Aesthetic Dermatology

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

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

PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

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

PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle

MIAMI BEACH — Although most U.S. dermatologists have limited experience with poly-L-lactic acid, this filler can be used successfully to correct lipoatrophy, Susan H. Weinkle, M.D., said at a seminar sponsored by the Skin Disease and Education Foundation.

Proper reconstitution, technique, and patient education were among the practical tips Dr. Weinkle presented for preparation of both the product and the patient.

Poly-L-lactic acid (Sculptra, Dermik Laboratories), which is indicated for restoration and/or correction of lipoatrophy in people with human immunodeficiency virus, was fast-tracked and approved by the Food and Drug Administration in August. Some physicians have been using the filler off label to restore volume to the aging face.

"Both the HIV and aging patients develop lipodystrophy, a loss of fat and a loss of volume. Our colleagues in plastic surgery think the way to deal with this is to pull and stretch. We want to volumize and fill," said Dr. Weinkle, a dermatologist in private practice in Bradenton, Fla., who is on the advisory boards for Galderma, Procter & Gamble, and Dermik.

Poly-L-lactic acid (PLLA) is not a site-specific wrinkle filler; it's a "global volume sculptor," Dr. Weinkle said. It returns desired contours by smoothing wrinkles and folds from the inside out. The product stimulates a patient's own fibroblasts to produce collagen. "We're not just filling a wrinkle, we're revolumizing from within," she said during a live patient demonstration.

The filler material is freeze dried. Reconstitution with 5 mL sterile water or 4 mL sterile water and 1 mL lidocaine with epinephrine is recommended. Reconstitution with only 3 mL is possible, but this formulation should be reserved for experienced injectors who are treating the most severe cases, Dr. Weinkle said.

Do not shake the vial during or immediately after reconstitution. Set it aside for at least 2 hours. "I like to hydrate it the night before," she added. Shake firmly just prior to injection.

Unlike some fillers, PLLA does not require an allergic skin test, and refrigeration is not needed. But because it has only a limited shelf life once reconstituted, PLLA can be a costly option if patients cancel or miss an appointment. Some physicians are requiring patients to prepay the estimated $800-$1,000 for each vial.

"The cost across the U.S. varies a lot. If the patient does not show up, you have 72 hours to use it. If you have some left, give it to your office staff, if suitable. Your office staff is your best marketer," she said.

Prepare the area with a topical anesthetic such as Betacaine Plus. Injections should be deeper than the dermis and placed 0.5 to 1 cm apart. Inject 0.1 mL to 0.2 mL at each site. Dr. Weinkle suggested using an 18G BD Luer Lock 1-cc syringe. She injects bevel up and massages the area after every three to four injections.

It is important to undercorrect rather than overcorrect, she noted. "I usually inject a half cc on either side of the face to start and have them return in a month."

Patients must be told to expect little immediate gratification, Dr. Weinkle said. "Think of this as a staged procedure, like Mohs surgery. It typically takes three to five monthly treatment sessions to yield desired results. Uninformed patients are likely to call a few days after the initial session—once the swelling has gone down—and say, 'I paid you so much and I have nothing,'" she said.

Dr. Weinkle likes to see patients every 4 weeks, which allows adequate time to gauge the results. "Then you can fine-tune it," she said. "As a physician you need an aesthetic eye. Next time I may think I need some more volumizing in a different area to get a little more lift."

The effect lasts 18-24 months, and PLLA is not permanent. Other fillers last 4-6 months.

Unlike collagen, injection of PLLA should stop as the needle is withdrawn, before the needle tip returns to the skin's surface. "I was injected myself 5 days ago, and I have some bruising from not using enough pressure," Dr. Weinkle said.

Another caveat is to inject PLLA rapidly to avoid clogging of the needle. If a clog does occur, it is necessary to change the needle. "There is a learning curve, but this is so easy," Dr. Weinkle said.

"Some patients will experience some minor discomfort and should be forewarned," Dr. Weinkle said. Most adverse events are technique dependent, such as the bruising. Also, if PLLA is injected too superficially, nodules can result.

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

PLLA for lipodystrophy volumizes and fills, thus restoring volume to the aging face.

After three sessions and half a vial of PLLA, there is significant improvement in volume and decrease in the nasolabial fold. Photos courtesy Dr. Susan H. Weinkle

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

SAN DIEGO — Hair restoration surgery can be a lucrative addition to a cosmetic surgery practice, but efficiency and speed are crucial, E. Antonio Mangubat, M.D., said at the annual meeting of the American Academy of Cosmetic Surgery.

Hair restoration surgery can be time consuming, with each procedure taking 2-6 hours depending on the amount of hair transplanted. But unlike most surgical procedures, the physician can work on up to four patients in parallel, if he or she has highly trained staff, said Dr. Mangubat, who practices in Tukwila, Wash.

"You're part of a team, and you've got to give up a little bit of that ego that says you have to do it all," Dr. Mangubat said. He estimates that his staff conducts 60%-80% of each operation. "I'm only in the operating room for my part of the operation, and I can go off and do other things."

Dr. Mangubat harvests the donor hair, designs and prepares the recipient sites, and supervises the other activities. Technicians place all the grafts and take care of all patient preparation and cleanup.

Competition in the hair restoration field is driving down prices at the same time that costs are increasing, in part because of the more refined approach required by follicular unit grafting. This gives much better cosmetic results, especially along the hair line, than do the old-style hair plugs.

So speed is important, but not only for increased production. Studies show that speed has a large effect on graft survival, with 95% of grafts surviving for 2 hours outside of the body, but only 86% surviving for 4 hours. Speed is also important for patient comfort. "Can you imagine being in there 12 hours versus 6 hours?" he asked.

