Aesthetic Dermatology

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n

MIAMI BEACH — Less pain on injection, less postprocedure swelling, and greater convenience are among the advantages of hyaluronic acid and lidocaine combination products, according to two studies and a live patient demonstration at the South Beach Symposium.

Prevelle (Mentor Corp.) and Dermal Gel Extra (Genzyme Corp.) come premixed with lidocaine, thus saving preparation time for physicians who might otherwise mix in their own anesthetic. Prevelle is approved for correction of moderate-to-severe facial wrinkles and folds via injection into the mid- to deep dermis. Dermal Gel Extra (DGE) is under FDA review.

Prevelle and DGE are fully hydrated, unlike existing hyaluronic acid fillers that absorb water and increase in volume after injection. "Prevelle is like Captique with lidocaine, versus Restylane [Medicis Pharmaceutical Corp.] and Juvéderm [Allergan Inc.], which are underhydrated," said Dr. Stephen H. Mandy of the department of dermatology at the University of Miami. His disclosures include Allergan, Bioform Medical Inc., Galderma Laboratories LP, OrthoNeutrogena, Procter & Gamble, Sanofi-Aventis, and Stiefel Laboratories Inc.

Dr. Mandy and his associates assessed 45 patients in a randomized, controlled, patient-blinded comparison between Captique and Prevelle. Although participants reported pain with both fillers, there was no swelling and very little erythema. "Pain at injection was lower with Prevelle, greater than 50% less, and improves over 45 minutes."

Dr. Mandy also participated in a multicenter safety and efficacy study. The split-face comparison between DGE and Restylane included 140 patients at six U.S. centers. Although he was unable to share data, he said, "I can tell you there is less volume and less pain with [DGE], with volume filling as great as Restylane at 9 months." He added that it takes much less volume to get maximum effect, "so we should fill very conservatively."

DGE is a "very robust" filler material, Dr. Mandy said. "You can feel the difference as you inject it."

"The nice thing about the Prevelle product is the price point," said Dr. Susan H. Weinkle, a dermatologist in private practice in Bradenton, Fla. Her disclosures include Allergan, Bioform, DermAvance Pharmaceuticals Inc., Medicis, Procter & Gamble, and Stiefel.

"This is a great product for a first-time patient, [one who may be] needle-phobic or concerned about pain," said Dr. Gary D. Monheit of the department of dermatology and ophthalmology at the University of Alabama at Birmingham. Dr. Monheit's disclosures include Allergan, Dermik Laboratories, Genzyme, Medicis, Mentor Corp., Merz Pharma, and Stiefel.

Dr. Monheit injected the first patient volunteer at the meeting, a woman with asymmetrical lips and a history of lip correction. "She could benefit from a lift to the malar crease," he noted.

Use a fanning technique for volume effect on the mid-face, Dr. Monheit said. Start with injections along the nasolabial fold. "Then I like to advance to the modiolus to see the commissures go up."

As lidocaine takes effect, subsequent injections become easier, Dr. Monheit said. Prevelle "requires very little manipulation afterward—it has an even flow."

"It is important to stop [during the procedure], get a frontal look, and make sure you get same volume on both sides," Dr. Monheit said. Remember this filler is not hydrophilic, "so what you see at the end is what you will get."

Patient follow-up is important, Dr. Weinkle said. Ask patients to come back in 2 weeks to check the results, including symmetry. "Don't charge them if you use another small amount. It's all about patient retention." n

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

MONTREAL — Topical 5-fluorouracil used for the treatment of actinic keratosis can also promote dermal remodeling in photoaged skin, according to a small study.

For years, clinicians and patients have noted that, in addition to treating actinic keratosis (AK), topical 5-fluorouracil (5-FU) treatment can result in skin softening and smoothing, Dr. Sewon Kang of Johns Hopkins University, Baltimore, said at the annual meeting of the Society for Investigative Dermatology.

"We knew this anecdotally, but it had never been documented or studied at a molecular level," he said in an interview. "We did this study to confirm people's clinical observation that this happens, and added a few lab measurements to support how it might be happening."

The nonrandomized, non-vehicle-controlled study was funded by Valeant Pharmaceuticals, and Dr. Kang did not disclose any conflicts of interest.

The study included 21 subjects, aged 56–85 years, who received 5% topical 5-FU cream twice daily for 2 weeks for the treatment of facial AK. In addition to AK lesions, all patients had moderate to severe photodamage.

