Aesthetic Dermatology

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

QUEBEC CITY — A series of deep injections with hyaluronic acid fillers to lift the cheek and lower eyelid regions appears to provide long-term cosmetic results, Wayne Carey, M.D., said at the annual conference of the Canadian Dermatology Association.

Deep injections of hyaluronic acids have been thought conventionally to be quickly absorbed if injected below the dermis, but deeper bolus injections appear to have long-lasting effects, said Dr. Carey, director of dermatologic surgery at McGill University, Montreal.

Dr. Carey's "tri-site bolus technique" delivers a bolus of hyaluronic acid to tissue about 3–15 mm deep into subcutaneous, supraperiosteal areas, unlike other procedures that employ a threading or microdroplet technique to inject filler to a depth of only 1–2 mm.

"This is a treatment that addresses the midface aging that is not corrected by facelifts or blepharoplasty," he said.

The technique increases the cheek volume, allows sculpting of the cheek in the zygomatic region, lifts or ablates the palpebral sulcus, and may increase the nasolabial fold indirectly by volumetric expansion of the cheek, he explained. It often makes a lower eyelid blepharoplasty or standard facelift unnecessary.

During the procedure, Dr. Carey asks his patients to sit erect while he delivers a continuous deep injection without anesthesia, without moving the needle, and without massaging the injection area; this forms a nonvisible, subcutaneous nodule. Right-handers inject with the right hand and control the migration of the material with the left hand.

He typically injects 1–5 syringes (each is 0.8 mL) into the upper cheek area on each side, although on average he injects 2.5–3 syringes per side. The first site of injection is usually around the location of the infraorbital nerve, followed by the zygomatic and nasal-jugal sulcus areas.

The effects of the technique have lasted over 18–24 months of follow-up and even up to 4 years in one woman, said Dr. Carey, who said he has no conflicts of interest regarding any hyaluronic acid products.

Although Dr. Carey has used only Perlane and Juvederm 30 in more than 75 patients he has treated with his technique, he suggested that deep, bolus injections with Restylane or Hylaform would theoretically give the same longevity seen in his patients, he said in an interview. Perlane and Restylane produce a more swollen appearance in the first few days after injection than other hyaluronic acid products, such as Juvederm, because they draw in more water from their surroundings.

The bolus technique may last longer than other procedures that inject hyaluronic acid products into the dermis because the nodule that is formed with the technique has a lower surface-area-to-volume ratio, making less hyaluronic acid available for hyaluronidase to break down. The body also might wall off the nodule, which would also make it less susceptible to hyaluronidase, Dr. Carey suggested. In a report, a biopsy of an injection site where Restylane persisted for 5 years showed a fibrotic reaction (Ophthal. Plast. Reconstr. Surg. 2004;20:317–8).

Heavy bruising lasting up to 1 week has been a significant problem in most patients who received the injections. One patient had prolonged pigmentation, which might be deposits of hemosiderin or postinflammatory hyperpigmentation, he said. Another patient has had persistent, unilateral lymphedema for about 2 months, but has improved during the last few weeks, Dr. Carey said. He is considering injecting hyaluronidase into the treatment site to relieve the complication.

Before treatment, this patient had malar bags and considerable loss of subcutaneous tissue of the cheeks.

Final results were achieved after injection of 13 syringes of hyaluronic acid. Photos courtesy Dr. Wayne Carey

LAS VEGAS — Six simple words stop Rona Z. Silkiss, M.D., in her tracks after she greets a cosmetic surgery patient by asking, "What can I do for you?"

Those words are the response: "I don't know, you're the doctor."

Within this seemingly innocuous exchange lies a warning that the balance of power between doctor and patient is already skewed, setting the scene for an unhappy outcome. In cosmetic procedures, the doctor-patient relationship must be bilateral, with each person coming to the table with a defined role and measurable expectations, Dr. Silkiss said at a facial cosmetic surgery symposium.

Don't bite when a patient says, "Take a look at me and tell me what you can do," Dr. Silkiss advised. The patient is not taking responsibility for the initial objectives of his or her cosmetic surgery, she explained. "The environment is wide open and ill defined. As a result, it is impossible for the surgeon to meet the patient's expectations" because they have not been clearly established, she said.

Maintaining a balance of power was just one of a series of tips offered by Dr. Silkiss, chief of the division of ophthalmic plastic, reconstructive, and orbital surgery at California Pacific Medical Center in Oakland.

Another patient to watch out for is one who presents at a young age with a very minor problem, saying she has read articles advocating early cosmetic surgery.

"This is what I call surgery in search of a problem," Dr. Silkiss said at the meeting, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence. Such a patient may be giving in to media pressure fueled by fashion magazines and reality TV shows such as "Nip and Tuck" and "Extreme Makeover."

Reassuring such a patient that she does not need surgery exemplifies surgical integrity that will be rewarded later, Dr. Silkiss said. She reminded her audience of the "Gucci Phenomenon": What is rare or withheld is valued more highly.

Patients who arrive in the traumatic aftermath of a divorce or job loss might be well advised to come back in a few months, when life has stabilized for them.

"The patient is at a stressful juncture in his or her life. What you do not want to do is give the patient the opportunity to transfer his or her unhappiness to the recent surgery and surgeon," she said.

Dr. Silkiss described a scenario in which a 50-year-old man, recently divorced, came to her because his new girlfriend told him he needed blepharoplasty. "Actually, he didn't notice he had a problem."

This patient, she said, had insufficient motivation to undergo an elective surgical procedure. "The patient is not personally committed to the surgery. This is his body and he has to want the surgery himself."

Such patients often come to a consultation hoping that the surgeon will agree that surgical correction for such an issue is purely optional. "They are trying to reestablish their self-esteem. Reassurance alone may be the best medicine," she said.

Difficult Patients Are Easy to Spot

Dr. Silkiss provides the following warning signs for surgeons:

▸ The patient's chief complaint is one concerning prior surgeons.

▸ The patient has already received multiple procedures and is still not satisfied.

▸ The patient has unrealistic expectations concerning the surgical outcome.

▸ The patient displays an inappropriate level of familiarity or flattery.

▸ The patient is inappropriately aggressive and/or hostile during the consultation. Remember, the consultation is the honeymoon!

