Aesthetic Dermatology

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS

LAS VEGAS — More than half of the dermatologists in the United States now spend at least part of their patient-care time providing cosmetic services, according to a survey conducted by the American Academy of Dermatology in 2007.

"You can see that it is becoming a more important part of the general dermatologist's practice," Dr. Diane R. Baker, president of the academy, said in presenting some of the survey results at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The survey was sent to 3,600 AAD members who are in private practice, of whom 1,146 (32%) responded, said Dr. Baker of Oregon Health and Science University, Portland, where she is also in private practice.

Fifty-five percent of respondents said that they spend at least some time practicing cosmetic dermatology.

Perhaps the most significant finding from the survery regarding cosmetic dermatology was that 3.5% of the respondents spend 50% or more of their patient-care time doing cosmetic care, which is up from 2.7% who reported the same in 2005, Dr. Baker said.

The mean amount of time that the dermatologists reported spending in direct patient care was 38 hr/wk, and 10% of that time overall was spent providing cosmetic care.

In addition, 3.7% of the dermatologists said that they spend no time doing medical dermatology, and the majority of those are Mohs surgeons, Dr. Baker said.

The cosmetic procedure performed by the most dermatologists was a chemical peel, reported by 51% of the responding dermatologists. The next most common procedure was botulinum toxin (botox) injection, which was performed by 49% of the respondents.

Other procedures that are commonly offered included UV light therapy (47%), collagen or filler injections (44%), sclerotherapy (44%), laser surgery (38%), and photodynamic therapy (24%).

Liposuction was performed by 6%, and hair transplants were performed by 2%, she said.

As a way of saying that the AAD tries to support dermatologists who provide cosmetic services as part of their practices, Dr. Baker noted that 18% of all the presentations given at the academy's last annual meeting were on cosmetic dermatology topics.

ELSEVIER GLOBAL MEDICAL NEWS

ORLANDO — Face-lifting using "mini-face-lift" techniques is well within the purview of the dermatologic surgeon, Dr. N. Fred Eaglstein said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"It's a natural progression for dermatologic surgeons to move into this area," said Dr. Eaglstein, medical director of a dermatology and laser group practice in Orange Park, Fla.

The skills required for mini-face-lifts are used often by dermatologic surgeons for procedures such as advancement flaps, and with the increasing number of cosmetic procedures being done, it makes sense for mini-face-lifts to be the next step, he said.

After trying various face-lifting approaches—including thread contouring and infrared and radiofrequency treatments—without much success, he found that the QuickLift technique, which was first described by Dr. Dominic A. Brandy (Cosmet. Dermatol. 2004;17:251–60), provided superior long-term results. He has used this approach in more than 30 patients over the past year.

"With this technique, we are getting really long-lasting, effective results that patients really would like to have," said Dr. Eaglstein, who reported no financial interest in the QuickLift or related procedures.

The approach stays above the level of the superficial musculoaponeurotic system (SMAS) and usually involves plication.

Because this is a type of procedure that dermatologic surgeons do all the time—and a type of procedure with less risk of morbidity than traditional face-lifts have—it helps in circumventing issues with insurance companies that say they cover face-lifts only by plastic surgeons, he noted.

The mini-face-lift actually is a lot like a large advancement flap, and it would be a very simple procedure if it weren't for the ears, he said.

Because of the ears, the procedure is more tedious, involving extension of the excision from the temporal hairline to the preauricular area, back behind the earlobe into the mastoid fascia and into the mastoid area of the scalp. Unlike traditional face-lifts, however, it doesn't involve cutting the SMAS and undermining and removing a portion of it.

The technique ultimately allows for tightening of the SMAS with the use of two anchored purse-string sutures that cause the SMAS to bunch up and create crevices that will form fibrosis and provide the enduring tightening result, Dr. Eaglstein explained.

The procedure is performed using tumescent local anesthesia and mild oral sedation. Incisions at the hairline should be beveled to allow the hair to regrow from follicles underneath, thus concealing the scar. Face-lift scissors are a particularly useful tool for the extensive undermining used in creating the flap, he said.

