Aesthetic Dermatology

NEW ORLEANS — Nonablative laser therapy for acne doesn't kill Propionibacterium acnes or decrease sebum production but instead appears to work by inducing a rapid and dramatic increase in transforming growth factor beta, Edward Seaton, M.D., and colleagues said in a poster presented at the annual meeting of the American Academy of Dermatology.

"TGF-β is very important anti-inflammatory cytokine that plays a pivotal role in decreasing inflammation and is the first stimulus of neocollagenesis," Dr. Seaton of Hammersmith Hospital, London, said in an interview. "This is the first time a biologic explanation of lasers' effect on acne has been proposed."

Dr. Seaton used nonablative laser therapy on the foreheads of 19 subjects with mild to moderate acne who had received no previous treatment. He took before and after measurements of P. acnes colony count, sebum production, and several cytokines and receptors: interleukin-1 (comedogenic), interleukin-1 receptor antagonist (anticomedogenic), interleukin-10 (anti-inflammatory), tumor necrosis factor (proinflammatory), TGF-βanti-inflammatory), and melanocortin-1 receptor (expressed in healthy sebaceous glands).

Each subject received one session of nonablative laser therapy (wavelength 585 nm, pulse duration 350 msec, 2 J/cm2, spot diameter 7 mm). Cytokine levels were obtained from 4-mm punch biopsies from the buttocks before laser treatment and 3 and 24 hours post treatment.

After 24 hours, there was no decrease in the number of P. acnes colonies on the treated area; in fact, there was a non-statistically significant increase in the number of colonies. There was no significant decrease in the sebum excretion rate at 2, 4, 8, or 24 weeks post treatment.

After 24 hours, there was a fivefold increase in TGF-β but no significant changes in any other cytokine or receptor levels. The TGF-β levels had increased slightly, but nonsignificantly, by 3 hours post therapy.

In addition to inhibiting the inflammatory response, Dr. Seaton said, TGF-βstimulates collagen, proteoglycan, fibronectin, and integrin production and inhibits matrix metalloproteinase-induced collagen degradation. Thus, the benefits of nonablative laser therapy in acne seem similar to those it exerts for photorejuvenation.

"They induce collagen remodeling at the ultrastructural level and increase collagen production," he said. "The molecular mechanism of this is unclear, but it is thought to be secondary to nonlethal dermal wounding."

NEW ORLEANS — Nonablative laser therapy for acne doesn't kill Propionibacterium acnes or decrease sebum production but instead appears to work by inducing a rapid and dramatic increase in transforming growth factor beta, Edward Seaton, M.D., and colleagues said in a poster presented at the annual meeting of the American Academy of Dermatology.

"TGF-β is very important anti-inflammatory cytokine that plays a pivotal role in decreasing inflammation and is the first stimulus of neocollagenesis," Dr. Seaton of Hammersmith Hospital, London, said in an interview. "This is the first time a biologic explanation of lasers' effect on acne has been proposed."

Dr. Seaton used nonablative laser therapy on the foreheads of 19 subjects with mild to moderate acne who had received no previous treatment. He took before and after measurements of P. acnes colony count, sebum production, and several cytokines and receptors: interleukin-1 (comedogenic), interleukin-1 receptor antagonist (anticomedogenic), interleukin-10 (anti-inflammatory), tumor necrosis factor (proinflammatory), TGF-βanti-inflammatory), and melanocortin-1 receptor (expressed in healthy sebaceous glands).

Each subject received one session of nonablative laser therapy (wavelength 585 nm, pulse duration 350 msec, 2 J/cm2, spot diameter 7 mm). Cytokine levels were obtained from 4-mm punch biopsies from the buttocks before laser treatment and 3 and 24 hours post treatment.

After 24 hours, there was no decrease in the number of P. acnes colonies on the treated area; in fact, there was a non-statistically significant increase in the number of colonies. There was no significant decrease in the sebum excretion rate at 2, 4, 8, or 24 weeks post treatment.

After 24 hours, there was a fivefold increase in TGF-β but no significant changes in any other cytokine or receptor levels. The TGF-β levels had increased slightly, but nonsignificantly, by 3 hours post therapy.

In addition to inhibiting the inflammatory response, Dr. Seaton said, TGF-βstimulates collagen, proteoglycan, fibronectin, and integrin production and inhibits matrix metalloproteinase-induced collagen degradation. Thus, the benefits of nonablative laser therapy in acne seem similar to those it exerts for photorejuvenation.

"They induce collagen remodeling at the ultrastructural level and increase collagen production," he said. "The molecular mechanism of this is unclear, but it is thought to be secondary to nonlethal dermal wounding."

NEW ORLEANS — Nonablative laser therapy for acne doesn't kill Propionibacterium acnes or decrease sebum production but instead appears to work by inducing a rapid and dramatic increase in transforming growth factor beta, Edward Seaton, M.D., and colleagues said in a poster presented at the annual meeting of the American Academy of Dermatology.

"TGF-β is very important anti-inflammatory cytokine that plays a pivotal role in decreasing inflammation and is the first stimulus of neocollagenesis," Dr. Seaton of Hammersmith Hospital, London, said in an interview. "This is the first time a biologic explanation of lasers' effect on acne has been proposed."

Dr. Seaton used nonablative laser therapy on the foreheads of 19 subjects with mild to moderate acne who had received no previous treatment. He took before and after measurements of P. acnes colony count, sebum production, and several cytokines and receptors: interleukin-1 (comedogenic), interleukin-1 receptor antagonist (anticomedogenic), interleukin-10 (anti-inflammatory), tumor necrosis factor (proinflammatory), TGF-βanti-inflammatory), and melanocortin-1 receptor (expressed in healthy sebaceous glands).

