Aesthetic Dermatology

TORONTO — The injectable filler Radiesse appears to offer an edge over Sculptra when it comes to ease of use, cost-effectiveness, and patient satisfaction, Dr. Stuart Bentkover said at the annual fall meeting of the American Academy of Facial and Reconstructive Plastic Surgery.

Dr. Bentkover offered results on 216 patients using both products at his facial plastic surgery practice in Worcester, Mass.

Radiesse "is, out of the box, very easy to use on day 1," he said. There is an immediate augmentation with the product, but about 10% will be lost by 2–6 months. He tells patients that the full effect lasts about 10–14 months.

The product, composed of calcium hydroxylapatite microspheres and sold by BioForm Medical Inc., is approved by the Food and Drug Administration for oral and maxillofacial defects, vocal fold insufficiency, and radiographic tissue marking. Approval is pending for HIV-related lipoatrophy and nasolabial folds (SKIN & ALLERGY NEWS, October 2006, p. 1).

Sculptra (injectable poly-L-lactic acid) is approved by the FDA for facial fat loss in HIV-infected patients and is used off-label for cosmetic purposes. It is not as patient- or user-friendly because patients must massage the area five times daily for 5 minutes for 5 days after injection, he said.

Sculptra is sold by Dermik Laboratories, a subsidiary of Sanofi-Aventis.

Unlike Radiesse, which can be used quickly, Sculptra has to be reconstituted 2 hours before the procedure. The product does not stay in suspension easily and often requires multiple syringes, as they tend to clog, Dr. Bentkover said.

He calculated the surgeon cost per session at $304 with Radiesse, compared with $480 for Sculptra. The costs are not radically different, but the need for a second session is higher with Sculptra, he said.

With Radiesse, he has seen persistent erythema in two patients, a viral infection, and skin slough. The most common complication is superficial injection. Four patients who received Sculptra injections developed nodules, mostly around their eyes.

Overall complication rates in his experience were 4.6% for Radiesse and 19% for Sculptra. These are, however, based on a small number of patients, he said.

Dr. Bentkover said that he has stopped using Sculptra because of the complication rate.

Another surgeon, Dr. Phillip Langsdon, chief of facial plastic surgery at the University of Tennessee in Memphis, said that he thinks Sculptra is a good product with few side effects. "I've been injecting Sculptra for 2 years and haven't seen any nodules yet," he told meeting attendees.

Dr. Langsdon said that he had no interest in Dermik or Sanofi-Aventis.

Dr. Bentkover is on the national teaching faculty for Radiesse and lectures for Rhytec Inc.

TORONTO — The injectable filler Radiesse appears to offer an edge over Sculptra when it comes to ease of use, cost-effectiveness, and patient satisfaction, Dr. Stuart Bentkover said at the annual fall meeting of the American Academy of Facial and Reconstructive Plastic Surgery.

Dr. Bentkover offered results on 216 patients using both products at his facial plastic surgery practice in Worcester, Mass.

Radiesse "is, out of the box, very easy to use on day 1," he said. There is an immediate augmentation with the product, but about 10% will be lost by 2–6 months. He tells patients that the full effect lasts about 10–14 months.

The product, composed of calcium hydroxylapatite microspheres and sold by BioForm Medical Inc., is approved by the Food and Drug Administration for oral and maxillofacial defects, vocal fold insufficiency, and radiographic tissue marking. Approval is pending for HIV-related lipoatrophy and nasolabial folds (SKIN & ALLERGY NEWS, October 2006, p. 1).

Sculptra (injectable poly-L-lactic acid) is approved by the FDA for facial fat loss in HIV-infected patients and is used off-label for cosmetic purposes. It is not as patient- or user-friendly because patients must massage the area five times daily for 5 minutes for 5 days after injection, he said.

Sculptra is sold by Dermik Laboratories, a subsidiary of Sanofi-Aventis.

Unlike Radiesse, which can be used quickly, Sculptra has to be reconstituted 2 hours before the procedure. The product does not stay in suspension easily and often requires multiple syringes, as they tend to clog, Dr. Bentkover said.

He calculated the surgeon cost per session at $304 with Radiesse, compared with $480 for Sculptra. The costs are not radically different, but the need for a second session is higher with Sculptra, he said.

