Aesthetic Dermatology

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

CHICAGO — The indications for negative-pressure wound therapy are expanding to include infected wounds and complicated wounds with exposed bone, tendon, or even orthopedic hardware, Dr. Anton Sidawy said.

"While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies," he said at a symposium on vascular surgery sponsored by Northwestern University.

"It is not," Dr. Sidawy cautioned, "going to substitute for a good blood supply to the wound area and appropriate local wound therapy."

Negative-pressure wound therapy, also known as vacuum-assisted closure (VAC) therapy, was developed roughly two decades ago, and involves the application of subatmospheric pressure to a wound through a pump attached to a foam sponge with an adhesive dressing. VAC is thought to accelerate wound contraction, increase local blood flow, and promote wound drainage and edema resolution.

Its widespread success in the diabetic population with microcirculatory pathology also suggests that the microdeformations of the wound surface caused by the negative pressure act on a cellular level to stimulate cell proliferation, angiogenesis, and granulation tissue formation, said Dr. Sidawy, chief of surgical services, Washington VA Medical Center, and professor of surgery at Georgetown and George Washington University Medical Centers, Washington.

Infected wounds typically do not do as well with VAC therapy, but progress has been made with recent studies demonstrating decreased bacterial burden after VAC therapy. Management of infected wounds has been aided by the use of VAC devices that allow for the instillation of fluids so contaminated wounds can be continuously irrigated with antibiotic fluids and by silver-impregnated dressings (GranuFoam Silver Dressing, KCI Inc., San Antonio, Texas) that have antimicrobial effects (Ann. Plast. Surg. 2007;59:58–62).

Physicians in the Iraqi theater have turned to VAC to manage contaminated soft-tissue injuries caused by the blast effect of high-energy missiles. Dr. Sidawy cited a retrospective pilot study of 88 high-energy, contaminated soft-tissue injuries in 77 patients in which all wounds treated with VAC were closed definitively before discharge, with no wound complications (J. Trauma 2006;61:1207–11).

Large, complex circumferential soft tissue defects or burns can be managed with VAC to facilitate the coverage of exposed vessels and stimulate the growth of granulation tissue, Dr. Charles Fox of the Walter Reed Army Medical Center in Washington said in an interview. At times, maintaining a seal on a VAC can be challenging, particularly with external fixation or wounds of the hands and feet.

"An impervious stockinette sealed at either end with a Coban [compression wrap] may be substituted for the large OpSites [dressings] that do not adhere to a very wet cavitary wound," Dr. Fox said. "This strategy has been used for some complicated wounds in the Iraqi theater."

By reducing tissue edema, and thereby reducing the circumference of the extremity and the surface area of the wound, VAC therapy has also revolutionized how physicians treat wounds with exposed bone, tendon, or orthopedic hardware. Such complicated wounds, particularly on the lower third of the leg, traditionally required microvascular free-tissue transfer for coverage of the defect. Now, both small and large defects can be treated with VAC, although larger surface wounds still need free-tissue transfer, Dr. Sidawy said.

In a landmark study, VAC therapy was used to obtain successful coverage without complication in 71 of 75 open wounds of the lower extremity with exposed bone, tendon, or hardware. Of these wounds, 52 were below the knee and orthopedic hardware was exposed in 12 (Plast. Reconstr. Surg. 2001;108:1184–91).

'While it's not a cure-all, this device can be applied to a variety of wounds caused by many etiologies.' DR. SIDAWY

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

WASHINGTON — The vascular surgeon insists that revascularization was a success—and there are outcome images to prove it—but the diabetic foot becomes ischemic anyway, and the wound fails to heal.

This is an all too common scenario for physicians who care for these at-risk limbs and problem wounds. Such failures can be explained in a push-pull model of perfusion in these patients, and this model may well indicate what needs to be done for effective treatment, according to Dr. William J. Ennis.

