Aesthetic Dermatology

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

NEW ORLEANS — In lower eyelid reconstruction, early division of a tarsoconjunctival pedicle can be safely performed 7 days after the first stage of a modified Hughes procedure, Igal Leibovitch, M.D., said at the annual meeting of the American Academy of Ophthalmology.

Dr. Leibovitch presented the results of a study showing good functional and cosmetic outcomes in 29 consecutive skin cancer patients (20 men and 9 women) who had surgery between January 2000 and April 2004.

All had their flaps separated 7 days after the first stage of the modified Hughes procedure and were followed for an average of 14 months.

Subjects ranged in age from 39 years to 87 years, with an average age of 69 years. All of the patients had tumors removed by Mohs surgery. Two cases involved squamous cell carcinoma, and the rest had basal cell carcinoma.

The most common complications were mild upper-lid lash ptosis in three patients and lower-lid margin erythema in two patients.

One case with lower-lid margin erythema and hypertrophy required excision and cautery. Another patient had a mild lateral upper-lid retraction that was repaired with an anterior approach levator recession 3 months later.

The overall complication rate was 20.7%, but most events were mild, and many involved the upper eyelid, said Dr. Leibovitch of Tel Aviv Medical Center. "These complications may not be attributable to early division, and all have been reported in other series where the flap was divided later," Dr. Leibovitch commented. No postoperative retraction of the lower eyelid, flap ischemia, or necrosis occurred.

"The authors conclusively demonstrate flap viability at 7 days," said Russell S. Gonnering, M.D., of the Medical College of Wisconsin, Milwaukee.

Lid retraction may still be a problem, he added, and discussion is still open on how best to best handle Müller's muscle when doing the procedure.

Neither factor is related to the timing of the second stage, Dr. Gonnering said. He also noted that while the investigators proposed early division as an option, they did not necessarily advocate it for all patients.

A similar procedure, published in 1911, described an upper-lid tarsoconjunctival flap that was divided with good cosmetic results at 7 days, according to Dr. Leibovitch.

In 1937, however, the initial description of the Hughes procedure called for division after 2-4 months. Although the procedure has since evolved, even a 4- to 6-week interval can preclude it as an option when the patient has only one good eye or a child is at risk for occlusional amblyopia, Dr. Leibovitch said.

A tarsoconjunctival flap is used to repair a large defect in the left lower eyelid after removal of a BCC.

After the flap is secured, a skin graft is sutured in place on the anterior surface to close the defect. Photos courtesy Dr. Mark S. Brown/

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

SAN DIEGO — In recent years, the transconjunctival approach to lower blepharoplasty has become a popular alternative to the traditional transcutaneous approach, but which technique is best?

The answer "is not entirely clear," Hayes B. Gladstone, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

"The transconjunctival approach to lower blepharoplasty is safe, but edema and wrinkled skin are the two most common complications," said Dr. Gladstone, director of the division of dermatologic surgery in the department of dermatology at Stanford (Calif.) University.

"It also seems that with the transconjunctival approach, an adjunct procedure such as laser resurfacing or chemical peels is an important consideration," he said.

Reported advantages of the transcutaneous approach are that it provides easy access to the skin, the fat pads are usually well visualized, and it removes excess skin, he said. The reported disadvantages of this approach include risk for eyelid malposition, risk for ectropion, and the fact that it leaves a visible scar.

Reported advantages of the transconjunctival approach are that it leaves no scar and it poses a decreased risk for eyelid malposition as well as ectropion. Reported disadvantages include difficult access to the skin, less visualization of all fat pads, potential for inferior oblique injury, and the fact that "it doesn't address excess infraorbital skin," he said.

Dr. Gladstone conducted a metaanalysis of the transcutaneous and transconjunctival approaches to lower blepharoplasty based on relevant studies published in the medical literature from 1970 to the present. He evaluated components of the studies that concerned complications, patient satisfaction, and physician assessment.

The studies he reviewed included 4,460 patients who underwent transcutaneous lower blepharoplasty and 3,438 patients who underwent transconjunctival lower blepharoplasty.

Edema occurred in 18% of patients who underwent the transconjunctival approach, compared with 0.2% of those who underwent the transcutaneous approach. In addition, 11% of patients in the transconjunctival group experienced wrinkling, compared with 2.4% of patients in the transcutaneous group.

Dr. Gladstone also observed that 32% of patients who underwent the transconjunctival approach required an adjunctive procedure such as laser resurfacing or chemical peels, compared with 1.5% of patients who underwent the transcutaneous approach.

The patient assessment of lower blepharoplasty "was not clear" in studies of the transcutaneous approach, he said.

Among patients who underwent the transconjunctival approach, more than half (52%) described being satisfied by the procedure, while only 29% described their results as excellent. "They wouldn't even consider that they had excellent results, which I think is a problem when you're doing a cosmetic procedure," Dr. Gladstone commented.

He was not able to quantify physician assessment of the two approaches from the studies he reviewed.

KEVIN FOLEY, RESEARCH/JULE KELLER, DESIGN

KEVIN FOLEY, RESEARCH/JULE KELLER, DESIGN

KEVIN FOLEY, RESEARCH/JULE KELLER, DESIGN

NEWPORT BEACH, CALIF. — What has a long track record of safety and is tailor-made for dermatologists wary of overcorrection? Radiesse, an injectable filler with a 30-year history of use in bone repair and dental work, Michael Churukian, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

"I have never had the courage to use a foreign body" to smooth and contour facial lines, explained Dr. Churukian, who practices in Beverly Hills, Calif. "I am a real sissy about it."

