Cosmetic Dermatology · Cosmetic Dermatology 2009 2 Update on Laser Resurfacing, Fillers, and Botulinum Toxin 5 Managing Fat and Cellulite: Current State of the Field 8 Avoiding Dermal

A Supplement to

Skin & Allergy News® Skin Disease

Education Foundation

Roundup onCosmetic Dermatology

2 0 0 9

2 Update on Laser Resurfacing, Fillers, and Botulinum Toxin

5 Managing Fat and Cellulite: Current State of the Field

8 Avoiding Dermal Filler Pitfalls Begins With a Mirror

10 Single Laser Tx Reduced Perioral Wrinkles

10 Fractional Laser Therapy Found Effective for Hands

TOPIC HIGHLIGHTS:

GUEST EDITORS:David J. Goldberg,

M.D., J.D.Clinical Professor of Dermatology

Director, Laser Research and Mohs Surgery

Mount Sinai School of MedicineAdjunct Professor of Law

Fordham Law SchoolNew York, N.Y.

Director, Skin Laser & SurgerySpecialists of New York/New Jersey

New York, N.Y.

Christopher B. Zachary,M.B.B.S., F.R.C.P.

Chair and Clinical Professor Department of Dermatology

Co-Director, Dermatologic Surgery andLaser Center

University of California at Irvine

Produced in affiliation with the 33rd Hawaii Dermatology SeminarTM and the Cosmetic Dermatology Seminar 2009TM.

CosDer(SA0040_15)3.qxd 4/17/2009 12:03 AM Page 1

President, Elsevier/IMNGAlan J. Imhoff

Sales Director, IMNGMark E. Altier

National Account ManagerSally Cioci

Director,Production/ManufacturingYvonne Evans

Production ManagerJudi Sheffer

Designer Lisa M. Marfori

Roundup on Cosmetic Dermatology 2009was produced by the customizedpublication department ofElsevier/International Medical NewsGroup. The ideas and opinions expressedin the interview articles in thissupplement do not necessarily reflect theviews of the Publisher or Skin DiseaseEducation Foundation.

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Skin & Allergy News®

The field of cosmetic dermatology has evolvedon several fronts in recent years. Three areasthat have attracted considerable attention are

laser fractional resurfacing, fillers, and botulinumtoxin.

Fractional resurfacing has taken standard ablativelasers and brought them into the 21st century withtechnologic modifications and enhancements thatgive cosmetic dermatologists the tools to achieve dy-namic results with respect to skin rejuvenation andskin tightening. Moreover, the results can be achievedwith minimal risk to the patient.

Carbon dioxide (CO2), erbium yttrium aluminiumgarnet (YAG), and erbium yttrium scandium gallium garnet (YSGG) lasers all havemodels developed for fractional resurfacing. Fractionated delivery of laser ener-gy has greatly reduced the amount of skin surface area that must be treated toachieve the desired results. Older lasers treated 100% of the skin surface in a flat,two-dimensional orientation. Fractional lasers treat about 60% of the skin sur-face in a vertically oriented approach to ablation.1

During a treatment session, a fractional laser creates millions of microscopicholes in the skin, involving both the epidermis and superficial dermis. However,the lasers also offer the capability to penetrate to a depth greater than 1 mm, whichhas been shown to achieve long-lasting benefits in terms of skin tightening andrejuvenation. The lasers give cosmetic dermatologists unprecedented capabilityto tailor the treatment and the results to the individual needs of a patient.

From an anatomic and physiologic perspective, the laser light passes throughthe skin surface and is preferentially absorbed by the water in the age- and envi-ronment-damaged collagen beneath the surface. The process enables the removalof very fine layers of skin, diminishing wrinkles and other unwanted textures.As new cells form during the healing process, the wrinkled and damaged skin isreplaced by skin that is smoother, softer, and younger looking. Fractional laserrejuvenation not only removes wrinkles and evens skin tone, but also instigatesthe growth of new collagen.2

The machines can be used to achieve overall improvement in skin texture ortargeted to the treatment of isolated areas, including the hands, chest, and neck.

Fractional lasers provide consistent, predictable results controlled by the op-erator and requires less recovery time compared with more invasive proceduresused to achieve skin rejuvenation. Depending upon the type of procedure per-formed, the recovery time can vary from a few days to a little more than a week.

Few areas of cosmetic dermatology can match the filler field with its ongoingresearch and development. The filler market has undergone rapid expansion inthe past few years, challenging the clinicians' ability to remain abreast of the lat-est developments and newest products that have become available. Expansion ofthe filler market increases the likelihood that a patient can find the right productto meet specific needs and goals.

During the past year, a new porcine collagen filler has become available in the Unit-ed States, representing an important addition to the options for filling wrinkles.3

Several other new fillers will likely become available over the course of the nextyear. Research continues to produce new candidate fillers at a steady pace, par-ticularly in the area of hyaluronic acid fillers. Moreover, several fillers have been

Update on LaserResurfacing, Fillers, andBotulinum Toxin

David J. Goldberg, M.D., J.D.

