Aesthetic Dermatology

LAS VEGAS — When using dermal fillers, think of yourself as an artist with a palette of colors, using this one here and that one there.

"There is no ideal filler for all occasions; we need to have a range of fillers," said Dr. Alastair Carruthers, who, with his wife Dr. Jean D.A. Carruthers, pioneered the cosmetic use of botulinum toxin A. "You must always match the patient with the indication and the filler."

At the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery, he went on to discuss his approach to treating specific anatomical areas with various dermal fillers:

▸ Glabella. For this area "you have to inject the frown line superficially, so you want a product that is relatively thin," said Dr. Carruthers, who practices dermatology in Vancouver, B.C.

"Good old Zyderm was wonderful in this area, but you don't want to inject anything that is likely to cause vascular occlusion." For the glabella, he will typically use Restylane, Juvéderm Ultra, or Evolence Breeze in conjunction with Botox.

▸ Infraorbital hollow. He called this area the most difficult to treat consistently well. Even a tiny overcorrection can cause bumps.

"My advice is to always undercorrect," he said. "Always inject supraperiosteally. Hyaluronic acid fillers are great in this area." Diluted Evolence Breeze is another option.

▸ Malar/zygomatic area. For this area, the optimal filler depends on the patient's aversion to risk. Radiesse is going to provide the patient with the best value for the money, "but you're going to get bruising and swelling," said Dr. Carruthers, who is also with the department of dermatology and skin science at the University of British Columbia in Vancouver.

"You're also going to get bruising and swelling to a lesser degree with hyaluronic acid fillers. So for the individual who has a dinner party that night, I would use Evolence."

▸ Cheeks. This is a challenging area to treat from a technical standpoint, but the results for patients with HIV-associated lipoatrophy can be striking. Dr. Carruthers likes to use Radiesse, hyaluronic acid fillers such as Juvéderm Ultra Plus or Perlane, or Evolence.

▸ Nasolabial folds. Since any dermal filler works well in the nasolabial folds, Dr. Carruthers uses "whatever I have in the syringe. I will always be treating other areas and will use the filler I'm already using in the nasolabial folds."

If someone comes in saying that they want their nasolabial folds corrected, "always look at their cheeks to see if they need improvement there as well," he suggested.

"Also, don't overdo it. We've all seen individuals who have seen their nasolabial folds corrected spectacularly. Babies have nasolabial folds. The nasolabial fold is a natural thing; you can soften it but don't try to get rid of it."

▸ Lips. This is another challenging area to treat, one "where you make or lose your reputation in your area of practice," Dr. Carruthers said.

He recommends avoiding the use of permanent fillers in the lips and those that cause fibroplasia, including AlloDerm, and products that contain Gore-Tex.

"Why? Because the lip is so mobile. Even with the soft fillers we put into lips you can still get problems," Dr. Carruthers explained during his presentation. "Be conservative and cautious, and don't try to overtreat the lips."

He said that he uses Evolence Breeze about 70% of the time for correction of the lips. He also uses Restylane and Juvéderm Ultra.

▸ Marionette lines. The area requires a relatively stiff filler such as Juvéderm Ultra Plus, Perlane, or Evolence. Even with these products, however, the results may not be optimal.

"You have to accept that fillers do not hold well in the marionette area," he said. "You should be injecting right down to the jaw line if you're attempting to improve this area."

▸ Chin. When adding volume to this area, be mindful of the branches of the facial artery. "Stay superficial where the facial artery crosses the mandible," he recommended.

Dr. Carruthers noted that bruising is most likely to occur when the dermatologist injects into the lateral part of the chin. To minimize bruising, he recommends injecting posterolaterally from the central chin.

Fillers he uses for the chin include Radiesse, Juvéderm Ultra Plus, Perlane, or Evolence.

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

A patient is shown before receiving Radiesse for lipoatrophy of the cheeks, which can be challenging to treat.

Noticeable results can be seen in the patient's cheek area after treatment with one syringe of Radiesse. PHOTOS COURTESY DR. ALASTAIR CARRUTHERS

'There is no ideal filler. … You must always match the patient with the indication and the filler.' DR. CARRUTHERS

LAS VEGAS — When using dermal fillers, think of yourself as an artist with a palette of colors, using this one here and that one there.

"There is no ideal filler for all occasions; we need to have a range of fillers," said Dr. Alastair Carruthers, who, with his wife Dr. Jean D.A. Carruthers, pioneered the cosmetic use of botulinum toxin A. "You must always match the patient with the indication and the filler."

At the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery, he went on to discuss his approach to treating specific anatomical areas with various dermal fillers:

▸ Glabella. For this area "you have to inject the frown line superficially, so you want a product that is relatively thin," said Dr. Carruthers, who practices dermatology in Vancouver, B.C.

"Good old Zyderm was wonderful in this area, but you don't want to inject anything that is likely to cause vascular occlusion." For the glabella, he will typically use Restylane, Juvéderm Ultra, or Evolence Breeze in conjunction with Botox.

▸ Infraorbital hollow. He called this area the most difficult to treat consistently well. Even a tiny overcorrection can cause bumps.

"My advice is to always undercorrect," he said. "Always inject supraperiosteally. Hyaluronic acid fillers are great in this area." Diluted Evolence Breeze is another option.

▸ Malar/zygomatic area. For this area, the optimal filler depends on the patient's aversion to risk. Radiesse is going to provide the patient with the best value for the money, "but you're going to get bruising and swelling," said Dr. Carruthers, who is also with the department of dermatology and skin science at the University of British Columbia in Vancouver.

"You're also going to get bruising and swelling to a lesser degree with hyaluronic acid fillers. So for the individual who has a dinner party that night, I would use Evolence."

▸ Cheeks. This is a challenging area to treat from a technical standpoint, but the results for patients with HIV-associated lipoatrophy can be striking. Dr. Carruthers likes to use Radiesse, hyaluronic acid fillers such as Juvéderm Ultra Plus or Perlane, or Evolence.

