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'Slow Mohs' advised for lentigo maligna
MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.
The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.
Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.
Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."
A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.
"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."
Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.
Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.
"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.
Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.
Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.
Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.
Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).
The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.
"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.
Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.
"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.
He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.
"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.
Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.
MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.
The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.
Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.
Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."
A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.
"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."
Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.
Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.
"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.
Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.
Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.
Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.
Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).
The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.
"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.
Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.
"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.
He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.
"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.
Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.
MAUI, HAWAII – "Slow Mohs" has gained near-universal acceptance among skin cancer specialists as a definitive surgical technique for complete removal of lentigo maligna melanoma while simultaneously sparing normal tissue, according to Dr. Ellen Marmur of Mount Sinai School of Medicine, New York.
The big advantage that slow Mohs has over standard wide local excision with 0.5- to 1-cm margins is a 5-year cure rate approaching 100%. In contrast, standard excision has a recurrence rate of up to 20%, she said at the Hawaii Dermatology Seminar, sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Slow Mohs is a modified form of Mohs micrographic surgery. The surgery compares with conventional Mohs: It is staged, margin-controlled excision. But in slow Mohs, rush permanent sections are sent off to the pathologist rather than the frozen sections integral to conventional Mohs.
Dr. Marmur relies upon slow Mohs, with "bread-loafing" of the central tumor by the pathologist, because the permanent sections better preserve the tumor’s microscopic features. Interpreting atypical melanocytes in frozen sections can be quite a challenge. However, she added, some Mohs surgeons have found that using rapid immunostains also markedly improves the sensitivity and specificity of frozen sections in lentigo maligna surgery.
Slow Mohs takes place over the course of days, she said. "Basically, you do your Wood’s lamp to define the lesion diameter, you measure out your margins, you excise the tumor, pack the area with a bandage, and send the patient home. You rush your pathology, and you don’t do any reconstruction until you get the margins clear."
A pathology report that comes back stating narrow margins are present is "a heart stopper," she added.
"You have the option of observing the area if the margin is clear but the tumor was close to the margin. That’s a good approach for an elderly patient or when the lentigo maligna was in a cosmetically important area."
Lentigo maligna melanoma accounts for 4% of all cases of melanoma. It typically arises on sun-damaged skin in individuals in their 70s or older. Common sites include the malar area, forehead, nose, and temple. The differential diagnosis includes seborrheic keratosis, pigmented actinic keratosis, and pigmented nevus.
Lentigo maligna becomes lentigo maligna melanoma when malignant melanoma cells invade the dermis and deeper appendages. Roughly 5% of lentigo malignas eventually progress to invasive melanoma, according to Dr. Marmur. Typically, a lentigo maligna undergoes extended gradual horizontal growth before beginning a vertical growth phase.
"It spreads like an oil slick for many years," Dr. Marmur said at the seminar.
Established treatment modalities for patients who aren’t surgical candidates include cryotherapy, radiotherapy, and topical imiquimod 5%. All have disadvantages, including high 5-year recurrence rates.
Dr. Marmur noted that a newer nonsurgical therapy drawing considerable interest involves off-label use of topical combination therapy with imiquimod and tazarotene gel. The concept is to use the topical retinoid to disrupt the stratum corneum in order to enhance imiquimod penetration, thereby achieving a greater inflammatory response than possible with imiquimod alone.
Initial data have been published by researchers at the University of Utah, Salt Lake City. They randomized 90 patients with 91 lentigo malignas to imiquimod 5% cream applied 5 days per week for 3 months or to the imiquimod regimen plus tazarotene 0.1% gel on the other 2 days per week. After 3 months of topical therapy, patients underwent conservative staged excision with frozen section analysis with Melan A immunostaining to confirm negative margins.
Of those treated with dual topical therapy for 3 months, 29 of 37 lesions (78%) had complete responses with no residual lentigo maligna at the time of staged excision. So did 27 of 42 (64%) treated with imiquimod alone (Arch. Dermatol. 2012;148:592-6).
The modest difference in outcome was not significant (P = .17). Nevertheless, the Utah investigators wrote that topical pretreatment appears to reduce surgical defect sizes, an important consideration in lentigo maligna because the lesions are often large and located on cosmetically sensitive facial sites. At the patient’s first visit, the researchers saucerize the entire tumor to remove all visible evidence of lentigo maligna and nip in the bud any invasive element that might be present. One month later, after the wound has healed by secondary intention, the patient begins topical imiquimod therapy 5 days per week. If no inflammation is observed, tazarotene gel is added on the other 2 days per week. After 3 months of topical therapy, the patient goes off treatment for 2 months so the inflammatory response can subside. Then a staged excision is performed with 2-mm margins around the perimeter of the original tumor outline.
"This is an interesting thought, but it’s still not considered standard of care," Dr. Marmur commented in describing the Utah research.
Session chair Dr. Allan C. Halpern, chief of the dermatology service at Memorial Sloan-Kettering Cancer Center in New York, said he and his colleagues, like the Utah group, are using a lot of topical imiquimod as adjunctive therapy for lentigo maligna.
"Because we’re a referral center, we see all those patients whose melanomas unfortunately do recur at the edge of large surgeries. We see a lot of patients whose local surgeons have chased around their faces for a certain amount of time. So I think the general concept of the cure rates of surgery is a bit overstated. I’m not trying to sell an off-label use of a drug, but I think sometimes imiquimod can be very helpful," Dr. Halpern said.
He offered a clinical pearl in diagnosing lentigo maligna: Consider a broad shave biopsy of a suspicious lesion rather than a deeper, smaller-diameter biopsy.
"Sampling errors are a real problem with lentigo maligna. We learned early on that if you take a large lentigo maligna and do multiple biopsies of the same lesion and send them to what we think are our very expert pathologists, on average, we get two or three back that were melanoma and two or three back that were pigmented actinic keratoses. The sampling error tends to be more in the horizontal than in the depth for these very early lesions," according to Dr. Halpern.
Dr. Marmur and Dr. Halpern reported having no relevant financial interests. SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
Toxins detected in laser hair removal plume
BOSTON – Performing laser hair removal might be hazardous to your health.
Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.
The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.
Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.
The compounds included:
• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.
• 2-Methylpyridine, which can cause headache and nausea.
• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.
• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.
• Various soap and perfume components of unknown toxicity.
The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.
Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.
"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.
Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.
"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.
The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.
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Neil Osterweil/IMNG Medical Media
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I think these findings raise a significant concern about safety, especially for those who repeatedly perform laser hair removal procedures. My guess is that we and our staff are at risk when we do these procedures, and so probably are the patients in that room, and the patients in the neighboring room and the hallway. For those repeatedly performing the procedure, those risks are magnified.
Short of wearing a re-breather-type respirator such as those worn by workers who handle hazardous materials, masks and evacuators may not offer sufficient protection against prolonged, repeated exposures to the chemical constituents of laser plumes.
Dr. Jeffrey Dover is the president of ASLMS and a dermatologist in private practice in Chestnut Hill, Mass.
|
Neil Osterweil/IMNG Medical Media
|
I think these findings raise a significant concern about safety, especially for those who repeatedly perform laser hair removal procedures. My guess is that we and our staff are at risk when we do these procedures, and so probably are the patients in that room, and the patients in the neighboring room and the hallway. For those repeatedly performing the procedure, those risks are magnified.
Short of wearing a re-breather-type respirator such as those worn by workers who handle hazardous materials, masks and evacuators may not offer sufficient protection against prolonged, repeated exposures to the chemical constituents of laser plumes.
Dr. Jeffrey Dover is the president of ASLMS and a dermatologist in private practice in Chestnut Hill, Mass.
|
Neil Osterweil/IMNG Medical Media
|
I think these findings raise a significant concern about safety, especially for those who repeatedly perform laser hair removal procedures. My guess is that we and our staff are at risk when we do these procedures, and so probably are the patients in that room, and the patients in the neighboring room and the hallway. For those repeatedly performing the procedure, those risks are magnified.
Short of wearing a re-breather-type respirator such as those worn by workers who handle hazardous materials, masks and evacuators may not offer sufficient protection against prolonged, repeated exposures to the chemical constituents of laser plumes.
Dr. Jeffrey Dover is the president of ASLMS and a dermatologist in private practice in Chestnut Hill, Mass.
BOSTON – Performing laser hair removal might be hazardous to your health.
Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.
The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.
Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.
The compounds included:
• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.
• 2-Methylpyridine, which can cause headache and nausea.
• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.
• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.
• Various soap and perfume components of unknown toxicity.
The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.
Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.
"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.
Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.
"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.
The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.
BOSTON – Performing laser hair removal might be hazardous to your health.
Laser plumes emitted during the procedure contain "a cocktail of volatile organic compounds," at least 13 of which are known to be hazardous to human health, Dr. Gary S. Chuang, of the department of dermatology at Tufts Medical Center, Boston, said at the annual meeting of the American Society for Laser Medicine and Surgery.
The findings further highlight the potential for harm that have already been demonstrated in association with laser procedures in the absence of safeguards such as adequate ventilation, smoke evacuators, and adequate personal protection.
Dr. Chuang and his colleagues at Massachusetts General Hospital, Harvard School of Public Health, and Boston University subjected donor hair samples to a single pulse from a diode or Alexandrite laser, captured the plumes produced, and examined them with gas chromatography. They detected the presence of approximately 300 distinct chemical compounds, 40 of which occurred in higher concentrations and 13 of which have been shown to be harmful in human and animal studies.
The compounds included:
• Benzene, toluene, and ethylbenzene (commonly found in car exhaust, cigarette smoke, glue, paint, wax and detergents, and linked to leukemia and bone marrow abnormalities.
• 2-Methylpyridine, which can cause headache and nausea.
• Diethyl phthalate, used in cosmetics and fragrances, has been shown to cause birth defects in pregnant rats.
• Trimethyl disulfide, which is primarily responsible for the foul odor from singed hair.
• Various soap and perfume components of unknown toxicity.
The researchers also collected dust samples over time to look for the concentration of particles smaller than 1 micron with and without a high-efficiency particulate air (HEPA) equipped smoke evacuator.
Normal street-level concentrations of ultrafine particles are about 4,000/cm3 per cubic centimeter, Dr. Chuang noted. When the investigators took the dust counter into the laser center waiting room, the level jumped to about 16,000/cc. During a laser procedure, the levels rose to nearly 450,000/cc. The levels slowly declined over the next 20 minutes, but still remained about fourfold higher than normal concentrations, he said.
"The National Institute of Occupational Safety and Health recommends that with any surgical procedure that produces a plume, you want a capture velocity of about 100-150 ft/minute, and hopefully, (the evacuator) will have a HEPA filter or ultralow penetrance filter that can remove about 99.97% of airborne particulates up to 0.3 microns or greater," he said.
Additionally, the vacuum must be no farther than 2 inches from the source, because the suction velocity decreases at greater distances. All personnel in the treatment room should wear surgical masks with a NIOSH rating of N95 or greater, he recommended.
"With chemicals, most masks are useless, so hopefully you will get an evacuator that has a chemical cartridge impregnated with charcoal, and that’s able to take out the majority of the [chemicals]," Dr Chuang said.
The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.
AT LASER 2013
Major finding: During a laser procedure, the level of ultrafine particles rose to nearly 450,000/cc.
Data source: Gas chromatography and dust-sample analysis of smoke plumes from laser-destroyed hair samples.
Disclosures: The study was internally supported. Dr. Chuang reported having no relevant financial disclosures.
FDA panel supports injectable midface filler
GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.
At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.
The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.
This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.
Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.
The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.
Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.
At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.
The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.
Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.
Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.
However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.
A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.
The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.
Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.
The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.
No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.
The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.
The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.
During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.
Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.
GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.
At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.
The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.
This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.
Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.
The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.
Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.
At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.
The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.
Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.
Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.
However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.
A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.
The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.
Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.
The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.
No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.
The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.
The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.
During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.
Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.
GAITHERSBURG, MD. – A Food and Drug Administration advisory panel unanimously recommended approval of an injectable filler specifically for use in the midface.
At a May 2 meeting, the members of the FDA’s General and Plastic Surgery Devices Panel supported approval of Allergan’s Juvéderm Voluma XC (Voluma) for the correction of age-related volume loss in the midface. The FDA usually follows the recommendations of its advisory panels, which are not binding.
The meeting was held for the panel to discuss, make recommendations, and vote on information related to the premarket approval application for Voluma. Voluma is a biodegradable dermal filler that combines low- and high-molecular-weight hyaluronic acid (20 mg/mL) and 0.3% lidocaine in phosphate-buffered saline.
