Aesthetic Dermatology

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

NEW ORLEANS — Botox is not just for wrinkles anymore. Botulinum toxin injections can correct nasal tip droop, a gummy smile, flat eyebrows, and more, according to a dermatologic surgeon.

"Botox has revolutionized the treatment of the aging face, and new indications are penetrating into clinical practice," Dr. Timothy C. Flynn said. "I have enjoyed venturing outside the glabella, and I encourage you to do so."

A droop in the tip of the nose can occur with aging, and younger patients can have movement of the nasal tip when they talk, which lends a distracting appearance. "Using Botox, you can lift the tip of the nose a few millimeters to produce a more attractive appearance," Dr. Flynn of the University of North Carolina at Chapel Hill said at a dermatology update sponsored by Tulane University.

The depressor septae muscle is responsible for the nasal tip depression on contraction. A few units of Botox placed into each depressor septae will elevate the tip. This elevation is noted at rest because of the reduction in resting tone of the depressor muscle, he said.

A gummy smile can also be a problem. While it might not be the reason for the visit, such patients might say that they "hate to have their picture taken" or are "not photogenic" because of the degree of gum that shows when they smile. The levator labii superioris alaeque nasi and the parallel levator labii superioris can be relaxed with Botox to allow less superior travel of the upper lip.

"Injections of a few units in the perialar sulcus will relax these muscles. Go slow and start with one or two units in the perialar crease," Dr. Flynn said. "Patients are usually thrilled with the result."

Flat eyebrows can also be corrected to give them an arch. "We seek to have the portion of frontalis in the center of each eyebrow fully functioning and, in fact, overcompensating for the portion of frontalis at the relaxed tip and tail of the brow," he said.

Treating the central glabellar complex and the tail of the eyebrow allows for this central hyperactivity. This also gives increased exposure of the skin overlying the upper tarsal plate, which makes it easier to apply eye makeup.

Dr. Flynn also advocated more aggressive use of Botox when treating crow's-feet. Traditionally, 12 units are injected periocularly in the orbicularis oculi. Two to four units can be added inferiorly in the midpupillary line to increase the eye aperture. The inferior ocular wrinkles are also relaxed and improved, but wrinkles can persist in the lower lateral portion of the eyelid.

"Microinjections of toxin can be helpful here. Half units can be gingerly placed superficially to just relax those fibers close to the skin and thus decrease the crinkling of the lower eyelid," he said. "Key to this concept is to use no more than one unit, which you can do by increasingly diluting the Botox."

Dr. Flynn also uses Botox intraoperatively during facial reconstruction to relax muscles that might put tension on the wound. "I have had no complications doing this, except for one hematoma in a patient undergoing a flap reconstruction while on coumadin," he said.

Dr. Flynn disclosed that he has conducted research for and holds stock in Allergan Inc.

To improve this patient's gummy smile, Botox was used to allow less superior travel of the upper lip. Photos courtesy Dr. Timothy C. Flynn

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Calcium hydroxylapatite, injected as an implant for soft-tissue augmentation of the nasolabial folds and other facial areas, was safe after 4 years of follow-up in a two-center study of over 100 patients.

The investigators found that results lasted about 8 months for the majority of patients; results lasted longer (about 10–12 months) in patients who received multiple injections and touch-up sessions.

Dr. Bruce E. Katz of the department of dermatology at Mount Sinai School of Medicine, New York, described the findings (Dermatol. Surg. 2007;33:122–7) during a presentation at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

The 113 patients in the study ranged in age from 26 to 78 years; 100 of them were women. The nasolabial folds were injected in 86 patients. A single injection was given at a single session to 75 patients (66%), and 38 (34%) had more than one session, said Dr. Katz. Most patients were given a 1-mL injection of calcium hydroxylapatite at a session; 12 were given a 2-mL injection.

Calcium hydroxylapatite (Radiesse) is a synthetically sourced, semipermanent, soft-tissue filler that comprises 25- to 45-mcm microspheres suspended in an aqueous gel. The microspheres "form a scaffold for tissue growth," he said. The calcium hydroxylapatite particles degrade over time to calcium particles and phosphate ions. "This material is highly biocompatible, it's durable, it does not migrate, it's not antigenic, and it's [radiopaque]."

Seven patients in the study reported adverse events, which were short term and minor, resolving within a month, according to Dr. Katz. These adverse events included three cases of transient ecchymoses, two patients with inflammation and edema, and two with nongranulomatous submucosal nodules of the lip.

A subset of 41 patients rated efficacy of treatment on a scale of 1 (satisfactory) to 5 (excellent), he said. The mean score of visual satisfaction after treatment was 4.6. The mean scores of those physicians who rated results using the same scale were 4.5 for visual satisfaction and 4.6 for the feel of the implant. At 6 months' follow-up, patients' mean scores were 4.8 for visual satisfaction and 4.9 for the feel of the treatment; physicians' mean scores were 4.5 for visual satisfaction and 4.9 for feel.

Dr. Katz has received compensation from BioForm Medical Inc. for making presentations on calcium hydroxylapatite.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.

"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.

"With the CO₂ lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.

In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."

Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."

Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."

Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.

Dr. Anderson disclosed that he had no relevant conflicts.

Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.

He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.

"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.

"With the CO₂ lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.

In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."

Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."

Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."

Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.

Dr. Anderson disclosed that he had no relevant conflicts.

Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.

He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Dr. Roy G. Geronemus warned against the cavalier approach of not using eye shields during laser surgery.

"The eyelid is very thin," he observed at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. When using a device that works at 1.5 mm, "you damned well better" protect the patient's eyelids.

"With the CO₂ lasers, I think you should put a shield underneath the eyelids if you're treating the lids." Because it is possible that plastic shields will melt, said Dr. Geronemus of the New York University Medical Center, he prefers to use metal eye shields.

In a subsequent presentation, Dr. R. Rox Anderson, professor of dermatology at Harvard Medical School, Boston, and director of the Wellman Center for Photomedicine at Massachusetts General Hospital, also advocated for routine use of an eye shield, "especially if you're going to be treating inside the bony orbit."

Both lasers and intense pulsed lights used for hair removal in this area can be extremely damaging to the patient's eyes, he noted. "These devices are made to kill melanin-containing structures at great depth in the tissue, and the greatest amount of melanin in the body is in the uveal tract and the retina," Dr. Anderson said. "They're retinal killers."

Eye shields can also protect against possible injury from cryogen spray, he said. "There are cases of cryogen spray freezing the cornea and hurting it."

Dr. Anderson cautioned not to let anesthetics get under the eye shields when inserting them. "Most of our anesthetics, particularly EMLA [combination lidocaine and prilocaine cream], are really quite irritating," Dr. Anderson said, and can cause corneal burns.

Dr. Anderson disclosed that he had no relevant conflicts.

