Aesthetic Dermatology

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.

Melasma can be a very frustrating, remitting, and relapsing condition, particularly in the summer months. Often patients get good results with at-home and in-office treatments and return frustrated as the melasma frequently recurs. A thorough history can help identify melasma triggers.

Ask about exposure to:

1. Any heat source. You will be surprised by the answers. Examples include overhead work lights, overhead desk lamps, extensive cooking over an oven or a grill, lamps used to treat seasonal affective disorder, heating lamps, and hair dryers. Heat is a very common trigger for melasma as it increases vasodilation. Melasma is typically thought of as solely hyperpigmentation; however, vascular dilatation often occurs in the affected area. In addition, heat may lead to more inflammation, also stimulating melanocyte pigment production.

2. UV sources. These include computer screens, car side windows, sunroofs (even if the roof glass is closed, UV can penetrate the glass, so the sunroof shade also should be closed), and a window near an office desk or a window near a bed (UVA penetrates window glass).

3. Visible light sources. Examples are overhead lights at home and in office buildings. These lights increase pigmentation. Iron oxide in sunscreens helps block visible light.

4. Hormonal triggers. These include birth control pills, hormone-releasing intrauterine devices, hormone therapy, and vitamin supplements such as those used for pregnancy, nursing, and perimenopausal symptoms (such as black cohosh and dong quai).

5. Other triggers:• Scented or deodorant soaps, toiletries, cosmetics, or fragrances that may cause phototoxic reactions. These reactions may in turn trigger melasma, which may then persist.

• Sunglasses. This is the most common avoidable trigger. Aviator sunglasses or sunglasses with metal rims, or metal attached to the inside handle or rim absorb the heat when in the sun and/or when left in the car. The metal gets warm, and the heat transfers to the skin when the sunglasses are placed on the face. I ask every melasma patient to bring in all their sunglasses so I can check for metal on the rim or handles. This is a very common trigger, and patients are shocked after they observe that streaks of melasma can often follow the pattern of their sunglasses.

• Autoimmune thyroid disorders, chronic stress, or adrenal dysfunction.

• Triggers of melanocyte-stimulating hormone.

The history is crucial to long-term clearance of melasma. Asking questions to get to the source of the trigger often can help isolate the cause and help eliminate significant recurrences of melasma in skin of color patients.

Dr. Wesley and Dr. Talakoub are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month's column is by Dr. Talakoub.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

As summertime approaches, opportunities for outdoor activities increase. For many of our patients, summer inspires a desire to have aesthetic procedures in preparation for outdoor events, such as weddings and vacations. We must, however, be mindful that increased sun exposure after some aesthetic procedures can mean an increased risk of complications.

The main complication we worry about with sun exposure is, of course, hyperpigmentation. The risk is low with injectable procedures such as botulinum toxin and fillers, but sun protection is still encouraged, especially in skin types III-VI. The risk increases greatly with chemical peels and laser and light-based procedures, such as intense pulsed light, vascular lasers, pigment lasers, laser hair removal, and especially nonablative and ablative resurfacing (including nonlaser resurfacing such as dermabrasion).

Sun protection should be encouraged, even with seemingly less invasive procedures, such as electrodessication. I once had a patient with type-IV skin tell me at her first visit that, years before, she had electrodessication on her face for DPN (dermatosis papulosa nigra), a procedure she had done on several occasions without complications and great results. However, she went to a party on a boat the weekend after the procedure and developed hyperpigmentation at the procedure areas, and she still had a few dark macules several years later.

At a follow-up visit, she said the doctor told her she should not have gone out on the boat and should have worn sunscreen. Of course, she was highly upset that she wasn’t advised about sun protection at the time of the procedure. This is one of several stories I’ve heard or seen of complications and postinflammatory hyperpigmentation after an aesthetic procedure, when the patients felt that the treating physician or practitioner did not counsel them about sun exposure during the consultation or treatment visit. It seems intuitive, but I’ve made it a habit to make sun protection part of my counseling routine.