Continued on page 6


BASELINE 24 WEEKS

RENOVA 0.02% is indicated as an adjunctive agent for use in the mitigation (palliation) of fi ne facial wrinkles in patients who use comprehensive skin care and sunlight avoidance programs. RENOVA 0.02% does not eliminate wrinkles, repair sun-damaged skin, reverse photoaging, or restore more youthful or younger skin. The safety and effi cacy of using RENOVA 0.02% daily for greater than 12 months have not been established. RENOVA 0.02% is proven effective on lightly pigmented skin, Fitzpatrick skin types l, ll, and lll. Do not use RENOVA 0.02% if the patient is taking drugs known to be photosensitizers, pregnant, attempting pregnancy, or nursing. RENOVA 0.02% is a dermal irritant. Almost all patients experience skin reactions, including dryness, peeling, burning/stinging, erythema, and itching. In some patients, this may be severe.

Please see Brief Prescribing Information on the next page.1. Nyirady J, Grossman R. Evaluation of the cumulative irritation potential of tretinoin: review of 2 clinical studies. Cosmetic Dermatol. 2002;15(7):33–36.

RENOVA is a registered trademark of OrthoNeutrogena™. © 2008 OrthoNeutrogena 08DD0147 8/08 Printed in USA ONLY FROM

First wrinkle.First home. First visit.

First choice.

For your fi rst-time retinoid patients, RENOVA delivers retinoid effi cacy with less irritation.1

All photographs are completely unretouched. Results are after 24 weeks’ treatment with RENOVA 0.02% and a comprehensive skin care program including sun protection. Results may vary.

Fi


© 2005 OrthoNeutrogena 05DD0022 2/05 Printed in USA

FOR TOPICAL USE ON THE FACE. NOT FOROPHTHALMIC,

ORAL, OR INTRAVAGINAL USE.

Brief SummaryRENOVA (tretinoin cream) 0.02% contains theactive ingredient tretinoin in a cream base.

IMPORTANT NOTE — This information is aBRIEF SUMMARY of the complete prescrib-ing information provided with the productand therefore should not be used as thebasis for prescribing the product. This sum-mary was prepared by deleting from thecomplete prescribing information certaintext, tables, and references. The physicianshould be thoroughly familiar with the com-plete prescribing information before pre-scribing the product.

INDICATIONS AND USAGE:(To understand fully the indication for this prod-uct, please read the entire INDICATIONS ANDUSAGE section of the labeling.)RENOVA (tretinoin cream) 0.02% is indicatedas an adjunctive agent (see second bullet pointbelow) for use in the mitigation (palliation) offine facial wrinkles in patients who use compre-hensive skin care and sunlight avoidance pro-grams. RENOVA DOES NOT ELIMINATEWRINKLES, REPAIR SUN-DAMAGED SKIN,REVERSE PHOTOAGING, or RESTOREMORE YOUTHFUL or YOUNGER SKIN. Indouble-blinded, vehicle-controlled clinicalstudies, many patients in the vehicle groupachieved desired palliative effects on fine wrin-kling of facial skin with the use of comprehen-sive skin care and sunlight avoidance programsincluding sunscreens, protective clothing, andnon-prescription emollient creams.

RENOVA 0.02% has NOT DEMONSTRATED AMITIGATING EFFECT on significant signs ofchronic sunlight exposure such as coarse ordeep wrinkling, tactile roughness, mottledhyperpigmentation, lentigines, telangiectasia,skin laxity, keratinocytic atypia, melanocyticatypia, or dermal elastosis.

RENOVA should be used under medical super-vision as an adjunct to a comprehensive skincare and sunlight avoidance program thatincludes the use of effective sunscreens (mini-mum SPF of 15) and protective clothing.

Patients with visible actinic keratoses andpatients with a history of skin cancer wereexcluded from clinical trials of RENOVA 0.02%.Thus the effectiveness and safety of RENOVA0.02% in these populations are not known atthis time.

Neither the safety nor the effectiveness ofRENOVA for the prevention or treatment ofactinic keratoses or skin neoplasms hasbeen established.

Neither the safety nor the efficacy of usingRENOVA 0.02% daily for greater than 52 weekshas been established, and daily use beyond52 weeks has not been systematically andhistologically investigated in adequate and well-controlled trials. (See WARNINGS section.)

CONTRAINDICATIONS:This drug is contraindicated in individuals with ahistory of sensitivity reactions to any of its compo-nents. It should be discontinued if hypersensitivityto any of its ingredients is noted.

WARNINGS:RENOVA 0.02% is a dermal irritant, and theresults of continued irritation of the skin forgreater than 52 weeks in chronic use withRENOVA are not known. There is evidence ofatypical changes in melanocytes and ker-atinocytes and of increased dermal elastosis insome patients treated with RENOVA 0.05% forlonger than 48 weeks. The significance of thesefindings and their relevance for RENOVA0.02% are unknown.

RENOVA should not be administered ifthe patient is also taking drugs known to bephotosensitizers (e.g., thiazides, tetracy-clines, fluoroquinolones, phenothiazines, sul-fonamides) because of the possibility of aug-mented phototoxicity.

