Aesthetic Dermatology

SAN DIEGO—Dermatologists should ask patients detailed questions about what medications they are taking before performing a procedure, Dr. Rainer E. Sachse said at a meeting sponsored by the American Society for Mohs Surgery.

Almost half of patients who undergo a dermatologic procedure are taking some type of anticoagulant, according to a recent survey. However, this scenario may not preclude surgery, Dr. Sachse said.

Patients may be taking an alternative medicine that has anticoagulant properties, such as garlic, fish oil, niacin, or vitamin E. Similarly, many patients routinely take aspirin each day, noted Dr. Sachse, a facial plastic surgeon who practices Mohs surgery in Fort Lauderdale, Fla.

If a patient can stop the anticoagulant, Dr. Sachse asks them to do so for at least 1 week before the procedure. But because of the possible risk involved in stopping that therapy, he has the patient consult with the doctor who prescribed the medication.

For patients who are taking warfarin (Coumadin), dermatologists should know the international normalized ratio before performing the procedure. A patient on any type of anticoagulant should keep the pressure dressing on longer and avoid a lot of activity afterward to prevent bruising, other physicians at the meeting said.

SAN DIEGO—Dermatologists should ask patients detailed questions about what medications they are taking before performing a procedure, Dr. Rainer E. Sachse said at a meeting sponsored by the American Society for Mohs Surgery.

Almost half of patients who undergo a dermatologic procedure are taking some type of anticoagulant, according to a recent survey. However, this scenario may not preclude surgery, Dr. Sachse said.

Patients may be taking an alternative medicine that has anticoagulant properties, such as garlic, fish oil, niacin, or vitamin E. Similarly, many patients routinely take aspirin each day, noted Dr. Sachse, a facial plastic surgeon who practices Mohs surgery in Fort Lauderdale, Fla.

If a patient can stop the anticoagulant, Dr. Sachse asks them to do so for at least 1 week before the procedure. But because of the possible risk involved in stopping that therapy, he has the patient consult with the doctor who prescribed the medication.

For patients who are taking warfarin (Coumadin), dermatologists should know the international normalized ratio before performing the procedure. A patient on any type of anticoagulant should keep the pressure dressing on longer and avoid a lot of activity afterward to prevent bruising, other physicians at the meeting said.

SAN DIEGO—Dermatologists should ask patients detailed questions about what medications they are taking before performing a procedure, Dr. Rainer E. Sachse said at a meeting sponsored by the American Society for Mohs Surgery.

Almost half of patients who undergo a dermatologic procedure are taking some type of anticoagulant, according to a recent survey. However, this scenario may not preclude surgery, Dr. Sachse said.

Patients may be taking an alternative medicine that has anticoagulant properties, such as garlic, fish oil, niacin, or vitamin E. Similarly, many patients routinely take aspirin each day, noted Dr. Sachse, a facial plastic surgeon who practices Mohs surgery in Fort Lauderdale, Fla.

If a patient can stop the anticoagulant, Dr. Sachse asks them to do so for at least 1 week before the procedure. But because of the possible risk involved in stopping that therapy, he has the patient consult with the doctor who prescribed the medication.

For patients who are taking warfarin (Coumadin), dermatologists should know the international normalized ratio before performing the procedure. A patient on any type of anticoagulant should keep the pressure dressing on longer and avoid a lot of activity afterward to prevent bruising, other physicians at the meeting said.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

CARLSBAD, CALIF.—Some acne patients may respond to various light-based treatments, but most of the time the improvement is modest and short-lived, Dr. E. Victor Ross Jr. said at a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians.

Most light-based therapies for acne "don't work as well as they should," said Dr. Ross, director of the Scripps Clinic Skin and Cosmetic Center in La Jolla, Calif. "The bar should be pretty high. If we're having patients sit under these lights and have these therapies, I think that means long remission periods with one treatment, not five treatments every 2 or 3 weeks, and evidence that there's some robust compromise of the sebaceous gland."

Most patients who seek light-based treatments for their acne have been on isotretinoin in the past yet are unwilling to be on systemic retinoids again. "They don't have severe acne, but they have cyclical moderate acne, and they're tired and frustrated with the typical" therapies, Dr. Ross said.

Light therapies don't work well for acne because a photochemical effect should prevail over any photothermal effect to excite endogenous porphyrins produced by Propionibacterium acnes. In addition, the only studies to show microscopic damage to the sebaceous gland have been those with long incubation times, continuous-wave light sources, and red light only. This regimen caused epidermal damage in every case, he noted.