In my practice, we often give patients sunscreen to apply immediately after a procedure. Specifically encouraging the use of zinc- and/or titanium-based, broad-spectrum, noncomedogenic physical blockers that are SPF 30 or higher may help reduce the risk of potential irritation or allergy and subsequent postinflammatory pigmentary alteration from chemical blocking ingredients. We provide a postprocedure handout, and the medical assistant also will counsel about sun protection when applying it to the patient or reviewing postprocedure instructions. So the patient is counseled at least three times: By me during consultation or pre-procedure, by the medical assistant post procedure, and by written instructions.

Vigorous sun protection is encouraged for at least 1 week after any aesthetic procedure (and longer if the downtime is longer or if multiple treatments are required). Some practices also use antioxidant serums to reduce free radicals, encourage healing, and reduce the risk of hyperpigmentation after procedures. Wide-brimmed hats also are encouraged, particularly after resurfacing or photodynamic therapy (PDT). We give patients sun-protective hats when they leave our office after PDT. We counsel them to practice vigorous sun protection for at least 1 week and to avoid sitting by a window for 48 hours after the procedure so as to not reactivate the levulan.

Delaying more high-risk procedures, such as laser treatments, until after the summer months may be appropriate if sun cannot be avoided to mitigate the risk of complications. If a patient comes to the office for a laser procedure and is visibly more tan than at the time of the last treatment, I will counsel about risks, adjust the settings appropriately, or even delay the treatment altogether to a time when the tan has faded. This is particularly important for lasers and light treatments for which melanin is the target chromosphere, such as intense pulsed light and laser hair removal. Although UV exposure is more intense in the summer, in our practice in Southern California we follow these principles year-round for the safety of our patients.

Dr. Wesley and Dr. Talakoub are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Cosmetic procedures in general should be postponed until after pregnancy. Factors to consider in a pregnant patient include the hormonal and physiologic changes of the patient during pregnancy, as well as the risk to the fetus.

Many dermatologic changes occur during a pregnancy. Pregnant women may develop hyperpigmentation, formation of vascular lesions and varicose veins, hirsutism, striae, acne, and increased skin growths. These changes may lead pregnant women to seek cosmetic treatments.

However, physiologic changes such as increased blood volume, decreased hematocrit, increased flushing, increased melanocyte stimulation, and decreased wound healing should prompt a delay of cosmetic procedures until 3-6 months after the postpartum period, when these factors return to normal and the risk of complications is reduced.

The safety of many cosmetic treatments during pregnancy remains unknown. This includes microdermabrasion, chemical peels, and laser treatments. Given the increased risk of postinflammatory hyperpigmentation, as well as poor wound healing and increased risk of hypertrophic and keloidal scarring in pregnancy, these procedures are often avoided.

The safety of injectable treatments during pregnancy, such as liquid sclerosants and fillers, has not been evaluated. However, the manufacturers list pregnancy and breastfeeding as contraindications to treatment. Neurotoxins are also avoided during pregnancy and breastfeeding, based on teratogenicity in animal studies. There have been no controlled trials in humans.

Though there have been incidental exposures of botulinum toxin in women who did not know they were pregnant, no documented reports of fetal anomaly during these incidental exposures has been reported. In addition, no studies have been conducted to evaluate whether the toxin is excreted in breast milk, or when it is safe to use neurotoxins, fillers, or liquid sclerosants prior to conception.

The 10 months of pregnancy and many months of nursing can be a long stretch to wait for women who get regular cosmetic treatments. The skin changes of pregnancy can be bothersome; however, the risks of complications to the mother and the fetus outweigh the transient benefits of cosmetic procedures. The hormonal and physiologic changes of pregnancy are widely different in each woman, and sometimes the long-term side effects and complications can be completely unpredictable. Thus, patience and thorough counseling are the best strategies for treating our pregnant and nursing moms.

References

Nussbaum, R. and Benedetto, A.V. Cosmetic aspects of pregnancy. Clinics in Dermatology 2006;24:133-41.

Morgan, J.C. et al. Botulinum Toxin and Pregnancy Skinmed 2006;5:308.

Monteiro, E. Botulinum toxin A during pregnancy: a survey of treating physicians. J. Neurol. Neurosurg. Psychiatry 2006;77:117-9.

