Aesthetic Dermatology

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — While cellulite can be easily identified, the basic science of its makeup remains a mystery.

"We still don't know what the definitive pathologic cause of cellulite is," Dr. Neil Sadick said at the annual meeting of the International Society for Dermatologic Surgery. "There are many aggravating factors such as weight loss that are thought to play a role, but none of them [has] been proven over the past 30 years. We believe that this is a sexual dimorphic secondary trait."

One theory he subscribes to is that cellulite "involves changes in the structure of the adipocyte and the surrounding septa, so that the septa are more vertically oriented, allowing movement of the adipocyte up to the dermis."

Dr. Sadick and his associates in the department of dermatology at Cornell University, New York, plan to launch a series of clinical trials with the New Jersey Medical School, Newark, in an effort to determine the content of fat found in cellulite.

They also plan to study receptors that have been shown to be involved and upregulated in people with cellulite, including peroxisome proliferator-activated receptors, uncoupling protein 1, and androgen receptors α-AR and β-AR. "By understanding more about the basic science of this condition, we hope to be able to introduce better therapies in the future," he said.

The current trend in cellulite therapy is marked by multimodal devices that "attempt to heat adipocytes, remodel adipocytes, and cause dermal remodeling in the septa surrounding the adipocyte cells," Dr. Sadick said. He discussed the following technologies:

▸ VelaShape (Syneron Medical Ltd.). This Food and Drug Administration-approved device combines bipolar radiofrequency power and infrared energy with vacuum and mechanical massage for circumferential reduction.

"There have been a number of publications in the scientific literature showing that there is some degree of efficacy in terms of remodeling the cellulite as well as circumferential fat reduction," he said.

In a study of 40 patients conducted at Dr. Sadick's clinic, 85% had a circumferential reduction of 1 cm or more after 12 treatments and 43% had a circumferential reduction of 2 cm or more.

"Up to 7.2-cm reduction in circumference was achieved" in some cases, he said.

▸ TriActive (Cynosure). This FDA-approved device combines a low-energy diode laser with suction massage that has been shown to achieve a global cellulite improvement in 75% of patients (Am. J. Cosmet. Surg. 2005;224:233–5). "This is a very nice technology that can be used in this setting," Dr. Sadick commented.

▸ Accent (Alma). This FDA-approved device uses dual radiofrequency technology for circumferential reduction.

The unipolar setting targets deep dermal and subdermal layers and is used to treat large volumes of tissue, while the bipolar setting delivers energy superficially and is used to treat areas with a thinner dermis such as the face.

One recent study of 30 patients with cellulite grade III-IV who were treated 6 times over a 2-week period found that 27 achieved clinical improvement with a mean decrease in thigh circumference of 2.45 cm as measured by MRI (Dermatol. Surg. 2008;34:204–9).

▸ SmoothShapes (Elemé Medical). This FDA-approved device combines a laser and an LED light source with mechanical rollers and a vacuum to "mold the adipocytes and to try and improve the metabolic parameters associated with cellulite," Dr. Sadick said.

One randomized trial of 74 patients treated twice a week for 4 weeks found that 81% had a significant volumetric reduction in subcutaneous fat (J. Lasers Surg. Med. 2004; suppl. 16:32). At 13 months post treatment, five patients underwent MRI and four of the five maintained their result.

In the future, he predicted, more "inside-outside" approaches to treating cellulite are likely to evolve, such as combining external technologies with internal laser lipolysis to "heat adipocytes and eat up septa. That probably will give the most effective results."

Dr. Sadick went on to note that while injectable treatment of cellulitis remains popular in the United States, "there is not a lot of good science behind it. We need to distinguish between true mesotherapy and injectable lipolysis. In true mesotherapy, we are attempting to eliminate some fat [and] have an effect on the metabolism of the adipocytes."

Agents being used for treating cellulite in mesotherapy include aminophylline, isoproterenol, ephedrine, calcium pyruvate, carnitine, and ma huang.