He added that 2 decades ago, after reports of hypersensitivity reactions from certain bulking agents, he decided to turn to a material he had seen used for skull restoration early in his medical career: Radiesse, which is manufactured by BioForm Medical Inc. and, until July 2004, was known as Radiance. It duplicates a naturally occurring mineral, and solid evidence suggests that it is incorporated into the surrounding tissue, then largely replaced by it, over several months' time, he said.

However, the reason for his increasing reliance on Radiesse—aside from his own confidence in it—centers on meeting patient demand, Dr. Churukian said at the meeting, which was also sponsored by Medical Education Resources. Since the advent of collagen and, more recently, Botox, patients have gotten used to the idea of undergoing procedures intermittently. However, they have also become more discerning. They want a product that has a track record of effective, long-term use. Radiesse fits the bill: It has been injected into thousand of patients with no reports of serious adverse effects, and no pretesting of any kind is required, Dr. Churukian said.

"When I started out, there was only one thing—collagen," he said. "Now there are almost too many choices, all these different injectables."

"Everything works; that is not the issue," he said. However, he uses Radiesse to avoid the risk of an allergic reaction, and he injects the microspheres in such tiny increments that the chance of "overdoing it" is almost zero.

Using quantities tantamount to about half of the recommended volume enables him to do less, not more, than he intends. "You never know how exuberant that implant is going to be," he said. "Rather than go for a home run, go for a double."

A subtle result is more likely to guarantee returning patients, he said. "They see you, they trust you, they come back," he said. On the other hand, overcorrection can mean disappointment, and "they will tell their friends [and] family about that."

Most patients who undergo treatment can count on the fact that it will last about 2 years, although there is some variation, he said. There have been some minor complications, such as lumpiness around the injection site, but most of those results have been transient, he said. In addition, Dr. Churukian has largely limited his use of this filler to frown lines and other kinds of furrows, and has avoided attempting to enhance asymmetrical features or augment underlying facial structure.

Responses to 120 patient questionnaires over the past few years showed that most patients believed the treatment adequately improved their appearance, found the cost to be reasonable, and said they would recommend the treatment to their friends.

NEWPORT BEACH, CALIF. — What has a long track record of safety and is tailor-made for dermatologists wary of overcorrection? Radiesse, an injectable filler with a 30-year history of use in bone repair and dental work, Michael Churukian, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

"I have never had the courage to use a foreign body" to smooth and contour facial lines, explained Dr. Churukian, who practices in Beverly Hills, Calif. "I am a real sissy about it."

He added that 2 decades ago, after reports of hypersensitivity reactions from certain bulking agents, he decided to turn to a material he had seen used for skull restoration early in his medical career: Radiesse, which is manufactured by BioForm Medical Inc. and, until July 2004, was known as Radiance. It duplicates a naturally occurring mineral, and solid evidence suggests that it is incorporated into the surrounding tissue, then largely replaced by it, over several months' time, he said.

However, the reason for his increasing reliance on Radiesse—aside from his own confidence in it—centers on meeting patient demand, Dr. Churukian said at the meeting, which was also sponsored by Medical Education Resources. Since the advent of collagen and, more recently, Botox, patients have gotten used to the idea of undergoing procedures intermittently. However, they have also become more discerning. They want a product that has a track record of effective, long-term use. Radiesse fits the bill: It has been injected into thousand of patients with no reports of serious adverse effects, and no pretesting of any kind is required, Dr. Churukian said.

"When I started out, there was only one thing—collagen," he said. "Now there are almost too many choices, all these different injectables."

"Everything works; that is not the issue," he said. However, he uses Radiesse to avoid the risk of an allergic reaction, and he injects the microspheres in such tiny increments that the chance of "overdoing it" is almost zero.

Using quantities tantamount to about half of the recommended volume enables him to do less, not more, than he intends. "You never know how exuberant that implant is going to be," he said. "Rather than go for a home run, go for a double."

A subtle result is more likely to guarantee returning patients, he said. "They see you, they trust you, they come back," he said. On the other hand, overcorrection can mean disappointment, and "they will tell their friends [and] family about that."

Most patients who undergo treatment can count on the fact that it will last about 2 years, although there is some variation, he said. There have been some minor complications, such as lumpiness around the injection site, but most of those results have been transient, he said. In addition, Dr. Churukian has largely limited his use of this filler to frown lines and other kinds of furrows, and has avoided attempting to enhance asymmetrical features or augment underlying facial structure.

Responses to 120 patient questionnaires over the past few years showed that most patients believed the treatment adequately improved their appearance, found the cost to be reasonable, and said they would recommend the treatment to their friends.

NEWPORT BEACH, CALIF. — What has a long track record of safety and is tailor-made for dermatologists wary of overcorrection? Radiesse, an injectable filler with a 30-year history of use in bone repair and dental work, Michael Churukian, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

"I have never had the courage to use a foreign body" to smooth and contour facial lines, explained Dr. Churukian, who practices in Beverly Hills, Calif. "I am a real sissy about it."

He added that 2 decades ago, after reports of hypersensitivity reactions from certain bulking agents, he decided to turn to a material he had seen used for skull restoration early in his medical career: Radiesse, which is manufactured by BioForm Medical Inc. and, until July 2004, was known as Radiance. It duplicates a naturally occurring mineral, and solid evidence suggests that it is incorporated into the surrounding tissue, then largely replaced by it, over several months' time, he said.

However, the reason for his increasing reliance on Radiesse—aside from his own confidence in it—centers on meeting patient demand, Dr. Churukian said at the meeting, which was also sponsored by Medical Education Resources. Since the advent of collagen and, more recently, Botox, patients have gotten used to the idea of undergoing procedures intermittently. However, they have also become more discerning. They want a product that has a track record of effective, long-term use. Radiesse fits the bill: It has been injected into thousand of patients with no reports of serious adverse effects, and no pretesting of any kind is required, Dr. Churukian said.

