Aesthetic Dermatology

PORTLAND, ORE. — Its ability to provide volume and spare tissue makes the island pedicle flap a valuable technique for deep facial defects.

"When you can just about close a defect primarily and have concerns that doing so might cause unnecessary contour deformity or free margin retraction, an island pedicle flap taken from the standing cutaneous cone will rescue the repair and provide excellent cosmesis with minimal tissue loss," Dr. Roberta Sengelmann said at the annual meeting of the Pacific Dermatologic Association.

Also known as the B-to-Y flap or the kite flap, the island pedicle flap "has a rich vascular supply which comes from the underlying subcutaneous and muscular pedicle," said Dr. Sengelmann, a cosmetic dermatologic surgeon who practices in Santa Barbara, Calif., and St. Louis. "It is a terrifically viable flap and has surprisingly good mobility."

She uses it for deep defects, in areas where cosmetic junction lines and relaxed skin tension lines can camouflage the flap's kite-shaped design, to advance hair-bearing skin in cases when like skin is needed where there is a limited tissue reservoir within the cosmetic subunit.

She described the technique at the meeting. First, design the flap so that the primary and secondary flap movement will not cause anatomic distortion. Designs may be pentagonal, curved, or tapered. "These designs are used to preserve adjacent anatomical structures so as to avoid tissue distortion, but you maximize gain of the soft tissues that you have available," Dr. Sengelmann explained. "You take advantage of tissue laxity and relaxed skin tension lines."

Movement of the island pedicle flap is usually linear, "but you can rotate it [30-90 degrees], flip it [90-180 degrees], or tunnel it," she said.

Incise the flap vertically to the full thickness of the skin, free the advancing edge a few millimeters to prevent tethering down of the leading edge, and free a distal third or so of the flap to prevent limitation of movement.

Next, use a vertical spreading technique to undermine the flap. "The goal here is to maintain the vascular and muscular pedicle and provide enough stretch to allow adequate movement," she said. Advance the flap into place and secure the leading edge with the key suture. Undermine the defect wound margins in the mid-fat, close the secondary defect, achieve hemostasis, and approximate the flap slightly below the plane of the surrounding skin while providing perfect wound edge coaptation and eversion.

"Flaps should not be oversized," she cautioned. "When the flap is oversized, it tends to buckle up during the wound-healing process and can leave a 'pincushion-like' deformity."

To achieve optimal results, "be sure that the secondary defect can be easily closed side-to-side without distortion of anatomic structures," she added.

Other clinical pearls she shared were to "slightly undersize the flap, keeping in mind the area you are moving it to and being sure that you have enough primary movement to close the defect without compromising contour at that site."

Dr. Sengelmann acknowledged certain limitations of the island pedicle flap, including "trapdooring" and the potential for poor outcomes in areas with inadequate subdermal tissue and/or poor mobility, such as radiated, burned, or scarred skin; the nasal dorsum; and helical rim.

Even so, she concluded that the tissue-sparing aspect of this flap is "unsurpassed." There is a learning curve to "getting it right," but once the execution is mastered it provides an exceptional option for reconstruction of facial cutaneous defects.

Dr. Sengelmann disclosed no relevant conflicts of interest.

There's a learning curve to 'getting it right,' but once mastered it provides an exceptional option.

Source Dr. Sengelmann

PORTLAND, ORE. — Its ability to provide volume and spare tissue makes the island pedicle flap a valuable technique for deep facial defects.

"When you can just about close a defect primarily and have concerns that doing so might cause unnecessary contour deformity or free margin retraction, an island pedicle flap taken from the standing cutaneous cone will rescue the repair and provide excellent cosmesis with minimal tissue loss," Dr. Roberta Sengelmann said at the annual meeting of the Pacific Dermatologic Association.

Also known as the B-to-Y flap or the kite flap, the island pedicle flap "has a rich vascular supply which comes from the underlying subcutaneous and muscular pedicle," said Dr. Sengelmann, a cosmetic dermatologic surgeon who practices in Santa Barbara, Calif., and St. Louis. "It is a terrifically viable flap and has surprisingly good mobility."

She uses it for deep defects, in areas where cosmetic junction lines and relaxed skin tension lines can camouflage the flap's kite-shaped design, to advance hair-bearing skin in cases when like skin is needed where there is a limited tissue reservoir within the cosmetic subunit.

She described the technique at the meeting. First, design the flap so that the primary and secondary flap movement will not cause anatomic distortion. Designs may be pentagonal, curved, or tapered. "These designs are used to preserve adjacent anatomical structures so as to avoid tissue distortion, but you maximize gain of the soft tissues that you have available," Dr. Sengelmann explained. "You take advantage of tissue laxity and relaxed skin tension lines."

Movement of the island pedicle flap is usually linear, "but you can rotate it [30-90 degrees], flip it [90-180 degrees], or tunnel it," she said.

Incise the flap vertically to the full thickness of the skin, free the advancing edge a few millimeters to prevent tethering down of the leading edge, and free a distal third or so of the flap to prevent limitation of movement.

Next, use a vertical spreading technique to undermine the flap. "The goal here is to maintain the vascular and muscular pedicle and provide enough stretch to allow adequate movement," she said. Advance the flap into place and secure the leading edge with the key suture. Undermine the defect wound margins in the mid-fat, close the secondary defect, achieve hemostasis, and approximate the flap slightly below the plane of the surrounding skin while providing perfect wound edge coaptation and eversion.

"Flaps should not be oversized," she cautioned. "When the flap is oversized, it tends to buckle up during the wound-healing process and can leave a 'pincushion-like' deformity."

To achieve optimal results, "be sure that the secondary defect can be easily closed side-to-side without distortion of anatomic structures," she added.

Other clinical pearls she shared were to "slightly undersize the flap, keeping in mind the area you are moving it to and being sure that you have enough primary movement to close the defect without compromising contour at that site."

Dr. Sengelmann acknowledged certain limitations of the island pedicle flap, including "trapdooring" and the potential for poor outcomes in areas with inadequate subdermal tissue and/or poor mobility, such as radiated, burned, or scarred skin; the nasal dorsum; and helical rim.

Even so, she concluded that the tissue-sparing aspect of this flap is "unsurpassed." There is a learning curve to "getting it right," but once the execution is mastered it provides an exceptional option for reconstruction of facial cutaneous defects.

Dr. Sengelmann disclosed no relevant conflicts of interest.

There's a learning curve to 'getting it right,' but once mastered it provides an exceptional option.

Source Dr. Sengelmann

PORTLAND, ORE. — Its ability to provide volume and spare tissue makes the island pedicle flap a valuable technique for deep facial defects.

"When you can just about close a defect primarily and have concerns that doing so might cause unnecessary contour deformity or free margin retraction, an island pedicle flap taken from the standing cutaneous cone will rescue the repair and provide excellent cosmesis with minimal tissue loss," Dr. Roberta Sengelmann said at the annual meeting of the Pacific Dermatologic Association.

Also known as the B-to-Y flap or the kite flap, the island pedicle flap "has a rich vascular supply which comes from the underlying subcutaneous and muscular pedicle," said Dr. Sengelmann, a cosmetic dermatologic surgeon who practices in Santa Barbara, Calif., and St. Louis. "It is a terrifically viable flap and has surprisingly good mobility."

She uses it for deep defects, in areas where cosmetic junction lines and relaxed skin tension lines can camouflage the flap's kite-shaped design, to advance hair-bearing skin in cases when like skin is needed where there is a limited tissue reservoir within the cosmetic subunit.

She described the technique at the meeting. First, design the flap so that the primary and secondary flap movement will not cause anatomic distortion. Designs may be pentagonal, curved, or tapered. "These designs are used to preserve adjacent anatomical structures so as to avoid tissue distortion, but you maximize gain of the soft tissues that you have available," Dr. Sengelmann explained. "You take advantage of tissue laxity and relaxed skin tension lines."

Movement of the island pedicle flap is usually linear, "but you can rotate it [30-90 degrees], flip it [90-180 degrees], or tunnel it," she said.

Incise the flap vertically to the full thickness of the skin, free the advancing edge a few millimeters to prevent tethering down of the leading edge, and free a distal third or so of the flap to prevent limitation of movement.

Next, use a vertical spreading technique to undermine the flap. "The goal here is to maintain the vascular and muscular pedicle and provide enough stretch to allow adequate movement," she said. Advance the flap into place and secure the leading edge with the key suture. Undermine the defect wound margins in the mid-fat, close the secondary defect, achieve hemostasis, and approximate the flap slightly below the plane of the surrounding skin while providing perfect wound edge coaptation and eversion.

"Flaps should not be oversized," she cautioned. "When the flap is oversized, it tends to buckle up during the wound-healing process and can leave a 'pincushion-like' deformity."

To achieve optimal results, "be sure that the secondary defect can be easily closed side-to-side without distortion of anatomic structures," she added.

Other clinical pearls she shared were to "slightly undersize the flap, keeping in mind the area you are moving it to and being sure that you have enough primary movement to close the defect without compromising contour at that site."

Dr. Sengelmann acknowledged certain limitations of the island pedicle flap, including "trapdooring" and the potential for poor outcomes in areas with inadequate subdermal tissue and/or poor mobility, such as radiated, burned, or scarred skin; the nasal dorsum; and helical rim.

