Aesthetic Dermatology

Darryl Shaw Hodson, MD, LTC

Laser and intense pulse light procedures, once limited to physician offices and operating rooms, have become increasingly available at a variety of nonmedical  sites such as spas. State regulations as to whom can perform these treatments varies greatly across the United States and, thus, in some states, the operators of these devices do not have any significant additional medical or laser knowledge more so than the patients who receive treatment. Although serious complications of laser treatments occur, they are rare when the procedure is performed correctly. Currently, there are 2 light devices approved by the Food and Drug Administration for home hair removal on the U.S. market, and several other companies are expected to release products in the near future. There are two home laser devices marketed for hair loss. As these light-based devices become smaller, safer, easier to use, as well as cheaper to manufacture, direct use by patients will increase. Results from home use devices are impressive but still inferior to office-based lasers and light devices. It is likely that home lasers and intense pulsed light devices will eventually receive other indications because many of these devices use wavelengths similar to currently available office based equipment.

*For a PDF of the full article, click on the link to the left of this introduction.

Darryl Shaw Hodson, MD, LTC

Laser and intense pulse light procedures, once limited to physician offices and operating rooms, have become increasingly available at a variety of nonmedical  sites such as spas. State regulations as to whom can perform these treatments varies greatly across the United States and, thus, in some states, the operators of these devices do not have any significant additional medical or laser knowledge more so than the patients who receive treatment. Although serious complications of laser treatments occur, they are rare when the procedure is performed correctly. Currently, there are 2 light devices approved by the Food and Drug Administration for home hair removal on the U.S. market, and several other companies are expected to release products in the near future. There are two home laser devices marketed for hair loss. As these light-based devices become smaller, safer, easier to use, as well as cheaper to manufacture, direct use by patients will increase. Results from home use devices are impressive but still inferior to office-based lasers and light devices. It is likely that home lasers and intense pulsed light devices will eventually receive other indications because many of these devices use wavelengths similar to currently available office based equipment.

*For a PDF of the full article, click on the link to the left of this introduction.

Darryl Shaw Hodson, MD, LTC

Laser and intense pulse light procedures, once limited to physician offices and operating rooms, have become increasingly available at a variety of nonmedical  sites such as spas. State regulations as to whom can perform these treatments varies greatly across the United States and, thus, in some states, the operators of these devices do not have any significant additional medical or laser knowledge more so than the patients who receive treatment. Although serious complications of laser treatments occur, they are rare when the procedure is performed correctly. Currently, there are 2 light devices approved by the Food and Drug Administration for home hair removal on the U.S. market, and several other companies are expected to release products in the near future. There are two home laser devices marketed for hair loss. As these light-based devices become smaller, safer, easier to use, as well as cheaper to manufacture, direct use by patients will increase. Results from home use devices are impressive but still inferior to office-based lasers and light devices. It is likely that home lasers and intense pulsed light devices will eventually receive other indications because many of these devices use wavelengths similar to currently available office based equipment.

*For a PDF of the full article, click on the link to the left of this introduction.

Douglas A. Winstanley, DO and Nathan S. Uebelhoer

Laser and light technology and their use in dermatology are rapidly advancing. Radiofrequency devices have recently integrated lasers to augment the beneficial effects of both while minimizing potential complications of each. Laser-assisted liposuction is becoming more commonplace, and new investigations into the noninvasive selective destruction of fat with lasers have been undertaken. A better understanding of photobiology has generated renewed interest in the effects of low-level laser therapy on skin and wound healing. Lasers also are being used in novel ways for the purposes of in vivo diagnosis, producing some incredible imaging that may prove useful in the early diagnosis and evaluation of cutaneous disease. Finally, more recent work in the field of photochemical tissue bonding may be bringing us closer to sutureless and scarless surgery. Although not an exhaustive review, this article explores some recent advances in laser and light technologies for dermatologic applications and diagnosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Douglas A. Winstanley, DO and Nathan S. Uebelhoer

Laser and light technology and their use in dermatology are rapidly advancing. Radiofrequency devices have recently integrated lasers to augment the beneficial effects of both while minimizing potential complications of each. Laser-assisted liposuction is becoming more commonplace, and new investigations into the noninvasive selective destruction of fat with lasers have been undertaken. A better understanding of photobiology has generated renewed interest in the effects of low-level laser therapy on skin and wound healing. Lasers also are being used in novel ways for the purposes of in vivo diagnosis, producing some incredible imaging that may prove useful in the early diagnosis and evaluation of cutaneous disease. Finally, more recent work in the field of photochemical tissue bonding may be bringing us closer to sutureless and scarless surgery. Although not an exhaustive review, this article explores some recent advances in laser and light technologies for dermatologic applications and diagnosis.

