Aesthetic Dermatology

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.

VANCOUVER, B.C. – A simple mnemonic – Talk, Time, Training, and Tools – can help dermatologists optimize outcomes when facing “bad” scars after skin surgery, Dr. Evans Bailey said at the World Congress of Dermatology.

Cosmetically challenging wounds can occur because the patient is on anticoagulants or for other reasons that the clinician cannot control, noted Dr. Bailey, a dermatologist with the Surgical Dermatology Group in Birmingham, Ala. Managing these situations begins during the informed consent process, when dermatologists should educate patients about the procedure and set reasonable expectations for cosmetic outcomes, he said.

“When it comes to scars, the battle is won or lost before you do surgery,” he said. “If you tell patients beforehand, it’s an explanation. If you tell them afterward, it’s an excuse.”

When obtaining informed consent, Dr. Bailey uses a digital tablet to take presurgical photos and draw options for surgical repair, he said. “I let them hold the tablet and show them the possibilities, because sometimes the smallest spots turn out to be the biggest tumors.”

When a patient returns after surgery with a “bad” scar, “never show surprise!” Dr. Bailey emphasized. “Don’t give up. Don’t show surprise, but be compassionate and pull hard for your patient.” Continuing to talk with patients at this point is key, he said. He shows patients the preoperative photographs and explains why he chose the surgical approach. Then he verbally commits to sticking with the patient during the entire process of wound healing and repair. “Say, ‘don’t worry; this is all under control; this will take longer than we thought. But I will make sure everything heals well.’ ”

Besides talking extensively with patients, dermatologists it is important to allow time for the scar to fully mature and involute before they intervene, said Dr. Bailey. “Allow scars to repair themselves,” he said. “Do not jump in too quickly. The body is really quite dynamic and capable – often more capable than we are.”

It’s equally important to stick to the fundamental principles of skin surgery, no matter how formidable the wound, Dr. Bailey noted. “Remember your training,” he said. “Protect the free margin and redefine the cosmetic subunits.” Tacking or suspension sutures can be used to redefine the cosmetic subunit and eliminate or minimize tension across the tissue flap, leading to better cosmetic outcomes.

For scars that still need improvement, tools such as wire brush dermabrasion can be used for raised scars, and TCA CROSS (trichloroacetic acid chemical reconstruction of skin scars) for depressed scars, Dr. Bailey noted. Both techniques can dramatically improve the final appearance of the scar, he noted.

“But the enemy of good is better,” he said. “So at some point I say, ‘you’re done.’ ”

Dr. Bailey reported having no relevant conflicts of interest.

VANCOUVER, B.C. – Laser treatment can markedly improve the appearance of lentigines and nevi of Ota, although response is variable for most other benign pigmented lesions of the epidermis and dermis, Dr. Jason Rivers said at the World Congress of Dermatology.

“The best approach is to choose the device based on the location of pigment within the skin,” said Dr. Rivers, a dermatologist with Pacific Dermaesthetics in Vancouver. “Melanin has a fairly wide absorption spectrum, from the 400s down into the infrared spectrum. As we go further down into the infrared spectrum, we need to use higher fluencies, because we need to penetrate deeper into the skin.”

Q-switched 532-nm Nd:YAG laser is a good choice for facial lentigines, according to Dr. Rivers. “You can see marked improvement after one treatment, but you can be quite effective with various modalities,” he said. Intense pulsed light (IPL) therapy also can be effective for lentigines, including for patients with darker skin, although there is a risk of postinflammatory hyperpigmentation, he cautioned. Another option is 1,927 nm fractionated thulium fiber laser, he said. “Mopping up a lot of things at one time can be extremely effective, especially for lentigines on the face.”

For patients seeking removal of freckles, intense pulse light can clear a wide area of dyschromia in one session, Dr. Rivers continued. For mucosal melanosis, Q-switched lasers such as 532-nm frequency-doubled Nd:YAG, 694-nm ruby, or 755-nm alexandrite can be effective and are associated with minimal or no scarring, he added.

Café au lait patches typically respond well to combined treatment with 532-nm and 1,064-nm lasers, according to Dr. Rivers. A total of 10 treatment sessions spaced over 2-3 years has given him a durable response and without skin changes as a result of laser treatment, he said. However, some data indicate that café au lait patches might respond even better to Q-switched 755-nm alexandrite laser instead of conventional Q-switched lasers, he noted.

Becker’s nevus presents a much greater challenge. “Studies have looked at many kinds of lasers, and in all cases results may be suboptimal,” Dr. Rivers said. “For one of my patients with Becker’s nevus, I’ve basically thrown the kitchen sink at her, and we’re pretty much back to square one.” Q-switched 755-nm alexandrite laser can provide substantial clearing after 3 treatments in 4 weeks, but results might not be durable, he added. Laser therapy of nevus spilus also is “hit or miss,” although some studies suggest that Q-switched ruby laser is more effective than alexandrite for these lesions, he added.

Among the benign pigmented lesions of the dermis, nevus of Ota usually responds best to laser treatment, particularly with Q-switched 694-nm ruby or Q-switched 1,064-nm Nd:YAG, Dr. Rivers said. Data indicate that children younger than 10 years might have more superficially placed pigment cells that can be treated with lower fluence, such as 2.2 instead of 2.8 J, he noted.