This new formulation distinguishes Voluma from other injectable products, noted Joseph Nielsen, Ph.D., a biologist with the FDA’s Center for Drug Evaluation and Research.
Voluma’s combination of high- and low-molecular-weight hyaluronic acid creates a thicker product with a jamlike consistency that is designed for deeper injections, said Dr. Rui Avelar, chief medical officer for Allergan. Voluma is indicated specifically for deep injections (subcutaneous and/or supraperiosteal) to correct age-related volume loss in the midface. No products are currently approved in the United States for this indication, although Voluma is approved in 65 countries, including Canada and Australia.
The approval was based on data from a randomized clinical trial. The study population included adults aged 35-65 years (mean age, 55 years). Approximately 80% of the patients were women, more than half were white, and 44% were Fitzpatrick skin types IV, V, and VI. A total of 235 patients were randomized to immediate treatment with Voluma, and 47 served as nontreatment controls to receive injections 6 months later; 208 treatment patients and 36 nontreatment controls had complete data for evaluation at 6 months.
Primary effectiveness was based on the blinded live evaluation of two investigators using the Mid-Face Volume Deficit Scale (MFVDS), a 0-5 point scale approved and validated for the study. Significant response was defined as at least a 1-point change in the MFVDS. In addition, three-dimensional imaging was used to assess changes in volume. Imaging data were not collected from nonresponders.
At 6 months, 86% of the treatment patients and 35% of the untreated controls met the response criteria. In addition, the evaluators rated 82% of treatment patients and 22% of controls as "improved" or "much improved," compared with pretreatment photos using the Global Aesthetic Improvement Scale, and 93% of treated patients rated themselves as improved or much improved, compared with pretreatment photos.
The average initial treatment was 5.2 mL, and 82% of treated patients received an optional touch-up injection of an average of 2 mL 30 days after the first treatment. The injection techniques were consistent with the methods used for other currently available fillers.
Individuals were excluded from the study if they had permanent or semipermanent facial aesthetic procedures, temporary facial aesthetic procedures within the washout period, midface volume loss unrelated to age, or very thin skin in the midface.
Greater baseline volume deficit was a stronger predictor than age of the volume of filler injected, although both factors were associated with a greater volume injected, said Todd Gross, Ph.D., a biostatistician for Allergan.
However, age, volume of product injected, and tunneling technique were associated with an increased risk of adverse events, said Dr. Janette Alexander, an FDA medical officer.
A total of 33% of the participants reported treatment-related adverse events. Five patients had late-onset adverse events; three of these were deemed severe and device related. The three severe treatment-related events involved lumps at the injection sites, all of which were treated with hyaluronidase, Dr. Alexander said.
The other two serious events included a death caused by stroke 1 year after treatment, and an ischemic optic neuropathy that the FDA could not definitely deem device related.
Approximately 78% of subjects reported an injection site response, but the majority of these resolved within 30 days. Injection site responses included firmness, lumps or bumps, tenderness, swelling, pain, bruising, redness, and discoloration. Approximately 20% of treated patients reported firmness or lumps/bumps persisting longer than 30 days.
The safety profile appears similar to that of other hyaluronic acid fillers except for the duration of firmness and lumps/bumps, and the occurrence of late adverse events, Dr. Alexander said.
No increase in risk of adverse events was observed in darker skin types, said Alvin Van Orden, of the FDA’s division of biostatistics.
The panel agreed that the postapproval study of 12 months’ follow-up proposed by Allergan is adequate, but extra attention should be paid to the subset of patients with darker skin, who might respond differently to the treatment, said panel chair Dr. Joseph LoCicero III, of the State University of New York, Brooklyn.
The panelists’ comments in support of their votes included acknowledgment of the safety profile and the reversibility of the product if needed, and the benefits of having an FDA-approved product for volume enhancement.
During their discussion, the panel members also agreed that setting upper limits on filler volume, age, and relative skin thickness should be left to clinical judgment, and not contraindicated.
Members of FDA advisory panels have been cleared of potential conflicts of interest related to the products under discussion prior to the meeting.
AT AN FDA ADVISORY COMMITTEE MEETING
Technique is key for filler injection in darker skin
MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.
People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.
Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.
"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.
"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."
Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.
Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.
Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).
There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).
Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.
On Twitter @NaseemSMiller
MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.
People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.
Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.
"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.
"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."
Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.
Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.
Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).
There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).
Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.
On Twitter @NaseemSMiller
MIAMI BEACH – When considering dermal fillers for skin of color patients, remember that fewer injections can help reduce the risk of keloid formation and pigmentary changes, Dr. Valerie D. Callender said at the annual meeting of the American Academy of Dermatology.
People with skin of color made up 20% of the patient population seeking cosmetic procedures in 2011, and they are the fastest-growing demographic group in the U.S. population, Dr. Callender said. Dermatologists can expect to see more patients with ethnic skin in their practices, and it’s important for them to remember that not all aging skin is created equal, and that different techniques come into play for different skin types, she added.
Aging in ethnic facial skin differs from aging in lighter skin, mainly because of the photoprotective effect of melanin against UV radiation, said Dr. Callender. The effects of photodamage usually appear 10-20 years later in skin of color patients and with less severity.
"Your typical skin of color patient is 45 years old, has some volume loss, some infraorbital hollowing, and is definitely concerned about laugh lines," said Dr. Callender.
"The No. 1 tip is to minimize the number of injections to minimize the risk of postinflammatory hyperpigmentation," she emphasized. "If there is erythema, apply a topical corticosteroid."
Hyaluronic acid fillers are among the top five nonsurgical cosmetic procedures in the United States, but there is a paucity of published studies in skin of color patients, said Dr. Callender of Howard University, Washington. The population included in large, pivotal clinical studies is composed mainly of white patients, and even if these studies include a subset of skin of color patients, they don’t specifically report on treatment and safety outcomes in those patients, Dr. Callender said.
Dr. Callender listed several published and unpublished studies including data on the use of fillers in patients with Fitzpatrick Skin Types IV to VI. The products studied included Restylane, Perlane, Juvéderm Ultra and Ultra Plus, Hylaform, Hylaform Plus, Captique, Belotero Balance, and Radiesse.