"When I started out, there was only one thing—collagen," he said. "Now there are almost too many choices, all these different injectables."

"Everything works; that is not the issue," he said. However, he uses Radiesse to avoid the risk of an allergic reaction, and he injects the microspheres in such tiny increments that the chance of "overdoing it" is almost zero.

Using quantities tantamount to about half of the recommended volume enables him to do less, not more, than he intends. "You never know how exuberant that implant is going to be," he said. "Rather than go for a home run, go for a double."

A subtle result is more likely to guarantee returning patients, he said. "They see you, they trust you, they come back," he said. On the other hand, overcorrection can mean disappointment, and "they will tell their friends [and] family about that."

Most patients who undergo treatment can count on the fact that it will last about 2 years, although there is some variation, he said. There have been some minor complications, such as lumpiness around the injection site, but most of those results have been transient, he said. In addition, Dr. Churukian has largely limited his use of this filler to frown lines and other kinds of furrows, and has avoided attempting to enhance asymmetrical features or augment underlying facial structure.

Responses to 120 patient questionnaires over the past few years showed that most patients believed the treatment adequately improved their appearance, found the cost to be reasonable, and said they would recommend the treatment to their friends.

NEWPORT BEACH, CALIF. — For any dermatologist who wonders whether patients will clamor for the permanent injectable Artecoll when and if it clinches approval from the Food and Drug Administration, David Ellis, M.D., has this answer: yes and no.

At a meeting sponsored by the Foundation for Facial Plastic Surgery, Dr. Ellis predicted a continuing need for a broad array of products to meet patient demand. However, he said that Artecoll may expand the patient population to include those who are squeamish about temporary fillers and want something permanent.

"There is no question that the technology [for permanent filling] is now available, and that it is safer and more effective" than ever before, said Dr. Ellis, professor of otolaryngology and facial and plastic surgery at the University of Toronto.

He has been using Artecoll for about 3 years in women and men in his practice in Canada who don't want to undergo surgery for a facelift but who don't like the idea of periodic injections.

His experience with the injectable has been very favorable, consistent with reports on its use in Europe over the past decade, he said, adding that he has no financial interest in the product. However, Artecoll isn't likely to dampen enthusiasm for existing methods, he predicted at the meeting, which was also sponsored by Medical Education Resources.

Because of heightened consumer awareness, many patients know the options before they ever come in for a consultation, and they often have strong opinions.

"It is very important to match the product with the desires" of the patient, Dr. Ellis stressed.

"I still have one patient who likes collagen, and so I get it for her," he said. It isn't that she is unaware of the benefits of Artecoll; she just prefers collagen.

Artecoll is made up of polymethylmethacrylate microspheres, which are suspended in collagen. The beads, which are a microimplant, spur collagen production to fill in lines over a 2- to 3-month period, Dr. Ellis explained.

Though this technique provides long-term augmentation, it does have its drawbacks. "Even people happy with the correction will feel the implant," according to Dr. Ellis. In clinical practice, Artecoll works best in grooves and creases, and the lip can be a "problem area," he said. In addition, Consumer Reports took a look at cosmetic fillers this past fall and noted that there had been preliminary reports of infection with Artecoll, with resulting red lines.

"These lines are removed through an incision that can scar," Consumer Reports magazine stated.

Dr. Ellis said he has had almost uniformly good results, with implant longevity that matched his use of the product, beginning in 2000.

However, he noted that Artecoll, which is likely to be marketed in the United States as Artefill, will be slightly different if and when it makes its American debut. Because of concerns on the part of the U.S. government and American public over the potential for bovine spongiform encephalitis (BSE), Artefill would be derived from a pristine herd of cattle reared separately in the western United States and subjected to frequent and intensive testing for BSE.

Dr. Ellis also speculated during his presentation that Artecoll users may prefer Dermalive, a permanent filler that may eventually receive federal approval for use in the United States.

Dermalive is made of flexible particles of acrylic hydrogel and hyaluronic acid, and it is not derived from animals. "So, there is no skin test," he noted.

Dr. Ellis has been using Dermalive for at least 1 year, with equally good results. "I find that I get more even flow and avoid lumpiness."

A "few patients will get a lot of swelling and redness," when Dermalive is administered as a permanent filler, so it has some disadvantages, too, he added.

NEWPORT BEACH, CALIF. — For any dermatologist who wonders whether patients will clamor for the permanent injectable Artecoll when and if it clinches approval from the Food and Drug Administration, David Ellis, M.D., has this answer: yes and no.

At a meeting sponsored by the Foundation for Facial Plastic Surgery, Dr. Ellis predicted a continuing need for a broad array of products to meet patient demand. However, he said that Artecoll may expand the patient population to include those who are squeamish about temporary fillers and want something permanent.

"There is no question that the technology [for permanent filling] is now available, and that it is safer and more effective" than ever before, said Dr. Ellis, professor of otolaryngology and facial and plastic surgery at the University of Toronto.

He has been using Artecoll for about 3 years in women and men in his practice in Canada who don't want to undergo surgery for a facelift but who don't like the idea of periodic injections.

His experience with the injectable has been very favorable, consistent with reports on its use in Europe over the past decade, he said, adding that he has no financial interest in the product. However, Artecoll isn't likely to dampen enthusiasm for existing methods, he predicted at the meeting, which was also sponsored by Medical Education Resources.

