Aesthetic Dermatology

The American Board of Dermatology's proposal to establish subspecialty certification for procedural dermatology is on hold while board leaders seek to address concerns raised by dermatology societies and individual physicians that certification could divide the specialty and lead to economic credentialing.

The board of directors of the American Board of Dermatology (ABD) will meet in December to discuss the status of the proposal.

“This process will not be completed in haste,” said Dr. Randall K. Roenigk, president of the ABD.

ABD leaders have heard the concerns of the dermatology community and are in deliberations to modify the proposal accordingly, but much of the controversy is the result of “mischaracterizations” about the impact that subspecialty certification would have for dermatologists without it, said Dr. Roenigk, chairman of the department of dermatology at the Mayo Clinic in Rochester, Minn.

The controversy began last year, when the ABD submitted an application to the American Board of Medical Specialties (ABMS) to create certification for the subspecialty of procedural dermatology. The American Society for Mohs Surgery took an early stand against the proposal and others followed.

Last month, the ABD was scheduled to submit a revised application to the ABMS Committee on Certification and Recertification but postponed on the advice of ABMS officials. In the meantime, the ABD has formed its own task force to review areas of concern raised by critics and to report back to the group's board of directors in December with specific recommendations.

Around the time that the ABD announced it was postponing its application, the American Academy of Dermatology also came out against the proposal. During an Aug. 1 meeting, the AAD board of directors approved a resolution opposing the ABD's proposal.

The American Society for Mohs Surgery, which has been critical of the move toward certification, is taking a wait-and-see attitude. Dr. Stephen Spencer, president of the society, said it will monitor the situation and evaluate a new proposal if and when it comes forward.

Despite the criticism, the ABD continues to argue that subspecialty certification in procedural dermatology is important both for patient care and for the specialty of dermatology.

There is a body of knowledge related to surgical and procedural dermatology that is not taught in dermatology residency programs and subspecialty certification would offer assurance to patients that the physician is qualified and possesses the necessary knowledge, experience, and skills. The specialty would also gain under the proposal because certification would establish surgery as an integral part of dermatology, according to ABD.

The ABD's board rebuts charges that subspecialty certification will lead to economic credentialing. Since certification would be voluntary, the lack of a subspecialty certificate would not indicate that a physician is unqualified to practice in the specialty, the ABD said.

Some critics, however, aren't satisfied with the ABD's assurances. Dr. Daniel E. Gormley, a dermatologist in Glendora, Calif., said that, as currently written, the ABD's proposal would only grant certification to dermatologists who have completed fellowship training in procedural dermatology, outside of those who would be grandfathered in. Eventually, only a small group of dermatologists would be certified to perform a wide range of procedures, he said.

Dr. Gormley said the main issue with the ABD proposal is that it will restrict the number of dermatologists who can performs Mohs surgery and related procedures. Instead of creating a small cadre of specially trained dermatologists, he said that all dermatology trainees should have the opportunity to learn these procedures during their residency.

“We want to share this knowledge and spread it around,” Dr. Gormley said.

The American Board of Dermatology's proposal to establish subspecialty certification for procedural dermatology is on hold while board leaders seek to address concerns raised by dermatology societies and individual physicians that certification could divide the specialty and lead to economic credentialing.

The board of directors of the American Board of Dermatology (ABD) will meet in December to discuss the status of the proposal.

“This process will not be completed in haste,” said Dr. Randall K. Roenigk, president of the ABD.

ABD leaders have heard the concerns of the dermatology community and are in deliberations to modify the proposal accordingly, but much of the controversy is the result of “mischaracterizations” about the impact that subspecialty certification would have for dermatologists without it, said Dr. Roenigk, chairman of the department of dermatology at the Mayo Clinic in Rochester, Minn.

The controversy began last year, when the ABD submitted an application to the American Board of Medical Specialties (ABMS) to create certification for the subspecialty of procedural dermatology. The American Society for Mohs Surgery took an early stand against the proposal and others followed.

Last month, the ABD was scheduled to submit a revised application to the ABMS Committee on Certification and Recertification but postponed on the advice of ABMS officials. In the meantime, the ABD has formed its own task force to review areas of concern raised by critics and to report back to the group's board of directors in December with specific recommendations.

Around the time that the ABD announced it was postponing its application, the American Academy of Dermatology also came out against the proposal. During an Aug. 1 meeting, the AAD board of directors approved a resolution opposing the ABD's proposal.

The American Society for Mohs Surgery, which has been critical of the move toward certification, is taking a wait-and-see attitude. Dr. Stephen Spencer, president of the society, said it will monitor the situation and evaluate a new proposal if and when it comes forward.

Despite the criticism, the ABD continues to argue that subspecialty certification in procedural dermatology is important both for patient care and for the specialty of dermatology.