Pigmentary changes were common throughout the studies, but they did not affected more than 9% of the study population, according to Dr. Callender. In the Radiesse study, the authors concluded that lack of pigmentary changes may have occurred from a deeper injection level, compared with HA fillers, she noted. No keloids or scarring were reported at 6 months’ follow-up and the investigators used a 25- to 27-gauge needle (Dermatol. Surg. 2009; 35:1641-5).
There have been no formal clinical trials evaluating safety of Sculptra in skin of color patients, said Dr. Callender, director of Callender Dermatology & Cosmetic Center, Glenn Dale, Md. However, the investigators in a 2010 study advised clinicians to lower the injection time, use proper product reconstitution and proper produce placement, perform immediate and postoperative massage, and avoid Sculptra on patients with a history of keloids in order to reduce the risk of adverse events (J. Drugs Dermatol. 2010;9:451-6).
Dr. Callender has been a consultant and investigator for Allergan, Galderma, Medicis, and Merz.
On Twitter @NaseemSMiller
EXPERT ANALYSIS FROM THE AAD ANNUAL MEETING
Microwaves offer solution for stubborn sweat glands
A novel noninvasive microwave technology is proving safe and effective for the treatment of axillary hyperhidrosis.
The treatment, which involves the delivery of microwave energy to eliminate sweat glands, has been used in more than 6,000 patients and is a welcome addition to a limited range of treatments for hyperhidrosis, Dr. Carolyn Jacob reported in Seminars in Cutaneous Medicine and Surgery.
Topical treatments, oral anticholinergics, surgical procedures, laser treatment, and injections all provide some benefit but have fallen short of the safe, long-term results patients want, said Dr. Jacob of Northwestern University, Chicago.
Microwaves, first introduced for medical use in the 1970s in surgical coagulation devices, can penetrate to depths where eccrine sweat glands are found.
"This depth is achieved by the use of an antenna that preferentially targets the skin-adipose interface, where most eccrine glands reside. There is an extremely dense network of sweat glands in the axillae (greater than 50,000), and their depth can vary from 2 to 5 mm below the skin surface, depending on the patient’s skin thickness," Dr. Jacob explained, adding that the microwave energy is concentrated along the dermal-adipose to create a focal energy zone.
"At the same time, continuous hydroceramic cooling prevents thermal conduction of heat superficially. The heat at the dermal-adipose energy zone leads to thermolysis of the eccrine glands," she said in her review article (Semin. Cutan. Med. Surg. 2013;32:2-8).
The current protocol for microwave therapy is two microwave treatments with a 3-month interval. Most patients experience mild edema and discomfort for a few days, and in rare cases, edema will occur outside of the treatment area (often in the dependent portion of the underarm and upper chest), Dr. Jacob noted. These effects resolve with standard posttreatment care, including application of ice packs for 20 minutes every 3-5 hours as needed and use of ibuprofen every 4-6 hours for 3 days.
In a recent Canadian study of this technology for axillary hyperhidrosis, 90% of 31 patients reported efficacy that persisted after 12 months, and patient satisfaction was 90% at 12 months (Dermatol. Surg. 2012;38:728-35).
Further follow-up showed 100% efficacy and 100% patient satisfaction at 18 months, the investigators reported.
"Efficacy was defined as a drop [in the Hyperhidrosis Disease Severity Scale] from 3 or 4 to a 1 or 2," noted Dr. Jacob, who was not involved in the study.
The average patient’s sweat reduction was 82%. Histology showed sweat gland necrosis at 11 days and sweat gland reduction at 6 months.
"The treatment of primary axillary hyperhidrosis can be rewarding using noninvasive microwave technology. Because the microwaves preferentially target the region of skin where the sweat glands reside, leading to localized thermolysis of the sweat glands, patients can now benefit from permanent targeted sweat reduction," Dr. Jacob said. With more studies and experience using this technology, parameters will be tightened, side effects further decreased, and patient satisfaction increased, she added.
Dr. Jacob is a board member of Miramar, which funded the Canadian study and manufactures microwave devices used to treat axillary hyperhidrosis.
A novel noninvasive microwave technology is proving safe and effective for the treatment of axillary hyperhidrosis.
The treatment, which involves the delivery of microwave energy to eliminate sweat glands, has been used in more than 6,000 patients and is a welcome addition to a limited range of treatments for hyperhidrosis, Dr. Carolyn Jacob reported in Seminars in Cutaneous Medicine and Surgery.
Topical treatments, oral anticholinergics, surgical procedures, laser treatment, and injections all provide some benefit but have fallen short of the safe, long-term results patients want, said Dr. Jacob of Northwestern University, Chicago.
Microwaves, first introduced for medical use in the 1970s in surgical coagulation devices, can penetrate to depths where eccrine sweat glands are found.
"This depth is achieved by the use of an antenna that preferentially targets the skin-adipose interface, where most eccrine glands reside. There is an extremely dense network of sweat glands in the axillae (greater than 50,000), and their depth can vary from 2 to 5 mm below the skin surface, depending on the patient’s skin thickness," Dr. Jacob explained, adding that the microwave energy is concentrated along the dermal-adipose to create a focal energy zone.
"At the same time, continuous hydroceramic cooling prevents thermal conduction of heat superficially. The heat at the dermal-adipose energy zone leads to thermolysis of the eccrine glands," she said in her review article (Semin. Cutan. Med. Surg. 2013;32:2-8).
The current protocol for microwave therapy is two microwave treatments with a 3-month interval. Most patients experience mild edema and discomfort for a few days, and in rare cases, edema will occur outside of the treatment area (often in the dependent portion of the underarm and upper chest), Dr. Jacob noted. These effects resolve with standard posttreatment care, including application of ice packs for 20 minutes every 3-5 hours as needed and use of ibuprofen every 4-6 hours for 3 days.
In a recent Canadian study of this technology for axillary hyperhidrosis, 90% of 31 patients reported efficacy that persisted after 12 months, and patient satisfaction was 90% at 12 months (Dermatol. Surg. 2012;38:728-35).
Further follow-up showed 100% efficacy and 100% patient satisfaction at 18 months, the investigators reported.
"Efficacy was defined as a drop [in the Hyperhidrosis Disease Severity Scale] from 3 or 4 to a 1 or 2," noted Dr. Jacob, who was not involved in the study.
