American Society of Dermatologic Surgeons Annual Meeting ...

46 Aesthetic Buyers Guide November/December 2005 www.miinews.com

American Society ofDermatologicSurgeons AnnualMeeting AdvancesSkin RelatedProcedures

By Michael Moretti, Editor

47Aesthetic Buyers Guide November/December 2005 www.miinews.com

Nearly 1,000 of the top U.S. dermato-

logic surgeons convened in Atlanta,

Georgia in late October for the 2005

American Society for Dermatologic Surgery

(ASDS) and American College of Mohs

Micrographic Surgery and Cutaneous Oncology

(ACMMSCO) combined annual meeting.

Physicians presented more than 300 abstracts

that addressed the newest research and tech-

niques in dermatologic procedures (both elec-

tive and medical).

The practice of medicine by the non-physi-

cian is a growing concern for this society. About

40% of ASDS physicians reported an increase

in patients seeking treatment because of dam-

age caused by untrained non-physicians per-

forming light-based rejuvenation techniques,

chemical peels, acne therapy and other skin

procedures. On the other hand, there was

enthusiasm for radiofrequency and newer

light-based devices that are safer, less painful,

and effective in diminishing a variety of skin

conditions. Attendees also had the opportunity

to observe live procedures using a variety of

innovative techniques for liposuction, laser

therapy and silicone injections.

Leading edge society of dermasurgeons gatherto chart new directions for aesthetic medicine field.


An ASDS survey released prior to the meeting indi-cated that some five million skin surgeries will be per-formed in the U.S. during 2005. This represents a 32%increase over the past four years. According to the sur-vey, the major reason for this sharp jump is the popu-larity of minimally invasive cosmetic procedures,which are up a staggering 58 percent from 2001. “In-office, minimally invasive treatments are driving thegrowth of skin surgery, primarily because these proce-dures are very safe and require minimal recoverytime,” said outgoing ASDS president Rhoda Narins,M.D. “As a result, an increasingnumber of patients are willing toundergo convenient outpatientsurgery for both medically neces-sary and cosmetic purposes.”Baby boomers account for 65%of all cosmetic procedures, accord-ing to the survey, which continuesa trend identified in 2001. “Themost common patient age is themid-forties. But it ranges fromage 35 to 55,” said Dr. Narins, a dermasurgeon in pri-vate practice in New York City and WestchesterCounty, N.Y. About 80% of light therapy patients arewomen, and women account for 88% of patients treat-ed with Botox (Allergan). In addition, 86% of soft tissueaugmentation procedures are for filling wrinkles, and

Restylane (Medicis) is the most frequently used filler(51%). Conversely, collagen now accounts for just 13%of augmentation procedures.

Cosmetic skin surgery is a strong competency fordermasurgeons. Two-thirds to three-quarters of therespondents reported doing Botox injections (71%),

vein treatment (70%), light-based therapy (65%), facialfiller injections (64%) and skin resurfacing (63%).Since 2003, the greatest relative increases haveoccurred in the categories of facial filler injections(+55%) and light treatment (+33%). “New fillers thatcan volumize as well as fill in lines have changed themarket dramatically,” Dr. Narins observed. “When youcan only fill in lines, you still needto perform surgery to get rid ofexcess skin. But now, youcan actually use up theexcess skin by replacing thevolume that is lost fromthat excess skin. In fact, Ithink fillers are the singlemost exciting developmentin aesthetics. The accept-ance of Botox is also verygratifying.”

Other notable changes in the industry includeincreases in non-ablative skin rejuvenation (+28%),resurfacing (+26%) and Botox injections (+25%). Theaverage patient age is 51 years old, remainingunchanged since 2003. However, women are substan-tially younger (48 years old) than men (59). Womenalso comprise the majority (69%) of patients.Light-based therapies are used primarily to treatpatients with vascular lesions (30%) or for hairremoval (28%). Other uses include wrinkles (11%, anew category in 2005), pigmented lesions (8%), acne(7%) and tattoo removal (6%). In contrast, Botox wasmost often used for frowns (25%), followed by wrinkles(12%), or a combination of frowns and wrinkles (39%).

