Aesthetic Dermatology

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.

WASHINGTON — Simple techniques can smooth the dermatologic surgery experience and outcomes for children, Dr. Brandie J. Metz said at the annual meeting of the American Academy of Dermatology.

For instance, while it may seem obvious to explain a procedure as thoroughly as possible without scaring the child, it's also important not to lie about any aspect of the procedure, to remain especially "bright and friendly" throughout the discussion, and to engage the child in discussion as much as possible.

Sitting at or below the level of the child can also help put him or her at ease, the dermatologic surgeon said.

Dr. Metz, of the University of California, Irvine, also recommended having the child's parent sit at the head of the table during a procedure and obscuring the child's view of the surgical tray and any blood-soaked gauze.

When it comes to injections, slow infiltration is less painful than rapid infiltration, she said.

It can also help to use topical anesthetics such as a eutectic mixture of lidocaine and prilocaine (EMLA) or 4% liposomal lidocaine (ELA-Max) to numb the area before injection. Technically, topical anesthetics do not need to be occluded, but "it doesn't seem wise to put a big glob of cream on a kid and then let [him] run around without occluding it," Dr. Metz said.

A nurse—not a parent—should be the one to restrain the child if he or she is squirming or very frightened.

"A lot of [children's] impressions of pain and anxiety are based on past experiences," she said. So for more extensive procedures in young children, "consider doing them under general anesthesia," even if that means referring the child to a pediatric dermatologist or a plastic surgeon.

After the operation is over, Dr. Metz said, "No matter how disastrous it was, always praise the child."

Also, reward the child with stickers, lollipops, or other treats to facilitate selective memory.

Pay special attention to dressings. If possible, let the child pick the color of the dressing before surgery, then make the dressing as bulky as possible.

"If you do a biopsy on an adult scalp, you might just need a little bit of antibiotic ointment," she said.

But with a child, "I'll often use a much larger dressing [than is needed], because this can be helpful in enforcing postoperative activity restrictions. There is generally not much discomfort or pain, so you kind of [need to] remind them that there's something there," Dr. Metz advised.

An oversized dressing also can help ensure that the child's experience is not minimized, Dr. Metz pointed out, adding that many children will need a note excusing them from physical education classes and after-school sports.

"It's also helpful to give them printed-out postoperative instructions," she added.

Dr. Metz said that 2-octyl cyanoacrylate tissue adhesives such as Dermabond also can be used to close wounds that would otherwise require up to a 5–0 suture.

These types of adhesives are especially beneficial for squirmy children and toddlers, and there is no need for a follow-up visit.

The wound can also get wet.

On the other hand, she cautioned that the cost—approximately $30 per vial—and the fact that it can be picked off or inadvertently dissolved by petrolatum-based products, are drawbacks.

Dr. Metz pointed out that the resilience of children is not to be underestimated.

"I'm surprised every time at how quickly kids bounce back after a procedure," she said.

"It may have gone terribly, but afterward they just bounce back. It really makes postoperative care a breeze," she commented.

PALM DESERT, CALIF. — Performing repeated plasma skin resurfacing at low fluences improves wrinkles and results in much less patient downtime than does the use of higher fluences, Dr. Melissa Bogle reported at the annual meeting of the American Society for Dermatologic Surgery.

Many previous case series of plasma skin resurfacing have reported patients undergoing a single treatment with a fluence of 3–4 J/cm

In Dr. Bogle's series, eight patients were treated at fluences of 1.2–1.8 J/cm

The plasma device, the Portrait PSR

Each patient in the series received three full face treatments, one every 3 weeks. Sloughing lasted longer after the first treatment (average 9 days) than after the second and third treatments (4 days).

Erythema persisted for 6 days and tended to be mild. The average erythema score of the patients following a treatment was 1.8 on a 0–4 erythema scale, which Dr. Bogle described as being "between minimal and mild, closer to mild."

Dr. Bogle could not account for why sloughing lasted longer with the first procedure. Some experts now use even lower fluences than she used in her study, and a lower fluence for the first treatment than for the second and third.

The investigators rated the improvement in facial rhytids at 23% after 1 month and 37% after 3 months. Histologic samples taken from the upper lip area of six of the patients before and after treatment showed an increase in collagen thickness at the dermal-epidermal junction and less dense elastin in the collagen zone.

Dr. Bogle received a research grant from Rhytec, the maker of the Portrait device.

PALM DESERT, CALIF. — Performing repeated plasma skin resurfacing at low fluences improves wrinkles and results in much less patient downtime than does the use of higher fluences, Dr. Melissa Bogle reported at the annual meeting of the American Society for Dermatologic Surgery.

Many previous case series of plasma skin resurfacing have reported patients undergoing a single treatment with a fluence of 3–4 J/cm

In Dr. Bogle's series, eight patients were treated at fluences of 1.2–1.8 J/cm

The plasma device, the Portrait PSR

Each patient in the series received three full face treatments, one every 3 weeks. Sloughing lasted longer after the first treatment (average 9 days) than after the second and third treatments (4 days).

Erythema persisted for 6 days and tended to be mild. The average erythema score of the patients following a treatment was 1.8 on a 0–4 erythema scale, which Dr. Bogle described as being "between minimal and mild, closer to mild."

Dr. Bogle could not account for why sloughing lasted longer with the first procedure. Some experts now use even lower fluences than she used in her study, and a lower fluence for the first treatment than for the second and third.

The investigators rated the improvement in facial rhytids at 23% after 1 month and 37% after 3 months. Histologic samples taken from the upper lip area of six of the patients before and after treatment showed an increase in collagen thickness at the dermal-epidermal junction and less dense elastin in the collagen zone.

Dr. Bogle received a research grant from Rhytec, the maker of the Portrait device.

PALM DESERT, CALIF. — Performing repeated plasma skin resurfacing at low fluences improves wrinkles and results in much less patient downtime than does the use of higher fluences, Dr. Melissa Bogle reported at the annual meeting of the American Society for Dermatologic Surgery.