The average patient’s sweat reduction was 82%. Histology showed sweat gland necrosis at 11 days and sweat gland reduction at 6 months.
"The treatment of primary axillary hyperhidrosis can be rewarding using noninvasive microwave technology. Because the microwaves preferentially target the region of skin where the sweat glands reside, leading to localized thermolysis of the sweat glands, patients can now benefit from permanent targeted sweat reduction," Dr. Jacob said. With more studies and experience using this technology, parameters will be tightened, side effects further decreased, and patient satisfaction increased, she added.
Dr. Jacob is a board member of Miramar, which funded the Canadian study and manufactures microwave devices used to treat axillary hyperhidrosis.
A novel noninvasive microwave technology is proving safe and effective for the treatment of axillary hyperhidrosis.
The treatment, which involves the delivery of microwave energy to eliminate sweat glands, has been used in more than 6,000 patients and is a welcome addition to a limited range of treatments for hyperhidrosis, Dr. Carolyn Jacob reported in Seminars in Cutaneous Medicine and Surgery.
Topical treatments, oral anticholinergics, surgical procedures, laser treatment, and injections all provide some benefit but have fallen short of the safe, long-term results patients want, said Dr. Jacob of Northwestern University, Chicago.
Microwaves, first introduced for medical use in the 1970s in surgical coagulation devices, can penetrate to depths where eccrine sweat glands are found.
"This depth is achieved by the use of an antenna that preferentially targets the skin-adipose interface, where most eccrine glands reside. There is an extremely dense network of sweat glands in the axillae (greater than 50,000), and their depth can vary from 2 to 5 mm below the skin surface, depending on the patient’s skin thickness," Dr. Jacob explained, adding that the microwave energy is concentrated along the dermal-adipose to create a focal energy zone.
"At the same time, continuous hydroceramic cooling prevents thermal conduction of heat superficially. The heat at the dermal-adipose energy zone leads to thermolysis of the eccrine glands," she said in her review article (Semin. Cutan. Med. Surg. 2013;32:2-8).
The current protocol for microwave therapy is two microwave treatments with a 3-month interval. Most patients experience mild edema and discomfort for a few days, and in rare cases, edema will occur outside of the treatment area (often in the dependent portion of the underarm and upper chest), Dr. Jacob noted. These effects resolve with standard posttreatment care, including application of ice packs for 20 minutes every 3-5 hours as needed and use of ibuprofen every 4-6 hours for 3 days.
In a recent Canadian study of this technology for axillary hyperhidrosis, 90% of 31 patients reported efficacy that persisted after 12 months, and patient satisfaction was 90% at 12 months (Dermatol. Surg. 2012;38:728-35).
Further follow-up showed 100% efficacy and 100% patient satisfaction at 18 months, the investigators reported.
"Efficacy was defined as a drop [in the Hyperhidrosis Disease Severity Scale] from 3 or 4 to a 1 or 2," noted Dr. Jacob, who was not involved in the study.
The average patient’s sweat reduction was 82%. Histology showed sweat gland necrosis at 11 days and sweat gland reduction at 6 months.
"The treatment of primary axillary hyperhidrosis can be rewarding using noninvasive microwave technology. Because the microwaves preferentially target the region of skin where the sweat glands reside, leading to localized thermolysis of the sweat glands, patients can now benefit from permanent targeted sweat reduction," Dr. Jacob said. With more studies and experience using this technology, parameters will be tightened, side effects further decreased, and patient satisfaction increased, she added.
Dr. Jacob is a board member of Miramar, which funded the Canadian study and manufactures microwave devices used to treat axillary hyperhidrosis.
FROM SEMINARS IN CUTANEOUS MEDICINE AND SURGERY
Major finding: Efficacy and patient satisfaction were 100% at 18 months after treatment.
Data source: Single-group unblinded study involving 31 adults with primary axillary hyperhidrosis.
Disclosures: Dr. Jacob reported having no disclosures.
RF technology altering skin rejuvenation, fat reduction
LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.
"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."
As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."
He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53 C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.
"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.
In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.
In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."
Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."
His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."
He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.
Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46 C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."
The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."
The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm2, 25 cm2, 30 cm2, and 40 cm2. This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.
Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."
In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m2 who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.
Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.
LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.
"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."
As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."
He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53 C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.
"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.
In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.
In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."
Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."
His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."
He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.
Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46 C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."
The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."
The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm2, 25 cm2, 30 cm2, and 40 cm2. This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.
Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."
In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m2 who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.
Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.
LAS VEGAS – Current radiofrequency technologies, which yield measurable results in little or no down time, have altered the way clinicians and patients alike think about cervicofacial skin tightening and reduction of body fat, according to Dr. Paul J. Carniol.
"These devices do not replace surgery," he said at the annual meeting of the American Academy of Cosmetic Surgery. "They do not replace a facelift or liposuction, but they have a role for patients who tell you they don’t want to undergo a surgical procedure."
As radiofrequency (RF) technology evolves, its application in cosmetic dermatology "is just going to get better," predicted Dr. Carniol, a cosmetic, laser, and reconstructive plastic surgeon in Summit, N.J. "It’s something to keep your eye on because these devices have changed in the past few years, and they continue evolving."
He discussed his experience using the Pellevè Wrinkle Reduction System (Ellman International, Oceanside, N.Y.) for skin tightening and wrinkle reduction. This 4.0-MHz high-frequency RF device produces lateral thermal spread on the dermal layer of skin, reducing the risk of injury to surrounding tissue and structures. Therapeutic levels of heat delivered at intradermal temperatures that range from 39 to 53 C induce collagen contraction, neocollagenesis, and elastin uniformity, resulting in firmer, denser rejuvenated skin with restored elasticity. The initial wound healing response takes 3-4 weeks.
"It’s great for the patient who comes in and wants no down time, a little bit of tightening, and they want some global facial rejuvenation," Dr. Carniol said of the Pellevè system, which was cleared by the Food and Drug Administration in 2009 for the nonablative treatment of mild to moderate facial wrinkles and rhytids for Fitzpatrick skin types I-IV. The technology is contraindicated for patients with pacemakers, implantable cardioverter defibrillators, and any other implanted devices.
In one study, 93 patients were followed for 6 months after a single treatment with the Pellevè system. The response rate was determined by three independent, blinded assessors, including two facial plastic surgeons and one dermatologist (J. Drugs Dermatol. 2007;6:381-6). The response rates at 30, 90, and 180 days were 90.3%, 88.2%, and 87.1%, respectively.