Both congenital and acquired melanocytic nevi respond variably to laser therapy, Dr. Rivers said. For acquired lesions, options include Q-switched 532-nm, fully ablative carbon dioxide resurfacing, and continuous wave laser, he said. Long-pulsed alexandrite laser therapy can partiallyly clear congenital lesions after just one treatment session, and patients can then be given the option of fully ablative carbon dioxide resurfacing, he said.

Dermatologic laser therapy can, of course, cause adverse effects. The best treatment for laser-induced chrysiasis is prevention, but lesions can clear with Q-switched 1,064-nm laser treatment, Dr. Rivers said. Pigmentation might occur at the lesion margin, but fades with time, he noted.

Melanoma also has been reported as a consequence of dermatologic laser therapy. While sublethal laser damage can increase DNA damage in vitro, Q-switched ruby laser does not seem to induce genetic changes, Dr. Rivers said. In addition, some lesions were probably melanoma to begin with, he said, noting that failure to diagnose malignant melanoma is among the most common allegations in medical liability claims against dermatologists.

Dr. Rivers disclosed no relevant conflicts of interest.

VANCOUVER, B.C. – Laser treatment can markedly improve the appearance of lentigines and nevi of Ota, although response is variable for most other benign pigmented lesions of the epidermis and dermis, Dr. Jason Rivers said at the World Congress of Dermatology.

“The best approach is to choose the device based on the location of pigment within the skin,” said Dr. Rivers, a dermatologist with Pacific Dermaesthetics in Vancouver. “Melanin has a fairly wide absorption spectrum, from the 400s down into the infrared spectrum. As we go further down into the infrared spectrum, we need to use higher fluencies, because we need to penetrate deeper into the skin.”

Q-switched 532-nm Nd:YAG laser is a good choice for facial lentigines, according to Dr. Rivers. “You can see marked improvement after one treatment, but you can be quite effective with various modalities,” he said. Intense pulsed light (IPL) therapy also can be effective for lentigines, including for patients with darker skin, although there is a risk of postinflammatory hyperpigmentation, he cautioned. Another option is 1,927 nm fractionated thulium fiber laser, he said. “Mopping up a lot of things at one time can be extremely effective, especially for lentigines on the face.”

For patients seeking removal of freckles, intense pulse light can clear a wide area of dyschromia in one session, Dr. Rivers continued. For mucosal melanosis, Q-switched lasers such as 532-nm frequency-doubled Nd:YAG, 694-nm ruby, or 755-nm alexandrite can be effective and are associated with minimal or no scarring, he added.

Café au lait patches typically respond well to combined treatment with 532-nm and 1,064-nm lasers, according to Dr. Rivers. A total of 10 treatment sessions spaced over 2-3 years has given him a durable response and without skin changes as a result of laser treatment, he said. However, some data indicate that café au lait patches might respond even better to Q-switched 755-nm alexandrite laser instead of conventional Q-switched lasers, he noted.

Becker’s nevus presents a much greater challenge. “Studies have looked at many kinds of lasers, and in all cases results may be suboptimal,” Dr. Rivers said. “For one of my patients with Becker’s nevus, I’ve basically thrown the kitchen sink at her, and we’re pretty much back to square one.” Q-switched 755-nm alexandrite laser can provide substantial clearing after 3 treatments in 4 weeks, but results might not be durable, he added. Laser therapy of nevus spilus also is “hit or miss,” although some studies suggest that Q-switched ruby laser is more effective than alexandrite for these lesions, he added.

Among the benign pigmented lesions of the dermis, nevus of Ota usually responds best to laser treatment, particularly with Q-switched 694-nm ruby or Q-switched 1,064-nm Nd:YAG, Dr. Rivers said. Data indicate that children younger than 10 years might have more superficially placed pigment cells that can be treated with lower fluence, such as 2.2 instead of 2.8 J, he noted.

Both congenital and acquired melanocytic nevi respond variably to laser therapy, Dr. Rivers said. For acquired lesions, options include Q-switched 532-nm, fully ablative carbon dioxide resurfacing, and continuous wave laser, he said. Long-pulsed alexandrite laser therapy can partiallyly clear congenital lesions after just one treatment session, and patients can then be given the option of fully ablative carbon dioxide resurfacing, he said.

Dermatologic laser therapy can, of course, cause adverse effects. The best treatment for laser-induced chrysiasis is prevention, but lesions can clear with Q-switched 1,064-nm laser treatment, Dr. Rivers said. Pigmentation might occur at the lesion margin, but fades with time, he noted.

Melanoma also has been reported as a consequence of dermatologic laser therapy. While sublethal laser damage can increase DNA damage in vitro, Q-switched ruby laser does not seem to induce genetic changes, Dr. Rivers said. In addition, some lesions were probably melanoma to begin with, he said, noting that failure to diagnose malignant melanoma is among the most common allegations in medical liability claims against dermatologists.

Dr. Rivers disclosed no relevant conflicts of interest.