▸ Nasolabial folds. Since any dermal filler works well in the nasolabial folds, Dr. Carruthers uses "whatever I have in the syringe. I will always be treating other areas and will use the filler I'm already using in the nasolabial folds."

If someone comes in saying that they want their nasolabial folds corrected, "always look at their cheeks to see if they need improvement there as well," he suggested.

"Also, don't overdo it. We've all seen individuals who have seen their nasolabial folds corrected spectacularly. Babies have nasolabial folds. The nasolabial fold is a natural thing; you can soften it but don't try to get rid of it."

▸ Lips. This is another challenging area to treat, one "where you make or lose your reputation in your area of practice," Dr. Carruthers said.

He recommends avoiding the use of permanent fillers in the lips and those that cause fibroplasia, including AlloDerm, and products that contain Gore-Tex.

"Why? Because the lip is so mobile. Even with the soft fillers we put into lips you can still get problems," Dr. Carruthers explained during his presentation. "Be conservative and cautious, and don't try to overtreat the lips."

He said that he uses Evolence Breeze about 70% of the time for correction of the lips. He also uses Restylane and Juvéderm Ultra.

▸ Marionette lines. The area requires a relatively stiff filler such as Juvéderm Ultra Plus, Perlane, or Evolence. Even with these products, however, the results may not be optimal.

"You have to accept that fillers do not hold well in the marionette area," he said. "You should be injecting right down to the jaw line if you're attempting to improve this area."

▸ Chin. When adding volume to this area, be mindful of the branches of the facial artery. "Stay superficial where the facial artery crosses the mandible," he recommended.

Dr. Carruthers noted that bruising is most likely to occur when the dermatologist injects into the lateral part of the chin. To minimize bruising, he recommends injecting posterolaterally from the central chin.

Fillers he uses for the chin include Radiesse, Juvéderm Ultra Plus, Perlane, or Evolence.

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

A patient is shown before receiving Radiesse for lipoatrophy of the cheeks, which can be challenging to treat.

Noticeable results can be seen in the patient's cheek area after treatment with one syringe of Radiesse. PHOTOS COURTESY DR. ALASTAIR CARRUTHERS

'There is no ideal filler. … You must always match the patient with the indication and the filler.' DR. CARRUTHERS

LAS VEGAS — When using dermal fillers, think of yourself as an artist with a palette of colors, using this one here and that one there.

"There is no ideal filler for all occasions; we need to have a range of fillers," said Dr. Alastair Carruthers, who, with his wife Dr. Jean D.A. Carruthers, pioneered the cosmetic use of botulinum toxin A. "You must always match the patient with the indication and the filler."

At the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery, he went on to discuss his approach to treating specific anatomical areas with various dermal fillers:

▸ Glabella. For this area "you have to inject the frown line superficially, so you want a product that is relatively thin," said Dr. Carruthers, who practices dermatology in Vancouver, B.C.

"Good old Zyderm was wonderful in this area, but you don't want to inject anything that is likely to cause vascular occlusion." For the glabella, he will typically use Restylane, Juvéderm Ultra, or Evolence Breeze in conjunction with Botox.

▸ Infraorbital hollow. He called this area the most difficult to treat consistently well. Even a tiny overcorrection can cause bumps.

"My advice is to always undercorrect," he said. "Always inject supraperiosteally. Hyaluronic acid fillers are great in this area." Diluted Evolence Breeze is another option.

▸ Malar/zygomatic area. For this area, the optimal filler depends on the patient's aversion to risk. Radiesse is going to provide the patient with the best value for the money, "but you're going to get bruising and swelling," said Dr. Carruthers, who is also with the department of dermatology and skin science at the University of British Columbia in Vancouver.

"You're also going to get bruising and swelling to a lesser degree with hyaluronic acid fillers. So for the individual who has a dinner party that night, I would use Evolence."

▸ Cheeks. This is a challenging area to treat from a technical standpoint, but the results for patients with HIV-associated lipoatrophy can be striking. Dr. Carruthers likes to use Radiesse, hyaluronic acid fillers such as Juvéderm Ultra Plus or Perlane, or Evolence.

▸ Nasolabial folds. Since any dermal filler works well in the nasolabial folds, Dr. Carruthers uses "whatever I have in the syringe. I will always be treating other areas and will use the filler I'm already using in the nasolabial folds."

If someone comes in saying that they want their nasolabial folds corrected, "always look at their cheeks to see if they need improvement there as well," he suggested.

"Also, don't overdo it. We've all seen individuals who have seen their nasolabial folds corrected spectacularly. Babies have nasolabial folds. The nasolabial fold is a natural thing; you can soften it but don't try to get rid of it."

▸ Lips. This is another challenging area to treat, one "where you make or lose your reputation in your area of practice," Dr. Carruthers said.

He recommends avoiding the use of permanent fillers in the lips and those that cause fibroplasia, including AlloDerm, and products that contain Gore-Tex.

"Why? Because the lip is so mobile. Even with the soft fillers we put into lips you can still get problems," Dr. Carruthers explained during his presentation. "Be conservative and cautious, and don't try to overtreat the lips."

He said that he uses Evolence Breeze about 70% of the time for correction of the lips. He also uses Restylane and Juvéderm Ultra.

▸ Marionette lines. The area requires a relatively stiff filler such as Juvéderm Ultra Plus, Perlane, or Evolence. Even with these products, however, the results may not be optimal.

"You have to accept that fillers do not hold well in the marionette area," he said. "You should be injecting right down to the jaw line if you're attempting to improve this area."

▸ Chin. When adding volume to this area, be mindful of the branches of the facial artery. "Stay superficial where the facial artery crosses the mandible," he recommended.

Dr. Carruthers noted that bruising is most likely to occur when the dermatologist injects into the lateral part of the chin. To minimize bruising, he recommends injecting posterolaterally from the central chin.

