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Three distinct scenarios for treating facial redness with lasers and light
SAN DIEGO – In the clinical experience of J. Stuart Nelson, MD, PhD,
“There’s the patient with telangiectasia without diffuse redness, the patient who has telangiectasia with diffuse redness, and the patient who has diffuse redness,” Dr. Nelson said at the annual Masters of Aesthetics Symposium. “Because the vessel sizes are different, your approach to the clinical management of each one of these patients is going to be very different.”
For patients with telangiectasia without the redness, using pulsed dye lasers with a wavelength of 585-600 nm can be effective. “If someone has a single isolated telangiectasia, it’s the simplest thing you’ll do that day in your office,” said Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine. “It’s like Tiger Woods putting for a 2-foot birdie. Similarly, with the millisecond green devices, you can focus the laser beam onto the spot and you will see the blood vessels go away in real time.”
Treating patients who have telangiectasia and diffuse redness requires two steps. First, treat the larger telangiectasia with pulse durations of 20 ms, he said, and then treat the global background redness with shorter pulse durations (of 3 ms and 6 ms). “You can do this with pulse dye lasers and with green millisecond devices,” he noted.
For patients who present with diffuse global redness, “you don’t have to worry about the larger blood vessels, so you’re not going to be using the long pulse durations of the laser exposure,” said Dr. Nelson, past president of the American Society for Laser Medicine and Surgery. “You’re going to be using much shorter pulse durations, because you’re targeting blood vessels that are much smaller. You’re trying to tease out that background redness.”
If you’re concerned about how a particular patient will fare, consider performing a test spot. “This allows you to check for any unusual tissue reaction and to gauge the potential success of the laser treatment you’re doing,” he said. “It allows the patient to sort of experience the swelling and healing process they’re going to be going through.”
Dr. Nelson advised against applying a “cookbook” approach to using lasers and light sources in dermatology. “Don’t memorize treatment parameters,” he said. “What you really need to do is look for the clinical endpoints. What is the tissue response you want to see? You also want to exercise caution in patients who are tanned. The epidermal melanin absorption by tanned patients can be significant, even with some of the cooling technologies we have.”
Dr. Nelson reported having intellectual property rights with Syneron/Candela.
SAN DIEGO – In the clinical experience of J. Stuart Nelson, MD, PhD,
“There’s the patient with telangiectasia without diffuse redness, the patient who has telangiectasia with diffuse redness, and the patient who has diffuse redness,” Dr. Nelson said at the annual Masters of Aesthetics Symposium. “Because the vessel sizes are different, your approach to the clinical management of each one of these patients is going to be very different.”
For patients with telangiectasia without the redness, using pulsed dye lasers with a wavelength of 585-600 nm can be effective. “If someone has a single isolated telangiectasia, it’s the simplest thing you’ll do that day in your office,” said Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine. “It’s like Tiger Woods putting for a 2-foot birdie. Similarly, with the millisecond green devices, you can focus the laser beam onto the spot and you will see the blood vessels go away in real time.”
Treating patients who have telangiectasia and diffuse redness requires two steps. First, treat the larger telangiectasia with pulse durations of 20 ms, he said, and then treat the global background redness with shorter pulse durations (of 3 ms and 6 ms). “You can do this with pulse dye lasers and with green millisecond devices,” he noted.
For patients who present with diffuse global redness, “you don’t have to worry about the larger blood vessels, so you’re not going to be using the long pulse durations of the laser exposure,” said Dr. Nelson, past president of the American Society for Laser Medicine and Surgery. “You’re going to be using much shorter pulse durations, because you’re targeting blood vessels that are much smaller. You’re trying to tease out that background redness.”
If you’re concerned about how a particular patient will fare, consider performing a test spot. “This allows you to check for any unusual tissue reaction and to gauge the potential success of the laser treatment you’re doing,” he said. “It allows the patient to sort of experience the swelling and healing process they’re going to be going through.”
Dr. Nelson advised against applying a “cookbook” approach to using lasers and light sources in dermatology. “Don’t memorize treatment parameters,” he said. “What you really need to do is look for the clinical endpoints. What is the tissue response you want to see? You also want to exercise caution in patients who are tanned. The epidermal melanin absorption by tanned patients can be significant, even with some of the cooling technologies we have.”
Dr. Nelson reported having intellectual property rights with Syneron/Candela.
SAN DIEGO – In the clinical experience of J. Stuart Nelson, MD, PhD,
“There’s the patient with telangiectasia without diffuse redness, the patient who has telangiectasia with diffuse redness, and the patient who has diffuse redness,” Dr. Nelson said at the annual Masters of Aesthetics Symposium. “Because the vessel sizes are different, your approach to the clinical management of each one of these patients is going to be very different.”
For patients with telangiectasia without the redness, using pulsed dye lasers with a wavelength of 585-600 nm can be effective. “If someone has a single isolated telangiectasia, it’s the simplest thing you’ll do that day in your office,” said Dr. Nelson, professor of surgery and biomedical engineering at the Beckman Laser Institute and Medical Clinic at the University of California, Irvine. “It’s like Tiger Woods putting for a 2-foot birdie. Similarly, with the millisecond green devices, you can focus the laser beam onto the spot and you will see the blood vessels go away in real time.”
Treating patients who have telangiectasia and diffuse redness requires two steps. First, treat the larger telangiectasia with pulse durations of 20 ms, he said, and then treat the global background redness with shorter pulse durations (of 3 ms and 6 ms). “You can do this with pulse dye lasers and with green millisecond devices,” he noted.
For patients who present with diffuse global redness, “you don’t have to worry about the larger blood vessels, so you’re not going to be using the long pulse durations of the laser exposure,” said Dr. Nelson, past president of the American Society for Laser Medicine and Surgery. “You’re going to be using much shorter pulse durations, because you’re targeting blood vessels that are much smaller. You’re trying to tease out that background redness.”
If you’re concerned about how a particular patient will fare, consider performing a test spot. “This allows you to check for any unusual tissue reaction and to gauge the potential success of the laser treatment you’re doing,” he said. “It allows the patient to sort of experience the swelling and healing process they’re going to be going through.”
Dr. Nelson advised against applying a “cookbook” approach to using lasers and light sources in dermatology. “Don’t memorize treatment parameters,” he said. “What you really need to do is look for the clinical endpoints. What is the tissue response you want to see? You also want to exercise caution in patients who are tanned. The epidermal melanin absorption by tanned patients can be significant, even with some of the cooling technologies we have.”
Dr. Nelson reported having intellectual property rights with Syneron/Candela.
EXPERT ANALYSIS FROM MOA 2019
Don’t let legal considerations drive your decision making about a new job offer
SAN DIEGO – When weighing an offer to join a dermatology practice, don’t allow legal considerations to drive your decision making, Mathew M. Avram, MD, JD, advised at the annual Masters of Aesthetics Symposium.
“Determine your professional interests and follow them accordingly,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “Your decision as to whether to join a particular practice should not be based upon a contract. Make certain to determine the business end of your deal with any new employer first: the compensation, the work hours, etc. Decide that upfront before you get into the legal details.”
The way he sees it, your relationship with your employer will always be paramount. “This is very important,” said Dr. Avram, who practiced law before he became a dermatologist. “A good contract with a bad employer will not save you from an unhappy employment experience. Few contracts ever end up in litigation, and you cannot sue your way to a happier work experience. Trust your intuition about people; trust your underlying interest in potentially working with this person, and work from there.”
Whether you choose to work in an academic practice, a private practice, or a hybrid, the key issues to address include compensation, benefits, work hours, job responsibilities, and future partnership possibilities. “As an employee, you have the greatest leverage prior to signing an agreement,” he said. “This is the time to ask for what you want.” This may include special requests such as asking the employer to purchase lasers or other special equipment for your office, or to set aside dedicated clinical time for cosmetic procedures, so that you can build a cosmetic practice.
If you’re mulling over a job offer in academics, consider asking for an academic title, what the scope of your authority is, and about your ability to hire or prevent the hiring of others. “Let’s say you’re starting a laser center in your academic center,” said Dr. Avram, who is a past president of the American Society for Laser Medicine and Surgery. “You may not want to find out after you’ve signed your contract that they’ve hired five other people to do the same thing.”
If you’re considering a job offer from a private practice, ask for specifics about bonuses, partnership track, scope of practice, and device purchases. “You want to have that decided before you sign,” he said. “But these are business issues, not legal issues. An agreement needs to be made between you and your employer as to these issues. Once they’ve been agreed upon, it’s time to proceed with a contract. This is where legal advice becomes helpful.” The trick is to negotiate in good faith while maintaining your relationship with your new employer. “Do not destroy your relationship over legal points, but do not cave on crucial issues for fear of upsetting your new employer,” he said.
In law school, Dr. Avram learned that there is no such thing as a standard employment contract. Any contract can be amended, no matter how large or small the institution. “You can amend a mortgage agreement, so you can certainly amend a physician employment contract,” he said. “If the employer is not going to put their commitments in writing, they are probably not going to honor that commitment to you. Written agreements supersede all preceding oral agreements. Each key term needs to be stated explicitly. If not, you have lost all leverage to enforce your initial agreement.”
Key provisions are restrictive covenants and at-will employment. Dr. Avram defined restrictive covenants as contractual agreements that attempt to restrict an employee so as to limit that person’s ability to compete. “This can include noncompete clauses, nonsolicitation agreements, and confidentiality agreements,” he said. “A noncompete agreement prohibits a doctor from competing against their former practice within a specific geographic area for a period of time after the employment has ended. The nonsolicitation agreement restricts the manner and time during which a physician can solicit patients or employees from a practice after termination of employment. A confidentiality agreement is usually indefinite as to time and it restricts the employee from disclosing confidential practice information.”