Even so, she concluded that the tissue-sparing aspect of this flap is "unsurpassed." There is a learning curve to "getting it right," but once the execution is mastered it provides an exceptional option for reconstruction of facial cutaneous defects.

Dr. Sengelmann disclosed no relevant conflicts of interest.

There's a learning curve to 'getting it right,' but once mastered it provides an exceptional option.

Source Dr. Sengelmann

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

BOSTON — Cosmetic dermatologists have the knowledge and training to choose the right fillers that will garner the best results, according to Dr. Mary Lupo.

"Every FDA-approved filler, in my opinion, has an appropriate indication. You just need to know the relative strengths and weaknesses," said Dr. Lupo, at the American Academy of Dermatology's Academy 2009 meeting.

Optimal results require an appropriate candidate, the choice of an appropriate product based on the patient's presentation, injection of a sufficient amount of product, the right complementing procedures, and maintenance of the effect with touch-ups, said Dr. Lupo, professor of dermatology at Tulane University in New Orleans.

Treating Older Patients

In general, older patients need more volume restoration, because their immune response is decreased. "So when one has an active filler, such as poly-L-lactic acid, the older patient may have less of an immune response to give you a final result," she said. However, the corollary is that the older patient may require so much volume with other fillers that it becomes financially unfeasible.

"Older patients always need complementing procedures to get a good result," she said.

When examining the defect being considered for correction, decide whether it is a line or a fold. Lines require less viscous fillers to avoid lumpiness. "When a skin fold is more redundant, however, you need a thicker, more structural filler in order to lift the fold." When working with folds, Dr. Lupo recommends improving the area superior to the fold in addition to filling the fold.

When talking with the patient, "it's important to point out that it really doesn't do much good to fill a line if the overall photoaging is so severe and the 'canvas of the skin' is so mottled and deformed that it will not give an overall improvement," she said. Fillers can be used adjunctively with other methods to achieve better results.

Filler Contraindications

Many of the hyaluronic acid (HA) fillers are manufactured from a streptococcal fermentation process, so ask about hypersensitivity to strep, she said. Some patients have sensitivity to lidocaine. If this is the case, avoid using Prevelle Silk, CosmoDerm, and CosmoPlast. Poly-L-lactic acid is a component of Vicryl sutures, so if a patient has a history of allergic reaction to these sutures, avoid using Sculptra.

The use of anticoagulants by a patient is not necessarily a contraindication, "but it certainly behooves you to discuss the incidence of bruising that might be significant in these patients," Dr. Lupo said. For smokers wanting fillers, she uses a consent form to make these patients aware of the increased risk of necrosis.

Managing Expectations

The issue of cost also should be part of the discussion. Older patients will need more filler, meaning that temporary fillers may not be as cost effective over time. Semipermanent fillers may offer more benefit and it might be worth considering permanent.

To get the most out of a filler, complementing procedures should be considered. Such procedures can include onabotulinumtoxinA (Botox), intense pulsed light, chemical peel, nonablative laser, and ablative laser. "At the end of the day, the more procedures that a patient can afford, the better they will look," Dr. Lupo noted.

The Fillers

▸ CosmoDerm and CosmoPlast (human collagen). These products are the best choice for immediate results. They are great for lining the lips and for fine perioral lines, and both are fairly painless. They have a short duration, however, and both will be discontinued in 2010, according to Dr. Lupo.

▸ Restylane (HA gel). The filler is versatile and can be reversed by using hyaluronidase. It also can be injected with a finer-gauge needle, which reduces pain and allows treatment of finer lines. One injection lasts about 6 months, but it can last longer with touch-ups. Swelling and bruising should be considered, she said.

▸ Perlane (HA gel). This filler is a larger-particle gel suspension of HA. It is typically used for nasolabial folds and cheeks, and it can be used for lips with good technique to avoid lumping. "I have not found that the duration is any better than with Restylane," said Dr. Lupo.

▸ Juvéderm Ultra and Juvéderm Ultra Plus (cross-linked HA). This product is malleable and soft. It is also great for lips; however, because it is so malleable, it is not the best choice for defining the lip border. This filler is also reversible. "It is a little bit harder to get through a 1-inch needle," she said. Duration is 7-9 months without touch-ups.

Juvéderm Ultra Plus is the same as Juvéderm Ultra, although increased crosslinking of HA results in improved longevity—up to 1 year without touch-ups. "It's never to be used in fine lines, in my opinion," Dr. Lupo said. It is best injected with a 30-gauge needle. This filler is extremely good in skin of color.

▸ Prevelle Silk (cross-linked HA and lidocaine). The added lidocaine decreases patient discomfort. There is very little swelling because of the low HA concentration, but as a result it does not last as long—3 months or less. "It's inexpensive, and it's a good introductory filler for the hesitant patient," she said.

▸ Elevess (cross-linked HA and lidocaine). Elevess has the highest concentration of HA available on the market. "My personal opinion, based on my limited experience with it, is that it tends to be highly inflammatory as a result of this high concentration of HA," she said.

▸ Radiesse (calcium hydroxylapatite). This structural filler is great for men. It does cause a lot of same-day redness. "I do routinely mix it with lidocaine, and that is now FDA approved and has been found not to decrease its longevity," she said. It's a good choice for marionette lines and the pre-jowl sulcus, but avoid using it for the lips, she said.

▸ Sculptra (poly-L-lactic acid). The FDA cleared Sculptra this year for cosmetic purposes—correction of mild-to-severe nasolabial folds and wrinkles and contour irregularities. "The optimal patient for this is a younger lipoatrophy patient, because these patients still have enough of an immune response to actually get a good bang for the buck," she said. This filler is not reversible. The most common problem with Sculptra is the presence of nodules if it is injected too superficially, said Dr. Lupo.

▸ Evolence (porcine collagen). "In my opinion, it's a stiffer, more structural filler," she said. It works well in the nasolabial folds. Dr. Lupo always mixes it with lidocaine, though this makes it flow more quickly, so she uses a 30-gauge needle. It is a good choice for men with thick skin. Evolence has a low incidence of bruising and swelling.

Dr. Lupo reported significant financial relationships with a number of pharmaceutical and skin care companies.

A patient is shown before treatment with one syringe of Restylane.

The effect was prolonged for 3.5 years by performing periodic touch-ups.

Source Photos courtesy Dr. Mary Lupo

The Food and Drug Administration's recent decision to require new generic, or “established,” names for botulinum toxins is not likely to have much of an impact on patient safety, say dermatologists.

Citing the introduction of Dysport in April as the agency's trigger, the FDA said that it was seeking to reduce confusion and the potential for prescribing errors. Dysport is a botulinum toxin A, similar to Botox.

Now, Botox will be known generically as onabotulinumtoxinA; Myobloc will be known as rimabotulinumtoxinB, and Dysport will be known as abobotulinumtoxinA.

Each product will also carry the same boxed warning of the potential for distant spreading, which can lead to life-threatening respiratory difficulties. FDA first required this warning in April, but Dysport was not then on the market.

All of the toxins also will have a Medication Guide for patients discussing the potential for adverse effects from distant spreading.

“The revised labels also emphasize that the different botulinum toxin products are not interchangeable, because the units used to measure the products are different,” the FDA said in a statement.

“With each product having a distinct established name, we believe the chance of serious medication errors is minimized,” an agency spokeswoman said in an interview.

But several dermatologists said that since botulinum toxins are generally ordered, purchased, and dispensed by physicians, the new requirement won't have much effect.

Dr. Christopher Zachary, who is chairman of the dermatology department at the University of California in Irvine, said that he supports the FDA's efforts to increase safety. But, he added, “I'd suggest from a practical point of view that people keep using trade names,” noting that these are the names that stick in the minds of physicians, staff, and patients.

Dr. Michael Kaminer, assistant clinical professor in the dermatologic surgery and oncology section at Yale University, New Haven, Conn., said in an interview, “I can't imagine this would have any impact on consumers or physicians.” Distinct established names for the toxins could make a difference when and if a generic version becomes available, added Dr. Kaminer.

Dr. Kaminer disclosed no conflict of interest. Dr. Zachary disclosed that he receives grants and research support from Allergan.

'I'd suggest from a practical point of view that people keep using trade names.'

Source DR. ZACHARY

The Food and Drug Administration's recent decision to require new generic, or “established,” names for botulinum toxins is not likely to have much of an impact on patient safety, say dermatologists.

Citing the introduction of Dysport in April as the agency's trigger, the FDA said that it was seeking to reduce confusion and the potential for prescribing errors. Dysport is a botulinum toxin A, similar to Botox.

Now, Botox will be known generically as onabotulinumtoxinA; Myobloc will be known as rimabotulinumtoxinB, and Dysport will be known as abobotulinumtoxinA.

Each product will also carry the same boxed warning of the potential for distant spreading, which can lead to life-threatening respiratory difficulties. FDA first required this warning in April, but Dysport was not then on the market.

All of the toxins also will have a Medication Guide for patients discussing the potential for adverse effects from distant spreading.

“The revised labels also emphasize that the different botulinum toxin products are not interchangeable, because the units used to measure the products are different,” the FDA said in a statement.

“With each product having a distinct established name, we believe the chance of serious medication errors is minimized,” an agency spokeswoman said in an interview.

But several dermatologists said that since botulinum toxins are generally ordered, purchased, and dispensed by physicians, the new requirement won't have much effect.