Light-based devices, microdermabrasion andchemical peels are the three primary procedures usedin resurfacing, almost equal in popularity (28%, 28%,and 26%, respectively). Of these three modalities, lighttreatment appears to be increasing from 15% in 2003,while chemical peels appear to be decreasing, downfrom 41% in 2003.“We are also finding out that liposuction with localanesthesia is a really safe procedure,” Dr. Narinsnoted. “More and more physicians are aware they can

Rhoda Narins, M.D.

“More and more physicians are awarethey can perform these procedures with-out the dangers of general anesthesia. I believe body contouring will continue to grow in popularity.”

Botox by Allergan


perform these procedures without the dangers of gen-eral anesthesia. I believe body contouring will continueto grow in popularity.”

“We continue to witness the same dramaticadvances that have led dermasurgery into the fore-front of the cosmetic arena,” said Alastair Carruthers,M.D., a clinical professor of der-matology at the University ofBritish Columbia in Vancouver,Canada. At the meeting, Dr.Carruthers reported on patientperception of Botox injections fortreating the entire upper face.“This is quite different from mostBotox studies, whereby resultsare recorded by a disinterestedobserver, typically the injectingphysician,” he reported. A total of 60 patients eachreceived 16 injections during one treatment session.“Our study showed that one can measure how well peo-ple perceive results,” Dr. Carruthers said. “The higherthe dose, the better the response, as perceived by theindividual. Higher doses also resulted in a prolongedeffect. But there was no increase in adverse events.”Dr. Carruthers, who is president-elect of the ASDS,is also excited about using fillers to treat facial wast-ing. “I believe that patients with HIV-associated facial

lypoatrophy face challenges that are much more basicthan cosmetic, such as self-esteem,” he said. “In a majorstudy on facial wasting using injectable silicone oil, weachieved great results.”

A second major study is ongoing using Radiesse(formerly Radiance FN, BioForm Medical), which is asynthetic injectable implant composed of smooth calcium

hydroxylapatite (CaHA) microspheres suspended in anaqueous gel carrier. “I think Radiesse shows greatpotential as a filler for the average practitioner treat-ing the average case of HIV facial wasting,” Dr.Carruthers said. Outcomes out to eight months showthat the effect of Radiesse lasts longer than thehyaluronics, but it is not a permanent treatment.In the same positive vein, Dr.Carruthers is finally con-vinced that radiofrequen-cy resurfacing “is work-ing and is going to deliverthe kind of results we areaccustomed to with theintense pulsed light (IPL)-type machines.” The new algo-rithm for the ThermaCool TC Systemfrom Thermage, Inc. (Hayward, Calif.) allows for “up toten passes, at lower energy levels, during a singletreatment session,” he explained. “This will often pro-duce the results that you desire. Patient discomfort isalso reduced.”

“Revising the treatment protocol of theThermaCool has allowed for a safer treatment and amuch more consistent response,” added RoyGeronemus, M.D., director of the Laser & Skin Surgeryof New York, in New York City. “The safety profile hasalso improved for those peoplewho are less experienced with thedevice.” Most patients requireonly one treatment session. A sec-ond session may be scheduledthree to four months later.“We’re enthusiastic about a newlarger treatment tip, which allowsfor more rapid treatment andwider patient acceptance,” Dr.Geronemus continued. “This newtip has also made the procedure easier to perform.”

Besides speaking on the ThermaCool, Dr.Geronemus discussed options in treating acne scar-ring. The Fraxel SR Laser from Reliant Technologies(San Diego, Calif.) “has become the treatment of

Roy Geronemus, M.D.

Alastair Carruthers, M.D.

“The higher the dose, the better theresponse, as perceived by the individual.Higher doses also resulted in a prolongedeffect. But there was no increase inadverse events.”

Radiesse by BioForm


choice,” he stated. “The Fraxel laser has the ability todeliver the microthermal zones into the deeper part ofthe dermis, which allows for the creation of new colla-gen in a broad area within the dermis itself. Thisprocess smoothes out the scars and tightens some ofthe pitted scars. The broader rolling scars also becomemore even, texturally. We generally do five treatments,but sometimes more, at normally two to three weekintervals.”

