Aesthetic Dermatology

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

TORONTO — Scar revision can be a challenge for dermatologists.

Many patients who are dissatisfied with their postsurgical result expect immediate improvement. Others request topical treatments recommended by a friend or the Internet. However, clinical efficacy varies widely. Lack of substantial evidence compounds the challenge, Dr. David Zloty said at the annual conference of the Canadian Dermatology Association.

Topical treatments, "pressure therapy," injectable agents, cryotherapy, lasers, and surgical revision are among the many choices for scar management. Although scarring can be minimized through good surgical technique, some patients seek to improve the appearance, making patient education and expectation management important. Some patients might have to adopt a wait-and-see approach because it can take up to 2 years to reach final scar appearance and strength, said Dr. Zloty of the University of British Columbia, Vancouver.

Only minimal strength returns immediately postprocedure, "so when you take stitches out at 1–2 weeks, the site only has 5%–10% of its final strength," he said.

Adhesive tape or semiocclusive dressings are an option, but "I rarely use this except for women on the upper back or chest," Dr. Zloty said.

Topical imiquimod (Aldara) is another possibility. One study in a small number of patients showed efficacy when it was applied following shave excision of earlobe keloids (Dermatol. Surg. 2006;32:380–6), but Dr. Zloty said he does not use imiquimod for scar revision.

He is more likely to suggest Cicaplast epidermal recovery accelerator. "It's reasonably priced and may help reduce scar erythema. I don't want to lead you to believe it's a great compound, but minimal improvement is still something," said Dr. Zloty, who disclosed that he was previously paid to lecture on this product.

Another topical, Dermatix C (a formulation available in Canada from Valeant Pharmaceuticals International) is a combination of silicone gel and vitamin C ester. It costs $40–$50 (in U.S. dollars) per tube in British Columbia, so it is expensive, said Dr. Zloty, who is also director of the skin care surgery centre at Vancouver General Hospital.

Mederma is a topical gel with allium cepa (onion extract). A prospective, double-blind study indicated that Mederma did not improve scar cosmesis or symptoms compared with Aquaphor petrolatum-based ointment (Dermatol. Surg. 2006;32:193–7).

Many fair-skinned patients are distressed by the redness of postsurgical scarring. "Don't forget use of makeup as a topical. Sometimes you have to teach them how to put it on correctly," Dr. Zloty said.

Dermatologists sometimes forget to mention sunscreen in their postsurgical instructions. "I am very strict about sunscreen use, recommending broad spectrum, [with] at least SPF 30, as soon as the site heals over."

Vitamin E "is one of the few topicals that I will say no to," Dr. Zloty said, citing insufficient evidence of its efficacy. This stance can be challenging, though, because many patients specifically ask for vitamin E.

Silicone sheets are another postsurgical scar option, but they "had their heyday about 5 years ago," Dr. Zloty said. He will still suggest the sheets for scars on the chest, back, and shoulders of young women to minimize redness. They must be used 24 hours per day for up to 6 months for best results, so compliance is an issue. A meeting attendee commented that the sheets are difficult to use and often fall off.

"Pressure therapy" for scars is used primarily for earlobes, but can be used anywhere. Massage can aid small scars by altering wound tension. Start 2–3 weeks after suture removal, he suggested. "This is an accepted part of our scar armamentarium."

Cryotherapy can be 50%–80% effective for keloids, Dr. Zloty said. However, he added, "I've never used cryo as a direct modality, but I use it to get steroid in a scar."

Steroid injections can take up to six injections. "Go into the heart of the scar," not too shallow or too deep, Dr. Zloty said.

Dr. Zloty does not use laser treatments like pulse dye or fractional resurfacing as initial therapy for scars. "I use the pulse dye after everything else is done to improve erythema." It is usually effective after one or two treatments. He also refers patients with hypopigmented facial scars for fractional resurfacing to help blend the area between hypopigmented and normal skin.

Surgical scar revision can be very effective. Dr. Zloty uses dermabrasion, direct scar excision, Z-plasty, or W-plasty.

There can be about a 50%–60% improvement with dermabrasion, but it can take up to 1 year for erythema to resolve. Dr. Zloty reserves the technique primarily for scars from full-thickness skin grafts on the nose or elsewhere on the face.