VANCOUVER, B.C. – Laser treatment can markedly improve the appearance of lentigines and nevi of Ota, although response is variable for most other benign pigmented lesions of the epidermis and dermis, Dr. Jason Rivers said at the World Congress of Dermatology.

“The best approach is to choose the device based on the location of pigment within the skin,” said Dr. Rivers, a dermatologist with Pacific Dermaesthetics in Vancouver. “Melanin has a fairly wide absorption spectrum, from the 400s down into the infrared spectrum. As we go further down into the infrared spectrum, we need to use higher fluencies, because we need to penetrate deeper into the skin.”

Q-switched 532-nm Nd:YAG laser is a good choice for facial lentigines, according to Dr. Rivers. “You can see marked improvement after one treatment, but you can be quite effective with various modalities,” he said. Intense pulsed light (IPL) therapy also can be effective for lentigines, including for patients with darker skin, although there is a risk of postinflammatory hyperpigmentation, he cautioned. Another option is 1,927 nm fractionated thulium fiber laser, he said. “Mopping up a lot of things at one time can be extremely effective, especially for lentigines on the face.”

For patients seeking removal of freckles, intense pulse light can clear a wide area of dyschromia in one session, Dr. Rivers continued. For mucosal melanosis, Q-switched lasers such as 532-nm frequency-doubled Nd:YAG, 694-nm ruby, or 755-nm alexandrite can be effective and are associated with minimal or no scarring, he added.

Café au lait patches typically respond well to combined treatment with 532-nm and 1,064-nm lasers, according to Dr. Rivers. A total of 10 treatment sessions spaced over 2-3 years has given him a durable response and without skin changes as a result of laser treatment, he said. However, some data indicate that café au lait patches might respond even better to Q-switched 755-nm alexandrite laser instead of conventional Q-switched lasers, he noted.

Becker’s nevus presents a much greater challenge. “Studies have looked at many kinds of lasers, and in all cases results may be suboptimal,” Dr. Rivers said. “For one of my patients with Becker’s nevus, I’ve basically thrown the kitchen sink at her, and we’re pretty much back to square one.” Q-switched 755-nm alexandrite laser can provide substantial clearing after 3 treatments in 4 weeks, but results might not be durable, he added. Laser therapy of nevus spilus also is “hit or miss,” although some studies suggest that Q-switched ruby laser is more effective than alexandrite for these lesions, he added.

Among the benign pigmented lesions of the dermis, nevus of Ota usually responds best to laser treatment, particularly with Q-switched 694-nm ruby or Q-switched 1,064-nm Nd:YAG, Dr. Rivers said. Data indicate that children younger than 10 years might have more superficially placed pigment cells that can be treated with lower fluence, such as 2.2 instead of 2.8 J, he noted.

Both congenital and acquired melanocytic nevi respond variably to laser therapy, Dr. Rivers said. For acquired lesions, options include Q-switched 532-nm, fully ablative carbon dioxide resurfacing, and continuous wave laser, he said. Long-pulsed alexandrite laser therapy can partiallyly clear congenital lesions after just one treatment session, and patients can then be given the option of fully ablative carbon dioxide resurfacing, he said.

Dermatologic laser therapy can, of course, cause adverse effects. The best treatment for laser-induced chrysiasis is prevention, but lesions can clear with Q-switched 1,064-nm laser treatment, Dr. Rivers said. Pigmentation might occur at the lesion margin, but fades with time, he noted.

Melanoma also has been reported as a consequence of dermatologic laser therapy. While sublethal laser damage can increase DNA damage in vitro, Q-switched ruby laser does not seem to induce genetic changes, Dr. Rivers said. In addition, some lesions were probably melanoma to begin with, he said, noting that failure to diagnose malignant melanoma is among the most common allegations in medical liability claims against dermatologists.

Dr. Rivers disclosed no relevant conflicts of interest.

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

koakes@frontlinemedcom.com

On Twitter @karioakes

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

koakes@frontlinemedcom.com

On Twitter @karioakes

Physicians seeking optimal body contouring results for their aesthetic medicine patients are increasingly turning to a variety of energy-based options. Newer technologies for body shaping deliver energy to heat or cool tissue, and each has its own side effect and tolerability profile. Finding the right technology fit for a practice and for a particular patient requires that clinicians understand how these technologies work and who is most likely to benefit.

Dr. Christopher Zachary, professor and chair of dermatology at the University of California, Irvine, reviewed current options for energy-based body sculpting at this year’s Summit in Aesthetic Medicine held in Dana Point, Calif. Current energy-based technologies, he said, either heat or cool tissue to achieve a deliberate panniculitis, followed by gradual apoptosis of fat cells. As adipocytes undergo apoptosis, intracellular contents are metabolized, so intact adipose tissue is not excreted as it is in liposuction, for example.

Dr. Zachary explained that fat destruction caused by cold was first noticed by physicians treating young children with cheek dimples after prolonged exposure to icy treats, a phenomenon they termed “Popsicle panniculitis.” However, heating fat tissue can have the same effect. Whether the technology uses heating or cooling to achieve body contouring, he said, is not as important as the volume and duration of treatment.

