Aesthetic Dermatology

ATLANTA — Dermatologic surgeons who shy away from brow lifts are losing about 80% of their blepharoplasty patients, as most blepharoplasty candidates also need a concomitant brow lift. But a fibrin glue technique could change all that, Steven Rotter, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Brow lifts typically should be done before or at the same time as blepharoplasty, but many dermatologic surgeons are uncomfortable with the bone tunnels and fasteners usually used for central fixation during a brow lift. The technique described by Dr. Rotter involves the use of Tisseal—a fibrin glue product—instead of the bony fixation.

The glue is applied following complete release of the periosteum, and the tissue is held in place with even pressure for 2–3 minutes. Because studies have shown that fixation is required for 6–12 weeks in patients undergoing a brow lift, botulinum toxin type A is used to treat all of the depressors and thereby serves as an effective fixator for the needed duration, said Dr. Rotter, a dermatologic surgeon in private practice in Vienna, Va.

The use of the Botox means that muscles don't need to be removed, and the use of the glue means that bone holes don't need to be created. "And any dermatologist can easily do this in an hour or an hour and a half," Dr. Rotter said.

ATLANTA — Dermatologic surgeons who shy away from brow lifts are losing about 80% of their blepharoplasty patients, as most blepharoplasty candidates also need a concomitant brow lift. But a fibrin glue technique could change all that, Steven Rotter, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Brow lifts typically should be done before or at the same time as blepharoplasty, but many dermatologic surgeons are uncomfortable with the bone tunnels and fasteners usually used for central fixation during a brow lift. The technique described by Dr. Rotter involves the use of Tisseal—a fibrin glue product—instead of the bony fixation.

The glue is applied following complete release of the periosteum, and the tissue is held in place with even pressure for 2–3 minutes. Because studies have shown that fixation is required for 6–12 weeks in patients undergoing a brow lift, botulinum toxin type A is used to treat all of the depressors and thereby serves as an effective fixator for the needed duration, said Dr. Rotter, a dermatologic surgeon in private practice in Vienna, Va.

The use of the Botox means that muscles don't need to be removed, and the use of the glue means that bone holes don't need to be created. "And any dermatologist can easily do this in an hour or an hour and a half," Dr. Rotter said.

ATLANTA — Dermatologic surgeons who shy away from brow lifts are losing about 80% of their blepharoplasty patients, as most blepharoplasty candidates also need a concomitant brow lift. But a fibrin glue technique could change all that, Steven Rotter, M.D., said at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

Brow lifts typically should be done before or at the same time as blepharoplasty, but many dermatologic surgeons are uncomfortable with the bone tunnels and fasteners usually used for central fixation during a brow lift. The technique described by Dr. Rotter involves the use of Tisseal—a fibrin glue product—instead of the bony fixation.

The glue is applied following complete release of the periosteum, and the tissue is held in place with even pressure for 2–3 minutes. Because studies have shown that fixation is required for 6–12 weeks in patients undergoing a brow lift, botulinum toxin type A is used to treat all of the depressors and thereby serves as an effective fixator for the needed duration, said Dr. Rotter, a dermatologic surgeon in private practice in Vienna, Va.

The use of the Botox means that muscles don't need to be removed, and the use of the glue means that bone holes don't need to be created. "And any dermatologist can easily do this in an hour or an hour and a half," Dr. Rotter said.

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

LOS ANGELES — A miniature roller equipped with dozens of microfine 30-gauge needles that repeatedly puncture the facial epidermis may be a good alternative to laser resurfacing or dermabrasion for some patients.

The Medical Roll-CIT induces collagen formation without destroying the epidermis, Philip Miller, M.D., said at the fall meeting of the American Academy of Facial Plastic and Reconstructive Surgeons. "It's straightforward, simple, and easy to do," said Dr. Miller, a plastic surgeon in New York City. "People are back in public in 2–5 days—and, most importantly, patients are highly satisfied with the results."

Patients prepare for the procedure with daily applications of concentrated vitamins A and C for about 3 weeks. Both the lotion and the roller are made by South Africa-based Environ Skin Care Ltd.

Before the procedure, a nerve block and topical anesthetic are given. The physician rolls the device over the areas to be treated multiple times, in a random pattern, creating hundreds to thousands of tiny puncture wounds. The wounds are about 1.5 mm deep—just deep enough to reach the papillary dermis, Dr. Miller said.

