammation, Dr. Avram said. Multiple expensive topical formulations have shown no significant efficacy, including xanthines, lactic acid, and aminophylline.

At least three laser devices that are cleared by the Food and Drug Administration are used to treat cellulite, but these devices only needed to prove safety, not efficacy, to achieve clearance, noted Dr. Avram, who is a lawyer as well as a physician. Studies of two of the laser devices suggested that they may produce temporary and limited decreases in limb circumference, which is a poor measure of cellulite.

A study of the third device treated 17 patients twice weekly for 4 weeks with a dual wavelength laser system with vacuum suction and mechanical massage (Plast. Reconstr. Surg. 2010;125:1788-96). The study suggested that 14 patients (82%) showed "improvement" at 1 month as measured by VECTRA 3-D photographs, but initial cellulite irregularities and any possible improvements were more difficult to see by conventional digital photography. The study did not define "improvement" and included no control sites or histology to assess improvement, noted Dr. Avram.

"This is really a flawed study," he said.

A separate study of a unipolar radiofrequency device for treating cellulite in 30 patients reported a mean 2.45-cm improvement in thigh circumference in 27 patients at 6 months with changes in upper dermis fibrosis on histology (Dermatol. Surg. 2008;34:204-9). However, circumference is an inherently imprecise measure that is irrelevant to cellulite, Dr. Avram noted.

"We need a set of criteria by which we can assess the efficacy of these technologies," he said. Photography is difficult and easily manipulated to exaggerate results. Ultrasound is imprecise and user dependent. MRI is expensive and requires specific coils for fat and 3-D imaging systems.

"At a minimum we need to have untreated controls, weight maintenance during studies, and laboratory data to confirm safety," Dr. Avram said. "We must hold our industry and our colleagues to high standards" and demand proof of scientifically important efficacy.

Physicians also should question whether the postulated mechanisms of action for these new technologies make sense with regard to cellulite. Any study without a histology report, for example, has no basis for a claim of efficacy in treating cellulite, he said.

Dr. Avram holds stock options in Zeltiq Aesthetics. SDEF and this news organization are owned by Elsevier.

CHICAGO – An Nd:YAG laser used for facial fat plasty and laser liposuction treatment has shown promise for targeting axillary bromhidrosis and hyperhidrosis, according to the first prospective, long-term follow-up study for these indications.

After an iodine starch test at baseline, researchers treated both axillae of 18 patients with the disorders with a 1,444-nm pulsed Nd:YAG laser (AccuSculpt, Lutronic). Each operative field was anesthetized. Participants were then assessed at day 1, 7, 30, 60, and 180 for clinical effects.

"Outcome was good in this study" Dr. Sang Min Yi said. Patients rated 61% of axillary bromhidrosis and 86% of hyperhidrosis results as excellent or good.

Patients judged the severity of their condition at baseline and regular intervals using a 10-point scale (10 being the most severe). For example, average bromhidrosis severity was 1.2 on day 7 and 1.7 on day 60. Patients also rated their average pain severity as 1.2 on day 7 and 0.3 on day 60. Severity of limitation on movement was an average 2.6 on day 7 after treatment and 0.4 on day 60.

Participants also rated the severity of remaining sweating as 1.4 on day 7 and 1.7 on day 60. Overall satisfaction was an average 9 out of 10 on both days 7 and 60. Results at day 180 are pending.

The 1,444-nm pulsed Nd:YAG laser targets apocrine sweat glands in the deep dermis and subcutaneous fat layer. Pulse energy was 175 mJ, pulse rate was 40 Hz, power was 7 watts, and the energy density ranged from 20 J/cm2 to 30 J/cm2.

Other treatments for axillary bromhidrosis and hyperhidrosis include local topical medications, botulinum toxin injections, ultrasonic therapy, and liposuction curettage. However, this laser is one of the best modalities to treat these disorders, said Dr. Yi, of the department of dermatology, Korea University, Ansan Hospital, South Korea.

Most adverse events were temporary and mild. Bullae, mild ecchymoses, and bruises on the operative sites all resolved within 30 days, Dr. Yi said. "The most severe and unwanted complication was skin necrosis." This occurred in two patients. Necrosis is preventable if the tip of the probe is held properly and delivery of excess energy to any unit area is avoided, he noted.

Dr. Yi received research funding from Lutronic, which also funded the study.

CHICAGO – An Nd:YAG laser used for facial fat plasty and laser liposuction treatment has shown promise for targeting axillary bromhidrosis and hyperhidrosis, according to the first prospective, long-term follow-up study for these indications.

After an iodine starch test at baseline, researchers treated both axillae of 18 patients with the disorders with a 1,444-nm pulsed Nd:YAG laser (AccuSculpt, Lutronic). Each operative field was anesthetized. Participants were then assessed at day 1, 7, 30, 60, and 180 for clinical effects.

"Outcome was good in this study" Dr. Sang Min Yi said. Patients rated 61% of axillary bromhidrosis and 86% of hyperhidrosis results as excellent or good.

Patients judged the severity of their condition at baseline and regular intervals using a 10-point scale (10 being the most severe). For example, average bromhidrosis severity was 1.2 on day 7 and 1.7 on day 60. Patients also rated their average pain severity as 1.2 on day 7 and 0.3 on day 60. Severity of limitation on movement was an average 2.6 on day 7 after treatment and 0.4 on day 60.

Participants also rated the severity of remaining sweating as 1.4 on day 7 and 1.7 on day 60. Overall satisfaction was an average 9 out of 10 on both days 7 and 60. Results at day 180 are pending.

The 1,444-nm pulsed Nd:YAG laser targets apocrine sweat glands in the deep dermis and subcutaneous fat layer. Pulse energy was 175 mJ, pulse rate was 40 Hz, power was 7 watts, and the energy density ranged from 20 J/cm2 to 30 J/cm2.

Other treatments for axillary bromhidrosis and hyperhidrosis include local topical medications, botulinum toxin injections, ultrasonic therapy, and liposuction curettage. However, this laser is one of the best modalities to treat these disorders, said Dr. Yi, of the department of dermatology, Korea University, Ansan Hospital, South Korea.

Most adverse events were temporary and mild. Bullae, mild ecchymoses, and bruises on the operative sites all resolved within 30 days, Dr. Yi said. "The most severe and unwanted complication was skin necrosis." This occurred in two patients. Necrosis is preventable if the tip of the probe is held properly and delivery of excess energy to any unit area is avoided, he noted.

Dr. Yi received research funding from Lutronic, which also funded the study.

CHICAGO – An Nd:YAG laser used for facial fat plasty and laser liposuction treatment has shown promise for targeting axillary bromhidrosis and hyperhidrosis, according to the first prospective, long-term follow-up study for these indications.

After an iodine starch test at baseline, researchers treated both axillae of 18 patients with the disorders with a 1,444-nm pulsed Nd:YAG laser (AccuSculpt, Lutronic). Each operative field was anesthetized. Participants were then assessed at day 1, 7, 30, 60, and 180 for clinical effects.

"Outcome was good in this study" Dr. Sang Min Yi said. Patients rated 61% of axillary bromhidrosis and 86% of hyperhidrosis results as excellent or good.

Patients judged the severity of their condition at baseline and regular intervals using a 10-point scale (10 being the most severe). For example, average bromhidrosis severity was 1.2 on day 7 and 1.7 on day 60. Patients also rated their average pain severity as 1.2 on day 7 and 0.3 on day 60. Severity of limitation on movement was an average 2.6 on day 7 after treatment and 0.4 on day 60.

Participants also rated the severity of remaining sweating as 1.4 on day 7 and 1.7 on day 60. Overall satisfaction was an average 9 out of 10 on both days 7 and 60. Results at day 180 are pending.

The 1,444-nm pulsed Nd:YAG laser targets apocrine sweat glands in the deep dermis and subcutaneous fat layer. Pulse energy was 175 mJ, pulse rate was 40 Hz, power was 7 watts, and the energy density ranged from 20 J/cm2 to 30 J/cm2.

Other treatments for axillary bromhidrosis and hyperhidrosis include local topical medications, botulinum toxin injections, ultrasonic therapy, and liposuction curettage. However, this laser is one of the best modalities to treat these disorders, said Dr. Yi, of the department of dermatology, Korea University, Ansan Hospital, South Korea.

Most adverse events were temporary and mild. Bullae, mild ecchymoses, and bruises on the operative sites all resolved within 30 days, Dr. Yi said. "The most severe and unwanted complication was skin necrosis." This occurred in two patients. Necrosis is preventable if the tip of the probe is held properly and delivery of excess energy to any unit area is avoided, he noted.

Dr. Yi received research funding from Lutronic, which also funded the study.

Botulinum toxins, including Botox and Dysport, are being associated with increasing reports of paralysis away from injection sites, difficulties in swallowing, incontinence, and breathing problems, according to the Institute for Safe Medication Practices.

The institute reviews and analyzes reports to the Food and Drug Administration's MedWatch Safety Information and Adverse Event Reporting Program.

Photo (c)DenGuy/istock.com

The group cited 6 deaths, 18 cases of disability, and 100 other serious injuries in the first quarter of 2010. Previous quarters have averaged 30-50 adverse events and one patient death associated with the toxin. Seventy-nine of the cases (64%) in the latest quarter were associated with Botox, 26 (21%) with Botox Cosmetic, 17 (14%) with Dysport, and 2 cases with undetermined brands.

The watchdog group charged that the Botox label downplays the potential for the drug to spread during dermatologic use.

Botulinum toxins, including Botox and Dysport, are being associated with increasing reports of paralysis away from injection sites, difficulties in swallowing, incontinence, and breathing problems, according to the Institute for Safe Medication Practices.

The institute reviews and analyzes reports to the Food and Drug Administration's MedWatch Safety Information and Adverse Event Reporting Program.

Photo (c)DenGuy/istock.com

The group cited 6 deaths, 18 cases of disability, and 100 other serious injuries in the first quarter of 2010. Previous quarters have averaged 30-50 adverse events and one patient death associated with the toxin. Seventy-nine of the cases (64%) in the latest quarter were associated with Botox, 26 (21%) with Botox Cosmetic, 17 (14%) with Dysport, and 2 cases with undetermined brands.

The watchdog group charged that the Botox label downplays the potential for the drug to spread during dermatologic use.

Botulinum toxins, including Botox and Dysport, are being associated with increasing reports of paralysis away from injection sites, difficulties in swallowing, incontinence, and breathing problems, according to the Institute for Safe Medication Practices.