With Radiesse, he has seen persistent erythema in two patients, a viral infection, and skin slough. The most common complication is superficial injection. Four patients who received Sculptra injections developed nodules, mostly around their eyes.

Overall complication rates in his experience were 4.6% for Radiesse and 19% for Sculptra. These are, however, based on a small number of patients, he said.

Dr. Bentkover said that he has stopped using Sculptra because of the complication rate.

Another surgeon, Dr. Phillip Langsdon, chief of facial plastic surgery at the University of Tennessee in Memphis, said that he thinks Sculptra is a good product with few side effects. "I've been injecting Sculptra for 2 years and haven't seen any nodules yet," he told meeting attendees.

Dr. Langsdon said that he had no interest in Dermik or Sanofi-Aventis.

Dr. Bentkover is on the national teaching faculty for Radiesse and lectures for Rhytec Inc.

TORONTO — The injectable filler Radiesse appears to offer an edge over Sculptra when it comes to ease of use, cost-effectiveness, and patient satisfaction, Dr. Stuart Bentkover said at the annual fall meeting of the American Academy of Facial and Reconstructive Plastic Surgery.

Dr. Bentkover offered results on 216 patients using both products at his facial plastic surgery practice in Worcester, Mass.

Radiesse "is, out of the box, very easy to use on day 1," he said. There is an immediate augmentation with the product, but about 10% will be lost by 2–6 months. He tells patients that the full effect lasts about 10–14 months.

The product, composed of calcium hydroxylapatite microspheres and sold by BioForm Medical Inc., is approved by the Food and Drug Administration for oral and maxillofacial defects, vocal fold insufficiency, and radiographic tissue marking. Approval is pending for HIV-related lipoatrophy and nasolabial folds (SKIN & ALLERGY NEWS, October 2006, p. 1).

Sculptra (injectable poly-L-lactic acid) is approved by the FDA for facial fat loss in HIV-infected patients and is used off-label for cosmetic purposes. It is not as patient- or user-friendly because patients must massage the area five times daily for 5 minutes for 5 days after injection, he said.

Sculptra is sold by Dermik Laboratories, a subsidiary of Sanofi-Aventis.

Unlike Radiesse, which can be used quickly, Sculptra has to be reconstituted 2 hours before the procedure. The product does not stay in suspension easily and often requires multiple syringes, as they tend to clog, Dr. Bentkover said.

He calculated the surgeon cost per session at $304 with Radiesse, compared with $480 for Sculptra. The costs are not radically different, but the need for a second session is higher with Sculptra, he said.

With Radiesse, he has seen persistent erythema in two patients, a viral infection, and skin slough. The most common complication is superficial injection. Four patients who received Sculptra injections developed nodules, mostly around their eyes.

Overall complication rates in his experience were 4.6% for Radiesse and 19% for Sculptra. These are, however, based on a small number of patients, he said.

Dr. Bentkover said that he has stopped using Sculptra because of the complication rate.

Another surgeon, Dr. Phillip Langsdon, chief of facial plastic surgery at the University of Tennessee in Memphis, said that he thinks Sculptra is a good product with few side effects. "I've been injecting Sculptra for 2 years and haven't seen any nodules yet," he told meeting attendees.

Dr. Langsdon said that he had no interest in Dermik or Sanofi-Aventis.

Dr. Bentkover is on the national teaching faculty for Radiesse and lectures for Rhytec Inc.

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

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

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

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

WILLIAMSBURG, VA. — Thread lifts produce pleasing results because the procedure corrects the downward shift of facial skin with age, something that excisional face-lifts don't address, Dr. Stephen H. Mandy said at a meeting sponsored by Skin Disease Education Foundation.

"Standard face-lifts tend to move the face posteriorly. … The problem [with the aging face] is a vertical descent," said Dr. Mandy, professor of dermatology at the University of Miami.

The descent of the malar fat pad creates the nasolabial folds, the hollow underneath the malar eminence, the jowl, and the prejowl sulcus, Dr. Mandy explained. He estimates that half of his patients have already had a face-lift but are still unhappy with the nasolabial folds and jowls.