"It's unlikely that one will achieve long-term and profound sebaceous gland compromise with short aminolevulinic acid times, either with pulsed light sources or with continuous-wave light sources," he said. "Right now we have to be honest with ourselves and say the prescription pad is still pretty darned good. … I've tried these [light] therapies, but I'm not ready to say these are a home run or even a triple or double right now."

He added that many patients who undergo light treatment for their acne fail what he calls the "come back" test. "They don't come back. If they don't come back, [we assume] they're probably better, but I suspect that most of them are not better, they're worse," he said.

Dr. Ross disclosed that he has research relationships with Palomar, Cutera, and Laserscope.

RHODES, GREECE—Photodynamic therapy using topical methyl aminolevulinate has efficacy comparable to cryotherapy for the treatment of basal cell carcinoma and actinic keratoses but provides substantially better cosmetic outcomes, according to data presented at the 15th Congress of the European Academy of Dermatology and Venereology.

In a multicenter study of 120 patients with superficial basal cell carcinoma who were randomized to photodynamic therapy with methyl aminolevulinate (MAL-PDT) or cryotherapy, complete responses were seen in 97% of those in the MAL-PDT group and 95% of those in the cryotherapy group at 3 months, Dr. Nicole Basset-Seguin reported in a poster.

The recurrence rate at 60 months also was similar in the two groups: 22% in the MAL-PDT group and 20% for cryotherapy patients, reported Dr. Basset-Seguin of Hôpital Saint Louis, Paris.

The investigators, however, rated cosmetic outcomes as excellent far more frequently in the MAL-PDT group (56%) than in the cryotherapy group (14%) at the 60-month follow-up.

In this study, MAL-PDT was provided as a single treatment. Patients who failed to respond at 3 months were retreated with an additional two consecutive MAL-PDT sessions 7 days apart. Cryotherapy was applied in two freeze-thaw cycles using liquid nitrogen spray. Patients who failed to respond were retreated with double freeze-thaw cryotherapy.

In another study presented at the meeting, MAL-PDT was superior to cryotherapy for treatment of actinic keratoses.

A total of 119 subjects with 1,501 cumulative lesions were treated on one side of the face or scalp with MAL-PDT and on the other side with double freeze-thaw cryotherapy. The treatments were randomly allocated to the sides of the face/scalp and were repeated at 12 weeks in those with incomplete response, Dr. Colin Morton of the Falkirk (Scotland) Royal Infirmary, reported in a poster.

At 12 weeks, significantly more patients in the MAL-PDT group had a reduction from baseline in the number of lesions, compared with cryotherapy (84% vs. 75%, respectively), and at 24 weeks, both groups showed similar reductions in the number of lesions from baseline (89% and 88%).

Both treatments were safe and well tolerated, and subject and investigator ratings of cosmetic outcome "clearly favored MAL-PDT," Dr. Morton wrote.

Both studies were sponsored by Galderma, maker of the PDT devices used.

RHODES, GREECE—Photodynamic therapy using topical methyl aminolevulinate has efficacy comparable to cryotherapy for the treatment of basal cell carcinoma and actinic keratoses but provides substantially better cosmetic outcomes, according to data presented at the 15th Congress of the European Academy of Dermatology and Venereology.

In a multicenter study of 120 patients with superficial basal cell carcinoma who were randomized to photodynamic therapy with methyl aminolevulinate (MAL-PDT) or cryotherapy, complete responses were seen in 97% of those in the MAL-PDT group and 95% of those in the cryotherapy group at 3 months, Dr. Nicole Basset-Seguin reported in a poster.

The recurrence rate at 60 months also was similar in the two groups: 22% in the MAL-PDT group and 20% for cryotherapy patients, reported Dr. Basset-Seguin of Hôpital Saint Louis, Paris.

The investigators, however, rated cosmetic outcomes as excellent far more frequently in the MAL-PDT group (56%) than in the cryotherapy group (14%) at the 60-month follow-up.

In this study, MAL-PDT was provided as a single treatment. Patients who failed to respond at 3 months were retreated with an additional two consecutive MAL-PDT sessions 7 days apart. Cryotherapy was applied in two freeze-thaw cycles using liquid nitrogen spray. Patients who failed to respond were retreated with double freeze-thaw cryotherapy.

In another study presented at the meeting, MAL-PDT was superior to cryotherapy for treatment of actinic keratoses.

A total of 119 subjects with 1,501 cumulative lesions were treated on one side of the face or scalp with MAL-PDT and on the other side with double freeze-thaw cryotherapy. The treatments were randomly allocated to the sides of the face/scalp and were repeated at 12 weeks in those with incomplete response, Dr. Colin Morton of the Falkirk (Scotland) Royal Infirmary, reported in a poster.

