the chronicle of cosmetic medicine+surgery q4 2011

The Chronicle of

CosmeticMedicine

In conversation with Dr. Alastair Carruthers, pioneer of the aesthetic use of neurotoxins

Suction-assisted liposuction: Still a preferred technique

Breast augmentation: Patients must want the procedure for the right reasons

On the leading edge of research,

discoveries and new clinical

findings in aesthetic medicine

Fractionated CO lasers: 2

Lighter use can produce less

hyperpigmentation and swelling

Fat removal: a non-surgical

revolution

A new journal from the publishers of The Chronicle of Skin & Allergy

Premiere Edition November 2011

+ Surgery

cosmetic_dermatology_nov-2011_ver_2_10-31-11.qxd:cosmetic_dermatology_nov-2011_ver_2_10-31-11.qxd 15/11/11 3:58 PM

A DIVISION OF DERMTEK PHARMACEUTICALS

MICHEL LAVOIE WEST EDMONTON MALL

C.D.A. — 2011

All of us at Dermtek are pleased to support the launch of The Chronicle of Cosmetic Medicine & Surgery. Congratulations to editors Drs. Sapra, Solish and Pollack, and the entire

Canadian Aesthetic Medicine community on this achievement.

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From the editors: Dr. Sheetal Sapra on the future of non-surgical cosmetic medicine..................................................4

Cosmetic Update: On the leading edge of research, discoveries and new clinical findings in aesthetic medicine. Ignoring the aging process: A conversation with Dr. Alastair Carruthers,pioneer of the aesthetic use of neurotoxins ..................................................................................6

Briefing: Wrinkles might indicate bone fracture risk; Bimatoprost gel effective in study; Treateddepression improves cosmetic surgery satisfaction; and more..........................................................8

Suction-assisted liposuction: Still a preferred technique, according to findings ofrecent ASPS survey, as explained by Dr. Jamil Ahmad ..................................................................9

Topical neuromodulators: They’re coming soon. So, says Dr. Vince Bertucci, thequestion becomes, how close is the end of your injectable practice?............................................10

Product reconstitution: It can be more effective, and last longer for facial injections,according to Dr. Steve Fagien—but, there are still concerns ........................................................11

Fractionated CO2 lasers: Lighter use can produce less hyperpigmentation andswelling, says Dr. Héctor Leal Silva ............................................................................................15

Fat removal, a non-surgical revolution: HIFU is effective for noninvasivebody contouring of the anterior abdomen, while a dual-technology device adds radiofrequency, poten-tially enabling treatment of higher volume of fat ........................................................................16

Breast augmentation: Patients must want the procedure for the right reasons, explainsDr. Julie Khanna ......................................................................................................................20

Published four times annually by the proprietor, Chronicle Infor mation Resources Ltd., from offices at 555 Burnhamthorpe Rd., Suite 306, Tor onto, Ont. M9C 2Y3Canada. Tele phone: 416.916.2476; Fax 416.352.6199.E-mail: cosmetic@chroni cle.caContents © Chronicle Information Resources Ltd, 2011,except where noted. All rights reserved worldwide. ThePublisher prohibits reproduction in any form, including print,broadcast, and electronic, without written permission. Printed in Canada.Subscriptions: $59.95 per year in Canada, $79.95 per yearin all other countries, in Canadian or US funds. Single copies:$7.95 per issue. Subscriptions and single copies are subjectto 13% HST.Canada Post Canadian Publications Mail Sales ProductAgreement Number 40016917. Please forward all correspon-dence on circulation matters to: Circulation Manager, DentalChronicle, 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont.M9C 2Y3 Canada.E-mail: [email protected] ISSN 1927-4955

Since 1995, Ideas in the Service of Medicine. Publishers of: The Chronicle of Skin & Allergy, The Chronicle of Neurology & Psychiatry, Dental Chronicle, The Chronicle of Healthcare Marketing, Drug Rep Chronicle, Best PracticesChronicle, healthminute.tv, and Linacre’s Books.

EditorsSheetal Sapra, Oakville, Ont.

Nowell Solish, Toronto

National Editorial Board

Sheldon V. Pollack, Toronto (Chairman)

Scott Barr, Sudbury, Ont.

Arie Benchetrit, Montreal

Vince Bertucci, Woodbridge, Ont.

Yves Hérbert, Montreal

Frances Jang, Vancouver

Julie Khanna, Oakville, Ont.

Mathew Mosher, Vancouver

Stuart Maddin, Vancouver

William McGillivray, Vancouver

Kent Remington, Calgary

Arthur Swift, Montreal

Jean-François Tremblay, Montreal

Fred Weksberg, Toronto

Industry AdvisorsAnn Kaplan, iFinance, Toronto

Roxane Chabot, RBC Consultants,Montreal/Miami

Publisher Mitchell Shannon

Editorial DirectorR. Allan RyanSenior Associate EditorLynn Bradshaw

Assistant EditorJohn Evans

Sales & Marketing Cynthia Mac LarenProduction & CirculationCathy Dusome

ComptrollerRose Arciero

www.chronicle.tkwww.twitter.com/[email protected]


4 The Chronicle of Cosmetic Medicine + Surgery

The future of non-surgicalcosmetic medicinen Dr. Sheetal Sapra, O A K V I L L E , O N T.

Welcome to the first issue of our brand new journal: The Chronicle of Cosmetic Medicine + Sur gery. This will be adistinctive publication, befitting the unique medical specialty it will ser ve. Our goal is to offer infor mation onclinical developments and practical therapeutics, to stimulate discussion of the broader issues in aesthetic medi-cine, and to encourage best practices. Born as a collaboration between the publishers of The Chronicle of Skin &Allergy and the organizers of the annual Cosmetic Update educational conference, this journal will be guidedby a National Editorial Board, each member of which is a respected leader in our sphere (see pag e 3.)

We are proud to provide the first Canadian journal for physicians practicing aesthetic medicine, and we look for-ward to working with you to create a vehicle for the exchange of experiences and information. It’s my privilege, alongwith my colleague Dr. Nowell Solish, to serve as co-Medical Editor of The Chronicle. Therefore, I have the duty andthe honor to begin this ongoing dialogue with readers, which I will undertake by throwing out the following question:

How many of you are familiar with the “new kids on the bloc k” for non-surgical rejuvenation? As physi-cians, we are generally kept well-informed by industry regarding new developments, and I’ll guess that most ofus are at least somewhat aware of the most recently available products and technologies. More to the point, asdoctors, we possess the medical knowledge and the clinical experience to assess these inno vations and judgethem open-mindedly, based on their efficacy and merits .

The same capacity may not necessarily be shared by our patients. To illustrate the point, I just typed thephrase “new products for non-surgical rejuvenation” into the Google search engine. It took precisely one-quar-ter of one second for Google to find what the top of my computer screen described as “about 3,680,000results.” Among that lengthy inventory were quite a few g ood products with which I am familiar, and severalthat I recommend—along with some items that could be described accurately as highly dubious (and sev eralthat will only cause the conscientious ph ysician to shake his or her head.) It’s necessary to keep in mind thatour patients navigate regularly through an extremely wide rang e of treatment options. The ones on our radarare sound and reputable, but we need on occasion to consider the unen viable position of our patients, left tosort through those 3,680,000 findings, with only their doctor able to place the infor mation in a legitimate med-ical context.

Non-invasive Cosmetic MedicineCollagen and volumization opened up the whole non-surgical cosmetic medicine field, as did lasers and theconcept of selective damage to cells, but I think the most impor tant development in non-surgical cosmeticmedicine was made by Drs. Alastair and Jean Carruthers, with Botox (see page 6.) Now, the non-surgical revo-lution is extending into fat removal. There are several unique devices currently available that can offer dramaticresults. We look at two of them on pages 16 and 17.

But a word of caution: When availing patients to the benefits of these devices, you’re going to be treatingsome who may not have realistic expectations, or much of an understanding of the scientific issues involved intheir therapy. A large part of our role as doctors is to comm unicate the potential advantages and risks associat-ed with each medical innovation that finds its way into our armamentarium.