Dr. Geronemus disclosed that he is a shareholder in Thermage Inc., Reliant Technologies Inc., and Light BioScience LLC.

He is on the medical advisory boards of PhotoMedex Inc., Lumenis Ltd., Rhytec Inc., Candela Corp., Zeltiq Aesthetics, and Skin Cancer Company, and is an investigator for Reliant Technologies, Medicis Pharmaceutical Corp., Rhytec, DUSA Pharmaceuticals Inc., L'Oreal, Cutera Inc., Allergan Inc., and DermTech International. SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

WAIKOLOA, HAWAII — Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.

"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

"This significantly contributes to facial age-related cosmetic deformities," he added.

Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.

Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.

"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."

Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.

Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).

When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightly—a technique he learned from Dr. Vleggaar.

He imagines a triangle in the corner of the nose and the nasal labial fold.

"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."

The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.

To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.

With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."

He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.

Dr. Steinman disclosed that he had no relevant conflicts of interest.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman

Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN

WAIKOLOA, HAWAII — Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.

"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

"This significantly contributes to facial age-related cosmetic deformities," he added.

Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.

Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.

"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."

Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.

Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).

When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightly—a technique he learned from Dr. Vleggaar.

He imagines a triangle in the corner of the nose and the nasal labial fold.

"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."

The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.

To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.

With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."

He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.

Dr. Steinman disclosed that he had no relevant conflicts of interest.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman

Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN

WAIKOLOA, HAWAII — Deep filler injections can address volume loss that occurs in facial bone structure during the aging process, according to Dr. Howard K. Steinman.

"The shape and volume of the maxilla and mandible change with aging," Dr. Steinman said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation.

"This significantly contributes to facial age-related cosmetic deformities," he added.

Injecting fillers deep, near the periosteum, can address these issues, he said. Although this has been well documented in plastic surgery literature, it is probably a new concept for most dermatologists.

Dr. Steinman, who is in private practice in Chula Vista, Calif., said that he first became aware of the clinical importance of facial skeletal movement last year at SDEF in Hawaii during a workshop that was led by Dr. William Philip Werschler of the University of Washington, Seattle, and Dr. Danny Vleggaar of the Nouvelle Clinique Vert Pré, Geneva.

"Ever since I discovered this and researched it, it has altered the way that I see my cosmetic patients and how I use fillers," he said. "Understanding these changes often permits more effective correction with less filler volume."

Dr. Steinman described the maxilla as a "ledge of the midface tissues." As the maxilla moves inferiorly and posteriorly, the muscles and other soft tissues attached to it descend. This aging process is in addition to laxity and the loss of fat volume over time. Lateral tear troughs, for example, begin to form as a result of the descent of the maxilla causing enlargement of the orbital rim, in addition to the soft tissue changes.

Putting filler immediately above the periosteum replaces orbital rim that has moved. "You're going to lift up the tissues, and you're going to help redrape and eliminate the lateral tear trough," he said, noting that he routinely does this using Radiesse (BioForm Medical).

When working on nasal labial folds, Dr. Steinman angles the needle down all the way to the periosteum and injects as he pulls back slightly—a technique he learned from Dr. Vleggaar.

He imagines a triangle in the corner of the nose and the nasal labial fold.

"I do three injections from the inferior apex of the triangle, injecting superiorly and filling this triangle," he said. "This is a great technique for doing rejuvenation of this fold with very little filler."

The mandible also changes as patients get older, he said. The height of the mandibular shortens, which the muscles and soft tissue attached to the mandible rim have to accommodate for, resulting in "jowling" and the formation of prejowl sulcus.

To correct this problem, he injects deeply along the mandibular rim "bulking it up" as best he can before injecting into the subdermal plane. Again, a small quantity of filler can be used in this procedure, he noted.

With the advent of botulinum toxin type A, said Dr. Steinman "all of us that were 'pre-Botox' in our training suddenly learned to see facial muscles and their cosmetic effects," he said. "They're part of [the] assessment armamentarium."

He predicted dermatologists will start to perceive facial skeletal changes the same way they now perceive facial muscles and will adapt treatments accordingly.

Dr. Steinman disclosed that he had no relevant conflicts of interest.

SDEF and SKIN & ALLERGY NEWS are wholly owned subsidiaries of Elsevier.

Dr.Steinman suggests imagining a triangle in the corner of the nose and nasal labial fold (before, left image). Perform "three injections from the inferior apex of the triangle, injecting superiorly and filling" it (after, right). Photos courtesy Dr. Howard K. Steinman

Facial skeletal changes will be perceived by dermatologists in the same way that facial muscles are now perceived. DR. STEINMAN

KISSIMMEE, FLA. — Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Over 15 months, 198 patients—mostly women aged 24–52 years—were treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.

Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighs—most patients received treatments on multiple areas during each session—followed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.

During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.

The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.

An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.

Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.

These treatments are indicated for the patient with a body mass index below 29 kg/m

The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.

The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.

A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Over 15 months, 198 patients—mostly women aged 24–52 years—were treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.

Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighs—most patients received treatments on multiple areas during each session—followed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.

During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.

The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.

An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.

Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.

These treatments are indicated for the patient with a body mass index below 29 kg/m

The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.

The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.

A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Body contouring using an external focused ultrasound device and a device that uses infrared light, bipolar radiofrequency energy, and mechanical massage is more effective than is ultrasound alone for treating localized fat, a study suggests. The combination approach also requires fewer treatments to achieve similar results, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Over 15 months, 198 patients—mostly women aged 24–52 years—were treated for localized fat, including 54 who were treated with UltraShape Ltd.'s Contour I ultrasound device and 144 who were treated with the Contour I in combination with Syneron Medical Ltd.'s VelaSmooth device.

Patients received up to three ultrasound treatment sessions targeting localized fat on the abdomen, flanks, and/or outer thighs—most patients received treatments on multiple areas during each session—followed immediately by a VelaSmooth treatment. VelaSmooth also was used weekly between ultrasound treatments, said Dr. Mazzi, who is in private practice in Verona, Italy.

During the study period, 1,082 ultrasound treatments (an average of 20 per patient) and 1,164 combination ultrasound and VelaSmooth treatments (8 per patient) were performed.

The outer thighs were the most commonly treated area (44% of treatments), followed by the abdomen (33% of treatments) and flanks (23% of patients), he noted.

An average circumference reduction of 4 cm per patient was noted after the last treatment with ultrasound plus VelaSmooth, versus 3 cm after the last treatment with ultrasound alone. Better results with fewer treatments were seen in the abdomen and flanks, whereas upper thighs with sclerotic fat tissue typically required more treatments to obtain satisfactory results, said Dr. Mazzi, who received honoraria from Syneron.

Side effects were comparable in both groups, with minor discomfort reported in 23% of patients; mild and transient erythema reported by 76%; and burning reported in 1%.

