Aesthetic Dermatology

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.

MIAMI BEACH – Do you cringe when a patient comes in wanting treatment for acne scars? Fear not; such patients are usually very motivated, and effective treatment options exist, according to Dr. Gary Monheit.

It’s true that you can’t perfect their skin, that there is a need to deal with the psychology of what their scarring has meant for them, and that it may take a significant amount of time to temper expectations, he said at the South Beach Symposium.

“But once you win them over, they can be some of the most grateful patients you have. … Don’t turn them away,” he said.

There’s not a lot of training available for treating acne scars, but using existing skill, good judgment, and a combination of tools and techniques can lead to excellent results, said Dr. Monheit, who is in private practice in Birmingham, Ala.

Leveling patient expectations comes down to educating patients about the different kinds of scars and the fact that each type requires different tools.

For example, fillers can be useful – but only for distensible scars. If the scar rises up when the skin is stretched, that’s a distensible scar that will respond to a filler, he explained.

Conversely, if injectable fillers are used in scars with bands that hold them down in deeper tissue, the filler will migrate, surround the scar, and exaggerate its appearance.

A classification system described by Dr. Greg Goodman (Int. J. Dermatol. 2011;50:1179-94]) is useful for determining the best treatment approach based on scar type, he said.

Dr. Goodman described level 1 scars as flat with red, white, or brown marks. Level 2 scars are mild scars visible primarily at close distance, such as while looking in the mirror. Level 3 scars are visible at a conversational distance, but are distensible. Level 4 scars are more severe and are nondistensible.

Peels, cosmeceuticals, and light resurfacing techniques such as the V-beam laser or intense pulsed light, are best for mild scars like level 1 scars, as they typically are erythematous and involve color change, Dr. Monheit said.

For hyperpigmented level 1 scars, consider using topical treatments such as salicylic acid or bleaching agents. For hypopigmented scars, there is a need to blend skin color.

The main thing with these types of scars is to address the color and texture, he said.

Level 2 scars are atrophic, and involve textural and color change. Other resurfacing techniques, including deeper peels, dermabrasion, and laser resurfacing such as with a fractional laser or an ablative laser are particularly useful for these, he said, noting that the treatments can be combined as necessary to achieve the desired results.

Dermarolling also can be helpful for deeper scars.

“As you get into the dermis and deeper, you are breaking collagen bonds and letting skin rise to the surface, and you can also use [dermarolling] as a conduit for whatever you are doing,” he explained.

Needling is another approach that is relatively safe, inexpensive, and involves minimal down time. However, the treatment can be bloody and painful with the depths typically needed for treating scars, he noted.

Moderate scars that are distensible, like level 3 scars, generally need lifting. Fillers are good for these types of scars, and often there is very little more that needs to be done.

Nondistensible scars that are more severe typically require a combination approach. One of the best tools for these types of scars is subcision to loosen them, which creates a pocket that then can be either allowed to fill with blood to raise the scar up or treated with an injectable filler. This is followed by resurfacing to smooth the surface of the skin.

Dr. Monheit described one patient in whom he subcised the nondistensible scars and injected a very small amount – just enough for a surface lift – of Radiesse filler. Significant improvement was seen after two treatment sessions, and then resurfacing was performed.

In another patient with nondistensible scars, he excised a little bit of skin at the scar and performed what amounted to a collagen graft by “chopping it into little pieces – making little pellets – and essentially stuffing those pellets into the pockets with a tiny little needle, giving it lift and stability.” This was followed by resurfacing.

“It really does give a nice result,” he said, noting that subcision may cause some red bumps at first, but these will settle down and the scar will smooth out.

A different approach is needed for other types of scars, such as ice pick scars.

One approach is to punch out the scar surgically and either float the scar up or put a little punch graft in, he said.

Another approach that he uses for ice pick scars is to lightly apply 90% trichloroacetic acid to the base of the scar with a toothpick. This causes an inflammatory reaction that destroys the scar and raises it up, making it distensible and resurfaceable, he said.

Ice pick scars, as well as boxcar scars, divot scars, and hypertrophic scars, need to be refined during the treatment process.

Also keep in mind that patients lose volume as they age, which can cause acne scars to become more prominent. Sometimes a patient will come in with old scars that never bothered them before, and suddenly the scars are much more visible.

“If you volume-fill the face, you’ll improve the scars,” he said, describing one 48-year-old woman who was treated successfully with three sessions of Sculptra, topped off with a little bit of Radiesse.

Dr. Monheit has consulted or performed contracted research for Allergan, Contura, Dermik Laboratories, Galderma Laboratories, Ipsen/Medicis, Kythera Biopharmaceuticals, MELA Sciences, Merz Pharmaceuticals, MyoScience, and Revance Therapeutics.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top sunscreens. Consideration must be given to:

• Anthelios 40 Sunscreen Cream
  La Roche-Posay Laboratoire Dermatologique
  
  “It has broad UV spectrum coverage that blocks harmful UVA and UVB rays. It has a combination of both physical and chemical sun protection ingredients including Mexoryl SX.”—Anthony M. Rossi, MD, New York, New York

• Anthelios 50 Mineral Ultra Light Sunscreen Fluid
  La Roche-Posay Laboratoire Dermatologique
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Coppertone Sport AccuSpray
  Bayer
  
  “I use this personally and recommend it for my patients who exercise outdoors. It’s a photostable, broad-spectrum formula that is water resistant and offers durable protection.”

• EltaMD UV Clear Broad-Spectrum SPF 46, EltaMD UV Facial Broad-Spectrum SPF 30+
  Swiss-American
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• EltaMD UV Daily Broad-Spectrum SPF 40
  Swiss-American
  
  "A perfect everyday sunscreen/moisturizer with broad-spectrum protection with the added benefits of an antioxidant (vitamin E) and hyaluronic acid to help reverse some evidence of photoaging. Additionally, the tinted version contains iron oxide, which previous research has shown to aid in treatment and prevention of melasma."—Michael Rains, Austin, Texas

• Physical Eye UV Defense SPF 50
  SkinCeuticals
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• Sensitive Skin Sunscreen Lotion Broad Spectrum SPF 60+
  Neutrogena Corporation
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Super Fluid UV Defense SPF 50+
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Triple Protection Factor Broad Spectrum SPF 50+ Sunscreen Lotion With DNA Enzyme Complex + Antioxidants
  Elizabeth Arden, Inc.
  
