Aesthetic Dermatology

MAUI, HAWAII — A key to minimizing the risk of bump and nodule formation when injecting poly-L-lactic acid is uniform product distribution by lengthening the dilution time, according to Dr. Douglas Mest.

"I will not inject PLLA if it hasn't been hydrated at least overnight. Longer is even better. The product insert allows for up to 72 hours hydration in sterile water; if you use bacteriostatic sterile water I think it's fine to keep it longer. Most experts keep it around for up to 3 weeks," Dr. Mest said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The hydrated product can be kept in the refrigerator but should be brought to room temperature before injection. It should not be heated because that can damage the microscopic PLLA particles, according to Dr. Mest of the Blue Pacific Aesthetic Medical Group, El Segundo, Calif.

Other tips he offered to avoid papules and nodules with PLLA (Sculptra) include:

▸ Adjust dilution volume to fit the clinical situation. Small dilution volumes can lead to nonhomogeneous distribution—and increased likelihood of nodules.

"The product insert says use 3-5 mL because that's how the original studies were done. But I've learned with this product that to have a more robust response, as in an on-label patient [with HIV-related facial lipoatrophy], I'll increase the total diluent to 6 mL per vial," he said.

▸ Use the appropriate gauge needle. Dr. Mest's analysis of the published literature suggests that adverse event rates are similar with 25- and 26-gauge needles. Using a smaller-gauge needle than 25 is not recommended, he said.

▸ Supraperiosteal placement is best. "This way you're only going to have volume go outward, so if you have any problems you're not going to feel them. Personally in the midface I'll do a supraperiosteal placement, then a more superficial placement, staying out of any active muscle areas," he explained.

▸ Don't overcorrect. PLLA is a pure biostimulant. The improvement may not be evident for 4-6 weeks or longer.

▸ Don't superficially place. "You should not see your needle when you're doing this. It's not a dermal product," he noted.

▸ Treat nodules conservatively. In a clinical trial led by Dr. Mest, 12 of 13 nodules that occurred resolved spontaneously during 36 months of follow-up. "I don't recommend aggressively treating the nodules and papules with high-dose steroids," said Dr. Mest, who serves as a consultant to Dermik Laboratories, which markets Sculptra.

SDEF and this news organization are owned by Elsevier.

MAUI, HAWAII — A key to minimizing the risk of bump and nodule formation when injecting poly-L-lactic acid is uniform product distribution by lengthening the dilution time, according to Dr. Douglas Mest.

"I will not inject PLLA if it hasn't been hydrated at least overnight. Longer is even better. The product insert allows for up to 72 hours hydration in sterile water; if you use bacteriostatic sterile water I think it's fine to keep it longer. Most experts keep it around for up to 3 weeks," Dr. Mest said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The hydrated product can be kept in the refrigerator but should be brought to room temperature before injection. It should not be heated because that can damage the microscopic PLLA particles, according to Dr. Mest of the Blue Pacific Aesthetic Medical Group, El Segundo, Calif.

Other tips he offered to avoid papules and nodules with PLLA (Sculptra) include:

▸ Adjust dilution volume to fit the clinical situation. Small dilution volumes can lead to nonhomogeneous distribution—and increased likelihood of nodules.

"The product insert says use 3-5 mL because that's how the original studies were done. But I've learned with this product that to have a more robust response, as in an on-label patient [with HIV-related facial lipoatrophy], I'll increase the total diluent to 6 mL per vial," he said.

▸ Use the appropriate gauge needle. Dr. Mest's analysis of the published literature suggests that adverse event rates are similar with 25- and 26-gauge needles. Using a smaller-gauge needle than 25 is not recommended, he said.

▸ Supraperiosteal placement is best. "This way you're only going to have volume go outward, so if you have any problems you're not going to feel them. Personally in the midface I'll do a supraperiosteal placement, then a more superficial placement, staying out of any active muscle areas," he explained.

▸ Don't overcorrect. PLLA is a pure biostimulant. The improvement may not be evident for 4-6 weeks or longer.

▸ Don't superficially place. "You should not see your needle when you're doing this. It's not a dermal product," he noted.

▸ Treat nodules conservatively. In a clinical trial led by Dr. Mest, 12 of 13 nodules that occurred resolved spontaneously during 36 months of follow-up. "I don't recommend aggressively treating the nodules and papules with high-dose steroids," said Dr. Mest, who serves as a consultant to Dermik Laboratories, which markets Sculptra.

SDEF and this news organization are owned by Elsevier.

MAUI, HAWAII — A key to minimizing the risk of bump and nodule formation when injecting poly-L-lactic acid is uniform product distribution by lengthening the dilution time, according to Dr. Douglas Mest.

"I will not inject PLLA if it hasn't been hydrated at least overnight. Longer is even better. The product insert allows for up to 72 hours hydration in sterile water; if you use bacteriostatic sterile water I think it's fine to keep it longer. Most experts keep it around for up to 3 weeks," Dr. Mest said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The hydrated product can be kept in the refrigerator but should be brought to room temperature before injection. It should not be heated because that can damage the microscopic PLLA particles, according to Dr. Mest of the Blue Pacific Aesthetic Medical Group, El Segundo, Calif.

Other tips he offered to avoid papules and nodules with PLLA (Sculptra) include:

▸ Adjust dilution volume to fit the clinical situation. Small dilution volumes can lead to nonhomogeneous distribution—and increased likelihood of nodules.

"The product insert says use 3-5 mL because that's how the original studies were done. But I've learned with this product that to have a more robust response, as in an on-label patient [with HIV-related facial lipoatrophy], I'll increase the total diluent to 6 mL per vial," he said.

▸ Use the appropriate gauge needle. Dr. Mest's analysis of the published literature suggests that adverse event rates are similar with 25- and 26-gauge needles. Using a smaller-gauge needle than 25 is not recommended, he said.

▸ Supraperiosteal placement is best. "This way you're only going to have volume go outward, so if you have any problems you're not going to feel them. Personally in the midface I'll do a supraperiosteal placement, then a more superficial placement, staying out of any active muscle areas," he explained.

▸ Don't overcorrect. PLLA is a pure biostimulant. The improvement may not be evident for 4-6 weeks or longer.

▸ Don't superficially place. "You should not see your needle when you're doing this. It's not a dermal product," he noted.

▸ Treat nodules conservatively. In a clinical trial led by Dr. Mest, 12 of 13 nodules that occurred resolved spontaneously during 36 months of follow-up. "I don't recommend aggressively treating the nodules and papules with high-dose steroids," said Dr. Mest, who serves as a consultant to Dermik Laboratories, which markets Sculptra.

SDEF and this news organization are owned by Elsevier.

