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Chronicle of

Medicine + Surgery

On the leading edge of research, discoveries and new clinical findings in aesthetic medicine Fractionated CO2 lasers: Lighter use can produce less hyperpigmentation and swelling Fat removal: a non-surgical revolution

In conversation with Dr. Alastair Carruthers, pioneer of the aesthetic use of neurotoxins Suctionassisted liposuction: Still a preferred technique Breast augmentation: Patients must want the procedure for the right reasons

A new journal from the publishers of The Chronicle of Skin & Allergy
Premiere Edition November 2011


All of us at Dermtek are pleased to support the launc of The Chronicle of C f pleased launch ch Cosmetic Medicine & Su Surgery. urgery. Congratulatio Congratulations to editors Drs. Sapra, Solish and Pollack, and the entire g ons Sapr , pra, , Canadian Aesthetic Medicine community on this achievement. Canadia an achi ievement.


reversa.ca reversa.ca

Sheetal Sapra, Oakville, Ont. Nowell Solish, Toronto
Published four times annually by the proprietor, Chronicle Information Resources Ltd., from offices at 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3 Canada. Telephone: 416.916.2476; Fax 416.352.6199. E-mail: cosmetic@chronicle.ca Contents Chronicle Information Resources Ltd, 2011, except where noted. All rights reserved worldwide. The Publisher 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 year in all other countries, in Canadian or US funds. Single copies: $7.95 per issue. Subscriptions and single copies are subject to 13% HST. Canada Post Canadian Publications Mail Sales Product Agreement Number 40016917. Please forward all correspondence on circulation matters to: Circulation Manager, Dental Chronicle, 555 Burnhamthorpe Rd., Suite 306, Toronto, Ont. M9C 2Y3 Canada. E-mail: circulation@chronicle.ca ISSN 1927-4955

National Editorial Board

Sheldon V. Pollack, Toronto (Chairman) Scott Barr, Sudbury, Ont. Arie Benchetrit, Montreal Vince Bertucci, Woodbridge, Ont. Yves Hrbert, Montreal Frances Jang, Vancouver Julie Khanna, Oakville, Ont. Mathew Mosher, Vancouver Stuart Maddin, Vancouver William McGillivray, Vancouver Kent Remington, Calgary Arthur Swift, Montreal Jean-Franois Tremblay, Montreal Fred Weksberg, Toronto

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; Treated depression improves cosmetic surgery satisfaction; and more..........................................................8

Industry Advisors
Ann Kaplan, iFinance, Toronto Roxane Chabot, RBC Consultants, Montreal/Miami Publisher Mitchell Shannon Editorial Director R. Allan Ryan Senior Associate Editor Lynn Bradshaw Assistant Editor John Evans Sales & Marketing Cynthia Mac Laren Production & Circulation Cathy Dusome Comptroller Rose Arciero www.chronicle.tk www.twitter.com/skinchronicle cosmetic@chronicle.tk

Suction-assisted liposuction:

Still a preferred technique, according to findings of recent ASPS survey, as explained by Dr. Jamil Ahmad ..................................................................9

Topical neuromodulators: Theyre coming soon. So, says Dr. Vince Bertucci, the question 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 Fagienbut, there are still concerns ........................................................11

Fractionated CO2 lasers: Lighter use can produce less hyperpigmentation and swelling, says Dr. Hctor Leal Silva ............................................................................................15 Fat removal, a non-surgical revolution:
HIFU is effective for noninvasive body contouring of the anterior abdomen, while a dual-technology device adds radiofrequency, potentially enabling treatment of higher volume of fat ........................................................................16

Breast augmentation:

Patients must want the procedure for the right reasons, explains Dr. Julie Khanna ......................................................................................................................20
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 Practices Chronicle, healthminute.tv, and Linacres Books.

The future of non-surgical cosmetic medicine

n Dr. Sheetal Sapra,
O A K V I L L E , O N T.

Commentary and opinion on current topics of interest in aesthetic medicine

Welcome to the first issue of our brand new jour nal: The Chronicle of Cosmetic Medicine + Sur gery. This will be a distinctive publication, befitting the unique medical specialty it will ser ve. Our goal is to offer infor mation on clinical developments and practical therapeutics, to stimulate discussion of the broader issues in aesthetic medicine, 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 guided by a National Editorial Board, eac h 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 forward to working with you to create a vehicle for the exchange of experiences and information. Its my privilege, along with my colleague Dr. Nowell Solish, to serve as co-Medical Editor of The Chronicle. Therefore, I have the duty and the 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 physicians, we are generally kept well-informed by industry regarding new developments, and Ill guess that most of us are at least somewhat a ware of the most recently available products and technologies. More to the point, as doctors, we possess the medical knowledge and the clinical experience to assess these inno vations and judge them open-mindedly, based on their efficacy and merits . The same capacity may not necessarily be shared b y our patients. To illustrate the point, I just typed the phrase new products for non-surgical rejuv enation into the Google search engine. It took precisely one-quarter of one second for Google to find what the top of my computer screen described as about 3,680,000 results. Among that lengthy inventory were quite a few g ood products with which I am familiar, and several that I recommendalong with some items that could be described accurately as highly dubious (and sev eral that will only cause the conscientious ph ysician to shake his or her head.) Its necessary to keep in mind that our patients navigate regularly through an extremely wide rang e of treatment options. The ones on our radar are sound and reputable, but we need on occasion to consider the unen viable position of our patients, left to sort through those 3,680,000 findings, with only their doctor able to place the infor mation in a legitimate medical context. Non-invasive Cosmetic Medicine Collagen and volumization opened up the whole non-surgical cosmetic medicine field, as did lasers and the concept of selective damage to cells, but I think the most impor tant development in non-surgical cosmetic medicine was made by Drs. Alastair and Jean Carruthers, with Botox (see page 6.) Now, the non-surgical revolution is extending into fat remo val. There are several unique devices cur rently available that can offer dramatic results. 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, youre going to be treating some who may not have realistic expectations, or much of an understanding of the scientific issues involved in their therapy. A large part of our role as doctors is to comm unicate the potential advantages and risks associated with each medical innovation that finds its way into our ar mamentarium. That, too, is part of the mission of The Chronicle of Cosmetic Medicine + Sur gery. By providing 7,000 Canadian physicians with a national for um to explore, examine, and discuss the ideas, theories, and views pertinent 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 at cosmetic@chronicle.ca, follow us on Twitter at www.twitter.com/skinchronicle, or visit us on the w eb at www.chronicle.tk. (That wasnt a typo. The address is chronicle.tk, not .com. And in case youre wondering, the designation TK stands for tool-kit.) drSapra@chronicle.ca