  “I like this product because in addition to being an elegant, chemical-free sunscreen it has antioxidants and DNA repair enzymes. It not only protects the skin, but published research suggests it may help reverse some photodamage that has already occurred.”—Mark G. Rubin, MD, Beverly Hills, California

Cutis invites readers to send us their recommendations. Cleansers for rosacea patients, antiaging moisturizers, OTC acne preparations, and products for babies will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to cutis@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top sunscreens. Consideration must be given to:

• Anthelios 40 Sunscreen Cream
  La Roche-Posay Laboratoire Dermatologique
  
  “It has broad UV spectrum coverage that blocks harmful UVA and UVB rays. It has a combination of both physical and chemical sun protection ingredients including Mexoryl SX.”—Anthony M. Rossi, MD, New York, New York

• Anthelios 50 Mineral Ultra Light Sunscreen Fluid
  La Roche-Posay Laboratoire Dermatologique
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Coppertone Sport AccuSpray
  Bayer
  
  “I use this personally and recommend it for my patients who exercise outdoors. It’s a photostable, broad-spectrum formula that is water resistant and offers durable protection.”

• EltaMD UV Clear Broad-Spectrum SPF 46, EltaMD UV Facial Broad-Spectrum SPF 30+
  Swiss-American
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• EltaMD UV Daily Broad-Spectrum SPF 40
  Swiss-American
  
  "A perfect everyday sunscreen/moisturizer with broad-spectrum protection with the added benefits of an antioxidant (vitamin E) and hyaluronic acid to help reverse some evidence of photoaging. Additionally, the tinted version contains iron oxide, which previous research has shown to aid in treatment and prevention of melasma."—Michael Rains, Austin, Texas

• Physical Eye UV Defense SPF 50
  SkinCeuticals
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• Sensitive Skin Sunscreen Lotion Broad Spectrum SPF 60+
  Neutrogena Corporation
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Super Fluid UV Defense SPF 50+
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Triple Protection Factor Broad Spectrum SPF 50+ Sunscreen Lotion With DNA Enzyme Complex + Antioxidants
  Elizabeth Arden, Inc.
  
  “I like this product because in addition to being an elegant, chemical-free sunscreen it has antioxidants and DNA repair enzymes. It not only protects the skin, but published research suggests it may help reverse some photodamage that has already occurred.”—Mark G. Rubin, MD, Beverly Hills, California

Cutis invites readers to send us their recommendations. Cleansers for rosacea patients, antiaging moisturizers, OTC acne preparations, and products for babies will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to cutis@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

To improve patient care and outcomes, leading dermatologists offered their recommendations on the top sunscreens. Consideration must be given to:

• Anthelios 40 Sunscreen Cream
  La Roche-Posay Laboratoire Dermatologique
  
  “It has broad UV spectrum coverage that blocks harmful UVA and UVB rays. It has a combination of both physical and chemical sun protection ingredients including Mexoryl SX.”—Anthony M. Rossi, MD, New York, New York

• Anthelios 50 Mineral Ultra Light Sunscreen Fluid
  La Roche-Posay Laboratoire Dermatologique
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Coppertone Sport AccuSpray
  Bayer
  
  “I use this personally and recommend it for my patients who exercise outdoors. It’s a photostable, broad-spectrum formula that is water resistant and offers durable protection.”

• EltaMD UV Clear Broad-Spectrum SPF 46, EltaMD UV Facial Broad-Spectrum SPF 30+
  Swiss-American
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• EltaMD UV Daily Broad-Spectrum SPF 40
  Swiss-American
  
  "A perfect everyday sunscreen/moisturizer with broad-spectrum protection with the added benefits of an antioxidant (vitamin E) and hyaluronic acid to help reverse some evidence of photoaging. Additionally, the tinted version contains iron oxide, which previous research has shown to aid in treatment and prevention of melasma."—Michael Rains, Austin, Texas

• Physical Eye UV Defense SPF 50
  SkinCeuticals
  
  Recommended by Julie Woodward, MD, Durham, North Carolina

• Sensitive Skin Sunscreen Lotion Broad Spectrum SPF 60+
  Neutrogena Corporation
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Super Fluid UV Defense SPF 50+
  Kiehl’s
  
  Recommended by Gary Goldenberg, MD, New York, New York

• Triple Protection Factor Broad Spectrum SPF 50+ Sunscreen Lotion With DNA Enzyme Complex + Antioxidants
  Elizabeth Arden, Inc.
  
  “I like this product because in addition to being an elegant, chemical-free sunscreen it has antioxidants and DNA repair enzymes. It not only protects the skin, but published research suggests it may help reverse some photodamage that has already occurred.”—Mark G. Rubin, MD, Beverly Hills, California

Cutis invites readers to send us their recommendations. Cleansers for rosacea patients, antiaging moisturizers, OTC acne preparations, and products for babies will be featured in upcoming editions of Cosmetic Corner. Please e-mail your recommendation(s) to cutis@frontlinemedcom.com.

Disclaimer: Opinions expressed herein do not necessarily reflect those of Cutis or Frontline Medical Communications Inc and shall not be used for product endorsement purposes. Any reference made to a specific commercial product does not indicate or imply that Cutis or Frontline Medical Communications Inc endorses, recommends, or favors the product mentioned. No guarantee is given to the effects of recommended products.

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

Dermatologists with a strictly medical or surgical practice may consider offering cosmetic procedures to their patients. Dr. Gary Goldenberg provides tips on how to market your practice as cosmetic by obtaining patient input, estimating start-up costs, and determining which procedures may benefit patients with medical conditions such as acne and rosacea.

