Hot Aesthetic Procedures for 2012, Part 2

Injectables are predicted to continue to surge in popularity, while other minimally- or non-invasive procedures also garner high patient interest.

Demand for non-invasive cosmetic procedures is expected to increase in 2012. Data indicate that continuing concern about the economy is driving patients to postpone more invasive procedures in favor of injectables and laser procedures. Research conducted by the American Society for Aesthetic Plastic Surgery (ASAPS) and published in Aesthetic Surgery Journal suggest that patients are looking to optimize their investment in aesthetic procedures by seeking treatments that provide relatively long-lasting results, even if the results of treatment are not immediate.

The latest survey of the membership of the International Association for Physicians in Aesthetic Medicine (IAPAM) seems to echo these findings, suggesting high demand for injectable procedures in the recovering economy. The expansion of the neurotoxin market with Xeomin (Merz Aesthetics; See last month’s edition at PracticalDermtology.com) and the filler market with Belotero (Merz Aesthetics) along with the introduction of LaViv have invigorated interest in injectabes, according to IAPAM representatives. IAPAM members also predict there will be a growing emphasis on combination procedures: medical skin care, facial injectables, plus laser conditioning. This so-called “Holy Triad” can be very effective, the organization suggests.

It’s worth noting that ASAPS data indicate a potential disconnect between patient desires and physician perceptions, with many physicians emphasizing immediate results over longevity. A remarkable 95 percent of surveyed patients reported that they would prefer a longer-lasting treatment over one with an immediate effect, but shorter duration and more than half (60 percent) felt that duration of treatment was more important than cost in selecting a facial aesthetic procedure. Yet only 61 percent of plastic surgeons felt that patients preferred longlasting results, while 82 percent said that they believed patients would prefer an immediate result lasting one year over a procedure with more gradual effects that lasts over two years. Nearly two-thirds of physicians (63 percent) indicated that they believed cost was a more important factor for their patients than treatment longevity.

In Part II of a review of Hot Cosmetic Procedures, experts offer an overview of more relatively new procedures that may be popular this year.

Why Another Filler? Belotero Addresses Unmet Patient Needs

By Valerie D. Callender, MD

According to the American Society for Aesthetic Plastic Surgery (ASAPS), in 2010 dermal fillers were the number two nonsurgical cosmetic procedure performed in the United States, with 1.3 million filler injections. Hyaluronic acid led the way.¹ Many cosmetic patients seek these treatments to alleviate facial wrinkles and maintain a youthful appearance with procedures that provide immediate results with little or no downtime.

Since 2003, the FDA has approved several injectable filling agents for cosmetic use. These include products containing collagen (Zyderm, Zyplast, Cosmoderm, Cosmoplast and Evolence), hyaluronic acid (Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Elevess, and Prevelle Silk), calcium hydroxylapetite (Radiesse), poly-L-lactic acid (Sculptra) and polymethylmethacrylate (Artefill). In November 2011, a new hyaluronic acid filler, called Belotero, (Merz Aesthetics) became available and is FDA-approved for the correction of facial wrinkles – nasolabial folds. Do we really need another filler on the market? Can this filler do anything that the others can’t?

I feel the answers to these questions are yes and yes! The reason lies in the understanding that one filler does not fit all. Every patient is unique and has different aesthetic needs. Every dermal filler is unique with different physical properties. As an aesthetic physician, I want an injectable product that produces a natural look and feel for my patients with low immunogenic potential. Currently, with the vast array of options available, this can be achieved.

Narins and colleagues² examined 118 subjects who were randomized to receive Belotero or bovine collagen on contralateral sides of the face (NLF). The Wrinkle Severity Rating scale (WSRS) was used to assess NLF severity. The results demonstrated that Belotero was superior to collagen and demonstrated clinical effectiveness over the course of a six-month postinjection follow-up period. Adverse events were mild to moderate (local reactions at the administration sites mostly due to injection process and unrelated to the study device), lasted less than seven days, and were well tolerated by the subjects.

Belotero is a homogenous hyaluronic acid (HA) gel made from streptococcal cultures and cross-linked with a binding agent (BDDE) in two separate cross-linking processes. It uses a cohesive polydensified matrix (CPM) technology that produces variable zones of cross-linking density (viscosity). This technique allows the product to integrate smoothly into the dermis. Cross-linking is a necessary process that affects longevity and allows the HA to persist over time. The concentration of HA in Belotero is 22.5 mg/ml.