Exposure to sunlight (including sunlamps) shouldbe avoided or minimized during use of RENOVAbecause of heightened sunburn susceptibility.Patients should be warned to use sunscreens(minimum SPF of 15) and protective clothingwhen using RENOVA. Patients with sunburnshould be advised not to use RENOVA until fullyrecovered. Patients who may have considerablesun exposure, e.g., due to their occupation, andthose patients with inherent sensitivity to sunlightshould exercise caution when using RENOVA andfollow the precautions outlined in the PatientPackage Insert.

RENOVA should be kept out of the eyes,mouth, angles of the nose, and mucous mem-branes. Topical use may cause severe localerythema, pruritus, burning, stinging, and peel-ing at the site of application. If the degree oflocal irritation warrants, patients should bedirected to use less medication, decrease thefrequency of application, discontinue use tem-porarily, or discontinue use altogether and con-sider additional appropriate therapy.

Tretinoin has been reported to cause severe irrita-tion on eczematous skin and should be used onlywith caution in patients with this condition.

Application of larger amounts of medication thanrecommended has not been shown to lead tomore rapid or better results, and marked redness,peeling, or discomfort may occur.

PRECAUTIONS:General: RENOVA should be used only as anadjunct to a comprehensive skin care and sunlightavoidance program. (See INDICATIONS ANDUSAGE section.)

If a drug sensitivity, chemical irritation, or a sys-temic adverse reaction develops, use of RENOVAshould be discontinued.

Weather extremes, such as wind or cold, maybe more irritating to patients using tretinoin-containing products.

Information for Patients: See PatientPackage Insert

Drug Interactions: Concomitant topical med-ications, medicated or abrasive soaps, shampoos,cleansers, cosmetics with a strong dryingeffect, products with high concentrations ofalcohol, astringents, spices or lime, permanentwave solutions, electrolysis, hair depilatories orwaxes, and products that may irritate the skinshould be used with caution in patients beingtreated with RENOVA because they mayincrease irritation with RENOVA.

RENOVA should not be administered if the patientis also taking drugs known to be photosensitizers(e.g., thiazides, tetracyclines, fluoroquinolones,phenothiazines, sulfonamides) because of the pos-sibility of augmented phototoxicity.

Carcinogenesis, Mutagenesis, Impairment ofFertility: In a 91-week dermal study in which CD-1mice were administered 0.017% and 0.035% for-mulations of tretinoin, cutaneous squamous cellcarcinomas and papillomas in the treatment areawere observed in some female mice. These con-centrations are near the tretinoin concentration ofthis clinical formulation (0.02%). A dose-relatedincidence of liver tumors in male mice wasobserved at those same doses. The maximumsystemic doses associated with the 0.017% and0.035% formulations are 0.5 and 1.0 mg/kg/day.These doses are 10 and 20 times the maximumhuman systemic dose, when adjusted for totalbody surface area. The biological significance ofthese findings is not clear because they occurredat doses that exceeded the dermal maximally tol-erated dose (MTD) of tretinoin and because theywere within the background natural occurrencerate for these tumors in this strain of mice. Therewas no evidence of carcinogenic potential when0.025 mg/kg/day of tretinoin was administeredtopically to mice (0.5 times the maximum humansystemic dose, adjusted for total body surfacearea). For purposes of comparisons of the animalexposure to systemic human exposure, the maxi-mum human systemic dose is defined as 1 gram of0.02% RENOVA applied daily to a 50 kg person(0.004 mg tretinoin/kg body weight).

Studies in hairless albino mice suggest that con-

current exposure to tretinoin may enhance thetumorigenic potential of carcinogenic doses ofUVB and UVA light from a solar simulator. Thiseffect has been confirmed in a later study in pig-mented mice, and dark pigmentation did notovercome the enhancement of photocarcino-genesis by 0.05% tretinoin. Although the signifi-cance of these studies to humans is not clear,patients should minimize exposure to sunlight orartificial ultraviolet irradiation sources.

The mutagenic potential of tretinoin was evaluatedin the Ames assay and in the in vivo mousemicronucleus assay, both of which were negative.

In dermal Segment I fertility studies in rats, slight(not statistically significant) decreases in spermcount and motility were seen at 0.5 mg/kg/day (20times the maximum human systemic dose adjust-ed for total body surface area), and slight (not sta-tistically significant) increases in the number andpercent of nonviable embryos in females treatedwith 0.25 mg/kg/day (10 times the maximumhuman systemic dose adjusted for total body sur-face area) and above were observed. A dermalSegment III study with RENOVA has not been per-formed in any species. In oral Segment I andSegment III studies in rats with tretinoin, decreasedsurvival of neonates and growth retardation wereobserved at doses in excess of 2 mg/kg/day (83times the human topical dose adjusted for totalbody surface area).