The institute reviews and analyzes reports to the Food and Drug Administration's MedWatch Safety Information and Adverse Event Reporting Program.

Photo (c)DenGuy/istock.com

The group cited 6 deaths, 18 cases of disability, and 100 other serious injuries in the first quarter of 2010. Previous quarters have averaged 30-50 adverse events and one patient death associated with the toxin. Seventy-nine of the cases (64%) in the latest quarter were associated with Botox, 26 (21%) with Botox Cosmetic, 17 (14%) with Dysport, and 2 cases with undetermined brands.

The watchdog group charged that the Botox label downplays the potential for the drug to spread during dermatologic use.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - In contrast to claims made about some noninvasive body-contouring devices, cryolipolysis can and does work, Dr. Elizabeth Tanzi said.

However, careful patient selection and realistic expectations – on both the part of the patient and the physician – are essential to a successful outcome, said Dr. Tanzi, a private practice dermatologist in Washington, D.C.

"Noninvasive removal of fat to contour the body is a reality. However, as we've all been told: If something seems to be too good to be true, it probably is," Dr. Tanzi said. "There are limitations."

Educate patients that cryolipolysis is not a replacement for liposuction to remove large amounts of fat. The technique, instead, is best suited to flatten discreet bulges of fat – around the abdomen, the back, or the "love handles," for example, that are resistant to diet and exercise, Dr. Tanzi said at the annual meeting of the American Society for Dermatologic Surgery, which was held jointly with the American Society of Cosmetic Dermatology and Aesthetic Surgery.

You may need to counter some patient misperceptions about cryolipolysis as well. "This is not 'fat freezing,' no matter how many times you hear that in the media," she said.

This procedure, instead, relies on precise, controlled cooling of fat cells or adipocytes. This strategy exploits the natural vulnerability of adipocytes to prolonged cold exposure, Dr. Tanzi said, and causes the death of these cells without damage to surrounding tissues. The destroyed fat cells are cleared through the body's natural clearance mechanisms. The Food and Drug Administration approved a cryolipolysis device (CoolSculpting, Zeltiq) for marketing in September 2010.

You can tell inquisitive patients that a single cryolipolysis treatment reduced the fat layer an average of 22% for 32 patients in a prospective multicenter study, Dr. Tanzi said. Dr. Jeffrey Dover presented the results at the 2009 American Society for Laser Medicine and Surgery annual meeting.

Counsel patients that cryolipolysis results are not immediate, Dr. Tanzi said. Adipocytes appear intact immediately post treatment, followed by an inflammatory response seen at days 3, 5, and 7. It can take several months for fat cell clearance and full clinical results.

Patients also can expect temporary dulling of sensation in the treated area that typically resolves in 1-2 weeks, Dr. Tanzi said. Erythema can last minutes to hours post treatment but purpura is uncommon. In addition, patients might experience a "dull, deep soreness for several days. It is tolerable, and feels like they have just done a lot of sit-ups."

Patient and physician expectations have to be realistic, Dr. Tanzi said. "I get asked questions by patients over and over again. Does it really work? The answer is yes, but you have to define the terms." Cryolipolysis will improve the body’s contour, but it is not for skin tightening, for example, and it is not a weight loss strategy. "Yes, clothes fit better," she said. "Patients tell me about that, and now it’s part of my conversation in my consultation."

The noninvasive fat removal field – including cryolipolysis and the other body-contouring devices – is still in its infancy, Dr. Tanzi said in a follow-up interview.

Technology changes underway will expand the application of these technologies beyond the abdomen and love handle areas. "Soon we’ll be able to treat other areas, such as arms and thighs, to really get a nice contour improvement there as well," she said.

Dr. Tanzi disclosed that she is on the medical advisory board for Zeltiq.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

CHICAGO - Some patients are ideal candidates for nonsurgical rhinoplasty to reshape the nose, according to experts.

Patients unready or unwilling to undergo surgery, for example, could opt for more temporary aesthetic changes through injectable products, two presenters noted at the annual meeting of the American Society for Dermatologic Surgery.

Photo credit: ©Dr. Vince Bertucci

Unlike more familiar facial cosmetic procedures, patients might need to be educated that injectables in the nose are a valid option, said Dr. Jean-François Tremblay, chief of the dermatologic surgery unit at the University of Montreal’s hospital center. Some will also need guidance as to what constitutes an ideal nose.

"We are not going to replace rhinoplasty, but there is a lot we can do with fillers in an in-and-out procedure," said Dr. Vince Bertucci, Immediate Past President of the Canadian Society for Dermatologic Surgery and the Medical Director of Bertucci MedSpa in Woodbridge, just outside Toronto.

Fillers can increase nasal tip projection and give the nose a longer, more refined appearance. Botulinum toxin can reduce dynamic changes that occur for some during facial expression, such as tip movement, "bunny lines," or alar flare. "Some patients with bunny lines really pull up their ali when they smile, but post botulinum toxin injection, they do not raise up as high," Dr. Bertucci said.

In some cases, fillers and botulinum toxin can be used in combination. Nasal tip droop is a common concern, Dr. Bertucci said. Botulinum toxin injected into the depressor septi nasi at the base of the columella can reverse this common effect of aging. He cautioned, however, the upper lip can be widened or elongated with this technique, and the upper lip tends to be already elongated in some elderly patients.

Photo credit: Damian McNamara

Dr. Bertucci emphasized the importance of knowing the nasal anatomy and danger zones. For example, inject botulinum toxin approximately half way between the nasal-facial junction and dorsum of the nose to avoid hitting the muscle that lifts the mouth. If the levator labii superioris alaeque nasi is inadvertently treated, the patient may end up with an unusual or asymmetric smile. "The message here is do not inject too far down the side of the nose."

The best candidates for nonsurgical rhinoplasty have minor deformities, not major deviations or bony anomalies, Dr. Tremblay said. Lower cost, little to no downtime, and the reversible or modifiable nature of the filler correction are among the appeals, he said. A temporary duration of effect can be a disadvantage. In addition, "we can only add volume and not remove anything," said Dr. Tremblay during the joint presentation.

An important caveat is patients who seek correction with injectables after a rhinoplasty require additional caution and expertise. "I would not recommend starting out on post-rhinoplasty patients," Dr. Bertucci said. Vascular changes and modification of bone and tissue from surgery can increase the risk of necrosis.

Regardless of history, begin by asking all patients what bothers them, Dr. Tremblay advised. "I want to understand their expectations, what their notion of an ideal nose is, and do a quick psychoanalysis 101." He added, "The rate of people having body dysmorphic disorder is higher when people complain about their noses versus other concerns. So it could be a sign someone does not have balanced psychological health."

Ensure you view the nose from all angles (frontal, lateral, and basal) and consider any aesthetic changes in the context of the entire face. "The basal view can show underlying anomalies that might explain superficial features we are trying to correct," Dr. Tremblay said.

An ideal nose "cannot be defined for any given individual without taking into consideration the rest of the facial features," Dr. Tremblay said. For example, he increased the chin projection of a woman who initially wanted the size of her nose reduced. She was happy with her nose after the chin augmentation.

Skin thickness varies in different parts of the nose. In general, the mid-nose skin tends to be thinner and more delicate than the proximal and distal areas. "So when you inject the mid-nose, keep in mind the need to [massage] material around so you don’t get a prominence," Dr. Bertucci said. Also avoid superficial placement and overcorrection with fillers (consider a staged correction). He added, "Injecting slowly is really important. It seems like a simple thing, but look at the skin as you inject is it blanching?"

A tip with filler enhancement on the dorsum of the nose is to pinch the skin and pull it gently up before injecting. Dr. Bertucci said, "I am still underneath the level of the skin, and I am off the vessels that may be lying on the bone or muscle."

"I also find that useful and that is what I do," Dr. Tremblay said. I try to generate with pinching the correction I am trying to achieve, and inject until I reach the volume I want."

A long-lasting but nonpermanent filler product is more ideal than a permanent one in the nose, Dr. Bertucci said. "This leaves you a way out, and the anatomy changes with age." Hyaluronic acid or calcium hydroxylapatite products are examples. In contrast, use of silicone can be riskier in terms of overcorrection and granulomatous effects.

A meeting attendee countered that he prefers silicone because hyaluronic acid corrections only last 2-3 months in his patients. Dr. Bertucci replied that, because of its permanent nature, "I would not use silicone unless you are very skilled in its use."

Injection-related pain, redness, bleeding, ecchymosis, and hematoma are possible complications regardless of the product type injected, Dr. Bertucci said.

Dr. Bertucci disclosed that he is a consultant for Allergan, Medicis Pharmaceutical Corp., and Merz Pharmaceutical, and an investigator for Allergen and Merz. Dr. Tromblay disclosed that he is a medical consultant for Allergan, Medicis, Canderm Pharma Inc., La Roche-Posay, Procter & Gamble, and Johnson & Johnson.

SANTA BARBARA, Calif. - Fat transfer for lipoatrophy is safe and cost effective, and provides excellent long-term results, lasting over a year in some cases, said Dr. Ilya Reyter.

Dr. Reyter, along with Dr. David Sawcer, launched a lipodystrophy clinic in the department of dermatology at the University of Southern California's Keck School of Medicine in early 2007. The clinic is dedicated to treating HIV-associated lipodystrophy and lipoatrophy using tumescent liposuction and fat transfer.

Photo courtesy Dr. Ilya Reyter

Dr. Reyter, an assistant clinical professor of dermatology at the university, also has extensive experience with fat transfer and liposuction for non-HIV cosmetic improvement, and performs the procedure in his private practice in Beverly Hills, Calif.

Lipodystrophy is marked by central fat deposition on the abdomen, dorsocervical area, salivary glands, breasts, face, and neck. "Before we started this clinic, a lot of our patients were being sent to plastic surgeons, especially for excision of lipodystrophy, particularly in the dorsocervical area," Dr. Reyter said. The dystrophic fat accumulations can be removed more simply using local anesthesia with tumescent liposuction, thereby avoiding the risks of surgery with general anesthesia, he said.

Patients are referred to the HIV lipodystrophy clinic by the HIV dermatology clinic and by other physicians working with HIV patients at the medical school. Dr. Reyter has treated numerous patients for non-HIV cosmetic fat transfer, "but in the HIV clinic, we have treated a few dozen patients," he said. "We select the patients carefully, to make sure that they are appropriate candidates. Not everyone with facial atrophy is a candidate for fat transfer, or fillers, for that matter."

