92 Dermatology Times SEPTEMBER 2005
Safe, effective 98 Sclerotherapy
Not just for legs 100 Fat removal
upper face and thighs tumescent The key is to assess the
treatments liposuction best patient, see what the
patient needs, and — if it’s
beyond the scope and
expertise of one’s practice
Cosmetic — refer the patient to the
Dermatology — Seth L. Matarasso, M.D., San Francisco,
giving advice on how to avoid filler pitfalls
See story, page 106
COSMETIC Upper face
Zoe Diana Draelos, M.D.
Sensitive skin BY JOHN JESITUS ments, but we’re also
increasing; STAFF CORRESPONDENT doing browlifts and
dandruff, itchy sculpting.Treatments
scalp update Chicago — Patients seeking upper-face for crow’s feet and
rejuvenation have never before enjoyed lower eyelids are pretty
as many safe,effective alternatives as are standard.Treating the
Why is the incidence of sensitive now available,says Kenneth Beer,M.D., nasalis or bunny lines
skin increasing in my patient popu- director,Palm Beach Esthetic Institute, also is commonplace,”
lation? and clinical instructor of dermatology, he says.
Your observation is correct. A University of Miami. Reloxin (botu-
number of skincare industry surveys “Rejuvenation of the upper face is linum toxin A,
of more than 40,000 women world- just now entering a renaissance,” he Inamed), now in
wide have documented the increase
in self-perceived sensitive skin. says. “Five years ago, all we had was phase 3 clinical trials,
No one is exactly sure why this is collagen and Botox (botulinum toxin will increase the
occurring, but I will try to explain A, Allergan). Now we have another armamentarium, Dr.
some of the reasons that have
been put forth.
toxin about to be released. The filler Beer adds.
First, there is a perception world has expanded exponentially.We In the filler cate-
among women that if they claim to also have threads such as the Thread- gory,he says,“We used
have sensitive skin this will Patient before (top) and after (bottom) injection with
lift (Contour Inc.). And for the first to have just collagen. approximately 1 ml of Restylane.
somehow protect them from using
products that might cause an time in history, the lasers actually do That wasn’t too great Photos:Kenneth Beer, M.D.
allergic or acneiform reaction. In what they’re supposed to do.” for a variety of reasons.
other words, sensitive skin is Dr. Beer says he is particularly But now we have
becoming another word for
hypoallergenic and nonacnegenic. excited about trying new fractional- Sculptra (polylactic acid, Sanofi- corner,as is Perlane (Q-Med).Hylaform
There is no doubt that the phrase beam capabilities for skin tightening Aventis/Dermik),Restylane (hyaluronic Plus (Inamed) is available. Silicone is
“appropriate for sensitive skin” is soon to be added to the StarLux line acid,Q-Med ),Radiesse (calcium hydrox- back, at least in some practices. So the
an important marketing label.
Second, women are using more
(Palomar). yapatite, BioForm Medical). Juvederm materials that we have for upper face
products than ever before on their “Other companies including Reliant, (hyaluronic acid,Inamed) is around the Upper face continues page 94
face. They are using all types of Lumenis and Syneron also have
cleansers, toners, moisturizers, sun- exciting products,” he says. Simulta-
screens, anti-aging serums, undereye
creams, facial foundations, lipsticks, neously, Dr. Beer says, cosmeceuticals
Let them eat jam
blushes, eyeshadows, eyeliners and are “living up to half their hype, which
mascaras. The average women 70 is twice what we expect. So it’s a great
years ago used soap and possibly a French women say a spoonful of a new “anti-
lip balm with some petrolatum or time to look at rejuvenation for the wrinkle jam” with their morning coffee and
cold cream on her face. This increase upper face.” croissant is their secret to youthful-looking skin.
in skincare and cosmetic product use The pharmaceutical “jam,” marketed by
has dramatically increased the expo- Noreva, sells for about $10 per 120-gram
sure of the facial skin to a variety of
Expanding options pot and comes in three flavors: green tomato
For starters, existing options are and green tea; melon and mango; and blue-
chemicals that may, indeed, cause an
berry and black currant. Along with antiox-
untoward reaction. Furthermore, expanding their scope. idants, the sugar- and additive-free jams
newer skincare formulations are “It used to be said that the only contain hemp oil, pearl barley, beta carotene,
loaded with botanical cocktails and a marine extract, an ingredient that targets
numerous other ingredients, such that place to inject botulinum toxin was
free radicals, and vitamins E and C.
the content disclosure has to be the glabella or frown line. Now, not
Conundrums continues page 104 only are we doing forehead treat-
94 DermatologyTimes SEPTEMBER 2005
Upper face continued from page 92
rejuvenation have increased exponen- glabella to get a really smooth area. three materials to treat temporal crow’s feet. There’s just so much
tially.” I inject into the tear trough of the atrophy. available now.”