Each subject received one session of nonablative laser therapy (wavelength 585 nm, pulse duration 350 msec, 2 J/cm2, spot diameter 7 mm). Cytokine levels were obtained from 4-mm punch biopsies from the buttocks before laser treatment and 3 and 24 hours post treatment.

After 24 hours, there was no decrease in the number of P. acnes colonies on the treated area; in fact, there was a non-statistically significant increase in the number of colonies. There was no significant decrease in the sebum excretion rate at 2, 4, 8, or 24 weeks post treatment.

After 24 hours, there was a fivefold increase in TGF-β but no significant changes in any other cytokine or receptor levels. The TGF-β levels had increased slightly, but nonsignificantly, by 3 hours post therapy.

In addition to inhibiting the inflammatory response, Dr. Seaton said, TGF-βstimulates collagen, proteoglycan, fibronectin, and integrin production and inhibits matrix metalloproteinase-induced collagen degradation. Thus, the benefits of nonablative laser therapy in acne seem similar to those it exerts for photorejuvenation.

"They induce collagen remodeling at the ultrastructural level and increase collagen production," he said. "The molecular mechanism of this is unclear, but it is thought to be secondary to nonlethal dermal wounding."

NEW ORLEANS — The pulsed dye lasers 585 nm and 595 nm are equally effective in surgical-scar ablation, Maria P. Rivas, M.D., reported at the annual meeting of the American Academy of Dermatology.

Although there were no significant histologic or clinical differences between the treated sites, the sites treated with the lower-fluence laser showed slightly more elastic fibers and slight advantages in pliability, vascularity, and scar height, said Dr. Rivas of the department of dermatology and cutaneous surgery at the University of Miami.

She and her colleagues examined outcomes on 19 linear postsurgical scars greater than 3 cm; the scars occurred on 14 patients aged 18-85 years. Their skin types were I-IV. A blinded examiner evaluated the scars on suture-removal day and after treatment using the Vancouver Scar Scale, which assesses pigmentation, vascularity, pliability, and height. The investigators also rated the scars for cosmetic appearance using a cosmetic visual-analog scale.

Each scar was divided into three equal segments. The center segment was left untreated, and the outer segments were randomized to treatment with either pulsed dye laser (PDL) 585 nm or 595 nm (10-mm spot size, 3.5 J/cm2).

Each scar was treated once a month for 3 months, and final assessment was made 1 month after series completion.

At that time, sites treated with the 585-nm PDL showed slightly more elastic fibers on histology than did sites treated with the 595-nm PDL.

All treated sites showed a greater improvement than control sites on the Vancouver Scar Scale. The control sites showed an average 32% improvement, the 595-nm sites showed an average 55% improvement, and the 585-nm sites showed and average 67% improvement. The difference between the treated sites was not statistically significant.

All the Vancouver Scar Scale parameters were more improved on the treated sites than on the control sites, with vascularity and pliability showing the greatest improvements. All treated sites scored significantly higher than the untreated sites on the cosmetic visual-analog scale. Again, the 585-nm sites score slightly higher than the 595-nm sites, but not significantly so.

Comparison of efficacy of 585-nm vs. 595-nm pulsed dye laser on treating surgical scars is shown on suture removal day. Courtesy Dr. Maria P. Rivas

NEW ORLEANS — The pulsed dye lasers 585 nm and 595 nm are equally effective in surgical-scar ablation, Maria P. Rivas, M.D., reported at the annual meeting of the American Academy of Dermatology.

Although there were no significant histologic or clinical differences between the treated sites, the sites treated with the lower-fluence laser showed slightly more elastic fibers and slight advantages in pliability, vascularity, and scar height, said Dr. Rivas of the department of dermatology and cutaneous surgery at the University of Miami.

She and her colleagues examined outcomes on 19 linear postsurgical scars greater than 3 cm; the scars occurred on 14 patients aged 18-85 years. Their skin types were I-IV. A blinded examiner evaluated the scars on suture-removal day and after treatment using the Vancouver Scar Scale, which assesses pigmentation, vascularity, pliability, and height. The investigators also rated the scars for cosmetic appearance using a cosmetic visual-analog scale.

Each scar was divided into three equal segments. The center segment was left untreated, and the outer segments were randomized to treatment with either pulsed dye laser (PDL) 585 nm or 595 nm (10-mm spot size, 3.5 J/cm2).

Each scar was treated once a month for 3 months, and final assessment was made 1 month after series completion.

At that time, sites treated with the 585-nm PDL showed slightly more elastic fibers on histology than did sites treated with the 595-nm PDL.

All treated sites showed a greater improvement than control sites on the Vancouver Scar Scale. The control sites showed an average 32% improvement, the 595-nm sites showed an average 55% improvement, and the 585-nm sites showed and average 67% improvement. The difference between the treated sites was not statistically significant.

All the Vancouver Scar Scale parameters were more improved on the treated sites than on the control sites, with vascularity and pliability showing the greatest improvements. All treated sites scored significantly higher than the untreated sites on the cosmetic visual-analog scale. Again, the 585-nm sites score slightly higher than the 595-nm sites, but not significantly so.

Comparison of efficacy of 585-nm vs. 595-nm pulsed dye laser on treating surgical scars is shown on suture removal day. Courtesy Dr. Maria P. Rivas

NEW ORLEANS — The pulsed dye lasers 585 nm and 595 nm are equally effective in surgical-scar ablation, Maria P. Rivas, M.D., reported at the annual meeting of the American Academy of Dermatology.

