LAST WEEK'S THEME:  BEST OF BOTOX PEARLS

Use caution with 1064 lasers -- window of safe parameters is narrow

SANTA MONICA – The 1064 laser can offer impressive results for a variety of purposes, but, like any lasers, there are risks, and physicians should use caution, noted Christopher Zachary, M.D., F.R.C.P., at the Skin Disease Education Foundation’s Cosmetic Dermatology Seminar 2008.

“The window of opportunity is narrow with 1064 lasers and if you go outside of it, there can be a real danger of complications including bruising, ulceration and scarring," said Dr. Zachary,  professor and chair of the Department of Dermatology, University of California, Irvine.

Problems can pop up without much warning, he said.  “You may be treating the patient and the laser is going pulse, pulse, pulse, and then suddenly it just sucks down and the tissue collapses and you’ve got a problem,” he said.

Note the individual patient’s characteristics and stick to the specific parameters that are needed, he said.

“Every patient and every vessel in that patient is different and requires different parameters, so you need to follow them, go slow and make sure the patient has reasonable expectations.”

Facial, leg telangiectasias like apples and oranges -- treatment should differ

SANTA MONICA, Calif. - Physicians may have great success in treating telangiectasias on the face with pulsed-dye lasers, but leg telangiectasias are another matter altogether, and are still usually best treated with the gold standard, sclerotherapy, said Margaret Mann, M.D., at the Skin Disease Education Foundation’s Cosmetic Dermatology Seminar 2008.

“It’s important to keep in mind that spider veins in the legs are much different than telangiectasias on the face, and comparing the two is like comparing apples and oranges,” said Dr. Mann, a dermatologic surgeon and vein specialist at the University of California, Irvine.

“You may have treated facial telangiectasias with a pulsed-dye laser and had great results, but the fact is, leg telangiectasias are a whole different species,” Dr. Mann said.  “Facial telangiectasias are small vessels and they’re pretty homogenous. They’re superficial in location and you’ll likely get predictable results with each treatment,” she said.

Leg veins, however, tend to be much larger in diameter and instead represent a heterogeneous population, she said.

“Some are thicker, some are thinner, and in general, they’re much deeper in location, so the same technique you use for facial telangiectasias --  a pulsed-dye laser – is not going to apply in this instance and you’ll generally get unpredictable results." 

In addition, physicians should remember that the spider veins appearing on the legs may be just the tip of the iceberg.

“The patient may be coming in just for those spider veins, but in general, there probably is more lurking below,” she said. “There could be reticular veins or some larger varicosities, so it’s important that you don’t just treat the spider veins, but you treat the source of the problem.”

Dr. Mann had no disclosures for her talk.
 

Avoid disappointment by letting fractional patients know results will take time
 
LAS VEGAS -- Fractional lasers can be true patient-pleasers for improving everything from skin tone and wrinkles to acne scars, but patients may experience initial disappointment if they haven’t been warned beforehand that results can take a while, said Bruce E. Katz, M.D., at the International Esthetics, Cosmetics & Spa Conference.

“It’s important to tell patients before the treatment that with any fractional technologies, result are not going to be seen  right away,” said Dr. Katz, a clinical professor at Mt. Sinai School of Medicine and director of Juva Skin & Laser Center in New York.

Even after a series of four treatments, the process of collagen remodeling can take months and patients will start to see the most improvement in three to six months.

“If you don’t warn patients, they will often not be satisfied with the results right after treatment,” he said. “They'll come back three months later and will be much happier because now they’re seeing results, but you want to let them know from the very start that it will take that long so they don't have to go through the initial disappointment.”

Dr. Katz’s disclosures included that he is on the Clinical Advisory Board for Alma Lasers and is a stockholder with Cynosure.

Dr. Katz is medical director of the Juva Skin & Laser Center in New York.