At 12 weeks, significantly more patients in the MAL-PDT group had a reduction from baseline in the number of lesions, compared with cryotherapy (84% vs. 75%, respectively), and at 24 weeks, both groups showed similar reductions in the number of lesions from baseline (89% and 88%).

Both treatments were safe and well tolerated, and subject and investigator ratings of cosmetic outcome "clearly favored MAL-PDT," Dr. Morton wrote.

Both studies were sponsored by Galderma, maker of the PDT devices used.

RHODES, GREECE—Photodynamic therapy using topical methyl aminolevulinate has efficacy comparable to cryotherapy for the treatment of basal cell carcinoma and actinic keratoses but provides substantially better cosmetic outcomes, according to data presented at the 15th Congress of the European Academy of Dermatology and Venereology.

In a multicenter study of 120 patients with superficial basal cell carcinoma who were randomized to photodynamic therapy with methyl aminolevulinate (MAL-PDT) or cryotherapy, complete responses were seen in 97% of those in the MAL-PDT group and 95% of those in the cryotherapy group at 3 months, Dr. Nicole Basset-Seguin reported in a poster.

The recurrence rate at 60 months also was similar in the two groups: 22% in the MAL-PDT group and 20% for cryotherapy patients, reported Dr. Basset-Seguin of Hôpital Saint Louis, Paris.

The investigators, however, rated cosmetic outcomes as excellent far more frequently in the MAL-PDT group (56%) than in the cryotherapy group (14%) at the 60-month follow-up.

In this study, MAL-PDT was provided as a single treatment. Patients who failed to respond at 3 months were retreated with an additional two consecutive MAL-PDT sessions 7 days apart. Cryotherapy was applied in two freeze-thaw cycles using liquid nitrogen spray. Patients who failed to respond were retreated with double freeze-thaw cryotherapy.

In another study presented at the meeting, MAL-PDT was superior to cryotherapy for treatment of actinic keratoses.

A total of 119 subjects with 1,501 cumulative lesions were treated on one side of the face or scalp with MAL-PDT and on the other side with double freeze-thaw cryotherapy. The treatments were randomly allocated to the sides of the face/scalp and were repeated at 12 weeks in those with incomplete response, Dr. Colin Morton of the Falkirk (Scotland) Royal Infirmary, reported in a poster.

At 12 weeks, significantly more patients in the MAL-PDT group had a reduction from baseline in the number of lesions, compared with cryotherapy (84% vs. 75%, respectively), and at 24 weeks, both groups showed similar reductions in the number of lesions from baseline (89% and 88%).

Both treatments were safe and well tolerated, and subject and investigator ratings of cosmetic outcome "clearly favored MAL-PDT," Dr. Morton wrote.

Both studies were sponsored by Galderma, maker of the PDT devices used.

RHODES, GREECE—Targeted ultraviolet B phototherapy—the use of fiber-optic light delivery systems—allows treatment of previously inaccessible body sites such as the scalp and the oral and intranasal mucosa, Dr. Lajos Kemeny said at the 15th Congress of the European Academy of Dermatology and Venereology.

The fiber optics guide delivery of incoherent ultraviolet light to small areas while protecting nonlesional skin from excessive UV exposure. This has further enhanced phototherapy, improving delivery to areas like the scalp and nasal mucosa, and has led to investigation of its use for new applications, namely intranasal treatment for allergic rhinitis, said Dr. Kemeny of the University of Szeged (Hungary).

In a randomized double-blind clinical trial using a novel device for intranasal phototherapy, "rhinophototherapy" significantly reduced the symptoms of hay fever, reported Dr. Kemeny, who is a cofounder of the Rhinolight company, maker of the Rhinolight device used in the study.

In 49 patients, each intranasal cavity was illuminated three times weekly for 3 weeks with 5% UVB, 25% UVA, and 70% visible light (an approach known as mUV/VIS), or with just low-intensity visible light. Scores for sneezing, rhinorrhea, and nasal itching improved significantly in the treated patients but not in the control patients, he said.

Furthermore, scores for nasal obstruction improved slightly in the treated patients and increased significantly in control patients (J. Allergy Clin. Immunol. 2005;115:541–7).

In an open-label follow-up study using a similar protocol but with gradual increases in doses of mUV/VIS light, rhinophototherapy significantly inhibited allergic rhinitis symptoms in 90% of 70 treated patients. Significant improvements were seen in sneezing, rhinorrhea, nasal itching, nasal obstruction, and total nasal scores in this study.

Evaluation of nasal lavage in treated patients suggests that the mechanism of action can be at least partially attributed to apoptosis induction of cells that play an important role in the pathogenesis of allergic rhinitis: The mUV/VIS irradiation induces a dose-dependent increase in apoptosis of memory T cells, naive T cells, and eosinophils, Dr. Kemeny noted.

