Cosmetic Dermatology Highlights
Good News and Bad News
There was good news and bad news for cosmetic dermatologists at the 2004 American Academy of Dermatology Annual Meeting. The good news is that dermatologists and dermatologic surgeons have an ever-expanding arsenal of products, devices, and techniques to treat their patients. The bad news is that a number of legal, regulatory, and political issues may hamper the practices of dermatologists and dermatologic surgeons.
Darrell Rigel, MD, New York University Medical Center, New York, NY, highlighted some of the threats to the cosmetic dermatologist. Number one on the list was the growing effort to restrict office-based surgery, the setting for the vast majority of dermatologic surgical procedures. Arguments for the restriction of office-based surgery are made in the name of patient safety, but Dr. Rigel reminded us that no stakeholder in this debate is free of conflicts of interest. Dr. Rigel observed that dermatologists pioneered the 6 most common cosmetic procedures performed in the United States, but, despite this leading role in the advancement of cosmetic surgery, credentialing and privileging issues are used to restrict the dermatologist's practice.
Botulinum Toxin
Although there are difficulties on the political front, it is clear that the growing availability of cosmetic treatments will continue to expand the realm of cosmetic dermatology. Botulinum toxin (BTX) chemodenervation remains the leading cosmetic procedure in the United States. BTX pioneers Alastair Carruthers, FRCP, FRCPC, and Jean Carruthers, MD, FRCS, Carruthers Dermatology Centre Inc, and the University of British Columbia, Vancouver, British Columbia, led a day-long symposium on state-of-the-art uses of BTX. The most exciting developments in BTX are the growing applications of the toxin and the availability of multiple products (Table).
Table. Currently Available/Most Studied BTXs
Thomas Rohrer, MD, Boston, Massachusetts, summarized the history of BTX and provided evidence that will make it more user-friendly for the clinician. Studies have demonstrated that the use of preserved normal saline to reconstitute both BTX-A and BTX-B decreases the pain of injection when compared with unpreserved saline, which had been the standard practice. Additionally, evidence suggests that BTX-A is hardier than initially believed, as there is no loss of efficacy if foaming occurs during reconstitution. Moreover, it appears that BTX-A will retain effectiveness for as long as 6 weeks after reconstitution.
Andrew Markey, MD, FRCP, London, United Kingdom, discussed his experiences with the various BTXs. The key consideration with the products is that they are not generic equivalents. He has found that BTX-B can provide a more solid "freeze" with a more rapid onset than BTX-A. Unfortunately, he has also noted greater pain on injection with a shorter duration of action. Dr. Markey does not see a "killer" application for BTX-B at this time. In comparing his experience with the 2 forms of BTX-A (Botox and Dysport), he found no significant differences in onset and duration of action, pain of injection, or aesthetic result. Finally, he warned the audience to be careful if switching between products because dosing confusion could result.
Although some patients may want the so-called solid freeze that chemodenervation can provide, several panelists questioned the aesthetic value of this result. Dr. Markey summarized the inherent dilemma of BTX usage. The goal of wrinkle reduction should not come at the expense of kinesis; thus muscle paresis -- not paralysis -- may be the optimal outcome. This paradigm is critical because BTX use has expanded from the glabella to highly functional muscles of the midface and lower face as well as the neck.
Timothy Flynn, MD, Cary Skin Center, Cary, North Carolina, described the research he has performed with Drs. Jean and Alastair Carruthers and Dr. Robert Clark on the use of Botox in the lower eyelid. They combined crow's feet injection (12 units per side) with variable dosing in the lower eyelid* and found that a widening of the palpebral fissure and a more opened eye appearance resulted. The optimal dose for the lower lid is 2-4 units because higher doses lead to increased side effects such as dry eye and scleral show. To avoid complications, the BTX should be placed just subdermally, with the needle angled away from the globe.
Roberta Sengelmann, MD, Washington University School of Medicine, St. Louis, Missouri, described the research that she and Dr. Natalie Semchyshyn conducted in the use of BTX in the lips. Dr. Sengelmann drew several conclusions from her work in this area. Lip injections of BTX are more painful than in other areas of the body, and she recommends the use of topical cutaneous anesthesia such as LMX Topical Anesthetic Cream and the application of ice just before the injections. Additionally, Dr. Sengelmann found that her greatest success was in treating the entire lip, not just the wrinkles. The injection should be very superficial, at the dermal-subcutaneous junction.