The subjects underwent a baseline clinical skin examination, which was repeated 1 day after the last treatment application and again at 4, 10, and 24 weeks post treatment.

Photographic evaluation was performed, and photoaging parameters were assessed according to a photonumeric scale that included wrinkling, roughness, lentigines, hyperpigmentation, and sallowness. Biopsies were also taken at the same time points.

At the end of the study, the number of AKs was reduced from almost 12 to less than 2 per patient. In addition, photoaging scores dropped from slightly less than 5.5 to about 4.6, he reported.

Biopsies were used to examine the molecular end points of epidermal injury, inflammation, dermal matrix degradation, and collagen, Dr. Kang said.

"Epidermal injury causes an inflammatory reaction in the skin, which triggers collagen repair, and we believe this is the mechanism by which topical 5-FU might improve wrinkles," he explained at the meeting.

Biopsies taken at the end of the study showed a seven-fold increase from baseline in keratin 16, a marker of epidermal injury, and a two-fold increase in inflammatory cytokine expression. Additionally, there was a statistically significant increase in the induction of collagenase (MMP-1) and stromelysin (MMP-3), markers of dermal matrix degradation, he said.

Finally, procollagen protein levels increased significantly from baseline, indicating collagen repair.

"Topical 5-FU induces epidermal wounding by a mechanism similar to microdermabrasion and certain lasers used for the treatment of photoaging. Agents that produce irritation could improve photoaging," Dr. Kang concluded.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

NATIONAL HARBOR, MD. — Improvement in melasma severity achieved by fractional photothermolysis lasted for a mean 13 months in five of eight patients, while the other three had recurrences in the first-ever study to follow these patients beyond 6 months.

"For refractory melasma, nonablative fractional photothermolysis is a good treatment option with long-term remission," Dr. Tracy M. Katz said at the annual meeting of the American Society for Laser Medicine and Surgery.

The device used in the study was a 1,550-nm erbium-doped Fraxel laser. Treatments were performed at 6–40 mJ (starting low in all patients and increasing in some), with eight passes per treatment at levels of 4–10; this corresponded to surface area coverage of 14%-29%. The laser settings were chosen based on the patients' skin type, with a maximum level of 7 for darker skin and up to 10 for lighter skin, said Dr. Katz of DermSurgery Associates, Houston.

A forced-air cooling device was set at low settings of 2–3 to decrease inflammation and reduce the risk of postinflammatory hyperpigmentation.

The eight women had a mean age of 44 years (range 27–57), with skin types II-IV, and they had melasma on the face that was refractory to hydroquinone and other traditional treatments. The mean duration of disease was 6 years. Each patient underwent two to seven treatments, at intervals of 4–6 weeks for lighter skin and 6–8 weeks for darker skin. Topical triple anesthetic was applied 1 hour prior to treatment.

Patients were instructed to use hydroquinone until 2–3 days prior to each treatment and then to restart it after their skin had healed and continue it for 2–6 months after the last laser treatment. They were seen for follow-up anywhere from 7 to 36 months after their last laser treatment, with a mean follow-up of 13 months.

Assessments were determined via side-by-side photo analysis by the treating physician (Dr. Paul Friedman) and a nontreating physician (Dr. Katz), based on a well-established quartile grading system of 1%-25%, 26%-50%, 51%-75%, and greater than 75%. At the last treatment session, two patients achieved more than 75% improvement, four had 51%-75% improvement, one had 26%-50%, and one had 1%-25% improvement.

During 7–36 months' follow-up, five patients had maintained their initial level of improvement and three had recurrence of their melasma. Two of those three patients had the lowest initial improvement (1%-25% and 26%-50%), Dr. Katz reported. Energy settings correlate with an increased depth of thermal injury, and pigment in dermal melasma is usually found up to the papillary/reticular dermal junction around 500 micrometers, with pigment being rare beyond 700 micrometers. Knowing this, energies up to 30 mJ should target most pigment, she noted.

Dr. Katz stated that there were no financial disclosures associated with her presentation.

MIAMI BEACH — Remember the three P's of perfect lip enhancement—proportion, profile, and plumping—and you are more likely to get a satisfied patient who will use their new lips to refer other patients to your office.

Always keep proportion in mind—the ideal lip size ratio is about 40% for the top lip to 60% bottom lip, Dr. Glynis R. Ablon said at the South Beach Symposium.

The main goal of augmentation is to give patients natural-looking lips versus an overdone or "trout" lip appearance. "Don't completely change their look," she said, because no one should be able to tell the lips were enhanced.