Pregnancy:Teratogenic effects: Pregnancy Category C.ORAL tretinoin has been shown to be teratogenic inrats, mice, rabbits, hamsters, and subhuman pri-mates. It was teratogenic and fetotoxic in Wistarrats when given orally or topically in doses greaterthan 1 mg/kg/day (42 times the maximum humansystemic dose normalized for total body surfacearea). However, variations in teratogenic dosesamong various strains of rats have been reported.In the cynomolgus monkey, which, metabolically, iscloser to humans for tretinoin than the other speciesexamined, fetal malformations were reported atdoses of 10 mg/kg/day or greater, but none wereobserved at 5 mg/kg/day (417 times the maximumhuman systemic dose adjusted for total body sur-face area), although increased skeletal variationswere observed at all doses. A dose-related increasein embryolethality and abortion was reported.Similar results have also been reported in pigtailmacaques.

TOPICAL tretinoin in animal teratogenicity tests hasgenerated equivocal results. There is evidence forteratogenicity (shortened or kinked tail) of topicaltretinoin in Wistar rats at doses greater than1 mg/kg/day (42 times the maximum humansystemic dose adjusted for total body surfacearea). Anomalies (humerus: short 13%, bent 6%,os parietal incompletely ossified 14%) havealso been reported when 10 mg/kg/day was der-mally applied.

There are other reports in New Zealand White rab-bits administered doses of greater than 0.2mg/kg/day (17 times the maximum human sys-temic dose adjusted for total body surface area) ofan increased incidence of domed head and hydro-cephaly, typical of retinoid-induced fetal malforma-tions in this species.

In contrast, several well-controlled animal studieshave shown that dermally applied tretinoin may befetotoxic, but not overtly teratogenic, in ratsand rabbits at doses of 1.0 and 0.5 mg/kg/day,respectively (42 times the maximum human sys-temic dose adjusted for total body surface area inboth species).

With widespread use of any drug, a small num-ber of birth defect reports associated tempo-rally with the administration of the drug wouldbe expected by chance alone. Thirty humancases of temporally-associated congenitalmalformations have been reported during twodecades of clinical use of another formulationof topical tretinoin (Retin-A). Although no defi-nite pattern of teratogenicity and no causalassociation has been established from thesecases, 5 of the reports describe the rare birthdefect category holoprosencephaly (defectsassociated with incomplete midline develop-ment of the forebrain). The significance of

these spontaneous reports in terms of risk tothe fetus is not known.

Non-teratogenic effects:Dermal tretinoin has been shown to be fetotoxic inrabbits when administered 0.5 mg/kg/day (42times the maximum human systemic dose normal-ized for total body surface area). Oral tretinoin hasbeen shown to be fetotoxic, resulting in skeletalvariations and increased intrauterine death, in ratswhen administered 2.5 mg/kg/day (104 times themaximum human systemic dose adjusted for totalbody surface area).

There are, however, no adequate and well-controlled studies in pregnant women. RENOVAshould not be used during pregnancy.

Nursing Mothers: It is not known whether this drugis excreted in human milk. Since many drugs areexcreted in human milk, mitigation of fine facialwrinkles with RENOVA 0.02% may be postponedin nursing mothers until after completion of thenursing period.

Pediatric Use: Safety and effectiveness inpatients less than 18 years of age have notbeen established.

Geriatric Use: In clinical studies with RENOVA0.02%, patients aged 65 to 71 did not demon-strate a significant difference for improvementin fine wrinkling when compared to patientsunder the age of 65. Patients aged 65 and overmay demonstrate slightly more irritation,although the differences were not statisticallysignificant in the clinical studies for RENOVA0.02%. Safety and effectiveness of RENOVA0.02% in individuals older than 71 years of agehave not been established.

ADVERSE REACTIONS:(See WARNINGS and PRECAUTIONS sections.)

In double-blind, vehicle-controlled studies involv-ing 339 patients who applied RENOVA 0.02% totheir faces, adverse reactions associated with theuse of RENOVA were limited primarily to the skin.Almost all patients reported one or more local reac-tions such as peeling, dry skin, burning, stinging,erythema, and pruritus. In 32% of all studypatients, skin irritation was reported that wassevere, led to temporary discontinuation ofRENOVA 0.02%, or led to use of a mild topicalcorticosteroid. About 7% of patients usingRENOVA 0.02%, compared to less than 1% of thecontrol patients, had sufficiently severe localirritation to warrant short-term use of mild topicalcorticosteroids to alleviate local irritation. About4% of patients had to discontinue use of RENOVAbecause of adverse reactions.

Approximately 2% of spontaneous post-marketingadverse event reporting for RENOVA 0.05% werefor skin hypo- or hyperpigmentation. Other sponta-neously reported adverse events for RENOVA0.05% predominantly appear to be local reactionssimilar to those seen in clinical trials.

OVERDOSAGE:Application of larger amounts of medication thanrecommended has not been shown to lead tomore rapid or better results, and marked redness,peeling, or discomfort may occur. Oral ingestion ofthe drug may lead to the same side effects asthose associated with excessive oral intake ofVitamin A.

Rx only.