Good candidates for this procedure have soft tissue facial ptosis and moderate soft tissue thickness. Without adequate subcutaneous tissue, there is nothing for the barbs to hook into. The threads can also be seen if there is not enough subcutaneous tissue, he said.

The most important portion of the procedure is marking where the threads will be placed. This should be done with the patient in a seated position. Determine where the facial descent is located. "If you have a heavily malar descent, you're going to put two threads to that malar fat pad," Dr. Mandy said. The threads will exit at the nasolabial folds and jowls, improving these two areas, unlike what occurs with a standard face-lift.

There are two types of threads. The two-sided Articulus 400 series (part of the Contour Threads family made by Surgical Specialties Corp.) has two straight needles with a single thread. The barbs face in the opposite direction to the needle on each end, with no barbs in the center of the thread. No knots need to be tied with this thread type. Contour Threads are single threads with barbs facing in the opposite direction to the needle. They are approved for midface, brow, and neck suspension.

The second type of thread, the Featherlift extended-length Aptos thread (Kolster Methods Inc.), has bidirectional barbs and is approved for use in midface suspension surgery to fix the cheek subdermis in an elevated position.

Dr. Mandy has received compensation as a Contour Threads instructor.

For a brow lift, one double thread (Articulus 400 series)—or two single threads (Aptos)—is fixed on each side just behind the hairline, and the ends exit at the eyebrow. A third double thread (or two single threads) comes from behind the hairline at the central forehead to the medial brow on each side. Dr. Mandy said that he always performs Botox injections at the brow 1 week prior to the thread lift. This prevents patients from pulling against the threads and allows healing in the correct position.

For the midface and lower face area, thread placement is highly variable, depending on the individual patient's degree of ptosis. Typically, two single threads or one double will go from the temporal fascia to the angle of the ala and to the corner of the mouth, skewering the malar fat pad. "If there's a significant jowl, [another] thread will come down to the top of the jowl and one to the apex of the jowl—right to the deepest point of the jowl," Dr. Mandy explained.

If a patient has mild ptosis, he will use only one double thread, running from the temporal fascia to the midpoint of the nasolabial fold and to the jowl.

Up to four single threads (or two double) may be used on each side of the neck to tighten this area, but most patients need only two singles (one double). Dr. Mandy frequently performs neck liposuction just prior to thread placement.

The average patient will require six single threads: two on each side for the midface and lower face, and one on each side of the neck.

In terms of sedation, "I use less and less sedation with this procedure," he said. For most patients, he simply administers oral diazepam. If patients are "a little too jittery, I might give them Tylenol with codeine along with that," he said. Local anesthesia is used: 1% lidocaine with epinephrine in a 25-gauge spinal needle. Dr. Mandy typically uses bupivacaine at the entry and exit sites, where the patients have discomfort.

The procedure starts with a 1.5- to 2.0-mm punch biopsy to open the entry point. For the double thread, the threaded needle grabs the fascia and is then passed through the subcutaneous tissue. A sinusoidal placement pattern—moving the needle back and forth while advancing it subcutaneously—will improve strength by increasing the number of barbs anchoring the thread. When the thread is positioned, pull back from the entry point to allow the barbs to "bite" into the tissue, he said.

Next, the tissue between the arms of the threads is bluntly dissected with a sharp-point dissector. The technique is similar to that used with a liposuction cannula. "The beauty of it is that when you do that, you're now creating a biplane face-lift … so that when you lift that skin, you're basically moving the top plane over the bottom plane," Dr. Mandy said. In addition, the tissue healing process occurs all along the "giant flap" of skin.

Finally, the tissue is contoured by basically "walking" the tissue up the threads. The wider the U-bend of the double thread, the better the thread will stay in place.

With the single threads, one end is threaded through a straight needle while the anchoring end is threaded through a curved needle. The curved needles are used to "bite" the fascia, to hold the thread. "The beauty of those is that they really anchor the fascia," he said.

The barbs of the suture will grab gauze, so dental cotton rolls are used around the exit and entry points. After the procedure, Dr. Mandy trims the threads and tapes them in place. This way, he can recorrect if necessary in the first 72 hours.