Dr. Christopher Zachary, who is chairman of the dermatology department at the University of California in Irvine, said that he supports the FDA's efforts to increase safety. But, he added, “I'd suggest from a practical point of view that people keep using trade names,” noting that these are the names that stick in the minds of physicians, staff, and patients.

Dr. Michael Kaminer, assistant clinical professor in the dermatologic surgery and oncology section at Yale University, New Haven, Conn., said in an interview, “I can't imagine this would have any impact on consumers or physicians.” Distinct established names for the toxins could make a difference when and if a generic version becomes available, added Dr. Kaminer.

Dr. Kaminer disclosed no conflict of interest. Dr. Zachary disclosed that he receives grants and research support from Allergan.

'I'd suggest from a practical point of view that people keep using trade names.'

Source DR. ZACHARY

The Food and Drug Administration's recent decision to require new generic, or “established,” names for botulinum toxins is not likely to have much of an impact on patient safety, say dermatologists.

Citing the introduction of Dysport in April as the agency's trigger, the FDA said that it was seeking to reduce confusion and the potential for prescribing errors. Dysport is a botulinum toxin A, similar to Botox.

Now, Botox will be known generically as onabotulinumtoxinA; Myobloc will be known as rimabotulinumtoxinB, and Dysport will be known as abobotulinumtoxinA.

Each product will also carry the same boxed warning of the potential for distant spreading, which can lead to life-threatening respiratory difficulties. FDA first required this warning in April, but Dysport was not then on the market.

All of the toxins also will have a Medication Guide for patients discussing the potential for adverse effects from distant spreading.

“The revised labels also emphasize that the different botulinum toxin products are not interchangeable, because the units used to measure the products are different,” the FDA said in a statement.

“With each product having a distinct established name, we believe the chance of serious medication errors is minimized,” an agency spokeswoman said in an interview.

But several dermatologists said that since botulinum toxins are generally ordered, purchased, and dispensed by physicians, the new requirement won't have much effect.

Dr. Christopher Zachary, who is chairman of the dermatology department at the University of California in Irvine, said that he supports the FDA's efforts to increase safety. But, he added, “I'd suggest from a practical point of view that people keep using trade names,” noting that these are the names that stick in the minds of physicians, staff, and patients.

Dr. Michael Kaminer, assistant clinical professor in the dermatologic surgery and oncology section at Yale University, New Haven, Conn., said in an interview, “I can't imagine this would have any impact on consumers or physicians.” Distinct established names for the toxins could make a difference when and if a generic version becomes available, added Dr. Kaminer.

Dr. Kaminer disclosed no conflict of interest. Dr. Zachary disclosed that he receives grants and research support from Allergan.

'I'd suggest from a practical point of view that people keep using trade names.'

Source DR. ZACHARY

A consumer information page, with alink to the approval letter, is posted at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm176124.htm

Sculptra Aesthetic

(injectable poly-L-lactic acid, Sanofi-aventis)

Sculptra is an injectable filler containing microparticles of poly-L-lactic acid approved by the Food and Drug Administration in August for use in immune-competent people as a single regimen for the correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles “in which deep dermal grid pattern (cross-hatch) injection technique is appropriate,” according to the manufacturer. The injectable was first approved in 2004 for correcting lipoatrophy in HIV patients.

▸ Recommended Usage: Injected into the deep dermis. Injection requirements for Sculptra Aesthetic are “unique,” and include “a tunneling technique in a grid pattern that is medial to the nasolabial fold contour defect” being corrected, according to prescription information.

▸ Special Considerations: Contraindicated in patients with a hypersensitivity to any of the components of this product and those with a known history of keloid formation or hypertrophic scarring. The product has not been studied in the periorbital area, but use in this area has been associated with an increased risk of papules and nodules, according to reports in the literature. Side effects can include injection site discomfort, redness, bruising, bleeding, itching, and swelling, noted the manufacturer.

▸Comment: Poly-L-lactic acid is a biodegradable synthetic polymer that has been widely used for years in dissolvable stitches, bone screws, and facial implants, according to the FDA. A randomized, multicenter, evaluator-blinded controlled study of 233 immune-competent mostly female patients (mean age 51 years) with previously untreated nasolabial fold wrinkles and wrinkle assessment scores of 2 (shallow) through 4 (deep) was conducted.

Patients were treated with bilateral injections of Sculptra Aesthetic (at 3-week intervals for up to four treatments) or with CosmoPlast (INAMED Aesthetics) for a maximum of four sessions over 9 weeks. At 13 months, those who received Sculptra had improvements in wrinkle assessment scores in correction of the contour deficiency of the nasolabial folds. Improvements were maintained among those patients followed for up to 25 months, according to the prescribing information. CosmoPlast results were maintained for up to 3 months.

In an interview, Dr. Leslie S. Baumann, director of cosmetic dermatology at the University of Miami, said that she has used Sculptra off-label for hundreds of patients since it was approved in 2004. It is not her first choice for nasolabial folds, but she likes to use it for improving cheek volume, which is similar to the HIV lipoatrophy indication.

The biggest issue with Sculptra is that patients need to have four to eight treatments before they see any improvement in cheek volume, which is more expensive initially than other treatments, she said. Also, it is difficult to predict how many treatments people will need.

Dr. Baumann tells patients that they will need four to eight treatments 1 month apart, and that they usually will not see changes until the third or fourth treatment. It is worth it, though, “because once you get them the way you want them to look, it lasts 2–3 years,” she said.

The University of Miami was among the Sculptra Aesthetic study sites, and Dr. Baumann said she has been an investigator for Dermik Laboratories (the dermatology division of sanofi-aventis) and other major cosmetic filler manufacturers.

She described Sculptra as a “dermal stimulator” rather than a filler because it stimulates the dermis to make collagen. She cautioned that it should not be used in areas where there is a lot of movement, such as the corner of the mouth, because of the risk of developing hard lumps. “I've seen people with horrible lumps under their eyes and there's nothing you can do,” she said.

Dr. Baumann stressed the need to be properly trained in how to inject Sculptra. When she trains residents, “this is the last thing I'll teach them, because they really have to get their skills down.”

A consumer information page, with alink to the approval letter, is posted at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm176124.htm

Sculptra Aesthetic

(injectable poly-L-lactic acid, Sanofi-aventis)

Sculptra is an injectable filler containing microparticles of poly-L-lactic acid approved by the Food and Drug Administration in August for use in immune-competent people as a single regimen for the correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles “in which deep dermal grid pattern (cross-hatch) injection technique is appropriate,” according to the manufacturer. The injectable was first approved in 2004 for correcting lipoatrophy in HIV patients.

▸ Recommended Usage: Injected into the deep dermis. Injection requirements for Sculptra Aesthetic are “unique,” and include “a tunneling technique in a grid pattern that is medial to the nasolabial fold contour defect” being corrected, according to prescription information.

▸ Special Considerations: Contraindicated in patients with a hypersensitivity to any of the components of this product and those with a known history of keloid formation or hypertrophic scarring. The product has not been studied in the periorbital area, but use in this area has been associated with an increased risk of papules and nodules, according to reports in the literature. Side effects can include injection site discomfort, redness, bruising, bleeding, itching, and swelling, noted the manufacturer.

▸Comment: Poly-L-lactic acid is a biodegradable synthetic polymer that has been widely used for years in dissolvable stitches, bone screws, and facial implants, according to the FDA. A randomized, multicenter, evaluator-blinded controlled study of 233 immune-competent mostly female patients (mean age 51 years) with previously untreated nasolabial fold wrinkles and wrinkle assessment scores of 2 (shallow) through 4 (deep) was conducted.

Patients were treated with bilateral injections of Sculptra Aesthetic (at 3-week intervals for up to four treatments) or with CosmoPlast (INAMED Aesthetics) for a maximum of four sessions over 9 weeks. At 13 months, those who received Sculptra had improvements in wrinkle assessment scores in correction of the contour deficiency of the nasolabial folds. Improvements were maintained among those patients followed for up to 25 months, according to the prescribing information. CosmoPlast results were maintained for up to 3 months.

In an interview, Dr. Leslie S. Baumann, director of cosmetic dermatology at the University of Miami, said that she has used Sculptra off-label for hundreds of patients since it was approved in 2004. It is not her first choice for nasolabial folds, but she likes to use it for improving cheek volume, which is similar to the HIV lipoatrophy indication.

The biggest issue with Sculptra is that patients need to have four to eight treatments before they see any improvement in cheek volume, which is more expensive initially than other treatments, she said. Also, it is difficult to predict how many treatments people will need.

Dr. Baumann tells patients that they will need four to eight treatments 1 month apart, and that they usually will not see changes until the third or fourth treatment. It is worth it, though, “because once you get them the way you want them to look, it lasts 2–3 years,” she said.

The University of Miami was among the Sculptra Aesthetic study sites, and Dr. Baumann said she has been an investigator for Dermik Laboratories (the dermatology division of sanofi-aventis) and other major cosmetic filler manufacturers.

She described Sculptra as a “dermal stimulator” rather than a filler because it stimulates the dermis to make collagen. She cautioned that it should not be used in areas where there is a lot of movement, such as the corner of the mouth, because of the risk of developing hard lumps. “I've seen people with horrible lumps under their eyes and there's nothing you can do,” she said.

Dr. Baumann stressed the need to be properly trained in how to inject Sculptra. When she trains residents, “this is the last thing I'll teach them, because they really have to get their skills down.”