Ortho DermatologicalDivision of Ortho-McNeil Pharmaceutical, Inc.Skillman, New Jersey 08558

© OMP 2000Issued September 2000653-10-856-1B

U.S. Patents 4,603,146 and 4,877,805


Though often discussedtogether, fat and celluliterepresent two distinct

types of cellular mass. As such,different health considerationsand management optionsshould enter into discussionsbetween clinicians and their pa-tients.

Any discussion of excess adi-posity or obesity must beginwith an emphasis on the roleand value of diet, exercise, and

lifestyle changes. Physicians have an obligation to encour-age and assist patients in the adoption of practices that canimprove patient health and reduce morbidity, as well as toimprove physical appearance.

The patient's health must remain foremost in the as-sessment of an individual for cosmetic procedures involv-ing the removal of adipose tissue. Before entering into adiscussion about cosmetic procedures, the physician shouldperform a thorough medical history and physical exami-nation to make sure that the patient is fit enough for a pro-cedure.

Clinicians and their patients also must keep in mind thatcosmetic procedures are designed for the removal of local-ized fat deposits that resist the effects of weight loss and ex-ercise. Cosmetic procedures cannot replace weight loss forpatients who are overweight or morbidly obese. Laparoscopicbanded gastroplasty and other surgical procedures for obe-sity can dramatically change a patient's life. That pointshould not be confused with procedures to remove specifictypes of localized adiposity.

Standard tumescent anesthesia remains the most appro-priate and effective treatment of localized fat collection, of-ten characterized by colloquial expressions such as “saddlebags” and “love handles.” Use of tumescent anesthetics tofacilitate fat removal has a long history in cosmetic proce-dures and has a large volume of support in basic and clini-cal science.1

The technique effectively removes fat deposits with min-imal bleeding, bruising, and patient discomfort.

Laser lipolysis continues to attract a following in cosmet-ic dermatology, but one questions whether the technique tru-ly achieves the results and overall success attributed to it.2,3

The technology has evolved from a good model. However,a relative paucity of basic science underlies the clinical ap-plication, making results and overall success difficult to in-terpret.

Laser lipolysis provides some skin tightening along withfat removal. Whether the skin tightening is superior to whatcan be achieved with tumescent anesthesia remains debat-

able. Some proponents have suggested that laser lipolysismakes tissue sculpting easier to accomplish. However, tra-ditional liposuction with cannulas can provide the same ben-efits.

Currently, my assessment is that laser lipolysis costs muchmore and takes more time to perform, compared withtumescent anesthesia, and the benefits are questionable.

In contrast to adiposity, it has been argued that celluliteevolves from a structural problem of the fibroseptae, a con-cept challenged by others, which tends to be more verticallyoriented in women and obliquely oriented in men. The dif-ference in orientation has been evaluated and confirmedwith various imaging techniques.4

Cellulite occurs predominantly in women, although an-drogen-deficient men and patients with prostate cancertreated with hormonal therapy also are prone to develop thetissue.

Several myths surround the development and treatment ofcellulite. One myth is that obesity aggravates cellulite. Lit-tle evidence in the medical literature supports that con-tention. Another myth is that weight loss will improve cel-lulite. Given the different evolutionary paths of cellulite andadipose tissue, weight loss is unlikely to have a beneficial ef-fect on cellulite, and little evidence supports that view.

A third myth is that liposuction can be used to treat cel-lulite. Some evidence supports that position, but far more sci-entific evidence argues against the value of liposuction formanaging cellulite. In fact, I think liposuction has the po-tential to cause harm when used to treat cellulite.

Numerous therapies can temporarily improve the appear-ance of cellulite. Examples include Triactive, Velasmooth,and SmoothShapes.5 I liken the effects of these treatmentsto a haircut. So long as the patient understands that the ben-efits are temporary, these interventions have a role in thetreatment of cellulite.

Several cosmetic procedures have demonstrated the po-tential to achieve long-term beneficial effects on cellulite. Anytechnique or procedure that thickens the dermis or inducessubdermal fibrosis is likely to improve the appearance of cel-lulite. For example, cellulite does not occur in patients withlocalized scleroderma; the condition is accompanied by athickening of the dermis

One intervention that could induce long-term changes incellulite is cryolipolysis (Zeltiq), which has been demon-strated to remove fat cells and also induce superficial fibrosisin the skin. While no such claim has been made by the com-pany, any procedure that thickens the dermis or causes an in-crease in upper fat fibrosis might prevent the herniation offat into the dermis and thus the appearance of cellulite. Theconcept of cryolipolysis is derived from the clinical obser-vation of cold induced neonatal fat atrophy.6

Other technologies offering promise for long-term changes

Managing Fat and Cellulite:Current State of the Field

Christopher B. Zachary,F.R.C.P., M.B.B.S.

Continued on page 6

Roundup on Cosmetic Dermatology 2009 5


available in Europe for some time and eventually could findtheir way to the US market.