Fillers he uses for the chin include Radiesse, Juvéderm Ultra Plus, Perlane, or Evolence.

Dr. Carruthers disclosed that he is a consultant and performs research for Allergan Inc., Merz GmbH & Co., and Biform Medical Inc.

A patient is shown before receiving Radiesse for lipoatrophy of the cheeks, which can be challenging to treat.

Noticeable results can be seen in the patient's cheek area after treatment with one syringe of Radiesse. PHOTOS COURTESY DR. ALASTAIR CARRUTHERS

'There is no ideal filler. … You must always match the patient with the indication and the filler.' DR. CARRUTHERS

LAS VEGAS — When Dr. Robert A. Weiss started using the SlimLipo liposuction unit for fat melting and fat sculpting, he was surprised to learn that most patients returned to work the day after the procedure.

"They had almost no bruising," he recalled at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "The tumescent fluid drainage was over in 12 hours instead of 2 or 3 days and I thought, 'We've found something pretty remarkable.'"

Of 10 patients who participated in an institutional review board study led by Dr. Weiss, 4 had their abdomens treated, 3 had their thighs treated, 2 had their flanks treated, and one had the arms treated. No side effects were seen at 6 weeks, and all patients rated the procedure as significantly improving the appearance of fat, said Dr. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, who is also in private practice in that city.

He credited the successful outcomes to technology that simultaneously blends 924-nm and 975-nm wavelengths and the unit's redesigned tip, which became available in May of 2008. "The problem with standard fiber tips is that the temperature gets very high, from 400° to 1,000° F," he said. The redesigned tip is rounded and distributes heat more efficiently.

In experiments on abdominoplasty skin, Dr. Weiss and his associates observed that wavelengths in the 920-nm range achieved fat absorption, whereas wavelengths in the 980-nm range achieved water absorption. He noted that SlimLipo's shorter wavelength and redesigned tip set it apart from other devices used for laser-assisted lipolysis. According to data on the manufacturer's (Palomar Medical Technologies Inc.) Web site, the Food and Drug Administration-cleared unit releases five times as much fat as does the 1,064-nm SmartLipo laser.

"What we're trying to do is overcome the potential disadvantages of laser-assisted lipolysis by making it a shorter procedure time instead of a longer one," he said. "We want to decrease the risk of skin injury [and] eliminate the risk of fibrin breakage, and we want to reduce bruising and tenderness. We can do this by using a wavelength that also shrinks capillaries. Nd:YAG lasers have been typically used to affect fat. These new wavelengths come from diode lasers."

After the SlimLipo tip smoothly irradiates adipose tissue, highly selective wavelengths "melt" adipocytes while coagulating the surrounding connective-tissue meshwork. Liquified fatty acid leaks out through the incision or is easily aspirated though a micro cannula. Coagulated subdermal collagen provides a shrinkage effect that, over time, is replaced by new septa and support meshwork for new improved body contour.

"There is no plasma or mechanical damage, just gentle thermal melting and coagulation," said Dr. Weiss, who noted that most procedures take about 45 minutes.

Dr. Weiss disclosed that he is a consultant, has performed research, and speaks on behalf of many medical device companies, including Palomar.

A 42-year-old patient is shown before and 6 weeks after undergoing treatment with the SlimLipo unit. She has noticed that all of her clothes fit more loosely, according to Dr. Robert A. Weiss. PHOTOS COURTESY DR. ROBERT A. WEISS

LAS VEGAS — When Dr. Robert A. Weiss started using the SlimLipo liposuction unit for fat melting and fat sculpting, he was surprised to learn that most patients returned to work the day after the procedure.

"They had almost no bruising," he recalled at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "The tumescent fluid drainage was over in 12 hours instead of 2 or 3 days and I thought, 'We've found something pretty remarkable.'"

Of 10 patients who participated in an institutional review board study led by Dr. Weiss, 4 had their abdomens treated, 3 had their thighs treated, 2 had their flanks treated, and one had the arms treated. No side effects were seen at 6 weeks, and all patients rated the procedure as significantly improving the appearance of fat, said Dr. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, who is also in private practice in that city.

He credited the successful outcomes to technology that simultaneously blends 924-nm and 975-nm wavelengths and the unit's redesigned tip, which became available in May of 2008. "The problem with standard fiber tips is that the temperature gets very high, from 400° to 1,000° F," he said. The redesigned tip is rounded and distributes heat more efficiently.

In experiments on abdominoplasty skin, Dr. Weiss and his associates observed that wavelengths in the 920-nm range achieved fat absorption, whereas wavelengths in the 980-nm range achieved water absorption. He noted that SlimLipo's shorter wavelength and redesigned tip set it apart from other devices used for laser-assisted lipolysis. According to data on the manufacturer's (Palomar Medical Technologies Inc.) Web site, the Food and Drug Administration-cleared unit releases five times as much fat as does the 1,064-nm SmartLipo laser.

"What we're trying to do is overcome the potential disadvantages of laser-assisted lipolysis by making it a shorter procedure time instead of a longer one," he said. "We want to decrease the risk of skin injury [and] eliminate the risk of fibrin breakage, and we want to reduce bruising and tenderness. We can do this by using a wavelength that also shrinks capillaries. Nd:YAG lasers have been typically used to affect fat. These new wavelengths come from diode lasers."

After the SlimLipo tip smoothly irradiates adipose tissue, highly selective wavelengths "melt" adipocytes while coagulating the surrounding connective-tissue meshwork. Liquified fatty acid leaks out through the incision or is easily aspirated though a micro cannula. Coagulated subdermal collagen provides a shrinkage effect that, over time, is replaced by new septa and support meshwork for new improved body contour.

"There is no plasma or mechanical damage, just gentle thermal melting and coagulation," said Dr. Weiss, who noted that most procedures take about 45 minutes.

Dr. Weiss disclosed that he is a consultant, has performed research, and speaks on behalf of many medical device companies, including Palomar.