▸ The consultation takes an unusually lengthy period of time, making the surgeon uncomfortable with the degree of self-absorption and detail demanded.

▸ There is excessive "negotiating" about price, location, and insurance prior to surgery.

▸ The patient repeatedly postpones the surgical date.

▸ The patient insists that his or her friend's cosmetic surgery was covered by insurance.

LAS VEGAS — Six simple words stop Rona Z. Silkiss, M.D., in her tracks after she greets a cosmetic surgery patient by asking, "What can I do for you?"

Those words are the response: "I don't know, you're the doctor."

Within this seemingly innocuous exchange lies a warning that the balance of power between doctor and patient is already skewed, setting the scene for an unhappy outcome. In cosmetic procedures, the doctor-patient relationship must be bilateral, with each person coming to the table with a defined role and measurable expectations, Dr. Silkiss said at a facial cosmetic surgery symposium.

Don't bite when a patient says, "Take a look at me and tell me what you can do," Dr. Silkiss advised. The patient is not taking responsibility for the initial objectives of his or her cosmetic surgery, she explained. "The environment is wide open and ill defined. As a result, it is impossible for the surgeon to meet the patient's expectations" because they have not been clearly established, she said.

Maintaining a balance of power was just one of a series of tips offered by Dr. Silkiss, chief of the division of ophthalmic plastic, reconstructive, and orbital surgery at California Pacific Medical Center in Oakland.

Another patient to watch out for is one who presents at a young age with a very minor problem, saying she has read articles advocating early cosmetic surgery.

"This is what I call surgery in search of a problem," Dr. Silkiss said at the meeting, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence. Such a patient may be giving in to media pressure fueled by fashion magazines and reality TV shows such as "Nip and Tuck" and "Extreme Makeover."

Reassuring such a patient that she does not need surgery exemplifies surgical integrity that will be rewarded later, Dr. Silkiss said. She reminded her audience of the "Gucci Phenomenon": What is rare or withheld is valued more highly.

Patients who arrive in the traumatic aftermath of a divorce or job loss might be well advised to come back in a few months, when life has stabilized for them.

"The patient is at a stressful juncture in his or her life. What you do not want to do is give the patient the opportunity to transfer his or her unhappiness to the recent surgery and surgeon," she said.

Dr. Silkiss described a scenario in which a 50-year-old man, recently divorced, came to her because his new girlfriend told him he needed blepharoplasty. "Actually, he didn't notice he had a problem."

This patient, she said, had insufficient motivation to undergo an elective surgical procedure. "The patient is not personally committed to the surgery. This is his body and he has to want the surgery himself."

Such patients often come to a consultation hoping that the surgeon will agree that surgical correction for such an issue is purely optional. "They are trying to reestablish their self-esteem. Reassurance alone may be the best medicine," she said.

Difficult Patients Are Easy to Spot

Dr. Silkiss provides the following warning signs for surgeons:

▸ The patient's chief complaint is one concerning prior surgeons.

▸ The patient has already received multiple procedures and is still not satisfied.

▸ The patient has unrealistic expectations concerning the surgical outcome.

▸ The patient displays an inappropriate level of familiarity or flattery.

▸ The patient is inappropriately aggressive and/or hostile during the consultation. Remember, the consultation is the honeymoon!

▸ The consultation takes an unusually lengthy period of time, making the surgeon uncomfortable with the degree of self-absorption and detail demanded.

▸ There is excessive "negotiating" about price, location, and insurance prior to surgery.

▸ The patient repeatedly postpones the surgical date.

▸ The patient insists that his or her friend's cosmetic surgery was covered by insurance.

LAS VEGAS — Six simple words stop Rona Z. Silkiss, M.D., in her tracks after she greets a cosmetic surgery patient by asking, "What can I do for you?"

Those words are the response: "I don't know, you're the doctor."

Within this seemingly innocuous exchange lies a warning that the balance of power between doctor and patient is already skewed, setting the scene for an unhappy outcome. In cosmetic procedures, the doctor-patient relationship must be bilateral, with each person coming to the table with a defined role and measurable expectations, Dr. Silkiss said at a facial cosmetic surgery symposium.

Don't bite when a patient says, "Take a look at me and tell me what you can do," Dr. Silkiss advised. The patient is not taking responsibility for the initial objectives of his or her cosmetic surgery, she explained. "The environment is wide open and ill defined. As a result, it is impossible for the surgeon to meet the patient's expectations" because they have not been clearly established, she said.

Maintaining a balance of power was just one of a series of tips offered by Dr. Silkiss, chief of the division of ophthalmic plastic, reconstructive, and orbital surgery at California Pacific Medical Center in Oakland.

Another patient to watch out for is one who presents at a young age with a very minor problem, saying she has read articles advocating early cosmetic surgery.

"This is what I call surgery in search of a problem," Dr. Silkiss said at the meeting, which was sponsored by the Multi-Specialty Foundation for Facial Aesthetic Surgical Excellence. Such a patient may be giving in to media pressure fueled by fashion magazines and reality TV shows such as "Nip and Tuck" and "Extreme Makeover."

Reassuring such a patient that she does not need surgery exemplifies surgical integrity that will be rewarded later, Dr. Silkiss said. She reminded her audience of the "Gucci Phenomenon": What is rare or withheld is valued more highly.

Patients who arrive in the traumatic aftermath of a divorce or job loss might be well advised to come back in a few months, when life has stabilized for them.

"The patient is at a stressful juncture in his or her life. What you do not want to do is give the patient the opportunity to transfer his or her unhappiness to the recent surgery and surgeon," she said.

Dr. Silkiss described a scenario in which a 50-year-old man, recently divorced, came to her because his new girlfriend told him he needed blepharoplasty. "Actually, he didn't notice he had a problem."

This patient, she said, had insufficient motivation to undergo an elective surgical procedure. "The patient is not personally committed to the surgery. This is his body and he has to want the surgery himself."

Such patients often come to a consultation hoping that the surgeon will agree that surgical correction for such an issue is purely optional. "They are trying to reestablish their self-esteem. Reassurance alone may be the best medicine," she said.

Difficult Patients Are Easy to Spot

Dr. Silkiss provides the following warning signs for surgeons:

▸ The patient's chief complaint is one concerning prior surgeons.