For guidance, look at very young women or men, depending on what you're doing, "and see what looks natural to you," she said.

Look at each patient in profile and keep in mind you are sculpting the appearance of their lips from all sides, Dr. Ablon said.

Err on the side of injecting less filler material versus too much. "Less is more," Dr. Ablon said.

Start with a small amount and have the patient return for additional enhancement if desired. "Make sure you don't create lips that enter the door before the patient does. Not everyone will look normal with large lips, especially in Hollywood, where I work," commented Dr. Ablon, who is in private practice in Manhattan Beach, Calif., and on the dermatology faculty at the University of California in Los Angeles.

The actress Demi Moore, for example, has thin lips and "might look strange with enhanced lips."

When injecting filler, pay particular attention to the philtrum and cupid's bow on the upper lip, she said. You can also enhance or recreate the Glogau-Klein point, the dimple in the lower lip.

A general rule for the lower lips is to only inject in the central two-thirds. "Don't go too lateral. It will look like sausage otherwise," Dr. Ablon said. One exception, she said, is a patient with significant facial wrinkles who might get improvement to the side of the mouth (below the nasolabial fold).

Always have patients seated upright to allow for normal gravity. Another tip is to start with a nonpermanent filler, something you can dissolve, Dr. Ablon said.

Juvederm (hyaluronic acid, Allergan) is her lip filler product of choice, which she also injects above the vermillion border in some patients to provide additional enhancement. "It is a softer filler, and very moldable and malleable. Patients cannot notice there is anything inside their lips." Collagen and calcium hydroxylapatite are other lip filler choices.

Surgical options include lifts and advanced flaps. "The only surgical approach I typically use is the butterfly lip lift," Dr. Ablon said at the meeting.

The technique is best suited for patients with an elongated philtrum.

The lips are very sensitive and Dr. Ablon recommends use of topical and injected analgesics, such as lidocaine, before augmentation. She also uses the ArTek cooling device (ThermoTek Inc.) to increase patient comfort during the procedure. "If the patient is miserable, they will not return."

Tips to minimize bruising include avoidance of aspirin, nonsteroidal anti-inflammatory drugs, and vitamin E, and addition of bromelain supplements (a compound from pineapple). Also, consider antiviral treatment if the patient has a history of herpes outbreaks.

Dr. Ablon disclosed that she is a member of the Medicis advisory board (makers of Restylane and Perlane fillers).

'Don't create lips that enter the door before the patient does. Not everyone will look normal with large lips.' DR. ABLON

MIAMI BEACH — Remember the three P's of perfect lip enhancement—proportion, profile, and plumping—and you are more likely to get a satisfied patient who will use their new lips to refer other patients to your office.

Always keep proportion in mind—the ideal lip size ratio is about 40% for the top lip to 60% bottom lip, Dr. Glynis R. Ablon said at the South Beach Symposium.

The main goal of augmentation is to give patients natural-looking lips versus an overdone or "trout" lip appearance. "Don't completely change their look," she said, because no one should be able to tell the lips were enhanced.

For guidance, look at very young women or men, depending on what you're doing, "and see what looks natural to you," she said.

Look at each patient in profile and keep in mind you are sculpting the appearance of their lips from all sides, Dr. Ablon said.

Err on the side of injecting less filler material versus too much. "Less is more," Dr. Ablon said.

Start with a small amount and have the patient return for additional enhancement if desired. "Make sure you don't create lips that enter the door before the patient does. Not everyone will look normal with large lips, especially in Hollywood, where I work," commented Dr. Ablon, who is in private practice in Manhattan Beach, Calif., and on the dermatology faculty at the University of California in Los Angeles.

The actress Demi Moore, for example, has thin lips and "might look strange with enhanced lips."

When injecting filler, pay particular attention to the philtrum and cupid's bow on the upper lip, she said. You can also enhance or recreate the Glogau-Klein point, the dimple in the lower lip.

A general rule for the lower lips is to only inject in the central two-thirds. "Don't go too lateral. It will look like sausage otherwise," Dr. Ablon said. One exception, she said, is a patient with significant facial wrinkles who might get improvement to the side of the mouth (below the nasolabial fold).

Always have patients seated upright to allow for normal gravity. Another tip is to start with a nonpermanent filler, something you can dissolve, Dr. Ablon said.