Although there were no significant histologic or clinical differences between the treated sites, the sites treated with the lower-fluence laser showed slightly more elastic fibers and slight advantages in pliability, vascularity, and scar height, said Dr. Rivas of the department of dermatology and cutaneous surgery at the University of Miami.

She and her colleagues examined outcomes on 19 linear postsurgical scars greater than 3 cm; the scars occurred on 14 patients aged 18-85 years. Their skin types were I-IV. A blinded examiner evaluated the scars on suture-removal day and after treatment using the Vancouver Scar Scale, which assesses pigmentation, vascularity, pliability, and height. The investigators also rated the scars for cosmetic appearance using a cosmetic visual-analog scale.

Each scar was divided into three equal segments. The center segment was left untreated, and the outer segments were randomized to treatment with either pulsed dye laser (PDL) 585 nm or 595 nm (10-mm spot size, 3.5 J/cm2).

Each scar was treated once a month for 3 months, and final assessment was made 1 month after series completion.

At that time, sites treated with the 585-nm PDL showed slightly more elastic fibers on histology than did sites treated with the 595-nm PDL.

All treated sites showed a greater improvement than control sites on the Vancouver Scar Scale. The control sites showed an average 32% improvement, the 595-nm sites showed an average 55% improvement, and the 585-nm sites showed and average 67% improvement. The difference between the treated sites was not statistically significant.

All the Vancouver Scar Scale parameters were more improved on the treated sites than on the control sites, with vascularity and pliability showing the greatest improvements. All treated sites scored significantly higher than the untreated sites on the cosmetic visual-analog scale. Again, the 585-nm sites score slightly higher than the 595-nm sites, but not significantly so.

Comparison of efficacy of 585-nm vs. 595-nm pulsed dye laser on treating surgical scars is shown on suture removal day. Courtesy Dr. Maria P. Rivas

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

MONTEREY, CALIF. — Nail surgery can be fun, and dermatologists are perfectly positioned to offer this treatment to patients, Dr. Stuart J. Salasche said at the annual meeting of the California Society of Dermatology and Dermatologic Surgery.

"The hand surgeons don't want nail surgery, and the plastics people don't want nail surgery, so it's ours," said Dr. Salasche of the University of Arizona Health Sciences Center, Tucson. He offered several pearls that reflect his years of experience:

▸ When a finger injury causes a hematoma, the blood normally collects under the proximal portion of the nail plate, where it's loose, and cannot progress further up the nail bed. A simple way of treating this short term is just to unfold a paper clip and heat the end. Touch the heated end to the nail plate and it sizzles right through, releasing the hematoma.

▸ Similarly, with acute paronychia, which is often caused by a staph infection, take a No. 11 blade and insert it into the lateral nail fold, releasing the pressure. "Generally a patient feels relief immediately," Dr. Salasche said.

▸ For more complex surgeries, such as nail avulsions and matricectomies, Dr. Salasche has two favorite instruments. The Freer septum elevator is critical in both proximal and distal approaches to nail avulsion. The English nail splitter is useful for partial nail avulsions. It has an anvil-like undersurface that slides between the nail bed and the nail plate and a scissorlike upper portion for cutting through the nail plate.

▸ For anesthesia, most nail surgery requires a nerve block, then a distal block, followed by a local injection. The dorsal digital nerve and the proper palmar digital nerve run along the lateral portion of the finger. Dr. Salasche injects about 1 cc of 2% lidocaine (without epinephrine and using a 30-gauge needle) into the medial side of the finger above the metacarpophalangeal joint. "I don't go down to the bone, and I don't march around," he said. "I just inject slowly until I balloon up the area and let the anesthetic diffuse down to the nerves. It's much less dangerous that way." After 10 minutes he uses the same needle to inject into the proximal lateral nail fold area. Once again waiting until the patient is comfortable, he then injects a local anesthetic into the distal area. This injection contains epinephrine to promote local vasoconstriction.

▸ Both distal and proximal approaches are possible for nail avulsion, depending on the patient. For the distal approach Dr. Salasche inserts the septum elevator under the nail tip, which takes some force. He pushes the elevator proximally as well as up underneath the nail plate to avoid digging down into the nail bed. When the elevator reaches the matrix, the force required will suddenly decrease, and the physician should take care not to jam the instrument back into the cul de sac of the proximal nail groove. Then the physician could either rock the elevator back and forth to loosen the rest of the nail or remove the elevator and reinsert it. Dr. Salasche prefers the latter technique because rocking the elevator back and forth tends to cause bleeding. After he has inserted the elevator several times, he uses the elevator on the nail plate's proximal edge to go back underneath the cuticle into the proximal nail fold, loosening any attachments back there. Then it's possible to grasp the nail with a hemostat and pull it off, snipping any remaining small attachments with a pair of scissors.

▸ If the patient's nail is so damaged that it has no distal free edge to get underneath, it's better to use a proximal approach. Take the septum elevator and come up underneath the proximal nail fold. Fulcrum this over to get underneath the newly developing nail and then run it out and up. There's a danger that one could damage the nail bed, so it's important to direct the elevator both distal and up underneath the surface of the nail bed.

▸ Ingrown nails respond well to a partial nail avulsion followed by a partial matricectomy. After removing the portion of the nail that's ingrowing, Dr. Salasche uses phenol to destroy the part of the nail matrix responsible for generating that part of the nail. He likes to make his own cotton-tip applicator by taking a sturdy, double-pointed toothpick and twisting some cotton around the top. It's important to use fresh, full-strength (88%) phenol. He dips the applicator into the bottle of phenol, removes excess liquid by holding it against the side of the bottle, and then applies it directly to the matrix, where he leaves it in place, rotating it for about 30 seconds.