With this expansion of options, lower eyelid, particularly with Resty- “When I’m doing browlifts with
Dr. Beer says,“I’m doing things now lane and Sculptra. And I inject the Botox,” he adds, “I’ll put a little bit Technique tips
that two or three years ago I wouldn’t upper zygomatic arch with Radiesse, of a filler right into the brow. And I As for technique tips, Dr. Beer says,
have considered. I routinely inject Restylane and Sculptra to get a little still use some of the soft fillers like “inject very slowly and avoid any vas-
soft tissue augmentation when I do bit of an upper-face and midface lift.” CosmoDerm (collagen, Inamed) or culature. When I teach people, I tell
botulinum toxin injections into the He says he also uses the preceding Hylaform for forehead wrinkles and them to inject in a very cautious
fashion and to take their time. I also
try to ensure that the right filler goes
into the right plane. By that I mean
if one is using a filler such as Cos-
moDerm, which is designed for the
superficial dermis, one must put it
there. If one puts it deeply, the patient
will waste their time and money.”
Conversely, he says that if one
injects Sculptra into the superficial
dermis rather than the deep dermis
where it belongs, patients will end
up with bumps.
“I use dental blocks and
a lot of dental anesthetic.
I’ve learned a great
deal from the cosmetic
dentists in my area, so I
will use Septocaine.”
— Kenneth Beer, M.D.
University of Miami
“Technique and knowledge of the
different products is critical,” he says.
Refusing to oversell products or
procedures also is crucial, Dr. Beer
“I tell patients, as well as the der-
matologists and plastic surgeons that
I teach, that it’s important for
patients to have realistic expectations.
Sometimes, patients may need mul-
tiple visits,” he notes.
When injecting Restylane or other
hyaluronic acids, he adds, “I tend to
put patients on nonsteroidals such
as Advil (ibuprofen, Wyeth) or
Motrin (ibuprofen, Pfizer) to mini-
mize the inflammatory reaction.”
By the same token, Dr. Beer says,
“I use dental blocks and a lot of
dental anesthetic. I’ve learned a great
deal from the cosmetic dentists in
my area, so I will use Septocaine
(lidocaine, epinephrine hydrochlo-
ride, Septodont). And I use a device
called CompuDent (Milestone Sci-
entific), which is a pedal-operated
injection system, to get a constant
flow of anesthetic, which can pro-
vide nearly pain-free injections.
SEPTEMBER 2005 www.dermatologytimes.com 95
Patients appreciate that.” as much swelling,” he says. going to get better.”
Although it may sound trivial, Dr. Overall, he notes, “The filler cat- In his own office, Dr. Beer adds, Disclosure: Dr. Beer has served as a clin-
Beer also recommends using ade- egory has grown so rapidly. And right “I’m really excited about the threads. ical investigator and speaker for Medicis
quate filler volume. around the corner are so many more I’ve just started to use them in my and as a speaker for Allergan.
“If one is not going to inject that I believe we’re going to have a practice, and it’s nice to be able to
enough,” he says, “don’t inject any- great opportunity to use the right reverse some of the upper-face For more information:
thing. Often, physicians will try to filler for the right place. And as more descent in a minimally invasive www.AAD.org
save patients time or money. But fillers come to market, the pricing is fashion.” DT www.cosmeticbootcamp.com
somebody who needs 3 ml of Resty-
lane is not going to be happy with
“I’m doing things now
that two or three years
ago I wouldn’t have con-
— Kenneth Beer, M.D.
University of Miami.
one. People who are trying to save
money are better off not getting filler
Additionally, he says that patients
concerned about swelling or bruising
tend to do better with Hylaform
(Inamed) or Captique (Genzyme)
“Hylaform and Captique are
about one-quarter as dense, so that
they tend not to act as such a strong
osmotic gradient. These products
don’t last as long, but they don’t cause