Direct surgical excision of the initial scar can "get a better scar with less shadow," he said. Z-plasty, W-plasty, and other surgical techniques change scar direction or reduce the straight line of a scar to make visual recognition of a scar more difficult.

Direct surgical excision can "get a better scar with less shadow," said Dr. David Zloty. The patient above is shown before and 3 months after revision using the W-plasty technique. Photos courtesy Dr. David Zloty

CORONADO, CALIF. — Over the next two decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, Dr. Ronald Moy predicted at the annual meeting of the Pacific Dermatologic Association.

"It's clear that what we're doing today is going to be considered barbaric if we look 15–20 years down the road," said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. "We've done projects on our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate," he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos.

"Lasers will be handheld and will be used by patients," he added.

Dr. Moy also expects that the use of Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers—such as those derived from stem cells—will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind the American Academy of Dermatology, and "dermatologic surgery procedures are the fastest growing and most commonly preferred procedures," he said. "The future promises that new technology will make these procedures better."

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as "our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery."

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

"There's this great shortage and it's hard to get an appointment," he said. "That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need."

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, "where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis."

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. "They're going to be better trained, and they'll be embracing new technology," he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

CORONADO, CALIF. — Over the next two decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, Dr. Ronald Moy predicted at the annual meeting of the Pacific Dermatologic Association.

"It's clear that what we're doing today is going to be considered barbaric if we look 15–20 years down the road," said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. "We've done projects on our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate," he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos.

"Lasers will be handheld and will be used by patients," he added.

Dr. Moy also expects that the use of Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers—such as those derived from stem cells—will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind the American Academy of Dermatology, and "dermatologic surgery procedures are the fastest growing and most commonly preferred procedures," he said. "The future promises that new technology will make these procedures better."

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as "our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery."

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

"There's this great shortage and it's hard to get an appointment," he said. "That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need."

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, "where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis."

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. "They're going to be better trained, and they'll be embracing new technology," he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

CORONADO, CALIF. — Over the next two decades, dermasurgery will transform into a field in which noninvasive treatments and nonsurgical approaches rule the day, Dr. Ronald Moy predicted at the annual meeting of the Pacific Dermatologic Association.

"It's clear that what we're doing today is going to be considered barbaric if we look 15–20 years down the road," said Dr. Moy of the University of California, Los Angeles, and the association's immediate past president.

One key aspect of dermasurgery's future will involve treatment of skin cancer nonsurgically with a cocktail of immunomodulators. "We've done projects on our lab where we can put interleukin-2 into skin cancer and get a 90% cure rate," he said.

Hair transplants won't be necessary because hair cloning will be readily available, and lasers will be used to prevent wrinkles, remove hair and fat, tighten and resurface skin, and for the early treatment of vessels and lentigos.

"Lasers will be handheld and will be used by patients," he added.

Dr. Moy also expects that the use of Botox will be replaced by the permanent relaxing of muscles; resurfacing of the skin will improve with new fractional resurfacing technology; tightening of the skin will improve with new energy devices; and permanent facial fillers—such as those derived from stem cells—will become mainstream.

Facelifts will fall in popularity because of new resurfacing and tightening devices. DNA repair enzymes, growth factor, and other futuristic creams will treat and prevent aging skin at a molecular level.

Dr. Moy, the past editor in chief of the journal Dermatologic Surgery, was quick to note that, while the long-term future of dermasurgery is questionable, the short-term future is promising.

The American Society for Dermatologic Surgery is the second largest dermatology organization in the world, behind the American Academy of Dermatology, and "dermatologic surgery procedures are the fastest growing and most commonly preferred procedures," he said. "The future promises that new technology will make these procedures better."

However, certain trends in today's practice environment threaten dermasurgery's future. Dr. Moy called the proliferation of nonphysicians performing Botox injections, microdermabrasion, chemical peels, and other cosmetic procedures as "our greatest threat right now. Everybody's doing what we're doing. We might be able to change some of that with legislation, but we won't be able to [prevent] other physicians [from] practicing dermasurgery."

To complicate matters, there is a shortage of dermatologists in the United States, said Dr. Moy, who has served as vice president of the Medical Board of California.

"There's this great shortage and it's hard to get an appointment," he said. "That's only going to get worse. Even if we double the enrollment of all the California medical schools, we won't come close to the need."