He went on to describe his methods for treating lipoatrophy using fat transfer. Lipoatrophy, also know as fat wasting, particularly affects the face, and is marked by prominent zygomata, reduction of Bichat’s fat pads, sunken eyeballs, and a cachectic appearance.

HIV-associated lipoatrophy was recognized shortly after the first protease inhibitors were approved in 1995. "You can see some of these features in patients who are HIV positive but not on any medication, but it's a really small subset, only about 3% of them," said Dr. Reyter.

He said that lipoatrophy has replaced Kaposi’s sarcoma as the "scarlet letter" of HIV disease, "and it can lead to noncompliance with therapy. It has been shown that correction of the problem can lead to physical and psychological improvement. Lipoatrophy is increasing in prevalence, because HIV is becoming a chronic disease. The longer patients are on medications for their disease, the more of this we will see. The patients have nowhere else to go. As dermatologists we are the experts of skin and subcutaneous fat. If we don't treat it, who will?"

The exact causes of lipoatrophy and lipodystrophy remain unclear, but they are most likely related to multiple factors, he said, including a decrease in retinoic acid receptors, a decrease in triglyceride uptake, inhibition of mitochondrial DNA, inhibition of lipid metabolism, and prevention of adenocyte development.

Photo courtesy Dr. Ilya Reyter

For small volume areas that need treatment, Dr. Reyter prefers hyaluronic acid fillers such as Restylane and Juvéderm, but for large volume areas such as the cheeks, fillers "don't last a very long time, and they cost a lot. To me, those are prohibitive features for being widely used in HIV. It was not a cost-effective model to be doing this about every 6 months, using 10-14 syringes per side on a patient's face. It just made no sense," he said.

Photo courtesy Dr. Ilya Reyter

Other filler options include poly-L-lactic acid (Sculptra) and calcium hydroxylapatite (Radiesse), but Dr. Reyter said that he has seen patients with and without HIV develop complications including granulomas after being treated with these agents. "I don't feel as comfortable offering these particular fillers," he said, even though they are Food and Drug Administration approved. "I think it's up to physicians to evaluate whether or not a filler is something they would want to use on their own patients."

Fat transfer wins out for larger volumes, he said, if donor fat is available. "Fat is very cheap to harvest; most patients have adequate fat reserves, and it can be done safely."

In one study of 38 HIV patients who were treated with fat transfer, researchers graded the results at 1 year on a scale from 1 to 4, with 4 being excellent. The mean score reported by the patients was 3.7 and the mean score reported by the surgeon who performed the procedure was 3.2 (Plast. Reconstr. Surg. 2004;114:551-5). No serious adverse effects were observed.

In a separate study of 33 HIV patients who were treated with fat transfer and surveyed 1 year later, 93% of patients reported being satisfied (14 reported being very satisfied and 17 reported being partly satisfied). Furthermore, 81% (27 patients) reported an improved quality of life.

Three independent evaluators reported a 52% improvement in the area treated at 1 year (Arch. Dermatol. 2005;141:1220-4). No significant complications were observed.

In Dr. Reyter's clinical experience, some patients might need another fat transfer at 1 year, "but even so, a year is a significant improvement, especially for a procedure that didn't entail a lot of risk, didn’t have a lot of cost of consumables, and resulted in a benefit for a person."

In another study, researchers used computed tomography analysis and volume calculating software to evaluate the effects of fat transfer in 26 patients (18 men and 8 women aged 34-59 years) with HIV (Aesthetic Surg. J. 2008;28:380-6). The investigators observed increasing volumes of fat after 1 year, leading some to speculate that fat transfer may involve the transfer of stem cells.

"Are stem cells somehow influencing this result?" Dr. Reyter asked, adding that the data on stem cells in fat transfer are inconclusive. "Stem cells have been shown to be present in fat, and they have been shown to be transferred."

According to Dr. Reyter, his pretreatment protocol is the same as for tumescent liposuction: a CBC test; CD4 measurement; a viral load test; confirmation serum transaminases levels are not elevated; and clearance from the primary care physician.

"An important step is marking," he added. "I like to view the sites of deficit as triangles on the face. I make a topographical overlay. After we numb up the area, a lot of that numbing will distort the facial architecture. So if youdidn’t do a good marking job beforehand, your landmarks will be distorted."

For the fat transfer procedure Dr. Reyter uses small, blunt microcannulas. To harvest donor fat, he uses a straight Coleman harvesting cannula connected to a 10-cc syringe.

"I harvest on manual pressure, and then I let the fat sit to allow it to separate" he said. "There's a lot of debate as to whether or not you should spin the fat. I prefer to do nothing that would introduce trauma to the fat or to expose the fat to contamination."

He uses a 1-cc syringe attached to a blunt-tipped 18-gauge cannula to re-inject the fat, injecting 0.1-0.2 cc per pass on withdrawal.

The donor harvesting of fat takes about 20-30 minutes, allowing the fat to sit takes about 10-12 minutes, and reinjecting the fat takes about 30 minutes. "The whole procedure can take an hour to an hour and 15 minutes to do 20-30 ccs of fat per side, which I think is pretty efficient," he remarked.

Typical filling volumes are 10-20 cc for each cheek, 5-8 ccs for the temple, and 5-10 ccs for nasolabial folds. "Edema during and after fat transfer is common," said Dr. Reyter. "Because of this you have to overfill by 25%-50%. That’s where the skill comes in."

The procedures appear to change the overlying skin texture, "producing a global rejuvenation effect," he said. "It brings people back to speculating what the role of stem cells is."

To date there have been no serious complications since the lipodystrophy clinic opened its doors, said Dr. Reyter, who estimated that 25%-50% of his current clinical work involves fat transfer.

"There is a high degree of patient satisfaction at 6-12 months, and very few touch-ups are necessary," he said.

The responses from patients who have gone through the fat transfer procedure "have been overwhelmingly positive," he added. "So many patients tell us that their lives have been transformed."

For example, one patient with severe facial atrophy and longstanding unemployment was able to finally find employment after the fat transfer – "because he no longer looked so ill," Dr. Reyter said. "Another patient just wrote 'thank you for my new face. ... I look so healthy!' The doctors in the clinic regularly receive thank you notes and tokens of appreciation from the patients – in my experience, much more than we typically get in the course of providing any other medical care."

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

SANTA BARBARA, Calif. - Fat transfer for lipoatrophy is safe and cost effective, and provides excellent long-term results, lasting over a year in some cases, said Dr. Ilya Reyter.

Dr. Reyter, along with Dr. David Sawcer, launched a lipodystrophy clinic in the department of dermatology at the University of Southern California's Keck School of Medicine in early 2007. The clinic is dedicated to treating HIV-associated lipodystrophy and lipoatrophy using tumescent liposuction and fat transfer.

Photo courtesy Dr. Ilya Reyter

Dr. Reyter, an assistant clinical professor of dermatology at the university, also has extensive experience with fat transfer and liposuction for non-HIV cosmetic improvement, and performs the procedure in his private practice in Beverly Hills, Calif.

Lipodystrophy is marked by central fat deposition on the abdomen, dorsocervical area, salivary glands, breasts, face, and neck. "Before we started this clinic, a lot of our patients were being sent to plastic surgeons, especially for excision of lipodystrophy, particularly in the dorsocervical area," Dr. Reyter said. The dystrophic fat accumulations can be removed more simply using local anesthesia with tumescent liposuction, thereby avoiding the risks of surgery with general anesthesia, he said.

Patients are referred to the HIV lipodystrophy clinic by the HIV dermatology clinic and by other physicians working with HIV patients at the medical school. Dr. Reyter has treated numerous patients for non-HIV cosmetic fat transfer, "but in the HIV clinic, we have treated a few dozen patients," he said. "We select the patients carefully, to make sure that they are appropriate candidates. Not everyone with facial atrophy is a candidate for fat transfer, or fillers, for that matter."

He went on to describe his methods for treating lipoatrophy using fat transfer. Lipoatrophy, also know as fat wasting, particularly affects the face, and is marked by prominent zygomata, reduction of Bichat’s fat pads, sunken eyeballs, and a cachectic appearance.

HIV-associated lipoatrophy was recognized shortly after the first protease inhibitors were approved in 1995. "You can see some of these features in patients who are HIV positive but not on any medication, but it's a really small subset, only about 3% of them," said Dr. Reyter.

He said that lipoatrophy has replaced Kaposi’s sarcoma as the "scarlet letter" of HIV disease, "and it can lead to noncompliance with therapy. It has been shown that correction of the problem can lead to physical and psychological improvement. Lipoatrophy is increasing in prevalence, because HIV is becoming a chronic disease. The longer patients are on medications for their disease, the more of this we will see. The patients have nowhere else to go. As dermatologists we are the experts of skin and subcutaneous fat. If we don't treat it, who will?"

The exact causes of lipoatrophy and lipodystrophy remain unclear, but they are most likely related to multiple factors, he said, including a decrease in retinoic acid receptors, a decrease in triglyceride uptake, inhibition of mitochondrial DNA, inhibition of lipid metabolism, and prevention of adenocyte development.

Photo courtesy Dr. Ilya Reyter

For small volume areas that need treatment, Dr. Reyter prefers hyaluronic acid fillers such as Restylane and Juvéderm, but for large volume areas such as the cheeks, fillers "don't last a very long time, and they cost a lot. To me, those are prohibitive features for being widely used in HIV. It was not a cost-effective model to be doing this about every 6 months, using 10-14 syringes per side on a patient's face. It just made no sense," he said.

Photo courtesy Dr. Ilya Reyter

Other filler options include poly-L-lactic acid (Sculptra) and calcium hydroxylapatite (Radiesse), but Dr. Reyter said that he has seen patients with and without HIV develop complications including granulomas after being treated with these agents. "I don't feel as comfortable offering these particular fillers," he said, even though they are Food and Drug Administration approved. "I think it's up to physicians to evaluate whether or not a filler is something they would want to use on their own patients."

Fat transfer wins out for larger volumes, he said, if donor fat is available. "Fat is very cheap to harvest; most patients have adequate fat reserves, and it can be done safely."

