Aesthetic Dermatology

LAS VEGAS — Porcine collagen crosslinked with D-ribose probably lasts as long or longer than does hyaluronic acid when used as a cosmetic filler for lips and nasolabial folds, Dr. Gary Monheit said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The product, Evolence (Dermicol-P35) manufactured by ColBar LifeScience Ltd. (Israel), is approved for use in Europe and Canada and is expected to be approved in the United States, according to Dr. Monheit, principal investigator in the U.S. trial. The company has submitted an approval application to the Food and Drug Administration.

The trial's split-face design compared Evolence injection with hyaluronic acid (Restylane) injection in the nasolabial folds of 149 patients. After 6 months, there was no significant difference in the mean amount of correction the patients had on either side, as judged by study observers using the Modified Fitzpatrick Wrinkle Scale score (Dermatol. Surg. 2007;33:S213–21). Dr. Monheit disclosed receiving supplies and financial support from ColBar.

The secret to Evolence's longevity is thought to be the high level of crosslinking between the individual collagen fibers in the material, he said. "Because of this extra crosslinking, this is a very stable product that lasts over a year, possibly 2 years."

At 1-year follow-up, 90% of the patients that received Evolence still had some degree of improvement, said Dr. Monheit of the University of Alabama, Tuscaloosa. Evolence has been found to last up to 2 years when implanted into rabbit ears.

Raw material for Evolence comes from the tendons of pigs. In the first step of processing, the pig collagen's natural crosslinking is broken down by pepsin into monomeric collagen. Then the telopeptide of each collagen strand is removed because that part is the most immunogenic.

Pig collagen is used by ColBar because it is probably less immunogenic than beef collagen, he said.

Once the telopeptides are removed the material is again crosslinked, but instead of using glutaraldehyde or some other potentially problematic chemical to create the crosslinking, ColBar uses D-ribose, Dr. Monheit said.

LAS VEGAS — Porcine collagen crosslinked with D-ribose probably lasts as long or longer than does hyaluronic acid when used as a cosmetic filler for lips and nasolabial folds, Dr. Gary Monheit said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The product, Evolence (Dermicol-P35) manufactured by ColBar LifeScience Ltd. (Israel), is approved for use in Europe and Canada and is expected to be approved in the United States, according to Dr. Monheit, principal investigator in the U.S. trial. The company has submitted an approval application to the Food and Drug Administration.

The trial's split-face design compared Evolence injection with hyaluronic acid (Restylane) injection in the nasolabial folds of 149 patients. After 6 months, there was no significant difference in the mean amount of correction the patients had on either side, as judged by study observers using the Modified Fitzpatrick Wrinkle Scale score (Dermatol. Surg. 2007;33:S213–21). Dr. Monheit disclosed receiving supplies and financial support from ColBar.

The secret to Evolence's longevity is thought to be the high level of crosslinking between the individual collagen fibers in the material, he said. "Because of this extra crosslinking, this is a very stable product that lasts over a year, possibly 2 years."

At 1-year follow-up, 90% of the patients that received Evolence still had some degree of improvement, said Dr. Monheit of the University of Alabama, Tuscaloosa. Evolence has been found to last up to 2 years when implanted into rabbit ears.

Raw material for Evolence comes from the tendons of pigs. In the first step of processing, the pig collagen's natural crosslinking is broken down by pepsin into monomeric collagen. Then the telopeptide of each collagen strand is removed because that part is the most immunogenic.

Pig collagen is used by ColBar because it is probably less immunogenic than beef collagen, he said.

Once the telopeptides are removed the material is again crosslinked, but instead of using glutaraldehyde or some other potentially problematic chemical to create the crosslinking, ColBar uses D-ribose, Dr. Monheit said.

LAS VEGAS — Porcine collagen crosslinked with D-ribose probably lasts as long or longer than does hyaluronic acid when used as a cosmetic filler for lips and nasolabial folds, Dr. Gary Monheit said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

The product, Evolence (Dermicol-P35) manufactured by ColBar LifeScience Ltd. (Israel), is approved for use in Europe and Canada and is expected to be approved in the United States, according to Dr. Monheit, principal investigator in the U.S. trial. The company has submitted an approval application to the Food and Drug Administration.

The trial's split-face design compared Evolence injection with hyaluronic acid (Restylane) injection in the nasolabial folds of 149 patients. After 6 months, there was no significant difference in the mean amount of correction the patients had on either side, as judged by study observers using the Modified Fitzpatrick Wrinkle Scale score (Dermatol. Surg. 2007;33:S213–21). Dr. Monheit disclosed receiving supplies and financial support from ColBar.

The secret to Evolence's longevity is thought to be the high level of crosslinking between the individual collagen fibers in the material, he said. "Because of this extra crosslinking, this is a very stable product that lasts over a year, possibly 2 years."

At 1-year follow-up, 90% of the patients that received Evolence still had some degree of improvement, said Dr. Monheit of the University of Alabama, Tuscaloosa. Evolence has been found to last up to 2 years when implanted into rabbit ears.

Raw material for Evolence comes from the tendons of pigs. In the first step of processing, the pig collagen's natural crosslinking is broken down by pepsin into monomeric collagen. Then the telopeptide of each collagen strand is removed because that part is the most immunogenic.

Pig collagen is used by ColBar because it is probably less immunogenic than beef collagen, he said.

Once the telopeptides are removed the material is again crosslinked, but instead of using glutaraldehyde or some other potentially problematic chemical to create the crosslinking, ColBar uses D-ribose, Dr. Monheit said.

Alaser system for skin rejuvenation that delivers ablative fractional resurfacing technology made its official debut at the annual meeting of the American Academy of Dermatology.