Despite the large and growing number of fillers, they allfall into one of three broad categories based on their per-manence: �SSiixx mmoonntthhss oorr lleessss.. This category includes softer and fin-er bioengineered collagen and several types of hyaluronicacid-based compounds. Short-duration fillers often are usedto treat smile lines and manage various types of wrinkles.Patients with no prior exposure to fillers might prefer ashort-duration product to assess the cosmetic effects beforedeciding on a more lasting solution. �SSiixx mmoonntthhss ttoo eeiigghhtteeeenn mmoonntthhss.. Products in this categoryinclude the more robust hyaluronic acid fillers, products con-taining calcium hydroxyapatite (CaHA), and fillers based onpoly-L-lactic acid (PLLA). CaHA products are ideally suitedfor the treatment of smile lines and for volume augmenta-tion. PLLA primarily is a volume enhancer, producing a grad-ual effect over time rather than immediately. This categoryalso includes porcine collagen, which was approved in thepast year, and bovine collagen. Porcine collagen already hasa history in clinical applications, most notable in the manu-facture of heart valves. The product has a consistency andsoftness similar to that of human collagen. Proven compat-ibility with human tissues may obviate the need for skin test-ing, which is required for bovine collagen and has con-tributed to its declining use in the United States. �PPeerrmmaanneenntt.. The only approved product in this category isan injectable gel filler consisting of synthetic microspheres sus-pected in bovine collagen. The microspheres are nonre-sorbable, which accounts for the lasting effect. Although theproduct is described as permanent, patients will require peri-odic supplementary treatments as their wrinkle lines deepenwith age. Unfortunately, the company marketing this filler inthe United States has filed for bankruptcy. It is expected thateventually the filler will once again be available.

Long-term and permanent fillers appeal to patients whohave experience with fillers, who know what to expect interms of results, and who are comfortable with the risk-ben-efit ratio of the products.

Use of botulinum toxin continues to evolve after morethan a decade of use in cosmetic dermatology. Common usesinclude treatment of wrinkle lines around the eyes and tofill dynamic lines and furrows on the forehead, although theinjections also work well as treatment for prominent neckbands or cords as well as for wrinkling around the upper lip.Many patients like botulinum toxin treatment because of itsrapid effects, which usually are evident within 3 to 5 days af-ter injection. Botulinum toxin often is used in combinationwith other filler materials to enhance the results.

Research aimed at improving botulinum toxin has been on-going for some time, and several new products could becomeavailable in the near future, including some that could be-come available during 2009. ■

in cellulite are monopolar radiofrequency energy and ul-trasound. Several devices have been developed to induce alocalized, heat-induced chronic inflammatory process withassociate apoptosis and a fibrotic reaction in the superficialfat tissues, leading to the tightening of deeper skin layers.This tightening should result in amelioration of the ap-pearance cellulite. None of these devices has approval by theUS Food and Drug Administration (FDA) for the permanentreduction of cellulite.

In summary, adiposity and cellulite are two distinct prob-lems with differing etiologies. As such, they require differ-ent approaches to treatment. Patient health should be fore-most in the cosmetic dermatologist's considerations whenevaluating a patient for the removal of localized fat accu-mulation. Cosmetic procedures are not for the treatment ofobesity.

Multiple interventions have been developed for the treat-ment of localized fat deposits and cellulite. Some haveshown promise for accomplishing cosmetic objectives, butmany others have not. Cosmetic dermatologists should stayabreast of developments in the field to make informed de-cisions about the application of technology to the treatmentof adiposity and cellulite. ■

RReeffeerreenncceess

1. Hanke W, Cox SE, Kuznets N, Coleman WP 3rd. Tumescent liposuction re

port performance measurement initiative: national survey results. Derma

tol Surg. 2004 Jul;30(7):967-977; discussion 978.

2. Parlette EC, Kaminer ME. Laser-assisted liposuction: Here's the skinny. Semin

Cutan Med Surg. 2008 Dec;27(4):259-263.

3. Katz B, McBean J. Laser-assisted lipolysis: a report on complications. J Cos

met Laser Surg. 2008;10:231-233.

4. Querleux B, Cornillon C, Jolivet O, Bittour J. Anatomy and physiology of

subcutaneous adipose tissue by in vivo magnetic resonance imaging and spec

troscopy :Relationships with sex and presence of cellulite. Skin Res Technol.

2002;8:118-124.

5. Nootheti PK, Magpantay A, Yosowitz G, Calderone S, Goldman MP. A sin

gle center, randomized, comparative, prospective clinical study to determine

the efficacy of the VelaSmooth system versus the Triactive system for the

treatment of cellulite. Lasers Surg Med. 2006;38:908-912.

6. Mahe E, Girszyn N, Hadj-Rabia S, Bodemer C, Hamel-Teillac D, DeProst Y.

Subcutaneous fat necrosis of the newborn: a systematic evaluation of risk fac

tors, clinical manifestations, complications and outcome of 16 children. Br J

Dermatol. 2007:156:709-715.

Update on LaserContinued from page 2

Managing Fat and CelluliteContinued from page 5

RReeffeerreenncceess

1. Rahman Z, Alam M, Dover JS. Fractional laser treatment for pigmentation

and texture improvement. Skin Therapy Lett. 2006;11:7-11.