1. Which of the following sunscreen agents is most likely to cause a photoallergic reaction on the skin?

a. homosalate

b. oxybenzone

c. PABA

d. padimate O

e. zinc oxide

2. Which of the following sunscreen agents is least likely to cause an allergic reaction when applied?

a. ecamsule

b. octisalate

c. padimate A

d. titanium dioxide

e. trolamine salicylate

3. Of the following, which is/are considered to be an inorganic sunscreen agent?

a. PABA

b. titanium dioxide

c. zinc oxide

d. A, B, and C

e. B and C

4. Sunscreens containing PABA or one of its derivatives may cross-react with which of the following?

a. bananas

b. doxycycline

c. griseofulvin

d. naproxen

e. sulfonamides

5. Which of the following is/are used in sunscreens for UVA protection?

a. avobenzone

b. ecamsule

c. octisalate

d. A, B, and C

e. A and B

1. Which of the following sunscreen agents is most likely to cause a photoallergic reaction on the skin?

a. homosalate

b. oxybenzone

c. PABA

d. padimate O

e. zinc oxide

2. Which of the following sunscreen agents is least likely to cause an allergic reaction when applied?

a. ecamsule

b. octisalate

c. padimate A

d. titanium dioxide

e. trolamine salicylate

3. Of the following, which is/are considered to be an inorganic sunscreen agent?

a. PABA

b. titanium dioxide

c. zinc oxide

d. A, B, and C

e. B and C

4. Sunscreens containing PABA or one of its derivatives may cross-react with which of the following?

a. bananas

b. doxycycline

c. griseofulvin

d. naproxen

e. sulfonamides

5. Which of the following is/are used in sunscreens for UVA protection?

a. avobenzone

b. ecamsule

c. octisalate

d. A, B, and C

e. A and B

1. Which of the following sunscreen agents is most likely to cause a photoallergic reaction on the skin?

a. homosalate

b. oxybenzone

c. PABA

d. padimate O

e. zinc oxide

2. Which of the following sunscreen agents is least likely to cause an allergic reaction when applied?

a. ecamsule

b. octisalate

c. padimate A

d. titanium dioxide

e. trolamine salicylate

3. Of the following, which is/are considered to be an inorganic sunscreen agent?

a. PABA

b. titanium dioxide

c. zinc oxide

d. A, B, and C

e. B and C

4. Sunscreens containing PABA or one of its derivatives may cross-react with which of the following?

a. bananas

b. doxycycline

c. griseofulvin

d. naproxen

e. sulfonamides

5. Which of the following is/are used in sunscreens for UVA protection?

a. avobenzone

b. ecamsule

c. octisalate

d. A, B, and C

e. A and B

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

The perioral region is second to the periorbital area in making a person appear tired, sad, happy, or healthy. Although a lot of emphasis has been given to improving the periorbital area, the perioral region has received less attention. The mainstay of addressing the perioral region is using fillers, mainly synthetic ones, to smooth rhytides and restore lost volume. Skin resurfacing is a second-line approach, in part due to the required 5 to 7 days of recovery time to heal. However, as we have learned through many other procedures, it is wrong to make one modality your hammer and every patient your nail.

In an article published online on November 20, 2014, in Aesthetic Plastic Surgery, Penna et al conducted a morphometric review of 462 perioral photographs to come up with a 2-dimensional classification system to evaluate the perioral region. The classification was based on 2 qualities: lip shape and surface changes. Lip shape was classified as (1) short concave upper lip with 2 to 3 mm of upper incisors visible and prominent everted vermilion; (2) moderately elongated and straight upper lip with upper incisors at the lower border of the upper lip and mild degree of vermilion inversion; and (3) strongly elongated upper lip that forms a convex curve around the frontal teeth row with upper incisors that are not visible and vermilion is inverted. Lip surface was classified as (1) distinct philtral columns, Cupid’s bow and white roll without static radial wrinkles, and minor dynamic radial wrinkles; (2) flattened philtral columns and Cupid’s bow, indistinct white roll, beginning static radial wrinkles, and strong dynamic radial wrinkles; and (3) invisible philtral columns, Cupid’s bow and white roll, and considerable static radial wrinkles.

This scale was validated for objectivity, interevaluator reliability, intraevaluator reliability, and reproducibility by having 3 plastic surgeons evaluate perioral photographs of 42 female patients. The scale proved to be valid to a significant degree using Cohen’s κ coefficient. Based on this evaluation scale, one can evaluate the anatomic structure of the lip to decide if no treatment is needed, if synthetic or autologous fillers would suffice, or if a surgical lip-lift is required. Furthermore, surface changes can help determine if no treatment is needed, if skin resurfacing is indicated, or if both skin resurfacing and volumizing is required. The authors studied female subjects because they constitute the majority of patients seeking perioral rejuvenation.

What’s the issue?

Certainly the field of noninvasive cosmetic procedures continues to grow yearly; however, one must temper the enthusiasm of the patient at times so that he/she does not undergo excessive procedures and end up with unnatural results. Furthermore, one must not neglect the importance of artistry and proper patient evaluation in order to achieve a natural rejuvenated appearance. For example, relying solely on fillers to address perioral aging has resulted in an astonishing number of celebrities and patients walking around with an unnatural and distorted appearance. In many instances, this look may age a patient rather than rejuvenate him/her. Cosmetic dermatology is a balance between knowing when to treat, how much to treat, and when to effectively combine modalities to ensure the best outcome. This classification system will be useful for training residents and newly graduated dermatologists.

We want to know your views! Tell us what you think.

SILVER SPRING, MD. – Expanding the approval of the Radiesse dermal filler to include cosmetic improvement of the hands was supported by the majority of a Food and Drug Administration Advisory Panel, whose confidence in the risk-benefit profile was bolstered in part by wide off-label use in the United States and approval of this indication in other countries.

At a meeting of the FDA’s General and Plastic Surgery Devices Panel on Feb. 27, the panel voted 9-4, with one abstention, that the benefits of the dermal filler, marketed as Radiesse by Merz North America , outweighed its risks for the proposed indication, “hand augmentation to correct volume deficit in the hands.” Despite some issues with the US pivotal study, and the unavailability of data some panelists said would have been helpful, such as X-rays of treated hands to determine if the filler obscured imaging of bone, most of the panel also voted that there was “reasonable assurance” that it was effective (12-2) and that it was safe (11-3) for this use.

Issues raised by panelists included the need to better define patients who should not receive this treatment, further evaluation of possible adverse effects of treatment on hand function and strength, and evaluation of the filler in patients with severe volume deficit in the hands, who were not included in the study.

Voting in favor of approval, Dr. Karen Burke, a dermatologist at Mt. Sinai Medical Center, New York City, cited the long history of Radiesse use for the hands in many countries and in many patients in the United States. “I believe it is safe and that efficacy was demonstrated,” and that FDA approval is necessary so this use can be properly regulated and “we can teach people openly how to use it,” she said.

If approved, Radiesse – a semisolid dermal filler made of synthetic calcium hyroxyapatite suspended in a gel – would be the first dermal filler approved for hand augmentation. Merz describes it as a “durable” filler that is not permanent, and is broken down over several months.

Radiesse was approved in 2006 for subdermal implantation for correction of moderate to severe facial wrinkles and folds, and for restoration and/or correction of facial lipoatrophy that occurs in people with HIV. It has been approved for hand augmentation in 52 countries, including in Europe and Canada, and like other fillers, has been used off-label in the United States for this use. Fillers are regulated by the FDA as devices.

The US study, a prospective, 12-month study at 6 sites, randomized 85 patients to Radiesse (who received a maximum of 3 cc injected per hand), and 29 initially to no treatment, who served as controls. Responses were evaluated by clinicians who could not see the patient, using the Merz Hand Grading Scale (MGHS), a 5-point scale ranging from 0 (no loss of fatty tissue) to 5 (very severe loss of fatty tissue, marked visibility of veins and tendons), with an improvement of at least 1 considered clinically meaningful, according to Merz, which validated the scale before the pivotal study. Most hands at baseline were rated as 2 or 3 on the MGHS scale (moderate or severe loss of fatty tissue with mild or moderate visibility of veins or tendons); most were women, their mean age was 53-54 years, and most were white.

At three months, 75% in the Radiesse group had at least a 1 point improvement on the MGHS scale, the primary effectiveness endpoint, vs. 3.4% of controls, a statistically significant difference. Based on the Global Aesthetic Improvement Scale (GAIS) at three months, a secondary endpoint, 76% of treated hands were rated as “much “ or “very much improved” in appearance; none were rated as worse and 2% were rated as having not changed. Among those who did not have a second treatment, the effect was durable through 12 months

Patients recorded adverse events in a diary. The most common adverse event among treated patients, which included controls who opted for treatment after the three month period, was swelling, in 99%. Other common adverse events included pain (92%), redness and bruising (74%), difficulty performing activities (46%), and loss of sensation (18%); 6% had nodules.

