Aesthetic Dermatology

WASHINGTON — Accumulating data suggest that botulinum toxin and injectable fillers are as safe and effective in ethnic minorities as they are in white patients, Dr. Gary Monheit said at the annual meeting of the American Academy of Dermatology.

Although most of the evidence supporting the use of botulinum toxin and fillers has come from whites, leading to hesitation about use in darker skin types, those modalities are likely to be the first ones used in ethnic minority patients, because the initial sign of aging in darker skin tends to be volume loss, leading to frown lines, marionette lines, nasolabial folds, and upper forehead lines, said Dr. Monheit of the University of Alabama, Birmingham.

Botox injection is the most common cosmetic procedure, with some 2.8 million Americans receiving a treatment in 2004, according to Dr. Monheit. Almost 19% of the injections were in minorities (8.5% in Hispanics, 6.2% in blacks, and 4.2% in Asians), he said.

The most commonly injected areas for white patients are the forehead and brow area. In black patients, crow's feet generally aren't a concern; more commonly, the brows, forehead, and frown lines are targeted.

Variables to consider with ethnic minorities include facial structure and musculature; the histology of thick skin, collagen, and elastin fibers; atrophy resulting from photoaging; and "sociocultural factors that may make one not want to totally paralyze the face" and lose certain expressions, Dr. Monheit said.

Botox dosages have been standardized for whites but not for other ethnic groups, which has led to questions of safety and effectiveness in those minorities, he said.

A study led by Dr. Pearl E. Grimes of the University of California, Los Angeles, may give dermatologists some direction, he said. The trial was funded by Allergan Inc. and has not yet been published. A total of 31 black women, aged 18–67 years and with Fitzpatrick skin types V and VI, were randomized to 20 or 30 units of Botox, in five divided doses to the glabella. They were assessed at 30, 60, 90, and 120 days.

Their outcomes were compared with results from a dose-ranging study in whites that was also funded by Allergan (J. Derm. Surg. 1992;18:17–21).

The therapy's longevity appeared to be the same in the black women as in white women, Dr. Monheit noted.

At 1 month, 94% of those receiving 20 units and 100% of those receiving 30 units were considered responders. The response dipped to 20% for 20 units and 40% for 30 units at day 90. Patient satisfaction was 100% on day 30 and 60% on day 120.

There was less than a 4% incidence of adverse events—mainly headache and tingling—and the authors concluded that Botox is safe, efficacious, and well tolerated in women of color, he said.

When using fillers in minorities, it is important to consider what and how much volume is missing, and what areas are to be treated.

Again, there has been little published specifically on the safety and efficacy of the older fillers, such as collagen and hyaluronic acid-based fillers, Dr. Monheit said.

Anecdotally, there have been reports of more bruising, increased postinflammatory hyperpigmentation, keloids, and granuloma.

"All of these are fears that patients bring to us, but at this point there's no real solid data to counteract these [fears]," Dr. Monheit stated.

A postmarketing study—funded by Genzyme Corp. and Inamed Corp. and led by Dr. Grimes and Dr. Monheit—may provide some answers.

The multicenter trial, the results of which have not been published, was done at the behest of the Food and Drug Administration. The agency was concerned about the side effects of hyaluronic acid-based fillers in darker skin types. In the trial, 55 nonwhites—the preponderance Hispanic and Asian, with about 10% African American—were compared with 261 white controls.

A total of 27 minority patients received Zyplast and 28 were given Hylaform. They were compared with 128 white Zyplast recipients and 133 who received Hylaform.

According to Dr. Monheit, the results were similar for both fillers in the minorities when compared with results in the white patients at 2 and 12 weeks.

There were no keloids or granulomas in minority patients. Interestingly, both fillers were better tolerated in nonwhites. Some of the initial adverse events reported by white patients—such as erythema—seem to be masked by darker skin, he said.