Following the procedure, a pressure dressing is applied with a garment for 1 day. Patients can expect swelling, bruising, and ecchymosis for the first day, and a fair amount of discomfort for about a week, but most patients heal adequately within a few weeks.

Complications encountered with QuickLift are similar to those seen with any large flap. If an expanding hematoma occurs, it will be necessary to go back in and open up the flap to drain the hematoma, he said.

Infection is rare but can occur, as can necrosis of the flap. The avoidance of excessive tension on the flap can reduce the risk of necrosis; most of the tension should be on the underlying connective tissue. Seroma and nerve injury can also occur, but they are rare, Dr. Eaglstein said.

Because the QuickLift technique is a procedure for tightening the neck and jowls rather than the midface region, it is typically used in conjunction with other cosmetic procedures—such as liposuction of the chin, cheek, and jowls—for a synergistic effect.

Submental tuck and platysmal plication, an extended neck lift (with undermining all the way down to the central portion of the neck to pull that area back), and lateral brow lift are among other procedures that can also be performed with the QuickLift, he noted.

Adjuvant procedures can also include Botox or filler injection, fat transfer for the midface, blepharoplasty, and forehead lift. Chemical peeling or laser resurfacing performed 4–6 weeks after the QuickLift can help reduce the appearance of the scars and provide an added cosmetic benefit.

A number of courses—including weekend courses and university-based cadaveric courses—as well as articles and books are available for those interested in learning QuickLift and other mini-face-lift techniques, said Dr. Eaglstein, who reported having no conflicts of interest.

A patient is shown before and after undergoing cosmetic surgery with the "long-lasting, effective" QuickLift technique. Photos courtesy Dr. N. Fred Eaglstein

ORLANDO — Face-lifting using "mini-face-lift" techniques is well within the purview of the dermatologic surgeon, Dr. N. Fred Eaglstein said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"It's a natural progression for dermatologic surgeons to move into this area," said Dr. Eaglstein, medical director of a dermatology and laser group practice in Orange Park, Fla.

The skills required for mini-face-lifts are used often by dermatologic surgeons for procedures such as advancement flaps, and with the increasing number of cosmetic procedures being done, it makes sense for mini-face-lifts to be the next step, he said.

After trying various face-lifting approaches—including thread contouring and infrared and radiofrequency treatments—without much success, he found that the QuickLift technique, which was first described by Dr. Dominic A. Brandy (Cosmet. Dermatol. 2004;17:251–60), provided superior long-term results. He has used this approach in more than 30 patients over the past year.

"With this technique, we are getting really long-lasting, effective results that patients really would like to have," said Dr. Eaglstein, who reported no financial interest in the QuickLift or related procedures.

The approach stays above the level of the superficial musculoaponeurotic system (SMAS) and usually involves plication.

Because this is a type of procedure that dermatologic surgeons do all the time—and a type of procedure with less risk of morbidity than traditional face-lifts have—it helps in circumventing issues with insurance companies that say they cover face-lifts only by plastic surgeons, he noted.

The mini-face-lift actually is a lot like a large advancement flap, and it would be a very simple procedure if it weren't for the ears, he said.

Because of the ears, the procedure is more tedious, involving extension of the excision from the temporal hairline to the preauricular area, back behind the earlobe into the mastoid fascia and into the mastoid area of the scalp. Unlike traditional face-lifts, however, it doesn't involve cutting the SMAS and undermining and removing a portion of it.

The technique ultimately allows for tightening of the SMAS with the use of two anchored purse-string sutures that cause the SMAS to bunch up and create crevices that will form fibrosis and provide the enduring tightening result, Dr. Eaglstein explained.

The procedure is performed using tumescent local anesthesia and mild oral sedation. Incisions at the hairline should be beveled to allow the hair to regrow from follicles underneath, thus concealing the scar. Face-lift scissors are a particularly useful tool for the extensive undermining used in creating the flap, he said.

Following the procedure, a pressure dressing is applied with a garment for 1 day. Patients can expect swelling, bruising, and ecchymosis for the first day, and a fair amount of discomfort for about a week, but most patients heal adequately within a few weeks.