Most of the adverse events were mild (61%) or moderate (35%); and most resolved without sequelae. Severe events included swelling, pain, and redness. No intervention was reported for 98% of adverse events, which lasted a mean of about 8 days, with 89% resolving within 14 days, according to Merz. There were no unanticipated events. (Over 12 years of experience with the use in the hand, swelling has been the most common adverse effect of treatment, according to Merz.)

In the study, 13 patients developed lumps, bumps and nodules, most were mild and none were severe and they resolved without intervention or sequelae. At the end of the study, no patients had a persistent granuloma. In three studies of 234 patients evaluating Radiesse in the hands, no granulomas have been reported, according to the company.

There were 8 severe recurrent adverse events in 7 patients: 5 reports of swelling, 1 report pf pain, 1 report of difficulty in performing activities, and 1 report of bruising.

FDA reviewers agreed that the clinical study appeared to meet the primary effectiveness endpoint, but pointed out that the amount of improvement varied between study sites. Among other issues they raised was the increased rate, severity, and duration of adverse events associated with treatment, particularly pain and swelling, which seemed to be higher and lasted longer than when Radiesse was used for the two facial indications. In addition, they indicated that the results of hand function tests were difficult to interpret.

Panelist Dr. Murad Alam, professor of dermatology, otolaryngology, and surgery, Northwestern University, Chicago, said there were some significant issues with the pivotal study, “but they do not undermine the overall conclusions” that treatment appeared to be safe and effective. The significant off-label use and experience elsewhere “was sufficient to sway me,” he added.

One of the panelists voting no on the risk-benefit question, Dr. Clayton Peimer, an orthopedic surgeon at Michigan State University, said he simply did not have enough information to support approval. He added that there were still unanswered questions, such as what would happen if the filler ends up next to synovial tissue, or if it was used in patients with systemic sclerosis, or calcinosis cutis. “I respect that board-certified plastic surgeons, dermatologists, and hand surgeons are using this safely” in the hands, he said, but added that he was concerned that FDA approval could lead to widespread use by cosmetologists and mid-level practitioners.

FDA usually follows the recommendations of its advisory panels. The panelists had no disclosures.

If approved, Merz has plans for a postapproval, open-label study that would follow at least 100 patients after they receive hand augmentation with Radiesse for three years after their initial treatment, monitoring for adverse events and satisfaction with treatment.

emechcatie@frontlinemedcom.com

SILVER SPRING, MD. – Expanding the approval of the Radiesse dermal filler to include cosmetic improvement of the hands was supported by the majority of a Food and Drug Administration Advisory Panel, whose confidence in the risk-benefit profile was bolstered in part by wide off-label use in the United States and approval of this indication in other countries.

At a meeting of the FDA’s General and Plastic Surgery Devices Panel on Feb. 27, the panel voted 9-4, with one abstention, that the benefits of the dermal filler, marketed as Radiesse by Merz North America , outweighed its risks for the proposed indication, “hand augmentation to correct volume deficit in the hands.” Despite some issues with the US pivotal study, and the unavailability of data some panelists said would have been helpful, such as X-rays of treated hands to determine if the filler obscured imaging of bone, most of the panel also voted that there was “reasonable assurance” that it was effective (12-2) and that it was safe (11-3) for this use.

Issues raised by panelists included the need to better define patients who should not receive this treatment, further evaluation of possible adverse effects of treatment on hand function and strength, and evaluation of the filler in patients with severe volume deficit in the hands, who were not included in the study.

Voting in favor of approval, Dr. Karen Burke, a dermatologist at Mt. Sinai Medical Center, New York City, cited the long history of Radiesse use for the hands in many countries and in many patients in the United States. “I believe it is safe and that efficacy was demonstrated,” and that FDA approval is necessary so this use can be properly regulated and “we can teach people openly how to use it,” she said.

If approved, Radiesse – a semisolid dermal filler made of synthetic calcium hyroxyapatite suspended in a gel – would be the first dermal filler approved for hand augmentation. Merz describes it as a “durable” filler that is not permanent, and is broken down over several months.

Radiesse was approved in 2006 for subdermal implantation for correction of moderate to severe facial wrinkles and folds, and for restoration and/or correction of facial lipoatrophy that occurs in people with HIV. It has been approved for hand augmentation in 52 countries, including in Europe and Canada, and like other fillers, has been used off-label in the United States for this use. Fillers are regulated by the FDA as devices.

The US study, a prospective, 12-month study at 6 sites, randomized 85 patients to Radiesse (who received a maximum of 3 cc injected per hand), and 29 initially to no treatment, who served as controls. Responses were evaluated by clinicians who could not see the patient, using the Merz Hand Grading Scale (MGHS), a 5-point scale ranging from 0 (no loss of fatty tissue) to 5 (very severe loss of fatty tissue, marked visibility of veins and tendons), with an improvement of at least 1 considered clinically meaningful, according to Merz, which validated the scale before the pivotal study. Most hands at baseline were rated as 2 or 3 on the MGHS scale (moderate or severe loss of fatty tissue with mild or moderate visibility of veins or tendons); most were women, their mean age was 53-54 years, and most were white.

At three months, 75% in the Radiesse group had at least a 1 point improvement on the MGHS scale, the primary effectiveness endpoint, vs. 3.4% of controls, a statistically significant difference. Based on the Global Aesthetic Improvement Scale (GAIS) at three months, a secondary endpoint, 76% of treated hands were rated as “much “ or “very much improved” in appearance; none were rated as worse and 2% were rated as having not changed. Among those who did not have a second treatment, the effect was durable through 12 months

Patients recorded adverse events in a diary. The most common adverse event among treated patients, which included controls who opted for treatment after the three month period, was swelling, in 99%. Other common adverse events included pain (92%), redness and bruising (74%), difficulty performing activities (46%), and loss of sensation (18%); 6% had nodules.

Most of the adverse events were mild (61%) or moderate (35%); and most resolved without sequelae. Severe events included swelling, pain, and redness. No intervention was reported for 98% of adverse events, which lasted a mean of about 8 days, with 89% resolving within 14 days, according to Merz. There were no unanticipated events. (Over 12 years of experience with the use in the hand, swelling has been the most common adverse effect of treatment, according to Merz.)

In the study, 13 patients developed lumps, bumps and nodules, most were mild and none were severe and they resolved without intervention or sequelae. At the end of the study, no patients had a persistent granuloma. In three studies of 234 patients evaluating Radiesse in the hands, no granulomas have been reported, according to the company.

There were 8 severe recurrent adverse events in 7 patients: 5 reports of swelling, 1 report pf pain, 1 report of difficulty in performing activities, and 1 report of bruising.