Ideally, energy-based contouring technologies should be able to achieve bulk treatment of a relatively large area for a significant amount of time, from 10 to 60 minutes. These criteria allow for the larger-scale controlled loss of cell viability critical for successful contouring, he said.

Zeltiq’s CoolSculpting has been a leader in body contouring using cold technologies, he continued. By achieving bulk cooling of adipose tissue, CoolSculpting can achieve both sculpting and debulking of abdominal, thigh, and flank problem areas. The procedure is generally well tolerated, and achieves gradual recontouring over the weeks following treatment.

Radiofrequency body contouring, said Dr. Zachary, has been led by Cutera. “Cutera has really done the best studies in this area,” he said. The technology uses large electrodes that heat tissue to 45-47° C for 3-6 minutes, “achieving some nice results.” This level of heating achieves significant apoptosis of adipose tissue but is well tolerated.

Near-infrared technology has been pioneered by Cynosure, which can be used to treat bulk areas of tissue. Again, said Dr. Zachary, “The company has done the right studies, using ultrasound and histology to measure results. They’re using the right parameters.”

Another technique is microfocused ultrasound, as pioneered by companies such as Liposonix. This technology creates a well-defined, focused injury and creates a painful acute necrosis. “This doesn’t fit my criteria for effective bulk heating or cooling,” he noted. Additionally, a significant number of patients will have local tenderness, ecchymosis, and edema that can persist for more than a month. Although there may be targeted applications for the technology, it is not likely to be as effective or as well tolerated as some other options, he said.

New areas of inquiry include adding massage to treatment, encouraging speedier and more uniform results. New flat applicators show promise for more effective treatment. Physicians are seeing more patients who have concerns about male breast tissue, submental fat, and acne, for whom these technologies hold promise.

“If we had been having this discussion 5 years ago,” he said, “I would have been rather jaundiced about the outlook in this field. These days, the future is quite bright.”

Dr. Zachary reports that he has financial disclosures related to Solta Medical, Zeltiq, Zimmer, Cutera, and Alma.

koakes@frontlinemedcom.com

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

koakes@frontlinemedcom.com

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

koakes@frontlinemedcom.com

On Twitter @karioakes

Hyaluronic acid fillers are a safe and effective aesthetic medicine modality, but some patients experience significant pain and bruising from dermal filler injections. Adding lidocaine may help with pain, and many clinicians also will add epinephrine to filler injections, believing they’ll achieve even less pain and mitigate bruising because of epinephrine’s vasoconstrictive effects.

However, quality evidence is lacking to support the addition of epinephrine, according to Dr. Amir Moradi, a facial plastic and reconstructive surgeon in private practice in San Diego. He conducted a split-face study that found no benefit from adding epinephrine to hyaluronic acid injections, and presented his results at the Summit in Aesthetic Medicine in Dana Point, Calif.

The study enrolled 30 patients in a double-blind, split-face comparison study of the hyaluronic acid filler Belotero (BEL) alone to Belotero with lidocaine (BEL-L), and to Belotero with lidocaine and epinephrine (BEL-LE). Patients received superficial to mid-dermal injections for perioral lines, and investigators obtained pretreatment photos and assessed wrinkle severity on the 5-point Merz scale.

Patients were allocated randomly and equally to treatment arms, so that 10 received BEL and BEL-L, 10 received BEL and BEL-LE, and 10 received BEL-L and BEL-LE. Each patient received a maximum of 1 mL of filler on each side of the face. An assistant prepared syringes in a manner that made them indistinguishable, so the operator and patient were blinded to treatment arm. All patients received massage and ice to the perioral area immediately after treatment.

Investigators asked patients to report the pain they experienced during injections on a 10-point Likert scale immediately after their injections were complete. Bruising was assessed by the physician investigator, by another blinded evaluator, and by the patients themselves pretreatment, and on days 1, 7, and 14 after injections. Because no validated standardized bruising scale exists, the investigators devised a scale of 0-3 to describe mild, moderate, and severe bruising according to the visibility and size of the discolored areas.

Contrary to anecdotal reports and against the investigators’ expectations, patients saw no significant difference in either pain or bruising with the addition of lidocaine, with or without epinephrine, to the hyaluronic acid dermal filler. Patients in all treatment arms generally had the worst bruising at day 1, with a resolution by about half at day 7, and bruising gone or nearly gone by day 14.

Calling for more and larger studies in this field, Dr. Moradi noted that the “limited benefit of lidocaine could be due to not waiting long enough for lidocaine to fully take effect.”

For pain, Dr. Moradi said in an interview, “How and when you ask the question really makes a difference. Because if you wait even 30 seconds afterward, it can change the answer.” He noted that his results showed no improvement in pain with lidocaine compared with hyaluronic acid alone. He plans further investigation using an assessment method that will allow patients to report pain during injections.