State laws, he continued, govern restrictive covenants. Some states prohibit them. States that allow them limit their scope to prevent undue burden on the employee’s ability to make a living after termination. “Restrictive covenants in cities need to be narrower than those in rural areas,” he said. “Overly broad restrictive covenants may be unenforceable. Courts can ‘blue line’ covenants to make them more reasonable in scope.”
Next, Dr. Avram discussed involuntary termination in the workplace. Termination with cause means that termination can only result from violation of policy or ethics code violation or significantly poor performance. “In the absence of these circumstances, termination cannot legally proceed,” he said. “This protects the employee from an arbitrary termination.”
On the other hand, at-will employees can be terminated without cause. “It’s a much easier standard to terminate an at-will employee, as long as the reason is not illegal,” he said. “In academic centers, your employment as a physician may require a for-cause termination, whereas your administrative title may be without cause.”
One way to avoid potential legal trouble is to abide by your employer’s rules governing a physician’s interactions with industry. “It is foolish to break those rules,” Dr. Avram said. “Transparency ahead of time is always your best policy. Remember: Your day job is far more valuable to you than part-time work with industry. Also, know that pharma payments are publicly reported by the Centers for Medicare & Medicaid Services.” When it comes to establishing contracts with industry, “read them carefully and have your academic center approve them, if applicable,” he said. “Watch out for noncompete clauses, and some contracts require that you do not speak negatively about your findings. That’s something you should try to avoid.”
Dr. Avram also advised clinicians not to discuss intellectual property with industry representatives. “Do not give away your intellectual property to industry when you’re consulting with them,” he said. “It is easier to do than you might think. If you have a great idea, keep it to yourself or get it protected. This is much easier for an institution where they want you to do these things. They take ownership of a lot of it, but they make it easier to do. Otherwise, you have to go through the expensive process of getting a patent.”
Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, InMode, and Zalea, and intellectual property rights with Cytrellis.
SAN DIEGO – When weighing an offer to join a dermatology practice, don’t allow legal considerations to drive your decision making, Mathew M. Avram, MD, JD, advised at the annual Masters of Aesthetics Symposium.
“Determine your professional interests and follow them accordingly,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “Your decision as to whether to join a particular practice should not be based upon a contract. Make certain to determine the business end of your deal with any new employer first: the compensation, the work hours, etc. Decide that upfront before you get into the legal details.”
The way he sees it, your relationship with your employer will always be paramount. “This is very important,” said Dr. Avram, who practiced law before he became a dermatologist. “A good contract with a bad employer will not save you from an unhappy employment experience. Few contracts ever end up in litigation, and you cannot sue your way to a happier work experience. Trust your intuition about people; trust your underlying interest in potentially working with this person, and work from there.”
Whether you choose to work in an academic practice, a private practice, or a hybrid, the key issues to address include compensation, benefits, work hours, job responsibilities, and future partnership possibilities. “As an employee, you have the greatest leverage prior to signing an agreement,” he said. “This is the time to ask for what you want.” This may include special requests such as asking the employer to purchase lasers or other special equipment for your office, or to set aside dedicated clinical time for cosmetic procedures, so that you can build a cosmetic practice.
If you’re mulling over a job offer in academics, consider asking for an academic title, what the scope of your authority is, and about your ability to hire or prevent the hiring of others. “Let’s say you’re starting a laser center in your academic center,” said Dr. Avram, who is a past president of the American Society for Laser Medicine and Surgery. “You may not want to find out after you’ve signed your contract that they’ve hired five other people to do the same thing.”
If you’re considering a job offer from a private practice, ask for specifics about bonuses, partnership track, scope of practice, and device purchases. “You want to have that decided before you sign,” he said. “But these are business issues, not legal issues. An agreement needs to be made between you and your employer as to these issues. Once they’ve been agreed upon, it’s time to proceed with a contract. This is where legal advice becomes helpful.” The trick is to negotiate in good faith while maintaining your relationship with your new employer. “Do not destroy your relationship over legal points, but do not cave on crucial issues for fear of upsetting your new employer,” he said.
In law school, Dr. Avram learned that there is no such thing as a standard employment contract. Any contract can be amended, no matter how large or small the institution. “You can amend a mortgage agreement, so you can certainly amend a physician employment contract,” he said. “If the employer is not going to put their commitments in writing, they are probably not going to honor that commitment to you. Written agreements supersede all preceding oral agreements. Each key term needs to be stated explicitly. If not, you have lost all leverage to enforce your initial agreement.”
Key provisions are restrictive covenants and at-will employment. Dr. Avram defined restrictive covenants as contractual agreements that attempt to restrict an employee so as to limit that person’s ability to compete. “This can include noncompete clauses, nonsolicitation agreements, and confidentiality agreements,” he said. “A noncompete agreement prohibits a doctor from competing against their former practice within a specific geographic area for a period of time after the employment has ended. The nonsolicitation agreement restricts the manner and time during which a physician can solicit patients or employees from a practice after termination of employment. A confidentiality agreement is usually indefinite as to time and it restricts the employee from disclosing confidential practice information.”
State laws, he continued, govern restrictive covenants. Some states prohibit them. States that allow them limit their scope to prevent undue burden on the employee’s ability to make a living after termination. “Restrictive covenants in cities need to be narrower than those in rural areas,” he said. “Overly broad restrictive covenants may be unenforceable. Courts can ‘blue line’ covenants to make them more reasonable in scope.”
Next, Dr. Avram discussed involuntary termination in the workplace. Termination with cause means that termination can only result from violation of policy or ethics code violation or significantly poor performance. “In the absence of these circumstances, termination cannot legally proceed,” he said. “This protects the employee from an arbitrary termination.”
On the other hand, at-will employees can be terminated without cause. “It’s a much easier standard to terminate an at-will employee, as long as the reason is not illegal,” he said. “In academic centers, your employment as a physician may require a for-cause termination, whereas your administrative title may be without cause.”
One way to avoid potential legal trouble is to abide by your employer’s rules governing a physician’s interactions with industry. “It is foolish to break those rules,” Dr. Avram said. “Transparency ahead of time is always your best policy. Remember: Your day job is far more valuable to you than part-time work with industry. Also, know that pharma payments are publicly reported by the Centers for Medicare & Medicaid Services.” When it comes to establishing contracts with industry, “read them carefully and have your academic center approve them, if applicable,” he said. “Watch out for noncompete clauses, and some contracts require that you do not speak negatively about your findings. That’s something you should try to avoid.”
Dr. Avram also advised clinicians not to discuss intellectual property with industry representatives. “Do not give away your intellectual property to industry when you’re consulting with them,” he said. “It is easier to do than you might think. If you have a great idea, keep it to yourself or get it protected. This is much easier for an institution where they want you to do these things. They take ownership of a lot of it, but they make it easier to do. Otherwise, you have to go through the expensive process of getting a patent.”
Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, InMode, and Zalea, and intellectual property rights with Cytrellis.
SAN DIEGO – When weighing an offer to join a dermatology practice, don’t allow legal considerations to drive your decision making, Mathew M. Avram, MD, JD, advised at the annual Masters of Aesthetics Symposium.
“Determine your professional interests and follow them accordingly,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital in Boston. “Your decision as to whether to join a particular practice should not be based upon a contract. Make certain to determine the business end of your deal with any new employer first: the compensation, the work hours, etc. Decide that upfront before you get into the legal details.”
The way he sees it, your relationship with your employer will always be paramount. “This is very important,” said Dr. Avram, who practiced law before he became a dermatologist. “A good contract with a bad employer will not save you from an unhappy employment experience. Few contracts ever end up in litigation, and you cannot sue your way to a happier work experience. Trust your intuition about people; trust your underlying interest in potentially working with this person, and work from there.”
Whether you choose to work in an academic practice, a private practice, or a hybrid, the key issues to address include compensation, benefits, work hours, job responsibilities, and future partnership possibilities. “As an employee, you have the greatest leverage prior to signing an agreement,” he said. “This is the time to ask for what you want.” This may include special requests such as asking the employer to purchase lasers or other special equipment for your office, or to set aside dedicated clinical time for cosmetic procedures, so that you can build a cosmetic practice.
If you’re mulling over a job offer in academics, consider asking for an academic title, what the scope of your authority is, and about your ability to hire or prevent the hiring of others. “Let’s say you’re starting a laser center in your academic center,” said Dr. Avram, who is a past president of the American Society for Laser Medicine and Surgery. “You may not want to find out after you’ve signed your contract that they’ve hired five other people to do the same thing.”
If you’re considering a job offer from a private practice, ask for specifics about bonuses, partnership track, scope of practice, and device purchases. “You want to have that decided before you sign,” he said. “But these are business issues, not legal issues. An agreement needs to be made between you and your employer as to these issues. Once they’ve been agreed upon, it’s time to proceed with a contract. This is where legal advice becomes helpful.” The trick is to negotiate in good faith while maintaining your relationship with your new employer. “Do not destroy your relationship over legal points, but do not cave on crucial issues for fear of upsetting your new employer,” he said.
In law school, Dr. Avram learned that there is no such thing as a standard employment contract. Any contract can be amended, no matter how large or small the institution. “You can amend a mortgage agreement, so you can certainly amend a physician employment contract,” he said. “If the employer is not going to put their commitments in writing, they are probably not going to honor that commitment to you. Written agreements supersede all preceding oral agreements. Each key term needs to be stated explicitly. If not, you have lost all leverage to enforce your initial agreement.”
Key provisions are restrictive covenants and at-will employment. Dr. Avram defined restrictive covenants as contractual agreements that attempt to restrict an employee so as to limit that person’s ability to compete. “This can include noncompete clauses, nonsolicitation agreements, and confidentiality agreements,” he said. “A noncompete agreement prohibits a doctor from competing against their former practice within a specific geographic area for a period of time after the employment has ended. The nonsolicitation agreement restricts the manner and time during which a physician can solicit patients or employees from a practice after termination of employment. A confidentiality agreement is usually indefinite as to time and it restricts the employee from disclosing confidential practice information.”