FDA reviewers agreed that the clinical study appeared to meet the primary effectiveness endpoint, but pointed out that the amount of improvement varied between study sites. Among other issues they raised was the increased rate, severity, and duration of adverse events associated with treatment, particularly pain and swelling, which seemed to be higher and lasted longer than when Radiesse was used for the two facial indications. In addition, they indicated that the results of hand function tests were difficult to interpret.

Panelist Dr. Murad Alam, professor of dermatology, otolaryngology, and surgery, Northwestern University, Chicago, said there were some significant issues with the pivotal study, “but they do not undermine the overall conclusions” that treatment appeared to be safe and effective. The significant off-label use and experience elsewhere “was sufficient to sway me,” he added.

One of the panelists voting no on the risk-benefit question, Dr. Clayton Peimer, an orthopedic surgeon at Michigan State University, said he simply did not have enough information to support approval. He added that there were still unanswered questions, such as what would happen if the filler ends up next to synovial tissue, or if it was used in patients with systemic sclerosis, or calcinosis cutis. “I respect that board-certified plastic surgeons, dermatologists, and hand surgeons are using this safely” in the hands, he said, but added that he was concerned that FDA approval could lead to widespread use by cosmetologists and mid-level practitioners.

FDA usually follows the recommendations of its advisory panels. The panelists had no disclosures.

If approved, Merz has plans for a postapproval, open-label study that would follow at least 100 patients after they receive hand augmentation with Radiesse for three years after their initial treatment, monitoring for adverse events and satisfaction with treatment.

emechcatie@frontlinemedcom.com

SILVER SPRING, MD. – Expanding the approval of the Radiesse dermal filler to include cosmetic improvement of the hands was supported by the majority of a Food and Drug Administration Advisory Panel, whose confidence in the risk-benefit profile was bolstered in part by wide off-label use in the United States and approval of this indication in other countries.

At a meeting of the FDA’s General and Plastic Surgery Devices Panel on Feb. 27, the panel voted 9-4, with one abstention, that the benefits of the dermal filler, marketed as Radiesse by Merz North America , outweighed its risks for the proposed indication, “hand augmentation to correct volume deficit in the hands.” Despite some issues with the US pivotal study, and the unavailability of data some panelists said would have been helpful, such as X-rays of treated hands to determine if the filler obscured imaging of bone, most of the panel also voted that there was “reasonable assurance” that it was effective (12-2) and that it was safe (11-3) for this use.

Issues raised by panelists included the need to better define patients who should not receive this treatment, further evaluation of possible adverse effects of treatment on hand function and strength, and evaluation of the filler in patients with severe volume deficit in the hands, who were not included in the study.

Voting in favor of approval, Dr. Karen Burke, a dermatologist at Mt. Sinai Medical Center, New York City, cited the long history of Radiesse use for the hands in many countries and in many patients in the United States. “I believe it is safe and that efficacy was demonstrated,” and that FDA approval is necessary so this use can be properly regulated and “we can teach people openly how to use it,” she said.

If approved, Radiesse – a semisolid dermal filler made of synthetic calcium hyroxyapatite suspended in a gel – would be the first dermal filler approved for hand augmentation. Merz describes it as a “durable” filler that is not permanent, and is broken down over several months.

Radiesse was approved in 2006 for subdermal implantation for correction of moderate to severe facial wrinkles and folds, and for restoration and/or correction of facial lipoatrophy that occurs in people with HIV. It has been approved for hand augmentation in 52 countries, including in Europe and Canada, and like other fillers, has been used off-label in the United States for this use. Fillers are regulated by the FDA as devices.

The US study, a prospective, 12-month study at 6 sites, randomized 85 patients to Radiesse (who received a maximum of 3 cc injected per hand), and 29 initially to no treatment, who served as controls. Responses were evaluated by clinicians who could not see the patient, using the Merz Hand Grading Scale (MGHS), a 5-point scale ranging from 0 (no loss of fatty tissue) to 5 (very severe loss of fatty tissue, marked visibility of veins and tendons), with an improvement of at least 1 considered clinically meaningful, according to Merz, which validated the scale before the pivotal study. Most hands at baseline were rated as 2 or 3 on the MGHS scale (moderate or severe loss of fatty tissue with mild or moderate visibility of veins or tendons); most were women, their mean age was 53-54 years, and most were white.

At three months, 75% in the Radiesse group had at least a 1 point improvement on the MGHS scale, the primary effectiveness endpoint, vs. 3.4% of controls, a statistically significant difference. Based on the Global Aesthetic Improvement Scale (GAIS) at three months, a secondary endpoint, 76% of treated hands were rated as “much “ or “very much improved” in appearance; none were rated as worse and 2% were rated as having not changed. Among those who did not have a second treatment, the effect was durable through 12 months

Patients recorded adverse events in a diary. The most common adverse event among treated patients, which included controls who opted for treatment after the three month period, was swelling, in 99%. Other common adverse events included pain (92%), redness and bruising (74%), difficulty performing activities (46%), and loss of sensation (18%); 6% had nodules.

Most of the adverse events were mild (61%) or moderate (35%); and most resolved without sequelae. Severe events included swelling, pain, and redness. No intervention was reported for 98% of adverse events, which lasted a mean of about 8 days, with 89% resolving within 14 days, according to Merz. There were no unanticipated events. (Over 12 years of experience with the use in the hand, swelling has been the most common adverse effect of treatment, according to Merz.)

In the study, 13 patients developed lumps, bumps and nodules, most were mild and none were severe and they resolved without intervention or sequelae. At the end of the study, no patients had a persistent granuloma. In three studies of 234 patients evaluating Radiesse in the hands, no granulomas have been reported, according to the company.

There were 8 severe recurrent adverse events in 7 patients: 5 reports of swelling, 1 report pf pain, 1 report of difficulty in performing activities, and 1 report of bruising.

FDA reviewers agreed that the clinical study appeared to meet the primary effectiveness endpoint, but pointed out that the amount of improvement varied between study sites. Among other issues they raised was the increased rate, severity, and duration of adverse events associated with treatment, particularly pain and swelling, which seemed to be higher and lasted longer than when Radiesse was used for the two facial indications. In addition, they indicated that the results of hand function tests were difficult to interpret.

Panelist Dr. Murad Alam, professor of dermatology, otolaryngology, and surgery, Northwestern University, Chicago, said there were some significant issues with the pivotal study, “but they do not undermine the overall conclusions” that treatment appeared to be safe and effective. The significant off-label use and experience elsewhere “was sufficient to sway me,” he added.

One of the panelists voting no on the risk-benefit question, Dr. Clayton Peimer, an orthopedic surgeon at Michigan State University, said he simply did not have enough information to support approval. He added that there were still unanswered questions, such as what would happen if the filler ends up next to synovial tissue, or if it was used in patients with systemic sclerosis, or calcinosis cutis. “I respect that board-certified plastic surgeons, dermatologists, and hand surgeons are using this safely” in the hands, he said, but added that he was concerned that FDA approval could lead to widespread use by cosmetologists and mid-level practitioners.