Technology can also help. Dr. Mangubat uses a multibladed knife that can harvest up to eight strips of donor skin and associated hair follicles simultaneously. He closes the donor site with staples—which takes 3 minutes and gives a good cosmetic result at the expense of some patient discomfort—instead of sutures, which can take up to 15-20 minutes to do correctly.

And he's a proponent of using a graft cutter, a device in which thin slivers of donor tissue are placed on a series of blades and smacked with a hammer into smaller pieces. In the pre-graft cutter era, a 1,000-graft session lasted 5 hours and required four staff members (three cutters and one placer) for a total of 20 person-hours, not counting the physician's time.

But using a graft cutter, a 1,000-graft session takes 4 hours and requires a single assistant to place the grafts, for a total of 4 person-hours. This greatly increases surgical productivity with no decrease in patient satisfaction, Dr. Mangubat said.

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

MIAMI BEACH — Combine drug and device to maximize safety and efficacy for cosmetic dermatology patients, Mark Steven Nestor, M.D., said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Assess each patient for the optimal combination of ablative or nonablative device with botulinum type A toxin, fillers, or pharmaceuticals. Options include the anti-inflammatory agent fluocinolone, the depigmentation agent hydroquinone, tretinoin, retinoids, and imiquimod. Follow up on the procedure with a cosmeceutical and sun protection combination to maintain good health and appearance, suggested Dr. Nestor of the University of Miami.

There are many combinations. Consider the degree of photoaging, severity of wrinkles, and other cosmetic concerns to match patients to the appropriate techniques. Also think about downtime, infection risk, patient desires, likely outcomes, and need for immediate vs. long-term results, Dr. Nestor advised.

There are pros and cons to all cosmetic techniques. (See box.) For example, ablative resurfacing with carbon dioxide or erbium:YAG lasers can be safe and effective, but there also can be significant complications, he said. Early recognition of complications is crucial to minimizing adverse outcomes.

Ablative lasers can be combined with botulinum type A toxin, intense pulsed light photorejuvenation, radiofrequency toning and tightening, pharmaceuticals, or cosmeceuticals. Combination with fillers is not usually necessary, Dr. Nestor said. He advised waiting 3-6 months before using a filler and suggested a hyaluronic acid if warranted.

Intense pulsed light rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals for correction of fine lines, pores, actinic damage, rosacea and redness, age spots, and brown pigmentation. Intense pulsed light can be applied over fillers, Dr. Nestor said, so they can be used in conjunction. He recommended hyaluronic acid or collagen.

Photodynamic therapy combines 5-aminolevulinic acid and light for correction of photodamage, skin cancer, scleroderma, keratosis pilaris, and warts. It also has significant promise for treatment of acne, Dr. Nestor said. Photodynamic skin rejuvenation can be combined with botulinum type A toxin, radiofrequency toning and tightening, pharmaceuticals, and cosmeceuticals. Fillers should be used prior to treatment or 1-2 weeks afterward. Again, he recommended a hyaluronic acid or collagen.

Radiofrequency toning and tightening can be combined with botulinum type A toxin, microlaser or ablative laser techniques, any nonablative therapy, pharmaceuticals, and cosmeceuticals. Fillers should be used 2-3 months prior to treatment or afterward. Radiofrequency toning and tightening may increase filler life, but their use in close conjunction could cause lumpiness or granuloma formation.

As ablative and nonablative techniques continue to evolve, combinations may become even safer and more effective. Dr. Nestor said, "The best results clinically and cosmetically come from the marriage of device and drug."

Assess each patient at baseline to determine the optimal drug and device combination.

The patient is shown 14 days after radiofrequency toning and tightening and treatment with an er:YAG laser. Photos courtesy Dr. Mark Steven Nestor

Cosmetic Procedures: Pros and Cons

Ablative Laser Resurfacing

Pros: Best results on deep rhytidsSignificant tightening Long-term results

Cons: PainfulLengthy healing phaseRisksHypopigmentation

Photodynamic Skin Rejuvenation

Pros: Excellent results on red and brown pigmentation

Better tightening and remodeling

Minimal downtime

Superb for actinic keratosis and damage

Acne and other applications

Long-term results

Can be used for skin types I-IV

Cons: Photosensitivity

Some downtime

Radiofrequency Toning and Tightening

Pros: Improvement for lax skinCan be used for all skin typesImprovement of acne scarsNo downtime Long-term results possibleSame day combination with ablative techniques

Cons: PainVariability

Intense Pulsed Light Photorejuvenation

Pros: Best results on brown and red pigmentation

Slight tightening and remodeling

No downtime

Long-term results

Cons: No effect on actinic keratosisSlight effect on rhytids

ORLANDO, FLA. — Mesotherapy targets and reduces spot fat without surgery and offers several advantages, compared with liposuction, said Gerald M. Parker, D.O., at an obesity symposium sponsored by the American Society of Bariatric Physicians.

Originally developed to manage localized pain, mesotherapy has aesthetic possibilities that have gained recognition in the past 2-3 years, said Dr. Parker. "It is now being touted as the latest breakthrough in body sculpting, cellulite reduction, and spot fat reduction," he said.

Proper patient selection is paramount. "This is a new therapy in the United States. If you get into this, make sure you are doing it on the right candidates," Dr. Parker emphasized. Appropriate candidates are 15-30 pounds overweight with small or moderate areas of fat. Patients who are more overweight than that will not get the same results, said Dr. Parker, a bariatric physician in private practice in Dallas.

