Aesthetic Dermatology

NAPLES, FLA. — Botulinum toxin may be a good treatment for primary focal hyperhidrosis, but for patients with hand or foot hyperhidrosis you should try iontophoresis first, Lewis P. Stolman, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

What you do not want to do for hyperhidrosis is refer patients for sympathectomy, he added, except as a very last resort.

The majority of patients who undergo sympathectomy for focal hyperhidrosis develop compensatory, and often severe, hyperhidrosis that can be more dispiriting and debilitating than their original condition, said Dr. Stolman of New Jersey Medical School, Newark.

"I don't think we as dermatologists should be referring patients for sympathectomy quite as quickly as we do," Dr. Stolman said.

Compensatory hyperhidrosis is an acknowledged consequence of sympathectomy, and in reported case series the incidence has ranged as high as 67%. In a recent review of reports, the incidence of compensatory hyperhidrosis in 22,000 patients was 52%.

For some patients, the compensatory hyperhidrosis is minor and localized to a limited area, and can be managed with botulinum toxin treatment. But it can also be much more severe, Dr. Stolman said.

Iontophoresis has a number of advantages over botulinum toxin, and may be equally effective, Dr. Stolman said. He was one of the early researchers in the use of iontophoresis for this condition but receives no money or grants from any manufacturer of iontophoresis equipment.

Botulinum toxin treatment has been reported to have an efficacy rate of 75%–95% for axillary hyperhidrosis. In his experience, 85%–90% of patients treated with iontophoresis for palmar or plantar hyperhidrosis have satisfactory improvement, and another 5% are improved when Robinul (glycopyrrolate) is added to the trays of water used for the technique, Dr. Stolman said.

Iontophoresis is probably less expensive than botulinum toxin. A 50-U botulinum toxin treatment costs at least $250, and about half of patients will require two treatments to achieve good control. Medicare reimburses an iontophoresis treatment at $24.69, and most patients need four to six treatments to achieve good control. Patients can also purchase their own equipment.

Two devices exist on the market. One costs $150, the battery-operated Drionic device, and the other costs $650, the Fischer MD-1a galvanic unit, which transforms alternating current to direct current. Though the devices are simple equipment, Dr. Stolman said he much prefers the more expensive device.

"The Drionic device in my opinion has given iontophoresis a bad rap because it is rarely effective," he said. "It is not the equal of the Fischer galvanic device in its efficacy, even though the literature may indicate that it is."

Moreover, unlike botulinum toxin, there is no chance of loss of any fine motor control with iontophoresis, Dr. Stolman added.

Most patients can treat themselves at home. The patient attaches the device's cathode to one tray of water and the anode to another tray, submerges their entire palms, one hand in each tray, and turns up the current to 15–18 mA for 10 minutes. Once patients have achieved control of their hyperhidrosis with four to six treatments, they repeat it whenever necessary, Dr. Stolman said. For some individuals that is every few weeks, and for others it is every week.

The sole drawback to iontophoresis is that it does not work well for axillary hyperhidrosis because it is difficult to attach the electrodes to the axillas, and many patients develop irritation.

The mechanism of action of iontophoresis is unclear, Dr. Stolman said. It may cause occlusion of the distal end of the sweat ducts by thickening the stratum corneum. It has been shown that when the stratum corneum in treated areas is stripped off with adhesive tape, the effect is reversed. Biopsy has shown no change in sweat gland structure.

An exciting recent development in the use of iontophoresis, Dr. Stolman said, is that it has now been shown that botulinum toxin can be added to the water trays, and is delivered effectively by the technique.

"Maybe we will find a way to get prolonged suppression of palmar hyperhidrosis for many months, as we do for the axillas, without painful injection," Dr. Stolman said.

NAPLES, FLA. — Botulinum toxin may be a good treatment for primary focal hyperhidrosis, but for patients with hand or foot hyperhidrosis you should try iontophoresis first, Lewis P. Stolman, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

What you do not want to do for hyperhidrosis is refer patients for sympathectomy, he added, except as a very last resort.

The majority of patients who undergo sympathectomy for focal hyperhidrosis develop compensatory, and often severe, hyperhidrosis that can be more dispiriting and debilitating than their original condition, said Dr. Stolman of New Jersey Medical School, Newark.

"I don't think we as dermatologists should be referring patients for sympathectomy quite as quickly as we do," Dr. Stolman said.

Compensatory hyperhidrosis is an acknowledged consequence of sympathectomy, and in reported case series the incidence has ranged as high as 67%. In a recent review of reports, the incidence of compensatory hyperhidrosis in 22,000 patients was 52%.

For some patients, the compensatory hyperhidrosis is minor and localized to a limited area, and can be managed with botulinum toxin treatment. But it can also be much more severe, Dr. Stolman said.

Iontophoresis has a number of advantages over botulinum toxin, and may be equally effective, Dr. Stolman said. He was one of the early researchers in the use of iontophoresis for this condition but receives no money or grants from any manufacturer of iontophoresis equipment.

Botulinum toxin treatment has been reported to have an efficacy rate of 75%–95% for axillary hyperhidrosis. In his experience, 85%–90% of patients treated with iontophoresis for palmar or plantar hyperhidrosis have satisfactory improvement, and another 5% are improved when Robinul (glycopyrrolate) is added to the trays of water used for the technique, Dr. Stolman said.

Iontophoresis is probably less expensive than botulinum toxin. A 50-U botulinum toxin treatment costs at least $250, and about half of patients will require two treatments to achieve good control. Medicare reimburses an iontophoresis treatment at $24.69, and most patients need four to six treatments to achieve good control. Patients can also purchase their own equipment.

Two devices exist on the market. One costs $150, the battery-operated Drionic device, and the other costs $650, the Fischer MD-1a galvanic unit, which transforms alternating current to direct current. Though the devices are simple equipment, Dr. Stolman said he much prefers the more expensive device.

"The Drionic device in my opinion has given iontophoresis a bad rap because it is rarely effective," he said. "It is not the equal of the Fischer galvanic device in its efficacy, even though the literature may indicate that it is."