FDA usually follows the recommendations of its advisory panels. The panelists had no disclosures.

If approved, Merz has plans for a postapproval, open-label study that would follow at least 100 patients after they receive hand augmentation with Radiesse for three years after their initial treatment, monitoring for adverse events and satisfaction with treatment.

emechcatie@frontlinemedcom.com

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

NEW ORLEANS – Identifying the right treatment for each type of acne scar and using a combination of modalities can yield the best results, according to Dr. Jennifer Chwalek.

Multiple safe, effective, and cost-effective options are available for the treatment of acne scarring, Dr. Chwalek said at the annual meeting of the American Academy of Cosmetic Surgery.

“These techniques are often underutilized, but they’re very easy to put into practice,” Dr. Chwalek said. “With laser resurfacing techniques, they can add to patient improvement and better outcomes.”

Acne is the most common skin disorder in the United States, affecting an estimated 40-50 million people, and by their mid-teens, more than 40% of Americans have had acne accompanied by some scarring, said Dr. Chwalek. The appearance of these scars often worsens and becomes more prominent with aging, she added.

Acne scars are classified by their morphology as ice-pick scars, boxcar scars, and rolling scars. Different categories of scars require different approaches to minimize their appearance and maximize patient satisfaction, said Dr. Chwalek of Mount Sinai Medical Center in New York. Ice pick scars are characterized by small, deep holes in the skin with a wide opening and a narrow base. Boxcar scars present as square or U-shaped depressions in the skin. Scar morphology is a key driver of treatment options; ice pick and boxcar scars can be treated surgically through punch excisions, grafts, and elevation, and through the chemical reconstruction of skin scars technique, Dr. Chwalek said. Skin resurfacing procedures such as chemical peels, dermabrasion, and ablative and nonablative laser resurfacing can also be used to address acne scars. “However, lasers cannot always penetrate deep enough to address deep ice pick and boxcar scars; as a result, outcomes from laser treatments really fall short of our expectations,” she said.

With a punch excision, the acne scar is surgically removed through a punch matching the size of the scar (ideally 1.5-3.5 mm), and the remaining wound is sealed. Punch excision is ideal for deep ice pick scars and narrow, deep boxcar scars (<3 mm), said Dr. Chwalek. “As scars become larger, it is often better to treat with elliptical excision – otherwise you risk contour deformities,” she advised.

The punch elevation method is best for shallow and deep boxcar scars, Dr. Chwalek said. Scars treated with this method should have sharp edges, so the center of the scar can be elevated to the level of the surrounding tissue and reattached by a suture, Steri-Strips thin adhesive strips, or 2-octyl cyanoacrylate glue. Punch elevation brings scars up to the surface level of the skin, making them appear less noticeable, she said.

Punch grafting is an option to treat very deep, large, and more atrophic scars, Dr. Chwalek said. Skin that is not cosmetically sensitive is ideal for this method, and pre- or postauricular skin is typically utilized. However, there is a risk of textural or color mismatch when using this method, Dr. Chwalek noted

For deep acne scars, punch excision, elevation, and grafting are particularly effective when combined with laser resurfacing. “Combining surgical approaches with laser can really result in improvement for the patients,” said Dr. Chwalek.

Histologically, acne scars show a reduction in collagen and elastin. “Chemical reconstruction of skin scars [CROSS] is a technique of applying high concentrations of trichloroacetic acid [TCA] to atrophic ice pick scars to induce inflammation and collagen production,” Dr. Chwalek explained. The CROSS method causes coagulative epidermal necrosis and collagen necrosis in the papillary and upper reticular dermis, resulting in scar remodeling over time.

With the CROSS method, a 50%-100% concentration of TCA should be utilized. The skin should be held taut, and the acid applied directly to the scar using a toothpick or sharp wooden applicator, Dr. Chwalek emphasized. “It’s very important to keep the TCA isolated to the acne scar – if it spills out to the surrounding area, this may result in a potentially larger scar for the patient,” she explained. Higher concentrations of TCA have been shown to be more effective at modifying deeper scars, and typically result in greater patient satisfaction with no significant complications, she added.

Frosting will occur at the site of treatment within 10-15 seconds, crusting will be observed 3 days post treatment, and after a week, the site of treatment will be fully resolved. It is crucial to warn darker-skinned patients of the risk of transient postinflammatory hypopigmentation as a result of the CROSS method, although this resolves within weeks of treatment. “It is also important to make patients aware of downtime associated with CROSS,” she added. “One week after treatment, they may still have crusting.”

“Patients who come to you for acne scarring are really anxious to see improvement,” said Dr. Chwalek, so it is imperative to address patient expectations and to explain that the treatment of acne scars is a gradual process. “It is important to let patients know that it’s going to take multiple treatments to get them to where they want to be,” she added.

Dr. Chwalek reported no relevant financial disclosures.

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

A 30-year-old woman cuts her finger on a glass jar. She goes to the clinic and needs to have sutures on her right ring finger. What would you recommend for anesthesia to prepare the patient for repair?

A. 1% lidocaine.

B. 1% lidocaine with epinephrine.

C. Bupivacaine.

Myth: You should not use lidocaine with epinephrine on a digit.

Many of us were taught to avoid the use of epinephrine on digits because of the concern of precipitating digital ischemia. This was a common warning in emergency and surgical textbooks (J.C. Vance. Anesthesia. R.K. Roenigk, H.H. Roenigk [Eds.], Dermatologic Surgery, Principles and Practice [2nd ed.], Marcel Decker, New York, N.Y. [1996], pp. 31-52.).

Over the past 20 years, there has been a growing body of evidence that the concern is unwarranted and that there may be benefit to the addition of epinephrine.

Dr. Bradon J. Wilhelmi and his colleagues performed a randomized, double-blind trial comparing lidocaine with epinephrine (31 patients) and lidocaine (29 patients) in patients with traumatic injuries or elective procedures (Plast. Reconstr. Surg. 2001;107:393-7). The need for control of bleeding required digital tourniquet use in 20 of 29 block procedures with plain lidocaine and in 9 of 31 procedures using lidocaine with epinephrine (P < .002). There were no complications in the patients who received lidocaine with epinephrine.

A retrospective study was done by Dr. Saeed Chowdhry and his colleagues of 1,111 patients who had hand surgery and received digital blocks (Plast. Reconstr. Surg. 2010;126:2031-4). A total of 611 patients received lidocaine with epinephrine, and 500 patients received lidocaine alone. The concentration of lidocaine with epinephrine was 1:100,000, with an average dose of 4.33 cc.

There were no cases of digital gangrene or other complications because of the use of epinephrine in this retrospective study.