Manufactured by Mountain View, Calif.-based Reliant Technologies, the 10,600-nm CO₂ Fraxel re:pair laser uses a continuous motion handpiece to create microscopic "zones of treatment" evenly across the surface of the skin. Clinical studies have demonstrated that it can treat up to 6 g of dermal tissue in a single treatment session with depths that range from 300 mcm to 1.6 mm, according to the manufacturer.

In May of 2007 the device was cleared by the Food and Drug Administration for ablation, coagulation, and skin resurfacing. In December of 2007 it received FDA 510(k) clearance for the treatment of wrinkles, rhytids, furrows, fine lines, textural irregularities, pigmented lesions, and vascular dyschromia. The current retail price of the Fraxel re:pair system is $129,000.

Studies of the device have included about 500 treatments over the last 2.5 years. In one recent study of its use on the forearm skin of 24 subjects with Fitzpatrick skin types II-IV, researchers tested pulse energies that ranged from 5 to 40 mJ and used hematoxylin and eosin to assess the legions histologically (Lasers Surg. Med. 2007;39:96–107). They found that changing the pulse energy from 5 to 30 mJ created a threefold increase in lesion depth and a twofold increase in width.

"Interestingly, ablative fractional resurfacing demonstrated much more rapid reepithelialization when compared to its nonfractional predecessors, whether powered by erbium or CO₂ lasers," reported the researchers (some of whom were employed by Reliant), led by Dr. Basil M. Hantash of Stanford (Calif.) University. "By 48 hours, most subjects demonstrated complete reepithelialization."

Subsequent studies of the system have used pulse energies that reach 70 mJ.

In an interview, one of the other study authors, Dr. Christopher Zachary, chair of the department of dermatology, University of California, Irvine, said that as long as physicians work within the recommended parameters, the Fraxel re:pair system "is going to give you a very predictable and reliable result and it's going to be much safer than the traditional carbon dioxide or erbium YAG lasers, which were associated with persistent redness, loss of pigmentation—which is delayed and permanent—scarring, and so forth."

In most cases, one treatment is sufficient and downtime is 2–4 days depending on the parameters used. "On day 5 you have redness and swelling," said Dr. Zachary, an unpaid consultant to Reliant Technologies.

Dr. Zachary said that he has limited experience using the device in dark-skinned patients, but "I absolutely intend to use it [on dark-skinned patients] on a regular basis," he said. "Darker skin types are going to have problems with skin pigmentation. To prevent it, we are pretreating for at least 2 weeks with a bleaching agent such as hydroquinone 4% cream, which will reside within the normal untreated skin after you have treated a fraction of the skin. That area that you do not treat will have a reservoir of hydroquinone which tends to prevent increased postinflammatory hyperpigmentation."

Trials are currently underway to study the use of the Fraxel re:pair system for treating acne scars, surgical scars, and striae. Dr. Zachary said that patients with severe acne scarring "are probably going to have two to three treatments separated by about a month each."

Dr. Robert A. Weiss, president-elect of the American Society for Dermatologic Surgery, called the Fraxel re:pair system an "elegant device" and noted that ablative fractional technology "is the next phase of fractional. It really does give a lot more improvement."

Dr. Weiss, who practices in Hunt Valley, Md., said that he currently uses a competing fractional laser procedure from Lumenis Ltd. called ActiveFX, which is delivered by the company's UltraCool Encore CO₂ system. Dr. Weiss is a member of the medical advisory board for Lumenis Ltd.

Dr. Zachary disclosed that he has received equipment and honoraria from Reliant Technologies and that he serves as a consultant for other laser companies.

A patient is shown before (left) and 1 month after treatment with the Fraxel re:pair laser, which is said to demonstrate "more rapid reepithelialization." Photos courtesy Dr. Zakia Rahman

Alaser system for skin rejuvenation that delivers ablative fractional resurfacing technology made its official debut at the annual meeting of the American Academy of Dermatology.

Manufactured by Mountain View, Calif.-based Reliant Technologies, the 10,600-nm CO₂ Fraxel re:pair laser uses a continuous motion handpiece to create microscopic "zones of treatment" evenly across the surface of the skin. Clinical studies have demonstrated that it can treat up to 6 g of dermal tissue in a single treatment session with depths that range from 300 mcm to 1.6 mm, according to the manufacturer.

In May of 2007 the device was cleared by the Food and Drug Administration for ablation, coagulation, and skin resurfacing. In December of 2007 it received FDA 510(k) clearance for the treatment of wrinkles, rhytids, furrows, fine lines, textural irregularities, pigmented lesions, and vascular dyschromia. The current retail price of the Fraxel re:pair system is $129,000.

Studies of the device have included about 500 treatments over the last 2.5 years. In one recent study of its use on the forearm skin of 24 subjects with Fitzpatrick skin types II-IV, researchers tested pulse energies that ranged from 5 to 40 mJ and used hematoxylin and eosin to assess the legions histologically (Lasers Surg. Med. 2007;39:96–107). They found that changing the pulse energy from 5 to 30 mJ created a threefold increase in lesion depth and a twofold increase in width.

"Interestingly, ablative fractional resurfacing demonstrated much more rapid reepithelialization when compared to its nonfractional predecessors, whether powered by erbium or CO₂ lasers," reported the researchers (some of whom were employed by Reliant), led by Dr. Basil M. Hantash of Stanford (Calif.) University. "By 48 hours, most subjects demonstrated complete reepithelialization."

Subsequent studies of the system have used pulse energies that reach 70 mJ.