Another approach to cellulite treatment is detergent lipolysis, or mesotherapy, in which phosphatidylcholine and deoxycholate act as detergents, causing adipose cell walls to dissolve and break down.

"This is not FDA approved to date but there are FDA studies underway to determine the optimal solution," Dr. Sadick said.

Future treatment approaches may include topical approaches such as Retinol Anti-Cellulite, a cosmeceutical from RoC, as well as electrolipolysis, carboxytherapy, and cryolipolysis.

But for now, "the technology has moved far in advance of what we know about cellulite," he said.

Dr. Sadick disclosed that he has received research funding from Syneron Medical Ltd., DEKA Corp., and Cynosure Inc.

'By understanding more about the basic science of this condition, we hope to be able to introduce better therapies.' DR. SADICK

A patient is shown before (left) and after (right) undergoing four treatments with VelaShape for cellulite reduction. Photos courtesy Dr. Neil Sadick

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

LAS VEGAS — About 8 years ago, Dr. Neil Sadick and other dermatologic surgeons nearly gave up on lasers as a treatment option for leg veins because of the high rate of complications that they were seeing.

"We were using shortwave technologies delivered at low energies," Dr. Sadick recalled at the annual meeting of the International Society for Dermatologic Surgery. "We were impeding vessels and using upregulation of inflammatory cytokines, not causing endothelial destruction, so the results were not good. We were seeing lots of side effects, lots of superficial burns."

However, thanks to the advent of lasers with longer wavelengths and multimodal technologies since that time—the Lux1064+ (Palomar Medical Technologies Inc.), the CoolGlide Excel (Cutera Inc.), and the Cynergy III (Cynosure Inc.)—greater clinical efficacy has been achieved. "No laser is a substitute for sclerotherapy," said Dr. Sadick, of the department of dermatology at Cornell University, New York. "That remains the gold standard. But with the use of longer wavelengths we are able to achieve great results in this setting."

Theoretical problems intrinsic to laser therapy in treating leg veins include increased hydrostatic pressure, compared with that required for treating facial telangiectasias. "It is going to be more difficult to eradicate lower extremity vessels even if they're small unless you address the hydrostatic pressure," he said. "We don't have these same concerns in dealing with facial veins."

In addition, compared with facial telangiectasias, lower extremity vessels are located deeper in the dermis, are larger, and have increased basal lamina. "We have also shown that there are altered cytokine patterns when you induce light on the legs, compared with that of the face," Dr. Sadick said. "There is much greater regulation of inflammatory cytokines. That's why we usually don't go back and retreat lower extremity veins for at least 8 weeks."

Dr. Sadick favors a monomodal approach for the laser treatment of leg veins. For vessels smaller than 1 mm his published recommendations include a spot size of 1.5 mm, a fluence of 150–400 J/cm

"A number of studies have shown nice results using 1,064-nm and 1,320-nm technologies, but most people are using 1,064-nm technologies today," he said, noting that most of his patients who present for treatment of leg veins undergo a combination of sclerotherapy and external laser therapy.

In his clinical experience one to three laser treatment sessions are needed for optimal results. "Because you have so much upregulation of cytokines over a long period of time, we wait 8–12 weeks between treatment sessions," Dr. Sadick said. "I've found that if you go back too quickly you get more hypopigmentation, more potential for hypopigmentation, and you're inducing more inflammation which theoretically could induce more neovascularization."

Complications from using 1,064-nm lasers can occur with pulse stacking, especially with longer wavelengths. "The good news about 1,064-nm lasers is that they deliver high energy so you can get efficient eradication of the vessels," Dr. Sadick said. "The bad news is that they are painful. They penetrate deeply so sometimes you need to use analgesia. Also, there is an increased incidence of epidermal necrosis, so you need to be very gentle with these technologies."

