Aesthetic Dermatology

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Low-dose sublingual clonidine given before treatment helps calm anxious, tachycardic patients undergoing laser skin resurfacing and other cosmetic procedures, according to Dr. Roberta D. Sengelmann.

"I've been using clonidine for about 8 years, since I did my first face-lift. I use it for patients with blood pressures above 130/90 mm Hg. I check their blood pressure after 30 minutes. The clonidine has a bit of a calming, sedative effect. It really is quite effective," Dr. Sengelmann said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. The dose is small, just 0.1 mg of clonidine sublingually. A second dose may be required after about 15 minutes in a larger man.

Dr. Sengelmann, a dermatologic surgeon in Santa Barbara, Calif., added that she finds clonidine particularly useful in patients undergoing lengthier aesthetic procedures lasting 90 minutes or more. But she won't use the antihypertensive agent in patients with blood pressures below 110/60–70 mm Hg, even if they're tachycardic and anxious. Instead she uses 10 mg of diazepam (Valium).

Dr. Christopher B. Zachary, session chair, said he has heard of periprocedural clonidine also being used in anxious Mohs surgery patients, adding that it strikes him as an intriguing way to minimize bleeding problems.

"In patients who are obviously a little anxious—maybe they didn't sleep too well, maybe they were caught in busy traffic—I can almost guarantee that if their blood pressure is up then they will have more bleeding problems," observed Dr. Zachary of the University of California, Irvine.

SDEF and this newspaper are owned by Elsevier.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MIAMI BEACH — Phosphatidylcholine injections were found to effectively dissolve submental fat deposits associated with a "double chin" appearance without any significant adverse effects.

Up to five injections of phosphatidylcholine (PC) over 6 months yielded a 40%-50% clinical fat reduction in patients, said Dr. Glynis R. Ablon at the South Beach Symposium.

PC is a linoleic acid with anticollagenase activity that provides antioxidant and antifibrotic benefits in both in vitro and in vivo studies, Dr. Ablon said. PC also has been used to treat hyperlipidemia, cardiac ischemia, and liver disease.

Lipolysis injections are often a combination of PC and deoxycholic acid (DC), a bile acid converted to a sodium salt that lyses fat cells. DC also is used in medications to reduce gallstones.

Dr. Ablon randomized 44 patients—38 women and 6 men—to a mixture of PC and DC, a DC solution, or bacteriostatic saline. Participants were aged 25–60 years and had mild, moderate, or severe submental fat deposits.

Caliper measurements of fat were made at a point midway between the submental crease and the hyoid bone. Injections alternated to the right or left side with up to five treatments over 6 months.

"We had great results with no significant complications. Patients were extremely happy," said Dr. Ablon of the University of California, Los Angeles.

This limited study showed 100% improvement and long-term benefit, she added.

All patients experienced some mild burning and edema. The burning lasted 15 minutes or less. The submental edema resolved within 8 days for 96% of participants, she said.

In addition, 28% of the patients reported submental erythema lasting 15 minutes or less; 16% reported discomfort; and 14% reported short-term paresthesia or numbness. No patient experienced hematoma, headache, or systemic complaints.

Additional studies are warranted, said Dr. Ablon, especially large, randomized trials with histologic images to confirm the dissolution of fat. "We are also doing studies of PC and DC for hips and thighs, as well as for anterior axillae," she said.

She pointed out that injection lipolysis differs from mesotherapy. With mesotherapy there are "no standard formulations, injection techniques or therapeutic doses, and that is a little frightening."

"Not only are non-MDs performing this procedure, there are people with no training doing this [mesotherapy]," Dr. Ablon added.

"In our practice, since 2003, we are doing strictly injection lipolysis with PC/DC or DC," she said.

Advantages of injection lipolysis include no downtime, typically minimal side effects, and use as an adjunct to liposuction.

She disclosed having no relevant conflicts of interest.

MAUI, HAWAII — Topical vitamin K oxide gel appears to help speed resolution of facial bruising induced by cosmetic procedures, reported Dr. Joel L. Cohen.

His randomized, double-blind, vehicle-controlled trial of 16 patients undergoing pulsed dye laser therapy for facial telangiectasias demonstrated that vitamin K oxide gel (Auriderm) resulted in a mean 15% reduction in laser-induced purpura, compared with placebo.

That's a modest benefit. Yet numerous studies have shown that patients opting for cosmetic procedures deem improvements of such magnitude clinically meaningful, noted Dr. Cohen, a dermatologist in Englewood, Colo.

Moreover, the protocol chosen for this study tended to underestimate the benefits of vitamin K oxide gel as used in everyday clinical practice, he said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

In his study, 16 patients with bilateral facial telangiectasias were treated once on each side with an equal number of pulses from a pulsed dye laser (PDL). Patients applied vitamin K oxide gel to one side of the face and a vehicle to the other side 15–30 minutes post procedure and twice daily thereafter. The severity of purpura was blindly evaluated on days 2, 4, 6, and 9.

Purpura resolution was consistently greater on the vitamin K oxide gel side of the face beginning on day 4. In fact, the greatest difference in bruising between the treatment and control sides was noted on day 4; thereafter, the natural bruise resolution process came to the fore.

The 15% advantage in purpura resolution favoring vitamin K oxide gel did not achieve statistical significance because of the small size of the trial, according to Dr. Cohen.

The control vehicle may have been a poor choice because it's not inert, according to Dr. Cohen. It contains vitamins C and E, which are known to reduce the ferric iron in hemosiderin to ferrous iron, which probably hastened the breakdown of hemosiderin and the clearing of bruises.

He said he routinely uses vitamin K oxide gel not only following laser therapy but after injecting fillers. "I usually have patients use it four to five times per day. First I use it as a lubricant to massage in the fillers; then I have patients purchase the product and go home with it," he explained. Vitamin K oxide gel is an OTC product dispensed in physicians' offices.

Dr. Suzanne L. Kilmer said she has found the PDL to be highly effective in hastening resolution of bruising caused by the filler injection. She uses the laser at 6 milliseconds and 7–10 J/cm₂ on postprocedure day 2 or later, adjusting the energy downward slightly if the bruise is especially dark to avoid blistering.