In an interview, one of the other study authors, Dr. Christopher Zachary, chair of the department of dermatology, University of California, Irvine, said that as long as physicians work within the recommended parameters, the Fraxel re:pair system "is going to give you a very predictable and reliable result and it's going to be much safer than the traditional carbon dioxide or erbium YAG lasers, which were associated with persistent redness, loss of pigmentation—which is delayed and permanent—scarring, and so forth."

In most cases, one treatment is sufficient and downtime is 2–4 days depending on the parameters used. "On day 5 you have redness and swelling," said Dr. Zachary, an unpaid consultant to Reliant Technologies.

Dr. Zachary said that he has limited experience using the device in dark-skinned patients, but "I absolutely intend to use it [on dark-skinned patients] on a regular basis," he said. "Darker skin types are going to have problems with skin pigmentation. To prevent it, we are pretreating for at least 2 weeks with a bleaching agent such as hydroquinone 4% cream, which will reside within the normal untreated skin after you have treated a fraction of the skin. That area that you do not treat will have a reservoir of hydroquinone which tends to prevent increased postinflammatory hyperpigmentation."

Trials are currently underway to study the use of the Fraxel re:pair system for treating acne scars, surgical scars, and striae. Dr. Zachary said that patients with severe acne scarring "are probably going to have two to three treatments separated by about a month each."

Dr. Robert A. Weiss, president-elect of the American Society for Dermatologic Surgery, called the Fraxel re:pair system an "elegant device" and noted that ablative fractional technology "is the next phase of fractional. It really does give a lot more improvement."

Dr. Weiss, who practices in Hunt Valley, Md., said that he currently uses a competing fractional laser procedure from Lumenis Ltd. called ActiveFX, which is delivered by the company's UltraCool Encore CO₂ system. Dr. Weiss is a member of the medical advisory board for Lumenis Ltd.

Dr. Zachary disclosed that he has received equipment and honoraria from Reliant Technologies and that he serves as a consultant for other laser companies.

A patient is shown before (left) and 1 month after treatment with the Fraxel re:pair laser, which is said to demonstrate "more rapid reepithelialization." Photos courtesy Dr. Zakia Rahman

Alaser system for skin rejuvenation that delivers ablative fractional resurfacing technology made its official debut at the annual meeting of the American Academy of Dermatology.

Manufactured by Mountain View, Calif.-based Reliant Technologies, the 10,600-nm CO₂ Fraxel re:pair laser uses a continuous motion handpiece to create microscopic "zones of treatment" evenly across the surface of the skin. Clinical studies have demonstrated that it can treat up to 6 g of dermal tissue in a single treatment session with depths that range from 300 mcm to 1.6 mm, according to the manufacturer.

In May of 2007 the device was cleared by the Food and Drug Administration for ablation, coagulation, and skin resurfacing. In December of 2007 it received FDA 510(k) clearance for the treatment of wrinkles, rhytids, furrows, fine lines, textural irregularities, pigmented lesions, and vascular dyschromia. The current retail price of the Fraxel re:pair system is $129,000.

Studies of the device have included about 500 treatments over the last 2.5 years. In one recent study of its use on the forearm skin of 24 subjects with Fitzpatrick skin types II-IV, researchers tested pulse energies that ranged from 5 to 40 mJ and used hematoxylin and eosin to assess the legions histologically (Lasers Surg. Med. 2007;39:96–107). They found that changing the pulse energy from 5 to 30 mJ created a threefold increase in lesion depth and a twofold increase in width.

"Interestingly, ablative fractional resurfacing demonstrated much more rapid reepithelialization when compared to its nonfractional predecessors, whether powered by erbium or CO₂ lasers," reported the researchers (some of whom were employed by Reliant), led by Dr. Basil M. Hantash of Stanford (Calif.) University. "By 48 hours, most subjects demonstrated complete reepithelialization."

Subsequent studies of the system have used pulse energies that reach 70 mJ.

In an interview, one of the other study authors, Dr. Christopher Zachary, chair of the department of dermatology, University of California, Irvine, said that as long as physicians work within the recommended parameters, the Fraxel re:pair system "is going to give you a very predictable and reliable result and it's going to be much safer than the traditional carbon dioxide or erbium YAG lasers, which were associated with persistent redness, loss of pigmentation—which is delayed and permanent—scarring, and so forth."

In most cases, one treatment is sufficient and downtime is 2–4 days depending on the parameters used. "On day 5 you have redness and swelling," said Dr. Zachary, an unpaid consultant to Reliant Technologies.

Dr. Zachary said that he has limited experience using the device in dark-skinned patients, but "I absolutely intend to use it [on dark-skinned patients] on a regular basis," he said. "Darker skin types are going to have problems with skin pigmentation. To prevent it, we are pretreating for at least 2 weeks with a bleaching agent such as hydroquinone 4% cream, which will reside within the normal untreated skin after you have treated a fraction of the skin. That area that you do not treat will have a reservoir of hydroquinone which tends to prevent increased postinflammatory hyperpigmentation."

Trials are currently underway to study the use of the Fraxel re:pair system for treating acne scars, surgical scars, and striae. Dr. Zachary said that patients with severe acne scarring "are probably going to have two to three treatments separated by about a month each."

Dr. Robert A. Weiss, president-elect of the American Society for Dermatologic Surgery, called the Fraxel re:pair system an "elegant device" and noted that ablative fractional technology "is the next phase of fractional. It really does give a lot more improvement."

Dr. Weiss, who practices in Hunt Valley, Md., said that he currently uses a competing fractional laser procedure from Lumenis Ltd. called ActiveFX, which is delivered by the company's UltraCool Encore CO₂ system. Dr. Weiss is a member of the medical advisory board for Lumenis Ltd.