Juvederm (hyaluronic acid, Allergan) is her lip filler product of choice, which she also injects above the vermillion border in some patients to provide additional enhancement. "It is a softer filler, and very moldable and malleable. Patients cannot notice there is anything inside their lips." Collagen and calcium hydroxylapatite are other lip filler choices.

Surgical options include lifts and advanced flaps. "The only surgical approach I typically use is the butterfly lip lift," Dr. Ablon said at the meeting.

The technique is best suited for patients with an elongated philtrum.

The lips are very sensitive and Dr. Ablon recommends use of topical and injected analgesics, such as lidocaine, before augmentation. She also uses the ArTek cooling device (ThermoTek Inc.) to increase patient comfort during the procedure. "If the patient is miserable, they will not return."

Tips to minimize bruising include avoidance of aspirin, nonsteroidal anti-inflammatory drugs, and vitamin E, and addition of bromelain supplements (a compound from pineapple). Also, consider antiviral treatment if the patient has a history of herpes outbreaks.

Dr. Ablon disclosed that she is a member of the Medicis advisory board (makers of Restylane and Perlane fillers).

'Don't create lips that enter the door before the patient does. Not everyone will look normal with large lips.' DR. ABLON

MIAMI BEACH — Remember the three P's of perfect lip enhancement—proportion, profile, and plumping—and you are more likely to get a satisfied patient who will use their new lips to refer other patients to your office.

Always keep proportion in mind—the ideal lip size ratio is about 40% for the top lip to 60% bottom lip, Dr. Glynis R. Ablon said at the South Beach Symposium.

The main goal of augmentation is to give patients natural-looking lips versus an overdone or "trout" lip appearance. "Don't completely change their look," she said, because no one should be able to tell the lips were enhanced.

For guidance, look at very young women or men, depending on what you're doing, "and see what looks natural to you," she said.

Look at each patient in profile and keep in mind you are sculpting the appearance of their lips from all sides, Dr. Ablon said.

Err on the side of injecting less filler material versus too much. "Less is more," Dr. Ablon said.

Start with a small amount and have the patient return for additional enhancement if desired. "Make sure you don't create lips that enter the door before the patient does. Not everyone will look normal with large lips, especially in Hollywood, where I work," commented Dr. Ablon, who is in private practice in Manhattan Beach, Calif., and on the dermatology faculty at the University of California in Los Angeles.

The actress Demi Moore, for example, has thin lips and "might look strange with enhanced lips."

When injecting filler, pay particular attention to the philtrum and cupid's bow on the upper lip, she said. You can also enhance or recreate the Glogau-Klein point, the dimple in the lower lip.

A general rule for the lower lips is to only inject in the central two-thirds. "Don't go too lateral. It will look like sausage otherwise," Dr. Ablon said. One exception, she said, is a patient with significant facial wrinkles who might get improvement to the side of the mouth (below the nasolabial fold).

Always have patients seated upright to allow for normal gravity. Another tip is to start with a nonpermanent filler, something you can dissolve, Dr. Ablon said.

Juvederm (hyaluronic acid, Allergan) is her lip filler product of choice, which she also injects above the vermillion border in some patients to provide additional enhancement. "It is a softer filler, and very moldable and malleable. Patients cannot notice there is anything inside their lips." Collagen and calcium hydroxylapatite are other lip filler choices.

Surgical options include lifts and advanced flaps. "The only surgical approach I typically use is the butterfly lip lift," Dr. Ablon said at the meeting.

The technique is best suited for patients with an elongated philtrum.

The lips are very sensitive and Dr. Ablon recommends use of topical and injected analgesics, such as lidocaine, before augmentation. She also uses the ArTek cooling device (ThermoTek Inc.) to increase patient comfort during the procedure. "If the patient is miserable, they will not return."

Tips to minimize bruising include avoidance of aspirin, nonsteroidal anti-inflammatory drugs, and vitamin E, and addition of bromelain supplements (a compound from pineapple). Also, consider antiviral treatment if the patient has a history of herpes outbreaks.

Dr. Ablon disclosed that she is a member of the Medicis advisory board (makers of Restylane and Perlane fillers).

'Don't create lips that enter the door before the patient does. Not everyone will look normal with large lips.' DR. ABLON

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Nonablative fractional laser resurfacing produced significant improvement in scar severity in a study of 10 patients with second- and third-degree burn scars.

A total of five treatments delivered at 4-week intervals using a 1,550-nm nonablative erbium-doped fiber laser (Fraxel re:store) resulted in objectively-assessed reductions in overall scar severity, as well as improvement in topographical and textural abnormalities, Dr. Jill Waibel reported at the annual meeting of the American Society of Laser Medicine and Surgery.