Moreover, unlike botulinum toxin, there is no chance of loss of any fine motor control with iontophoresis, Dr. Stolman added.

Most patients can treat themselves at home. The patient attaches the device's cathode to one tray of water and the anode to another tray, submerges their entire palms, one hand in each tray, and turns up the current to 15–18 mA for 10 minutes. Once patients have achieved control of their hyperhidrosis with four to six treatments, they repeat it whenever necessary, Dr. Stolman said. For some individuals that is every few weeks, and for others it is every week.

The sole drawback to iontophoresis is that it does not work well for axillary hyperhidrosis because it is difficult to attach the electrodes to the axillas, and many patients develop irritation.

The mechanism of action of iontophoresis is unclear, Dr. Stolman said. It may cause occlusion of the distal end of the sweat ducts by thickening the stratum corneum. It has been shown that when the stratum corneum in treated areas is stripped off with adhesive tape, the effect is reversed. Biopsy has shown no change in sweat gland structure.

An exciting recent development in the use of iontophoresis, Dr. Stolman said, is that it has now been shown that botulinum toxin can be added to the water trays, and is delivered effectively by the technique.

"Maybe we will find a way to get prolonged suppression of palmar hyperhidrosis for many months, as we do for the axillas, without painful injection," Dr. Stolman said.

NAPLES, FLA. — Botulinum toxin may be a good treatment for primary focal hyperhidrosis, but for patients with hand or foot hyperhidrosis you should try iontophoresis first, Lewis P. Stolman, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

What you do not want to do for hyperhidrosis is refer patients for sympathectomy, he added, except as a very last resort.

The majority of patients who undergo sympathectomy for focal hyperhidrosis develop compensatory, and often severe, hyperhidrosis that can be more dispiriting and debilitating than their original condition, said Dr. Stolman of New Jersey Medical School, Newark.

"I don't think we as dermatologists should be referring patients for sympathectomy quite as quickly as we do," Dr. Stolman said.

Compensatory hyperhidrosis is an acknowledged consequence of sympathectomy, and in reported case series the incidence has ranged as high as 67%. In a recent review of reports, the incidence of compensatory hyperhidrosis in 22,000 patients was 52%.

For some patients, the compensatory hyperhidrosis is minor and localized to a limited area, and can be managed with botulinum toxin treatment. But it can also be much more severe, Dr. Stolman said.

Iontophoresis has a number of advantages over botulinum toxin, and may be equally effective, Dr. Stolman said. He was one of the early researchers in the use of iontophoresis for this condition but receives no money or grants from any manufacturer of iontophoresis equipment.

Botulinum toxin treatment has been reported to have an efficacy rate of 75%–95% for axillary hyperhidrosis. In his experience, 85%–90% of patients treated with iontophoresis for palmar or plantar hyperhidrosis have satisfactory improvement, and another 5% are improved when Robinul (glycopyrrolate) is added to the trays of water used for the technique, Dr. Stolman said.

Iontophoresis is probably less expensive than botulinum toxin. A 50-U botulinum toxin treatment costs at least $250, and about half of patients will require two treatments to achieve good control. Medicare reimburses an iontophoresis treatment at $24.69, and most patients need four to six treatments to achieve good control. Patients can also purchase their own equipment.

Two devices exist on the market. One costs $150, the battery-operated Drionic device, and the other costs $650, the Fischer MD-1a galvanic unit, which transforms alternating current to direct current. Though the devices are simple equipment, Dr. Stolman said he much prefers the more expensive device.

"The Drionic device in my opinion has given iontophoresis a bad rap because it is rarely effective," he said. "It is not the equal of the Fischer galvanic device in its efficacy, even though the literature may indicate that it is."

Moreover, unlike botulinum toxin, there is no chance of loss of any fine motor control with iontophoresis, Dr. Stolman added.

Most patients can treat themselves at home. The patient attaches the device's cathode to one tray of water and the anode to another tray, submerges their entire palms, one hand in each tray, and turns up the current to 15–18 mA for 10 minutes. Once patients have achieved control of their hyperhidrosis with four to six treatments, they repeat it whenever necessary, Dr. Stolman said. For some individuals that is every few weeks, and for others it is every week.

The sole drawback to iontophoresis is that it does not work well for axillary hyperhidrosis because it is difficult to attach the electrodes to the axillas, and many patients develop irritation.

The mechanism of action of iontophoresis is unclear, Dr. Stolman said. It may cause occlusion of the distal end of the sweat ducts by thickening the stratum corneum. It has been shown that when the stratum corneum in treated areas is stripped off with adhesive tape, the effect is reversed. Biopsy has shown no change in sweat gland structure.

An exciting recent development in the use of iontophoresis, Dr. Stolman said, is that it has now been shown that botulinum toxin can be added to the water trays, and is delivered effectively by the technique.

"Maybe we will find a way to get prolonged suppression of palmar hyperhidrosis for many months, as we do for the axillas, without painful injection," Dr. Stolman said.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Light-emitting diode phototherapy improves tissue quality and leads to accelerated wound healing after cosmetic and medical surgical procedures, Mario Trelles, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Dr. Trelles uses combination light-emitting diode (LED) therapy with both near-infrared and visible red LED extremely narrowband (plus or minus 3- to 8-nm) arrays.

LED therapy promotes the anti-inflammatory process, activates blood circulation, and realigns collagen fibers. It reduces scabbing and erythema, without promoting keloids, he said.

Dr. Trelles is a pioneer of this application of LED energy. "It is not yet widespread because LED therapy is just at the beginning of its clinical practice, and like all 'new' therapies, it will take time to overcome the inherent 'conservatism' of many clinicians, particularly in the United States," Dr. Trelles told this newspaper.

In a series of 22 patients who underwent full face resurfacing and subsequent LED therapy, 12 patients experienced complete healing of facial tissue in 7 days, and the remaining 10 experienced complete healing in 9–11 days.