2. Pozner JN, Glanz S, Goldberg DJ, Glanz S. Fractional erbium resurfacing:

Histologic and early clinical experience. Lasers Surg Med 2007;39(suppl 19):73.

Poster 239.

3. Narins RS, Brandt FS, Lorenc ZP, Maas CS, Monheit GD, Smith SR. Twelve-

month persistency of a novel ribose-cross-linked collagen dermal filler. Der

matol Surg. 2008;34(suppl 1):S31-S39.

6 Roundup on Cosmetic Dermatology 2009

R_6_R8_CosDer(SA0040_15)3.qxd 4/21/2009 3:57 PM Page 6

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As part of her pretreatment consultation before provid-ing dermal fillers, Dr. Ranella Hirsch hands a mirror toher patients and instructs them to advise her on their

specific goals and expectations.“I can’t tell you how many times I have looked at the pa-

tient on a consult, assessed precisely what I thought the ide-al aesthetic outcome is, and then be told that it’s actuallysomething completely different that they are here for me totreat,” Dr. Hirsch said at the annual meeting of the Ameri-can Society of Cosmetic Dermatology and Aesthetic Surgery.“A mirror is your friend.”

She went on to discuss other ways to avoid potential pit-falls:� Always snap before and after photographs. “There arelimited legal protections,” said Dr. Hirsch, a dermatologistwho practices in Cambridge, Mass. “Before-and-after pho-tographs are one of the few things that will objectively cap-ture accurate data.”� Beware of unrealistic expectations. “You need to knowwhat unrealistic expectations are and not treat those peoplein the first place,” she said. “You’re not going to make themhappy and you’re going to make yourself miserable in theprocess.”� Assess for medical contraindications. These include his-tory of hypersensitivity or allergy to known filler ingredi-ents, history of oral herpes simplex virus and keloids, andany problems with scarring. “In my office, we check for theseproblems three times,” said Dr. Hirsch, who is the immedi-ate past president of the ASCDAS. “And it is remarkable howmany people neglect to mention these critical points untilbeing asked repeatedly.”� Make sure patients can afford the services required forthe outcome desired. Be wary of patients who require threesyringes of product for optimal results, yet only want to payfor one.� Have patients fill out a consent form during every visit.Nothing is more important to the aesthetic physician than in-formed consent, she emphasized. “I am surprised everytime I hear a physician say, ‘I use the consent form that camewith the job.’ Should complications arise, it is critical that thishas been done properly to protect yourself.”

Describing her own consent forms, she noted, “It’s not

enough that patients sign at the very bottom of removedpages of small print. They have to sign next to each poten-tial complication and initial it. It has to be witnessed by some-one and time stamped. These are critical aspects.” She advisedchecking with an attorney for the best relevant advice.� Educate patients about common side effects. To help re-duce the occurrence of purpura, Dr. Hirsch advises patientsto eat a lot of pineapple preprocedure, because it containsbromelain. Another option is to take five tablets of arnica, asubstance commonly used for muscle pain and bruising, thenight before the procedure and another five on the day of theprocedure.

Other ways to minimize bruising include applying pressureduring and immediately following the injections, using top-ical anesthesia, mixing the filler with collagen products to sta-bilize platelets, adding a lidocaine wash to injectables that donot contain an anticoagulant, and using the “push ahead”technique, whereby you get the needle tip to the plane andextrude the needle ahead of the tip. By using this technique,which Dr. Hirsch attributes to Dr. Jean Carruthers, one al-lows the product rather than the sharp edge of the needleto create the injection plane for the product, thereby reduc-ing tissue trauma (Dermatol. Surg. 2005;31:1604-12).

Should evidence of infection develop after the procedure,incise and drain the abscess as rapidly as possible. Culture thepatient for both routine and atypical bacteria and prescribea course of empiric antibiotics followed by specific antibiotics.“Follow up on those cultures,” Dr. Hirsch advised.

If blanching or pain occurs at the injection site, stop im-mediately, because this can be the only sign of an impend-ing vascular injury. Immediate administration of heat, mas-sage, and nitroglycerin paste helps minimize or reversepermanent injury. A recent case report demonstrated that im-mediate administration of hyaluronidase can also be of greatvalue ( J. Drugs Dermatol. 2007;6:325-8). Once the vascularaccident is managed, consider treatment with a pulsed-dyelaser or intense pulsed light to improve discoloration.

Dr. Hirsch had no conflicts to disclose relevant to her pre-sentation. ■

By Doug Brunk, Elsevier Global Medical News. Reprinted from Skin & Allergy News, February 2009.