That, too, is part of the mission of The Chronicle of Cosmetic Medicine + Sur gery. By providing 7,000Canadian physicians with a national for um to explore, examine, and discuss the ideas, theories, and views perti-nent to our practices, we hope to play a significant role in educating our colleagues , humanizing our avocation,and improving outcomes for those under our care . Let us know what you think of this first issue. Write us [email protected], follow us on Twitter at www.twitter.com/skinchronicle, or visit us on the w eb atwww.chronicle.tk. (That wasn’t a typo. The address is “chronicle.tk,” not “.com.” And in case you’re wonder-ing, the designation TK stands for tool-kit.) —[email protected]

Commentaryand opinion oncurrent topics of interest in aesthetic medicine


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Ignoring the aging processA conversation with Dr. Alastair Carruthers, pioneer of the aesthetic use of neurotoxins n Dr. Alastair Carruthers, a clinical professor of dermatology in the faculty of medicine at the University ofBritish Columbia and president of Carruthers Dermatology Centre Inc. in Vancouver, was the 2010 recipientof the Samuel J. Stegman award for Distinguished Service, presented by the American Society for Der mato -logic Surgery (ASDS). Dr. Carruthers served as president of the ASDS in 2006-2007.

The Stegman Award is designed to recognize a member of the medical community who has made a significantcontribution toward furthering the goals of the society through education, org anizational services, and/or research.

Dr. Carruthers is probably best known for pioneering the use of botulinum toxin in cosmetic medicinewith his wife, ophthalmologist Dr. Jean Carruthers. Correspondent Louise Gagnon of The Chronicle ofCosmetic Medicine + Sur gery spoke to Dr. Carruthers about the award.

What was your reaction when you found out you were selected as the recipient of the Samuel J. Stegman award?It is a real recognition by my colleagues that what I have been doing is worthwhile. I got quite emotional whenthey rang me and told me . It's a big deal. Although the a ward went to me, it’s really Jean’s as well.

What areas of research are you currently involved in?We’re continuing to work with botulinum toxins and various fillers, and are conducting a study on safety and theuse of topical anesthetic since what clinicians do routinely [with anesthetic] has not been w ell investigated. Onearea that seems to have captured a lot of attention is fat removal. We are continuing to do studies in that area.We are principally working on the cool sculpting, or Zeltiq. It seems to be a procedure that is astoundingly safe.

Why do you think there has been an explosion in cosmetic medicine in the last two decades?It may have something to do with the attitudes of the baby boomers, that they are attempting to igno re the agingprocess. They are going to continue to look their best and they are n ot allowing themselves to slide into old ag e.At the same time, I think people realize that products like Botox are outstandingly safe. It works, it’s a simple pro-cedure for the recipients, and the side effects are minimal. W hat else does that? The answer is, “Not much.”

What do you see as recent cosmetic medicine advances? Where do you think inroads can be made?There is always a risk of a bruise with fillers, but we are getting good at creating the ‘wow’ effect with fillers,and not producing any downtime [for patients]. We are getting there but it has taken 20 years. We still have along way to go on tightening skin. If we can come up with a w ay that really works to tighten skin on the fore-head and neck, that is the next big frontier . That is the area where I see the most potential. T here may be adevice that would do as good a job as surgery on the neck and forehead.

What approach are most patients taking with cosmetic medicine today compared to years ago?You used to wait until you were 50, had multiple procedures done, disappeared for two weeks, and when youreappeared no one recognized you. The paradigm now is about maintenance. We are getting people out of thesun, and they should be using Retin-A (tretinoin) on a daily basis . We are using Botox and gradually switchingthem to other fillers as they ag e. Facelifts are much safer, and the results are much less obvious.

How do you decide what is appropriate treatment for a patient?When you look at an individual, that person may need IPL, Botox, fillers, and surgery. You may not get asgood a result with one modality v ersus if you have all of the modalities available to you. I think that is the situ-ation at the present time.

What is your impression of the emergence of a topical gel formulation of botulinum toxin?It’s fascinating. I never dreamed that it would work, and it does.

n Topical toxin? See page 10

On the leadingedge of research,discoveries andnew clinical findings in aesthetic medicine

Dr. Carruthers accepting the Stegman award


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Bimatoprost gel effective in studyn Bimatoprost 0.03% gel for cosmet-ic eyelash growth and enhancementappears to be effective, researchersreported in the June 2011 issue ofJournal of Cosmetic Dermatology (Vol.9(2):96-102). During this prospective,double-masked, randomized controlledstudy, 52 patients without ocular dis-ease were assigned a control orbimatoprost 0.03% gel to apply to theeyelid margin once a day. Data showthat the adjusted mean change in eye-lash length from baseline to sixmonths was 0.77 mm in the bimato-prost group and -0.12 mm in the con-trol group (p=0.004). Overall, adverseeffects were experienced by two of 16patients (12.5%) in the control g roup

and nine of 36 patients (25%) in thebimatoprost gel group. Mean changein intraocular pressure from baselineto six months was0.685 mmHg in thecontrol group and -2.04mmHg in the bimato-prost group (p=0.009).

—Read the original study athttp://ow.ly/5mPYt

Fewer treat-ments possible?n After approximately two yearspatients can decrease the frequency ofBotox Cosmetic injections and stillreceive most of the same wrinkle-smoothing cosmetic benefits, accordingto new research at Oregon Health &Science University.

In this investigation, researchers

studied 50 women ages 30 to 50 years,who received regular Botox injectionsfor two years. “We found that after thepatient receives Botox Cosmetic injec-tions every four months for two years,the frequency of the injections can bechanged to every six months and stillachieve good results,” said Dr. Roger A.Dailey. “This demonstrates patients havethe ability to achievegood results with broad-er treatment schedulesand ultimately at a loweroverall treatment cost.”

—Read the origi-nal study at http://ow.ly/5mOT6

New hyaluronicdermal filler studiedn Data show that a new hyaluronic aciddermal filler, HAE (Emervel Deep)provides superior efficacy comparedwith HAP (Restylane Perlane) at sixmonths after the treatment of severenasolabial fold lines, according to areport published in the Journal of CosmeticDermatology (June 2011; 10(2):94-98).

During the investigation subjectswere randomized to receive injectionof HAE or HAP on their left or rightnasolabial fold lines. Overall, at bothweeks 12 and 24, the mean impro ve-ment in the Wrinkle Severity RatingScale (WSRS) frombaseline was reportedto be significantlygreater for HAE thanfor HAP (1.58 ± 0.89vs. 1.33 ± 0.82 at week24; p=0.002).

—Read the original study athttp://ow.ly/5nbbb

Dr. Sheldon V. Pollack of Toronto, Chairman of the

Editorial Board of The Chronicle of Cosmetic Medicine +

Surgery, was recently named President-Elect of the

Dermatologic & Aesthetic Surgery International League

(DASIL.) According to the group, headquartered in

Chicago, the election of Dr. Pollack, along with other officers and direc-

tors, highlights its mission to be a worldwide professional dermatologic

organization. Dr. Michael H. Gold of Nashville, Tenn. was appointed

President of DASIL, Dr. Marc B. Röscher, of Durban, South Africa, was

named Treasurer. Says Dr. Gold: “I truly believe that we have assembled

the finest collective group of dermatology and aesthetic

professionals, to lead. The designations create an

international leadership cadre encompassing the most

talented dermatologic surgeons around the world.”

DASIL is preparing for its 1st International Congress to

be held in Malta October 31st - November 4th, 2012.

Wrinkles might indicate bone fracture riskn Wrinkles might not just be a telltale sign of aging, accord-ing to Yale School of Medicine researchers. They report in anew study that the severity and distribution of skin wrinklesmight aid in predicting a woman’s bone fracture risk.

During the investigation researchers assessed skin wrin-kles at 11 locations on the face and nec k using a pictoralscale in 114 of the Kronos Early Estrogen Prevention Study(KEEPS) enrollees, and assessed skin rigidity at the foreheadand the cheek using a durometer, a gauge used to measurethe density of a material. Skeletal mass and density werestudied by dual X-ray absorptiometery as well as by a

portable heel ultrasound device.“We found that deepening and worsening skin wrinkles

are related to lower bone density among the study par ticipants,”said Lubna Pal, an associate professor in the De partment ofObstetrics, Gynecology & ReproductiveScience at Yale School of Medicine.