Many previous case series of plasma skin resurfacing have reported patients undergoing a single treatment with a fluence of 3–4 J/cm

In Dr. Bogle's series, eight patients were treated at fluences of 1.2–1.8 J/cm

The plasma device, the Portrait PSR

Each patient in the series received three full face treatments, one every 3 weeks. Sloughing lasted longer after the first treatment (average 9 days) than after the second and third treatments (4 days).

Erythema persisted for 6 days and tended to be mild. The average erythema score of the patients following a treatment was 1.8 on a 0–4 erythema scale, which Dr. Bogle described as being "between minimal and mild, closer to mild."

Dr. Bogle could not account for why sloughing lasted longer with the first procedure. Some experts now use even lower fluences than she used in her study, and a lower fluence for the first treatment than for the second and third.

The investigators rated the improvement in facial rhytids at 23% after 1 month and 37% after 3 months. Histologic samples taken from the upper lip area of six of the patients before and after treatment showed an increase in collagen thickness at the dermal-epidermal junction and less dense elastin in the collagen zone.

Dr. Bogle received a research grant from Rhytec, the maker of the Portrait device.

LAS VEGAS — The use of botulinum toxin type A in a dermatologic surgical practice extends far beyond touching up the results of a brow lift or smoothing crow's feet to complement a facial laser procedure.

Surgeons speaking at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery said that they have incorporated botulinum toxin type A (Botox) into many facets of their practice, from stabilizing healing tissue to treating fellow surgeons' sweaty palms.

"Botox is a great adjunct to surgery," said Dr. Steven Dayan, a facial, plastic, and reconstructive surgeon and otolaryngologist in Chicago.

Dr. Dayan injects every patient undergoing a forehead lift with Botox to immobilize the frontalis muscle and prevent scars from being pulled apart. "It helps quite a bit in closing these scars and keeping the area splinted," he said.

Dr. Joel Cohen, a dermatologist and Mohs surgeon in Denver, uses the same immobilizing effect of Botox to hold tissue in place following extensive Mohs cases of the face.

If a nerve is weakened during surgery, Botox can restore symmetry of the face, said Dr. Dayan. He uses it to smooth platysmal bands that remain following a neck lift, to rotate the nasal tip upward when it has become elongated with age, and to raise the corners of the mouth.

He's even used it on surgeons' hands—once they've signed explicit informed-consent agreements—to reduce perspiration in their surgical gloves.

Despite the risks, some surgeons are so concerned that their hands become slippery in their gloves during procedures that they are more than willing to undergo Botox injections, Dr. Dayan said.

LAS VEGAS — The use of botulinum toxin type A in a dermatologic surgical practice extends far beyond touching up the results of a brow lift or smoothing crow's feet to complement a facial laser procedure.

Surgeons speaking at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery said that they have incorporated botulinum toxin type A (Botox) into many facets of their practice, from stabilizing healing tissue to treating fellow surgeons' sweaty palms.

"Botox is a great adjunct to surgery," said Dr. Steven Dayan, a facial, plastic, and reconstructive surgeon and otolaryngologist in Chicago.

Dr. Dayan injects every patient undergoing a forehead lift with Botox to immobilize the frontalis muscle and prevent scars from being pulled apart. "It helps quite a bit in closing these scars and keeping the area splinted," he said.

Dr. Joel Cohen, a dermatologist and Mohs surgeon in Denver, uses the same immobilizing effect of Botox to hold tissue in place following extensive Mohs cases of the face.

If a nerve is weakened during surgery, Botox can restore symmetry of the face, said Dr. Dayan. He uses it to smooth platysmal bands that remain following a neck lift, to rotate the nasal tip upward when it has become elongated with age, and to raise the corners of the mouth.

He's even used it on surgeons' hands—once they've signed explicit informed-consent agreements—to reduce perspiration in their surgical gloves.

Despite the risks, some surgeons are so concerned that their hands become slippery in their gloves during procedures that they are more than willing to undergo Botox injections, Dr. Dayan said.

LAS VEGAS — The use of botulinum toxin type A in a dermatologic surgical practice extends far beyond touching up the results of a brow lift or smoothing crow's feet to complement a facial laser procedure.

Surgeons speaking at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery said that they have incorporated botulinum toxin type A (Botox) into many facets of their practice, from stabilizing healing tissue to treating fellow surgeons' sweaty palms.

"Botox is a great adjunct to surgery," said Dr. Steven Dayan, a facial, plastic, and reconstructive surgeon and otolaryngologist in Chicago.

Dr. Dayan injects every patient undergoing a forehead lift with Botox to immobilize the frontalis muscle and prevent scars from being pulled apart. "It helps quite a bit in closing these scars and keeping the area splinted," he said.

Dr. Joel Cohen, a dermatologist and Mohs surgeon in Denver, uses the same immobilizing effect of Botox to hold tissue in place following extensive Mohs cases of the face.

If a nerve is weakened during surgery, Botox can restore symmetry of the face, said Dr. Dayan. He uses it to smooth platysmal bands that remain following a neck lift, to rotate the nasal tip upward when it has become elongated with age, and to raise the corners of the mouth.

He's even used it on surgeons' hands—once they've signed explicit informed-consent agreements—to reduce perspiration in their surgical gloves.

Despite the risks, some surgeons are so concerned that their hands become slippery in their gloves during procedures that they are more than willing to undergo Botox injections, Dr. Dayan said.

VAIL, COLO. — The superficial injection of many botulinum toxin type A microdroplets may create a more natural-looking brow lift than more aggressive treatment of the central frontalis and nearby depressor muscles, Dr. Kenneth D. Steinsapir said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

In the area where Dr. Steinsapir practices, a common technique for raising the brow includes botulinum toxin type A (Botox) injections to the central forehead (leaving the lateral frontalis alone), aggressive treatment of the corrugator and procerus muscles, and "pretty aggressive treatment" in the crow's feet area, he said.

This technique creates a central depression and smoothing of the forehead and significant, unopposed elevation of the frontalis, which produces a taut, arching central brow. Extreme versions of this have been given the moniker "Klingon forehead," said Dr. Steinsapir, a cosmetic, eye, and facial plastic surgeon in private practice in Los Angeles.