Dr. Geronemus noted that one of the more importantadvances in aesthetics “is the ability to have morereproducible results in a broader range of skin types.Historically, lasers have been most effective in treatingpatients with lighter skin types (Fitzpatrick I – III).Over the next few years, though, Ithink we’re going to see a muchgreater emphasis and improvedresults in skin types IV throughVI, using such technologies asradiofrequency and fractionalresurfacing.”

Gary Monheit, M.D., the newpresident of ASDS, is enthusedabout new fillers from Europe.Juvederm from L.E.A. Derm(Paris, France) is a long lasting hyaluronic acid fillerthat is “showing excellent results,” said Dr. Monheit,who helped conduct the North American clinical trials.“Juvederm has longevity, stability and there is mini-mal inflammation and swelling. In my experience, theduration of effect is at least six months. It is also aneasy filler to inject.”In contrast, Evolence from ColBar LifeScience(Herzliya, Israel) is a collagen filler. “The bonding is

different from our collagen fillers. Evolence is porcinecollagen as opposed to bovine collagen,” said Dr.Monheit, a dermatologic and cosmetic surgeon in pri-vate practice in Birmingham, Ala. “One of the advan-tages of Evolence is that it is long lasting. The claimsin Europe state that it can last up to two years. Thisfiller is also very natural in feel and appearance, likethe other collagen fillers. Evolence has the stiffness totruly hold up nasolabial folds and marionette linesvery naturally, as well as for lip augmentation.”

Reloxin from Ipsen Pharmaceuticals (London,United Kingdom) is a botulinum toxin type A productsimilar to Botox. “In our experience, the onset of actionof Reloxin may occur a bit earlier than Botox. Thelongevity may be slightly longer as well,” reported Dr.Monheit, an associate clinical professor of dermatology

Gary Monheit, M.D.

Evolence by ColBar (Clockwise: Before Tx, After Tx, During Tx)

“Over the next few years, though, I thinkwe’re going to see a much greater empha-sis and improved results in skin types IVthrough VI, using such technologies asradiofrequency and fractional resurfacing.”


at the University of Alabama Medical Center inBirmingham. Both Reloxin and Botox are injected thesame way. “I think Reloxin will become a strong com-petitor to Botox. There is already growing acceptancein Europe.”

Overall in aesthetics, “we are decreasing theaggressiveness of our procedures, making them moreoffice oriented and simpler, with less downtime andreduced risk,” Dr. Monheit conveyed.Among the acne treatment presentations, JeffreyDover, M.D., FRCPC, a clinical associate professor ofdermatology at Yale University School of Medicine,shared the results of two studies that will be submittedfor publication. “The Smoothbeam (Candela) and theAramis (Quantel Medical) are both mid-infrared lasersthat are pretty effective in treating moderate-to-severeacne,” Dr. Dover said. Each laser was studied in a sep-arate trial. “The advantage of the Aramis is that ithurts less and a topical anesthetic is not necessarybefore the procedure,” he said. “However, we feel theSmoothbeam may be slightly more effective per treat-ment session.”

For both studies, patients committed to four ses-sions, spaced three weeks apart. “However, in clinicalpractice, we typically schedule six sessions, at aboutone month intervals,” Dr. Doversaid. “There is usually improve-ment after one or two sessions. Ifwe see no improvement after twosessions, we stop and determinethat it is not going to work.” Long-term follow-up with the Aramisstudy showed that adding onebooster treatment session severalmonths after the final sessionhelped prolong the effect.Dr. Dover also participated in acontroversies session on using silicone oil as a filler.In a multicenter study comparing silicone oil (Silikonfrom Richard-James, Inc.) to bovine collagen (Zyplastfrom Inamed) for treating nasolabial folds, “the dif-ference was staggering,” pointed out Dr. Dover, whowas one of the investigators. “The silicone produced

better results and much longer lasting results in100% of patients. Silikon is a product approved foruse in the vitreous of the eye for a retinal detach-ment. Despite patients being able to have as much

collagen as they wanted, with repeat treatments, thesilicone lasted and the collagen did not. The siliconelasted at least 18 months, which was the follow-upperiod of the study, compared to the collagen, whichlasted only several months.”