"It works really well. It's amazing. We routinely now tell our patients, 'If you have a lot of bruising, give me a call tomorrow and we'll get you in the next day for the PDL.' If you do a lot of fillers, it really improves patient satisfaction," according to Dr. Kilmer of the University of California at San Diego.

Dr. Cohen emphasized the importance of teaching the office staff how to tell the difference between filler-related bruising and impending tissue necrosis: If a filler patient phones in and reports significant pain, it's a red flag. Anatomic areas where the underlying vascular distribution should raise extra concern when a patient reports pain are the glabella, the nasolabial fold, alar groove, superior and inferior labial artery, and parotid duct, especially in patients with HIV-related facial lipoatrophy.

Dr. Cohen reported that he is a consultant to Biopelle Inc., which supported the Auriderm trial. SDEF and this newspaper are owned by Elsevier.

'I use [vitamin Kgel] as a lubricant to massage in the fillers; then I have the patients purchase the product' for home. DR. COHEN

MAUI, HAWAII — Topical vitamin K oxide gel appears to help speed resolution of facial bruising induced by cosmetic procedures, reported Dr. Joel L. Cohen.

His randomized, double-blind, vehicle-controlled trial of 16 patients undergoing pulsed dye laser therapy for facial telangiectasias demonstrated that vitamin K oxide gel (Auriderm) resulted in a mean 15% reduction in laser-induced purpura, compared with placebo.

That's a modest benefit. Yet numerous studies have shown that patients opting for cosmetic procedures deem improvements of such magnitude clinically meaningful, noted Dr. Cohen, a dermatologist in Englewood, Colo.

Moreover, the protocol chosen for this study tended to underestimate the benefits of vitamin K oxide gel as used in everyday clinical practice, he said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

In his study, 16 patients with bilateral facial telangiectasias were treated once on each side with an equal number of pulses from a pulsed dye laser (PDL). Patients applied vitamin K oxide gel to one side of the face and a vehicle to the other side 15–30 minutes post procedure and twice daily thereafter. The severity of purpura was blindly evaluated on days 2, 4, 6, and 9.

Purpura resolution was consistently greater on the vitamin K oxide gel side of the face beginning on day 4. In fact, the greatest difference in bruising between the treatment and control sides was noted on day 4; thereafter, the natural bruise resolution process came to the fore.

The 15% advantage in purpura resolution favoring vitamin K oxide gel did not achieve statistical significance because of the small size of the trial, according to Dr. Cohen.

The control vehicle may have been a poor choice because it's not inert, according to Dr. Cohen. It contains vitamins C and E, which are known to reduce the ferric iron in hemosiderin to ferrous iron, which probably hastened the breakdown of hemosiderin and the clearing of bruises.

He said he routinely uses vitamin K oxide gel not only following laser therapy but after injecting fillers. "I usually have patients use it four to five times per day. First I use it as a lubricant to massage in the fillers; then I have patients purchase the product and go home with it," he explained. Vitamin K oxide gel is an OTC product dispensed in physicians' offices.

Dr. Suzanne L. Kilmer said she has found the PDL to be highly effective in hastening resolution of bruising caused by the filler injection. She uses the laser at 6 milliseconds and 7–10 J/cm₂ on postprocedure day 2 or later, adjusting the energy downward slightly if the bruise is especially dark to avoid blistering.

"It works really well. It's amazing. We routinely now tell our patients, 'If you have a lot of bruising, give me a call tomorrow and we'll get you in the next day for the PDL.' If you do a lot of fillers, it really improves patient satisfaction," according to Dr. Kilmer of the University of California at San Diego.

Dr. Cohen emphasized the importance of teaching the office staff how to tell the difference between filler-related bruising and impending tissue necrosis: If a filler patient phones in and reports significant pain, it's a red flag. Anatomic areas where the underlying vascular distribution should raise extra concern when a patient reports pain are the glabella, the nasolabial fold, alar groove, superior and inferior labial artery, and parotid duct, especially in patients with HIV-related facial lipoatrophy.

Dr. Cohen reported that he is a consultant to Biopelle Inc., which supported the Auriderm trial. SDEF and this newspaper are owned by Elsevier.

'I use [vitamin Kgel] as a lubricant to massage in the fillers; then I have the patients purchase the product' for home. DR. COHEN

MAUI, HAWAII — Topical vitamin K oxide gel appears to help speed resolution of facial bruising induced by cosmetic procedures, reported Dr. Joel L. Cohen.

His randomized, double-blind, vehicle-controlled trial of 16 patients undergoing pulsed dye laser therapy for facial telangiectasias demonstrated that vitamin K oxide gel (Auriderm) resulted in a mean 15% reduction in laser-induced purpura, compared with placebo.

That's a modest benefit. Yet numerous studies have shown that patients opting for cosmetic procedures deem improvements of such magnitude clinically meaningful, noted Dr. Cohen, a dermatologist in Englewood, Colo.

Moreover, the protocol chosen for this study tended to underestimate the benefits of vitamin K oxide gel as used in everyday clinical practice, he said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

In his study, 16 patients with bilateral facial telangiectasias were treated once on each side with an equal number of pulses from a pulsed dye laser (PDL). Patients applied vitamin K oxide gel to one side of the face and a vehicle to the other side 15–30 minutes post procedure and twice daily thereafter. The severity of purpura was blindly evaluated on days 2, 4, 6, and 9.

Purpura resolution was consistently greater on the vitamin K oxide gel side of the face beginning on day 4. In fact, the greatest difference in bruising between the treatment and control sides was noted on day 4; thereafter, the natural bruise resolution process came to the fore.

The 15% advantage in purpura resolution favoring vitamin K oxide gel did not achieve statistical significance because of the small size of the trial, according to Dr. Cohen.

The control vehicle may have been a poor choice because it's not inert, according to Dr. Cohen. It contains vitamins C and E, which are known to reduce the ferric iron in hemosiderin to ferrous iron, which probably hastened the breakdown of hemosiderin and the clearing of bruises.

He said he routinely uses vitamin K oxide gel not only following laser therapy but after injecting fillers. "I usually have patients use it four to five times per day. First I use it as a lubricant to massage in the fillers; then I have patients purchase the product and go home with it," he explained. Vitamin K oxide gel is an OTC product dispensed in physicians' offices.

