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THIS WEEK'S THEME:
BEST OF LASER/LIGHT PEARLS |
WEDNESDAY,
AUGUST 27, 2008
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Don't let topical anesthetic
mask laser pain
LAS VEGAS -- When treating a
patient with IPL, the patient’s expression of pain can be the doctor’s
most important tool in preventing burns, so it’s critical that nothing
interferes with that pain during the first session, said George
Martin, M.D., at the annual meeting of the American Society of
Cosmetic Dermatology and Aesthetic Surgery.
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“You need to stress that
(patients) don’t even think about taking any medications or
topical anesthetics before the session or it will affect their
outcome.”
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George Martin, M.D. |
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“The key point we make to any
staff members doing IPL is that patients’ pain is our index for
treatment limits,” he said. “Obviously you want to observe the skin
after a treatment pulse, but most importantly, you’re assessing what
the patient’s pain threshold is, so our rule is that we simply never
use topical anesthetic on the first session.”
As an extra precaution, if a
patient is more tanned than is desired, Dr. Martin begins with 30%
lower fluences than the anticipated treatment level and checks to see
how the skin reacts.
Sometimes patients themselves can
undermine efforts by pre-medicating themselves with pain medication or
a topical anesthetic before the appointment.
“If a patient is has pre-medicated
him- or herself, it throws off their pain index, so these patients
will tolerate higher fluences and they’ll cook,” said Dr. Martin, who
is in private dermatology practice in Maui, Hawaii.
“You need to stress that they
don’t even think about taking any medications or topical anesthetics
before the session or it will affect their outcome,” Dr. Martin said.
Dr. Martin had no disclosures
pertaining to his talk.
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Special Advertising Section
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TUESDAY,
AUGUST 26, 2008 |
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PDT, ablative laser combo can give rhinophyma
patients something to smile about
PHOENIX -- Rhinophyma can be can be an extremely emotionally
distressing condition for patients, but dermatologists can potentially
offer substantial improvements with a unique combination of
photodynamic therapy and ablative lasers, said Mark Nestor, M.D., at
the recent Valley of the Sun Conference on Clinical Dermatology.
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“We
can really remove a lot of tissue and essentially reconstruct a very rhinophymous
nose to make it normal and natural looking.”
-
Mark Nestor, M.D. |
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“We can totally reconstruct noses
with a combination of PDT and ablative lasers, and this is a key area
where lasers can work so well,” said Dr. Nestor, clinical associate
professor in the Department of Dermatology and Cutaneous Surgery at
the University of Miami’s Miller School of Medicine.
Dr. Nestor said his technique is
to first pretreat with photodynamic therapy to shut down the sebaceous
gland and then he sculpts the nose with CO2 laser.
“We can really remove a lot of
tissue and essentially reconstruct a very rhinophymous nose to make it
normal and natural looking.”
The rewards of such treatments are
highly gratifying, he added. “I really enjoy doing these treatments
because it truly changes these patients’ lives.”
Dr. Nestor’s disclosures included that he has served on
the physician advisory board and as a speaker for DUSA
Pharmaceuticals.
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LAST WEEK'S THEME:
BEST
OF BOTOX PEARLS |
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FRIDAY,
AUGUST 22, 2008 |
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Botox on the
brain? Keep a cool head, one surgeon suggests
SAN DIEGO --
A recent,
well-publicized study linking the traveling of botulinum toxin type A
to the brain in rats succeeded in launching the latest wave of public
concern over the widespread use of Botox.
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“The
fact that they found something like this should alarm no one.”
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Michael Kane, M.D. |
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While the paper
indeed warrants more investigation, at least one surgeon suggests
there’s not yet any cause for alarm. “The fact is, we’ve known just
about forever that Botox travels around the body,” said Michael Kane,
M.D., attending surgeon at the Manhattan Eye, Ear & Throat
Hospital.
“Studies going
back a decade show cervical dystonia patients that have changes in the
muscle of the thigh after being treated with Botox in the neck,” he
explained at the annual meeting of the
American Society for Aesthetic Plastic Surgery.
“The idea has
always been that the toxin didn’t get into the brain because it’s too
big to cross the blood brain barrier. But when you’re injecting into
the cranial nerve, which is the facial nerve, it doesn’t have to cross
the blood brain barrier because it’s basically already across,” he
said. “So the fact that they found something like this should alarm no
one.”