Blood work is recommended before starting. A physician injects various substances into the skin's mesoderm layer—which gives mesotherapy its name—including vitamins, minerals, amino acids, essential phospholipids, homeopathic remedies, or medication. The selected substances target fat cell surface receptors and lyse the cell walls.

"Just about anywhere you have fat, you can treat it," Dr. Parker said. Generally, patients request 4-6 treatment sessions. Mesotherapy can be used for the abdominals, legs, inner thighs, arms, and cellulite.

"Cellulite is a big area because there are no effective treatments. Cellulite is even a problem in younger women who are not overweight," he said.

Another application is treatment of lower eyelid fat pads. In a study at the University of California at Los Angeles, 80% of 13 patients injected with the lecithin-derived phospholipid phosphatidylcholine showed improvement (Dermatol. Surg. 2004;30:422-7). Results after three to five sessions indicate that mesotherapy may be a good alternative to blepharoplasty surgery, according to the authors.

In an unpublished study conducted for the American College of Medical Meso-Lipotherapy, Dr. Parker treated the abdominal area of 50 patients in four sessions. After 6 weeks, the average reduction in waist circumference was 3.34 inches, although there was a "pretty typical" range of 1-8 inches.

"I tell my patients they can expect to lose about a quarter inch per session if they do nothing else and half an inch with diet and exercise," Dr. Parker said. "We've seen up to 2 inches to 3 inches at a time—striking results—if people are very aggressive."

Researchers agree that to maintain results, patients treated with mesotherapy need to eat properly and exercise. "About the only people who do not get a response to mesotherapy are those who go out and do everything they shouldn't," Dr. Parker said.

Unlike liposuction, mesotherapy carries no risk of postprocedure "denting" if a patient gains weight, and almost no risk of infection if good hygiene practices are followed. Patients typically experience some minor swelling.

ORLANDO, FLA. — Mesotherapy targets and reduces spot fat without surgery and offers several advantages, compared with liposuction, said Gerald M. Parker, D.O., at an obesity symposium sponsored by the American Society of Bariatric Physicians.

Originally developed to manage localized pain, mesotherapy has aesthetic possibilities that have gained recognition in the past 2-3 years, said Dr. Parker. "It is now being touted as the latest breakthrough in body sculpting, cellulite reduction, and spot fat reduction," he said.

Proper patient selection is paramount. "This is a new therapy in the United States. If you get into this, make sure you are doing it on the right candidates," Dr. Parker emphasized. Appropriate candidates are 15-30 pounds overweight with small or moderate areas of fat. Patients who are more overweight than that will not get the same results, said Dr. Parker, a bariatric physician in private practice in Dallas.

Blood work is recommended before starting. A physician injects various substances into the skin's mesoderm layer—which gives mesotherapy its name—including vitamins, minerals, amino acids, essential phospholipids, homeopathic remedies, or medication. The selected substances target fat cell surface receptors and lyse the cell walls.

"Just about anywhere you have fat, you can treat it," Dr. Parker said. Generally, patients request 4-6 treatment sessions. Mesotherapy can be used for the abdominals, legs, inner thighs, arms, and cellulite.

"Cellulite is a big area because there are no effective treatments. Cellulite is even a problem in younger women who are not overweight," he said.

Another application is treatment of lower eyelid fat pads. In a study at the University of California at Los Angeles, 80% of 13 patients injected with the lecithin-derived phospholipid phosphatidylcholine showed improvement (Dermatol. Surg. 2004;30:422-7). Results after three to five sessions indicate that mesotherapy may be a good alternative to blepharoplasty surgery, according to the authors.

In an unpublished study conducted for the American College of Medical Meso-Lipotherapy, Dr. Parker treated the abdominal area of 50 patients in four sessions. After 6 weeks, the average reduction in waist circumference was 3.34 inches, although there was a "pretty typical" range of 1-8 inches.

"I tell my patients they can expect to lose about a quarter inch per session if they do nothing else and half an inch with diet and exercise," Dr. Parker said. "We've seen up to 2 inches to 3 inches at a time—striking results—if people are very aggressive."

Researchers agree that to maintain results, patients treated with mesotherapy need to eat properly and exercise. "About the only people who do not get a response to mesotherapy are those who go out and do everything they shouldn't," Dr. Parker said.

Unlike liposuction, mesotherapy carries no risk of postprocedure "denting" if a patient gains weight, and almost no risk of infection if good hygiene practices are followed. Patients typically experience some minor swelling.

ORLANDO, FLA. — Mesotherapy targets and reduces spot fat without surgery and offers several advantages, compared with liposuction, said Gerald M. Parker, D.O., at an obesity symposium sponsored by the American Society of Bariatric Physicians.

Originally developed to manage localized pain, mesotherapy has aesthetic possibilities that have gained recognition in the past 2-3 years, said Dr. Parker. "It is now being touted as the latest breakthrough in body sculpting, cellulite reduction, and spot fat reduction," he said.

Proper patient selection is paramount. "This is a new therapy in the United States. If you get into this, make sure you are doing it on the right candidates," Dr. Parker emphasized. Appropriate candidates are 15-30 pounds overweight with small or moderate areas of fat. Patients who are more overweight than that will not get the same results, said Dr. Parker, a bariatric physician in private practice in Dallas.

Blood work is recommended before starting. A physician injects various substances into the skin's mesoderm layer—which gives mesotherapy its name—including vitamins, minerals, amino acids, essential phospholipids, homeopathic remedies, or medication. The selected substances target fat cell surface receptors and lyse the cell walls.