It is not clear whether these results can be extrapolated to other fillers or for other areas of the face, and more questions will likely arise as new fillers—especially those that stimulate collagen development—come to the market, Dr. Monheit said.

For now, though, it appears that the safety and efficacy of Botox and fillers are at least comparable in whites and ethnic minorities, he said.

Dr. Monheit said that he is an investigator and consultant for most of the neurotoxin and filler manufacturers.

In an unpublished postmarketing study, Zyplast and Hylaform were better tolerated in nonwhite patients. DR. MONHEIT

WASHINGTON — Accumulating data suggest that botulinum toxin and injectable fillers are as safe and effective in ethnic minorities as they are in white patients, Dr. Gary Monheit said at the annual meeting of the American Academy of Dermatology.

Although most of the evidence supporting the use of botulinum toxin and fillers has come from whites, leading to hesitation about use in darker skin types, those modalities are likely to be the first ones used in ethnic minority patients, because the initial sign of aging in darker skin tends to be volume loss, leading to frown lines, marionette lines, nasolabial folds, and upper forehead lines, said Dr. Monheit of the University of Alabama, Birmingham.

Botox injection is the most common cosmetic procedure, with some 2.8 million Americans receiving a treatment in 2004, according to Dr. Monheit. Almost 19% of the injections were in minorities (8.5% in Hispanics, 6.2% in blacks, and 4.2% in Asians), he said.

The most commonly injected areas for white patients are the forehead and brow area. In black patients, crow's feet generally aren't a concern; more commonly, the brows, forehead, and frown lines are targeted.

Variables to consider with ethnic minorities include facial structure and musculature; the histology of thick skin, collagen, and elastin fibers; atrophy resulting from photoaging; and "sociocultural factors that may make one not want to totally paralyze the face" and lose certain expressions, Dr. Monheit said.

Botox dosages have been standardized for whites but not for other ethnic groups, which has led to questions of safety and effectiveness in those minorities, he said.

A study led by Dr. Pearl E. Grimes of the University of California, Los Angeles, may give dermatologists some direction, he said. The trial was funded by Allergan Inc. and has not yet been published. A total of 31 black women, aged 18–67 years and with Fitzpatrick skin types V and VI, were randomized to 20 or 30 units of Botox, in five divided doses to the glabella. They were assessed at 30, 60, 90, and 120 days.

Their outcomes were compared with results from a dose-ranging study in whites that was also funded by Allergan (J. Derm. Surg. 1992;18:17–21).

The therapy's longevity appeared to be the same in the black women as in white women, Dr. Monheit noted.

At 1 month, 94% of those receiving 20 units and 100% of those receiving 30 units were considered responders. The response dipped to 20% for 20 units and 40% for 30 units at day 90. Patient satisfaction was 100% on day 30 and 60% on day 120.

There was less than a 4% incidence of adverse events—mainly headache and tingling—and the authors concluded that Botox is safe, efficacious, and well tolerated in women of color, he said.

When using fillers in minorities, it is important to consider what and how much volume is missing, and what areas are to be treated.

Again, there has been little published specifically on the safety and efficacy of the older fillers, such as collagen and hyaluronic acid-based fillers, Dr. Monheit said.

Anecdotally, there have been reports of more bruising, increased postinflammatory hyperpigmentation, keloids, and granuloma.

"All of these are fears that patients bring to us, but at this point there's no real solid data to counteract these [fears]," Dr. Monheit stated.

A postmarketing study—funded by Genzyme Corp. and Inamed Corp. and led by Dr. Grimes and Dr. Monheit—may provide some answers.

The multicenter trial, the results of which have not been published, was done at the behest of the Food and Drug Administration. The agency was concerned about the side effects of hyaluronic acid-based fillers in darker skin types. In the trial, 55 nonwhites—the preponderance Hispanic and Asian, with about 10% African American—were compared with 261 white controls.