A consumer information page, with alink to the approval letter, is posted at www.fda.gov/MedicalDevices/ProductsandMedicalProcedures/DeviceApprovalsandClearances/Recently-ApprovedDevices/ucm176124.htm

Sculptra Aesthetic

(injectable poly-L-lactic acid, Sanofi-aventis)

Sculptra is an injectable filler containing microparticles of poly-L-lactic acid approved by the Food and Drug Administration in August for use in immune-competent people as a single regimen for the correction of shallow to deep nasolabial fold contour deficiencies and other facial wrinkles “in which deep dermal grid pattern (cross-hatch) injection technique is appropriate,” according to the manufacturer. The injectable was first approved in 2004 for correcting lipoatrophy in HIV patients.

▸ Recommended Usage: Injected into the deep dermis. Injection requirements for Sculptra Aesthetic are “unique,” and include “a tunneling technique in a grid pattern that is medial to the nasolabial fold contour defect” being corrected, according to prescription information.

▸ Special Considerations: Contraindicated in patients with a hypersensitivity to any of the components of this product and those with a known history of keloid formation or hypertrophic scarring. The product has not been studied in the periorbital area, but use in this area has been associated with an increased risk of papules and nodules, according to reports in the literature. Side effects can include injection site discomfort, redness, bruising, bleeding, itching, and swelling, noted the manufacturer.

▸Comment: Poly-L-lactic acid is a biodegradable synthetic polymer that has been widely used for years in dissolvable stitches, bone screws, and facial implants, according to the FDA. A randomized, multicenter, evaluator-blinded controlled study of 233 immune-competent mostly female patients (mean age 51 years) with previously untreated nasolabial fold wrinkles and wrinkle assessment scores of 2 (shallow) through 4 (deep) was conducted.

Patients were treated with bilateral injections of Sculptra Aesthetic (at 3-week intervals for up to four treatments) or with CosmoPlast (INAMED Aesthetics) for a maximum of four sessions over 9 weeks. At 13 months, those who received Sculptra had improvements in wrinkle assessment scores in correction of the contour deficiency of the nasolabial folds. Improvements were maintained among those patients followed for up to 25 months, according to the prescribing information. CosmoPlast results were maintained for up to 3 months.

In an interview, Dr. Leslie S. Baumann, director of cosmetic dermatology at the University of Miami, said that she has used Sculptra off-label for hundreds of patients since it was approved in 2004. It is not her first choice for nasolabial folds, but she likes to use it for improving cheek volume, which is similar to the HIV lipoatrophy indication.

The biggest issue with Sculptra is that patients need to have four to eight treatments before they see any improvement in cheek volume, which is more expensive initially than other treatments, she said. Also, it is difficult to predict how many treatments people will need.

Dr. Baumann tells patients that they will need four to eight treatments 1 month apart, and that they usually will not see changes until the third or fourth treatment. It is worth it, though, “because once you get them the way you want them to look, it lasts 2–3 years,” she said.

The University of Miami was among the Sculptra Aesthetic study sites, and Dr. Baumann said she has been an investigator for Dermik Laboratories (the dermatology division of sanofi-aventis) and other major cosmetic filler manufacturers.

She described Sculptra as a “dermal stimulator” rather than a filler because it stimulates the dermis to make collagen. She cautioned that it should not be used in areas where there is a lot of movement, such as the corner of the mouth, because of the risk of developing hard lumps. “I've seen people with horrible lumps under their eyes and there's nothing you can do,” she said.

Dr. Baumann stressed the need to be properly trained in how to inject Sculptra. When she trains residents, “this is the last thing I'll teach them, because they really have to get their skills down.”

BOSTON — Noninvasive fat removal is now technically possible, but media hype of new devices may lead to unrealistic expectations.

"We can absolutely remove fat without breaking the stratum corneum [using the new devices], but it's important to put context to this," Dr. Mathew M. Avram said at the American Academy of Dermatology's Academy 2009 meeting.

"While [the devices] are effective, the technology is truly limited at this point. There is a long and deserved reputation of snake oil salesmanship in the field of fat, so it is essential that we assess the new tools critically," said Dr. Avram of Harvard Medical School and Massachusetts General Hospital, Boston.

Focused ultrasound, high-intensity focused ultrasound, radiofrequency, and, most recently, cryolipolysis have shown promise as nonsurgical options for trimming fat from the hips, thighs, abdomen, and buttocks, but they are limited in what they can achieve, said Dr. Avram.

Focused ultrasound, for example, uses mechanical energy to target subcutaneous adipose tissue and break up fat cells, which are then flushed out through the liver, he said.

Clinical studies of patients treated with focused ultrasound, which has not yet received FDA approval for this indication, have demonstrated circumference reductions of 2–3 cm at the thighs, flanks, and abdomen with no associated lipid or liver function abnormalities after three treatments.

"The findings are limited, however, because none of the studies used an untreated control group for comparison and all relied on change in circumference as an outcome measure, which is an imprecise measure of improvement. To truly show a reduction in the fat layer, you really need to use MRI, which is expensive, or high-resolution ultrasound—neither of which were done in these studies." The commercial device that uses this technology is used around the world except in the United States, he said.

High-intensity focused ultrasound devices similarly target and ablate subcutaneous fat while leaving the epidermis, dermis, and surrounding tissue unharmed, but they do so by inducing thermal versus mechanical fat injury, said Dr. Avram.

The efficacy of this method of body contouring, which has also not yet received FDA approval, has yet to be demonstrated in clinical studies.

Unipolar and bipolar radiofrequency-based, nonsurgical skin tightening devices, which many clinicians use for "nonsurgical facelift," are also being used to remove localized fat deposits. These devices, which are cleared by the FDA, deliver radiofrequency energy, and sometimes infrared light energy, into fat deposits over multiple weeks to destroy the fat cell membranes and release the fatty acids for removal through the liver, said Dr. Avram. Although the devices are being used and marketed for fat removal, "at this point we're still awaiting studies to determine the efficacy of the technology."

The latest contender to enter the fat-removal ring is a concept known as cryolipolysis, developed at Massachusetts General Hospital, which cools fat to selectively cause cell breakdown without damaging the surrounding tissue ("Cryolipolysis on Track to Become First Cool Way to Remove Cellulite," April 2009, p. 11).

"The technology is based on the concept of cold panniculitis, or popsicle panniculitis, through which cold exposure causes clinically [and histologically] evident inflammation in fat. The inflammation peaks several days or weeks after the exposure with subsequent focal lipoatrophy," said Dr. Avram.

"What we believe is happening is a selective crystallization in lipids in fat cells at temperatures above freezing—in other words there is a different melting point for fat cells than for the [surrounding tissue]—and there is fat cell apoptosis, followed by slow dissolution of the cell with gradual release of lipids over a period of 2–6 weeks," he said.

The technology, which has not received FDA clearance, has shown promise in an initial human study, said Dr. Avram.

The multicenter investigation included 32 male and female subjects with visible fat on the flank (love handles) or back. The patients were treated using a prototype cryolipolysis device on one side with exposure times ranging from 30 to 45 minutes, while the contralateral side served as the untreated control. Outcome measures included fat-layer reduction as measured by ultrasound, comparison of pre- and posttreatment photographs, and physician assessment.

"At 4 months post treatment, a visible contour change was observed in most of the subjects," said Dr. Avram. Specifically, he noted, ultrasound measurements taken on a subset of 10 subjects demonstrated a fat layer reduction in all; the average reduction was 22.4%.

Among the treatment-related side effects, some of the patients experienced redness at the treatment site that lasted for minutes to hours, as well as bruising and dulling of sensation in the treatment area that resolved within 1–8 weeks, Dr. Avram said, noting that "there were no pigmentary changes, nor were there any lab abnormalities suggesting systemic side effects."

Further studies are needed to establish optimal treatment parameters, but these early results suggest that cryolipolysis will likely be best suited for localized fat removal in areas that are particularly resistant to exercise, he said.

Despite the apparent promise of the new technologies, Dr. Avram was quick to stress that the "clear but limited noninvasive fat removal achieved with these devices is in no way, shape, or form a competitor for liposuction." They are noninvasive alternatives that can achieve certain results, which should be made clear to patients.

Dr. Avram has conducted research for Candela Corp. and owns stock options in Zeltiq Aesthetics, which holds the cryolipolysis patent.

BOSTON — Noninvasive fat removal is now technically possible, but media hype of new devices may lead to unrealistic expectations.

"We can absolutely remove fat without breaking the stratum corneum [using the new devices], but it's important to put context to this," Dr. Mathew M. Avram said at the American Academy of Dermatology's Academy 2009 meeting.

"While [the devices] are effective, the technology is truly limited at this point. There is a long and deserved reputation of snake oil salesmanship in the field of fat, so it is essential that we assess the new tools critically," said Dr. Avram of Harvard Medical School and Massachusetts General Hospital, Boston.

Focused ultrasound, high-intensity focused ultrasound, radiofrequency, and, most recently, cryolipolysis have shown promise as nonsurgical options for trimming fat from the hips, thighs, abdomen, and buttocks, but they are limited in what they can achieve, said Dr. Avram.

Focused ultrasound, for example, uses mechanical energy to target subcutaneous adipose tissue and break up fat cells, which are then flushed out through the liver, he said.

Clinical studies of patients treated with focused ultrasound, which has not yet received FDA approval for this indication, have demonstrated circumference reductions of 2–3 cm at the thighs, flanks, and abdomen with no associated lipid or liver function abnormalities after three treatments.