Because of heightened consumer awareness, many patients know the options before they ever come in for a consultation, and they often have strong opinions.

"It is very important to match the product with the desires" of the patient, Dr. Ellis stressed.

"I still have one patient who likes collagen, and so I get it for her," he said. It isn't that she is unaware of the benefits of Artecoll; she just prefers collagen.

Artecoll is made up of polymethylmethacrylate microspheres, which are suspended in collagen. The beads, which are a microimplant, spur collagen production to fill in lines over a 2- to 3-month period, Dr. Ellis explained.

Though this technique provides long-term augmentation, it does have its drawbacks. "Even people happy with the correction will feel the implant," according to Dr. Ellis. In clinical practice, Artecoll works best in grooves and creases, and the lip can be a "problem area," he said. In addition, Consumer Reports took a look at cosmetic fillers this past fall and noted that there had been preliminary reports of infection with Artecoll, with resulting red lines.

"These lines are removed through an incision that can scar," Consumer Reports magazine stated.

Dr. Ellis said he has had almost uniformly good results, with implant longevity that matched his use of the product, beginning in 2000.

However, he noted that Artecoll, which is likely to be marketed in the United States as Artefill, will be slightly different if and when it makes its American debut. Because of concerns on the part of the U.S. government and American public over the potential for bovine spongiform encephalitis (BSE), Artefill would be derived from a pristine herd of cattle reared separately in the western United States and subjected to frequent and intensive testing for BSE.

Dr. Ellis also speculated during his presentation that Artecoll users may prefer Dermalive, a permanent filler that may eventually receive federal approval for use in the United States.

Dermalive is made of flexible particles of acrylic hydrogel and hyaluronic acid, and it is not derived from animals. "So, there is no skin test," he noted.

Dr. Ellis has been using Dermalive for at least 1 year, with equally good results. "I find that I get more even flow and avoid lumpiness."

A "few patients will get a lot of swelling and redness," when Dermalive is administered as a permanent filler, so it has some disadvantages, too, he added.

NEWPORT BEACH, CALIF. — For any dermatologist who wonders whether patients will clamor for the permanent injectable Artecoll when and if it clinches approval from the Food and Drug Administration, David Ellis, M.D., has this answer: yes and no.

At a meeting sponsored by the Foundation for Facial Plastic Surgery, Dr. Ellis predicted a continuing need for a broad array of products to meet patient demand. However, he said that Artecoll may expand the patient population to include those who are squeamish about temporary fillers and want something permanent.

"There is no question that the technology [for permanent filling] is now available, and that it is safer and more effective" than ever before, said Dr. Ellis, professor of otolaryngology and facial and plastic surgery at the University of Toronto.

He has been using Artecoll for about 3 years in women and men in his practice in Canada who don't want to undergo surgery for a facelift but who don't like the idea of periodic injections.

His experience with the injectable has been very favorable, consistent with reports on its use in Europe over the past decade, he said, adding that he has no financial interest in the product. However, Artecoll isn't likely to dampen enthusiasm for existing methods, he predicted at the meeting, which was also sponsored by Medical Education Resources.

Because of heightened consumer awareness, many patients know the options before they ever come in for a consultation, and they often have strong opinions.

"It is very important to match the product with the desires" of the patient, Dr. Ellis stressed.

"I still have one patient who likes collagen, and so I get it for her," he said. It isn't that she is unaware of the benefits of Artecoll; she just prefers collagen.

Artecoll is made up of polymethylmethacrylate microspheres, which are suspended in collagen. The beads, which are a microimplant, spur collagen production to fill in lines over a 2- to 3-month period, Dr. Ellis explained.

Though this technique provides long-term augmentation, it does have its drawbacks. "Even people happy with the correction will feel the implant," according to Dr. Ellis. In clinical practice, Artecoll works best in grooves and creases, and the lip can be a "problem area," he said. In addition, Consumer Reports took a look at cosmetic fillers this past fall and noted that there had been preliminary reports of infection with Artecoll, with resulting red lines.

"These lines are removed through an incision that can scar," Consumer Reports magazine stated.

Dr. Ellis said he has had almost uniformly good results, with implant longevity that matched his use of the product, beginning in 2000.

However, he noted that Artecoll, which is likely to be marketed in the United States as Artefill, will be slightly different if and when it makes its American debut. Because of concerns on the part of the U.S. government and American public over the potential for bovine spongiform encephalitis (BSE), Artefill would be derived from a pristine herd of cattle reared separately in the western United States and subjected to frequent and intensive testing for BSE.

Dr. Ellis also speculated during his presentation that Artecoll users may prefer Dermalive, a permanent filler that may eventually receive federal approval for use in the United States.

Dermalive is made of flexible particles of acrylic hydrogel and hyaluronic acid, and it is not derived from animals. "So, there is no skin test," he noted.

Dr. Ellis has been using Dermalive for at least 1 year, with equally good results. "I find that I get more even flow and avoid lumpiness."

A "few patients will get a lot of swelling and redness," when Dermalive is administered as a permanent filler, so it has some disadvantages, too, he added.

NEWPORT BEACH, CALIF. — Light therapy with a photosensitizing agent is an effective treatment for acne vulgaris and provides an important alternative to other approaches, Dore Gilbert, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

Though treatment with retin-A compounds is the front-line option for most dermatologists who have patients with sebaceous acne, this is another way to see visible improvement—and to satisfy patients, said Dr. Gilbert, who practices in Newport Beach, Calif. "It is not a cure, but we do see a long-term deterrence of the condition."