These patients have smoother horizontal forehead lines, but often at the expense of brow position depression in which the eyebrows crowd into the eyes.

"We have these treatment patterns because we're concerned that we'll get a ptosis after Botox treatment," he noted.

"Aesthetically, I think we can all agree that there is something not optimal about these faces," which are often seen in actresses, Dr. Steinsapir said. "This type of fakeness creates an impression in the public that Botox is a paralytic and undesirable at best."

"The key is, I think, to have a clearer picture of the anatomy and how these muscles interact," he continued.

"Brow position is really determined by the antagonists—the frontalis is really the only elevator in the brow. A substantial portion of the other muscles are brow depressors—the corrugators, the procerus, and the depressor supercilii," he said at the symposium, which was also sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

To lessen the pronounced brow arch that occurs with that technique, Dr. Steinsapir developed his microdroplet technique, in which he aggressively treats the frontalis at and below the brow by injecting "smaller and smaller volumes of fluid in multiple locations." These microdroplets have volumes of 10–50 mcL of injectable saline; he has worked with microdroplets that contain 0.001–1 U Botox.

Dr. Steinsapir's currently preferred starting treatment is based on 100 U Botox and 3 mL of injectable saline, which equals about 0.33 U of Botox per 10 mcL.

He uses 32- and 33-gauge needles, which are more comfortable for the patient than a 30-gauge needle. He also uses magnification and subsurface illumination to see the subsurface vasculature "a little bit better," although he has not performed a study to determine if it reduces the rate of bruising, he said.

A typical treatment involves a total of about 100 microdroplets placed in double or triple rows just above, in, and below the brow, stopping around the level of the lowest brow cilia. The microdroplet injections are placed superficially about 1 mm into the skin to trap the Botox at the interface between the orbicularis oculi and the skin. For crow's feet, he will usually stop just before the midline of the lateral palpebral raphe. The glabellar area is also treated. The combination of these treatments produces a "uniform brow-lift effect," he said.

Dr. Steinsapir estimated that his starting treatment of about 100 microdroplets (about 33 U) works well for about 70% of women and about 50% of men. Of 75 consecutive patients (56 of them women) that he has treated with this technique, 61 returned at 3-week follow-up and had no ptosis, he said.

Caution should be used in performing this technique on patients who have had aggressive upper eyelid surgery, because their anatomy is slightly different and they may be at higher risk for ptosis, especially if their eyelids are thin, Dr. Steinsapir advised.

"If your patients are used to other techniques, it's a tough road because this is a very different treatment paradigm," he said.

Dr. Steinsapir has filed for a patent on the method and has asserted a trademark for the term microdroplet. "If you adopt it in your practice, you'll have to come up with a different name for it," he said.

VAIL, COLO. — The superficial injection of many botulinum toxin type A microdroplets may create a more natural-looking brow lift than more aggressive treatment of the central frontalis and nearby depressor muscles, Dr. Kenneth D. Steinsapir said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

In the area where Dr. Steinsapir practices, a common technique for raising the brow includes botulinum toxin type A (Botox) injections to the central forehead (leaving the lateral frontalis alone), aggressive treatment of the corrugator and procerus muscles, and "pretty aggressive treatment" in the crow's feet area, he said.

This technique creates a central depression and smoothing of the forehead and significant, unopposed elevation of the frontalis, which produces a taut, arching central brow. Extreme versions of this have been given the moniker "Klingon forehead," said Dr. Steinsapir, a cosmetic, eye, and facial plastic surgeon in private practice in Los Angeles.

These patients have smoother horizontal forehead lines, but often at the expense of brow position depression in which the eyebrows crowd into the eyes.

"We have these treatment patterns because we're concerned that we'll get a ptosis after Botox treatment," he noted.

"Aesthetically, I think we can all agree that there is something not optimal about these faces," which are often seen in actresses, Dr. Steinsapir said. "This type of fakeness creates an impression in the public that Botox is a paralytic and undesirable at best."

"The key is, I think, to have a clearer picture of the anatomy and how these muscles interact," he continued.

"Brow position is really determined by the antagonists—the frontalis is really the only elevator in the brow. A substantial portion of the other muscles are brow depressors—the corrugators, the procerus, and the depressor supercilii," he said at the symposium, which was also sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

To lessen the pronounced brow arch that occurs with that technique, Dr. Steinsapir developed his microdroplet technique, in which he aggressively treats the frontalis at and below the brow by injecting "smaller and smaller volumes of fluid in multiple locations." These microdroplets have volumes of 10–50 mcL of injectable saline; he has worked with microdroplets that contain 0.001–1 U Botox.

Dr. Steinsapir's currently preferred starting treatment is based on 100 U Botox and 3 mL of injectable saline, which equals about 0.33 U of Botox per 10 mcL.

He uses 32- and 33-gauge needles, which are more comfortable for the patient than a 30-gauge needle. He also uses magnification and subsurface illumination to see the subsurface vasculature "a little bit better," although he has not performed a study to determine if it reduces the rate of bruising, he said.

A typical treatment involves a total of about 100 microdroplets placed in double or triple rows just above, in, and below the brow, stopping around the level of the lowest brow cilia. The microdroplet injections are placed superficially about 1 mm into the skin to trap the Botox at the interface between the orbicularis oculi and the skin. For crow's feet, he will usually stop just before the midline of the lateral palpebral raphe. The glabellar area is also treated. The combination of these treatments produces a "uniform brow-lift effect," he said.

Dr. Steinsapir estimated that his starting treatment of about 100 microdroplets (about 33 U) works well for about 70% of women and about 50% of men. Of 75 consecutive patients (56 of them women) that he has treated with this technique, 61 returned at 3-week follow-up and had no ptosis, he said.

Caution should be used in performing this technique on patients who have had aggressive upper eyelid surgery, because their anatomy is slightly different and they may be at higher risk for ptosis, especially if their eyelids are thin, Dr. Steinsapir advised.

"If your patients are used to other techniques, it's a tough road because this is a very different treatment paradigm," he said.