"The findings are limited, however, because none of the studies used an untreated control group for comparison and all relied on change in circumference as an outcome measure, which is an imprecise measure of improvement. To truly show a reduction in the fat layer, you really need to use MRI, which is expensive, or high-resolution ultrasound—neither of which were done in these studies." The commercial device that uses this technology is used around the world except in the United States, he said.

High-intensity focused ultrasound devices similarly target and ablate subcutaneous fat while leaving the epidermis, dermis, and surrounding tissue unharmed, but they do so by inducing thermal versus mechanical fat injury, said Dr. Avram.

The efficacy of this method of body contouring, which has also not yet received FDA approval, has yet to be demonstrated in clinical studies.

Unipolar and bipolar radiofrequency-based, nonsurgical skin tightening devices, which many clinicians use for "nonsurgical facelift," are also being used to remove localized fat deposits. These devices, which are cleared by the FDA, deliver radiofrequency energy, and sometimes infrared light energy, into fat deposits over multiple weeks to destroy the fat cell membranes and release the fatty acids for removal through the liver, said Dr. Avram. Although the devices are being used and marketed for fat removal, "at this point we're still awaiting studies to determine the efficacy of the technology."

The latest contender to enter the fat-removal ring is a concept known as cryolipolysis, developed at Massachusetts General Hospital, which cools fat to selectively cause cell breakdown without damaging the surrounding tissue ("Cryolipolysis on Track to Become First Cool Way to Remove Cellulite," April 2009, p. 11).

"The technology is based on the concept of cold panniculitis, or popsicle panniculitis, through which cold exposure causes clinically [and histologically] evident inflammation in fat. The inflammation peaks several days or weeks after the exposure with subsequent focal lipoatrophy," said Dr. Avram.

"What we believe is happening is a selective crystallization in lipids in fat cells at temperatures above freezing—in other words there is a different melting point for fat cells than for the [surrounding tissue]—and there is fat cell apoptosis, followed by slow dissolution of the cell with gradual release of lipids over a period of 2–6 weeks," he said.

The technology, which has not received FDA clearance, has shown promise in an initial human study, said Dr. Avram.

The multicenter investigation included 32 male and female subjects with visible fat on the flank (love handles) or back. The patients were treated using a prototype cryolipolysis device on one side with exposure times ranging from 30 to 45 minutes, while the contralateral side served as the untreated control. Outcome measures included fat-layer reduction as measured by ultrasound, comparison of pre- and posttreatment photographs, and physician assessment.

"At 4 months post treatment, a visible contour change was observed in most of the subjects," said Dr. Avram. Specifically, he noted, ultrasound measurements taken on a subset of 10 subjects demonstrated a fat layer reduction in all; the average reduction was 22.4%.

Among the treatment-related side effects, some of the patients experienced redness at the treatment site that lasted for minutes to hours, as well as bruising and dulling of sensation in the treatment area that resolved within 1–8 weeks, Dr. Avram said, noting that "there were no pigmentary changes, nor were there any lab abnormalities suggesting systemic side effects."

Further studies are needed to establish optimal treatment parameters, but these early results suggest that cryolipolysis will likely be best suited for localized fat removal in areas that are particularly resistant to exercise, he said.

Despite the apparent promise of the new technologies, Dr. Avram was quick to stress that the "clear but limited noninvasive fat removal achieved with these devices is in no way, shape, or form a competitor for liposuction." They are noninvasive alternatives that can achieve certain results, which should be made clear to patients.

Dr. Avram has conducted research for Candela Corp. and owns stock options in Zeltiq Aesthetics, which holds the cryolipolysis patent.

BOSTON — Noninvasive fat removal is now technically possible, but media hype of new devices may lead to unrealistic expectations.

"We can absolutely remove fat without breaking the stratum corneum [using the new devices], but it's important to put context to this," Dr. Mathew M. Avram said at the American Academy of Dermatology's Academy 2009 meeting.

"While [the devices] are effective, the technology is truly limited at this point. There is a long and deserved reputation of snake oil salesmanship in the field of fat, so it is essential that we assess the new tools critically," said Dr. Avram of Harvard Medical School and Massachusetts General Hospital, Boston.

Focused ultrasound, high-intensity focused ultrasound, radiofrequency, and, most recently, cryolipolysis have shown promise as nonsurgical options for trimming fat from the hips, thighs, abdomen, and buttocks, but they are limited in what they can achieve, said Dr. Avram.

Focused ultrasound, for example, uses mechanical energy to target subcutaneous adipose tissue and break up fat cells, which are then flushed out through the liver, he said.

Clinical studies of patients treated with focused ultrasound, which has not yet received FDA approval for this indication, have demonstrated circumference reductions of 2–3 cm at the thighs, flanks, and abdomen with no associated lipid or liver function abnormalities after three treatments.

"The findings are limited, however, because none of the studies used an untreated control group for comparison and all relied on change in circumference as an outcome measure, which is an imprecise measure of improvement. To truly show a reduction in the fat layer, you really need to use MRI, which is expensive, or high-resolution ultrasound—neither of which were done in these studies." The commercial device that uses this technology is used around the world except in the United States, he said.

High-intensity focused ultrasound devices similarly target and ablate subcutaneous fat while leaving the epidermis, dermis, and surrounding tissue unharmed, but they do so by inducing thermal versus mechanical fat injury, said Dr. Avram.

The efficacy of this method of body contouring, which has also not yet received FDA approval, has yet to be demonstrated in clinical studies.

Unipolar and bipolar radiofrequency-based, nonsurgical skin tightening devices, which many clinicians use for "nonsurgical facelift," are also being used to remove localized fat deposits. These devices, which are cleared by the FDA, deliver radiofrequency energy, and sometimes infrared light energy, into fat deposits over multiple weeks to destroy the fat cell membranes and release the fatty acids for removal through the liver, said Dr. Avram. Although the devices are being used and marketed for fat removal, "at this point we're still awaiting studies to determine the efficacy of the technology."

The latest contender to enter the fat-removal ring is a concept known as cryolipolysis, developed at Massachusetts General Hospital, which cools fat to selectively cause cell breakdown without damaging the surrounding tissue ("Cryolipolysis on Track to Become First Cool Way to Remove Cellulite," April 2009, p. 11).

"The technology is based on the concept of cold panniculitis, or popsicle panniculitis, through which cold exposure causes clinically [and histologically] evident inflammation in fat. The inflammation peaks several days or weeks after the exposure with subsequent focal lipoatrophy," said Dr. Avram.

"What we believe is happening is a selective crystallization in lipids in fat cells at temperatures above freezing—in other words there is a different melting point for fat cells than for the [surrounding tissue]—and there is fat cell apoptosis, followed by slow dissolution of the cell with gradual release of lipids over a period of 2–6 weeks," he said.

The technology, which has not received FDA clearance, has shown promise in an initial human study, said Dr. Avram.

The multicenter investigation included 32 male and female subjects with visible fat on the flank (love handles) or back. The patients were treated using a prototype cryolipolysis device on one side with exposure times ranging from 30 to 45 minutes, while the contralateral side served as the untreated control. Outcome measures included fat-layer reduction as measured by ultrasound, comparison of pre- and posttreatment photographs, and physician assessment.

"At 4 months post treatment, a visible contour change was observed in most of the subjects," said Dr. Avram. Specifically, he noted, ultrasound measurements taken on a subset of 10 subjects demonstrated a fat layer reduction in all; the average reduction was 22.4%.

Among the treatment-related side effects, some of the patients experienced redness at the treatment site that lasted for minutes to hours, as well as bruising and dulling of sensation in the treatment area that resolved within 1–8 weeks, Dr. Avram said, noting that "there were no pigmentary changes, nor were there any lab abnormalities suggesting systemic side effects."

Further studies are needed to establish optimal treatment parameters, but these early results suggest that cryolipolysis will likely be best suited for localized fat removal in areas that are particularly resistant to exercise, he said.

Despite the apparent promise of the new technologies, Dr. Avram was quick to stress that the "clear but limited noninvasive fat removal achieved with these devices is in no way, shape, or form a competitor for liposuction." They are noninvasive alternatives that can achieve certain results, which should be made clear to patients.

Dr. Avram has conducted research for Candela Corp. and owns stock options in Zeltiq Aesthetics, which holds the cryolipolysis patent.

Just as patients are beginning to come into the office seeking eyelashes as long and thick as those belonging to Brooke Shields, Dr. Christopher B. Zachary gave his run-down on the safety and efficacy of bimatoprost 0.03%.

The bottom line appears to be that the product has a clinically meaningful benefit and is well tolerated in healthy adults, Dr. Zachary said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

"Appropriate studies have been performed to demonstrate the efficacy and safety of this product," he said in an interview. "But as with any new cosmetic procedure, patients need to be aware of the potential for side effects."

Eyelash growth using bimatoprost was first characterized in two controlled phase III trials in glaucoma. The discovery of a secondary application for bimatoprost is not a surprise, said Dr. Zachary, chair of the department of dermatology at the University of California, Irvine. "Many products when developed and utilized extensively for one indication will inevitably be associated with effects in other systems," said Dr. Zachary, who serves on various academic advisory boards for Allergan Inc.

Since the benefit was first observed in glaucoma patients, researchers performed an open-label trial showing the efficacy of bimatoprost when directly applied to the eyelid margin.