A total of 27 minority patients received Zyplast and 28 were given Hylaform. They were compared with 128 white Zyplast recipients and 133 who received Hylaform.

According to Dr. Monheit, the results were similar for both fillers in the minorities when compared with results in the white patients at 2 and 12 weeks.

There were no keloids or granulomas in minority patients. Interestingly, both fillers were better tolerated in nonwhites. Some of the initial adverse events reported by white patients—such as erythema—seem to be masked by darker skin, he said.

It is not clear whether these results can be extrapolated to other fillers or for other areas of the face, and more questions will likely arise as new fillers—especially those that stimulate collagen development—come to the market, Dr. Monheit said.

For now, though, it appears that the safety and efficacy of Botox and fillers are at least comparable in whites and ethnic minorities, he said.

Dr. Monheit said that he is an investigator and consultant for most of the neurotoxin and filler manufacturers.

In an unpublished postmarketing study, Zyplast and Hylaform were better tolerated in nonwhite patients. DR. MONHEIT

WASHINGTON — Accumulating data suggest that botulinum toxin and injectable fillers are as safe and effective in ethnic minorities as they are in white patients, Dr. Gary Monheit said at the annual meeting of the American Academy of Dermatology.

Although most of the evidence supporting the use of botulinum toxin and fillers has come from whites, leading to hesitation about use in darker skin types, those modalities are likely to be the first ones used in ethnic minority patients, because the initial sign of aging in darker skin tends to be volume loss, leading to frown lines, marionette lines, nasolabial folds, and upper forehead lines, said Dr. Monheit of the University of Alabama, Birmingham.

Botox injection is the most common cosmetic procedure, with some 2.8 million Americans receiving a treatment in 2004, according to Dr. Monheit. Almost 19% of the injections were in minorities (8.5% in Hispanics, 6.2% in blacks, and 4.2% in Asians), he said.

The most commonly injected areas for white patients are the forehead and brow area. In black patients, crow's feet generally aren't a concern; more commonly, the brows, forehead, and frown lines are targeted.

Variables to consider with ethnic minorities include facial structure and musculature; the histology of thick skin, collagen, and elastin fibers; atrophy resulting from photoaging; and "sociocultural factors that may make one not want to totally paralyze the face" and lose certain expressions, Dr. Monheit said.

Botox dosages have been standardized for whites but not for other ethnic groups, which has led to questions of safety and effectiveness in those minorities, he said.

A study led by Dr. Pearl E. Grimes of the University of California, Los Angeles, may give dermatologists some direction, he said. The trial was funded by Allergan Inc. and has not yet been published. A total of 31 black women, aged 18–67 years and with Fitzpatrick skin types V and VI, were randomized to 20 or 30 units of Botox, in five divided doses to the glabella. They were assessed at 30, 60, 90, and 120 days.

Their outcomes were compared with results from a dose-ranging study in whites that was also funded by Allergan (J. Derm. Surg. 1992;18:17–21).

The therapy's longevity appeared to be the same in the black women as in white women, Dr. Monheit noted.

At 1 month, 94% of those receiving 20 units and 100% of those receiving 30 units were considered responders. The response dipped to 20% for 20 units and 40% for 30 units at day 90. Patient satisfaction was 100% on day 30 and 60% on day 120.

There was less than a 4% incidence of adverse events—mainly headache and tingling—and the authors concluded that Botox is safe, efficacious, and well tolerated in women of color, he said.

When using fillers in minorities, it is important to consider what and how much volume is missing, and what areas are to be treated.

Again, there has been little published specifically on the safety and efficacy of the older fillers, such as collagen and hyaluronic acid-based fillers, Dr. Monheit said.

Anecdotally, there have been reports of more bruising, increased postinflammatory hyperpigmentation, keloids, and granuloma.

"All of these are fears that patients bring to us, but at this point there's no real solid data to counteract these [fears]," Dr. Monheit stated.