These treatments are indicated for the patient with a body mass index below 29 kg/m

The treatments are not intended for weight loss or for treating cellulite or skin laxity, although Dr. Mazzi believes the combined approach used in this study appears to result in improved skin tightening.

The Contour I device is used in Europe and Canada but is not yet approved for use in the United States. Approval by the Food and Drug Administration is anticipated later this year, he said.

A 45-year-old woman is shown before undergoing combination therapy to treat localized fat on her outer thighs (left). She is shown again after undergoing one treatment with ultrasound plus four treatments with VelaSmooth (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

KISSIMMEE, FLA. — Laser lipolysis using a 1,064-nm Nd:YAG laser has been shown to be effective—and is safer than traditional liposuction—according to the results of two studies.

Few complications have occurred with SmartLipo laser lipolysis (Cynosure Inc.), a fat-melting and skin-tightening device that was approved by the Food and Drug Administration in 2006 for the treatment of localized fat deposits, Dr. Luigi Mazzi reported at the annual meeting of the American Society for Laser Medicine and Surgery.

Dr. Mazzi of Verona, Italy, reported his 4-year experience using the laser on 386 patients aged 18–55.

The patients—mostly women (82%)—underwent an average of three treatments in a variety of areas, including the arms, flanks, abdomen, inner and outer thighs, and inner knees.

Only two serious complications occurred, both superficial burns. Swelling and ecchymosis occurred often; they are considered normal after treatment, however, and regress within 8–10 days.

Dr. Mazzi said that in addition to localized fat, larger areas of adiposity can be treated using SmartLipo, but suction of the emulsified fat tissue in these cases is imperative, and the safety outcomes when suction is used are similar to those seen with traditional liposuction.

Dr. Mazzi said that he had no financial interest related to the SmartLipo technology.

SmartLipo is indeed exceedingly safe, agreed Dr. Bruce E. Katz, who reported on his experience using the technology in patients aged 17–77 years who underwent SmartLipo laser lipolysis over an 18-month period.

The review showed that 3 of the 537 patients experienced minor skin burns, all of which healed with no permanent sequelae, for a complication rate of less than 1%, said Dr. Katz of Juva Skin & Laser Center, New York. The complication rate in this review of cases was much lower than that reported in the literature for traditional liposuction.

Only 3% of patients underwent touch-up procedures, compared with about 10%–12% of those undergoing traditional liposuction, noted Dr. Katz. "Most importantly, there were no major complications."

Most patients underwent treatment of the abdomen, hips, and/or thighs, said Dr. Katz, who receives consulting fees from El.En Engineering, a major Cynosure shareholder.

The SmartLipo device uses a small, 1-mm cannula, which causes less trauma than is associated with traditional liposuction. A 300-mcm optic fiber is inserted into the cannula and energy is then delivered using a 150-microsecond pulse duration.

Other advantages of SmartLipo include the fat emulsion and skin tightening that occur with the procedure, which is indicated for small areas of local adiposities, and in areas where liposuction would be indicated, but where skin laxity might be worsened by the fat removal.

A number of studies have demonstrated efficacy, ease of use, and other benefits with the minimally invasive SmartLipo procedure, including reduced trauma to tissues, less blood loss, and greater postoperative comfort, compared with traditional liposuction, said Dr. Katz.

A patient is shown before laser lipolysis therapy (left) and 8 months after undergoing two separate treatments with the SmartLipo device (right). Photos courtesy Dr. Luigi Mazzi

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

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

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

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

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

WAIKOLOA, HAWAII — The look of an ancient royal Egyptian female statue—referred to as "Nefertiti"—can be achieved with well-placed injections of Botox, according to Dr. David J. Goldberg.

"It's called the 'Nefertiti lift,'" Dr. Goldberg said at the annual Hawaii dermatology seminar sponsored by Skin Disease Education Foundation. (Nefertiti was the wife of the pharaoh Akhenaten; she lived from 1370 to 1330 BC.)

"It's a softening of the chin by getting the bands of the platysma as they insert along the mandible. It's a way of recontouring the jawline." He described the look as a "liquid facelift."

Dr. Phillip M. Levy first described the Nefertiti lift and reported the results of injecting Botox (Allergan Inc.) using this method into the lower chin (J. Cosmet. Laser Ther. 2007;9:249–52). Of 130 patients who were treated over a 6-month period, 126 achieved immediate results with minimum adverse events.

The patients, all female, with a median age of 47 years, had noticeable recontouring of the chin and elevation of the skin at the jawline.

"The success of this technique is due to manipulation of the opposing effects of the platysmal complex" with Botox, wrote Dr. Levy, of Geneva.

Injected in this area, the substance will improve the definition of the mandibular border and angle, while elevating the corners of the mouth, said Dr. Goldberg. And you are able to get to the platysma and its small bands. It gives the visual effect of a minilift.

"It really drapes the skin of the jawline," he added. "It's amazing how much we can accomplish without surgery," said Dr. Goldberg, director of laser research and Mohs surgery at Mount Sinai School of Medicine, New York.

The patients received 2–3 U of Botox injected along and under each mandible, and to the upper part of the posterior platysmal band. Patients were asked to contract their platysmal muscle during injection.

"You have to see those bands inserted along the mandible. You can't just haphazardly inject," he said.

The total amount of Botox used was 15–20 U per side.

Dr. Goldberg recommended following up with patients at 2 weeks but described the results as being "really quite impressive."

Touch-ups can be performed at follow-up if needed, he added.

Dr. Levy has been a consultant to Allergan. Dr. Goldberg disclosed no relevant financial conflicts of interest.

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

Nefertiti has been said to have the perfect mandibular contour. ©Aurelio/Fotolia

LAS VEGAS — Dermatologists should tell their patients to be skeptical of "peptide" cosmeceuticals and to stick with proven agents, Dr. Kathy A. Fields said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Agents such as palmitoyl pentapeptide-3 have been shown to stimulate collagen production in a skin culture, but as with so many cosmeceutical products, none of the peptides has been proven to be effective in a published clinical trial or has any compelling scientific data, said Dr. Fields, a dermatologist in San Francisco who is a coinventor of Proactiv Solution, the popular acne treatment, and has her own line of cosmeceuticals, Rodan + Fields.

The peptides in cosmeceuticals may or may not penetrate the stratum corneum to any great degree, and they need to reach the dermis to be taken up by cells to have their effects.

"They don't last long," she said of the cosmeceutical peptides. "When you apply them on the skin, they go away rapidly. So they either don't penetrate or if they do, they may not have enough time or enough concentration to get to the target organs to make collagen."

Peptide-containing cosmeceuticals can also cost a lot, Dr. Fields said. StriVectin-SD, for example, costs about $135 for a 6-ounce tube when purchased from the manufacturer, and it contains palmitoyl pentapeptide as a reported active ingredient.