Dr. Jean Carruthers described her technique for treating downward angulation of the lateral oral commissures, the so-called mouth frown. This problem leaves the patient with an unhappy look even when other areas of the face do not convey that emotion. She treats the depressor anguli oris with 3 units of BTX-A. The depressor anguli oris injection location lies in a zone at the jawline between the masseter muscle and a line extended from the nasolabial fold. Dr. Carruthers cautioned that care must be taken to avoid injection into the medially positioned depressor labii.
Fredric Brandt, MD, Coral Gables, Florida, described his experience with BTX rejuvenation of the neck. Treatment of the platysma serves 2 roles: The platysma itself is subject to banding, producing an aged appearance to the neck; furthermore, as the platysma extends to the lower face, the muscle can exert an undesirable downward force on the lower face. Dr. Brandt sees 3 main indications for BTX rejuvenation of the neck:
Kevin Smith, MD, FRCPC, Niagara Falls, Ontario, Canada, described the research he has conducted on the use of BTX in treating the pain of postherpetic neuralgia. In addition to blocking acetylcholine at the neuromuscular junction, it is thought that BTX may inhibit a number of mediators in the pain-signaling pathways. It is through its action on calcitonin gene-related peptide, vasoactive intestinal peptide, glutamate, and substance P that BTX effectively treats postherpetic neuralgia. Dr. Smith's approach is to inject 2-2.5 units of BTX approximately 1.5-2.5 cm apart. Although it is still preliminary, Dr. Smith noted effective and long-lasting pain relief.
Dr. Smith and Francisco Perez-Atamoros, MD, Mexico City, Mexico, independently discussed their experiences with BTX in nonsurgical breast lifting. Both physicians reported good results by injecting BTX into the pectoralis minor muscle. A total of 30-45 units per side is injected into 3 sites. They found that the optimal candidate is a younger patient with smaller breasts.
Although it is clear that BTX as a stand-alone agent has revolutionized cosmetic surgery, the synergistic effects of BTX combined with other modalities were also highlighted. Dr. Jean Carruthers emphasized the complementary effects of BTX and fillers such as Restylane ( nonanimal stabilized hyaluronic acid; Medicis; Scottsdale, Arizona). Tina Alster, MD, Washington, DC, relayed her positive experiences combining BTX and laser resurfacing. Dr. Alster found that the use of BTX decreased rhytids after CO2 laser resurfacing as compared with CO2 laser alone.
The panelists and many in the audience acknowledged an increase in the number of men seeking cosmetic enhancement. Chris Zachary, MD, University of California, San Francisco, discussed BTX in the male patient. Sales of cosmetic products and services to men is increasing, and it is estimated that nearly 15% of BTX patients are men. The motivation in the male patient appears to be primarily economic. Studies have indicated that men perceived to be attractive earn more money than those perceived to be less attractive.
Tissue Filler Update
Richard Glogau, MD, University of California, San Francisco, provided an update on fillers. The 2 most dramatic, recent events were the launch of CosmoDerm and CosmoPlast collagen fillers (Inamed Aesthetics; Santa Barbara, California) and the US Food and Drug Administration (FDA) approval of Restylane. CosmoDerm and CosmoPlast are human collagen; thus, it is thought that no pretreatment testing is required. Dr. Glogau's opinion is that these 2 products will replace Inamed's bovine collagen products, Zyderm and Zyplast. The hope is that the evidence that Restylane lasts longer than collagen products will be corroborated clinically in the long run.
There is considerable excitement and trepidation surrounding the so-called permanent fillers. Artefill (Artes Medical; San Diego, California), which is bovine collagen suspended in polymethylmethacrylate microspheres, received FDA advisory panel approval in 2003. Radiance (Bioform Medical; Franksville, Wisconsin) is FDA-approved for the treatment of vocal fold insufficiency and for radiographic tissue marking. The product is a particulate of synthetic calcium hydroxylapatite. There is extensive off-label use of Radiance for cosmetic soft tissue augmentation. The longevity is believed to be in the 2- to 6-year range.