▸ The patient has already received multiple procedures and is still not satisfied.

▸ The patient has unrealistic expectations concerning the surgical outcome.

▸ The patient displays an inappropriate level of familiarity or flattery.

▸ The patient is inappropriately aggressive and/or hostile during the consultation. Remember, the consultation is the honeymoon!

▸ The consultation takes an unusually lengthy period of time, making the surgeon uncomfortable with the degree of self-absorption and detail demanded.

▸ There is excessive "negotiating" about price, location, and insurance prior to surgery.

▸ The patient repeatedly postpones the surgical date.

▸ The patient insists that his or her friend's cosmetic surgery was covered by insurance.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — Several longstanding myths and misconceptions about the botulinum toxin type A technique have recently been refuted, James M. Spencer, M.D., said at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

"When botulinum toxin first came out, we were told a number of things about using it," he said.

Some of the directives propagated included: It must be reconstituted with nonpreserved saline; the protein is fragile and cannot be shaken or made to foam; and, it must be used within 4 hours of reconstitution, again because the protein is fragile. "None of these are true," said Dr. Spencer, who is director of Mohs micrographic surgery at Mount Sinai Medical Center, New York, and maintains a private practice in St. Petersburg, Fla.

Preserved saline is actually preferable, he said. The preservative in saline is usually benzyl alcohol, which not only kills bacteria but is a mild anesthetic.

In a recently published study, 93 subjects were treated with botulinum toxin type A (Botox). Sixty of those patients received Botox reconstituted with preserved saline. They had a lot less pain, as measured by a visual analog scale, than did the patients who received Botox in preservative-free saline—a mean score of 1.2 out of 10 for those treated in the face with preserved-saline Botox vs. a mean 4.5 for those treated with preservative-free Botox (Aesthetic Plast. Surg. 2005;29:113–5).

"The other good thing about using the preservative is that you don't have to throw it away in 4 hours, because it is preserved," he added.

In a Brazilian study, 88 patients were treated with Botox that was reconstituted the day before, or for various periods of time up to 6 weeks before. There was no difference in efficacy when the patients were followed every 2 weeks for 4 months, with blinded observers evaluating their maximum frown (Dermatol. Surg. 2003;29:523–9).

In a third study, investigators treated patients with Botox that was reconstituted gently, or with Botox that was shaken vigorously. Again, there was no difference in efficacy, at 2 months and 4 months, Dr. Spencer said (Dermatol. Surg. 2003;29:530–1).

Many physicians also got the idea that patients could not lie down for 4 hours after a treatment. Dr. Spencer said he once told patients that, though he is not sure where he picked up this notion, and in trying to trace it, he could find nothing about its provenance.

"It turns out that is ridiculous," he said. "I've been looking for the holes in the skull that Botox would drain through to get to the brain. And, in fact, those holes are not there. There is no reason not to have patients lay down.

"Somebody must have said that, and we all believed it," he added.

Since Botox has been available, there has been a trend toward using higher and higher doses, with even the most reputable experts advocating doses as high as 80 units for the glabella, Dr. Spencer said. Dosing has not been well studied, until now.

There is one study that compared doses of 10 units, 20 units, 30 units, and 40 units to treat the glabella. And another study looked at Botox dosing for the lateral canthus for crow's feet, using escalating doses.

The glabella study said that 10 units was ineffective, but that there was no difference between 20 units and 40 units in either initial effect or duration of action (Dermatol. Surg. 2005;31:414–22). The lateral canthus study likewise reported that efficacy improved with higher dosing, but only to a point, which was about 12 units (6 units per side) (Dermatol. Surg. 2005;31:257–62).

"What these two papers said is that the clinical effect and duration of action plateaus at some point, so I am not sure that these higher doses make any sense," Dr. Spencer said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

NAPLES, FLA. — The best place to acquire surgical blades and materials for abrading is not necessarily the medical supply house, said Daniel M. Siegel, M.D.

The hardware store has supplies for medical procedures that are usually much cheaper, and often actually work better.

"During medical school, internship, and residency, I used to think about gadgets I grew up with that could be used in the medical office," explained the dermatologist and son of a hardware store owner.

The old double-edged razor blade is a case in point of the hardware store item being both cheaper and better, Dr. Siegel said. The classic blade is the old Gillette Blue Blade. Those blades are much sharper and much thinner (4/10,000th of an inch) than a scalpel, said Dr. Siegel of State University of New York Downstate Medical Center, New York.

Their thinness makes them easier to handle, and they can be bent and bowed to curettage (but practice on an orange first). Their sharpness allows the user to cut more cleanly with less collateral damage. This has even been touted in the literature, Dr. Siegel said, citing a paper that said one can perform excision biopsies of melanocytic nevi with less scarring. "Only a diamond knife is sharper."

The thicker, carpet-cutting blades sold in the hardware store are ideal for harvesting split thickness skin grafts because of their stiffness. The razor blades sometimes are covered with anticorrosive oil that is bacteriostatic, but the carpet blades need to be cleaned with Betadine and alcohol, he said.

Sandpaper, sanding sponges, and even drywall screens can be handy for—what else?—abrading, Dr. Siegel said. Sandpaper, which he makes wet with Betadine, can be used on warts, small scars, and even onychomycotic nails. The sponges are handy because they can be used and then washed in a dishwasher or washing machine. Drywall screen can be quite rough but it works well for treating larger areas, hypertrophic scars, or actinic keratoses, because it can be rinsed during use.

Dr. Siegel even suggested that sandpaper could be used for cosmetic dermabrasion, perhaps to advantage.

"It clogs quickly, so you have to use a lot of it," he said. "But it is difficult to do any real harm because it is a slow-moving, not very aggressive abrader."

For microdermabrasion, he suggested using Lava soap, which contains pumice from volcanic lava. Lava soap can be used before phototherapy or a peel, to remove some of the stratum corneum.

Dr. Siegel said he has made his own silicone gel sheeting using silicone caulking. He spreads it between two sheets of wax paper or into a plastic bag to flatten it out, and then lets it dry overnight.

As with all the hardware items, the cost of this sheeting is much less than the medical-grade sheeting, Dr. Siegel stressed. In fact, the first time he used the caulking was specifically for a patient who needed an economic alternative.