In one study of 38 HIV patients who were treated with fat transfer, researchers graded the results at 1 year on a scale from 1 to 4, with 4 being excellent. The mean score reported by the patients was 3.7 and the mean score reported by the surgeon who performed the procedure was 3.2 (Plast. Reconstr. Surg. 2004;114:551-5). No serious adverse effects were observed.

In a separate study of 33 HIV patients who were treated with fat transfer and surveyed 1 year later, 93% of patients reported being satisfied (14 reported being very satisfied and 17 reported being partly satisfied). Furthermore, 81% (27 patients) reported an improved quality of life.

Three independent evaluators reported a 52% improvement in the area treated at 1 year (Arch. Dermatol. 2005;141:1220-4). No significant complications were observed.

In Dr. Reyter's clinical experience, some patients might need another fat transfer at 1 year, "but even so, a year is a significant improvement, especially for a procedure that didn't entail a lot of risk, didn’t have a lot of cost of consumables, and resulted in a benefit for a person."

In another study, researchers used computed tomography analysis and volume calculating software to evaluate the effects of fat transfer in 26 patients (18 men and 8 women aged 34-59 years) with HIV (Aesthetic Surg. J. 2008;28:380-6). The investigators observed increasing volumes of fat after 1 year, leading some to speculate that fat transfer may involve the transfer of stem cells.

"Are stem cells somehow influencing this result?" Dr. Reyter asked, adding that the data on stem cells in fat transfer are inconclusive. "Stem cells have been shown to be present in fat, and they have been shown to be transferred."

According to Dr. Reyter, his pretreatment protocol is the same as for tumescent liposuction: a CBC test; CD4 measurement; a viral load test; confirmation serum transaminases levels are not elevated; and clearance from the primary care physician.

"An important step is marking," he added. "I like to view the sites of deficit as triangles on the face. I make a topographical overlay. After we numb up the area, a lot of that numbing will distort the facial architecture. So if youdidn’t do a good marking job beforehand, your landmarks will be distorted."

For the fat transfer procedure Dr. Reyter uses small, blunt microcannulas. To harvest donor fat, he uses a straight Coleman harvesting cannula connected to a 10-cc syringe.

"I harvest on manual pressure, and then I let the fat sit to allow it to separate" he said. "There's a lot of debate as to whether or not you should spin the fat. I prefer to do nothing that would introduce trauma to the fat or to expose the fat to contamination."

He uses a 1-cc syringe attached to a blunt-tipped 18-gauge cannula to re-inject the fat, injecting 0.1-0.2 cc per pass on withdrawal.

The donor harvesting of fat takes about 20-30 minutes, allowing the fat to sit takes about 10-12 minutes, and reinjecting the fat takes about 30 minutes. "The whole procedure can take an hour to an hour and 15 minutes to do 20-30 ccs of fat per side, which I think is pretty efficient," he remarked.

Typical filling volumes are 10-20 cc for each cheek, 5-8 ccs for the temple, and 5-10 ccs for nasolabial folds. "Edema during and after fat transfer is common," said Dr. Reyter. "Because of this you have to overfill by 25%-50%. That’s where the skill comes in."

The procedures appear to change the overlying skin texture, "producing a global rejuvenation effect," he said. "It brings people back to speculating what the role of stem cells is."

To date there have been no serious complications since the lipodystrophy clinic opened its doors, said Dr. Reyter, who estimated that 25%-50% of his current clinical work involves fat transfer.

"There is a high degree of patient satisfaction at 6-12 months, and very few touch-ups are necessary," he said.

The responses from patients who have gone through the fat transfer procedure "have been overwhelmingly positive," he added. "So many patients tell us that their lives have been transformed."

For example, one patient with severe facial atrophy and longstanding unemployment was able to finally find employment after the fat transfer – "because he no longer looked so ill," Dr. Reyter said. "Another patient just wrote 'thank you for my new face. ... I look so healthy!' The doctors in the clinic regularly receive thank you notes and tokens of appreciation from the patients – in my experience, much more than we typically get in the course of providing any other medical care."

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

SANTA BARBARA, Calif. - Fat transfer for lipoatrophy is safe and cost effective, and provides excellent long-term results, lasting over a year in some cases, said Dr. Ilya Reyter.

Dr. Reyter, along with Dr. David Sawcer, launched a lipodystrophy clinic in the department of dermatology at the University of Southern California's Keck School of Medicine in early 2007. The clinic is dedicated to treating HIV-associated lipodystrophy and lipoatrophy using tumescent liposuction and fat transfer.

Photo courtesy Dr. Ilya Reyter

Dr. Reyter, an assistant clinical professor of dermatology at the university, also has extensive experience with fat transfer and liposuction for non-HIV cosmetic improvement, and performs the procedure in his private practice in Beverly Hills, Calif.

Lipodystrophy is marked by central fat deposition on the abdomen, dorsocervical area, salivary glands, breasts, face, and neck. "Before we started this clinic, a lot of our patients were being sent to plastic surgeons, especially for excision of lipodystrophy, particularly in the dorsocervical area," Dr. Reyter said. The dystrophic fat accumulations can be removed more simply using local anesthesia with tumescent liposuction, thereby avoiding the risks of surgery with general anesthesia, he said.

Patients are referred to the HIV lipodystrophy clinic by the HIV dermatology clinic and by other physicians working with HIV patients at the medical school. Dr. Reyter has treated numerous patients for non-HIV cosmetic fat transfer, "but in the HIV clinic, we have treated a few dozen patients," he said. "We select the patients carefully, to make sure that they are appropriate candidates. Not everyone with facial atrophy is a candidate for fat transfer, or fillers, for that matter."

He went on to describe his methods for treating lipoatrophy using fat transfer. Lipoatrophy, also know as fat wasting, particularly affects the face, and is marked by prominent zygomata, reduction of Bichat’s fat pads, sunken eyeballs, and a cachectic appearance.

HIV-associated lipoatrophy was recognized shortly after the first protease inhibitors were approved in 1995. "You can see some of these features in patients who are HIV positive but not on any medication, but it's a really small subset, only about 3% of them," said Dr. Reyter.

He said that lipoatrophy has replaced Kaposi’s sarcoma as the "scarlet letter" of HIV disease, "and it can lead to noncompliance with therapy. It has been shown that correction of the problem can lead to physical and psychological improvement. Lipoatrophy is increasing in prevalence, because HIV is becoming a chronic disease. The longer patients are on medications for their disease, the more of this we will see. The patients have nowhere else to go. As dermatologists we are the experts of skin and subcutaneous fat. If we don't treat it, who will?"

The exact causes of lipoatrophy and lipodystrophy remain unclear, but they are most likely related to multiple factors, he said, including a decrease in retinoic acid receptors, a decrease in triglyceride uptake, inhibition of mitochondrial DNA, inhibition of lipid metabolism, and prevention of adenocyte development.

Photo courtesy Dr. Ilya Reyter

For small volume areas that need treatment, Dr. Reyter prefers hyaluronic acid fillers such as Restylane and Juvéderm, but for large volume areas such as the cheeks, fillers "don't last a very long time, and they cost a lot. To me, those are prohibitive features for being widely used in HIV. It was not a cost-effective model to be doing this about every 6 months, using 10-14 syringes per side on a patient's face. It just made no sense," he said.

Photo courtesy Dr. Ilya Reyter

Other filler options include poly-L-lactic acid (Sculptra) and calcium hydroxylapatite (Radiesse), but Dr. Reyter said that he has seen patients with and without HIV develop complications including granulomas after being treated with these agents. "I don't feel as comfortable offering these particular fillers," he said, even though they are Food and Drug Administration approved. "I think it's up to physicians to evaluate whether or not a filler is something they would want to use on their own patients."

Fat transfer wins out for larger volumes, he said, if donor fat is available. "Fat is very cheap to harvest; most patients have adequate fat reserves, and it can be done safely."

In one study of 38 HIV patients who were treated with fat transfer, researchers graded the results at 1 year on a scale from 1 to 4, with 4 being excellent. The mean score reported by the patients was 3.7 and the mean score reported by the surgeon who performed the procedure was 3.2 (Plast. Reconstr. Surg. 2004;114:551-5). No serious adverse effects were observed.

In a separate study of 33 HIV patients who were treated with fat transfer and surveyed 1 year later, 93% of patients reported being satisfied (14 reported being very satisfied and 17 reported being partly satisfied). Furthermore, 81% (27 patients) reported an improved quality of life.

Three independent evaluators reported a 52% improvement in the area treated at 1 year (Arch. Dermatol. 2005;141:1220-4). No significant complications were observed.

In Dr. Reyter's clinical experience, some patients might need another fat transfer at 1 year, "but even so, a year is a significant improvement, especially for a procedure that didn't entail a lot of risk, didn’t have a lot of cost of consumables, and resulted in a benefit for a person."

In another study, researchers used computed tomography analysis and volume calculating software to evaluate the effects of fat transfer in 26 patients (18 men and 8 women aged 34-59 years) with HIV (Aesthetic Surg. J. 2008;28:380-6). The investigators observed increasing volumes of fat after 1 year, leading some to speculate that fat transfer may involve the transfer of stem cells.

"Are stem cells somehow influencing this result?" Dr. Reyter asked, adding that the data on stem cells in fat transfer are inconclusive. "Stem cells have been shown to be present in fat, and they have been shown to be transferred."

According to Dr. Reyter, his pretreatment protocol is the same as for tumescent liposuction: a CBC test; CD4 measurement; a viral load test; confirmation serum transaminases levels are not elevated; and clearance from the primary care physician.

"An important step is marking," he added. "I like to view the sites of deficit as triangles on the face. I make a topographical overlay. After we numb up the area, a lot of that numbing will distort the facial architecture. So if youdidn’t do a good marking job beforehand, your landmarks will be distorted."

For the fat transfer procedure Dr. Reyter uses small, blunt microcannulas. To harvest donor fat, he uses a straight Coleman harvesting cannula connected to a 10-cc syringe.

"I harvest on manual pressure, and then I let the fat sit to allow it to separate" he said. "There's a lot of debate as to whether or not you should spin the fat. I prefer to do nothing that would introduce trauma to the fat or to expose the fat to contamination."

He uses a 1-cc syringe attached to a blunt-tipped 18-gauge cannula to re-inject the fat, injecting 0.1-0.2 cc per pass on withdrawal.

The donor harvesting of fat takes about 20-30 minutes, allowing the fat to sit takes about 10-12 minutes, and reinjecting the fat takes about 30 minutes. "The whole procedure can take an hour to an hour and 15 minutes to do 20-30 ccs of fat per side, which I think is pretty efficient," he remarked.