Although a variety of injectable cosmetic fillers are in high demand, physicians should be aware that rare adverse reactions—like foreign body granulomas—are being reported, according to a case report.

Injectable permanent fillers containing polymethyl methacrylate (PMMA) immersed in a solution of collagen have been implicated in several types of adverse reactions, reported Dr. M.C. da Costa Miguel of the department of oral pathology at the Federal University of Rio Grande do Norte, Brazil, and his colleagues.

Foreign body granulomas only develop in some patients, and this particular granuloma formation caused by a reaction to injectable fillers is only observed in 0.01% of patients, further adding to the diagnostic challenge, the researchers wrote.

Dr. da Costa and his colleagues found the granulomas in a 56-year-old woman after performing a number of examinations. Initial examinations showed a "firm, pink nodule covered with non-ulcerated mucosa located in the right anterior inferior alveolar mucosa." The swelling was painless and moveable. There was no bone involvement, no palpable adenopathies, and the patient showed no symptoms of atopy (Int. J. Oral Maxillofac. Surg. 2009;38:385-7).

Salivary gland mucocoele was considered initiallly. After a biopsy, the researchers found that "immunohistochemical analysis using anti-CD68 antibody confirmed the presence of numerous macrophages and CD68-positive multinucleated giant cells."

The patient was asked if any aesthetic procedure had been performed close to the site of her swelling and she confirmed that she had an injection of a cosmetic filler containing PMMA for lip enlargement about 1 year earlier.

According to Dr. da Costa and his colleagues, what made this case particularly rare was its "unusual clinical presentation as a painless nodule located exclusively inside the oral cavity." They described the lesion as "indistinguishable from other pathologies such as salivary gland mucocoele or soft tissue neoplasm."

Foreign body granulomas can be successfully treated with intralesional or systemic corticosteroids, they noted. In this case, simple surgical excision was performed because it was a well-demarcated lesion.

Dr. da Costa and colleagues reported having no conflicts of interest.

Although a variety of injectable cosmetic fillers are in high demand, physicians should be aware that rare adverse reactions—like foreign body granulomas—are being reported, according to a case report.

Injectable permanent fillers containing polymethyl methacrylate (PMMA) immersed in a solution of collagen have been implicated in several types of adverse reactions, reported Dr. M.C. da Costa Miguel of the department of oral pathology at the Federal University of Rio Grande do Norte, Brazil, and his colleagues.

Foreign body granulomas only develop in some patients, and this particular granuloma formation caused by a reaction to injectable fillers is only observed in 0.01% of patients, further adding to the diagnostic challenge, the researchers wrote.

Dr. da Costa and his colleagues found the granulomas in a 56-year-old woman after performing a number of examinations. Initial examinations showed a "firm, pink nodule covered with non-ulcerated mucosa located in the right anterior inferior alveolar mucosa." The swelling was painless and moveable. There was no bone involvement, no palpable adenopathies, and the patient showed no symptoms of atopy (Int. J. Oral Maxillofac. Surg. 2009;38:385-7).

Salivary gland mucocoele was considered initiallly. After a biopsy, the researchers found that "immunohistochemical analysis using anti-CD68 antibody confirmed the presence of numerous macrophages and CD68-positive multinucleated giant cells."

The patient was asked if any aesthetic procedure had been performed close to the site of her swelling and she confirmed that she had an injection of a cosmetic filler containing PMMA for lip enlargement about 1 year earlier.

According to Dr. da Costa and his colleagues, what made this case particularly rare was its "unusual clinical presentation as a painless nodule located exclusively inside the oral cavity." They described the lesion as "indistinguishable from other pathologies such as salivary gland mucocoele or soft tissue neoplasm."

Foreign body granulomas can be successfully treated with intralesional or systemic corticosteroids, they noted. In this case, simple surgical excision was performed because it was a well-demarcated lesion.

Dr. da Costa and colleagues reported having no conflicts of interest.

Although a variety of injectable cosmetic fillers are in high demand, physicians should be aware that rare adverse reactions—like foreign body granulomas—are being reported, according to a case report.

Injectable permanent fillers containing polymethyl methacrylate (PMMA) immersed in a solution of collagen have been implicated in several types of adverse reactions, reported Dr. M.C. da Costa Miguel of the department of oral pathology at the Federal University of Rio Grande do Norte, Brazil, and his colleagues.

Foreign body granulomas only develop in some patients, and this particular granuloma formation caused by a reaction to injectable fillers is only observed in 0.01% of patients, further adding to the diagnostic challenge, the researchers wrote.

Dr. da Costa and his colleagues found the granulomas in a 56-year-old woman after performing a number of examinations. Initial examinations showed a "firm, pink nodule covered with non-ulcerated mucosa located in the right anterior inferior alveolar mucosa." The swelling was painless and moveable. There was no bone involvement, no palpable adenopathies, and the patient showed no symptoms of atopy (Int. J. Oral Maxillofac. Surg. 2009;38:385-7).

Salivary gland mucocoele was considered initiallly. After a biopsy, the researchers found that "immunohistochemical analysis using anti-CD68 antibody confirmed the presence of numerous macrophages and CD68-positive multinucleated giant cells."

The patient was asked if any aesthetic procedure had been performed close to the site of her swelling and she confirmed that she had an injection of a cosmetic filler containing PMMA for lip enlargement about 1 year earlier.

According to Dr. da Costa and his colleagues, what made this case particularly rare was its "unusual clinical presentation as a painless nodule located exclusively inside the oral cavity." They described the lesion as "indistinguishable from other pathologies such as salivary gland mucocoele or soft tissue neoplasm."

Foreign body granulomas can be successfully treated with intralesional or systemic corticosteroids, they noted. In this case, simple surgical excision was performed because it was a well-demarcated lesion.

Dr. da Costa and colleagues reported having no conflicts of interest.

MAUI, HAWAII — Snapping a set of before and after photos at an unconventional 22.5-degree angle in addition to the standard anteroposterior, lateral, and oblique shots often makes it easier for patients to recognize the improvement they have gained with poly-L-lactic acid injections, according to one expert.

"The mechanism of action with PLLA [Sculptra] is so delayed that patients forget what they looked like. A set of photos taken at a less acute 22.5-degree angle shows the convexity of the malar eminence better. You notice the baseline volume loss much more," Dr. Douglas R. Mest explained at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Facial volume loss averages 1 teaspoon per year after age 40. It's due to a combination of facial fat loss and redistribution, bone resorption, facial muscle atrophy, and dermal thinning. This volume deficit is a three-dimensional cosmetic problem, and PLLA—a pure biostimulant—is the best treatment for it yet, according to Dr. Mest, an anesthesiologist specializing in cosmetic dermatology in Manhattan Beach, Calif., and the chief investigator in the phase III trial that won approval of PLLA for the treatment of HIV-related facial lipoatrophy.