“The worse the wrinkles, the lesser thebone density, and this relationship was inde-pendent of age or of factors known to influ-ence bone mass.”

—Read the original study at http://ow.ly/5nKf3

Treated depression improves cosmetic surgery satisfactionn Data show that patients treated for de pression show a trend toward greater sat-isfaction from facial plastic surgical procedures than those not treated for de pres-sion, according to a report in Archives of Facial Plastic Surgery (2010; 12(3):192-196).

This study involved 51 patients (mean [SD] ag e, 53 [13.0]; 69%female; 98% white) from the Center for F acial Cosmetic Surgery atthe University of Michigan between Jan. 1, 2007, and Jan. 1, 2008.Findings reveal that patients who were treated for depression priorto and during the investigation were more satisfied with surgicaloutcomes than those not being treated (p=0.05).

—Read the original study at http://ow.ly/5mNoX

Catch a code: Scan thesebriefs on your smartphone


n Data from a recent sur veyconducted by representatives fromthe American Society for AestheticPlastic Surgery (ASAPS) suggeststhat suction-assisted liposuctionremains the preferred method forfat removal compared to newerliposuction modalities includingultrasound-assisted, power-assist-ed, laser-assisted, and noninvasive

devices, according to Dr. Jamil Ahmad.

“I think that these types of sur veys are impor tantbecause they help us to gauge what the industry trendsare and help us determine where and how we canimprove to in turn benefit our patients,” said Dr. Ahmad,a plastic surg eon from T he Plastic Surg ery Clinic inMississauga, Ont. He was speaking at the University ofToronto’s Aesthetic Plastic Surgery Symposium in April.

This survey was sent to all ASAPS members , andoverall there was a 30% response rate, Dr. Ahmad said.

Survey respondents seemed to favour suction-assist-ed liposuction, whic h is b y far the most common tec h-nique that surgeons have experience with, he indicated.

“It is quite amazing that suction-assisted liposuctionseems to still stand the testof time . Ov erall, dataseemed to suggest that thepreferred liposuctionmethods b y plastic sur-geons a re t hose w ith t he

longest track records.” The fat remo val techniques that w ere used least

commonly by plastic surg eons included laser -assistedliposuction and nonin vasive devices , Dr . Ahmad re -ported.

“Of all the liposuction methods questioned withinthe survey, ultrasound-assisted liposuction w as voted asthe technique with highest complication rate—possiblybecause of earlier experiences when energ y was beingapplied directly under the der mis and ma ybe that hasstuck with a lot of us,” he said. Of more concern, “laser-assisted liposuction and mesotherapy were associatedwith a disproportionately high complication rate.”

Laser-assisted liposuction“When we focused in on the responses from the sur-geons who have performed laser-assisted liposuction,we found that about half of them conduct less than25 such procedures annually,” he said.

About 40% of the plastic surgeons surveyed indi-cated that they ha ve had to actually tak e care ofpatients with complications from this procedure suc has scarring, burning, and overall unsatisfactory results.

“I think that’s pretty dramatic considering thatnot a lot of surg eons seem to be perfor ming laser -assisted liposuction,” Dr. Ahmad commented.

Marketing geared toward patients“On a side note, there seems to be a lot of marketingdriven toward patients, which is making it tough tonavigate in medicine these days,” Dr. Ahmad said.

“What happens is that industr y markets directlyto patients and then patients call the surg eon’s officeto inquire about whether that surgeon conducts theprocedure. They might not, but it puts the surg eon ina difficult position when they g et a lot of phone callsrequesting the latest and g reatest technology.”

“We, as surg eons, have been put into an a wkwardposition because we have to make decisions in the bestinterests of our patients , but w e also h ave to tr y tostructure our practice in suc h a w ay to ensure th at weare successful. Patient demands for the latest procedureplace pressures on the surgeon to offer these technolo-gies even if there hasn’t been anyproven benefit,” Dr. Ahmad con-cluded.

The full results of this survey werepublished in the Feb. 2011 issue

of Aesthetic Surgery Journal

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ASPS survey suggests suction-assisted liposuction is still a preferred technique

Data suggests thatthe preferred lipo-

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n by Lynn BradshawO F T H E C H R O N I C L E

RT001 botulinimtoxin type A (BoNTA)topical gel, designedto reduce crow’s feetwrinkles by temporari-ly relaxing the musclesaround the eye,appears to be safe andeffective, Dr. VinceBertucci said duringa presentation at the2011 Cosmetic

Update in Playacar Riviera Maya, Mexico.“The goals of treatment with topical

botulinum toxin are quite similar to thegoals with the injectable for m,” said Dr,Bertucci, Medical Director at BertucciMedSpa in Woodbridge, Ont., and aConsultant Dermatologist at Women’sCollege Hospital in Toronto.

“We would like it to be easily applied,delivered precisely without spreadingbeyond the target area, and for it to gi vepredictable and reproducible results.”

Gel appears to be well toleratedData published in Dermatologic Surgery sug-gests that RT001 BoNTA topical geltreatment is well tolerated and effective atsmoothing the appearance of lateral can-thal lines (LCLs) (2010; 36:2111-2118).

The overall goal of this randomized,double-blind, repeat-dose, place-controlledstudy was to assess the efficacy and safetyof RT001 for the treatment of LCLs.

During the study healthy subjectswere randomized to receive RT001(n=19) or placebo (n=17) applied to their lateral canthal areas (LCAs).

“To evaluate safety of repeat exposure, treatment was administered at baselineand week 4. The primary efficacy measure was improvement in baseline LCL sever-ity using the Investigator’s Global Assessment of Lateral Canthal Line at Rest(IGA-LCL) Severity Scale,” the authors wrote. They added that the gel is applied bythe physician and then wiped off using a simple proprietar y cleansing procedure.

Findings reveal that at eight weeks, 19 (50%) LCAs treated with RT001 showeda 2-point or greater improvement in baseline IGA-LCL severity, versus none (0%) ofthe placebo-treated subjects (p<0.001); 36 (94.7%) LCAs treated with R T001 showeda 1-point or more improvement in baseline IGA-LCL severity, versus five (14.7%)placebo-treated LCAs (p<0.001). There were no treatment-related adverse events.

“A treatment that shows such promising results should appeal to a wide v ari-ety of new patients, many of whom do not like having a needle so close to heir

eyes and have been hesitant to come in fora cosmetic procedure,” Dr. Fredric Brandt,a dermatologist in private practice in NewYork and Miami, and lead investigator saidin a press release.

Further data from two multi-center,double-blind, randomized, controlled stud-ies showed that RT001 was well toleratedand demonstrated statistically significantefficacy versus controls.

The first study enrolled 90 subjectsand utilized a primary composite endpointthat included ratings by both the investiga-tor and the patient on validated wrinkleseverity scales. Researchers reported that tobe a responder, each subject had todemonstrate greater-than or equal to a 2-point improvement on both sides of theface as graded by the investigator’s assess-ment and the patient’s self-assessment.Overall, findings revealed that RT001 metthe primary endpoint and all secondar yendpoints with p<0.0001.

A total of 180 subjects were enrolledin the second study, which was designed tocompare the individual components com-prising RT001. These components includedBoNTA, the proprietary peptide carrier andthe vehicle. RT001 met the primary end-point of greater-than or equal to a 2-pointimprovement in LCL severity on both sidesof the face as measured by the investigator.

Overall, the results were found to bestatistically significant (p<0.0001) com-pared to each component of RT001 indi-vidually and all the components com-bined. RT001 also met the more stringentcomposite endpoint of greater-than orequal to a 2-point improvement on both

the investigator assessment and the patient’s self assessment compared to con-trols (p<0.0001). Researchers reported that these results suggest that the peptidecarrier is necessary for topically applied botulinum toxin to achieve positiveresults.

“Data showed that RT001 was well tolerated and there were no safety con-cerns or evidence of systemic exposure including symptoms, signs, and antibod-ies,” Dr. Bertucci said.

He added that there was no evidence of diffusion away from the target area,which is reassuring to clinicians considering the use of topical boutlinum toxin.