The push-pull model essentially states that despite the "push" of restored macrocirculation from revascularization, the patient still needs the ability to "pull" blood nutrients into all parts of the limb via a functional microcirculation, said Dr. Ennis of the St. James Center for Comprehensive Wound & Disease Management in Chicago. He spoke at a meeting sponsored by George Washington University Hospital.

But creating "pull" is not an easy task, especially for patients with diabetes. In such individuals, a functional microcirculation may be a problem in its own right because of both physical and physiologic changes in their microvascular system brought on by the long-term chronic disease. In patients with poor microcirculation, successful revascularization of the larger vessels can lead to ischemic reperfusion injury in the tissues that they service. White cells stick and create reactive oxygen species that make it almost impossible for wounds to heal.

Damage models in diabetic foot wound responses after revascularization can borrow from cardiology, according to Dr. Ennis—concepts such as tissue "stunning," whereby tissue is traumatized by the reperfusion injury without being killed and remains capable of recuperating; no reflow, such as that caused by a mechanical obstruction from thrombus; or functional alterations, such as the endothelial dysfunction that is known to occur in diabetics.

It is critical to restore a microvascular "pull" as soon as possible in order for the wound to heal and, in many cases, in order for the limb to survive, according to Dr. Ennis. "It is almost silly for us to think that we can solve the entire process with a simple bypass. We may end up with a mixed pattern, persistent ischemia, and something known as no reflow. These are the patients who get bypass and nothing happens—the wound continues or the open-air site never heals…. It is so frustrating for us as wound clinicians to see a great bypass and still lose a limb. It's not uncommon, and this [microcirculatory problem] is why."

Angiogenesis agents are one option for restoring microcirculatory "pull." One such treatment may be ultrasound. Pulsatile flow in tissue pushes and pulls on the endothelium and causes nitric oxide release. Ultrasound can be used to "fake the tissue out that it is receiving pulsatile flow," according to Dr. Ennis, who along with his colleagues has studied the use of ultrasound to induce angiogenesis, pulsatile flow, and ultimately wound healing.

"We were able to show that there was a difference in angiogenesis at approximately 41/2 weeks with ultrasound therapy. … This was one of the first times we were actually able to quantify the angiogenesis response and correlate it to wound healing," he explained (Advances in Skin & Wound Care 2006;19:437–46).

The future may include novel treatments for reperfusion injury and ischemia such as bone marrow stem cell therapy, which may be available in 5–10 years, and growth factor molecules, many of which are currently being tested in phase I trials, according to Dr. Ennis.

Regardless of which treatment is chosen, it is also important for the vascular and wound-care teams to collaborate on prevention of ischemia after revascularization, Dr. Ennis stated. The certainty of appropriate return of macrovascular circulation must be confirmed, and all other barriers to blood flow need to be addressed.

Preoperatively, it may be possible to use free-radical scavengers or systemic vasodilators. Postoperatively, he advised that tissue-level perfusion be tested for adequacy of revascularization and cautioned against relying on the return of palpable pulse or flow in the bypass graft to do that.

Dr. Ennis disclosed that he was a consultant and received an honorarium from Celleration, which manufactures an ultrasound device for stimulation of wound healing.

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

BALTIMORE — The increasing need for wound care centers in the United States may present an opportunity for dermatologists to wed their interests in both medical and surgical dermatology, according to Dr. Robert S. Kirsner.

"Wound care is at the junction of surgical and medical dermatology. To somebody with broad interests, it may be attractive because there are certain wound problems that require the internist in you and some wound problems that require the surgeon in you," said Dr. Kirsner, director of the Wound CURE (Cutaneous Ulcer Rehabilitation and Education) Center at the University of Miami.

Dermatologists can offer their expertise in wound care by directing or even opening up their own wound care clinic or by practicing or consulting part-time with a center, he said.

Some wound centers have a dermatologist who works there a half or full day per week, but typically a dermatologist is a consultant to a wound center and sees patients with dermatologic conditions such as pyoderma gangrenosum, vasculitis, or immunobullous disease, Dr. Kirsner said in an interview.