He uses a chin strap for moderate support and lots of ice postoperatively. He also has patients take 20 mg of prednisone that night and again the next morning. "That greatly reduces facial swelling," he said

Although a thread lift is not a surgical procedure, there is still considerable recovery time involved. "This is not a weekend face-lift. These patients have to anticipate [that it will be] 1 week before they look relatively normal," Dr. Mandy noted.

Don't be concerned if patients look weird with rolls of excess skin immediately after the procedure. "The worse they look post-op, the better they're going to look a month later," he said.

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

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

PALM DESERT, CALIF. — An ultrasound machine does appear to reduce waist size without changing a person's weight, Dr. Karyn L. Grossman said at the annual meeting of the American Society of Dermatologic Surgery.

The treatment produced an average 2-cm reduction in circumference of thighs or abdomens treated and a 3-mm reduction in the fat layer of treated areas, relative to controls, reported Dr. Grossman, who practices in Santa Monica, Calif.

"This is probably a safe alternative to low-volume liposuction," she said.

The device used was the UltraShape Contour I (UltraShape Inc., Tel Aviv). The study enrolled 162 patients who received a single treatment of the abdomen or thighs at one of five centers, two of which were in the United States. Those patients were compared with control patients.

The reduction in circumference of the treated patients became noticeable at 7 days in some patients and was measurable in the overall group by 28 days. In the patients who had a single thigh treated, the average reduction observed in the treated thigh was 2 cm relative to the untreated thigh at 21 days. That reduction persisted throughout the 84 days of the trial.

"I really can't imagine that after 84 days the fat is going to grow back," Dr. Grossman said.

There was a measurable reduction in circumference of the treatment areas in 82% of the treated patients, and 76% of patients expressed moderate to excellent satisfaction with the procedure. Neither the treated patients nor the controls lost any weight as groups during the trial, she added.

Safety evaluation to detect nerve damage or blood vessel destruction was conducted rigorously, and there were no abnormalities observed in any patient. The only adverse events occurred in two patients who experienced burns when treated over the trochanter, probably because the area did not have enough fat, Dr. Grossman said.

The device is not approved in the United States, but it is available in other countries. Dr. Grossman said that she has no financial connections with UltraShape Inc., but her partner in practice is a paid consultant to the company.

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

LAS VEGAS — There are not enough data to recommend mesotherapy to patients, although some evidence supports a specific form—injected lipolysis—for localized fat reduction, according to two presentations at an international symposium on cosmetic and laser surgery.

Mesotherapy is touted for many indications worldwide, including cellulite reduction and pain management. Confusion abounds, however, because people often refer to mesotherapy and injected lipolysis interchangeably, said Dr. Paul T. Rose of Tampa.

"Oftentimes I am asked: Does mesotherapy work?" said Dr. Adam M. Rotunda of the division of dermatology at the University of California, Los Angeles. "We cannot say it works or does not work—it is such a general term."

An injected combination of the soy-derived phospholipid phosphatidylcholine (PC) and the solvent sodium deoxycholate (DC) "is well proven" for localized fat lysis, Dr. Rose said. He and colleague Dr. Michael Morgan assessed punch biopsies from a patient after PC/DC injections, and histology showed destruction of fat (J. Cosmet. Laser Ther. 2005;7:17–9). "There is a profound inflammatory response with neutrophils, plasma cells, and hopefully, macrophages to eat up the fat," he said.

Another study of 30 patients demonstrated some benefit of this combination for correction of lower eyelid bulging (Dermatol. Surg. 2001;27:391–2), Dr. Rotunda said. An open-label study of 43 patients who received a "pretty aggressive" regimen of up to 100 mL PC/DC per treatment session demonstrated some improvements in abdominal fat, he said.

"I'm not impressed with the abdomen—you need a significant amount. I am impressed with jowl-area results," Dr. Rotunda said. Other commonly treated areas include inferior orbital fat, chins, arms, flanks, lateral and medial thighs, and knees.

Even with this evidence, more research is needed. "Most of these studies are unblinded, open case series. But we are moving in the direction of having peer review literature," Dr. Rotunda said. For example, Dr. David Goldberg and his associates conducted a study in 10 patients who received four monthly injections of multivitamin and conjugated hyaluronic acid for facial rejuvenation (Dermatol. Surg., in press). Although thickened collagen fibers were noted, "no clinical benefits were seen," Dr. Rotunda said.