Lee, K.C., et al. Safety of cosmetic dermatologic procedures during pregnancy. Dermatol. Surg. 2013;39:1573-86.

Goldberg, D. and Maloney, M. Dermatologic surgery and cosmetic procedures during pregnancy and the postpartum period. Dermatologic Therapy 2013;26:321-30.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

How many times a week are we asked by our patients about “dark circles” under the eyes? The term “dark circles” is a catch-all term that refers to problems that have a vast range of genetic, environmental, and skin causes. However, it is a common frustrating problem with little structure in its definition and few foolproof treatments.

We propose a classification system for the definition of dark circles, and offer some clinical pearls in their treatment. Most patients, however, have dark circles with multifactorial causes that need to be addressed.

I. Infraorbital fat pad protrusion (“bags under my eyes”)

Blepharoplasty is the best solution and for now, the only solution for fat pad prominence. The fat may be removed in lower lid blepharoplasty or repositioned. Referral to a board certified plastic surgeon, oculoplastic surgeon, or dermatologic surgeon is recommended. If there is also significant tear trough deformity, fillers may be placed in the tear trough to help “camouflage” the appearance of the fat pad protrusion but it does not rid the patient of the fat pads.

II. Infraorbital edema (“puffiness”)

The infraorbital skin is very thin and highly sensitive to fluid compartmentalization. Seasonal allergies, sinus infections, crying, or water retention from high blood pressure or consumption of high sodium foods are some of the reasons the loose, thin epidermis becomes edematous. Recommendations for patients:

• Treat seasonal allergies with over-the-counter allergy medications, or see your doctor for prescription medications for resistant allergies or possible sinus infections.

• Switch your sleep position. Sleep position can be contributing to under-eye bags through gravity. Sleeping on your side or stomach can encourage fluids to collect under your eyes. If you’re a side sleeper, you may notice a heavier bag on the side you sleep on. Patients who wake up with puffy eyes can sleep on their backs and add an extra pillow under the head.

• Avoid rubbing eyes frequently, going to bed with makeup on, and harsh cleansers. Anything that irritates the eyes can cause fluids to pool. Sleeping in eye makeup can irritate eyes, causing undereye edema.

• Eye bags might be a sign of an underlying medical condition, if they appear suddenly and none of the above conditions apply. Thyroid, cardiovascular, or kidney problems can cause under-eye fluid retention and the patients need to see their primary care doctors for further evaluation.

• Place an ice pack, slices of cucumbers, chilled tea bags, or even a package of frozen peas on eyes. This can constrict leaky blood vessels and lessen the periorbital edema.

• A few topical eye creams have been developed, such as Neotensil, that temporarily reduce the appearance of lower eyelid puffiness. The product is a blend of polymers that provide compression, smoothing, and hydrating benefits to the skin. In addition, a makeup is often applied over it to reduce the appearance further.

III: Periorbital hyperpigmentation (“dark circles”)

Pigmentation of the periorbital skin is very common in skin of color because of the increased melanin content. Genetics, rubbing, and inflammatory skin diseases such as eczema may play a role in exacerbating the pigmentation of the thin under-eye skin. Recommendations for patients:

• Remind them to avoid rubbing the area – chronic rubbing and the development of lichen simplex chronicus can lead to dark, thickened under-eye skin.

• Retinoic acid creams can help slough the dark pigmented skin. However, it should be used in very small amounts with increasing use over several weeks to avoid severe irritation.

• Skin lightening creams with azaleic acid, kojic acid, and glycolic acid, can be found in varying strengths in dermatologist office preparations, over-the-counter creams, or prescriptions. Hydroquinone creams have demonstrated success in lightening under-eye hyperpigmentation. Strengths in over-the-counter preparations start at 1%-2% and in prescription strength can be compounded to higher than 4%.

• Chemical peels: Light chemical peels such as glycolic acid and Jessner’s peels will assist in lightening dark under-eye pigmentation. Dermatologists also can use peels with hydroquinone or retinoic acid for an added lightening benefit.

• Intense pulsed light (IPL) can help minimize under eye pigmentation, particularly UV-induced pigmentation.

