46 Aesthetic Buyers Guide November/December 2005 www.miinews.com
American Society of
Dermatologic
Surgeons Annual
Meeting ...
47Aesthetic Buyers Guide November/December 2005 www.miinews.com
N
early 1,000 of the top U.S. dermato-
logic surgeons conv...
48 Aesthetic Buyers Guide November/December 2005 www.miinews.com
An ASDS survey released prior to the meeting indi-
cated ...
52 Aesthetic Buyers Guide November/December 2005 www.miinews.com
perform these procedures without the dangers of gen-
eral...
53Aesthetic Buyers Guide November/December 2005 www.miinews.com
choice,” he stated. “The Fraxel laser has the ability to
d...
54 Aesthetic Buyers Guide November/December 2005 www.miinews.com
at the University of Alabama Medical Center in
Birmingham...
56 Aesthetic Buyers Guide November/December 2005 www.miinews.com
I think we can come close, if not mimic, the results of
a...
57Aesthetic Buyers Guide November/December 2005 www.miinews.com
strands of fat will develop a blood supply more readi-
ly ...
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American Society of Dermatologic Surgeons Annual Meeting ...

  1. 1. 46 Aesthetic Buyers Guide November/December 2005 www.miinews.com American Society of Dermatologic Surgeons Annual Meeting Advances Skin Related Procedures By Michael Moretti, Editor
  2. 2. 47Aesthetic Buyers Guide November/December 2005 www.miinews.com N early 1,000 of the top U.S. dermato- logic surgeons convened in Atlanta, Georgia in late October for the 2005 American Society for Dermatologic Surgery (ASDS) and American College of Mohs Micrographic Surgery and Cutaneous Oncology (ACMMSCO) combined annual meeting. Physicians presented more than 300 abstracts that addressed the newest research and tech- niques in dermatologic procedures (both elec- tive and medical). The practice of medicine by the non-physi- cian is a growing concern for this society. About 40% of ASDS physicians reported an increase in patients seeking treatment because of dam- age caused by untrained non-physicians per- forming light-based rejuvenation techniques, chemical peels, acne therapy and other skin procedures. On the other hand, there was enthusiasm for radiofrequency and newer light-based devices that are safer, less painful, and effective in diminishing a variety of skin conditions. Attendees also had the opportunity to observe live procedures using a variety of innovative techniques for liposuction, laser therapy and silicone injections. Leading edge society of dermasurgeons gather to chart new directions for aesthetic medicine field.
  3. 3. 48 Aesthetic Buyers Guide November/December 2005 www.miinews.com An ASDS survey released prior to the meeting indi- cated that some five million skin surgeries will be per- formed in the U.S. during 2005. This represents a 32% increase over the past four years. According to the sur- vey, the major reason for this sharp jump is the popu- larity of minimally invasive cosmetic procedures, which are up a staggering 58 percent from 2001. “In- office, minimally invasive treatments are driving the growth of skin surgery, primarily because these proce- dures are very safe and require minimal recovery time,” said outgoing ASDS president Rhoda Narins, M.D. “As a result, an increasing number of patients are willing to undergo convenient outpatient surgery for both medically neces- sary and cosmetic purposes.” Baby boomers account for 65% of all cosmetic procedures, accord- ing to the survey, which continues a trend identified in 2001. “The most common patient age is the mid-forties. But it ranges from age 35 to 55,” said Dr. Narins, a dermasurgeon in pri- vate practice in New York City and Westchester County, N.Y. About 80% of light therapy patients are women, and women account for 88% of patients treat- ed with Botox (Allergan). In addition, 86% of soft tissue augmentation procedures are for filling wrinkles, and Restylane (Medicis) is the most frequently used filler (51%). Conversely, collagen now accounts for just 13% of augmentation procedures. Cosmetic skin surgery is a strong competency for dermasurgeons. Two-thirds to three-quarters of the respondents reported doing Botox injections (71%), vein treatment (70%), light-based therapy (65%), facial filler injections (64%) and skin resurfacing (63%). Since 2003, the greatest relative increases have occurred in the categories of facial filler injections (+55%) and light treatment (+33%). “New fillers that can volumize as well as fill in lines have changed the market dramatically,” Dr. Narins observed. “When you can only fill in lines, you still need to perform surgery to get rid of excess skin. But now, you can actually use up the excess skin by replacing the volume that is lost from that excess skin. In fact, I think fillers are the single most exciting development in aesthetics. The accept- ance of Botox is also very gratifying.” Other notable changes in the industry include increases in non-ablative skin rejuvenation (+28%), resurfacing (+26%) and Botox injections (+25%). The average patient age is 51 years old, remaining unchanged since 2003. However, women