Among the other items available at the hardware store that Dr. Siegel mentioned using were electrical tape (to put over imiquimod), duct tape (on warts), foam tapes (to protect areas during cryotherapy), headlamps (only about $20), and dimethyl sulfoxide (DMSO).

DMSO can be bought in many hardware stores. He mixes it with 50% water then adds whatever medication he wants to have better penetration, such as fluconazole (Diflucan). He even suggested that someone might want to try adding it to ciclopirox (Penlac) for infected nails.

"You may actually get something that works," he said.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

ANAHEIM, CALIF. — Ablative laser resurfacing offers perhaps the most effective means for smoothing wrinkles and acne scars, but its success depends on the "five Ps": prepared patients, a good preop evaluation, pain control, a perfectly done procedure, and postop diligence, Suzanne L. Kilmer, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

Requiring just a single treatment, ablative laser resurfacing removes the epidermis in a first pass, thereby eliminating epidermal lesions and helping to decrease the risk for actinic keratoses and basal cell carcinomas.

To achieve the best possible outcome, however, it's important to pay attention to the details included in the five Ps, said Dr. Kilmer of the department of dermatology at the University of California, Davis.

Prepared Patients

"The consult is critical," Dr. Kilmer said. "Educated patients are going to be much better prepared for what they will be dealing with and will have more realistic expectations."

To help alleviate fear, Dr. Kilmer said she shows patients a video of the procedure (supplied by the manufacturer), along with typical before-and-after photos—and not just the best cases. "I'll even show my worst," she said. "I'll also show photos to give them an idea of how they can expect to look in a couple of days, a couple of weeks, and as time goes on."

In addition to the informed consent form, patients receive handouts describing the procedure (including preop preparation and postop care) and risk/benefit options.

Preoperative Evaluation

Because hyperpigmentation is one of the most common problems in ablative laser resurfacing, patients' skin type should be checked for that tendency, Dr. Kilmer said.

If patients have acne or other scars, the shallow, dish-shaped scars tend to respond the best, although the treatment significantly improves most acne scars, she said.

Photos of patients should be taken preoperatively and at 1 week, 6 weeks, 3–6 months, and 1 year. Full-face shots as well as close-ups of all anatomical units should be taken with good lighting and consistent settings.

"I can't emphasize enough the need to document with photographs in various stages," Dr. Kilmer said. "It's amazing how often patients won't see much improvement or will say some spot wasn't there and you can look back and show them that it was."

Pain Medications

Dr. Kilmer recommended EMLA with hydration for pain control. Not only does it enhance comfort, she said, but it also enhances safety, with less superficial coagulative thermal damage and less prolonged erythema. Redness has a much shorter duration, and the tendency for hyperpigmentation decreases, she added.

Dr. Kilmer instructs her patients to begin with hot, soapy soaks for 15 minutes at home and then immediately apply the EMLA and cover with a plastic wrap. A second tube is applied when they come to the office.

Patients who have previously had cold sores receive antiviral medications, and they also get antiyeast pills because persistent itching and redness can represent a low-grade yeast infection.

Valium (5–10 mg) and oral nonsteroidals are also given around the clock for the first few days to relieve pain.

Perfectly Done Procedure

Dr. Kilmer said she typically treats in quadrants, with a first pass using slightly higher intensity because the epidermis is so hydrated. Feathering peripherally in the first pass is also important to prevent a stop and start line.

She advises wiping everywhere except the neck, jaw line, and hairline, and giving a lighter treatment to fair or thin-skinned patients, who should never be wiped on the lateral third of the cheek.

Treatment of the neck can have good results and helps blend the entire treatment area nicely, Dr. Kilmer said, but she emphasized that EMLA should be used for extra protection from thermal damage and the neck should never be wiped.

Postop Diligence

Dr. Kilmer emphasized the need to stay on top of any potential problems, such as contact dermatitis from unexpected sources. "Fabric softening agents and dryer sheets … tend to have perfume and dyes, which can really be a problem," she said. Use of topical steroids can help in such situations.

If scarring is suspected, treatment should be given right away. A bubbly reaction seen on the skin texture signals a scarring problem, and she advises physicians to consult with others and seek help.

Likewise, treatment of hyperpigmentation cases should be swift, and patients should get zinc oxide right away, with hydroquinones and Retin-A at about a month after treatment.

In the thousands of cases she's done, Dr. Kilmer said she's never seen hyperpigmentation become permanent. EMLA and hydration help provide a greater margin of safety, making ablative laser resurfacing a highly effective tool, she noted.

"There is great efficacy, and you definitely see tightening, so I would say this is the most predictable device we have for resurfacing or regeneration," Dr. Kilmer concluded.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — Ablative laser resurfacing offers perhaps the most effective means for smoothing wrinkles and acne scars, but its success depends on the "five Ps": prepared patients, a good preop evaluation, pain control, a perfectly done procedure, and postop diligence, Suzanne L. Kilmer, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

Requiring just a single treatment, ablative laser resurfacing removes the epidermis in a first pass, thereby eliminating epidermal lesions and helping to decrease the risk for actinic keratoses and basal cell carcinomas.

To achieve the best possible outcome, however, it's important to pay attention to the details included in the five Ps, said Dr. Kilmer of the department of dermatology at the University of California, Davis.

Prepared Patients

"The consult is critical," Dr. Kilmer said. "Educated patients are going to be much better prepared for what they will be dealing with and will have more realistic expectations."

To help alleviate fear, Dr. Kilmer said she shows patients a video of the procedure (supplied by the manufacturer), along with typical before-and-after photos—and not just the best cases. "I'll even show my worst," she said. "I'll also show photos to give them an idea of how they can expect to look in a couple of days, a couple of weeks, and as time goes on."

In addition to the informed consent form, patients receive handouts describing the procedure (including preop preparation and postop care) and risk/benefit options.

Preoperative Evaluation

Because hyperpigmentation is one of the most common problems in ablative laser resurfacing, patients' skin type should be checked for that tendency, Dr. Kilmer said.

If patients have acne or other scars, the shallow, dish-shaped scars tend to respond the best, although the treatment significantly improves most acne scars, she said.