The Chronicle of Cosmetic Medicine + Surgery





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Ignoring the aging process

A conversation with Dr. Alastair Carruthers, pioneer of the aesthetic use of neurotoxins
British Columbia and president of Carruthers Dermatology Centre Inc. in Vancouver, was the 2010 recipient of the Samuel J. Stegman award for Distinguished Ser vice, presented by the American Society for Der matologic 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 significant contribution 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 medicine with his wife, ophthalmologist Dr. Jean Carruthers. Correspondent Louise Gagnon of The Chronicle of Cosmetic 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 b y my colleagues that what I ha ve been doing is worthwhile. I got quite emotional when they rang me and told me . It's a big deal. Although the a ward went to me, its really Jeans as well. What areas of research are you currently involved in? Were continuing to work with botulinum toxins and various fillers, and are conducting a study on safety and the use of topical anesthetic since what clinicians do routinely [with anesthetic] has not been w ell investigated. One area 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 aging process. 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, its a simple procedure for the recipients, and the side effects are minimal. W hat else does that? T he 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 tak en 20 years. We still have a long way to go on tightening skin. If we can come up with a w ay that really works to tighten skin on the forehead and neck, that is the next big frontier . That is the area where I see the most potential. T here may be a device that would do as good a job as surg ery 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 you reappeared no one recognized you. The paradigm now is about maintenance. We are getting people out of the sun, and they should be using R etin-A (tretinoin) on a daily basis. We are using Botox and gradually switching them to other fillers as they ag e. Facelifts are much safer, and the results are m uch 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 as good a result with one modality v ersus if you have all of the modalities available to you. I think that is the situation at the present time. Dr. Carruthers accepting the Stegman award What is your impression of the emergence of a topical gel formulation of botulinum toxin? Its fascinating. I never dreamed that it would work, and it does. n Topical toxin? See page 10
The Chronicle of Cosmetic Medicine + Surgery

n Dr. Alastair Carruthers, a clinical professor of dermatology in the faculty of medicine at the University of

On the leading edge of research, discoveries and new clinical findings in aesthetic medicine

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n Cosmetic Update

Wrinkles might indicate bone fracture risk

n Wrinkles might not just be a telltale sign of aging, accord-

ing to Yale School of Medicine researchers. They report in a new study that the severity and distribution of skin wrinkles might aid in predicting a womans bone fracture risk. During the investigation researchers assessed skin wrinkles at 11 locations on the face and nec k using a pictoral scale in 114 of the Kronos Early Estrogen Prevention Study (KEEPS) enrollees, and assessed skin rigidity at the forehead and the cheek using a durometer, a gauge used to measure the density of a material. Skeletal mass and density were studied 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 of Obstetrics, Gynecology & Reproductive Science at Yale School of Medicine. The worse the wrinkles, the lesser the bone density, and this relationship was independent of age or of factors known to influence bone mass. Read the original study at http://ow.ly/5nKf3 studied 50 women ages 30 to 50 years, who received regular Botox injections for two years. We found that after the patient receives Botox Cosmetic injections every four months for two years, the frequency of the injections can be changed to every six months and still achieve good results, said Dr. Roger A. Dailey. This demonstrates patients have the ability to achieve good results with broader treatment schedules and ultimately at a lower overall treatment cost. Read the original study at http://ow.ly/5mOT6

New hyaluronic dermal filler studied

Bimatoprost gel effective in study

ic eyelash growth and enhancement appears to be effective, researchers reported in the June 2011 issue of Journal of Cosmetic Dermatology (Vol. 9(2):96-102). During this prospective, double-masked, randomized controlled study, 52 patients without ocular disease were assigned a control or bimatoprost 0.03% gel to apply to the eyelid margin once a day. Data show that the adjusted mean change in eyelash length from baseline to six months was 0.77 mm in the bimatoprost group and -0.12 mm in the control group (p=0.004). Overall, adverse effects were experienced by two of 16 patients (12.5%) in the control g roup

n Bimatoprost 0.03% gel for cosmet-

and nine of 36 patients (25%) in the bimatoprost gel group. Mean change in intraocular pressure from baseline to six months was 0.685 mmHg in the control group and -2.04 mmHg in the bimatoprost group (p= 0.009). Read the original study at http://ow.ly/5mPYt

Fewer treatments possible?

n After approximately two years

dermal filler, HAE (Emervel Deep) provides superior efficacy compared with HAP (Restylane Perlane) at six months after the treatment of severe nasolabial fold lines, according to a report published in the Journal of Cosmetic Dermatology (June 2011; 10(2):94-98). During the investigation subjects were randomized to receive injection of HAE or HAP on their left or right nasolabial fold lines. Overall, at both weeks 12 and 24, the mean impro vement in the Wrinkle Severity Rating Scale (WSRS) from baseline was reported to be significantly greater for HAE than for HAP (1.58 0.89 vs. 1.33 0.82 at week 24; p= 0.002). Read the original study at http://ow.ly/5nbbb Catch a code: Scan these briefs on your smartphone

n Data show that a new hyaluronic acid

patients can decrease the frequency of Botox Cosmetic injections and still receive most of the same wrinklesmoothing cosmetic benefits, according to new research at Oregon Health & Science University. In this investigation, researchers

Treated depression improves cosmetic surgery satisfaction

isfaction from facial plastic surgical procedures than those not treated for de pression, according to a re port 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 at the University of Michigan between Jan. 1, 2007, and Jan. 1, 2008. Findings reveal that patients who were treated for depression prior to and during the investigation were more satisfied with surgical outcomes than those not being treated (p=0.05). Read the original study at http://ow.ly/5mNoX
n Data show that patients treated for de pression show a trend toward greater sat-

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 directors, 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. Rscher, 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.
The Chronicle of Cosmetic Medicine + Surgery