A postmarketing study—funded by Genzyme Corp. and Inamed Corp. and led by Dr. Grimes and Dr. Monheit—may provide some answers.

The multicenter trial, the results of which have not been published, was done at the behest of the Food and Drug Administration. The agency was concerned about the side effects of hyaluronic acid-based fillers in darker skin types. In the trial, 55 nonwhites—the preponderance Hispanic and Asian, with about 10% African American—were compared with 261 white controls.

A total of 27 minority patients received Zyplast and 28 were given Hylaform. They were compared with 128 white Zyplast recipients and 133 who received Hylaform.

According to Dr. Monheit, the results were similar for both fillers in the minorities when compared with results in the white patients at 2 and 12 weeks.

There were no keloids or granulomas in minority patients. Interestingly, both fillers were better tolerated in nonwhites. Some of the initial adverse events reported by white patients—such as erythema—seem to be masked by darker skin, he said.

It is not clear whether these results can be extrapolated to other fillers or for other areas of the face, and more questions will likely arise as new fillers—especially those that stimulate collagen development—come to the market, Dr. Monheit said.

For now, though, it appears that the safety and efficacy of Botox and fillers are at least comparable in whites and ethnic minorities, he said.

Dr. Monheit said that he is an investigator and consultant for most of the neurotoxin and filler manufacturers.

In an unpublished postmarketing study, Zyplast and Hylaform were better tolerated in nonwhite patients. DR. MONHEIT

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Cosmetic enhancement with Radiesse is technique dependent, and three experts shared their clinical tips to optimize success with this filler at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

Radiesse (calcium hydroxylapatite, BioForm Medical) is manufactured as synthetic microspheres that are suspended in a resorbable aqueous gel.

Calcium hydroxylapatite provides immediate results and is versatile, moldable, and longer lasting than some other filler products, said Dr. Susan H. Weinkle, who is with the University of South Florida in Tampa.

The product's gel carrier degrades in 3–6 months for 70% of patients, she said.

During this time, new collagen formation is ongoing. "If you avoid the temptation to retreat patients at 6 months when the gel drops, you will see continued improvement," said Dr. David J. Goldberg of the department of dermatology at Mount Sinai School of Medicine in New York.

A meeting attendee wanted to know how to choose between Radiesse, Restylane (Q-Med), and Sculptra (Sanofi-Aventis).

"A lot has to do with what you think will benefit the patient more. If they need a lot of volume, I would go with Sculptra," Dr. Weinkle said. "If they have deep nasolabial folds and [deep wrinkles in] the chin area, I would use Radiesse. There are a lot of considerations, including longevity and cost. With Radiesse, you can have immediate correction, but with Sculptra you cannot promise that."

Radiesse can fill nasolabial folds and marionette lines, but the product is generally not recommended for the glabellar area or lips. Any long-acting filler can cause nodules in the lips, Dr. Goldberg said.

"Success is very technique dependent. This is not a filler to start with," Dr. Weinkle added.

"I get a lot of questions about what needle to use with which filler. Start with what the company recommends," said Dr. Marta Rendon of the University of Miami.

"For smaller areas, use a shorter needle and 27-G—the product will flow nicely," Dr. Goldberg said. "I use mostly the longer needles for nasolabial folds. This stuff is thicker, so you need to push harder. If you do that with Juvederm [Allergan], all the material will be gone right away."

Anesthesia is recommended before the procedure. "Let's be honest, it hurts. It is thicker [than some other fillers]. It's a 25-G needle," Dr. Weinkle said. "Use anesthesia and keep the patient as comfortable as possible."

Dr. Goldberg does a block with 1% lidocaine without epinephrine, and Dr. Rendon blocks with 2% lidocaine without epinephrine.

Inject a small amount of Radiesse on the way in and lay it down retrograde as you pull the needle out, Dr. Weinkle suggested.

Remember to stop injecting as you pull the needle out, Dr. Rendon said. "You don't want to bring out the product. My tip here is to use the blunt end of a Q-tip to push it back in."