are substan- tially younger (48 years old) than men (59). Women also comprise the majority (69%) of patients. Light-based therapies are used primarily to treat patients with vascular lesions (30%) or for hair removal (28%). Other uses include wrinkles (11%, a new category in 2005), pigmented lesions (8%), acne (7%) and tattoo removal (6%). In contrast, Botox was most often used for frowns (25%), followed by wrinkles (12%), or a combination of frowns and wrinkles (39%). Light-based devices, microdermabrasion and chemical peels are the three primary procedures used in resurfacing, almost equal in popularity (28%, 28%, and 26%, respectively). Of these three modalities, light treatment appears to be increasing from 15% in 2003, while chemical peels appear to be decreasing, down from 41% in 2003. “We are also finding out that liposuction with local anesthesia is a really safe procedure,” Dr. Narins noted. “More and more physicians are aware they can Rhoda Narins, M.D. “More and more physicians are aware they can perform these procedures with- out the dangers of general anesthesia. I believe body contouring will continue to grow in popularity.” Botox by Allergan
  4. 4. 52 Aesthetic Buyers Guide November/December 2005 www.miinews.com perform these procedures without the dangers of gen- eral anesthesia. I believe body contouring will continue to grow in popularity.” “We continue to witness the same dramatic advances that have led dermasurgery into the fore- front of the cosmetic arena,” said Alastair Carruthers, M.D., a clinical professor of der- matology at the University of British Columbia in Vancouver, Canada. At the meeting, Dr. Carruthers reported on patient perception of Botox injections for treating the entire upper face. “This is quite different from most Botox studies, whereby results are recorded by a disinterested observer, typically the injecting physician,” he reported. A total of 60 patients each received 16 injections during one treatment session. “Our study showed that one can measure how well peo- ple perceive results,” Dr. Carruthers said. “The higher the dose, the better the response, as perceived by the individual. Higher doses also resulted in a prolonged effect. But there was no increase in adverse events.” Dr. Carruthers, who is president-elect of the ASDS, is also excited about using fillers to treat facial wast- ing. “I believe that patients with HIV-associated facial lypoatrophy face challenges that are much more basic than cosmetic, such as self-esteem,” he said. “In a major study on facial wasting using injectable silicone oil, we achieved great results.” A second major study is ongoing using Radiesse (formerly Radiance FN, BioForm Medical), which is a synthetic injectable implant composed of smooth calcium hydroxylapatite (CaHA) microspheres suspended in an aqueous gel carrier. “I think Radiesse shows great potential as a filler for the average practitioner treat- ing the average case of HIV facial wasting,” Dr. Carruthers said. Outcomes out to eight months show that the effect of Radiesse lasts longer than the hyaluronics, but it is not a permanent treatment. In the same positive vein, Dr. Carruthers is finally con- vinced that radiofrequen- cy resurfacing “is work- ing and is going to deliver the kind of results we are accustomed to with the intense pulsed light (IPL)- type machines.” The new algo- rithm for the ThermaCool TC System from Thermage, Inc. (Hayward, Calif.) allows for “up to ten passes, at lower energy levels, during a single treatment session,” he explained. “This will often pro- duce the results that you desire. Patient discomfort is also reduced.” “Revising the treatment protocol of the ThermaCool has allowed for a safer treatment and a much more consistent response,” added Roy Geronemus, M.D., director of the Laser & Skin Surgery of New York, in New York City. “The safety profile has also improved for those people who are less experienced with the device.” Most patients require only one treatment session. A sec- ond session may be scheduled three to four months later. “We’re enthusiastic about a new larger treatment tip, which allows for more rapid treatment and wider patient acceptance,” Dr. Geronemus continued. “This new tip has also made the procedure easier to perform.” Besides speaking on the ThermaCool, Dr. Geronemus discussed options in treating acne scar- ring. The Fraxel SR Laser from Reliant Technologies (San Diego, Calif.) “has become the treatment of Roy Geronemus, M.D. Alastair Carruthers, M.D. “The higher the dose, the better the response, as perceived by the individual. Higher doses also resulted in a prolonged effect. But there was no increase in adverse events.” Radiesse by BioForm