"Just about anywhere you have fat, you can treat it," Dr. Parker said. Generally, patients request 4-6 treatment sessions. Mesotherapy can be used for the abdominals, legs, inner thighs, arms, and cellulite.

"Cellulite is a big area because there are no effective treatments. Cellulite is even a problem in younger women who are not overweight," he said.

Another application is treatment of lower eyelid fat pads. In a study at the University of California at Los Angeles, 80% of 13 patients injected with the lecithin-derived phospholipid phosphatidylcholine showed improvement (Dermatol. Surg. 2004;30:422-7). Results after three to five sessions indicate that mesotherapy may be a good alternative to blepharoplasty surgery, according to the authors.

In an unpublished study conducted for the American College of Medical Meso-Lipotherapy, Dr. Parker treated the abdominal area of 50 patients in four sessions. After 6 weeks, the average reduction in waist circumference was 3.34 inches, although there was a "pretty typical" range of 1-8 inches.

"I tell my patients they can expect to lose about a quarter inch per session if they do nothing else and half an inch with diet and exercise," Dr. Parker said. "We've seen up to 2 inches to 3 inches at a time—striking results—if people are very aggressive."

Researchers agree that to maintain results, patients treated with mesotherapy need to eat properly and exercise. "About the only people who do not get a response to mesotherapy are those who go out and do everything they shouldn't," Dr. Parker said.

Unlike liposuction, mesotherapy carries no risk of postprocedure "denting" if a patient gains weight, and almost no risk of infection if good hygiene practices are followed. Patients typically experience some minor swelling.

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

LAS VEGAS — Combining liposuction with Thermage—a radiofrequency energy system that heats the skin to produce collagen tightening and shortening—led to clinically significant tightening of abdominal skin at 28 weeks, compared with either treatment alone, results from a small study suggest.

Combining the two procedures "can be particularly useful in patients with loose skin or striae prior to liposuction," David Avram, M.D., said at the 13th International Symposium on Cosmetic Laser Surgery. "This can be a way of enhancing our results in those patients. However, this was a small study. We obviously need to perform more studies with more patients."

For the study, Dr. Avram and his associates treated 14 patients with standard tumescent liposuction plus Thermage (group 1), four patients with liposuction only (group 2), and two patients with Thermage only (group 3).

After liposuction, patients in group 1 had four tattoo markers placed in a rectangular pattern in areas of loose abdominal skin. The area was calculated and recorded prior to treatment with Thermage, said Dr. Avram, a cosmetic dermatologist who practices in New York City.

Patients were treated three times with Thermage at 4-week intervals (4, 8, and 12 weeks postoperatively). The treatments were done in a single pass using the ThermaCool TC System. Energy levels ranged from 13.5 J/sec to 15.0 J/sec at each visit. Patients were asked to return for follow-up visits at 1 month and at 4 months after the last Thermage treatment. Two independent observers recorded the size of the treated area at each follow-up visit.

"We've heard a lot of subjective data about Thermage," Dr. Avram commented. "I think what's nice here is that we really went for objective data with tattoo markers to see if there would be any [skin] tightening."

Patients in group 2 had tattoo markers placed in the abdominal area 4 weeks after liposuction. Investigators recorded the area of tattoo markers during postoperative follow-up visits at 8, 12, 16, and 28 weeks.

Patients in group 3 had tattoo markers placed in the abdominal area on the initial visit and then underwent the same Thermage treatment and follow-up regimen as patients in group 1.

At 4 weeks, there were no differences in skin tightening among patients in the three groups. (See box.) However, by 28 weeks, patients in group 1 achieved 18% skin tightening while patients in groups 2 and 3 achieved only 10% skin tightening.

The 10% tightening seen in the group 2 patients "is probably from the trauma that's caused from liposuction," Dr. Avram said. So Thermage is as effective in tightening skin as is liposuction only. "When you combine the treatment modalities, you are able to have skin tightening up to 18%."

Dr. Avram noted that patients treated with Thermage had "moderate discomfort" during treatment, but no long-term adverse events were observed. Lidocaine topical anesthetic cream was applied 1 hour before treatment, and no oral pain medicines were given.

One patient had four superficial blisters after treatment, "but they healed without a scar," he said.

He added that he is using combined liposuction and Thermage to treat fat on the arms and noted that some clinicians are applying it to breast reduction.

The current Food and Drug Administration-approved indications for the ThermaCool TC System are for noninvasive treatment of wrinkles in the periorbital area as well as full-face treatment.

SAN DIEGO — The best laser for treatment of follicular disorders in individuals who have very dark skin is the neodymium:YAG laser, E. Victor Ross, M.D., reported at the annual conference of the National Medical Association.

Based on the optical properties of light in skin, the longer-wavelength lasers achieve an optimal combination of hair reduction and epidermal sparing, he said.

Dr. Ross presented the case of a 26-year-old African American man with Fitzpatrick skin type IV who had longstanding folliculitis decalvans.

The patient had received multiple therapies for 6 years, including courses of multiple antibiotics. He was initially treated with dicloxacillin. In addition, antimicrobial shampoos were used. According to Dr. Ross, the patient also underwent two 6-month trials of isotretinoin in 1997 and 1999, which produced some improvement in the disease. The condition reappeared after isotretinoin was discontinued.

The patient received one session of radiation therapy with an epilating dose of 450 cGy in 2001, said Dr. Ross, chief of the laser surgery department of dermatology at the Naval Medical Center, San Diego.