Problems can also occur with improper matching of skin type and wavelength. "If someone is tanned or of a darker skinned phenotype, it's important to be conservative or do a spot test first," he advised. "Also, be sure you address hydrostatic pressures. If you use an external laser, a key way to not have successful results is to not treat a small refluxing vein or tiny varicosity before you use a laser to try to eradicate it. That will give you a high complication profile."

Dr. Sadick disclosed that he has received workshop funding and discounted equipment from Syneron Medical Ltd. and Laserscope and workshop funding from Cutera.

Dr. John J. Voorhees will receive the 2009 Eugene J. Van Scott Award for Innovative Therapy of the Skin. The award recognizes his key contributions in the treatment of psoriasis and aging skin, including work leading to the greater use of immunosuppressive agents for psoriasis, as well as research in the use of retinoids to combat photoaging.

Dr. Voorhees will receive the award at the American Academy of Dermatology's 2009 annual meeting in March. For more information, contact the academy at 888-462-3376.

Dr. John J. Voorhees

Dr. John J. Voorhees will receive the 2009 Eugene J. Van Scott Award for Innovative Therapy of the Skin. The award recognizes his key contributions in the treatment of psoriasis and aging skin, including work leading to the greater use of immunosuppressive agents for psoriasis, as well as research in the use of retinoids to combat photoaging.

Dr. Voorhees will receive the award at the American Academy of Dermatology's 2009 annual meeting in March. For more information, contact the academy at 888-462-3376.

Dr. John J. Voorhees

Dr. John J. Voorhees will receive the 2009 Eugene J. Van Scott Award for Innovative Therapy of the Skin. The award recognizes his key contributions in the treatment of psoriasis and aging skin, including work leading to the greater use of immunosuppressive agents for psoriasis, as well as research in the use of retinoids to combat photoaging.

Dr. Voorhees will receive the award at the American Academy of Dermatology's 2009 annual meeting in March. For more information, contact the academy at 888-462-3376.

Dr. John J. Voorhees

SANTA BARBARA, CALIF. — Resist temptation.

When the patient looks good, but the syringe in your hand still contains leftover Restylane or Juvéderm, "Put it down," advised Dr. Allan Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif.

"Don't feel that you have to use an entire syringe on these patients."

"[Don't say,] I'll find a place to put it." You don't have to put it anywhere, he said during a panel on aesthetic complications during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Wirtzer said most of the cases he sees for correction of aesthetic filler procedures boil down to technique error. "Many times, people are injecting too much, too superficial, too soon, and sometimes, it's just a poor choice of material," he said.

Filler materials are expensive, so some physicians want to inject every drop. But overfilled cheeks, nodular lips, and bumpy chins do not lead to patients satisfied that they got their money's worth, he said.

Overtreating a patient with permanent fillers doesn't last forever. "But you can see the results of overtreatment even with Restylane or Perlane or Radiesse for months and months, and these patients are not going to be happy," he said.

Silicone fillers are not for beginners. "If you don't have years of experience with long-term fillers and short-term fillers, don't go near silicone," Dr. Wirtzer said.

Among his other tips:

▸ Inject deeply, using as few needle sticks as possible.

▸ To avoid drift with Radiesse, massage "a great deal." Around the orbicularis muscle, stay very medial so that the facial muscles used in smiling do not create forces that push the material to the outside edges of the lips.

▸ When using Restylane, avoid bulges by injecting below the orbital ridge.

▸ Minimize pain with ice and topical and local anesthetics.

▸ Invest in $3 handheld squeeze balls, which create a distraction for the patient during filler injections.

▸ If you see a blanch and realize you have an infarction in a vessel, "vigorously massage the hell out of it."

Above all, be meticulous in preprocedure discussions with patients about expected sequelae of the treatment, Dr. Wirtzer advised. "When you discuss that a person's going to get red or going to get swollen, this isn't [seen as] a complication; it's a natural event that follows the treatment."

If it is discussed only after the fact, however, it is seen by the patient as an "excuse" meant to explain away a perceived complication, he said.