IV: Infraorbital tear trough depression

Most often, dark circles aren’t about changes in the color of the skin at all. Instead, they’re created by a loss of volume in the area around the eye. This exposes the underlying blue veins and orbital bone, creating a hollow trough that shows up as a dark circle. These changes are often caused by genetics; however, significant weight loss and aging with resorption or displacement of the infraorbital fat pads can also expose under-eye tear trough depressions.

The best way to treat this problem is with a small amount of a hyaluronic acid filler placed by a dermatologist in the trough. Very small aliquots are needed in even the deepest trough but can give outstanding results. Caution however, must be taken as this is a highly specialized technique and injector dependent procedure. There are crucial vascular structures around the eye that need to be avoided, and overfilled troughs will give patients a puffy appearance that may pose a worse and more difficult problem to fix. Hyaluronic acid fillers are not approved by the Food and Drug Administration for treatment of under-eye depressions, so patients should be educated about the risks and benefits prior to undergoing these procedures.

V: Periorbital vascular prominence

With age, the skin around the eye becomes thinner, exposing the small capillaries and venules just below the thin epidermal layer. Vascular prominence can leave a bluish undertone to the infraorbital skin which can cast dark shadows and make the area appear dark or sallow.

• Eye creams that contain caffeine can constrict the underlying blood vessels and temporarily diminish small vessel prominence.

• For large blue veins, vascular lasers such as a long pulse Nd:Yag lasers can be recommended. But in darker skin types these lasers can cause hyperpigmented scars if not used with adequate skin cooling techniques. Proper eye protection should also be used.

VI: Periorbital static and dynamic rhytids

• Botulinum toxin placed in small aliquots around the orbital rim will reduce the dynamic rhytids in this area. Treatments spaced 3 months apart will ensure long-lasting benefits as botulinum toxin often wears off.

• Laser resurfacing with CO₂, fractionated CO₂, or erbium lasers may also be used to treat periorbital rhytides.

Additional tips for your patients:

• For most of the types of infraorbital issues, makeup can help conceal some skin imperfections. Patients should choose a concealer that matches or is slightly lighter than their skin tone. If the patient has mild discoloration, choose a liquid formula. For more prominent imperfections, a cream full-coverage concealer works best.

• Recommend that patients avoid smoking, which dehydrates the skin and causes premature aging and collagen degradation.

• Remind patients to apply a sunscreen around the eye area. Hyperpigmentation and tear troughs can accentuate with UV-induced skin pigmentation. Physical blocking sunscreens may be less irritating than chemical blockers for those with sensitive eyelid skin.

• Remind patients to apply a moisturizer to the eye area nightly to keep the skin from becoming dry, irritated, and dehydrated.

• Advise patients not to break the bank with over-the-counter creams that promise cures for under-eye circles. Most over-the-counter preparations provide temporary, mild benefits at most, and often do not provide any lasting benefit.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is an update by Dr. Wesley of a previous column by Dr. Talakoub.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.

It’s a myth that children don’t scar like adults, according to Dr. Jon A. Dyer.

In fact, children often scar worse than adults, he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.

Children have more aggressive healing and inflammatory responses, a highly elastic dermis and connective tissues, and a high activity level that increases the risk of stressing the wound, and they may pay less attention to it, he explained.

Additionally, children can be more difficult to treat for scars because they are often more fearful and anxious, they have a short attention span, and they move around – a lot, he said. This leads to greater anxiety on the part of both the dermatologist and the family, which can lead to rapidly completing a procedure, said Dr. Dyer of the University of Missouri, Columbia.

Successful treatment of a wound or lesion – that is, getting the best initial scar possible – requires good planning, proactive application of surgical principles, and careful patient and family counseling and follow-up, he said.

Among Dr. Dyer’s tips for minimizing scarring when treating lesions in children:

• Do the simplest possible procedure.

• Make the scar as small as possible, keeping in mind that pediatric skin is more elastic.

• Remember that fusiform closures in children do not always require a 3:1 ratio. Tips settle, and divots fill in in young children, he said.

