Don't let botulinum toxin injections leave Asian patients feeling odd 

SAN FRANCISCO – Botulinum toxin injections can feel awkward on most first-time patients, but the effect can be particularly pronounced on Asian patients, and physicians should keep that in mind when treating those patients at first, recommended Jenny Kim, M.D., at the annual meeting of the American Academy of Dermatology.

“You need to be very careful and use lower doses of botulinum toxin among Asian patients, not because of what you see but what they feel,” said Dr. Kim, dermatologist and assistant professor of medicine at the University of California, Los Angeles.

Dr. Kim said she experienced the feeling first-hand and could testify to the odd sensation. “It’s not anything that can be measured or photographed, but it just feels like there is something very heavy on the forehead.”

“It may be because Asians’ upper eyelids are thinner and there’s more fat, but particularly on elderly Asian women, I would say it’s very important to keep the doses low.”

Additionally, Dr. Kim said she will inject a small amount in the lower lid if Asian patients want a slightly rounder look to their eyes – but only if the patient makes that request. “You want to make sure to ask if that’s an effect the patient desires, because not all will want it.”

And in the lower lid, use extreme care if in the vicinity of the orbit. “You want to make sure to stick the needle away from the orbit laterally,” Dr. Kim cautioned.

Dr. Kim's disclosures include that she is on the advisory board for Allergan.

Use a light touch on first-time botulinum toxin patients

SAN FRANCISCO -- When injecting botulinum toxin in first-time patients, keep in mind that what may look like a great result may feel awkward to patients, and it’s therefore a good idea to use a light touch at first, said Jenny Kim, M.D., at the annual meeting of the American Academy of Dermatology. 

“First-time patients may come in wanting botulinum toxin injections in multiple areas, but I will typically stay in the glabellar area,” said Dr. Kim, dermatologist and assistant professor of medicine at the University of California, Los Angeles.

“If I do inject in the forehead, I’ll go very high because what may look good can feel odd, and you don’t want your patients to start their experience with botulinum toxin feeling that way,” she said.

Moving down the face, Dr. Kim said she will also take a conservative approach if patients are newcomers to perioral injections. “When patients have botulinum toxin injections in the orbicularis oris area for the first time, it will feel funny if they can’t move their lips or talk or eat the way they used to, so I will start very low in that area.”

And contrary to a botulinum toxin consensus panel’s recommendations of injecting in 10 sites in the orbicularis oris area, Dr. Kim said she will usually start with only about four injection sites. “I’ll stick to injecting perhaps only where there are lines when the patient puckers.”

Pilot study gives thumbs-up to fractional lasers on the hands

PHOENIX -- In the quest to replicate on the hands some of the successful rejuvenation seen on the face, fractional lasers are proving to offer safe and moderately impressive results.

Speaking at the annual meeting of the American Academy of Cosmetic Surgery, Neil S. Sadick, M.D., presented the results of a small but important pilot study looking at the use of fractional 1550 nm erbium diode fiber laser to treat moderate hand photodamage.

The study involved nine subjects with a mean age of 57 years and Fitzpatrick wrinkle score of 4.44. Each individual was given five to six laser treatments involving three to four passes on the dorsum of the hand, depending on how photodamaged the skin was. The treatments were given about three to four weeks apart, and the patients were followed for six months after treatment.

“We wanted to look at safety, global efficiency, and particularly skin tone, texture dyschromia and improvement of wrinkles, which we thought would be the major targets of this treatment,” said Dr. Sadick, a clinical professor of dermatology at the Weill Medical School at Cornell.

Physician analysis of the treated hands showed subjects to have 26% to 50% improvement, with pigmentation, wrinkle reduction and moderate improvement of the overall surface of the hand and no long-term side effects.

“We saw significant improvement in that kind of spotty lentiginous hyperpigmentation that occurs, as well as in elasticity,” Dr. Sadick said. “This is moderate improvement, but it’s hard to achieve these kinds of global changes with any other type of technology.”