Dr. Suzanne L. Kilmer said she has found the PDL to be highly effective in hastening resolution of bruising caused by the filler injection. She uses the laser at 6 milliseconds and 7–10 J/cm₂ on postprocedure day 2 or later, adjusting the energy downward slightly if the bruise is especially dark to avoid blistering.

"It works really well. It's amazing. We routinely now tell our patients, 'If you have a lot of bruising, give me a call tomorrow and we'll get you in the next day for the PDL.' If you do a lot of fillers, it really improves patient satisfaction," according to Dr. Kilmer of the University of California at San Diego.

Dr. Cohen emphasized the importance of teaching the office staff how to tell the difference between filler-related bruising and impending tissue necrosis: If a filler patient phones in and reports significant pain, it's a red flag. Anatomic areas where the underlying vascular distribution should raise extra concern when a patient reports pain are the glabella, the nasolabial fold, alar groove, superior and inferior labial artery, and parotid duct, especially in patients with HIV-related facial lipoatrophy.

Dr. Cohen reported that he is a consultant to Biopelle Inc., which supported the Auriderm trial. SDEF and this newspaper are owned by Elsevier.

'I use [vitamin Kgel] as a lubricant to massage in the fillers; then I have the patients purchase the product' for home. DR. COHEN

MAUI, HAWAII — Have contemporary laser resurfacing methods rendered chemical peels obsolete?

Not by a long shot, according to Dr. Roberta Sengelmann, a dermatologic surgeon in Santa Barbara, Calif. "I still use chemical peels quite a bit in my practice," she said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Peels are versatile, cost effective, and safe, and require no special equipment. "Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?" she asked.

Dr. Sengelmann shared tips on getting the most out of her peel of choice: the Jessner's solution-trichloroacetic acid (TCA) peel. It's a midlevel peel that penetrates the papillary dermis up to the level of the upper reticular dermis, stimulating collagen production for wrinkle reduction, she explained.

Jessner's 25%-35% TCA peel can be used to treat a wide variety of skin surface irregularities, including lentigos, flat actinic and seborrheic keratoses, melasma, and fine lines, although it's only minimally helpful for rhytids. The combination peel reliably brings an 80% reduction in dyschromia, according to Dr. Sengelmann. "It's my first choice for dyschromia on a budget," she said.

Outcomes with a Jessner's-TCA peel, in her experience, are analogous to those obtained with a single treatment using a fractional erbium laser, a single pass with an ablative erbium: YAG laser, or four to six sessions with an intense pulsed light laser.

Dr. Sengelmann offered tips on the following aspects of treating patients with the peel:

▸ Preoperative skin preparation. A daily UVA/UVB sunscreen along with 2–6 weeks of once-daily tretinoin and once- or twice-daily hydroquinones should be used before treatment. The topical retinoid thins the stratum corneum so that the TCA penetrates deeper. It also speeds wound healing and minimizes postoperative milia. Lastly, the weeks of skin preparation help the physician to gauge the patient's tolerance for the more intense redness and peeling to come.

▸ Materials. Jessner's solution is composed of resorcinol, salicylic acid, lactic acid, and ethanol. The function of the solution is to break up the epidermal barrier, permitting deeper, more even, and safer wounding with the TCA that follows.

The TCA can be compounded using weight to volume at a reliable pharmacy, but Dr. Sengelmann recommended ordering a large, acid-resistant, dark bottle from the supply house Delasco (www.delasco.com

TCA is a keratocoagulant. It's more caustic than phenol, but it has an excellent safety profile, because there is no systemic absorption. Unlike with phenol, occlusion does not increase peel depth with TCA, and TCA cannot be neutralized, so it's important to plan the treatment strategy before application.

▸ Pain management. Dr. Sengelmann said she gives pretreatment diazepam to those who want it. She always uses regional nerve blocks for her Jessner's-TCA peels. And she provides ice-cold wet towels for comfort during the 5–10 minutes of pain that follow TCA application.

▸ Technique. First, the skin is cleaned and degreased. Then, two to four coats of Jessner's solution are applied, with 6 minutes between applications. This creates a light frost. Next, it's time for the regional nerve blocks, often supplemented by local anesthetic around the temple area. This is followed by the TCA, which feels quite hot. Dr. Sengelmann said she applies it evenly with firm pressure using damp cotton balls, a cotton-tip applicator, or gauze. She avoids using abrasive gauze on dark skin types because it can cause postinflammatory changes. She works in compartmental fashion, applying the TCA first to the forehead, then to the central face, moving down below the jawline and into the hairline so the results will blend.

▸ End points. It's all about the frost, which develops 30–60 seconds after TCA application, peaks in 3–4 minutes, and fades to a florid erythema in 15–30 minutes, she said. Dr. Sengelmann aims for a level 2 or 3 frost using the classification scheme credited to Dr. Mark G. Rubin of the University of California, San Francisco. A level 2 frost—that is, an even frost with pink showing through—is reserved for fair-skinned, thin-skinned patients with moderate to severe actinic damage, including many older white women with small pores. But even with thin-skinned patients Dr. Sengelmann will go to level 3 around the mouth. Level 3 is a blanched, opaque, white frost suitable for the treatment of severe actinic damage or melasma.

Inadequately frosted areas can be touched up after 3–6 minutes. Sebaceous areas often need a second coat in order to achieve even frosting.

▸ Postpeel wound care. Most patients spend postop day 1 resting at home. Beginning on postop day 2, patients should apply 0.25% acetic acid compresses two to four times daily for their antibacterial effect and to help slough off dead epidermis. Liberal use of a petroleum jelly or other bland ointment helps keep the treated area moist and prevents crusting. Showers and gentle use of the finger pads to remove exudate and desiccated tissue are helpful.

On about day 3–4, and often sooner in men, the flakes of dead skin become whole sheets of dead skin. Reepithelialization is typically complete in 5–7 days.

▸ Safety. Resorcinol is such a rare cause of contact dermatitis that Dr. Sengelmann doesn't pretest for it; she said she has seen just one case of resorcinol contact dermatitis in her career. She has never had a scar or infection as a complication of a Jessner's-TCA peel. The worst complication she's encountered was a corneal abrasion that resulted from a small amount of 35% TCA leaking into the orbit despite shielding; it responded favorably to conservative management. Occasionally a patient experiences a persistent splotchy erythema.

SDEF and this newspaper are owned by Elsevier.

'Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?' DR. SENGELMANN

MAUI, HAWAII — Have contemporary laser resurfacing methods rendered chemical peels obsolete?

Not by a long shot, according to Dr. Roberta Sengelmann, a dermatologic surgeon in Santa Barbara, Calif. "I still use chemical peels quite a bit in my practice," she said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Peels are versatile, cost effective, and safe, and require no special equipment. "Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?" she asked.

Dr. Sengelmann shared tips on getting the most out of her peel of choice: the Jessner's solution-trichloroacetic acid (TCA) peel. It's a midlevel peel that penetrates the papillary dermis up to the level of the upper reticular dermis, stimulating collagen production for wrinkle reduction, she explained.

Jessner's 25%-35% TCA peel can be used to treat a wide variety of skin surface irregularities, including lentigos, flat actinic and seborrheic keratoses, melasma, and fine lines, although it's only minimally helpful for rhytids. The combination peel reliably brings an 80% reduction in dyschromia, according to Dr. Sengelmann. "It's my first choice for dyschromia on a budget," she said.

Outcomes with a Jessner's-TCA peel, in her experience, are analogous to those obtained with a single treatment using a fractional erbium laser, a single pass with an ablative erbium: YAG laser, or four to six sessions with an intense pulsed light laser.

Dr. Sengelmann offered tips on the following aspects of treating patients with the peel:

▸ Preoperative skin preparation. A daily UVA/UVB sunscreen along with 2–6 weeks of once-daily tretinoin and once- or twice-daily hydroquinones should be used before treatment. The topical retinoid thins the stratum corneum so that the TCA penetrates deeper. It also speeds wound healing and minimizes postoperative milia. Lastly, the weeks of skin preparation help the physician to gauge the patient's tolerance for the more intense redness and peeling to come.

▸ Materials. Jessner's solution is composed of resorcinol, salicylic acid, lactic acid, and ethanol. The function of the solution is to break up the epidermal barrier, permitting deeper, more even, and safer wounding with the TCA that follows.

The TCA can be compounded using weight to volume at a reliable pharmacy, but Dr. Sengelmann recommended ordering a large, acid-resistant, dark bottle from the supply house Delasco (www.delasco.com

TCA is a keratocoagulant. It's more caustic than phenol, but it has an excellent safety profile, because there is no systemic absorption. Unlike with phenol, occlusion does not increase peel depth with TCA, and TCA cannot be neutralized, so it's important to plan the treatment strategy before application.

▸ Pain management. Dr. Sengelmann said she gives pretreatment diazepam to those who want it. She always uses regional nerve blocks for her Jessner's-TCA peels. And she provides ice-cold wet towels for comfort during the 5–10 minutes of pain that follow TCA application.

▸ Technique. First, the skin is cleaned and degreased. Then, two to four coats of Jessner's solution are applied, with 6 minutes between applications. This creates a light frost. Next, it's time for the regional nerve blocks, often supplemented by local anesthetic around the temple area. This is followed by the TCA, which feels quite hot. Dr. Sengelmann said she applies it evenly with firm pressure using damp cotton balls, a cotton-tip applicator, or gauze. She avoids using abrasive gauze on dark skin types because it can cause postinflammatory changes. She works in compartmental fashion, applying the TCA first to the forehead, then to the central face, moving down below the jawline and into the hairline so the results will blend.

▸ End points. It's all about the frost, which develops 30–60 seconds after TCA application, peaks in 3–4 minutes, and fades to a florid erythema in 15–30 minutes, she said. Dr. Sengelmann aims for a level 2 or 3 frost using the classification scheme credited to Dr. Mark G. Rubin of the University of California, San Francisco. A level 2 frost—that is, an even frost with pink showing through—is reserved for fair-skinned, thin-skinned patients with moderate to severe actinic damage, including many older white women with small pores. But even with thin-skinned patients Dr. Sengelmann will go to level 3 around the mouth. Level 3 is a blanched, opaque, white frost suitable for the treatment of severe actinic damage or melasma.

Inadequately frosted areas can be touched up after 3–6 minutes. Sebaceous areas often need a second coat in order to achieve even frosting.

▸ Postpeel wound care. Most patients spend postop day 1 resting at home. Beginning on postop day 2, patients should apply 0.25% acetic acid compresses two to four times daily for their antibacterial effect and to help slough off dead epidermis. Liberal use of a petroleum jelly or other bland ointment helps keep the treated area moist and prevents crusting. Showers and gentle use of the finger pads to remove exudate and desiccated tissue are helpful.

On about day 3–4, and often sooner in men, the flakes of dead skin become whole sheets of dead skin. Reepithelialization is typically complete in 5–7 days.

▸ Safety. Resorcinol is such a rare cause of contact dermatitis that Dr. Sengelmann doesn't pretest for it; she said she has seen just one case of resorcinol contact dermatitis in her career. She has never had a scar or infection as a complication of a Jessner's-TCA peel. The worst complication she's encountered was a corneal abrasion that resulted from a small amount of 35% TCA leaking into the orbit despite shielding; it responded favorably to conservative management. Occasionally a patient experiences a persistent splotchy erythema.

SDEF and this newspaper are owned by Elsevier.

'Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?' DR. SENGELMANN

MAUI, HAWAII — Have contemporary laser resurfacing methods rendered chemical peels obsolete?

Not by a long shot, according to Dr. Roberta Sengelmann, a dermatologic surgeon in Santa Barbara, Calif. "I still use chemical peels quite a bit in my practice," she said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

Peels are versatile, cost effective, and safe, and require no special equipment. "Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?" she asked.

Dr. Sengelmann shared tips on getting the most out of her peel of choice: the Jessner's solution-trichloroacetic acid (TCA) peel. It's a midlevel peel that penetrates the papillary dermis up to the level of the upper reticular dermis, stimulating collagen production for wrinkle reduction, she explained.

Jessner's 25%-35% TCA peel can be used to treat a wide variety of skin surface irregularities, including lentigos, flat actinic and seborrheic keratoses, melasma, and fine lines, although it's only minimally helpful for rhytids. The combination peel reliably brings an 80% reduction in dyschromia, according to Dr. Sengelmann. "It's my first choice for dyschromia on a budget," she said.