MIAMI BEACH — Modern-day hair transplantation yields high patient satisfaction and a low risk of side effects, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Dermatologists who offer hair transplantation must battle the legacy of poor techniques and suboptimal outcomes from previous techniques. With more advances in technology, donor hair density is the only limiting factor, said Marc R. Avram, M.D., of the department of dermatology, Weill Cornell Medical Center, New York.

Even though consistent, natural-looking results are now the rule rather than the exception, practical tips can help optimize outcomes. Dr. Avram recommends using polarized light with magnification for both donor and recipient zones. Other keys to success include thorough staff training and good office ergonomics because the work is labor intensive. Dr. Avram said it takes three to five assistants 40-60 minutes to create 1,000-1,500 follicular grafts. Each graft unit consists of one to four hair follicles.

Physicians employ elliptical donor harvesting for more than 95% of patients. An elliptical donor strip of hair is taken from the back of the scalp. The width of the ellipse should be no greater than 1 cm and should be longer rather than wider, Dr. Avram said. Exercise care when working on the area behind the ears and below the occipital protuberance because of higher risk of broad or hypertrophy scarring. Place the blade into subcutaneous tissue and check the angle of the blade every 2-3 cm to monitor transaction of hair follicles; the angle of hair follicles can change across the back of the scalp, he added. Undermine the graft only if necessary.

Less common is 1.25-1.5 mm punch harvesting. Fewer than 5% of patients are potential candidates. People with limited hair loss in the recipient site (from a trauma or scar) or those with limited donor tissue because of a history of multiple surgeries are typical candidates for this technique.

Patients can resume normal activities immediately after the procedure but should avoid heavy exercise for 1 week. Patients are instructed to wear an overnight dressing and take oral antibiotics for 5 days. Dr. Avram also prescribes Tylenol 3, one to two tablets every 4-6 hours as needed and instructs patients to call if pain or discomfort persists beyond the first night. He also typically prescribes prednisone 40 mg to be taken for 3 consecutive days.

Special considerations for women undergoing hair transplantation include an increased risk of telogen effluvium and a more unpredictable donor region. All three hairlines—the frontal, temporal, and posterior—generally remain intact in women. So the goal of hair transplantation in this population is to increase hair density within these stable hairlines.

The future of hair transplantation will feature improved instrumentation, robotics, and cloning, Dr. Avram said. For example, lasers will be able to separate one to three hair grafts with zero transection. Robotics may assist implantation. And if hair cloning becomes a reality, it will alleviate the limiting factor of donor hair density.

MIAMI BEACH — Modern-day hair transplantation yields high patient satisfaction and a low risk of side effects, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Dermatologists who offer hair transplantation must battle the legacy of poor techniques and suboptimal outcomes from previous techniques. With more advances in technology, donor hair density is the only limiting factor, said Marc R. Avram, M.D., of the department of dermatology, Weill Cornell Medical Center, New York.

Even though consistent, natural-looking results are now the rule rather than the exception, practical tips can help optimize outcomes. Dr. Avram recommends using polarized light with magnification for both donor and recipient zones. Other keys to success include thorough staff training and good office ergonomics because the work is labor intensive. Dr. Avram said it takes three to five assistants 40-60 minutes to create 1,000-1,500 follicular grafts. Each graft unit consists of one to four hair follicles.

Physicians employ elliptical donor harvesting for more than 95% of patients. An elliptical donor strip of hair is taken from the back of the scalp. The width of the ellipse should be no greater than 1 cm and should be longer rather than wider, Dr. Avram said. Exercise care when working on the area behind the ears and below the occipital protuberance because of higher risk of broad or hypertrophy scarring. Place the blade into subcutaneous tissue and check the angle of the blade every 2-3 cm to monitor transaction of hair follicles; the angle of hair follicles can change across the back of the scalp, he added. Undermine the graft only if necessary.

Less common is 1.25-1.5 mm punch harvesting. Fewer than 5% of patients are potential candidates. People with limited hair loss in the recipient site (from a trauma or scar) or those with limited donor tissue because of a history of multiple surgeries are typical candidates for this technique.

Patients can resume normal activities immediately after the procedure but should avoid heavy exercise for 1 week. Patients are instructed to wear an overnight dressing and take oral antibiotics for 5 days. Dr. Avram also prescribes Tylenol 3, one to two tablets every 4-6 hours as needed and instructs patients to call if pain or discomfort persists beyond the first night. He also typically prescribes prednisone 40 mg to be taken for 3 consecutive days.

Special considerations for women undergoing hair transplantation include an increased risk of telogen effluvium and a more unpredictable donor region. All three hairlines—the frontal, temporal, and posterior—generally remain intact in women. So the goal of hair transplantation in this population is to increase hair density within these stable hairlines.

The future of hair transplantation will feature improved instrumentation, robotics, and cloning, Dr. Avram said. For example, lasers will be able to separate one to three hair grafts with zero transection. Robotics may assist implantation. And if hair cloning becomes a reality, it will alleviate the limiting factor of donor hair density.

MIAMI BEACH — Modern-day hair transplantation yields high patient satisfaction and a low risk of side effects, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Dermatologists who offer hair transplantation must battle the legacy of poor techniques and suboptimal outcomes from previous techniques. With more advances in technology, donor hair density is the only limiting factor, said Marc R. Avram, M.D., of the department of dermatology, Weill Cornell Medical Center, New York.