Complications encountered with QuickLift are similar to those seen with any large flap. If an expanding hematoma occurs, it will be necessary to go back in and open up the flap to drain the hematoma, he said.

Infection is rare but can occur, as can necrosis of the flap. The avoidance of excessive tension on the flap can reduce the risk of necrosis; most of the tension should be on the underlying connective tissue. Seroma and nerve injury can also occur, but they are rare, Dr. Eaglstein said.

Because the QuickLift technique is a procedure for tightening the neck and jowls rather than the midface region, it is typically used in conjunction with other cosmetic procedures—such as liposuction of the chin, cheek, and jowls—for a synergistic effect.

Submental tuck and platysmal plication, an extended neck lift (with undermining all the way down to the central portion of the neck to pull that area back), and lateral brow lift are among other procedures that can also be performed with the QuickLift, he noted.

Adjuvant procedures can also include Botox or filler injection, fat transfer for the midface, blepharoplasty, and forehead lift. Chemical peeling or laser resurfacing performed 4–6 weeks after the QuickLift can help reduce the appearance of the scars and provide an added cosmetic benefit.

A number of courses—including weekend courses and university-based cadaveric courses—as well as articles and books are available for those interested in learning QuickLift and other mini-face-lift techniques, said Dr. Eaglstein, who reported having no conflicts of interest.

A patient is shown before and after undergoing cosmetic surgery with the "long-lasting, effective" QuickLift technique. Photos courtesy Dr. N. Fred Eaglstein

ORLANDO — Face-lifting using "mini-face-lift" techniques is well within the purview of the dermatologic surgeon, Dr. N. Fred Eaglstein said at the annual meeting of the Florida Society of Dermatologic Surgeons.

"It's a natural progression for dermatologic surgeons to move into this area," said Dr. Eaglstein, medical director of a dermatology and laser group practice in Orange Park, Fla.

The skills required for mini-face-lifts are used often by dermatologic surgeons for procedures such as advancement flaps, and with the increasing number of cosmetic procedures being done, it makes sense for mini-face-lifts to be the next step, he said.

After trying various face-lifting approaches—including thread contouring and infrared and radiofrequency treatments—without much success, he found that the QuickLift technique, which was first described by Dr. Dominic A. Brandy (Cosmet. Dermatol. 2004;17:251–60), provided superior long-term results. He has used this approach in more than 30 patients over the past year.

"With this technique, we are getting really long-lasting, effective results that patients really would like to have," said Dr. Eaglstein, who reported no financial interest in the QuickLift or related procedures.

The approach stays above the level of the superficial musculoaponeurotic system (SMAS) and usually involves plication.

Because this is a type of procedure that dermatologic surgeons do all the time—and a type of procedure with less risk of morbidity than traditional face-lifts have—it helps in circumventing issues with insurance companies that say they cover face-lifts only by plastic surgeons, he noted.

The mini-face-lift actually is a lot like a large advancement flap, and it would be a very simple procedure if it weren't for the ears, he said.

Because of the ears, the procedure is more tedious, involving extension of the excision from the temporal hairline to the preauricular area, back behind the earlobe into the mastoid fascia and into the mastoid area of the scalp. Unlike traditional face-lifts, however, it doesn't involve cutting the SMAS and undermining and removing a portion of it.

The technique ultimately allows for tightening of the SMAS with the use of two anchored purse-string sutures that cause the SMAS to bunch up and create crevices that will form fibrosis and provide the enduring tightening result, Dr. Eaglstein explained.

The procedure is performed using tumescent local anesthesia and mild oral sedation. Incisions at the hairline should be beveled to allow the hair to regrow from follicles underneath, thus concealing the scar. Face-lift scissors are a particularly useful tool for the extensive undermining used in creating the flap, he said.

Following the procedure, a pressure dressing is applied with a garment for 1 day. Patients can expect swelling, bruising, and ecchymosis for the first day, and a fair amount of discomfort for about a week, but most patients heal adequately within a few weeks.

Complications encountered with QuickLift are similar to those seen with any large flap. If an expanding hematoma occurs, it will be necessary to go back in and open up the flap to drain the hematoma, he said.