The looming possibility of a national health insurance program also could affect the development of dermasurgery. Such a program probably would be modeled on dental insurance, he explained, "where your health insurance will be for catastrophic conditions. But all the little things that we do in dermatology will be on a cash basis."

On the bright side, increasing numbers of women are entering medical school and dermatology residency programs, and the dermatologists of tomorrow have a strong sense of volunteerism. "They're going to be better trained, and they'll be embracing new technology," he said.

Dr. Moy disclosed that he is a member of the scientific advisory boards for Rhytec Inc. and Bioform Medical Inc.

A patient is shown before injection of Sculptra (left)and then 2 months after treatment (right). Sculptra is an example of a long-lasting filler that is becoming an emerging trend. Photos courtesy Dr. Ronald Moy

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

PHOENIX — A 10-patient experiment comparing Juvéderm with Restylane revealed little difference between the two hyaluronic acid fillers, Dr. Seth L. Matarasso reported at a clinical dermatology conference sponsored by Medicis.

Half of each patient's face was injected with Restylane, the other half with Juvéderm. The only difference observed was "perhaps" a little less edema in the lip area with Juvéderm. Cost, flow, redness, and bruising were otherwise comparable, said Dr. Matarasso, professor of dermatology at the University of California, San Francisco.

"As far as discomfort and appearance, I didn't find it that much different," he said.

Two patients returned for botulinum toxin treatments after 6–7 months, he added. The durability of the two fillers appeared comparable at that point, he said.

The U.S. Food and Drug Administration approved Juvéderm, a hyaluronic acid gel marketed by Allergan Inc. for "injection into the mid to deep dermis for correction of moderate to severe facial wrinkles and folds (such as nasolabial folds)."

The approval was based on a 6-month, double-blind, randomized controlled clinical trial in which Juvéderm compared favorably to Zyplast, a bovine-based collagen. Juvéderm provided longer wrinkle correction in that trial, but Dr. Mattarasso said that studies comparing it to other hyaluronic acids are needed. "My suspicion is the complication rate will be [the] same as other hyaluronic acids. I don't know what the advantages will be. … I think it is way too early to tell," he said.

He did not recommend switching from Restylane, which is marketed by Medicis, to Juvéderm, based on the results of his small study. Juvéderm may cause slightly less swelling, but Dr. Matarasso said that the limited evidence was not a reason to change products. "I think you should pick a product you feel comfortable with, and then branch out," he said.

The ideal filler does not exist, according to Dr. Matarasso, but new products are giving cosmetic dermatologists "an incredible buffet" from which to choose. The deciding factors ultimately will be how the product feels in the clinician's hands and how much the patient likes it, he predicted.

Theoretically, hyaluronic acid fillers are nonallergenic, but Dr. Matarasso said they can cause hypersensitivity reactions. Juvéderm is contraindicated in patients with severe allergies and/or a history of allergies to gram-positive bacterial proteins.

Hyaluronic acid fillers do not include anesthesia and can cause discomfort, so a topical anesthetic—he uses EMLA cream or Betacaine—should be applied before procedures. "Patients don't want a nerve block," he said, and added that patients should be told to expect some edema.

Another new hyaluronic acid filler, Perlane, was approved by the FDA in May ("New Hyaluronic Acid Gel Filler Receives Approval," SKIN & ALLERGY NEWS, June 2007, p. 9).

Clinicians should be aware of products available abroad because patients are returning from overseas trips with complications from injections of fillers not approved by the FDA. "I see a lot of people from the Pacific rim and Australia," he said. "What is astonishing to me is they have injectables, and they don't know what was injected into their face."

Dr. Matarasso has served as a consultant to Allergan and Medicis.

Juvéderm may cause slightlyless swelling, but there's not enough evidence to change products. DR. MATARASSO

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

PALM BEACH, FLA. — Technical tips to optimize use of injectable facial fillers and botulinum toxin were offered during a live patient demonstration at the annual meeting of the Florida Society of Dermatology and Dermatologic Surgery.

A natural-looking result is the goal. "We want to return patients to what they looked like when they were younger. That is what our patients want," Dr. Mark S. Nestor said. "Really, the idea is combining [products], such as Botox and some of these fillers, to get optimal results."