Silikon 1000 (Alcon Laboratories; Fort Worth, Texas), an FDA-approved silicone for ophthalmic use, has received attention as off-label use for soft-tissue augmentation. Dr. Glogau cautioned that prior experiences with silicone products revealed that complications may not be apparent for 10 years or more. A premarket approval application is being reviewed by the FDA for Sculptra (Dermik Laboratories; Berwyn, Pennsylvania), a polylactic acid dermal-contouring product that is marketed in Europe under the trade name NewFill. Polylactic acid is a biodegradable compound that has been used in suture materials as well as orthopaedic and brow-fixation devices.
The concerns with permanent and semipermanent fillers are 2-fold. From an aesthetic standpoint, aging is a dynamic process, and an optimal correction today may not be suitable for the patient as further aging changes occur. Second, there is little room for error in placing the agents. Dr. Glogau summed up the situation well when he noted that all fillers cause problems, but temporary fillers cause temporary problems and permanent fillers can cause permanent problems.
Conclusion
The realm of cosmetic dermatology continues to expand in ways that benefit the patient. Patients appear to desire less and less recovery time from their cosmetic enhancements, and many of the advances described at the 2004 American Academy of Dermatology annual meeting fill that need.
*All units referred to in this report refer to the amount of Botox used. For the application of Dysport or Myobloc, conversion to the appropriate amount of that agent is required. References
There was good news and bad news for cosmetic dermatologists at the 2004 American Academy of Dermatology Annual Meeting. The good news is that dermatologists and dermatologic surgeons have an ever-expanding arsenal of products, devices, and techniques to treat their patients. The bad news is that a number of legal, regulatory, and political issues may hamper the practices of dermatologists and dermatologic surgeons.
Darrell Rigel, MD, New York University Medical Center, New York, NY, highlighted some of the threats to the cosmetic dermatologist. Number one on the list was the growing effort to restrict office-based surgery, the setting for the vast majority of dermatologic surgical procedures. Arguments for the restriction of office-based surgery are made in the name of patient safety, but Dr. Rigel reminded us that no stakeholder in this debate is free of conflicts of interest. Dr. Rigel observed that dermatologists pioneered the 6 most common cosmetic procedures performed in the United States, but, despite this leading role in the advancement of cosmetic surgery, credentialing and privileging issues are used to restrict the dermatologist's practice.
Botulinum Toxin
Although there are difficulties on the political front, it is clear that the growing availability of cosmetic treatments will continue to expand the realm of cosmetic dermatology. Botulinum toxin (BTX) chemodenervation remains the leading cosmetic procedure in the United States. BTX pioneers Alastair Carruthers, FRCP, FRCPC, and Jean Carruthers, MD, FRCS, Carruthers Dermatology Centre Inc, and the University of British Columbia, Vancouver, British Columbia, led a day-long symposium on state-of-the-art uses of BTX. The most exciting developments in BTX are the growing applications of the toxin and the availability of multiple products (Table).
Table. Currently Available/Most Studied BTXs
| Trade Name | Botox | Dysport | Myobloc/Neurobloc |
|---|---|---|---|
| Toxin type | A | A | B |
| Manufacturer/distributor | Allergan | Ipsen Biopharm Ltd. | Elan Pharmaceuticals |
| FDA indication(s) | Glabellar lines, blepharospasm, strabismus, cervical dystonia | None; cervical dystonia in other countries | Cervical dystonia |
Thomas Rohrer, MD, Boston, Massachusetts, summarized the history of BTX and provided evidence that will make it more user-friendly for the clinician. Studies have demonstrated that the use of preserved normal saline to reconstitute both BTX-A and BTX-B decreases the pain of injection when compared with unpreserved saline, which had been the standard practice. Additionally, evidence suggests that BTX-A is hardier than initially believed, as there is no loss of efficacy if foaming occurs during reconstitution. Moreover, it appears that BTX-A will retain effectiveness for as long as 6 weeks after reconstitution.
Andrew Markey, MD, FRCP, London, United Kingdom, discussed his experiences with the various BTXs. The key consideration with the products is that they are not generic equivalents. He has found that BTX-B can provide a more solid "freeze" with a more rapid onset than BTX-A. Unfortunately, he has also noted greater pain on injection with a shorter duration of action. Dr. Markey does not see a "killer" application for BTX-B at this time. In comparing his experience with the 2 forms of BTX-A (Botox and Dysport), he found no significant differences in onset and duration of action, pain of injection, or aesthetic result. Finally, he warned the audience to be careful if switching between products because dosing confusion could result.