Current drug therapies for acne have side effects, and some adolescents cannot tolerate them, he observed. However, there are no such concerns with light therapy. By adding levulinic acid to the regimen, "you get a much quicker response and better skin texture changes," he said. The effect on the sebaceous gland is fairly well documented: Light activation in the presence of a photosensitizing agent diminishes the sebaceous product inside the pustule and kills the bacteria thriving in it. Shrinkage occurs quickly, Dr. Gilbert said.

The term photodynamic therapy was coined a century ago by German scientists who observed that targeted light benefited certain skin conditions, including acne. Only a few decades ago, it was not unusual to see adolescents with serious involvement who suffered periodic sunburns, thanks to popular home treatments with a UV lamp. Now, with the addition of photosensitizing compounds to activate certain target cells, the administration of light is proving much safer than, and just as effective as, some topical treatments, Dr. Gilbert said at the meeting, which was also sponsored by Medical Education Resources.

He has treated patients with the combination of a photosensitizer and both blue light and intense pulsed-light therapy. Significant clearance with a few treatments, sometimes only one, is achieved about 75% of the time in patients with cystic or superpustular acne, he said. About 50% of his patients have had a quantifiable decrease in pore size.

The photosensitizing compound needs to be activated by wavelengths with good penetration of the skin, he advised. Any wavelength in the range of 415–640 nm seems to work well. Moreover, any type of light source will work in this wavelength zone. Dr. Gilbert said he has relied mostly on blue light and intense pulsed-light lasers. In some cases, a combination of these two is substantially better than either alone, he noted.

Dr. Gilbert recommends using a facial scrub with acetone followed by application of the photosensitizer, which can be left on for at least an hour prior to light treatment. The chemical photosensitizing compound should be one that metabolizes well over a 60-minute waiting period. This should give it significant intracellular photodynamic properties with the introduction of light. The process should result "in rapidly dividing target cells and have a short time between administration of compound and accumulation in the target cells," he said.

"One downside to phototherapy is that for 3–4 days there is redness and scaling," he pointed out. "That can be tough for kids in school." He tries to schedule these patients so that their recovery time does not coincide with school days.

NEWPORT BEACH, CALIF. — Light therapy with a photosensitizing agent is an effective treatment for acne vulgaris and provides an important alternative to other approaches, Dore Gilbert, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

Though treatment with retin-A compounds is the front-line option for most dermatologists who have patients with sebaceous acne, this is another way to see visible improvement—and to satisfy patients, said Dr. Gilbert, who practices in Newport Beach, Calif. "It is not a cure, but we do see a long-term deterrence of the condition."

Current drug therapies for acne have side effects, and some adolescents cannot tolerate them, he observed. However, there are no such concerns with light therapy. By adding levulinic acid to the regimen, "you get a much quicker response and better skin texture changes," he said. The effect on the sebaceous gland is fairly well documented: Light activation in the presence of a photosensitizing agent diminishes the sebaceous product inside the pustule and kills the bacteria thriving in it. Shrinkage occurs quickly, Dr. Gilbert said.

The term photodynamic therapy was coined a century ago by German scientists who observed that targeted light benefited certain skin conditions, including acne. Only a few decades ago, it was not unusual to see adolescents with serious involvement who suffered periodic sunburns, thanks to popular home treatments with a UV lamp. Now, with the addition of photosensitizing compounds to activate certain target cells, the administration of light is proving much safer than, and just as effective as, some topical treatments, Dr. Gilbert said at the meeting, which was also sponsored by Medical Education Resources.

He has treated patients with the combination of a photosensitizer and both blue light and intense pulsed-light therapy. Significant clearance with a few treatments, sometimes only one, is achieved about 75% of the time in patients with cystic or superpustular acne, he said. About 50% of his patients have had a quantifiable decrease in pore size.

The photosensitizing compound needs to be activated by wavelengths with good penetration of the skin, he advised. Any wavelength in the range of 415–640 nm seems to work well. Moreover, any type of light source will work in this wavelength zone. Dr. Gilbert said he has relied mostly on blue light and intense pulsed-light lasers. In some cases, a combination of these two is substantially better than either alone, he noted.

Dr. Gilbert recommends using a facial scrub with acetone followed by application of the photosensitizer, which can be left on for at least an hour prior to light treatment. The chemical photosensitizing compound should be one that metabolizes well over a 60-minute waiting period. This should give it significant intracellular photodynamic properties with the introduction of light. The process should result "in rapidly dividing target cells and have a short time between administration of compound and accumulation in the target cells," he said.

"One downside to phototherapy is that for 3–4 days there is redness and scaling," he pointed out. "That can be tough for kids in school." He tries to schedule these patients so that their recovery time does not coincide with school days.

NEWPORT BEACH, CALIF. — Light therapy with a photosensitizing agent is an effective treatment for acne vulgaris and provides an important alternative to other approaches, Dore Gilbert, M.D., said at a meeting sponsored by the Foundation for Facial Plastic Surgery.

Though treatment with retin-A compounds is the front-line option for most dermatologists who have patients with sebaceous acne, this is another way to see visible improvement—and to satisfy patients, said Dr. Gilbert, who practices in Newport Beach, Calif. "It is not a cure, but we do see a long-term deterrence of the condition."

Current drug therapies for acne have side effects, and some adolescents cannot tolerate them, he observed. However, there are no such concerns with light therapy. By adding levulinic acid to the regimen, "you get a much quicker response and better skin texture changes," he said. The effect on the sebaceous gland is fairly well documented: Light activation in the presence of a photosensitizing agent diminishes the sebaceous product inside the pustule and kills the bacteria thriving in it. Shrinkage occurs quickly, Dr. Gilbert said.