An initial patient assessment should include realistic expectations. Know what fillers can and cannot achieve. "What you see as a physician may be different than what a patient is concerned about. When you have done this for a while, it's interesting to look at why something bothers patients," said Dr. Nestor of Aventura, Fla.

Along with Dr. James M. Spencer and Dr. Joely Kaufman, Dr. Nestor treated a series of volunteers at the meeting with combined treatments of injectable fillers and botulinum toxin.

Treatment was halted for one person who experienced an adverse reaction. She was tilted back in the chair while ice was applied to her forehead. "She is having a vasovagal response, which is not that uncommon," Dr. Nestor said. "This happened in South Beach [at a meeting in February 2007]. Patients need to be laid back, and they will come out of it quickly."

The newest filler option is Perlane (hyaluronic acid, Medicis), which was approved by the Food and Drug Administration in May for correction of moderate to severe facial folds and wrinkles. Perlane's nonimmunogenic, stabilized hyaluronic acid gel particles are similar to Restylane (hyaluronic acid, Medicis) but larger. Perlane adds volume to restore surface contour in facial wrinkles and folds, including the nasolabial fold. The product should be injected into the deep dermis up to the superficial layer of the subcutis.

Dr. Nestor injected Perlane with a 27-G needle. "You can actually feel the filler going in. What you are seeing right away is the significant lift you get because this product is really robust."

After injecting the nasolabial folds, he massaged inside and outside of the mouth to get an even distribution, noting that "Perlane smooths out very, very nicely." The next step involved superficial injections of Restylane on top of the same area. He finished the treatment with botulinum toxin injections to the crow's feet area.

Perlane can also be injected to accentuate areas below the mouth, said Dr. Nestor, who disclosed a relationship with Medicis.

While treating another volunteer, he noted that Perlane can replace significant volume loss in the midcheek for an extended period. "It doesn't roll off. Studies have shown it can remain there 5 or 6 years."

In contrast, Dr. Nestor advised undercorrection of volume loss when using Juvederm Ultra (hyaluronic acid gel, Allergan). "The idea here is that you can always inject more. You don't want to inject too much to begin with." He typically injects the filler as he withdraws the syringe. "You can feel it going into the deeper aspect of the dermis."

Dr. Kaufman injected another volunteer with Juvederm. Another option would be Sculptra (poly-L-lactic acid, Sanofi-Aventis). "By using Sculptra, you would need less hyaluronic acid in the nasolabial folds," said Dr. Kaufman of the University of Miami. The direction of product flow can make a big difference. For marionette lines, for example, she injects downward toward the center of the face below a patient's mouth. In addition, one little bolus of hyaluronic acid right under the vermilion border on either side of the mouth "really turns the lip up," she said.

Another combination approach uses injection of Radiesse (calcium hydroxylapatite, BioForm Medical) to restore facial volume and botulinum toxin to lift the corners of the mouth, said Dr. Spencer, who has a skin cancer and cosmetic dermatology practice in St. Petersburg, Fla.

Dr. Spencer used a 27-G needle and a 1.3-cc syringe during the demonstration. Radiesse is "more viscous, so it takes a little more effort to inject," he said. Threading or serial puncture down are the two technique options. "I always see them back in a week to make sure everything is okay." He estimated that the volume enhancement with Radiesse will last 1-2 years.

Dr. Kaufman and Dr. Spencer had no relevant disclosures regarding the products used in the demonstration.

GRAPEVINE, TEX. — The outcomes of cosmetic dermatologic procedures are in the eyes of the beholders.

The mindset of expert evaluators and their level of blinding can play critical roles in how the results of a cosmetic procedure are judged, Dr. David Horne said at the annual meeting of the American Society for Laser Medicine and Surgery.

He tested this hypothesis in a "Rashomon"-like study in which the same set of before-and-after clinical images from a noninvasive dermatologic procedure performed on about 10 patients was presented to five different groups of evaluators. In each case, the evaluators reached different conclusions about the treatment's efficacy.

The first group of evaluators comprised enthusiasts for the procedure who were unblinded as to which images were taken before treatment and which were taken after. These experts judged the results as impressive, with all patients having at least 25% improvement, said Dr. Horne of New York-Presbyterian Hospital.

The experts in the second group were ambivalent about the procedure and were unblinded. They rated the images as showing modest benefit, with selected patients getting up to 25% improvement, he said.