Planning more study into whether lidocaine, alone or with epinephrine, helps pain and bruising, Dr. Moradi expects to see some benefit for the adjuncts when a physician needs to go back and reinject an area. However, the field needs more well-designed studies with standardized assessments, he said. “We need to look at what the evidence says,”

Dr. Moradi reports that he has financial disclosures related to Allergan, Galderma, and Merz.

koakes@frontlinemedcom.com

On Twitter @karioakes

The use of local anesthetics, particularly local anesthetic injections, is a core part of the practice of dermatology. The use of anesthetics in both diagnosis and management make the administration and usage of these medications a foundational skill for all dermatology residents. Minimizing that familiar “pinch and burn” and giving patients a nearly pain-free experience can result in satisfaction for both patients and physicians. This column describes several useful and easily implemented techniques that residents can incorporate into their daily practice.

Buffer

Plain lidocaine is less acidic than the more commonly utilized lidocaine 1% with 1:100,000 epinephrine. When the latter is buffered with sodium bicarbonate in a 10:1 dilution, it is superior to its unbuffered counterpart.¹ This method works by raising the pH of the solution, which is normally 4.2, to a physiologic and more comfortable 7.4.² Of note, bupivacaine is more acidic than lidocaine.³

Warm

Warming anesthetics has been shown to reduce injection pain. Warming anesthetics to body temperature or up to 40°C to 54.4°C (104°F–130°F) has been studied and recommended.^4-7 Warming combined with buffering may result in the least painful injection.^4-6

Use Smaller-Gauge Needles

A more obvious tip, using smaller-gauge needles can reduce injection pain. Generally, 27- or 30-gauge needles are commonly recommended.^8,9

Limit Repeated Use of the Same Needle

Switch to a fresh needle when you have to inject multiple times in the same lesion or when you have multiple injection sites. In addition, use different needles for drawing up and for the actual injection procedure. A dull needle means more pain.

Perpendicular Injection Technique

Compared to a 45° injection angle, lidocaine injected at a 90° angle reduces pain,¹⁰ as this technique minimizes the number of nerve endings that come in contact with the needle.⁸

Inject Slowly

A slow injection technique using small volumes can substantially minimize pain, as it allows for the nerve endings in the skin to accommodate for the distortion caused by anesthetic infiltration.²

Pulse Injection

Pulse injections can be less painful than injecting an anesthetic in a continuous fashion. It has been recommended that 0.1 cc of anesthetic be injected followed by a 3-second pause, then repeating this step 2 to 3 times. More volumes may subsequently be administered.⁸

Thoughtful Reinsertion

When larger surface areas must be anesthetized, the needle may have to be reinserted multiple times. In these instances, injection within 1 cm of the visibly blanched area of skin ensures that lidocaine (and epinephrine, if such a solution is used) has already infiltrated that area.²

Distraction

There is merit to the idea of distracting the patient when injecting local anesthetics. Distraction methods including engaging in simple conversation with the patient, having the patient look away, playing background music, and even suggesting that the procedure is painless or has minimal pain have shown utility in minimizing injection pain.^8,11

Other distraction techniques are physical, including stretching and scratching the skin, pinching, local vibration, and pressure.^12,13

Combination Anesthetic Technique

Topical anesthetic application, such as lidocaine 2.5%–prilocaine 2.5% cream, can be applied 60 to 120 minutes prior to intralesional anesthetic injection to attenuate injection pain.^2,8 Ice or ethyl chloride spray also can be utilized and has a faster onset of action than topical anesthetics.^2,8

Conclusion

The knowledge and application of techniques to minimize pain associated with local anesthetic injection can greatly enhance a resident’s practice. Learning and incorporating these techniques early on in resident training can help instill these skills that can be useful for the remainder of a dermatologist’s career.

The use of local anesthetics, particularly local anesthetic injections, is a core part of the practice of dermatology. The use of anesthetics in both diagnosis and management make the administration and usage of these medications a foundational skill for all dermatology residents. Minimizing that familiar “pinch and burn” and giving patients a nearly pain-free experience can result in satisfaction for both patients and physicians. This column describes several useful and easily implemented techniques that residents can incorporate into their daily practice.

Buffer

Plain lidocaine is less acidic than the more commonly utilized lidocaine 1% with 1:100,000 epinephrine. When the latter is buffered with sodium bicarbonate in a 10:1 dilution, it is superior to its unbuffered counterpart.¹ This method works by raising the pH of the solution, which is normally 4.2, to a physiologic and more comfortable 7.4.² Of note, bupivacaine is more acidic than lidocaine.³

Warm

Warming anesthetics has been shown to reduce injection pain. Warming anesthetics to body temperature or up to 40°C to 54.4°C (104°F–130°F) has been studied and recommended.^4-7 Warming combined with buffering may result in the least painful injection.^4-6

Use Smaller-Gauge Needles

A more obvious tip, using smaller-gauge needles can reduce injection pain. Generally, 27- or 30-gauge needles are commonly recommended.^8,9

Limit Repeated Use of the Same Needle

Switch to a fresh needle when you have to inject multiple times in the same lesion or when you have multiple injection sites. In addition, use different needles for drawing up and for the actual injection procedure. A dull needle means more pain.