A 42-year-old patient is shown before and 6 weeks after undergoing treatment with the SlimLipo unit. She has noticed that all of her clothes fit more loosely, according to Dr. Robert A. Weiss. PHOTOS COURTESY DR. ROBERT A. WEISS

LAS VEGAS — When Dr. Robert A. Weiss started using the SlimLipo liposuction unit for fat melting and fat sculpting, he was surprised to learn that most patients returned to work the day after the procedure.

"They had almost no bruising," he recalled at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "The tumescent fluid drainage was over in 12 hours instead of 2 or 3 days and I thought, 'We've found something pretty remarkable.'"

Of 10 patients who participated in an institutional review board study led by Dr. Weiss, 4 had their abdomens treated, 3 had their thighs treated, 2 had their flanks treated, and one had the arms treated. No side effects were seen at 6 weeks, and all patients rated the procedure as significantly improving the appearance of fat, said Dr. Weiss of the department of dermatology at Johns Hopkins University, Baltimore, who is also in private practice in that city.

He credited the successful outcomes to technology that simultaneously blends 924-nm and 975-nm wavelengths and the unit's redesigned tip, which became available in May of 2008. "The problem with standard fiber tips is that the temperature gets very high, from 400° to 1,000° F," he said. The redesigned tip is rounded and distributes heat more efficiently.

In experiments on abdominoplasty skin, Dr. Weiss and his associates observed that wavelengths in the 920-nm range achieved fat absorption, whereas wavelengths in the 980-nm range achieved water absorption. He noted that SlimLipo's shorter wavelength and redesigned tip set it apart from other devices used for laser-assisted lipolysis. According to data on the manufacturer's (Palomar Medical Technologies Inc.) Web site, the Food and Drug Administration-cleared unit releases five times as much fat as does the 1,064-nm SmartLipo laser.

"What we're trying to do is overcome the potential disadvantages of laser-assisted lipolysis by making it a shorter procedure time instead of a longer one," he said. "We want to decrease the risk of skin injury [and] eliminate the risk of fibrin breakage, and we want to reduce bruising and tenderness. We can do this by using a wavelength that also shrinks capillaries. Nd:YAG lasers have been typically used to affect fat. These new wavelengths come from diode lasers."

After the SlimLipo tip smoothly irradiates adipose tissue, highly selective wavelengths "melt" adipocytes while coagulating the surrounding connective-tissue meshwork. Liquified fatty acid leaks out through the incision or is easily aspirated though a micro cannula. Coagulated subdermal collagen provides a shrinkage effect that, over time, is replaced by new septa and support meshwork for new improved body contour.

"There is no plasma or mechanical damage, just gentle thermal melting and coagulation," said Dr. Weiss, who noted that most procedures take about 45 minutes.

Dr. Weiss disclosed that he is a consultant, has performed research, and speaks on behalf of many medical device companies, including Palomar.

A 42-year-old patient is shown before and 6 weeks after undergoing treatment with the SlimLipo unit. She has noticed that all of her clothes fit more loosely, according to Dr. Robert A. Weiss. PHOTOS COURTESY DR. ROBERT A. WEISS

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.

LAS VEGAS — As part of her pretreatment consultation before providing dermal fillers, Dr. Ranella Hirsch hands a mirror to her patients and instructs them to advise her on their specific goals and expectations.

"I can't tell you how many times I have looked at the patient on a consult, assessed precisely what I thought the ideal aesthetic outcome is, and then be told that it's actually something completely different that they are here for me to treat," Dr. Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "A mirror is your friend."

She went on to discuss other ways to avoid potential pitfalls:

▸ Always snap before and after photographs. "There are limited legal protections," said Dr. Hirsch, a dermatologist who practices in Cambridge, Mass. "Before-and-after photographs are one of the few things that will objectively capture accurate data."

▸ Beware of unrealistic expectations. "You need to know what unrealistic expectations are and not treat those people in the first place," she said. "You're not going to make them happy and you're going to make yourself miserable in the process."

▸ Assess for medical contraindications. These include history of hypersensitivity or allergy to known filler ingredients, history of oral herpes simplex virus and keloids, and any problems with scarring. "In my office, we check for these problems three times," said Dr. Hirsch, who is the immediate past president of the ASCDAS. "And it is remarkable how many people neglect to mention these critical points until being asked repeatedly."

▸ Make sure patients can afford the services required for the outcome desired. Be wary of patients who require three syringes of product for optimal results yet only want to pay for one.

▸ Have patients fill out a consent form during every visit. Nothing is more important to the aesthetic physician than informed consent, she emphasized. "I am surprised every time I hear a physician say, 'I use the consent form that came with the job.' Should complications arise, it is critical that this has been done properly to protect yourself."

Describing her own consent forms, she noted, "It's not enough that patients sign at the very bottom of removed pages of small print. They have to sign next to each potential complication and initial it. It has to be witnessed by someone and time stamped. These are critical aspects." She advised checking with an attorney for the best relevant advice.

▸ Educate patients about common side effects. To help reduce the occurrence of purpura, Dr. Hirsch advises patients to eat a lot of pineapple preprocedure, because it contains bromelain. Another option is to take five tablets of arnica, a substance commonly used for muscle pain and bruising, the night before the procedure and another five on the day of the procedure.

Other ways to minimize bruising include applying pressure during and immediately following the injections, using topical anesthesia, mixing the filler with collagen products to stabilize platelets, adding a lidocaine wash to injectables that do not contain an anticoagulant, and using the "push ahead" technique, whereby you get the needle tip to the plane and extrude the needle ahead of the tip. By using this technique, which Dr. Hirsch attributes to Dr. Jean Carruthers, one allows the product rather than the sharp edge of the needle to create the injection plane for the product, thereby reducing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure, incise and drain the abscess as rapidly as possible. Culture the patient for both routine and atypical bacteria and prescribe a course of empiric antibiotics followed by specific antibiotics. "Follow up on those cultures," Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop immediately, because this can be the only sign of an impending vascular injury. Immediate administration of heat, massage, and nitroglycerin paste helps minimize or reverse permanent injury. A recent case report demonstrated that immediate administration of hyaluronidase can also be of great value (J. Drugs Dermatol. 2007;6:325-8). Once the vascular accident is managed, consider treatment with a pulsed-dye laser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her presentation.