Outcomes with a Jessner's-TCA peel, in her experience, are analogous to those obtained with a single treatment using a fractional erbium laser, a single pass with an ablative erbium: YAG laser, or four to six sessions with an intense pulsed light laser.

Dr. Sengelmann offered tips on the following aspects of treating patients with the peel:

▸ Preoperative skin preparation. A daily UVA/UVB sunscreen along with 2–6 weeks of once-daily tretinoin and once- or twice-daily hydroquinones should be used before treatment. The topical retinoid thins the stratum corneum so that the TCA penetrates deeper. It also speeds wound healing and minimizes postoperative milia. Lastly, the weeks of skin preparation help the physician to gauge the patient's tolerance for the more intense redness and peeling to come.

▸ Materials. Jessner's solution is composed of resorcinol, salicylic acid, lactic acid, and ethanol. The function of the solution is to break up the epidermal barrier, permitting deeper, more even, and safer wounding with the TCA that follows.

The TCA can be compounded using weight to volume at a reliable pharmacy, but Dr. Sengelmann recommended ordering a large, acid-resistant, dark bottle from the supply house Delasco (www.delasco.com

TCA is a keratocoagulant. It's more caustic than phenol, but it has an excellent safety profile, because there is no systemic absorption. Unlike with phenol, occlusion does not increase peel depth with TCA, and TCA cannot be neutralized, so it's important to plan the treatment strategy before application.

▸ Pain management. Dr. Sengelmann said she gives pretreatment diazepam to those who want it. She always uses regional nerve blocks for her Jessner's-TCA peels. And she provides ice-cold wet towels for comfort during the 5–10 minutes of pain that follow TCA application.

▸ Technique. First, the skin is cleaned and degreased. Then, two to four coats of Jessner's solution are applied, with 6 minutes between applications. This creates a light frost. Next, it's time for the regional nerve blocks, often supplemented by local anesthetic around the temple area. This is followed by the TCA, which feels quite hot. Dr. Sengelmann said she applies it evenly with firm pressure using damp cotton balls, a cotton-tip applicator, or gauze. She avoids using abrasive gauze on dark skin types because it can cause postinflammatory changes. She works in compartmental fashion, applying the TCA first to the forehead, then to the central face, moving down below the jawline and into the hairline so the results will blend.

▸ End points. It's all about the frost, which develops 30–60 seconds after TCA application, peaks in 3–4 minutes, and fades to a florid erythema in 15–30 minutes, she said. Dr. Sengelmann aims for a level 2 or 3 frost using the classification scheme credited to Dr. Mark G. Rubin of the University of California, San Francisco. A level 2 frost—that is, an even frost with pink showing through—is reserved for fair-skinned, thin-skinned patients with moderate to severe actinic damage, including many older white women with small pores. But even with thin-skinned patients Dr. Sengelmann will go to level 3 around the mouth. Level 3 is a blanched, opaque, white frost suitable for the treatment of severe actinic damage or melasma.

Inadequately frosted areas can be touched up after 3–6 minutes. Sebaceous areas often need a second coat in order to achieve even frosting.

▸ Postpeel wound care. Most patients spend postop day 1 resting at home. Beginning on postop day 2, patients should apply 0.25% acetic acid compresses two to four times daily for their antibacterial effect and to help slough off dead epidermis. Liberal use of a petroleum jelly or other bland ointment helps keep the treated area moist and prevents crusting. Showers and gentle use of the finger pads to remove exudate and desiccated tissue are helpful.

On about day 3–4, and often sooner in men, the flakes of dead skin become whole sheets of dead skin. Reepithelialization is typically complete in 5–7 days.

▸ Safety. Resorcinol is such a rare cause of contact dermatitis that Dr. Sengelmann doesn't pretest for it; she said she has seen just one case of resorcinol contact dermatitis in her career. She has never had a scar or infection as a complication of a Jessner's-TCA peel. The worst complication she's encountered was a corneal abrasion that resulted from a small amount of 35% TCA leaking into the orbit despite shielding; it responded favorably to conservative management. Occasionally a patient experiences a persistent splotchy erythema.

SDEF and this newspaper are owned by Elsevier.

'Why buy a $130,000 laser you'll use once a week when a midlevel peel might do the trick?' DR. SENGELMANN

MAUI, HAWAII — Noninvasive selective cooling of subcutaneous fat is a novel and particularly promising method of getting rid of love handles, back fat, and cellulite, according to Dr. Christopher B. Zachary.

The fat-freeze method, cryolipolysis, was developed by Dr. R. Rox Anderson and his colleagues at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, and is being commercially developed by Zeltiq Aesthetics.

The project is being advanced with a level of scientific rigor and openness traditionally lacking in the field of excess fat removal, Dr. Zachary said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. Dr. Zachary isn't involved with the cryolipolysis project but is working on other next-generation, energy-based methods for removing subcutaneous fat.

Cryolipolysis crystallizes the lipids in fat cells when temperatures are above the freezing point of water. Dr. Anderson and his colleagues have developed a device for controlled energy extraction that's applied to the skin surface to accomplish this. The result is adipocyte death by apoptosis without damage to surrounding nerves, vasculature, or the skin surface.

Histologic studies in both pigs and people have documented that a cryolipolysis session lasting 60 minutes or less results in a low-grade inflammatory process that continues for 3 months, during which fat cells are engulfed and digested by inflammatory cells and a dermal fibrotic response occurs.

Pig studies have documented—both by ultrasound and histology—a 40% reduction in subcutaneous fat layer thickness over 90 days in treated areas, which is a dramatic effect, noted Dr. Zachary, professor and chair of dermatology at the University of California, Irvine. He added that he found the procedure “totally convincing.”

An ongoing, initial, multicenter cryolipolysis clinical trial has enlisted over 120 of a planned 240 dermatology and plastic surgery patients.

An initial subset of 32 patients with discrete love handles was treated with one-time conservative energy extraction (intensity ranging from −33 mW/cm₂ for 60 minutes to −72 mW/cm₂ for 45 minutes). At 4-month follow-up, 27 of the 32 patients (84%) demonstrated reproducible, visually-evident improvement of the treated area, compared with the untreated contralateral love handle. The study design eliminated diet or exercise as potential explanations for the change.

Ultrasound assessment documented a mean 22% reduction in the treated fat layer thickness, compared with baseline, with the shrinkage coming primarily from the suprafascial fat component.