Intranasal phototherapy may represent a novel treatment for allergic rhinitis as well as other inflammatory and immune-mediated mucosal diseases, he said.

The Rhinolight device is available in Europe but has not yet been approved in the United States.

RHODES, GREECE—Targeted ultraviolet B phototherapy—the use of fiber-optic light delivery systems—allows treatment of previously inaccessible body sites such as the scalp and the oral and intranasal mucosa, Dr. Lajos Kemeny said at the 15th Congress of the European Academy of Dermatology and Venereology.

The fiber optics guide delivery of incoherent ultraviolet light to small areas while protecting nonlesional skin from excessive UV exposure. This has further enhanced phototherapy, improving delivery to areas like the scalp and nasal mucosa, and has led to investigation of its use for new applications, namely intranasal treatment for allergic rhinitis, said Dr. Kemeny of the University of Szeged (Hungary).

In a randomized double-blind clinical trial using a novel device for intranasal phototherapy, "rhinophototherapy" significantly reduced the symptoms of hay fever, reported Dr. Kemeny, who is a cofounder of the Rhinolight company, maker of the Rhinolight device used in the study.

In 49 patients, each intranasal cavity was illuminated three times weekly for 3 weeks with 5% UVB, 25% UVA, and 70% visible light (an approach known as mUV/VIS), or with just low-intensity visible light. Scores for sneezing, rhinorrhea, and nasal itching improved significantly in the treated patients but not in the control patients, he said.

Furthermore, scores for nasal obstruction improved slightly in the treated patients and increased significantly in control patients (J. Allergy Clin. Immunol. 2005;115:541–7).

In an open-label follow-up study using a similar protocol but with gradual increases in doses of mUV/VIS light, rhinophototherapy significantly inhibited allergic rhinitis symptoms in 90% of 70 treated patients. Significant improvements were seen in sneezing, rhinorrhea, nasal itching, nasal obstruction, and total nasal scores in this study.

Evaluation of nasal lavage in treated patients suggests that the mechanism of action can be at least partially attributed to apoptosis induction of cells that play an important role in the pathogenesis of allergic rhinitis: The mUV/VIS irradiation induces a dose-dependent increase in apoptosis of memory T cells, naive T cells, and eosinophils, Dr. Kemeny noted.

Intranasal phototherapy may represent a novel treatment for allergic rhinitis as well as other inflammatory and immune-mediated mucosal diseases, he said.

The Rhinolight device is available in Europe but has not yet been approved in the United States.

RHODES, GREECE—Targeted ultraviolet B phototherapy—the use of fiber-optic light delivery systems—allows treatment of previously inaccessible body sites such as the scalp and the oral and intranasal mucosa, Dr. Lajos Kemeny said at the 15th Congress of the European Academy of Dermatology and Venereology.

The fiber optics guide delivery of incoherent ultraviolet light to small areas while protecting nonlesional skin from excessive UV exposure. This has further enhanced phototherapy, improving delivery to areas like the scalp and nasal mucosa, and has led to investigation of its use for new applications, namely intranasal treatment for allergic rhinitis, said Dr. Kemeny of the University of Szeged (Hungary).

In a randomized double-blind clinical trial using a novel device for intranasal phototherapy, "rhinophototherapy" significantly reduced the symptoms of hay fever, reported Dr. Kemeny, who is a cofounder of the Rhinolight company, maker of the Rhinolight device used in the study.

In 49 patients, each intranasal cavity was illuminated three times weekly for 3 weeks with 5% UVB, 25% UVA, and 70% visible light (an approach known as mUV/VIS), or with just low-intensity visible light. Scores for sneezing, rhinorrhea, and nasal itching improved significantly in the treated patients but not in the control patients, he said.

Furthermore, scores for nasal obstruction improved slightly in the treated patients and increased significantly in control patients (J. Allergy Clin. Immunol. 2005;115:541–7).

In an open-label follow-up study using a similar protocol but with gradual increases in doses of mUV/VIS light, rhinophototherapy significantly inhibited allergic rhinitis symptoms in 90% of 70 treated patients. Significant improvements were seen in sneezing, rhinorrhea, nasal itching, nasal obstruction, and total nasal scores in this study.

Evaluation of nasal lavage in treated patients suggests that the mechanism of action can be at least partially attributed to apoptosis induction of cells that play an important role in the pathogenesis of allergic rhinitis: The mUV/VIS irradiation induces a dose-dependent increase in apoptosis of memory T cells, naive T cells, and eosinophils, Dr. Kemeny noted.

Intranasal phototherapy may represent a novel treatment for allergic rhinitis as well as other inflammatory and immune-mediated mucosal diseases, he said.