Intravenous PC can lower blood lipids, and a similar mechanism of action might lyse subcutaneous fat. "In our lab, however, phosphatidylcholine has not demonstrated any antifat property. Sodium deoxycholate, however, is a detergent known to lyse fat [Dermatol. Surg. 2004;30:1001–8]. So could this solvent actually be the active ingredient?" Dr. Rotunda asked.

"We are working on a double-blind study of PC vs. DC [for submental fat] to see if you need PC at all," Dr. Rotunda said. He disclosed a relationship with Kythera Biopharmaceuticals Inc., codeveloper of a patent-pending process owned by the University of California, Los Angeles, for the use of detergent in treating fat. Dr. Rose had no relevant disclosure.

Injected lipolysis is contraindicated in patients on blood thinners or those with severe hypertension or cardiac disease, HIV, severe renal disease, allergies to medication, or unrealistic expectations, Dr. Rose said. "This is not a procedure for profound weight loss. If I have a patient come in and they are markedly obese, I tell them mesotherapy is not an option." The therapy can be an adjunct to liposuction or other procedures, he added.

Patients can receive the treatment every 2- 4 weeks at up to four areas at a time. "It is not magic. It can be four or five treatments," Dr. Rose noted. It is important to inform patients that they can get significant swelling and that bruising almost always occurs, he said.

Other effects, such as erythema, burning, tenderness, a jelly-like edema post injection, and nodularity, will go away within weeks, Dr. Rotunda said.

Mesotherapy Is a No Go for Cellulite

Not enough evidence of efficacy exists to recommend mesotherapy for treatment of cellulite.

Although some evidence supports a form of mesotherapy for local fat lysis, "I am far more skeptical about this area, it's more sketchy. Objective data are lacking for cellulite," said Dr. Rose.

Proponents of mesotherapy for cellulite say connective tissue dissolution can degrade and smooth out skin, Dr. Rotunda said, "but there are no published data that demonstrate improvements of 'skin dimpling.'"

"There is a lack of controlled studies or histologic studies [but] there are people doing this," Dr. Rose said.

"Unscrupulous individuals are administering this," agreed Dr. Rotunda.

"Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy," Dr. Rotunda and his colleagues said in a review article on injectables used for cellulite (J. Cosmet. Laser Ther. 2005;7:147–54).

RHODES, GREECE — Combining topical immunomodulatory therapy or topical chemotherapy with cryosurgery provides an excellent alternative to excisional treatment for many skin malignancies, Dr. Paola Pasquali said at the 15th Congress of the European Academy of Dermatology and Venereology.

Cryosurgery itself represents an excellent option for many skin malignancies, including most basal cell carcinomas. Exceptions include morpheaform, metatypical, and neurotropic basal cell carcinomas, for which Mohs surgery is preferable. Cryosurgery is also beneficial for well-differentiated squamous cell carcinomas and lentigo maligna, she said.

The use of the immune response modifier imiquimod before any surgical intervention can improve local immune response and reduce treatment areas. Cryosurgery can then be used to treat areas that failed to respond, said Dr. Pasquali, a dermatologist in private practice in Caracas, Venezuela.

This approach is particularly useful in patients with severe sun damage with multiple actinic keratoses or superficial basal cell carcinomas, she said, noting that she has her patients use imiquimod 5 days a week for 6 weeks, followed by cryotherapy for remaining lesions.

This reduces the need for surgical treatment and provides a better cosmetic outcome, she said.

For nodular basal cell carcinomas, biopsy and curettage is performed, and the lesion is allowed to heal before imiquimod treatment is initiated and cryosurgery is used to treat remaining lesions.

Topical chemotherapy with the antimetabolite 5-fluorouracil can also be used along with cryosurgery in some patients, such as those with actinic keratoses or Bowen's disease.

As with imiquimod, the topical treatment is used to reduce the number and size of lesions and the remaining lesions are treated with cryosurgery.

These combinations also are useful for palliation in patients with large tumors, Dr. Pasquali noted.