There is also little need for a patient interested in a skin rejuvenating regimen to use a peptide product because there are proven agents such as α-hydroxy acids and salicylic acid, and retinoids such as tretinoin and retinol.

Those are the agents she recommends to patients. "I love the old technology," she said.

If a patient does not tolerate a retinoid or one of the other older agents, she tells them to just use it twice a week to get started, rather than switch to a product that may be dubious. The patient can probably work up to using it more often.

LAS VEGAS — Dermatologists should tell their patients to be skeptical of "peptide" cosmeceuticals and to stick with proven agents, Dr. Kathy A. Fields said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Agents such as palmitoyl pentapeptide-3 have been shown to stimulate collagen production in a skin culture, but as with so many cosmeceutical products, none of the peptides has been proven to be effective in a published clinical trial or has any compelling scientific data, said Dr. Fields, a dermatologist in San Francisco who is a coinventor of Proactiv Solution, the popular acne treatment, and has her own line of cosmeceuticals, Rodan + Fields.

The peptides in cosmeceuticals may or may not penetrate the stratum corneum to any great degree, and they need to reach the dermis to be taken up by cells to have their effects.

"They don't last long," she said of the cosmeceutical peptides. "When you apply them on the skin, they go away rapidly. So they either don't penetrate or if they do, they may not have enough time or enough concentration to get to the target organs to make collagen."

Peptide-containing cosmeceuticals can also cost a lot, Dr. Fields said. StriVectin-SD, for example, costs about $135 for a 6-ounce tube when purchased from the manufacturer, and it contains palmitoyl pentapeptide as a reported active ingredient.

There is also little need for a patient interested in a skin rejuvenating regimen to use a peptide product because there are proven agents such as α-hydroxy acids and salicylic acid, and retinoids such as tretinoin and retinol.

Those are the agents she recommends to patients. "I love the old technology," she said.

If a patient does not tolerate a retinoid or one of the other older agents, she tells them to just use it twice a week to get started, rather than switch to a product that may be dubious. The patient can probably work up to using it more often.

LAS VEGAS — Dermatologists should tell their patients to be skeptical of "peptide" cosmeceuticals and to stick with proven agents, Dr. Kathy A. Fields said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Agents such as palmitoyl pentapeptide-3 have been shown to stimulate collagen production in a skin culture, but as with so many cosmeceutical products, none of the peptides has been proven to be effective in a published clinical trial or has any compelling scientific data, said Dr. Fields, a dermatologist in San Francisco who is a coinventor of Proactiv Solution, the popular acne treatment, and has her own line of cosmeceuticals, Rodan + Fields.

The peptides in cosmeceuticals may or may not penetrate the stratum corneum to any great degree, and they need to reach the dermis to be taken up by cells to have their effects.

"They don't last long," she said of the cosmeceutical peptides. "When you apply them on the skin, they go away rapidly. So they either don't penetrate or if they do, they may not have enough time or enough concentration to get to the target organs to make collagen."

Peptide-containing cosmeceuticals can also cost a lot, Dr. Fields said. StriVectin-SD, for example, costs about $135 for a 6-ounce tube when purchased from the manufacturer, and it contains palmitoyl pentapeptide as a reported active ingredient.

There is also little need for a patient interested in a skin rejuvenating regimen to use a peptide product because there are proven agents such as α-hydroxy acids and salicylic acid, and retinoids such as tretinoin and retinol.

Those are the agents she recommends to patients. "I love the old technology," she said.

If a patient does not tolerate a retinoid or one of the other older agents, she tells them to just use it twice a week to get started, rather than switch to a product that may be dubious. The patient can probably work up to using it more often.

Recent months have had a raft of bad news about injection lipolysis. Two prominent medical spas whose business was providing the popular treatments abruptly closed their doors, leaving patients in the lurch. Then, the Kansas Board of Healing Arts took action to strictly control the practice, a few months after trying to ban it.

Dr. Joel Schlessinger, immediate past president of the American Society of Cosmetic Dermatology and Aesthetic Surgery, warned the society that lipolysis might be neither effective nor safe, and he urged society members not to practice lipolysis until the ingredients used in the injections become Food and Drug Administration approved.

Recent news articles about this increasingly practiced treatment, popularly known as Lipodissolve, have tended to focus on individuals who complain of having permanent nodules or indentations from the procedure or who tell of rushing to the emergency department.

On the Web site www.realself.com

The Web site reported that an analysis of the IP addresses of the reviewers showed that many of the positive reviews came from one of the two now-defunct companies, Go Fig Inc., without the authors identifying themselves, and some came from MedSculpt (both companies are now out of business).

But while agreeing that better regulation might be a good idea, physicians who perform the procedure think that their experience and studies suggest the risks of complications are quite low and the results, in properly selected patients, generally good.

Support for Mesotherapy

"Injection lipolysis is not without risk, but it is pretty darn safe," said Dr. Thomas Wright, an internist who has a cosmetic practice in suburban St. Louis. He has been collecting reports of cases and complications from members of the American Society of Nonsurgical Aesthetics.

In reviewing about 200,000 treatment cases either reported to him or that he has sought out, he has found only 2 definite cases in which there was a serious complication. Both were cases of skin ulceration at or near sites of injection that needed skin graft repair. Overall, he said that he has found about 20 cases of skin breakdown or a pigment change, though some of those were extremely small, a millimeter in size.

He reported having recorded no other confirmed complications.

"We've been using injection lipolysis in my clinic for 2 years now and getting excellent results," said Dr. Charles E. Crutchfield III, a dermatologist who practices in Minneapolis.

Dr. Crutchfield said the only serious complications he has seen or heard of are cases of skin ulceration. It is thought ulceration happens because of injections placed too superficially.

Dr. Crutchfield is a member of the medical advisory board of the American Society of Aesthetic Lipodissolve, a professional organization that owns a copyright on the term Lipodissolve and provides training in the procedure. Dr. Wright is also a medical advisory board member with the group.

Reports of Complications Conflict

Andrew Noel, a photographer from Las Vegas, had treatments at a Go Fig spa, and he said that 4 months after his last treatment, he still has welts "the size of 50-cent pieces" on his abdomen where he received the injections.

"My tummy is disfigured and I am steaming mad," he said.

Dr. Alastair Carruthers, a dermatologist in Vancouver, B.C., has seen two patients who had complications presumed to be from Lipodissolve treatments, the first in a woman who was injected in her lower eyelids and the second in a woman injected in her thighs.

The second woman developed significant ulceration that caused scarring, Dr. Carruthers said.

Dr. Elizabeth Tanzi, a dermatologist in practice in Washington, has seen four patients with complications from Lipodissolve treatment, two with "an unnatural firmness" that resolved only slowly, one with a vascular pattern over the treated area that lasted for a year and required laser treatment, and another patient who had a draining nodule.

