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  • 1. 92 Dermatology Times SEPTEMBER 2005 92 Blossoming Safe, effective 98 Sclerotherapy Not just for legs 100 Fat removal Expert says QUOTABLE upper face and thighs tumescent The key is to assess the treatments liposuction best patient, see what the abound patient needs, and — if it’s beyond the scope and expertise of one’s practice Cosmetic — refer the patient to the appropriate physician. Dermatology — Seth L. Matarasso, M.D., San Francisco, giving advice on how to avoid filler pitfalls See story, page 106 COSMETIC Upper face CONUNDRUMS Zoe Diana Draelos, M.D. treatments Q&A blossom 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 DTExtra 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 Source: Canada.com Conundrums continues page 104 only are we doing forehead treat-
  • 2. 94 DermatologyTimes SEPTEMBER 2005 CosmeticDermatology 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 adds. “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.
  • 3. SEPTEMBER 2005 www.dermatologytimes.com 95 CosmeticDermatology 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- sidered.” — Kenneth Beer, M.D. University of Miami. one. People who are trying to save money are better off not getting filler treatments.” Additionally, he says that patients concerned about swelling or bruising tend to do better with Hylaform (Inamed) or Captique (Genzyme) than Restylane. “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