Typical filling volumes are 10-20 cc for each cheek, 5-8 ccs for the temple, and 5-10 ccs for nasolabial folds. "Edema during and after fat transfer is common," said Dr. Reyter. "Because of this you have to overfill by 25%-50%. That’s where the skill comes in."

The procedures appear to change the overlying skin texture, "producing a global rejuvenation effect," he said. "It brings people back to speculating what the role of stem cells is."

To date there have been no serious complications since the lipodystrophy clinic opened its doors, said Dr. Reyter, who estimated that 25%-50% of his current clinical work involves fat transfer.

"There is a high degree of patient satisfaction at 6-12 months, and very few touch-ups are necessary," he said.

The responses from patients who have gone through the fat transfer procedure "have been overwhelmingly positive," he added. "So many patients tell us that their lives have been transformed."

For example, one patient with severe facial atrophy and longstanding unemployment was able to finally find employment after the fat transfer – "because he no longer looked so ill," Dr. Reyter said. "Another patient just wrote 'thank you for my new face. ... I look so healthy!' The doctors in the clinic regularly receive thank you notes and tokens of appreciation from the patients – in my experience, much more than we typically get in the course of providing any other medical care."

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

Hypopigmentation is a result of inflammatory conditions or trauma in patients with darker skin. While there are many treatments for hyperpigmentation, there are fewer options for hypo.

Some of the clearly defined options that exist for hypopigmentation include using anti-inflammatories for conditions such as vitiligo and pityriasis alba (topical corticosteroids, tacrolimus, or pimecrolimus).

Photo credit: Klaus J. Busan, M.D., ed. Dermatopathology (NY: Elsevier Inc., 2010).

For hypopigmentation from tinea versicolor, repigmentation after treatment with antifungals does occur although it can be delayed for months. But for postinflammatory hypopigmentation or hypopigmented scars, what can be done?

Pharmaceutical treatments

Puvasol, topical psoralen, and ultraviolet light (natural sunlight or UVA phototherapy), may help speed the repigmentation of hypopigmented patches, particularly in cases caused by laser therapy.

In patients with postinflammatory hypopigmentation following laser hair removal, the repigmentation may also recur on its own if the initial insult from the laser was superficial, although repigmentation can take months. Topical psoralen can be applied to affected areas, and should be done 20-30 minutes before the patient sits in direct sunlight (for just a few minutes). Caution must be taken to avoid blistering and sunburn.

V-Tar, a 30% standardized, water-soluble, coal tar topical, has been used successfully in many patients with vitiligo and other hypopigmentary disorders. It is available by prescription, and is applied once daily (Skin & Allergy News, March 2002, pg. 39).

Laser Treatments

The 308-nm excimer laser has been studied as an effective treatment for localized hypopigmented scars and striae alba. In one study, minimal erythema dose tests were performed for 31 patients at 100, 150, 200, 250, 300, and 350 mJ/cm². Each patient was then treated with his or her minimal erythema dose minus 50 mJ/cm². Subsequent treatments were performed biweekly until 50%-75% pigment correction was achieved, and every 2 weeks thereafter for a maximum of 10 treatments, a 75% increase in colorimetric measurements, or 100% visual pigment correction. However, maintenance treatment every 1-4 months was required to sustain cosmetic benefit (Arch. Dermatol. 2004;140:955-60).

In another study, a 1550-nm Fraxel laser was used to treat seven patients with hypopigmented scars on the face. Energy settings ranged from 7 mJ to 20 mJ and a total density of 1,000-2,500 microthermal zones/cm². Six patients experienced 51%-75% improvement in hypopigmentation after two to four consecutive treatments spaced 4 weeks apart.  One patient had a 26%-50% improvement (Dermatol. Surg. 2007;33:289-94).

Fractionated resurfacing is also helpful in evening out skin tone when there is a mixture of hypo- and hyperpigmentation from chronic UV exposure or poikiloderma. In addition, cultured epithelial autografts have been used to treat hypopigmentation secondary to burns.

Dyspigmentation is a common concern among patients with skin of color. Hypopigmentation caused by disease or scarring can be ameliorated by treatments using psoralens, tar, and lasers; however, more data and additional treatment options are needed to address the common and often difficult-to-treat dyschromia we see in this patient population.

Hypopigmentation is a result of inflammatory conditions or trauma in patients with darker skin. While there are many treatments for hyperpigmentation, there are fewer options for hypo.

Some of the clearly defined options that exist for hypopigmentation include using anti-inflammatories for conditions such as vitiligo and pityriasis alba (topical corticosteroids, tacrolimus, or pimecrolimus).

Photo credit: Klaus J. Busan, M.D., ed. Dermatopathology (NY: Elsevier Inc., 2010).

For hypopigmentation from tinea versicolor, repigmentation after treatment with antifungals does occur although it can be delayed for months. But for postinflammatory hypopigmentation or hypopigmented scars, what can be done?

Pharmaceutical treatments

Puvasol, topical psoralen, and ultraviolet light (natural sunlight or UVA phototherapy), may help speed the repigmentation of hypopigmented patches, particularly in cases caused by laser therapy.

In patients with postinflammatory hypopigmentation following laser hair removal, the repigmentation may also recur on its own if the initial insult from the laser was superficial, although repigmentation can take months. Topical psoralen can be applied to affected areas, and should be done 20-30 minutes before the patient sits in direct sunlight (for just a few minutes). Caution must be taken to avoid blistering and sunburn.

V-Tar, a 30% standardized, water-soluble, coal tar topical, has been used successfully in many patients with vitiligo and other hypopigmentary disorders. It is available by prescription, and is applied once daily (Skin & Allergy News, March 2002, pg. 39).

Laser Treatments

The 308-nm excimer laser has been studied as an effective treatment for localized hypopigmented scars and striae alba. In one study, minimal erythema dose tests were performed for 31 patients at 100, 150, 200, 250, 300, and 350 mJ/cm². Each patient was then treated with his or her minimal erythema dose minus 50 mJ/cm². Subsequent treatments were performed biweekly until 50%-75% pigment correction was achieved, and every 2 weeks thereafter for a maximum of 10 treatments, a 75% increase in colorimetric measurements, or 100% visual pigment correction. However, maintenance treatment every 1-4 months was required to sustain cosmetic benefit (Arch. Dermatol. 2004;140:955-60).

In another study, a 1550-nm Fraxel laser was used to treat seven patients with hypopigmented scars on the face. Energy settings ranged from 7 mJ to 20 mJ and a total density of 1,000-2,500 microthermal zones/cm². Six patients experienced 51%-75% improvement in hypopigmentation after two to four consecutive treatments spaced 4 weeks apart.  One patient had a 26%-50% improvement (Dermatol. Surg. 2007;33:289-94).

Fractionated resurfacing is also helpful in evening out skin tone when there is a mixture of hypo- and hyperpigmentation from chronic UV exposure or poikiloderma. In addition, cultured epithelial autografts have been used to treat hypopigmentation secondary to burns.

Dyspigmentation is a common concern among patients with skin of color. Hypopigmentation caused by disease or scarring can be ameliorated by treatments using psoralens, tar, and lasers; however, more data and additional treatment options are needed to address the common and often difficult-to-treat dyschromia we see in this patient population.

Hypopigmentation is a result of inflammatory conditions or trauma in patients with darker skin. While there are many treatments for hyperpigmentation, there are fewer options for hypo.

Some of the clearly defined options that exist for hypopigmentation include using anti-inflammatories for conditions such as vitiligo and pityriasis alba (topical corticosteroids, tacrolimus, or pimecrolimus).

Photo credit: Klaus J. Busan, M.D., ed. Dermatopathology (NY: Elsevier Inc., 2010).

For hypopigmentation from tinea versicolor, repigmentation after treatment with antifungals does occur although it can be delayed for months. But for postinflammatory hypopigmentation or hypopigmented scars, what can be done?

Pharmaceutical treatments

Puvasol, topical psoralen, and ultraviolet light (natural sunlight or UVA phototherapy), may help speed the repigmentation of hypopigmented patches, particularly in cases caused by laser therapy.

In patients with postinflammatory hypopigmentation following laser hair removal, the repigmentation may also recur on its own if the initial insult from the laser was superficial, although repigmentation can take months. Topical psoralen can be applied to affected areas, and should be done 20-30 minutes before the patient sits in direct sunlight (for just a few minutes). Caution must be taken to avoid blistering and sunburn.

V-Tar, a 30% standardized, water-soluble, coal tar topical, has been used successfully in many patients with vitiligo and other hypopigmentary disorders. It is available by prescription, and is applied once daily (Skin & Allergy News, March 2002, pg. 39).

Laser Treatments

The 308-nm excimer laser has been studied as an effective treatment for localized hypopigmented scars and striae alba. In one study, minimal erythema dose tests were performed for 31 patients at 100, 150, 200, 250, 300, and 350 mJ/cm². Each patient was then treated with his or her minimal erythema dose minus 50 mJ/cm². Subsequent treatments were performed biweekly until 50%-75% pigment correction was achieved, and every 2 weeks thereafter for a maximum of 10 treatments, a 75% increase in colorimetric measurements, or 100% visual pigment correction. However, maintenance treatment every 1-4 months was required to sustain cosmetic benefit (Arch. Dermatol. 2004;140:955-60).

In another study, a 1550-nm Fraxel laser was used to treat seven patients with hypopigmented scars on the face. Energy settings ranged from 7 mJ to 20 mJ and a total density of 1,000-2,500 microthermal zones/cm². Six patients experienced 51%-75% improvement in hypopigmentation after two to four consecutive treatments spaced 4 weeks apart.  One patient had a 26%-50% improvement (Dermatol. Surg. 2007;33:289-94).

Fractionated resurfacing is also helpful in evening out skin tone when there is a mixture of hypo- and hyperpigmentation from chronic UV exposure or poikiloderma. In addition, cultured epithelial autografts have been used to treat hypopigmentation secondary to burns.

Dyspigmentation is a common concern among patients with skin of color. Hypopigmentation caused by disease or scarring can be ameliorated by treatments using psoralens, tar, and lasers; however, more data and additional treatment options are needed to address the common and often difficult-to-treat dyschromia we see in this patient population.

Enlarged facial pores are a frequent complaint from patients. But the mechanism behind why some patients develop larger pores than others remains unclear.