*For a PDF of the full article, click on the link to the left of this introduction.

Douglas A. Winstanley, DO and Nathan S. Uebelhoer

Laser and light technology and their use in dermatology are rapidly advancing. Radiofrequency devices have recently integrated lasers to augment the beneficial effects of both while minimizing potential complications of each. Laser-assisted liposuction is becoming more commonplace, and new investigations into the noninvasive selective destruction of fat with lasers have been undertaken. A better understanding of photobiology has generated renewed interest in the effects of low-level laser therapy on skin and wound healing. Lasers also are being used in novel ways for the purposes of in vivo diagnosis, producing some incredible imaging that may prove useful in the early diagnosis and evaluation of cutaneous disease. Finally, more recent work in the field of photochemical tissue bonding may be bringing us closer to sutureless and scarless surgery. Although not an exhaustive review, this article explores some recent advances in laser and light technologies for dermatologic applications and diagnosis.

*For a PDF of the full article, click on the link to the left of this introduction.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — Breast reduction by liposuction using tumescent local anesthesia is a safe and effective procedure, results from a study of 131 patients showed.

The patients ranged in age from 16 to 77 years and their average age was 45 years, Dr. Loek Habbema reported at the annual meeting of the International Society for Dermatologic Surgery.

Breast volume was measured preoperatively and postoperatively in two ways: the amount of fat removed as a percent of breast volume and the percent reduction measured as a difference between breast volumes.

Each patient lost an average of 51% total breast volume, said Dr. Habbema, a dermatologist who practices in Bussum, the Netherlands. The minimum volume lost was 20%, while the maximum volume was 87%. He said that the average loss of fat was 1,040 mL in both breasts combined.

"In women under the age of 30, the percent of breast volume reduction is variable due to the variability of fat content in the breast, but in older women, a reduction of 40% or more is typically reached," Dr. Habbema said.

The average lifting of breast tissue that occurred after the procedure was 2.8 cm. The minimum lift was 0.8 cm and the maximum lift was 7.0 cm, he said.

Complications from the procedure included three cases of erythema, two cases of blistering, two cases of hematoma, one case of contact dermatitis, and one case of retracted nipple.

"This is a great opportunity to help patients, a better way than normally used in breast reduction by excision," Dr. Habbema said of the procedure.

Dr. Habbema had no conflicts to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — When it comes to lidocaine concentration in tumescent local anesthesia for liposuction, how low can you go?

The recommended dose in the medical literature ranges from 500 to 1,500 mg per 1,000 mL of saline, but in Dr. Loek Habbema's clinical experience in Bussum, the Netherlands, the lower the concentration of lidocaine, the better.

In fact, no more than 500 mg of lidocaine per 1,000 mL of saline is required in patients who undergo liposuction using tumescent local anesthesia, Dr. Habbema said at the annual meeting of the International Society for Dermatologic Surgery.

"A specific complication related to tumescent local anesthesia is lidocaine toxicity," he said. "For this reason, it's important to use a lidocaine concentration as low as possible that still creates adequate anesthesia."

Between 1996 and 2008, Dr. Habbema performed liposuction using tumescent local anesthesia on 3,000 patients. Initially, the concentration of lidocaine was taken from guidelines published in the medical literature, but over time the concentration was reduced to find the minimum concentration required for complete anesthesia.

No intravenous or intramuscular pain management or sedation was used. Lorazepam 1 mg or clonidine 0.05 mg was administered as needed.

In 1996, the majority of his patients received 1,000 mg of lidocaine per 1,000 mL of saline, but by 2008, the majority received 400–500 mg per 1,000 mL of saline. He now uses 400 mg per 1,000 mL of saline for all body areas except the abdomen and breast, which require 500 mg per 1,000 mL of saline, he said.

"No more than 500 mg per 1,000 mL saline is ever necessary," he noted. "That creates adequate anesthesia in all body areas."

In cases where a patient may feel some discomfort during liposuction, "it's no problem to add some tumescent solution during the procedure," Dr. Habbema noted. "Experience has lowered the need for this touch-up during the procedures, thanks to the learning curve for creating optimal tumescence. The more you do it, the less you will need during the procedure."