Several kinds of aesthetic procedures benefit from subsequent LED therapy, including surgical face-lifting, facial resurfacing, nonablative laser or intense pulsed light skin rejuvenation, upper eyelid blepharoplasty, breast augmentation or reduction, and removal of abnormally pigmented or nonpigmented cutaneous lesions.

Results are less dramatic with diabetic ulcers or chronic ulcers caused by vascular conditions.

"All surgical wounds respond well, but in general the more extensive the wound, the better the response," said Dr. Trelles, a plastic surgeon with the Institut Mèdic Vilafortuny in Cambrils, Spain.

Dr. Trelles outlined his treatment protocol: a 633-nm wavelength treatment and an 833-nm treatment in the first week; three treatments at 830 nm in the second week; and one treatment at 633 nm in the third week, followed by a 1-month treatment-free rest period and a single treatment at 633 nm.

The 20-minute sessions deliver a radiant flux of approximately 96 J/cm

Postprocedural maintenance is not usually required if patients are compliant in using skin moisturizers and photoprotection, he said.

Dr. Trelles currently uses no pretreatment preparation of the skin, even with antiherpes medication. In more than 300 resurfacing cases, his rate of herpes infection was "virtually nil," he said.

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

PARIS — Add the curl lift technique to the growing list of so-called lunchtime face-lifts.

First popularized in the 1970s by René Guillemain, M.D., in Paris, the curl lift technique is being rediscovered, thanks to the use of a double-bevel needle like those used by upholsterers, according to Jean-Luc H. Vigneron, M.D., of the Centre Villabianca Dermatologie, Saint Paul de Vence, France.

The needle has two tips and a central eye that allow the surgeon to place stitches or long portions of threads subcutaneously, without an incision. The curl lift uses one loop of thread to lift selected parts of the face and a second loop of the same thread to anchor it to the more resistant tissues of the scalp, typically the galea. The procedure is done under local anesthetic, with little downtime, and leaves only a small scar in the scalp near the hairline.

"The future of the curl lift is clearly the lateral part of the neck," Dr. Vigneron told SKIN & ALLERGY NEWS. "My first five cases are really amazing."

The first line of polypropylene threads is placed in the upper subcutaneous layer. The needle is rotated 180 degrees and then moved upward in a second line parallel to the first. The 230-mm to 250-mm threads are knotted once the desired tension is obtained, then the knot is slipped 5 mm below the skin surface.

The main problem encountered using this technique is dimpling at the lifted area of the face, Dr. Vigneron said at the 4th International Academy of Cosmetic Dermatology World Congress. The dimples tend to disappear after 3 months, he said.

About 200 dermatologic and plastic surgeons have been trained in the curl lift technique in the last year through the American Society of Aesthetics and Mesotherapy or the Vitality Institute, both of Miami Beach.

ASAM chair and president Abdala Kalil, M.D., said in an interview that he has performed more than 300 curl lifts in the last 2 years, and that dimpling occurred only once or twice when he first began. He has modified the technique to carry his institute's name, Vitality Lift, and said it offers dramatic, lasting results that are far superior to those seen with Aptos threads.

The Aptos threads or FeatherLift technique is more widely known in the United States and gained Food and Drug Administration approval in March 2005.

Both procedures take about 1 hour, require good vascularization in the skin, and are best suited to patients without heavy ptosis.

Dimpling is seen 8 days after a curl lift was done from the hair of the temple to the cheek. Courtesy Dr. Jean-Luc H. Vigneron

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

CHICAGO — Add facial rejuvenation to the growing list of indications for topical photodynamic therapy.

Short-contact, broad-area application of 20% 5-aminolevulinic acid and photodynamic therapy (ALA-PDT) can enhance or improve all parameters of facial rejuvenation—skin tone, texture, fine wrinkles, telangiectasis, and pore size, Kevin Pinski, M.D., said at the American Academy of Dermatology's Academy 2005 meeting.

There's little pain or downtime associated with the combination therapy, and it appears to shorten the number of intense pulsed light (IPL) treatments needed to achieve results.

The only approved indication for ALA-PDT is nonhyperkeratotic actinic keratoses on the face and scalp, requiring 14- to 18-hour drug incubation and blue-light therapy.

Investigators have experimented with shorter drug incubation periods and found no difference in efficacy in actinic keratosis with as little as 1 hour incubation, said Dr. Pinski of Northwestern University in Chicago.

New vascular lasers and IPL devices have also virtually eliminated the pain previously associated with the therapy.

Now ALA-PDT is being used off label in a variety of indications from basal and squamous cell carcinoma to Bowen's disease, acne vulgaris, hidradenitis suppurativa, and port-wine stains.

Split-face comparison trials in facial rejuvenation have been done for the first time, and they demonstrated that clinical improvement scores were higher on the sides treated with combination ALA-IPL, compared with areas treated with IPL alone (J. Drugs Dermatol. 2005;4:35–8). Mild edema, erythema, and desquamation were reported with the use of combination therapy.

The most recent study (J. Cosmet. Laser Ther. 2005;7:21–4) showed that ALA-IPL increased the production of type I collagen, compared with IPL monotherapy.

Dr. Pinski prepares patients for facial rejuvenation with an acetone scrub to increase the penetration of the ALA (Levulan Kerastick, DUSA Pharmaceuticals Inc.) before exposure with an N-Lite laser. Levulan comes in two glass ampules that must be mixed thoroughly for 2–3 minutes or results will be inconsistent, he said.

Levulan should incubate on the skin for a minimum of 1 hour for facial rejuvenation and actinic keratoses, and for up to 1 hour for acne vulgaris.

It's imperative that patients avoid sun exposure for 72 hours post treatment to avoid a phototoxic reaction, he said. Iron chelating agents are being developed that may reduce this potential reaction.

Finally, mounting evidence from animal models suggests that ALA-PDT could be used for skin cancer prevention, he said.

Data from hairless mice models suggest that protoporphyrin IX, an effective photosensitizer that is converted from 5-ALA, is activated by visible light, and that highly carcinogenic ultraviolet radiation may be filtered out by blue-light therapy.

"Hypothetically, we could treat large surface areas in patients that are at risk of developing skin cancer, such as our renal transplant cases, and thereby prevent them from developing actinic keratoses and squamous cell carcinomas," he said.