But surveys, like Dr. Wright's, of physicians who practice injection lipolysis suggest that the procedure—while sometimes causing discomfort and leaving temporary nodules in treated areas that resolve over time—only rarely has complications.

And another survey of 75 practitioners reported that among 17,376 patients treated there were no hospitalizations, no deaths, and no cases of skin necrosis (Aesthetic Surg. J. 2006;26:575–85). Moreover, less than 1% of patients reported to their physicians pain that lasted beyond 2 weeks, and the most common complaint of patients was a less than desired result, reported for 12% of patients. Nineteen of the practitioners reported having seen hyperpigmentation, but in the majority of cases this resolved within 3 months.

Safety Concerns

Another of the concerns with lipolysis treatment is whether there might be long-term effects from phosphatidylcholine or sodium deoxycholate, or acute problems from exposure to those ingredients or from the release of so much fat at once.

The substances are both naturally present in the human body already, and used the way they are to reduce fat, have only "relatively benign, localized effects," said Dr. Adam Rotunda, a physician who now works as a medical director of research and development at Allergan Inc., but who conducted research on injection lipolysis as a dermatology resident at the University of California, Los Angeles.

Dr. Rotunda has a patent for a formulation of sodium deoxycholate (licensed to Kythera Biopharmaceuticals Inc.) alone for injection lipolysis, which he claims might be as effective as the phosphatidylcholine/sodium deoxycholate combination. That formulation is at present in clinical trials. Dr. Rotunda has no financial interest in the product, though he has received consulting fees from Kythera. The licensing fees are paid to the University of California, Los Angeles, he disclosed.

A Flawed Business Plan?

Dr. Wright said he is very familiar with one of the now-defunct companies, Fig, which was based in the St. Louis area. He is not only well acquainted with the former principals in the company, but he has treated about 30 former Fig patients. And he suggests that many of the complaints and complications being reported about injection lipolysis come from Fig clients, who were guaranteed results or a refund.

The company often had no physician onsite at its locations and many sometimes used doses too high and treated inappropriate patients. Dr. Wright recalled one patient who went to a Fig location every month for a year to be treated and never once saw a physician.

"The company was selling to inappropriate candidates and overselling," he said.

Many Fig patients that Dr. Wright said he treated were extremely overweight, and the proper candidate for lipolysis is one who is not overweight but simply has a localized area with a small amount of fat they would like to be rid of. Fig—which had 18 locations in various states—ceased its operations in December and filed for chapter 11 bankruptcy in January. The other prominent company that recently closed was MedSculpt, a firm with locations in Rockville, Md., and Fairfax, Va., which went into receivership in January.

Officials from both companies were unavailable for comment, and physicians connected with the companies either declined to comment or did not return calls and e-mails. However, in statements, Fig representatives said their investors pulled funding, and blamed the situation in part on a downturn in customers and bad press. MedSculpt needed a cash infusion and had investors lined up, but when Fig closed those investors balked, the representatives claim.

Recent Studies

Two studies have looked at whether the treatment has any identifiable systemic effects, and neither found any, said Dr. Rotunda. "We don't have the quality of data we need, but what we do have is pretty reassuring."

Brazilian investigators treated 30 patients with a series of four sessions of abdominal injections of sodium deoxycholate and looked at the local and systemic effects. At different time periods—ranging from 2 hours after an injection to 12 weeks—they measured lipids and kidney and liver function and found no significant changes (Dermatol. Surg. 2007;33:178–89).

In his own work, Dr. Rotunda has found that injecting phosphatidylcholine and sodium deoxycholate can produce changes in muscle architecture but the substances have to be injected directly into the muscles (Dermatol. Surg. 2004;30:1001–8).

Patients can experience nausea from the procedure, but that appears to be a cholinergic effect that occurs when too high a dose is used, he said.

Currently the evidence of the efficacy of injection lipolysis is anecdotal. But in November, a clinical trial of the combination solution got underway, sponsored by the Aesthetic Surgery Education and Research Foundation, run by Dr. V. Leroy Young, a former professor of plastic and reconstructive surgery at Washington University, St. Louis, who is now in private practice. The trial will enroll 20 subjects, who will be followed for 46 weeks.

In the meantime, both Dr. Crutchfield and Dr. Wright said they would have no problem if the FDA or some other agency came to regulate lipolysis procedures or the compounded ingredients used.

But Dr. Crutchfield also noted that injection lipolysis is not the first cosmetic product to be used off-label, and he cited Botox as an example. Botox was used cosmetically before its approval and currently is used in locations where it is not approved.

"If you are going to talk about this lacking FDA approval as a reason physicians should not be doing it, you are going to have to point the finger at everybody who does Botox," Dr. Crutchfield said.

Lipolysis has grown in popularity, while at the same time, a number of groups have expressed concern that it has no Food and Drug Administration approval, and have issued warnings about the procedure, saying there is no good clinical trial data to affirm benefit from the procedure and safety is not established.

Lipolysis may be neither safe nor effective, and shouldn't be used until approved by the FDA. DR. SCHLESSINGER

Ihave seen two patients who have had complications presumed to be from Lipodissolve treatments. DR. CARRUTHERS

Recent months have had a raft of bad news about injection lipolysis. Two prominent medical spas whose business was providing the popular treatments abruptly closed their doors, leaving patients in the lurch. Then, the Kansas Board of Healing Arts took action to strictly control the practice, a few months after trying to ban it.

Dr. Joel Schlessinger, immediate past president of the American Society of Cosmetic Dermatology and Aesthetic Surgery, warned the society that lipolysis might be neither effective nor safe, and he urged society members not to practice lipolysis until the ingredients used in the injections become Food and Drug Administration approved.

Recent news articles about this increasingly practiced treatment, popularly known as Lipodissolve, have tended to focus on individuals who complain of having permanent nodules or indentations from the procedure or who tell of rushing to the emergency department.

On the Web site www.realself.com

The Web site reported that an analysis of the IP addresses of the reviewers showed that many of the positive reviews came from one of the two now-defunct companies, Go Fig Inc., without the authors identifying themselves, and some came from MedSculpt (both companies are now out of business).

But while agreeing that better regulation might be a good idea, physicians who perform the procedure think that their experience and studies suggest the risks of complications are quite low and the results, in properly selected patients, generally good.

Support for Mesotherapy

"Injection lipolysis is not without risk, but it is pretty darn safe," said Dr. Thomas Wright, an internist who has a cosmetic practice in suburban St. Louis. He has been collecting reports of cases and complications from members of the American Society of Nonsurgical Aesthetics.

In reviewing about 200,000 treatment cases either reported to him or that he has sought out, he has found only 2 definite cases in which there was a serious complication. Both were cases of skin ulceration at or near sites of injection that needed skin graft repair. Overall, he said that he has found about 20 cases of skin breakdown or a pigment change, though some of those were extremely small, a millimeter in size.