State laws, he continued, govern restrictive covenants. Some states prohibit them. States that allow them limit their scope to prevent undue burden on the employee’s ability to make a living after termination. “Restrictive covenants in cities need to be narrower than those in rural areas,” he said. “Overly broad restrictive covenants may be unenforceable. Courts can ‘blue line’ covenants to make them more reasonable in scope.”
Next, Dr. Avram discussed involuntary termination in the workplace. Termination with cause means that termination can only result from violation of policy or ethics code violation or significantly poor performance. “In the absence of these circumstances, termination cannot legally proceed,” he said. “This protects the employee from an arbitrary termination.”
On the other hand, at-will employees can be terminated without cause. “It’s a much easier standard to terminate an at-will employee, as long as the reason is not illegal,” he said. “In academic centers, your employment as a physician may require a for-cause termination, whereas your administrative title may be without cause.”
One way to avoid potential legal trouble is to abide by your employer’s rules governing a physician’s interactions with industry. “It is foolish to break those rules,” Dr. Avram said. “Transparency ahead of time is always your best policy. Remember: Your day job is far more valuable to you than part-time work with industry. Also, know that pharma payments are publicly reported by the Centers for Medicare & Medicaid Services.” When it comes to establishing contracts with industry, “read them carefully and have your academic center approve them, if applicable,” he said. “Watch out for noncompete clauses, and some contracts require that you do not speak negatively about your findings. That’s something you should try to avoid.”
Dr. Avram also advised clinicians not to discuss intellectual property with industry representatives. “Do not give away your intellectual property to industry when you’re consulting with them,” he said. “It is easier to do than you might think. If you have a great idea, keep it to yourself or get it protected. This is much easier for an institution where they want you to do these things. They take ownership of a lot of it, but they make it easier to do. Otherwise, you have to go through the expensive process of getting a patent.”
Dr. Avram reported that he has received consulting fees from Allergan, Merz Pharma, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis Biosystems, InMode, and Zalea, and intellectual property rights with Cytrellis.
EXPERT ANALYSIS FROM MOAS 2019
Longer-lasting neuromodulators coming down the pike
SAN DIEGO – In the coming years, expect to see an increasing number of neuromodulators hit the market, Joel L. Cohen, MD, predicted at the annual Masters of Aesthetics Symposium.
One such product, DaxibotulinumtoxinA (Daxi), formerly known as RT002, contains a proprietary peptide that may contribute to extending its duration of action beyond currently available neuromodulator products. “Another difference for Daxi is that it does not contain human serum albumin,” said Dr. Cohen, who’s in private practice in Greenwood Village and Lone Tree, both in Colo.
In trials of the agent conducted by Revance, the manufacturer, for the treatment of moderate to severe glabellar lines, DaxibotulinumtoxinA achieved a 1-point change in results from baseline in a median of 24 weeks, while the return to baseline wrinkle severity occurred in a median of 28 weeks. According to the Revance web site, DaxibotulinumtoxinA is up for possible Food and Drug Administration approval in 2020.
Though current neuromodulators on the market may be most effective for 3-4 months, the reality is that patients often don’t come in for longer stretches of time – as there is still some degree of efficacy. Dr. Cohen shared interim data from an ongoing study that showed that at 6 months 69% of patients remain satisfied with the result of their last injection. “With Dysport, for example, even though we know the durability is to 3-4 months, we have patients who may still be happy with the results at 6 months,” he said.
Another trend he discussed is the increasing interest in QM1114, a novel, ready-to-use type A botulinum toxin formulation being developed by Galderma for the aesthetic treatment of glabellar lines. Unlike Botox, Dysport, Xeomin, and Jueveau, QM1114 is a liquid and thus does not require reconstitution.
“Myobloc is also a liquid but it is a type B botulinum toxin,” Dr. Cohen said. “It’s always been formulated as a liquid toxin, but it’s not something we can use commonly in our aesthetic practices [unless a patient is suspected of having extremely rare type A antibodies] for many reasons beyond simply it not being approved for aesthetic use. Though Myobloc kicks in faster, it spreads more, it hurts more, and it doesn’t last as long.”
In a phase 2 study presented at the 2019 World Congress of Dermatology, investigators, including Dr. Cohen, evaluated the safety and efficacy of QM1114 for the treatment of glabellar lines in 359 patients aged 23-79 years. Patients were randomly assigned to one of three single-treatment groups – 35 units, 45 units, or 60 units – or to placebo. Two weeks post treatment, wrinkle severity improved by at least two grades based on the assessment of investigators (a range from 83%-91%) and by that of treated subjects (a range from 73%-86%), compared with 6% and 8%, respectively, in the placebo group. In addition, 90%-98% of subjects rated themselves as “very satisfied” or “satisfied” with the treatment at month 1, compared with 72%-80% of subjects at month 6. Treatment-related adverse events occurred in little more than 1% of subjects in any QM1114 group and presented as mild to moderate injection-site pain, headache, eyelid ptosis, injection-site pruritus, injection-site swelling, and eyelid edema.
Dr. Cohen reported having research and financial ties to numerous pharmaceutical and device companies including Merz, Galderma, Allergan, Revance, Evolus, and Croma.
SAN DIEGO – In the coming years, expect to see an increasing number of neuromodulators hit the market, Joel L. Cohen, MD, predicted at the annual Masters of Aesthetics Symposium.
One such product, DaxibotulinumtoxinA (Daxi), formerly known as RT002, contains a proprietary peptide that may contribute to extending its duration of action beyond currently available neuromodulator products. “Another difference for Daxi is that it does not contain human serum albumin,” said Dr. Cohen, who’s in private practice in Greenwood Village and Lone Tree, both in Colo.
In trials of the agent conducted by Revance, the manufacturer, for the treatment of moderate to severe glabellar lines, DaxibotulinumtoxinA achieved a 1-point change in results from baseline in a median of 24 weeks, while the return to baseline wrinkle severity occurred in a median of 28 weeks. According to the Revance web site, DaxibotulinumtoxinA is up for possible Food and Drug Administration approval in 2020.
Though current neuromodulators on the market may be most effective for 3-4 months, the reality is that patients often don’t come in for longer stretches of time – as there is still some degree of efficacy. Dr. Cohen shared interim data from an ongoing study that showed that at 6 months 69% of patients remain satisfied with the result of their last injection. “With Dysport, for example, even though we know the durability is to 3-4 months, we have patients who may still be happy with the results at 6 months,” he said.
Another trend he discussed is the increasing interest in QM1114, a novel, ready-to-use type A botulinum toxin formulation being developed by Galderma for the aesthetic treatment of glabellar lines. Unlike Botox, Dysport, Xeomin, and Jueveau, QM1114 is a liquid and thus does not require reconstitution.
“Myobloc is also a liquid but it is a type B botulinum toxin,” Dr. Cohen said. “It’s always been formulated as a liquid toxin, but it’s not something we can use commonly in our aesthetic practices [unless a patient is suspected of having extremely rare type A antibodies] for many reasons beyond simply it not being approved for aesthetic use. Though Myobloc kicks in faster, it spreads more, it hurts more, and it doesn’t last as long.”
In a phase 2 study presented at the 2019 World Congress of Dermatology, investigators, including Dr. Cohen, evaluated the safety and efficacy of QM1114 for the treatment of glabellar lines in 359 patients aged 23-79 years. Patients were randomly assigned to one of three single-treatment groups – 35 units, 45 units, or 60 units – or to placebo. Two weeks post treatment, wrinkle severity improved by at least two grades based on the assessment of investigators (a range from 83%-91%) and by that of treated subjects (a range from 73%-86%), compared with 6% and 8%, respectively, in the placebo group. In addition, 90%-98% of subjects rated themselves as “very satisfied” or “satisfied” with the treatment at month 1, compared with 72%-80% of subjects at month 6. Treatment-related adverse events occurred in little more than 1% of subjects in any QM1114 group and presented as mild to moderate injection-site pain, headache, eyelid ptosis, injection-site pruritus, injection-site swelling, and eyelid edema.
Dr. Cohen reported having research and financial ties to numerous pharmaceutical and device companies including Merz, Galderma, Allergan, Revance, Evolus, and Croma.
SAN DIEGO – In the coming years, expect to see an increasing number of neuromodulators hit the market, Joel L. Cohen, MD, predicted at the annual Masters of Aesthetics Symposium.
One such product, DaxibotulinumtoxinA (Daxi), formerly known as RT002, contains a proprietary peptide that may contribute to extending its duration of action beyond currently available neuromodulator products. “Another difference for Daxi is that it does not contain human serum albumin,” said Dr. Cohen, who’s in private practice in Greenwood Village and Lone Tree, both in Colo.
In trials of the agent conducted by Revance, the manufacturer, for the treatment of moderate to severe glabellar lines, DaxibotulinumtoxinA achieved a 1-point change in results from baseline in a median of 24 weeks, while the return to baseline wrinkle severity occurred in a median of 28 weeks. According to the Revance web site, DaxibotulinumtoxinA is up for possible Food and Drug Administration approval in 2020.
Though current neuromodulators on the market may be most effective for 3-4 months, the reality is that patients often don’t come in for longer stretches of time – as there is still some degree of efficacy. Dr. Cohen shared interim data from an ongoing study that showed that at 6 months 69% of patients remain satisfied with the result of their last injection. “With Dysport, for example, even though we know the durability is to 3-4 months, we have patients who may still be happy with the results at 6 months,” he said.
Another trend he discussed is the increasing interest in QM1114, a novel, ready-to-use type A botulinum toxin formulation being developed by Galderma for the aesthetic treatment of glabellar lines. Unlike Botox, Dysport, Xeomin, and Jueveau, QM1114 is a liquid and thus does not require reconstitution.
“Myobloc is also a liquid but it is a type B botulinum toxin,” Dr. Cohen said. “It’s always been formulated as a liquid toxin, but it’s not something we can use commonly in our aesthetic practices [unless a patient is suspected of having extremely rare type A antibodies] for many reasons beyond simply it not being approved for aesthetic use. Though Myobloc kicks in faster, it spreads more, it hurts more, and it doesn’t last as long.”