"Burn scars are a challenge because they have traditionally been difficult to treat, and they are among the worst scars seen in clinical medicine. There is compelling evidence to suggest that nonablative fractional resurfacing improves the appearance and functionality of scarred tissue following burns. I think fractional lasers are the gold standard for scars," said Dr. Waibel, who is in private practice in West Palm Beach, Fla.

Burn scars are extremely heterogeneous, often comprising areas of hypertrophy, atrophy, and hyperpigmentation. Fractional photothermolysis, which provides a greater depth of penetration than traditional CO2 laser resurfacing, appears to benefit the variety of scar types that arise from burn injury, she said.

The eight men and two women in the study ranged in age from 23 to 68 years. Nine had third-degree burns and one had second-degree burns. Treatment areas included the face, neck, chest, arms, hands, abdomen, calf, and leg. Patients were treated with energy levels ranging from 40–70 mJ/pulse, treatment level range 6–13, density 29–65 MTZ/cm

Three blinded investigators evaluated changes in overall improvement, dyschromia, degree of atrophy or hypertrophy improvement, and texture improvement graded on a quartile scale of 0–3, with 0 being none, 1 mild (1%-33%), 2 moderate (34%-66%), and 3 excellent (67%-100%). The patients also scored their own levels of self-esteem, and both the patients and the investigators independently evaluated changes in erythema, edema, hyper- and hypopigmentation, and burn scars overall at 1, 3, and 6 months after the final treatment. Photos were also taken at baseline and at 3 months post treatment.

Based on a protocol recommended by the Food and Drug Administration, the evaluators were given random before and after patient photographs. In one patient, none of the three blinded investigators identified the before and after photos correctly. All three investigators correctly identified the other 9 patient photos, so those 27 evaluations were used for the data analysis.

Overall improvement was noted in all 27 (100%), with 37% scored as excellent, 41% as moderate, and 22% as mild. Improved dyschromia was noted in 96% of the blinded evaluations, with 60% having at least moderately improved. Improvements in atrophy/hypertrophy were also noted in 96%, with 63% having at least moderately improved. Improved skin texture was seen in 100%, with 63% having at least moderately improved texture, Dr. Waibel reported.

The average of the patients' self-assessments of self-esteem at 3 months was 8.2 on a scale of 1–10 with 10 being "I feel great about myself." On a 0–3 scale of improvement in burn scar area with 0 being "no improvement" and 3 being "excellent improvement," the average of the patients' self-assessment at 3 months was 2.3. Anecdotally, patients also spoke of diminished pain, improved motion with a decrease in contractures, and better cosmesis, Dr. Waibel added.

The findings from this study will be submitted to the FDA to support a new indication for burn scars. (Fraxel re:store is currently approved for skin resurfacing.) Additional studies will be necessary to determine the optimal parameters for burn patients, Dr. Waibel said in an interview.

The next phase of studies that Dr. Waibel and her associates are studying include the use of nonablative fractional resurfacing in combination with intralesional triamcinolone (Kenalog), and also the use of ablative fractional resurfacing devices.

Dr. Waibel and her associates received a research grant from Reliant Technologies Inc. (now Solta Medical, Fraxel manufacturer) to conduct this study, and have received honoraria from the company for lectures.

The patient's hand is shown before undergoing treatment with the Fraxel re:store laser.

Three months and five laser treatments later, overall severity of the burn scar is reduced. Photos courtesy Dr. Waibel

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — Fractional laser resurfacing produced long-term results in a small study of patients treated for acne scarring or photodamage.

Fractional deep dermal ablation is a newer modality that produces clinical improvement in photodamaged skin and acne scarring but with reduced downtime and a lower risk of complications, compared with traditional carbon dioxide resurfacing. However, the long-term outcomes of patients treated with fractional resurfacing have not been previously reported, Dr. Arisa Ortiz said at the annual meeting of the American Society for Laser Medicine and Surgery.

In the current study, results at 1–2 years were somewhat diminished, compared with those seen at 3 months, but were still better than at baseline and patient satisfaction was maintained, said Dr. Ortiz of the University of California, Irvine.

The single-center study involved six patients with acne scarring and four with photodamage. All had been previously enrolled in studies of fractional resurfacing for those two conditions. They were aged 24–63 years, with skin types I-V. There were no serious adverse events associated with the treatment, she said.