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

conducted by representatives from the American Society for Aesthetic Plastic Surgery (ASAPS) suggests that suction-assisted liposuction remains the preferred method for fat removal compared to newer liposuction modalities including ultrasound-assisted, power-assisted, laser-assisted, and noninvasive devices, according to Dr. Jamil Ahmad. I think that these types of sur veys are impor tant because they help us to gauge what the industry trends are and help us determine where and how we can improve to in turn benefit our patients, said Dr. Ahmad, a plastic surg eon from T he Plastic Surg ery Clinic in Mississauga, Ont. He was speaking at the University of Torontos Aesthetic Plastic Surgery Symposium in April. This survey was sent to all ASAPS members , and overall there was a 30% response rate, Dr. Ahmad said. Survey respondents seemed to favour suction-assisted liposuction, whic h is b y far the most common tec hnique that surgeons have experience with, he indicated. It is quite amazing that suction-assisted liposuction seems to still stand the test of time . Ov erall, data seemed to suggest that the Data suggests that the preferred lipopreferred liposuction suction methods methods b y plastic surby plastic surgeons geons a re t hose w ith t he are those with the longest track records

n Data from a recent sur vey

longest track records. The fat remo val techniques that w ere used least commonly by plastic surg eons included laser -assisted liposuction and nonin vasive devices , Dr . Ahmad re ported. Of all the liposuction methods questioned within the survey, ultrasound-assisted liposuction w as voted as the technique with highest complication ratepossibly because of earlier experiences when energ y was being applied directly under the der mis and ma ybe that has stuck with a lot of us, he said. Of more concern, laserassisted liposuction and mesotherapy were associated with a disproportionately high complication rate. Laser-assisted liposuction When we focused in on the responses from the surgeons who ha ve perfor med laser-assisted liposuction, we found that about half of them conduct less than 25 such procedures annually, he said. About 40% of the plastic surgeons surveyed indicated that they ha ve had to actually tak e care of patients with complications from this procedure suc h as scarring, burning, and overall unsatisfactory results. I think thats pretty dramatic considering that not 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 marketing driven toward patients, which is making it tough to navigate in medicine these days, Dr. Ahmad said. What happens is that industr y mark ets directly to patients and then patients call the surg eons office to inquire about whether that surgeon conducts the procedure. They might not, but it puts the surg eon in a difficult position when they g et a lot of phone calls requesting the latest and g reatest technology. We, as surg eons, have been put into an a wkward position because we have to make decisions in the best interests of our patients , but w e also h ave to tr y to structure our practice in suc h a w ay to ensure th at we are successful. Patient demands for the latest procedure place pressures on the surgeon to offer these technologies even if there hasnt been any proven benefit, Dr. Ahm ad concluded.
The full results of this survey were published in the Feb. 2011 issue of Aesthetic Surgery Journal

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n Cosmetic Update

n by Lynn Bradshaw

Coming soon:

RT001 botulinim toxin type A (BoNTA) topical gel, designed to reduce crows feet wrinkles by temporarily relaxing the muscles around the eye, appears to be safe and effective, Dr. Vince Bertucci said during a presentation at the 2011 Cosmetic Update in Playacar Riviera Maya, Mexico. The goals of treatment with topical botulinum toxin are quite similar to the goals with the injectable for m, said Dr, Bertucci, Medical Director at Bertucci MedSpa in Woodbridge, Ont., and a Consultant Dermatologist at Womens College Hospital in Toronto. We would like it to be easily applied, delivered precisely without spreading beyond the target area, and for it to gi ve predictable and reproducible results.

Topical neuromodulators

Gel appears to be well tolerated Data published in Dermatologic Surgery suggests that RT001 BoNTA topical gel treatment is well tolerated and effective at smoothing the appearance of lateral canHow close is thal lines (LCLs) (2010; 36:2111-2118). The overall goal of this randomized, double-blind, repeat-dose, place-controlled study was to assess the efficacy and safety of RT001 for the treatment of LCLs. During the study healthy subjects were 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 baseline and week 4. The primary efficacy measure was improvement in baseline LCL severity using the Investigators Global Assessment of Lateral Canthal Line at Rest (IGA-LCL) Severity Scale, the authors wrote. They added that the gel is applied by the physician and then wiped off using a simple proprietar y cleansing procedure. Findings reveal that at eight weeks, 19 (50%) LCAs treated with R T001 showed a 2-point or greater improvement in baseline IGA-LCL severity, versus none (0%) of the placebo-treated subjects (p<0.001); 36 (94.7%) LCAs treated with R T001 showed a 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 ariety of new patients, many of whom do not like having a needle so close to heir

the end of your injectable practice?

eyes and have been hesitant to come in for a cosmetic procedure, Dr. Fredric Brandt, a dermatologist in private practice in New York and Miami, and lead in vestigator said in a press release. Further data from two multi-center, double-blind, randomized, controlled studies showed that RT001 was well tolerated and demonstrated statistically significant efficacy versus controls. The first study enrolled 90 subjects and utilized a primar y composite endpoint that included ratings by both the investigator and the patient on v alidated wrinkle severity scales. Researchers reported that to be a responder, each subject had to demonstrate greater-than or equal to a 2point improvement on both sides of the face as graded by the investigators assessment and the patients self-assessment. Overall, findings revealed that RT001 met the primary endpoint and all secondar y endpoints with p<0.0001. A total of 180 subjects were enrolled in the second study, which was designed to compare the individual components comprising RT001. These components included BoNTA, the proprietary peptide carrier and the vehicle. RT001 met the primary endpoint of greater-than or equal to a 2-point improvement in LCL severity on both sides of the face as measured by the investigator. Overall, the results were found to be statistically significant (p<0.0001) compared to each component of RT001 individually and all the components combined. RT001 also met the more stringent composite endpoint of greater-than or equal to a 2-point improvement on both the investigator assessment and the patients self assessment compared to controls (p<0.0001). Researchers reported that these results suggest that the peptide carrier is necessary for topically applied botulinum toxin to achieve positive results. Data showed that RT001 was well tolerated and there were no safety concerns or evidence of systemic exposure including symptoms, signs, and antibodies, 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 reported cases of brow elevation after lateral orbicularis oculi treatment, whic h is something you might expect when treating this area, Dr. Bertucci concluded.

We welcome your views on this subject. Please send them to cosmetic@chronicle.ca The Chronicle of Cosmetic Medicine + Surgery


Dilute a product? It can be more effective, and last longerbut, still...