In a phase 2 study presented at the 2019 World Congress of Dermatology, investigators, including Dr. Cohen, evaluated the safety and efficacy of QM1114 for the treatment of glabellar lines in 359 patients aged 23-79 years. Patients were randomly assigned to one of three single-treatment groups – 35 units, 45 units, or 60 units – or to placebo. Two weeks post treatment, wrinkle severity improved by at least two grades based on the assessment of investigators (a range from 83%-91%) and by that of treated subjects (a range from 73%-86%), compared with 6% and 8%, respectively, in the placebo group. In addition, 90%-98% of subjects rated themselves as “very satisfied” or “satisfied” with the treatment at month 1, compared with 72%-80% of subjects at month 6. Treatment-related adverse events occurred in little more than 1% of subjects in any QM1114 group and presented as mild to moderate injection-site pain, headache, eyelid ptosis, injection-site pruritus, injection-site swelling, and eyelid edema.
Dr. Cohen reported having research and financial ties to numerous pharmaceutical and device companies including Merz, Galderma, Allergan, Revance, Evolus, and Croma.
EXPERT ANALYSIS FROM MOA 2019
Laser treatment of basal cell carcinoma continues to be refined
SAN DIEGO – Using laser and light sources to treat nonaggressive basal cell carcinoma (BCC) is emerging as a promising treatment option, especially for those with multiple tumors and those who are poor surgical candidates, Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
“Topical therapies often result in recurrence, so there really is a need for an alternative [to surgery] that’s effective, efficient, and carries a low risk of side effects,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego,
“The prototypic feature of BCC is the presence of telangiectatic vessels,” she explained, and the postulated mechanism of action is selective photothermolysis of the tumor vasculature. “These vessels are slightly larger in caliber, compared with normal skin – 40 micrometers versus 15 micrometers – and more fragile. You can tailor your pulse duration to the size of the vessels. Theoretically, by targeting the vasculature then you get tumor regression with sparing of normal tissue.”
Initial studies of this approach have used the 595-nm pulsed-dye laser, which is well absorbed by oxyhemoglobin, but more recent studies have used the 1064-nm Nd:YAG to reach deep arterial vessels. In a prospective, open-label study, 10 patients with 13 BCCs less than 1.5 cm in diameter received one treatment with a 10-ms pulsed 1064-nm Nd:YAG laser delivered on the trunk or extremities at a fluence of 80-120 J/cm2 (Lasers Surg Med. 2015;47[2]:106-10). Dr. Ortiz and her colleagues observed a 92% clearance rate overall.
She described other earlier studies of the approach as flawed, because they relied on confirmation of clearance rates with clinical exam or biopsy rather than with surgical excision. “Also, some of the protocols weren’t standardized, multiple treatments were required, and subjects with suboptimal response were currently on anticoagulation,” she said. “Intravascular coagulation is important for effective treatment with vascular lasers, so anticoagulation may interfere with efficacy.”
In a more recent multicenter study, Dr. Ortiz and her colleagues treated 33 BCCs once with the long-pulsed 1064-nm Nd:YAG laser delivered with a 5-6 mm spot size at a fluence of 125-140 J/cm2 and a 7-10 ms pulse duration (Laser Surgery Med. Feb 13 2018. doi: 10.1002/lsm.22803). Standard surgical excision with 5-mm margins was performed 4 weeks after laser treatment. Among 31 subjects who completed the study, 28 of 31 BCC tumors (90%) cleared after one treatment.
“The treatments were performed without anesthesia, because we didn’t want the vasculature to be affected, but in clinical practice I am now using lidocaine with no epinephrine,” Dr. Ortiz said. She characterized the results as “at least comparable to, if not superior to” common modalities including methyl aminolevulinate–PDT (72.8%), imiquimod cream (83.4%), and fluorouracil cream (80.1%). “One criticism I hear is that with such high fluences, you’re probably getting some bulk heating,” she said. “Maybe so, but it seems to work and there’s no scarring, which suggests otherwise.”
Advantages of using a 1064-nm Nd:YAG for treating nonaggressive BCCs are that it requires just one treatment, it takes about 5 minutes, and there is no significant downtime, with no limitations in posttreatment activity. “Potentially there is a relatively decreased risk for complications, including infection and bleeding,” she added. “It’s a good alternative for treating patients with multiple tumors or those who are poor surgical candidates.”
She and her colleagues are currently performing a long-term follow-up study of 35 BCC lesions. Only one has potentially recurred, but that recurrence has not yet been confirmed.
Dr. Ortiz treats BCCs with a standard 5-mm margin and uses lidocaine without epinephrine to avoid vasoconstriction. She typically uses a 1064-nm Cutera excel V laser delivered at a pulse duration of 8 ms and a fluence of 140 J/cm2, with no cooling. “Theoretically, any 1064-nm pulsed-dye laser could work, but the way the pulse is delivered is different, depending on which device” is used, she said.
“I always like waiting between passes to avoid any bulk heating. The immediate endpoint to strive for is slight graying and slight contraction,” she said. Billing codes for malignant destruction/electrodesiccation and curettage can be used (codes 17260-17266 for the trunk and 17280-17283 for the face).
In order to determine the mechanism of cell death and to optimize results, Dr. Ortiz said that further studies need to be conducted in vitro and in vivo. In order to determine treatment efficacy, clinical studies involving various heat sources and low concentrations of lidocaine are also required.
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOAS.
SAN DIEGO – Using laser and light sources to treat nonaggressive basal cell carcinoma (BCC) is emerging as a promising treatment option, especially for those with multiple tumors and those who are poor surgical candidates, Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
“Topical therapies often result in recurrence, so there really is a need for an alternative [to surgery] that’s effective, efficient, and carries a low risk of side effects,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego,
“The prototypic feature of BCC is the presence of telangiectatic vessels,” she explained, and the postulated mechanism of action is selective photothermolysis of the tumor vasculature. “These vessels are slightly larger in caliber, compared with normal skin – 40 micrometers versus 15 micrometers – and more fragile. You can tailor your pulse duration to the size of the vessels. Theoretically, by targeting the vasculature then you get tumor regression with sparing of normal tissue.”
Initial studies of this approach have used the 595-nm pulsed-dye laser, which is well absorbed by oxyhemoglobin, but more recent studies have used the 1064-nm Nd:YAG to reach deep arterial vessels. In a prospective, open-label study, 10 patients with 13 BCCs less than 1.5 cm in diameter received one treatment with a 10-ms pulsed 1064-nm Nd:YAG laser delivered on the trunk or extremities at a fluence of 80-120 J/cm2 (Lasers Surg Med. 2015;47[2]:106-10). Dr. Ortiz and her colleagues observed a 92% clearance rate overall.
She described other earlier studies of the approach as flawed, because they relied on confirmation of clearance rates with clinical exam or biopsy rather than with surgical excision. “Also, some of the protocols weren’t standardized, multiple treatments were required, and subjects with suboptimal response were currently on anticoagulation,” she said. “Intravascular coagulation is important for effective treatment with vascular lasers, so anticoagulation may interfere with efficacy.”
In a more recent multicenter study, Dr. Ortiz and her colleagues treated 33 BCCs once with the long-pulsed 1064-nm Nd:YAG laser delivered with a 5-6 mm spot size at a fluence of 125-140 J/cm2 and a 7-10 ms pulse duration (Laser Surgery Med. Feb 13 2018. doi: 10.1002/lsm.22803). Standard surgical excision with 5-mm margins was performed 4 weeks after laser treatment. Among 31 subjects who completed the study, 28 of 31 BCC tumors (90%) cleared after one treatment.
“The treatments were performed without anesthesia, because we didn’t want the vasculature to be affected, but in clinical practice I am now using lidocaine with no epinephrine,” Dr. Ortiz said. She characterized the results as “at least comparable to, if not superior to” common modalities including methyl aminolevulinate–PDT (72.8%), imiquimod cream (83.4%), and fluorouracil cream (80.1%). “One criticism I hear is that with such high fluences, you’re probably getting some bulk heating,” she said. “Maybe so, but it seems to work and there’s no scarring, which suggests otherwise.”
Advantages of using a 1064-nm Nd:YAG for treating nonaggressive BCCs are that it requires just one treatment, it takes about 5 minutes, and there is no significant downtime, with no limitations in posttreatment activity. “Potentially there is a relatively decreased risk for complications, including infection and bleeding,” she added. “It’s a good alternative for treating patients with multiple tumors or those who are poor surgical candidates.”
She and her colleagues are currently performing a long-term follow-up study of 35 BCC lesions. Only one has potentially recurred, but that recurrence has not yet been confirmed.
Dr. Ortiz treats BCCs with a standard 5-mm margin and uses lidocaine without epinephrine to avoid vasoconstriction. She typically uses a 1064-nm Cutera excel V laser delivered at a pulse duration of 8 ms and a fluence of 140 J/cm2, with no cooling. “Theoretically, any 1064-nm pulsed-dye laser could work, but the way the pulse is delivered is different, depending on which device” is used, she said.
“I always like waiting between passes to avoid any bulk heating. The immediate endpoint to strive for is slight graying and slight contraction,” she said. Billing codes for malignant destruction/electrodesiccation and curettage can be used (codes 17260-17266 for the trunk and 17280-17283 for the face).
In order to determine the mechanism of cell death and to optimize results, Dr. Ortiz said that further studies need to be conducted in vitro and in vivo. In order to determine treatment efficacy, clinical studies involving various heat sources and low concentrations of lidocaine are also required.
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOAS.
SAN DIEGO – Using laser and light sources to treat nonaggressive basal cell carcinoma (BCC) is emerging as a promising treatment option, especially for those with multiple tumors and those who are poor surgical candidates, Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium.