Perpendicular Injection Technique

Compared to a 45° injection angle, lidocaine injected at a 90° angle reduces pain,¹⁰ as this technique minimizes the number of nerve endings that come in contact with the needle.⁸

Inject Slowly

A slow injection technique using small volumes can substantially minimize pain, as it allows for the nerve endings in the skin to accommodate for the distortion caused by anesthetic infiltration.²

Pulse Injection

Pulse injections can be less painful than injecting an anesthetic in a continuous fashion. It has been recommended that 0.1 cc of anesthetic be injected followed by a 3-second pause, then repeating this step 2 to 3 times. More volumes may subsequently be administered.⁸

Thoughtful Reinsertion

When larger surface areas must be anesthetized, the needle may have to be reinserted multiple times. In these instances, injection within 1 cm of the visibly blanched area of skin ensures that lidocaine (and epinephrine, if such a solution is used) has already infiltrated that area.²

Distraction

There is merit to the idea of distracting the patient when injecting local anesthetics. Distraction methods including engaging in simple conversation with the patient, having the patient look away, playing background music, and even suggesting that the procedure is painless or has minimal pain have shown utility in minimizing injection pain.^8,11

Other distraction techniques are physical, including stretching and scratching the skin, pinching, local vibration, and pressure.^12,13

Combination Anesthetic Technique

Topical anesthetic application, such as lidocaine 2.5%–prilocaine 2.5% cream, can be applied 60 to 120 minutes prior to intralesional anesthetic injection to attenuate injection pain.^2,8 Ice or ethyl chloride spray also can be utilized and has a faster onset of action than topical anesthetics.^2,8

Conclusion

The knowledge and application of techniques to minimize pain associated with local anesthetic injection can greatly enhance a resident’s practice. Learning and incorporating these techniques early on in resident training can help instill these skills that can be useful for the remainder of a dermatologist’s career.

The use of local anesthetics, particularly local anesthetic injections, is a core part of the practice of dermatology. The use of anesthetics in both diagnosis and management make the administration and usage of these medications a foundational skill for all dermatology residents. Minimizing that familiar “pinch and burn” and giving patients a nearly pain-free experience can result in satisfaction for both patients and physicians. This column describes several useful and easily implemented techniques that residents can incorporate into their daily practice.

Buffer

Plain lidocaine is less acidic than the more commonly utilized lidocaine 1% with 1:100,000 epinephrine. When the latter is buffered with sodium bicarbonate in a 10:1 dilution, it is superior to its unbuffered counterpart.¹ This method works by raising the pH of the solution, which is normally 4.2, to a physiologic and more comfortable 7.4.² Of note, bupivacaine is more acidic than lidocaine.³

Warm

Warming anesthetics has been shown to reduce injection pain. Warming anesthetics to body temperature or up to 40°C to 54.4°C (104°F–130°F) has been studied and recommended.^4-7 Warming combined with buffering may result in the least painful injection.^4-6

Use Smaller-Gauge Needles

A more obvious tip, using smaller-gauge needles can reduce injection pain. Generally, 27- or 30-gauge needles are commonly recommended.^8,9

Limit Repeated Use of the Same Needle

Switch to a fresh needle when you have to inject multiple times in the same lesion or when you have multiple injection sites. In addition, use different needles for drawing up and for the actual injection procedure. A dull needle means more pain.

Perpendicular Injection Technique

Compared to a 45° injection angle, lidocaine injected at a 90° angle reduces pain,¹⁰ as this technique minimizes the number of nerve endings that come in contact with the needle.⁸

Inject Slowly

A slow injection technique using small volumes can substantially minimize pain, as it allows for the nerve endings in the skin to accommodate for the distortion caused by anesthetic infiltration.²

Pulse Injection

Pulse injections can be less painful than injecting an anesthetic in a continuous fashion. It has been recommended that 0.1 cc of anesthetic be injected followed by a 3-second pause, then repeating this step 2 to 3 times. More volumes may subsequently be administered.⁸

Thoughtful Reinsertion

When larger surface areas must be anesthetized, the needle may have to be reinserted multiple times. In these instances, injection within 1 cm of the visibly blanched area of skin ensures that lidocaine (and epinephrine, if such a solution is used) has already infiltrated that area.²

Distraction

There is merit to the idea of distracting the patient when injecting local anesthetics. Distraction methods including engaging in simple conversation with the patient, having the patient look away, playing background music, and even suggesting that the procedure is painless or has minimal pain have shown utility in minimizing injection pain.^8,11

Other distraction techniques are physical, including stretching and scratching the skin, pinching, local vibration, and pressure.^12,13

Combination Anesthetic Technique

Topical anesthetic application, such as lidocaine 2.5%–prilocaine 2.5% cream, can be applied 60 to 120 minutes prior to intralesional anesthetic injection to attenuate injection pain.^2,8 Ice or ethyl chloride spray also can be utilized and has a faster onset of action than topical anesthetics.^2,8

Conclusion

The knowledge and application of techniques to minimize pain associated with local anesthetic injection can greatly enhance a resident’s practice. Learning and incorporating these techniques early on in resident training can help instill these skills that can be useful for the remainder of a dermatologist’s career.

Unwanted tattoos, beware: Picosecond pulse duration lasers shatter tattoo particles with lower fluence and fewer treatments than nanosecond pulses, according to Dr. Emil A. Tanghetti.