  5. 5. 53Aesthetic Buyers Guide November/December 2005 www.miinews.com choice,” he stated. “The Fraxel laser has the ability to deliver the microthermal zones into the deeper part of the dermis, which allows for the creation of new colla- gen in a broad area within the dermis itself. This process smoothes out the scars and tightens some of the pitted scars. The broader rolling scars also become more even, texturally. We generally do five treatments, but sometimes more, at normally two to three week intervals.” Dr. Geronemus noted that one of the more important advances in aesthetics “is the ability to have more reproducible results in a broader range of skin types. Historically, lasers have been most effective in treating patients with lighter skin types (Fitzpatrick I – III). Over the next few years, though, I think we’re going to see a much greater emphasis and improved results in skin types IV through VI, using such technologies as radiofrequency and fractional resurfacing.” Gary Monheit, M.D., the new president of ASDS, is enthused about new fillers from Europe. Juvederm from L.E.A. Derm (Paris, France) is a long lasting hyaluronic acid filler that is “showing excellent results,” said Dr. Monheit, who helped conduct the North American clinical trials. “Juvederm has longevity, stability and there is mini- mal inflammation and swelling. In my experience, the duration of effect is at least six months. It is also an easy filler to inject.” In contrast, Evolence from ColBar LifeScience (Herzliya, Israel) is a collagen filler. “The bonding is different from our collagen fillers. Evolence is porcine collagen as opposed to bovine collagen,” said Dr. Monheit, a dermatologic and cosmetic surgeon in pri- vate practice in Birmingham, Ala. “One of the advan- tages of Evolence is that it is long lasting. The claims in Europe state that it can last up to two years. This filler is also very natural in feel and appearance, like the other collagen fillers. Evolence has the stiffness to truly hold up nasolabial folds and marionette lines very naturally, as well as for lip augmentation.” Reloxin from Ipsen Pharmaceuticals (London, United Kingdom) is a botulinum toxin type A product similar to Botox. “In our experience, the onset of action of Reloxin may occur a bit earlier than Botox. The longevity may be slightly longer as well,” reported Dr. Monheit, an associate clinical professor of dermatology Gary Monheit, M.D. Evolence by ColBar (Clockwise: Before Tx, After Tx, During Tx) “Over the next few years, though, I think we’re going to see a much greater empha- sis and improved results in skin types IV through VI, using such technologies as radiofrequency and fractional resurfacing.”
  6. 6. 54 Aesthetic Buyers Guide November/December 2005 www.miinews.com at the University of Alabama Medical Center in Birmingham. Both Reloxin and Botox are injected the same way. “I think Reloxin will become a strong com- petitor to Botox. There is already growing acceptance in Europe.” Overall in aesthetics, “we are decreasing the aggressiveness of our procedures, making them more office oriented and simpler, with less downtime and reduced risk,” Dr. Monheit conveyed. Among the acne treatment presentations, Jeffrey Dover, M.D., FRCPC, a clinical associate professor of dermatology at Yale University School of Medicine, shared the results of two studies that will be submitted for publication. “The Smoothbeam (Candela) and the Aramis (Quantel Medical) are both mid-infrared lasers that are pretty effective in treating moderate-to-severe acne,” Dr. Dover said. Each laser was studied in a sep- arate trial. “The advantage of the Aramis is that it hurts less and a topical anesthetic is not necessary before the procedure,” he said. “However, we feel the Smoothbeam may be slightly more effective per treat- ment session.” For both studies, patients committed to four ses- sions, spaced three weeks apart. “However, in clinical practice, we typically schedule six sessions, at about one month intervals,” Dr. Dover said. “There is usually improve- ment after one or two sessions. If we see no improvement after two sessions, we stop and determine that it is not going to work.” Long- term follow-up with the Aramis study showed that adding one booster treatment session several months after the final session helped prolong the effect. Dr. Dover also participated in a controversies session on using silicone oil as a filler. In a multicenter study comparing silicone oil (Silikon from Richard-James, Inc.) to bovine collagen (Zyplast from Inamed) for treating nasolabial folds, “the dif- ference was staggering,” pointed out Dr. Dover, who was one of the investigators. “The silicone produced better results and much longer lasting results in 100% of patients. Silikon is a product approved for use in the vitreous of the eye for a retinal detach- ment. Despite patients being able to have as much collagen as they wanted, with repeat treatments, the silicone lasted and the collagen did not. The silicone lasted at least 18 months, which was the follow-up period of the study, compared to the collagen, which lasted only several months.” In a separate presentation on pearls of wisdom for fillers, Dr. Dover noted that “the more you practice, the better you get at it. It is also much more of an art form than Botox. The more attention you pay to detail and to the art form, along with closer patient follow-up, the better you will get over time. Fillers are very tech- nique-dependent. But