In a separate presentation on pearls of wisdom forfillers, Dr. Dover noted that “the more you practice, thebetter you get at it. It is also much more of an art formthan Botox. The more attention you pay to detail andto the art form, along with closer patient follow-up, thebetter you will get over time. Fillers are very tech-nique-dependent. But once you master the technique,the results are exquisite. However, there is no univer-sal ideal filler. And in some patients, it makes sense touse multiple fillers, even up to three. There are lots ofnew, interesting fillers being developed, which I thinkare slowly but surely changing the way we practiceaesthetic medicine. Restylane has already made ahuge difference in how we practice over the past twoto three years.”Similarly, improved techniques are achieving “muchbetter results with non-ablative laser technologies,such as fractional laser resurfacing,” Dr. Dover said.Foremost in this arena is the Fraxel laser.

“I now have two years of experience treating alarge variety of patients with the Fraxel laser,” saidTina Alster, M.D., director of the Washington Instituteof Dermatologic Laser Surgery in Washington, D.C. “Iam very happy with the results. In fact, I no longer per-form skin resurfacing with CO2 and erbium lasers. TheFraxel laser has basically replaced my ablative lasers.

Jeffrey Dover, M.D.,FRCPC

“The silicone lasted at least 18 months,which was the follow-up period of thestudy, compared to the collagen, whichlasted only several months.”


I think we can come close, if not mimic, the results ofablative skin resurfacing by scheduling a series ofFraxel treatments. Even though itis a series as opposed to one treat-ment, the series is much easier forpatients post-operatively. Anablative procedure requires manyreturn visits anyway. Well over90% of my Fraxel patients needonly three treatments at three tofour week intervals, rather thanfive or six sessions.”With Fraxel treatment, patientsexperience only a few days of redness and swelling,“indistinguishable from a sunburn, followed by a cou-ple of days of peeling,” said Dr. Alster, who outlinedthe advantages of the Fraxel laser during a contro-versies session on this new technology. “In mostpatients, this peeling amounts to a gritty feel to theskin, like sandpaper, so the patient is not peeling all

at once. I’m very happy with improvements in blotchyskin or dyspigmented skin, fine rhytides, atrophicacne scars or other types of atrophic scars, pore tight-ening and skin tightening. With repeated treatments,we have also observed some collagen contraction andsome tightening.”

Dr. Alster also shared the results of a cellulitestudy using the VelaSmooth from Syneron, Inc.(Richmond Hill, Ontario, Canada). “We treated onethigh and not the other in 20 adult women with differ-ent types of skin and moderate bilateral thigh and but-tocks cellulite,” Dr. Alster conveyed. Each patientunderwent eight treatment sessions over a four weekperiod. “The contralateral side was used as a non-treat-ed control,” she said. Patients were evaluated withstandardized digital photography and leg measure-ments before each treatment session and at one, three

and six months after the final session. Before and afterphotographs were evaluated by two masked medicalassessors after the series of treatments were complete.Clinical scores improved about 50%. “Circumferentialthigh measurements were reduced by 0.8 centimeterson the treatment side.”Nearly all patients (18 of 20) noticed an overall clin-ical improvement “and 17 of those 18 indicated theywould pursue treatment of the contralateral thigh,” Dr.Alster reported. “Side effects were limited to transienterythema. Bruising was observed in two patients, butstopped after the first couple of sessions.” In practice, amaintenance session is commonly scheduled once amonth “to further enhance the clinical results and pre-vent any decrease,” Dr. Alster said.

Two sessions on rejuvenation of the hands, includ-ing a video demonstration on fat injection, were pre-sented by Kimberly Butterwick, M.D., a dermatologicsurgeon in private practice in La Jolla, Calif. “Up untilnow, the hand has been relativelyignored,” she said. “Many womencomment to me that their handsdon’t match their rejuvenatedface. And the public is now awarethat the hand gives away a per-son’s age.”Fat injection is one of only a fewtreatment modalities that caneffectively address the soft tissueatrophy on the back of the hand.“We are unable to resurface thehand aggressively enough to thicken up the skin,” Dr.Butterwick said. “Fat is a very simple, straightforwardprocedure that can be performed at the same time asfacial rejuvenation, or at a different time.”