The face is home to some of the thinnest areas of skin on the body, excluding the skin of the eyelid.  It has both large terminal hair follicles, as well as thin vellus hairs. The hairs are a transition point between the skin and the follicular ostia (or openings) that lead to the base of the follicle. 

This follicular opening is connected to the underlying sebaceous glands, the “pore.” The texture of the face is in part the result of mounds around follicular ostia and valleys in the interfollicular space. The larger the pores, the coarser the skin, and the smaller the pores, the more even and smooth the skin surface.

Pores can become packed and dilated with sebum, makeup, dirt, and bacteria. Pore size is dependent not only on the contents of the pore, but also on genetic factors.

Ethnic differences in the appearance of pores can contribute to different aesthetic concerns, as well as to treatment options for patients.

A recent study was conducted to elucidate ethnicity-dependent differences in facial pore size and in epidermal architecture (J. Dermatol. Sci. 2009;53:135-9). Surface replicas of 80 patients – healthy white, Hispanic, Asian, and African American women (aged 30-39 years) – were created to compare pore sizes in cheek skin.

Horizontal cross-sectioned images from cheek skin were obtained noninvasively from the same subjects using in vivo confocal laser scanning microscopy to determine the severity of impairment of epidermal architecture around facial pores. Finally, the interfollicular epidermal architecture of the cheek skin of the different ethnic types was evaluated with horizontal cross-sectioned images and counts of dermal papillae.

The study showed that all ethnic groups had similar morphologic features. Asians had the smallest pore areas, compared with other ethnic groups, while African Americans showed substantially more severe impairment of architecture around facial pores.

Although this study did not account for amount of sebum production or bacteria in epidermal pore dilation, it did highlight an intrinsic difference in pore size among various types of skin of color.

Other factors that can extrinsically affect pore size include smoking, sun exposure, and age. Ultraviolet radiation and free radicals can degrade collagen and elastin, thereby altering the dermal structure of the skin,which influences its texture and integrity.

Some methods to decrease pore size include:

Retinoids: By increasing cell turnover and decreasing sebum and bacteria content, retinoids can prevent dilation of pores.

Exfoliants: Alpha and beta hydroxy acids can remove sebum, dirt, bacteria, and keratin from pores, creating a smoother-looking texture to the skin. Keeping pores clean and free of debris can make pores appear smaller though the actual size may not differ.

Ablative and nonablative fractional laser: These treatments help exfoliate the skin, increase cell turnover, and increase collagen and elastin production, thereby helping tighten the skin and reduce pore size.

Sunscreen: Photodamage can delay cell turnover, degrade collagen and elastin, and thicken the top layer of skin, causing pores to look larger. Aggressive photoprotection will ensure healthier skin and overall improved skin texture.

Alcohol based toners and heating may temporarily give the illusion of tightened skin but do not actually alter pore size.

Many women and men seek the advice of their dermatologist to help decrease the appearance of enlarged pores. We now understand that there are both extrinsic and intrinsic differences in pore size and skin texture, and vast differences among our patients of color. This understanding can help direct treatment modalities and help educate our patients in the skin care regimens they choose.

Enlarged facial pores are a frequent complaint from patients. But the mechanism behind why some patients develop larger pores than others remains unclear.

The face is home to some of the thinnest areas of skin on the body, excluding the skin of the eyelid.  It has both large terminal hair follicles, as well as thin vellus hairs. The hairs are a transition point between the skin and the follicular ostia (or openings) that lead to the base of the follicle. 

This follicular opening is connected to the underlying sebaceous glands, the “pore.” The texture of the face is in part the result of mounds around follicular ostia and valleys in the interfollicular space. The larger the pores, the coarser the skin, and the smaller the pores, the more even and smooth the skin surface.

Pores can become packed and dilated with sebum, makeup, dirt, and bacteria. Pore size is dependent not only on the contents of the pore, but also on genetic factors.

Ethnic differences in the appearance of pores can contribute to different aesthetic concerns, as well as to treatment options for patients.

A recent study was conducted to elucidate ethnicity-dependent differences in facial pore size and in epidermal architecture (J. Dermatol. Sci. 2009;53:135-9). Surface replicas of 80 patients – healthy white, Hispanic, Asian, and African American women (aged 30-39 years) – were created to compare pore sizes in cheek skin.

Horizontal cross-sectioned images from cheek skin were obtained noninvasively from the same subjects using in vivo confocal laser scanning microscopy to determine the severity of impairment of epidermal architecture around facial pores. Finally, the interfollicular epidermal architecture of the cheek skin of the different ethnic types was evaluated with horizontal cross-sectioned images and counts of dermal papillae.

The study showed that all ethnic groups had similar morphologic features. Asians had the smallest pore areas, compared with other ethnic groups, while African Americans showed substantially more severe impairment of architecture around facial pores.

Although this study did not account for amount of sebum production or bacteria in epidermal pore dilation, it did highlight an intrinsic difference in pore size among various types of skin of color.

Other factors that can extrinsically affect pore size include smoking, sun exposure, and age. Ultraviolet radiation and free radicals can degrade collagen and elastin, thereby altering the dermal structure of the skin,which influences its texture and integrity.

Some methods to decrease pore size include:

Retinoids: By increasing cell turnover and decreasing sebum and bacteria content, retinoids can prevent dilation of pores.

Exfoliants: Alpha and beta hydroxy acids can remove sebum, dirt, bacteria, and keratin from pores, creating a smoother-looking texture to the skin. Keeping pores clean and free of debris can make pores appear smaller though the actual size may not differ.

Ablative and nonablative fractional laser: These treatments help exfoliate the skin, increase cell turnover, and increase collagen and elastin production, thereby helping tighten the skin and reduce pore size.

Sunscreen: Photodamage can delay cell turnover, degrade collagen and elastin, and thicken the top layer of skin, causing pores to look larger. Aggressive photoprotection will ensure healthier skin and overall improved skin texture.

Alcohol based toners and heating may temporarily give the illusion of tightened skin but do not actually alter pore size.

Many women and men seek the advice of their dermatologist to help decrease the appearance of enlarged pores. We now understand that there are both extrinsic and intrinsic differences in pore size and skin texture, and vast differences among our patients of color. This understanding can help direct treatment modalities and help educate our patients in the skin care regimens they choose.

Enlarged facial pores are a frequent complaint from patients. But the mechanism behind why some patients develop larger pores than others remains unclear.

The face is home to some of the thinnest areas of skin on the body, excluding the skin of the eyelid.  It has both large terminal hair follicles, as well as thin vellus hairs. The hairs are a transition point between the skin and the follicular ostia (or openings) that lead to the base of the follicle. 

This follicular opening is connected to the underlying sebaceous glands, the “pore.” The texture of the face is in part the result of mounds around follicular ostia and valleys in the interfollicular space. The larger the pores, the coarser the skin, and the smaller the pores, the more even and smooth the skin surface.

Pores can become packed and dilated with sebum, makeup, dirt, and bacteria. Pore size is dependent not only on the contents of the pore, but also on genetic factors.

Ethnic differences in the appearance of pores can contribute to different aesthetic concerns, as well as to treatment options for patients.

A recent study was conducted to elucidate ethnicity-dependent differences in facial pore size and in epidermal architecture (J. Dermatol. Sci. 2009;53:135-9). Surface replicas of 80 patients – healthy white, Hispanic, Asian, and African American women (aged 30-39 years) – were created to compare pore sizes in cheek skin.

Horizontal cross-sectioned images from cheek skin were obtained noninvasively from the same subjects using in vivo confocal laser scanning microscopy to determine the severity of impairment of epidermal architecture around facial pores. Finally, the interfollicular epidermal architecture of the cheek skin of the different ethnic types was evaluated with horizontal cross-sectioned images and counts of dermal papillae.

The study showed that all ethnic groups had similar morphologic features. Asians had the smallest pore areas, compared with other ethnic groups, while African Americans showed substantially more severe impairment of architecture around facial pores.

Although this study did not account for amount of sebum production or bacteria in epidermal pore dilation, it did highlight an intrinsic difference in pore size among various types of skin of color.

Other factors that can extrinsically affect pore size include smoking, sun exposure, and age. Ultraviolet radiation and free radicals can degrade collagen and elastin, thereby altering the dermal structure of the skin,which influences its texture and integrity.

Some methods to decrease pore size include:

Retinoids: By increasing cell turnover and decreasing sebum and bacteria content, retinoids can prevent dilation of pores.

Exfoliants: Alpha and beta hydroxy acids can remove sebum, dirt, bacteria, and keratin from pores, creating a smoother-looking texture to the skin. Keeping pores clean and free of debris can make pores appear smaller though the actual size may not differ.

Ablative and nonablative fractional laser: These treatments help exfoliate the skin, increase cell turnover, and increase collagen and elastin production, thereby helping tighten the skin and reduce pore size.

Sunscreen: Photodamage can delay cell turnover, degrade collagen and elastin, and thicken the top layer of skin, causing pores to look larger. Aggressive photoprotection will ensure healthier skin and overall improved skin texture.

Alcohol based toners and heating may temporarily give the illusion of tightened skin but do not actually alter pore size.

Many women and men seek the advice of their dermatologist to help decrease the appearance of enlarged pores. We now understand that there are both extrinsic and intrinsic differences in pore size and skin texture, and vast differences among our patients of color. This understanding can help direct treatment modalities and help educate our patients in the skin care regimens they choose.

Pasadena, Calif. - No one lip architecture is inherently more beautiful than another, and there are many aesthetically pleasing shapes for lips.

With that said, bigger is not necessarily better. Really listen to what patients are asking for—even watch body language to understand expectations. Don’t rush. Don’t do anything out of your comfort level. And make it painless, said Dr. Roberta D. Sengelmann. It’s not so much what you do. but how you do it that counts.

Ask patients to bring in photos or fashion magazines with images of lips that they like, and address their expectations, she suggested.

Fillers for lip augmentation are used off-label, so explaining the risks and getting informed consent from patients are essential. A dozen or more potential adverse outcomes can range from a shorter-than-expected duration of the bulking effect to infection, necrosis, or scaring.

To meet a patient’s desire for more pleasing lips, keep in mind widely accepted characteristics of a “beautiful” face and mouth, she advised.

Lips are symmetrical. The width of the lips is 30%-50% of facial width, and the width between the oral commissures equals the distance between the medial limbi. The upper lip is slightly thinner than the lower one—making the upper lip too big looks unnatural. The commissures should angle up slightly.