“Topical therapies often result in recurrence, so there really is a need for an alternative [to surgery] that’s effective, efficient, and carries a low risk of side effects,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego,
“The prototypic feature of BCC is the presence of telangiectatic vessels,” she explained, and the postulated mechanism of action is selective photothermolysis of the tumor vasculature. “These vessels are slightly larger in caliber, compared with normal skin – 40 micrometers versus 15 micrometers – and more fragile. You can tailor your pulse duration to the size of the vessels. Theoretically, by targeting the vasculature then you get tumor regression with sparing of normal tissue.”
Initial studies of this approach have used the 595-nm pulsed-dye laser, which is well absorbed by oxyhemoglobin, but more recent studies have used the 1064-nm Nd:YAG to reach deep arterial vessels. In a prospective, open-label study, 10 patients with 13 BCCs less than 1.5 cm in diameter received one treatment with a 10-ms pulsed 1064-nm Nd:YAG laser delivered on the trunk or extremities at a fluence of 80-120 J/cm2 (Lasers Surg Med. 2015;47[2]:106-10). Dr. Ortiz and her colleagues observed a 92% clearance rate overall.
She described other earlier studies of the approach as flawed, because they relied on confirmation of clearance rates with clinical exam or biopsy rather than with surgical excision. “Also, some of the protocols weren’t standardized, multiple treatments were required, and subjects with suboptimal response were currently on anticoagulation,” she said. “Intravascular coagulation is important for effective treatment with vascular lasers, so anticoagulation may interfere with efficacy.”
In a more recent multicenter study, Dr. Ortiz and her colleagues treated 33 BCCs once with the long-pulsed 1064-nm Nd:YAG laser delivered with a 5-6 mm spot size at a fluence of 125-140 J/cm2 and a 7-10 ms pulse duration (Laser Surgery Med. Feb 13 2018. doi: 10.1002/lsm.22803). Standard surgical excision with 5-mm margins was performed 4 weeks after laser treatment. Among 31 subjects who completed the study, 28 of 31 BCC tumors (90%) cleared after one treatment.
“The treatments were performed without anesthesia, because we didn’t want the vasculature to be affected, but in clinical practice I am now using lidocaine with no epinephrine,” Dr. Ortiz said. She characterized the results as “at least comparable to, if not superior to” common modalities including methyl aminolevulinate–PDT (72.8%), imiquimod cream (83.4%), and fluorouracil cream (80.1%). “One criticism I hear is that with such high fluences, you’re probably getting some bulk heating,” she said. “Maybe so, but it seems to work and there’s no scarring, which suggests otherwise.”
Advantages of using a 1064-nm Nd:YAG for treating nonaggressive BCCs are that it requires just one treatment, it takes about 5 minutes, and there is no significant downtime, with no limitations in posttreatment activity. “Potentially there is a relatively decreased risk for complications, including infection and bleeding,” she added. “It’s a good alternative for treating patients with multiple tumors or those who are poor surgical candidates.”
She and her colleagues are currently performing a long-term follow-up study of 35 BCC lesions. Only one has potentially recurred, but that recurrence has not yet been confirmed.
Dr. Ortiz treats BCCs with a standard 5-mm margin and uses lidocaine without epinephrine to avoid vasoconstriction. She typically uses a 1064-nm Cutera excel V laser delivered at a pulse duration of 8 ms and a fluence of 140 J/cm2, with no cooling. “Theoretically, any 1064-nm pulsed-dye laser could work, but the way the pulse is delivered is different, depending on which device” is used, she said.
“I always like waiting between passes to avoid any bulk heating. The immediate endpoint to strive for is slight graying and slight contraction,” she said. Billing codes for malignant destruction/electrodesiccation and curettage can be used (codes 17260-17266 for the trunk and 17280-17283 for the face).
In order to determine the mechanism of cell death and to optimize results, Dr. Ortiz said that further studies need to be conducted in vitro and in vivo. In order to determine treatment efficacy, clinical studies involving various heat sources and low concentrations of lidocaine are also required.
Dr. Ortiz disclosed having financial relationships with numerous pharmaceutical and device companies. She is also cochair of the MOAS.
EXPERT ANALYSIS FROM MOAS 2019
Expert shares tips for laser hair removal prior to gender reassignment surgery
SAN DIEGO – prior to undergoing the procedures.
“In the last year, in terms of hair removal, this has been the biggest change in my practice,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium.
R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at Massachusetts General Hospital, and Melanie Grossman, MD, who practices in New York City, developed laser hair removal in the 1990s, and today laser hair removal stands as the most common laser treatment in medicine, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston. He described it as “safe and effective in skilled hands,” requiring about six treatments. Indications are for hypertrichosis, hirsutism (sometimes in the setting of polycystic ovary syndrome), pseudofolliculitis barbae, pilonidal cysts, and gender reassignment surgery.
Laser hair removal works by the extended theory of selective photothermolysis. “You’re targeting by proxy,” Dr. Avram explained. “The laser targets eumelanin in darkly pigmented hairs, with the secondary target being the follicular stem cells. Pigment is a prerequisite for effective treatment. So if there is no pigment in the hair, with current technology, it’s not going to work.”
He advises clinicians to avoid a cookbook approach to fluences when performing laser hair removal. Even though higher fluences have been correlated with greater permanent hair removal, they are also more likely to cause unexpected side effects. “The recommended treatment fluences are often provided with each individual laser device for nonexperienced operators, but I would not recommend doing that,” he said. “You want to evaluate for the desired clinical endpoint of perifollicular erythema and edema. The highest possible tolerated fluence, which yields this endpoint, without any adverse effects, is often the best fluence for treatment.” In 2016, Dr. Avram and his colleagues published a paper that focuses on desirable and therapeutic endpoints when performing laser and light treatments (J Am Acad Dermatol 2016;74[5]:821-33).
The best candidates for laser hair removal are those with light skin color and dark hair. “The more pigment that’s in the hair, the more it’s going to absorb the energy,” he said. Coarse, thick hair responds better than thin vellus hairs, and blond, gray hairs do not respond. A new silver nanoparticle technology is being developed that may improve efficacy for people with blond or gray hair in the future. “Modest initial data showed that it works, but it requires several treatments,” Dr. Avram said.
A past president of the American Society for Laser Medicine and Surgery, Dr. Avram went on to note that laser hair removal is often delegated to nonphysicians and is the most common cause of lawsuits for laser injury. “The rates of lawsuits rise dramatically when delegated to nonphysicians,” he said. “They even rise higher when performed by nonphysicians without supervision such as in medi-spas. Some of the side effects when performed by nonexperienced users can include temporary hyperpigmentation and longterm hypopigmentation.”
One of his clinical pearls is to never perform laser hair removal on suntanned individuals (“you will get obvious, bizarre-appearing hypopigmentation,” he said) and to exercise caution in patients with darker skin types. “If you do a test spot, give it a couple of weeks to see if hyperpigmentation develops,” he advised. “However, their sun exposure may change, and the area you treat with a test spot may be different than the entire area you intend to treat, so don’t think that a test spot is going to guarantee a particular result. You also have to be aware of paradoxical hypertrichosis, where you get more hair growth rather than less.”
Laser hair removal is mandatory prior to neovaginoplasty surgery. Surgeons use skin from the penile shaft and the midscrotum to create the new vagina, Dr. Avram said, so all hair must be removed prior to surgery so that the inside of the new vagina will be free of hair.
“You can use laser or electrolysis for this,” he said. “Electrolysis takes a lot more treatments and is going to be much more tedious than laser hair removal.” Areas to be targeted include all hair on the scrotum and all hair on the penile shaft, plus one inch around the base. “In the perineum, you want to remove hair from the bottom of the scrotum to one inch above the anus in order to clear a 2.5-inch-wide strip,” he said.
For a phalloplasty, surgeons use skin from the underside of arm to create a urethra. This means that all hair should be removed from the crease of the wrist to 15-18 cm up the arm. “You treat the underside of the arm at 4 cm distally and 5.5 cm proximally,” Dr. Avram said. “It should be 15-18 cm in length, and you cannot have any hair that remains within the new urethra.”
To create a penis, surgeons use skin from the prone arm and around. This requires removing hair at 10 cm distally, 13 cm proximally, and 14 cm in length.
Dr. Avram emphasized the importance of patient and staff education and use of preferred pronouns when performing laser hair removal on patients prior to their gender reassignment surgery. “It requires an explanation that this requires multiple treatments and will not remove all hair,” he said. “You can work with an experienced electrologist for nonresponsive hair.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
SAN DIEGO – prior to undergoing the procedures.
“In the last year, in terms of hair removal, this has been the biggest change in my practice,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium.
R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at Massachusetts General Hospital, and Melanie Grossman, MD, who practices in New York City, developed laser hair removal in the 1990s, and today laser hair removal stands as the most common laser treatment in medicine, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston. He described it as “safe and effective in skilled hands,” requiring about six treatments. Indications are for hypertrichosis, hirsutism (sometimes in the setting of polycystic ovary syndrome), pseudofolliculitis barbae, pilonidal cysts, and gender reassignment surgery.
Laser hair removal works by the extended theory of selective photothermolysis. “You’re targeting by proxy,” Dr. Avram explained. “The laser targets eumelanin in darkly pigmented hairs, with the secondary target being the follicular stem cells. Pigment is a prerequisite for effective treatment. So if there is no pigment in the hair, with current technology, it’s not going to work.”
He advises clinicians to avoid a cookbook approach to fluences when performing laser hair removal. Even though higher fluences have been correlated with greater permanent hair removal, they are also more likely to cause unexpected side effects. “The recommended treatment fluences are often provided with each individual laser device for nonexperienced operators, but I would not recommend doing that,” he said. “You want to evaluate for the desired clinical endpoint of perifollicular erythema and edema. The highest possible tolerated fluence, which yields this endpoint, without any adverse effects, is often the best fluence for treatment.” In 2016, Dr. Avram and his colleagues published a paper that focuses on desirable and therapeutic endpoints when performing laser and light treatments (J Am Acad Dermatol 2016;74[5]:821-33).