The procedure does cause bleeding; the skin should be covered with damp swabs for absorption. Bleeding stops quickly, and after it does, the vitamin lotion is applied again. Patients are instructed to apply the lotion for 3 weeks. "The needle wounds serve as channels to direct the nutrients to the dermis," Dr. Miller said.

There is no need for postoperative narcotic medication. After healing is complete, there is no photosensitivity, he said.

Dr. Miller has performed the procedure on 11 patients (6 for acne scars and 5 for mild rhytids). Nine patients (82%) said they experienced a 70%–79% improvement from baseline, while two rated their improvement as 50%–59%. There were no pigmentary changes on any treated skin, even Fitzpatrick types V and VI.

Dr. Miller said he has no financial interest in the device.

Micropunctures surround islands of uninvolved epidermis after the procedure. Courtesy Dr. Philip Miller

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

PARIS — The latest developments in cosmetic dermatology showcase a range of new light sources, focused ultrasound, and home devices.

Here's a quick look at a few of the devices that were reviewed by experts in sessions at the Fourth International Academy of Cosmetic Dermatology World Congress.

▸ Light emitting diode (LED) devices. The latest generation of these lasers provides more focused light and can be used for a variety of indications such as wound healing and photo rejuvenation, said Peter Bjerring, M.D., Aarhus (Denmark) University Hospital.

Gentle Waves (Light BioScience, Virginia Beach, Va.), the first LED approved in the United States for the treatment of periorbital wrinkles and rhytids, uses nonthermal, pulsed shortwave light to stimulate collagen development. Large areas can be treated at once, with no anesthesia or downtime.

There is a synergistic effect when LEDs are combined with 5-aminolevulinic acid (5-ALA), suggesting that this combination also could be useful for acne vulgaris.

▸ Photorejuvenation. Dr. Bjerring noted that one of the most interesting developments in this area is to use the synergistic effect of the Ellipse Flex (Danish Dermatologic Development, Hoersholm, Denmark), a second-generation intense pulsed light source, and 5-ALA in low concentrations of 0.5% and 1%.

Unlike the first-generation lamp, it has an extra filter to remove infrared light, which ensures that the light directed at the skin contains only the required wavelengths.

The Fraxel SR laser (Reliant Technologies, Palo Alto, Calif.) was approved in the United States in late July for the treatment of melasma. This midinfrared laser also provides uncomfortable, but tolerable, therapy for aging or sun-damaged skin, with 10%–20% linear collagen shrinkage reported after three treatments, he said.

The Titan lamp system (Cutera Inc., Brisbane, Calif.) also uses midinfrared light to contract collagen while preserving the epidermis with continuous cooling. The contraction effect was observed 3 months after two treatments in the periorbital area, providing an eye lift effect, he said.

The RelaxF radio frequency device (MSq Ltd., Caesarea, Israel) is being touted for skin as well as fat tightening, said Moshe Lapidoth, M.D., laser unit head at Rabin Medical Center, Petach-Tikva, Israel.

▸ Ultrasound. Another promising approach is the use of focused ultrasound, which Dr. Lapidoth said "is going to be the next thing in medicine."

The Contour I ultrasound device (UltraShape Ltd., Tel Aviv) received European Union clearance in late July, and provides a temporary reduction in body circumference and the appearance of cellulite.

The ultrasonic energy causes the targeted rupture of fat cells, while residual fat tissue is cleared from the body through normal processes. The device lyses 500 cc of fat tissue per treatment, or about one-quarter the quantity removed in a single liposuction operation.

Patients lost an average of about 2.5 cm in circumference in a study of more than 300 people in the United States, United Kingdom, Japan, and Israel, according to the company's Web site. The company also claims there is no thermal damage, a hazard associated with some forms of liposuction. The treatment is safer than liposuction, but takes longer since sessions are spaced 1 month apart, Dr. Lapidoth said.

▸ Hair removal devices. A wave of next-generation personal hair removal devices is expected. Researchers at Radiancy (Yavne, Israel) are in the final stages of developing NolNol, which combines light and heat for selective photothermolysis. Applisonix Ltd. (Be'er Sheva, Israel) is developing a device based on high-intensity focused ultrasound. The Applisonix machine has the most potential because it can be used in all skin types, since ultrasound is not color dependent, he said.