With age, the mouth starts to angle down and to look smaller (the lips “cave in”), radial lip lines develop, 3-D volume decreases, and there’s inversion of the lip’s white roll, said Dr. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif.

Pay attention to anatomy to plan your approach to lip augmentation. The first step is to elevate the oral commissures. If you run out of product or need to stop, the patient still will look better, said Dr. Sengelmann.

If you can do more, define the vermilion border or white roll. Then add volume to the pink part of the lip. If needed, redefine the philtral columns. And, if you have some product left, ablate vertical lip lines. One main caveat applies: The patient’s desires take precedence in deciding which of those steps to address, she said.

Consider antiviral prophylaxis before lip injections, and definitely use it treat anyone who’s had more than six annual outbreaks of herpes simplex virus, she advised. If the patient is on blood-thinning medication, discontinue it a week before lip augmentation. “I don’t treat people on Coumadin, ever,” she said.

Before you start injecting, remove any makeup, and evaluate the patient at rest and in motion. Take photos before and after the first treatment. Mark the philtral columns with an eyeliner pencil, because they can be difficult to see once filled. Review your plans and the patient’s expectations before you begin.

“You can’t rush this technique,” Dr. Sengelmann said. Make it as painless as possible by applying ice, topical anesthesia, or nerve blocks. Consider local anesthesia at the commissures. Vibration seems to work, too, but “I’m not comfortable” using it, she added.

Use only the finest fillers when injecting into dermis, and more viscous fillers for potential space under the skin. Dr. Sengelmann avoids Radiesse for lips because nodules can be a problem, she cautioned. Again, use a slow hand. “Hasty injectors have a much higher complication rate,” Dr. Sengelmann said.

For augmenting the angle of the mouth, she uses Radiesse, Juvéderm Ultra Plus, Perlane, or Restylane. For the vermilion border and philtral columns or to augment the pink lip, she prefers Juvéderm Ultra, Restylane, Juvéderm Ultra Plus, or Perlane. For radial lines, she injects Prevelle Silk, Restylane, or Juvéderm Ultra using a 32-gauge needle.

After treatment, assess lip symmetry before the product is gone—consider saving a little as leftover in case it is needed. Massaging and molding the injected area may help distribution, “but remember, you can’t correct for poor technique,” she said. Apply ice packs after the procedure and have the patient rest for about 6 hours, with no exercise of vigorous activity for the rest of the day.

For a patient whose only complaint is dynamic lip lines (with no vertical lines at rest), botulinum toxin alone may soften those lines, provide some lip eversion, and give the perception of fullness to lips, Dr. Sengelmann suggested.

She advised using caution when considering lip augmentation for a patient with a long upper lip, inverted white roll, coarse radial lip lines, or deep Marionette lines. Other features that should inspire caution include very thin lips, lip incompetence, recessed bone or dentition, lip asymmetry, and unrealistic expectations.

Disclosures: Dr. Sengelmann has been an advisor to Allergan (Juvéderm), BioForm Medical (maker of Radiesse), and MicroAire (formally Coapt Systems), and has received research support from MicroAire.

Pasadena, Calif. - No one lip architecture is inherently more beautiful than another, and there are many aesthetically pleasing shapes for lips.

With that said, bigger is not necessarily better. Really listen to what patients are asking for—even watch body language to understand expectations. Don’t rush. Don’t do anything out of your comfort level. And make it painless, said Dr. Roberta D. Sengelmann. It’s not so much what you do. but how you do it that counts.

Ask patients to bring in photos or fashion magazines with images of lips that they like, and address their expectations, she suggested.

Fillers for lip augmentation are used off-label, so explaining the risks and getting informed consent from patients are essential. A dozen or more potential adverse outcomes can range from a shorter-than-expected duration of the bulking effect to infection, necrosis, or scaring.

To meet a patient’s desire for more pleasing lips, keep in mind widely accepted characteristics of a “beautiful” face and mouth, she advised.

Lips are symmetrical. The width of the lips is 30%-50% of facial width, and the width between the oral commissures equals the distance between the medial limbi. The upper lip is slightly thinner than the lower one—making the upper lip too big looks unnatural. The commissures should angle up slightly.

With age, the mouth starts to angle down and to look smaller (the lips “cave in”), radial lip lines develop, 3-D volume decreases, and there’s inversion of the lip’s white roll, said Dr. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif.

Pay attention to anatomy to plan your approach to lip augmentation. The first step is to elevate the oral commissures. If you run out of product or need to stop, the patient still will look better, said Dr. Sengelmann.

If you can do more, define the vermilion border or white roll. Then add volume to the pink part of the lip. If needed, redefine the philtral columns. And, if you have some product left, ablate vertical lip lines. One main caveat applies: The patient’s desires take precedence in deciding which of those steps to address, she said.

Consider antiviral prophylaxis before lip injections, and definitely use it treat anyone who’s had more than six annual outbreaks of herpes simplex virus, she advised. If the patient is on blood-thinning medication, discontinue it a week before lip augmentation. “I don’t treat people on Coumadin, ever,” she said.

Before you start injecting, remove any makeup, and evaluate the patient at rest and in motion. Take photos before and after the first treatment. Mark the philtral columns with an eyeliner pencil, because they can be difficult to see once filled. Review your plans and the patient’s expectations before you begin.

“You can’t rush this technique,” Dr. Sengelmann said. Make it as painless as possible by applying ice, topical anesthesia, or nerve blocks. Consider local anesthesia at the commissures. Vibration seems to work, too, but “I’m not comfortable” using it, she added.

Use only the finest fillers when injecting into dermis, and more viscous fillers for potential space under the skin. Dr. Sengelmann avoids Radiesse for lips because nodules can be a problem, she cautioned. Again, use a slow hand. “Hasty injectors have a much higher complication rate,” Dr. Sengelmann said.

For augmenting the angle of the mouth, she uses Radiesse, Juvéderm Ultra Plus, Perlane, or Restylane. For the vermilion border and philtral columns or to augment the pink lip, she prefers Juvéderm Ultra, Restylane, Juvéderm Ultra Plus, or Perlane. For radial lines, she injects Prevelle Silk, Restylane, or Juvéderm Ultra using a 32-gauge needle.

After treatment, assess lip symmetry before the product is gone—consider saving a little as leftover in case it is needed. Massaging and molding the injected area may help distribution, “but remember, you can’t correct for poor technique,” she said. Apply ice packs after the procedure and have the patient rest for about 6 hours, with no exercise of vigorous activity for the rest of the day.

For a patient whose only complaint is dynamic lip lines (with no vertical lines at rest), botulinum toxin alone may soften those lines, provide some lip eversion, and give the perception of fullness to lips, Dr. Sengelmann suggested.

She advised using caution when considering lip augmentation for a patient with a long upper lip, inverted white roll, coarse radial lip lines, or deep Marionette lines. Other features that should inspire caution include very thin lips, lip incompetence, recessed bone or dentition, lip asymmetry, and unrealistic expectations.

Disclosures: Dr. Sengelmann has been an advisor to Allergan (Juvéderm), BioForm Medical (maker of Radiesse), and MicroAire (formally Coapt Systems), and has received research support from MicroAire.

Pasadena, Calif. - No one lip architecture is inherently more beautiful than another, and there are many aesthetically pleasing shapes for lips.

With that said, bigger is not necessarily better. Really listen to what patients are asking for—even watch body language to understand expectations. Don’t rush. Don’t do anything out of your comfort level. And make it painless, said Dr. Roberta D. Sengelmann. It’s not so much what you do. but how you do it that counts.

Ask patients to bring in photos or fashion magazines with images of lips that they like, and address their expectations, she suggested.

Fillers for lip augmentation are used off-label, so explaining the risks and getting informed consent from patients are essential. A dozen or more potential adverse outcomes can range from a shorter-than-expected duration of the bulking effect to infection, necrosis, or scaring.

To meet a patient’s desire for more pleasing lips, keep in mind widely accepted characteristics of a “beautiful” face and mouth, she advised.

Lips are symmetrical. The width of the lips is 30%-50% of facial width, and the width between the oral commissures equals the distance between the medial limbi. The upper lip is slightly thinner than the lower one—making the upper lip too big looks unnatural. The commissures should angle up slightly.

With age, the mouth starts to angle down and to look smaller (the lips “cave in”), radial lip lines develop, 3-D volume decreases, and there’s inversion of the lip’s white roll, said Dr. Sengelmann, a dermatologic surgeon in private practice in Santa Barbara, Calif.

Pay attention to anatomy to plan your approach to lip augmentation. The first step is to elevate the oral commissures. If you run out of product or need to stop, the patient still will look better, said Dr. Sengelmann.

If you can do more, define the vermilion border or white roll. Then add volume to the pink part of the lip. If needed, redefine the philtral columns. And, if you have some product left, ablate vertical lip lines. One main caveat applies: The patient’s desires take precedence in deciding which of those steps to address, she said.

Consider antiviral prophylaxis before lip injections, and definitely use it treat anyone who’s had more than six annual outbreaks of herpes simplex virus, she advised. If the patient is on blood-thinning medication, discontinue it a week before lip augmentation. “I don’t treat people on Coumadin, ever,” she said.

Before you start injecting, remove any makeup, and evaluate the patient at rest and in motion. Take photos before and after the first treatment. Mark the philtral columns with an eyeliner pencil, because they can be difficult to see once filled. Review your plans and the patient’s expectations before you begin.

“You can’t rush this technique,” Dr. Sengelmann said. Make it as painless as possible by applying ice, topical anesthesia, or nerve blocks. Consider local anesthesia at the commissures. Vibration seems to work, too, but “I’m not comfortable” using it, she added.

Use only the finest fillers when injecting into dermis, and more viscous fillers for potential space under the skin. Dr. Sengelmann avoids Radiesse for lips because nodules can be a problem, she cautioned. Again, use a slow hand. “Hasty injectors have a much higher complication rate,” Dr. Sengelmann said.

For augmenting the angle of the mouth, she uses Radiesse, Juvéderm Ultra Plus, Perlane, or Restylane. For the vermilion border and philtral columns or to augment the pink lip, she prefers Juvéderm Ultra, Restylane, Juvéderm Ultra Plus, or Perlane. For radial lines, she injects Prevelle Silk, Restylane, or Juvéderm Ultra using a 32-gauge needle.