The Rhinolight device is available in Europe but has not yet been approved in the United States.

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

LAS VEGAS—An aging Asian face can be rejuvenated with application of carbon followed by nonablative laser treatment.

"My nonablative toy at the moment is carbon plus a Q-switched Nd:YAG laser," Dr. Ruban Nathan said at an international symposium on cosmetic and laser surgery.

Carbon applied to skin serves as an artificial chromophore to transfer energy into the epidermis, Dr. Nathan said. "You leave carbon on for half an hour or steam it in to skin for even better results."

With the growth of ethnic populations in the United States, addressing dermatologic concerns specific to ethnic skin is of growing importance to U.S. dermatologists, said Dr. Nathan, who is in private practice in Kuala Lumpur, Malaysia.

Pigmentation and sagging are the cosmetic concerns of older Asians—"end of story," Dr. Nathan said. These patients will come for treatment of lentigos, dyschromias, ephelides, melasma, periorbital hyperpigmentation, and maturational hyperpigmentation. Depigmentation agents, microdermabrasion, fruit acids, intense pulsed light (IPL), and fractional resurfacing are treatment options.

Researchers assessed 10 women with Fitzpatrick skin types III-V with melasma unresponsive to previous therapy treated with fractional thermolysis, for example (Dermatol. Surg. 2005;31:1645–50). "This study showed some moderate improvement, but the cost is prohibitive where I come from," Dr. Nathan said.

"Lasers are not available everywhere in the world," Dr. Nathan said. "I wish these were more affordable. They are available for the few." In addition, there is a paucity of data on reactions of Asian patients to laser treatment.

Radiofrequency devices might also benefit ethnic skin types. This treatment was effective for cosmetic improvement of nasolabial folds, marionette lines, and jowls in a study of 85 Japanese women (Lasers Surg. Med. 2005;36:92–7). "They had good results," Dr. Nathan said.

Counsel patients about potential side effects, such as risk of hypopigmentation with IPLs, Dr. Nathan said. Also provide strict sun avoidance strategies, such as UV screening on car windows and limitations on outdoor activities.

Postinflammatory hyperpigmentation is another clinical concern following laser treatment of Asian skin. The risk is relatively low with the carbon plus Q-switched Nd:YAG laser regimen, Dr. Nathan said. "I've done this in 60 or 70 patients and I think two had postinflammatory hyperpigmentation."

Dr. Nathan emphasized a need for additional physician education on the unique issues affecting Asian skin. "Anyone who is seeing a lot of Asian patients should go to conferences like this or conferences in Asia so you know the parameters and pitfalls."

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

CARLSBAD, CALIF.—At a symposium on laser and cosmetic surgery sponsored by SkinCare Physicians, Dr. E. Victor Ross Jr., shared what he looks for in a good intense pulsed light device.

First, he looks for variability in spectral shapes. This allows tailoring and fine-tuning of applications to control the clinical outcome, said Dr. Ross, director of the Scripps Clinic Laser and Cosmetic Center in San Diego.

The ability to predictably treat vascular lesions while preserving epidermal pigmentation includes the ability to treat through a tan. "I always hear people from the northeast say, 'We don't treat tanned patients.' You have to be cautious, but you can do it," he said. With tanned patients you need to use "all the weapons [you have], which means external cooling and internal cooling, particularly between the vascular lesions."

Efficient cooling is also important. "It's not about cooling the skin," he said. "It's about keeping the hand piece cool."

IPL devices should also support some laser platforms, such as the erbium:YAG, the neodymium:YAG, or the erbium glass laser, he said, adding that a reliable external calibration system that interrogates the entire system from the power supply to the quartz or sapphire end piece is important. He also recommended user-selectable pulse durations that allow for the proper balance of fluence, wavelength, and cooling.

Dr. Ross also mentioned the importance of reproducibility in outcomes from machine to machine based on the same panel settings, and long lamp lifetimes with minimal degradation over thousands of pulses.

Rounding out the list of qualities are flexibility in spot size, reasonably fast repetition rates, and ergonomic simplicity.

Undesirable IPL features, he said, include no integrated cooling, small spot size, no capability for laser upgrades, and subpar calibration algorithms.

Candidates for his "Miss IPL" contest include the StarLux, the Luminus One, the Omnilight and the Xeo. "But there are many [others] I just haven't gotten in contact with," said Dr. Ross, who disclosed that he has research relationships with Palomar, Cutera, and Laserscope. "These are the ones I like and know."

He concluded that the best IPL "is the one you feel most comfortable with, the one you use so much that your fingers intuitively move to the right locations on the instrument panel, and the one you feel comfortable teaching people about."