Photos of patients should be taken preoperatively and at 1 week, 6 weeks, 3–6 months, and 1 year. Full-face shots as well as close-ups of all anatomical units should be taken with good lighting and consistent settings.

"I can't emphasize enough the need to document with photographs in various stages," Dr. Kilmer said. "It's amazing how often patients won't see much improvement or will say some spot wasn't there and you can look back and show them that it was."

Pain Medications

Dr. Kilmer recommended EMLA with hydration for pain control. Not only does it enhance comfort, she said, but it also enhances safety, with less superficial coagulative thermal damage and less prolonged erythema. Redness has a much shorter duration, and the tendency for hyperpigmentation decreases, she added.

Dr. Kilmer instructs her patients to begin with hot, soapy soaks for 15 minutes at home and then immediately apply the EMLA and cover with a plastic wrap. A second tube is applied when they come to the office.

Patients who have previously had cold sores receive antiviral medications, and they also get antiyeast pills because persistent itching and redness can represent a low-grade yeast infection.

Valium (5–10 mg) and oral nonsteroidals are also given around the clock for the first few days to relieve pain.

Perfectly Done Procedure

Dr. Kilmer said she typically treats in quadrants, with a first pass using slightly higher intensity because the epidermis is so hydrated. Feathering peripherally in the first pass is also important to prevent a stop and start line.

She advises wiping everywhere except the neck, jaw line, and hairline, and giving a lighter treatment to fair or thin-skinned patients, who should never be wiped on the lateral third of the cheek.

Treatment of the neck can have good results and helps blend the entire treatment area nicely, Dr. Kilmer said, but she emphasized that EMLA should be used for extra protection from thermal damage and the neck should never be wiped.

Postop Diligence

Dr. Kilmer emphasized the need to stay on top of any potential problems, such as contact dermatitis from unexpected sources. "Fabric softening agents and dryer sheets … tend to have perfume and dyes, which can really be a problem," she said. Use of topical steroids can help in such situations.

If scarring is suspected, treatment should be given right away. A bubbly reaction seen on the skin texture signals a scarring problem, and she advises physicians to consult with others and seek help.

Likewise, treatment of hyperpigmentation cases should be swift, and patients should get zinc oxide right away, with hydroquinones and Retin-A at about a month after treatment.

In the thousands of cases she's done, Dr. Kilmer said she's never seen hyperpigmentation become permanent. EMLA and hydration help provide a greater margin of safety, making ablative laser resurfacing a highly effective tool, she noted.

"There is great efficacy, and you definitely see tightening, so I would say this is the most predictable device we have for resurfacing or regeneration," Dr. Kilmer concluded.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — Ablative laser resurfacing offers perhaps the most effective means for smoothing wrinkles and acne scars, but its success depends on the "five Ps": prepared patients, a good preop evaluation, pain control, a perfectly done procedure, and postop diligence, Suzanne L. Kilmer, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

Requiring just a single treatment, ablative laser resurfacing removes the epidermis in a first pass, thereby eliminating epidermal lesions and helping to decrease the risk for actinic keratoses and basal cell carcinomas.

To achieve the best possible outcome, however, it's important to pay attention to the details included in the five Ps, said Dr. Kilmer of the department of dermatology at the University of California, Davis.

Prepared Patients

"The consult is critical," Dr. Kilmer said. "Educated patients are going to be much better prepared for what they will be dealing with and will have more realistic expectations."

To help alleviate fear, Dr. Kilmer said she shows patients a video of the procedure (supplied by the manufacturer), along with typical before-and-after photos—and not just the best cases. "I'll even show my worst," she said. "I'll also show photos to give them an idea of how they can expect to look in a couple of days, a couple of weeks, and as time goes on."

In addition to the informed consent form, patients receive handouts describing the procedure (including preop preparation and postop care) and risk/benefit options.

Preoperative Evaluation

Because hyperpigmentation is one of the most common problems in ablative laser resurfacing, patients' skin type should be checked for that tendency, Dr. Kilmer said.

If patients have acne or other scars, the shallow, dish-shaped scars tend to respond the best, although the treatment significantly improves most acne scars, she said.

Photos of patients should be taken preoperatively and at 1 week, 6 weeks, 3–6 months, and 1 year. Full-face shots as well as close-ups of all anatomical units should be taken with good lighting and consistent settings.

"I can't emphasize enough the need to document with photographs in various stages," Dr. Kilmer said. "It's amazing how often patients won't see much improvement or will say some spot wasn't there and you can look back and show them that it was."

Pain Medications

Dr. Kilmer recommended EMLA with hydration for pain control. Not only does it enhance comfort, she said, but it also enhances safety, with less superficial coagulative thermal damage and less prolonged erythema. Redness has a much shorter duration, and the tendency for hyperpigmentation decreases, she added.

Dr. Kilmer instructs her patients to begin with hot, soapy soaks for 15 minutes at home and then immediately apply the EMLA and cover with a plastic wrap. A second tube is applied when they come to the office.

Patients who have previously had cold sores receive antiviral medications, and they also get antiyeast pills because persistent itching and redness can represent a low-grade yeast infection.

Valium (5–10 mg) and oral nonsteroidals are also given around the clock for the first few days to relieve pain.

Perfectly Done Procedure

Dr. Kilmer said she typically treats in quadrants, with a first pass using slightly higher intensity because the epidermis is so hydrated. Feathering peripherally in the first pass is also important to prevent a stop and start line.

She advises wiping everywhere except the neck, jaw line, and hairline, and giving a lighter treatment to fair or thin-skinned patients, who should never be wiped on the lateral third of the cheek.

Treatment of the neck can have good results and helps blend the entire treatment area nicely, Dr. Kilmer said, but she emphasized that EMLA should be used for extra protection from thermal damage and the neck should never be wiped.

Postop Diligence

Dr. Kilmer emphasized the need to stay on top of any potential problems, such as contact dermatitis from unexpected sources. "Fabric softening agents and dryer sheets … tend to have perfume and dyes, which can really be a problem," she said. Use of topical steroids can help in such situations.

If scarring is suspected, treatment should be given right away. A bubbly reaction seen on the skin texture signals a scarring problem, and she advises physicians to consult with others and seek help.