Dr. Pinski reported that he has no relevant conflicts of interest.

LAS VEGAS — A novel device that transfers energy from nitrogen gas into the skin may be capable of producing improvements in skin quality and texture comparable with those produced by the carbon dioxide laser, but with a less traumatic recovery.

Ronald L. Moy, M.D., a Los Angeles-based dermatologic surgeon, reviewed early results that were produced by the Portrait PSR3 system at a facial cosmetic surgery symposium sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

A 40%–50% improvement in wrinkles, 10%–15% skin contraction, and significant improvement in skin texture have been demonstrated in a small number of patients who were followed for 2 years after Portrait PSR3 treatments by Dr. Moy and colleagues investigating the new device.

The technology consists of a handpiece that produces nitrogen plasma, which is converted into a heated gas for delivery into the skin in millisecond pulses.

"It hits the skin but leaves the epidermis intact," said Dr. Moy, who serves on the scientific advisory panel of Rhytec Inc., the device's manufacturer.

A popping sound can be heard as energy pulses impact the skin, but topical anesthesia and nerve blocks are adequate for patients' pain control during the 10- to 15-minute full-face procedure.

Over several days after the procedure, a zone of thermal damage develops below the skin surface, eventually stimulating new collagen formation. The epidermis develops a bronze hue and flakes away.

Variable settings can produce modest skin surface changes roughly equivalent to a "long-weekend peel" with healing complete in 3–4 days, or a deep effect that requires about 7 days of healing.

At a setting of 4 J/cm

LAS VEGAS — A novel device that transfers energy from nitrogen gas into the skin may be capable of producing improvements in skin quality and texture comparable with those produced by the carbon dioxide laser, but with a less traumatic recovery.

Ronald L. Moy, M.D., a Los Angeles-based dermatologic surgeon, reviewed early results that were produced by the Portrait PSR3 system at a facial cosmetic surgery symposium sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

A 40%–50% improvement in wrinkles, 10%–15% skin contraction, and significant improvement in skin texture have been demonstrated in a small number of patients who were followed for 2 years after Portrait PSR3 treatments by Dr. Moy and colleagues investigating the new device.

The technology consists of a handpiece that produces nitrogen plasma, which is converted into a heated gas for delivery into the skin in millisecond pulses.

"It hits the skin but leaves the epidermis intact," said Dr. Moy, who serves on the scientific advisory panel of Rhytec Inc., the device's manufacturer.

A popping sound can be heard as energy pulses impact the skin, but topical anesthesia and nerve blocks are adequate for patients' pain control during the 10- to 15-minute full-face procedure.

Over several days after the procedure, a zone of thermal damage develops below the skin surface, eventually stimulating new collagen formation. The epidermis develops a bronze hue and flakes away.

Variable settings can produce modest skin surface changes roughly equivalent to a "long-weekend peel" with healing complete in 3–4 days, or a deep effect that requires about 7 days of healing.

At a setting of 4 J/cm

LAS VEGAS — A novel device that transfers energy from nitrogen gas into the skin may be capable of producing improvements in skin quality and texture comparable with those produced by the carbon dioxide laser, but with a less traumatic recovery.

Ronald L. Moy, M.D., a Los Angeles-based dermatologic surgeon, reviewed early results that were produced by the Portrait PSR3 system at a facial cosmetic surgery symposium sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

A 40%–50% improvement in wrinkles, 10%–15% skin contraction, and significant improvement in skin texture have been demonstrated in a small number of patients who were followed for 2 years after Portrait PSR3 treatments by Dr. Moy and colleagues investigating the new device.

The technology consists of a handpiece that produces nitrogen plasma, which is converted into a heated gas for delivery into the skin in millisecond pulses.

"It hits the skin but leaves the epidermis intact," said Dr. Moy, who serves on the scientific advisory panel of Rhytec Inc., the device's manufacturer.

A popping sound can be heard as energy pulses impact the skin, but topical anesthesia and nerve blocks are adequate for patients' pain control during the 10- to 15-minute full-face procedure.

Over several days after the procedure, a zone of thermal damage develops below the skin surface, eventually stimulating new collagen formation. The epidermis develops a bronze hue and flakes away.

Variable settings can produce modest skin surface changes roughly equivalent to a "long-weekend peel" with healing complete in 3–4 days, or a deep effect that requires about 7 days of healing.

At a setting of 4 J/cm

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

CHICAGO — Dermatologists shouldn't shy away from sclerotherapy to treat facial and even periocular veins, David Green, M.D., reported at the American Academy of Dermatology's Academy 2005 meeting.

Although sclerotherapy is widely used to remove varicose and telangiectatic veins on the lower extremities, it is underutilized at other sites, such as the face, hands, chest, and feet, he said.

Physicians are particularly reluctant to remove periocular veins.

"Everyone seems to have this universal caveat: 'Don't treat them because there's a risk it may cause blindness or stroke,'" he said, "but there are no reports of anyone ever having such an adverse event."

More to the point, such complications are unlikely because the periocular veins treated by sclerotherapy do not directly communicate with the orbital and cerebral venous systems, said Dr. Green, who is in private practice in Bethesda, Md.

Preseptal veins of the eyelid drain into the superficial temporal vein or the anterior facial vein, which themselves drain into the external jugular vein and the internal jugular vein, respectively.

Postseptal veins more directly join the orbital veins, but these are not visible on the eyelid and, as such, are never treated by sclerotherapy.

For sclerosant to drain into the superior ophthalmic vein, the flow would have to be toward the top of the head from the angular vein. This is hemodynamically unlikely because a liquid tends to follow the course of least resistance. Sclerosant travels in an antegrade direction into progressively larger veins.

Even if some sclerosant entered the superior ophthalmic vein, it would be rapidly diluted, making it increasingly harmless to the endothelial and mural layers, he said. As a precaution, Dr. Green injects laterally away from the angular vein and applies pressure just above the angular vein during the infusion.

Injections should never be made into the angular vein, he said.