Product reconstitution

n by Joshua Long

A high concentration of product is not necessarily the way to g o for all applications of facial injections , sa ys cosmetic surgeon Dr. Steve Fagien, who has an aesthetic eyelid plastic surgery practice in Boca Raton, Fla. In many w ays, w e ha ve made sev eral assumptions r egarding e xisting i njectable p roducts, s uch a s hyaluronic acid (HA) gels, for example; that the concentration has been optimized or that the amount of product deg radation after injection is linear . F or instance, m any o f t he p roducts a re f ormulated t o a concentration of greater than 20 mg/mL and no one has c hallenged what w ould occur if the pac kaged concentration was reduced with regard to issues like performance and persistence. For example, if I had a 2 4 m g/mL p roduct ( like J uvderm U ltra) a nd I reduced (diluted) it to 12 mg/mL, one would assume that it wouldnt last as long and perhaps last around half as long. That is actually not what happens at all, said Dr. Fagien, during a presentation at the Toronto Aesthetic Plastic Surgery Symposium. I think deg radation of product is not necessarily concentration related. One thing for sure is that the degradation is not linear. I dont know what the curves are but my experience sug gests that persistence of the product doesn t quantify with the amount of product thats necessarily in there. Part of the reason is that undiluted product ma y not redistribute itself after it is injected and physicians are limited on how and where these agents can be injectVolume 1 Number 1

ed. T he applications can no w be expanded b y altering existing concentrations by reconstitution, he said. Some of the irregularities we see with some of the injectable HA gels, he says, are partly due to technique and partly because these agents pretty-much stay where or near where y ou place it. T his is fine when y ou want that effect and apply with optimal technique. In some situations, contrary to some current thoughts, HA gels may have a better aesthetic effect when the product is allowed to drift a bit from the intended site This is especially true . when placing HA in the superficial der mis for the treatment of fine lines . Dilution allo ws for sev eral changes that allow you to inject these products with smaller needles more superficially and by reducing the concentration you can distribute product in a more even way and thereby eliminate fine lines without ir regularities. Though throughout his presentation he does occasionally refer to it as dilution, he prefers referring to the method as reconstitution. I use the word reconstitution because dilution might sound like youre giving someone less than they should get; like diluting Botox, he said. To the contrary, with reconstitution, you actually make the product more versatile by allowing treatments in areas previously not appropriate with a par ticular pac kaged product and the effective injectant is actually now of greater volume (i.e.,. there is more of it). Adding local anesthetic was how Dr. Fagien said he started reconstituting products . Before anesthetic w as premixed with most injectable agents, he would add lidocaine with e pinephrine primarily for pain control. He

immediately noticed improvement w ith flow characteristics of the products e ven Dr. Fagien with small degrees o f dilution. Another problem we were seeing with products that more recently contain lidocaine is that since it b y itself is a v asodilator both in theor y and practice the bruising after injection could actually be w orse, he said. He also added that lik e other physicians he star ted adding 1 or 2% epinephrine, because I believe, and I still do, that the epinephrine effect reduces bruising. Patients might require several syringes of product for full treatment, perhaps for pan-facial v olumization, and sometimes there is a bit left o ver in the final syringe. Dr . F agien w ould tak e the residual amount and fur ther dilute this with local anesthetic with the presumption that this lesser concentration could be injected with finer needles and could benefit those who required additional fine-line treatment (much like was achieved with collagen). I star ted more carefully obser ving the utility of these diluted products b y no w pur posefully v arying the concentration. I would add maybe more lidocaine or saline to reduce the concentration not from just 24


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n Product reconstitution
mg/mL to 20 mg/mL, whic h is what happens when lidocaine is added for comfor t, but perhaps do wn to 16 or 14 or less, he said. While others w ould typically add 10% v olume dilution with local anesthetic, Dr. Fagien said he would add up to 50%, in order to reduce the concentration of the existing product to betw een 12 to 18%. And doing so has allowed him to treat patients in ways that might ha ve otherwise required tec hniques for the treatment of fine lines including peels or energy-based devices, as was the case with one patient who was unhappy with her skin follo wing c hemotherapy, but did not want laser resurfacing. I decided to treat her with 1 cc of diluted Juvderm, diluted down to about 16 mix per mL, he said. At that concentration, the f low c haracteristics changed so that it was possible to inject her in a much more superficial dermal plane with a 32 g auge needle, he said. Radial Cheek Lines With f low c haracteristics as w ell as other ph ysical properties of the HA altered, said Dr . F agien, it becomes easier to treat other features as w ell. Radial c heek lines , whic h Dr . F agien said is a problem of increasing concern for patients can also be treated through a method of reconstitution. I have lots of patients complaining about these kinds of fine facial lines, he said Believing t hat t he e ffects o f H A o n t issues a re misunderstood, Dr. Fagien set up a comparison study between J uvderm and Cosmoder m on a series of patients, using one of each ag ent on either side of a patient's face to see if the radial cheek and/or lip lines could be removed and to monitor these patients carefully to evaluate comparative longevity. I lik ed Cosmoder m, he said. T he problem with Cosmoder m was that it just didn t last but most patients w ere v ery pleased with the results . Once it became apparent that collag en ag ents w ere soon to become una vailable, Dr. Fagien explored alter natives for the treatment of facial fine lines including altering existing products for these applications. Indicating pictures of the patient at the presentation to be a six-month result or more , he noted the lasting effects of Juvderm, and how it compared with Cosmoderm. You could see her right side w as treated with reconstituted Juvderm at six months, still looks pretty good, said Dr . Fagien, but the same could not be said of the side treated with Cosmoder m. Although the results with Cosmoderm are usually initially very good, the results are much more transient. Even at four months , he said, the diminishing effects of Cosmoder m w ere apparent. I also used much less Juvderm by volume on these patients compared with the Cosmoder m treated side, he said. Collagen replacement With the demise of collagens in the U.S.and everywhere f or t hat m atterI star ted resor ting to using reconstituted Juvderm. And I reconstituted to about 16 millig rams per mL for most applications for the treatment of facial fine lines, Dr. Fagien said. In a par ticular patient with significant fur rowing of her forehead who wanted Botox injections to raise her brows, Dr. Fagien used the solution to fill the depression and then the botulinum as well. I was able to shape the brows without worsening these forehead lines and de pressions, he said. He has also used this fine line treatment on a patient who had eyelid surg ery and also w anted deep crows feet treated. You can see it f low lik e collag en, he said, describing the process of injecting his patients when treating with reconstituted Juvderm. When you change the concentration, you change the rheology and actually the flow characteristics among other physical properties of the ag ents. By these alterations, you can [now] place these reconstituted products in the same plane that y ou did with collagen. He said the effects at eight months and ev en at one year can be pretty substantial. Other uses So in m y practice , I ha ve a lot of y oung athletic women that lose a lot of facial fat, particularly in the temporal fossa, they ha ve these little scallop areas here, he said, refer ring to the temple area. When you use full strength HA in the temples to try to ref late the temples , you can g et a whole lot of lumps and ir regularities, he said. Y ou can massag e them until the cows come home, yet due to the nature of these agents and the requirement of a lot of product to get any appreciable improvement they can get a considerable amount of visible contour irregularities. The problem with full strength products that we have packaged, they don t always distribute v ery well after being injected, he explained. But I have found, if I can reconstitute Juvderm I can get a far g reater even distribution of product in this region. Its a very quick recovery and a very natural aesthetic effect with minimal cost. He says the mix he uses in these situations includes 3 to 4 mL of saline mixed with local anesthetic. I was using about one cc to star t, diluting it to about 4 or 5 cc and injecting a total of 5 cc. This procedure usually requires 2 cc or tw o syringes [which is then reconstituted to 5-10 mL of total product] for one 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 mL because y ou will be a bit sur prised ho w they look when 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 compression and b y the time he s finished injecting the other temple. He said the injection he makes is often superficial in the subcutaneous plane, which he calls an easy plane to find and a more forgi ving plane to inject and one can achieve to most amount of reflation with a specified amount of product: You also avoid a lot of discomfort. One requires a more robust product (undiluted) and far more of any agent when attempting to do this procedure b y injecting on top of , into or beneath temporalis muscle. Dr. F agien sho wed a video demonstration. Ill do one side and Ill first show you how I mark out the area to be injected, carefully and slo wly injected the region with the diluted Juvderm. I then have the patient participate by having them apply pressure with the palm of their hand while I proceed then with treatment to the other side. He then proceeded to go step by step through the procedure. I mark out the line of temporal fusion. I mark out the posterior; and extend to where I need to inject. And equally as important, I mark out where the veins are. If you hit a v ein there, theyve got a br uise and it is likely to last quite a while . You can see this def lationary effect here, referring to a picture of a patient he conducted this procedure on. Here y ou can see a nice , even, smooth aesthetic result on this patient with resolution of the temporal depression, yet not overdone. A problem often seen in this procedure is significant venous dilation which dissipates in most patients in a few days but can last for a few w eeks, and does not occur in every patient. Patients need to be made aware of this so they don t get concerned that something is not quite right. The results he sa ys, last at least one year in most patients. Cost While Dr. Fagien said he did not want to dictate how people charge at their practices, he is often asked how much he charges. I will tell y ou that in m y practice , I don t just charge for the syring e. I c harge for m y exper tise and time. It takes a bit more time and finesse to treat temples, he said. Youre doing a lot more , youre taking a bit more time with the planning and it requires a higher level of artistic sense. The patients are usually quite gratified and can see the significant difference it makes and contributes to their o verall facial appearance. Do you agree that it makes sense to start with low quantities in facial injections? Please share your thoughts, and we will publish a selection of comments. Send them to cosmetic@chronicle.ca
The Chronicle of Cosmetic Medicine + Surgery