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

LAS VEGAS — In Dr. David M. Duffy's opinion, the perfect cosmetic filler doesn't exist and probably never will.

Current fillers on the market "are really a trade-off between results that don't last long enough and complications that last forever," he said. "In my view, the ideal filler would last 2-3 years, enough to give patients their money's worth, but not long enough to give them the problems that may occur."

Dr. Duffy, who practices dermatology in Torrance, Calif., discussed the contraindications and benefits of permanent fillers at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Patients demand permanent fillers for superficial defects from time to time without understanding that "there may be lots of serious, unreported complications with permanent fillers, particularly silicone, which has been used (pure or adulterated) in over 1 million patients," he said. "In fact, for every complication we see published, there are probably 10 that we've never heard about."

Key reasons to avoid permanent fillers in most patients, he said, are that temporary and semipermanent fillers are more profitable and less demanding to use, and more forgiving. "If you make mistakes with permanent fillers, they're for good; there's no margin for error," he noted.

Permanent fillers also require more time to inject, which makes them an unattractive option for hurried patients who want a true "lunchtime" procedure.

"You shouldn't use permanent filler before you get to know your patient," Dr. Duffy advised. "Temporary fillers give you an idea of how they're going to comply and respond."

Then there's the need for thorough training to properly place the filler. "Patient selection is quite demanding and there is a narrower range of appropriate defects than you have for the temporary fillers," he said.

"Be careful of the psychologically unstable patient who's had permanent filler placed by another practitioner and wants more," Dr. Duffy warned. "I won't treat patients who have had silicone placed previously. Problems can be delayed for 20 years, and you'll be blamed if they occur. I won't use permanent filler in polyallergic patients, and I won't make lips the size of Cleveland, no matter what they ask for."

Permanent fillers can be used appropriately in defects that are pliable enough so that when elevated the surrounding tissue is unaffected. They should not be used in areas where the skin is thin and hyperdistensible. Superficial defects "are very easy to overcorrect with permanent fillers, and if you do, it's there for good," Dr. Duffy said. "You can have delayed excessive fibrosis, particularly in high motion areas like the lips. And the implant may become visible as patients age."

Despite his misgivings about permanent fillers, Dr. Duffy currently uses liquid silicone in some cases. The product he uses most often is 1000 centistoke liquid silicone (Silikon 1000), which has 10 times the viscosity of water. "It's appealing because it's permanent, inexpensive, and wonderful to use," Dr. Duffy said.

For patients with atrophy related to HIV, he prefers 5000 centistoke liquid silicone (AdatoSil 5000), which has 50 times the viscosity of water.

The liquid silicone fillers don't have to be refrigerated, they will not support bacterial growth, and patients don't require allergy testing prior to use, said Dr. Duffy. "Most of the problems that I've see with silicone have occurred with infectious processes, particularly in patients with dental problems or sinus problems."

The most serious problems occur following misuse of silicone in "back room" operations. These include ulceration, cellulitis, granulomas, fistulation, blindness, and death.

"There are people who have made a lifestyle of criticizing silicone, because they see nothing but complications" and would never use them, he said. "Meanwhile, I've received some wonderful letters from patients who've received liquid silicone. I think there is a place for these products."

The conundrum about liquid silicone is the lack of objective data supporting its use and the lack of standardized product in years past, Dr. Duffy said. "Everything's anecdotal, with the exception of one unpublished study. This makes it difficult. Can you use these safely? Yes, you can. But you have to pick your patients well and know what you're doing. In the proper patient, silicone has no equal; good results are the norm and patients are enormously satisfied. Conversely, silicone's reputation makes it risky to use and the risk is particularly prominent for the physician, not the patient."

Dr. Duffy had no relevant conflicts of interest to disclose.

Despite Dr. David M. Duffy's misgivings about permanent fillers, he uses liquid silicone in some cases, such as in the patient above (shown before and after). PHOTOS COURTESY DR. DAVID M. DUFFY

The Food and Drug Administration has approved bimatoprost for increasing the growth of eyelashes, a side effect of the glaucoma-treating drug that was first observed several years ago in clinical trials.

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 will be marketed under the trade name Latisse by Allergan Inc., which markets the same product (Lumigan) for treating intraocular pressure in patients with open angle glaucoma or ocular hypertension. Lumigan was approved for glaucoma in 2001.

Unlike Lumigan, which is administered directly in the eye, Latisse is applied at night to the skin of the upper eyelid margin at the base of the eyelashes using a disposable applicator (one for each eye), which is to be used only once.

The new indication was approved on Dec. 26, 3 weeks after the FDA's Dermatologic and Ophthalmic Drugs Advisory Committee met to review bimatoprost for the cosmetic indication. The panel unanimously agreed that the benefit-risk profile of bimatoprost for hypotrichosis of the eyelashes was favorable.

The panel decision was based on the efficacy data in a study comparing bimatoprost with a control vehicle in 278 people (aged 22-78 years) with hypotrichosis of the eyelashes, as well as a large bimatoprost safety database (SKIN & ALLERGY NEWS, January 2009, p. 1).

After 16 weeks, 78% of those in the bimatoprost group had at least a 1-point increase on a scale that measured eyelash prominence (the primary efficacy end point), compared with 18% of those on the vehicle, a statistically significant difference.

Exactly how bimatoprost, a prostaglandin analog, promotes eyelash growth has not been determined, but growth “is believed to occur by increasing the [percentage] of hairs in, and the duration of, the anagen or growth phase,” according to the labeling. Eye pruritus, conjunctival hyperemia, and skin hyperpigmentation are listed in the label as the most common adverse events, affecting about 3%-4% of people treated. Warnings include the possibility of pigmentation of the iris (which is likely to be permanent) and the eyelids.