“Picosecond pulse duration lasers open a new mechanism for breaking up tattoo particles that is not currently accessible using nanosecond laser pulses,” he said at the meeting held by Global Academy for Medical Education.

Courtesy Dr. Tanghetti

The targets in tattoo removal treatment are the individual tattoo particles, which generally range from 40 to 100 nm and are loosely packed, said Dr. Tanghetti of the Center for Dermatology and Laser Surgery in Sacramento, Calif.

When using nanosecond pulses, “Graphite particles common in tattoo removal have a larger absorption at 755 nm vs. 1064 nm,” he noted. Although the fluence is greater for the 1064 nm, the energy absorbed in the target particles is greater (16%-40% higher) for 755 nm, combined with epidermal and dermal screening.

By contrast, the picosecond pulse provides a sufficiently powerful impact to shatter small tattoo particles, and the picosecond pulse duration is 7-10 times shorter than a Q-switched Nd:YAG and 70-100 times shorter than a Q-switched Alexandrite laser, Dr. Tanghetti explained. The greater photomechanical impact means that less fluence is required.

The picosecond laser allows for fewer treatments with “significantly better clearance,” including stubborn green and blue tattoos (with only the 755-nm devices) and previously treated but hard-to-clear tattoos, he said. Clinical data show effective treatment of tattoos with one-half to one-third of the fluence and one-half the number of treatments needed to achieve the same result with a nanosecond laser, he added.

“These devices work in different ways and have different powers,” he said in an interview. “The one strong point about Alexandrite technology is that it works much better for green and blue.”

Dr. Tanghetti noted that the picosecond Alexandrite nonablative laser with the fractional optic focus lens array can be useful because of the minimal downtime with no need for anesthesia, and the focus lens allows for targeting of pigment as well as acne scars. “This type of device can be an important asset in a practice with active working clients, as well as patients with darker skin, and those with acne scars and dyspigmentation where downtime and postinflammatory hyperpigmentation is a concern,” he said.

The picosecond devices, “add a new dimension to what we can do,” he remarked.

Dr. Tanghetti disclosed serving as an advisor for Cynosure and receiving discounts on equipment from the company.

Global Academy and this news organization are owned by the same company.

hsplete@frontlinemedcom.com

Unwanted tattoos, beware: Picosecond pulse duration lasers shatter tattoo particles with lower fluence and fewer treatments than nanosecond pulses, according to Dr. Emil A. Tanghetti.

“Picosecond pulse duration lasers open a new mechanism for breaking up tattoo particles that is not currently accessible using nanosecond laser pulses,” he said at the meeting held by Global Academy for Medical Education.

Courtesy Dr. Tanghetti

The targets in tattoo removal treatment are the individual tattoo particles, which generally range from 40 to 100 nm and are loosely packed, said Dr. Tanghetti of the Center for Dermatology and Laser Surgery in Sacramento, Calif.

When using nanosecond pulses, “Graphite particles common in tattoo removal have a larger absorption at 755 nm vs. 1064 nm,” he noted. Although the fluence is greater for the 1064 nm, the energy absorbed in the target particles is greater (16%-40% higher) for 755 nm, combined with epidermal and dermal screening.

By contrast, the picosecond pulse provides a sufficiently powerful impact to shatter small tattoo particles, and the picosecond pulse duration is 7-10 times shorter than a Q-switched Nd:YAG and 70-100 times shorter than a Q-switched Alexandrite laser, Dr. Tanghetti explained. The greater photomechanical impact means that less fluence is required.

The picosecond laser allows for fewer treatments with “significantly better clearance,” including stubborn green and blue tattoos (with only the 755-nm devices) and previously treated but hard-to-clear tattoos, he said. Clinical data show effective treatment of tattoos with one-half to one-third of the fluence and one-half the number of treatments needed to achieve the same result with a nanosecond laser, he added.

“These devices work in different ways and have different powers,” he said in an interview. “The one strong point about Alexandrite technology is that it works much better for green and blue.”

Dr. Tanghetti noted that the picosecond Alexandrite nonablative laser with the fractional optic focus lens array can be useful because of the minimal downtime with no need for anesthesia, and the focus lens allows for targeting of pigment as well as acne scars. “This type of device can be an important asset in a practice with active working clients, as well as patients with darker skin, and those with acne scars and dyspigmentation where downtime and postinflammatory hyperpigmentation is a concern,” he said.

The picosecond devices, “add a new dimension to what we can do,” he remarked.

Dr. Tanghetti disclosed serving as an advisor for Cynosure and receiving discounts on equipment from the company.

Global Academy and this news organization are owned by the same company.

hsplete@frontlinemedcom.com

Unwanted tattoos, beware: Picosecond pulse duration lasers shatter tattoo particles with lower fluence and fewer treatments than nanosecond pulses, according to Dr. Emil A. Tanghetti.

“Picosecond pulse duration lasers open a new mechanism for breaking up tattoo particles that is not currently accessible using nanosecond laser pulses,” he said at the meeting held by Global Academy for Medical Education.

Courtesy Dr. Tanghetti

The targets in tattoo removal treatment are the individual tattoo particles, which generally range from 40 to 100 nm and are loosely packed, said Dr. Tanghetti of the Center for Dermatology and Laser Surgery in Sacramento, Calif.