Dr. Steinsapir has filed for a patent on the method and has asserted a trademark for the term microdroplet. "If you adopt it in your practice, you'll have to come up with a different name for it," he said.

VAIL, COLO. — The superficial injection of many botulinum toxin type A microdroplets may create a more natural-looking brow lift than more aggressive treatment of the central frontalis and nearby depressor muscles, Dr. Kenneth D. Steinsapir said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

In the area where Dr. Steinsapir practices, a common technique for raising the brow includes botulinum toxin type A (Botox) injections to the central forehead (leaving the lateral frontalis alone), aggressive treatment of the corrugator and procerus muscles, and "pretty aggressive treatment" in the crow's feet area, he said.

This technique creates a central depression and smoothing of the forehead and significant, unopposed elevation of the frontalis, which produces a taut, arching central brow. Extreme versions of this have been given the moniker "Klingon forehead," said Dr. Steinsapir, a cosmetic, eye, and facial plastic surgeon in private practice in Los Angeles.

These patients have smoother horizontal forehead lines, but often at the expense of brow position depression in which the eyebrows crowd into the eyes.

"We have these treatment patterns because we're concerned that we'll get a ptosis after Botox treatment," he noted.

"Aesthetically, I think we can all agree that there is something not optimal about these faces," which are often seen in actresses, Dr. Steinsapir said. "This type of fakeness creates an impression in the public that Botox is a paralytic and undesirable at best."

"The key is, I think, to have a clearer picture of the anatomy and how these muscles interact," he continued.

"Brow position is really determined by the antagonists—the frontalis is really the only elevator in the brow. A substantial portion of the other muscles are brow depressors—the corrugators, the procerus, and the depressor supercilii," he said at the symposium, which was also sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

To lessen the pronounced brow arch that occurs with that technique, Dr. Steinsapir developed his microdroplet technique, in which he aggressively treats the frontalis at and below the brow by injecting "smaller and smaller volumes of fluid in multiple locations." These microdroplets have volumes of 10–50 mcL of injectable saline; he has worked with microdroplets that contain 0.001–1 U Botox.

Dr. Steinsapir's currently preferred starting treatment is based on 100 U Botox and 3 mL of injectable saline, which equals about 0.33 U of Botox per 10 mcL.

He uses 32- and 33-gauge needles, which are more comfortable for the patient than a 30-gauge needle. He also uses magnification and subsurface illumination to see the subsurface vasculature "a little bit better," although he has not performed a study to determine if it reduces the rate of bruising, he said.

A typical treatment involves a total of about 100 microdroplets placed in double or triple rows just above, in, and below the brow, stopping around the level of the lowest brow cilia. The microdroplet injections are placed superficially about 1 mm into the skin to trap the Botox at the interface between the orbicularis oculi and the skin. For crow's feet, he will usually stop just before the midline of the lateral palpebral raphe. The glabellar area is also treated. The combination of these treatments produces a "uniform brow-lift effect," he said.

Dr. Steinsapir estimated that his starting treatment of about 100 microdroplets (about 33 U) works well for about 70% of women and about 50% of men. Of 75 consecutive patients (56 of them women) that he has treated with this technique, 61 returned at 3-week follow-up and had no ptosis, he said.

Caution should be used in performing this technique on patients who have had aggressive upper eyelid surgery, because their anatomy is slightly different and they may be at higher risk for ptosis, especially if their eyelids are thin, Dr. Steinsapir advised.

"If your patients are used to other techniques, it's a tough road because this is a very different treatment paradigm," he said.

Dr. Steinsapir has filed for a patent on the method and has asserted a trademark for the term microdroplet. "If you adopt it in your practice, you'll have to come up with a different name for it," he said.

VAIL, COLO. — A bioengineered skin substitute may have applications in reconstructive surgery that extend beyond its indication for burn victims, Dr. Kapil Saigal said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The recent development of biomaterials for head and neck reconstruction has provided alternatives to autologous skin transplantation, such as cadaveric allograft skin, xenografts, and bioengineered skin substitutes, said Dr. Saigal, a fourth-year resident in the department of otolaryngology-head and neck surgery at Jefferson Medical College, Philadelphia.

A biologic skin substitute can be used as a permanent replacement or as a temporary biologic dressing. These skin substitutes can decrease bacterial counts; slow the loss of water, proteins, and electro-lytes from the wound; reduce pain and fever; help restore function and facilitate early motion; and prevent desiccation of vessels, tendons, and nerves.

Fewer data are available on the functionality of biological skin substitutes in reconstructive surgery than in burn treatment and chronic wound healing, he said.

Integra artificial dermis is a composite bilayer dermal regeneration template that is used for skin replacement. It was approved by the Food and Drug Administration in 2003 for the treatment of life-threatening third-degree burns to provide immediate coverage for as much as 95% of body surface area.

The biomaterial is composed of a dermal replacement layer of a porous matrix of crosslinked bovine tendon collagen coated with a glycosaminoglycan (chondroitin-6-sulfate); a temporary epidermal layer of polysiloxane polymer (silicone) prevents moisture loss.

After Integra has been in place for 2–3 weeks, the template changes from its original color of pink to yellow or an orange-peach color, which indicates that the graft is vascularized and a new dermal-like layer has been generated. The epidermal polysiloxane layer can be removed so that a very thin epidermal autograft can be placed on the new dermis. Very little wound contraction occurs because of the thick dermal component, Dr. Saigal explained.

The template is thought to improve "fibroblast proliferation from the wound edges, while the addition of a glycosaminoglycan actually decreases the inflammatory component of wound healing and prevents the formation of granulation tissue," he said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Dr. Saigal reported that he and his associates have used Integra in 15 patients for wounds ranging from those on the eyelid to radiated scalp wounds with graft sizes of 10–140 cm

They have used the skin substitute to perform a delayed reconstruction after removal of a cutaneous malignancy, repair a defect after surgery for severe rhinophyma, cover wounds of the head and neck that were not amenable to primary or focal closure, and heal areas that have been irradiated or will be irradiated postoperatively. The product may be useful in closing wounds in children and elderly patients, he suggested.