In addition to recommending shooting those 22.5-degree before and after photos, Dr. Mest shared other tips in getting the most out of PLLA:

▸ Start with the standard treatment areas. PLLA is quite unlike other facial fillers, and there is a definite learning curve in its use. The cheeks are the easiest area in which to achieve volume replacement. Other standard areas are the nasolabial folds, submental area and jawline, and marionette lines.

"What we've learned about staying out of trouble is that there are areas that are very easy to treat with biostimulating products, including calcium hydroxyapatite [Radiesse] and PLLA, and if you're starting out, that's where to start," he said.

Advanced treatment areas are those where treatment-induced lumps or bumps are more apt to show, either due to thin skin or because active muscle groups sweep up the product and make it more visible. The upper lip, temples, hands, and neck fall into this category.

▸ Delay treatment. The product labeling says to wait at least 4 weeks between PLLA treatments. Dr. Mest said he now routinely waits at least 6 weeks. That's because collagen synthesis doesn't really get underway until 2-3 weeks after treatment.

"Sometimes when you treat at 4 weeks, patients will not necessarily have seen the improvement. I think if you wait another 2 weeks you'll see it," he explained.

Some experienced physicians now wait 3 months between PLLA treatments, but "I find 6 weeks is a nice compromise," Dr. Mest added.

▸ Treat the whole face, not individual lines. "Patients often come in asking for treatment of certain lines or wrinkles, when what they really need is treatment of the underlying region with a deep revolumizing agent. The example I use with patients is instead of treating each line on the raisin to make it a grape, we add volume back to the raisin to make it a grape," he said.

▸ Tackle the temple hollows. This reproportions the face, restoring the triangle of youth and making for a less severe look, but is best taken on after gaining skill with PLLA.

"Patients seldom come in asking for treatment of temple hollowing, but once you see it done you start noticing how many people need it," according to Dr. Mest.

He disclosed that he is a consultant to Dermik Laboratories Inc. and a physician trainer for BioForm Medical Inc.

SDEF and this news organization are owned by Elsevier.

The pretreatment photo at left was taken at a 45-degee angle. In the photo at right, taken at a 22.5-degree angle, the area needing treatment is more obvious. Photos courtesy Dr. Douglas Mest

MAUI, HAWAII — Snapping a set of before and after photos at an unconventional 22.5-degree angle in addition to the standard anteroposterior, lateral, and oblique shots often makes it easier for patients to recognize the improvement they have gained with poly-L-lactic acid injections, according to one expert.

"The mechanism of action with PLLA [Sculptra] is so delayed that patients forget what they looked like. A set of photos taken at a less acute 22.5-degree angle shows the convexity of the malar eminence better. You notice the baseline volume loss much more," Dr. Douglas R. Mest explained at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Facial volume loss averages 1 teaspoon per year after age 40. It's due to a combination of facial fat loss and redistribution, bone resorption, facial muscle atrophy, and dermal thinning. This volume deficit is a three-dimensional cosmetic problem, and PLLA—a pure biostimulant—is the best treatment for it yet, according to Dr. Mest, an anesthesiologist specializing in cosmetic dermatology in Manhattan Beach, Calif., and the chief investigator in the phase III trial that won approval of PLLA for the treatment of HIV-related facial lipoatrophy.

In addition to recommending shooting those 22.5-degree before and after photos, Dr. Mest shared other tips in getting the most out of PLLA:

▸ Start with the standard treatment areas. PLLA is quite unlike other facial fillers, and there is a definite learning curve in its use. The cheeks are the easiest area in which to achieve volume replacement. Other standard areas are the nasolabial folds, submental area and jawline, and marionette lines.

"What we've learned about staying out of trouble is that there are areas that are very easy to treat with biostimulating products, including calcium hydroxyapatite [Radiesse] and PLLA, and if you're starting out, that's where to start," he said.

Advanced treatment areas are those where treatment-induced lumps or bumps are more apt to show, either due to thin skin or because active muscle groups sweep up the product and make it more visible. The upper lip, temples, hands, and neck fall into this category.

▸ Delay treatment. The product labeling says to wait at least 4 weeks between PLLA treatments. Dr. Mest said he now routinely waits at least 6 weeks. That's because collagen synthesis doesn't really get underway until 2-3 weeks after treatment.

"Sometimes when you treat at 4 weeks, patients will not necessarily have seen the improvement. I think if you wait another 2 weeks you'll see it," he explained.

Some experienced physicians now wait 3 months between PLLA treatments, but "I find 6 weeks is a nice compromise," Dr. Mest added.

▸ Treat the whole face, not individual lines. "Patients often come in asking for treatment of certain lines or wrinkles, when what they really need is treatment of the underlying region with a deep revolumizing agent. The example I use with patients is instead of treating each line on the raisin to make it a grape, we add volume back to the raisin to make it a grape," he said.

▸ Tackle the temple hollows. This reproportions the face, restoring the triangle of youth and making for a less severe look, but is best taken on after gaining skill with PLLA.

"Patients seldom come in asking for treatment of temple hollowing, but once you see it done you start noticing how many people need it," according to Dr. Mest.

He disclosed that he is a consultant to Dermik Laboratories Inc. and a physician trainer for BioForm Medical Inc.

SDEF and this news organization are owned by Elsevier.

The pretreatment photo at left was taken at a 45-degee angle. In the photo at right, taken at a 22.5-degree angle, the area needing treatment is more obvious. Photos courtesy Dr. Douglas Mest

MAUI, HAWAII — Snapping a set of before and after photos at an unconventional 22.5-degree angle in addition to the standard anteroposterior, lateral, and oblique shots often makes it easier for patients to recognize the improvement they have gained with poly-L-lactic acid injections, according to one expert.

"The mechanism of action with PLLA [Sculptra] is so delayed that patients forget what they looked like. A set of photos taken at a less acute 22.5-degree angle shows the convexity of the malar eminence better. You notice the baseline volume loss much more," Dr. Douglas R. Mest explained at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Facial volume loss averages 1 teaspoon per year after age 40. It's due to a combination of facial fat loss and redistribution, bone resorption, facial muscle atrophy, and dermal thinning. This volume deficit is a three-dimensional cosmetic problem, and PLLA—a pure biostimulant—is the best treatment for it yet, according to Dr. Mest, an anesthesiologist specializing in cosmetic dermatology in Manhattan Beach, Calif., and the chief investigator in the phase III trial that won approval of PLLA for the treatment of HIV-related facial lipoatrophy.