ATLANTA — A novel surgical technique for aesthetic remodeling of the navel is proving safe and effective, Betssy C. Hazoury, M.D., reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 42 patients aged 15–40 years, the simple technique—which involves relocation of the umbilical fundus at the lower level of fascia—resulted in aesthetic improvement of congenital or acquired umbilical deformities in all patients, high overall patient satisfaction, and only one complication, said Dr. Hazoury, a dermatologic surgeon in private practice in Santo Domingo, Dominican Republic.

Of all the patients, 20% said they were satisfied with the outcome, and 80% said they were very satisfied. One patient experienced a deep broken suture and required an additional procedure, but no other complications, such as hematoma, infection, or dehiscence occurred, she said.

The ambulatory technique involves a semicircular incision of the skin of the navel, suture fixation to the deep fascia, and posterior cerclage of the skin. It is associated with only minor discomfort and is appropriate for patients with deformities resulting from aging, pregnancy, or weight gain, as well as for those with congenital deformities, Dr. Hazoury noted. Most patients seeking this procedure have a protruding umbilicus and desire "omphaloplasty" for a deeper-looking belly button, she said, noting that umbilical hernia must be ruled out in patients with protrusions.

ATLANTA — A novel surgical technique for aesthetic remodeling of the navel is proving safe and effective, Betssy C. Hazoury, M.D., reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 42 patients aged 15–40 years, the simple technique—which involves relocation of the umbilical fundus at the lower level of fascia—resulted in aesthetic improvement of congenital or acquired umbilical deformities in all patients, high overall patient satisfaction, and only one complication, said Dr. Hazoury, a dermatologic surgeon in private practice in Santo Domingo, Dominican Republic.

Of all the patients, 20% said they were satisfied with the outcome, and 80% said they were very satisfied. One patient experienced a deep broken suture and required an additional procedure, but no other complications, such as hematoma, infection, or dehiscence occurred, she said.

The ambulatory technique involves a semicircular incision of the skin of the navel, suture fixation to the deep fascia, and posterior cerclage of the skin. It is associated with only minor discomfort and is appropriate for patients with deformities resulting from aging, pregnancy, or weight gain, as well as for those with congenital deformities, Dr. Hazoury noted. Most patients seeking this procedure have a protruding umbilicus and desire "omphaloplasty" for a deeper-looking belly button, she said, noting that umbilical hernia must be ruled out in patients with protrusions.

ATLANTA — A novel surgical technique for aesthetic remodeling of the navel is proving safe and effective, Betssy C. Hazoury, M.D., reported at the joint annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

In 42 patients aged 15–40 years, the simple technique—which involves relocation of the umbilical fundus at the lower level of fascia—resulted in aesthetic improvement of congenital or acquired umbilical deformities in all patients, high overall patient satisfaction, and only one complication, said Dr. Hazoury, a dermatologic surgeon in private practice in Santo Domingo, Dominican Republic.

Of all the patients, 20% said they were satisfied with the outcome, and 80% said they were very satisfied. One patient experienced a deep broken suture and required an additional procedure, but no other complications, such as hematoma, infection, or dehiscence occurred, she said.

The ambulatory technique involves a semicircular incision of the skin of the navel, suture fixation to the deep fascia, and posterior cerclage of the skin. It is associated with only minor discomfort and is appropriate for patients with deformities resulting from aging, pregnancy, or weight gain, as well as for those with congenital deformities, Dr. Hazoury noted. Most patients seeking this procedure have a protruding umbilicus and desire "omphaloplasty" for a deeper-looking belly button, she said, noting that umbilical hernia must be ruled out in patients with protrusions.

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

KEVIN FOLEY, RESEARCH

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.

LOS ANGELES — Non- or minimally ablative facial resurfacing offers patients the results they desire without extended downtime, said several presenters at the annual fall meeting of the American Academy of Facial Plastic and Reconstructive Surgery.

"Most of my patients want nonsurgical treatments with no downtime," said Elizabeth Rostan, M.D., a cosmetic dermatologist in Charlotte, N.C. "In my community, I can't give away a CO₂ laser resurfacing."

Most of Dr. Rostan's fractional resurfacing patients are women who want treatment for photoaging, acne scars, or melasma. "Many of these patients are the ones for whom you might consider intense pulsed light. It would burn off the pigmentary lesions, but it would not give you the same improvement you see in fine wrinkling."