Dr. Habbema had no conflicts of interest to disclose relevant to his presentation.

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

LAS VEGAS — Tumescent liposuction may be the current preferred method for removing unwanted fat, but laser lipolysis and other minimally invasive innovations may be the next frontier in body contouring.

"The toned body look is the new fashion statement and the reflection of youth," said Dr. Mark Nestor at the annual meeting of the International Society for Dermatologic Surgery. "Our patients are scared off by liposuction. They are looking for safe and effective minimally invasive treatments, not only for the face, but for removing unwanted fat."

What's more, he said, tumescent liposuction "is certainly technique dependent. Some people are wonderful at it; others are not as good."

One minimally invasive device for body contouring currently on the market is the Smartlipo (Cynosure Inc.), a 1064-nm and 1320-nm Nd:YAG laser, which requires a small incision to accommodate a 1- to 2-mm cannula and 300- or 600-mcm fiber that will heat and disrupt fat cells.

Cleared by the Food and Drug Administration in November 2006, the device is used in conjunction with tumescent solution and requires local anesthesia. Its photothermal and photomechanical effects cause coagulation of tissue, which results in skin tightening, said Dr. Nestor, a dermatologist who practices in Aventura, Fla. Hemostasis of blood vessels causes less bleeding and bruising, compared with traditional liposuction.

"You're heating the fat, but you're also dragging it behind the dermis," he explained. "Because of that, you're causing collagen remodeling and tightening."

Smartlipo's 1064-nm wavelengths are broadly absorbed by hemoglobin, and the energy delivered is distributed homogeneously into fat, "so it's very good at coagulation," he said. "You get enhanced hemostasis and you get healing."

The 1320-nm wavelengths are absorbed by water and the energy delivered is localized at the tip of the laser, "so you get a lot of fat disruption."

The combination of both wavelengths "tends to work the best," Dr. Nestor said, by allowing for safer, more even and efficient energy delivery. In his clinical experience, patients usually require a single treatment but may require a touch-up for optimal results.

Another system he discussed is the LipoSonix (Medicis Inc.), which has not been cleared by the FDA but is available for use in Europe. This device uses a transducer to focus high-intensity ultrasound within adipose tissue at depths up to 13 mm without harming the skin or underlying tissues and organs.

The transducer is automatically scanned over a relatively large area of skin for ease of use and to ensure uniform energy deposition, "similar to the way a pattern generator works in a cosmetic laser system," Dr. Nestor said.

The transducer scans out a defined volume of tissue, creating what he called "a controlled injury zone." Chemotactic signals "then draw macrophages to the site of the injury, where they engulf lipid and cellular debris and carry it away through the lymphatics," Dr. Nestor said. This results in a reduction of the volume of the treated tissue.

The cellular debris eventually gets absorbed through the liver, and the process does not appear to cause spikes in triglycerides or cholesterol.

LipoSonix "is very precise and sophisticated, and it's easy to use," Dr. Nestor said. "This is a very exciting technology and becoming a prototype for high-energy cellulite removal using ultrasound."

Dr. Nestor disclosed that he has received equipment discounts from Cynosure, and has also received fees for speaking and consulting on behalf of the company. He also disclosed being a member of Medicis's scientific advisory board. He has also received fees for speaking engagements and research conducted on behalf of the company.

'Our patients are scared off by liposuction. They are looking for safe and effective' procedures. DR. NESTOR

Within the next 5 years, researchers at the University of Miami's newly launched Cosmetic Medicine and Research Institute hope to make a major genetic breakthrough related to skin appearance.

Dr. Leslie Baumann, a cosmetic dermatologist who directs the Cosmetic Medicine and Research Institute (CMRI), said that she and her colleagues will team up with researchers at the university's Miami Institute for Human Genomics to conduct basic science to find the genetic factors that protect some individuals from the effects of skin aging. For example, Dr. Baumann has about 20 patients over age 60 whose skin is in excellent shape despite engaging in years of harmful behaviors such as tanning and smoking.

"Hopefully we'll come out with discoveries of new medications and new treatments that will help dermatologists have more in their armamentarium," she said.

In an effort to make a significant genetic discovery, researchers at CMRI have created a skin repository. Instead of discarding extra skin after surgery, patients can choose to donate it. The skin, and information on its phenotype, are being stored for future research. The phenotype information can be especially helpful in identifying genes, Dr. Baumann said.