The open label, proof-of-concept study included 28 women who applied the product daily over the course of 12 weeks. The study demonstrated the effectiveness of the product, with all women who responded to questions about efficacy reporting at least some improvement in their eyelashes. None of the patients discontinued treatment as a result of adverse events, and only minor, transient adverse events were reported. Additionally, changes in intraocular pressure were not statistically significant, Dr. Zachary said.

A confirmatory phase III trial of 278 patients used a global eyelash assessment, digital image analysis, and patient-reported outcome measures to assess the efficacy of the product. At the end of 16 weeks, a statistically significant percentage of patients in the bimatoprost group had improvements in eyelash prominence, length, thickness, and darkness, compared with the vehicle group. The results of the randomized, double-blind, placebo-controlled study were consistent across age and race.

In terms of safety, four patients in the bimatoprost group and four patients in the control group discontinued due to adverse events. All of the treatment-related events were minor: eczematous change, irritant dermatitis, dry eye, eyelid erythema, and low intraocular pressure.

When used by glaucoma patients over long periods, bimatoprost resulted in darkening of the iris in some, Dr. Zachary said. Although this effect was not found in any of the cosmetic trials, patients should be informed of this possibility.

SDEF and this news organization are owned by Elsevier.

'As with any new cosmetic procedure, patients need to be aware of the potential for side effects.'

Source DR. ZACHARY

Treatment results can be seen in these photos from Allergan's clinical trial.

Source Courtesy Allergan Inc.

Just as patients are beginning to come into the office seeking eyelashes as long and thick as those belonging to Brooke Shields, Dr. Christopher B. Zachary gave his run-down on the safety and efficacy of bimatoprost 0.03%.

The bottom line appears to be that the product has a clinically meaningful benefit and is well tolerated in healthy adults, Dr. Zachary said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

"Appropriate studies have been performed to demonstrate the efficacy and safety of this product," he said in an interview. "But as with any new cosmetic procedure, patients need to be aware of the potential for side effects."

Eyelash growth using bimatoprost was first characterized in two controlled phase III trials in glaucoma. The discovery of a secondary application for bimatoprost is not a surprise, said Dr. Zachary, chair of the department of dermatology at the University of California, Irvine. "Many products when developed and utilized extensively for one indication will inevitably be associated with effects in other systems," said Dr. Zachary, who serves on various academic advisory boards for Allergan Inc.

Since the benefit was first observed in glaucoma patients, researchers performed an open-label trial showing the efficacy of bimatoprost when directly applied to the eyelid margin.

The open label, proof-of-concept study included 28 women who applied the product daily over the course of 12 weeks. The study demonstrated the effectiveness of the product, with all women who responded to questions about efficacy reporting at least some improvement in their eyelashes. None of the patients discontinued treatment as a result of adverse events, and only minor, transient adverse events were reported. Additionally, changes in intraocular pressure were not statistically significant, Dr. Zachary said.

A confirmatory phase III trial of 278 patients used a global eyelash assessment, digital image analysis, and patient-reported outcome measures to assess the efficacy of the product. At the end of 16 weeks, a statistically significant percentage of patients in the bimatoprost group had improvements in eyelash prominence, length, thickness, and darkness, compared with the vehicle group. The results of the randomized, double-blind, placebo-controlled study were consistent across age and race.

In terms of safety, four patients in the bimatoprost group and four patients in the control group discontinued due to adverse events. All of the treatment-related events were minor: eczematous change, irritant dermatitis, dry eye, eyelid erythema, and low intraocular pressure.

When used by glaucoma patients over long periods, bimatoprost resulted in darkening of the iris in some, Dr. Zachary said. Although this effect was not found in any of the cosmetic trials, patients should be informed of this possibility.

SDEF and this news organization are owned by Elsevier.

'As with any new cosmetic procedure, patients need to be aware of the potential for side effects.'

Source DR. ZACHARY

Treatment results can be seen in these photos from Allergan's clinical trial.

Source Courtesy Allergan Inc.

Just as patients are beginning to come into the office seeking eyelashes as long and thick as those belonging to Brooke Shields, Dr. Christopher B. Zachary gave his run-down on the safety and efficacy of bimatoprost 0.03%.

The bottom line appears to be that the product has a clinically meaningful benefit and is well tolerated in healthy adults, Dr. Zachary said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

"Appropriate studies have been performed to demonstrate the efficacy and safety of this product," he said in an interview. "But as with any new cosmetic procedure, patients need to be aware of the potential for side effects."

Eyelash growth using bimatoprost was first characterized in two controlled phase III trials in glaucoma. The discovery of a secondary application for bimatoprost is not a surprise, said Dr. Zachary, chair of the department of dermatology at the University of California, Irvine. "Many products when developed and utilized extensively for one indication will inevitably be associated with effects in other systems," said Dr. Zachary, who serves on various academic advisory boards for Allergan Inc.

Since the benefit was first observed in glaucoma patients, researchers performed an open-label trial showing the efficacy of bimatoprost when directly applied to the eyelid margin.

The open label, proof-of-concept study included 28 women who applied the product daily over the course of 12 weeks. The study demonstrated the effectiveness of the product, with all women who responded to questions about efficacy reporting at least some improvement in their eyelashes. None of the patients discontinued treatment as a result of adverse events, and only minor, transient adverse events were reported. Additionally, changes in intraocular pressure were not statistically significant, Dr. Zachary said.

A confirmatory phase III trial of 278 patients used a global eyelash assessment, digital image analysis, and patient-reported outcome measures to assess the efficacy of the product. At the end of 16 weeks, a statistically significant percentage of patients in the bimatoprost group had improvements in eyelash prominence, length, thickness, and darkness, compared with the vehicle group. The results of the randomized, double-blind, placebo-controlled study were consistent across age and race.

In terms of safety, four patients in the bimatoprost group and four patients in the control group discontinued due to adverse events. All of the treatment-related events were minor: eczematous change, irritant dermatitis, dry eye, eyelid erythema, and low intraocular pressure.

When used by glaucoma patients over long periods, bimatoprost resulted in darkening of the iris in some, Dr. Zachary said. Although this effect was not found in any of the cosmetic trials, patients should be informed of this possibility.

SDEF and this news organization are owned by Elsevier.

'As with any new cosmetic procedure, patients need to be aware of the potential for side effects.'

Source DR. ZACHARY

Treatment results can be seen in these photos from Allergan's clinical trial.

Source Courtesy Allergan Inc.

When enhancing a patient's lips, consider the patient's aesthetic goals and the natural anatomy of the lip, and remember to think aesthetically about the entire face, said Dr. Kimberly Butterwick.

"Take care to achieve a lip that does not look like it's been done," advised Dr. Butterwick, a cosmetic dermatologist in La Jolla, Calif. "We're not just correcting a defect, but making a patient look prettier, and we have to be mindful how the lips contribute" to the symmetry and proportions of the entire face.

The anatomy of the lip—the vermilion border, the red portion of the lip, the philtral columns, and the balance of the upper and lower lip—and its proportions are the elements that need to be considered to create a lip that is natural looking, "yet enhanced and more beautiful," she said in an interview.

The lip is divided into red and white segments, "at a well-defined and arched vermilion border." Think about the M-shaped cupid's bow of the upper lip, and the lower lip as shaped like a W, with two lateral lobes and a midline groove, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

The relationship to the nose and chin, and facial proportions also should be considered, with the width of the lip falling between a straight line drawn from each inner iris.

A mistake that can be made with the red portion of the lip is to create a fat lip all the way across the upper and lower lip, like a sausage instead of being attentive to the normal contours. There is also a tendency to overstress the upper lip in an attempt to get a pouty look. Ideally, the lower lip should be bigger by 10%-25%, Dr. Butterwick added, noting that often, physicians try to make the upper lip equal to or bigger than the lower lip, which appears unnatural.

Areas of the lips that should be fuller and emphasized to achieve a natural look include the two anatomic mounds of fullness at the highest point of the upper lip, right under the peak of the cupid's bow, as well as the two mounds of volume of the lower lip of the "four pillows." It also often helps to add a little volume to the midline tubercle of the upper lips and the philtral columns.

Hyaluronic acid is the main option used for lip correction and enhancement, "because it is safe, soft, and natural, and it lasts long enough in most cases," Dr. Butterwick said. Currently available hyaluronic acid products are Restylane, Hyalaform, Juvèderm Ultra or Ultra Plus, and Prevelle Silk.

Prevelle Silk is a good option for beginners because it is lightweight, contains anesthetic, and does not last as long as the others. It also can be used first, injected along the vermilion for its anesthetic effects, and can be followed by another hyaluronic acid product that provides for more volume and lasts longer, using the rest of Prevelle Silk for fine lines, she said.

Restylane and Juvèderm are similar, although Juvèderm causes a little less swelling and, therefore, "may be a little softer and more natural in the lips," she said, but a product that is a little thicker may be appropriate for those patients who want more pronounced lips, she added. "That's when you can strike a balance between what the patient wants and still achieve a natural look."

Fat augmentation of the lips provides a natural appearance, but does not last as long as it does in other locations. "I would not go out of my way to put fat in the lips, unless you are already using fat for other indications in the face," she advised.

Semipermanent or permanent injectables that are associated with a high rate of adverse reactions when used in the lips are Radiesse, Sculptra, Evolence, and Artefill, as well as silicone, which should be avoided in lips altogether, she said. Their labels state they should not be used in lips, "yet physicians think that they can get away with it, and wind up every so often having a problem, and it is a big problem."