Dr. Wirtzer disclosed that he serves as a consultant to Medicis Pharmaceutical Corp., maker of Restylane, and Aventis Dermatology, maker of Sculptra.

'You can see the results of overtreatment … for months and months, and these patients are not going to be happy.' DR. WIRTZER

SANTA BARBARA, CALIF. — Resist temptation.

When the patient looks good, but the syringe in your hand still contains leftover Restylane or Juvéderm, "Put it down," advised Dr. Allan Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif.

"Don't feel that you have to use an entire syringe on these patients."

"[Don't say,] I'll find a place to put it." You don't have to put it anywhere, he said during a panel on aesthetic complications during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Wirtzer said most of the cases he sees for correction of aesthetic filler procedures boil down to technique error. "Many times, people are injecting too much, too superficial, too soon, and sometimes, it's just a poor choice of material," he said.

Filler materials are expensive, so some physicians want to inject every drop. But overfilled cheeks, nodular lips, and bumpy chins do not lead to patients satisfied that they got their money's worth, he said.

Overtreating a patient with permanent fillers doesn't last forever. "But you can see the results of overtreatment even with Restylane or Perlane or Radiesse for months and months, and these patients are not going to be happy," he said.

Silicone fillers are not for beginners. "If you don't have years of experience with long-term fillers and short-term fillers, don't go near silicone," Dr. Wirtzer said.

Among his other tips:

▸ Inject deeply, using as few needle sticks as possible.

▸ To avoid drift with Radiesse, massage "a great deal." Around the orbicularis muscle, stay very medial so that the facial muscles used in smiling do not create forces that push the material to the outside edges of the lips.

▸ When using Restylane, avoid bulges by injecting below the orbital ridge.

▸ Minimize pain with ice and topical and local anesthetics.

▸ Invest in $3 handheld squeeze balls, which create a distraction for the patient during filler injections.

▸ If you see a blanch and realize you have an infarction in a vessel, "vigorously massage the hell out of it."

Above all, be meticulous in preprocedure discussions with patients about expected sequelae of the treatment, Dr. Wirtzer advised. "When you discuss that a person's going to get red or going to get swollen, this isn't [seen as] a complication; it's a natural event that follows the treatment."

If it is discussed only after the fact, however, it is seen by the patient as an "excuse" meant to explain away a perceived complication, he said.

Dr. Wirtzer disclosed that he serves as a consultant to Medicis Pharmaceutical Corp., maker of Restylane, and Aventis Dermatology, maker of Sculptra.

'You can see the results of overtreatment … for months and months, and these patients are not going to be happy.' DR. WIRTZER

SANTA BARBARA, CALIF. — Resist temptation.

When the patient looks good, but the syringe in your hand still contains leftover Restylane or Juvéderm, "Put it down," advised Dr. Allan Wirtzer, a dermatologist in private practice in Sherman Oaks, Calif.

"Don't feel that you have to use an entire syringe on these patients."

"[Don't say,] I'll find a place to put it." You don't have to put it anywhere, he said during a panel on aesthetic complications during the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

Dr. Wirtzer said most of the cases he sees for correction of aesthetic filler procedures boil down to technique error. "Many times, people are injecting too much, too superficial, too soon, and sometimes, it's just a poor choice of material," he said.

Filler materials are expensive, so some physicians want to inject every drop. But overfilled cheeks, nodular lips, and bumpy chins do not lead to patients satisfied that they got their money's worth, he said.

Overtreating a patient with permanent fillers doesn't last forever. "But you can see the results of overtreatment even with Restylane or Perlane or Radiesse for months and months, and these patients are not going to be happy," he said.

Silicone fillers are not for beginners. "If you don't have years of experience with long-term fillers and short-term fillers, don't go near silicone," Dr. Wirtzer said.

Among his other tips:

▸ Inject deeply, using as few needle sticks as possible.