In a large, retrospective study of nine hand surgeons’ practices, looking at 3,110 cases of elective injection of low-dose epinephrine in hands and fingers, there were no cases of digital tissue loss or need for phentolamine rescue (J. Hand Surg. Am. 2005;30:1061-7).

Several studies have been done using epinephrine digital injections of the toes. In a prospective, randomized, controlled trial, 44 patients undergoing phenolization matricectomy involving digital block injection of 70 toes received either anesthetic and epinephrine or anesthetic and digital tourniquet (J. Eur. Acad. Dermatol. Venereol. 2014 [doi:10.1111/jdv.12746]). The outcome measures were rate of recurrence, bleeding, pain, and duration of anesthetic effect.

There was no difference in recurrence rates, but postoperative bleeding was higher in the procedures done with digital tourniquet and no epinephrine (P = .001). Anesthetic effect as measured by less pain and duration of effect was superior in the patients receiving digital block with epinephrine (P = .001).

In another study looking at chemical matricectomy, Dr. Cevdet Altinyazar and his colleagues randomized patients to receive either 2% lidocaine or lidocaine with epinephrine for anesthesia for chemical matricectomy of ingrown toenails of the great toe (Dermatol. Surg. 2010;36:1568-71). There was less anesthetic needed in the patients who received lidocaine with epinephrine, and a statistically significant reduction in days of drainage following procedure in the lidocaine with epinephrine group (11.1 days +/- 2.5 days), compared with the lidocaine-only group (19.0 days +/- 3.8 days). There were no complications because of the use of epinephrine.

The belief in this myth is still quite common, despite the evidence from randomized, controlled trials and the experience of more than 3,500 patients who have received epinephrine in the fingers without any complications. The evidence from the podiatry literature on safety in use in the toes mirrors the evidence of safety in the fingers.

Dr. Paauw is a professor of medicine in the division of general internal medicine at the University of Washington, Seattle, and he serves as third-year medical student clerkship director at the University of Washington Medical School. He is the Rathmann Family Foundation Chair in Patient-Centered Clinical Education. Contact Dr. Paauw at dpaauw@uw.edu.

NEW ORLEANS – Patients must be psychologically stable to tolerate laser resurfacing procedures, according to Dr. Ronald L. Moy, a board-certified cosmetic surgeon and dermatologist.

“It’s difficult for patients to go through a laser resurfacing, because the skin on their face will look bad for 3 to 4 days, compared to a facelift where things are hidden behind an ear, sutures are neat, and there is very little bleeding,” Dr. Moy said at the annual meeting of the American Academy of Cosmetic Surgery. “Out of all the procedures that we do, it is perhaps most important to screen patients prior to resurfacing procedures.”

It is important to get to know patients and to become familiar with issues that bother them about their appearance. Patient concerns such as skin wrinkling, lax brows, asymmetry, and brow positioning should be discussed. “We as physicians tend to lecture people, but the consultation is the time to get to know them – this is the time you might find out how fragile someone is,” said Dr. Moy, who is based in Beverly Hills, Calif.

Having another person in the room might be beneficial, and the use of a mirror can aid in getting patients to talk about skin concerns such as wrinkle lines. “What really bothers them might not be what really bothers us,” he advised. “So these tools can be valuable in addressing the issues that arise from a communication gap.”

Stretching the skin, particularly around the mouth, can simulate the outcome of some laser resurfacing procedures. Simulation programs and before/after photographs also can be used to manage patients’ expectations. It is important to also show photos of results that are not ideal, Dr. Moy advised.

“It’s always better to undertreat and do the procedure again, and to even do a free treatment if you have to, than it is to overtreat and give the patient a scar.” Showing a photograph of your best work might sell the procedure to a patient, but it is important to prepare patients by showing them an average result as well, he added.

Having the patient lie back can simulate blepharoplasty by causing the fat pads to fall backward and flatten. This method is not ideal to simulate the results of laser resurfacing but can be beneficial when procedures are being combined. “In truth, laser resurfacing is usually done with another procedure,” Dr. Moy said. “In my practice, the most common scenario is laser resurfacing and an isolated neck lift, as the popularity of facelifts seems to be decreasing.”

“After you listen to the patient, it’s time to explain to them what the process is going to be like and to warn them of the risk of depression on day 2 or 3 after a resurfacing procedure,” Dr. Moy recommended.

Patient medical history to consider includes any physical or psychological diagnosis, history of medication (over-the-counter, prescription, and herbal), allergies, history of scarring, tolerance for local anesthesia, recent sun exposure (natural or artificial), recent resurfacing procedures (laser, chemical, and/or mechanical), history of herpes simplex (cold sore), current skin care regimen, radiation exposure, and history of tattoo in the area to be treated.

History of isotretinoin (Accutane) also should be discussed. Evidence in the literature of isotretinoin suggests use causing scarring after a resurfacing procedure, so it might be best to advise patients to discontinue its use for several months before resurfacing, he advised.

Certain patients should be ruled out when it comes to laser resurfacing, Dr. Moy stressed. These patients include those who are psychologically unstable, have a history of money troubles, and threaten lawsuits. In addition, avoid rude, unfriendly patients who talk negatively about other surgeons. Patients who do not smile or make eye contact also might be poor candidates, although that isn’t always an accurate assumption, he added.

Other patients to avoid include those who do not listen and only talk, and patients who “know more” than the surgeon. “Often, patients will try to lecture the surgeon based on what they’ve researched on the Internet,” he said. Additionally, those who request surgeries normally reserved for older patients, patients with unrealistic expectations, and those seeking to have surgery for the wrong reasons, such as saving a marriage, should be avoided, Dr. Moy said.

Social factors to consider include a patient’s work and living situation, hygiene, and history of medications, particularly antidepressants. But perhaps most paramount is a patient’s ability to cope, Dr. Moy said. “In the end, screening a new candidate for a laser resurfacing procedure is really about getting to know them, and also using and trusting your gut instinct,” he added.

Dr. Moy reported no relevant financial disclosures.

sknews@frontlinemedcom.com

NEW ORLEANS – Patients must be psychologically stable to tolerate laser resurfacing procedures, according to Dr. Ronald L. Moy, a board-certified cosmetic surgeon and dermatologist.

“It’s difficult for patients to go through a laser resurfacing, because the skin on their face will look bad for 3 to 4 days, compared to a facelift where things are hidden behind an ear, sutures are neat, and there is very little bleeding,” Dr. Moy said at the annual meeting of the American Academy of Cosmetic Surgery. “Out of all the procedures that we do, it is perhaps most important to screen patients prior to resurfacing procedures.”

It is important to get to know patients and to become familiar with issues that bother them about their appearance. Patient concerns such as skin wrinkling, lax brows, asymmetry, and brow positioning should be discussed. “We as physicians tend to lecture people, but the consultation is the time to get to know them – this is the time you might find out how fragile someone is,” said Dr. Moy, who is based in Beverly Hills, Calif.