Even though consistent, natural-looking results are now the rule rather than the exception, practical tips can help optimize outcomes. Dr. Avram recommends using polarized light with magnification for both donor and recipient zones. Other keys to success include thorough staff training and good office ergonomics because the work is labor intensive. Dr. Avram said it takes three to five assistants 40-60 minutes to create 1,000-1,500 follicular grafts. Each graft unit consists of one to four hair follicles.

Physicians employ elliptical donor harvesting for more than 95% of patients. An elliptical donor strip of hair is taken from the back of the scalp. The width of the ellipse should be no greater than 1 cm and should be longer rather than wider, Dr. Avram said. Exercise care when working on the area behind the ears and below the occipital protuberance because of higher risk of broad or hypertrophy scarring. Place the blade into subcutaneous tissue and check the angle of the blade every 2-3 cm to monitor transaction of hair follicles; the angle of hair follicles can change across the back of the scalp, he added. Undermine the graft only if necessary.

Less common is 1.25-1.5 mm punch harvesting. Fewer than 5% of patients are potential candidates. People with limited hair loss in the recipient site (from a trauma or scar) or those with limited donor tissue because of a history of multiple surgeries are typical candidates for this technique.

Patients can resume normal activities immediately after the procedure but should avoid heavy exercise for 1 week. Patients are instructed to wear an overnight dressing and take oral antibiotics for 5 days. Dr. Avram also prescribes Tylenol 3, one to two tablets every 4-6 hours as needed and instructs patients to call if pain or discomfort persists beyond the first night. He also typically prescribes prednisone 40 mg to be taken for 3 consecutive days.

Special considerations for women undergoing hair transplantation include an increased risk of telogen effluvium and a more unpredictable donor region. All three hairlines—the frontal, temporal, and posterior—generally remain intact in women. So the goal of hair transplantation in this population is to increase hair density within these stable hairlines.

The future of hair transplantation will feature improved instrumentation, robotics, and cloning, Dr. Avram said. For example, lasers will be able to separate one to three hair grafts with zero transection. Robotics may assist implantation. And if hair cloning becomes a reality, it will alleviate the limiting factor of donor hair density.

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

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

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

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

SCOTTSDALE, ARIZ. — Radiofrequency tissue tightening using Thermage's ThermaCool TC system has gained favor for wrinkle reduction with the standard use of a single pass of the device, but better results and greater tolerance are seen with a multiple-passes approach using reduced treatment-level settings, said Bill H. Halmi, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

The ThermaCool system, which has received Food and Drug Administration approval for smoothing wrinkles and sagging skin around the face, has yielded only modest results, and subtle changes were often not even noticeable, said Dr. Halmi, a dermatologist and owner of Arizona Advanced Dermatology in Phoenix.

Furthermore, the treatment was not without some discomfort, and early safety observations showed a 6% rate of scarring or texture change 6 months post treatment.

In a new technique introduced last year by Brian Zelickson, M.D., however, use of multiple passes in a single treatment with lower frequency showed the achievement of greater deep-collagen denaturation. In addition, the already rare risk of surface tissue damage was further decreased, as was patient discomfort.

Dermatologists including Dr. Halmi have picked up on the multiple-passes approach and report much improved results. "The newer treatment paradigm is much better tolerated, reduces the risks, and appears so far to offer better results," Dr. Halmi said.

With the multiple-passes approach, frequency should be reduced and as many as four or five passes can be used. "One pass is made over the entire surface area, then on the second pass you concentrate on the areas of interest, and you can go on to four or five passes on the face to reach a clinical point of physical tightening," Dr. Halmi said.

Since there is immediate collagen contraction, visible results are seen right away, but this response usually lasts only a matter of hours or days. It typically takes about 2 months, however, to see the maximum results of the more important secondary response showing collagen remodeling and tightening.

While radiofrequency (RF) waves have long been used in dermatology for purposes such as electrocoagulation and skin resurfacing, the ThermaCool system is unique in that it uses a patented capacitive coupling to give greater uniformity in heating and tightening deeper tissue, Dr. Halmi explained.

The device also uses cooling before, during, and after the delivery of the RF energy to protect the epidermis.

Slides presented from Dr. Halmi's practice showed dramatic improvement in areas including the nasolabial fold, the jowls, and especially the neck.

"It turns out neck tightening is probably the area this [treatment] does the best in," Dr. Halmi said. "Using the 'traditional' protocol of one pass usually achieves at least subtle results, but multiple passes appear to be yielding much better results."

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

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Tissue removal during traditional blepharoplasty is often a counterproductive approach, Robert Alan Goldberg, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Deflation caused by the progressive loss of subcutaneous, deep, and periorbital fat is the most important part of orbital aging, he added. And the solution is to add volume, which can be done several ways.

"Certainly removing tissue has its value," said Dr. Goldberg of the Jules Stein Eye Institute at the University of California, Los Angeles. "It helps us amortize our investment in surgical instruments, it's predictable, and it's technically straightforward. Compare that to adding volume. Adding volume is more difficult from a technical standpoint. It's less predictable with current technologies. And I'm only half kidding when I say that it renders scissors and scalpel obsolete. A lot of physicians have an emotional investment in surgery."

While patients often complain of excess skin around the upper and lower eyelids, Dr. Goldberg says he believes in most cases the body is not making new tissue. What is happening is a loss of elasticity, which can be addressed by resurfacing and other skin-rejuvenation techniques.

Traditional blepharoplasty often results in an aging—not rejuvenation—of the periorbital area, as it tends to emphasize hollows that result from the loss of fat.

"In the paradigm of removing tissue, we study the face for evidence of fullness, and I'm not arguing there's no role for that," Dr. Goldberg said. "But there's another paradigm of adding tissue in which we look for hollows."