After treatment, assess lip symmetry before the product is gone—consider saving a little as leftover in case it is needed. Massaging and molding the injected area may help distribution, “but remember, you can’t correct for poor technique,” she said. Apply ice packs after the procedure and have the patient rest for about 6 hours, with no exercise of vigorous activity for the rest of the day.

For a patient whose only complaint is dynamic lip lines (with no vertical lines at rest), botulinum toxin alone may soften those lines, provide some lip eversion, and give the perception of fullness to lips, Dr. Sengelmann suggested.

She advised using caution when considering lip augmentation for a patient with a long upper lip, inverted white roll, coarse radial lip lines, or deep Marionette lines. Other features that should inspire caution include very thin lips, lip incompetence, recessed bone or dentition, lip asymmetry, and unrealistic expectations.

Disclosures: Dr. Sengelmann has been an advisor to Allergan (Juvéderm), BioForm Medical (maker of Radiesse), and MicroAire (formally Coapt Systems), and has received research support from MicroAire.

PASADENA, Calif. - Stem cell therapies, molecular medicine, less-invasive procedures and robotic surgery might play prominent roles in the future of cosmetic dermatology.

That's what Dr. Ronald Moy sees when he looks into his figurative crystal ball. And it means many, many cosmetic procedures, he said at the annual meeting of the Pacific Dermatologic Association.

"Stem cell research is most exciting," said Dr. Moy, who practices in Beverly Hills, Calif. and is president-elect of the American Academy of Dermatology. As many as an eighth to a quarter of presentations at cosmetic surgery meetings these days mention stem cells, he estimated. Cosmetic procedures in general have increased by 228% since 1997 in the United States, he said.

Dermatologists in his area who do a lot of marketing are advertising "stem cell facelifts," he added. In his own office, he or his partner may extract fat from a patient and then centrifuge or decant it to get fat for reinjecting, and that fat contains some stem cells. Fat injections can improve skin quality over the injection area and may add volume; however, volume results are not as predictable, compared with injections of other fillers.

Once researchers find a way to extract stem cells reliably, they might replace use of these fillers in many cases, he suggested. Stem cells also might be used in the future to grow skin, fat, and hair. "Fillers that we are using might be considered archaic; it will be people’s own skin" used in procedures and, hair cloning and gene therapy will replace hair transplants, he predicted.

A forerunner of this scenario that is widely used today is the biostimulator Sculptra, an injectable poly-l-lactic acid, he said. Sculptra can help thicken the skin and stimulate collagen production.

Molecular tools also will be part of cosmetic dermatologists' armamentarium, switching genes on and off via synthetic medicines individualized to patients. These "are in the near future," Dr. Moy predicted.

Cocktails of immunostimulants that cure skin cancer are close at hand and probably will replace surgical treatments, he added: "Many of our Mohs surgeons and probably many of our skin cancer surgeons will probably be dinosaurs in the near future."

As baby boomers age, they’ll want less-invasive procedures, so radiofrequency devices that tighten the skin and fractional laser resurfacing to remove some wrinkles and sun-damaged skin will be used more and more, he believes. The results aren't as dramatic as with phenol peels or conventional carbon dioxide laser resurfacing, but those techniques require longer recovery times and carry a higher risk for complications. When surgery is used for brow lifts, facelifts, or fat removal, the trend will be toward smaller incisions.

Lasers will evolve like other mobile devices to become hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more, Dr. Moy said.

More muscle-relaxing products will come on the market to compete with Botox or Dysport, including a topical version that’s now being tested and seems to work well for superficial areas, he said.

He also foresees new concoctions of creams that will go beyond sunscreens to prevent skin cancers, adding that prevention already is a booming trend, with some emphasis shifting toward greater attention to the molecular benefits of nutrition in preventing skin problems, he said. "Nutrition is important, and we haven't thought about that much in dermatology," he remarked.

Still, much of cosmetic dermatology will continue to involve new and expensive technology, which will affect not just how patients are treated, but how dermatologists practice, he said. Machines that cost $100,000 will be hard for solo practitioners to afford. "Unless you're practicing as a group, it's going to be very difficult" to offer the most modern services."

Dr. Moy made no disclosures.

PASADENA, Calif. - Stem cell therapies, molecular medicine, less-invasive procedures and robotic surgery might play prominent roles in the future of cosmetic dermatology.

That's what Dr. Ronald Moy sees when he looks into his figurative crystal ball. And it means many, many cosmetic procedures, he said at the annual meeting of the Pacific Dermatologic Association.

"Stem cell research is most exciting," said Dr. Moy, who practices in Beverly Hills, Calif. and is president-elect of the American Academy of Dermatology. As many as an eighth to a quarter of presentations at cosmetic surgery meetings these days mention stem cells, he estimated. Cosmetic procedures in general have increased by 228% since 1997 in the United States, he said.

Dermatologists in his area who do a lot of marketing are advertising "stem cell facelifts," he added. In his own office, he or his partner may extract fat from a patient and then centrifuge or decant it to get fat for reinjecting, and that fat contains some stem cells. Fat injections can improve skin quality over the injection area and may add volume; however, volume results are not as predictable, compared with injections of other fillers.

Once researchers find a way to extract stem cells reliably, they might replace use of these fillers in many cases, he suggested. Stem cells also might be used in the future to grow skin, fat, and hair. "Fillers that we are using might be considered archaic; it will be people’s own skin" used in procedures and, hair cloning and gene therapy will replace hair transplants, he predicted.

A forerunner of this scenario that is widely used today is the biostimulator Sculptra, an injectable poly-l-lactic acid, he said. Sculptra can help thicken the skin and stimulate collagen production.

Molecular tools also will be part of cosmetic dermatologists' armamentarium, switching genes on and off via synthetic medicines individualized to patients. These "are in the near future," Dr. Moy predicted.

Cocktails of immunostimulants that cure skin cancer are close at hand and probably will replace surgical treatments, he added: "Many of our Mohs surgeons and probably many of our skin cancer surgeons will probably be dinosaurs in the near future."

As baby boomers age, they’ll want less-invasive procedures, so radiofrequency devices that tighten the skin and fractional laser resurfacing to remove some wrinkles and sun-damaged skin will be used more and more, he believes. The results aren't as dramatic as with phenol peels or conventional carbon dioxide laser resurfacing, but those techniques require longer recovery times and carry a higher risk for complications. When surgery is used for brow lifts, facelifts, or fat removal, the trend will be toward smaller incisions.

Lasers will evolve like other mobile devices to become hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more, Dr. Moy said.

More muscle-relaxing products will come on the market to compete with Botox or Dysport, including a topical version that’s now being tested and seems to work well for superficial areas, he said.

He also foresees new concoctions of creams that will go beyond sunscreens to prevent skin cancers, adding that prevention already is a booming trend, with some emphasis shifting toward greater attention to the molecular benefits of nutrition in preventing skin problems, he said. "Nutrition is important, and we haven't thought about that much in dermatology," he remarked.

Still, much of cosmetic dermatology will continue to involve new and expensive technology, which will affect not just how patients are treated, but how dermatologists practice, he said. Machines that cost $100,000 will be hard for solo practitioners to afford. "Unless you're practicing as a group, it's going to be very difficult" to offer the most modern services."

Dr. Moy made no disclosures.

PASADENA, Calif. - Stem cell therapies, molecular medicine, less-invasive procedures and robotic surgery might play prominent roles in the future of cosmetic dermatology.

That's what Dr. Ronald Moy sees when he looks into his figurative crystal ball. And it means many, many cosmetic procedures, he said at the annual meeting of the Pacific Dermatologic Association.

"Stem cell research is most exciting," said Dr. Moy, who practices in Beverly Hills, Calif. and is president-elect of the American Academy of Dermatology. As many as an eighth to a quarter of presentations at cosmetic surgery meetings these days mention stem cells, he estimated. Cosmetic procedures in general have increased by 228% since 1997 in the United States, he said.

Dermatologists in his area who do a lot of marketing are advertising "stem cell facelifts," he added. In his own office, he or his partner may extract fat from a patient and then centrifuge or decant it to get fat for reinjecting, and that fat contains some stem cells. Fat injections can improve skin quality over the injection area and may add volume; however, volume results are not as predictable, compared with injections of other fillers.

Once researchers find a way to extract stem cells reliably, they might replace use of these fillers in many cases, he suggested. Stem cells also might be used in the future to grow skin, fat, and hair. "Fillers that we are using might be considered archaic; it will be people’s own skin" used in procedures and, hair cloning and gene therapy will replace hair transplants, he predicted.

A forerunner of this scenario that is widely used today is the biostimulator Sculptra, an injectable poly-l-lactic acid, he said. Sculptra can help thicken the skin and stimulate collagen production.

Molecular tools also will be part of cosmetic dermatologists' armamentarium, switching genes on and off via synthetic medicines individualized to patients. These "are in the near future," Dr. Moy predicted.

Cocktails of immunostimulants that cure skin cancer are close at hand and probably will replace surgical treatments, he added: "Many of our Mohs surgeons and probably many of our skin cancer surgeons will probably be dinosaurs in the near future."

As baby boomers age, they’ll want less-invasive procedures, so radiofrequency devices that tighten the skin and fractional laser resurfacing to remove some wrinkles and sun-damaged skin will be used more and more, he believes. The results aren't as dramatic as with phenol peels or conventional carbon dioxide laser resurfacing, but those techniques require longer recovery times and carry a higher risk for complications. When surgery is used for brow lifts, facelifts, or fat removal, the trend will be toward smaller incisions.

Lasers will evolve like other mobile devices to become hand-held and used by patients to remove hair, fat, wrinkles, lentigos, and more, Dr. Moy said.

More muscle-relaxing products will come on the market to compete with Botox or Dysport, including a topical version that’s now being tested and seems to work well for superficial areas, he said.

He also foresees new concoctions of creams that will go beyond sunscreens to prevent skin cancers, adding that prevention already is a booming trend, with some emphasis shifting toward greater attention to the molecular benefits of nutrition in preventing skin problems, he said. "Nutrition is important, and we haven't thought about that much in dermatology," he remarked.

Still, much of cosmetic dermatology will continue to involve new and expensive technology, which will affect not just how patients are treated, but how dermatologists practice, he said. Machines that cost $100,000 will be hard for solo practitioners to afford. "Unless you're practicing as a group, it's going to be very difficult" to offer the most modern services."

Dr. Moy made no disclosures.