In addition to recommending shooting those 22.5-degree before and after photos, Dr. Mest shared other tips in getting the most out of PLLA:

▸ Start with the standard treatment areas. PLLA is quite unlike other facial fillers, and there is a definite learning curve in its use. The cheeks are the easiest area in which to achieve volume replacement. Other standard areas are the nasolabial folds, submental area and jawline, and marionette lines.

"What we've learned about staying out of trouble is that there are areas that are very easy to treat with biostimulating products, including calcium hydroxyapatite [Radiesse] and PLLA, and if you're starting out, that's where to start," he said.

Advanced treatment areas are those where treatment-induced lumps or bumps are more apt to show, either due to thin skin or because active muscle groups sweep up the product and make it more visible. The upper lip, temples, hands, and neck fall into this category.

▸ Delay treatment. The product labeling says to wait at least 4 weeks between PLLA treatments. Dr. Mest said he now routinely waits at least 6 weeks. That's because collagen synthesis doesn't really get underway until 2-3 weeks after treatment.

"Sometimes when you treat at 4 weeks, patients will not necessarily have seen the improvement. I think if you wait another 2 weeks you'll see it," he explained.

Some experienced physicians now wait 3 months between PLLA treatments, but "I find 6 weeks is a nice compromise," Dr. Mest added.

▸ Treat the whole face, not individual lines. "Patients often come in asking for treatment of certain lines or wrinkles, when what they really need is treatment of the underlying region with a deep revolumizing agent. The example I use with patients is instead of treating each line on the raisin to make it a grape, we add volume back to the raisin to make it a grape," he said.

▸ Tackle the temple hollows. This reproportions the face, restoring the triangle of youth and making for a less severe look, but is best taken on after gaining skill with PLLA.

"Patients seldom come in asking for treatment of temple hollowing, but once you see it done you start noticing how many people need it," according to Dr. Mest.

He disclosed that he is a consultant to Dermik Laboratories Inc. and a physician trainer for BioForm Medical Inc.

SDEF and this news organization are owned by Elsevier.

The pretreatment photo at left was taken at a 45-degee angle. In the photo at right, taken at a 22.5-degree angle, the area needing treatment is more obvious. Photos courtesy Dr. Douglas Mest

SAN FRANCISCO — A cream containing an onion extract and UVA and UVB sun protection significantly improves the appearance and feel of postsurgical scars, a small randomized trial found.

Nonprescription Mederma cream plus SPF 30 performed in the study comparably to Mederma onion extract gel without SPF for reduction of postsurgical scarring. Additionally, patients rated the cream as significantly more soothing than Mederma gel, Dr. Zoe D. Draelos reported at the annual meeting of the American Academy of Dermatology.

No placebo arm was included in the comparative trial because the study aim was to establish whether parity exists between the two onion extract formulations, both marketed OTC by Merz Pharmaceuticals, which sponsored the study. The gel formulation, which doesn't include sun protection, had already demonstrated superiority to placebo in an earlier randomized trial conducted by Dr. Draelos (J. Cosmet. Dermatol. 2008;7:101-4).

The new trial involved 20 patients with symmetric seborrheic keratoses at least 8 mm in diameter located on their right and left upper chest. The lesions were removed with a scalpel shave under local anesthesia. After the wound sites were permitted to heal for 2 weeks, patients returned for randomization. Three times daily for 8 weeks, they put a thin layer of the onion extract cream on the right chest scar and a layer of gel on the left chest scar, or vice versa, explained Dr. Draelos, who practices in High Point, N.C.

Blinded investigator assessment of the scars documented by photography showed significant improvement over time on 4-point scales assessing scar redness, texture, softness, and global appearance. The degree of improvement was similar for onion extract cream- and gel-treated scars.

There was also significantly less transepidermal water loss at the onion extract cream-treated excision sites than the gel-treated sites after treatment, probably because of the moisturizing base in the cream vehicle.

The therapeutic basis for the onion extract product's efficacy is believed to lie in its anti-inflammatory effects and its inhibition of fibroblast proliferation. The SPF 30 sun protection was incorporated into the cream formulation because scars are sunlight sensitive, and once they sunburn they often darken and become cosmetically unacceptable, she explained.

Dr. Draelos disclosed that she is a consultant to Merz and has been paid to conduct research for numerous pharmaceutical companies.

SAN FRANCISCO — A cream containing an onion extract and UVA and UVB sun protection significantly improves the appearance and feel of postsurgical scars, a small randomized trial found.

Nonprescription Mederma cream plus SPF 30 performed in the study comparably to Mederma onion extract gel without SPF for reduction of postsurgical scarring. Additionally, patients rated the cream as significantly more soothing than Mederma gel, Dr. Zoe D. Draelos reported at the annual meeting of the American Academy of Dermatology.

No placebo arm was included in the comparative trial because the study aim was to establish whether parity exists between the two onion extract formulations, both marketed OTC by Merz Pharmaceuticals, which sponsored the study. The gel formulation, which doesn't include sun protection, had already demonstrated superiority to placebo in an earlier randomized trial conducted by Dr. Draelos (J. Cosmet. Dermatol. 2008;7:101-4).

The new trial involved 20 patients with symmetric seborrheic keratoses at least 8 mm in diameter located on their right and left upper chest. The lesions were removed with a scalpel shave under local anesthesia. After the wound sites were permitted to heal for 2 weeks, patients returned for randomization. Three times daily for 8 weeks, they put a thin layer of the onion extract cream on the right chest scar and a layer of gel on the left chest scar, or vice versa, explained Dr. Draelos, who practices in High Point, N.C.

Blinded investigator assessment of the scars documented by photography showed significant improvement over time on 4-point scales assessing scar redness, texture, softness, and global appearance. The degree of improvement was similar for onion extract cream- and gel-treated scars.

There was also significantly less transepidermal water loss at the onion extract cream-treated excision sites than the gel-treated sites after treatment, probably because of the moisturizing base in the cream vehicle.

The therapeutic basis for the onion extract product's efficacy is believed to lie in its anti-inflammatory effects and its inhibition of fibroblast proliferation. The SPF 30 sun protection was incorporated into the cream formulation because scars are sunlight sensitive, and once they sunburn they often darken and become cosmetically unacceptable, she explained.

Dr. Draelos disclosed that she is a consultant to Merz and has been paid to conduct research for numerous pharmaceutical companies.

SAN FRANCISCO — A cream containing an onion extract and UVA and UVB sun protection significantly improves the appearance and feel of postsurgical scars, a small randomized trial found.