In the lower periorbital region, Dr. Goldberg has identified three hollows. One he calls the "orbital rim hollow," along the bony rim. Then there is the "septal confluence hollow" at the edge of the orbicularis muscle. Finally the "zygomatic hollow" runs along the zygomatic ligament.

The upper eyelid also is characterized by hollows. "What I see is deflation of that eyebrow fat pad," Dr. Goldberg said. "If you thought of this as a breast with breast ptosis, it's become flattened, and it's sagging. It's the same principle."

Several techniques may fill those hollows:

▸ Fat injections. For years, Dr. Goldberg's favorite technique was fat injections. "Although the periorbital area can be tricky, with some skill and a reasonable amount of luck you can get a pretty smooth improvement there," Dr. Goldberg said. "But when it doesn't work, it's difficult. Fat can really be lumpy and granulomatous."

▸ Fat transfer. For the lower periorbital area, Dr. Goldberg often releases the orbital fat surgically and uses it to fill the orbital rim hollow. He uses a transconjunctival subperiosteal approach. This technique seems to work particularly well in patients who truly have an anterior projection in the bags under their eyes.

With the upper eyelid, Dr. Goldberg uses what he calls an "eyebrow brassiere suture." The concept is to fixate the inferior edge of the eyebrow fat pad, lifting and filling the pad in three dimensions. "This is not a brow-lifting suture," he said. "What we're doing is stabilizing the brow in three dimensions, trying to refill the brow fat pad and recreate that beautiful full convexity of youth."

▸ Implants. This technique, which is both safe and effective, has a role, especially in cases of severe hollowness.

▸ Synthetic fillers. In many cases synthetic fillers are best, Dr. Goldberg said. He particularly likes the hyaluronic acid gels because they're very forgiving. (Dr. Goldberg serves on the scientific advisory board of Medicis Pharmaceutical Corp., which makes Restylane.)

The injection technique must respect the delicate anatomy of the periorbital region. Dr. Goldberg uses a multiple-injection feathering technique for the lower periorbital region, trying to place the filler below the orbicularis but above the bony orbital rim. He uses a series of fanning passes, often injecting as many as 100 times. "The key is to get a very soft, even, feathered distribution. Any lump shows up like the princess and the pea," he said.

These injections last 6 months, after which a patient needs a repeat procedure."I think that's one of the beauties of this whole paradigm," he said."The fact that it's not permanent is part of its beauty both for the patient and the … physician."

The key, though, is to make the paradigm shift from looking for excess tissue to analyzing facial hollows. This paradigm, he says, is safer, more effective, and less destructive of tissue. And, compared with traditional blepharoplasty, it allows the physician to do a better job of facial rejuvenation using a minimally invasive approach.

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

SAN DIEGO — Temporalis grafts, performed at the same time as endoscopic brow lifts, can reduce residual glabellar furrows, Allan E. Wulc, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Of the 78 patients who received such grafts and who were followed for 6 months to 3 years, 100% were judged by an independent observer to be "improved," and in 80% the results were "good."

A total of 20% of the patients still had some residual furrowing, and 22.5% returned for Botox (botulinum toxin type A) treatments, said Dr. Wulc, an ophthalmologist and plastic surgeon in private practice in Abington, Pa.

In contrast, Dr. Wulc estimated that 48% of his patients who underwent technically successful endoscopic brow lifting without additional temporalis grafts required further Botox treatments for glabellar furrows.

The procedure involves first harvesting temporalis fascia at the temporal incision site for the endoscopic brow lift. After incisions in two locations with a No. 11 blade, Dr. Wulc explained that he subcises the glabellar furrow with an 18-gauge needle.

Early in his development of this procedure, Dr. Wulc discovered that simply entering with the 18-gauge needle and subcising without the prior incisions can result in a depressed scar.

After the subcision, Dr. Wulc inserts the graft with a 0.3-mm or 0.5-mm Castroviejo forceps. Then he said he puts in a single 6-0 Prolene suture to control scarring. He then removes the suture 1-2 days later.

A dermis graft works as well as a temporalis graft, he said, especially when the procedure is done separately from an endoscopic brow lift.

Dr. Wulc cautioned that it is important to harvest dermis from a non-hair-bearing area of the patient's body or the patients will start growing hair under their skin.

Another possibility is that the surgeon can use filler material instead of the temporalis graft. "I think that the way [subcision] works is by denuding the underlying dermis from its attachment," thereby preventing muscular readhesion, Dr. Wulc said.

"The temporalis functions as a useful spacer, and the dermal-subdermal pocket is filled. It's possible that you could use a filler … and maybe get the same effect without going to the trouble of getting a temporalis graft. On the other hand, I'm there [at the temporalis for the endoscopic brow lift], so it's an easy thing to do at the same time."

Among the 78 patients, 7 reportedly complained of palpable lumps, and 1 patient had an infection that required antibiotics.

Bilateral brow ptosis is shown at baseline and 6 months after endoscopic brow lifting with subcision of glabellar furrows and insertion of temporalis grafts. Photos courtesy Dr. Allan E. Wulc

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

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

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

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

SCOTTSDALE, ARIZ. — The tissue adhesive Dermabond has gained popularity, especially in pediatric and emergency settings, because of its short application time and improved cosmesis over older adhesives, and despite its limitations, the product has many uses, said Bari Cunningham, M.D., at a meeting sponsored by the Skin Disease Education Foundation.