• Operate before puberty when the lesion is located in a cosmetically important area.

Also, consider performing a staged excision if possible; this allows a reduction in final scar length, provides tissue expansion, and allows assessment of individual wound healing. Take as much of the lesion as possible the first time, and remember that central excision is preferable to lateral excision, Dr. Dyer said.

The ideal time to wait between stage 1 and 2 is 4-6 weeks. Longer intervals will lead to more spread and more hypertrophy, and will negate the benefits of staging, he said.

Keep in mind that purse-string sutures can be particularly effective for suturing small spaces and for closing dead spaces, he said, adding that use of a purse-string closure for a round defect can reduce the final scar length by at least 50%.

Scar prevention or minimization requires strict adherence to good surgical principles, Dr. Dyer said, explaining that attention must be paid to perfecting the excision through proper use of skin tension lines, clean wound edges, sharp corners with no or minimal boating, undermining, and removing bulk if necessary.

Track marks are more likely on nonfacial skin and can be avoided by using running subcuticular sutures; in some cases of excellent approximation with no tension, the wound surface can be secured with Dermabond, he said.

Dr. Dyer also outlined the best closure choices for specific areas. For the scalp, use running cuticular sutures; for the extremities, trunk, axilla, or groin, use running subcuticular sutures; for the face, feet, or hands, use interrupted sutures; and for a punch biopsy, consider not using any closure, he advised.

If cuticular stitches are used, minimize scarring by pulling them within 5 days on the face, and within 7-10 days on the body. If dehiscence is a concern, pull the cuticulars and follow with either Dermabond or SteriStrips, he said, but strongly consider using running subcuticular sutures.

Once a wound is closed, secure it with Dermabond or with Steri-Strips and Mastisol and provide protective dressing.

“The bulkier and more colorful the dressing, the happier and more compliant the child,” he said.

Minimize postoperative wound tension in high-risk scars or sites and restrict movement and trauma for as long as possible; 6 weeks is ideal, he added, noting that movement restriction is critical for ensuring a good outcome.

To reduce the trauma of suture removal, “cut ’em long and leave ’em long,” and be sure to use proper scissors, he said.

Running subcuticular suture removal doesn’t hurt; enlist parents’ help in convincing the child of this, he suggested.

Finally, be specific when counseling patients about restrictions, discuss possible complications, provide a written summary including contact numbers, address the scar, and give the follow-up appointment time in writing, he said.

If dehiscence occurs – and it’s not uncommon in children – let it heal and restart the process, he said, noting that prevention is best and can be achieved in many cases with aggressive pre- and postop education, restriction of movement, and proper dressing.

Dr. Dyer stressed that good surgical principles for use in children can also be utilized to improve results in adult patients.

Dr. Dyer reported having no disclosures. SDEF and this new organization are owned by the same parent company.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The three most exposed areas of the body that give away a person’s age are the face, neck, and hands. Rejuvenation of the hands is an often simple and nice addition to facial and neck aesthetic rejuvenation.

When examining aging hands, the three most prominent features are decreased volume in the interosseous spaces (leading to increased crepiness of the skin and increased show of extensor tendons), lentigines, and prominent veins. Therefore, the treatment for hands is quite simple: Restore volume, treat the pigmented lesions, and if needed, treat the prominent veins.

The anatomy of the dorsal hand can be divided into three major compartments. First, the skin, which on the dorsal hand is quite pliable. Second, the subcutaneous tissue, which consists of a loose areolar tissue where the lymphatics and veins lie. Third, beneath the subcutaneous tissue is the dorsal fascia of the hand, which is contiguous with extensor tendons and underlying compartments. It is in the subcutaneous layer (or loose areolar tissue) where fillers or fat are placed to treat volume loss.

While several fillers are currently used off label for hand rejuvenation, the Food and Drug Administration is meeting in February to consider officially approving Radiesse for this indication. Currently, hyaluronic acid (HA) fillers, calcium- hydroxylapatite (Radiesse), poly-L-lactic acid, and autologous fat are all utilized. I tend to use HAs in this location because of the reversibility, if needed, and decreased risk of nodule formation. Several techniques exist, including injecting between each tendon space vs. a bolus technique. I tend to use a bolus technique, where one or two boluses are injected while tenting the skin up to ensure injection into the correct plane and to avoid the vessels. Subsequently, the boluses are massaged into place while the patient makes a fist.