Nonprescription Mederma cream plus SPF 30 performed in the study comparably to Mederma onion extract gel without SPF for reduction of postsurgical scarring. Additionally, patients rated the cream as significantly more soothing than Mederma gel, Dr. Zoe D. Draelos reported at the annual meeting of the American Academy of Dermatology.

No placebo arm was included in the comparative trial because the study aim was to establish whether parity exists between the two onion extract formulations, both marketed OTC by Merz Pharmaceuticals, which sponsored the study. The gel formulation, which doesn't include sun protection, had already demonstrated superiority to placebo in an earlier randomized trial conducted by Dr. Draelos (J. Cosmet. Dermatol. 2008;7:101-4).

The new trial involved 20 patients with symmetric seborrheic keratoses at least 8 mm in diameter located on their right and left upper chest. The lesions were removed with a scalpel shave under local anesthesia. After the wound sites were permitted to heal for 2 weeks, patients returned for randomization. Three times daily for 8 weeks, they put a thin layer of the onion extract cream on the right chest scar and a layer of gel on the left chest scar, or vice versa, explained Dr. Draelos, who practices in High Point, N.C.

Blinded investigator assessment of the scars documented by photography showed significant improvement over time on 4-point scales assessing scar redness, texture, softness, and global appearance. The degree of improvement was similar for onion extract cream- and gel-treated scars.

There was also significantly less transepidermal water loss at the onion extract cream-treated excision sites than the gel-treated sites after treatment, probably because of the moisturizing base in the cream vehicle.

The therapeutic basis for the onion extract product's efficacy is believed to lie in its anti-inflammatory effects and its inhibition of fibroblast proliferation. The SPF 30 sun protection was incorporated into the cream formulation because scars are sunlight sensitive, and once they sunburn they often darken and become cosmetically unacceptable, she explained.

Dr. Draelos disclosed that she is a consultant to Merz and has been paid to conduct research for numerous pharmaceutical companies.

MAUI, HAWAII — Two studies have further demonstrated the safety and efficacy of bimatoprost for increased eyelash growth.

The Food and Drug Administration approved bimatoprost for increasing eyelash growth, a side effect of the glaucoma-treating drug that was observed several years ago.

In the first study presented at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation, Dr. David Wirta, an ophthalmologist in private practice in Newport Beach, Calif., and colleagues, conducted a safety analysis of bimatoprost based on the aggregated profile of six double-blind, active-controlled, long-term clinical studies.

Of the 1,459 patients treated with bimatoprost 0.03% once or twice daily for glaucoma, approximately 10% reported side effects that were of mild severity and led to a low study-discontinuation rate. The most commonly reported adverse effects were conjunctival hyperemia, eye pruritus, dry eye, eyelash growth, and skin hyperpigmentation.

In the second study, Dr. Wendy W. Lee and colleagues reported that bimatoprost increased eyelash growth by 2.01 mm in treated eyes, compared with 1.13 mm in controls. The patients reported no change in visual acuity or iris discoloration. The study patients received two vials of gel suspension, one containing bimatoprost and the other containing saline. The vials' contents were each mixed with 1:1 hypromellose solution and labeled "right eye" and "left eye." The suspensions were applied to the lashes once daily, each on the designated eye, for 6 weeks. Lashes were measured with a caliper at enrollment and at 1 and 3 months, according to Dr. Lee, assistant professor of clinical ophthalmology at the University of Miami.

The new indication for bimatoprost 0.03% ophthalmic solution is for "the treatment of hypotrichosis of the eyelashes by increasing their growth including length, thickness, and darkness." It is being marketed as Latisse by Allergan Inc. SDEFand this newspaper are owned by Elsevier.

MAUI, HAWAII — Two studies have further demonstrated the safety and efficacy of bimatoprost for increased eyelash growth.

The Food and Drug Administration approved bimatoprost for increasing eyelash growth, a side effect of the glaucoma-treating drug that was observed several years ago.

In the first study presented at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation, Dr. David Wirta, an ophthalmologist in private practice in Newport Beach, Calif., and colleagues, conducted a safety analysis of bimatoprost based on the aggregated profile of six double-blind, active-controlled, long-term clinical studies.

Of the 1,459 patients treated with bimatoprost 0.03% once or twice daily for glaucoma, approximately 10% reported side effects that were of mild severity and led to a low study-discontinuation rate. The most commonly reported adverse effects were conjunctival hyperemia, eye pruritus, dry eye, eyelash growth, and skin hyperpigmentation.

In the second study, Dr. Wendy W. Lee and colleagues reported that bimatoprost increased eyelash growth by 2.01 mm in treated eyes, compared with 1.13 mm in controls. The patients reported no change in visual acuity or iris discoloration. The study patients received two vials of gel suspension, one containing bimatoprost and the other containing saline. The vials' contents were each mixed with 1:1 hypromellose solution and labeled "right eye" and "left eye." The suspensions were applied to the lashes once daily, each on the designated eye, for 6 weeks. Lashes were measured with a caliper at enrollment and at 1 and 3 months, according to Dr. Lee, assistant professor of clinical ophthalmology at the University of Miami.

The new indication for bimatoprost 0.03% ophthalmic solution is for "the treatment of hypotrichosis of the eyelashes by increasing their growth including length, thickness, and darkness." It is being marketed as Latisse by Allergan Inc. SDEFand this newspaper are owned by Elsevier.

MAUI, HAWAII — Two studies have further demonstrated the safety and efficacy of bimatoprost for increased eyelash growth.

The Food and Drug Administration approved bimatoprost for increasing eyelash growth, a side effect of the glaucoma-treating drug that was observed several years ago.

In the first study presented at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation, Dr. David Wirta, an ophthalmologist in private practice in Newport Beach, Calif., and colleagues, conducted a safety analysis of bimatoprost based on the aggregated profile of six double-blind, active-controlled, long-term clinical studies.

Of the 1,459 patients treated with bimatoprost 0.03% once or twice daily for glaucoma, approximately 10% reported side effects that were of mild severity and led to a low study-discontinuation rate. The most commonly reported adverse effects were conjunctival hyperemia, eye pruritus, dry eye, eyelash growth, and skin hyperpigmentation.

In the second study, Dr. Wendy W. Lee and colleagues reported that bimatoprost increased eyelash growth by 2.01 mm in treated eyes, compared with 1.13 mm in controls. The patients reported no change in visual acuity or iris discoloration. The study patients received two vials of gel suspension, one containing bimatoprost and the other containing saline. The vials' contents were each mixed with 1:1 hypromellose solution and labeled "right eye" and "left eye." The suspensions were applied to the lashes once daily, each on the designated eye, for 6 weeks. Lashes were measured with a caliper at enrollment and at 1 and 3 months, according to Dr. Lee, assistant professor of clinical ophthalmology at the University of Miami.