Although studies have shown that Dermabond offers no significant improvement in cosmesis over traditional suturing, its benefits are reflected in substantially higher pain scores and shorter procedure time, which have made the product ideal in emergency department and pediatric settings (JAMA 1997;277:1527-30; J. Pediatr. 1998;132:1067-70).

"It's a few seconds versus the time it takes for stitches—which with children can take upward of half an hour. So the benefit is obvious," said Dr. Cunningham of Children's Hospital, San Diego, and the University of California, San Diego.

Another advantage of Dermabond over suturing is that a follow-up visit is not needed, which is convenient for patients needing to travel a long distance. In addition, wounds treated with Dermabond can withstand wetness, which is indispensable for patients who want to swim.

Dermabond's maker, Ethicon Inc., says the product seals out most infection-causing bacteria, such as certain staph, pseudomonas, and Escherichia coli. Although it's not yet certain whether that will translate into fewer postop infections, the possible antibacterial properties are intriguing, Dr. Cunningham said.

Dermabond is a relatively new tissue adhesive about three times as strong as the old cyanoacrylates, which were too weak for widespread use and tended to be brittle and prone to cracking, Dr. Cunningham said.

The product has evolved in response to dermatologists' preferences, with newer formulations being more viscous and featuring better applicator tips.

Most studies that have shown benefits to Dermabond looked at uses in incisional surgery, whereas a majority of dermatologists work more with excisional surgery. To determine the adhesive's benefits in that context, Dr. Cunningham and her colleagues conducted a study comparing suturing with tissue adhesive. In a 2-month follow-up, they found significantly better cosmesis with suturing than with the skin glue (Arch. Derm. 2001;137:1177-80).

The adhesive is ideal for incisions such as low-tension closures for cysts but is not appropriate for high-tension areas. She urged care in the eye area; there have been cases of doctors accidentally gluing a patient's eye shut. In such instances, avoid trying to pry the eye open or using water, which can make the situation worse. Instead, apply a petrolatum-based product to gently ease the eye open.

In addition to Dermabond's inappropriateness for high-tension areas, another disadvantage is that the adhesive doesn't obviate sutures altogether, because subcutaneous sutures are still required.

And then there's the price; at about $30 a vial, some question whether Dermabond is worth the cost. But, Dr. Cunningham argued, "if you factor in the cost of time taken for a postoperative visit, suture removal, and nursing, it is often more cost effective to use the Dermabond."

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

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

MIAMI BEACH — Demanding cosmetic dermatology patients who are never satisfied might have underlying psychiatric conditions to identify and treat, according to a presentation at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

In addition to body dysmorphic disorder, "difficult" cosmetic patients can have narcissistic personality disorder or histrionic personality disorder, or they can be "self-destructive deniers," said Eva C. Ritvo, M.D. Also possible are mood disorders, anxiety disorders, and substance abuse issues.

Certain red flags can help identify such patients. Dermatologists should be wary of people with unrealistic expectations or a history of numerous procedures. Other warning signs include routinely complaining about previous procedures or other providers, calling or visiting an office excessively, or spending money they do not have for cosmetic enhancement.

Take a careful history, get to know the patient, and be explicit about the plan and expected results, suggested Dr. Ritvo, chief of the department of psychiatry at Mount Sinai Medical Center, Miami Beach.

Take before and after photographs, and have the patient sign a written contract, she added.

"Think like a shrink," Dr. Ritvo said. Dermatologists should be aware of their reactions and check the emotions that arise when they deal with challenging patients, Dr. Ritvo suggested.

If possible, use the "24-hour rule." If a patient calls a few days after a procedure to complain about the outcome, tell him or her to come in the next day to discuss any concerns, Dr. Ritvo said. This delay allows a physician time to approach the patient more objectively and not act on impulse.

Dr. Ritvo highlighted some common underlying psychiatric conditions in these patients:

▸ Body dysmorphic disorder. Patients with this disorder become preoccupied with an imaginary defect in their appearance or excessively concerned with a slight anomaly. The preoccupation causes significant distress or impairs functioning. The disorder usually begins during adolescence, and diagnosis often takes years. Contrary to the common perception, Dr. Ritvo said, the disorder is equally prevalent in women and men.

Do not perform inappropriate procedures in these patients, Dr. Ritvo emphasized. Instead, refer them to a mental health professional. She suggested that you say, "I would like you to see a colleague of mine before we proceed."

▸ Narcissistic personality disorder. Patients with this disorder are grandiose, seek admiration, and have fragile self-esteem. They can be preoccupied with fantasies of personal beauty, and although frequently dissatisfied, continuously return to the cosmetic dermatologist's office.

"These patients are the entitled demanders," Dr. Ritvo said. They might call and demand an immediate appointment because their botulinum toxin type A is wearing off, for example.

Do not attack them, and never disparage their feelings. Instead, acknowledge their right to good health care, and try to restore their sense of control, Dr. Ritvo suggested. Involve the person's family. Review realistic expectations, and set limits. If you refer them, make sure you document the reason carefully, she suggested.

▸ Histrionic personality disorder. Patients with histrionic personality disorder have a pervasive pattern of excessive emotionality and attention seeking. Some display inappropriate, sexually seductive behaviors. Others refer to doctors by their first names. Make the diagnosis, communicate clearly and carefully, and review expectations, Dr. Ritvo suggested. Document everything, and stay alert for shifting moods in these patients.

▸ Self-destructive deniers. These patients include smokers, drinkers, sun abusers, skin pickers, and drug seekers, Dr. Ritvo said. They are noncompliant, at a high risk for complications, and generally "out of control."

Avoid being judgmental or punitive, Dr. Ritvo suggested. Remember the disease model for addiction. Set clear, realistic goals with the patient, and do not be seduced by their stories. Do not perform unnecessary cosmetic procedures, and consider a psychiatric consultation.