The term photodynamic therapy was coined a century ago by German scientists who observed that targeted light benefited certain skin conditions, including acne. Only a few decades ago, it was not unusual to see adolescents with serious involvement who suffered periodic sunburns, thanks to popular home treatments with a UV lamp. Now, with the addition of photosensitizing compounds to activate certain target cells, the administration of light is proving much safer than, and just as effective as, some topical treatments, Dr. Gilbert said at the meeting, which was also sponsored by Medical Education Resources.

He has treated patients with the combination of a photosensitizer and both blue light and intense pulsed-light therapy. Significant clearance with a few treatments, sometimes only one, is achieved about 75% of the time in patients with cystic or superpustular acne, he said. About 50% of his patients have had a quantifiable decrease in pore size.

The photosensitizing compound needs to be activated by wavelengths with good penetration of the skin, he advised. Any wavelength in the range of 415–640 nm seems to work well. Moreover, any type of light source will work in this wavelength zone. Dr. Gilbert said he has relied mostly on blue light and intense pulsed-light lasers. In some cases, a combination of these two is substantially better than either alone, he noted.

Dr. Gilbert recommends using a facial scrub with acetone followed by application of the photosensitizer, which can be left on for at least an hour prior to light treatment. The chemical photosensitizing compound should be one that metabolizes well over a 60-minute waiting period. This should give it significant intracellular photodynamic properties with the introduction of light. The process should result "in rapidly dividing target cells and have a short time between administration of compound and accumulation in the target cells," he said.

"One downside to phototherapy is that for 3–4 days there is redness and scaling," he pointed out. "That can be tough for kids in school." He tries to schedule these patients so that their recovery time does not coincide with school days.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

FLORENCE, ITALY — Complete remission of nearly 90% of keloids followed surgery and postoperative radiation, according to a report at the 13th Congress of the European Academy of Dermatology and Venereology.

With her colleagues, Monica Bellinvia, M.D., of the Institute of Dermatological Sciences of the University of Milan's Ospedale Maggiore, retrospectively analyzed the charts of 152 patients with 187 keloids treated with surgery and orthovoltage radiotherapy over the past 22 years (follow-up: 6 months to 18 years).

Complete remission occured in 166 lesions (89%), with a partial response in 21 lesions (11%). Relapses occurred in 17 lesions from 1 month to 6 years' post treatment, but the 5-year relapse-free rate was 85%, she said.

Excisional surgery was performed on all patients, with care taken to minimize tension at the wound site. Radiation followed within 48 hours in 48 lesions, within 3–7 days in 108 lesions, and within 8–23 days in 31 lesions. Surrounding tissues were protected from radiation.

Total radiation administered ranged from 15 Gy to 40 Gy, although a subanalysis of the data determined that the most therapeutic and cosmetically effective dose was between 25 Gy and 30 Gy.

MONT TREMBLANT, QUE. — Objective improvement of atrophic facial acne scars can be achieved with the 1,064-nm Q-switched neodymium:YAG laser, according to recently published study.

"This is one of the few papers that [exist] actually showing objective criteria for a problem that's difficult, sometimes, to visually assess in terms of degree of improvement," Roy Geronemus, M.D., told this newspaper. Dr. Geronemus coauthored the study, which is in press, with Paul Friedman, M.D., who is in private practice in Houston, and Greg Skover, Ph.D., of Johnson & Johnson.

Speaking at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill, Dr. Geronemus outlined the study, which used the Primos 3-D optical imaging system to assess skin topography in 11 patients at baseline, and at 1, 3, and 6 months after their fifth and last laser treatment.

"One of the problems we face in dermatology, and specifically in the area of laser medicine, is that there is a tremendous lack of objective evidence to substantiate the benefits, or lack thereof, of a particular treatment," Dr. Geronemus said.

At midtreatment (1 month after the third treatment), an 8.9% improvement in patients' Ra scores was seen. The Ra score is a measurement of skin smoothness and is calculated by averaging the height of all points of the topographic profile (Arch. Dermatol. 2004;140:1337–41).

This improvement in Ra score increased to 23% at 1 month after the last treatment and to 32% and then 39% at 3 months and 6 months after the last treatment, said Dr. Geronemus, who is in private practice in New York.

"The continued incremental improvements were an indication of ongoing dermal collagen remodeling long after the last treatment session," he explained at the meeting.

He has no associations with any company involved in these treatments.

MONT TREMBLANT, QUE. — Objective improvement of atrophic facial acne scars can be achieved with the 1,064-nm Q-switched neodymium:YAG laser, according to recently published study.

"This is one of the few papers that [exist] actually showing objective criteria for a problem that's difficult, sometimes, to visually assess in terms of degree of improvement," Roy Geronemus, M.D., told this newspaper. Dr. Geronemus coauthored the study, which is in press, with Paul Friedman, M.D., who is in private practice in Houston, and Greg Skover, Ph.D., of Johnson & Johnson.

Speaking at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill, Dr. Geronemus outlined the study, which used the Primos 3-D optical imaging system to assess skin topography in 11 patients at baseline, and at 1, 3, and 6 months after their fifth and last laser treatment.

"One of the problems we face in dermatology, and specifically in the area of laser medicine, is that there is a tremendous lack of objective evidence to substantiate the benefits, or lack thereof, of a particular treatment," Dr. Geronemus said.

At midtreatment (1 month after the third treatment), an 8.9% improvement in patients' Ra scores was seen. The Ra score is a measurement of skin smoothness and is calculated by averaging the height of all points of the topographic profile (Arch. Dermatol. 2004;140:1337–41).