The new indication for bimatoprost 0.03% ophthalmic solution is for "the treatment of hypotrichosis of the eyelashes by increasing their growth including length, thickness, and darkness." It is being marketed as Latisse by Allergan Inc. SDEFand this newspaper are owned by Elsevier.

The number of cosmetic medical procedures performed in the United States last year increased slightly because of growing demand for minimally invasive procedures like Botox and laser skin resurfacing, according to data from the American Society of Plastic Surgeons.

Despite the faltering economy, Americans opted for nearly 12.1 million cosmetic medical procedures last year, up 3% from 2007. That 3% rise, however, was the smallest increase recorded in cosmetic procedures since 2000. Popular surgical procedures such as liposuction and breast augmentation had double-digit decreases in the percentage of procedures performed in 2008. Overall, Americans spent $10.3 billion on cosmetic procedures last year, down 9% from 2007.

Botox continues to be the most popular cosmetic procedure in the United States, with more than 5 million procedures performed last year, up 8% from 2007. The number of procedures performed with hyaluronic acid fillers increased from about 1 million to 1.1 million, a 6% increase. The number of laser skin resurfacing procedures jumped 15% from 2007 to 2008, rising to more than 400,000 procedures, but microdermabrasion fell somewhat in 2008. The number of microdermabrasion procedures was down 6%, to about 841,000.

It seems that the most effective procedures, such as Botox and fillers, are increasing, while interest in less effective procedures like microdermabrasion is dropping, said Dr. Leslie Baumann, director of cosmetic dermatology at the University of Miami.

"This is not surprising," she said. "Patients quickly realize that these ineffective procedures are a waste of money."

The statistics on cosmetic procedures from the ASPS are based on a combination of data from its online national database of plastic surgery procedures and the results of an annual survey of about 21,000 board-certified dermatologists; ear, nose and throat specialists; and plastic surgeons. The responses are then aggregated and extrapolated to the entire population of physicians most likely to perform cosmetic and reconstructive plastic surgery procedures.

The 2008 statistics also highlight a trend toward greater use of cosmetic procedures by ethnic minorities. Cosmetic procedures increased slightly in all ethnic groups except in white patients, though white patients still accounted for the vast majority of cosmetic procedures performed last year.

The greatest level of increased interest was among Hispanic and black patients. The use of cosmetic procedures jumped 18% among Hispanic patients and 10% among blacks patients, compared with 2007. The most commonly requested procedures for ethnic minorities were Botox, injectable fillers, and chemical peels.

The increased use of cosmetic procedures by ethnic minorities is encouraging, said Dr. Eliot F. Battle Jr., a cosmetic dermatologist in Washington and an expert in treating ethnic skin. However, it raises serious concerns that some physicians are performing these procedures without the proper understanding of skin of color. Dr. Battle said that he is seeing more patients who come to him after experiencing side effects from laser treatments performed by other physicians.

He urged physicians to use care when treating patients with skin of color even if the laser used is marketed for all skin types. Without understanding the nuances of darker skin, patients can be harmed. "These patients cannot be treated as guinea pigs," he said.

Procedures rose 18% in Hispanic and 10% in black patients. Success relies on knowing the nuances of skin of color. DR. BATTLE

ELSEVIER GLOBAL MEDICAL NEWS

The number of cosmetic medical procedures performed in the United States last year increased slightly because of growing demand for minimally invasive procedures like Botox and laser skin resurfacing, according to data from the American Society of Plastic Surgeons.

Despite the faltering economy, Americans opted for nearly 12.1 million cosmetic medical procedures last year, up 3% from 2007. That 3% rise, however, was the smallest increase recorded in cosmetic procedures since 2000. Popular surgical procedures such as liposuction and breast augmentation had double-digit decreases in the percentage of procedures performed in 2008. Overall, Americans spent $10.3 billion on cosmetic procedures last year, down 9% from 2007.

Botox continues to be the most popular cosmetic procedure in the United States, with more than 5 million procedures performed last year, up 8% from 2007. The number of procedures performed with hyaluronic acid fillers increased from about 1 million to 1.1 million, a 6% increase. The number of laser skin resurfacing procedures jumped 15% from 2007 to 2008, rising to more than 400,000 procedures, but microdermabrasion fell somewhat in 2008. The number of microdermabrasion procedures was down 6%, to about 841,000.

It seems that the most effective procedures, such as Botox and fillers, are increasing, while interest in less effective procedures like microdermabrasion is dropping, said Dr. Leslie Baumann, director of cosmetic dermatology at the University of Miami.

"This is not surprising," she said. "Patients quickly realize that these ineffective procedures are a waste of money."

The statistics on cosmetic procedures from the ASPS are based on a combination of data from its online national database of plastic surgery procedures and the results of an annual survey of about 21,000 board-certified dermatologists; ear, nose and throat specialists; and plastic surgeons. The responses are then aggregated and extrapolated to the entire population of physicians most likely to perform cosmetic and reconstructive plastic surgery procedures.

The 2008 statistics also highlight a trend toward greater use of cosmetic procedures by ethnic minorities. Cosmetic procedures increased slightly in all ethnic groups except in white patients, though white patients still accounted for the vast majority of cosmetic procedures performed last year.

The greatest level of increased interest was among Hispanic and black patients. The use of cosmetic procedures jumped 18% among Hispanic patients and 10% among blacks patients, compared with 2007. The most commonly requested procedures for ethnic minorities were Botox, injectable fillers, and chemical peels.

The increased use of cosmetic procedures by ethnic minorities is encouraging, said Dr. Eliot F. Battle Jr., a cosmetic dermatologist in Washington and an expert in treating ethnic skin. However, it raises serious concerns that some physicians are performing these procedures without the proper understanding of skin of color. Dr. Battle said that he is seeing more patients who come to him after experiencing side effects from laser treatments performed by other physicians.

He urged physicians to use care when treating patients with skin of color even if the laser used is marketed for all skin types. Without understanding the nuances of darker skin, patients can be harmed. "These patients cannot be treated as guinea pigs," he said.

Procedures rose 18% in Hispanic and 10% in black patients. Success relies on knowing the nuances of skin of color. DR. BATTLE

ELSEVIER GLOBAL MEDICAL NEWS

The number of cosmetic medical procedures performed in the United States last year increased slightly because of growing demand for minimally invasive procedures like Botox and laser skin resurfacing, according to data from the American Society of Plastic Surgeons.