In a panel discussion, Dr. Christopher B. Zachary echoed that notion. "It's all about getting a device that you trust, that you know, that you are capable of using day in and day out," said Dr. Zachary, professor and chair of the department of dermatology at the University of California, Irvine. "There's a huge difference between using the old intense pulsed light devices and the new ones. The new ones are much more efficient."

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

LAS VEGAS—A new version of the Fraxel laser penetrates more deeply—yet causes less pain and requires fewer treatments—than does the original Fraxel system, speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new Fraxel SR1500, approved by the Food and Drug Administration in August 2006, promised enhanced efficacy and safety, said Dr. Richard Fitzpatrick, a dermatologist in private practice in La Jolla, Calif.

"For the most part, I think that has held up," he said.

The idea behind Fraxel lasers is to deeply penetrate dermal tissue in a specific pixel-like pattern, leaving behind healthy tissue surrounding the tiny wounds.

The original Fraxel was approved by the FDA in 2003 for the treatment of wrinkles, melasma, and scars from acne and surgery, among other indications. The new Fraxel, which costs in the range of $110,000, is capable of deep penetration—to 1,200 microns—and includes a telescopic lens and dosage-control system that permits the use of much higher energy ranges.

"You almost have to rethink Fraxel" in adjusting to the new device, said Dr. Vic Narurkar, who is in private practice in San Francisco. "Depth really does matter."

Moreover, it is important to understand the confusion regarding the term "fractional resurfacing," he said in an interview following the meeting.

True nonablative fractional resurfacing requires a midinfrared wavelength, such as the 1550-nm wavelength of the Fraxel SR1500 and the original Fraxel SR750. "Most other fractional devices are marketing toys and are not supported by clinical and histologic studies," Dr. Narurkar said.

Although Dr. Fitzpatrick limited his energy settings to about 8–20 mJ/cm

Dr. Narurkar now routinely treats Fitzpatrick skin types I-III at 40 mJ/cm

"Coverage"—the number of microthermal zones of damage required—depends on the condition being treated and the anatomical location, the speakers agreed.

A level 6 setting on the laser translates to 20% coverage, with levels building or declining in 3% increments, Dr. Fitzpatrick explained. A level 7 achieves 23% coverage, for example.

The ease of the system does not negate the importance of being careful, however. The laser's capability of going to extreme depths with a high degree of energy can produce "an intense collimated dermal reaction," which Dr. Fitzpatrick said is unlike any he has ever seen.

Choosing a coverage setting that is too high can be dangerous.

"You will reach the point, if you go too far, where you will risk bulk heating. You will generate thermal necrosis of the area," he said.

On the other hand, significant swelling and erythema are very unusual, and the increased energy delivery makes for better results, Dr. Fitzpatrick said, adding, "High pulse energies are more effective for almost everything."

For mild to moderate photodamage on the face, he performs four treatments using energy in the range of 10–20 mJ/cm

For acne scars, he starts at 25 mJ/cm

"The Fraxel does better with acne scars than any device I've ever used," he said.

Dr. Narurkar agreed, saying that both the first- and second-generation Fraxel lasers are "rapidly becoming the treatment of choice" for this indication.

Across indications, fewer treatments are required with the second-generation Fraxel, although patients can expect more edema when higher settings are used, he said.

"They will see results in three treatments instead of five," Dr. Narurkar said. "It hurts less and my patients are extremely satisfied with the treatment."

Both speakers disclosed that they have received grant or research support from Reliant Technologies Inc., maker of the Fraxel laser. Dr. Fitzpatrick is a paid consultant to the company as well.

'Most other fractional devices are marketingtoys' that are not supported by clinical studies. DR. NARURKAR

PALM DESERT, CALIF.—The larger particle-sized hyaluronic acid product called Perlane has been shown in a trial to be as safe as another approved filler, and the data have been submitted to the Food and Drug Administration as part of the approval process.

"Perlane provides excellent volume correction, with a single injection, and lasts over 6 months in most patients," said Dr. Jeffrey S. Dover, who presented the trial data at the annual meeting of the American Society for Dermatologic Surgery.

The 6-month trial found no significant difference between Restylane, an FDA-approved hyaluronic acid, and Perlane, said Dr. Dover, a dermatologic surgeon in Chestnut Hill, Mass.

The sole distinction between the two products appeared to be that slightly less Perlane was needed, on average, for the wrinkle corrections.

Perlane and Restylane are both hyaluronic acids made from streptococcus by the same company, Q-Med Esthetics of Uppsala, Sweden. Both products contain the same concentration of hyaluronic acid, 20 mg/mL. The sole difference is the particle size, which is larger for Perlane (700–1,000 mum, vs. 250–500 mum for Restylane), which makes it more viscous and better suited for larger corrections.