All 10 patients returned at 3 months for assessments of improvement in skin texture, rhytids, pigmentation, skin laxity, acne scarring, and overall appearance, compared with baseline.

The patients with acne scarring were then reassessed at 1 year and the patients with photodamage, at 2 years. Three investigators clinically rated improvement on a quartile scale: 0% (no improvement), less than 25% (minor), 25%-50% (minor to moderate), 51%-75% (moderate), and greater than 75% (marked).

Among the acne scarring patients, at 1 year there was 83% maintenance of the initial overall improvement seen at 3 months. For those treated for photoaging, 50% of the 3-month improvement was maintained at 2 years. Overall, there was a 74% improvement from 3 months to the 1- or 2-year follow-up assessment. No patient returned to baseline levels, Dr. Ortiz reported.

Possible explanations for the difference in results between 3 months and the long-term visit include relaxation of tightening, progression of normal aging, or persistent inflammatory changes present at 3 months, as evidenced by heat shock protein activity and ongoing collagen remodeling seen in previous histologic studies.

These results suggest that additional treatments may be necessary to enhance long-term results. It also appeared that acne scarring requires more treatments at higher energies, compared with photodamaged skin, and that performing more frequent treatments early on may result in less bleeding and less downtime for all patients, Dr. Ortiz said.

The original study was funded by Reliant Technologies Inc., but this long-term follow-up study was departmentally funded, she said.

As demonstrated above, results at 1 year (far right) were somewhat diminished—compared with those seen at 3 months (center)—but were still better than at baseline (left), and patient satisfaction was maintained, according to Dr. Arisa Ortiz. Photos courtesy Dr. Arisa Ortiz

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.

NATIONAL HARBOR, MD. — A long-pulsed 595-nm pulsed dye laser rapidly improved ecchymosis resulting from either cosmetic procedures or traumatic injury in a study of 10 patients.

Postprocedural and traumatic ecchymosis is an extremely common problem, particularly with the recent explosive growth in minimally invasive procedures that potentially induce bruising, Dr. Julie K. Karen noted at the annual meeting of the American Society for Laser Medicine and Surgery.

Patients are often motivated to minimize or camouflage bruising to conceal the fact that they have had cosmetic intervention. Current strategies to minimize the bruising, such as discontinuation of nonessential blood thinners; meticulous intraoperative technique; and topical or oral agents such as arnica, vitamin K, and hirudin are not always effective, she said.

"Long-pulsed [pulsed dye laser] may alleviate this common stigma associated with cosmetic intervention by expediting healing," said Dr. Karen of the Laser & Skin Surgery Center of New York, N.Y.

The 10 adult patients had skin types I-IV, with one or more ecchymoses. Each subject served as his or her own control.

One ecchymosis was treated in those who had two, while those with just one ecchymosis had half of the lesion treated. None of the patients had active infections, photosensitivity/photoallergy, pregnancy/lactation, prior irradiation to the ecchymosis site, use of oral retinoids or photosensitizing drugs in the previous 2 years, or a history of keloid formation.

Each patient received a single treatment with a long-pulsed 595-nm pulsed-dye laser (Vbeam, Candela) with these parameters: spot size, 10 mm; fluence, 7.5 J/cm

Treated lesions resolved more rapidly than untreated lesions in all 10 patients. All 10 treated lesions showed improvement within 24 hours, with some improvement evident as early as 6 hours post treatment.

At 24 hours post treatment, there was an average 62% improvement from baseline in the treated lesion compared with just 13% of the untreated lesion. At 48 hours, the improvements were 76% and 37%, respectively. At 1 week post treatment, there was no longer a significant difference between the treated and untreated areas, with both lesions largely resolved (87% vs. 81%).

Side effects were minimal, including slight discomfort, erythema, and edema. Transient crusting occurred in the first two patients, in whom pulse-stacking was attempted. That was avoided in the subsequent eight patients and none had crusting, Dr. Karen said.

The precise mechanism by which laser treatment accelerates the resolution of ecchymosis is unknown. Ecchymoses result when extravasated blood accumulates in tissue. The yellow color that develops in older bruises correlates with macrophage degradation of hemoglobin to bilirubin.

The pulsed dye laser emits yellow light (595-nm) matching an absorption peak of oxyhemoglobin. Since bilirubin has a broad absorption peak of 460-nm, "we posit that laser intervention is most effective if initiated early, when hemoglobin predominates," she commented.

Dr. Karen stated that she had no relevant disclosures.