Although some patients may want the so-called solid freeze that chemodenervation can provide, several panelists questioned the aesthetic value of this result. Dr. Markey summarized the inherent dilemma of BTX usage. The goal of wrinkle reduction should not come at the expense of kinesis; thus muscle paresis -- not paralysis -- may be the optimal outcome. This paradigm is critical because BTX use has expanded from the glabella to highly functional muscles of the midface and lower face as well as the neck.
Timothy Flynn, MD, Cary Skin Center, Cary, North Carolina, described the research he has performed with Drs. Jean and Alastair Carruthers and Dr. Robert Clark on the use of Botox in the lower eyelid. They combined crow's feet injection (12 units per side) with variable dosing in the lower eyelid* and found that a widening of the palpebral fissure and a more opened eye appearance resulted. The optimal dose for the lower lid is 2-4 units because higher doses lead to increased side effects such as dry eye and scleral show. To avoid complications, the BTX should be placed just subdermally, with the needle angled away from the globe.
Roberta Sengelmann, MD, Washington University School of Medicine, St. Louis, Missouri, described the research that she and Dr. Natalie Semchyshyn conducted in the use of BTX in the lips. Dr. Sengelmann drew several conclusions from her work in this area. Lip injections of BTX are more painful than in other areas of the body, and she recommends the use of topical cutaneous anesthesia such as LMX Topical Anesthetic Cream and the application of ice just before the injections. Additionally, Dr. Sengelmann found that her greatest success was in treating the entire lip, not just the wrinkles. The injection should be very superficial, at the dermal-subcutaneous junction.
Dr. Jean Carruthers described her technique for treating downward angulation of the lateral oral commissures, the so-called mouth frown. This problem leaves the patient with an unhappy look even when other areas of the face do not convey that emotion. She treats the depressor anguli oris with 3 units of BTX-A. The depressor anguli oris injection location lies in a zone at the jawline between the masseter muscle and a line extended from the nasolabial fold. Dr. Carruthers cautioned that care must be taken to avoid injection into the medially positioned depressor labii.
Fredric Brandt, MD, Coral Gables, Florida, described his experience with BTX rejuvenation of the neck. Treatment of the platysma serves 2 roles: The platysma itself is subject to banding, producing an aged appearance to the neck; furthermore, as the platysma extends to the lower face, the muscle can exert an undesirable downward force on the lower face. Dr. Brandt sees 3 main indications for BTX rejuvenation of the neck:
The prior facelift or necklift patient who needs additional enhancement;
Poor surgical candidates; and
Younger patients not yet ready for surgical intervention.
Kevin Smith, MD, FRCPC, Niagara Falls, Ontario, Canada, described the research he has conducted on the use of BTX in treating the pain of postherpetic neuralgia. In addition to blocking acetylcholine at the neuromuscular junction, it is thought that BTX may inhibit a number of mediators in the pain-signaling pathways. It is through its action on calcitonin gene-related peptide, vasoactive intestinal peptide, glutamate, and substance P that BTX effectively treats postherpetic neuralgia. Dr. Smith's approach is to inject 2-2.5 units of BTX approximately 1.5-2.5 cm apart. Although it is still preliminary, Dr. Smith noted effective and long-lasting pain relief.
Dr. Smith and Francisco Perez-Atamoros, MD, Mexico City, Mexico, independently discussed their experiences with BTX in nonsurgical breast lifting. Both physicians reported good results by injecting BTX into the pectoralis minor muscle. A total of 30-45 units per side is injected into 3 sites. They found that the optimal candidate is a younger patient with smaller breasts.
Although it is clear that BTX as a stand-alone agent has revolutionized cosmetic surgery, the synergistic effects of BTX combined with other modalities were also highlighted. Dr. Jean Carruthers emphasized the complementary effects of BTX and fillers such as Restylane ( nonanimal stabilized hyaluronic acid; Medicis; Scottsdale, Arizona). Tina Alster, MD, Washington, DC, relayed her positive experiences combining BTX and laser resurfacing. Dr. Alster found that the use of BTX decreased rhytids after CO2 laser resurfacing as compared with CO2 laser alone.