Once the interosseous spaces have been treated, the veins often appear less prominent and often don’t require direct treatment. I typically do not treat the dorsal hand veins, but sclerotherapy can be performed. Lentigines may be treated with a variety of devices including intense pulse light, Q-switched lasers, and fractionated nonablative lasers. Chemical peels and topical antipigment agents also may help to a lesser degree or also may be used for maintenance to keep the lentigines away.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Microneedling, or skin needling, is an aesthetic technique used for decades prior to resurfacing lasers, but it has recently experienced a surge in popularity, particularly for ethnic skin. In 1995, subcision or dermal needling was identified as an effective treatment for scars. Since then, the technique initially referred to as collagen induction therapy has become a staple in the treatment of acne scars, surgical scars, photo aging, and stretch marks.

The skin needling technique involves using fine sterile needles 0.1mm-2.5 mm in length that repeatedly pierce the stratum corneum, producing microscopic “holes” in the dermis. These microscopic wounds lead to the release of growth factors stimulating the formation of new collagen, elastin, and neovascularization in the dermis. There are many brands and manufacturers of microneedling tools on the market, including dermarollers, Dermapen, Dermastamp, Cosmopen, and multiple other in-office and at-home devices. At-home devices usually have shorter needles and provide significantly less penetration and injury, and therefore may be less effective.

Prior to the procedure, patients are often anesthetized with topical anesthesia without vasoconstrictors for 1 hour. The area is cleaned with sterile gauze and alcohol or Hibiclens, and a microneedling device is used to either roll or prick the skin in multiple alternating passes. The depth of penetration, number of passes, and degree of overlap is highly dependent on the underlying condition, the area being treated, the brand of device used, and the length and frequency of the needle insertion. Petechiae and pinpoint bleeding occur during the treatment. Treatments are usually done 4-6 weeks apart. Post procedure, the patient often experiences mild erythema, bruising, and some mild edema.

This technique has been particularly beneficial to patients with skin of color who are not candidates for factional lasers because of the risks of hyperpigmentation and scarring. There is low risk of hyper- or hypopigmentation with microneedling, and multiple treatments can be performed in patients with types III-VI skin and those with a history of melasma.

Contraindications and precautions when considering microneedling include: history of keloid or hypertrophic scarring,recent skin rashes, history of herpes simplex infections if the perioral area is being treated, and the presence of raised moles, warts, or any raised lesions on the targeted area. Absolute contraindications include: scleroderma, collagen vascular diseases clotting problems, active bacterial or fungal infection, and immunosuppression.

Microneedling is a safe, effective, in-office procedure with a range of uses. Many new indications are currently being explored. In my practice, we have used microneedling for atrophic scars, repigmentation of depigmented scars and vitiligo, stimulation of hair regrowth in noninflammatory alopecias, and treatment of burn scars. Patients are generally very happy with the quick treatment time, minimal downtime, and overall long-term results.

References

1. Orentreich DS, Orentreich N. Subcutaneous incisionless (subcision) surgery for the correction of depressed scars and wrinkles. Dermatol. Surg. 1995;21:6543-9.

2. Camirand A, Doucet J. Needle dermabrasion. Aesthetic Plast. Surg. 1997;21:48-51.

3. Fernandes D. Minimally invasive percutaneous collagen induction. Oral Maxillofac. Surg. Clin. North Am. 2006;17:51-63.

4. Aust MC, Fernandes D, Kolokythas P, Kaplan HM, Vogt PM. Percutaneous collagen induction therapy: An alternative treatment for scars, wrinkles and skin laxity. Plast. Reconstr. Surg. 2008;21:1421-9.

5. Fernandes D, Signorini M. Combating photoaging with percutaneous collagen induction. Clin. Dermatol. 2008;26:192-9.

6. Aust MC, Reimers K, Repenning C, Stahl F, Jahn S, Guggenheim M et al. Percutaneous collagen induction: Minimally invasive skin rejuvenation without risk of hyperpigmentation – fact or fiction? Plast. Reconstr. Surg. 2008;122:1553-63.