He reported having recorded no other confirmed complications.

"We've been using injection lipolysis in my clinic for 2 years now and getting excellent results," said Dr. Charles E. Crutchfield III, a dermatologist who practices in Minneapolis.

Dr. Crutchfield said the only serious complications he has seen or heard of are cases of skin ulceration. It is thought ulceration happens because of injections placed too superficially.

Dr. Crutchfield is a member of the medical advisory board of the American Society of Aesthetic Lipodissolve, a professional organization that owns a copyright on the term Lipodissolve and provides training in the procedure. Dr. Wright is also a medical advisory board member with the group.

Reports of Complications Conflict

Andrew Noel, a photographer from Las Vegas, had treatments at a Go Fig spa, and he said that 4 months after his last treatment, he still has welts "the size of 50-cent pieces" on his abdomen where he received the injections.

"My tummy is disfigured and I am steaming mad," he said.

Dr. Alastair Carruthers, a dermatologist in Vancouver, B.C., has seen two patients who had complications presumed to be from Lipodissolve treatments, the first in a woman who was injected in her lower eyelids and the second in a woman injected in her thighs.

The second woman developed significant ulceration that caused scarring, Dr. Carruthers said.

Dr. Elizabeth Tanzi, a dermatologist in practice in Washington, has seen four patients with complications from Lipodissolve treatment, two with "an unnatural firmness" that resolved only slowly, one with a vascular pattern over the treated area that lasted for a year and required laser treatment, and another patient who had a draining nodule.

But surveys, like Dr. Wright's, of physicians who practice injection lipolysis suggest that the procedure—while sometimes causing discomfort and leaving temporary nodules in treated areas that resolve over time—only rarely has complications.

And another survey of 75 practitioners reported that among 17,376 patients treated there were no hospitalizations, no deaths, and no cases of skin necrosis (Aesthetic Surg. J. 2006;26:575–85). Moreover, less than 1% of patients reported to their physicians pain that lasted beyond 2 weeks, and the most common complaint of patients was a less than desired result, reported for 12% of patients. Nineteen of the practitioners reported having seen hyperpigmentation, but in the majority of cases this resolved within 3 months.

Safety Concerns

Another of the concerns with lipolysis treatment is whether there might be long-term effects from phosphatidylcholine or sodium deoxycholate, or acute problems from exposure to those ingredients or from the release of so much fat at once.

The substances are both naturally present in the human body already, and used the way they are to reduce fat, have only "relatively benign, localized effects," said Dr. Adam Rotunda, a physician who now works as a medical director of research and development at Allergan Inc., but who conducted research on injection lipolysis as a dermatology resident at the University of California, Los Angeles.

Dr. Rotunda has a patent for a formulation of sodium deoxycholate (licensed to Kythera Biopharmaceuticals Inc.) alone for injection lipolysis, which he claims might be as effective as the phosphatidylcholine/sodium deoxycholate combination. That formulation is at present in clinical trials. Dr. Rotunda has no financial interest in the product, though he has received consulting fees from Kythera. The licensing fees are paid to the University of California, Los Angeles, he disclosed.

A Flawed Business Plan?

Dr. Wright said he is very familiar with one of the now-defunct companies, Fig, which was based in the St. Louis area. He is not only well acquainted with the former principals in the company, but he has treated about 30 former Fig patients. And he suggests that many of the complaints and complications being reported about injection lipolysis come from Fig clients, who were guaranteed results or a refund.

The company often had no physician onsite at its locations and many sometimes used doses too high and treated inappropriate patients. Dr. Wright recalled one patient who went to a Fig location every month for a year to be treated and never once saw a physician.

"The company was selling to inappropriate candidates and overselling," he said.

Many Fig patients that Dr. Wright said he treated were extremely overweight, and the proper candidate for lipolysis is one who is not overweight but simply has a localized area with a small amount of fat they would like to be rid of. Fig—which had 18 locations in various states—ceased its operations in December and filed for chapter 11 bankruptcy in January. The other prominent company that recently closed was MedSculpt, a firm with locations in Rockville, Md., and Fairfax, Va., which went into receivership in January.

Officials from both companies were unavailable for comment, and physicians connected with the companies either declined to comment or did not return calls and e-mails. However, in statements, Fig representatives said their investors pulled funding, and blamed the situation in part on a downturn in customers and bad press. MedSculpt needed a cash infusion and had investors lined up, but when Fig closed those investors balked, the representatives claim.

Recent Studies

Two studies have looked at whether the treatment has any identifiable systemic effects, and neither found any, said Dr. Rotunda. "We don't have the quality of data we need, but what we do have is pretty reassuring."

Brazilian investigators treated 30 patients with a series of four sessions of abdominal injections of sodium deoxycholate and looked at the local and systemic effects. At different time periods—ranging from 2 hours after an injection to 12 weeks—they measured lipids and kidney and liver function and found no significant changes (Dermatol. Surg. 2007;33:178–89).

In his own work, Dr. Rotunda has found that injecting phosphatidylcholine and sodium deoxycholate can produce changes in muscle architecture but the substances have to be injected directly into the muscles (Dermatol. Surg. 2004;30:1001–8).

Patients can experience nausea from the procedure, but that appears to be a cholinergic effect that occurs when too high a dose is used, he said.

Currently the evidence of the efficacy of injection lipolysis is anecdotal. But in November, a clinical trial of the combination solution got underway, sponsored by the Aesthetic Surgery Education and Research Foundation, run by Dr. V. Leroy Young, a former professor of plastic and reconstructive surgery at Washington University, St. Louis, who is now in private practice. The trial will enroll 20 subjects, who will be followed for 46 weeks.

In the meantime, both Dr. Crutchfield and Dr. Wright said they would have no problem if the FDA or some other agency came to regulate lipolysis procedures or the compounded ingredients used.

But Dr. Crutchfield also noted that injection lipolysis is not the first cosmetic product to be used off-label, and he cited Botox as an example. Botox was used cosmetically before its approval and currently is used in locations where it is not approved.

"If you are going to talk about this lacking FDA approval as a reason physicians should not be doing it, you are going to have to point the finger at everybody who does Botox," Dr. Crutchfield said.

Lipolysis has grown in popularity, while at the same time, a number of groups have expressed concern that it has no Food and Drug Administration approval, and have issued warnings about the procedure, saying there is no good clinical trial data to affirm benefit from the procedure and safety is not established.

Lipolysis may be neither safe nor effective, and shouldn't be used until approved by the FDA. DR. SCHLESSINGER

Ihave seen two patients who have had complications presumed to be from Lipodissolve treatments. DR. CARRUTHERS

Recent months have had a raft of bad news about injection lipolysis. Two prominent medical spas whose business was providing the popular treatments abruptly closed their doors, leaving patients in the lurch. Then, the Kansas Board of Healing Arts took action to strictly control the practice, a few months after trying to ban it.