Wound care centers that include a physician may be run from a solo or group practice or based in an ambulatory center or at a hospital. Hospital-based centers may be the more "economically savvy way of doing it," Dr. Robert D. Galiano said at the annual meeting of the American Society of Plastic Surgeons.

A center can be established independently by a physician, fully staffed by an outside company, set up by an outside company that the physician then runs, or formed by a mix of these approaches. Regardless of the type of wound care center, about 35% of all hospitals now have some sort of formal wound care center, "and I think this number is only going to increase," said Dr. Galiano, who is in the process of establishing a wound care center at Northwestern Memorial Hospital in Chicago, where he is a plastic surgeon.

To determine the best course to take for Northwestern's wound care center, Dr. Galiano visited a wound care clinic at an academic medical center, a research-intensive podiatry-based center within an academic medical center, a small university-based center that was affiliated with a wound management company, and a wound care center at a large state academic medical center that also was affiliated with a management company.

During his visits, Dr. Galiano learned that most wound care centers "will be met with a high rate of skepticism. There's a feeling out there that wound centers are loss leaders and certainly not profitable." The success of centers at large academic institutions will depend on the costs of the facility, rent, and personnel; the types of wounds treated; and the role of research as an adjunct to revenue.

All of the centers that Dr. Galiano visited were well established and profitable. Such centers were also very labor intensive and left little time for other clinical activities.

Facility costs need to be shared with or underwritten by the hospital since the costs of running a center will probably not be covered by the revenues that the center itself brings in for ambulatory visits. "You have to incorporate downstream revenue," Dr. Galiano advised.

The costs of durable medical equipment and goods, such as the best dressings, need to be controlled in some way because most academic medical centers are nonprofit and will not allow physicians to bill for the best, most expensive dressings. Arrangements could be made with another provider not affiliated with the hospital to provide those materials on-site and then bill the patient directly for them, he suggested.

The most successful centers that Dr. Galiano visited had a large volume of inpatients with chronic wounds that consisted mostly of diabetic foot ulcers, which are associated with the highest-paying diagnosis-related groups.

Dr. David L. Steed, a vascular surgeon who is director of the wound healing/limb preservation clinic at the University of Pittsburgh, handles about 4,000 patient visits per year with his colleagues. The clinic cares for venous stasis ulcers (41%), diabetic neuropathy foot ulcers (27%), ischemic ulcers (13%), pressure ulcers (10%), and other types of chronic wounds (9%).

Dr. Steed's clinic, which is not hospital based, handles all charges itself, and must break even. The clinic employs a nurse practitioner, research nurse, patient care technician, diabetes educator, and podiatrist and has one student (medical or nursing) or resident (surgery or dermatology) present at a time. Plastic and orthopedic surgeons, as well as dermatologists and diabetologists, frequently consult on cases.

"We break even in the clinic, but all the things I send to the hospital make money," he said at the meeting.

At a wound care center, it is reasonable to expect about 40% of patients to be new to the hospital and that 15% on their first visit will require hospital admission, ambulatory surgery, or angiography, Dr. Steed said. Nearly all wound center patients use radiology and laboratory services.

In another presentation, Dr. David Hurley said that he initially balked at the idea of opening a comprehensive wound care center at the hospital in which he worked as a general plastic surgeon and vice president. After the hospital opened a center without his support, he was later offered the opportunity to become its medical director.

He learned that his skepticism of wound care treatments, such as hyperbaric oxygen therapy, was unfounded. "They sent me off to a couple courses, and what I learned was that my understanding of comprehensive wound care had really stopped back with my residency training. It had not been a focus of my training," he said.

"One of the things driving the interest in the development of comprehensive wound care centers is the fact that we now have a much better understanding of the biochemistry and physiology of problem wounds," he said.

Dr. Hurley spent more and more time at the center and began looking at it as a possible exit strategy from his plastic surgery practice. Three years ago, he left his medical practice to become the chief medical officer of the management company that had helped to set up the center. That company, Diversified Clinical Services, Jacksonville, Fla., partners with hospitals to manage, operate, and develop comprehensive wound care centers.