"Here is another little pearl," Dr. Rendon said, "The hardest corner to correct is the nasolabial fold just above and lateral to the corner of the mouth. Tent the skin to lift the corner when you inject, and be careful not to inject too superficially."

Place your finger inside the mouth when you first start injecting, Dr. Goldberg said, to feel the material going in. "Early on I injected it right through into the mouth," he said. "Patients will tell you they can taste a granular substance. It doesn't harm them, but you have to start over."

It is important to fill just below the corner of each side of the mouth, Dr. Weinkle said. "I put my finger inside the mouth and mold it right away."

Be careful not to overcorrect the patient's face, she pointed out. "I tell patients there is more where this came from."

A meeting attendee asked about the cost to physicians. "It's actually cost effective. Originally, it was $500 for 1.3 cc, and about a year ago, the company reduced the price to $298 per 1.3-cc syringe. Now that the price has come down, it's much more affordable," Dr. Weinkle said.

The range of what dermatologists charge patients ranges from $500 to $3,000 across the country. Dr. Goldberg said, "It's longer acting, so I think it's fair to charge more for this, compared to what you are charging for hyaluronic acid."

Patient follow-up is essential. "I stress the importance of seeing the patient back at 2 weeks. If they are unhappy with results, you want to be the one to know," Dr. Weinkle said. "I've learned that the 0.3 cc [syringe] is nice for topping off someone who comes back for a touch-up."

Dr. Goldberg and Dr. Weinkle are consultants for BioForm Medical and Dr. Rendon is on the company's advisory board.

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

MIAMI BEACH — Inappropriate placement and potential sensitivity reactions are possible complications of fillers, and asymmetry, swelling, and bruising can occur after injections with botulinum toxin, Dr. Joel L. Cohen said at a symposium sponsored by the Florida Society of Dermatology and Dermatologic Surgery.

"Most people have moved away from injecting Radiesse in lips—it can migrate superficially and give a 'popcorn' appearance," he said. "Most of our patients are of the age that they think back to Goldie Hawn in the 'The First Wives Club.'"

Permanent fillers can be less forgiving and require more expertise to inject. ArteFill became the first nonresorbable, injectable filler implant approved for aesthetic use in the United States in October 2006. Complications reported with an earlier formulation approved outside the United States, ArteColl, might apply to ArteFill as well. "If placed too superficially, like any filler, it can cause nodules, but these are long-term nodules," said Dr. Cohen, a dermatologist in Englewood, Colo.

Adverse events associated with poly-L-lactic acid (Sculptra) include granulomas reported in several studies, especially from the European experience (Dermatol. Surg. 2005;31:772–6), and infections. "Infraorbital skin can be thinner, so infraorbital area injections with Sculptra can be problematic," Dr. Cohen said. To avoid pitfalls, "inject deeper and use higher volume reconstitutions."

When hyaluronic acid fillers are not injected deeply enough, especially in the tear-trough area, there can be a Tyndall effect, he said. Treatment of this adverse event is to nick the skin and try to express the product, or treat with a laser, or try to dissolve the product with hyaluronidase.

Dr. Cohen treated a woman who had previously been injected with a hyaluronic acid product and then developed delayed erythematous nodules (Dermatol. Surg. 2006;32:426–34). It is hard to know if this was an infection or a type of sensitivity. Three negative cultures were performed, and her indurated nodules finally cleared after a few courses of antibiotics over several months, he added.

Other adverse scenarios with fillers include the potential of inducing a herpes simplex virus (HSV) sore. "Think about prophylaxis [for HSV] when doing lip augmentation or injecting etched-in lip lines, especially in patients with a significant history of cold sores. Though, fortunately, I have not yet seen a postprocedure HSV flare with an aesthetic patient, I did see this in one of my Mohs surgery patients a few days after a lip repair," he said.