once you master the technique, the results are exquisite. However, there is no univer- sal ideal filler. And in some patients, it makes sense to use multiple fillers, even up to three. There are lots of new, interesting fillers being developed, which I think are slowly but surely changing the way we practice aesthetic medicine. Restylane has already made a huge difference in how we practice over the past two to three years.” Similarly, improved techniques are achieving “much better results with non-ablative laser technologies, such as fractional laser resurfacing,” Dr. Dover said. Foremost in this arena is the Fraxel laser. “I now have two years of experience treating a large variety of patients with the Fraxel laser,” said Tina Alster, M.D., director of the Washington Institute of Dermatologic Laser Surgery in Washington, D.C. “I am very happy with the results. In fact, I no longer per- form skin resurfacing with CO2 and erbium lasers. The Fraxel laser has basically replaced my ablative lasers. Jeffrey Dover, M.D., FRCPC “The silicone lasted at least 18 months, which was the follow-up period of the study, compared to the collagen, which lasted only several months.”
  7. 7. 56 Aesthetic Buyers Guide November/December 2005 www.miinews.com I think we can come close, if not mimic, the results of ablative skin resurfacing by scheduling a series of Fraxel treatments. Even though it is a series as opposed to one treat- ment, the series is much easier for patients post-operatively. An ablative procedure requires many return visits anyway. Well over 90% of my Fraxel patients need only three treatments at three to four week intervals, rather than five or six sessions.” With Fraxel treatment, patients experience only a few days of redness and swelling, “indistinguishable from a sunburn, followed by a cou- ple of days of peeling,” said Dr. Alster, who outlined the advantages of the Fraxel laser during a contro- versies session on this new technology. “In most patients, this peeling amounts to a gritty feel to the skin, like sandpaper, so the patient is not peeling all at once. I’m very happy with improvements in blotchy skin or dyspigmented skin, fine rhytides, atrophic acne scars or other types of atrophic scars, pore tight- ening and skin tightening. With repeated treatments, we have also observed some collagen contraction and some tightening.” Dr. Alster also shared the results of a cellulite study using the VelaSmooth from Syneron, Inc. (Richmond Hill, Ontario, Canada). “We treated one thigh and not the other in 20 adult women with differ- ent types of skin and moderate bilateral thigh and but- tocks cellulite,” Dr. Alster conveyed. Each patient underwent eight treatment sessions over a four week period. “The contralateral side was used as a non-treat- ed control,” she said. Patients were evaluated with standardized digital photography and leg measure- ments before each treatment session and at one, three and six months after the final session. Before and after photographs were evaluated by two masked medical assessors after the series of treatments were complete. Clinical scores improved about 50%. “Circumferential thigh measurements were reduced by 0.8 centimeters on the treatment side.” Nearly all patients (18 of 20) noticed an overall clin- ical improvement “and 17 of those 18 indicated they would pursue treatment of the contralateral thigh,” Dr. Alster reported. “Side effects were limited to transient erythema. Bruising was observed in two patients, but stopped after the first couple of sessions.” In practice, a maintenance session is commonly scheduled once a month “to further enhance the clinical results and pre- vent any decrease,” Dr. Alster said. Two sessions on rejuvenation of the hands, includ- ing a video demonstration on fat injection, were pre- sented by Kimberly Butterwick, M.D., a dermatologic surgeon in private practice in La Jolla, Calif. “Up until now, the hand has been relatively ignored,” she said. “Many women comment to me that their hands don’t match their rejuvenated face. And the public is now aware that the hand gives away a per- son’s age.” Fat injection is one of only a few treatment modalities that can effectively address the soft tissue atrophy on the back of the hand. “We are unable to resurface the hand aggressively enough to thicken up the skin,” Dr. Butterwick said. “Fat is a very simple, straightforward procedure that can be performed at the same time as facial rejuvenation, or at a different time.” The patient’s own fat (typically 10 cc) is taken from a donor site, such as the abdomen, hips or outer thigh. “The fat is centrifuged, then transferred to 1 cc syringes and injected with a blunt tip cannula,” Dr. Butterwick explained. Most patients require only one treatment session, consisting of approximately 10 cc per hand. “It is best to use a 1 cc syringe because it will deliver smaller parcels of fat. Those very thin Kimberly Butterwick, M.D. Tina Alster, M.D. “Well over 90% of my Fraxel patients need only three treatments at three to four-week intervals, rather than five or six sessions.”