Histologic evaluation meanwhile backed up some of the findings, showing  a reduction in atypical keratinocytes, improvement in rete ridge formations, increased collagen density and a reduction in solar elastosis at 6 months post-treatment. (J Cosmet Laser Ther. 2009 Mar;11(1):29-33)

Dr. Sadick noted that, as can be expected with fractional lasers, erythema lasted for several weeks. “Most patients had immediate post-therapy erythema, which we know can last up to four weeks after treatment, even with the first generation Fraxel on the hand,” he said.  “So this is something you need to inform your patients about if you’re going to use this modality.”

He encouraged further studies to look at the relationship between increases in energy density, the number of treatments and clinical endpoints to see how efficacy could be improved, and added that his own research with CO2 fractional lasers looks promising.

“We’re still looking at CO2 fractional treatments on the hand and the results with just two treatment sessions appear to even be better than this initial pilot study.”

Patient discomfort, recovery time key issues in picking the right laser for acne scars

PHOENIX – New and improved fractional carbon dioxide and erbium lasers seem to be hitting the market  every day, offering powerful new tools for tackling acne scars. But in choosing just the right machine, doctors should keep in mind some key considerations, said Paul J. Carniol, M.D., at the Annual Meeting of the American Academy of Cosmetic Surgery.

Some basics include how the machine is used and how much time it will take for each procedure, but a critical factor is patient discomfort, said Dr. Carniol, a cosmetic surgeon based in Summit, N.J.

“The lasers do differ when it comes to patient discomfort, and one thing you can be sure of is if the patient is not comfortable, they’re not going be happy,” he said.

Also key is the recovery time. A big benefit of CO2 fractional lasers over standard CO2 lasers is the shorter recovery time, but don’t lose track of the fact that the recovery time is per treatment.

“Don’t forget to multiply the number of days of recovery time per procedure by the number of procedures that will be required,” Dr. Carniol said. “If it’s a four-day recovery, but will take two procedures, that’s actually an eight-day recovery, and that’s how many days the patient may need to take off, and you really need to be up front about that.”

Look at the data on the device and consider what kind of results you can realistically expect to see. “The fact is, there is simply no single laser treatment giving 100% improvement to get rid of all of your patient’s acne scars. What we’re looking at, for most devices, is 20% to 40% improvement,” Dr. Carniol said. “And acne scar improvement can vary, not only from patient to patient, but even from one side versus the other on the same patient.”

Finally, consider all of the costs, including acquisition of the device, warranties and other costs, and how – or if -- the benefit of having the laser may offset those costs.

“I do not believe that new technology alone attracts patients into your office,” he said. “I think there are a multitude of factors that bring in patients, but you need to consider whether the cost is justifiable, or if you could wind up losing money.”

LAST WEEK'S THEME:  THE LIPS

Balance, symmetry and harmony: The keys to lovely lips

LAS VEGAS – In addition to 0ver-filling the lips, injections that simply weren't made carefully or evenly can also cause changes and small nuances that may not look right and will not result in a happy patient. The culprits, according to Gary Monheit, M.D., can be violations of the three key considerations: balance, symmetry and harmony.

“When doing your injections, it’s important to keep in the basic principles of lip injection,” said Dr. Monheit at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

“First, always look for balance. Ask yourself if you have changed the balance between the upper lip and the lower lip,” he stressed. A standard proportion of the lips is that the upper lip should make up about one-third and the lower lip two thirds of the size of the closed mouth.

“The second consideration is to look to see if the lips are symmetrical, and thirdly, make sure they harmonize as a cosmetic unit with the rest of the face. These all play key roles in natural-looking lip results,” said Dr. Monheit, associate clinical professor of the departments of dermatology and ophthalmology at the University of Alabama, Birmingham, Ala.