In terms of both efficacy and recovery, fractional resurfacing falls between nonablative and ablative techniques.

"The results we get are better than what we would see with a nonablative technique, but not quite as good as what we would see with an ablative resurfacing," she said. "However, with the fractional resurfacing, patients aren't experiencing the 2 weeks of downtime that they would with a CO₂ laser resurfacing, either."

The device directs its energy along the path of a computer-generated pattern, producing about 2,000 tiny holes (microthermal injury zones) per square centimeter. Because the areas of injury are so tiny, "you are treating about 20% of the skin surface, leaving 80% to renew and heal," Dr. Rostan said.

The laser intensity can be varied for different applications. The 8-J/cm

Patients require a topical anesthetic, which takes about 1 hour to achieve maximum effect. The actual resurfacing procedure lasts about 20 minutes, she said. However, three to five treatments, spaced about a week apart, are usually necessary to achieve the desired result.

Afterward, there is mild erythema and edema. "Patients are usually pink for 2 days, but it can sometimes last as long as 4 days," Dr. Rostan said. "But they can easily cover it with makeup and be back to work the day after the procedure."

Fractional resurfacing is also a good alternative for elderly patients or for those with health issues that might compromise wound healing in an ablative resurfacing, she said. "I've done a healthy 87-year-old, as well as a transplant patient, with no adverse effects."

But she said she would carefully consider patients with scleroderma or rheumatoid problems. "Anyone who you'd have concerns about for laser resurfacing, you would also have to think about for fractional resurfacing."

The in-office erbium laser provides a one-time minimally ablative resurfacing with results similar to a whole course of intense fractional resurfacing, said James Newman, M.D., a facial plastic surgeon from San Mateo, Calif.

"I began using office-based laser treatments in response to patients' wanting a treatment without much downtime or prolonged healing, but who also didn't want to come into the office four or five times to treat a brown spot," he said.

The small erbium lasers are also relatively inexpensive (about $30,000), which allows the physician to rapidly recoup the investment and offer patients a modestly priced treatment. "For the removal of brown spots from the face or hands, it would be about $300, and for a perioral regional resurfacing, maybe $1,000 or less," he said.

The small, portable lasers have lower fluences (about 5–7 J/cm

"They also have a pulse duration of about 300 milliseconds, and because they are lower powered, they can't go as fast. The maximum repetition rate is about 2 Hz," Dr. Newman said.

This makes the in-office erbium laser good for localized or regional (perioral or periorbital) resurfacing, but not appropriate for a full-face procedure, he said.

The main indications for this device are solar lentigines, early elastosis of periorbital skin, sebaceous hyperplasia, scar modification, and epidermal keratosis, Dr. Newman said. Downtime is 4–7 days, "similar to what you would expect with intense fractional resurfacing or a medium-depth chemical peel."

"If they can come in and get it over with in one treatment, and then put up with a week at most of healing, patients will be very happy with this," he said.

The plasma resurfacer gives similar results, without the epidermal sloughing that the erbium laser generates, said Edgar Fincher, M.D., a dermatologic surgeon in Los Angeles.

These devices feature a nitrogen canister that pumps the gas into a handpiece, where a radiofrequency generator heats it and delivers it through a nozzle to the skin surface. They can deliver energy ranging from 1 to 4 J/cm

Like a CO₂ or erbium laser, the plasma resurfacer causes an immediate zone of thermal damage, with heat dissipation into the deeper tissues, stimulating fibroblast action.

The difference with the plasma resurfacer, Dr. Fincher said, is that the lower fluences preserve the epidermis until reepithelialization is complete. "It does not vaporize the epidermis, which accelerates wound healing. About 4 days later, you have reepithelialization and necrotic keratinocytes moving up and beginning to slough." By day 10, histology shows a fully reformed stratified epidermis and increased number of active fibroblasts generating collagen, he said.

These devices have received Food and Drug Administration approval for use in single-pass, low-energy repeat treatments and single-pass, high-energy treatment of facial rhytids, and for the treatment of superficial skin lesions.

Dr. Fincher has used a plasma resurfacer for about 2 years, with no incidence of scarring or hypopigmentation. He has seen some transient hyperpigmentation, however, and two patients have had prolonged (4–6 weeks) erythema.