  8. 8. 57Aesthetic Buyers Guide November/December 2005 www.miinews.com strands of fat will develop a blood supply more readi- ly than a 10 cc syringe.” Patients can anticipate “a much smoother, younger looking hand, with loss of the skeletal appearance and the tendons showing,” Dr. Butterwick said. “You can also expect the veins to be much less prominent. The skin overlying the fat will have a brighter, younger appearance. The duration of effect lasts usually in the order of two to three years.” Sometimes, the patient’s excess fat is frozen for a touch-up session about one year later. Dr. Butterwick also discussed alternative treat- ment options for rejuvenating the aging hands. “For cutaneous rejuvenation, there are chemical peels. Light-based treatments can also be quite effective. And for the veins, sclerotherapy is a relatively simple pro- cedure that can be performed quite safely. Some physi- cians are also beginning to use some dermal fillers for the backs of the hands, such as Sculptra (Dermik Labs), although there are not any studies as of yet. In summary, both surgeons and patients alike need to be aware that there are simple treatments for the hands that can be done concomi- tantly with facial proce- dures. Having increased awareness will prevent this discrepancy that reveals the patient’s age.” The Portrait PSR (plas- ma skin regeneration) sys- tem from Rhytec, Inc. (Waltham, Mass.) “is anoth- er form of resurfacing that improves wrinkles more significantly than any of the non-invasive procedures,” said Ron Moy, M.D., a clini- cal professor of dermatology at the University of California, Los Angeles. “Plasma is a new form of ener- gy we are working with. I think plasma causes signifi- cant tightening because of the fair amount of heat gen- erated. The side effect profile of the Portrait PSR also appears to be better than CO2 laser resurfacing. I, along with many other physicians, have not seen hypopigmentation, and the results may approach CO2 laser resurfacing. Patient downtime ranges from roughly seven to ten days.” The Portrait PSR usually requires only one treat- ment session. “However, you can use the device in a minimally invasive mode, where it acts similar to a medium depth chemical peel,” Dr. Moy said. In a separate presentation, Dr. Moy shared what’s new in cosmetic surgery, including the contour lift, which is FDA approved. The Contour Threads lift from Surgical Specialties Corp. (Redding, Penn.) is a non-absorbable barbed stitch made of permanent polypropylene stitches. “This is a lifting that is relatively minimal- ly invasive,” Dr. Moy explained. “You don’t have to make any inci- sions and it can be performed under local anesthesia. You can achieve significant mid-face lift- ing. However, improvement is not as noticeable in lower-face lift- ing. But you can get some brow lifting, some neck lifting and some jowl lifting.” Dr. Moy believes the contour lift is much better than the FeatherLift. “The FeatherLift is not fixated – it is not attached or tightened to anything – so it is sort of free-floating sutures. In contrast, the ContourLift is tightened to the deep temporal fascia. As with a face lift, results will likely last years, but it will not be permanent.” In general, “the aesthetic arena is growing by leaps and bounds,” Dr. Moy observed. “We can’t even anticipate the new fillers and new technology that will be introduced. Who could have imagined products like the Fraxel laser, the Portrait PSR and Contour Threads?” I Ron Moy, M.D. Contour Threads by Surgical Specialties Sculptra by Dermik

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