Although Belotero is FDA approved for the correction of moderate-to-severe NLFs, off-label use of this dermal filler is where it will shine. Being able to place this filler superficially, mid- or deep-dermis, gives it a flexibility that other HA fillers do not have. For example, a common problem of injecting HA dermal fillers too superficially in the skin is a bluish discoloration of the skin (Tyndall effect). When injecting Belotero into the skin, no Tyndall effect is seen. So therefore, potential off-labeled injection sites and uses of Belotero, other than NLF, include perioral lines, Marionette lines, glabellar lines, tear troughs, augmentation of the lips (vermillion border and body of the lip), cheeks and chin, pre-jowl sulcus, correction of facial depressions, and acne scars.

A disadvantage of this new filler compared to the other marketed HA fillers is that it does not contain an anesthetic. Pain management is a very important aspect of soft tissue augmentation. Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus and Prevelle Silk all contain 0.3% lidocaine. Clinicians will have the option of mixing lidocaine with Belotero prior to injection, using a similar technique that used for Radiesse injection.

A global approach to aesthetic enhancement of the face involves much more than the correction of NLFs. With the introduction of Belotero to our armamentarium, it has provided the cosmetic physician and their patients with yet another alternative for facial rejuvenation and contouring.

Dr. Callender is the founder of Callender Dermatology & Cosmetic Center, in Glenn Dale, MD. She is as an Associate Professor of Dermatology at Howard University.

LaViv Offers “Natural,” Autologous Cell Therapy Approach

By Robert Weiss, MD

Unique among injectable therapies for rejuvenation, LaViv (azficel‐T, Fibrocell Science) is the first and only personalized aesthetic cell therapy approved by the FDA for the improvement of the appearance of moderate to severe nasolabial fold wrinkles in adults. Treatment involves the harvesting, growth, and reinjection of an individual’s own fibroblasts in order to elicit neocollagenesis.

The treatment process is rather straightforward. The area behind the ear is anesthetized with lidocaine before 2-3mm punch biopsies are taken. The biopsy materials are placed in a transport medium and then shipped out for processing. The roughly 12-week processing technique purifies and multiplies fibroblasts, which are then harvested and shipped back to the clinic for arrival one day before the patient’s scheduled treatment. Materials need only be refrigerated, not frozen. When the patient returns for their treatment, fibroblasts are injected superficially in the dermis.

Physicians who provide LaViv therapy receive training on harvesting and injection techniques. The physician and/ or appropriate staff members receive training on packaging and handling harvested material. Dermatologists have been receptive to the notion of autologous cell therapy, perhaps because they recognize the high level of patient interest in it and potential benefits. In particular, this treatment approach appeals to patients who are dedicated to all natural or organic products. Many patients, once educated on the treatment, consider it as an essential part of an antiaging skin regimen.

Treatment with LaViv is appropriate for patients in their 40s, 50s, or 60s who are seeking natural and long-lasting rejuvenation results. LaViv will likely continue to gain traction as the long duration of effect and the understanding of the ease of treatment will become more widespread. New applications that could be FDA-cleared, such as treatment of acne scars, will also greatly enhance interest in LaViv.

The price is very competitive. There is no risk of allergy to one’s own cells. The longer term benefits will be more clearly understood in 2012 as more data are available. As more doctors observe the results, they will be able to recommend LaViv based on their experience. Similarly, as more patients experience positive results, there will be more experienced based and most likely positive reviews on websites as well as more blogs about the benefits.

Dr. Weiss is an Associate Professor of Dermatology at the Johns Hopkins Hospital and is in practice at the Maryland Laser, Skin, and Vein Institute.

Photodynamic Cosmetic Therapy: A Noninvasive Approach to Rejuvenation

By Anna Paré, MD

Photodynamic cosmetic treatments with Allumera (Photocure) offer a new approach to the cosmetic improvement of texture, tone, fine lines and wrinkles, and pore size in photodamaged skin. The noninvasive novel therapy, which reached the market last year, may be used alone or as an adjunct to other cosmetic interventions; it can be used as a gateway procedure for the new patient or as an adjunctive or supportive intervention for the veteran cosmetic patient.