Dr. Monheit said some of his personal preferences for lip augmentation include hyaluronic acid fillers Juvederm (Allergan) and Restylane (Medicis). “Juvederm is really great for the lips,” he said. “It’s soft and flows evenly. If you need something stiffer or more robust, you can try Restylane, which can be used for deeper nasolabial folds, or Juvederm Ultra Plus.”

Dr. Monheit is a consultant and clinical investigator for Allergan, Genzyme, Colbar/J&J and Ipsen/Medicis.

Nerve blocks can mean relaxed patients, improved injection

LAS VEGAS – An infraorbital nerve block may result in a good two hours of numbness for lip augmentation patients, but the two hours are well worth it – not just for the patient’s reduction in pain, but for the physician’s increase in accuracy, said Anne T. Stubbs, M.D., at the International Esthetics, Cosmetics & Spa Conference.

“I use blocks for several reasons – first, patients will be more likely to come back for rejuvenation again if they’re comfortable,” said Dr. Stubbs, a Columbus, Ohio-based physician specializing in non-surgical aesthetic medicine. 

“I’ve had so many people who had their lips done elsewhere say they would never have them done again because it hurt so much they literally tears streaming down their faces.” 

Importantly, the block allows for a more accurate injection technique because if the patient is more relaxed, the injector is more relaxed. 

“It’s hard to be creative when the patient is wincing every time you put a needle in their skin,” she said. “They’re tense, so you become tense and hesitant to put the needle in, and you really want them to be numb so you use the right amount of volume.”

“And if you inject the area locally with lidocaine, you’re already are putting volume in the area and you can wind up not knowing how much of the volume is lidocaine and how much is your filler product. Next thing you know, you wind up with repeat visits because you have to add more.” 

“If you use a block, however, you know exactly how much you’re putting in.”

Dr. Stubbs said she uses Septocaine, (articaine hydrochloride 4% with epinephrine, Septodont), because the onset is somewhat faster.

“Lidocaine has an onset of about five to seven minutes, whereas Septocaine’s onset is within about a minute and a half, so patents numb very quickly,” she said. “I’ll tell patients they’ll be numb for about an hour or two after the procedure and if they can’t be numb for that long, we’ll try for a different day when they can.”

Dr. Stubbs’ disclosures include that she is a physician trainer with Allergan, Medicis and Cynosure.

Cannula a big, but less traumatic alternative to needle sticks for lip augmentation

PHOENIX – The use of a cannula for lip augmentation may not seem like the gentlest approach, but it can offer a nifty alternative to multiple needle pricks, said Joe Niamtu, D.M.D., at the annual meeting of the American Academy of Cosmetic Surgery.

“Use of a fat injection cannula can really represent a far less traumatic method for injecting into the lip,” said Dr. Niamtu, a Richmond, Va.-based oral and maxillofacial surgeon specializing in cosmetic surgery.

“You simply anesthetize the lip, make a puncture with an 18 gauge needle and use the cannula, which fits right on to the syringe, and you inject as you withdraw,” he explained.

“Patients are appreciative, and the actual treatment time is shortened.”

Dr. Niamtu said he uses a 0.9 mm (20 gauge) micro injection cannula (Tulip Biomedical, San Diego, Calif.) which is available in 4 or 5 cm length disposable and autoclavable model.

“It may look painful, but it is much less traumatic than six to 10 needle sticks, and it cuts down on the postoperative swelling and bruising that can come with volume injection.  It has really changed my filler practice.”

Dr. Niamtu’s disclosures included that he is a paid consultant for Allergan and Medicis and has received honorarium for speaking.
 

Focus on center third of mouth to prevent 'duck lips'

PHOENIX – Over-inflated ‘duck lips' may be a common sight in Hollywood, but they hardly represent a fashion statement elsewhere, and a key strategy for doctors to avoid such results is to stick with injections in the central section of the lips, said Joe Niamtu, D.M.D., at the annual meeting of the American Academy of Cosmetic Surgery.