Injections also are made under low pressure to minimize the risk of retrograde flow into smaller diameter veins and to prolong the duration of contact between the sclerosant and the mural layers of the targeted veins.

A concentration of 0.5%–1% sodium tetradecyl sulfate is used for facial veins, compared with a 0.25% solution usually required for lower-extremity veins of comparable diameter. The volume infused is 1–6 mL, depending upon the length of the veins and number of tributaries present.

"It's counterintuitive based upon gravitational hydrostatic pressures and vein wall diameters, but if we infuse the same concentration on facial veins as we use on the lower extremities, full mural denaturation is apparently not achieved and the veins persist," he explained.

Hypertonic saline should not be used for periocular sclerotherapy because it is quite painful and causes significant muscle cramping because of its high sodium concentration.

Complications such as linear hyperpigmentation and capillary telangiectatic matting—which occur in about 30% and 16%, respectively, of lower-extremity sclerotherapy cases—are rare after treating periocular veins.

Although capillary telangiectasias on the nose or face respond well to a variety of lasers, venous telangiectasias in these areas are more effectively treated with sclerotherapy. The amount of light from a laser needed to heat the volume of blood in a venous telangiectasia and achieve full mural denaturation may be high enough to burn the skin, Dr. Green noted.

Unlike lower-extremity sclerotherapy, posttreatment compression is not necessary in the periocular area.

If a vein is visually gone at 6 months, it can be safely assumed that it has been permanently ablated and will not reappear, he said.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

PARIS — A new device that uses vacuum suction in combination with radio frequency painlessly treats facial lines and wrinkles, Michael H. Gold, M.D., reported at the Fourth International Academy of Cosmetic Dermatology World Congress.

Radio frequency (RF) devices have been used successfully over the last 5 years to improve skin texture and laxity, but their use has been limited because patients complain the treatments are too painful, said Dr. Gold of Nashville, Tenn.

Efforts have been made with varying degrees of success to reduce the pain by changing machine parameters, using multiple passes at lower power, or by incorporating RF with intense pulsed light devices. General anesthesia or intravenous medications have been used, but few patients have been willing to incur the associated risks.

The new bipolar RF device, Aluma Skin Renewal System (Lumenis Inc.), uses vacuum suction to pull the skin about one-quarter inch into the vacuum, where there are RF electrodes on either side.

The device holds the skin for 1 second of vacuum at 20-mm Hg suction and delivers about 10 W of RF energy, he said. The overall treatment takes 15–30 minutes and treatments occur once weekly for 5–8 weeks. How the device reduces pain is unclear.

"I think because we're taking up the skin and compressing the nerves or the circulation affecting those nerves, we're doing something. We're just not sure what, but it is effective and doesn't hurt," Dr. Gold said in an interview.

In a study of 46 patients aged 30–65 years with periorbital and nasal labial wrinkles, 1%–2% of patients reported pain with the first two treatments. Patients reported pain of 0 or 1 on a 4-point scale, with 0 being no pain and 4 being intractable pain, he said. Seven patients were lost to follow-up. No one dropped out of the study because of pain or an adverse event, said Dr. Gold. All of the 39 patients who completed the study had at least a 50% improvement in wrinkling based on evaluation by blinded clinicians. Patients were able to maintain the improvements 6 months posttreatment.

The maximum benefit is seen after the fifth or sixth treatment. The optimal number and best interval between treatments have yet to be determined. Studies are planned to evaluate the device to reduce tissue laxity on the jowls, upper arms, stomach, and thighs. The device will be launched in the United States and Europe this month.

Dr. Gold is an investigator, advisory board member, consultant, and stockholder with Lumenis Inc., and has received honoraria to speak on behalf of the company.

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

QUEBEC CITY — A quasi-Mohs micrographic surgery procedure involving excision and curettage with pathologic analysis of margins may be a practical way of treating skin cancer patients in areas that do not have access to Mohs surgeons, Louis Weatherhead, M.B., said at the annual conference of the Canadian Dermatology Association.

"In many areas in Canada, we do not have access to Mohs surgery," said Dr. Weatherhead, director of surgical dermatology at the University of Ottawa.

"Many plastic surgeons in the Ottawa region will not deal with a skin malignancy," he said.

The alternative to Mohs surgery, which Dr. Weatherhead teaches to his residents in Ottawa, is easy to learn and provides "clinically good results in clearance of tumor as well as postoperative appearance," he said.

The "poor man's Mohs procedure" has had a recurrence rate of about 2%–4% over a 5-year period, he said. The relatively simple technique involves simple shaving and curettage plus excision, which most dermatologists know how to do, Dr. Weatherhead said in an interview.

At the dermatology clinic at the Ottawa Hospital, Dr. Weatherhead has not had positive margins in any patient who has undergone the procedure.

"In my hands it's been a very good tool, but there's always risk, when you do any surgical procedure, that you might have a margin that's still involved," he said, "in which case, then, many times in [basal cell carcinomas] you have to determine the amount of involvement and whether or not you're going to go back and do surgery or just observe, because in many instances the healing gets rid of residual tumor."

The first step of the procedure is "like doing your first Mohs cut," Dr. Weatherhead said, because it involves tangentially excising the lesion and submitting the specimen for pathologic—but not immediate—analysis. But the similarity between the procedure and Mohs stops there, because "we don't have the facility to continue it."

Curettage is performed to remove any residual tumor up to normal tissue and to delineate the borders of the tumor. Following hemostasis of the wound, Dr. Weatherhead excises a surgical margin of about 3–4 mm. The specimen obtained from that excision is then sent for pathologic analysis of the margin. The dermatologist chooses a method to close the wound depending on the location and size of the defect.

Skin cancer patient undergoing a quasi-Mohs procedure. From left to right: malignant lesion is excised; curettage ensures clear margins; a rotational flap closes wound.

Rotational flap is sutured in place (left). Good healing of the wound is seen after 1 week (right).