▸ To avoid drift with Radiesse, massage "a great deal." Around the orbicularis muscle, stay very medial so that the facial muscles used in smiling do not create forces that push the material to the outside edges of the lips.

▸ When using Restylane, avoid bulges by injecting below the orbital ridge.

▸ Minimize pain with ice and topical and local anesthetics.

▸ Invest in $3 handheld squeeze balls, which create a distraction for the patient during filler injections.

▸ If you see a blanch and realize you have an infarction in a vessel, "vigorously massage the hell out of it."

Above all, be meticulous in preprocedure discussions with patients about expected sequelae of the treatment, Dr. Wirtzer advised. "When you discuss that a person's going to get red or going to get swollen, this isn't [seen as] a complication; it's a natural event that follows the treatment."

If it is discussed only after the fact, however, it is seen by the patient as an "excuse" meant to explain away a perceived complication, he said.

Dr. Wirtzer disclosed that he serves as a consultant to Medicis Pharmaceutical Corp., maker of Restylane, and Aventis Dermatology, maker of Sculptra.

'You can see the results of overtreatment … for months and months, and these patients are not going to be happy.' DR. WIRTZER

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Developing rapport with someone who seeks cosmetic surgery—first as a person and then as a patient—can help weed out potentially problematic patients.

Dr. Roberta D. Sengelmann enters the room for a patient's first consultation "without any preconceived notion about what they're here for," and spends a few minutes asking the patient about herself before moving on to cosmetic topics, she said. "I want to know who I'm embarking on this journey with," said Dr. Sengelmann, a dermatologist in Santa Barbara, Calif. and St. Louis, Mo.

She and three other cosmetic surgeons practicing in California offered tips for managing cosmetic patients in a panel discussion at the annual meeting of the Pacific Dermatologic Association.

Have a mirror handy at that first visit, because often patients do not have a very good idea of what they want done, said Dr. David R. Harris of Campbell, Calif. Help them focus by asking, "If I were a genie, and could pop out of a bottle and satisfy one problem that you have, what would that problem be?" he suggested.

Dr. Ronald L. Moy of Los Angeles agreed that listening to patients is extremely important. He added that listing the main categories of procedures offered, for resurfacing, lifting or tightening, filling, or Botox (botulinum toxin type A) treatments, may help the patient focus.

In addition to developing rapport with patients and helping them decide which treatment to get, the panelists discussed:

▸ Care coordinators. Dr. Greg S. Morganroth of Mountain View, Calif., relies on cosmetic consultants to explain his philosophy, background, and approaches, so when he enters the room, the patient already is feeling good about being there. "It's not just your rapport with them" that matters, he said. "Make them aware it's a team that's taking care of them."

In Dr. Morganroth's practice, the cosmetic consultants not only help during the consultation by handling preoperative education and through extensive "hand-holding" in the postoperative phase. "They're the liaison for the patient throughout the entire process," he said.

The role can be filled by a dedicated cosmetic consultant, or by a nurse, medical assistant, or receptionist. "They all can be trained to do it," he said.

Dr. Sengelmann employs a nurse to fill this role of patient advocate, liaison and care provider.

If a consultant screens cosmetic patients for you, it's still important for you to get acquainted with the patient to decide whether to proceed, Dr. Harris cautioned.

▸ Duration of the consultation. Dr. Sengelmann charges for initial consultations, which last 30 minutes or as long as she thinks is needed. "This all boils down to really getting to know who you're working with and may eventually be operating on. It's just like dating," she said. Many times a patient needs to return for a second or even third consultation, or she will start with more minor treatments prior to scheduling a more involved procedure.

Before he accepts patients, Dr. Moy meets with them two or three times and makes himself accessible by e-mail.

Another strategy is to offer to take care of smaller problems such as dyschromia, an unsightly mole, telangiectasias, lumps, or bumps, and see how the patient handles that before agreeing to do a larger procedure, Dr. Harris said.