Likewise, treatment of hyperpigmentation cases should be swift, and patients should get zinc oxide right away, with hydroquinones and Retin-A at about a month after treatment.

In the thousands of cases she's done, Dr. Kilmer said she's never seen hyperpigmentation become permanent. EMLA and hydration help provide a greater margin of safety, making ablative laser resurfacing a highly effective tool, she noted.

"There is great efficacy, and you definitely see tightening, so I would say this is the most predictable device we have for resurfacing or regeneration," Dr. Kilmer concluded.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — An in-office camouflage makeup expert can help mask postoperative bruising, swelling, or redness, which can make the difference to patients who feel injured or disfigured, said Howard Steinman, M.D., at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

It's not uncommon for dermatologists to simply give patients a list of a few paramedical products and send them on their way, without considering that most patients will not want to be seen in public, even by strangers, immediately after the procedure. "You may see a normal postop result—bruising, redness, or asymmetry—and you think it looks like a normal, great result, but the patient probably doesn't see it that way," said Dr. Steinman, a dermatologist in private practice in Chula Vista, Calif.

The last thing a patient likely wants to do is go to a cosmetic counter with an unsightly face when the salespeople look like models, he added. "Having to buy the products outside the office is simply not a viable option for cosmetic patients."

The difficulties of using past-generation paramedical products turned many practitioners away from offering in-house camouflage makeup services.

But mineral makeup has changed all that. Newer products are much easier for staff people to use and for patients to learn to apply themselves. The products can be highly effective in normalizing or almost normalizing regular bruising, covering redness, and masking pigmentary changes.

The makeup helps cover expected discoloration caused by everything from ablative procedures, deeper peels, and S-lifts to blepharoplasty, Mohs surgery, and even botulinum type A injections.

The products are formulated for postsurgical use, are waterproof, have an SPF, and are easy to apply and remove, Dr. Steinman said. The paramedical products he uses include Youngblood Mineral Makeup, DermaColor Camouflage, and Lycogel. He said he does not have financial ties to any of the manufacturers.

There are some limitations—the makeup usually won't cover three-dimensional conditions, for instance. And it often can't cover very dark bruising or a lack of texture, he noted.

The staff person in charge of applying the camouflage makeup can offer an added level of care and understanding that boosts patient satisfaction.

"If you use someone who's experienced in paramedical camouflage makeup, they understand the psyche of the postop patient, the procedures, and they have great credibility in your office." In Dr. Steinman's practice, the makeup expert is his wife, Diedre, but estheticians or other staff members with experience in paramedical camouflage makeup can take on the role.

To allow adequate time and planning for makeup application and training, the service is best offered as a postsurgical session, arranged along with the other procedures, Dr. Steinman recommended.

Makeup should be matched to patients' facial skin prior to laser or chemical peels to ensure the appropriate color will be available postoperatively, and patients should be told to bring in their own makeup to help them feel as "normal" as possible when they leave.

Considering the low cost and risk of camouflage makeup, the minimal office space required, and the high level of patient satisfaction, the inclusion of such services is very worthwhile, Dr. Steinman said.

"When this is incorporated in your office, the fear we all have of doing procedures that have downtime can be ameliorated," he said. "With something like CO₂ laser resurfacing, for instance, I have no concerns about downtime."

"If you're not offering camouflage makeup, then you're missing the boat, because this really completes the whole package for the patient and makes you, the physician, feel much more secure," he added.

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — Liquid injectable silicone can be a highly effective means of tissue augmentation, especially for acne scarring and HIV-related lipoatrophy, Derek Jones, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

"This can be an ideal filler that is long lasting and cosmetically elegant," said Dr. Jones of the department of dermatology at the University of California, Los Angeles.

A "wealth of anecdotal data" indicates that liquid injectable silicone is safe and effective, but the following critical rules are key to its safe usage, he said:

▸ Use only pure, Food and Drug Administration-approved, injectable-grade liquid silicone; in the United States that means only Silikon-1000, made by Alcon Laboratories. The product has FDA approval for intraocular injection to treat retinal detachment, but it may be legally used off label, under the 1997 FDA modernization act that allowed medical devices to be used off label.

It's important to note, however, that the law prohibits advertisement of off-label uses, and malpractice insurance carriers have different policies regarding such uses.

▸ Adhere to a strict serial puncture microdroplet technique, defined as 0.01 cc injected into the immediate subdermal plane or deeper at 2- to 4-mm intervals, with no double pass in the same plane. Intradermal injection should be strongly avoided except among the most skilled practitioners.

The technique is necessary to allow a fibroproliferative response that develops around each microdroplet between treatments, not only causing each droplet to become anchored and less likely to drift but contributing to further augmentation, Dr. Jones said.

"This is an oil, and if you inject a lot all at once, it's like throwing olive oil on the floor—it's going to spread out and track tissue planes along the path of least resistance," he said. "But the microdroplet technique addresses this problem."

▸ Inject only small volumes—2 cc or less for lipoatrophy, or 0.5 cc or less for other indications. "Avoid the temptation to use larger volumes," Dr. Jones said, adding that injections should be spread out at intervals of at least 4 weeks.

In addition to these three critical rules, important considerations for silicone use include informing patients that liquid injectable silicone is permanent, and that its use is still investigational and likely to remain so for years. And, while patients can resume a normal routine immediately, they are advised to avoid activities that could predispose them to blunt trauma.

Dr. Jones demonstrated the injection technique on a patient with HIV-related facial lipoatrophy at the conference and said that most patients are highly pleased with the results.

Liquid silicone injections "really give an extraordinarily natural-appearing correction," he said. "When you touch the cheeks of these individuals, they feel nice, soft, and supple, and the injections really can restore subtle and refined facial contours."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

This HIV patient shows lipoatrophy before his silicone treatment.

Augmentation with injectable silicone gives a natural-appearing correction. Photos courtesy Dr. Derek Jones

ANAHEIM, CALIF. — Liquid injectable silicone can be a highly effective means of tissue augmentation, especially for acne scarring and HIV-related lipoatrophy, Derek Jones, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

"This can be an ideal filler that is long lasting and cosmetically elegant," said Dr. Jones of the department of dermatology at the University of California, Los Angeles.