The best candidates for laser hair removal are those with light skin color and dark hair. “The more pigment that’s in the hair, the more it’s going to absorb the energy,” he said. Coarse, thick hair responds better than thin vellus hairs, and blond, gray hairs do not respond. A new silver nanoparticle technology is being developed that may improve efficacy for people with blond or gray hair in the future. “Modest initial data showed that it works, but it requires several treatments,” Dr. Avram said.
A past president of the American Society for Laser Medicine and Surgery, Dr. Avram went on to note that laser hair removal is often delegated to nonphysicians and is the most common cause of lawsuits for laser injury. “The rates of lawsuits rise dramatically when delegated to nonphysicians,” he said. “They even rise higher when performed by nonphysicians without supervision such as in medi-spas. Some of the side effects when performed by nonexperienced users can include temporary hyperpigmentation and longterm hypopigmentation.”
One of his clinical pearls is to never perform laser hair removal on suntanned individuals (“you will get obvious, bizarre-appearing hypopigmentation,” he said) and to exercise caution in patients with darker skin types. “If you do a test spot, give it a couple of weeks to see if hyperpigmentation develops,” he advised. “However, their sun exposure may change, and the area you treat with a test spot may be different than the entire area you intend to treat, so don’t think that a test spot is going to guarantee a particular result. You also have to be aware of paradoxical hypertrichosis, where you get more hair growth rather than less.”
Laser hair removal is mandatory prior to neovaginoplasty surgery. Surgeons use skin from the penile shaft and the midscrotum to create the new vagina, Dr. Avram said, so all hair must be removed prior to surgery so that the inside of the new vagina will be free of hair.
“You can use laser or electrolysis for this,” he said. “Electrolysis takes a lot more treatments and is going to be much more tedious than laser hair removal.” Areas to be targeted include all hair on the scrotum and all hair on the penile shaft, plus one inch around the base. “In the perineum, you want to remove hair from the bottom of the scrotum to one inch above the anus in order to clear a 2.5-inch-wide strip,” he said.
For a phalloplasty, surgeons use skin from the underside of arm to create a urethra. This means that all hair should be removed from the crease of the wrist to 15-18 cm up the arm. “You treat the underside of the arm at 4 cm distally and 5.5 cm proximally,” Dr. Avram said. “It should be 15-18 cm in length, and you cannot have any hair that remains within the new urethra.”
To create a penis, surgeons use skin from the prone arm and around. This requires removing hair at 10 cm distally, 13 cm proximally, and 14 cm in length.
Dr. Avram emphasized the importance of patient and staff education and use of preferred pronouns when performing laser hair removal on patients prior to their gender reassignment surgery. “It requires an explanation that this requires multiple treatments and will not remove all hair,” he said. “You can work with an experienced electrologist for nonresponsive hair.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
SAN DIEGO – prior to undergoing the procedures.
“In the last year, in terms of hair removal, this has been the biggest change in my practice,” Mathew M. Avram, MD, JD, said at the annual Masters of Aesthetics Symposium.
R. Rox Anderson, MD, director of the Wellman Center for Photomedicine at Massachusetts General Hospital, and Melanie Grossman, MD, who practices in New York City, developed laser hair removal in the 1990s, and today laser hair removal stands as the most common laser treatment in medicine, said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital, Boston. He described it as “safe and effective in skilled hands,” requiring about six treatments. Indications are for hypertrichosis, hirsutism (sometimes in the setting of polycystic ovary syndrome), pseudofolliculitis barbae, pilonidal cysts, and gender reassignment surgery.
Laser hair removal works by the extended theory of selective photothermolysis. “You’re targeting by proxy,” Dr. Avram explained. “The laser targets eumelanin in darkly pigmented hairs, with the secondary target being the follicular stem cells. Pigment is a prerequisite for effective treatment. So if there is no pigment in the hair, with current technology, it’s not going to work.”
He advises clinicians to avoid a cookbook approach to fluences when performing laser hair removal. Even though higher fluences have been correlated with greater permanent hair removal, they are also more likely to cause unexpected side effects. “The recommended treatment fluences are often provided with each individual laser device for nonexperienced operators, but I would not recommend doing that,” he said. “You want to evaluate for the desired clinical endpoint of perifollicular erythema and edema. The highest possible tolerated fluence, which yields this endpoint, without any adverse effects, is often the best fluence for treatment.” In 2016, Dr. Avram and his colleagues published a paper that focuses on desirable and therapeutic endpoints when performing laser and light treatments (J Am Acad Dermatol 2016;74[5]:821-33).
The best candidates for laser hair removal are those with light skin color and dark hair. “The more pigment that’s in the hair, the more it’s going to absorb the energy,” he said. Coarse, thick hair responds better than thin vellus hairs, and blond, gray hairs do not respond. A new silver nanoparticle technology is being developed that may improve efficacy for people with blond or gray hair in the future. “Modest initial data showed that it works, but it requires several treatments,” Dr. Avram said.
A past president of the American Society for Laser Medicine and Surgery, Dr. Avram went on to note that laser hair removal is often delegated to nonphysicians and is the most common cause of lawsuits for laser injury. “The rates of lawsuits rise dramatically when delegated to nonphysicians,” he said. “They even rise higher when performed by nonphysicians without supervision such as in medi-spas. Some of the side effects when performed by nonexperienced users can include temporary hyperpigmentation and longterm hypopigmentation.”
One of his clinical pearls is to never perform laser hair removal on suntanned individuals (“you will get obvious, bizarre-appearing hypopigmentation,” he said) and to exercise caution in patients with darker skin types. “If you do a test spot, give it a couple of weeks to see if hyperpigmentation develops,” he advised. “However, their sun exposure may change, and the area you treat with a test spot may be different than the entire area you intend to treat, so don’t think that a test spot is going to guarantee a particular result. You also have to be aware of paradoxical hypertrichosis, where you get more hair growth rather than less.”
Laser hair removal is mandatory prior to neovaginoplasty surgery. Surgeons use skin from the penile shaft and the midscrotum to create the new vagina, Dr. Avram said, so all hair must be removed prior to surgery so that the inside of the new vagina will be free of hair.
“You can use laser or electrolysis for this,” he said. “Electrolysis takes a lot more treatments and is going to be much more tedious than laser hair removal.” Areas to be targeted include all hair on the scrotum and all hair on the penile shaft, plus one inch around the base. “In the perineum, you want to remove hair from the bottom of the scrotum to one inch above the anus in order to clear a 2.5-inch-wide strip,” he said.
For a phalloplasty, surgeons use skin from the underside of arm to create a urethra. This means that all hair should be removed from the crease of the wrist to 15-18 cm up the arm. “You treat the underside of the arm at 4 cm distally and 5.5 cm proximally,” Dr. Avram said. “It should be 15-18 cm in length, and you cannot have any hair that remains within the new urethra.”
To create a penis, surgeons use skin from the prone arm and around. This requires removing hair at 10 cm distally, 13 cm proximally, and 14 cm in length.
Dr. Avram emphasized the importance of patient and staff education and use of preferred pronouns when performing laser hair removal on patients prior to their gender reassignment surgery. “It requires an explanation that this requires multiple treatments and will not remove all hair,” he said. “You can work with an experienced electrologist for nonresponsive hair.”
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
EXPERT ANALYSIS FROM MOA 2019
Novel dermal microcoring device holds promise for moderate to severe wrinkles
SAN DIEGO – is poised to become a game-changer in the minimally invasive aesthetics field.
A brainchild of dermatologists and plastic surgeons at Massachusetts General Hospital, Boston, the device features a proprietary needle design that makes a series of high throughput microexcisions in epidermal and dermal tissue, with minimal downtime and without using thermal energy.
“The idea is to get more significant improvement of tissue laxity by fractionally removing the skin,” Mathew M. Avram, MD, JD, explained at the annual Masters of Aesthetics Symposium. “You can do a facelift by cutting the skin on the side and pulling it back. This is skin tightening and improvement of wrinkles with a thousand micro punches. It’s called fractional tissue extraction.”
Instead of relying on laser, heat, light, or radiofrequency, the device uses needle mechanics to extract microsized cores of full-thickness skin below the size threshold that causes scarring. “Then, you have biomechanical remodeling; you close the channels right away,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital. “If you remove skin that is smaller than 500 micrometers in size, no scar is left behind.”
In trials of the device being carried out by Cytrellis Biosystems, more than 100 patients have been treated one to two times. During a separate presentation, one of the device investigators, Jill S. Waibel, MD, said that areas of treatment have included the upper and lower cheeks, perioral areas, and the submentum. On average, the amount of skin removed during each treatment session ranges from 5% to 8.5% and the mean down time is 3.8 days. According to combined data from two studies of 30 patients who had 60 areas treated and were followed at 90 or 180 days, subjects experienced an average 1.1 grade improvement on the Lemperle Rating Scale and showed an 80% improvement in moderate or severe wrinkles. In addition, 91% of investigators rated treatment areas as “improved” or “very much improved” on the Global Aesthetic Improvement Scale, and 88% of subjects were “satisfied” or “extremely satisfied” with the results.
“The safety profile of this device is amazing,” said Dr. Waibel, a dermatologist and owner of the Miami Dermatology and Laser Institute. “It provides an entirely new mode of treatment for skin laxity through highly approachable tissue removal with minimal to no pain or downtime. You can visually see the cores close through Optical Coherence Tomography before patients even leave the office. There have also been virtually no side effects except in one patient at another site who had minor postinflammatory hyperpigmentation.”