In a case series of seven patients with an average age of 70 years who received the Integra artificial dermis, 100% of the split-thickness skin grafts that were applied after a mean of about 5 weeks survived without any complications (Plast. Reconstr. Surg. 2005;115:1010–7).

Other reports in the literature suggest that Integra has a better "take rate" in complicated wounds when it is combined with a vacuum-assisted closure or with fibrin glue, said Dr. Saigal, who disclosed that he and his colleagues have no financial interest in Integra.

Integra costs about $700–$900 per graft, he said.

VAIL, COLO. — A bioengineered skin substitute may have applications in reconstructive surgery that extend beyond its indication for burn victims, Dr. Kapil Saigal said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The recent development of biomaterials for head and neck reconstruction has provided alternatives to autologous skin transplantation, such as cadaveric allograft skin, xenografts, and bioengineered skin substitutes, said Dr. Saigal, a fourth-year resident in the department of otolaryngology-head and neck surgery at Jefferson Medical College, Philadelphia.

A biologic skin substitute can be used as a permanent replacement or as a temporary biologic dressing. These skin substitutes can decrease bacterial counts; slow the loss of water, proteins, and electro-lytes from the wound; reduce pain and fever; help restore function and facilitate early motion; and prevent desiccation of vessels, tendons, and nerves.

Fewer data are available on the functionality of biological skin substitutes in reconstructive surgery than in burn treatment and chronic wound healing, he said.

Integra artificial dermis is a composite bilayer dermal regeneration template that is used for skin replacement. It was approved by the Food and Drug Administration in 2003 for the treatment of life-threatening third-degree burns to provide immediate coverage for as much as 95% of body surface area.

The biomaterial is composed of a dermal replacement layer of a porous matrix of crosslinked bovine tendon collagen coated with a glycosaminoglycan (chondroitin-6-sulfate); a temporary epidermal layer of polysiloxane polymer (silicone) prevents moisture loss.

After Integra has been in place for 2–3 weeks, the template changes from its original color of pink to yellow or an orange-peach color, which indicates that the graft is vascularized and a new dermal-like layer has been generated. The epidermal polysiloxane layer can be removed so that a very thin epidermal autograft can be placed on the new dermis. Very little wound contraction occurs because of the thick dermal component, Dr. Saigal explained.

The template is thought to improve "fibroblast proliferation from the wound edges, while the addition of a glycosaminoglycan actually decreases the inflammatory component of wound healing and prevents the formation of granulation tissue," he said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Dr. Saigal reported that he and his associates have used Integra in 15 patients for wounds ranging from those on the eyelid to radiated scalp wounds with graft sizes of 10–140 cm

They have used the skin substitute to perform a delayed reconstruction after removal of a cutaneous malignancy, repair a defect after surgery for severe rhinophyma, cover wounds of the head and neck that were not amenable to primary or focal closure, and heal areas that have been irradiated or will be irradiated postoperatively. The product may be useful in closing wounds in children and elderly patients, he suggested.

In a case series of seven patients with an average age of 70 years who received the Integra artificial dermis, 100% of the split-thickness skin grafts that were applied after a mean of about 5 weeks survived without any complications (Plast. Reconstr. Surg. 2005;115:1010–7).

Other reports in the literature suggest that Integra has a better "take rate" in complicated wounds when it is combined with a vacuum-assisted closure or with fibrin glue, said Dr. Saigal, who disclosed that he and his colleagues have no financial interest in Integra.

Integra costs about $700–$900 per graft, he said.

VAIL, COLO. — A bioengineered skin substitute may have applications in reconstructive surgery that extend beyond its indication for burn victims, Dr. Kapil Saigal said at a symposium sponsored by the American Academy of Facial Plastic and Reconstructive Surgery.

The recent development of biomaterials for head and neck reconstruction has provided alternatives to autologous skin transplantation, such as cadaveric allograft skin, xenografts, and bioengineered skin substitutes, said Dr. Saigal, a fourth-year resident in the department of otolaryngology-head and neck surgery at Jefferson Medical College, Philadelphia.

A biologic skin substitute can be used as a permanent replacement or as a temporary biologic dressing. These skin substitutes can decrease bacterial counts; slow the loss of water, proteins, and electro-lytes from the wound; reduce pain and fever; help restore function and facilitate early motion; and prevent desiccation of vessels, tendons, and nerves.

Fewer data are available on the functionality of biological skin substitutes in reconstructive surgery than in burn treatment and chronic wound healing, he said.

Integra artificial dermis is a composite bilayer dermal regeneration template that is used for skin replacement. It was approved by the Food and Drug Administration in 2003 for the treatment of life-threatening third-degree burns to provide immediate coverage for as much as 95% of body surface area.

The biomaterial is composed of a dermal replacement layer of a porous matrix of crosslinked bovine tendon collagen coated with a glycosaminoglycan (chondroitin-6-sulfate); a temporary epidermal layer of polysiloxane polymer (silicone) prevents moisture loss.

After Integra has been in place for 2–3 weeks, the template changes from its original color of pink to yellow or an orange-peach color, which indicates that the graft is vascularized and a new dermal-like layer has been generated. The epidermal polysiloxane layer can be removed so that a very thin epidermal autograft can be placed on the new dermis. Very little wound contraction occurs because of the thick dermal component, Dr. Saigal explained.

The template is thought to improve "fibroblast proliferation from the wound edges, while the addition of a glycosaminoglycan actually decreases the inflammatory component of wound healing and prevents the formation of granulation tissue," he said at the symposium, which also was sponsored by the American Society for Dermatologic Surgery and the American Society of Ophthalmic Plastic and Reconstructive Surgery.

Dr. Saigal reported that he and his associates have used Integra in 15 patients for wounds ranging from those on the eyelid to radiated scalp wounds with graft sizes of 10–140 cm

They have used the skin substitute to perform a delayed reconstruction after removal of a cutaneous malignancy, repair a defect after surgery for severe rhinophyma, cover wounds of the head and neck that were not amenable to primary or focal closure, and heal areas that have been irradiated or will be irradiated postoperatively. The product may be useful in closing wounds in children and elderly patients, he suggested.