n by Louise Gagnon

Light use of fractionated CO 2 lasers produces less hyperpigmentation, says a dermatologic surgeon and dermatologist based in Monter rey, Mexico. Since some skin types ha ve a high tendency to hyperpigmentation, treatment with a CO 2 laser has to be adapted to a void that side effect in those patients , explained Dr. Hctor Leal Silva, speaking at Cosmetic Update. We star ted using the F raxel 750, and in some cases we saw that many of our patients exhibit some degree of post-inflammatory hyperpigmentation, and it was sometimes hard to define ho w we could address these patients , said Dr . Leal Silva. Some pat ients w ould exhibit hyperpigmentation after a second session of treatment while others displayed h yperpigmentation after a third session, noted Dr . Dr. Leal Silva Leal Silva. Dr. Leal Silva tried mini fraxel, which is designed to apply lo w energies and m ultiple treatments . Unfortunately, h yperpigmentation w as still present, and it worsened with each session. W hat he beg an to notice was that the colour in palmar creases , particularly the inter -digital creases , did not matc h the skin colour. It doesnt have to do with Fitzpatric k skin type because I believ e its due to ancestr y and not directly related to skin colour, he said. Dr. Leal Silva developed a four-point scale, with 0 representing no pigment, 1 re presenting low pigment, two re presenting medium pigment, and three re presenting high pigment. They found by the third session that patients with medium pigment w ere developing post-inflammatory hyperpigmentation (PIH), and so they dev eloped longer intervals between treatments. The frequency of treatment is more significant than the energies that are used in the treatments in ter ms of a voiding PIH, according to Dr. Leal Silva. You can use two sessions one month apart, and then you have to stop, he said, referring to the protocol for treating a patient at medium lev el risk for hyperpigmentation. You ha ve to let the skin reg ain the whole surface to become intact, that tak es about four-and-a-half months , and so w e let the patients recover for a pulse or a space of five months before retreating. If we want to do more than two sessions in these patients, we have to wait five months for a third session. The protocol is tw eaked for patients who ha ve a high lev el of pigment in their creases , said Dr . Leal Silva. Such patients ma y develop PIH after a second
Volume 1 Number 1

Different approach with produces less hyperpigmentation, swelling


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
session of treatment. T he protocol is suc h that they are treated once monthly ev ery five months. Patients with low or null level of pigment can be treated safely once a month without any additional inter vals between treatment. The tec hnology is selected based on the assessment of the skin, said Dr. Leal Silva. He chooses the 1927 nm (thulium) to treat melasma and other shallo w indications. For mild wrinkles and acne, he selects the erbium 1550 nm. W hen photodamage or deep wrinkles are present, and elastosis or laxity of the skin is evident, he c hooses the 10,600 nm (CO2). The most significant factor to consider is the inflammation and the coagulation or healing, said Dr . Leal Silva. The thulium tends to be v ery shallo w while when you increase the energ y of an erbium, y ou can get very deep treatments that are useful for deep wrinkles and scars while the pigment is v ery shallo w, explains Dr. Leal Silva. The number of passes that he selects depends on the injury to the skin, whether sun damage, striae, acne scars, or wrinkles. I see the indications as a spectrum that g oes from dee p pigment to dee p elastosis, so w e mo ve from the thulium to the CO 2, h e s ays. We h ave all of the fractionated tec hnologies. W e realized that w e d ont n eed t oo m uch e nergy t o g et g ood results. Where regular CO2 treatment promotes swelling, Dr. Leal Silv a applies light CO 2 treatment, a n approach he has dev eloped. T here is still some swelling, but v ery different than the sw elling y ou observe with regular CO 2 [treatment], he said. The effect produced with light CO 2, involving 5 millijoules and 5 per cent co verage of the skin, is comparable to the long-lasting effect that is produced with standard CO 2 therapy, said Dr . Leal Silva. Dr. Leal Silva sometime uses fillers as an adjunct to fractionated laser treatment to optimize the outcome or perfor ms another procedure suc h as blepharoplasty. We like treatments that allow the patients not to be afraid of technology, and they w ant to come bac k for as many sessions as required, he says. Do you also use Dr. Leal Silvas laser techniques in your practice to avoid hyperpigmentation? Wed like to hear about your experiences. Write to us at cosmetic@chronicle.ca