LAST WEEK'S THEME:  TISSUE TIGHTENING

Unipolar radiofrequency device takes aim at cellulite

SANTA MONICA -- A truly effective treatment for cellulite may remain elusive, but the unipolar radiofrequency device Accent (Alma Lasers), shows some promise in helping to improve the condition, said David J. Goldberg, M.D., at the Skin Disease Education Foundation’s Cosmetic Dermatology Seminar 2008.

Dr. Goldberg authored a recent study in which 37 patients with upper thigh cellulite were treated every other week with the Accent device for a total of six treatments. The results showed clinical improvement in 27 of the patients, with a mean decrease in leg circumference of 2.45 cm. (Dermatol Surg. 2008 Feb;34(2):204-9; discussion 209. Epub 2007 Dec 17).

“That might not seem like a big decrease, but compared to some studies on bipolar radiofrequency devices, which show only about .8 cm of tightening, it’s actually a lot more,” said Dr. Goldberg, Director of Skin Laser & Surgery Specialists of New York and New Jersey and director of Mohs Surgery and Laser Research, Mt. Sinai School of Medicine.

The study also included MRI evaluation that found no lipid abnormalities. 

Monopolar RF devices such as Thermage can score a home run, but doctors report results that tend to be inconsistent. Bipolar heating devices have followed monopolar, but  Dr. Goldberg said the results he has found with the unipolar device, which is more deeply penetrating, have been better.

“What makes unipolar RF different is it is diffusive, meaning there is no ground at all, as opposed to bipolar RF, which is grounded," he said. "So with unipolar, you’re really putting a lot of deep bulk heat to the skin  that is spread all around."

He noted that his study used a localized application of RF, but Dr. Goldman has since determined that a more generalized application can be more effective.

“We treated the upper lateral thigh, but it’s a mistake to treat a localized area,” he said. “You really have to treat a generalized area.”

Dr. Goldberg’s disclosures included that his has received research grants from Cynosure, Hoya, Lumenis, Mentor and Rhytec, and he is on the Speaker’s Bureau for UltraShape.

Lax skin, strong bony structure keys to successful RF treatment 

SANTA MONICA – In the best cases, radiofrequency devices can offer impressive tightening and even a nifty, nonablative alternative to a face lift, but the technology’s inconsistency is still something physicians struggle with.

Two  important factors, however, have emerged as being key to offering the best chances for a good result -- good bone structure and lax skin, as opposed to lax muscle or fat, said David J. Goldberg, M.D., at the Skin Disease Education Foundation’s Cosmetic Dermatology Seminar 2008.

“What we’ve learned over the years with radiofrequency is that patients with lax skin and a strong bony structure will typically do well with any deep bulk device, and the type of device really doesn’t even matter,” said Dr. Goldberg, Director of Skin Laser & Surgery Specialists of New York and New Jersey and director of Mohs Surgery and Laser Research, Mt. Sinai School of Medicine.

“To get the kind of home run that you see in some studies, lax fat and muscle really cannot be issues,” he said. 

And contrary to suggestions that RF devices cannot offer tightening in older patients, Dr. Goldberg said he has found that age does not appear to be an issue in the amount of improvement.

When it comes to upper arm laxity in women, Dr. Goldberg described several studies, including his own, looking at monopolar RF (Thermage) showing only so-so results, while the procedure can take quite a while.

“Basically, it takes a long time to do – it took us an hour or so to treat just one arm – and the results simply aren’t that dramatic,” he said. 

Meanwhile, the procedure involves delivering a lot of energy into the tissue, and Dr. Goldberg expressed concern that little is known about the effects of so much energy.

“We really don’t know what happens to people who get all of this energy over time, or to physicians who may be pregnant and are repeatedly doing this to multiple patients,” he said. “I don’t know the answer, but it certainly is food for thought.”

Dr. Goldberg’s disclosures included that his has received research grants from Cynosure, Hoya, Lumenis, Mentor and Rhytec, and he is on the Speaker’s Bureau for UltraShape.
 

Follow parameters carefully to prevent serious RF complications

Radiofrequency may be  an energy source, as opposed to a light or laser source, but RF devices can be just as harmful to the skin if physicians don’t follow the right parameters, said Jeffrey S. Dover, M.D., at the annual meeting of the American Academy of Dermatology.