A total of 30 of 32 patients (94%) indicated they felt no or minimal discomfort during and after the procedure. “It's not like you need anesthesia for this. People can be working on their computers or whatever,” Dr. Zachary noted. The lipids in the destroyed fat cells are gradually resorbed. Importantly, serial blood lipid measures have shown no increase in lipid levels post treatment.

The investigators are cautiously introducing higher energy extraction parameters while expanding the trial to include participants with excess body fat at other locations, including the abdomen, back, thighs, and upper arms.

The duration of benefit from cryolipolysis, or any of the other emerging fat-removing technologies, remains to be seen. It may turn out that the treatments need to be repeated periodically, akin to a haircut, said Dr. Zachary. That would be fine as long as physicians and patients are informed, he added.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Noninvasive selective cooling of subcutaneous fat is a novel and particularly promising method of getting rid of love handles, back fat, and cellulite, according to Dr. Christopher B. Zachary.

The fat-freeze method, cryolipolysis, was developed by Dr. R. Rox Anderson and his colleagues at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, and is being commercially developed by Zeltiq Aesthetics.

The project is being advanced with a level of scientific rigor and openness traditionally lacking in the field of excess fat removal, Dr. Zachary said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. Dr. Zachary isn't involved with the cryolipolysis project but is working on other next-generation, energy-based methods for removing subcutaneous fat.

Cryolipolysis crystallizes the lipids in fat cells when temperatures are above the freezing point of water. Dr. Anderson and his colleagues have developed a device for controlled energy extraction that's applied to the skin surface to accomplish this. The result is adipocyte death by apoptosis without damage to surrounding nerves, vasculature, or the skin surface.

Histologic studies in both pigs and people have documented that a cryolipolysis session lasting 60 minutes or less results in a low-grade inflammatory process that continues for 3 months, during which fat cells are engulfed and digested by inflammatory cells and a dermal fibrotic response occurs.

Pig studies have documented—both by ultrasound and histology—a 40% reduction in subcutaneous fat layer thickness over 90 days in treated areas, which is a dramatic effect, noted Dr. Zachary, professor and chair of dermatology at the University of California, Irvine. He added that he found the procedure “totally convincing.”

An ongoing, initial, multicenter cryolipolysis clinical trial has enlisted over 120 of a planned 240 dermatology and plastic surgery patients.

An initial subset of 32 patients with discrete love handles was treated with one-time conservative energy extraction (intensity ranging from −33 mW/cm₂ for 60 minutes to −72 mW/cm₂ for 45 minutes). At 4-month follow-up, 27 of the 32 patients (84%) demonstrated reproducible, visually-evident improvement of the treated area, compared with the untreated contralateral love handle. The study design eliminated diet or exercise as potential explanations for the change.

Ultrasound assessment documented a mean 22% reduction in the treated fat layer thickness, compared with baseline, with the shrinkage coming primarily from the suprafascial fat component.

A total of 30 of 32 patients (94%) indicated they felt no or minimal discomfort during and after the procedure. “It's not like you need anesthesia for this. People can be working on their computers or whatever,” Dr. Zachary noted. The lipids in the destroyed fat cells are gradually resorbed. Importantly, serial blood lipid measures have shown no increase in lipid levels post treatment.

The investigators are cautiously introducing higher energy extraction parameters while expanding the trial to include participants with excess body fat at other locations, including the abdomen, back, thighs, and upper arms.

The duration of benefit from cryolipolysis, or any of the other emerging fat-removing technologies, remains to be seen. It may turn out that the treatments need to be repeated periodically, akin to a haircut, said Dr. Zachary. That would be fine as long as physicians and patients are informed, he added.

SDEF and this newspaper are owned by Elsevier.

MAUI, HAWAII — Noninvasive selective cooling of subcutaneous fat is a novel and particularly promising method of getting rid of love handles, back fat, and cellulite, according to Dr. Christopher B. Zachary.

The fat-freeze method, cryolipolysis, was developed by Dr. R. Rox Anderson and his colleagues at the Wellman Center for Photomedicine at Massachusetts General Hospital, Boston, and is being commercially developed by Zeltiq Aesthetics.

The project is being advanced with a level of scientific rigor and openness traditionally lacking in the field of excess fat removal, Dr. Zachary said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. Dr. Zachary isn't involved with the cryolipolysis project but is working on other next-generation, energy-based methods for removing subcutaneous fat.

Cryolipolysis crystallizes the lipids in fat cells when temperatures are above the freezing point of water. Dr. Anderson and his colleagues have developed a device for controlled energy extraction that's applied to the skin surface to accomplish this. The result is adipocyte death by apoptosis without damage to surrounding nerves, vasculature, or the skin surface.

Histologic studies in both pigs and people have documented that a cryolipolysis session lasting 60 minutes or less results in a low-grade inflammatory process that continues for 3 months, during which fat cells are engulfed and digested by inflammatory cells and a dermal fibrotic response occurs.

Pig studies have documented—both by ultrasound and histology—a 40% reduction in subcutaneous fat layer thickness over 90 days in treated areas, which is a dramatic effect, noted Dr. Zachary, professor and chair of dermatology at the University of California, Irvine. He added that he found the procedure “totally convincing.”

An ongoing, initial, multicenter cryolipolysis clinical trial has enlisted over 120 of a planned 240 dermatology and plastic surgery patients.

An initial subset of 32 patients with discrete love handles was treated with one-time conservative energy extraction (intensity ranging from −33 mW/cm₂ for 60 minutes to −72 mW/cm₂ for 45 minutes). At 4-month follow-up, 27 of the 32 patients (84%) demonstrated reproducible, visually-evident improvement of the treated area, compared with the untreated contralateral love handle. The study design eliminated diet or exercise as potential explanations for the change.

Ultrasound assessment documented a mean 22% reduction in the treated fat layer thickness, compared with baseline, with the shrinkage coming primarily from the suprafascial fat component.

A total of 30 of 32 patients (94%) indicated they felt no or minimal discomfort during and after the procedure. “It's not like you need anesthesia for this. People can be working on their computers or whatever,” Dr. Zachary noted. The lipids in the destroyed fat cells are gradually resorbed. Importantly, serial blood lipid measures have shown no increase in lipid levels post treatment.