Fat removal: The n

HIFU effective for non-invasive body contouring of the anterior abdomen
High-intensity focused ultrasound (HIFU) tec hnology, such as the LipoSonix system, uses more energ y and offers the adv antage of heat at a threshold of 56 deg rees C (one second) compared with other lo w energ y body-contouring ultrasound devices , indicated Dr. Nowell Solish, who presented at the 2011 Cos metic Up date in Playacar Riviera Maya. When the LipoSonix system is used for nonin vasive body contouring it utilizes a focused thermal effect to destro y subcutaneous adipose tissue via coagulative necrosis, whereas a low-energy ultrasound device utilizes a mec hanical effect to destro y subcutaneous adipose tissue via cavitation, said Dr. Solish, Assistant Professor at the University of Toronto. Overall, the LipoSonix system utilizes energ y levels at > 1000 W/cm2 versus a low-energy ultrasound device that utilizes energ y levels around 17.5 W/cm 2, said Dr. Solish. The LipoSonix system causes a contraction of collagen in the treatment area, whereas a lo w-energy ultrasound device causes no contraction of collagen in the treatment area, he noted. Sometimes when collagen contraction happens when using HIFU tec hnology w e actually see skin c hanges as w ell as fat changes. Dr. Solish added that the LipoSonix has a significant treatment depth 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 in terms of fat necrosis , because when y ou compare data from m y study where I used m ultiple de pths using the LipoSonix v ersus a LipoSonix 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 units unique pattern delivery system enables a uniform treatment of the abdomen in about one hour . Typically, the majority of the treatment zone is resorbed within eight to 12 weeks after treatment. At week 14 findings have shown that the gross pathology shows normal wound healing with minimal fibrosis in the treatment zone and no damage to the skin, Dr. Solish said. During his presentation Dr. Solish referenced a study he completed that involved the evaluation of patients 18 to 65 years of age with a body mass index of <30 kg/m2 who had noninvasive body contouring of the anterior abdomen. Each of the par ticipants had an abdominal subcutaneous tissue thickness of >2.6 cm in the target treatment area of the anterior abdomen. Additionally, patients had to ag ree that they w ould not change their diet or ex ercise during the study ev aluation period. This particular investigation involved assessment by Dr. Solish of t hree H IFU t reatment g roups a t 4 7 J /cm2, 52 J/cm 2 and 59 J/cm2. Overall, treatment with the specified energy level was delivered in three consecutive passes at depths of 1.6 cm, 1.3 cm, and 1.1 cm to the anterior abdomen. All randomized patients (n=45) completed the study and were included in the intent-to-treat population, said Dr Solish. He added . that >86% were women and >79% were Caucasian. Findings reveal that a significant c hange from baseline w aist circumference (CBWC) was observed with 59 J/cm2 at week 4 and with all groups at weeks 8 and 12. Overall, there was no significant difference in CBW C betw een treatment g roups at any point in time, explained Dr. Solish. He added that a significant least squares (LS) mean in CBWC at week 12 w as also obser ved in all g roups when using measurements obtained 2 cm above and below the umbilicus. There was really no difference between energy levels statistically, but after a month y ou could see a bit of change. However, most of the patients did not notice the c hange themselves, he said. In all of the groups a trend toward the best results occur red at week 12. Additionally , at w eek 12 the patients and in vestigator global aesthetic impro vement scale ratings w ere similar across the three groups. Overall, 80% of pati ents who had noninvasive body contouring of the anterior abdomen w ere satisfied with the results of the procedure, 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 7 and w eeks 2, 4, 8, 12, and 24 after treatment. In all, results showed that no clinically significant changes were seen after treat m ent. One of the biggest issues with LipoSonix was not safety, but pain tolerability. It seemed that patients experience more discomfor t when higher energ y w as used opposed to when lower energy was used, he said. I found that using the LipoSonix at higher lev els did not impro ve the results and it really made the procedure more i ntolerable, w hereas u sing t he device at lower levels actually improved patient pain tolerability. Dr. Solish concluded that Lipo Sonix is a practical alternative to surgical lipoplasty. Approximately 80 per cent of patients are satisfied with the results of the HIFU procedure. There appears to be little to no side effects; and the a verage loss of waste circumference is 2.5 cm. Dr. Solish
The Chronicle of Cosmetic Medicine + Surgery

New LipoSonix, UltraShape devices enable more flexible treatment options

n by Lynn Bradshaw

Have you used these devices in your practice? If so, lets hear from you. Share your clinical observations at cosmetic@chronicle.ca