An important element of lip correction is consideration of the way lips appear in motion: When Dr. Butterwick consults with a patient, she said she observes their lips while they are talking. Some people have vertical lip lines from excessive pursing while they talk, or they pull down the corners of their mouth while talking, which are excess movements that can be "softened" with Botox, she said. Botox also can address a gummy smile.

Treating the surrounding tissue to support volume loss—such as deep marionette lines, a jowl, or a deep nasolabial fold right near the lip—will also improve the appearance of the lips.

Dr. Butterwick disclosed receiving grant research support from Mentor Corp., and is a consultant for Medicis Pharmaceutical Corp., Allergan Inc., Sanofi-Aventis, and Neutrogena Corp.

SDEF and this news organization are owned by Elsevier.

Photo shows patient prior to injection of 1 cc of Hyalaform to the upper lip.

Two weeks post injection, the cupid's bow is narrowed and more defined.

Source Photos courtesy Dr. Kimberly Butterwick

'We have to be mindful how the lips contribute' to the symmetry and proportions of the entire face.

Source DR. BUTTERWICK

When enhancing a patient's lips, consider the patient's aesthetic goals and the natural anatomy of the lip, and remember to think aesthetically about the entire face, said Dr. Kimberly Butterwick.

"Take care to achieve a lip that does not look like it's been done," advised Dr. Butterwick, a cosmetic dermatologist in La Jolla, Calif. "We're not just correcting a defect, but making a patient look prettier, and we have to be mindful how the lips contribute" to the symmetry and proportions of the entire face.

The anatomy of the lip—the vermilion border, the red portion of the lip, the philtral columns, and the balance of the upper and lower lip—and its proportions are the elements that need to be considered to create a lip that is natural looking, "yet enhanced and more beautiful," she said in an interview.

The lip is divided into red and white segments, "at a well-defined and arched vermilion border." Think about the M-shaped cupid's bow of the upper lip, and the lower lip as shaped like a W, with two lateral lobes and a midline groove, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

The relationship to the nose and chin, and facial proportions also should be considered, with the width of the lip falling between a straight line drawn from each inner iris.

A mistake that can be made with the red portion of the lip is to create a fat lip all the way across the upper and lower lip, like a sausage instead of being attentive to the normal contours. There is also a tendency to overstress the upper lip in an attempt to get a pouty look. Ideally, the lower lip should be bigger by 10%-25%, Dr. Butterwick added, noting that often, physicians try to make the upper lip equal to or bigger than the lower lip, which appears unnatural.

Areas of the lips that should be fuller and emphasized to achieve a natural look include the two anatomic mounds of fullness at the highest point of the upper lip, right under the peak of the cupid's bow, as well as the two mounds of volume of the lower lip of the "four pillows." It also often helps to add a little volume to the midline tubercle of the upper lips and the philtral columns.

Hyaluronic acid is the main option used for lip correction and enhancement, "because it is safe, soft, and natural, and it lasts long enough in most cases," Dr. Butterwick said. Currently available hyaluronic acid products are Restylane, Hyalaform, Juvèderm Ultra or Ultra Plus, and Prevelle Silk.

Prevelle Silk is a good option for beginners because it is lightweight, contains anesthetic, and does not last as long as the others. It also can be used first, injected along the vermilion for its anesthetic effects, and can be followed by another hyaluronic acid product that provides for more volume and lasts longer, using the rest of Prevelle Silk for fine lines, she said.

Restylane and Juvèderm are similar, although Juvèderm causes a little less swelling and, therefore, "may be a little softer and more natural in the lips," she said, but a product that is a little thicker may be appropriate for those patients who want more pronounced lips, she added. "That's when you can strike a balance between what the patient wants and still achieve a natural look."

Fat augmentation of the lips provides a natural appearance, but does not last as long as it does in other locations. "I would not go out of my way to put fat in the lips, unless you are already using fat for other indications in the face," she advised.

Semipermanent or permanent injectables that are associated with a high rate of adverse reactions when used in the lips are Radiesse, Sculptra, Evolence, and Artefill, as well as silicone, which should be avoided in lips altogether, she said. Their labels state they should not be used in lips, "yet physicians think that they can get away with it, and wind up every so often having a problem, and it is a big problem."

An important element of lip correction is consideration of the way lips appear in motion: When Dr. Butterwick consults with a patient, she said she observes their lips while they are talking. Some people have vertical lip lines from excessive pursing while they talk, or they pull down the corners of their mouth while talking, which are excess movements that can be "softened" with Botox, she said. Botox also can address a gummy smile.

Treating the surrounding tissue to support volume loss—such as deep marionette lines, a jowl, or a deep nasolabial fold right near the lip—will also improve the appearance of the lips.

Dr. Butterwick disclosed receiving grant research support from Mentor Corp., and is a consultant for Medicis Pharmaceutical Corp., Allergan Inc., Sanofi-Aventis, and Neutrogena Corp.

SDEF and this news organization are owned by Elsevier.

Photo shows patient prior to injection of 1 cc of Hyalaform to the upper lip.

Two weeks post injection, the cupid's bow is narrowed and more defined.

Source Photos courtesy Dr. Kimberly Butterwick

'We have to be mindful how the lips contribute' to the symmetry and proportions of the entire face.

Source DR. BUTTERWICK

When enhancing a patient's lips, consider the patient's aesthetic goals and the natural anatomy of the lip, and remember to think aesthetically about the entire face, said Dr. Kimberly Butterwick.

"Take care to achieve a lip that does not look like it's been done," advised Dr. Butterwick, a cosmetic dermatologist in La Jolla, Calif. "We're not just correcting a defect, but making a patient look prettier, and we have to be mindful how the lips contribute" to the symmetry and proportions of the entire face.

The anatomy of the lip—the vermilion border, the red portion of the lip, the philtral columns, and the balance of the upper and lower lip—and its proportions are the elements that need to be considered to create a lip that is natural looking, "yet enhanced and more beautiful," she said in an interview.

The lip is divided into red and white segments, "at a well-defined and arched vermilion border." Think about the M-shaped cupid's bow of the upper lip, and the lower lip as shaped like a W, with two lateral lobes and a midline groove, she said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

The relationship to the nose and chin, and facial proportions also should be considered, with the width of the lip falling between a straight line drawn from each inner iris.

A mistake that can be made with the red portion of the lip is to create a fat lip all the way across the upper and lower lip, like a sausage instead of being attentive to the normal contours. There is also a tendency to overstress the upper lip in an attempt to get a pouty look. Ideally, the lower lip should be bigger by 10%-25%, Dr. Butterwick added, noting that often, physicians try to make the upper lip equal to or bigger than the lower lip, which appears unnatural.

Areas of the lips that should be fuller and emphasized to achieve a natural look include the two anatomic mounds of fullness at the highest point of the upper lip, right under the peak of the cupid's bow, as well as the two mounds of volume of the lower lip of the "four pillows." It also often helps to add a little volume to the midline tubercle of the upper lips and the philtral columns.

Hyaluronic acid is the main option used for lip correction and enhancement, "because it is safe, soft, and natural, and it lasts long enough in most cases," Dr. Butterwick said. Currently available hyaluronic acid products are Restylane, Hyalaform, Juvèderm Ultra or Ultra Plus, and Prevelle Silk.

Prevelle Silk is a good option for beginners because it is lightweight, contains anesthetic, and does not last as long as the others. It also can be used first, injected along the vermilion for its anesthetic effects, and can be followed by another hyaluronic acid product that provides for more volume and lasts longer, using the rest of Prevelle Silk for fine lines, she said.

Restylane and Juvèderm are similar, although Juvèderm causes a little less swelling and, therefore, "may be a little softer and more natural in the lips," she said, but a product that is a little thicker may be appropriate for those patients who want more pronounced lips, she added. "That's when you can strike a balance between what the patient wants and still achieve a natural look."

Fat augmentation of the lips provides a natural appearance, but does not last as long as it does in other locations. "I would not go out of my way to put fat in the lips, unless you are already using fat for other indications in the face," she advised.

Semipermanent or permanent injectables that are associated with a high rate of adverse reactions when used in the lips are Radiesse, Sculptra, Evolence, and Artefill, as well as silicone, which should be avoided in lips altogether, she said. Their labels state they should not be used in lips, "yet physicians think that they can get away with it, and wind up every so often having a problem, and it is a big problem."

An important element of lip correction is consideration of the way lips appear in motion: When Dr. Butterwick consults with a patient, she said she observes their lips while they are talking. Some people have vertical lip lines from excessive pursing while they talk, or they pull down the corners of their mouth while talking, which are excess movements that can be "softened" with Botox, she said. Botox also can address a gummy smile.

Treating the surrounding tissue to support volume loss—such as deep marionette lines, a jowl, or a deep nasolabial fold right near the lip—will also improve the appearance of the lips.

Dr. Butterwick disclosed receiving grant research support from Mentor Corp., and is a consultant for Medicis Pharmaceutical Corp., Allergan Inc., Sanofi-Aventis, and Neutrogena Corp.

SDEF and this news organization are owned by Elsevier.

Photo shows patient prior to injection of 1 cc of Hyalaform to the upper lip.

Two weeks post injection, the cupid's bow is narrowed and more defined.