There is a body of knowledge related to surgical and procedural dermatology that is not taught in dermatology residency programs and subspecialty certification would offer assurance to patients that the physician is qualified and possesses the necessary knowledge, experience, and skills. The specialty would also gain under the proposal because certification would establish surgery as an integral part of dermatology, according to ABD.

The ABD's board rebuts charges that subspecialty certification will lead to economic credentialing. Since certification would be voluntary, the lack of a subspecialty certificate would not indicate that a physician is unqualified to practice in the specialty, the ABD said.

Some critics, however, aren't satisfied with the ABD's assurances. Dr. Daniel E. Gormley, a dermatologist in Glendora, Calif., said that, as currently written, the ABD's proposal would only grant certification to dermatologists who have completed fellowship training in procedural dermatology, outside of those who would be grandfathered in. Eventually, only a small group of dermatologists would be certified to perform a wide range of procedures, he said.

Dr. Gormley said the main issue with the ABD proposal is that it will restrict the number of dermatologists who can performs Mohs surgery and related procedures. Instead of creating a small cadre of specially trained dermatologists, he said that all dermatology trainees should have the opportunity to learn these procedures during their residency.

“We want to share this knowledge and spread it around,” Dr. Gormley said.

The American Board of Dermatology's proposal to establish subspecialty certification for procedural dermatology is on hold while board leaders seek to address concerns raised by dermatology societies and individual physicians that certification could divide the specialty and lead to economic credentialing.

The board of directors of the American Board of Dermatology (ABD) will meet in December to discuss the status of the proposal.

“This process will not be completed in haste,” said Dr. Randall K. Roenigk, president of the ABD.

ABD leaders have heard the concerns of the dermatology community and are in deliberations to modify the proposal accordingly, but much of the controversy is the result of “mischaracterizations” about the impact that subspecialty certification would have for dermatologists without it, said Dr. Roenigk, chairman of the department of dermatology at the Mayo Clinic in Rochester, Minn.

The controversy began last year, when the ABD submitted an application to the American Board of Medical Specialties (ABMS) to create certification for the subspecialty of procedural dermatology. The American Society for Mohs Surgery took an early stand against the proposal and others followed.

Last month, the ABD was scheduled to submit a revised application to the ABMS Committee on Certification and Recertification but postponed on the advice of ABMS officials. In the meantime, the ABD has formed its own task force to review areas of concern raised by critics and to report back to the group's board of directors in December with specific recommendations.

Around the time that the ABD announced it was postponing its application, the American Academy of Dermatology also came out against the proposal. During an Aug. 1 meeting, the AAD board of directors approved a resolution opposing the ABD's proposal.

The American Society for Mohs Surgery, which has been critical of the move toward certification, is taking a wait-and-see attitude. Dr. Stephen Spencer, president of the society, said it will monitor the situation and evaluate a new proposal if and when it comes forward.

Despite the criticism, the ABD continues to argue that subspecialty certification in procedural dermatology is important both for patient care and for the specialty of dermatology.

There is a body of knowledge related to surgical and procedural dermatology that is not taught in dermatology residency programs and subspecialty certification would offer assurance to patients that the physician is qualified and possesses the necessary knowledge, experience, and skills. The specialty would also gain under the proposal because certification would establish surgery as an integral part of dermatology, according to ABD.

The ABD's board rebuts charges that subspecialty certification will lead to economic credentialing. Since certification would be voluntary, the lack of a subspecialty certificate would not indicate that a physician is unqualified to practice in the specialty, the ABD said.

Some critics, however, aren't satisfied with the ABD's assurances. Dr. Daniel E. Gormley, a dermatologist in Glendora, Calif., said that, as currently written, the ABD's proposal would only grant certification to dermatologists who have completed fellowship training in procedural dermatology, outside of those who would be grandfathered in. Eventually, only a small group of dermatologists would be certified to perform a wide range of procedures, he said.

Dr. Gormley said the main issue with the ABD proposal is that it will restrict the number of dermatologists who can performs Mohs surgery and related procedures. Instead of creating a small cadre of specially trained dermatologists, he said that all dermatology trainees should have the opportunity to learn these procedures during their residency.

“We want to share this knowledge and spread it around,” Dr. Gormley said.

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. ZACHARY

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

Source Courtesy Allergan Inc.

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. ZACHARY

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

Source Courtesy Allergan Inc.

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. ZACHARY

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

Source Courtesy Allergan Inc.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

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

Source Photos courtesy Dr. Kimberly Butterwick

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

Source DR. BUTTERWICK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

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

Source Photos courtesy Dr. Kimberly Butterwick

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

Source DR. BUTTERWICK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

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

Source Photos courtesy Dr. Kimberly Butterwick

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

Source DR. BUTTERWICK

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source DR. MOY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source DR. MOY

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Source DR. MOY

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. SENGELMANN

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. SENGELMANN

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

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

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

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

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

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

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

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

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

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

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

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

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

SDEF and this news organization are owned by Elsevier.

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

Source DR. SENGELMANN