Then Dr. Ross and members of his clinic tested the patient with the 1,064-nm Nd:YAG laser on the affected area of the scalp. At follow-up sessions, the patient was premedicated before each procedure with 5 mg diazepam and 5 mg/500 mg hydrocodone/acetaminophen in conjunction with the topical anesthetic cream. The Nd:YAG laser was used with settings of 28 J/cm2, 3-ms pulse duration, a 12-minute spot, and dynamic cryogen spray cooling set at a 50-ms spray, a 20-ms delay.

Dr. Ross reported after eight treatments at 4- to 6-week intervals, the patient's scalp improved significantly, and he remained disease-free 6 months later.

SAN DIEGO — The best laser for treatment of follicular disorders in individuals who have very dark skin is the neodymium:YAG laser, E. Victor Ross, M.D., reported at the annual conference of the National Medical Association.

Based on the optical properties of light in skin, the longer-wavelength lasers achieve an optimal combination of hair reduction and epidermal sparing, he said.

Dr. Ross presented the case of a 26-year-old African American man with Fitzpatrick skin type IV who had longstanding folliculitis decalvans.

The patient had received multiple therapies for 6 years, including courses of multiple antibiotics. He was initially treated with dicloxacillin. In addition, antimicrobial shampoos were used. According to Dr. Ross, the patient also underwent two 6-month trials of isotretinoin in 1997 and 1999, which produced some improvement in the disease. The condition reappeared after isotretinoin was discontinued.

The patient received one session of radiation therapy with an epilating dose of 450 cGy in 2001, said Dr. Ross, chief of the laser surgery department of dermatology at the Naval Medical Center, San Diego.

Then Dr. Ross and members of his clinic tested the patient with the 1,064-nm Nd:YAG laser on the affected area of the scalp. At follow-up sessions, the patient was premedicated before each procedure with 5 mg diazepam and 5 mg/500 mg hydrocodone/acetaminophen in conjunction with the topical anesthetic cream. The Nd:YAG laser was used with settings of 28 J/cm2, 3-ms pulse duration, a 12-minute spot, and dynamic cryogen spray cooling set at a 50-ms spray, a 20-ms delay.

Dr. Ross reported after eight treatments at 4- to 6-week intervals, the patient's scalp improved significantly, and he remained disease-free 6 months later.

SAN DIEGO — The best laser for treatment of follicular disorders in individuals who have very dark skin is the neodymium:YAG laser, E. Victor Ross, M.D., reported at the annual conference of the National Medical Association.

Based on the optical properties of light in skin, the longer-wavelength lasers achieve an optimal combination of hair reduction and epidermal sparing, he said.

Dr. Ross presented the case of a 26-year-old African American man with Fitzpatrick skin type IV who had longstanding folliculitis decalvans.

The patient had received multiple therapies for 6 years, including courses of multiple antibiotics. He was initially treated with dicloxacillin. In addition, antimicrobial shampoos were used. According to Dr. Ross, the patient also underwent two 6-month trials of isotretinoin in 1997 and 1999, which produced some improvement in the disease. The condition reappeared after isotretinoin was discontinued.

The patient received one session of radiation therapy with an epilating dose of 450 cGy in 2001, said Dr. Ross, chief of the laser surgery department of dermatology at the Naval Medical Center, San Diego.

Then Dr. Ross and members of his clinic tested the patient with the 1,064-nm Nd:YAG laser on the affected area of the scalp. At follow-up sessions, the patient was premedicated before each procedure with 5 mg diazepam and 5 mg/500 mg hydrocodone/acetaminophen in conjunction with the topical anesthetic cream. The Nd:YAG laser was used with settings of 28 J/cm2, 3-ms pulse duration, a 12-minute spot, and dynamic cryogen spray cooling set at a 50-ms spray, a 20-ms delay.

Dr. Ross reported after eight treatments at 4- to 6-week intervals, the patient's scalp improved significantly, and he remained disease-free 6 months later.

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."

SAN DIEGO — A combination radiofrequency, infrared, and suction device has achieved mixed results in the treatment of cellulite according to two papers presented at the annual meeting of the American Academy of Cosmetic Surgery.

Twelve of 20 patients (60%) treated with the VelaSmooth device (Syneron Medical Ltd.) by Neil Sadick, M.D., eight times in 4 weeks achieved only mild improvement in cellulite, said Thomas W. Barnes, M.D., who delivered the paper for Dr. Sadick. Another seven patients (35%) were judged to have "good" improvement, and one patient had "very good" improvement.

The results were better among patients who were treated by R. Stephen Mulholland, M.D., 16 times over 8 weeks, said Dr. Barnes, who practices in Newport Beach, Calif. Two of 11 patients (18%) achieved excellent improvement in cellulite, 4 (36%) achieved very good improvement, 4 (36%) achieved good improvement, and in 1 patient (9%) the improvement was mild.

Already available in Europe and Canada, the VelaSmooth device has not yet been approved for sale in the United States. In January 2005, Syneron, based in Yokneam Illit, Israel, announced that the company would soon be applying to the Food and Drug Administration for marketing clearance in the United States.

The intense pulsed light and radiofrequency components of the device increase tissue temperature and are claimed to cause an increase in the available oxygen for fat metabolism, possibly also having an effect on adipocyte integrity.

The suction component is said to physically break down fat-cell clusters, stretch fibrous bands, and increase lymphatic drainage and evacuation of fat metabolism end products. The suction may also push adipocytes back into the subcutaneous compartment.

Dr. Barnes acknowledged receiving compensation from Syneron when speaking about the company's products, and Dr. Sadick acknowledged serving as a consultant to Syneron and other companies.