Source Photos courtesy Dr. Kimberly Butterwick

'We have to be mindful how the lips contribute' to the symmetry and proportions of the entire face.

Source DR. BUTTERWICK

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

AUSTIN, TEX. — Adding cosmetic dermatology to a Mohs practice is a natural transition, according to Dr. Christopher B. Zachary and Dr. Ronald L Moy.

However, do not expect such a practice to be lucrative, especially not immediately, Dr. Zachary said at the meeting of the American College of Mohs Surgery. "If you want to make a lot of money, I'd stick with cancer because that actually pays the bills."

Although the public might not perceive Mohs surgeons as "real" plastic surgeons, "we are facial plastic surgeons … we are dermatologic surgeons," Dr. Moy, president-elect of the American Academy of Dermatology, said in a panel presentation.

He said he would not be ashamed to have a Mohs defect patient sitting next to a Botox (botulinum toxin type A) candidate because it would demonstrate that he performed "real" surgery. Dr. Zachary, however, cautioned against mixing the cancer patients with the cosmetic clients.

Another reason to add cosmetic procedures is "there are a lot more new things going on in cosmetic surgery than in Mohs," said Dr. Moy, a dermatologist in Los Angeles. "I get more excited about new procedures."

Dr. Zachary agreed, "The newness is quite interesting." But, he added, "My Mohs day is my best day—the day I enjoy the most because the patients are the most appreciative and you get to do really good things."

Another plus: Many of the cosmetic techniques can be applied to Mohs patients, such as using fractionated lasers to improve scar appearance, said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine.

When Dr. Moy decided to add cosmetic services, he spent $5,000 on a consultant and closed the practice for 2 days of meetings, personality tests, and management quizzes.

Both dermatologists suggested starting out slowly so as to minimize initial capital outlays. Dr. Zachary said intense pulsed light devices were a good beginning purchase, and noted that some older techniques such as chemical peels were still extremely useful. "Nobody in private practice can afford to have all the devices we have in a big university environment," he said.

Dr. Moy said his practice started out by renting lasers. Now, the practice owns 20.

Also important: marketing. Older practices do not need to do as much marketing because "the best patients you have are your existing patients," Dr. Moy said. Pamphlets on face-lifts placed in the waiting room are effective because they could be seen by someone who has had reconstruction, for instance. His practice also plays DVDs on available procedures in the waiting room. "Most patients I see are existing patients," he said.

Dr. Zachary agreed that marketing is necessary, but lamented the unsavory aspect of many advertisements. "You almost have to prostitute yourself," he said. He suggested creating a good Web site that is easily accessible, and that registers near the top of various search engines.

It also pays to have staff trained specifically for the cosmetic services. Dr. Zachary said a call center is important because it is the patient's first contact. Nurse practitioners and aestheticians might be needed.

Dr. Moy said that he does not use staff for initial interviews. He also tries to spend as much time as possible with the patient, pre- and postoperatively. This helps reduce misunderstandings and malpractice, he said.

Dr. Moy made no disclosures. Dr. Zachary disclosed that he is a speaker for Solta Medical Inc. and Cutera Inc. and is on the advisory board for Primaeva Medical Inc.

'There are a lot more new [exciting] things going on in cosmetic surgery than in Mohs.'

Source DR. MOY

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

Nonsurgical options may improve the appearance of the face for some, but patients with more skin redundancy and platysmal banding may require surgical neck or face lifts, according to Dr. Roberta D. Sengelmann.

The goal for treating the aging face is to bring back some of the attributes of the young face, Dr. Sengelmann said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF). The solution is to restore the skin, contour the soft tissues, and resuspend sagging tissues.

Several nonsurgical treatments for restoring the neck—peels, intense pulsed light/broadband light, and pulsed dye laser—improve skin quality and color, said Dr. Sengelmann, a dermatologic and cosmetic surgeon in private practice.

Nonsurgical options to improve neck contour include botulinum toxin type A injections (Botox) and possibly Thermage (radiofrequency treatment).

The next option is tumescent liposculpture, which can be used to redefine the neck and jowls by removing excess adipose tissue that weighs down the skin. With this treatment, skin retraction is excellent, especially in young patients.

Dr. Sengelmann offered her approach to tumescent liposuction of the neck. She uses 100-250 cc of dilute anesthesia—0.1% lidocaine with 1:1,000,000 epinephrine—and uses a 1.5- to 2.5-mm blunt spatula cannula. She advises against over-resecting fat to avoid a crepey, unnatural appearance and to prevent complications of contour irregularities. She also suggests leaving a subdermal fat layer. In general, for each 150 cc infiltrated, 25-50 cc of fat are removed.

Some patients will also require rhytidectomy and tightening. Surgical treatment options for platysmal bands include resuspension/suture sling, resection, and corset platysmal plication.

A neck lift involves tumescent liposuction, platysmal plication, and possibly skin resection. This procedure may be indicated when there is platysmal banding and/or redundant skin and fat. Significant jowling may necessitate a face-lift.

Dr. Sengelmann also shared her technique for a neck lift. She uses tumescent anesthesia of 0.1% lidocaine with 1:1,000,000 epinephrine. First she performs liposuction of the neck and jowls. Then she creates a 2- to 3-cm submental incision that is 2-5 mm anterior to the crease. She undermines to the medial aspect of the sternocleidomastoid muscle and the base of the neck. She uses a corset suture for midline platysmal plication. Once diligent hemostatis is obtained, she closes the submental incision.

The patient will need to wear a chin strap or head wrap all day for 2 days and then for 6-8 hours a day for the balance of 1 week. Patients are advised to avoid exercise and vigorous activity. Follow-up should occur after 1-2 days and at 1 week.

Direct neck lifts tend to be more common in men. A direct neck lift involves direct anterior neck skin and subcutaneous tissue resection with plication of the platysma. The midline incision can be camouflaged using Z-plasty or jagged closure, said Dr. Sengelmann.

A face-lift is indicated when there is excessive neck skin redundancy and jowling, said Dr. Sengelmann, who offered her technique for a vertical face-lift. She uses 0.25% lidocaine with 1:250,000 epinephrine anesthesia, generally 50-80 cc per side. She makes a pre- and minimal post-auricular skin incision. She then performs subcutaneous dissection and superficial musculoaponeurotic system plication, with or without suture suspension. Finally, she redrapes and closes with 5.0 Vicryl and 6.0 epidermal suture of choice.

Dr. Sengelmann reported that she has no relevant financial disclosures.

SDEF and this news organization are owned by Elsevier.

The goal for treating the aging face is to bring back some of the attributes of the young face.

Source DR. SENGELMANN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN

Dermatologists who master the use of facial nerve blocks can make nonsurgical procedures more comfortable for patients, according to Dr. Howard K. Steinman.

The concept of "nonsurgical" cosmetic procedures creates an expectation that the procedures may be painless, said Dr. Steinman, who is in private practice in Chula Vista, Calif. Facial nerve blocks help doctors deliver on that expectation.

Other advantages include minimizing tissue distortion and allowing physicians to use smaller doses of local anesthetic, which means less risk of systemic toxicity, he said at a cosmetic dermatology seminar sponsored by Skin Disease Education Foundation (SDEF).

Because facial nerve blocks provide significant regional anesthesia with minimal vasoconstriction, physicians still may wish to inject local anesthesia containing epinephrine, he said. Prime locations include the forehead, nose, nasolabial fold, cheek and upper lip, and chin and lower lip.

The injections for forehead nerve blocks are placed to block the supraorbital, supratrochlear, and infratrochlear nerves as they exit the skull. "Enter just lateral to the supraorbital notch above the eyebrow and advance the needle submuscularly just above the brow to the middle of the medial canthus," Dr. Steinman explained.

For an external nasal nerve block, inject the block just lateral to the midline just below the junction of the lateral cartilage and the nasal bone, he said. Advance the needle from this single point.

An infraorbital block may be placed using either an external or internal (intraoral) approach. Dr. Steinman said that he prefers the intraoral approach. To take the intraoral route, place the third finger of the nondominant hand near the midline of the inferior orbital rim, and retract the lip between your nondominant thumb and index finger. "Insert the needle above the canine tooth at the gingival buccal sulcus—advance the needle about 1 cm towards your third finger while injecting," said Dr. Steinman. Alternatively, take the percutaneous route: Palpate for the infraorbital foramen and insert the needle perpendicular to the skin just below it to near the maxillary bone, and inject anesthetic.

Similarly, nerve blocks injected in the chin and lower lip can be performed with an internal or external approach.

Injections through the labial mucosa to anesthetize just the upper and lower lip also can be part of a facial nerve block protocol, said Dr. Steinman. Start with the upper lip by applying topical anesthesia gel and injecting small amounts of anesthesia approximately half a centimeter above the gingival-labial sulcus above the oral commissure, he explained.

Then inject submucosally, medially from this point along the sulcus to the frenulum and repeat on the opposite side. Be sure to inject a small amount of anesthesia at the midline, directly from the sulcus next to the frenulum toward the nasal septum, he added.

For the lower lip, start at the point below the oral commissure on the contralateral side and inject submucosally in the sulcus. The mucosal block will not anesthetize the skin at the oral commissures, so those areas must be anesthetized by direct submucosal injections after applying anesthetic gel.

He reported having no financial conflicts to disclose. SDEFand this news organization are owned by Elsevier.

An injection in the midline toward the nose will block the midline upper lip. COURTESY DR. HOWARD K. STEINMAN