In a case series of seven patients with an average age of 70 years who received the Integra artificial dermis, 100% of the split-thickness skin grafts that were applied after a mean of about 5 weeks survived without any complications (Plast. Reconstr. Surg. 2005;115:1010–7).

Other reports in the literature suggest that Integra has a better "take rate" in complicated wounds when it is combined with a vacuum-assisted closure or with fibrin glue, said Dr. Saigal, who disclosed that he and his colleagues have no financial interest in Integra.

Integra costs about $700–$900 per graft, he said.

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — Large, depressed abdominal scars that complicate liposuction can be safely removed using "a novel technique" involving standard laparoscopic scissors, Dr. Marco A. Pelosi II said at the annual meeting of the American Academy of Cosmetic Surgery.

The technique has no laparoscopic component, he said in an interview, and following his success with standard laparoscopic scissors in this study, he has since designed the Pelosi Liposcar scissors, which are specifically intended for this purpose.

Surgical scars that do not involve direct adherence of the dermis to the muscle fascia are relatively simple to manage at the time of liposuction using either small-diameter liposuction cannulas or V-tip dissector cannulas, Dr. Pelosi said. However, more complicated scars that involve the aponeurosis cannot be eliminated using these tools.

In a study of 20 consecutive patients who required release of such depressed abdominal scars prior to office liposuction, standard laparoscopic scissors were safe and effective, reported Dr. Pelosi, who is a gynecologist in Bayonne, N.J.

Computed axial tomography scans of all scars were performed preoperatively to rule out incisional hernias, and all surgeries were performed under tumescent anesthesia.

The laparoscopic scissors were introduced through a 3- to 4-mm incision parallel to the skin surface in the superficial subcutaneous layer and advanced toward the scar. As soon as fibrotic resistance was encountered, the operator's free hand was used to stabilize the area while the other hand moved the scissors in "a lancing and fanning motion" to cut the subcutaneous fibrotic strands, Dr. Pelosi explained.

The scissors were then directed into the deep dermis to cut the fibrotic strands attached to the muscle fascia. Finally, the scissors were used to feel and release any remnants of fibrotic tissue holding the scar. After full release of the scar, standard liposuction was performed.

Complete release of the scar was achieved in all of the study subjects without any intraoperative or postoperative complications.

At 12 months post procedure there was no evidence of recurring subcutaneous fibrotic strands, he said.

JULIE KELLER/ELSEVIER GLOBAL MEDICAL NEWS

This depressed scar, caused by three previous laparotomies, can be released with standard laparoscopic scissors.

The scar has been safely and fully released in preparation for liposuction. Photos courtesy Dr. Marco A. Pelosi II

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PHOENIX — In the face of myriad short-scar rhytidectomy techniques, suture extrusion rates and efficacy of lift are two variables that can help surgeons identify their preferred approach, Dr. Neil Tanna said at the annual meeting of the American Academy of Cosmetic Surgery.

Although secure suspension of the superficial musculoaponeurotic system (SMAS) is indispensable for effective results, there are numerous SMAS suspension techniques and no consensus on which is superior, said Dr. Tanna, who is a resident in otolaryngology and head and neck surgery at George Washington University in Washington.

"Surgeon preference is usually based on the efficacy of the achieved lift and the rate of suture extrusion," he said in an interview, explaining that suture extrusion disrupts the biomechanical properties of the manipulated tissue.

"With the loss of deep tissue support, there is an increase in wound tension and an increased risk of necrosis, scarring, trophic changes, and contour defect," Dr. Tanna said.

His retrospective study compared 1,850 short-scar rhytidectomies performed by one surgeon between January 2002 and January 2006, with the primary outcome being the rate of suture extrusion. All patients also received cervicofacial liposuction at the time of the surgery and were divided into six groups based on the type of SMAS plication they underwent.

In group A, 100 patients received O-shaped purse-string sutures (2–0 Ethibond). For the 100 patients in group B, both O-shaped and U-shaped purse-string sutures (2–0 Ethibond) were used. Interrupted horizontal mattress sutures were used for the 50 patients in group C (2–0 Ethibond), 50 patients in group D (2–0 Vicryl), and 50 patients in group E (2–0 Mersilene). Group F included 1,500 patients in whom a two-layer running locked plication stitch was used with a braided, nonabsorbable suture (2–0 Mersilene).

After at least 6 months of follow-up, the patients were compared in terms of rate, type, and location of suture extrusion.

Group A had a 5% rate of suture extrusion, compared with 8% for group B, 6% for group C, and 1.2% for group F, reported Dr. Tanna. Although groups D and E had no suture extrusions, he concluded that patients in group F had achieved the best overall outcome in terms of both lift and a low rate of suture extrusion.

Although the study didn't formally "evaluate the efficacy of the achieved lift while looking at suture extrusion … anecdotal experience suggests that the two-layer plication stitch employing a braided nonabsorbable suture allows an effective SMAS suspension with a tolerable rate of suture extrusion," he said.

This patient is undergoing the two-layer running locked superficial musculoaponeurotic system plication with a braided, nonabsorbable suture. Courtesy Dr. Neil Tanna

PALM DESERT, CALIF. — The 755-nm alexandrite laser was highly effective in improving lentigines in 18 volunteers treated at Naval Hospital Camp Pendleton, Lt. Cmdr. John Paul Trafeli, USN, said at the annual meeting of the American Society for Dermatologic Surgery.

Independent reviewers judged that the patients had a 60% average improvement in their lentigines after a single treatment with one or two passes of the alexandrite laser, which is more commonly used for hair removal.

Dr. Trafeli said that 18 patients were also treated for facial telangiectasis in the same study, but the results were not quite as good. Those patients had a 30% average improvement.

"For telangiectasis, the alexandrite laser is a ground ball, but for lentigo, it is a definite home run," he said.

After experimenting with several parameters on test areas, the investigators generally settled on a 3-millisecond pulse duration at 34 J/cm

Increasing the pulse duration improved the background epidermal tolerance and did not work as well.