The repository could help reduce both the cost of cosmetic research and the need for animal testing, she said. For example, a pharmaceutical company testing a new acne drug could use skin collected from individuals with acne. The CMRI researchers will also collect extra fat from liposuction procedures and use it for stem cell research.

CMRI was launched in August, and is believed to be the first multispecialty, university-based research center to explore the role of genetics in skin appearance.

The CMRI staff includes experts in cosmetic dermatology, facial plastic surgery, oculoplastic surgery, and nutrition. The dermatology faculty includes experts in skin care and fillers, cosmetic surgery, lasers and light devices, and ethnic skin care.

"Most of the time these specialties compete against each other," Dr. Baumann said. "We're teaming up." The multispecialty team approach is helpful across the board in research, education, and day-to-day activities in the clinic.

About 65 residents a year are being trained at the CMRI clinic, of whom 22- 25 on average are coming from dermatology. Since it is a multispecialty clinic, residents rotate not only with faculty in their specialty but with other experts, Dr. Baumann said.

The multispecialty nature of CMRI also lends itself to easy consults, said Dr. Heather Woolery-Lloyd, director of ethnic skin care. She performs a lot of skin tightening, but a patient who is a better candidate for a face lift can be sent to a colleague and never has to leave the practice.

"I love practicing in this environment," Dr. Woolery-Lloyd said. "It really does give you the opportunity to provide patients with the best care."

She predicts that more private practices will use the multidisciplinary team approach as a way to expand. Instead of hiring another cosmetic dermatologist or a nurse practitioner, practices can recruit someone who does facial plastic surgery or an ophthalmologist who does oculoplastic and reconstructive surgery, Dr. Woolery-Lloyd said.

CMRI's faculty includes Dr. Leslie Baumann (third from left) and Dr. Heather Woolery-Lloyd (third from right). Cosmetic Medicine and Research Institute

Within the next 5 years, researchers at the University of Miami's newly launched Cosmetic Medicine and Research Institute hope to make a major genetic breakthrough related to skin appearance.

Dr. Leslie Baumann, a cosmetic dermatologist who directs the Cosmetic Medicine and Research Institute (CMRI), said that she and her colleagues will team up with researchers at the university's Miami Institute for Human Genomics to conduct basic science to find the genetic factors that protect some individuals from the effects of skin aging. For example, Dr. Baumann has about 20 patients over age 60 whose skin is in excellent shape despite engaging in years of harmful behaviors such as tanning and smoking.

"Hopefully we'll come out with discoveries of new medications and new treatments that will help dermatologists have more in their armamentarium," she said.

In an effort to make a significant genetic discovery, researchers at CMRI have created a skin repository. Instead of discarding extra skin after surgery, patients can choose to donate it. The skin, and information on its phenotype, are being stored for future research. The phenotype information can be especially helpful in identifying genes, Dr. Baumann said.

The repository could help reduce both the cost of cosmetic research and the need for animal testing, she said. For example, a pharmaceutical company testing a new acne drug could use skin collected from individuals with acne. The CMRI researchers will also collect extra fat from liposuction procedures and use it for stem cell research.

CMRI was launched in August, and is believed to be the first multispecialty, university-based research center to explore the role of genetics in skin appearance.

The CMRI staff includes experts in cosmetic dermatology, facial plastic surgery, oculoplastic surgery, and nutrition. The dermatology faculty includes experts in skin care and fillers, cosmetic surgery, lasers and light devices, and ethnic skin care.

"Most of the time these specialties compete against each other," Dr. Baumann said. "We're teaming up." The multispecialty team approach is helpful across the board in research, education, and day-to-day activities in the clinic.

About 65 residents a year are being trained at the CMRI clinic, of whom 22- 25 on average are coming from dermatology. Since it is a multispecialty clinic, residents rotate not only with faculty in their specialty but with other experts, Dr. Baumann said.

The multispecialty nature of CMRI also lends itself to easy consults, said Dr. Heather Woolery-Lloyd, director of ethnic skin care. She performs a lot of skin tightening, but a patient who is a better candidate for a face lift can be sent to a colleague and never has to leave the practice.

"I love practicing in this environment," Dr. Woolery-Lloyd said. "It really does give you the opportunity to provide patients with the best care."