Final cosmetic result seen 1 year after having a quasi-Mohs micrographic surgery procedure. Photos courtesy Dr. Louis Weatherhead

LAS VEGAS — Don't overpromise results to patients considering facial soft tissue augmentation with Radiesse, says a facial plastic and reconstructive surgeon who has now treated 1,174 patients with the filler previously known as Radiance FN.

"I think like most technologies, when we first get them, we kind of oversell them. We think they're a lot better than they really are," said Thomas L. Tzikas, M.D., a physician in private practice in Del Ray, Fla.

The early word on Radiesse, a filler made of spherical particles of synthetic calcium hydroxylapatite, was that it would last between 3 and 5 years, justifying its high price tag. Current prices for a 1-vial treatment range from $800 to $1,400.

But Dr. Tzikas told colleagues at a facial cosmetic surgery symposium that 1 vial often isn't enough to achieve satisfactory correction of facial structures, such as the nasolabial folds. Moreover, its results are unpredictable after 2 years.

"How long does it last? In my experience, it definitely lasts 1 year. There are variable results at 1.5 years and longer," he said at the meeting sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

Dr. Tzikas' experience with Radiesse, manufactured by BioForm Inc., is considerable. He conducted a pivotal trial of the filler in 90 patients, concluding that it was highly effective and well tolerated, with excellent results and high patient satisfaction at 6 months (Arch. Facial Plast. Surg. 2004;6:234–9).

Over time, he's treated more than 10 times that number of patients, ranging in age from 21 to 85.

He continues to praise the product's convenience (delivered, as it is, in prefilled vials) and safety (requiring no sensitivity testing and resulting in no serious adverse events in years of use in otolaryngology, oral surgery, or orthopedics).

He likes it as subdermal filler for deep rhytids, marionette lines, deep acne and traumatic scars, and the nasolabial folds.

"It's a very nice bulking agent," he explained, comparing the results achieved by 1 syringe of Radiesse (1 mL) with what can be accomplished using 2.5 cc of Zyplast, a bovine collagen filler.

But he has virtually ceased using Radiesse for the lips or for vertical lip rhytids.

"I don't think it's a user-friendly material in the lips," said Dr. Tzikas.

He found a 5.9% incidence of lip nodules in 341 patients whose lips he treated, and despite the reduction in nodules as his experience increased, he still feels the results don't justify the risks in treating that area.

Specifically, he said 12% of his first 100 lip patients developed nodules, compared with 2% of his second hundred patients.

"It really, really decreases with just being more conservative. Don't go too superficial in lips," he said.

Lip nodules generally resolve on their own within 6–9 months, but they can also be treated with Kenalog injections and massage, or by disrupting them with a 22-gauge needle and manual compression.

Using too much Radiesse superficially can also result in nodules along the nasolabial grooves, which can take up to a year to resolve, he said at the meeting.

Dr. Tzikas noted that older patients may require larger volumes of Radiesse or more treatments, since their diminished fibroblastic response prevents robust long-term correction.

"I would advise taking very good [before and after] photos of patients. They spend a fair amount of money, and they expect more from fillers," he said, showing an image of a patient who received 3 cc of Radiance FN 2 years before the photo was taken. Although the material could still be palpated under the skin, "the clinical effect is basically gone," he said.

BioForm of Franksville, Wisc., has supported Dr. Tzikas' studies of Radiesse, but he has no financial interest in the company.

LAS VEGAS — Don't overpromise results to patients considering facial soft tissue augmentation with Radiesse, says a facial plastic and reconstructive surgeon who has now treated 1,174 patients with the filler previously known as Radiance FN.

"I think like most technologies, when we first get them, we kind of oversell them. We think they're a lot better than they really are," said Thomas L. Tzikas, M.D., a physician in private practice in Del Ray, Fla.

The early word on Radiesse, a filler made of spherical particles of synthetic calcium hydroxylapatite, was that it would last between 3 and 5 years, justifying its high price tag. Current prices for a 1-vial treatment range from $800 to $1,400.

But Dr. Tzikas told colleagues at a facial cosmetic surgery symposium that 1 vial often isn't enough to achieve satisfactory correction of facial structures, such as the nasolabial folds. Moreover, its results are unpredictable after 2 years.

"How long does it last? In my experience, it definitely lasts 1 year. There are variable results at 1.5 years and longer," he said at the meeting sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

Dr. Tzikas' experience with Radiesse, manufactured by BioForm Inc., is considerable. He conducted a pivotal trial of the filler in 90 patients, concluding that it was highly effective and well tolerated, with excellent results and high patient satisfaction at 6 months (Arch. Facial Plast. Surg. 2004;6:234–9).

Over time, he's treated more than 10 times that number of patients, ranging in age from 21 to 85.

He continues to praise the product's convenience (delivered, as it is, in prefilled vials) and safety (requiring no sensitivity testing and resulting in no serious adverse events in years of use in otolaryngology, oral surgery, or orthopedics).

He likes it as subdermal filler for deep rhytids, marionette lines, deep acne and traumatic scars, and the nasolabial folds.

"It's a very nice bulking agent," he explained, comparing the results achieved by 1 syringe of Radiesse (1 mL) with what can be accomplished using 2.5 cc of Zyplast, a bovine collagen filler.

But he has virtually ceased using Radiesse for the lips or for vertical lip rhytids.

"I don't think it's a user-friendly material in the lips," said Dr. Tzikas.

He found a 5.9% incidence of lip nodules in 341 patients whose lips he treated, and despite the reduction in nodules as his experience increased, he still feels the results don't justify the risks in treating that area.

Specifically, he said 12% of his first 100 lip patients developed nodules, compared with 2% of his second hundred patients.

"It really, really decreases with just being more conservative. Don't go too superficial in lips," he said.

Lip nodules generally resolve on their own within 6–9 months, but they can also be treated with Kenalog injections and massage, or by disrupting them with a 22-gauge needle and manual compression.

Using too much Radiesse superficially can also result in nodules along the nasolabial grooves, which can take up to a year to resolve, he said at the meeting.

Dr. Tzikas noted that older patients may require larger volumes of Radiesse or more treatments, since their diminished fibroblastic response prevents robust long-term correction.