Patients in the trial had mesolabial and/or nasolabial folds corrected.

Of the patients in the trial, who were treated at 17 different centers, 141 received the Perlane and 142 received Restylane.

At 2 weeks after treatment, 96% of the subjects who received Perlane had an improvement in their folds of at least one grade according to a wrinkle severity rating score, compared with 92% of those who received Restylane.

At 24 weeks, 63% of Perlane-treated subjects had at least a single grade improvement, vs. 74% of Restylane-treated subjects. The difference was not statistically significant, "despite the large numbers in the trial," Dr. Dover said.

The average amount of each product used per nasolabial fold was 1.1 mL for Perlane and 1.2 mL for Restylane.

Extensive immunogenicity tests were performed during the trial and included skin testing at 24 weeks after the corrections, in which the test area was biopsied a few days later for examination.

"Both of these products are completely nonimmunogenic," Dr. Dover said of all the testing.

Side effects were similar between the two products. The most commonly reported side effect was itching, experienced by about 90% of the subjects.

The itching, as well as any pain, redness, or bruising experienced by patients, "dropped off quickly," Dr. Dover said.

Restylane is distributed in this country by Medicis, which sponsored the trial and would also distribute Perlane. Dr. Dover reported no financial interest in the study.

PALM DESERT, CALIF.—The larger particle-sized hyaluronic acid product called Perlane has been shown in a trial to be as safe as another approved filler, and the data have been submitted to the Food and Drug Administration as part of the approval process.

"Perlane provides excellent volume correction, with a single injection, and lasts over 6 months in most patients," said Dr. Jeffrey S. Dover, who presented the trial data at the annual meeting of the American Society for Dermatologic Surgery.

The 6-month trial found no significant difference between Restylane, an FDA-approved hyaluronic acid, and Perlane, said Dr. Dover, a dermatologic surgeon in Chestnut Hill, Mass.

The sole distinction between the two products appeared to be that slightly less Perlane was needed, on average, for the wrinkle corrections.

Perlane and Restylane are both hyaluronic acids made from streptococcus by the same company, Q-Med Esthetics of Uppsala, Sweden. Both products contain the same concentration of hyaluronic acid, 20 mg/mL. The sole difference is the particle size, which is larger for Perlane (700–1,000 mum, vs. 250–500 mum for Restylane), which makes it more viscous and better suited for larger corrections.

Patients in the trial had mesolabial and/or nasolabial folds corrected.

Of the patients in the trial, who were treated at 17 different centers, 141 received the Perlane and 142 received Restylane.

At 2 weeks after treatment, 96% of the subjects who received Perlane had an improvement in their folds of at least one grade according to a wrinkle severity rating score, compared with 92% of those who received Restylane.

At 24 weeks, 63% of Perlane-treated subjects had at least a single grade improvement, vs. 74% of Restylane-treated subjects. The difference was not statistically significant, "despite the large numbers in the trial," Dr. Dover said.

The average amount of each product used per nasolabial fold was 1.1 mL for Perlane and 1.2 mL for Restylane.

Extensive immunogenicity tests were performed during the trial and included skin testing at 24 weeks after the corrections, in which the test area was biopsied a few days later for examination.

"Both of these products are completely nonimmunogenic," Dr. Dover said of all the testing.

Side effects were similar between the two products. The most commonly reported side effect was itching, experienced by about 90% of the subjects.

The itching, as well as any pain, redness, or bruising experienced by patients, "dropped off quickly," Dr. Dover said.

Restylane is distributed in this country by Medicis, which sponsored the trial and would also distribute Perlane. Dr. Dover reported no financial interest in the study.

PALM DESERT, CALIF.—The larger particle-sized hyaluronic acid product called Perlane has been shown in a trial to be as safe as another approved filler, and the data have been submitted to the Food and Drug Administration as part of the approval process.

"Perlane provides excellent volume correction, with a single injection, and lasts over 6 months in most patients," said Dr. Jeffrey S. Dover, who presented the trial data at the annual meeting of the American Society for Dermatologic Surgery.

The 6-month trial found no significant difference between Restylane, an FDA-approved hyaluronic acid, and Perlane, said Dr. Dover, a dermatologic surgeon in Chestnut Hill, Mass.

The sole distinction between the two products appeared to be that slightly less Perlane was needed, on average, for the wrinkle corrections.

Perlane and Restylane are both hyaluronic acids made from streptococcus by the same company, Q-Med Esthetics of Uppsala, Sweden. Both products contain the same concentration of hyaluronic acid, 20 mg/mL. The sole difference is the particle size, which is larger for Perlane (700–1,000 mum, vs. 250–500 mum for Restylane), which makes it more viscous and better suited for larger corrections.