The 755-nm alexandrite laser is an "interesting" wavelength because it appears to be optimal for absorption in areas of dyspigmentation, Dr. Trafeli said.

It has a high absorption by melanin relative to hemoglobin, compared with the 532-nm and 595-nm lasers, and it has three times the melanin absorption of the 1064-nm laser.

"The nicest thing about this alexandrite is that it is very fast and simple," he added.

"I liken it to a lawn mower. You don't need much skill. You just kind of go over the whole face."

PALM DESERT, CALIF. — The 755-nm alexandrite laser was highly effective in improving lentigines in 18 volunteers treated at Naval Hospital Camp Pendleton, Lt. Cmdr. John Paul Trafeli, USN, said at the annual meeting of the American Society for Dermatologic Surgery.

Independent reviewers judged that the patients had a 60% average improvement in their lentigines after a single treatment with one or two passes of the alexandrite laser, which is more commonly used for hair removal.

Dr. Trafeli said that 18 patients were also treated for facial telangiectasis in the same study, but the results were not quite as good. Those patients had a 30% average improvement.

"For telangiectasis, the alexandrite laser is a ground ball, but for lentigo, it is a definite home run," he said.

After experimenting with several parameters on test areas, the investigators generally settled on a 3-millisecond pulse duration at 34 J/cm

Increasing the pulse duration improved the background epidermal tolerance and did not work as well.

The 755-nm alexandrite laser is an "interesting" wavelength because it appears to be optimal for absorption in areas of dyspigmentation, Dr. Trafeli said.

It has a high absorption by melanin relative to hemoglobin, compared with the 532-nm and 595-nm lasers, and it has three times the melanin absorption of the 1064-nm laser.

"The nicest thing about this alexandrite is that it is very fast and simple," he added.

"I liken it to a lawn mower. You don't need much skill. You just kind of go over the whole face."

PALM DESERT, CALIF. — The 755-nm alexandrite laser was highly effective in improving lentigines in 18 volunteers treated at Naval Hospital Camp Pendleton, Lt. Cmdr. John Paul Trafeli, USN, said at the annual meeting of the American Society for Dermatologic Surgery.

Independent reviewers judged that the patients had a 60% average improvement in their lentigines after a single treatment with one or two passes of the alexandrite laser, which is more commonly used for hair removal.

Dr. Trafeli said that 18 patients were also treated for facial telangiectasis in the same study, but the results were not quite as good. Those patients had a 30% average improvement.

"For telangiectasis, the alexandrite laser is a ground ball, but for lentigo, it is a definite home run," he said.

After experimenting with several parameters on test areas, the investigators generally settled on a 3-millisecond pulse duration at 34 J/cm

Increasing the pulse duration improved the background epidermal tolerance and did not work as well.

The 755-nm alexandrite laser is an "interesting" wavelength because it appears to be optimal for absorption in areas of dyspigmentation, Dr. Trafeli said.

It has a high absorption by melanin relative to hemoglobin, compared with the 532-nm and 595-nm lasers, and it has three times the melanin absorption of the 1064-nm laser.

"The nicest thing about this alexandrite is that it is very fast and simple," he added.

"I liken it to a lawn mower. You don't need much skill. You just kind of go over the whole face."

PALM DESERT, CALIF. — The one-two punch of a combination pulsed dye/Nd:YAG laser system can enhance the treatment of hypertrophic port wine stains, Dr. Elizabeth Tanzi said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Tanzi presented data on 25 patients with recalcitrant and hypertrophic port wine stains that she treated using the Cynergy laser workstation. All of the patients had at least 10 previous treatments that had not yielded a satisfactory result.

With the combined laser system, which was introduced in the United States last year by Cynosure Inc., all of the patients had "continued" improvement with four to six treatments, as judged by two independent reviewers 3 months after the last treatment, said Dr. Tanzi, a dermatologist in practice in Washington.

"This is a double whammy, so to speak. We really get a double hit on the vasculature," she said.

Pulsed dye laser treatment works well for many port wine stains, but not those that are thick and hypertrophic. The combination system appears to be better because treatment first with the pulsed dye laser heats hemoglobin and damages the vasculature but also creates a new chromophore susceptible to the Nd:YAG treatment that follows, she said.

One patient who had improvement with the Cynergy laser had received 16 previous treatments.

The Cynergy system allows the operator to fire both lasers through the same handpiece, so there is no need to change between treatments, which allows for quick firing between lasers, Dr. Tanzi said.

The patients were each treated at 6-month intervals. The spot size was 1 mm. The fluence used for the pulsed dye laser (595 nm) was 77.5 J with a pulse duration of 100 milliseconds; the fluence for the Nd:YAG laser was 30–50 J, with a pulse duration of 15 milliseconds. The delay between the two lasers' pulses was 0.5–1 millisecond.

Patients had some edema afterward that lasted for 1–4 days, but there was no vesicle formation, no dyspigmentation, and no scarring, she reported.

Dr. Tanzi said that the Cynergy workstation was provided to her clinic for the investigation by Cynosure.

PALM DESERT, CALIF. — The one-two punch of a combination pulsed dye/Nd:YAG laser system can enhance the treatment of hypertrophic port wine stains, Dr. Elizabeth Tanzi said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Tanzi presented data on 25 patients with recalcitrant and hypertrophic port wine stains that she treated using the Cynergy laser workstation. All of the patients had at least 10 previous treatments that had not yielded a satisfactory result.

With the combined laser system, which was introduced in the United States last year by Cynosure Inc., all of the patients had "continued" improvement with four to six treatments, as judged by two independent reviewers 3 months after the last treatment, said Dr. Tanzi, a dermatologist in practice in Washington.

"This is a double whammy, so to speak. We really get a double hit on the vasculature," she said.

Pulsed dye laser treatment works well for many port wine stains, but not those that are thick and hypertrophic. The combination system appears to be better because treatment first with the pulsed dye laser heats hemoglobin and damages the vasculature but also creates a new chromophore susceptible to the Nd:YAG treatment that follows, she said.

One patient who had improvement with the Cynergy laser had received 16 previous treatments.