"We tell people that, pretty reliably, they will be back to normal in 10 days," he said.

A full-face treatment can be done in about 15 minutes. Patients who are being treated for dyschromia or photodamage will probably require two or three treatments about 1 month apart. These low-energy treatments are usually performed with a topical anesthetic, although nerve blocks may be necessary for some patients. The high-energy treatments necessary for treating acne scars usually require local anesthetic or IV sedation.

"We still have a CO₂ laser and use it occasionally, but this has replaced it as our workhorse resurfacing device," Dr. Fincher said.

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

ORLANDO — Bone or perineural involvement portends a poorer prognosis when it comes to aggressive and extensive tumors of the scalp, according to a study presented at the annual meeting of the Florida Society of Dermatologic Surgeons.

In the study, 6 of 11 patients with aggressive squamous cell carcinoma of the scalp had bone involvement, said Pearon G. Lang Jr., M.D.

"We don't think of this—tumors in bony areas such as the scalp."

The nine men and two women who were diagnosed with aggressive squamous cell carcinoma over a 9-year period all had alopecia or thinning hair. "Their scalps were exposed to chronic actinic damage," explained Dr. Lang, professor of dermatology, pathology, otolaryngology, and communicative sciences at the Medical University of South Carolina, Charleston.

"You have to strip off the periosteum when these tumors go down to the bone. This may be the source of recurrence, and tumors may progress rapidly," Dr. Lang said.

Consider a CT scan but be aware, however, that pitting of the bone is helpful as a sign but not always reliable. "To cure, you must resect the bone. Decortication is not recommended—I've seen cases over the years where the tumor goes deeper," he said.

All tumors were moderately or well differentiated. A total of 4 of the 11 patients had satellite lesions, including 1 patient with a satellite lesion at time of initial treatment. Six patients developed regional or systemic metastases; five of them died.

The study also included four patients with aggressive basal cell carcinoma of the scalp.

"These aggressive basal cell carcinomas all occurred in women with full hair," Dr. Lang said.

Tumors were 3 cm or bigger in size, up to the entire vertex of the scalp. One case of basal cell carcinoma mimicked recalcitrant seborrheic dermatitis. All of the patients had Mohs surgery along with extensive reconstruction. There were no recurrences or metastases among the patients.

"Remember that a recurrent tumor can look like granulation tissue," Dr. Lang said at the meeting.

Most squamous cell and basal cell tumors recur within 2–6 years (average, 3 years). "You can get near a 100% cure rate if there is only skin involvement," Dr. Lang said, but there is less than a 30% cure rate if there is perineural involvement.

Perineural tumors can be asymptomatic for years. Lesions are often small and benign in appearance.

MRI imaging is preferable to CT scans, Dr. Lang said, although only 50% of patients with such tumors will have positive findings.

DENVER — A margin of 10 mm beyond the gross tumor border of a nonmelanoma skin cancer is required to achieve a 95% probability of obtaining clear resection margins, C. Richard Choo, M.D., said at the annual meeting of the American Society for Therapeutic Radiology and Oncology.

In contrast, a 5-mm margin will fully cover the microscopic tumor extent in only 62% of cases, added Dr. Choo, a radiation oncologist at the Mayo Clinic, Rochester, Minn.

This sort of information is critical to the success of radiation therapy, a modality that does not provide resection margins. The radiation therapy volume selected must be sufficient to cover the potential microscopic tumor extent beyond the clinical lesion while avoiding treatment of normal tissue, he explained.

Dr. Choo and his coworkers quantified microscopic tumor extension beyond the clinical gross tumor borders of 71 nonmelanoma skin cancers from 64 consecutive patients. Thirty-eight lesions were sclerosing basal cell carcinomas, 19 were other types of basal cell carcinoma, and 14 were squamous cell carcinomas. Thirty-one were previously treated recurrent malignancies. Sixty were located on the face. The mean tumor size was 2.1 cm.

Preoperatively, the visible border of each lesion was marked with a fine felt-tip pen, and marks were placed at 5-mm intervals in four directions from the outlined borders. A plastic surgeon then excised the gross tumor under local anesthesia, and a dermatopathologist exam-ined frozen tissue sections. A positive resection margin led to further excision using thin slices until clear margins were achieved.