Patients in the trial had mesolabial and/or nasolabial folds corrected.

Of the patients in the trial, who were treated at 17 different centers, 141 received the Perlane and 142 received Restylane.

At 2 weeks after treatment, 96% of the subjects who received Perlane had an improvement in their folds of at least one grade according to a wrinkle severity rating score, compared with 92% of those who received Restylane.

At 24 weeks, 63% of Perlane-treated subjects had at least a single grade improvement, vs. 74% of Restylane-treated subjects. The difference was not statistically significant, "despite the large numbers in the trial," Dr. Dover said.

The average amount of each product used per nasolabial fold was 1.1 mL for Perlane and 1.2 mL for Restylane.

Extensive immunogenicity tests were performed during the trial and included skin testing at 24 weeks after the corrections, in which the test area was biopsied a few days later for examination.

"Both of these products are completely nonimmunogenic," Dr. Dover said of all the testing.

Side effects were similar between the two products. The most commonly reported side effect was itching, experienced by about 90% of the subjects.

The itching, as well as any pain, redness, or bruising experienced by patients, "dropped off quickly," Dr. Dover said.

Restylane is distributed in this country by Medicis, which sponsored the trial and would also distribute Perlane. Dr. Dover reported no financial interest in the study.

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

LAS VEGAS—Fine wrinkling of the eyelids seemed to respond "quite nicely" to fractional laser resurfacing with a specially designed tip, Dr. Brian S. Biesman said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The new 0.25-cm

This innovative approach is "not quite" a lunchtime procedure, requiring an hour for topical anesthetic application prior to each of four sessions and several days of downtime while swelling and erythema subside, he said.

The preliminary results, however, have been "very impressive," Dr. Biesman said following the meeting.

In his study, Dr. Biesman enrolled 20 patients, aged 38–70 years (average age 49), to receive four treatments at intervals of 9–28 days (average interval 14 days). At the time of his meeting presentation, 15 of the 20 patients had completed all four sessions and a 1-month follow-up was available on nine patients. Preliminary results suggest that patients tolerated the procedure well, despite mild to moderate erythema and edema lasting 3–4 days.

"Patients typically returned to their activities in 2–3 days," he said.

For the first patients to complete the treatment and follow-up, improvements in texture and the appearance of wrinkling were rated 2.14 and 1.74, respectively, on a 0–4 scale. Dr. Biesman emphasized that not all patients in the study have completed the follow-up examinations.

"There's definitely something there," he said in an interview. "We're not seeing any regression [in improvement] over time."

Dr. Biesman disclosed that he has received grant and research support from, and is a paid consultant to, Reliant Technologies, manufacturer of the Fraxel laser.

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.

LAS VEGAS—Carbon dioxide insufflation of the eyelids provides patients with an improved cosmetic appearance and is the only effective treatment option for vascular pooling, according to a presentation at an international symposium on cosmetic and laser surgery.

"After four or five treatments, we have seen marked improvement in eyelid texture, rhytidosis, hyperpigmentation, vascular pooling, fatty prolapse, and tissue luminosity," Dr. Stephen Bosniak said. "This is a unique treatment for vascular pooling. A lot of people have this shadowing of the skin below the eye, and we have not had a treatment for this prior to this."

Using what is called the CO₂ Cellulair technique, the lower eyelid is insufflated with carbon dioxide through a 30-gauge needle at 20 mm/minute. The targeted delivery of carbon dioxide gas increases blood flow and oxygenation, leading to improvements in skin irregularities and elasticity, according to studies done by Dr. Bosniak and his colleague, Dr. Marian Cantisano-Zikha of Rio de Janeiro, Brazil.

The theory is that local insufflation of carbon dioxide gas tricks the body into thinking there is not enough oxygen and it responds, said Dr. Bosniak, ophthalmology surgeon, Manhattan Eye, Ear and Throat Hospital, New York.

Each treatment session takes about 10 minutes with no downtime. Dr. Bosniak's technique is safe to use in combination with other skin improvement therapies. Some swelling and erythema are possible immediately after treatment, but these effects are transient, he said. Some patients might be alarmed by the bulging area of insufflation below their eye, he added, but it disappears in 3–5 minutes. "We don't let them look in the mirror while this is happening."

Improvements in rhytidosis and luminosity occur in patients regardless of skin type, Dr. Bosniak said. Some lightening of hyperpigmentation in darker skin types he has observed could be an effect of carbon dioxide on melanin, he added.

Clinical improvements tend to level off after five treatments. "For some patients, the changes appear to be permanent. Others need to return for retreatment in 6–9 months," he said.