"I would advise taking very good [before and after] photos of patients. They spend a fair amount of money, and they expect more from fillers," he said, showing an image of a patient who received 3 cc of Radiance FN 2 years before the photo was taken. Although the material could still be palpated under the skin, "the clinical effect is basically gone," he said.

BioForm of Franksville, Wisc., has supported Dr. Tzikas' studies of Radiesse, but he has no financial interest in the company.

LAS VEGAS — Don't overpromise results to patients considering facial soft tissue augmentation with Radiesse, says a facial plastic and reconstructive surgeon who has now treated 1,174 patients with the filler previously known as Radiance FN.

"I think like most technologies, when we first get them, we kind of oversell them. We think they're a lot better than they really are," said Thomas L. Tzikas, M.D., a physician in private practice in Del Ray, Fla.

The early word on Radiesse, a filler made of spherical particles of synthetic calcium hydroxylapatite, was that it would last between 3 and 5 years, justifying its high price tag. Current prices for a 1-vial treatment range from $800 to $1,400.

But Dr. Tzikas told colleagues at a facial cosmetic surgery symposium that 1 vial often isn't enough to achieve satisfactory correction of facial structures, such as the nasolabial folds. Moreover, its results are unpredictable after 2 years.

"How long does it last? In my experience, it definitely lasts 1 year. There are variable results at 1.5 years and longer," he said at the meeting sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence.

Dr. Tzikas' experience with Radiesse, manufactured by BioForm Inc., is considerable. He conducted a pivotal trial of the filler in 90 patients, concluding that it was highly effective and well tolerated, with excellent results and high patient satisfaction at 6 months (Arch. Facial Plast. Surg. 2004;6:234–9).

Over time, he's treated more than 10 times that number of patients, ranging in age from 21 to 85.

He continues to praise the product's convenience (delivered, as it is, in prefilled vials) and safety (requiring no sensitivity testing and resulting in no serious adverse events in years of use in otolaryngology, oral surgery, or orthopedics).

He likes it as subdermal filler for deep rhytids, marionette lines, deep acne and traumatic scars, and the nasolabial folds.

"It's a very nice bulking agent," he explained, comparing the results achieved by 1 syringe of Radiesse (1 mL) with what can be accomplished using 2.5 cc of Zyplast, a bovine collagen filler.

But he has virtually ceased using Radiesse for the lips or for vertical lip rhytids.

"I don't think it's a user-friendly material in the lips," said Dr. Tzikas.

He found a 5.9% incidence of lip nodules in 341 patients whose lips he treated, and despite the reduction in nodules as his experience increased, he still feels the results don't justify the risks in treating that area.

Specifically, he said 12% of his first 100 lip patients developed nodules, compared with 2% of his second hundred patients.

"It really, really decreases with just being more conservative. Don't go too superficial in lips," he said.

Lip nodules generally resolve on their own within 6–9 months, but they can also be treated with Kenalog injections and massage, or by disrupting them with a 22-gauge needle and manual compression.

Using too much Radiesse superficially can also result in nodules along the nasolabial grooves, which can take up to a year to resolve, he said at the meeting.

Dr. Tzikas noted that older patients may require larger volumes of Radiesse or more treatments, since their diminished fibroblastic response prevents robust long-term correction.

"I would advise taking very good [before and after] photos of patients. They spend a fair amount of money, and they expect more from fillers," he said, showing an image of a patient who received 3 cc of Radiance FN 2 years before the photo was taken. Although the material could still be palpated under the skin, "the clinical effect is basically gone," he said.

BioForm of Franksville, Wisc., has supported Dr. Tzikas' studies of Radiesse, but he has no financial interest in the company.

PARIS — To obtain the best cosmetic results, you must intervene early in pediatric dermatologic tumors, Patrick A. Diner, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

A common misconception is that surgery should be delayed in children because of the potential risks associated with general anesthesia. But research shows that the risk is not relevant after 1 year of age, and that waiting does not guarantee that local anesthesia can be used, especially when a lesion is located on the face, he said.

Dr. Diner recommended early surgical intervention because of the loss of skin elasticity, the potential for a lesion to grow, and the risk of infection, deformity, and loss of function associated with some lesions.

Larger excisions can be performed with better results because younger skin is more elastic and has a significantly thick layer of fat, and there is decreased muscular activity in younger patients, he said.

Early intervention should also be considered to reduce the psychological impact of dermatologic tumors on children, said Dr. Diner, a plastic and reconstructive surgeon with the Armand Trousseau Children's Hospital, University of Paris.

"How can we refuse this early surgery, which can change their quality of life … when later on we will not obtain the same results?" he said.

Waiting to excise dermoid cysts, midline nasal fistulas, and preauricular fistulas can increase the risk of local infection and also lead to a more complex surgery.

In severe cases of preauricular fistula, waiting can put the facial nerve at risk because the resection has to be extended, he said.

Dr. Diner also advocates early surgery with periorbital and orbital hemangiomas because of the risk of amblyopia, astigmatism, and intraorbital infiltration resulting in displacement of the eyeball.

Emergency prophylactic surgery should be considered—despite a normal first ophthalmic examination—with a hemangioma with partial closure of more than one-third of the eye, or with a bulky localized hemangioma.

In his study of 62 patients, average age at surgery was 8 months for orbital hemangiomas. However, he contends that the surgery should happen as soon as possible if there is any risk of visual impairment.

Among 450 patients aged 5 days to 20 years who were treated for calvarial tumors and alopecia at the Armand Trousseau Children's Hospital, 72% were operated on before they were 2 years old, and 15% before they were 3 years old, fellow plastic surgeon Gérald Franchi, M.D., said during the same session at the meeting.

Dr. Franchi said a combination of techniques—such as simple excision, tissue expansion, and skin grafting—is best when dealing with calvarial tumors and alopecia in children. Large skin resection can be performed before the age of 3 months, when skin laxity is greatest. Wound care and skin grafts are the most reasonable approach for aplasia cutis congenita. Simple excision and tissue expansion are suggested for congenital pigmentary nevi, he said, especially if they involve two-thirds of the scalp. The approach doesn't result in growth-related problems later on, although the density of the hair will be affected.