Having another person in the room might be beneficial, and the use of a mirror can aid in getting patients to talk about skin concerns such as wrinkle lines. “What really bothers them might not be what really bothers us,” he advised. “So these tools can be valuable in addressing the issues that arise from a communication gap.”

Stretching the skin, particularly around the mouth, can simulate the outcome of some laser resurfacing procedures. Simulation programs and before/after photographs also can be used to manage patients’ expectations. It is important to also show photos of results that are not ideal, Dr. Moy advised.

“It’s always better to undertreat and do the procedure again, and to even do a free treatment if you have to, than it is to overtreat and give the patient a scar.” Showing a photograph of your best work might sell the procedure to a patient, but it is important to prepare patients by showing them an average result as well, he added.

Having the patient lie back can simulate blepharoplasty by causing the fat pads to fall backward and flatten. This method is not ideal to simulate the results of laser resurfacing but can be beneficial when procedures are being combined. “In truth, laser resurfacing is usually done with another procedure,” Dr. Moy said. “In my practice, the most common scenario is laser resurfacing and an isolated neck lift, as the popularity of facelifts seems to be decreasing.”

“After you listen to the patient, it’s time to explain to them what the process is going to be like and to warn them of the risk of depression on day 2 or 3 after a resurfacing procedure,” Dr. Moy recommended.

Patient medical history to consider includes any physical or psychological diagnosis, history of medication (over-the-counter, prescription, and herbal), allergies, history of scarring, tolerance for local anesthesia, recent sun exposure (natural or artificial), recent resurfacing procedures (laser, chemical, and/or mechanical), history of herpes simplex (cold sore), current skin care regimen, radiation exposure, and history of tattoo in the area to be treated.

History of isotretinoin (Accutane) also should be discussed. Evidence in the literature of isotretinoin suggests use causing scarring after a resurfacing procedure, so it might be best to advise patients to discontinue its use for several months before resurfacing, he advised.

Certain patients should be ruled out when it comes to laser resurfacing, Dr. Moy stressed. These patients include those who are psychologically unstable, have a history of money troubles, and threaten lawsuits. In addition, avoid rude, unfriendly patients who talk negatively about other surgeons. Patients who do not smile or make eye contact also might be poor candidates, although that isn’t always an accurate assumption, he added.

Other patients to avoid include those who do not listen and only talk, and patients who “know more” than the surgeon. “Often, patients will try to lecture the surgeon based on what they’ve researched on the Internet,” he said. Additionally, those who request surgeries normally reserved for older patients, patients with unrealistic expectations, and those seeking to have surgery for the wrong reasons, such as saving a marriage, should be avoided, Dr. Moy said.

Social factors to consider include a patient’s work and living situation, hygiene, and history of medications, particularly antidepressants. But perhaps most paramount is a patient’s ability to cope, Dr. Moy said. “In the end, screening a new candidate for a laser resurfacing procedure is really about getting to know them, and also using and trusting your gut instinct,” he added.

Dr. Moy reported no relevant financial disclosures.

sknews@frontlinemedcom.com

NEW ORLEANS – Patients must be psychologically stable to tolerate laser resurfacing procedures, according to Dr. Ronald L. Moy, a board-certified cosmetic surgeon and dermatologist.

“It’s difficult for patients to go through a laser resurfacing, because the skin on their face will look bad for 3 to 4 days, compared to a facelift where things are hidden behind an ear, sutures are neat, and there is very little bleeding,” Dr. Moy said at the annual meeting of the American Academy of Cosmetic Surgery. “Out of all the procedures that we do, it is perhaps most important to screen patients prior to resurfacing procedures.”

It is important to get to know patients and to become familiar with issues that bother them about their appearance. Patient concerns such as skin wrinkling, lax brows, asymmetry, and brow positioning should be discussed. “We as physicians tend to lecture people, but the consultation is the time to get to know them – this is the time you might find out how fragile someone is,” said Dr. Moy, who is based in Beverly Hills, Calif.

Having another person in the room might be beneficial, and the use of a mirror can aid in getting patients to talk about skin concerns such as wrinkle lines. “What really bothers them might not be what really bothers us,” he advised. “So these tools can be valuable in addressing the issues that arise from a communication gap.”

Stretching the skin, particularly around the mouth, can simulate the outcome of some laser resurfacing procedures. Simulation programs and before/after photographs also can be used to manage patients’ expectations. It is important to also show photos of results that are not ideal, Dr. Moy advised.

“It’s always better to undertreat and do the procedure again, and to even do a free treatment if you have to, than it is to overtreat and give the patient a scar.” Showing a photograph of your best work might sell the procedure to a patient, but it is important to prepare patients by showing them an average result as well, he added.

Having the patient lie back can simulate blepharoplasty by causing the fat pads to fall backward and flatten. This method is not ideal to simulate the results of laser resurfacing but can be beneficial when procedures are being combined. “In truth, laser resurfacing is usually done with another procedure,” Dr. Moy said. “In my practice, the most common scenario is laser resurfacing and an isolated neck lift, as the popularity of facelifts seems to be decreasing.”

“After you listen to the patient, it’s time to explain to them what the process is going to be like and to warn them of the risk of depression on day 2 or 3 after a resurfacing procedure,” Dr. Moy recommended.

Patient medical history to consider includes any physical or psychological diagnosis, history of medication (over-the-counter, prescription, and herbal), allergies, history of scarring, tolerance for local anesthesia, recent sun exposure (natural or artificial), recent resurfacing procedures (laser, chemical, and/or mechanical), history of herpes simplex (cold sore), current skin care regimen, radiation exposure, and history of tattoo in the area to be treated.

History of isotretinoin (Accutane) also should be discussed. Evidence in the literature of isotretinoin suggests use causing scarring after a resurfacing procedure, so it might be best to advise patients to discontinue its use for several months before resurfacing, he advised.

Certain patients should be ruled out when it comes to laser resurfacing, Dr. Moy stressed. These patients include those who are psychologically unstable, have a history of money troubles, and threaten lawsuits. In addition, avoid rude, unfriendly patients who talk negatively about other surgeons. Patients who do not smile or make eye contact also might be poor candidates, although that isn’t always an accurate assumption, he added.

Other patients to avoid include those who do not listen and only talk, and patients who “know more” than the surgeon. “Often, patients will try to lecture the surgeon based on what they’ve researched on the Internet,” he said. Additionally, those who request surgeries normally reserved for older patients, patients with unrealistic expectations, and those seeking to have surgery for the wrong reasons, such as saving a marriage, should be avoided, Dr. Moy said.

Social factors to consider include a patient’s work and living situation, hygiene, and history of medications, particularly antidepressants. But perhaps most paramount is a patient’s ability to cope, Dr. Moy said. “In the end, screening a new candidate for a laser resurfacing procedure is really about getting to know them, and also using and trusting your gut instinct,” he added.

Dr. Moy reported no relevant financial disclosures.

sknews@frontlinemedcom.com