Allergan has agreed to conduct a 4-month, randomized, controlled study of bimatoprost solution in at least 50 black subjects, according to the FDA's approval letter. The one black patient in the hypotrichosis study was in the vehicle group. Another postmarketing requirement is that the company conduct a study of the safety and efficacy of bimatoprost in patients aged 0-17 years with hypotrichosis.

Allergan plans to launch Latisse in the first quarter of 2009, according to a written statement from the company.

The Food and Drug Administration has approved bimatoprost for increasing the growth of eyelashes, a side effect of the glaucoma-treating drug that was first observed several years ago in clinical trials.

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 will be marketed under the trade name Latisse by Allergan Inc., which markets the same product (Lumigan) for treating intraocular pressure in patients with open angle glaucoma or ocular hypertension. Lumigan was approved for glaucoma in 2001.

Unlike Lumigan, which is administered directly in the eye, Latisse is applied at night to the skin of the upper eyelid margin at the base of the eyelashes using a disposable applicator (one for each eye), which is to be used only once.

The new indication was approved on Dec. 26, 3 weeks after the FDA's Dermatologic and Ophthalmic Drugs Advisory Committee met to review bimatoprost for the cosmetic indication. The panel unanimously agreed that the benefit-risk profile of bimatoprost for hypotrichosis of the eyelashes was favorable.

The panel decision was based on the efficacy data in a study comparing bimatoprost with a control vehicle in 278 people (aged 22-78 years) with hypotrichosis of the eyelashes, as well as a large bimatoprost safety database (SKIN & ALLERGY NEWS, January 2009, p. 1).

After 16 weeks, 78% of those in the bimatoprost group had at least a 1-point increase on a scale that measured eyelash prominence (the primary efficacy end point), compared with 18% of those on the vehicle, a statistically significant difference.

Exactly how bimatoprost, a prostaglandin analog, promotes eyelash growth has not been determined, but growth “is believed to occur by increasing the [percentage] of hairs in, and the duration of, the anagen or growth phase,” according to the labeling. Eye pruritus, conjunctival hyperemia, and skin hyperpigmentation are listed in the label as the most common adverse events, affecting about 3%-4% of people treated. Warnings include the possibility of pigmentation of the iris (which is likely to be permanent) and the eyelids.

Allergan has agreed to conduct a 4-month, randomized, controlled study of bimatoprost solution in at least 50 black subjects, according to the FDA's approval letter. The one black patient in the hypotrichosis study was in the vehicle group. Another postmarketing requirement is that the company conduct a study of the safety and efficacy of bimatoprost in patients aged 0-17 years with hypotrichosis.

Allergan plans to launch Latisse in the first quarter of 2009, according to a written statement from the company.

The Food and Drug Administration has approved bimatoprost for increasing the growth of eyelashes, a side effect of the glaucoma-treating drug that was first observed several years ago in clinical trials.

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 will be marketed under the trade name Latisse by Allergan Inc., which markets the same product (Lumigan) for treating intraocular pressure in patients with open angle glaucoma or ocular hypertension. Lumigan was approved for glaucoma in 2001.

Unlike Lumigan, which is administered directly in the eye, Latisse is applied at night to the skin of the upper eyelid margin at the base of the eyelashes using a disposable applicator (one for each eye), which is to be used only once.

The new indication was approved on Dec. 26, 3 weeks after the FDA's Dermatologic and Ophthalmic Drugs Advisory Committee met to review bimatoprost for the cosmetic indication. The panel unanimously agreed that the benefit-risk profile of bimatoprost for hypotrichosis of the eyelashes was favorable.

The panel decision was based on the efficacy data in a study comparing bimatoprost with a control vehicle in 278 people (aged 22-78 years) with hypotrichosis of the eyelashes, as well as a large bimatoprost safety database (SKIN & ALLERGY NEWS, January 2009, p. 1).

After 16 weeks, 78% of those in the bimatoprost group had at least a 1-point increase on a scale that measured eyelash prominence (the primary efficacy end point), compared with 18% of those on the vehicle, a statistically significant difference.

Exactly how bimatoprost, a prostaglandin analog, promotes eyelash growth has not been determined, but growth “is believed to occur by increasing the [percentage] of hairs in, and the duration of, the anagen or growth phase,” according to the labeling. Eye pruritus, conjunctival hyperemia, and skin hyperpigmentation are listed in the label as the most common adverse events, affecting about 3%-4% of people treated. Warnings include the possibility of pigmentation of the iris (which is likely to be permanent) and the eyelids.

Allergan has agreed to conduct a 4-month, randomized, controlled study of bimatoprost solution in at least 50 black subjects, according to the FDA's approval letter. The one black patient in the hypotrichosis study was in the vehicle group. Another postmarketing requirement is that the company conduct a study of the safety and efficacy of bimatoprost in patients aged 0-17 years with hypotrichosis.

Allergan plans to launch Latisse in the first quarter of 2009, according to a written statement from the company.

ORLANDO — Patients getting an investigational hyaluronic acid gel filler for lip augmentation reported less pain and greater satisfaction with a 24-mg/mL dose than with a 20-mg/mL dose, interim study results have shown.

Patients who received the 24-mg/mL hyaluronic acid gel filler required fewer touch-ups and trended toward less severe injection-site reactions than did patients treated with the 20-mg/mL dose, reported Dr. William Philip Werschler in a poster at the annual meeting of the American Society for Dermatologic Surgery.

Sponsored by Allergan Inc., the randomized, double-blind (to the patient and evaluator) parallel study included 30 women aged 30 years or older (mean age, 51 years) whose lips were rated as 0 (none) or 1 (mild) on a fullness assessment scale by the treating investigator.

All participants had to agree not to undergo other antiwrinkle or augmentation procedures in the lower two-thirds of the face during the 6-month study, said Dr. Werschler of the University of Washington, Seattle. He coauthored the study with Dr. Steven Fagien, who is in private practice in Boca Raton, Fla.