Dermatologists can offer their expertise in wound care by directing or even opening up their own clinic. DR. KIRSNER

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

Kishwer S. Nehal, MD, Dan Gareau, PhD, and Milind Rajadhyaksha, PhD

Confocal microscopy is a new imaging modality for noninvasive real-time tissue imaging with high resolution and contrast comparable with conventional histology. Application of this technology to skin imaging during the last decade has been an exciting advance in dermatology, allowing a virtual widow into living skin without the need for a conventional biopsy or histologic processing of tissue. High-resolution noninvasive skin imaging with confocal microscopy has potential broad applications in the clinical and research arenas, including differentiating between benign and malignant skin lesions, tumor margin mapping, monitoring response to medical or surgical treatments, and pathophysiologic study of inflammatory processes.

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

Kishwer S. Nehal, MD, Dan Gareau, PhD, and Milind Rajadhyaksha, PhD

Confocal microscopy is a new imaging modality for noninvasive real-time tissue imaging with high resolution and contrast comparable with conventional histology. Application of this technology to skin imaging during the last decade has been an exciting advance in dermatology, allowing a virtual widow into living skin without the need for a conventional biopsy or histologic processing of tissue. High-resolution noninvasive skin imaging with confocal microscopy has potential broad applications in the clinical and research arenas, including differentiating between benign and malignant skin lesions, tumor margin mapping, monitoring response to medical or surgical treatments, and pathophysiologic study of inflammatory processes.

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

Kishwer S. Nehal, MD, Dan Gareau, PhD, and Milind Rajadhyaksha, PhD

Confocal microscopy is a new imaging modality for noninvasive real-time tissue imaging with high resolution and contrast comparable with conventional histology. Application of this technology to skin imaging during the last decade has been an exciting advance in dermatology, allowing a virtual widow into living skin without the need for a conventional biopsy or histologic processing of tissue. High-resolution noninvasive skin imaging with confocal microscopy has potential broad applications in the clinical and research arenas, including differentiating between benign and malignant skin lesions, tumor margin mapping, monitoring response to medical or surgical treatments, and pathophysiologic study of inflammatory processes.

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

Ming H. Jih, MD, PhD, and Arash Kimyai-Asadi, MD

Fractional resurfacing is a new laser treatment modality that creates numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing for rapid repair of laser-induced thermal injury. This unique modality, if implemented with proper laserdelivery systems, enables high-energy treatments while minimizing risks. In this article, we review the various fractional laser devices, including the new fractional ablative devices, as well as the results of studies on the clinical efficacy of fractional photothermolysis. This technology offers patients significant clinical improvement in photodamage, melasma, and scarring with modest treatment-related downtime and minimal risk of complications.

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

Ming H. Jih, MD, PhD, and Arash Kimyai-Asadi, MD

Fractional resurfacing is a new laser treatment modality that creates numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing for rapid repair of laser-induced thermal injury. This unique modality, if implemented with proper laserdelivery systems, enables high-energy treatments while minimizing risks. In this article, we review the various fractional laser devices, including the new fractional ablative devices, as well as the results of studies on the clinical efficacy of fractional photothermolysis. This technology offers patients significant clinical improvement in photodamage, melasma, and scarring with modest treatment-related downtime and minimal risk of complications.

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

Ming H. Jih, MD, PhD, and Arash Kimyai-Asadi, MD

Fractional resurfacing is a new laser treatment modality that creates numerous microscopic thermal injury zones of controlled width, depth, and density that are surrounded by a reservoir of spared epidermal and dermal tissue, allowing for rapid repair of laser-induced thermal injury. This unique modality, if implemented with proper laserdelivery systems, enables high-energy treatments while minimizing risks. In this article, we review the various fractional laser devices, including the new fractional ablative devices, as well as the results of studies on the clinical efficacy of fractional photothermolysis. This technology offers patients significant clinical improvement in photodamage, melasma, and scarring with modest treatment-related downtime and minimal risk of complications.

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