The device allows for local and scarless treatment of wrinkles in the areas in which they form, she continued, so results are natural and true to the underlying anatomy. “While its target testing has been in more severely lax patients, I think it has a great future for younger patients who want to stave off a future face lift,” Dr. Waibel said. “Initial treatments required preoperative lidocaine injections. However, recent trials using more tolerable analgesic methods have shown that this may not even be necessary. This is very exciting new technology and I have high hopes for the future of this device.”
Histological analysis from baseline to 60-90 days post treatment showed homogenization of elastosis, which signals reorganization of the papillary dermis, Dr. Avram said. It also showed a decrease in the grenz zone, rete ridge flattening, a slight increase in the collagen-to-elastin ratio, and no scarring. Pending clearance, he said, the device could be commercially available in 2020.
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
Dr. Waibel disclosed that she has conducted clinical research for AbbVie, Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.
SAN DIEGO – is poised to become a game-changer in the minimally invasive aesthetics field.
A brainchild of dermatologists and plastic surgeons at Massachusetts General Hospital, Boston, the device features a proprietary needle design that makes a series of high throughput microexcisions in epidermal and dermal tissue, with minimal downtime and without using thermal energy.
“The idea is to get more significant improvement of tissue laxity by fractionally removing the skin,” Mathew M. Avram, MD, JD, explained at the annual Masters of Aesthetics Symposium. “You can do a facelift by cutting the skin on the side and pulling it back. This is skin tightening and improvement of wrinkles with a thousand micro punches. It’s called fractional tissue extraction.”
Instead of relying on laser, heat, light, or radiofrequency, the device uses needle mechanics to extract microsized cores of full-thickness skin below the size threshold that causes scarring. “Then, you have biomechanical remodeling; you close the channels right away,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital. “If you remove skin that is smaller than 500 micrometers in size, no scar is left behind.”
In trials of the device being carried out by Cytrellis Biosystems, more than 100 patients have been treated one to two times. During a separate presentation, one of the device investigators, Jill S. Waibel, MD, said that areas of treatment have included the upper and lower cheeks, perioral areas, and the submentum. On average, the amount of skin removed during each treatment session ranges from 5% to 8.5% and the mean down time is 3.8 days. According to combined data from two studies of 30 patients who had 60 areas treated and were followed at 90 or 180 days, subjects experienced an average 1.1 grade improvement on the Lemperle Rating Scale and showed an 80% improvement in moderate or severe wrinkles. In addition, 91% of investigators rated treatment areas as “improved” or “very much improved” on the Global Aesthetic Improvement Scale, and 88% of subjects were “satisfied” or “extremely satisfied” with the results.
“The safety profile of this device is amazing,” said Dr. Waibel, a dermatologist and owner of the Miami Dermatology and Laser Institute. “It provides an entirely new mode of treatment for skin laxity through highly approachable tissue removal with minimal to no pain or downtime. You can visually see the cores close through Optical Coherence Tomography before patients even leave the office. There have also been virtually no side effects except in one patient at another site who had minor postinflammatory hyperpigmentation.”
The device allows for local and scarless treatment of wrinkles in the areas in which they form, she continued, so results are natural and true to the underlying anatomy. “While its target testing has been in more severely lax patients, I think it has a great future for younger patients who want to stave off a future face lift,” Dr. Waibel said. “Initial treatments required preoperative lidocaine injections. However, recent trials using more tolerable analgesic methods have shown that this may not even be necessary. This is very exciting new technology and I have high hopes for the future of this device.”
Histological analysis from baseline to 60-90 days post treatment showed homogenization of elastosis, which signals reorganization of the papillary dermis, Dr. Avram said. It also showed a decrease in the grenz zone, rete ridge flattening, a slight increase in the collagen-to-elastin ratio, and no scarring. Pending clearance, he said, the device could be commercially available in 2020.
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
Dr. Waibel disclosed that she has conducted clinical research for AbbVie, Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.
SAN DIEGO – is poised to become a game-changer in the minimally invasive aesthetics field.
A brainchild of dermatologists and plastic surgeons at Massachusetts General Hospital, Boston, the device features a proprietary needle design that makes a series of high throughput microexcisions in epidermal and dermal tissue, with minimal downtime and without using thermal energy.
“The idea is to get more significant improvement of tissue laxity by fractionally removing the skin,” Mathew M. Avram, MD, JD, explained at the annual Masters of Aesthetics Symposium. “You can do a facelift by cutting the skin on the side and pulling it back. This is skin tightening and improvement of wrinkles with a thousand micro punches. It’s called fractional tissue extraction.”
Instead of relying on laser, heat, light, or radiofrequency, the device uses needle mechanics to extract microsized cores of full-thickness skin below the size threshold that causes scarring. “Then, you have biomechanical remodeling; you close the channels right away,” said Dr. Avram, director of laser, cosmetics, and dermatologic surgery at Massachusetts General Hospital. “If you remove skin that is smaller than 500 micrometers in size, no scar is left behind.”
In trials of the device being carried out by Cytrellis Biosystems, more than 100 patients have been treated one to two times. During a separate presentation, one of the device investigators, Jill S. Waibel, MD, said that areas of treatment have included the upper and lower cheeks, perioral areas, and the submentum. On average, the amount of skin removed during each treatment session ranges from 5% to 8.5% and the mean down time is 3.8 days. According to combined data from two studies of 30 patients who had 60 areas treated and were followed at 90 or 180 days, subjects experienced an average 1.1 grade improvement on the Lemperle Rating Scale and showed an 80% improvement in moderate or severe wrinkles. In addition, 91% of investigators rated treatment areas as “improved” or “very much improved” on the Global Aesthetic Improvement Scale, and 88% of subjects were “satisfied” or “extremely satisfied” with the results.
“The safety profile of this device is amazing,” said Dr. Waibel, a dermatologist and owner of the Miami Dermatology and Laser Institute. “It provides an entirely new mode of treatment for skin laxity through highly approachable tissue removal with minimal to no pain or downtime. You can visually see the cores close through Optical Coherence Tomography before patients even leave the office. There have also been virtually no side effects except in one patient at another site who had minor postinflammatory hyperpigmentation.”
The device allows for local and scarless treatment of wrinkles in the areas in which they form, she continued, so results are natural and true to the underlying anatomy. “While its target testing has been in more severely lax patients, I think it has a great future for younger patients who want to stave off a future face lift,” Dr. Waibel said. “Initial treatments required preoperative lidocaine injections. However, recent trials using more tolerable analgesic methods have shown that this may not even be necessary. This is very exciting new technology and I have high hopes for the future of this device.”
Histological analysis from baseline to 60-90 days post treatment showed homogenization of elastosis, which signals reorganization of the papillary dermis, Dr. Avram said. It also showed a decrease in the grenz zone, rete ridge flattening, a slight increase in the collagen-to-elastin ratio, and no scarring. Pending clearance, he said, the device could be commercially available in 2020.
Dr. Avram disclosed that he has received consulting fees from Allergan, Merz, Sciton, Soliton, and Zalea. He also reported having ownership and/or shareholder interest in Cytrellis, Invasix, and Zalea and intellectual property rights with Cytrellis.
Dr. Waibel disclosed that she has conducted clinical research for AbbVie, Aquavit, Cytrellis, Lumenis, Lutronic, Michelson Diagnostics, RegenX, Sciton, Sebacia, and Syneron/Candela. She is also a consultant for RegenX, Strata, and Syneron/Candela and is a member of the advisory board for Dominion Technologies, Sciton, and Sebacia.
EXPERT ANALYSIS FROM MOA 2019
Thread lifts making a comeback, but long-term effects remain unclear
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
SAN DIEGO – The use of threads to improve skin laxity is making a comeback, thanks largely to advances in absorbable sutures.
“Thread lifts were popularized in the 1990s, but I think they were misrepresented as an alternative to a surgical face-lift, which remains the gold standard,” Arisa E. Ortiz, MD, said at the annual Masters of Aesthetics Symposium. “A thread lift is certainly not like a traditional face-lift; it’s much more subtle.”
In the 1990s, clinicians used nonabsorbable sutures for thread lifts, including polypropylene-barbed threads, which caused adverse events ranging from extrusion and migration to thread expulsion, dimpling, granuloma formation, and prolonged pain. As a result, the Food and Drug Administration withdrew its approval of contour thread aesthetic procedures in 2009. Since then, the development of absorbable threads made from polydioxanone (PDO) and poly-
“There are some nice benefits to thread lifts,” said Dr. Ortiz, who is director of laser and cosmetic dermatology at the University of California, San Diego. “You get immediate results, which is always nice for patients, but with tissue tightening using energy-based devices, results are unpredictable and it can take 6 months to see the results. With resorbable sutures, we’re seeing fewer complications, and the amount of lifting is more predictable because you’re physically lifting the tissue. In some cases, threads are able to lift tissue more than energy-based devices. There is minimal recovery, it requires local anesthesia, and it’s less expensive than a surgical face-lift, which can run $10,000-$15,000 or more.”
For skin lifting, clinicians implant threads subcutaneously. When tugged in the opposite direction, the barbs anchor in adipose tissue, increasing tensile strength while suspended in the dermis and overlying tissue. This produces a fibrous adhesion capsule that helps to solidify anchorage of the suture long term. Fibrosis has been shown to increase local collagen production. PDO and PLLA are known collagen stimulants and are postulated to stimulate a long-term benefit in rejuvenation, Dr. Ortiz said, but overall evidence regarding their use in thread lifts is weak.
“Existing studies have a very short follow-up period and there is really no standardized protocol, so we don’t know really know a lot about them yet,” she said. Lana Tong, MD, and Evan A. Rieder, MD, of New York University recently published a systematic review of the literature on the topic (Dermatol Surg. 2019 45[7]:931-40).
PDO is biodegradable by hydrolysis over 4-8 months and is used as absorbable suture material for prolonged tension–bearing areas. “It causes neocollagenesis with a foreign-body reaction,” Dr. Ortiz said. Meanwhile, PLLA is a collagen stimulator used for prolonged volume restoration. “It’s used an aesthetic filler, but a known complication with PLLA injections is the formation of subcutaneous nodules and late onset granulomas,” she said.