Scalp hemangiomas in children should not be operated on unless ulcerated because of a risk of bleeding, he said.

A large palpebral hemangioma put the development of good vision at risk.

Prophylactic emergency surgery was performed to correct the occlusion. Photos courtesy Dr. Patrick A. Diner

PARIS — To obtain the best cosmetic results, you must intervene early in pediatric dermatologic tumors, Patrick A. Diner, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

A common misconception is that surgery should be delayed in children because of the potential risks associated with general anesthesia. But research shows that the risk is not relevant after 1 year of age, and that waiting does not guarantee that local anesthesia can be used, especially when a lesion is located on the face, he said.

Dr. Diner recommended early surgical intervention because of the loss of skin elasticity, the potential for a lesion to grow, and the risk of infection, deformity, and loss of function associated with some lesions.

Larger excisions can be performed with better results because younger skin is more elastic and has a significantly thick layer of fat, and there is decreased muscular activity in younger patients, he said.

Early intervention should also be considered to reduce the psychological impact of dermatologic tumors on children, said Dr. Diner, a plastic and reconstructive surgeon with the Armand Trousseau Children's Hospital, University of Paris.

"How can we refuse this early surgery, which can change their quality of life … when later on we will not obtain the same results?" he said.

Waiting to excise dermoid cysts, midline nasal fistulas, and preauricular fistulas can increase the risk of local infection and also lead to a more complex surgery.

In severe cases of preauricular fistula, waiting can put the facial nerve at risk because the resection has to be extended, he said.

Dr. Diner also advocates early surgery with periorbital and orbital hemangiomas because of the risk of amblyopia, astigmatism, and intraorbital infiltration resulting in displacement of the eyeball.

Emergency prophylactic surgery should be considered—despite a normal first ophthalmic examination—with a hemangioma with partial closure of more than one-third of the eye, or with a bulky localized hemangioma.

In his study of 62 patients, average age at surgery was 8 months for orbital hemangiomas. However, he contends that the surgery should happen as soon as possible if there is any risk of visual impairment.

Among 450 patients aged 5 days to 20 years who were treated for calvarial tumors and alopecia at the Armand Trousseau Children's Hospital, 72% were operated on before they were 2 years old, and 15% before they were 3 years old, fellow plastic surgeon Gérald Franchi, M.D., said during the same session at the meeting.

Dr. Franchi said a combination of techniques—such as simple excision, tissue expansion, and skin grafting—is best when dealing with calvarial tumors and alopecia in children. Large skin resection can be performed before the age of 3 months, when skin laxity is greatest. Wound care and skin grafts are the most reasonable approach for aplasia cutis congenita. Simple excision and tissue expansion are suggested for congenital pigmentary nevi, he said, especially if they involve two-thirds of the scalp. The approach doesn't result in growth-related problems later on, although the density of the hair will be affected.

Scalp hemangiomas in children should not be operated on unless ulcerated because of a risk of bleeding, he said.

A large palpebral hemangioma put the development of good vision at risk.

Prophylactic emergency surgery was performed to correct the occlusion. Photos courtesy Dr. Patrick A. Diner

PARIS — To obtain the best cosmetic results, you must intervene early in pediatric dermatologic tumors, Patrick A. Diner, M.D., said at the Fourth International Academy of Cosmetic Dermatology World Congress.

A common misconception is that surgery should be delayed in children because of the potential risks associated with general anesthesia. But research shows that the risk is not relevant after 1 year of age, and that waiting does not guarantee that local anesthesia can be used, especially when a lesion is located on the face, he said.

Dr. Diner recommended early surgical intervention because of the loss of skin elasticity, the potential for a lesion to grow, and the risk of infection, deformity, and loss of function associated with some lesions.

Larger excisions can be performed with better results because younger skin is more elastic and has a significantly thick layer of fat, and there is decreased muscular activity in younger patients, he said.

Early intervention should also be considered to reduce the psychological impact of dermatologic tumors on children, said Dr. Diner, a plastic and reconstructive surgeon with the Armand Trousseau Children's Hospital, University of Paris.

"How can we refuse this early surgery, which can change their quality of life … when later on we will not obtain the same results?" he said.

Waiting to excise dermoid cysts, midline nasal fistulas, and preauricular fistulas can increase the risk of local infection and also lead to a more complex surgery.

In severe cases of preauricular fistula, waiting can put the facial nerve at risk because the resection has to be extended, he said.

Dr. Diner also advocates early surgery with periorbital and orbital hemangiomas because of the risk of amblyopia, astigmatism, and intraorbital infiltration resulting in displacement of the eyeball.

Emergency prophylactic surgery should be considered—despite a normal first ophthalmic examination—with a hemangioma with partial closure of more than one-third of the eye, or with a bulky localized hemangioma.

In his study of 62 patients, average age at surgery was 8 months for orbital hemangiomas. However, he contends that the surgery should happen as soon as possible if there is any risk of visual impairment.

Among 450 patients aged 5 days to 20 years who were treated for calvarial tumors and alopecia at the Armand Trousseau Children's Hospital, 72% were operated on before they were 2 years old, and 15% before they were 3 years old, fellow plastic surgeon Gérald Franchi, M.D., said during the same session at the meeting.

Dr. Franchi said a combination of techniques—such as simple excision, tissue expansion, and skin grafting—is best when dealing with calvarial tumors and alopecia in children. Large skin resection can be performed before the age of 3 months, when skin laxity is greatest. Wound care and skin grafts are the most reasonable approach for aplasia cutis congenita. Simple excision and tissue expansion are suggested for congenital pigmentary nevi, he said, especially if they involve two-thirds of the scalp. The approach doesn't result in growth-related problems later on, although the density of the hair will be affected.

Scalp hemangiomas in children should not be operated on unless ulcerated because of a risk of bleeding, he said.

A large palpebral hemangioma put the development of good vision at risk.

Prophylactic emergency surgery was performed to correct the occlusion. Photos courtesy Dr. Patrick A. Diner