In Dr. Carniol’s clinical experience, the ideal patients for the Pellevè system include those aged 35-60 years who present with modest to moderate laxity, but relatively elastic skin, moderate submental sagging, lax jaw lines and early jowls, moderate nasolabial folds, perioral and periorbital wrinkles, and/or relatively thin connective tissue layers. "You also want patients who aren’t that heavy," he said. "If someone is very overweight, the device is not going to work because the effect of all the excess tissue is too much."
Other poor candidates for the procedure include those with severely photodamaged skin, severe laxity or sagging, very deep wrinkles or muscle motion–induced rhytids, thick connective tissues, and/or unrealistic expectations. Post treatment, he said, "there is essentially no down time, which is one of the reasons that it’s such a great procedure, because your patients can take a break from work, come in, and return right to work."
His posttreatment instructions include washing the skin with tepid water and a gentle cleanser, use of nonirritating moisturizers, and use of sun block with UVA and UVB protection with an SPF of 30 or greater. The Pellevè treatment may be combined with fractionated resurfacing, but RF treatment "should be done at least 4 weeks prior to the laser treatment," he advised. "Pellevè may also be given with other treatments such as neurotoxins and fillers. Most physicians recommend this either at least 2 weeks prior to radiofrequency or at 1-2 weeks after injection after tissue reactions have subsided."
He also advised suspending the use of topical agents, which may cause erythema or irritation, for a week before and a week after Pellevè treatment; these agents include retinol/Retin-A (tretinoin)/isotretinoin, glycolic acid, and salicylic acid.
Dr. Carniol also discussed his experience with truSculpt (Cutera, Brisbane, Calif.), a monopolar RF device cleared for deep tissue heating and the temporary reduction in the appearance of cellulite. It features a large applicator that delivers energy 1.3-3 cm into the skin to targeted subcutaneous tissue before dispersing in underlying highly conductive fluids and tissues. The goal is for patients to be treated at the highest temperature that they can comfortably tolerate, typically between 42 and 46 C. Pulse durations of 4 minutes are recommended for each imprint. "Treatment should be uncomfortable, but not unbearable," he said. "Moderate hyperemia is expected and will persist for several hours."
The subcutaneous heating creates apoptosis, "a process whereby the cells resorb over a period of 3-12 weeks," explained Dr. Carniol. "It’s a very slow and gradual loss of fat cells compared with necrosis, which gives you instantaneous cell death and an acute inflammatory response and indurations."
The truSculpt device includes a proprietary contoured design to ensure uniform delivery and current. The electrode is available in four sizes: 15 cm2, 25 cm2, 30 cm2, and 40 cm2. This design "optimizes treatment uniformity over large exposure areas, which results in enhanced patient comfort and no hot spots or edge effects to cause pain," Dr. Carniol said.
Studies using before and after ultrasound images have demonstrated that the technology reduces treated areas of subcutaneous fat by up to 25%. "In general, I don’t think you see as much improvement with just one treatment," he noted. "I think it takes two to three treatments for best results."
In his clinical experience, the ideal patients for the procedure include those in generally good health with a body mass index between 22 and 28 kg/m2 who have focal areas that they want reduced. The device is indicated for use on all Fitzpatrick skin types and tanned skin.
Dr. Carniol disclosed that he has given presentations for Ellman and Cutera, but said that he has no relevant financial interests in either company.
EXPERT ANALYSIS FROM THE AACS ANNUAL MEETING
Where Belotero Balance excels in cosmetic dermatology
MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.
"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.
The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.
For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.
"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.
Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.
To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.
Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.
"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.
On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.
"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.
The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:
– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."
– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.
– Expect the results to last at least 6 months before beginning to fade.
– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.
– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.
Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.
MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.
"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.
The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.
For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.
"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.
Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.
To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.
Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.
"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.
On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.
"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.
The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:
– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."
– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.
– Expect the results to last at least 6 months before beginning to fade.
– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.
– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.
Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.
MAUI, HAWAII – Belotero Balance, the most recent filler to receive Food and Drug Administration approval, offers unique advantages over other hyaluronic acid fillers in treatment of superficial fine lines and wrinkles in the perioral area, according to Dr. Mark G. Rubin, a dermatologist in Beverly Hills, Calif.
"This product has become my collagen replacement. It’s a filler you want to inject into the dermis. It enables dermatologists to go after very superficial thin lines without causing lumpiness, ridges, or the Tyndall effect," he said at the Hawaii Dermatology Seminar sponsored by Global Academy for Medical Education/Skin Disease Education Foundation.
Be aware, though, that this is not a product to use straight out of the box. Unlike the older, widely used hyaluronic acid fillers Restylane and Juvederm, it doesn’t come premixed with anesthetic, so patients will find that Belotero injected without first being diluted with lidocaine hurts more than other fillers.
The other reason Dr. Rubin dilutes Belotero is that even though it is thinner and softer than other hyaluronic acid fillers, it can still result in unsightly ridges lasting for several weeks if injected intradermally in too strong a concentration.
For treatment of thin perioral lines, he typically dilutes 1 cc of Belotero with 0.5 cc of 1% lidocaine with epinephrine. He favors a serial puncture technique, although some other cosmetic dermatologists prefer a linear threading strategy.
"This behaves a lot like Zyderm did. It can be injected superficially and still give people significant improvement in very fine lines," said Dr. Rubin, also of the University of California, San Diego.
Zyderm and other collagen implants were taken off the U.S. market by FDA request. Cosmetic dermatologists have been looking for a suitable replacement thin filler for superficial use ever since – and Belotero is it, he said.
To treat deeper folds and contour irregularities, Dr. Rubin will dilute 1 cc of Belotero with 0.3 cc of 1% lidocaine with epinephrine, which provides more lift. Sometimes he’ll partially fill in a deeper perioral line with the less dilute product before topping it off with the more dilute version in the same treatment session.
Belotero Balance is a non-animal–derived hyaluronic acid–based cohesive gel that is crosslinked twice. Its clinical behavior is significantly different from the other hyaluronic acid products; it’s stretchy, like a rubber band, while the earlier-generation hyaluronic acid fillers tend to break when stretched, the dermatologist explained.