Necrosis is really the complication of most concern. This process can occur from excessive product placement compressing arterioles or from frank intravascular placement of product, Dr. Cohen said.

To avoid this complication, know the facial vasculature of the areas being injected, he advised. "I have participated in treatment of three patients that received hyaluronic acid fillers who were diagnosed by their injecting physicians with 'impending necrosis' a few hours later. The skin was developing localized areas of patchy, purple reticulated discoloration [visible] on photos sent to me. I recommended hyaluronidase injections in and around the area to try to decompress the vessels and to facilitate flow, and fortunately this was successful." (Case report in press.)

There are fewer adverse events reported with use of botulinum toxin, compared with fillers, but asymmetry, unwanted migration, swelling, and bruising have all been seen and have been reported to the FDA after botulinum toxin injections (J. Am. Acad. Dermatol. 2005;53:407–15).

"Complications from fillers, botulinum toxins, and lasers are very often related to inexperienced injectors/providers or … unsupervised and inadequately trained nonphysician providers," he said.

The physicians who are supposed to be supervising these procedures are rarely present and "have no training or experience themselves in the procedures in which they are supervising and just want to make a buck," said Dr. Cohen, chair of the American Society for Dermatologic Surgery's patient education committee.

He applauded the Florida legislature for passing "very appropriate" supervision guidelines in 2006 and said that these kinds of guidelines are needed on a national basis.

For any procedure, appropriate patient selection is important to minimize complications. For example, "some patients with a significant redundancy in their brow and lid skin should not be treated with botulinum toxin in their lower forehead, as this will only accentuate the problem and exacerbate the brow ptosis and redundant eyelid skin," Dr. Cohen said.

Dr. Cohen evaluates patients while they are animated to help determine botulinum toxin dosing and placement, but he recommends injecting while the patient's face is relaxed. A zygomaticus muscle pulled up at the cheekbone when the lower crow's-feet are being injected, for example, might have a higher risk of inadvertent spread to the muscle that would cause an asymmetric smile for 3–4 months, he said.

Dr. Cohen is a consultant, speaker, clinical trial investigator, and instructor for Allergan (Botox); a consultant, speaker, clinical trial investigator, and instructor for Medicis (Restylane); and a consultant and clinical trial investigator for BioForm, manufacturer of Radiesse.

Many poorly trained physicians are inadequately supervisingpoorly trained nonphysician providers. DR. COHEN

When fillers are not injected deeply enough, lumps under the eye can result. Courtesy Dr. Joel L. Cohen

MAUI, HAWAII — An upper and lower lip mucosal block provides fast, easy, and effective regional anesthesia for lip procedures, Dr. Howard K. Steinman said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

"Learn this mucosal block," he urged. "It has revolutionized my practice more than any other simple technique I have learned in the last 5 years."

"When patients come to your office, they're secretly praying that what you're going to do is going to be painless," said Dr. Steinman of the University of California, San Diego.

"When you get patients ready for what they expect to be a happy, painless, rejuvenating experience, and they're unhappy," he explained, "everyone in the room is unhappy." Using the mucosal block greatly improves the satisfaction of patients.

Equipment required for the mucosal block procedure is simple and modestly priced.

"You don't need a multithousand-dollar energy device," Dr. Steinman said.

The supplies needed include topical anesthetic (such as Hurricaine gel), dental needles, lidocaine Carpules, and a Carpule syringe. Dental syringes, which can be purchased from dental supply companies, are "incredibly" inexpensive, he noted.

The anesthesia requires nothing that is not already in the office, including anesthetic gel and "lots and lots of Q tips," he said.

If there's going to be a lot of dental gel in a patient's mouth during a cosmetic procedure, be sure to have some bottled water available, because many people really don't like the gel's taste.

Injected anesthetics that can be used to perform the mucosal block include lidocaine, bupivacaine, mepivacaine, and others.