When using nanosecond pulses, “Graphite particles common in tattoo removal have a larger absorption at 755 nm vs. 1064 nm,” he noted. Although the fluence is greater for the 1064 nm, the energy absorbed in the target particles is greater (16%-40% higher) for 755 nm, combined with epidermal and dermal screening.

By contrast, the picosecond pulse provides a sufficiently powerful impact to shatter small tattoo particles, and the picosecond pulse duration is 7-10 times shorter than a Q-switched Nd:YAG and 70-100 times shorter than a Q-switched Alexandrite laser, Dr. Tanghetti explained. The greater photomechanical impact means that less fluence is required.

The picosecond laser allows for fewer treatments with “significantly better clearance,” including stubborn green and blue tattoos (with only the 755-nm devices) and previously treated but hard-to-clear tattoos, he said. Clinical data show effective treatment of tattoos with one-half to one-third of the fluence and one-half the number of treatments needed to achieve the same result with a nanosecond laser, he added.

“These devices work in different ways and have different powers,” he said in an interview. “The one strong point about Alexandrite technology is that it works much better for green and blue.”

Dr. Tanghetti noted that the picosecond Alexandrite nonablative laser with the fractional optic focus lens array can be useful because of the minimal downtime with no need for anesthesia, and the focus lens allows for targeting of pigment as well as acne scars. “This type of device can be an important asset in a practice with active working clients, as well as patients with darker skin, and those with acne scars and dyspigmentation where downtime and postinflammatory hyperpigmentation is a concern,” he said.

The picosecond devices, “add a new dimension to what we can do,” he remarked.

Dr. Tanghetti disclosed serving as an advisor for Cynosure and receiving discounts on equipment from the company.

Global Academy and this news organization are owned by the same company.

hsplete@frontlinemedcom.com

VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.

However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.

Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.

Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.

When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.

If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.

For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.

Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.

She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.

VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.

However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.

Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.

Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.

When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.

If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.

For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.

Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.

She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.

VANCOUVER – Fillers can greatly improve the age-related effects of atrophy of subcutaneous fat of the central forehead and temples, where volume loss can create an unhealthy or even skeletal appearance, according to Dr. Tatjana Pavicic.

However, dermatologists in Western countries often neglect to use fillers in the forehead and temples, said Dr. Pavicic, whose private practice in Munich specializes in cosmetic surgery and aesthetic procedures. They can learn from their colleagues in eastern Asia, where a “high, gently curved, round, or even slightly protruding forehead” is traditionally a sign of wealth, and the forehead and temples are among the most popular sites for fillers, she noted in a presentation at the World Congress of Dermatology.

Restoring volume to the central forehead and temples can shave years off patients’ appearance, but clinicians should be mindful of anatomy and use proper tools and techniques when filling these areas, Dr. Pavicic emphasized. Otherwise patients can suffer serious adverse effects, including tissue necrosis or even permanent blindness as a result of filler entering the vasculature, she said. Likewise, because the bone at the temples is thin, clinicians must be especially careful not to penetrate it. Dr. Pavicic noted that there has been at least one case in Europe of intracranial injection of filler associated with treatment of the temples.

Dr. Pavicic offered several tips for optimizing cosmetic results and keeping patients safe when filling the temples and forehead. For white patients, the cosmetic goal is to neutralize age-related concavities, while for Asian patients, it is to restore lost convexity, particularly of the forehead, she noted.

When treating the forehead, Dr. Pavicic said she places filler above the frontal bone at the subfascial level. For deep injections, the needle should be “really on the bone,” she noted. Inject small boluses of filler instead of a single large bolus, and aspirate back before injecting filler to ensure that needles are not intravascular, she said.

If using the blunt cannula technique, the cannula must be stiff enough to achieve good control – Dr. Pavicic recommends using a 22-gauge – and it should be placed into the medial and central fat pads of the forehead.

For superficial filler injections of the temples, Dr. Pavicic introduces the cannula at the zygomatic arch instead of trying to clean behind the hairline. She also recommended warning patients that the superficial veins in their temples might be more prominent for about a week after treatment. “Otherwise, they will call you in shock,” she said.

Regardless of the filler technique or the site in question, always use a high-quality product that exhibits good moldability, Dr. Pavicic concluded.

She reported having advisory or consulting relationships with Merz Pharmaceuticals, Dermaceutica, Eucerin, Galderma, and Ulthera, and receiving research support from Bayer and Ipsen.

Both men and women seek to improve their appearance with cosmetic procedures, but treatment areas and ideal results typically vary. Dr. Gary Goldenberg discusses the differences that dermatologists should consider when consulting with and treating male versus female cosmetic patients.

Both men and women seek to improve their appearance with cosmetic procedures, but treatment areas and ideal results typically vary. Dr. Gary Goldenberg discusses the differences that dermatologists should consider when consulting with and treating male versus female cosmetic patients.

Both men and women seek to improve their appearance with cosmetic procedures, but treatment areas and ideal results typically vary. Dr. Gary Goldenberg discusses the differences that dermatologists should consider when consulting with and treating male versus female cosmetic patients.