"It’s like an amoeba, working its way between cells and fibers. It really does smooth out better than the hyaluronic acids we’re used to," he continued.
On the other hand, Belotero provides less lift when injected deep than the other hyaluronic acid fillers.
"It’s not a go-to product for volume replacement. It requires more product to achieve a similar result. I still use a lot of Restylane and Juvederm, particularly where I’m looking for volume," Dr. Rubin said.
The FDA approval of Belotero Balance was based upon a phase III study of 118 patients. In contrast, Dr. Rubin has injected more than 1,300 syringes of Belotero into his patients. He offered several tips based upon his experience:
– Don’t overcorrect. "Correct to 100%. Because of the dilution, a week or two later the patient will no longer be filled all the way and may need a second treatment," Dr. Rubin said. "I tell patients who come in for superficial wrinkle therapy that they’re going to be treated twice. They’ll have a good result the first time and they’ll have a great result the second time when they come in a couple weeks later."
– Massage the treated area vigorously right after the injection to help smooth out the product. "I’ll stick my finger inside their cheek and squash them hard for 5 seconds," he said.
– Expect the results to last at least 6 months before beginning to fade.
– Anticipate a day or two of beadiness or ridging until the Belotero settles into the skin. Occasionally this can take up to 5 or 6 days.
– Consider prescribing an antihistamine if the ridging and edema lasts more than about 5 days. "There is some type of a histamine-mediated response in those patients. It almost looks urticarial. It’s a small group, probably no greater than 5%-10% of the people I inject, who have this persistent ridginess and puffiness," Dr. Rubin said.
Dr. Rubin reported serving as a paid researcher and consultant for Medicis, but has no financial relationship with Merz, which markets Belotero Balance. SDEF and this news organization are owned by the same parent company.
EXPERT ANALYSIS FROM SDEF HAWAII DERMATOLOGY SEMINAR
The nose knows: Improved rhinophyma with fractional CO2 ablation
BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Patients with rhinophyma who were treated with a fractional ablative CO2 laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.
"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.
Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.
Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.
CO2 laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO2 lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.
In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.
Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.
"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.
Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.
Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.
In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.
The study was internally funded. Dr. Serowka had no financial conflicts to disclose.
BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Patients with rhinophyma who were treated with a fractional ablative CO2 laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.
"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.
Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.
Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.
CO2 laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO2 lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.
In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.
Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.
"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.
Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.
Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.
In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.
The study was internally funded. Dr. Serowka had no financial conflicts to disclose.
BOSTON – Fractional ablative carbon dioxide lasers are safe and effective for the treatment of mild to moderate rhinophyma, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
Patients with rhinophyma who were treated with a fractional ablative CO2 laser had less downtime and good cosmetic results with few complications compared with other therapies in a case series of five patients, reported Dr. Kathryn Serowka, a dermatology resident at the University of California at Irvine.
"All our patients show complete re-epithelialization within 4-7 days, edema and erythema are mild and self-limited, and there is a low risk for adverse events, Dr. Serowa said. "We recommend this treatment for your patients with mild to moderate rhinophyma, as you’re not going to get the efficacy of a fully ablative laser, but by using higher [energy] densities, you can get good debulking while still maintaining the advantages of your fractionated treatment," she said.
Rhinophyma is a common form of rosacea characterized by erythema, sebaceous hyperplasia, and nodular swelling of skin on the nose. The comedian W.C. Fields, with his famously bulbous nose, is probably the best known example of a person with rhinophyma, Dr. Serowka noted.
Many treatments for rhinophyma have been tried, alone or in combination, and many have been found wanting, she said. Treatments include loop cautery argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel.
CO2 laser resurfacing is effective, and it is often regarded as a first-line therapy for significant debulking of severe rhinophyma, with the potential for dramatically improving the texture and contour of the nose. But fully ablative CO2 lasers have a high side-effect profile, and have the potential to cause persistent erythema and edema, scarring, and loss of pigmentation.
In contrast, fractional ablative lasers allow delivery of thermal energy to tissue in an array of microscopic treatment zones surrounded by uninvolved skin. Following laser application, the untreated skin areas can rapidly repopulate the ablated areas of tissue, leading to healing with shorter downtime and minimal side effects.
Although the settings vary slightly according to the device used, Dr. Serowa and colleagues set their laser at 70 mJ energy at 70% density for 8 passes, but instead deliver the energy in 14-18 passes, yielding an approximate energy density of 92%.
"This allows for significant debulking of the nose, and we can then perform fewer passes and lower our density in the less sebaceous areas of the nose, and feather the treatment at the periphery in order to get a natural, blended appearance," she said.
Because of the significant tissue debulking involved, Dr. Serowa and colleagues give patients herpes simplex virus prophylaxis with acyclovir or valacyclovir prior to treatment, and all are anesthetized with a lidocaine and epinephrine regional perinasal nerve block.
Patients are discharged from the clinic with instructions for wound care with daily changes of dressing for the week after surgery, Dr. Serowka said. But most do not require pain medication, because discomfort with the procedure is minimal, she added.
In her experience, patients with mild to moderate rhinophyma had significant physician-rated and patient-rated reduction of rhinophyma and improvement of appearance with no adverse events and no scarring, she said.
The study was internally funded. Dr. Serowka had no financial conflicts to disclose.
AT LASER 2013
Major finding: Rhinophyma patients treated with fractional ablative CO2 laser therapy re-epithelialize with 4-7 days and heal without scarring.
Data source: Single-center case series.
Disclosures: The study was internally funded. Dr. Serowka reported having no financial disclosures.
Pulsed-dye laser erased evidence of breast radiation
BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.
"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.
Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).
The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.
For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.
He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.
The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.
Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.
The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm2. The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.
The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.
Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.
The study was internally funded. Dr. Rossi reported having no financial disclosures.
BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.
"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.
Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).
The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.
For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.
He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.
The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.
Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.
The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm2. The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.
The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.
Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.
The study was internally funded. Dr. Rossi reported having no financial disclosures.
BOSTON – The appearance of radiation-induced telangectasias of the breast can be significantly improved by treatment with a pulsed-dye laser, investigators reported at the annual meeting of the American Society for Laser Medicine and Surgery.
There were no adverse treatment-associated effects, and the treatment was safe to use in breast cancer patients and women with reconstructed breasts, said Dr. Anthony Rossi, a fellow in procedural dermatology/Mohs surgery at Memorial Sloan-Kettering Cancer Center in New York.