Dr. Joel Schlessinger, immediate past president of the American Society of Cosmetic Dermatology and Aesthetic Surgery, warned the society that lipolysis might be neither effective nor safe, and he urged society members not to practice lipolysis until the ingredients used in the injections become Food and Drug Administration approved.

Recent news articles about this increasingly practiced treatment, popularly known as Lipodissolve, have tended to focus on individuals who complain of having permanent nodules or indentations from the procedure or who tell of rushing to the emergency department.

On the Web site www.realself.com

The Web site reported that an analysis of the IP addresses of the reviewers showed that many of the positive reviews came from one of the two now-defunct companies, Go Fig Inc., without the authors identifying themselves, and some came from MedSculpt (both companies are now out of business).

But while agreeing that better regulation might be a good idea, physicians who perform the procedure think that their experience and studies suggest the risks of complications are quite low and the results, in properly selected patients, generally good.

Support for Mesotherapy

"Injection lipolysis is not without risk, but it is pretty darn safe," said Dr. Thomas Wright, an internist who has a cosmetic practice in suburban St. Louis. He has been collecting reports of cases and complications from members of the American Society of Nonsurgical Aesthetics.

In reviewing about 200,000 treatment cases either reported to him or that he has sought out, he has found only 2 definite cases in which there was a serious complication. Both were cases of skin ulceration at or near sites of injection that needed skin graft repair. Overall, he said that he has found about 20 cases of skin breakdown or a pigment change, though some of those were extremely small, a millimeter in size.

He reported having recorded no other confirmed complications.

"We've been using injection lipolysis in my clinic for 2 years now and getting excellent results," said Dr. Charles E. Crutchfield III, a dermatologist who practices in Minneapolis.

Dr. Crutchfield said the only serious complications he has seen or heard of are cases of skin ulceration. It is thought ulceration happens because of injections placed too superficially.

Dr. Crutchfield is a member of the medical advisory board of the American Society of Aesthetic Lipodissolve, a professional organization that owns a copyright on the term Lipodissolve and provides training in the procedure. Dr. Wright is also a medical advisory board member with the group.

Reports of Complications Conflict

Andrew Noel, a photographer from Las Vegas, had treatments at a Go Fig spa, and he said that 4 months after his last treatment, he still has welts "the size of 50-cent pieces" on his abdomen where he received the injections.

"My tummy is disfigured and I am steaming mad," he said.

Dr. Alastair Carruthers, a dermatologist in Vancouver, B.C., has seen two patients who had complications presumed to be from Lipodissolve treatments, the first in a woman who was injected in her lower eyelids and the second in a woman injected in her thighs.

The second woman developed significant ulceration that caused scarring, Dr. Carruthers said.

Dr. Elizabeth Tanzi, a dermatologist in practice in Washington, has seen four patients with complications from Lipodissolve treatment, two with "an unnatural firmness" that resolved only slowly, one with a vascular pattern over the treated area that lasted for a year and required laser treatment, and another patient who had a draining nodule.

But surveys, like Dr. Wright's, of physicians who practice injection lipolysis suggest that the procedure—while sometimes causing discomfort and leaving temporary nodules in treated areas that resolve over time—only rarely has complications.

And another survey of 75 practitioners reported that among 17,376 patients treated there were no hospitalizations, no deaths, and no cases of skin necrosis (Aesthetic Surg. J. 2006;26:575–85). Moreover, less than 1% of patients reported to their physicians pain that lasted beyond 2 weeks, and the most common complaint of patients was a less than desired result, reported for 12% of patients. Nineteen of the practitioners reported having seen hyperpigmentation, but in the majority of cases this resolved within 3 months.

Safety Concerns

Another of the concerns with lipolysis treatment is whether there might be long-term effects from phosphatidylcholine or sodium deoxycholate, or acute problems from exposure to those ingredients or from the release of so much fat at once.

The substances are both naturally present in the human body already, and used the way they are to reduce fat, have only "relatively benign, localized effects," said Dr. Adam Rotunda, a physician who now works as a medical director of research and development at Allergan Inc., but who conducted research on injection lipolysis as a dermatology resident at the University of California, Los Angeles.

Dr. Rotunda has a patent for a formulation of sodium deoxycholate (licensed to Kythera Biopharmaceuticals Inc.) alone for injection lipolysis, which he claims might be as effective as the phosphatidylcholine/sodium deoxycholate combination. That formulation is at present in clinical trials. Dr. Rotunda has no financial interest in the product, though he has received consulting fees from Kythera. The licensing fees are paid to the University of California, Los Angeles, he disclosed.

A Flawed Business Plan?

Dr. Wright said he is very familiar with one of the now-defunct companies, Fig, which was based in the St. Louis area. He is not only well acquainted with the former principals in the company, but he has treated about 30 former Fig patients. And he suggests that many of the complaints and complications being reported about injection lipolysis come from Fig clients, who were guaranteed results or a refund.

The company often had no physician onsite at its locations and many sometimes used doses too high and treated inappropriate patients. Dr. Wright recalled one patient who went to a Fig location every month for a year to be treated and never once saw a physician.

"The company was selling to inappropriate candidates and overselling," he said.

Many Fig patients that Dr. Wright said he treated were extremely overweight, and the proper candidate for lipolysis is one who is not overweight but simply has a localized area with a small amount of fat they would like to be rid of. Fig—which had 18 locations in various states—ceased its operations in December and filed for chapter 11 bankruptcy in January. The other prominent company that recently closed was MedSculpt, a firm with locations in Rockville, Md., and Fairfax, Va., which went into receivership in January.

Officials from both companies were unavailable for comment, and physicians connected with the companies either declined to comment or did not return calls and e-mails. However, in statements, Fig representatives said their investors pulled funding, and blamed the situation in part on a downturn in customers and bad press. MedSculpt needed a cash infusion and had investors lined up, but when Fig closed those investors balked, the representatives claim.

Recent Studies

Two studies have looked at whether the treatment has any identifiable systemic effects, and neither found any, said Dr. Rotunda. "We don't have the quality of data we need, but what we do have is pretty reassuring."

Brazilian investigators treated 30 patients with a series of four sessions of abdominal injections of sodium deoxycholate and looked at the local and systemic effects. At different time periods—ranging from 2 hours after an injection to 12 weeks—they measured lipids and kidney and liver function and found no significant changes (Dermatol. Surg. 2007;33:178–89).

In his own work, Dr. Rotunda has found that injecting phosphatidylcholine and sodium deoxycholate can produce changes in muscle architecture but the substances have to be injected directly into the muscles (Dermatol. Surg. 2004;30:1001–8).