This female patient had a hypertrophic actinic keratosis that was associated with a squamous cell carcinoma and severe actinic damage.

Improvement was evident after cryosurgery of the nodular lesion and treatment with imiquimod on the rest of the patient's damaged skin. Photos Courtesy Dr. Paola Pasquali

RHODES, GREECE — Combining topical immunomodulatory therapy or topical chemotherapy with cryosurgery provides an excellent alternative to excisional treatment for many skin malignancies, Dr. Paola Pasquali said at the 15th Congress of the European Academy of Dermatology and Venereology.

Cryosurgery itself represents an excellent option for many skin malignancies, including most basal cell carcinomas. Exceptions include morpheaform, metatypical, and neurotropic basal cell carcinomas, for which Mohs surgery is preferable. Cryosurgery is also beneficial for well-differentiated squamous cell carcinomas and lentigo maligna, she said.

The use of the immune response modifier imiquimod before any surgical intervention can improve local immune response and reduce treatment areas. Cryosurgery can then be used to treat areas that failed to respond, said Dr. Pasquali, a dermatologist in private practice in Caracas, Venezuela.

This approach is particularly useful in patients with severe sun damage with multiple actinic keratoses or superficial basal cell carcinomas, she said, noting that she has her patients use imiquimod 5 days a week for 6 weeks, followed by cryotherapy for remaining lesions.

This reduces the need for surgical treatment and provides a better cosmetic outcome, she said.

For nodular basal cell carcinomas, biopsy and curettage is performed, and the lesion is allowed to heal before imiquimod treatment is initiated and cryosurgery is used to treat remaining lesions.

Topical chemotherapy with the antimetabolite 5-fluorouracil can also be used along with cryosurgery in some patients, such as those with actinic keratoses or Bowen's disease.

As with imiquimod, the topical treatment is used to reduce the number and size of lesions and the remaining lesions are treated with cryosurgery.

These combinations also are useful for palliation in patients with large tumors, Dr. Pasquali noted.

This female patient had a hypertrophic actinic keratosis that was associated with a squamous cell carcinoma and severe actinic damage.

Improvement was evident after cryosurgery of the nodular lesion and treatment with imiquimod on the rest of the patient's damaged skin. Photos Courtesy Dr. Paola Pasquali

RHODES, GREECE — Combining topical immunomodulatory therapy or topical chemotherapy with cryosurgery provides an excellent alternative to excisional treatment for many skin malignancies, Dr. Paola Pasquali said at the 15th Congress of the European Academy of Dermatology and Venereology.

Cryosurgery itself represents an excellent option for many skin malignancies, including most basal cell carcinomas. Exceptions include morpheaform, metatypical, and neurotropic basal cell carcinomas, for which Mohs surgery is preferable. Cryosurgery is also beneficial for well-differentiated squamous cell carcinomas and lentigo maligna, she said.

The use of the immune response modifier imiquimod before any surgical intervention can improve local immune response and reduce treatment areas. Cryosurgery can then be used to treat areas that failed to respond, said Dr. Pasquali, a dermatologist in private practice in Caracas, Venezuela.

This approach is particularly useful in patients with severe sun damage with multiple actinic keratoses or superficial basal cell carcinomas, she said, noting that she has her patients use imiquimod 5 days a week for 6 weeks, followed by cryotherapy for remaining lesions.

This reduces the need for surgical treatment and provides a better cosmetic outcome, she said.

For nodular basal cell carcinomas, biopsy and curettage is performed, and the lesion is allowed to heal before imiquimod treatment is initiated and cryosurgery is used to treat remaining lesions.

Topical chemotherapy with the antimetabolite 5-fluorouracil can also be used along with cryosurgery in some patients, such as those with actinic keratoses or Bowen's disease.

As with imiquimod, the topical treatment is used to reduce the number and size of lesions and the remaining lesions are treated with cryosurgery.

These combinations also are useful for palliation in patients with large tumors, Dr. Pasquali noted.

This female patient had a hypertrophic actinic keratosis that was associated with a squamous cell carcinoma and severe actinic damage.

Improvement was evident after cryosurgery of the nodular lesion and treatment with imiquimod on the rest of the patient's damaged skin. Photos Courtesy Dr. Paola Pasquali