“I think when you see these celebrities that have that duck-lipped look, the problem is that they were injected all the way to the corners of their mouth,” said Dr. Niamtu, a Richmond, Va.-based oral and maxillofacial surgeon specializing in cosmetic surgery.

Dr. Niamtu said lips can still look volumized, but have a much more natural appearance when augmentation focuses on the central third section.

“My injection technique is to avoid augmenting out toward the commissures,” he said. “Most women look good with filler just in that puckered area of the mouth, so I concentrate most of the filler in the central third of the lip.”

Dr. Niamtu begins with the chevron in the central lip while staying at the wet-dry line. “When injecting deep in the lip, I go to the wet-dry line and inject the filler right in the middle of the pucker area. I tell patients to just think of it as putting the air in the tire.”

For an extra lift to the central lip correction, don’t forget the philtral columns: “A lot of doctors ignore the philtral columns, but with a conical injection putting just a small amount of filler near the base of the column, you provide some nice correction there as well.”

Dr. Niamtu’s disclosures included that he is a paid consultant for Allergan and Medicis and has received honorarium for speaking.

LAST WEEK'S THEME:  RADIOFREQUENCY TISSUE TIGHTENING

Nifty tips help give RF devices new niches

LAS VEGAS -- Innovative device tips and refined techniques have helped radiofrequency tissue tightening devices gain favor for specific treatment areas.  Two areas that can be ideal for RF treatment include the eyelids and the upper lip area, said Jean Carruthers, M.D., at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

“We’re big fans of Thermage in my office, and we have seen great results on the eyelid,"  said Dr. Carruthers, a clinical professor in the Department of Ophthalmology at the University of British Columbia in Vancouver.

"We mark a grid on the lid and use a small tip with 10 passes to get a result.”

Dr. Carruthers helped conduct some of the original research on treating the eyelid skin with Thermage, including a pilot study showing mild to moderate effectiveness with the 0.25-cm monopolar radiofrequency tip in shrinking eyelid skin.

The study also looked at safety, and with protective haptic contact lenses used to protect the globe from RF energy, no adverse events were seen with 20 subjects with the exception of one subject who had minimal corneal epithelial punctuate defects that resolved within several hours on the treatment day. (Dermatol Surg. 2007 Jul;33(7):802-9).

“(Thermage) may not provide a surgical result, but there is definitely some lifting and I think it’s really a nice technique for people who either can’t take a week off to let everything heal or who don’t want as  obvious a cosmetic result that a blepharoplasty,” Dr. Carruthers said.

She added that she also has seen good results for the ‘bar code’ lines above the upper lip. “I think it’s a great treatment for the bar code on the lip. If you use it regularly, it helps build new collagen in the skin and we use this every day in our practice.”

Dr. Carruthers’ disclosures included that she has served as an investigator for Thermage.

Part Two: Keep RF patient expectations in check

MONTREAL -- Physicians need to avoid being taken in by the hype surrounding radiofrequency tissue tightening devices in order to prevent dissatisfaction, said Arie Benchetrit, M.D., at the 1^st Pan American Congress on Anti-Aging & Aesthetic Medicine. Some additional key issues that should be considered with the devices include:

Efficacy: The true efficacy of tissue tightening devices remains unclear. “There are no standardized ways to measure results of these, so the efficacy is in question,” Dr. Benchetrit said. “Many studies that suggest improvement rely on histological results, but often these results don’t translate to clinical results.”
The solution: Take matters into your own hands. “It’s up to us as doctors to verify the results ourselves -- try it before you buy it.  I own about eight energy devices, but I never bought one without trying it myself for at least three months. If it works, if it has high patient acceptance, if the staff enjoy using it and the results are there, then I can go ahead with it.”

Unrealistic patient expectations: The result not just of hype, but the desire for a magic bullet or a quick fix solution with no down time.
The solution: In addition to reminding patients RF is simply not a facelift, quantify the expected results for them. “You can tell patients that they will likely see some improvement in their skin laxity and texture,” he said. “I tell all of my Thermage and Accent patients that if the expected improvement from surgery results is a score of 10 out of 10, they should expect a result of three out of 10 with RF. It’s as clear as that.”