In two separate studies, Loek Habbema, M.D., of Medical Centre 't Gooi (Bussum, the Netherlands) treated a total of 17 patients with the VelaSmooth device. He stopped the first study, which included 8 patients, early because of an apparent lack of efficacy. Upon examining the device, the distributor noted inadequate suction, which necessitated repair.

Dr. Habbema then treated another nine patients, conducting a blinded study in which one of the patient's outer, inner, posterior, and anterior thighs and buttocks were treated. Each patient was treated eight times over 4 weeks, and was evaluated 5 days following the final treatment. An investigator scored the extent and intensity of the patient's cellulite.

At the end of the treatment period, the investigator found that none of the patients showed any left-right improvement. The patients themselves completed a survey, and none of the nine noticed any improvement. In addition, none said that they would be willing to pay for treatment.

Dr. Habbema, who declared that he had no financial conflicts of interest (although the VelaSmooth device was placed in his office at no charge) offered several possible explanations for the apparent lack of efficacy: The device may inherently lack efficacy; the treatment schedule may need to be changed; the device's output may need adjustment; or the indications for treatment and the patient selection criteria may need alteration.

Dr. Habbema noted that the device's user manual has changed recently. In July 2004 the manual read, "The VelaSmooth system is indicated for the treatment and reduction of cellulite, and the improvement of adipose tissue metabolism."

But in January 2005 he said he saw that a new version of the manual read, "The VelaSmooth Shaper system is indicated for temporary reduction in the appearance of cellulite, to relieve minor muscle aches and pain and for temporary improvement in the local blood circulation."

MONT TREMBLANT, QUE. — Photodynamic therapy for port wine stains could improve the low success rates of traditional pulsed dye laser therapy, because it overcomes the barrier of thermal confinement, according to J. Stuart Nelson, M.D., who spoke at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"The problem we have with current treatment is that port wine stains are made up of blood vessels of very different sizes—but based on the pulse duration and the wavelength of the laser treatment you choose, you only get thermal confinement of certain blood vessels," said Dr. Nelson of the Beckman Laser Institute at the University of California, Irvine.

"If you inject photosensitizers intravenously into the port wine stain's blood vessels and then you irradiate with the wavelength that is absorbed by the photosensitizer, you get destruction of the endothelial cells, wherever the photosensitizer is," he said in an interview.

His group has internal review board approval to use this approach under an experimental protocol that excludes children, facial lesions, and lesions larger than 2 cm.

"It boils down to us working out the appropriate drug and light dissymmetry parameters for human skin. We are currently using a benzoporphyrin derivative called verteporfin with great success. This is a drug used for macular degeneration, which is confined to the vascular compartment, where we want it, and has also had extensive clinical use—so there are no issues there," he said.

But Dr. Nelson stressed that the key to safety with this approach is real-time in situ vascular monitoring using a technique called optical Doppler flow tomography.

"What happens in PDT is that you get a slowing down of the blood flow as the endothelial cells are injured. And so what we wanted to be able to do is to monitor that change in blood flow. You can't just arbitrarily irradiate; otherwise, you are going to get into problems. The good thing about PDT is that is destroys all the blood vessels, but that is the dangerous thing about it too," he said.

MONT TREMBLANT, QUE. — Photodynamic therapy for port wine stains could improve the low success rates of traditional pulsed dye laser therapy, because it overcomes the barrier of thermal confinement, according to J. Stuart Nelson, M.D., who spoke at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"The problem we have with current treatment is that port wine stains are made up of blood vessels of very different sizes—but based on the pulse duration and the wavelength of the laser treatment you choose, you only get thermal confinement of certain blood vessels," said Dr. Nelson of the Beckman Laser Institute at the University of California, Irvine.

"If you inject photosensitizers intravenously into the port wine stain's blood vessels and then you irradiate with the wavelength that is absorbed by the photosensitizer, you get destruction of the endothelial cells, wherever the photosensitizer is," he said in an interview.

His group has internal review board approval to use this approach under an experimental protocol that excludes children, facial lesions, and lesions larger than 2 cm.

"It boils down to us working out the appropriate drug and light dissymmetry parameters for human skin. We are currently using a benzoporphyrin derivative called verteporfin with great success. This is a drug used for macular degeneration, which is confined to the vascular compartment, where we want it, and has also had extensive clinical use—so there are no issues there," he said.

But Dr. Nelson stressed that the key to safety with this approach is real-time in situ vascular monitoring using a technique called optical Doppler flow tomography.

"What happens in PDT is that you get a slowing down of the blood flow as the endothelial cells are injured. And so what we wanted to be able to do is to monitor that change in blood flow. You can't just arbitrarily irradiate; otherwise, you are going to get into problems. The good thing about PDT is that is destroys all the blood vessels, but that is the dangerous thing about it too," he said.

MONT TREMBLANT, QUE. — Photodynamic therapy for port wine stains could improve the low success rates of traditional pulsed dye laser therapy, because it overcomes the barrier of thermal confinement, according to J. Stuart Nelson, M.D., who spoke at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"The problem we have with current treatment is that port wine stains are made up of blood vessels of very different sizes—but based on the pulse duration and the wavelength of the laser treatment you choose, you only get thermal confinement of certain blood vessels," said Dr. Nelson of the Beckman Laser Institute at the University of California, Irvine.

"If you inject photosensitizers intravenously into the port wine stain's blood vessels and then you irradiate with the wavelength that is absorbed by the photosensitizer, you get destruction of the endothelial cells, wherever the photosensitizer is," he said in an interview.

His group has internal review board approval to use this approach under an experimental protocol that excludes children, facial lesions, and lesions larger than 2 cm.