She predicts that more private practices will use the multidisciplinary team approach as a way to expand. Instead of hiring another cosmetic dermatologist or a nurse practitioner, practices can recruit someone who does facial plastic surgery or an ophthalmologist who does oculoplastic and reconstructive surgery, Dr. Woolery-Lloyd said.

CMRI's faculty includes Dr. Leslie Baumann (third from left) and Dr. Heather Woolery-Lloyd (third from right). Cosmetic Medicine and Research Institute

Within the next 5 years, researchers at the University of Miami's newly launched Cosmetic Medicine and Research Institute hope to make a major genetic breakthrough related to skin appearance.

Dr. Leslie Baumann, a cosmetic dermatologist who directs the Cosmetic Medicine and Research Institute (CMRI), said that she and her colleagues will team up with researchers at the university's Miami Institute for Human Genomics to conduct basic science to find the genetic factors that protect some individuals from the effects of skin aging. For example, Dr. Baumann has about 20 patients over age 60 whose skin is in excellent shape despite engaging in years of harmful behaviors such as tanning and smoking.

"Hopefully we'll come out with discoveries of new medications and new treatments that will help dermatologists have more in their armamentarium," she said.

In an effort to make a significant genetic discovery, researchers at CMRI have created a skin repository. Instead of discarding extra skin after surgery, patients can choose to donate it. The skin, and information on its phenotype, are being stored for future research. The phenotype information can be especially helpful in identifying genes, Dr. Baumann said.

The repository could help reduce both the cost of cosmetic research and the need for animal testing, she said. For example, a pharmaceutical company testing a new acne drug could use skin collected from individuals with acne. The CMRI researchers will also collect extra fat from liposuction procedures and use it for stem cell research.

CMRI was launched in August, and is believed to be the first multispecialty, university-based research center to explore the role of genetics in skin appearance.

The CMRI staff includes experts in cosmetic dermatology, facial plastic surgery, oculoplastic surgery, and nutrition. The dermatology faculty includes experts in skin care and fillers, cosmetic surgery, lasers and light devices, and ethnic skin care.

"Most of the time these specialties compete against each other," Dr. Baumann said. "We're teaming up." The multispecialty team approach is helpful across the board in research, education, and day-to-day activities in the clinic.

About 65 residents a year are being trained at the CMRI clinic, of whom 22- 25 on average are coming from dermatology. Since it is a multispecialty clinic, residents rotate not only with faculty in their specialty but with other experts, Dr. Baumann said.

The multispecialty nature of CMRI also lends itself to easy consults, said Dr. Heather Woolery-Lloyd, director of ethnic skin care. She performs a lot of skin tightening, but a patient who is a better candidate for a face lift can be sent to a colleague and never has to leave the practice.

"I love practicing in this environment," Dr. Woolery-Lloyd said. "It really does give you the opportunity to provide patients with the best care."

She predicts that more private practices will use the multidisciplinary team approach as a way to expand. Instead of hiring another cosmetic dermatologist or a nurse practitioner, practices can recruit someone who does facial plastic surgery or an ophthalmologist who does oculoplastic and reconstructive surgery, Dr. Woolery-Lloyd said.

CMRI's faculty includes Dr. Leslie Baumann (third from left) and Dr. Heather Woolery-Lloyd (third from right). Cosmetic Medicine and Research Institute

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun

LAS VEGAS — Time after time, Dr. Martin Braun encounters new patients in his Vancouver, B.C.-based practice who have undergone previous cosmetic filler treatments in Europe as well as Asia, but who have no idea what product was used.

Determining product history can be a daunting task because there are more than 100 cosmetic fillers currently being used in the European Union (EU), Dr. Braun said at the annual meeting of the International Society for Dermatologic Surgery.

"Frequently, we have to contact the physician, and I'm introduced to a new filler," he said. "Considering today's sense of a global village, I think it's important for physicians in North America to be familiar with some of these products." Filler products approved for use in the EU are designated with a so-called CE mark, which does not indicate conformity to a standard but rather conformity to the legal requirements of EU directives.

"There may not have been any human trials done on the filler," Dr. Braun said. "It could be something as simple as a certified quality system to ISO 9000 and that's it." (ISO is the International Organization for Standardization.)

He highlighted the following products to keep on the radar:

▸ Evolence (ColBar LifeScience Ltd.). Approved in Canada in 2006 and in the United States in 2008, this product contains 35 mg/mL of porcine collagen (telopeptides removed) cross-linked with D-ribose (nontoxic). No skin testing is required and studies have shown that results last up to 12 months.