Dr. Zachary disclosed that he has received equipment and honoraria from Reliant Technologies and that he serves as a consultant for other laser companies.

A patient is shown before (left) and 1 month after treatment with the Fraxel re:pair laser, which is said to demonstrate "more rapid reepithelialization." Photos courtesy Dr. Zakia Rahman

The Food and Drug Administration has updated the information that is available on its Web site for consumers and health professionals on injectable fillers. In late January, the agency posted data on materials used; indications; risks; contraindications; and, for patients, questions to consider before they receive such an injection. The information is at www.fda.gov/cdrh/wrinklefillers

The Food and Drug Administration has updated the information that is available on its Web site for consumers and health professionals on injectable fillers. In late January, the agency posted data on materials used; indications; risks; contraindications; and, for patients, questions to consider before they receive such an injection. The information is at www.fda.gov/cdrh/wrinklefillers

The Food and Drug Administration has updated the information that is available on its Web site for consumers and health professionals on injectable fillers. In late January, the agency posted data on materials used; indications; risks; contraindications; and, for patients, questions to consider before they receive such an injection. The information is at www.fda.gov/cdrh/wrinklefillers

In treating cosmetic dermatology patients for symptoms associated with aging, procedures are not enough, Dr. Leslie Baumann said in a Galderma-sponsored symposium held during the 21st World Congress of Dermatology in Buenos Aires.

"Skin care is also important," she said. "When you think about skin rejuvenation, you need to think about all components." Combination therapy is a key to treating aging-related skin problems.

In the epidermis, pigmentary therapy targets the melanocytes, and "barrier-restoring therapy" targets the keratinocytes. "Skin needs to be hydrated to look young," said Dr. Baumann, director of cosmetic dermatology at the University of Miami.

As skin ages, the levels of collagen and glycosaminoglycans in the dermis decrease and alterations in elastic tissue occur, she noted. Injection of hyaluronic acid or collagen fillers helps restore the structural integrity of the dermis. Vascular therapy prevents the enlargement of blood vessels in the dermis that is seen in the blushing associated with rosacea. Volume-restoring therapy targets the adipocytes in the subcutaneous tissue, and therapy that controls muscular movements, such as botulinum toxin, targets muscle fibers.

Retinoids prevent skin aging by increasing the production of collagen and hyaluronic acid. "You are doing your patients a disservice to give them botulinum toxin or fillers and not give them a retinoid," said Dr. Baumann.

Nearly half of the cosmetic dermatologists interviewed in a recent market survey acknowledged discussing makeup with their patients. Surprisingly, only a slightly higher percentage of those surveyed talked to their patients about the use of retinoids in skin rejuvenation. "If we are going to talk to our patients about how to look better, we need to tell them about the science," she said. Cosmetic dermatologists should explain to their patients the scientific basis underpinning the use of retinoids in skin rejuvenation.

Tolerability appears to be a problem. "We're just not seeing a lot of retinoid use. I think it is because retinoids cause redness and flaking, and patients don't want to use them," she said. "Doctors don't have time to explain to the patients how to use retinoids properly and how to get through that initial redness."

Dr. Baumann recommends the use of topical retinoids for treatment of photoaging, acne, pigmentation disorders such as melasma and solar lentigos, and rosacea. All retinoids that affect the retinoic acid receptor are thought to improve photoaging, but only tretinoin and Avage (tazarotene, Allergan) are approved by the Food and Drug Administration for the treatment of photoaging, she said.

Photoaging leads not just to wrinkles, but also to sunspots and pigmentary damage. In her own practice, Dr. Baumann uses Tri-Luma cream (fluocinolone acetonide/hydroquinone/tretinoin, Galderma) off label for treatment of photoaging.

"I use retinoids in rosacea patients," she said. "I know you've been taught not to, but I put all my rosacea patients on retinoids. I can do it by teaching them how to use the retinoids properly."

Dr. Baumann is an investigator for Galderma and other manufacturers of skin care products.

In treating cosmetic dermatology patients for symptoms associated with aging, procedures are not enough, Dr. Leslie Baumann said in a Galderma-sponsored symposium held during the 21st World Congress of Dermatology in Buenos Aires.

"Skin care is also important," she said. "When you think about skin rejuvenation, you need to think about all components." Combination therapy is a key to treating aging-related skin problems.

In the epidermis, pigmentary therapy targets the melanocytes, and "barrier-restoring therapy" targets the keratinocytes. "Skin needs to be hydrated to look young," said Dr. Baumann, director of cosmetic dermatology at the University of Miami.

As skin ages, the levels of collagen and glycosaminoglycans in the dermis decrease and alterations in elastic tissue occur, she noted. Injection of hyaluronic acid or collagen fillers helps restore the structural integrity of the dermis. Vascular therapy prevents the enlargement of blood vessels in the dermis that is seen in the blushing associated with rosacea. Volume-restoring therapy targets the adipocytes in the subcutaneous tissue, and therapy that controls muscular movements, such as botulinum toxin, targets muscle fibers.

Retinoids prevent skin aging by increasing the production of collagen and hyaluronic acid. "You are doing your patients a disservice to give them botulinum toxin or fillers and not give them a retinoid," said Dr. Baumann.

Nearly half of the cosmetic dermatologists interviewed in a recent market survey acknowledged discussing makeup with their patients. Surprisingly, only a slightly higher percentage of those surveyed talked to their patients about the use of retinoids in skin rejuvenation. "If we are going to talk to our patients about how to look better, we need to tell them about the science," she said. Cosmetic dermatologists should explain to their patients the scientific basis underpinning the use of retinoids in skin rejuvenation.