What’s also clear is that doctors can count on improved results when combining RF treatments with fillers or Botox, and studies have shown such combinations to be safe. (See this DailyDermPearl on the topic).

Dr. Benchetrit says he has seen the best results in general with RF in treating the abdomen, the  midface when there is moderate laxity, and the brow.

Dr. Benchetrit's disclosures include that he has been a paid speaker for the following companies: Allergan; Medicis; Clarion; Ultrashape; Canderm.

Don't let radiofrequency hype hinder satisfaction -- problems and solutions

MONTREAL – Radiofrequency tissue tightening devices have been among the most promoted cosmetic devices to hit the market in recent years, yet popular consumer sites such as RealSelf.com show them to also offer some of the most disappointing results.

While the hype itself is a big part of the problem, physicians can take measures to improve results along with patient satisfaction, said Arie Benchetrit, M.D., at the 1^st Pan American Congress on Anti-Aging & Aesthetic Medicine.

“We see published results on tissue tightening devices that are positive, yet there is probably more dissatisfaction with them than any of the new noninvasive or invasive technologies,” said Dr. Benchetrit, a Montreal-based plastic surgeon.

The discrepancy, he says, comes down to some key issues:

Hype: Over-promotion, including the comparison of tissue-tightening to a facelift. “These devices are hyped to the gills, in ads and in shows like “Oprah,” and they talk about this as an easy alternative to a facelift,” Dr. Benchetrit said.
The solution: Clarify that tissue tightening is not an alternative to a facelift, otherwise, patients will be disappointed.

Patient selection: Patients are often not selected properly. “This is not a one-size-fits-all treatment,” Dr. Benchetrit said.
The solution: “Evaluate patients properly and know that those with adipose tissue or poor skin quality, for instance, will not do well with RF. If a patient wants something only a lift can accomplish, don’t offer them RF. You'll avoid having a disappointed patient.”

Photos: Before-after photographs used by device makers and doctors alike can be misleading. “The photos will often only show the best results and not the consistent results.”
The solution: “Look at the photos with a critical eye and consider whether they represent the best-case scenario or expected results. You need to consider things like the lighting, the angle and the use of a flash.”

Dr. Benchetrit's disclosures include that he has been a paid speaker for the following companies: Allergan; Medicis; Clarion; Ultrashape; Canderm.

Tomorrow: Issues Four and Five -- Keep expectations in check

PREVIOUS WEEK'S THEME:  BOTOX INJECTION

Botox may not go the distance with runners, athletes

LAS VEGAS – If a patient seems to be burning off his or her Botox injections at an unusually fast rate, you might want to look at their physique. Remember – a greater muscle mass typically requires high doses of Botox, and athletes will usually fall into that category, said Jean Carruthers, M.D., at the annual meeting of the American Society of Cosmetic Dermatology and Aesthetic Surgery.

“I go through a lot of Botox, and the reason is largely because we treat a lot of really fit people,” said Dr. Carruthers, a clinical professor in the Department of Ophthalmology at the University of British Columbia in Vancouver.

“Female athletes don’t just have bigger muscles in their limbs – their facial muscles are bigger too,” she noted. “If you see a female athlete and put 35 to 40 units of Botox in her brow, she could easily be back in five weeks saying it’s gone, so you need to use more because higher doses are necessary.”

Speaking on the same panel, Gary Monheit, M.D., noted that the muscle mass differences between men and women also need to be considered in determining Botox dosages.

“The Allergan packaging currently calls for 20 units of Botox in the glabella, for instance, but we now have clinical trials indicating the necessity of different doses based on the strength of the muscle mass, and that includes male versus female and large muscle mass versus small muscle mass.”

Dr. Carruthers is a consultant and investigator for Allergan.