So how should
physicians respond when patients come in with justifiable concerns?
Perhaps remind them that most of the press didn’t really get the
science right.
“The press
routinely reported that Botox was found in the brain, but that wasn’t
really true,” Dr. Kane said. “They found some protein snippets that
appear to be cleaved, SNAP-25 associated protein, which is probably a
marker for Botox, but no one actually recovered Botox from the brain.”
Dr. Kane’s
disclosures include that he is a consultant for Allergan, Medicis and
Revance.
Read the study:
Long-Distance Retrograde Effects of Botulinum
Neurotoxin A
(Registration required for full-text)
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THURSDAY,
AUGUST 21, 2008 |
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Fresh vs. refrigerated Botox: Is one
more effective?
MIAMI -- Does previously reconstituted and refrigerated botulinum
toxin work as effectively as freshly reconstituted botulinum toxin?
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“This
study demonstrates that two weeks of refrigeration does not appear
to significantly affect the time of onset or efficacy of botulinum
toxin in the treatment of lateral periorbital rhytids.” |
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Researchers at the Bascom Palmer Eye Institute in Miami asked that
question and concluded that, when it comes to periorbital rhytids, the
answer is yes -- at least when it's two weeks old.
In
a double-blinded, controlled study involving 45 subjects, patients
interested in treatment of their lateral periorbital rhytids were
randomized to receive fresh botulinum toxin on one side and on the
other side, they received botulinum
toxin that had been reconstituted two weeks earlier and refrigerated. (Ophthal Plast Reconstr Surg.
2007 Nov-Dec;23(6):433-8).
The patients were asked to describe their appearance at two-week,
six-week and six-month post-treatment visits. In addition, an
independent ophthalmic plastic and reconstructive surgery fellow with
no knowledge of the study protocol or purpose was asked to evaluate
photos of the patients taken at each timeline over the three months.
The results showed no consistent improvement of one side over the
other: Five patients felt that there was a greater effect on the
freshly constituted side, and six indicated greater effect on the
refrigerated side. The independent physician noted difference in
effect between sides in four patients, with two improved on the
freshly constituted side, and two on the refrigerated side.
“This study
demonstrates that two weeks of refrigeration does not appear to
significantly affect the time of onset or efficacy of botulinum toxin
in the treatment of lateral periorbital rhytids,” the study concluded.
Source:
Ophthal Plast Reconstr Surg.
2007 Nov-Dec;23(6):433-8
(Subscription required for full study access) |
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WEDNESDAY,
AUGUST 20, 2008 |
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Botox gives HA
filler a big boost in longevity
SAN ANTONIO – Research has shown that
the combination of Botox and hyaluronic acid offers more than just an
ideal mix of wrinkle smoothing and soft-tissue augmentation – the
combination can also boost the longevity of HA, said Mitchel P.
Goldman, M.D., at the annual meeting of the American Academy of
Dermatology.
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“My
clinical experience has been that the
improvement in the glabellar is seen for probably more like a year
if I’m combining Restylane and Botox, compared to just
Restylane alone.”
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Mitchel P. Goldman, M.D. |
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Dr. Goldman cited a
landmark prospective study from Botox pioneers Drs. Jean and Alastair
Carruthers in which 38 subjects were split into two groups, with one
group receiving treatments of Botox combined and HA for moderate to
severe glabellar rhytides, and the other group receiving HA alone.
The results
showed that the median time for return to the pre-injection furrow
status was 32 weeks for the group with the combination of Botox and
HA, compared with just 18 weeks for the group with HA alone. (Dermatol
Surg. 2003 Aug;29(8):802-9)
The study ended at
32 weeks, but Dr. Goldman says he has seen even more impressive
results with the combination.
“My clinical
experience has been that the improvement in the glabellar is seen for
probably more like a year if I’m combining (HA filler) Restylane and
Botox, compared to just Restylane alone,” said Dr. Goldman, a
clinical professor of dermatology, University of California, San Diego,
and medical director of La Jolla Spa MD, in La Jolla, Calif.
“The glabella is
probably the primary reason why you want to use Botox and a filler at
the same time,” he said.
Dr. Goldman’s
disclosures include work as a consultant and clinical investigator
for Allergan and Medicis.