A total of 12 patients were treated with the 24-mg/mL hyaluronic acid gel filler and received a mean injection volume of 0.88 mL in their upper lip and 0.78 mL in their lower lip. The 18 patients treated with the 20-mg/mL formulation received a mean injection volume of 0.97 mL in their upper lip and 0.85 mL in their lower lip.

Slight injection-site swelling occurred in 6 (50%) of the patients receiving the 24-mg/mL injection, compared with 10 (56%) of the patients receiving the 20-mg/mL dose. Two patients receiving the lower-dose treatment also had mild or severe swelling.

The patients returned for follow-up at weeks 1 and 2 and months 2, 4, and 6. Touch-up treatments were permitted at week 2 and were limited to half of the amount of the previous treatment.

Two (17%) of the patients treated with the 24-mg/mL hyaluronic acid gel filler received touch-up treatment, compared with 10 (56%) of the patients treated with the 20-mg/mL hyaluronic acid gel filler.

Two weeks after treatment, investigators and expert reviewers indicated that the 24-mg/mL hyaluronic acid gel filler was associated with a higher percentage of patients with no lines or shallow lines in the perioral area, Dr. Werschler said.

In addition, more investigators reported being "very satisfied" or "satisfied" with overall appearance, lip fullness, perioral or lipstick lines, curvature of the upper and lower lip, smile lines, and marionette lines associated with the 24-mg/mL hyaluronic acid gel filler.

Similarly, more patients receiving the higher dose reported that they were "satisfied" or "very satisfied," compared with those who received the 20-mg/mL hyaluronic acid gel filler.

The treatment effect lasted up to 216 days for patients receiving the 24-mg/mL injection (mean, 193 days) and for up to 178 days (mean, 158 days) for those receiving the 20-mg/mL dose.

Dr. Werschler said that full results of the study will be reported in late 2009.

Asked to comment on why the 24-mg/mL filler was superior, he cautioned that these are interim results. However, "the data points were clearly distinguished," he added. "Perhaps in the final results, this will be discussed further."

Dr. Werschler is a speaker, consultant, and clinical investigator for Allergan Inc. and Medicis Aesthetics Inc. Dr. Fagien is a consultant and clinical investigator for Allergan Inc. and Medicis Aesthetics.

Patients who received a higher dose of the investigational hyaluronic acid gel required fewer touch-ups. DR. WERSCHLER

ORLANDO — Patients getting an investigational hyaluronic acid gel filler for lip augmentation reported less pain and greater satisfaction with a 24-mg/mL dose than with a 20-mg/mL dose, interim study results have shown.

Patients who received the 24-mg/mL hyaluronic acid gel filler required fewer touch-ups and trended toward less severe injection-site reactions than did patients treated with the 20-mg/mL dose, reported Dr. William Philip Werschler in a poster at the annual meeting of the American Society for Dermatologic Surgery.

Sponsored by Allergan Inc., the randomized, double-blind (to the patient and evaluator) parallel study included 30 women aged 30 years or older (mean age, 51 years) whose lips were rated as 0 (none) or 1 (mild) on a fullness assessment scale by the treating investigator.

All participants had to agree not to undergo other antiwrinkle or augmentation procedures in the lower two-thirds of the face during the 6-month study, said Dr. Werschler of the University of Washington, Seattle. He coauthored the study with Dr. Steven Fagien, who is in private practice in Boca Raton, Fla.

A total of 12 patients were treated with the 24-mg/mL hyaluronic acid gel filler and received a mean injection volume of 0.88 mL in their upper lip and 0.78 mL in their lower lip. The 18 patients treated with the 20-mg/mL formulation received a mean injection volume of 0.97 mL in their upper lip and 0.85 mL in their lower lip.

Slight injection-site swelling occurred in 6 (50%) of the patients receiving the 24-mg/mL injection, compared with 10 (56%) of the patients receiving the 20-mg/mL dose. Two patients receiving the lower-dose treatment also had mild or severe swelling.

The patients returned for follow-up at weeks 1 and 2 and months 2, 4, and 6. Touch-up treatments were permitted at week 2 and were limited to half of the amount of the previous treatment.

Two (17%) of the patients treated with the 24-mg/mL hyaluronic acid gel filler received touch-up treatment, compared with 10 (56%) of the patients treated with the 20-mg/mL hyaluronic acid gel filler.

Two weeks after treatment, investigators and expert reviewers indicated that the 24-mg/mL hyaluronic acid gel filler was associated with a higher percentage of patients with no lines or shallow lines in the perioral area, Dr. Werschler said.

In addition, more investigators reported being "very satisfied" or "satisfied" with overall appearance, lip fullness, perioral or lipstick lines, curvature of the upper and lower lip, smile lines, and marionette lines associated with the 24-mg/mL hyaluronic acid gel filler.

Similarly, more patients receiving the higher dose reported that they were "satisfied" or "very satisfied," compared with those who received the 20-mg/mL hyaluronic acid gel filler.

The treatment effect lasted up to 216 days for patients receiving the 24-mg/mL injection (mean, 193 days) and for up to 178 days (mean, 158 days) for those receiving the 20-mg/mL dose.

Dr. Werschler said that full results of the study will be reported in late 2009.

Asked to comment on why the 24-mg/mL filler was superior, he cautioned that these are interim results. However, "the data points were clearly distinguished," he added. "Perhaps in the final results, this will be discussed further."

Dr. Werschler is a speaker, consultant, and clinical investigator for Allergan Inc. and Medicis Aesthetics Inc. Dr. Fagien is a consultant and clinical investigator for Allergan Inc. and Medicis Aesthetics.

Patients who received a higher dose of the investigational hyaluronic acid gel required fewer touch-ups. DR. WERSCHLER

ORLANDO — Patients getting an investigational hyaluronic acid gel filler for lip augmentation reported less pain and greater satisfaction with a 24-mg/mL dose than with a 20-mg/mL dose, interim study results have shown.