"After treatment, all patients reported improvement, including an improved sense of confidence and aesthetic appearance, and one patient commented that she was now able to change in front of her partner without embarrassment," said Dr. Rossi.
Chronic radiation dermatitis can occur within 1 or 2 years of treatment for breast cancer. In one study, 59% of women had telangectasias within 5 years of undergoing electron-beam radiotherapy, and 72% had telangectasias at the treatment site within 7 years (Br. J. Radiol. 2002;75:444-7).
The clinical characteristics include skin atrophy, hypo- or hyperpigmentation, and prominent lesions believed to be caused by dilation of reduced or poorly supported skin vasculature. Telangectasias of the breast are typically confined to the site of the highest radiation dose and to areas that received radiation boosts, such as surgical scars.
For women who have undergone breast cancer therapy, telangectasias "can serve as a reminder of their cancer, almost akin to a surgical scar, and can prompt fears of recurrence or even social anxiety," Dr. Rossi said.
He and his colleagues conducted a retrospective study of 11 patients treated with a pulsed-dye laser for radiation-induced telangectasias, looking at radiation type and dose received; onset, color, thickness, and distribution of telangectasias; laser fluence parameters; and complications. They also evaluated patient perceptions and quality of life, and had pre- and postlaser clinical photos assessed by two independent raters to judge percentage clearance of telangectasias.
The women had received an average of 5,000 cGy (50 Gy) in 25 fractions, often with radiation boosts to the surgical scars. The telangectasias developed a mean of 3.7 years after radiation exposure.
Five patients were treated with a 595-nm pulsed-dye laser, and two with a 585-nm laser. The endpoint for all treatments was transient purpura.
The mean clearance was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9). The average laser fluence used was 7.2 J/cm2. The energy was applied with a 10-mm spot size in 3- to 6-ms pulses.
The investigators saw no adverse effects of therapy, including in women with reconstructed breasts, whether with implants or flaps.
Based on their findings, the investigators are embarking on a prospective study designed to evaluate the effect of radiation-induced telangiectasias on patient quality of life and changes in quality of life measures after laser therapy, using the Skindex-16 and BREAST-Q validated scales. They also plan to assess long-term effects on quality of life and recurrence, if any, of treated telangectasias.
The study was internally funded. Dr. Rossi reported having no financial disclosures.
AT LASER 2013
Major finding: The mean clearance of radiation-induced telangiectasias with a pulsed-dye laser was 72.7% (range, 50%-90%), after a mean of 4.3 treatments (2-9).
Data source: Retrospective case series of 11 breast cancer patients.
Disclosures: The study was internally funded. Dr. Rossi reported having no financial disclosures
Fillers a popular option for periorbital rejuvenation
LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.
"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."
According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.
"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."
Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."
Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."
When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."
When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."
In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."
When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."
Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.
LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.
"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."
According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.
"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."
Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."
Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."
When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."
When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."
In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."
When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."
Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.
LAS VEGAS – Periorbital fillers are an attractive option to the myriad of surgical face-lift procedures available to patients seeking skin rejuvenation, according to Dr. Janet M. Neigel.
"The advantages to using fillers for periorbital rejuvenation are that they are a lunchtime treatment, there’s minimal risk, it results in a natural appearance, it’s minimally invasive, and it’s a good nonsurgical alternative, especially if a patient is not ready for surgery," Dr. Neigel said at the annual meeting of the American Academy of Cosmetic Surgery. "It’s also a great way to get to know your patients before they undergo a bigger procedure."
According to statistics from the American Society of Plastic Surgeons, clinicians performed 12.2 million nonsurgical cosmetic surgical procedures in the United States in 2011. Of these, 1.9 million were fillers.
"With aging there are certain structural changes to the face, including dermal thinning, fat loss, prolapse, redistribution, and skeletal bone remodeling," said Dr. Neigel, a West Orange, N.J.–based cosmetic surgeon who specializes in plastic and reconstructive surgery of the eyes and face. "The natural oval, upside down egg shape of the face changes more to a peanut-shaped face."
Prior to using any fillers, Dr. Neigel said she examines the intended treatment area of skin for hyperpigmentation and points out the relevant spots to patients. "Sometimes patients think that the use of fillers is going to make them have normal skin," she said. "With fillers you’ll improve the shadows, but you’re not going to be able to improve the hyperpigmentation."
Her go-to products for periorbital rejuvenation include the hyaluronic acids Juvederm, Restylane, and Belotero as well as the stimulatory fillers Sculptra (poly-l-lactic acid) and Radiesse (calcium hydroxylapatite). "Crow’s feet are difficult to deal with if they don’t respond completely to your neuromodulator of choice," Dr. Neigel noted. "Botox, Dysport, or Xeomin are the first injections of choice, but I have recently been using Belotero and have been very impressed with how it can improve the eyelid area. It’s used superficially in a layered manner."
When treating the lower-lid tear trough Dr. Neigel said she makes it a point to inject deep just over the periosteum and more inferiorly on the cheek. "Many times if you just inject above the orbital rim, you’re not going to address the full defect," she said. "Oftentimes you need to inject in multiple tissue planes. I use Restylane and Belotero around the eyes, and I inject in a retrograde fashion. I’m always nervous that Juvederm is going to cause too much water to be brought in and too much swelling. I reserve Juvederm for the lower face."
When treating the midface region, Dr. Neigel said that she most often uses Sculptra. "The goal in this area is to volumize the deep medial cheek fat, try to get anterior projection of the cheek and effacement of the lower-lid bags," she said. "We’re reflating the tissue, fighting some gravity, and filling Ristow’s space."
In her clinical experience, the most common complications from using stimulator fillers are ecchymosis and edema. "I have not seen any infections," she said. "I have seen several granulomas, papules, and nodules. If you get lumpiness, you can massage and most of the time it goes away, or you can use hyaluronidase. You can get a Tyndall effect, but I have not seen it in this area. You can also get overcorrection or undercorrection."
When nodules occur, "most of the time they’re not visible," she added. "You can palpate them, but as long as they’re not visible I leave them be."
Dr. Neigel disclosed that she is a consultant for Allergan, Medicis, and Valeant.
EXPERT ANALYSIS FROM THE AACS ANNUAL MEETING