7. Fabbrocini G, De Vita V, Pastore F, et al. Collagen induction therapy for the treatment of upper lip wrinkles. J. Dermatolog. Treat. 2012;23:144-52. 8. Majid I. Microneedling therapy in atrophic facial scars: an objective assessment. J. Cutan. Aesthet. Surg. 2009;2:26-30.

9. Doddaballapur S. Microneedling with dermaroller. J. Cutan. Aesthet. Surg 2009;2: 110-11.

10. Dogra S, Yadav S. Sarangal R. Microneedling for acne scars in Asian skin type: an effective low cost treatment modality. J. Cosmet. Dermatol. 2014;13:180-7.

Dr. Talakoub and Dr. Wesley are cocontributors to a monthly Aesthetic Dermatology column in Dermatology News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

The field of body contouring and tissue tightening has expanded over the years, with many new devices appearing on the market that utilize radiofrequency (RF) energy to tighten and rejuvenate the skin. What originally began with a single monopolar RF device has progressed to a world in which there are skin-tightening devices that use bipolar energy and tripolar energy, as well as monopolar, and newer machines that boast five and eight poles of RF energy.

In addition to in-office radiofrequency devices, at-home devices are now available.

Radiofrequency energy uses the tissue’s resistance within the various layers of the skin to transform the RF energy given to the skin into thermal energy. This process induces collagen remodeling and neocollagenesis, resulting in skin tightening. Since RF energy produces an electrical current instead of a light source like lasers, tissue damage can be minimized, and epidermal melanin is not targeted or typically damaged. Therefore, RF energies can be used for patients of all skin types and colors. Adverse events to RF therapy in general may include pain, erythema, swelling, and rare reports of burns or fat atrophy with first-generation devices.

Many at-home devices delivering RF energy have been developed and are now on the market for skin tightening and rejuvenation. These devices range in cost from about $30 to more than $1,000, and are marketed for skin tightening as well as body contouring. Most machines require multiple uses, daily or weekly, to achieve desired results, compared with in-office devices that are typically used once, or not more than once every 6 months. A recent study published in the Journal of Drugs in Dermatology of a newer at-home device that uses phase-controlled multisource radiofrequency technology found statistically significant improvement using a Fitzpatrick wrinkle and elastosis scale of 62 patients when pre- and post-photographs of 62 patients were evaluated by three independent board-certified dermatologists.

At-home devices do not deliver energies as high as in-office devices, and no head-to-head studies comparing in-office versus at-home RF devices are currently available. As even in-office radiofrequency device results can be subtle, or occur over 6 months, patient expectations should be managed, and clinicians should be realistic when counseling patients about the use of these devices. Patient selection is key for successful therapy. If skin laxity is severe enough that the patient warrants a face lift or surgical correction to achieve the desired results, then they may not be the best candidate for RF therapy alone.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

In our final segment on male dermatology, we will be focusing on laser treatments in men. There has been a steady increase in cosmetic procedures in men over the last decade, and laser procedures tend to be some of the most popular. In general, laser treatments provide faster results than topical or oral treatments and offer subtle aesthetic improvements with little to no downtime depending on the procedure. These factors appeal to male patients, who generally are generally less risk tolerant than women, and want masculinizing treatments with little downtime and natural results.

• Hair growth. Men tend to have highly pigmented, thicker hair in contrast to women, and often seek laser hair removal for excess body hair. Common sites include the back, upper arms, posterior hairline, lower beardline, and chest. Similar precautions apply to both men and women, such as proper cooling of the skin and avoidance of tanned skin. However, laser settings for male patients may need to be adjusted given the thicker, darkly pigmented hairs and often lower pain threshold. In addition, proper counseling of men is necessary with laser hair removal, because men often need more treatments than women and may need a topical anesthetic for highly sensitive areas.