The mean distance of microscopic tumor extension beyond the clinically delineated border was 5.2 mm, with a maximum of 15 mm. The distance correlated positively with the size of the gross tumor, but not with histologic type, location, or history of prior treatment, perhaps due to the limited sample size.

DENVER — A margin of 10 mm beyond the gross tumor border of a nonmelanoma skin cancer is required to achieve a 95% probability of obtaining clear resection margins, C. Richard Choo, M.D., said at the annual meeting of the American Society for Therapeutic Radiology and Oncology.

In contrast, a 5-mm margin will fully cover the microscopic tumor extent in only 62% of cases, added Dr. Choo, a radiation oncologist at the Mayo Clinic, Rochester, Minn.

This sort of information is critical to the success of radiation therapy, a modality that does not provide resection margins. The radiation therapy volume selected must be sufficient to cover the potential microscopic tumor extent beyond the clinical lesion while avoiding treatment of normal tissue, he explained.

Dr. Choo and his coworkers quantified microscopic tumor extension beyond the clinical gross tumor borders of 71 nonmelanoma skin cancers from 64 consecutive patients. Thirty-eight lesions were sclerosing basal cell carcinomas, 19 were other types of basal cell carcinoma, and 14 were squamous cell carcinomas. Thirty-one were previously treated recurrent malignancies. Sixty were located on the face. The mean tumor size was 2.1 cm.

Preoperatively, the visible border of each lesion was marked with a fine felt-tip pen, and marks were placed at 5-mm intervals in four directions from the outlined borders. A plastic surgeon then excised the gross tumor under local anesthesia, and a dermatopathologist exam-ined frozen tissue sections. A positive resection margin led to further excision using thin slices until clear margins were achieved.

The mean distance of microscopic tumor extension beyond the clinically delineated border was 5.2 mm, with a maximum of 15 mm. The distance correlated positively with the size of the gross tumor, but not with histologic type, location, or history of prior treatment, perhaps due to the limited sample size.

DENVER — A margin of 10 mm beyond the gross tumor border of a nonmelanoma skin cancer is required to achieve a 95% probability of obtaining clear resection margins, C. Richard Choo, M.D., said at the annual meeting of the American Society for Therapeutic Radiology and Oncology.

In contrast, a 5-mm margin will fully cover the microscopic tumor extent in only 62% of cases, added Dr. Choo, a radiation oncologist at the Mayo Clinic, Rochester, Minn.

This sort of information is critical to the success of radiation therapy, a modality that does not provide resection margins. The radiation therapy volume selected must be sufficient to cover the potential microscopic tumor extent beyond the clinical lesion while avoiding treatment of normal tissue, he explained.

Dr. Choo and his coworkers quantified microscopic tumor extension beyond the clinical gross tumor borders of 71 nonmelanoma skin cancers from 64 consecutive patients. Thirty-eight lesions were sclerosing basal cell carcinomas, 19 were other types of basal cell carcinoma, and 14 were squamous cell carcinomas. Thirty-one were previously treated recurrent malignancies. Sixty were located on the face. The mean tumor size was 2.1 cm.

Preoperatively, the visible border of each lesion was marked with a fine felt-tip pen, and marks were placed at 5-mm intervals in four directions from the outlined borders. A plastic surgeon then excised the gross tumor under local anesthesia, and a dermatopathologist exam-ined frozen tissue sections. A positive resection margin led to further excision using thin slices until clear margins were achieved.

The mean distance of microscopic tumor extension beyond the clinically delineated border was 5.2 mm, with a maximum of 15 mm. The distance correlated positively with the size of the gross tumor, but not with histologic type, location, or history of prior treatment, perhaps due to the limited sample size.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

PARIS — One of the newest trends in nonablative skin rejuvenation is the use of plasma energy to rid patients of sun damage, fine lines, and wrinkles.

The advantage of plasma energy technology is in the conduction of uniform and efficient thermal energy to the dermis without epidermal vaporization or charring, reported Alan T. Lewis, M.D., at the Fourth International Academy of Cosmetic Dermatology World Congress.

"Unlike CO₂ lasers where you're taking away the epidermis and the protection that it affords, the epidermis is left behind with this device," he said. The intact epithelium provides posttreatment protection and speeds healing, resulting in less downtime.