The investigators are cautiously introducing higher energy extraction parameters while expanding the trial to include participants with excess body fat at other locations, including the abdomen, back, thighs, and upper arms.

The duration of benefit from cryolipolysis, or any of the other emerging fat-removing technologies, remains to be seen. It may turn out that the treatments need to be repeated periodically, akin to a haircut, said Dr. Zachary. That would be fine as long as physicians and patients are informed, he added.

SDEF and this newspaper are owned by Elsevier.

PHOENIX — Time is money. And with operating room time running $30 per minute or more at many hospitals, some cosmetic surgeons are switching from the hallowed traditional stitching techniques to considerably faster knotless means of wound closure.

Two novel technologies that garnered favorable reviews in studies presented at the annual meeting of the American Academy of Cosmetic Surgery were the Quill bidirectional barbed suture and 3M's Steri Strip S device.

Dr. Michael S. Kluska presented a comparative study involving 40 patients undergoing abdominoplasty or bilateral breast reduction. He closed half of the patients' wounds using traditional techniques, mainly multilayered interrupted individual absorbable sutures with Vicryl 3–0 or Monocryl 3–0 or 4–0. He closed the other half with Angiotech Pharmaceutical Inc.'s Quill double-barbed monofilament absorbable sutures.

With 22–27 traditional sutures being placed per breast reduction procedure, the cost of material is $325–$375 per patient treated. In contrast, the cost of the eight Quill sutures Dr. Kluska typically uses in breast reduction cases is $240. Moreover, total operating room time averages 2 hours with traditional wound closure versus 1 hour 40 minutes with the barbed suture, a hefty 20-minute savings in OR time.

Similar cost and time savings accrued through the use of barbed sutures in the abdominoplasty patients, noted Dr. Kluska of a plastic and cosmetic surgery center in Greensburg, Pa. The Quill sutures provided other advantages, too. Tissue approximation was better because of the continuous controlled tension achieved along the length of the wound.

“You don't have the scalloping that you get with individual interrupted sutures,” he said. “Individual sutures placed in subcutaneous and subcuticular space create microischemic changes, with chronic edema at the wound site. It can be a challenge to tie each suture to create closure without tissue death.”

Anecdotally, Dr. Kluska has noted that surgical wounds closed with barbed sutures heal much faster.

The technique involves placing a Quill suture in the subcutaneous space, bringing both ends out and making sure they're equal in length, then running the suture in one direction while the surgeon or an assistant runs it in the opposite direction.

“You run it very similar to a subcuticular stitch, in a linear U or horizontal fashion. When you finish, you pull it snug, cut it, and you're done. When you pull this suture taut in a linear fashion, the barbs deploy in a helical pattern. It creates a drawstring effect in the tissues,” he explained.

Applications for the barbed suture are “pretty much anywhere you do multiple-layer closures in the subcutaneous and subcuticular space,” he said.

Separately at the meeting, Dr. Abhishek Chatterjee presented a cost-savings analysis comparing the 3M Steri Strip S (3S) device and conventional sutures for the final layer of skin closure in abdominoplasty or bilateral breast reduction. Unlike prior studies that compared novel methods of wound closure, this analysis incorporated the opportunity cost (the dollar value of an activity that is forgone in order to participate in some other activity—in this case, conventional suture closure). Folding in the opportunity cost provides the truest estimate of the cost savings provided by an innovative device, because it includes the profit a surgeon could earn by doing something else in the time saved by not suturing, explained Dr. Chatterjee of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

He presented a randomized trial involving 27 abdominoplasty and 23 bilateral breast reduction patients. Each patient had half of their incision closed in traditional fashion using 4–0 polydioxanone (PDS) suture and the other half closed with 3S, all by the same surgeon.

The 3S closure saved 20 minutes in the breast reduction cases and 12 minutes per abdominoplasty. The hospital OR cost was an estimated $30 per minute.

A 3S device cost $14.82, with an average of 16 sutures used for the final layer of skin closure per bilateral breast reduction and 14 per abdominal closure. At $3.75 per PDS suture, the material cost for 3S closure was greater, but this was outweighed by the reduced operating room time.

With incorporation of the opportunity cost into the cost analysis, the true cost savings obtained by using the 3S instead of 4–0 PDS suture was $2,298 per bilateral breast reduction and $1,277 per abdominoplasty, Dr. Chatterjee concluded.

Dr. Chatterjee disclosed receipt of a research grant from 3M to conduct his study. Dr. Kluska indicated he had no financial conflicts of interest regarding his study.

PHOENIX — Time is money. And with operating room time running $30 per minute or more at many hospitals, some cosmetic surgeons are switching from the hallowed traditional stitching techniques to considerably faster knotless means of wound closure.

Two novel technologies that garnered favorable reviews in studies presented at the annual meeting of the American Academy of Cosmetic Surgery were the Quill bidirectional barbed suture and 3M's Steri Strip S device.

Dr. Michael S. Kluska presented a comparative study involving 40 patients undergoing abdominoplasty or bilateral breast reduction. He closed half of the patients' wounds using traditional techniques, mainly multilayered interrupted individual absorbable sutures with Vicryl 3–0 or Monocryl 3–0 or 4–0. He closed the other half with Angiotech Pharmaceutical Inc.'s Quill double-barbed monofilament absorbable sutures.

With 22–27 traditional sutures being placed per breast reduction procedure, the cost of material is $325–$375 per patient treated. In contrast, the cost of the eight Quill sutures Dr. Kluska typically uses in breast reduction cases is $240. Moreover, total operating room time averages 2 hours with traditional wound closure versus 1 hour 40 minutes with the barbed suture, a hefty 20-minute savings in OR time.

Similar cost and time savings accrued through the use of barbed sutures in the abdominoplasty patients, noted Dr. Kluska of a plastic and cosmetic surgery center in Greensburg, Pa. The Quill sutures provided other advantages, too. Tissue approximation was better because of the continuous controlled tension achieved along the length of the wound.

“You don't have the scalloping that you get with individual interrupted sutures,” he said. “Individual sutures placed in subcutaneous and subcuticular space create microischemic changes, with chronic edema at the wound site. It can be a challenge to tie each suture to create closure without tissue death.”

Anecdotally, Dr. Kluska has noted that surgical wounds closed with barbed sutures heal much faster.