"It boils down to us working out the appropriate drug and light dissymmetry parameters for human skin. We are currently using a benzoporphyrin derivative called verteporfin with great success. This is a drug used for macular degeneration, which is confined to the vascular compartment, where we want it, and has also had extensive clinical use—so there are no issues there," he said.

But Dr. Nelson stressed that the key to safety with this approach is real-time in situ vascular monitoring using a technique called optical Doppler flow tomography.

"What happens in PDT is that you get a slowing down of the blood flow as the endothelial cells are injured. And so what we wanted to be able to do is to monitor that change in blood flow. You can't just arbitrarily irradiate; otherwise, you are going to get into problems. The good thing about PDT is that is destroys all the blood vessels, but that is the dangerous thing about it too," he said.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FAJARDO, P.R. — Epinephrine use in hand and finger surgery doesn't deserve its bad rap, Donald Lalonde, M.D., said at the annual meeting of the American Association for Hand Surgery.

Although epinephrine is commonly thought to be dangerous in the hands and fingers, that belief is based on limited data derived from cases several decades old, said Dr. Lalonde of St. John (N.B.) Regional Hospital. Newer evidence suggests epinephrine is not only safe but beneficial for hand and finger surgery, he added.

"There is a serious disconnect between the experience and the dogma," he said, noting that he has used epinephrine for almost every hand and finger operation in the last 5 years.

A paper published in Plastic Reconstructive Surgery in 2001 suggests the dogma is based on only 21 cases of epinephrine-associated finger infarction. Of 48 reported cases of digital death associated with local anesthesia, 27 occurred in patients who did not receive epinephrine. After reviewing all of these cases, Dr. Lalonde outlined several findings:

▸ More cases of finger infarction occurred without epinephrine than with it, so epinephrine couldn't have been the only factor involved in the poor outcomes.

▸ Almost all the cases took place before 1950, so something occurring prior to that time likely was involved in the poor outcomes.

▸ Until 1948, procaine was the only injected anesthetic available for use with epinephrine. Papers published in 1949 and 1950 in the Journal of the American Medical Association confirmed that there was a recall of toxic lots of procaine with acid pH as low as 1.0, which is extremely toxic, and that the shelf life of procaine was limited, especially in warm temperatures. Expiration dates weren't instituted for procaine, which is no longer used for injections in humans, until 1978.

▸ Lidocaine, which became available after 1948, replaced procaine as the anesthetic of choice because it was associated with less pain and longer duration. As a result, no further investigation was made of procaine toxicity relative to the finger infarction cases.

▸ Despite continued use of lidocaine in finger and hand surgery in various parts of the world, including Canada, no documented cases of finger infarction associated with lidocaine, when used with low-dose epinephrine, have been reported.

▸ There is now an antidote for epinephrine: phentolamine, which became available after the cases in question. No cases of epinephrine-induced digital loss have occurred in which phentolamine was used or considered. The availability of phentolamine further invalidates the meager evidence suggesting epinephrine is unsafe, he said.

Numerous papers on the successful use of epinephrine in hand and finger surgery have been published in recent years, he said.

Dr. Lalonde's own prospective study of more than 3,100 cases over 2 years revealed no incidents of finger infarction. The study, including cases from nine surgeons in six cities, is being revised for publication in the Journal of Hand Surgery, he said.

"With combined clinical experience of well over 100 surgeon-years of [epinephrine] injection in fingers, we have not killed one finger, and not one surgeon had to use phentolamine reversal," he said.

Conversely, he has encountered at least six potentially fatal complications from the use of general anesthesia for hand and finger surgery. Even if finger loss did occur, it would be better to lose a finger than a life, he noted.

FLORENCE, ITALY — Recalcitrant lichen amyloidosis can be safely and effectively treated with dermabrasion in an office setting using tumescent anesthesia, William Y.M. Tang, M.D., said at the 13th Congress of the European Academy of Dermatology and Venereology.

Lichen amyloidosis is a rare, chronic condition characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules symmetrically dispersed over the extremities and (sometimes) the trunk. Pathology reveals insoluble fibrillar protein, or amyloid. The condition is seen more frequently in males than females and is believed to be more common in people of Asian descent.

Management is difficult, said Dr. Tang, a Sai Ying Pung-based dermatologist with the social hygiene service in the government department of health in Hong Kong.

Dermabrasion has been described as an effective, long-lasting treatment modality, and Dr. Tang concurs. However, he said pain control is a substantial problem when dermabrasion is performed over the large areas of skin affected by lichen amyloidosis. General anesthesia is usually required.

In an attempt to determine whether the procedure could be done in an office setting, Dr. Tang performed it on five male patients aged 43-73 years who had lichen amyloidosis for 3-20 years on their shins (four patients) and/or forearms (three patients). They were not responsive to potent topical steroids, emollients, or oral antihistamines. Dr. Tang infiltrated standard tumescent anesthesia solution into the subcutaneous compartment through a 22-gauge spinal cannula in a fan-shaped manner to his patients' most severely pruritic regions. Treated areas ranged from 72 cm2 to 150 cm2 and required 42-113 mL of tumescent solution.

After 30 minutes, he performed dermabrasion using an electric motor-driven dermabrader fitted with a stainless, olive-shaped head with spiral cutting edges rotating at 20,000 rpm. "The [dermabrader] head was moved with even, light pressure across the skin surface to remove the epidermis down to the papillary dermis," he said. A paraffin gauze dressing was applied and a mild analgesic prescribed. Dressings were changed daily for 2-3 weeks until reepithelialization occurred.