The Cynergy system allows the operator to fire both lasers through the same handpiece, so there is no need to change between treatments, which allows for quick firing between lasers, Dr. Tanzi said.

The patients were each treated at 6-month intervals. The spot size was 1 mm. The fluence used for the pulsed dye laser (595 nm) was 77.5 J with a pulse duration of 100 milliseconds; the fluence for the Nd:YAG laser was 30–50 J, with a pulse duration of 15 milliseconds. The delay between the two lasers' pulses was 0.5–1 millisecond.

Patients had some edema afterward that lasted for 1–4 days, but there was no vesicle formation, no dyspigmentation, and no scarring, she reported.

Dr. Tanzi said that the Cynergy workstation was provided to her clinic for the investigation by Cynosure.

PALM DESERT, CALIF. — The one-two punch of a combination pulsed dye/Nd:YAG laser system can enhance the treatment of hypertrophic port wine stains, Dr. Elizabeth Tanzi said at the annual meeting of the American Society for Dermatologic Surgery.

Dr. Tanzi presented data on 25 patients with recalcitrant and hypertrophic port wine stains that she treated using the Cynergy laser workstation. All of the patients had at least 10 previous treatments that had not yielded a satisfactory result.

With the combined laser system, which was introduced in the United States last year by Cynosure Inc., all of the patients had "continued" improvement with four to six treatments, as judged by two independent reviewers 3 months after the last treatment, said Dr. Tanzi, a dermatologist in practice in Washington.

"This is a double whammy, so to speak. We really get a double hit on the vasculature," she said.

Pulsed dye laser treatment works well for many port wine stains, but not those that are thick and hypertrophic. The combination system appears to be better because treatment first with the pulsed dye laser heats hemoglobin and damages the vasculature but also creates a new chromophore susceptible to the Nd:YAG treatment that follows, she said.

One patient who had improvement with the Cynergy laser had received 16 previous treatments.

The Cynergy system allows the operator to fire both lasers through the same handpiece, so there is no need to change between treatments, which allows for quick firing between lasers, Dr. Tanzi said.

The patients were each treated at 6-month intervals. The spot size was 1 mm. The fluence used for the pulsed dye laser (595 nm) was 77.5 J with a pulse duration of 100 milliseconds; the fluence for the Nd:YAG laser was 30–50 J, with a pulse duration of 15 milliseconds. The delay between the two lasers' pulses was 0.5–1 millisecond.

Patients had some edema afterward that lasted for 1–4 days, but there was no vesicle formation, no dyspigmentation, and no scarring, she reported.

Dr. Tanzi said that the Cynergy workstation was provided to her clinic for the investigation by Cynosure.

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz

SCOTTSDALE, ARIZ. — The introduction of dynamic cooling devices has made pulsed dye laser therapy of infantile hemangiomas safer and less painful, but rare complications do occur, Dr. Brandie J. Metz said at a dermatology conference sponsored by Skin Disease Education Foundation.

Pulsed dye laser is a common treatment for superficial cutaneous vascular lesions. The 585-nm pulsed dye laser reaches a depth of about 1.2 mm, and the newer 595-nm pulsed dye laser penetrates slightly deeper without losing vascular specificity. Typical treatment for infantile hemangiomas uses short pulses (0.45–1.5 milliseconds) in spot sizes of 7 or 10 mm, noted Dr. Metz, chief of pediatric dermatology at the University of California, Irvine.

Dynamic cooling devices allow higher fluences, make the procedure less painful, and reduce the risk of dyspigmentation or scarring from pulsed dye laser therapy, a recent study found (Lasers Surg. Med. 2006;38:112–5).

Selection of the laser parameters still plays a key role, however, in the risk for complications, she said. Because hemangiomas are dynamic lesions with a higher risk for ulceration than are lesions like port-wine stains, pulsed dye laser treatment for hemangiomas generally uses lower energy levels.

A separate study characterized 12 cases of complications culled from multiple reports of pulsed dye laser therapy for superficial infantile hemangiomas. Eleven were infants treated with 585-nm pulsed dye laser without a dynamic cooling device, using fluences of 4.7–7 J/cm

All patients were treated early in life (between 5 days and 4 months of age), and all had hemangiomas on the face. Half had segmental hemangiomas, which are more prone to ulceration than localized hemangiomas.

Four patients developed permanent atrophic scarring without ulceration. Eight infants developed severe ulceration with subsequent pain and scarring, including the infant treated with higher fluences using the dynamic cooling device. The latter infant also developed a life-threatening hemorrhage.

Even though the risk of complications like scarring and ulceration from pulsed dye laser is very low, "It's important to choose your parameters carefully, identify the risk, and counsel parents" about the risk before treatment, she said.

The infant treated with the 595-nm pulsed dye laser and dynamic cooling device had done well after receiving three test spots of 6.5 J/cm

Pulsed dye laser more commonly helps manage hemangioma ulcerations than causes them, Dr. Metz noted.

Several recent studies showed that one to three treatments at 2- to 4-week intervals can help heal hemangioma ulcerations, and help alleviate pain from the ulceration within 1–2 days of the first treatment.

The first step in managing hemangioma ulceration is local wound care using barrier creams and ointments and occlusive dressing. These alone often are sufficient for smaller ulcerations and should be employed even when combined with other management strategies.

Use topical or systemic antibiotics to manage infection of ulcerated infantile hemangiomas, and use topical anesthetics or oral analgesia to manage pain. Oral acetaminophen plus codeine can be helpful, especially when changing dressings, she noted. Specific therapies for hemangiomas like systemic or intralesional corticosteroids aim to decrease proliferation and can help decrease the ulceration, she added.

Dr. Metz has no financial associations with the companies that make pulsed dye lasers. Skin Disease Education Foundation and this news organization are wholly owned subsidiaries of Elsevier.

'It's important to choose your parameters carefully, identify the risk, and counsel parents.' DR. METZ

Inappropriate laser therapy can cause infantile hemangiomas to ulcerate, but the devices can help heal some ulcerated hemangiomas. Courtesy Dr. Brandie J. Metz