One-year clinical histology studies show continuing regeneration and improvement over time. Elastosis is reduced, and there is a widening of the collagen band at the dermoepidermal junction. There have been no reports of scarring or hypopigmentation in clinical studies to date, according to Rhytec Inc., which markets the plasma energy device, Portrait PSR

The Portrait PSR

Topical anesthesia, with or without oral medication, is used.

The Portrait PSR

It can be used for people with darker skin tones without affecting skin color because the energy absorption is not chromophore dependent.

The device can deliver either low- or high-energy treatments, said Dr. Lewis, director of Mohs micrographic surgery and cutaneous oncology at Tulane University Hospital and Clinic in New Orleans.

Full-face rejuvenation using low-energy typically requires three 15-minute sessions spaced 21 days apart. There is no skin sloughing, minimal erythema, and little downtime, he said. Patients undergoing a single high-energy treatment may notice tight skin after the treatment and sloughing at about 7 days.

Another trend in nonablative facial rejuvenation is to "stack," or combine, different laser treatments to elicit a response in different layers of the skin, he said.

The approach takes a little more time but results in greater patient satisfaction.

Dr. Lewis cited a study in which 10 women who received five treatment sessions with a 595-nm pulsed dye laser immediately followed by a 1450-nm diode laser had overall better and faster results than did 20 women treated with either laser alone (Dermatol. Surg. 2004;30:1292–8).

The 6-month clinical outcome was best for patients receiving the combination treatment, followed by those treated with the 1450-nm diode laser and the 595-nm pulsed dye laser, respectively.

When stacking lasers, it's important to use the 595-nm laser first because infrared lasers can cause a good deal of redness that can become quite problematic if followed with a vascular laser.

ATLANTA — Recently completed phase III data on Reloxin, a botulinum toxin type A formulation known as Dysport in Europe, may hasten the product's availability in the United States, Gary Monheit, M.D., said at the annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new data on this "other Botox" have not been released, but Dr. Monheit described his experience with patients involved in the trial.

In a phase II trial in the United States, Reloxin was shown to be safe and effective at 30 days' follow-up. The phase III trial included 300 patients and tracked safety and efficacy for at least 5 months, he said.

The product had an excellent safety profile in both trials, and in some patients has an early onset of action, compared with Botox (Allergan Inc.), he said, noting that results were often seen in his patients in days rather than weeks.

"There was a very smooth, natural elimination of frown lines, a significant number of responders at 4 months, and action was still noted in a significant number of patients at up to 6 months," explained Dr. Monheit, an investigator for Ipsen Pharmaceuticals Ltd., the product's manufacturer, and Inamed Corp., which will develop and market the product in the United States.

Younger patients with significant frown lines had excellent results with full correction, and with very early onset—many within 24 hours. Furthermore, some had full response well beyond 4 months, he reported. Likewise, forehead and brow response was good at 4 months—and often well beyond that.

Older patients tended to take longer to respond, and some did not achieve the response that was expected. This might have been because of redundant skin, photodamage, or delayed or incomplete muscle response, Dr. Monheit speculated.

In a repeat-dose study that is now underway, investigators are evaluating whether repeat doses are as potent as the initial dose. A total of 1,200 patients are enrolled in the study and will be followed for 1 year, he said, noting that this will be the largest trial to date for the botulinum toxin.

Reloxin is identical to Botox except in its preparation. For example, Reloxin is provided in 500-unit vials, and Botox is provided in 100-unit vials; moreover, Reloxin is suspended in lactose, whereas Botox is suspended is sodium chloride, explained Dr. Monheit, of the department of dermatology at the University of Alabama at Birmingham, and president of the American Association for Dermatologic Surgery.

Given the differences in how Reloxin is prepared and in its onset and duration, it will likely require unique and individualized dosing and injection techniques, Dr. Monheit said.

Patient is shown at baseline in a "maximal frown" pose.

Smoothing is evident after treatment with Reloxin. Photos courtesy Dr. Gary Monheit

ATLANTA — Recently completed phase III data on Reloxin, a botulinum toxin type A formulation known as Dysport in Europe, may hasten the product's availability in the United States, Gary Monheit, M.D., said at the annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new data on this "other Botox" have not been released, but Dr. Monheit described his experience with patients involved in the trial.