• Body contouring. Men tend to deposit fat in hard-to-lose areas, such as the central abdomen and flanks. The expanding array of noninvasive devices using cold temperatures to freeze the fat, or ultrasound and radiofrequency devices to heat and thereby tighten the subcutaneous tissue have made body contouring one of the fastest growing cosmetic markets for men. Men are great candidates for these procedures given the fast results, minor discomfort, and noninvasive nature. Although many men have visceral abdominal fat that does not respond to these treatments, areas often treated with great long-term results include the upper and lower abdomen, flanks, arms, chest, and back.

• Rosacea. Men have a higher density of facial blood vessels than women, and they often seek treatment for telangiectasias and overall facial erythema. For noninflammatory erythematotelangiectatic rosacea, vascular laser treatments are the most effective treatments. Pulsed dye laser is often the best laser to target both large and small facial blood vessels and flushing erythema. Intense pulsed light (IPL) lasers are often a more popular choice for men because they involve less downtime and can treat brown spots as well. However, IPL must be used with caution in skin of color and tanned skin because of the risks of scarring and hyperpigmentation. Men may need more treatments and higher energy settings than women. Men also prefer minimal downtime and thus more frequent nonpurpuric settings are often preferred with any vascular laser. In addition, with IPL, men should be warned of the possibility of the laser temporarily stunting hair growth or causing hair to grow in patchy temporarily when using the device in the beard or mustache area.

• Laser resurfacing. Laser skin resurfacing can be performed for acne scars, rhytids, age sports, sun spots, melasma, and overall skin laxity. Options include ablative and nonablative skin resurfacing. The choice of procedure depends on the type of problem being treated, skin type, and downtime. Ablative CO₂, erbium:YAG, and fractional ablative lasers provide the best results for deep rhytids, acne scars, surgical scars, and skin laxity. However, men often shy away from these procedures given the pain, postprocedure care necessary, and downtime. Nonablative lasers may be a better choice for men, particularly for fine rhytids, melasma, and sun spots. With multiple treatments, they also may be used for scars and skin laxity. Postprocedure skincare and downtime are the critical factors for men when choosing resurfacing procedures, and detailed review of the care, complexity, and side effects are essential in the care of male patients.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Talakoub.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.

Idealized masculine facial features tend to include an overhanging, horizontal brow with minimal arch, deeper-set eyes that look closer together, a somewhat larger nose, a wider mouth, a squared lower face, and a beard or coarser texture to the lower facial skin. A major component of aesthetic disharmony in the aging face in both men and women, however, is the loss or redistribution of subcutaneous fat. Detailed studies by Rohrich and Pessa have demonstrated that facial fat (unlike fat elsewhere in the body) is partitioned into discrete compartments that may age independently of one another. Redistribution and loss of these fat pads contribute to formation of the nasojugal fold, malar crease, nasolabial fold, prejowl sulcus and marionette lines, as well as wasting of the temples, superior brow, and buccal fat. These changes can be visualized most strikingly in cases of cachexia and severe HIV-associated lipodystrophy.

When using fillers to restore volume loss and wrinkles in men, care must be taken to not overfeminize the male face. Filler placement in the anteromedial cheek, submalar cheek, temples, tear trough area, nasolabial folds, and marionette areas are often similar to filler placement in women if the patient has an issue with volume loss in those areas. The main difference is placement in the zygomaticomalar region of the cheek (or the point where the maximal light reflection is off of the highest point of the zygoma, or cheek bone) and the lips. Care must be taken not to overvolumize this region in men.

Also, even within ethnic groups, the male lip is typically not as tall and curvy as the female lip; it often appears less full, with more of a shadow cast by the lower lip.

Men tend to prefer treatments with less downtime and more natural results and are less risk tolerant than women are. Keeping these points in mind can increase patient satisfaction when offering fillers to male patients.

Source: Rohrich R., Pessa J. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. J. Plast. Reconstr. Surg. 2007;119:2219-27.

Dr. Talakoub and Dr. Wesley are co-contributors to a monthly Aesthetic Dermatology column in Skin & Allergy News. Dr. Talakoub is in private practice in McLean, Va. Dr. Wesley practices dermatology in Beverly Hills, Calif. This month’s column is by Dr. Wesley.