Read the
Carruthers' study:
Dermatol Surg. 2003 Aug;29(8):802-9 |
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TUESDAY,
AUGUST 19, 2008 |
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Fees should
reflect doctor's skill, not commodity
CHICAGO – It may be human nature
to try to undercut the competition and boost business, but Botox
injections aren’t cars, and patients are not looking for the red light
special. They’re looking for expertise, and most know that’s something
that doesn’t come cheap, said Michael S. Kaminer, M.D.,
F.A.A.D., at the annual meeting of the American Society for
Dermatologic Surgery.
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"In
my opinion, if you charge per unit, it suggests the price of a
commodity rather than a skill set.”
- Michael S. Kaminer,
M.D., F.A.A.D. |
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“You may increase your patient
volume by charging lower fees, but the catch-22 is that some patients
equate low fees with low skill,” said
Dr. Kaminer, an
assistant professor of dermatology at Yale University in New Haven,
Conn., and Dartmouth College in Hanover, N.H.
Charging Botox injections by the
unit, instead of by the area, can also undermine the role of value in
a pricing strategy, he said.
“In my opinion, if you charge per
unit, it suggests the price of a commodity rather than a skill set,”
Dr. Kaminer explained. “The value patients get from this treatment is
certainly your skill set. You need to charge for that and patients
understand that.”
They also can appreciate that per
area means the doctor will use just the right amount needed to achieve
the best results, regardless of how much or how little it takes.
“Per area pricing is better suited
because it allows you to be flexible with doses and help patients with
what they need,” he said. “You can tell patients: ‘Here’s what I
charge to do everything I can to make that area look as good as
possible'.”
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MONDAY,
AUGUST 18, 2008 |
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Keep Botox
patients smiling with free touch-ups
CHICAGO – Various factors can
influence a patient’s decision to jump ship and go to another doctor
for Botox injections. But a relatively simple service that can go a
long way in keeping patients – and keeping them happy -- is the free
touch-up, said Michael S. Kaminer, M.D.,
F.A.A.D., at the annual meeting of the American Society for
Dermatologic Surgery.
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"I
personally think that offering free touch-ups is very important
because your patients feel confident that they are getting a fair
value.”
- Michael S. Kaminer,
M.D., F.A.A.D. |
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“I offer all (Botox) patients
touch-up treatments at no charge at anything less than four weeks,”
said Dr.
Kaminer, an assistant professor of dermatology at Yale University in
New Haven, Conn., and Dartmouth College in Hanover, N.H.
“I personally think that offering
free touch-ups is very important because your patients feel confident
that they are getting a fair value.”
“If someone needs a touch-up, I
ask my staff to get them in right away. It just takes 5 to 10 minutes,
it doesn’t cost them anything, and the patients are highly
appreciative,” he added.
Conversely, charging patients for
a touch-up can send a negative message and perhaps even give the
patient the impression of having to pay extra for your mistake.
“Most people expect us to be
experts, and they expect us to nail it on the first time,” Dr. Kaminer
said. “So if you charge them for a touch-up, you will likely lose a
certain percentage of patients. It may be small, but you probably will
lose some.”
Dr. Kaminer disclosed that he is a
consultant for Cynosure,
Thermage and Sciton.
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THURSDAY,
JULY 31, 2008 |
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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.
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"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."
- Christopher Zachary, M.D., F.R.C.P. |
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“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.” |
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TUESDAY,
JULY 29, 2008 |
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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.
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"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."
- Margaret Mann, M.D. |
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“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.
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MONDAY,
JULY 28, 2008 |
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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.
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"It’s
important to tell patients before the
treatment
that with any fractional technologies, result are not going to be
seen right away."
- Bruce E. Katz, M.D. |
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“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.
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LAST WEEK'S THEME:
TISSUE
TIGHTENING |
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FRIDAY,
JULY 25, 2008 |
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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.
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THURSDAY,
JULY 24, 2008 |
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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.
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"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 heating device, and the type of device really doesn’t
even matter."
- David J. Goldberg, M.D. |
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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.
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WEDNESDAY,
JULY 23, 2008 |
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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.
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"The device not
only tightened tissue, but it melted fat, and that is absolutely
not something you want to have happen on the face."
- Jeffrey S. Dover, M.D. |
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“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.” |
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TUESDAY,
JULY 22, 2008 |
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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.
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"There
appears to be a stimulatory
effect
of the collagen that makes RF more effective in these patients."
- Cheryl Burgess, M.D. |
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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.
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MONDAY,
JULY 21, 2008 |
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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.
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