“I should note, however, that among RT001 subjects there were reportedcases of brow elevation after lateral orbicularis oculi treatment, whic h is some-thing you might expect when treating this area, ” Dr. Bertucci concluded.We welcome your views on this subject. Please send them to [email protected]

10 The Chronicle of Cosmetic Medicine + Surgery Volu

Coming soon:

Topical neuromodulators

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the end of your injectable practice?

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n by Joshua LongO F T H E C H R O N I C L E

A high concentration of product is not necessarily theway to g o for all applications of facial injections , sayscosmetic surgeon Dr. Steve Fagien, who has an aes-thetic eyelid plastic surgery practice in Boca Raton, Fla.

“In many w ays, we have made sev eral assump-tions r egarding existing in jectable p roducts, such a shyaluronic acid (HA) gels, for example; that the con-centration has been optimized or that the amount ofproduct deg radation after injection is linear . F orinstance, many of the products a re formulated to aconcentration of greater than 20 mg/mL and no onehas c hallenged what w ould occur if the pac kagedconcentration was reduced with regard to issues likeperformance and persistence. For example, if I hada 2 4 m g/mL p roduct ( like J uvéderm U ltra) a nd Ireduced (diluted) it to 12 mg/mL, one would assumethat it wouldn’t last as long and perhaps last aroundhalf as long. That is actually not what happens at all,”said Dr. Fagien, during a presentation at the TorontoAesthetic Plastic Surgery Symposium.

“I think deg radation of product is not neces-sarily concentration related. One thing for sure isthat the degradation is not linear. I don’t know whatthe curves are but my experience suggests that per-sistence of the product doesn ’t quantify with theamount of product that’s necessarily in there.”

Part of the reason is that undiluted product ma ynot redistribute itself after it is injected and physiciansare limited on how and where these agents can be inject-

ed. The applications can no w be expanded b y alteringexisting concentrations by reconstitution, he said.

“Some of the irregularities we see with some of theinjectable HA gels,” he says, “are partly due to techniqueand partly because these agents pretty-much stay whereor near where y ou place it. T his is fine when y ou wantthat effect and apply with optimal technique. In some sit-uations, contrary to some current thoughts, HA gels mayhave a better aesthetic effect when the product is allowedto drift a bit from the intended site. This is especially truewhen placing HA in the superficial der mis for the treat-ment of fine lines . Dilution allo ws for sev eral changesthat allow you to inject these products with smaller nee-dles more superficially and by reducing the concentrationyou can distribute product in a more even way and there-by eliminate fine lines without ir regularities.”

Though throughout his presentation he doesoccasionally refer to it as dilution, he prefers referringto the method as “reconstitution.”

“I use the word ‘reconstitution’ because ‘dilution’might sound like you’re giving someone less than theyshould get; like diluting Botox,” he said. “To the con-trary, with reconstitution, you actually make the prod-uct more versatile by allowing treatments in areas pre-viously not appropriate with a par ticular pac kagedproduct and the effective injectant is actually now ofgreater volume (i.e.,. there is ‘more of it’).”

Adding local anesthetic was how Dr. Fagien said hestarted reconstituting products . Before anesthetic w aspremixed with most injectable agents, he would add lido-caine with e pinephrine primarily for pain control. He

immediatelyn o t i c e di m p r o v e -ment w ithflow charac-teristics ofthe prod-ucts e venwith smalldegrees o fdilution.

“Another problem we were seeing with productsthat more recently contain lidocaine is that since it b yitself is a v asodilator both in theor y and practice thebruising after injection could actually be w orse,” hesaid. He also added that lik e other physicians he star t-ed adding 1 or 2% epinephrine, “because I believe, andI still do, that the epinephrine effect reduces bruising.”

Patients might require several syringes of productfor full treatment, perhaps for pan-facial volumization,and sometimes there is a bit left o ver in the finalsyringe. Dr . F agien w ould tak e the residual amountand fur ther dilute this with local anesthetic with thepresumption that this lesser concentration could beinjected with finer needles and could benefit thosewho required additional fine-line treatment (much likewas achieved with collagen).

“I star ted more carefully obser ving the utility ofthese diluted products b y no w pur posefully v aryingthe concentration. I would add maybe more lidocaineor saline to reduce the concentration not from just 24

Product reconstitutionDilute a product? It can be more effective, and last longer—but, still...

Dr. Fagien


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Carol, Age 49. Actual RADIESSE® Volumizing Filler Patient. Brampton, Ontario Unretouched Photo


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RADIESSE Volumizing Filler is indicated for subdermal implantation for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds and the rejuvenation of the hand. After injection, patients may experience redness, bruising, swelling or other local side effects. Most side effects of treatment resolve within a few days. More rare side effects may include swelling that lasts longer, unevenness or firmness in the area injected, and as with any injection, there may be a risk of infection.

1 Berlin A, Hussain M, Goldberg D. (2008) Calcium Hydroxylapatite Filler (RADIESSE®) for Facial Rejuvenation: A Histologic and Immunohistochemical Analysis. Dermatologic Surgery, Volume 34, S64-S67.

2 Bass LS, Smith S, Busso M, McClaren M. (2010) Calcium Hydroxylapatite (RADIESSE®) for Treatment of Nasolabial Folds: Long-Term Safety and Efficacy Results, Aesthetic Surgery Journal, 30 (2), 235-238.

Copyright © 2011 Merz Aesthetics, Inc. All rights reserved. MERZ AESTHETICS is a trademark of Merz Pharma GmbH & Co. KGaA. RADIESSE is a registered trademark of Merz Aesthetics, Inc.

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mg/mL to 20 mg/mL, whic h is what happens whenlidocaine is added for comfor t, but perhaps do wn to16 or 14 or less,” he said.

While others w ould typically add 10% v olumedilution with local anesthetic, Dr. Fagien said he wouldadd up to 50%, in order to reduce the concentrationof the existing product to between 12 to 18%.

And doing so has allowed him to treat patients inways that might ha ve otherwise required tec hniquesfor the treatment of fine lines including peels or ener-gy-based devices, as was the case with one patient whowas unhappy with her skin follo wing c hemotherapy,but did not want laser resurfacing.

“I decided to treat her with 1 cc of dilutedJuvéderm, diluted down to about 16 mix per mL,” hesaid. At that concentration, the f low c haracteristicschanged so that it was possible to inject her in a muchmore superficial dermal plane with a 32 g auge needle,he said.

Radial Cheek LinesWith f low c haracteristics as w ell as other ph ysicalproperties of the HA altered, said Dr . F agien, itbecomes easier to treat other features as w ell.

Radial c heek lines , whic h Dr . F agien said is aproblem of increasing concern for patients can also betreated through a method of reconstitution.

“I have lots of patients complaining about thesekinds of fine facial lines,” he said

Believing t hat t he e ffects o f H A o n t issues a remisunderstood, Dr. Fagien set up a comparison studybetween J uvéderm and Cosmoder m on a series ofpatients, using one of each agent on either side of apatient's face to see if the radial cheek and/or lip linescould be removed and to monitor these patients care-fully to evaluate comparative longevity.

“I lik ed Cosmoder m,” he said. “T he problemwith Cosmoderm was that it just didn ’t last but mostpatients were very pleased with the results .” Once itbecame apparent that collag en ag ents w ere soon tobecome unavailable, Dr. Fagien explored alter nativesfor the treatment of facial fine lines including alteringexisting products for these applications.

Indicating pictures of the patient at the presenta-tion to be a six-month result or more , he noted thelasting effects of Juvéderm, and how it compared withCosmoderm.

“You could see her right side w as treated withreconstituted Juvéderm at six months, still looks pret-ty good,” said Dr . Fagien, but the same could not besaid of the side treated with Cosmoder m.

“Although the results with Cosmoderm are usuallyinitially very good, the results are much more transient.”

Even at four months , he said, the diminishingeffects of Cosmoder m w ere apparent. “I also usedmuch less Juvéderm by volume on these patients com-pared with the Cosmoderm treated side,” he said.

Collagen replacement“With the demise of collagens in the U.S.—and every-where f or t hat m atter—I star ted resor ting to usingreconstituted Juvéderm. And I reconstituted to about16 millig rams per mL for most applications for thetreatment of facial fine lines,” Dr. Fagien said.