Patients who received the 24-mg/mL hyaluronic acid gel filler required fewer touch-ups and trended toward less severe injection-site reactions than did patients treated with the 20-mg/mL dose, reported Dr. William Philip Werschler in a poster at the annual meeting of the American Society for Dermatologic Surgery.

Sponsored by Allergan Inc., the randomized, double-blind (to the patient and evaluator) parallel study included 30 women aged 30 years or older (mean age, 51 years) whose lips were rated as 0 (none) or 1 (mild) on a fullness assessment scale by the treating investigator.

All participants had to agree not to undergo other antiwrinkle or augmentation procedures in the lower two-thirds of the face during the 6-month study, said Dr. Werschler of the University of Washington, Seattle. He coauthored the study with Dr. Steven Fagien, who is in private practice in Boca Raton, Fla.

A total of 12 patients were treated with the 24-mg/mL hyaluronic acid gel filler and received a mean injection volume of 0.88 mL in their upper lip and 0.78 mL in their lower lip. The 18 patients treated with the 20-mg/mL formulation received a mean injection volume of 0.97 mL in their upper lip and 0.85 mL in their lower lip.

Slight injection-site swelling occurred in 6 (50%) of the patients receiving the 24-mg/mL injection, compared with 10 (56%) of the patients receiving the 20-mg/mL dose. Two patients receiving the lower-dose treatment also had mild or severe swelling.

The patients returned for follow-up at weeks 1 and 2 and months 2, 4, and 6. Touch-up treatments were permitted at week 2 and were limited to half of the amount of the previous treatment.

Two (17%) of the patients treated with the 24-mg/mL hyaluronic acid gel filler received touch-up treatment, compared with 10 (56%) of the patients treated with the 20-mg/mL hyaluronic acid gel filler.

Two weeks after treatment, investigators and expert reviewers indicated that the 24-mg/mL hyaluronic acid gel filler was associated with a higher percentage of patients with no lines or shallow lines in the perioral area, Dr. Werschler said.

In addition, more investigators reported being "very satisfied" or "satisfied" with overall appearance, lip fullness, perioral or lipstick lines, curvature of the upper and lower lip, smile lines, and marionette lines associated with the 24-mg/mL hyaluronic acid gel filler.

Similarly, more patients receiving the higher dose reported that they were "satisfied" or "very satisfied," compared with those who received the 20-mg/mL hyaluronic acid gel filler.

The treatment effect lasted up to 216 days for patients receiving the 24-mg/mL injection (mean, 193 days) and for up to 178 days (mean, 158 days) for those receiving the 20-mg/mL dose.

Dr. Werschler said that full results of the study will be reported in late 2009.

Asked to comment on why the 24-mg/mL filler was superior, he cautioned that these are interim results. However, "the data points were clearly distinguished," he added. "Perhaps in the final results, this will be discussed further."

Dr. Werschler is a speaker, consultant, and clinical investigator for Allergan Inc. and Medicis Aesthetics Inc. Dr. Fagien is a consultant and clinical investigator for Allergan Inc. and Medicis Aesthetics.

Patients who received a higher dose of the investigational hyaluronic acid gel required fewer touch-ups. DR. WERSCHLER

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

ORLANDO — Consider turning dermatology patients into aesthetic ones, to help stay afloat during these tough economic times.

Patients may come into your office needing a medical procedure, but will return for a cosmetic procedure if you educate them, said Dr. Mark S. Nestor, a dermatologist in private practice in Aventura, Fla.

Dr. Nestor said he always has educational videos for patients to watch as they sit in his waiting room. "A mother who brings her child in for acne treatment learns about cosmetic procedures that I do, and she will come back for Botox. The thing is to start small, let your patients walk into it slowly, especially if they've never had aesthetic procedures," he said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Laurie J. Polis, who was part of a panel with Dr. Nestor that discussed dermatology marketing practices, suggested that a crucial part of the education process is to reassure patients about your expertise.

This can be done by displaying your diplomas and awards prominently on the wall, said Dr. Polis, a dermatologist in private practice in New York.

Developing good relationships with the media is also key to marketing and promoting your practice. You can spend money on advertising, or you can become known as an expert by being interviewed for magazine articles. "If you give good interviews … and you get yourself quoted in an article, that will work better than any dollar that you can spend," Dr. Polis said.

Frame any articles and display them on your walls.

"If you are lucky enough to get editorial coverage, don't be shy. Make sure your patients know about it. It will make them proud of you," she said.

Keep in touch with your patients through regular e-mails and newsletters informing them of your services, Dr. Polis said.

"If I had to give just one take-home message, it would be this: Inundate your patients with awareness of what you do. Send e-mail blasts monthly or quarterly, whatever you are comfortable with. List all the things you do in your office. The worst thing to hear is, 'I didn't know you had a spa upstairs,' or 'I didn't know you did fillers and Botox,' so awareness is key," she said.

Keep these communications to patients educational, Dr. Polis said. "If they are educationally flavored, it does not sound like a sales pitch. Instead, it opens up questions, inquiries, and interest, and that will lead to sales of those procedures."

Buff up your Web presence and use HTML so that you can be found on the Web. Also, make sure your Web site is listed on every letter and collateral you send out to patients.

First impressions are vital. Make sure your office environment conveys a professional but relaxed and inviting atmosphere.

Pay attention to your office staff. Everyone connected with your practice—from your receptionists to your aestheticians—should be well spoken, well groomed, and polite.

"Remember that your patients are coming to you for an aesthetic service.

Pay attention to how your staff answers the phone. Are there messages when patients and clients are on hold? How long are they on hold? Think about how you want to project yourself and your practice from the minute your patient walks into your office," she said.

Remember that tough economic times mean that advertising dollars are scarce. Now is a great time to negotiate for reduced rates with different advertising venues, from print to radio to TV, Dr. Polis advised.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR