Aesthetic Dermatology

SPOKANE, WASH. — Combined chin-jowl implants give a better, longer-lasting cosmetic result than central chin implants alone, Greg S. Morganroth, M.D., said at the annual Pacific Northwest Dermatological Conference.

Central chin implants provide only frontal projection and can shift over time. The chin-jowl implants, on the other hand, are anchored laterally and are better retained. They can improve the appearance of the anterior mandibular groove (also called the prejowl sulcus) and can be sculpted to help restore facial symmetry in patients with hemifacial atrophy.

"This procedure can be performed solo, or it can be integrated into your neck lipo," said Dr. Morganroth, a dermatologic surgeon in private practice in Mountain View, Calif. "It can be integrated into your facelifts. It makes a huge difference because part of that great facial result is having that nice, sharp jawline."

When combined with a "facial lipolift" (which includes neck and jowl liposuction, a laser peel, and a short-scar facelift), implants can rival the results of a traditional surgical facelift. Unlike a traditional facelift, however, the full implant procedure can be performed in 2-3 hours under local anesthesia and allows patients to return to work in a week.

Any patient whose recessed chin is less than 2 cm behind his or her forehead is a candidate for a chin-jowl implant. Patients whose chins are more than 2 cm behind the forehead will more likely require maxillofacial surgery to bring the jaw forward.

The procedure is relatively simple, Dr. Morganroth said at the conference, sponsored by the Washington State Dermatology Association. It requires the same instrument pack a dermatologist would use for the excision of a basal cell carcinoma, with the addition of a Freer elevator. For anesthesia, he performs a mental nerve block followed by five or six injections of 1% lidocaine with 1:100,000 epinephrine into the periosteum along the chin.

The surgery starts with a 1.5- to 2-cm submental incision down to the periosteum that is elevated to allow the creation of pockets on the right and left sides of the mandible. These pockets must extend at least 5.3 cm laterally and must be slightly larger than the implant.

The surgeon then positions the implant along the mandible, checking for symmetrical placement. One or two sutures anchor the central part of the implant to the underlying periosteum so the implant won't shift upward. All that remains then is to suture the periosteal, muscular, subcutaneous, and skin layers.

Dr. Morganroth said that in his hands the procedure is very safe, although all patients experience temporary bruising and swelling. Other potential complications include bone resorption under the implant, slurred speech from swelling in the mentalis muscle, infection, hematoma, and injury to the mental nerve or the marginal mandibular nerve. Asymmetry is also a possibility, as are migration of the implant, hypertrophic scarring, and an overcorrected appearance.

Central chin implants provide only frontal projection, making this patient a good candidate for combined implants.

The patient is shown after neck and jowl liposuction combined with a chin-jowl subperiosteal implant. Photos courtesy Dr. Greg S. Morganroth

SPOKANE, WASH. — Combined chin-jowl implants give a better, longer-lasting cosmetic result than central chin implants alone, Greg S. Morganroth, M.D., said at the annual Pacific Northwest Dermatological Conference.

Central chin implants provide only frontal projection and can shift over time. The chin-jowl implants, on the other hand, are anchored laterally and are better retained. They can improve the appearance of the anterior mandibular groove (also called the prejowl sulcus) and can be sculpted to help restore facial symmetry in patients with hemifacial atrophy.

"This procedure can be performed solo, or it can be integrated into your neck lipo," said Dr. Morganroth, a dermatologic surgeon in private practice in Mountain View, Calif. "It can be integrated into your facelifts. It makes a huge difference because part of that great facial result is having that nice, sharp jawline."

When combined with a "facial lipolift" (which includes neck and jowl liposuction, a laser peel, and a short-scar facelift), implants can rival the results of a traditional surgical facelift. Unlike a traditional facelift, however, the full implant procedure can be performed in 2-3 hours under local anesthesia and allows patients to return to work in a week.

Any patient whose recessed chin is less than 2 cm behind his or her forehead is a candidate for a chin-jowl implant. Patients whose chins are more than 2 cm behind the forehead will more likely require maxillofacial surgery to bring the jaw forward.

The procedure is relatively simple, Dr. Morganroth said at the conference, sponsored by the Washington State Dermatology Association. It requires the same instrument pack a dermatologist would use for the excision of a basal cell carcinoma, with the addition of a Freer elevator. For anesthesia, he performs a mental nerve block followed by five or six injections of 1% lidocaine with 1:100,000 epinephrine into the periosteum along the chin.

The surgery starts with a 1.5- to 2-cm submental incision down to the periosteum that is elevated to allow the creation of pockets on the right and left sides of the mandible. These pockets must extend at least 5.3 cm laterally and must be slightly larger than the implant.

The surgeon then positions the implant along the mandible, checking for symmetrical placement. One or two sutures anchor the central part of the implant to the underlying periosteum so the implant won't shift upward. All that remains then is to suture the periosteal, muscular, subcutaneous, and skin layers.

Dr. Morganroth said that in his hands the procedure is very safe, although all patients experience temporary bruising and swelling. Other potential complications include bone resorption under the implant, slurred speech from swelling in the mentalis muscle, infection, hematoma, and injury to the mental nerve or the marginal mandibular nerve. Asymmetry is also a possibility, as are migration of the implant, hypertrophic scarring, and an overcorrected appearance.

Central chin implants provide only frontal projection, making this patient a good candidate for combined implants.

The patient is shown after neck and jowl liposuction combined with a chin-jowl subperiosteal implant. Photos courtesy Dr. Greg S. Morganroth

SPOKANE, WASH. — Combined chin-jowl implants give a better, longer-lasting cosmetic result than central chin implants alone, Greg S. Morganroth, M.D., said at the annual Pacific Northwest Dermatological Conference.

Central chin implants provide only frontal projection and can shift over time. The chin-jowl implants, on the other hand, are anchored laterally and are better retained. They can improve the appearance of the anterior mandibular groove (also called the prejowl sulcus) and can be sculpted to help restore facial symmetry in patients with hemifacial atrophy.

"This procedure can be performed solo, or it can be integrated into your neck lipo," said Dr. Morganroth, a dermatologic surgeon in private practice in Mountain View, Calif. "It can be integrated into your facelifts. It makes a huge difference because part of that great facial result is having that nice, sharp jawline."

When combined with a "facial lipolift" (which includes neck and jowl liposuction, a laser peel, and a short-scar facelift), implants can rival the results of a traditional surgical facelift. Unlike a traditional facelift, however, the full implant procedure can be performed in 2-3 hours under local anesthesia and allows patients to return to work in a week.

Any patient whose recessed chin is less than 2 cm behind his or her forehead is a candidate for a chin-jowl implant. Patients whose chins are more than 2 cm behind the forehead will more likely require maxillofacial surgery to bring the jaw forward.

The procedure is relatively simple, Dr. Morganroth said at the conference, sponsored by the Washington State Dermatology Association. It requires the same instrument pack a dermatologist would use for the excision of a basal cell carcinoma, with the addition of a Freer elevator. For anesthesia, he performs a mental nerve block followed by five or six injections of 1% lidocaine with 1:100,000 epinephrine into the periosteum along the chin.

The surgery starts with a 1.5- to 2-cm submental incision down to the periosteum that is elevated to allow the creation of pockets on the right and left sides of the mandible. These pockets must extend at least 5.3 cm laterally and must be slightly larger than the implant.

The surgeon then positions the implant along the mandible, checking for symmetrical placement. One or two sutures anchor the central part of the implant to the underlying periosteum so the implant won't shift upward. All that remains then is to suture the periosteal, muscular, subcutaneous, and skin layers.

Dr. Morganroth said that in his hands the procedure is very safe, although all patients experience temporary bruising and swelling. Other potential complications include bone resorption under the implant, slurred speech from swelling in the mentalis muscle, infection, hematoma, and injury to the mental nerve or the marginal mandibular nerve. Asymmetry is also a possibility, as are migration of the implant, hypertrophic scarring, and an overcorrected appearance.

Central chin implants provide only frontal projection, making this patient a good candidate for combined implants.

The patient is shown after neck and jowl liposuction combined with a chin-jowl subperiosteal implant. Photos courtesy Dr. Greg S. Morganroth

NEW YORK — Digital sympathectomy appeared highly effective for pain relief in patients with severe, longstanding Raynaud's phenomenon associated with limited cutaneous systemic sclerosis, Andrew D. Thomas, M.D., said at the annual meeting of the American Society for Surgery of the Hand.

Raynaud's phenomenon in the context of CREST syndrome, the symptoms of which can include calcinosis, esophageal dysmotility, sclerodactyly, and telangiectasia, is initially treated with calcium channel blockers.

Biofeedback, smoking cessation, and avoidance of cold also are central to management, Dr. Thomas said.

But if medical management fails, patients can face intractable fingertip pain and severe digital ulceration requiring amputation.

Studies have demonstrated that digital sympathectomy improves blood supply to the chronically ischemic hand. However, the long-term outcomes are unknown because of the infrequency with which it is performed and the diversity of conditions it is used to treat.

"We have attempted to clarify the effectiveness by analyzing the results from 17 patients, each with a firmly established diagnosis of CREST syndrome and painfully disabling Raynaud's phenomenon," said Dr. Thomas, a surgical resident at St. Luke's-Roosevelt Hospital, New York.

The patients underwent a total of 95 digital sympathectomies. Chronic ulceration was present in 22 digits, and 14 of the ulcers were 1 cm or greater. Bony exposure was present in five.

By way of standard microsurgical techniques, the digital artery was stripped of its sympathetic innervation and fibrotic adventitia for 2.5-3 cm distal to its origin from the common digital artery, he explained.

In 10 digits with major pulp loss, local flap resurfacing was performed to enhance wound healing, he said.

"All but one patient reported pain relief following the operation, and all 22 ulcerations healed after a period of meticulous local wound care," Dr. Thomas said at the meeting.

The time until healing ranged from 39 to 125 days based on the size and depth of the lesion. No amputations were necessary. Patient satisfaction was consistently high, he said.

Five patients developed recurrent ulcers after the initial healing, but these rehealed by secondary intention with meticulous outpatient care.

Follow-up ranged from 1.5 to 8 years.

"Despite the progressive nature of scleroderma, this study indicates that the efficacy of digital sympathectomy can persist for periods as long as 8 years after surgery," he said.

Of 17 patients who underwent the procedure, 16 reported pain relief after the operation. There were no amputations. Courtesy Dr. Andrew D. Thomas

NEW YORK — Digital sympathectomy appeared highly effective for pain relief in patients with severe, longstanding Raynaud's phenomenon associated with limited cutaneous systemic sclerosis, Andrew D. Thomas, M.D., said at the annual meeting of the American Society for Surgery of the Hand.

Raynaud's phenomenon in the context of CREST syndrome, the symptoms of which can include calcinosis, esophageal dysmotility, sclerodactyly, and telangiectasia, is initially treated with calcium channel blockers.

Biofeedback, smoking cessation, and avoidance of cold also are central to management, Dr. Thomas said.

But if medical management fails, patients can face intractable fingertip pain and severe digital ulceration requiring amputation.

Studies have demonstrated that digital sympathectomy improves blood supply to the chronically ischemic hand. However, the long-term outcomes are unknown because of the infrequency with which it is performed and the diversity of conditions it is used to treat.

"We have attempted to clarify the effectiveness by analyzing the results from 17 patients, each with a firmly established diagnosis of CREST syndrome and painfully disabling Raynaud's phenomenon," said Dr. Thomas, a surgical resident at St. Luke's-Roosevelt Hospital, New York.

The patients underwent a total of 95 digital sympathectomies. Chronic ulceration was present in 22 digits, and 14 of the ulcers were 1 cm or greater. Bony exposure was present in five.

By way of standard microsurgical techniques, the digital artery was stripped of its sympathetic innervation and fibrotic adventitia for 2.5-3 cm distal to its origin from the common digital artery, he explained.

In 10 digits with major pulp loss, local flap resurfacing was performed to enhance wound healing, he said.

"All but one patient reported pain relief following the operation, and all 22 ulcerations healed after a period of meticulous local wound care," Dr. Thomas said at the meeting.

The time until healing ranged from 39 to 125 days based on the size and depth of the lesion. No amputations were necessary. Patient satisfaction was consistently high, he said.

Five patients developed recurrent ulcers after the initial healing, but these rehealed by secondary intention with meticulous outpatient care.

Follow-up ranged from 1.5 to 8 years.

"Despite the progressive nature of scleroderma, this study indicates that the efficacy of digital sympathectomy can persist for periods as long as 8 years after surgery," he said.

Of 17 patients who underwent the procedure, 16 reported pain relief after the operation. There were no amputations. Courtesy Dr. Andrew D. Thomas

NEW YORK — Digital sympathectomy appeared highly effective for pain relief in patients with severe, longstanding Raynaud's phenomenon associated with limited cutaneous systemic sclerosis, Andrew D. Thomas, M.D., said at the annual meeting of the American Society for Surgery of the Hand.

Raynaud's phenomenon in the context of CREST syndrome, the symptoms of which can include calcinosis, esophageal dysmotility, sclerodactyly, and telangiectasia, is initially treated with calcium channel blockers.

Biofeedback, smoking cessation, and avoidance of cold also are central to management, Dr. Thomas said.

But if medical management fails, patients can face intractable fingertip pain and severe digital ulceration requiring amputation.

Studies have demonstrated that digital sympathectomy improves blood supply to the chronically ischemic hand. However, the long-term outcomes are unknown because of the infrequency with which it is performed and the diversity of conditions it is used to treat.

"We have attempted to clarify the effectiveness by analyzing the results from 17 patients, each with a firmly established diagnosis of CREST syndrome and painfully disabling Raynaud's phenomenon," said Dr. Thomas, a surgical resident at St. Luke's-Roosevelt Hospital, New York.

The patients underwent a total of 95 digital sympathectomies. Chronic ulceration was present in 22 digits, and 14 of the ulcers were 1 cm or greater. Bony exposure was present in five.

By way of standard microsurgical techniques, the digital artery was stripped of its sympathetic innervation and fibrotic adventitia for 2.5-3 cm distal to its origin from the common digital artery, he explained.

In 10 digits with major pulp loss, local flap resurfacing was performed to enhance wound healing, he said.

"All but one patient reported pain relief following the operation, and all 22 ulcerations healed after a period of meticulous local wound care," Dr. Thomas said at the meeting.

The time until healing ranged from 39 to 125 days based on the size and depth of the lesion. No amputations were necessary. Patient satisfaction was consistently high, he said.

Five patients developed recurrent ulcers after the initial healing, but these rehealed by secondary intention with meticulous outpatient care.

Follow-up ranged from 1.5 to 8 years.

"Despite the progressive nature of scleroderma, this study indicates that the efficacy of digital sympathectomy can persist for periods as long as 8 years after surgery," he said.

Of 17 patients who underwent the procedure, 16 reported pain relief after the operation. There were no amputations. Courtesy Dr. Andrew D. Thomas

MONT-TREMBLANT, QUE. — Although sclerotherapy remains the standard for the treatment of leg veins, it is rivaled by laser therapy in a few select cases, according to several experts.

Superficial, small vessels (less than 1.5 mm) in skin types I, II, and III can respond well to laser treatment, Jeffrey Hsu, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"I have been criticized for saying this, but I also believe that in some cases it is important to provide what the patient wants. Many patients come in determined to have laser therapy either because they are 'needle phobics' or because they are 'high techers,' and even when you explain that this may not be the best choice, they still want it. We are helping people feel better about how they look, so if they insist on lasers, I will try it," said Dr. Hsu of SkinCare Physicians of Chestnut Hill (Mass.).

For very small vessels (less than 0.3 mm), Dr. Hsu recommends either pulsed dye laser (PDL): 595 nm, for 1.5-20 milliseconds; potassium titanyl phosphate (KTP): 532 nm, for 10-20 milliseconds; or intense pulsed light (IPL): 512-1,200 nm, for up to 25 milliseconds.

Small vessels (between 0.3 mm and 1.5 mm) respond well to either KTP: 532 nm, for 10-50 milliseconds; long pulsed dye: 595 nm, for 1.5-40 milliseconds; Alexandrite: 755 nm, for 3-40 milliseconds; diode: 810 nm, for 50-100 milliseconds; neodymium:YAG: 1,064 nm for 20-100 milliseconds; or IPL: 515-1,200 nm, for 25 milliseconds., he said.

Dr. Hsu said patients with medium to large vessels (more than 1.5 mm) and darker skin types (IV, V, and VI), who have a moderate response to laser and higher risk of dyspigmentation, should be triaged to sclerotherapy as a first choice.

The strikes against sclerotherapy are that it requires skill; has side effects, such as matting, ulceration, and postinflammatory hyperpigmentation; and requires multiple treatments, said Arielle Kauvar, M.D., director of New York Laser and Skin Care, New York.

Speaking at the same symposium, she said one of the potential advantages of laser therapy for leg veins is that, when performed properly, it is relatively operator independent. There are no needles, no potential for allergies to the sclerosant solutions, no skin necrosis from sclerosant extravasation, and matting is rare.

She also said that an increasing number of studies have demonstrated a relatively similar efficacy and side-effect profile for lasers when compared with sclerotherapy for the treatment of telangiectasia and venulectasia.

Dr. Kauvar recommended PDL and IPL as the most useful therapies for matting (either after laser treatment or after sclerotherapy), and said near-infrared lasers provide deeper penetration, full-thickness pulses, and low melanin absorption.

"The long-pulsed 1,064-nanometer Nd:YAG lasers are the newest and most interesting because they are versatile and can deliver high fluences and deep penetration with minimal melanin interference. This enables effective treatment of telangiectasia, venulectasia, and larger leg veins. But these lasers can be painful and require cooling," she said, adding that most of these lasers are equipped with skin-cooling devices both for pain control and epidermal protection.

While acknowledging that sclerotherapy costs considerably less than laser therapy, Dr. Kauvar recommended lasers as first-line therapy for patients with a predisposition to deep vein thrombosis or pulmonary embolism, blood clotting disorders, hypersensitivity to sclerosant, severe allergies or asthma, or pregnancy.

Laser therapy would also be indicated for patients responding poorly to sclerotherapy, those with matted telangiectasia who are generally unresponsive to subsequent sclerotherapy injections, and those with isolated telangiectasia of the leg, which is difficult to treat with sclerotherapy.

MONT-TREMBLANT, QUE. — Although sclerotherapy remains the standard for the treatment of leg veins, it is rivaled by laser therapy in a few select cases, according to several experts.

Superficial, small vessels (less than 1.5 mm) in skin types I, II, and III can respond well to laser treatment, Jeffrey Hsu, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"I have been criticized for saying this, but I also believe that in some cases it is important to provide what the patient wants. Many patients come in determined to have laser therapy either because they are 'needle phobics' or because they are 'high techers,' and even when you explain that this may not be the best choice, they still want it. We are helping people feel better about how they look, so if they insist on lasers, I will try it," said Dr. Hsu of SkinCare Physicians of Chestnut Hill (Mass.).

For very small vessels (less than 0.3 mm), Dr. Hsu recommends either pulsed dye laser (PDL): 595 nm, for 1.5-20 milliseconds; potassium titanyl phosphate (KTP): 532 nm, for 10-20 milliseconds; or intense pulsed light (IPL): 512-1,200 nm, for up to 25 milliseconds.

Small vessels (between 0.3 mm and 1.5 mm) respond well to either KTP: 532 nm, for 10-50 milliseconds; long pulsed dye: 595 nm, for 1.5-40 milliseconds; Alexandrite: 755 nm, for 3-40 milliseconds; diode: 810 nm, for 50-100 milliseconds; neodymium:YAG: 1,064 nm for 20-100 milliseconds; or IPL: 515-1,200 nm, for 25 milliseconds., he said.

Dr. Hsu said patients with medium to large vessels (more than 1.5 mm) and darker skin types (IV, V, and VI), who have a moderate response to laser and higher risk of dyspigmentation, should be triaged to sclerotherapy as a first choice.

The strikes against sclerotherapy are that it requires skill; has side effects, such as matting, ulceration, and postinflammatory hyperpigmentation; and requires multiple treatments, said Arielle Kauvar, M.D., director of New York Laser and Skin Care, New York.

Speaking at the same symposium, she said one of the potential advantages of laser therapy for leg veins is that, when performed properly, it is relatively operator independent. There are no needles, no potential for allergies to the sclerosant solutions, no skin necrosis from sclerosant extravasation, and matting is rare.

She also said that an increasing number of studies have demonstrated a relatively similar efficacy and side-effect profile for lasers when compared with sclerotherapy for the treatment of telangiectasia and venulectasia.

Dr. Kauvar recommended PDL and IPL as the most useful therapies for matting (either after laser treatment or after sclerotherapy), and said near-infrared lasers provide deeper penetration, full-thickness pulses, and low melanin absorption.

"The long-pulsed 1,064-nanometer Nd:YAG lasers are the newest and most interesting because they are versatile and can deliver high fluences and deep penetration with minimal melanin interference. This enables effective treatment of telangiectasia, venulectasia, and larger leg veins. But these lasers can be painful and require cooling," she said, adding that most of these lasers are equipped with skin-cooling devices both for pain control and epidermal protection.

While acknowledging that sclerotherapy costs considerably less than laser therapy, Dr. Kauvar recommended lasers as first-line therapy for patients with a predisposition to deep vein thrombosis or pulmonary embolism, blood clotting disorders, hypersensitivity to sclerosant, severe allergies or asthma, or pregnancy.

Laser therapy would also be indicated for patients responding poorly to sclerotherapy, those with matted telangiectasia who are generally unresponsive to subsequent sclerotherapy injections, and those with isolated telangiectasia of the leg, which is difficult to treat with sclerotherapy.

MONT-TREMBLANT, QUE. — Although sclerotherapy remains the standard for the treatment of leg veins, it is rivaled by laser therapy in a few select cases, according to several experts.

Superficial, small vessels (less than 1.5 mm) in skin types I, II, and III can respond well to laser treatment, Jeffrey Hsu, M.D., said at a symposium on cutaneous laser surgery sponsored by SkinCare Physicians of Chestnut Hill.

"I have been criticized for saying this, but I also believe that in some cases it is important to provide what the patient wants. Many patients come in determined to have laser therapy either because they are 'needle phobics' or because they are 'high techers,' and even when you explain that this may not be the best choice, they still want it. We are helping people feel better about how they look, so if they insist on lasers, I will try it," said Dr. Hsu of SkinCare Physicians of Chestnut Hill (Mass.).

For very small vessels (less than 0.3 mm), Dr. Hsu recommends either pulsed dye laser (PDL): 595 nm, for 1.5-20 milliseconds; potassium titanyl phosphate (KTP): 532 nm, for 10-20 milliseconds; or intense pulsed light (IPL): 512-1,200 nm, for up to 25 milliseconds.

Small vessels (between 0.3 mm and 1.5 mm) respond well to either KTP: 532 nm, for 10-50 milliseconds; long pulsed dye: 595 nm, for 1.5-40 milliseconds; Alexandrite: 755 nm, for 3-40 milliseconds; diode: 810 nm, for 50-100 milliseconds; neodymium:YAG: 1,064 nm for 20-100 milliseconds; or IPL: 515-1,200 nm, for 25 milliseconds., he said.

Dr. Hsu said patients with medium to large vessels (more than 1.5 mm) and darker skin types (IV, V, and VI), who have a moderate response to laser and higher risk of dyspigmentation, should be triaged to sclerotherapy as a first choice.

The strikes against sclerotherapy are that it requires skill; has side effects, such as matting, ulceration, and postinflammatory hyperpigmentation; and requires multiple treatments, said Arielle Kauvar, M.D., director of New York Laser and Skin Care, New York.

Speaking at the same symposium, she said one of the potential advantages of laser therapy for leg veins is that, when performed properly, it is relatively operator independent. There are no needles, no potential for allergies to the sclerosant solutions, no skin necrosis from sclerosant extravasation, and matting is rare.

She also said that an increasing number of studies have demonstrated a relatively similar efficacy and side-effect profile for lasers when compared with sclerotherapy for the treatment of telangiectasia and venulectasia.

Dr. Kauvar recommended PDL and IPL as the most useful therapies for matting (either after laser treatment or after sclerotherapy), and said near-infrared lasers provide deeper penetration, full-thickness pulses, and low melanin absorption.

"The long-pulsed 1,064-nanometer Nd:YAG lasers are the newest and most interesting because they are versatile and can deliver high fluences and deep penetration with minimal melanin interference. This enables effective treatment of telangiectasia, venulectasia, and larger leg veins. But these lasers can be painful and require cooling," she said, adding that most of these lasers are equipped with skin-cooling devices both for pain control and epidermal protection.

While acknowledging that sclerotherapy costs considerably less than laser therapy, Dr. Kauvar recommended lasers as first-line therapy for patients with a predisposition to deep vein thrombosis or pulmonary embolism, blood clotting disorders, hypersensitivity to sclerosant, severe allergies or asthma, or pregnancy.

Laser therapy would also be indicated for patients responding poorly to sclerotherapy, those with matted telangiectasia who are generally unresponsive to subsequent sclerotherapy injections, and those with isolated telangiectasia of the leg, which is difficult to treat with sclerotherapy.

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.

NEW YORK — Tumescent liposuction is one of the safest office-based cosmetic procedures, and probably the most effective way to manage localized adipose deposits, said Naomi Lawrence, M.D., chief of procedural dermatology, Cooper University Hospital, Marlton, N.J.

Speaking at an update sponsored by the American Academy of Dermatology, Dr. Lawrence noted that tumescent liposuction now ranks as the most popular cosmetic procedure in the United States, and it has rendered traditional liposuction under general anesthesia virtually obsolete.

One of the major trends over the years has been a progressive reduction in the size of the cannulas. Today's cannulas give surgeons far greater precision and control, which lead to better cosmetic results with far less tissue injury than was possible in 1985 when the technique first went public.

Dr. Lawrence was part of a research team that in 2001 surveyed 517 members of the American Society for Dermatologic Surgery who had listed liposuction as a part of their practices regarding their experience with performing office-based tumescent liposuction. A total of 267 surgeons answered the survey, and provided complete data on 66,570 liposuction procedures.

Within this cohort, there were no deaths, and the overall serious adverse event rate was only 0.68 per 1,000 cases, a finding that underscores the overall safety of this procedure when performed by well-trained dermatologic surgeons. Adverse event rates were higher for hospitals and ambulatory surgery centers than for nonaccredited office settings. Serious adverse event rates also rose when tumescent liposuction was combined with intravenous or intramuscular sedation, compared with oral sedation or no sedation at all (Dermatol. Surg. 2002;28:971-8).

Elimination of localized adipose deposits is the most common indication for tumescent liposuction.

Although it is important to encourage patients to continue with diet and lifestyle changes to control weight, it is equally important to foster realistic expectations. "Contrary to what a lot of people believe, 'spot' exercise does not reduce localized fat deposits. For example, abdominal crunches will not necessarily get rid of abdominal fatty deposits. The best way to deal localized adiposity is by liposuction," she said.

Many women develop fat deposits on the posterior aspects of their waists and hips after menopause, and Dr. Lawrence has found liposuction to be effective. "This 'back fat' causes obvious and unattractive bumps and ripples underneath clothing, and many women have a hard time with this. We can successfully smooth them out with liposuction."

She says she believes that many women who seek abdominoplasties ("tummy tucks") would be better off with liposuction. Even if they have stretch marks and poor elasticity, most women with abdominal rolls can get good cosmetic results with liposuction, obviating the need for a more invasive surgical procedure.

"Liposuction can also cause the skin to retract, reducing the prominence of the stomach. Overall, it is a safer alternative," she said.

It is also a safer than open surgery for breast reduction, an area that Dr. Lawrence sees as one of the procedure's fastest-growing indications. "In the past, the only solution for a woman who wanted to reduce her breast size was to undergo a breast reduction procedure under general anesthesia, which usually caused a lot of discomfort and limited her activity for several weeks. Liposuction is much less invasive than traditional breast reduction surgery, and requires a lot less recovery time."

The technique works best when the patient is seeking a reduction of one to two cup sizes. Women with fattier, less fibrous breasts tend to have the best outcomes. As a general rule, Dr. Lawrence said, make sure the patient has had a recent mammogram before undertaking a liposuction procedure for breast reduction.