Pebbly-chin fix a pleasing bonus for Botox patients

MONTREAL – When patients come in for Botox injections in common areas of the upper face, doctors can offer an added bonus if the patient has a pebbly chin, said Phillip M. Levy, M.D., at the 1^st Pan American Congress on Anti-Aging & Aesthetic Medicine.

“The chin is a very rewarding area,” said Dr. Levy, a dermatologist based in Geneva, Switzerland.

“Many women may not even  realize that when they’re talking, they have hyper-contraction in their perioral region that causes pebbly chin,” he explained.

“I would never mention it on the patient’s first visit, but if I still see it after the second or third visit and have established a high level of confidence with the patient, then I will bring up the fact that I could easily treat their chin.”

While some physicians will inject the chin with one injection of five to 10 units into the tip of the chin, Dr. Levy said his approach is to give three injections of about 2.5 to three units per injection site.  

As with any Botox injections in the lower face, Dr. Levy urged caution and follow-up when injecting in the area. “You need to be very careful because all of the muscles in the lower part of the face actually interdigitate, and above all, be close with your patients,” he urged.

“You need to bring them back and I will never do a chin now unless I can see the patient two weeks later. I don’t care if they have to fly in from some other part of the world – they have to come in.”

Dr. Levy has worked as a consultant for Allergan.

Use caution to avoid perils of perioral injection

MONTREAL – When venturing into the lower face with Botox, extra levels of caution, skill, and anatomic knowledge are important, and some injectors simply avoid the region altogether. But with a careful approach, just a few injections can offer pleasing results, said Phillip M. Levy, M.D., at the 1^st Pan American Congress on Anti-Aging & Aesthetic Medicine. 

“I know some people don’t like using Botox in the perioral region, but I have to say I am a great fan of doing it, and there are just a couple of rules that have to be kept in mind,” said Dr. Levy, a dermatologist based in Geneva, Switzerland.

“The first is to remember that the result you get is going to depend on where you inject, and the second rule is to never put in more than one unit per wrinkle site and no more than two units per half lip (top or bottom).”

Dr. Levy said he rarely does the lower lip area and noted that upper lip injections should be carefully made to provide a natural look.

“When you inject near the vermillion border you will get a lip eversion.  If you don’t want that, then it’s important to inject about a centimeter above the vermillion,” he explained. “But you don’t want to make the lips flat – what you want is a softer pout and a natural look.”

“Most importantly, don’t over-treat,” he added.

Dr. Levy has worked as a consultant for Allergan.
 

Let your skill level determine Botox dilution

MONTREAL – Physicians may tweak their dilution levels when reconstituting Botox, but when starting out, it's best to play it safe with a higher dilution, said a panel of experts at the 1^st Pan American Congress on Anti-Aging & Aesthetic Medicine. 

Toronto-based dermatologist Vince Bertucci, M.D., said he typically will use a 1.1 cc dilution of normal saline without preservatives, per vial of Botox.

“My syringe will be 0.3 ml and I’ll use 1.1 cc as opposed to one to compensate for the small amount of loss that will occur in the needle,” said Dr. Bertucci, medical director of Bertucci MedSpa in Toronto and director of undergraduate dermatology at the University of Toronto.

“When you use higher amounts, volume can become an issue and the product may go beyond the intended area, so I find I can deliver precise amounts exactly where I want when I use just 1.1 cc.”

Injectors who are just starting out, however, may want to consider a higher dilution, warned Pierre Andre, M.D., a dermatologist in private practice in France: “If you’re a beginner, I would strongly recommend not starting with 1.0 or 1.1 cc dilution levels."

"When you have only 1.0 cc of dilution, you really have a strong weapon in your hands and if you push your finger even slightly faster than intended, you may suddenly have injected three or four more units than you wanted,” said Dr. Andre.

“If you are just starting out, I would recommend starting with a 2.5 ml or even up to 4.0 ml.”