Dr. Steinman outlined the procedure for performing the upper- and lower-lip mucosal block. "What you're blocking is the infraorbital nerve," he explained.

The first step in the procedure is to apply topical anesthetic. Then, at the gingival-buccal sulcus, just lateral to the apex of the canine tooth, inject a small amount of anesthetic approximately 0.5 cm upward along the maxilla. The next step is to inject from this point medially—in the potential space between the mucosa and the periosteum—along the sulcus to the frenulum.

The procedure should be repeated on the contralateral side. Inject a small amount from the sulcus next to the frenulum toward the anterior nasal spine, he added.

For the patient's lower lip, inject submucosally in the sulcus from the point below the oral commissure to the contralateral side.

Finally, because the nerve block does not reach the corners of the mouth, it is necessary to apply topical anesthetic on the mucosal surface of the oral commissures and then inject a small amount of anesthetic to anesthetize the corners of the mouth. Injecting these areas takes a total of about 15 seconds, Dr. Steinman noted.

It is also important to keep in mind that facial blocks do not impart any vasoconstriction, so consider injecting locally for procedures that result in bleeding, he added.

Dr. Steinman emphasized that the mucosal block works fast.

"This block will numb up someone's lip in approximately 10–15 seconds," he said. "As a matter of fact, when I'm doing it, the side I've numbed up will largely be numb by the time I get to the other side of the lip.

"So it's very effective for lip procedures, very effective for fillers especially," he said. "As we say in Southern California," he concluded, "this block rocks."

Dr. Steinman said that he had no relevant conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Your patients are secretly praying that what you're going to do is going to be painless. DR. STEINMAN

MAUI, HAWAII — An upper and lower lip mucosal block provides fast, easy, and effective regional anesthesia for lip procedures, Dr. Howard K. Steinman said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

"Learn this mucosal block," he urged. "It has revolutionized my practice more than any other simple technique I have learned in the last 5 years."

"When patients come to your office, they're secretly praying that what you're going to do is going to be painless," said Dr. Steinman of the University of California, San Diego.

"When you get patients ready for what they expect to be a happy, painless, rejuvenating experience, and they're unhappy," he explained, "everyone in the room is unhappy." Using the mucosal block greatly improves the satisfaction of patients.

Equipment required for the mucosal block procedure is simple and modestly priced.

"You don't need a multithousand-dollar energy device," Dr. Steinman said.

The supplies needed include topical anesthetic (such as Hurricaine gel), dental needles, lidocaine Carpules, and a Carpule syringe. Dental syringes, which can be purchased from dental supply companies, are "incredibly" inexpensive, he noted.

The anesthesia requires nothing that is not already in the office, including anesthetic gel and "lots and lots of Q tips," he said.

If there's going to be a lot of dental gel in a patient's mouth during a cosmetic procedure, be sure to have some bottled water available, because many people really don't like the gel's taste.

Injected anesthetics that can be used to perform the mucosal block include lidocaine, bupivacaine, mepivacaine, and others.

Dr. Steinman outlined the procedure for performing the upper- and lower-lip mucosal block. "What you're blocking is the infraorbital nerve," he explained.

The first step in the procedure is to apply topical anesthetic. Then, at the gingival-buccal sulcus, just lateral to the apex of the canine tooth, inject a small amount of anesthetic approximately 0.5 cm upward along the maxilla. The next step is to inject from this point medially—in the potential space between the mucosa and the periosteum—along the sulcus to the frenulum.

The procedure should be repeated on the contralateral side. Inject a small amount from the sulcus next to the frenulum toward the anterior nasal spine, he added.

For the patient's lower lip, inject submucosally in the sulcus from the point below the oral commissure to the contralateral side.

Finally, because the nerve block does not reach the corners of the mouth, it is necessary to apply topical anesthetic on the mucosal surface of the oral commissures and then inject a small amount of anesthetic to anesthetize the corners of the mouth. Injecting these areas takes a total of about 15 seconds, Dr. Steinman noted.