Despite the faltering economy, Americans opted for nearly 12.1 million cosmetic medical procedures last year, up 3% from 2007. That 3% rise, however, was the smallest increase recorded in cosmetic procedures since 2000. Popular surgical procedures such as liposuction and breast augmentation had double-digit decreases in the percentage of procedures performed in 2008. Overall, Americans spent $10.3 billion on cosmetic procedures last year, down 9% from 2007.

Botox continues to be the most popular cosmetic procedure in the United States, with more than 5 million procedures performed last year, up 8% from 2007. The number of procedures performed with hyaluronic acid fillers increased from about 1 million to 1.1 million, a 6% increase. The number of laser skin resurfacing procedures jumped 15% from 2007 to 2008, rising to more than 400,000 procedures, but microdermabrasion fell somewhat in 2008. The number of microdermabrasion procedures was down 6%, to about 841,000.

It seems that the most effective procedures, such as Botox and fillers, are increasing, while interest in less effective procedures like microdermabrasion is dropping, said Dr. Leslie Baumann, director of cosmetic dermatology at the University of Miami.

"This is not surprising," she said. "Patients quickly realize that these ineffective procedures are a waste of money."

The statistics on cosmetic procedures from the ASPS are based on a combination of data from its online national database of plastic surgery procedures and the results of an annual survey of about 21,000 board-certified dermatologists; ear, nose and throat specialists; and plastic surgeons. The responses are then aggregated and extrapolated to the entire population of physicians most likely to perform cosmetic and reconstructive plastic surgery procedures.

The 2008 statistics also highlight a trend toward greater use of cosmetic procedures by ethnic minorities. Cosmetic procedures increased slightly in all ethnic groups except in white patients, though white patients still accounted for the vast majority of cosmetic procedures performed last year.

The greatest level of increased interest was among Hispanic and black patients. The use of cosmetic procedures jumped 18% among Hispanic patients and 10% among blacks patients, compared with 2007. The most commonly requested procedures for ethnic minorities were Botox, injectable fillers, and chemical peels.

The increased use of cosmetic procedures by ethnic minorities is encouraging, said Dr. Eliot F. Battle Jr., a cosmetic dermatologist in Washington and an expert in treating ethnic skin. However, it raises serious concerns that some physicians are performing these procedures without the proper understanding of skin of color. Dr. Battle said that he is seeing more patients who come to him after experiencing side effects from laser treatments performed by other physicians.

He urged physicians to use care when treating patients with skin of color even if the laser used is marketed for all skin types. Without understanding the nuances of darker skin, patients can be harmed. "These patients cannot be treated as guinea pigs," he said.

Procedures rose 18% in Hispanic and 10% in black patients. Success relies on knowing the nuances of skin of color. DR. BATTLE

ELSEVIER GLOBAL MEDICAL NEWS

MAUI, HAWAII — Laser and radiofrequency-based devices for the treatment of cellulite have gotten more efficient in the last half decade, according to Dr. David J. Goldberg.

Recent rapid advances in device therapy have led to improved regimens featuring fewer treatment sessions and better results, Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Cellulite is not a disease—it is the product of normal skin exposed to estrogen—so there can be no "cure," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. "Cellulite is really an annuity, not a disease. You never get rid of it. It always will come back." The improved skin appearance achieved with these devices results primarily from their skin-tightening effect.

The devices that work for cellulite are the same ones that achieve good results for facial skin tightening.

The devices work in the same general way, regardless of whether they utilize low-energy lasers, infrared, or unipolar, bipolar, or monopolar radiofrequency, he said. They achieve skin tightening by combining deep bulk heating with epidermal cooling to prevent blistering.

Dr. Goldberg explained how device therapy for cellulite has improved in the last 5 years.

▸ The early days. A prospective study in 35 women showed measurable improvement in buttock and thigh cellulite using the VelaSmooth (Synernon) device, which combines bipolar radiofrequency and infrared energy with suction (J. Cosmet. Laser Ther. 2004;6:187-90).

But bipolar radiofrequency does not penetrate nearly as deep as unipolar, so the skin-tightening effect was relatively modest, said Dr. Goldberg. "The problem is it took 12-14 treatments biweekly. That's pretty impractical for patients. And the results disappear pretty much as soon as you stop."

▸ Last year. Using the Accent unipolar diffuse radiofrequency device marketed by Alma Lasers, Dr. Goldberg treated 30 women with upper-thigh cellulite. Using 6 treatments spread over 12 weeks, he documented a mean 2.5-cm reduction in thigh circumference at 6 months follow-up. Twenty-seven of the 30 patients showed clinical improvement rated a mean 2.9 on a 1-4 scale. The benefit was achieved with no change in body weight (Dermatol. Surg. 2008;34:204-9).

The treatment sessions were brief and fairly painless, with no blistering, pigmentary changes, or scarring. Patients experienced no changes in blood lipid levels but had some diffuse erythema lasting 30-120 minutes

▸ Today. Dr. Goldberg was an investigator in a just-completed multisite study using a new 16-cm

"It's very time consuming. It takes a good, solid hour. And it's pretty uncomfortable. But you can still see improvement 6 months after a single treatment. So we've gone from 12-14 treatments with the original devices, to 6, to 1," he said.

He disclosed that he receives research grants from, and is on the speakers bureaus of, numerous medical device and pharmaceutical companies. SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Laser and radiofrequency-based devices for the treatment of cellulite have gotten more efficient in the last half decade, according to Dr. David J. Goldberg.

Recent rapid advances in device therapy have led to improved regimens featuring fewer treatment sessions and better results, Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Cellulite is not a disease—it is the product of normal skin exposed to estrogen—so there can be no "cure," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. "Cellulite is really an annuity, not a disease. You never get rid of it. It always will come back." The improved skin appearance achieved with these devices results primarily from their skin-tightening effect.

The devices that work for cellulite are the same ones that achieve good results for facial skin tightening.

The devices work in the same general way, regardless of whether they utilize low-energy lasers, infrared, or unipolar, bipolar, or monopolar radiofrequency, he said. They achieve skin tightening by combining deep bulk heating with epidermal cooling to prevent blistering.

Dr. Goldberg explained how device therapy for cellulite has improved in the last 5 years.

▸ The early days. A prospective study in 35 women showed measurable improvement in buttock and thigh cellulite using the VelaSmooth (Synernon) device, which combines bipolar radiofrequency and infrared energy with suction (J. Cosmet. Laser Ther. 2004;6:187-90).

But bipolar radiofrequency does not penetrate nearly as deep as unipolar, so the skin-tightening effect was relatively modest, said Dr. Goldberg. "The problem is it took 12-14 treatments biweekly. That's pretty impractical for patients. And the results disappear pretty much as soon as you stop."