Tolerability appears to be a problem. "We're just not seeing a lot of retinoid use. I think it is because retinoids cause redness and flaking, and patients don't want to use them," she said. "Doctors don't have time to explain to the patients how to use retinoids properly and how to get through that initial redness."

Dr. Baumann recommends the use of topical retinoids for treatment of photoaging, acne, pigmentation disorders such as melasma and solar lentigos, and rosacea. All retinoids that affect the retinoic acid receptor are thought to improve photoaging, but only tretinoin and Avage (tazarotene, Allergan) are approved by the Food and Drug Administration for the treatment of photoaging, she said.

Photoaging leads not just to wrinkles, but also to sunspots and pigmentary damage. In her own practice, Dr. Baumann uses Tri-Luma cream (fluocinolone acetonide/hydroquinone/tretinoin, Galderma) off label for treatment of photoaging.

"I use retinoids in rosacea patients," she said. "I know you've been taught not to, but I put all my rosacea patients on retinoids. I can do it by teaching them how to use the retinoids properly."

Dr. Baumann is an investigator for Galderma and other manufacturers of skin care products.

In treating cosmetic dermatology patients for symptoms associated with aging, procedures are not enough, Dr. Leslie Baumann said in a Galderma-sponsored symposium held during the 21st World Congress of Dermatology in Buenos Aires.

"Skin care is also important," she said. "When you think about skin rejuvenation, you need to think about all components." Combination therapy is a key to treating aging-related skin problems.

In the epidermis, pigmentary therapy targets the melanocytes, and "barrier-restoring therapy" targets the keratinocytes. "Skin needs to be hydrated to look young," said Dr. Baumann, director of cosmetic dermatology at the University of Miami.

As skin ages, the levels of collagen and glycosaminoglycans in the dermis decrease and alterations in elastic tissue occur, she noted. Injection of hyaluronic acid or collagen fillers helps restore the structural integrity of the dermis. Vascular therapy prevents the enlargement of blood vessels in the dermis that is seen in the blushing associated with rosacea. Volume-restoring therapy targets the adipocytes in the subcutaneous tissue, and therapy that controls muscular movements, such as botulinum toxin, targets muscle fibers.

Retinoids prevent skin aging by increasing the production of collagen and hyaluronic acid. "You are doing your patients a disservice to give them botulinum toxin or fillers and not give them a retinoid," said Dr. Baumann.

Nearly half of the cosmetic dermatologists interviewed in a recent market survey acknowledged discussing makeup with their patients. Surprisingly, only a slightly higher percentage of those surveyed talked to their patients about the use of retinoids in skin rejuvenation. "If we are going to talk to our patients about how to look better, we need to tell them about the science," she said. Cosmetic dermatologists should explain to their patients the scientific basis underpinning the use of retinoids in skin rejuvenation.

Tolerability appears to be a problem. "We're just not seeing a lot of retinoid use. I think it is because retinoids cause redness and flaking, and patients don't want to use them," she said. "Doctors don't have time to explain to the patients how to use retinoids properly and how to get through that initial redness."

Dr. Baumann recommends the use of topical retinoids for treatment of photoaging, acne, pigmentation disorders such as melasma and solar lentigos, and rosacea. All retinoids that affect the retinoic acid receptor are thought to improve photoaging, but only tretinoin and Avage (tazarotene, Allergan) are approved by the Food and Drug Administration for the treatment of photoaging, she said.

Photoaging leads not just to wrinkles, but also to sunspots and pigmentary damage. In her own practice, Dr. Baumann uses Tri-Luma cream (fluocinolone acetonide/hydroquinone/tretinoin, Galderma) off label for treatment of photoaging.

"I use retinoids in rosacea patients," she said. "I know you've been taught not to, but I put all my rosacea patients on retinoids. I can do it by teaching them how to use the retinoids properly."

Dr. Baumann is an investigator for Galderma and other manufacturers of skin care products.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Botanicals have become the new hot commodity in cosmeceuticals, as part of a larger trend that has consumers searching for natural ingredients in all kinds of products.

"Natural ingredients have become popular again," Dr. Diane Berson said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery. "They have always been popular, but they definitely are having a renaissance."

"Part of this is consumer driven. Patients want things that are natural, so they want botanicals," she added.

It is estimated that 40%–50% of new skin care products include a botanical agent, said Dr. Berson, who is with the department of dermatology at Cornell University, New York.

According to Dr. Berson, here are some of the currently popular botanicals:

▸ Soy. This highly potent anti-inflammatory and antioxidant contains the phytoestrogen genistein.

It may inhibit hair growth, and it probably lightens pigment, which is why it is used for lightening and brightening skin. There are also suggestions that it can stimulate collagen synthesis and initiate skin elastin repair processes. "It's also a good product for sensitive skin," Dr. Berson said.

▸ Mushroom. Several companies sell products containing shiitake mushroom, including the Aveeno Positively Ageless line. According to Johnson & Johnson Consumer Products Co., the mushroom has anti-inflammatory and antioxidant properties. It may also inhibit production of matrix metalloproteinases, which break down collagen, and it has been reported to stimulate epidermal proliferation.

"If this is true, that would be very interesting," Dr. Berson said. "It would actually be getting into retinoid territory."

As with so many cosmeceuticals that may have properties when tested in animals or culture, however, one cannot be sure—in the absence of randomized controlled trials—that the topical application actually penetrates human skin in adequate concentration, she noted.

▸ Feverfew. Feverfew PFE (parthenolide-free extract) has anti-inflammatory, antioxidant, and anti-irritant properties. It appears to inhibit tumor necrosis factor-α production, interleukin-2 and interleukin-4 production, and neutrophil chemotaxis, activities that may explain its anti-inflammatory properties, Dr. Berson said.