It is also important to keep in mind that facial blocks do not impart any vasoconstriction, so consider injecting locally for procedures that result in bleeding, he added.

Dr. Steinman emphasized that the mucosal block works fast.

"This block will numb up someone's lip in approximately 10–15 seconds," he said. "As a matter of fact, when I'm doing it, the side I've numbed up will largely be numb by the time I get to the other side of the lip.

"So it's very effective for lip procedures, very effective for fillers especially," he said. "As we say in Southern California," he concluded, "this block rocks."

Dr. Steinman said that he had no relevant conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Your patients are secretly praying that what you're going to do is going to be painless. DR. STEINMAN

MAUI, HAWAII — An upper and lower lip mucosal block provides fast, easy, and effective regional anesthesia for lip procedures, Dr. Howard K. Steinman said at the annual Hawaii Dermatology Seminar sponsored by Skin Disease Education Foundation.

"Learn this mucosal block," he urged. "It has revolutionized my practice more than any other simple technique I have learned in the last 5 years."

"When patients come to your office, they're secretly praying that what you're going to do is going to be painless," said Dr. Steinman of the University of California, San Diego.

"When you get patients ready for what they expect to be a happy, painless, rejuvenating experience, and they're unhappy," he explained, "everyone in the room is unhappy." Using the mucosal block greatly improves the satisfaction of patients.

Equipment required for the mucosal block procedure is simple and modestly priced.

"You don't need a multithousand-dollar energy device," Dr. Steinman said.

The supplies needed include topical anesthetic (such as Hurricaine gel), dental needles, lidocaine Carpules, and a Carpule syringe. Dental syringes, which can be purchased from dental supply companies, are "incredibly" inexpensive, he noted.

The anesthesia requires nothing that is not already in the office, including anesthetic gel and "lots and lots of Q tips," he said.

If there's going to be a lot of dental gel in a patient's mouth during a cosmetic procedure, be sure to have some bottled water available, because many people really don't like the gel's taste.

Injected anesthetics that can be used to perform the mucosal block include lidocaine, bupivacaine, mepivacaine, and others.

Dr. Steinman outlined the procedure for performing the upper- and lower-lip mucosal block. "What you're blocking is the infraorbital nerve," he explained.

The first step in the procedure is to apply topical anesthetic. Then, at the gingival-buccal sulcus, just lateral to the apex of the canine tooth, inject a small amount of anesthetic approximately 0.5 cm upward along the maxilla. The next step is to inject from this point medially—in the potential space between the mucosa and the periosteum—along the sulcus to the frenulum.

The procedure should be repeated on the contralateral side. Inject a small amount from the sulcus next to the frenulum toward the anterior nasal spine, he added.

For the patient's lower lip, inject submucosally in the sulcus from the point below the oral commissure to the contralateral side.

Finally, because the nerve block does not reach the corners of the mouth, it is necessary to apply topical anesthetic on the mucosal surface of the oral commissures and then inject a small amount of anesthetic to anesthetize the corners of the mouth. Injecting these areas takes a total of about 15 seconds, Dr. Steinman noted.

It is also important to keep in mind that facial blocks do not impart any vasoconstriction, so consider injecting locally for procedures that result in bleeding, he added.

Dr. Steinman emphasized that the mucosal block works fast.

"This block will numb up someone's lip in approximately 10–15 seconds," he said. "As a matter of fact, when I'm doing it, the side I've numbed up will largely be numb by the time I get to the other side of the lip.

"So it's very effective for lip procedures, very effective for fillers especially," he said. "As we say in Southern California," he concluded, "this block rocks."

Dr. Steinman said that he had no relevant conflicts of interest.

SDEF and this news organization are wholly owned subsidiaries of Elsevier.

Your patients are secretly praying that what you're going to do is going to be painless. DR. STEINMAN