The technique involves placing a Quill suture in the subcutaneous space, bringing both ends out and making sure they're equal in length, then running the suture in one direction while the surgeon or an assistant runs it in the opposite direction.

“You run it very similar to a subcuticular stitch, in a linear U or horizontal fashion. When you finish, you pull it snug, cut it, and you're done. When you pull this suture taut in a linear fashion, the barbs deploy in a helical pattern. It creates a drawstring effect in the tissues,” he explained.

Applications for the barbed suture are “pretty much anywhere you do multiple-layer closures in the subcutaneous and subcuticular space,” he said.

Separately at the meeting, Dr. Abhishek Chatterjee presented a cost-savings analysis comparing the 3M Steri Strip S (3S) device and conventional sutures for the final layer of skin closure in abdominoplasty or bilateral breast reduction. Unlike prior studies that compared novel methods of wound closure, this analysis incorporated the opportunity cost (the dollar value of an activity that is forgone in order to participate in some other activity—in this case, conventional suture closure). Folding in the opportunity cost provides the truest estimate of the cost savings provided by an innovative device, because it includes the profit a surgeon could earn by doing something else in the time saved by not suturing, explained Dr. Chatterjee of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

He presented a randomized trial involving 27 abdominoplasty and 23 bilateral breast reduction patients. Each patient had half of their incision closed in traditional fashion using 4–0 polydioxanone (PDS) suture and the other half closed with 3S, all by the same surgeon.

The 3S closure saved 20 minutes in the breast reduction cases and 12 minutes per abdominoplasty. The hospital OR cost was an estimated $30 per minute.

A 3S device cost $14.82, with an average of 16 sutures used for the final layer of skin closure per bilateral breast reduction and 14 per abdominal closure. At $3.75 per PDS suture, the material cost for 3S closure was greater, but this was outweighed by the reduced operating room time.

With incorporation of the opportunity cost into the cost analysis, the true cost savings obtained by using the 3S instead of 4–0 PDS suture was $2,298 per bilateral breast reduction and $1,277 per abdominoplasty, Dr. Chatterjee concluded.

Dr. Chatterjee disclosed receipt of a research grant from 3M to conduct his study. Dr. Kluska indicated he had no financial conflicts of interest regarding his study.

PHOENIX — Time is money. And with operating room time running $30 per minute or more at many hospitals, some cosmetic surgeons are switching from the hallowed traditional stitching techniques to considerably faster knotless means of wound closure.

Two novel technologies that garnered favorable reviews in studies presented at the annual meeting of the American Academy of Cosmetic Surgery were the Quill bidirectional barbed suture and 3M's Steri Strip S device.

Dr. Michael S. Kluska presented a comparative study involving 40 patients undergoing abdominoplasty or bilateral breast reduction. He closed half of the patients' wounds using traditional techniques, mainly multilayered interrupted individual absorbable sutures with Vicryl 3–0 or Monocryl 3–0 or 4–0. He closed the other half with Angiotech Pharmaceutical Inc.'s Quill double-barbed monofilament absorbable sutures.

With 22–27 traditional sutures being placed per breast reduction procedure, the cost of material is $325–$375 per patient treated. In contrast, the cost of the eight Quill sutures Dr. Kluska typically uses in breast reduction cases is $240. Moreover, total operating room time averages 2 hours with traditional wound closure versus 1 hour 40 minutes with the barbed suture, a hefty 20-minute savings in OR time.

Similar cost and time savings accrued through the use of barbed sutures in the abdominoplasty patients, noted Dr. Kluska of a plastic and cosmetic surgery center in Greensburg, Pa. The Quill sutures provided other advantages, too. Tissue approximation was better because of the continuous controlled tension achieved along the length of the wound.

“You don't have the scalloping that you get with individual interrupted sutures,” he said. “Individual sutures placed in subcutaneous and subcuticular space create microischemic changes, with chronic edema at the wound site. It can be a challenge to tie each suture to create closure without tissue death.”

Anecdotally, Dr. Kluska has noted that surgical wounds closed with barbed sutures heal much faster.

The technique involves placing a Quill suture in the subcutaneous space, bringing both ends out and making sure they're equal in length, then running the suture in one direction while the surgeon or an assistant runs it in the opposite direction.

“You run it very similar to a subcuticular stitch, in a linear U or horizontal fashion. When you finish, you pull it snug, cut it, and you're done. When you pull this suture taut in a linear fashion, the barbs deploy in a helical pattern. It creates a drawstring effect in the tissues,” he explained.

Applications for the barbed suture are “pretty much anywhere you do multiple-layer closures in the subcutaneous and subcuticular space,” he said.

Separately at the meeting, Dr. Abhishek Chatterjee presented a cost-savings analysis comparing the 3M Steri Strip S (3S) device and conventional sutures for the final layer of skin closure in abdominoplasty or bilateral breast reduction. Unlike prior studies that compared novel methods of wound closure, this analysis incorporated the opportunity cost (the dollar value of an activity that is forgone in order to participate in some other activity—in this case, conventional suture closure). Folding in the opportunity cost provides the truest estimate of the cost savings provided by an innovative device, because it includes the profit a surgeon could earn by doing something else in the time saved by not suturing, explained Dr. Chatterjee of Dartmouth-Hitchcock Medical Center, Lebanon, N.H.

He presented a randomized trial involving 27 abdominoplasty and 23 bilateral breast reduction patients. Each patient had half of their incision closed in traditional fashion using 4–0 polydioxanone (PDS) suture and the other half closed with 3S, all by the same surgeon.

The 3S closure saved 20 minutes in the breast reduction cases and 12 minutes per abdominoplasty. The hospital OR cost was an estimated $30 per minute.

A 3S device cost $14.82, with an average of 16 sutures used for the final layer of skin closure per bilateral breast reduction and 14 per abdominal closure. At $3.75 per PDS suture, the material cost for 3S closure was greater, but this was outweighed by the reduced operating room time.

With incorporation of the opportunity cost into the cost analysis, the true cost savings obtained by using the 3S instead of 4–0 PDS suture was $2,298 per bilateral breast reduction and $1,277 per abdominoplasty, Dr. Chatterjee concluded.

Dr. Chatterjee disclosed receipt of a research grant from 3M to conduct his study. Dr. Kluska indicated he had no financial conflicts of interest regarding his study.