▸ Last year. Using the Accent unipolar diffuse radiofrequency device marketed by Alma Lasers, Dr. Goldberg treated 30 women with upper-thigh cellulite. Using 6 treatments spread over 12 weeks, he documented a mean 2.5-cm reduction in thigh circumference at 6 months follow-up. Twenty-seven of the 30 patients showed clinical improvement rated a mean 2.9 on a 1-4 scale. The benefit was achieved with no change in body weight (Dermatol. Surg. 2008;34:204-9).

The treatment sessions were brief and fairly painless, with no blistering, pigmentary changes, or scarring. Patients experienced no changes in blood lipid levels but had some diffuse erythema lasting 30-120 minutes

▸ Today. Dr. Goldberg was an investigator in a just-completed multisite study using a new 16-cm

"It's very time consuming. It takes a good, solid hour. And it's pretty uncomfortable. But you can still see improvement 6 months after a single treatment. So we've gone from 12-14 treatments with the original devices, to 6, to 1," he said.

He disclosed that he receives research grants from, and is on the speakers bureaus of, numerous medical device and pharmaceutical companies. SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Laser and radiofrequency-based devices for the treatment of cellulite have gotten more efficient in the last half decade, according to Dr. David J. Goldberg.

Recent rapid advances in device therapy have led to improved regimens featuring fewer treatment sessions and better results, Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Cellulite is not a disease—it is the product of normal skin exposed to estrogen—so there can be no "cure," said Dr. Goldberg, director of dermatologic laser research at Mount Sinai School of Medicine, New York. "Cellulite is really an annuity, not a disease. You never get rid of it. It always will come back." The improved skin appearance achieved with these devices results primarily from their skin-tightening effect.

The devices that work for cellulite are the same ones that achieve good results for facial skin tightening.

The devices work in the same general way, regardless of whether they utilize low-energy lasers, infrared, or unipolar, bipolar, or monopolar radiofrequency, he said. They achieve skin tightening by combining deep bulk heating with epidermal cooling to prevent blistering.

Dr. Goldberg explained how device therapy for cellulite has improved in the last 5 years.

▸ The early days. A prospective study in 35 women showed measurable improvement in buttock and thigh cellulite using the VelaSmooth (Synernon) device, which combines bipolar radiofrequency and infrared energy with suction (J. Cosmet. Laser Ther. 2004;6:187-90).

But bipolar radiofrequency does not penetrate nearly as deep as unipolar, so the skin-tightening effect was relatively modest, said Dr. Goldberg. "The problem is it took 12-14 treatments biweekly. That's pretty impractical for patients. And the results disappear pretty much as soon as you stop."

▸ Last year. Using the Accent unipolar diffuse radiofrequency device marketed by Alma Lasers, Dr. Goldberg treated 30 women with upper-thigh cellulite. Using 6 treatments spread over 12 weeks, he documented a mean 2.5-cm reduction in thigh circumference at 6 months follow-up. Twenty-seven of the 30 patients showed clinical improvement rated a mean 2.9 on a 1-4 scale. The benefit was achieved with no change in body weight (Dermatol. Surg. 2008;34:204-9).

The treatment sessions were brief and fairly painless, with no blistering, pigmentary changes, or scarring. Patients experienced no changes in blood lipid levels but had some diffuse erythema lasting 30-120 minutes

▸ Today. Dr. Goldberg was an investigator in a just-completed multisite study using a new 16-cm

"It's very time consuming. It takes a good, solid hour. And it's pretty uncomfortable. But you can still see improvement 6 months after a single treatment. So we've gone from 12-14 treatments with the original devices, to 6, to 1," he said.

He disclosed that he receives research grants from, and is on the speakers bureaus of, numerous medical device and pharmaceutical companies. SDEF and this newspaper are owned by Elsevier.

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MIAMI BEACH — Sure, it's nice to tell patients that laser-assisted lipolysis will tighten their skin, but now there is evidence to prove it.

Dr. Bruce E. Katz and his colleagues demonstrated the tightening effects of laser-assisted lipolysis by tattooing a 4-by 4-cm square on the abdomen, arms, hips, or thighs of 30 patients.

At 3 months' follow-up, a mean 18% reduction was observed in an ongoing, multicenter study, accroding to Dr. Katz.

"This is the first evidence of skin tightening," he said at the South Beach Symposium. "And we've seen similar findings out to 6 months."

The investigators also performed punch biopsies to examine the histology at treated sites. Results showed new fibrosis, adipocytes, histiocytes, and markers of fat-cell lysis, said Dr. Katz of the department of dermatology at Mount Sinai School of Medicine, New York.

Patients were treated using the Smartlipo system (Cynosure Inc.), which features a hollow, 1- to 2-mm cannula inserted through a small incision to deliver Nd:YAG laser energy. After the laser liquefies fat cells, they are drained away through the same cannula.

This device combines a 1,064-nm wavelength for a gradual thermal effect and to mediate coagulation of blood vessels, as well as a 1,320-nm wavelength to promote energy absorption by fat and water. For this study, Dr. Katz set the system to deliver 20 W of the 1,064-nm energy and 12 W of the 1,320-nm wavelength.

The tightening results are supported by another study in process by Dr. Barry E. DiBernardo, a plastic surgeon in private practice in Montclair, N.J. Dr. DiBernardo compared laser-assisted lipolysis with liposuction in a split-treatment study of 10 women.

Dr. DiBernardo tattooed a 5- by 5-cm square on areas to be treated and found 37% greater skin tightening with laser-assisted lipolysis versus liposuction alone at 1 month. "At 3 months, he found 54% greater tightening with laser lipolysis," Dr. Katz said.

In addition to a stand-alone treatment for skin tightening, the system could be a nice alternative for patients who are candidates for face and neck tightening surgery, Dr. Katz said. Laser lipolysis is indicated for all areas with localized adipocyte deposits, as well as places where liposuction is indicated but the treatment could worsen skin laxity.

With any technology it is important to ask: "Do the risks outweigh the benefits?" Dr. Katz said. "We saw this in ultrasonic liposuction years ago."

To find out, he and a colleague assessed the incidence of adverse events and touch-up treatments required by 537 patients treated over 18 months at a single center (J. Cosmet. Laser Ther. 2008;10:231–3). They found a 1% complication rate, including one local infection and three minor burns, all of which resolved, Dr. Katz said at the meeting.

There were 19 touch-up procedures for a 3.4% rate, versus the 10%-12% reported in the liposuction literature. "The most important finding was there were no serious side effects at all," he said.

Dr. Katz disclosed that he is a Cynosure stockholder.

Two studies provide the "first evidence of skin tightening," with laser-assisted lipolysis. The above patient is shown before and after undergoing the procedure. Photos courtesy Dr. Bruce E. Katz

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.