In fact, because feverfew naturally contains parthenolide, a compound that relieves smooth muscle spasm, it is being used orally as a prophylactic agent to prevent migraine, Dr. Berson noted.

In the skin care market, it is being sold to people with rosacea.

Feverfew (Tanacetum parthenium) is a member of the sunflower family and has been used for centuries as a folk remedy for headache, arthritis, and fevers.

▸ Coffeeberry. The extract of the husk around the coffee cherry contains quite powerful antioxidants. According to Stiefel Laboratories Inc., the company that makes the product (Revaléskin), its antioxidants have a free radical-absorbing capacity that is 10 times greater than those in green tea.

In a trial of 10 women treated in a split-face fashion for 6 weeks, the coffeeberry extract produced a 30% global improvement on the treated sides, versus 7% improvement on the control sides ("Novel Antioxidant Shows Promise as Photoaging Topical," April 2007, p. 1). The problem is that the study involved only 10 patients, Dr. Berson noted.

Even so, "I think we are going to be hearing more about this extract," she said.

▸ Witch hazel. The old folk remedy for sunburns is now included in a number of skin rejuvenation and skin toner products, such as SkinMedica Inc.'s Rejuvenative Toner.

Witch hazel (Hamamelis virginiana), it turns out, contains anti-inflammatory polyphenols, Dr. Berson said at the meeting.

"It would be great if we could see that these natural compounds do indeed do what they are supposed to do," she said. "But, even so, a lot of these products are very popular."

Dr. Berson said that she has financial conflicts of interest with many cosmeceutical manufacturers, including her service as a consultant to Medicis Pharmaceutical Corp., Kao Corp., Stiefel Laboratories, Dusa Pharmaceuticals Inc., OrthoNeutrogena, and CollaGenex Pharmaceuticals Inc.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

LAS VEGAS — Dispensing cosmeceuticals from the office can be as lucrative as injecting fillers or performing laser procedures, said Dr. Ira Berman, a dermatologist in York, Pa., who has been dispensing products for 30 years.

With that income comes temptation, however, and the dermatologist who dispenses has to resist becoming greedy, he said. The patient's welfare must always come first, or the whole arrangement will come down like a house of cards, he said.

"Ethics is always important because the most important thing you have besides your education is your reputation," said Dr. Berman, speaking at the annual meeting of the American Society for Cosmetic Dermatology and Aesthetic Surgery.

He developed a list 10 years ago of what he considers to be the 10 commandments of ethical office dispensing. (See box.)

"If we don't follow basic ethical guidelines, we risk losing the privilege of … dispensing altogether," he added.

In his talk on this subject, Dr. Berman presented several of the lessons he has learned from his 30 years of experience. Among those lessons were:

▸ Pay your taxes. Most states require that a retail business acquire a sales tax license, Dr. Berman said.

He has a computer program at his office that figures the sales tax on items sold. "You do not want to wind up in the newspaper because your office has been raided due to a failure to pay sales tax," he said.

▸ Have adequate storage. The minimum amount of a product that a physician should keep on hand is a 1-month supply. The storage area should also be in a convenient location so members of your staff do not have to go too far to retrieve items and become resentful of the imposition. "If people come back and want refills, and you don't have them, it is an embarrassing situation," Dr. Berman said.

▸ Put one person in charge. Have one staff person assigned to keeping track of inventory. That gives that person incentive to be more attentive than they otherwise might be, and it prevents confusion about the responsibility for tracking sales and ordering.

▸ Don't offer freebies. Members of the staff need to be told clearly that they cannot take any free samples for themselves, friends, or family. Charge them cost, but make sure everyone knows that they cannot just help themselves, Dr. Berman said.

▸ Decide whether to carry name brands or use boutique labeling instead. The decision over whether to carry name-brand products or to create your own products with your own label is one that needs to be based on several factors.

For a physician who is selling small amounts of cosmeceuticals, name-brand items might be a more efficient choice, but if he or she is selling large amounts, it may behoove the office to create its own labeling.

A rule of thumb is that dermatologists can price the items they sell at twice their cost, but this can be trickier with brand-name items, he said.

"The one thing with carrying [a] brand-name item is that you must remember you are going to be competing with some people who are selling it on the Internet, and that affects how you can price it," he pointed out.

▸ Determine whether employees will receive a commission. Decide whether the members of your staff are going to get a percentage of the product sales before you start selling, and remember that if you consider the sales of items to be a low priority so will your staff, Dr. Berman said.

His office has two separate reception areas, one for cosmetic patients and one for medical patients.

Members of the staff who work in the medical area earn a straight salary, while those in the cosmetic area earn commissions. Be sure that the members of your staff understand the office is not a retail store and that they should not engage in high-pressure sales tactics, he added.

Dr. Berman noted that the American Academy of Dermatology has articulated the position that selling products is an appropriate practice. But the position statement says that those products should have proven benefit.

Office Dispensing Commandments

1. The best interests of the patient come first.

2. There must be a legitimate basis for the patient's use of the product.

3. There must be valid scientific evidence for the product.

4. The cost should be reasonable and be of true value to the patient.

5. Office staff should maintain the same values as the physician—that the patient comes first.

6. Office staff should also maintain an unconditional money-back guarantee.

7. The dispensing physician should not charge for a consultation when any product causes problems.

8. The physician should obtain the products from responsible manufacturers who carry insurance.

9. The product labeling should provide full disclosure of what is in the product.

10. The office should never sell outdated, damaged, or chemically altered products.

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

WASHINGTON — The dermatologists who successfully add aesthetic services to their practices are those who use their expertise to show patients that they are the safe, smart choice, Catherine Maley said at the annual meeting of the American Academy for Facial Plastic and Reconstructive Surgery.