The patient’s own fat (typically 10 cc) is takenfrom a donor site, such as the abdomen, hips or outerthigh. “The fat is centrifuged, then transferred to 1 ccsyringes and injected with a blunt tip cannula,” Dr.Butterwick explained. Most patients require only onetreatment session, consisting of approximately 10 ccper hand. “It is best to use a 1 cc syringe because itwill deliver smaller parcels of fat. Those very thin

Kimberly Butterwick, M.D.

Tina Alster, M.D.

“Well over 90% of my Fraxel patients needonly three treatments at three to four-weekintervals, rather than five or six sessions.”


strands of fat will develop a blood supply more readi-ly than a 10 cc syringe.”Patients can anticipate “a much smoother, youngerlooking hand, with loss of the skeletal appearance andthe tendons showing,” Dr. Butterwick said. “You canalso expect the veins to be much less prominent. Theskin overlying the fat will have a brighter, youngerappearance. The duration of effect lasts usually in theorder of two to three years.” Sometimes, the patient’sexcess fat is frozen for a touch-up session about oneyear later.

Dr. Butterwick also discussed alternative treat-ment options for rejuvenating the aging hands. “Forcutaneous rejuvenation, there are chemical peels.Light-based treatments can also be quite effective. Andfor the veins, sclerotherapy is a relatively simple pro-cedure that can be performed quite safely. Some physi-cians are also beginning to use some dermal fillers forthe backs of the hands, such as Sculptra (DermikLabs), although there are not any studies as of yet. Insummary, both surgeons and patients alike need to beaware that there are simpletreatments for the handsthat can be done concomi-tantly with facial proce-dures. Having increasedawareness will prevent thisdiscrepancy that revealsthe patient’s age.”The Portrait PSR (plas-ma skin regeneration) sys-tem from Rhytec, Inc.(Waltham, Mass.) “is anoth-er form of resurfacing thatimproves wrinkles more significantly than any of thenon-invasive procedures,” said Ron Moy, M.D., a clini-cal professor of dermatology at the University ofCalifornia, Los Angeles. “Plasma is a new form of ener-gy we are working with. I think plasma causes signifi-cant tightening because of the fair amount of heat gen-erated. The side effect profile of the Portrait PSR alsoappears to be better than CO2 laser resurfacing. I,along with many other physicians, have not seen

hypopigmentation, and the results may approach CO2

laser resurfacing. Patient downtime ranges fromroughly seven to ten days.”

The Portrait PSR usually requires only one treat-ment session. “However, you can use the device in aminimally invasive mode, where it acts similar to amedium depth chemical peel,” Dr. Moy said.In a separate presentation, Dr. Moy shared what’snew in cosmetic surgery, including the contour lift,which is FDA approved. The Contour Threads liftfrom Surgical Specialties Corp. (Redding, Penn.) is anon-absorbable barbed stitch made of permanentpolypropylene stitches. “This is alifting that is relatively minimal-ly invasive,” Dr. Moy explained.“You don’t have to make any inci-sions and it can be performedunder local anesthesia. You canachieve significant mid-face lift-ing. However, improvement is notas noticeable in lower-face lift-ing. But you can get some browlifting, some neck lifting andsome jowl lifting.”

Dr. Moy believes the contour lift is much betterthan the FeatherLift. “The FeatherLift is not fixated –it is not attached or tightened to anything – so itis sort of free-floating sutures. In contrast, theContourLift is tightened to the deep temporal fascia.As with a face lift, results will likely last years, but itwill not be permanent.”In general, “the aesthetic arena is growing by leaps andbounds,” Dr. Moy observed. “We can’t even anticipate thenew fillers and new technology that will be introduced.Who could have imagined products like the Fraxel laser,the Portrait PSR and Contour Threads?” n

Ron Moy, M.D.

Contour Threads by Surgical Specialties

Sculptra by Dermik

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