ST. LOUIS — Beware of the patient who considers liposuction just another type of "extreme makeover," Richard L. Schloemer, M.D., said at the World Congress on Liposuction Surgery.

"You cannot stress enough that liposuction is a major operation, and that if not done right it can lead to deformity, major complications, and death," he said.

Liposuction is not for weight loss, though it can contribute to an overall weight loss plan. It's absolutely essential that patients lower their body mass index one level before surgery, and that they maintain a diet afterward, said Dr. Schloemer, a surgeon in private practice in Troy, Ala. "I recommend the 'no white diet.' If it's white, don't eat it—potatoes, bread, rice, dairy products," he said at the congress, sponsored by the American Academy of Cosmetic Surgery.

Informed consent is vital. "You can't give a person too much information, and even when you do, you'd be surprised at how little they retain," he said. For example, one of his patients ignored instructions and took a soapy whirlpool bath 4 hours post procedure, and then spent 3 days in the hospital with a soap burn.

Preventing hypothermia is another important consideration. A cold operating room, cold solutions, and sedation can contribute to severe shaking.

But never use electric heating pads, he said. That practice resulted in a third-degree burn requiring a skin graft in one of his patients. "A heating pad that may fluctuate to greater than 100° F, and a wet solution in a numb patient can be a terrible combination. You have to warm the room and the solutions even if it is uncomfortable for you," Dr. Schloemer said.

Given the availability of tumescent anesthesia and intravenous sedation, general anesthesia is simply not necessary for liposuction. It's generally advisable to keep the lidocaine dose at 50 mg/kg or below to prevent toxicity, however.

"At the end of the procedure, have the patient stand up so you can assess the effects of gravity and ensure symmetry," he said. "Finally, don't promise too much, and remember that liposuction isn't for everyone. Declining to operate often shows good judgment and gains patient respect," he said.

ST. LOUIS — Beware of the patient who considers liposuction just another type of "extreme makeover," Richard L. Schloemer, M.D., said at the World Congress on Liposuction Surgery.

"You cannot stress enough that liposuction is a major operation, and that if not done right it can lead to deformity, major complications, and death," he said.

Liposuction is not for weight loss, though it can contribute to an overall weight loss plan. It's absolutely essential that patients lower their body mass index one level before surgery, and that they maintain a diet afterward, said Dr. Schloemer, a surgeon in private practice in Troy, Ala. "I recommend the 'no white diet.' If it's white, don't eat it—potatoes, bread, rice, dairy products," he said at the congress, sponsored by the American Academy of Cosmetic Surgery.

Informed consent is vital. "You can't give a person too much information, and even when you do, you'd be surprised at how little they retain," he said. For example, one of his patients ignored instructions and took a soapy whirlpool bath 4 hours post procedure, and then spent 3 days in the hospital with a soap burn.

Preventing hypothermia is another important consideration. A cold operating room, cold solutions, and sedation can contribute to severe shaking.

But never use electric heating pads, he said. That practice resulted in a third-degree burn requiring a skin graft in one of his patients. "A heating pad that may fluctuate to greater than 100° F, and a wet solution in a numb patient can be a terrible combination. You have to warm the room and the solutions even if it is uncomfortable for you," Dr. Schloemer said.

Given the availability of tumescent anesthesia and intravenous sedation, general anesthesia is simply not necessary for liposuction. It's generally advisable to keep the lidocaine dose at 50 mg/kg or below to prevent toxicity, however.

"At the end of the procedure, have the patient stand up so you can assess the effects of gravity and ensure symmetry," he said. "Finally, don't promise too much, and remember that liposuction isn't for everyone. Declining to operate often shows good judgment and gains patient respect," he said.

ST. LOUIS — Beware of the patient who considers liposuction just another type of "extreme makeover," Richard L. Schloemer, M.D., said at the World Congress on Liposuction Surgery.

"You cannot stress enough that liposuction is a major operation, and that if not done right it can lead to deformity, major complications, and death," he said.

Liposuction is not for weight loss, though it can contribute to an overall weight loss plan. It's absolutely essential that patients lower their body mass index one level before surgery, and that they maintain a diet afterward, said Dr. Schloemer, a surgeon in private practice in Troy, Ala. "I recommend the 'no white diet.' If it's white, don't eat it—potatoes, bread, rice, dairy products," he said at the congress, sponsored by the American Academy of Cosmetic Surgery.

Informed consent is vital. "You can't give a person too much information, and even when you do, you'd be surprised at how little they retain," he said. For example, one of his patients ignored instructions and took a soapy whirlpool bath 4 hours post procedure, and then spent 3 days in the hospital with a soap burn.

Preventing hypothermia is another important consideration. A cold operating room, cold solutions, and sedation can contribute to severe shaking.

But never use electric heating pads, he said. That practice resulted in a third-degree burn requiring a skin graft in one of his patients. "A heating pad that may fluctuate to greater than 100° F, and a wet solution in a numb patient can be a terrible combination. You have to warm the room and the solutions even if it is uncomfortable for you," Dr. Schloemer said.

Given the availability of tumescent anesthesia and intravenous sedation, general anesthesia is simply not necessary for liposuction. It's generally advisable to keep the lidocaine dose at 50 mg/kg or below to prevent toxicity, however.

"At the end of the procedure, have the patient stand up so you can assess the effects of gravity and ensure symmetry," he said. "Finally, don't promise too much, and remember that liposuction isn't for everyone. Declining to operate often shows good judgment and gains patient respect," he said.