This improvement in Ra score increased to 23% at 1 month after the last treatment and to 32% and then 39% at 3 months and 6 months after the last treatment, said Dr. Geronemus, who is in private practice in New York.

"The continued incremental improvements were an indication of ongoing dermal collagen remodeling long after the last treatment session," he explained at the meeting.

He has no associations with any company involved in these treatments.

MONT TREMBLANT, QUE. — Objective improvement of atrophic facial acne scars can be achieved with the 1,064-nm Q-switched neodymium:YAG laser, according to recently published study.

"This is one of the few papers that [exist] actually showing objective criteria for a problem that's difficult, sometimes, to visually assess in terms of degree of improvement," Roy Geronemus, M.D., told this newspaper. Dr. Geronemus coauthored the study, which is in press, with Paul Friedman, M.D., who is in private practice in Houston, and Greg Skover, Ph.D., of Johnson & Johnson.

Speaking at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill, Dr. Geronemus outlined the study, which used the Primos 3-D optical imaging system to assess skin topography in 11 patients at baseline, and at 1, 3, and 6 months after their fifth and last laser treatment.

"One of the problems we face in dermatology, and specifically in the area of laser medicine, is that there is a tremendous lack of objective evidence to substantiate the benefits, or lack thereof, of a particular treatment," Dr. Geronemus said.

At midtreatment (1 month after the third treatment), an 8.9% improvement in patients' Ra scores was seen. The Ra score is a measurement of skin smoothness and is calculated by averaging the height of all points of the topographic profile (Arch. Dermatol. 2004;140:1337–41).

This improvement in Ra score increased to 23% at 1 month after the last treatment and to 32% and then 39% at 3 months and 6 months after the last treatment, said Dr. Geronemus, who is in private practice in New York.

"The continued incremental improvements were an indication of ongoing dermal collagen remodeling long after the last treatment session," he explained at the meeting.

He has no associations with any company involved in these treatments.

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

NEWPORT BEACH, CALIF. — A foam-rubber pad with a hole in it helps many patients avoid surgery for chondrodermatitis nodularis chronica helicis, P. Haines Ely, M.D., said at the annual meeting of the Pacific Derma-tologic Association.

Chondrodermatitis nodularis chronica helicis (CNCH) is a painful pressure sore on the ear that occurs on actinically damaged skin. It is usually seen in middle-aged men, although rare cases have been reported in children who were paralyzed and always slept on the same side.

Traditionally, CNCH is removed by making a small slit in the skin with a scalpel and using curved scissors or a scalpel to snip out the damaged cartilage. The wound is then closed with sutures or with a drop of cyanoacrylate glue.

This approach is associated with a cure rate of about 80%, but there is also a recurrence rate of 10%–30%, said Dr. Ely, a dermatologist in private practice in Grass Valley, Calif.

He has had longer-term results with 1-inch-thick foam pads that he buys at a local surplus store in 8-foot sheets for about $10 a sheet. He cuts the sheets into smaller pieces approximately the size of a standard pillow, and then cuts a hole where the patient's ear will go. He instructs the patient to slip the foam between the pillowcase and the pillow, and to sleep with the ear resting in the depression formed by the hole.

If the CNCH does not resolve within 1 month, Dr. Ely has the patient come in for surgical excision. So far, virtually none of his patients have returned for surgery.

"I've actually ruined my surgical practice for chondrodermatitis because this almost always works," Dr. Ely said.

SANTA FE, N.M. — Botox is an effective treatment for hyperhidrosis, but the large number of units required is painful unless the clinician uses nerve blocks, George J. Hruza, M.D., said at a conference sponsored by the Skin Disease Education Foundation. However, topical anesthesia is sufficient for the axilla, said Dr. Hruza of the Laser and Dermatologic Surgery Center in Town and Country, Mo.

Treating palmar surfaces with Botox (botulinum toxin type A) requires blocks of the median and ulnar nerves. A radial nerve block is unnecessary, since that nerve innervates the dorsal surface of the hand.

The median nerve is right under the palmaris longus tendon and is best reached in the carpal tunnel. Have the patient touch his or her thumb and little fingers; the nerve will be found at the most proximal crease. One can approach from either side, angling the needle to go under the tendon. If an approach from one side proves unsuccessful, try from the opposite side.

"You can feel it pop in when you get to the carpal tunnel," Dr. Hruza said. "Then inject your anesthetic right in there. There's no big vein or artery there to worry about."

While the ulnar nerve can be reached in the wrist, he prefers to block this nerve by injecting at the elbow between the medial epicondyle and the olecranon process. It's important to avoid injections directly into the nerve, so if the patient shows any sign of paresthesia when the needle goes in, one should back away a bit before injecting. Dr. Hruza recalled one patient who suffered from paresthesia for 4 months as a result of an anesthetic injection into the ulnar nerve.

Treating plantar surfaces requires blocks of the posterior tibial, sural, and superficial peroneal nerves, and, optionally, the deep peroneal nerve.

The posterior tibial nerve is next to the tibial artery, which is easy to find if you can feel the pulse. If you can't feel the pulse, you may want to use Doppler ultrasound to localize the artery. Dr. Hruza has one patient whose tibial artery and nerve are 2 cm out of place. For the first few treatments, Dr. Hruza used Doppler ultrasound; after that, he was able to locate the artery without assistance.

After localizing the artery, insert the needle posterior to anterior, anteromedial to the bone, retract a few millimeters, and inject several milliliters of anesthetic.

The sural nerve is at about the same location on the other side of the ankle. However, there's no artery to guide the injection, which should be placed between the lateral malleolus and the Achilles tendon.

Anesthetize the superficial peroneal nerve by laying down a row of anesthetic in the subcutaneous plane on the front of the foot, extending from the medial to the lateral malleolus.

One may also choose to anesthetize the deep peroneal nerve with a deep injection lateral to the extensor hallucis longus tendon. Dr. Hruza chooses not to block this nerve, because it only innervates the web space between the first and second toes, and only one or two botulinum toxin injections will be made in that location.

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

SANTA FE, N.M. — Botox is an effective treatment for hyperhidrosis, but the large number of units required is painful unless the clinician uses nerve blocks, George J. Hruza, M.D., said at a conference sponsored by the Skin Disease Education Foundation. However, topical anesthesia is sufficient for the axilla, said Dr. Hruza of the Laser and Dermatologic Surgery Center in Town and Country, Mo.

Treating palmar surfaces with Botox (botulinum toxin type A) requires blocks of the median and ulnar nerves. A radial nerve block is unnecessary, since that nerve innervates the dorsal surface of the hand.

The median nerve is right under the palmaris longus tendon and is best reached in the carpal tunnel. Have the patient touch his or her thumb and little fingers; the nerve will be found at the most proximal crease. One can approach from either side, angling the needle to go under the tendon. If an approach from one side proves unsuccessful, try from the opposite side.

"You can feel it pop in when you get to the carpal tunnel," Dr. Hruza said. "Then inject your anesthetic right in there. There's no big vein or artery there to worry about."

While the ulnar nerve can be reached in the wrist, he prefers to block this nerve by injecting at the elbow between the medial epicondyle and the olecranon process. It's important to avoid injections directly into the nerve, so if the patient shows any sign of paresthesia when the needle goes in, one should back away a bit before injecting. Dr. Hruza recalled one patient who suffered from paresthesia for 4 months as a result of an anesthetic injection into the ulnar nerve.

Treating plantar surfaces requires blocks of the posterior tibial, sural, and superficial peroneal nerves, and, optionally, the deep peroneal nerve.

The posterior tibial nerve is next to the tibial artery, which is easy to find if you can feel the pulse. If you can't feel the pulse, you may want to use Doppler ultrasound to localize the artery. Dr. Hruza has one patient whose tibial artery and nerve are 2 cm out of place. For the first few treatments, Dr. Hruza used Doppler ultrasound; after that, he was able to locate the artery without assistance.

After localizing the artery, insert the needle posterior to anterior, anteromedial to the bone, retract a few millimeters, and inject several milliliters of anesthetic.

The sural nerve is at about the same location on the other side of the ankle. However, there's no artery to guide the injection, which should be placed between the lateral malleolus and the Achilles tendon.

Anesthetize the superficial peroneal nerve by laying down a row of anesthetic in the subcutaneous plane on the front of the foot, extending from the medial to the lateral malleolus.

One may also choose to anesthetize the deep peroneal nerve with a deep injection lateral to the extensor hallucis longus tendon. Dr. Hruza chooses not to block this nerve, because it only innervates the web space between the first and second toes, and only one or two botulinum toxin injections will be made in that location.

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

SANTA FE, N.M. — Botox is an effective treatment for hyperhidrosis, but the large number of units required is painful unless the clinician uses nerve blocks, George J. Hruza, M.D., said at a conference sponsored by the Skin Disease Education Foundation. However, topical anesthesia is sufficient for the axilla, said Dr. Hruza of the Laser and Dermatologic Surgery Center in Town and Country, Mo.

Treating palmar surfaces with Botox (botulinum toxin type A) requires blocks of the median and ulnar nerves. A radial nerve block is unnecessary, since that nerve innervates the dorsal surface of the hand.

The median nerve is right under the palmaris longus tendon and is best reached in the carpal tunnel. Have the patient touch his or her thumb and little fingers; the nerve will be found at the most proximal crease. One can approach from either side, angling the needle to go under the tendon. If an approach from one side proves unsuccessful, try from the opposite side.

"You can feel it pop in when you get to the carpal tunnel," Dr. Hruza said. "Then inject your anesthetic right in there. There's no big vein or artery there to worry about."

While the ulnar nerve can be reached in the wrist, he prefers to block this nerve by injecting at the elbow between the medial epicondyle and the olecranon process. It's important to avoid injections directly into the nerve, so if the patient shows any sign of paresthesia when the needle goes in, one should back away a bit before injecting. Dr. Hruza recalled one patient who suffered from paresthesia for 4 months as a result of an anesthetic injection into the ulnar nerve.

Treating plantar surfaces requires blocks of the posterior tibial, sural, and superficial peroneal nerves, and, optionally, the deep peroneal nerve.

The posterior tibial nerve is next to the tibial artery, which is easy to find if you can feel the pulse. If you can't feel the pulse, you may want to use Doppler ultrasound to localize the artery. Dr. Hruza has one patient whose tibial artery and nerve are 2 cm out of place. For the first few treatments, Dr. Hruza used Doppler ultrasound; after that, he was able to locate the artery without assistance.

After localizing the artery, insert the needle posterior to anterior, anteromedial to the bone, retract a few millimeters, and inject several milliliters of anesthetic.

The sural nerve is at about the same location on the other side of the ankle. However, there's no artery to guide the injection, which should be placed between the lateral malleolus and the Achilles tendon.

Anesthetize the superficial peroneal nerve by laying down a row of anesthetic in the subcutaneous plane on the front of the foot, extending from the medial to the lateral malleolus.

One may also choose to anesthetize the deep peroneal nerve with a deep injection lateral to the extensor hallucis longus tendon. Dr. Hruza chooses not to block this nerve, because it only innervates the web space between the first and second toes, and only one or two botulinum toxin injections will be made in that location.

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