"Itch reduction was immediate in all patients," Dr. Tang said. Patients also experienced symptomatic relief for the duration of follow-up, which in some patients lasted 21 months. All patients rated their results as cosmetically improved. Although a few papules returned in two of five patients, they were less pruritic than in the initial cases. No procedure-related complications were reported. Adverse events included mild cellulitis and hypopigmentation; the latter improved with time.

Lichen amyloidosis is characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules.

Dermabrasion using in-office tumescent anesthesia eased pain and resulted in immediate itch reduction. Photos courtesy Dr. William Y.M. Tang

FLORENCE, ITALY — Recalcitrant lichen amyloidosis can be safely and effectively treated with dermabrasion in an office setting using tumescent anesthesia, William Y.M. Tang, M.D., said at the 13th Congress of the European Academy of Dermatology and Venereology.

Lichen amyloidosis is a rare, chronic condition characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules symmetrically dispersed over the extremities and (sometimes) the trunk. Pathology reveals insoluble fibrillar protein, or amyloid. The condition is seen more frequently in males than females and is believed to be more common in people of Asian descent.

Management is difficult, said Dr. Tang, a Sai Ying Pung-based dermatologist with the social hygiene service in the government department of health in Hong Kong.

Dermabrasion has been described as an effective, long-lasting treatment modality, and Dr. Tang concurs. However, he said pain control is a substantial problem when dermabrasion is performed over the large areas of skin affected by lichen amyloidosis. General anesthesia is usually required.

In an attempt to determine whether the procedure could be done in an office setting, Dr. Tang performed it on five male patients aged 43-73 years who had lichen amyloidosis for 3-20 years on their shins (four patients) and/or forearms (three patients). They were not responsive to potent topical steroids, emollients, or oral antihistamines. Dr. Tang infiltrated standard tumescent anesthesia solution into the subcutaneous compartment through a 22-gauge spinal cannula in a fan-shaped manner to his patients' most severely pruritic regions. Treated areas ranged from 72 cm2 to 150 cm2 and required 42-113 mL of tumescent solution.

After 30 minutes, he performed dermabrasion using an electric motor-driven dermabrader fitted with a stainless, olive-shaped head with spiral cutting edges rotating at 20,000 rpm. "The [dermabrader] head was moved with even, light pressure across the skin surface to remove the epidermis down to the papillary dermis," he said. A paraffin gauze dressing was applied and a mild analgesic prescribed. Dressings were changed daily for 2-3 weeks until reepithelialization occurred.

"Itch reduction was immediate in all patients," Dr. Tang said. Patients also experienced symptomatic relief for the duration of follow-up, which in some patients lasted 21 months. All patients rated their results as cosmetically improved. Although a few papules returned in two of five patients, they were less pruritic than in the initial cases. No procedure-related complications were reported. Adverse events included mild cellulitis and hypopigmentation; the latter improved with time.

Lichen amyloidosis is characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules.

Dermabrasion using in-office tumescent anesthesia eased pain and resulted in immediate itch reduction. Photos courtesy Dr. William Y.M. Tang

FLORENCE, ITALY — Recalcitrant lichen amyloidosis can be safely and effectively treated with dermabrasion in an office setting using tumescent anesthesia, William Y.M. Tang, M.D., said at the 13th Congress of the European Academy of Dermatology and Venereology.

Lichen amyloidosis is a rare, chronic condition characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules symmetrically dispersed over the extremities and (sometimes) the trunk. Pathology reveals insoluble fibrillar protein, or amyloid. The condition is seen more frequently in males than females and is believed to be more common in people of Asian descent.

Management is difficult, said Dr. Tang, a Sai Ying Pung-based dermatologist with the social hygiene service in the government department of health in Hong Kong.

Dermabrasion has been described as an effective, long-lasting treatment modality, and Dr. Tang concurs. However, he said pain control is a substantial problem when dermabrasion is performed over the large areas of skin affected by lichen amyloidosis. General anesthesia is usually required.

In an attempt to determine whether the procedure could be done in an office setting, Dr. Tang performed it on five male patients aged 43-73 years who had lichen amyloidosis for 3-20 years on their shins (four patients) and/or forearms (three patients). They were not responsive to potent topical steroids, emollients, or oral antihistamines. Dr. Tang infiltrated standard tumescent anesthesia solution into the subcutaneous compartment through a 22-gauge spinal cannula in a fan-shaped manner to his patients' most severely pruritic regions. Treated areas ranged from 72 cm2 to 150 cm2 and required 42-113 mL of tumescent solution.

After 30 minutes, he performed dermabrasion using an electric motor-driven dermabrader fitted with a stainless, olive-shaped head with spiral cutting edges rotating at 20,000 rpm. "The [dermabrader] head was moved with even, light pressure across the skin surface to remove the epidermis down to the papillary dermis," he said. A paraffin gauze dressing was applied and a mild analgesic prescribed. Dressings were changed daily for 2-3 weeks until reepithelialization occurred.

"Itch reduction was immediate in all patients," Dr. Tang said. Patients also experienced symptomatic relief for the duration of follow-up, which in some patients lasted 21 months. All patients rated their results as cosmetically improved. Although a few papules returned in two of five patients, they were less pruritic than in the initial cases. No procedure-related complications were reported. Adverse events included mild cellulitis and hypopigmentation; the latter improved with time.

Lichen amyloidosis is characterized by profoundly pruritic yellow to reddish-brown hyperkeratotic papules.

Dermabrasion using in-office tumescent anesthesia eased pain and resulted in immediate itch reduction. Photos courtesy Dr. William Y.M. Tang