The third group included experts who were skeptics of the procedure and were unblinded. They rated the images as showing minimal improvement, with several patients showing no response.

The fourth group was the same set of ambivalent experts as in group 2. They were reshown the images 3 months after their first assessment, but they were completely blinded as to which images were taken before treatment and which were made after treatment and this time they said that most patients were not changed by their treatment, and in some cases the treatment seemed to worsen their appearance.

The fifth group, the patients themselves, said that they all had at least a 20% improvement in appearance, with an average improvement of 50%, said Dr. Horne.

GRAPEVINE, TEX. — The outcomes of cosmetic dermatologic procedures are in the eyes of the beholders.

The mindset of expert evaluators and their level of blinding can play critical roles in how the results of a cosmetic procedure are judged, Dr. David Horne said at the annual meeting of the American Society for Laser Medicine and Surgery.

He tested this hypothesis in a "Rashomon"-like study in which the same set of before-and-after clinical images from a noninvasive dermatologic procedure performed on about 10 patients was presented to five different groups of evaluators. In each case, the evaluators reached different conclusions about the treatment's efficacy.

The first group of evaluators comprised enthusiasts for the procedure who were unblinded as to which images were taken before treatment and which were taken after. These experts judged the results as impressive, with all patients having at least 25% improvement, said Dr. Horne of New York-Presbyterian Hospital.

The experts in the second group were ambivalent about the procedure and were unblinded. They rated the images as showing modest benefit, with selected patients getting up to 25% improvement, he said.

The third group included experts who were skeptics of the procedure and were unblinded. They rated the images as showing minimal improvement, with several patients showing no response.

The fourth group was the same set of ambivalent experts as in group 2. They were reshown the images 3 months after their first assessment, but they were completely blinded as to which images were taken before treatment and which were made after treatment and this time they said that most patients were not changed by their treatment, and in some cases the treatment seemed to worsen their appearance.

The fifth group, the patients themselves, said that they all had at least a 20% improvement in appearance, with an average improvement of 50%, said Dr. Horne.

GRAPEVINE, TEX. — The outcomes of cosmetic dermatologic procedures are in the eyes of the beholders.

The mindset of expert evaluators and their level of blinding can play critical roles in how the results of a cosmetic procedure are judged, Dr. David Horne said at the annual meeting of the American Society for Laser Medicine and Surgery.

He tested this hypothesis in a "Rashomon"-like study in which the same set of before-and-after clinical images from a noninvasive dermatologic procedure performed on about 10 patients was presented to five different groups of evaluators. In each case, the evaluators reached different conclusions about the treatment's efficacy.

The first group of evaluators comprised enthusiasts for the procedure who were unblinded as to which images were taken before treatment and which were taken after. These experts judged the results as impressive, with all patients having at least 25% improvement, said Dr. Horne of New York-Presbyterian Hospital.

The experts in the second group were ambivalent about the procedure and were unblinded. They rated the images as showing modest benefit, with selected patients getting up to 25% improvement, he said.

The third group included experts who were skeptics of the procedure and were unblinded. They rated the images as showing minimal improvement, with several patients showing no response.

The fourth group was the same set of ambivalent experts as in group 2. They were reshown the images 3 months after their first assessment, but they were completely blinded as to which images were taken before treatment and which were made after treatment and this time they said that most patients were not changed by their treatment, and in some cases the treatment seemed to worsen their appearance.

The fifth group, the patients themselves, said that they all had at least a 20% improvement in appearance, with an average improvement of 50%, said Dr. Horne.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Approval of Reloxin, a botulinum toxin type A product marketed in Europe as Dysport, is expected in the United States within the next 8-12 months, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

The product, which is similar to Botox, has been proved safe and effective in various trials worldwide, including in recently completed phase III U.S. trials, she said.

"The phase III clinical trial data for Reloxin in this country have not all been collated at this point, but I thank [Medicis Pharmaceutical Corp.] for sharing a little bit of it with me," said Dr. Farris, referring to the company that will develop and market Reloxin in the United States and which sponsored her talk at the meeting.

The 150-day, double-blind, placebo-controlled trial, which was designed to determine the efficacy of a single 50-unit dose for the treatment of glabellar lines, involved 300 patients. Response at 30 days in the 200 patients treated with Reloxin was excellent. "Slightly less than 90% of treated patients, compared with 0% of placebo patients, responded," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Patients were considered responders if they improved from a score of 2 or 3 to a score of 0 or 1 on a 4-point scale, with 0 indicating no frown lines, 1 indicating mild frown lines, 2 indicating moderate frown lines, and 3 indicating severe frown lines.