In a par ticular patient with significant fur rowingof her forehead who wanted Botox injections to raiseher brows, Dr. Fagien used the solution to fill thedepression and then the botulinum as well.

“I was able to shape the brows without worseningthese forehead lines and depressions,” he said.

He has also used this fine line treatment on apatient who had eyelid surg ery and also w anted deepcrow’s feet treated.

“You can see it f low lik e collag en,” he said,describing the process of injecting his patients whentreating with reconstituted Juvéderm.

“When you change the concentration, you changethe rheology and actually the flow characteristics amongother physical properties of the ag ents. By these alter-ations, you can [now] place these reconstituted productsin the same plane that you did with collagen.”

He said the effects at eight months and ev en atone year can be “pretty substantial.”

Other uses“So in m y practice , I ha ve a lot of y oung athleticwomen that lose a lot of facial fat, particularly in thetemporal fossa, they ha ve these little scallop areashere,” he said, referring to the temple area.

“When you use full strength HA in the temples totry to ref late the temples , you can g et a whole lot oflumps and ir regularities,” he said. “Y ou can massag ethem until the cows come home, yet due to the natureof these agents and the requirement of a lot of prod-uct to get any appreciable improvement they can get aconsiderable amount of visible contour irregulari-ties.”

“The problem with full strength products that wehave packaged, they don ’t always distribute v ery wellafter being injected,” he explained.

“But I have found, if I can reconstitute JuvédermI can get a far g reater even distribution of product inthis region. It’s a very quick recovery and a very natu-ral aesthetic effect with minimal cost.”

He says the mix he uses in these situations includes3 to 4 mL of saline mixed with local anesthetic.

“I was using about one cc to star t, diluting it toabout 4 or 5 cc and injecting a total of 5 cc. This pro-cedure usually requires 2 cc or tw o syringes [which isthen reconstituted to 5-10 mL of total product] forone treatment for each temple,” he said.

“When you star t with this procedure , star t slow,perhaps with only one syring e reconstituted to 5 mLbecause y ou will be a bit sur prised ho w they lookwhen they have 5 cc of product in each temple.”

The surprise can come when the patient g ets an

egg-like nodule immediately after injection, which Dr.Fagien said will dissipate as the patient applies com-pression and b y the time he’ s finished injecting theother temple.

He said the injection he makes is often superficialin the subcutaneous plane, which he calls an easy planeto find and a more forgi ving plane to inject and onecan achieve to most amount of reflation with a speci-fied amount of product: “You also avoid a lot of dis-comfort. One requires a more robust product (undi-luted) and far more of any agent when attempting todo this procedure b y injecting on top of , into orbeneath temporalis muscle.”

Dr. F agien sho wed a video demonstration. “I’lldo one side and I’ll first show you how I mark out thearea to be injected, carefully and slo wly injected theregion with the diluted Juvéderm. I then have thepatient participate by having them apply pressure withthe palm of their hand while I proceed then with treat-ment to the other side.”

He then proceeded to go step by step through theprocedure. “I mark out the line of temporal fusion. Imark out the posterior; and extend to where I need toinject. And equally as important, I mark out where theveins are. If you hit a v ein there, they’ve got a br uiseand it is likely to last quite a while .

“You can see this def lationary effect here,” refer-ring to a picture of a patient he conducted this proce-dure on. “Here y ou can see a nice , even, smooth aes-thetic result on this patient with resolution of the tem-poral depression, yet not overdone.”

A problem often seen in this procedure is signifi-cant venous dilation which dissipates in most patientsin a few days but can last for a few weeks, and does notoccur in every patient. Patients need to be made awareof this so they don ’t get concerned that something isnot quite right.

The results he sa ys, last at least one year in mostpatients.

CostWhile Dr. Fagien said he did not want to dictate howpeople charge at their practices, he is often asked howmuch he charges.

“I will tell y ou that in m y practice , I don ’t justcharge for the syring e. I c harge for m y exper tise andtime. It takes a bit more time and finesse to treat tem-ples,” he said. “You’re doing a lot more , you’re takinga bit more time with the planning and it requires ahigher level of artistic sense. The patients are usuallyquite gratified and can see the significant difference itmakes and contributes to their o verall facial appear-ance.”

Do you agree that it makes sense to start with lowquantities in facial injections? Please share yourthoughts, and we will publish a selection of com-ments. Send them to [email protected]

n Product reconstitution


n by Louise GagnonF O R T H E C H R O N I C L E

“Light” use of fractionated CO 2 lasers produces lesshyperpigmentation, says a dermatologic surgeon anddermatologist based in Monterrey, Mexico.

Since some skin types ha ve a high tendency tohyperpigmentation, treatment with a CO2 laser has tobe adapted to a void that side effect in those patients ,explained Dr. Héctor Leal Silva, speaking at Cos -metic Update.

“We star ted using the F raxel 750, and in somecases we saw that many of our patients exhibit somedegree of post-inflammatory hyperpigmentation, and

it was sometimes hard to define ho w wecould address these patients ,” said Dr .Leal Silva.

Some pat ients w ould exhibithyperpigmentation after a second ses-

sion of treatment while othersdisplayed h yperpigmentationafter a third session, noted Dr .Leal Silva.

Dr. Leal Silva tried mini fraxel, which is designedto apply lo w energies and m ultiple treatments .Unfortunately, h yperpigmentation w as still present,and it worsened with each session. What he beg an tonotice was that the colour in palmar creases , particu-larly the inter -digital creases , did not matc h the skincolour.

“It doesn’t have to do with Fitzpatric k skin typebecause I believ e it’s due to ancestr y and not directlyrelated to skin colour,” he said.

Dr. Leal Silva developed a four-point scale, with 0representing no pigment, 1 re presenting low pigment,two re presenting medium pigment, and three re pre-senting high pigment.

They found by the third session that patients withmedium pigment w ere developing post-inf lammatoryhyperpigmentation (PIH), and so they dev elopedlonger intervals between treatments. The frequency oftreatment is more significant than the energies that areused in the treatments in ter ms of a voiding PIH,according to Dr. Leal Silva.

“You can use two sessions one month apart, andthen you have to stop,” he said, referring to the proto-col for treating a patient at medium lev el risk forhyperpigmentation. “You have to let the skin reg ainthe whole surface to become intact, that tak es aboutfour-and-a-half months , and so w e let the patientsrecover for a pulse or a space of five months beforeretreating. If we want to do more than two sessions inthese patients, we have to wait five months for a thirdsession.”

The protocol is tw eaked for patients who ha ve ahigh level of pigment in their creases , said Dr . LealSilva. Such patients ma y develop PIH after a second

session of treatment. T he protocol is suc h that theyare treated once monthly ev ery five months. Patientswith low or null level of pigment can be treated safelyonce a month without any additional inter valsbetween treatment.

The technology is selected based on the assess-ment of the skin, said Dr. Leal Silva.

He chooses the 1927 nm (thulium) to treat melas-ma and other shallo w indications . For mild wrinklesand acne, he selects the erbium 1550 nm. W hen pho-todamage or deep wrinkles are present, and elastosisor laxity of the skin is evident, he c hooses the 10,600nm (CO2).

The most significant factor to consider is theinflammation and the coagulation or healing, said Dr .Leal Silva.

“The thulium tends to be v ery shallo w whilewhen you increase the energ y of an erbium, y ou canget very deep treatments that are useful for deep wrin-kles and scars while the pigment is v ery shallo w,”explains Dr. Leal Silva.

The number of passes that he selects depends onthe injury to the skin, whether sun damage, striae, acnescars, or wrinkles.

“I see the indications as a spectrum that goesfrom dee p pigment to dee p elastosis , so w e move

from the thulium to the CO 2,” he s ays. “We haveall of the fractionated tec hnologies. W e realizedthat w e d on’t n eed t oo m uch e nergy t o g et g oodresults.”

Where regular CO2 treatment promotes swelling,Dr. Leal Silv a applies “light” CO 2 treatment, a napproach he has dev eloped. “T here is still someswelling, but v ery different than the sw elling y ouobserve with regular CO2 [treatment],” he said.