“It’s essential to follow the parameters called for with a device in order to prevent complications,” said Dr. Dover, an Associate Clinical Professor of Dermatology, at Yale University School of Medicine and Adjunct Professor of Medicine (Dermatology) at Dartmouth Medical School.

Dr. Dover presented a case of a patient who suffered a serious complication after a faulty Thermage procedure.

“The patient received Thermage treatments on the face with fluences that were too high and she developed atrophy,” he explained. “The device not only tightened tissue, but it melted fat, and that is absolutely not something you want to have happen on the face.”

The patient eventually received a fat transplant to reverse the problem, but the case serves as a lesson for using caution with RF.

“This side effect, I believe, was caused by user error,” Dr. Dover said. “If you use fluences that are too high and they are used in areas that are fully anesthetized, the patient can’t tell you it hurts and you can deliver too much RF.” 

Impressive radiofrequency results seen on darker skin

SAN ANTONIO – As radiofrequency tissue tightening evolves, physicians are finding niches where the technique may be particularly effective, and one such use appears to be among patients with darker skin types, said Cheryl Burgess, M.D., at the annual meeting of the American Academy of Dermatology.

Many physicians report only subtle improvement from monopolar radiofrequency, but Dr. Burgess says she has seen impressive results with the Thermage monopolar RF technology on darker skin types.

“I think skin of color responds much better to monopolar radiofrequency,” said Dr. Burgess, assistant clinical professor of dermatology at Georgetown University and medical director of the Center for Dermatology and Dermatologic Surgery in Washington, D.C.

“There appears to be a stimulatory effect of the collagen that makes RF more effective in those patients.”

Dr. Burgess has skin Type V and said her first-hand experience with Thermage treatments on the nasolabial folds and neck has been impressive.

“I wanted to find out if this would be helpful in skin tightening and I treated my nasolabial folds and neck with Thermage and I have seen results last six months out, so far.”

“It’s worked very well for me and I’m still counting the months,” she said.

Studies:  RF, lasers OK after filler

Combining fillers with radiofrequency tissue tightening, laser or  light-based therapies can offer improved cosmetic results,  and if offered in one appointment, reduce recovery time for the patient. But can the treatments be safely administered without compromising the fillers? Recent research indicates that the answer is yes.

In one study, researchers treated 36 patients who had prominent nasolabial folds with an HA filler such as  Restylane (Medicis Inc.) on one side of the face and the filler immediately followed by either monopolar radiofrequency, 1,320-nm Nd:YAG laser, 1,450-nm diode laser or intense pulsed light on the other side.

At no time point did the researchers observe any clinically significant differences between wrinkle severity or global aesthetic scores between the side of the face with filler alone and the other side with the combined therapies. A small sample also showed no histological changes after the combination treatment. (Dermatol Surg. 2007 May;33(5):535-42).

“Based on this small pilot study, laser, RF, and IPL treatments can safely be administered immediately after hyaluronic acid gel implantation without reduction in overall clinical effect,” the study concluded.

Another smaller study involving just five patients found similar results when RF was administered two weeks after a filler. In that study, the patients received injections of Restylane and calcium hydroxylapatite filler Radiesse (Bioform) in the upper inner arm. Two weeks later, the experimental arm was treated with two non-overlapping passes of RF (Thermage ThermaCool TC) at a setting of 63.5 and a medium-fast 1.5 cm2 tip over the filler injection site.

Punch biopsies obtained three days after the treatments showed no difference in filler materials between the experimental and control arms, and patients and physicians reported no differences in signs and symptoms between the two. (Lasers Surg Med. 2006 Mar;38(3):205-10).

“Applying RF treatment over the same area 2 weeks after deep dermal injection with hyaluronic acid derivatives or calcium hydroxylapatite does not appear to cause gross morphological changes in the filler material or surrounding skin,” the study concluded.