Patients can experience nausea from the procedure, but that appears to be a cholinergic effect that occurs when too high a dose is used, he said.

Currently the evidence of the efficacy of injection lipolysis is anecdotal. But in November, a clinical trial of the combination solution got underway, sponsored by the Aesthetic Surgery Education and Research Foundation, run by Dr. V. Leroy Young, a former professor of plastic and reconstructive surgery at Washington University, St. Louis, who is now in private practice. The trial will enroll 20 subjects, who will be followed for 46 weeks.

In the meantime, both Dr. Crutchfield and Dr. Wright said they would have no problem if the FDA or some other agency came to regulate lipolysis procedures or the compounded ingredients used.

But Dr. Crutchfield also noted that injection lipolysis is not the first cosmetic product to be used off-label, and he cited Botox as an example. Botox was used cosmetically before its approval and currently is used in locations where it is not approved.

"If you are going to talk about this lacking FDA approval as a reason physicians should not be doing it, you are going to have to point the finger at everybody who does Botox," Dr. Crutchfield said.

Lipolysis has grown in popularity, while at the same time, a number of groups have expressed concern that it has no Food and Drug Administration approval, and have issued warnings about the procedure, saying there is no good clinical trial data to affirm benefit from the procedure and safety is not established.

Lipolysis may be neither safe nor effective, and shouldn't be used until approved by the FDA. DR. SCHLESSINGER

Ihave seen two patients who have had complications presumed to be from Lipodissolve treatments. DR. CARRUTHERS

CHICAGO — The clinical results of fractional skin resurfacing may be improved by pretreatment with an infrared laser or broadband infrared light source, according to a pilot study presented at the annual meeting of the American Society for Dermatologic Surgery.

"In the treatment of scars and wrinkles, combination deep heating immediately prior to fractional resurfacing gives better results in less time than fractional laser treatment alone," said Dr. Robert Weiss, of the dermatology department at Johns Hopkins University, Baltimore.

For this study, a control group of 20 patients received the usual fractional resurfacing on the face or neck with the Lux 1540 (Palomar Medical Technologies), while 20 others first received deep heating with an infrared pulsed laser using the 1,320-nm CoolTouch 3 (CoolTouch Inc.).

"Using the CoolTouch, we preheated the skin from a typical baseline temperature of 32° up to 40°, and then we applied the fractional resurfacing to the scar or wrinkle with the 1540-nm stamped mode at 50 mJ per little dot," Dr. Weiss said.

The control group received four monthly treatments, while the deep heating plus fractional group received two monthly treatments, he said, adding that the results were evaluated out to 3 months after the last treatment.

Down times caused by erythema ranged from 12 to 24 hours in the control group and increased to 48–96 hours for those receiving the combination treatment. That compares with 48–96 hours for patients who receive CO₂ laser fraction treatment, Dr. Weiss explained.

Pretreatment with heat produced both faster and visually better results, Dr. Weiss said, adding that, in some cases, two combination treatments improved scarring as much as five fractional-only treatments.

The investigators concluded that the combination treatment demonstrated a 30% improvement in scars and rhytids, compared with fractional only, and reduced the number of treatments from four to two.

Dr. Weiss is a consultant for Palomar and CoolTouch and performs research for Palomar, Cynosure, and CoolTouch.

CHICAGO — The clinical results of fractional skin resurfacing may be improved by pretreatment with an infrared laser or broadband infrared light source, according to a pilot study presented at the annual meeting of the American Society for Dermatologic Surgery.

"In the treatment of scars and wrinkles, combination deep heating immediately prior to fractional resurfacing gives better results in less time than fractional laser treatment alone," said Dr. Robert Weiss, of the dermatology department at Johns Hopkins University, Baltimore.

For this study, a control group of 20 patients received the usual fractional resurfacing on the face or neck with the Lux 1540 (Palomar Medical Technologies), while 20 others first received deep heating with an infrared pulsed laser using the 1,320-nm CoolTouch 3 (CoolTouch Inc.).

"Using the CoolTouch, we preheated the skin from a typical baseline temperature of 32° up to 40°, and then we applied the fractional resurfacing to the scar or wrinkle with the 1540-nm stamped mode at 50 mJ per little dot," Dr. Weiss said.

The control group received four monthly treatments, while the deep heating plus fractional group received two monthly treatments, he said, adding that the results were evaluated out to 3 months after the last treatment.

Down times caused by erythema ranged from 12 to 24 hours in the control group and increased to 48–96 hours for those receiving the combination treatment. That compares with 48–96 hours for patients who receive CO₂ laser fraction treatment, Dr. Weiss explained.

Pretreatment with heat produced both faster and visually better results, Dr. Weiss said, adding that, in some cases, two combination treatments improved scarring as much as five fractional-only treatments.

The investigators concluded that the combination treatment demonstrated a 30% improvement in scars and rhytids, compared with fractional only, and reduced the number of treatments from four to two.

Dr. Weiss is a consultant for Palomar and CoolTouch and performs research for Palomar, Cynosure, and CoolTouch.

CHICAGO — The clinical results of fractional skin resurfacing may be improved by pretreatment with an infrared laser or broadband infrared light source, according to a pilot study presented at the annual meeting of the American Society for Dermatologic Surgery.

"In the treatment of scars and wrinkles, combination deep heating immediately prior to fractional resurfacing gives better results in less time than fractional laser treatment alone," said Dr. Robert Weiss, of the dermatology department at Johns Hopkins University, Baltimore.

For this study, a control group of 20 patients received the usual fractional resurfacing on the face or neck with the Lux 1540 (Palomar Medical Technologies), while 20 others first received deep heating with an infrared pulsed laser using the 1,320-nm CoolTouch 3 (CoolTouch Inc.).

"Using the CoolTouch, we preheated the skin from a typical baseline temperature of 32° up to 40°, and then we applied the fractional resurfacing to the scar or wrinkle with the 1540-nm stamped mode at 50 mJ per little dot," Dr. Weiss said.

The control group received four monthly treatments, while the deep heating plus fractional group received two monthly treatments, he said, adding that the results were evaluated out to 3 months after the last treatment.

Down times caused by erythema ranged from 12 to 24 hours in the control group and increased to 48–96 hours for those receiving the combination treatment. That compares with 48–96 hours for patients who receive CO₂ laser fraction treatment, Dr. Weiss explained.

Pretreatment with heat produced both faster and visually better results, Dr. Weiss said, adding that, in some cases, two combination treatments improved scarring as much as five fractional-only treatments.

The investigators concluded that the combination treatment demonstrated a 30% improvement in scars and rhytids, compared with fractional only, and reduced the number of treatments from four to two.

Dr. Weiss is a consultant for Palomar and CoolTouch and performs research for Palomar, Cynosure, and CoolTouch.