The effect produced with “light” CO 2, involv-ing 5 millijoules and 5 per cent coverage of the skin,is comparable to the long-lasting effect that is pro-duced with standard CO 2 therapy, said Dr . LealSilva.

Dr. Leal Silva sometime uses fillers as an adjunctto fractionated laser treatment to optimize the out-come or perfor ms another procedure suc h as ble-pharoplasty.

“We like treatments that allow the patients not tobe afraid of technology, and they w ant to come bac kfor as many sessions as required,” he says.

Do you also use Dr. Leal Silva’s laser techniquesin your practice to avoid hyperpigmentation?We’d like to hear about your experiences. Writeto us at [email protected]

Dr. Leal SilvaDr. Leal Silva

less less hyperpigmentation,

swelling

Dermatologic surgeon tells Cosmetic Update delegates: Dermatologic surgeon tells Cosmetic Update delegates:

“We like treatments that allow the patients not to be afraid of technology, and they want to come back for as many sessions as required”

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Fat removal: The noHigh-intensity focused ultrasound (HIFU) tec hnology, such as theLipoSonix system, uses more energ y and offers the adv antage ofheat at a threshold of 56 deg rees C (one second) compared withother lo w energ y body-contouring ultrasound devices , indicatedDr. Nowell Solish, who presented at the 2011 Cos metic Up -date in Play acar Riviera Maya.

“When the LipoSonix system is used for nonin vasive bodycontouring it utilizes a focused thermal effect to destro y subcuta-neous adipose tissue via coagulative necrosis, whereas a low-energyultrasound device utilizes a mec hanical effect to destro y subcuta-neous adipose tissue via cavitation,” said Dr. Solish, AssistantProfessor at the University of Toronto.

Overall, the LipoSonix system utilizes energ y levels at >1000W/cm2 versus a low-energy ultrasound device that utilizes energ ylevels around 17.5 W/cm2, said Dr. Solish.

The LipoSonix system causes a contraction of collagen in thetreatment area, whereas a lo w-energy ultrasound device causes nocontraction of collagen in the treatment area, he noted.

“Sometimes when collagen contraction happens when usingHIFU tec hnology w e actually see skin c hanges as w ell as fatchanges.”

Dr. Solish added that the LipoSonix has a significant treatmentdepth from 1.1 cm to 1.8 cm in de pth in the target treatment area.

“Although I am not sure that de pth mak es a difference interms of fat necrosis , because when y ou compare data from m ystudy where I used m ultiple depths using the LipoSonix v ersus aLipoSonix FDA study where the researc hers only used one de pth,I think that the findings are about the same ,” he said.

“Depth can make a difference in terms of heat to skin contact,which results in collagen contraction.”Alternative to surgical lipoplasty The LipoSonix unit’s unique pattern delivery system enables a uni-form treatment of the abdomen in about one hour .

“Typically, the majority of the treatment zone is resorbedwithin eight to 12 weeks after treatment. At week 14 findings haveshown that the gross pathology shows normal wound healing withminimal fibrosis in the treatment zone and no damage to the skin,”Dr. Solish said.

During his presentation Dr. Solish referenced a study he com-pleted that involved the evaluation of patients 18 to 65 years of agewith a body mass index of <30 kg/m2 who had noninvasive bodycontouring of the anterior abdomen.

Each of the par ticipants had an abdominal subcutaneous tis-sue thickness of >2.6 cm in the target treatment area of the ante-rior abdomen. Additionally, patients had to ag ree that they w ouldnot change their diet or ex ercise during the study ev aluation peri-od.

This particular investigation involved assessment by Dr. Solishof three HIFU t reatment g roups a t 47 J/cm2, 52 J/cm 2 and 59

J/cm2. Overall, treatment with the specified energy level was deliv-ered in three consecutive passes at depths of 1.6 cm, 1.3 cm, and1.1 cm to the anterior abdomen.

All randomized patients (n=45) completed the study and wereincluded in the intent-to-treat population, said Dr. Solish. He addedthat >86% were women and >79% were Caucasian.

Findings reveal that a significant c hange from baseline w aistcircumference (CBWC) was observed with 59 J/cm2 at week 4 andwith all groups at weeks 8 and 12. Overall, there was no significantdifference in CBW C betw een treatment g roups at any point intime, explained Dr. Solish.

He add ed that a significant least squares (LS) mean in CBWCat week 12 w as also obser ved in all g roups when using measure-ments obtained 2 cm above and below the umbilicus.

“There was really no difference between energy levels statisti-cally, but after a month y ou could see a bit of change. However,most of the patients did not notice the change themselves,” he said.

“In all of the groups a trend toward the best results occur redat week 12. Additionally , at w eek 12 the patients and in vestigatorglobal aesthetic impro vement scale ratings w ere similar across thethree groups.”

Overall, 80% of pati ents who had noninvasive body contour-ing of the anterior abdomen w ere satisfied with the results of theprocedure, he said.

In order to deter mine the safety of HIFU using LipoSonix,Dr. Solish said that blood analysis were conducted at days 1 to 7and w eeks 2, 4, 8, 12, and 24 after treatment. In all, resultsshowed that no clinically significant changes were seen aftertreat ment.

“One of the biggest issues with LipoSonix was not safety, butpain tolerability. It seemed that patientsexperience more discomfor t whenhigher energ y w as used opposed towhen lower energy was used,” he said.

“I found that using the LipoSonixat higher lev els did not impro ve theresults and it really made the proceduremore i ntolerable, w hereas u sing t hedevice at lower levels actually improvedpatient pain tolerability.”

Dr. Solish concluded that Lipo -Sonix is a practical alternative to surgi-cal lipoplasty.

“Approximately 80 per cent ofpatients are satisfied with the results ofthe HIFU procedure. There appears tobe little to no side effects; and the aver-age loss of waste circumference is 2.5cm.”


HIFU effective for non-invasive body contouring of the anterior abdomen

New LipoSonix,UltraShapedevices enablemore flexibletreatmentoptions

n by Lynn BradshawO F T H E C H R O N I C L E

Have you used thesedevices in your practice? Ifso, let’s hear from you.Share your clinical obser-vations [email protected]

Dr. Solish


The latest UltraShape device , the V3, is 25% morepowerful than the earlier v ersion and no w also has atechnology called VDF (V ertical Dynamic F ocus) totreat a greater volume of fat, says Dr. Mark Lupin.

“So far, the newest version of UltraShape, the V3,has shown that it can remo ve 3.5 cm of fat with onetreatment whereas before i t would t ake two to threetreatments to get this type of result,” said Dr. Lupin,who first acquired the original UltraShape devicewhen it was approved by Health Canada in 2007.

According to Dr . Lupin, the UltraShape man ufac-turer has added a radiofrequency (RF) device to the V3UltraShape unit—it is now a dual technology device. Headded that the RF helps maximize the effecti veness ofthe treatments and may help stimulate a little tightening.

Dr. Lupin explained that the UltraShape works byutilizing focused ultrasound to remove fat.

“[Overall], the focused ultrasound of UltraShapecreates a non-ther mal cavitation effect to adipocytes ,which leads to immediate cell lysis ,” said Dr. Lupin.

He added that the fat is then cleared by the body’snormal healing processes. Dr. Lupin commented thatbecause this is a non-ther mal process , UltraShapetreatments are only minimally uncomfortable and gen-erally do not require taking any pain medications .

“What is great about the UltraShape,” explained Dr.Arie Benchetrit, a plastic surg eon from Mont realwho p resented a t t he 2 011 U niversity o f T orontoAesthetics Symposium, “is that it is a non-in vasive tech-nology scientifically v alidated to immediately , selectively

and permanently destroy fat cells.”From a scientific perspective, Dr. Lupin says that

he is impressed with the many peer review ed studiesand data documenting the safety and effecti veness ofthis technology.

Device is mobileThe V3 has a platfor m that is quite mobile comparedto the older UltraShape platform, which typically takesup space in an entire room, Dr. Benchetrit said. “Sure,I think the V3 is still a bulk y machine, but at least it ismovable.”