The panelists and many in the audience acknowledged an increase in the number of men seeking cosmetic enhancement. Chris Zachary, MD, University of California, San Francisco, discussed BTX in the male patient. Sales of cosmetic products and services to men is increasing, and it is estimated that nearly 15% of BTX patients are men. The motivation in the male patient appears to be primarily economic. Studies have indicated that men perceived to be attractive earn more money than those perceived to be less attractive.
Tissue Filler Update
Richard Glogau, MD, University of California, San Francisco, provided an update on fillers. The 2 most dramatic, recent events were the launch of CosmoDerm and CosmoPlast collagen fillers (Inamed Aesthetics; Santa Barbara, California) and the US Food and Drug Administration (FDA) approval of Restylane. CosmoDerm and CosmoPlast are human collagen; thus, it is thought that no pretreatment testing is required. Dr. Glogau's opinion is that these 2 products will replace Inamed's bovine collagen products, Zyderm and Zyplast. The hope is that the evidence that Restylane lasts longer than collagen products will be corroborated clinically in the long run.
There is considerable excitement and trepidation surrounding the so-called permanent fillers. Artefill (Artes Medical; San Diego, California), which is bovine collagen suspended in polymethylmethacrylate microspheres, received FDA advisory panel approval in 2003. Radiance (Bioform Medical; Franksville, Wisconsin) is FDA-approved for the treatment of vocal fold insufficiency and for radiographic tissue marking. The product is a particulate of synthetic calcium hydroxylapatite. There is extensive off-label use of Radiance for cosmetic soft tissue augmentation. The longevity is believed to be in the 2- to 6-year range.
Silikon 1000 (Alcon Laboratories; Fort Worth, Texas), an FDA-approved silicone for ophthalmic use, has received attention as off-label use for soft-tissue augmentation. Dr. Glogau cautioned that prior experiences with silicone products revealed that complications may not be apparent for 10 years or more. A premarket approval application is being reviewed by the FDA for Sculptra (Dermik Laboratories; Berwyn, Pennsylvania), a polylactic acid dermal-contouring product that is marketed in Europe under the trade name NewFill. Polylactic acid is a biodegradable compound that has been used in suture materials as well as orthopaedic and brow-fixation devices.
The concerns with permanent and semipermanent fillers are 2-fold. From an aesthetic standpoint, aging is a dynamic process, and an optimal correction today may not be suitable for the patient as further aging changes occur. Second, there is little room for error in placing the agents. Dr. Glogau summed up the situation well when he noted that all fillers cause problems, but temporary fillers cause temporary problems and permanent fillers can cause permanent problems.
Conclusion
The realm of cosmetic dermatology continues to expand in ways that benefit the patient. Patients appear to desire less and less recovery time from their cosmetic enhancements, and many of the advances described at the 2004 American Academy of Dermatology annual meeting fill that need.
*All units referred to in this report refer to the amount of Botox used. For the application of Dysport or Myobloc, conversion to the appropriate amount of that agent is required. References
Cosmetic Surgery. Symposium 315. Program and abstracts of the American Academy of Dermatology 62nd Annual Meeting; February 6-11, 2004; Washington, DC.
Botulinum Toxin: Facial Cosmetic Use. Course 101. Program and abstracts of the American Academy of Dermatology 62nd Annual Meeting; February 6-11, 2004; Washington, DC.
Alam M, Dover JS, Arndt KA. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a double-blind, randomized controlled trial. Arch Dermatol. 2002;138:510-514.
van Laborde S, Dover JS, Moore M, et al. Reduction in injection pain with botulinum toxin type B further diluted using saline with preservative: a double blind, randomized controlled trial. J Am Acad Dermatol. 2003;48:875-977.
Trindade De Almeida AR, Kadunc BV, Di Chiacchio N, Neto DR. Foam during reconstitution does not affect the potency of botulinum toxin type A. Dermatol Surg. 2003;29:530-531.
Hexsel DM, De Almeida AT, Rutowitsch M, et al. Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application. Dermatol Surg. 2003;29:523-529.
Flynn TC, Carruthers JA, Carruthers JA, Clark RE. Botulin A toxin (Botox) in the lower eyelid: dose-finding study. Dermatol Surg. 2003;29:943-950.
Semchyshyn N, Sengelmann RD. Botulinum toxin A treatment of perioral rhytides. Dermatol Surg. 2003;29:490-495.
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