In a phase II trial in the United States, Reloxin was shown to be safe and effective at 30 days' follow-up. The phase III trial included 300 patients and tracked safety and efficacy for at least 5 months, he said.

The product had an excellent safety profile in both trials, and in some patients has an early onset of action, compared with Botox (Allergan Inc.), he said, noting that results were often seen in his patients in days rather than weeks.

"There was a very smooth, natural elimination of frown lines, a significant number of responders at 4 months, and action was still noted in a significant number of patients at up to 6 months," explained Dr. Monheit, an investigator for Ipsen Pharmaceuticals Ltd., the product's manufacturer, and Inamed Corp., which will develop and market the product in the United States.

Younger patients with significant frown lines had excellent results with full correction, and with very early onset—many within 24 hours. Furthermore, some had full response well beyond 4 months, he reported. Likewise, forehead and brow response was good at 4 months—and often well beyond that.

Older patients tended to take longer to respond, and some did not achieve the response that was expected. This might have been because of redundant skin, photodamage, or delayed or incomplete muscle response, Dr. Monheit speculated.

In a repeat-dose study that is now underway, investigators are evaluating whether repeat doses are as potent as the initial dose. A total of 1,200 patients are enrolled in the study and will be followed for 1 year, he said, noting that this will be the largest trial to date for the botulinum toxin.

Reloxin is identical to Botox except in its preparation. For example, Reloxin is provided in 500-unit vials, and Botox is provided in 100-unit vials; moreover, Reloxin is suspended in lactose, whereas Botox is suspended is sodium chloride, explained Dr. Monheit, of the department of dermatology at the University of Alabama at Birmingham, and president of the American Association for Dermatologic Surgery.

Given the differences in how Reloxin is prepared and in its onset and duration, it will likely require unique and individualized dosing and injection techniques, Dr. Monheit said.

Patient is shown at baseline in a "maximal frown" pose.

Smoothing is evident after treatment with Reloxin. Photos courtesy Dr. Gary Monheit

ATLANTA — Recently completed phase III data on Reloxin, a botulinum toxin type A formulation known as Dysport in Europe, may hasten the product's availability in the United States, Gary Monheit, M.D., said at the annual meeting of the American Society for Dermatologic Surgery and the American College of Mohs Micrographic Surgery and Cutaneous Oncology.

The new data on this "other Botox" have not been released, but Dr. Monheit described his experience with patients involved in the trial.

In a phase II trial in the United States, Reloxin was shown to be safe and effective at 30 days' follow-up. The phase III trial included 300 patients and tracked safety and efficacy for at least 5 months, he said.

The product had an excellent safety profile in both trials, and in some patients has an early onset of action, compared with Botox (Allergan Inc.), he said, noting that results were often seen in his patients in days rather than weeks.

"There was a very smooth, natural elimination of frown lines, a significant number of responders at 4 months, and action was still noted in a significant number of patients at up to 6 months," explained Dr. Monheit, an investigator for Ipsen Pharmaceuticals Ltd., the product's manufacturer, and Inamed Corp., which will develop and market the product in the United States.

Younger patients with significant frown lines had excellent results with full correction, and with very early onset—many within 24 hours. Furthermore, some had full response well beyond 4 months, he reported. Likewise, forehead and brow response was good at 4 months—and often well beyond that.

Older patients tended to take longer to respond, and some did not achieve the response that was expected. This might have been because of redundant skin, photodamage, or delayed or incomplete muscle response, Dr. Monheit speculated.

In a repeat-dose study that is now underway, investigators are evaluating whether repeat doses are as potent as the initial dose. A total of 1,200 patients are enrolled in the study and will be followed for 1 year, he said, noting that this will be the largest trial to date for the botulinum toxin.

Reloxin is identical to Botox except in its preparation. For example, Reloxin is provided in 500-unit vials, and Botox is provided in 100-unit vials; moreover, Reloxin is suspended in lactose, whereas Botox is suspended is sodium chloride, explained Dr. Monheit, of the department of dermatology at the University of Alabama at Birmingham, and president of the American Association for Dermatologic Surgery.

Given the differences in how Reloxin is prepared and in its onset and duration, it will likely require unique and individualized dosing and injection techniques, Dr. Monheit said.

Patient is shown at baseline in a "maximal frown" pose.

Smoothing is evident after treatment with Reloxin. Photos courtesy Dr. Gary Monheit