A "wealth of anecdotal data" indicates that liquid injectable silicone is safe and effective, but the following critical rules are key to its safe usage, he said:

▸ Use only pure, Food and Drug Administration-approved, injectable-grade liquid silicone; in the United States that means only Silikon-1000, made by Alcon Laboratories. The product has FDA approval for intraocular injection to treat retinal detachment, but it may be legally used off label, under the 1997 FDA modernization act that allowed medical devices to be used off label.

It's important to note, however, that the law prohibits advertisement of off-label uses, and malpractice insurance carriers have different policies regarding such uses.

▸ Adhere to a strict serial puncture microdroplet technique, defined as 0.01 cc injected into the immediate subdermal plane or deeper at 2- to 4-mm intervals, with no double pass in the same plane. Intradermal injection should be strongly avoided except among the most skilled practitioners.

The technique is necessary to allow a fibroproliferative response that develops around each microdroplet between treatments, not only causing each droplet to become anchored and less likely to drift but contributing to further augmentation, Dr. Jones said.

"This is an oil, and if you inject a lot all at once, it's like throwing olive oil on the floor—it's going to spread out and track tissue planes along the path of least resistance," he said. "But the microdroplet technique addresses this problem."

▸ Inject only small volumes—2 cc or less for lipoatrophy, or 0.5 cc or less for other indications. "Avoid the temptation to use larger volumes," Dr. Jones said, adding that injections should be spread out at intervals of at least 4 weeks.

In addition to these three critical rules, important considerations for silicone use include informing patients that liquid injectable silicone is permanent, and that its use is still investigational and likely to remain so for years. And, while patients can resume a normal routine immediately, they are advised to avoid activities that could predispose them to blunt trauma.

Dr. Jones demonstrated the injection technique on a patient with HIV-related facial lipoatrophy at the conference and said that most patients are highly pleased with the results.

Liquid silicone injections "really give an extraordinarily natural-appearing correction," he said. "When you touch the cheeks of these individuals, they feel nice, soft, and supple, and the injections really can restore subtle and refined facial contours."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

This HIV patient shows lipoatrophy before his silicone treatment.

Augmentation with injectable silicone gives a natural-appearing correction. Photos courtesy Dr. Derek Jones

ANAHEIM, CALIF. — Liquid injectable silicone can be a highly effective means of tissue augmentation, especially for acne scarring and HIV-related lipoatrophy, Derek Jones, M.D., said at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation.

"This can be an ideal filler that is long lasting and cosmetically elegant," said Dr. Jones of the department of dermatology at the University of California, Los Angeles.

A "wealth of anecdotal data" indicates that liquid injectable silicone is safe and effective, but the following critical rules are key to its safe usage, he said:

▸ Use only pure, Food and Drug Administration-approved, injectable-grade liquid silicone; in the United States that means only Silikon-1000, made by Alcon Laboratories. The product has FDA approval for intraocular injection to treat retinal detachment, but it may be legally used off label, under the 1997 FDA modernization act that allowed medical devices to be used off label.

It's important to note, however, that the law prohibits advertisement of off-label uses, and malpractice insurance carriers have different policies regarding such uses.

▸ Adhere to a strict serial puncture microdroplet technique, defined as 0.01 cc injected into the immediate subdermal plane or deeper at 2- to 4-mm intervals, with no double pass in the same plane. Intradermal injection should be strongly avoided except among the most skilled practitioners.

The technique is necessary to allow a fibroproliferative response that develops around each microdroplet between treatments, not only causing each droplet to become anchored and less likely to drift but contributing to further augmentation, Dr. Jones said.

"This is an oil, and if you inject a lot all at once, it's like throwing olive oil on the floor—it's going to spread out and track tissue planes along the path of least resistance," he said. "But the microdroplet technique addresses this problem."

▸ Inject only small volumes—2 cc or less for lipoatrophy, or 0.5 cc or less for other indications. "Avoid the temptation to use larger volumes," Dr. Jones said, adding that injections should be spread out at intervals of at least 4 weeks.

In addition to these three critical rules, important considerations for silicone use include informing patients that liquid injectable silicone is permanent, and that its use is still investigational and likely to remain so for years. And, while patients can resume a normal routine immediately, they are advised to avoid activities that could predispose them to blunt trauma.

Dr. Jones demonstrated the injection technique on a patient with HIV-related facial lipoatrophy at the conference and said that most patients are highly pleased with the results.

Liquid silicone injections "really give an extraordinarily natural-appearing correction," he said. "When you touch the cheeks of these individuals, they feel nice, soft, and supple, and the injections really can restore subtle and refined facial contours."

The SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

This HIV patient shows lipoatrophy before his silicone treatment.

Augmentation with injectable silicone gives a natural-appearing correction. Photos courtesy Dr. Derek Jones

ANAHEIM, CALIF. — Light-based therapies are heavily promoted as options for treating acne, but issues of cost and convenience should rule them out as a first line of treatment, said dermatologists at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation. The market is filling up with dozens of different lasers claiming to help treat acne with wide-ranging treatment mechanisms and even wider-ranging price tags, said Jerome Garden, M.D., of the department of dermatology at Northwestern University in Chicago.

"I found 26 different products out there all claiming they treat acne, and it's very hard to sort all of these out," he said.

Most of the claims are backed by some research—infrared laser treatment, for instance, has some strong studies showing shrinkage of the sebaceous glands; blue light and photodynamic therapy (PDT) are gaining recognition for their efficacy; and radiofrequency devices have shown some success.

But for all of the devices and claims, several confounding factors give dermatologists pause in embracing light-based therapies as a first-line treatment.

First, there is broad inconsistency in the literature. An analysis of acne literature published in the Journal of the American Academy of Dermatology in 2002 underscored the wide-ranging measures used in determining not only outcomes but the very definitions of acne, said James Spencer, M.D., a clinical professor of dermatology at Mount Sinai School of Medicine, New York (J. Am. Acad. Dermatol. 2002;47:231–40).

"There were over 25 methods for assessing acne severity and 19 methods for counting lesions," he said. "That makes comparing one study to another very difficult."

With a treatment like PDT, the evidence of efficacy in treating acne is strong, but there is the trade-off of the process being a negative experience for the patient.