“Because of its unique imaging tec hnology,UltraShape pro vides the most ev en treatment forremoving fat; in fact, w e ha ve treated patients whohave had liposuction and are left with irregular, lumpyareas of fat. UltraShape can help create a smoother,more ev en effect, ” Dr . Lupin told The Chr onicle ofCosmetic Medicine + Sur gery

In Canada, there are only tw o other non-invasivecomparison products that remo ve fat cells: theLipoSonix and Zeltiq, indicated Dr. Lupin.

Dr. Lupin said that he also has LipoSonix in hisoffice and he uses it in a manner similar to UltraShape.He added that LipoSonix, unlike UltraShape, employsa high frequency ultrasound which means it creates athermal effect to remove the fat.

“The upside to LipoSonix is that the heat shouldlead to more significant skin tightening; the do wnsideto LipoSonix compared to UltraShape is that patientsmay find LipoSonix an uncomfortable procedure that

requires medication, leadsto br uising and sorenessthat will last tw o to threeweeks, and tak es tw o tothree months to seeresults,” Dr. Lupin noted.

“You cannot useLipo Sonix on the innerthighs but UltraShape isfine for this area. W e alsotreat gynecomastia in menwith UltraShape but notwith LipoSonix.”

UltraShape and ZeltiqZeltiq emplo ys a tec h-nique of cr yolipolysiswhereby the skin and fat

are cooled until the adipocytes are destro yed, Dr .Lupin explained.

“Since Zeltiq is pro-inflammatory and it will takemonths to realize result; Zeltiq is restricted to areaswhere it can be used [primarily the “lo ve handles” ofthe hips and abdomen] and is not lik ely to pro videresults as even as UltraShape,” Dr. Lupin said.

“Compared to LipoSonix and Zeltiq, UltraShapetreatments are lik ely to gi ve the most ev en result andstudies to date ha ve sho wn that a course of threeUltraShape treatments remo ves more fat that theother two technologies with their standard one to twotreatment regimens.”

“I prefer the Ultrashape because it provides fasterresults and hurts patients much less than the two othertreatment options,” added Dr. Martie Gidon, whoowns Gidon Aesthetics and MediSpa, a cosmetic der-matology practice in Toronto.

Not a weight loss solutionDr. Gidon told The C hronicle that the UltraShape isdesigned for the removal of stubborn fat deposits in apatient who is of average weight, with a BMI below 30.

“UltraShape is no t d esigned to be a completeweight loss solution, but for someone who has a healthydiet and exercises regularly and has stubborn fat that noamount of exercise will remove,” said Dr. Gidon.

Dr. Gidon said that there needs to be at least 0.75 to1 cm of fa t, an d one does not need 1.5 cm of fat asbefore.

UltraShape can be considered as an option forpatients who are not candidates for surgical inter ven-tions suc h as liposuction or abdominoplasty whoeither ha ve no other options or who simply do notwish to underg o surg ery with its risks and reco verytimes, added Dr. Lupin.

Although the most common procedures Dr .Benchetrit perfor ms as a plastic surg eon includeabdominoplasty and liposuction, he says that sometimespatients do not want invasive surgery. In those cases, herecommends Ultrashape as another treatment option.

Dr. Benc hetrit commented that he has usedUltrashape in his practice for o ver three years and hehas not witnessed incidents or heard re ports of seri-ous adverse events resulting from its use.

“I have, however, had two patient cases of blister-ing caused b y Ultrashape treatment, but the blisterswent on to heal nor mally without any per manentsequelae,” said Dr. Benchetrit.Dr. Benchetrit Dr. Gidon Dr. Lupin

Dual-technology adds radiofrequency, enables treatment of higher volume of fat

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In this Special Report, Dr . Sattler,director of the Rosenparkklinik inDarmstadt, Germany, reflects on howthe clinical uses and techniques relat-ed to neuromodulator treatment havedeveloped over the last de cade.

“Today we have clearer concepts

of how to use these neuromodulatorseffectively, and we also ha ve thechoice of three [botulinum] productsincluding Bocouture/Xeomin [clostridi-um botulinum neurotoxin type A fromMerz Pharma], Botox [botulinum toxintype A from Allergan], and Dysport[abobotulinumtoxin A from Medicis],”said Dr. Sattler.

“Being aware of the usage anddosage ra te of all three [botulinum]products is important in cl inical dailyuse. [This knowledge] helps erase theneed to use more than one neuro-modulator in your of fice sin ce thera-peutically desired ef fects can be cre-ated by using dif ferent dilutions,” Dr .Sattler said. “In clinical daily use, youcan use only one [neuromodulator]because yo u can modify the actionyou want to achieve by using a dif fer-ent dilution.”

In terms of differences in the usageof the three botulinum products, Dr .Sattler explained that 1 unit ofBocouture/Xeomin is equivalent to 1unit of Botox and 2.5 units of Dy sport.

“Although I like all three of the

products, I mostly use Xeomin/Bo -couture or Botox,” Dr. Sattler said.

His criteria for the choice of a neu-romodulator to use in his practiceinclude:

• Therapeutic efficacy• Patient satisfaction• Safety• Price• Handling

Unreconstituted Bocouture/Xeomin isstable for three years at temperaturesranging from -20 degrees Celsius to25 degrees Celsius. ReconstitutedBocouture/Xeomin i s s table f or 2 4hours at 2 degrees Celsius to 8degrees Celsius.

Dr. Sattler described further hispoint about varying dilutions withrespect to the ef fect he is trying toachieve.

“The therapeutic aim is to use dif-ferent dilutions, not to harm thepatient, and to use shorter intervalsof botulinum with fewer units in orderto minimize the risk of undesiredaction. Also, in 90 per cent of cases,neuromodulator therapy is used aspart of a combined therapeuticapproach.”

Dr. Sattler said the aims of neuro-modulator treatment are:• “to treat or influence the mimic action

to desired reduction of activity (nota light switch, not on/off);

• “to reorganize the balance of agonistand antagonist muscle activity;

• “to generate a general mimic stressrelief for a secondary compen-


Clinical use and benefits of nspecial reportspecial report from the 2011 cosmecosmetictic

Clinicians in 2011 have clearer concepts regarding how touse botulinum toxins effectively, which is especially importantsince there are now three different botulinum productson the market, said Dr. Gerhard Sattler during a presentationat the 2011 Cosmetic Update in Playacar RivieraMaya, Mexico.

Dr. Sattler

NOTE: The units provided in this article are for administration of Bocouture/Xeomin and Botox. The units are not appropriate for Dysport.


sative skin surface smoothing toachieve a global face rebalancedmimic activity.”

Total face approachDr. Sattler outlined in some detail histotal face approach with neuromodula-tors.

“My treatment approach tends tobe not just treating one area of theface, but treating as much of the faceas possible provided that the patient isin agreement,” said Dr. Sattler.

ForeheadTreatment of the forehead involvesdeep muscle injection into the medialarea in a V -configuration at 2 units ofbotulinum per site, as well as injectingsuperficial blebs on the lateral area ofthe forehead at 1 unit per site injection.

GlabellaFor tr eatment o f t he gl abella, D r.Sattler indicated that he performs oneto two injections of 2 units each cranialin the median line and further injec-tions medial and cranial in the centralparts of the muscle.

He added that when treating theglabella he also treats the M. corruga-tor supercilli by placing one medialinjection using 2 units of botulinum in afibrous direction.

E y e b r o wEyebrow treatment involves four injec-tions of two units of botulinum in thepart of the eyebrow above the orbitalrim, Dr. Sattler said. He added that heplaces a superficial injection in thefibres of the M. orbicularis and deep

injection in the fibres of M. corrugatorsupercilli, again at 2 units per injection.

Crow’s feet/smile lines“Crow’s feet treatment has beenknown to be over exaggerated by sev-eral units, but I like to use three to amaximum of four injection points forthis area. Each injection consists of 2units of botulinum,” he said.

EyelidsFor treatment of the lower eyelid, Dr.Sattler added that he likes to use fourintradermal depots with 0.5 units witha triple dilution, which is spread overthe entire area in general just to tamethe muscle activity.

“In cases where you want an openeye you can place a very superficialone unit of [botulinum] in the M. orbic-ularis oculi,” he said.