"Aesthetic dermatology is the business of feelings and emotions," said Ms. Maley, president of Cosmetic Image Marketing, a San Francisco-based marketing, public relations, and advertising firm that specializes in helping physicians build aesthetic practices.

"What you want to do is differentiate yourself from the medispas," she pointed out. A dermatologist competing in the aesthetic market should emphasize his or her medical training so patients recognize that they are paying for expertise.

"The aesthetic patient needs to understand that you are not the cheapest: You are the best," she said.

"Think of the psychology of the aesthetic patient. The bottom line is that she wants to look and feel better but she wants peace of mind. She wants to know that she is not going to regret anything and she is going to get a good result every time," Ms. Maley said.

Don't try to compete with medispas on price. Instead, sell the value. "You want those preferred patients who care about safety and credibility," she said.

How do dermatologists sell value? By emphasizing their credentials.

Use the logo from every society to which you belong on your cards, flyers, and promotional materials, including hospital and school affiliations. Put those logos everywhere because it enhances credibility with patients. "If you are board certified, say so in your promotional materials and explain to patients just what that means in terms of extra training," Ms. Maley said.

"If you work with vendors, use those affiliations and let patients know that you have been called on to speak or do research or train others," she added.

Create high-quality promotional handouts and cards to promote the aesthetic practice. A public relations agent can help create promotional materials, or there may be an interested and talented staff member who can design promotional pieces. Be sure to include patient photos and testimonials in your in-office and external promotional material. A dermatologist who is lucky enough to have a celebrity patient should ask for his or her permission to display a photo and short testimonial in the office.

Use testimonials generously, Ms. Maley emphasized. Provide high-quality photo albums with patients from a range of ages and ethnic backgrounds. Create a "what our patients say about us" album for written thank-you notes, e-mails, or postprocedure surveys.

"It's very compelling for patients to read about how great you are from other patients, not just from you," Ms. Maley said. The more testimonials, the better. Patient survey data have shown that prospective aesthetic patients associate quantity of patient testimonials with experience and expertise. Consider taking videos of patients who want to share their positive experiences, and put the videos together on a loop to show in the waiting room or post them on a Web site, Ms. Maley suggested.

And don't underestimate the importance of appearing in print.

"Any time you publish or you are quoted, don't miss that opportunity for public relations," she said.

Pull together a collection of quotes and design a PR piece for patient information packets and for the practice's Web site. One way to get written about or interviewed is to send a media kit to local print and TV reporters and to follow up with a personal phone call to pitch story ideas related to your expertise.

"Remember that it is not about you. It is about what you can do for their readers and viewers," Ms. Maley cautioned. "But the PR can really pay off and set you up as an expert in your community."

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Laser treatment complications can come not just from the light; they can result from the cryogen cooling as well.

Cooling with ice offers a safe alternative for laser therapies, Dr. Ranella Hirsch said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

Ice packs are cheap, reliable, and they work, she said.

The use of cryogen and other forms of cooling has been a major advance, but it is not entirely without risk, said Dr. Hirsch, who practices in Cambridge, Mass., and is president of the society.

"As any dermatologist who has performed cryotherapy knows, you can get bullae and epidermal necrosis just from the cryogen cooling," she said.

Because of the risk, Dr. Hirsch uses ice packs instead of cryogen for just about every use of the laser, she said in an interview.

She first started using the technique for hair removal, and now she has an assistant whose main job is just to do the ice cooling. The risk of cooling injury is slight, but "a little extra safety goes a long way," she said in the interview.

To test the efficacy of ice cooling, Dr. Hirsch conducted a study to look at the effects of contact cooling with ice at different skin depths, a study that was supported by a research grant from laser maker Candela Corp.

Dr. Hirsch is a clinical investigator for Candela Corp., Cynosure Inc., and Palomar Medical Technologies Inc.

In that study, she placed thermocouples connected to a computer monitoring system in ex vivo pigskin to acquire temperature and time data after ice was applied to the surface.

The top of the epidermis adequately cooled almost instantaneously, but there was very little cooling beyond 0.5–1.0 mm unless the ice was kept in place for 15 seconds or longer, suggesting that the areas generally targeted by the laser would not be adversely cooled.

She found that cooling the temperature of the skin by 10° C at a depth of 1 mm, the usual depth of sebaceous glands, took 15 seconds with the ice in place, and that the temperature at 3.3 mm did not change even when the ice was kept in place for as long as 60 seconds.

It took about 4 seconds to cool a depth of 0.75 mm by 10° C and about 6 seconds to cool that depth by 15° C.

The study "strongly supports" the idea that ice-pack cooling protects the epidermis without compromising the laser's ability to heat the deeper regions where most laser targets are found, Dr. Hirsch said in the interview.

"The general take-home message with ice is that longer is better," she noted.

Cryogen cooling, on the other hand, can lead to scarring, she said in her talk at the meeting.

Dr. Hirsch showed photos of some presumably permanent injuries caused by cryogen cooling, including a small spot of hypopigmentation around the umbilicus of one patient and scarring on the back of another patient's knee that had lasted 24 months after laser treatment for a spider vein.

These types of injuries can occur when the cooling sprays get overlapped as the operator moves from one area to the next while treating.

The way to avoid any injuries when using cryogen cooling and a laser is to pay close attention to proper technique and to the changes occurring in skin as it is treated, and to be wary when patients complain of disproportionate discomfort, Dr. Hirsch said.