"Photochemicals [used in PDT] cause cell membrane damage, and with the process there's pain. The outcome may be positive, but this is not a positive event in the life of the patient," Dr. Garden said.

When PDT is used to treat something like cancerous lesions, the process is entirely justified, but as a repetitive treatment for acne, it is far more questionable, he said.

"What we have to ask ourselves is this—do we really want this for our patients? And what's the long-term effect? We don't know," he said. "The approach is new, and at the moment I'm very uncomfortable with this."

And then there is the cost of light-based therapies, which are far more expensive than a medical option. "These are highly expensive cash procedures requiring multiple visits to the office," Dr. Spencer said. "I think light-based therapy for acne represents one more tool in the tool chest, but it's quite unreasonable for it to be the first thing that pops into your head."

Dr. Garden agreed. "It's tempting to have a nonmedical option for treating acne, and this may have a role for those very selective, noncompliant patients," he said.

"But when you look at this and ask if it's something that should be a first-line treatment for patients, the answer should be, unequivocally, no," he asserted. "It's not worth it—not yet."

SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — Light-based therapies are heavily promoted as options for treating acne, but issues of cost and convenience should rule them out as a first line of treatment, said dermatologists at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation. The market is filling up with dozens of different lasers claiming to help treat acne with wide-ranging treatment mechanisms and even wider-ranging price tags, said Jerome Garden, M.D., of the department of dermatology at Northwestern University in Chicago.

"I found 26 different products out there all claiming they treat acne, and it's very hard to sort all of these out," he said.

Most of the claims are backed by some research—infrared laser treatment, for instance, has some strong studies showing shrinkage of the sebaceous glands; blue light and photodynamic therapy (PDT) are gaining recognition for their efficacy; and radiofrequency devices have shown some success.

But for all of the devices and claims, several confounding factors give dermatologists pause in embracing light-based therapies as a first-line treatment.

First, there is broad inconsistency in the literature. An analysis of acne literature published in the Journal of the American Academy of Dermatology in 2002 underscored the wide-ranging measures used in determining not only outcomes but the very definitions of acne, said James Spencer, M.D., a clinical professor of dermatology at Mount Sinai School of Medicine, New York (J. Am. Acad. Dermatol. 2002;47:231–40).

"There were over 25 methods for assessing acne severity and 19 methods for counting lesions," he said. "That makes comparing one study to another very difficult."

With a treatment like PDT, the evidence of efficacy in treating acne is strong, but there is the trade-off of the process being a negative experience for the patient.

"Photochemicals [used in PDT] cause cell membrane damage, and with the process there's pain. The outcome may be positive, but this is not a positive event in the life of the patient," Dr. Garden said.

When PDT is used to treat something like cancerous lesions, the process is entirely justified, but as a repetitive treatment for acne, it is far more questionable, he said.

"What we have to ask ourselves is this—do we really want this for our patients? And what's the long-term effect? We don't know," he said. "The approach is new, and at the moment I'm very uncomfortable with this."

And then there is the cost of light-based therapies, which are far more expensive than a medical option. "These are highly expensive cash procedures requiring multiple visits to the office," Dr. Spencer said. "I think light-based therapy for acne represents one more tool in the tool chest, but it's quite unreasonable for it to be the first thing that pops into your head."

Dr. Garden agreed. "It's tempting to have a nonmedical option for treating acne, and this may have a role for those very selective, noncompliant patients," he said.

"But when you look at this and ask if it's something that should be a first-line treatment for patients, the answer should be, unequivocally, no," he asserted. "It's not worth it—not yet."

SDEF and this newspaper are wholly owned subsidiaries of Elsevier.

ANAHEIM, CALIF. — Light-based therapies are heavily promoted as options for treating acne, but issues of cost and convenience should rule them out as a first line of treatment, said dermatologists at a cosmetic dermatology seminar sponsored by the Skin Disease Education Foundation. The market is filling up with dozens of different lasers claiming to help treat acne with wide-ranging treatment mechanisms and even wider-ranging price tags, said Jerome Garden, M.D., of the department of dermatology at Northwestern University in Chicago.

"I found 26 different products out there all claiming they treat acne, and it's very hard to sort all of these out," he said.

Most of the claims are backed by some research—infrared laser treatment, for instance, has some strong studies showing shrinkage of the sebaceous glands; blue light and photodynamic therapy (PDT) are gaining recognition for their efficacy; and radiofrequency devices have shown some success.

But for all of the devices and claims, several confounding factors give dermatologists pause in embracing light-based therapies as a first-line treatment.

First, there is broad inconsistency in the literature. An analysis of acne literature published in the Journal of the American Academy of Dermatology in 2002 underscored the wide-ranging measures used in determining not only outcomes but the very definitions of acne, said James Spencer, M.D., a clinical professor of dermatology at Mount Sinai School of Medicine, New York (J. Am. Acad. Dermatol. 2002;47:231–40).

"There were over 25 methods for assessing acne severity and 19 methods for counting lesions," he said. "That makes comparing one study to another very difficult."

With a treatment like PDT, the evidence of efficacy in treating acne is strong, but there is the trade-off of the process being a negative experience for the patient.

"Photochemicals [used in PDT] cause cell membrane damage, and with the process there's pain. The outcome may be positive, but this is not a positive event in the life of the patient," Dr. Garden said.

When PDT is used to treat something like cancerous lesions, the process is entirely justified, but as a repetitive treatment for acne, it is far more questionable, he said.

"What we have to ask ourselves is this—do we really want this for our patients? And what's the long-term effect? We don't know," he said. "The approach is new, and at the moment I'm very uncomfortable with this."

And then there is the cost of light-based therapies, which are far more expensive than a medical option. "These are highly expensive cash procedures requiring multiple visits to the office," Dr. Spencer said. "I think light-based therapy for acne represents one more tool in the tool chest, but it's quite unreasonable for it to be the first thing that pops into your head."

Dr. Garden agreed. "It's tempting to have a nonmedical option for treating acne, and this may have a role for those very selective, noncompliant patients," he said.

"But when you look at this and ask if it's something that should be a first-line treatment for patients, the answer should be, unequivocally, no," he asserted. "It's not worth it—not yet."

SDEF and this newspaper are wholly owned subsidiaries of Elsevier.