non-surgical revolution
Dual-technology adds radiofrequency, enables treatment of higher volume of fat
The latest UltraShape device , the V3, is 25% more powerful than the earlier v ersion and no w also has a technology called VDF (V ertical Dynamic F ocus) to treat 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 one treatment w hereas b efore i t would t ake t wo t o t hree treatments to get this type of result, said Dr. Lupin, who first acquired the original UltraShape device when it was approved by Health Canada in 2007. According to Dr . Lupin, the UltraShape man ufacturer has added a radiofrequency (RF) device to the V3 UltraShape unitit is now a dual technology device. He added that the RF helps maximize the effecti veness of the treatments and may help stimulate a little tightening. Dr. Lupin explained that the UltraShape works by utilizing focused ultrasound to remove fat. [Overall], the focused ultrasound of UltraShape creates 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 bodys normal healing processes. Dr. Lupin commented that because this is a non-ther mal process , UltraShape treatments are only minimally uncomfortable and generally do not require taking any pain medications . What is great about the UltraShape, explained Dr. Arie Benchetrit, a plastic surg eon from Mont real who p resented a t t he 2 011 U niversity o f T oronto Aesthetics Symposium, is that it is a non-in vasive technology 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 studies and data documenting the safety and effecti veness of this technology. Device is mobile The V3 has a platfor m that is quite mobile compared to the older UltraShape platform, which typically takes up space in an entire room, Dr. Benchetrit said. Sure, I think the V3 is still a bulk y machine, but at least it is movable. Because of its unique imaging tec hnology, UltraShape pro vides the most ev en treatment for removing fat; in fact, w e ha ve treated patients who have had liposuction and are left with irregular, lumpy areas of fat. UltraShape can help create a smoother, more ev en effect, Dr . Lupin told The Chr onicle of Cosmetic Medicine + Sur gery In Canada, there are only tw o other non-invasive comparison products that remo ve fat cells: the LipoSonix and Zeltiq, indicated Dr. Lupin. Dr. Lupin said that he also has LipoSonix in his office and he uses it in a manner similar to UltraShape . He added that LipoSonix, unlik e UltraShape, employs a high frequency ultrasound which means it creates a thermal effect to remove the fat. The upside to LipoSonix is that the heat should lead to more significant skin tightening; the do wnside to LipoSonix compared to UltraShape is that patients may find LipoSonix an uncomfortable procedure that requires medication, leads to br uising and soreness that will last tw o to three weeks, and tak es tw o to three months to see results, Dr. Lupin noted. You cannot use LipoSonix on the inner thighs but UltraShape is fine for this area. W e also treat gynecomastia in men with UltraShape but not with LipoSonix. UltraShape and Zeltiq Zeltiq emplo ys a tec hnique of cr yolipolysis whereby the skin and fat are cooled until the adipocytes are destro yed, Dr . Lupin explained. Since Zeltiq is pro-inflammatory and it will take months to realize result; Zeltiq is restricted to areas where it can be used [primarily the lo ve handles of the hips and abdomen] and is not lik ely to pro vide results as even as UltraShape, Dr. Lupin said. Compared to LipoSonix and Zeltiq, UltraShape treatments are lik ely to gi ve the most ev en result and studies to date ha ve sho wn that a course of three UltraShape treatments remo ves more fat that the other two technologies with their standard one to two treatment regimens. I prefer the Ultrashape because it provides faster results and hurts patients much less than the two other treatment options, added Dr. Martie Gidon, who owns Gidon Aesthetics and MediSpa, a cosmetic dermatology practice in Toronto. Not a weight loss solution Dr. Gidon told The C hronicle that the UltraShape is designed for the removal of stubborn fat deposits in a patient who is of average weight, with a BMI below 30. UltraShape is no t d esigned to be a complete weight loss solution, but for someone who has a healthy diet and exercises regularly and has stubborn fat that no amount of exercise will remove, said Dr. Gidon. Dr. Gidon said that there needs to be at least 0.75 to 1 cm of fa t, an d one does not need 1.5 cm of fat as before. UltraShape can be considered as an option for patients who are not candidates for surgical inter ventions suc h as liposuction or abdominoplasty who either ha ve no other options or who simply do not wish to underg o surg ery with its risks and reco very times, added Dr. Lupin. Although the most common procedures Dr . Benchetrit perfor ms as a plastic surg eon include abdominoplasty and liposuction, he says that sometimes patients do not want invasive surgery. In those cases, he recommends Ultrashape as another treatment option. Dr. Benc hetrit commented that he has used Ultrashape in his practice for o ver three years and he has not witnessed incidents or heard re ports of serious adverse events resulting from its use. I have, however, had two patient cases of blistering caused b y Ultrashape treatment, but the blisters went on to heal nor mally without any per manent sequelae, said Dr. Benchetrit.

Dr. Benchetrit

Dr. Gidon

Dr. Lupin

Volume 1 Number 1


special report from the 2011 cosmet

Clinical use and benefits of

Clinicians in 2011 have clearer concepts regarding how to use botulinum toxins effectively, which is especially important since there are now three different botulinum products on the market, said Dr. Gerhard Sattler during a presentation at the 2011 Cosmetic Update in Playacar Riviera Maya, Mexico.
of how to use these neuromodulators effectively, and we also ha ve the choice of three [botulinum] products including Bocouture/Xeomin [clostridium botulinum neurotoxin type A from Merz Pharma], Botox [botulinum toxin type A from Allergan], and Dysport [abobotulinumtoxin A from Medicis], said Dr. Sattler. Being aware of the usage and dosage ra te of all three [botulinum] products is important in cl inical daily use. [This knowledge] helps erase the need to use more than one neuromodulator in your of fice sin ce therapeutically desired ef fects can be created by using dif ferent dilutions, Dr . Sattler said. In clinical daily use, you can use only one [neuromodulator] because yo u can modify the action you want to a chieve by using a dif ferent dilution. In terms of differences in the usage of the three botulinum products, Dr . Sattler explained that 1 unit of Bocouture/Xeomin is equivalent to 1 unit 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 neuromodulator to use in his practice include: Therapeutic efficacy Patient satisfaction Safety Price Handling Unreconstituted Bocouture/Xeomin is stable for three years at temperatures ranging from -20 degrees Celsius to 25 degrees Celsius. Reconstituted Bocouture/Xeomin i s s table f or 2 4 hours at 2 degrees Celsius to 8 degrees Celsius. Dr. Sattler described further his point about varying dilutions with respect to the ef fect he is trying to achieve. The therapeutic aim is to use different dilutions, not to harm the patient, and to use shorter intervals of botulinum with fewer units in order to minimize the risk of undesired action. Also, in 90 per cent of cases, neuromodulator therapy is used as part of a combined therapeutic approach. Dr. Sattler said the aims of neuromodulator treatment are: to treat or influence the mimic action to desired reduction of activity (not a light switch, not on/off); to reorganize the balance of agonist and antagonist muscle activity; to generate a general mimic stress relief for a secondary compenThe Chronicle of Cosmetic Medicine + Surgery

Dr. Sattler In this Special Report, Dr . Sattler, director of the Rosenparkklinik in Darmstadt, Germany, reflects on how the clinical uses and techniques related to neuromodulator treatment have developed over the last decade. Today we have clearer concepts

NOTE: The units provided in this article are for administration of Bocouture/ Xeomin and Botox. The units are not appropriate for Dysport. 18

tic update sessions

neuromodulator treatment
sative skin surface smoothing to achieve a global face rebalanced mimic activity. Total face approach Dr. Sattler outlined in some detail his total face approach with neuromodulators. My treatment approach tends to be not just treating one area of the face, but treating as much of the face as possible provided that the patient is in agreement, said Dr. Sattler. Forehead Treatment of the forehead involves deep muscle injection into the medial area in a V -configuration at 2 units of botulinum per site, as well as injecting superficial blebs on the lateral area of the forehead at 1 unit per site injection. Glabella For tr eatment o f t he gl abella, D r. Sattler indicated that he performs one to two injections of 2 units each cranial in the median line and further injections medial and cranial in the central parts of the muscle. He added that when treating the glabella he also treats the M. corrugator supercilli by placing one medial injection using 2 units of botulinum in a fibrous direction. Eyebrow Eyebrow treatment involves four injections of two units of botulinum in the part of the eyebrow above the orbital rim, Dr. Sattler said. He added that he places a superficial injection in the fibres of the M. orbicularis and deep
Volume 1 Number 1

injection in the fibres of M. corrugator supercilli, again at 2 units per injection. Crows feet/smile lines Crows feet treatment has been known to be over exaggerated by several units, but I like to use three to a maximum of four injection points for this area. Each injection consists of 2 units of botulinum, he said. Eyelids For treatment of the lower eyelid, Dr. Sattler added that he likes to use four intradermal depots with 0.5 units with a triple dilution, which is spread over the entire area in general just to tame the muscle activity. In cases where you want an open eye you can place a very superficial one unit of [botulinum] in the M. orbicularis oculi, he said. Bunny lines Dr. Sattler recommends a superficial puncture, one to two injections lateral to the mid cranial parts of the nose. Gummy smile To treat the gummy smile, Dr . Sattler recommends a deep caudal injection in part of the M. levator labii superioris using two units of botulinum.