Investigators used a 5-point injection technique, with two 10-unit injections in each of the corrugator muscles, and a single 10-unit injection in the procerus muscle. The 50-unit dose was shown in previous studies to be optimal. Median time to onset was 2 days, and by day 7 about 80% of patients had responded. Median duration was 117 days, Dr. Farris noted.

The product also proved to be safe. The most common adverse event was headache, and there were some ocular events, including two cases of probable Reloxin-related ptosis, she said.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.

DESTIN, FLA. — Rosé or cabernet?

Hyaluronic acid cosmetic fillers, it turns out, are a bit like wine: selection depends on whether the occasion calls for something soft and light or something big and bold, Dr. Patricia Farris said at a meeting sponsored by the Alabama Dermatology Society.

"Not all wines are the same, and not all hyaluronic fillers are the same either. … If I'm injecting crow's feet, I'm probably not going to pull for Perlane or Restylane," said Dr. Farris of the department of dermatology at Tulane University, New Orleans.

Those "cabernets" are bolder than necessary for that application. A light "rosé" like Hylaform or a slightly more complex "pinot" like Juvéderm would do the trick, she said.

On the other hand, if a patient comes in asking for a "really, really big Paris lip," her choice is Restylane. If a patient says she wants a fuller lip but doesn't want to look like Angelina Jolie, something like Hylaform or Juvéderm is better, Dr. Farris said.

"These are just softer fillers, and … they are far more forgiving," she said, which is particularly important for novice injectors. Although they can't do what Restylane and Perlane can do, Hylaform and Juvéderm are "easier, smoother, and the flow properties are really good," she noted.

The important thing is to be comfortable with the product. Everyone has their own level of comfort and their own favorites for each application, and it is important to go with what you like and what you know works for that application, and not with what the patient comes in asking for, Dr. Farris stressed.

A patient who wants Restylane for crow's feet doesn't necessarily understand that such a bold filler isn't necessary. The wine analogy is a great way of explaining this to patients.

"I think they get the point," she said.

For deep nasolabial folds, however, go with the cabernet—unless the patient would prefer something lighter, she advised, describing one patient who had a prior bad experience with lumpiness following Restylane injection (probably because of bad injection technique), and wanted to steer clear of that.

"So I got my pinot [Juvéderm] out for her," she said.

Because the various hyaluronic acid fillers are so different, it pays to be experienced with a variety of them.

The hyaluronic acids work well for a number of problem areas, including prejowl grooves, tear troughs, lips, and noses.

The "puffing up" of the prejowl groove area following injection with a hyaluronic acid filler improves contour, and patients tend to be very happy with the "lighter, much nicer look they get with this," Dr. Farris said.

For undereye circles, a filler such as Juvéderm can be injected in the tear trough with a great result.

When it comes to lip enhancement, a number of different fillers will work. Be sure to ask patients what they are looking for. If lipstick line bleeding is the concern, then running the vermilion border with a filler will suffice. In addition to the hyaluronic acids, CosmoPlast also works well for this.

If the patient wants a bigger lip, then both the border and the body of the lip should be injected.

As for noses, the hyaluronic acids can be use to "straighten" a crooked nose, Dr. Faris said. Restylane is great for filling in the area around a bump and thereby deaccentuating it, or for filling in narrow areas.

The hyaluronic acids are easy to use and complications are rare, with the exception of some injection phenomena such as bruising and swelling. Lumpiness and bluish nodules may occur, but these are typically a result of poor injection technique. Sterile abscesses are also common, but they can be effectively treated intralesionally, she said.

A caveat with Perlane is the likelihood of injection phenomena such as bruising and a needle-stick line resulting from the need to use a 27-gauge needle.

"I'll spare you the pain. I tried the 30-gauge needle, but it's almost impossible to get [the product] out because of the 100-micron particle size," Dr. Farris said.

Use the 27-gauge needle but warn the patient of the potential effects, she advised, noting that the product is otherwise great.

Dr. Farris' presentation at the meeting was sponsored by Medicis, manufacturer of Perlane and Restylane.