Avoiding Dermal Filler Pitfalls Begins With a Mirror


SKIN DISEASE EDUCATION FOUNDATION’S 34TH ANNUAL

A C O N T I N U I N G M E D I C A L E D U C A T I O N C O N F E R E N C E

HILTON WAIKOLOA HOTEL, BIG ISLAND HAWAII

FEBRUARY 14-19, 2010

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A single treatment with a microfractional 2940-nm er-bium:YAG laser resulted in perioral wrinkle reductionof greater than 40% and an improvement of 2-3 grades

on the Fitzpatrick wrinkle assessment scale in a recent study.In all, 23 patients with a score of 5-9 on the 9-point Fitz-

patrick scale underwent full-face laser treatment. The im-provements from baseline were noted after the first treat-ment, Dr. E. Victor Ross reported at the annual meeting ofthe American Society for Laser Medicine and Surgery.

The patients, who had skin types ranging from I-III, weretreated with a 6- to 10-mm spot size and energy ranging from400-920 microbeams/cm2. Between one and three passeswere used in less photodamaged areas, and three to eightpasses were used in more severely damaged areas. Addi-tionally, small areas were treated with a traditional short-pulse erbium:YAG laser at four passes and 5 J/cm2 to allowcomparison of wound healing time and clinical end pointsbetween the two lasers.

Preliminary findings suggest that the microfractional er-bium:YAG treatments resulted in a similar wrinkle responseto that observed with traditional short-pulse erbium:YAGlaser treatments; however, healing times were reduced withthe microfractional erbium:YAG, said Dr. Ross of the ScrippsClinic in San Diego.

Dr. Ross acknowledged that he has received equipment,consulting fees, and a research grant from Palomar MedicalTechnologies Inc.

“There was very rapid recovery, both histologically andclinically,” he said, noting that the average full-face treatmenttime was 48 minutes. Re-epithelialization of the basal layerof the epidermis occurred within 12-24 hours, and completere-epithelialization occurred within 4-5 days.

Bronzed skin was noted immediately after the treatments,and some patients experienced focal pinpoint hemorrhage.At 2 weeks, however, only mild erythema remained, he said.

On microscopic examination, separated columns of ablationwere noted, typically with a depth of 200 microns and 20-30microns of residual thermal damage at the periphery of theconical microwounds. Not only did the treatment lead tosmoothing of the skin and reduction of perioral wrinkles, butimprovements in dyschromia were also noted, Dr. Ross said.

Although optimal treatment parameters for wrinkle reduc-tion remain to be defined, these findings suggest that mi-crofractional 2940-nm laser treatment is superior to tradition-al short-pulse erbium:YAG laser treatment for this purpose. ■

By Sharon Worcester, Elsevier Global Medical News. Reprintedfrom Skin & Allergy News, June 2008

Single Laser Tx Reduced Perioral Wrinkles


Fractional Laser Therapy Found Effective for Hands

Nonablative fractional laser therapy applied at conservativesettings achieved moderate global improvement in pho-

todamaged hands in a pilot study.Six months following last treatment sessions, 8 of 10 pa-

tients in the study showed a 26%-50% improvement in wrin-kles, pigmentation, and skin texture, based on a formal in-vestigator-rated scoring system, Dr. Neil S. Sadick reportedat the annual meeting of the American Academy of CosmeticSurgery.

The results improved from 1-month post treatment to the6-month follow-up mark, Dr. Sadick noted. The treatment ses-sions were well tolerated, side effects were mild and self-lim-ited, and return to daily activities was immediate, said Dr.Sadick, a dermatologist at Cornell University, New York, andimmediate past president of the Cosmetic Surgery Foundation.

The 10 patients (mean age, 57 years) were Fitzpatrick skintypes I-III. Their bilateral photodamage on the dorsum ofthe hands was treated with a fractional 1550-nm erbium-doped fiber laser, the first-generation Fraxel laser market-ed by Reliant Technologies Inc.

Patients underwent five or six treatment sessions 3-4 weeksapart, with topical anesthesia. The laser energy setting was6 mJ at the first session, increasing as tolerated by 2 mJ at eachsubsequent session. The total microthermal zone density was1,000-2,000/cm2.

The technique used in treating the hands was the same as

with Fraxel therapy on the face, with three or four passes persession being done. All patients had immediate posttreatmenterythema. Unlike on the face, where it resolves within a dayor two, the erythema on the hands lasted for as long as 4weeks.

Half of the patients developed mild edema. This was mostprominent after the first treatment session. Patients report-ed that the discomfort associated with treatment was mildbut increased slightly with increasing laser energy.

Three patients underwent biopsies at baseline and again 3 and6 months after their last session. Histologic evaluation usinghematoxylin and eosin and elastin tissue stains showed a treat-ment-related decrease in atypical keratinocytes, increased reteridge formation in the epidermis, enhanced collagen density inthe epidermis and papillary and reticular dermis, improvementin the baseline irregular dermal architecture, and reduced so-lar elastosis. There was no histologic evidence of scarring orinflammatory changes.

Dr. Sadick disclosed that he performed his pilot study forReliant in return for discounted equipment. He is on thespeakers bureaus for laser and medical device manufacturersCynosure, Palomar Medical Technologies Inc., Syneron Med-ical Ltd., and Cutera Inc. ■

By Bruce Jancin, Elsevier Global Medical News. Reprinted from Skin & Allergy News, March 2009



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