Bunny linesDr. Sattler recommends a superficialpuncture, one to two injections lateralto the mid cranial parts of the nose.

Gummy smileTo treat the gummy smile, Dr . Sattlerrecommends a deep caudal injectionin part of the M. levator labii superiorisusing two units of botulinum.

Upper and lower lipFor treatment of the upper and lowerlip, Dr. Sattler injects between the ver-million border and the white portion ofthe upper and lower lip using 1 unit ofbotulinum per injection.

Marionette linesDr. Sattler performs one deep lateralinjection of the marionette line tobypass the proximal parts of theplatysma. The distance to the cornerof the mouth should be in at least 1 cmin the caudal direction, to prevent dif-fusion in the M. orbicularis.

M. mentalisDr. Sattler injects the left and rightpart of the muscle, with a minimumdistance of 2 cm from the lower lip, toexclude a treatment of M. orbicularis.

“Overall, regardless of what treat-ment approach I use, I have found thatmost of my patients seem to want tokeep their natural look,” Dr . Sattlersaid in conclusion.

ReferenceSattler G, Callander M, Grablowitz D, et al:Noninferiority of incobotulinumtoxinA, free fromcomplexing proteins, compared with another botu-linum toxin type A in the treatment of glabellarfrown lines. Dermatol Surg 2010; 36:2146–2154.

Supplement to The Chronicle of Cosmetic Medicine + Surgery , Autumn 2011. Chronicle is an independ-ent medical news service that provides educational updates regarding medical developments around theworld. Views expressed are those of the participants and do not necessarily reflect those of the publisheror sponsor.

Support for distribution of this report was provided by Merz Pharma Canada Ltd. through an educa-tional grant without conditions. Information provided in this report is not intended to serve as the solebasis for individual care.

Printed in Canada for Chronicle Information Resources Ltd., 555 Burnhamthorpe Rd., Suite 306,Toronto, Ont. M9C 2Y3. Telephone 416.916.2476; facsimile 416.352.6199; e-mail: [email protected] 2011 by Chronicle Information Resources Ltd., except where noted. All rights reserved.Reproduction in any form is expressly prohibited without written permission of the publisher .

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UNSIGHTLYMARK

n Breast augmentation is only advisable when aperson has good overall physical and mentalhealth, says Dr. Julie Khanna, a plastic sur-geon from Oakville, Ont.

“It is important for the patient to be in theright frame of mind and w ant the breast implantprocedure for the right reasons ,” Dr. Khanna saidin an interview with THE CHRONICLE OF COSMETIC

MEDICINE + SUR GERY.“Also, it is impor tant that the patient has real-

istic expectations. For example, if they ha ve an Acup and they want to have surgery to change theirbreast size to a triple H cup , then I think that isunrealistic and disrespectful for their body.”

In cases where an indi vidual doesn’t meet Dr.Khanna’s surgical criteria either for health reasonsor because of unrealistic expectations , then shesaid that she will not conduct the surg ery.

After Dr. Khanna deter mines that a person isan appropriate candidate for breast augmentation,she starts off by measuring the width and height ofher patient’s natural breasts in order totailor the implant surg ery to the clientshe’s dealing with.

“Being aware of the measurementsof the patient’s natural breasts allowsme to ensure that I respect the parame-ters of where I am putting the implant.Other wise, if I am unaware of the nat-ural breast measurements , then theimplant could potentially look unnatu-ral,” Dr. Khanna said.

As an additional measure toensure that the patient is pleased withthe end result of the procedure , Dr .Khanna asks the patient to provide herwith photog raphs of w omen whohave the ideal breasts that they areseeking.

“I request the images because I want to havean understanding of what they are looking for asan end result,” she said.

“I cannot gi ve another person ’s breast tosomeone else, but at least then I can examine theideal breast photog raphs to help me deter minewhat implant w ould be best to suit the patient’ sneeds.”

Dr. Khanna said that there are tw o choices offillers or implants that are a vailable in Canada:

saline and silicone-g el breast implants . She addedthat saline implants ha ve more of a balloon typefeeling, whereas the silicone-gel is a little softer.

“The ability to feel or see the edg e of theimplant is lower with silicone-gel implants than it iswith saline implants,” she said.

“I think that silicone-g el implants allo w formore of an opportunity to deliver the right opera-tion for the patient because these come in a g reatvariety of sizes and shapes.”

In ter ms of breast implant size requests andtrends, Dr. Khanna sa id, “Breast augmentatio n haschanged to some deg ree. I think w e ha ve mo vedaway from the Victoria Bec kham huge breastimplant look. Instead now I think the general publichas moved toward seeking more of a natural look.”

Breast augmentation pros and cons“I alw ays sa y to m y patients that m uch lik e anyoperation there are pros and cons ,” she said.

“It is the patient’ s job to kno w what the prosare and it is m y job toinform eac h patientabout the cons of breastaugmentation.”

As with any opera-tion there are risks asso-ciated with surg ery, Dr .Khanna indicated. Sheadded that unlik e otheroperations breast aug-mentation is not a onetime operation.

“A patient will ha veto ha ve surg ery ag ain atsome point because theimplant product leaksover time,” she said.

“I alw ays tell m ypatients with implants

that they may require surgery in 10 to 15 years. Butif there are no problems then with some people wedo not ha ve to conduct another surg ery.Sometimes people don’t require surgery for over 30years.”

Dr. Khanna told THE CHRONICLE that there isno such thing as an operation without some risks ,but the key is to minimize risk by having the breastimplant surg ery conducted b y a fully accreditedplastic surgeon.

Patients must want breastaugmentation for the rightreasons, surgeon says


llFor rhinoplasty patients, preoperative evaluation should include examination of the nasal airway because

one of the most common complaints among patients after nasal surg ery is that they notice problems with

their breathing. However, these problems may have existed before surgery without the patient’s awareness.

It is critical for us to mak e appropriate corrections to the nasal airway during rhinoplasty to ensure that our

patients can breathe well, look great and have a positive experience overall following nasal surgery.

—Dr. Jamil Ahmad, plastic surgeon from The Plastic Surgery Clinic in Mississauga, Ont.

llApplying vibration at the same time as injecting local anesthetic seems to significantly decrease the pain of

the injection. It works by the gate control theory. Vibration is stimulating the fast A-fibers and therefore

blocking the slower C-fibers, which carry pain. It is like when you hit your head and rub it—it helps reduce

pain. A good massager to use is Acuvibe. It is cordless and produces a strong vibration.

—Dr. Christine Tang is a Royal College of Physicians and Surgeons board certified surgeon. She has been in practice at William Osler Health Centre, Etobicoke General Hospital since 1998

llWhen using BD 31 gauge 0.3 mL syringes to inject dermal fillers, it is critical that these not be confused with

the same syringes that are used to inject botulin um toxin. While I have contacted the company to request that

they offer two different color caps beyond the one orange cap now available, in the meantime I have found it

helpful to take a black Sharpie marker and create a small black mark on the tip of the orange cap of those

syringes that contain dermal filler.

—Dr. Mark Lupin is Clinical Instructor – UBC Department of Dermatology and Skin Science,

Vancouver; and Director – Cosmedica Laser Centre, Victoria BC (www.cosmetica.ca)

“Take a markerand create a smallblack mark on thetip of the orangecap of syringes that contain dermalfiller”

“Decrease painsignificantly byapplying vibrationconcurrent withinjection”

“Always evaluatethe nasal airwayand make corrections as necessary prior to rhinoplasty”

Pearls

Have you (or your colleagues) determined a Best Practice in aesthetic medicine that might deserve wider attention among your peers? Or have you picked upa takeaway message from a conference that you’d like to disseminate further? By all means, here’s the opportunity to share your knowledge and expertise.Forward your pearl to [email protected]


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AtelierBeauty of the idealized human form, depicted through artistic expression through the ages

Madame RécamierJacques-Louis David (1748-1825)

1800Musée du Louvre, Paris


MORE TO

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Now readers of The Chronicle of Cosmetic Medicine + Surgery can pre-order a copy of More to Skin Than Meets the Eye: The Making of a Dermatologist prior to publication, at a special discounted price, directly

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