According to the standard product protocol, Allumera is applied to the skin and left in place for a one-hour incubation period. After incubation it is washed off, and then the treated skin is exposed to an activating light source. To help patients understand the procedure, it is useful to explain that Allumera is preferentially absorbed by photodamaged skin cells, which are destroyed upon light activation and then regenerated over time. In my experience, many patients are already familiar with the concept of photodynamic therapy (PDT) for the treatment of precancerous lesions. Many of my patients have already received a form of PDT, or they have researched this therapy. Now with the first in class of photodynamic cosmetic treatments, patients are very receptive and understand this type of non-invasive procedures.

Although patients are not yet asking for Allumera by name, most are interested in learning about something new that may provide additional benefit in the management of photodamage with minimal downtime. Given that my patient base is largely cosmetic and I have established a practice based on the management of photodamage, many of my patients are candidates for photodynamic cosmetic therapy. For certain patients who have already undergone light-based procedures, such as IPL, the addition of a photosensitizer may offer a new level of efficacy. For others, it might simply be an option to treat their specific cosmetic concerns, particularly if those include large pores or uneven skin tone. Allumera has also been useful in the management of acne or rosacea in my practice.

For a cosmetic practice such as mine with multiple light sources available, Allumera offers flexibility and allows us to expand the treatment option for patients. However, the treatment is also well suited for smaller cosmetic practices. With just one light source, a practice can provide treatment to a broad range of patients.

Because of its potentially broad appeal across the cosmetic patient population, Allumera will likely grow in popularity. It is easy to incorporate into practice and appeals to patients as an innovative therapy and one that expands the available treatment options.

Dr. Pare specializes in cosmetic dermatology at and is Vice President of Dermatology Consultants, PC in Buckhead and Marietta, GA.

CoolSculpting Continues to Generate Patient Interest

By Marguerite Germain, MD and Linda Cooke, MD

Cryolipolysis or CoolSculpting (Zeltiq), one of the newest forms of non-invasive fat reduction, consists of the non-invasive cooling of fat tissue to induce lipolysis without damage to other cells or tissue. Cooling is applied for a pre-determined time period, causing fat cells to undergo apoptosis. Natural inflammatory processes remove dead fat cells over time, resulting in reduction of the fat layer. The CoolSculpting procedure using Cryolipolysis induces apoptosis only in fat, yielding a permanent fat reduction while preserving other tissues.

Demand for fat-fighting therapies is high, with the American Society of Aesthetic Plastic Surgery reporting that more than 289,000 individuals underwent liposuction in 2010, making it the second most common surgical cosmetic procedure. Despite the popularity of liposuction, safety concerns exist in the public, and these are magnified by media reports of botched procedures and legislative efforts, such as those in Florida, to restrict the procedure. Non-invasive CoolSculpting is, therefore, an attractive option for many patients. (CoolSculpting doesn’t result in an increase in malpractice rates as does any type of invasive liposuction.) There is very little discomfort and no downtime associated with the procedure. Some patients experience mild discomfort or a “pins and needles” feeling and a dullness of sensation that can last for up to two months following the procedure.

The lack of downtime and relative comfort of the procedure make it more appealing to men than other procedures. Many men that are generally fit have a difficult time with love handles, particularly as they get older. They are attracted to a procedure that is painless and will allow them to leave the office and continue with all their regular activities. CoolSculpting is also a good option for patients that have already gone through an extensive weight loss period but need assistance with small, persistent bulges. CoolSculpting is indicated for people who are relatively fit but want to reduce distinct fat bulges by up to 25 percent.

One important aspect of treatment is to capture good baseline metrics for before/after comparisons. We rely mainly on photos. Weighing and measuring patients is also useful, though it is difficult to get the tape measurement in the exact same place to produce a true comparison. Patients should have realistic expectations of potential outcomes as well as possible treatment-associated discomfort before the procedure.

The high level of media coverage of Zeltiq CoolSculpting has made the procedure popular, and it is expected to continue to grow in popularity. Because a non-physician can administer the treatment based on physician orders, it need not erode the physician’s time to see other patients. Additionally, it may be a gateway procedure to other cosmetic services in your practices.

Linda Cooke, MD, FAAD provides medical, surgical and aesthetic dermatology serives at Riverside Dermatology in Hannibal, MO.

Marguerite Germain, MD, FAAD provides medical, surgical, and cosmetic dermatology services at Germain Dermatology in Mt. Pleasant, SC.

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