However, using it for lip augmentation has resulted in several cases of nodule formation, Dr. Braun said. Of 20 patients he treated in 2006, 16 developed multiple lip nodules that have persisted in one-quarter of the cases for nearly 2 years. "Be very cautious with this product in and around the lips," Dr. Braun said.

He did not evaluate Evolence Breeze, which is said to be less problematic in the lips.

▸ Radiesse (BioForm Medical). Data from clinical studies suggest that this Food and Drug Administration-approved product lasts a few more months than do hyaluronic acid (HA) fillers. "It's the filler of choice for me for very deep nasolabial folds in men, as it appears to lift better than many hyaluronic acid fillers," Dr. Braun commented. "The one disadvantage is that 70% of that Radiesse syringe contains a gel carrier that disappears in 3–4 months. You have to warn the patient[s] of this because they will see a huge decrease in their filling after 3–4 months and have to be injected again." In his experience, Radiesse tends to bruise more than other fillers, feels indurated for the first few weeks, and can't be dissolved with anything.

▸ Juvéderm (Allergan Inc.). Developed from Streptococcus equi fermentation, this FDA-approved product "is very similar to Restylane [Medicis Aesthetics Inc.], but it's not as stiff," Dr. Braun said. "So if you want a skin-stiffening agent to perform the fern injection techniques, Restylane will likely do a better job for you." Juvéderm with lidocaine just became available in Canada but is not yet available in the United States. Dr. Braun predicted that this will become his filler of choice for patients who do not wish to have a proper dental block performed.

▸ Sculptra (Sanofi-Aventis). This product is FDA approved for HIV-associated facial lipoatrophy, but in Canada, it's approved for dermal contouring of the face in all patients. Dr. Braun said he uses Sculptra (poly-L-lactic acid) filler in patients with marked hollowing of the buccal fat pads and temporal fat pads and in those with thin skin, because after it's injected "the skin gets a nice glow, similar to [what] you obtain with IPL [intense pulsed light] photorejuvenation."

▸ Atléan (Stiefel Laboratories Inc.). Purchased by Stiefel in 2008, this product contains hyaluronic acid mixed with tricalcium phosphate. "The idea is that the tricalcium phosphate stimulates new collagen formation which is long lasting, like that associated with calcium hydroxyapatite," Dr. Braun said. In split-face injections, Dr. Braun had to use 5 cc of Atléan for 4 cc of Radiesse to get a similar correction. "So Radiesse will have a competitor here," he said. "And unlike Sculptra (where the water absorbs in 2 days), the immediate volumization achieved with Atléan will endure due to the HA component."

Atléan is not approved for use in the United States.

▸ Laresse (FzioMed Inc.). This polyethylene oxide product is marketed as being nonanimal, nonbacterial, nonpermanent, nontoxic, and nonparticulate—"everything we would want in a filler," Dr. Braun said.

However, when he injected it into the glabellar folds of two patients, induration developed that lasted more than 3 weeks. "I don't think it has a future, because when you inject it, you get an induration."

Laresse is not approved for use in the United States.

▸ ArteFill (Artes Medical Inc.). This FDA-approved product is a successor of Artecoll, a formulation of polymethyl methacrylate (PMMA) spheres suspended in collagen that was found to cause a high incidence of lumps when injected into the lips and delayed granulomatous reactions in the face. "Now the product's PMMA crystals have been polished, and it's being marketed as ArteFill," Dr. Braun said. "Many of the complications I saw came out in year 7, so be very careful injecting this. It remains to be seen if this product is safer than Artecoll."

▸ DermaLive and DermaDeep (DermaTech). This permanent filler, a combination of polyethyl methacrylate and hyaluronic acid, was withdrawn from France in 2003 and later from Canada because nodules and granulomas were reported years after injection.

"I ask patients on my medical history sheet if they've had this filler, because if you inject other things in a DermaLive recipient, you can activate a foreign body reaction," Dr. Braun said.

Dr. Braun disclosed that he has received honoraria from Medicis, which markets Restylane, and Allergan, which markets Juvéderm. He owns no stock in either company.

"Be very cautious,"when using Evolence in the lips, said Dr. Martin Braun. Nodule formation—as shown in the patient above 15 months after injection—can occur. Courtesy Dr. Martin Braun