▸ Red flags. Patients treated for general dermatologic problems such as psoriasis or acne may become dissatisfied, frustrated, or unhappy with the results, but cosmetic patients in addition can become terribly angry, especially if they have unjustified expectations, Dr. Harris cautioned.

Watch out for patients who complain about every other dermatologist they've seen, or someone who complains about a previous surgeon's work that seems well done to you. "They're going to hate you next," he warned. If the horrible problem a patient complains of is a nearly imperceptible defect, don't treat it. If a patient doesn't listen well and can't focus or make eye contact, be cautious.

▸ Rejections. If you do not want to work with a patient, speak as you would in other troubled relationships, Dr. Sengelmann suggested. Start sentences with "I don't feel that I will be able to meet your expectations …" or "I'm concerned you will not be satisfied with what think I can accomplish for you."

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN

SAN FRANCISCO — Dermatologists who perform cosmetic surgery take a variety of approaches to obtain a patient's informed consent, with differing views on the best method to do so.

Some try to list every possible complication of a procedure on informed consent forms. Others see that as a trap if they omit the one problem that the patient develops, and prefer more generic references to potential complications.

Four experts in private cosmetic surgery practices shared best practices in obtaining informed consent on a panel at the annual meeting of the Pacific Dermatologic Association. All agreed that there should be two copies of consent forms—one for the patient's chart, and the other to go home with the patient.

Dr. Roberta D. Sengelmann uses a fairly generic consent form in her current practice in Santa Barbara, Calif., and St. Louis, Mo., and after a thorough discussion with the patient, documents specific pertinent risks in their medical record.

In her experience as an expert witness for dermatologic procedures, she has found that the danger of itemizing every possible risk is that should something occur that was not listed, problems will arise.

Dr. Sengelmann said that important phrases to include in consent forms are that "No guarantee can be made" for specific results, and "Sometimes additional procedures are needed to obtain the desired result."

Dr. Ronald L. Moy of Los Angeles takes a different approach, influenced by his 8 years of service on the Medical Board of California. Many of the cases handled by the board involved patients who said they were not aware that they were at risk for a particular complication.

"It's true that you're not going to include everything, but you can include 99.9%" of potential complications on the form, he said, adding that an extensive list is best.

Dr. David R. Harris, who is from Campbell, Calif., agreed, and added that the form also should point out the cost of additional procedures; otherwise, patients might assume that the work is free.

His office developed an easy-to-understand format that uses bullets and short explanations on the consent form instead of "legal mumbo jumbo." He asks patients to sign a clause saying they will go to arbitration rather than file a lawsuit if they end up in a conflict over the results, even knowing that an arbitration clause is not binding.

Dr. Moy takes a different tack, asking patients to sign a statement saying that if they were to take legal action, they would use an expert witness from one of the four medical specialty societies in which Dr. Moy is a member. This would exclude expert witnesses from specialties that have had turf wars with dermatologic surgeons.

Dr. Greg S. Morganroth of Mountain View, Calif., asks patients to sign an arbitration agreement and tells them it is not binding. He uses the discussion primarily to develop a mindset that he and the patient are collaborators working together.

Malpractice carriers tend to frown on arbitration agreements, he noted, because physicians are more likely to win a case in a court of law than with an arbitration panel. The nonbinding nature of these agreements cut both ways, however, so that he could opt out of the agreement if it ever came to that.

His informed consent form includes a checklist of items that patients must initial. Patients must acknowledge, for example, that they are aware of how long healing may take, that Dr. Morganroth is not a plastic surgeon, and that some physicians would be critical of a dermatologic surgeon doing cosmetic surgery.

For larger facial surgeries, he numbers them, telling a patient that she is the third case he will have done for a particular procedure, or number 364. "I go a little bit overboard," but it avoids a patient getting angry later if he learns of this fact, he said.

The danger of itemizing every risk is that should something occur that was not listed, problems will arise. DR. SENGELMANN