Dr. Hirsch said another technique that can prevent overcooling is using the back of her hand to judge skin temperature as she is cooling and treating. One can get quite good at judging when skin is too hot or too cold, she said.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Complications from liquid silicone injections often occur when the immune system is triggered by a stimulus or an infection, according to a dermatologist with more than 22 years of experience in the use of silicone.

"I would say 80% of problems I see are associated with inflammatory events," said Dr. David Duffy, who practices in Torrance, Calif., and is a clinical faculty member at the University of California, Los Angeles.

The big problem with silicone is that it will interact with infectious processes, including herpes infections, bacterial infections from surgical procedures, or serious dental problems such as large numbers of cavities, he said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

One patient he saw developed reactions around her silicone injections when she moved into a house that had mold in the basement.

When the mold was cleaned up, her reactions went away. Another patient developed a reaction around her silicone injection when she underwent botulinum toxin treatment, said Dr. Duffy, who did not note any relevant conflicts of interest.

Because reactions seem to be prompted when someone with silicone implants experiences an immune response, Dr. Duffy said that he avoids silicone in patients who have a history of herpes simplex outbreaks, significant dental work, allergies, and a predisposition to sinus infections.

He also does not use silicone in patients who regularly ride motorcycles because they have particulate matter hitting them in the face, and he studiously avoids using it in lips.

Despite its risks, Dr. Duffy does like to use silicone for certain applications, such as revising scars and sometimes nasolabial folds.

The use of silicone for cosmetic procedures has become an issue that is often portrayed as black and white. Either physicians use silicone and like it, or they believe it should never be used. But "I have a long experience with it and I think it is going to remain a routine practice," he said. "I can tell you that in my practice it has revolutionized some people's lives and they aren't spending a fortune on fillers.

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT

LAS VEGAS — Poly-L-lactic acid needs to be used somewhat differently than other cosmetic fillers to correct nasolabial folds and wrinkles, and it requires more technique and more real familiarity with the product, a number of speakers said at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

"I think Sculptra [poly-L-lactic acid] is the most interesting filler and the most difficult to use," said Dr. David Duffy, a dermatologist who practices in Torrance, Calif., and is a clinical faculty member at the University of Southern California, Los Angeles.

"You really have to learn how to use this. I suggest that someone starts with injecting the hyalurons, then Radiesse [calcium hydroxylapatite], and then tries Sculptra," said Dr. Duffy, who is a consultant for Aventis, the maker of Sculptra.

Dr. Duffy and the others who discussed poly-L-lactic acid at the meeting talked about what they have learned in the first few years since the filler was approved for the treatment of lipoatrophy in patients with HIV and gave some pointers they have picked up.

"Sculptra has shown us a whole new venue and approach," said Dr. Gary Monheit of the University of Alabama, Birmingham.

"We're creating almost a cheek implant with Sculptra these days," added Dr. Cherie M. Ditre, director of the University of Pennsylvania's Cosmetic Dermatology and Skin Enhancement Center in Radnor.

The speakers offered a number of tips:

▸ Make it painless. The frequently recommended dilution of poly-L-lactic acid is to take the vial, which contains 150 mg of material, and dilute it with 5 mL of sterile water. Dr. Ditre said that she adds another 2 mL of lidocaine anesthetic and then gives patients about 3 mL in each cheek per session.

Dr. Duffy said he actually uses nerve blocks, and that he often uses smaller injections of lidocaine and epinephrine to help map his poly-L-lactic acid injections since the epinephrine leaves areas slightly blanched.

▸ Put it deep. Although many recommendations suggest that poly-L-lactic acid should be injected into the deep dermis, Dr. Monheit said he goes deeper, just into the subcutaneous tissue.

"For me, it is all injected in the subcutaneous now," he said. "I use little aliquots, at least four sessions, each 6 weeks apart. And we see new collagen in 4–6 months."

He injects in a crisscross pattern, with a tunneling technique. One advantage of injecting into the subcutaneous space is that the material spreads out more easily, Dr. Monheit said.

▸ Tap the syringe. The material does not stay in solution, so it is necessary to tap the syringe periodically when injecting to prevent the material from accumulating at the bottom, Dr. Duffy said.

"You really have to keep snapping the syringe," he said.

Dr. Monheit said he shakes the syringe well. A 25-gauge or 26-gauge needle is recommended, but he uses a larger one to prevent clogging.

▸ Massage, massage, massage. Each of the physicians stressed that the treating physician must massage the area after injection, and that patients must massage every day, a few times a day, for about a week after injection. The massaging spreads the material out, almost into a sheet, and prevents nodule formation, which is not uncommon otherwise, Dr. Monheit said.

▸ Rejuvenate gradually. A patient should get three separate treatments, spaced 4–6 weeks apart, and then wait before any more, Dr. Ditre said. With poly-L-lactic acid there is gradual improvement, which often takes 6 months or more to fully appear as collagen remodeling occurs.

Because of the gradual, continued improvement that patients have, it is important not to use too much and overcorrect, Dr. Monheit said.

▸ What to treat. Poly-L-lactic acid can be injected into the cheeks, the chin, and the temple, but one should be careful to avoid superficial injection, to not treat the folds themselves, and to spread the material out evenly, Dr. Monheit said.

He noted that he has used it successfully to reduce the appearance of acne scars.

The corrections associated with poly-L-lactic acid treatment are thought to last 18–24 months for most patients, but there are reports of patients having adequate correction that has lasted 5 years and more, Dr. Ditre said.

Dr. Ditre and Dr. Monheit have no relevant disclosures to report.

Because ofthe gradual improvement that patients have, itis important notto overcorrect. DR. MONHEIT