Infection is rare but can occur, as can necrosis of the flap. The avoidance of excessive tension on the flap can reduce the risk of necrosis; most of the tension should be on the underlying connective tissue. Seroma and nerve injury can also occur, but they are rare, Dr. Eaglstein said.

Because the QuickLift technique is a procedure for tightening the neck and jowls rather than the midface region, it is typically used in conjunction with other cosmetic procedures—such as liposuction of the chin, cheek, and jowls—for a synergistic effect.

Submental tuck and platysmal plication, an extended neck lift (with undermining all the way down to the central portion of the neck to pull that area back), and lateral brow lift are among other procedures that can also be performed with the QuickLift, he noted.

Adjuvant procedures can also include Botox or filler injection, fat transfer for the midface, blepharoplasty, and forehead lift. Chemical peeling or laser resurfacing performed 4–6 weeks after the QuickLift can help reduce the appearance of the scars and provide an added cosmetic benefit.

A number of courses—including weekend courses and university-based cadaveric courses—as well as articles and books are available for those interested in learning QuickLift and other mini-face-lift techniques, said Dr. Eaglstein, who reported having no conflicts of interest.

A patient is shown before and after undergoing cosmetic surgery with the "long-lasting, effective" QuickLift technique. Photos courtesy Dr. N. Fred Eaglstein

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN

LAS VEGAS — Dermatologists do not often think of using Botox in the lower face, but they should, Dr. Roberta D. Sengelmann said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

It is possible to treat and improve perioral rhytids, an asymmetric smile, a gummy smile, and even "apple-dumpling" chin, said Dr. Sengelmann of Santa Barbara, Calif.

The key to using botulinum toxin type A in the lower face is to be extremely careful not to use too much since those muscles are used for so many different functions. Also, the botulinum toxin option probably should be reserved for patients with mild to moderate aging changes, as there are better alternatives for serious rhytids of the lower face, she said.

Botulinum toxin "is a different animal when you get below the canthus," Dr. Sengelmann said. "Volume loss and soft-tissue ptosis play a large role in the lower face, and this cannot always be remedied by botulinum toxin injections. The lower face and neck are functionally important as well.

"The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze," she added.

In treating perioral rhytids, inject into the orbicularis oris. The injections should be fairly superficial, into just the first layer of what is a "very thick and robust muscle," Dr. Sengelmann said.

The injections should be given right above the vermilion border, evenly spaced, and they need to be symmetric.

She gives 1–3 U per injection, with a maximum of 6 U in the upper lip and 4 U in the lower lip, so there is not too much deadening of function. She advised against injecting only the upper lip because treated lips lengthen and can protrude over the lower lip.

Results in the lower face often do not last as long as treatment of the glabella because less botulinum toxin is used. Dr. Sengelmann said that her treatments of perioral rhytids usually last 2–3 months.

Downturned lips can be treated with injections to the depressor labii inferioris—she gives 2–4 U into the mid-muscle. Radial perioral rhytids, or marionette lines, can be treated with injections to the depressor anguli oris. She does two injections per side, in the middle and lower third of the muscle, starting about 1 cm below the oral commissure and injecting 3–5 U per side.

Apple-dumpling chin, or a chin that gets lumpy when someone smiles or tightens their lips, is treated with an injection to the mentalis, at the mental crease, of about 5 U. "You want to be fairly inferior so you don't knock out the depressor labii, and it is a deep muscle," Dr. Sengelmann said.

Finally, patients with smiles that they don't like because they get a lot of upper gum showing can be treated with equal injections of 1–2 units into the levator labii superioris on each side of the nasal prominence.

Dr. Sengelmann also said that she always takes photographs before she does lower face treatments, that she marks her injection sites when she identifies the muscle before giving the actual injections, and that she often uses ice for the patients since lower face injections can be quite painful.

Dr. Sengelmann is on the advisory board and the speakers bureau for Allergan Inc., maker of Botox.

'The goal when we are treating the lower face is to soften dynamic lines and not to completely freeze.' DR. SENGELMANN