Early in 2019, Korean researchers published results of a study that set out to evaluate the collagen-producing effects of powdered PDO injection, compared with PLLA injection, in a murine model (J Cosmet Dermatol. 2019 Feb 27. doi: 10.1111/jocd.12894). “It showed both PDO and PLLA induced granulomatous reactions and collagen formation, but this decreased at 12 weeks,” said Dr. Ortiz, who was not involved with the work. “PDO had slightly more collagen formation than PLLA.”
Indications for thread lifts, she continued, are for jawline lift, cheek enhancement, brow lift, wrinkle reduction, body contouring, acne scarring, and texturing. “Choose patients with good skin quality: not too thick/heavy, and not too thin. Patients with moderate skin sagging are going to better candidates than those with severe skin sagging.”
One type of absorbable suspension suture, the Silhouette InstaLift, is made of polyglycolide/
In terms of adverse events following thread lift procedures, patients usually feel tender for about a week or 2. “They can have some bruising, mostly from the anesthesia,” she said.
To prevent temporary dimpling, Dr. Ortiz undermines with an 18-gauge needle and inserts perpendicular to the skin surface. “Extrusions can still occur,” she said. To prevent this, she pulls on the end and makes sure it’s buried subcutaneously.
Dr. Ortiz reported having financial relationships with numerous pharmaceutical and device companies, though none related to the content of her presentation. She is also cochair of the Masters of Aesthetics symposium.
EXPERT ANALYSIS FROM MOA 2019
Tips for adding cosmeceuticals to your aesthetic practice
SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice
First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.
“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.
A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”
A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.
“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”
Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”
She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”
Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”
In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.
SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice
First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.
“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.
A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”
A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.
“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”
Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”
She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”
Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”
In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.
SAN DIEGO – In the opinion of Kimberly J. Butterwick, MD, there are at least three reasons why dermatologists should consider incorporating cosmeceuticals into their aesthetic practice
First, if you don’t, patients will buy products elsewhere. “There’s good data showing that 80% of patients will purchase a product within 24 hours of an office visit,” Dr. Butterwick said at the annual Masters of Aesthetics Symposium.
“You should be the one giving them unbiased advice, because patients waste a lot of money on products which aren’t that effective. Female patients spend an average of $2,000 per year on cosmetics. The average woman uses 15 different cosmetics per day,” according to Dr. Butterwick.
A second reason to consider selling cosmeceuticals is that patients visit dermatologists in order to have healthy, beautiful skin. “Patients want and need your expertise,” said Dr. Butterwick, one of five board-certified dermatologists who practices at the San Diego-based Cosmetic Laser Dermatology. “Patients who are educated and are given advice have better compliance and outcomes. You also want to care for patients for life, to show that you have an interest in treating them beyond what they come to see you for. That will make them come back to you. They’ll get refills and visits and more advice.”
A third reason to consider selling moisturizers, bleaching agents, and other cosmeceuticals is that it’s good for business. “It can be profitable, not just to you, but it’s an opportunity for employees to be creative and earn more with a product sales incentive,” Dr. Butterwick said. “Some of them are great sellers.” She and her colleagues at Cosmetic Laser Dermatology hit more than $1 million in gross revenue from cosmeceutical sales in 2016, 2017, and 2018. In 2018 alone, they sold 167 different products across 27 skin care lines. Six product lines brought in 84% of total sales: SkinMedica, Calecim, SkinCeuticals, Neocutis, Colorescience, and Topix. “Antiaging products are always going to be the number one seller,” she said, including antioxidants, peptides, growth factors, retinoids, hydroxyacids, botanicals, nutriceuticals, teeth-whitening agents, and supplements. New serums with solid science behind them, she continued, include Multi-Action Cream, a product from Calecim that contains a cytokine and growth factor blend from umbilical cord stem cells of red deer to stimulate collagen production and healing after procedures. In 2020, Dr. Butterwick said that SkinMedica’s TNS Essential Serum will contain human fibroblasts grown at low oxygen levels. These are designed to behave as embryonic fibroblasts with more effective growth factors, resulting in better collagen production.
“You want to take the high road when selling cosmeceuticals,” said Dr. Butterwick, who also was a co-founder of SkinMedica. “Provide guidance and education to steer your patients toward products that have proven efficacy, safety, are well tolerated, and are tested and approved by office staff and patients.”
Her tips for effective dispensing include selecting products that target your patient base and the climate in your area, and starting with a specific product line such as SkinMedica, Obagi, SkinCeuticals, Colorescience, Alastin, or Skin Better. “When you choose a company, make sure they have good return policies,” she said. “Get that in writing. Make sure they’ll educate your staff, and make sure they have some system in place to monitor unauthorized sales online. A lot of companies have this now. At trade shows, I’ve learned that some companies will dump expired products, which people buy at a discount and sell online. You don’t want to be competing with that kind of situation.”
She recommends setting aside a dedicated area in your office to display products, “whether it’s the checkout counter in your waiting room or a separate room that resembles a store,” she said. “For effective dispensing, physician-directed products are best. Explain the science: why you are recommending a product and why it is effective. Staff can review the regimen and try products with the patient. A written regimen assures compliance. You also want to offer patients discounts for multiple products or a featured brand of the month. Offer free shipping for refills, and consider linking products with procedures for a discount.”
Citing independent research conducted for a major cosmetics company, Dr. Butterwick said that patients are initially excited to purchase a cosmeceutical product, but once they get home compliance wanes. Only 30% buy the product a second time, and only 12% buy it a third time. “Reasons why so many drop off include that they find it inconvenient to buy, they forgot how to use the product, they become demotivated or distracted, or they shop around for a lower price,” she explained. “Remind your patients not to buy products online. Many of these products are expired or counterfeit. There’s so much information available online, but why not be a source of truth and tell them what’s really going to help? That’s going to assure your patient of the best outcome. It will also keep your patient loyal to you and your practice.”
In addition to co-founding SkinMedica, Dr. Butterwick disclosed that she has received grants/research support from Allergan, Galderma, and Histogen, and consulting fees from Allergan, Colorescience, Evolus, Galderma, Merz, and Sinclair. She is also a member of the speakers’ bureau for Allergan and Merz.
EXPERT ANALYSIS FROM MOAS 2019
Should you market your aesthetic services to the ‘Me Me Me Generation’?
SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.
A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.
Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.
They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.
According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.
“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”
He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”
Dr. Biesman reported having no relevant disclosures related to his presentation.
SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.
A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.
Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.
They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.
According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.
“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”
He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”
Dr. Biesman reported having no relevant disclosures related to his presentation.
SAN DIEGO – If the idea of marketing your aesthetic dermatology services to Millennials is an afterthought, Brian Biesman, MD, recommends that you reconsider that outlook. At the annual Masters of Aesthetics Symposium, Dr. Biesman told attendees that the age group dubbed as the “Me Me Me Generation” by Joel Stein of Time Magazine is slowly overtaking Baby Boomers as the largest shopping generation in history.
A large consumer survey conducted by Accenture found that by 2020, spending by Millennials will account for $1.4 trillion in U.S. retail sales. This segment of the population, which the Pew Research Center defines as those born from 1981 to 1996, also spends more online than any other generation. According to data from the consulting firm Bain & Company, 25% of luxury goods will be purchased online by 2025, up from 8% in 2016. “Millennials are going to be a huge economic driving force,” Dr. Biesman said.
Dr. Biesman, an oculofacial plastic surgeon who practices in Nashville, Tenn., said Millennials were born into a digital age. “They are very socially connected, sometimes to their detriment,” said Dr. Biesman, who is a past president of the American Society for Laser Medicine and Surgery. “They’re definitely in debt ... but they’re comfortable with that and don’t mind spending. Their priorities are different. They tend to put off marriage and having kids, and they’re driven by social media.
They also hold a strong interest in appearance, said Dr, Biesman, who noted that the average Millennial woman is more likely to be aware of beauty issues by a factor of 10 years younger than her mother’s generation. “At age 25, Millennial women are getting interested in aesthetics, whereas the older generation didn’t start until about 35,” he said. Millennials “are educated, and they use the Internet to read up on procedures.” In his clinical experience, The most popular procedures include neuromodulators, fillers (especially in the lips and in the infraorbital hollow), minimally invasive laser hair removal, superficial laser resurfacing, and prescription skin care and cosmeceuticals.
According to a 2018 survey of 500 Millennials conducted by the aesthetics site Zalea, 32% were considering a cosmetic procedure and 6.6% had undergone one. Of the 149 Millennials who completed all of the survey questions, 65% indicated that they relied on Google search for information about cosmetic treatments, which was a higher proportion than for physicians (63%), friends and family (60%), and social networks such as Instagram, Facebook, and Twitter (25%). Dr. Biesman said that a paradigm shift is under way in aesthetic dermatology, in which the traditional means of achieving a strong reputation amongst patients by excellent training, publications, and research can be replaced by building a visible social media presence/personality.
“The social media influencer factor is a real phenomenon, and can carry tremendous weight due to their perceived relationship with their audience/followers,” Dr. Biesman said. “Some physicians are influencers, while others collaborate with influencers.” He emphasized that the decision to work with social media influencers depends on your preference, your comfort level/trust, the professionalism of the influencer, and your overall social media strategy. “The more you share about yourself, the more successful your social media account will be,” he said. “You need to determine your comfort zone, such as how much of your life you want to share.”
He advises aesthetic dermatologists to develop a strategy for reaching out to and incorporating Millennials into their practice. “Be deliberate in assessing the profile of your practice demographics, and determine which patient groups you want to serve, and to what extent,” he said. “If your practice is focused on minimally invasive aesthetics, it’s important to understand the Millennial mindset, because this is the largest group of consumers.”
Dr. Biesman reported having no relevant disclosures related to his presentation.
EXPERT ANALYSIS FROM MOAS 2019