Upper and lower lip For treatment of the upper and lower lip, Dr. Sattler injects between the vermillion border and the white portion of the upper and lower lip using 1 unit of botulinum per injection. Marionette lines Dr. Sattler performs one deep lateral injection of the marionette line to bypass the proximal parts of the platysma. The distance to the corner of the mouth should be in at least 1 cm in the caudal direction, to prevent diffusion in the M. orbicularis.

M. mentalis Dr. Sattler injects the left and right part of the muscle, with a minimum distance of 2 cm from the lower lip, to exclude a treatment of M. orbicularis. Overall, regardless of what treatment approach I use, I have found that most of my patients seem to want to keep their natural look, Dr . Sattler said in conclusion.
Sattler G, Callander M, Grablowitz D, et al: Noninferiority of incobotulinumtoxinA, free from complexing proteins, compared with another botulinum toxin type A in the treatment of glabellar frown lines. Dermatol Surg 2010; 36:21462154.

Supplement to The Chronicle of Cosmetic Medicine + Surgery , Autumn 2011. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the participants and do not necessarily reflect those of the publisher or sponsor. Support for distribution of this report was provided by Merz Pharma Canada Ltd. through an educational grant without conditions. Information provided in this report is not intended to serve as the sole basis 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: health@chronicle.org. Copyright 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 .



Patients must want breast augmentation for the right reasons, surgeon says
n Breast augmentation is only advisable when a

person has good overall physical and mental health, says Dr. Julie Khanna, a plastic surgeon from Oakville, Ont.

(THE TK STAnds for tool-kit)

It is important for the patient to be in the right frame of mind and w ant the breast implant procedure for the right reasons , Dr. Khanna said in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SUR GER . Y Also, it is impor tant that the patient has realistic expectations. For example, if they ha ve an A cup and they w ant to have surgery to change their breast size to a triple H cup , then I think that is unrealistic and disrespectful for their body. In cases where an indi vidual doesnt meet Dr. Khannas surgical criteria either for health reasons or because of unrealistic expectations , then she said that she will not conduct the surg ery. After Dr. Khanna deter mines that a person is an appropriate candidate for breast augmentation, she starts off by measuring the width and height of her patients natural breasts in order to tailor the implant surg ery to the client shes dealing with. Being aware of the measurements of the patients natural breasts allows me to ensure that I respect the parameters of where I am putting the implant. Otherwise, if I am una ware of the natural breast measurements , then the implant could potentially look unnatural, Dr. Khanna said. As an additional measure to ensure that the patient is pleased with the end result of the procedure , Dr . Khanna asks the patient to provide her with photog raphs of w omen who have the ideal breasts that they are seeking. I request the images because I want to have an understanding of what they are looking for as an end result, she said. I cannot gi ve another person s breast to someone else, but at least then I can examine the ideal breast photog raphs to help me deter mine what implant w ould be best to suit the patient s needs. Dr. Khanna said that there are tw o choices of fillers or implants that are a vailable in Canada:

saline and silicone-g el breast implants . She added that saline implants ha ve more of a balloon type feeling, whereas the silicone-gel is a little softer. The ability to feel or see the edg e of the implant is lower with silicone-gel implants than it is with saline implants, she said. I think that silicone-g el implants allo w for more of an opportunity to deliver the right operation for the patient because these come in a g reat variety of sizes and shapes. In ter ms of breast implant size requests and trends, Dr. Khanna sa id, Breast augmentatio n has changed to some deg ree. I think w e ha ve mo ved away from the Victoria Bec kham huge breast implant look. Instead now I think the general public has 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 any operation there are pros and cons, she said. It is the patient s job to kno w what the pros are and it is m y job to inform eac h patient about the cons of breast augmentation. As with any operation there are risks associated with surg ery, Dr . Khanna indicated. She added that unlik e other operations breast augmentation is not a one time operation. A patient will ha ve to ha ve surg ery ag ain at some point because the implant product leaks over time, she said. I alw ays tell m y patients with implants that they may require surgery in 10 to 15 years. But if there are no problems then with some people we do not ha ve to conduct another surg ery. Sometimes people dont require surgery for over 30 years. Dr. Khanna told THE CHRONICLE that there is no such thing as an operation without some risks , but the key is to minimize risk by having the breast implant surg ery conducted b y a fully accredited plastic surgeon.

The Chronicle of Cosmetic Medicine + Surgery

Always evaluate the nasal airway and make corrections as necessary prior to rhinoplasty Decrease pain significantly by applying vibration concurrent with injection

For 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 patients 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.


Applying 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 r ub itit 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

Take a marker and create a small black mark on the tip of the orange cap of syringes that contain dermal filler

When using BD 31 g auge 0.3 mL syringes to inject der mal 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 ha ve found it helpful to take a black Sharpie marker and create a small blac k mark on the tip of the orange cap of those syringes that contain der mal 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)

Have you (or your colleagues) determined a Best Practice in aesthetic medicine that might deserve wider attention among your peers? Or have you picked up a takeaway message from a conference that youd like to disseminate further? By all means, heres the opportunity to share your knowledge and expertise. Forward your pearl to cosmetic@chronicle.ca
Volume 1 Number 1


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

Madame Rcamier
Jacques-Louis David
(1748-1825) 1800 Muse du Louvre, Paris





RE TO The future, ORE T O MO M present and past KIMNTSS S AN MEEEET TH AN YE TH of skin therapy, as HE E YE T HE E T seen by a doctor at the forefront of all three phases


Through his career (65-years-and-counting) as an international practitioner, educator, researcher, and public advocate of dermatology, Dr. Stuart Maddin has helped to lead the evolution of the specialty, from the front-lines. In his most recent contribution to medicine, Dr. Maddin provides through his memoirs a revealing look forwardand an intimate glimpse backat a lifetime devoted to the study, care, consideration, and celebration of skin. 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 from Linacre's Books. To place your order, using American Express, MasterCard or Visa, telephone toll-free 866-63-CHRON (24766), extension 106. Special pre-publication price: $24.95, plus $1.25 GST and $3.80 P&P, for a total of $30.00. For a preview of the book, visit www.drmaddin.com


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