Cosmetic Dermatology Update

By Larisa Hubbs, Executive Editor and Stefanie Tuleya, Managing Editor

Enhancing Cosmetic Surgical Dermatologic Procedures

By Michael H. Gold, M.D.

As dermatologists, we are constantly bombarded with new products with claims of greatness. Companies bring to us new lotions and potions designed to make every wrinkle disappear, make every red or brown spot disappear, and make the skin look younger and healthier. We know better, hopefully, and want to examine the science behind any of the skin-care products we bring into our office to sell to our patients or clients.
Recently, I was introduced to the Clarisonic cleansing device and now have available the new Clarisonic MD, which we have incorporated into our retail environment and have begun to use on a regular basis. I am impressed with the efficacy of the device, and it has been well received by patients when we use it to prepare their skin for cosmetic surgical procedures.

How It Works

The Clarisonic skincare cleansing device, manufactured by Pacific Bioscience, uses sonic oscillating brushes to deeply cleanse, stimulate and clarify the skin by differential manipulation of the microanatomy of the skin for deep cleansing without stripping skincare layers. The device, developed by the lead inventor of the Sonicare toothbrush, brings the proprietary sonic technology to skin care. The Clarisonic MD, which is available only through skincare professionals, adds a third power to the original dual-power device.
Clarisonic works with the natural elasticity of the skin to provide gentle daily cleansing. Oscillating at a sonic frequency of more than 300 movements per second, it works deep within the pores to loosen dirt and oil, and leaves the skin looking and feeling softer, smoother and healthier.

What the Research Shows

Draelos1 studied the Clarisonic brush, and in a recent review article of facial skin cleansing, summarized her findings. First, six individuals applied a dark foundation to their skin and then used various facial cleansers — a lipid-free cleanser, foaming syndet-based face wash, an abrasive polyethylene beaded scrub, a face cloth, and the sonic skincare brush — to remove the makeup. Following a timed cleansing period, an isopropyl alcohol soaked sponge was applied to the skin to remove any remaining makeup foundation. Results showed that the sonic skincare brush removed the most cosmetic from the skin, followed by face cloth, the abrasive scrub, the syndet-based face wash, and then the lipid-free cleanser. She concluded that the bristles on the sonic skincare brush were able to “traverse the dermatolglyphics, facial pores and facial scars more adeptly than any other cleansing method.” Draelos also commented on 10 individuals who had various dermatologic conditions, including acne vulgaris, trichostasis spinulosa, pseudofolliculitis barbae and seborrheic dermatitis, and found that the sonic skincare brush provided “excellent cleansing on the uneven skin surface caused by these conditions.”
The Tennessee Clinical Research Center, with which I’m affiliated, looked at a prototype of the Clarisonic device for skin cleansing in patients with acne vulgaris by looking at Sebutape Skin Indicator Strips and evaluating trans-epidermal water loss. Five individuals completed the trial and all agreed, in questionnaires, that the device was superior to their previous skin cleansing systems. They reported their skin felt “stimulated” while using the device, and that the skin felt smoother and cleaner after using the device. They noted that the sonic brush made their faces feel rejuvenated following cleansing, reduced the oily feeling on the skin, and exfoliated better than other methods. Most significantly, the individuals noted improvement in their acne vulgaris as a result of the use of the sonic skin-care brush.2
Recent presentations utilizing Sebutape strips plus NIH analysis software (see photos above) showed that the sonic skin-care brush was more consistent at skin cleansing than a mild cleanser with a manual cleansing method and more than twice as effective in actual skin cleansing.3 A second presentation, utilizing trans-epidermal water loss, skin temperature, and a new exfoliation model confirmed the gentleness and safety of the sonic skincare brush.4
More recently, researchers performed a study to evaluate the deep cleansing ability of the sonic skincare brush utilizing a fluorescent liquid cosmetic makeup methodology. They noted that the makeup was still trapped in the fine lines and pores on the manually cleansed side, yet it was effectively removed on the side cleansed with the sonic skincare device (see photo B).5


How to Use the Device

The aestheticians in my spa, Advanced Aesthetics Medi Spa, use the Clarisonic as the first step before every facial treatment or microdermabrasion procedure they perform. They claim that it more thoroughly removes patients’ makeup, dirt, and superficial skin oils than manual cleansing of the skin with their hands. The staff of The Laser and Rejuvenation Center of Gold Skin Care Center also regularly uses the Clarisonic brush prior to all of their chemical peel procedures, laser- and light-based therapies, and filler procedures. Our office routinely uses the Clarisonic brush before all of our intense pulsed light procedures and our photodynamic therapy (PDT) procedures. We have found increased absorption of the sensitizing drug 20%
5-aminolevulinic acid (Levulan Kerastick) with the use of the Clarisonic brush prior to our PDT procedures.

Increasing Revenue

The Clarisonic, and now the Clarisonic MD, have been very useful for our patients and our overall revenue stream. Our patients find it safe and effective for their daily cleansing of the skin, and our staff finds it very useful as a back bar-item. According to Patricia Buchanan, Director of Operations for Gold Skin Care Center, “The use of the Clarisonic brushes in our practice has greatly impacted our revenue. The use of the brush by the aesthetician when performing a facial or our laser staff before using lasers/light sources or fillers leaves a lasting impact with the client as they discuss their experiences with their friends.” n
Dr. Gold is Medical Director of the Gold Skin Care Center, the Tennessee Clinical Research Center, The Laser and Rejuvenation Center and Advanced Aesthetics Medi Spa. He is also Clinical Assistant Professor, Department of Medicine, Division of Dermatology at Vanderbilt University Medical School and Vanderbilt University School of Nursing in Nashville, TN.

Disclosure: Dr. Gold is a member of the Pacific Bioscience Medical Marketing Board, performs research, has stock options and speaks on the company’s behalf.

1. Draelos ZD. Re-examining methods of facial cleansing. Vol 18, No 2;
Cos Dermatol. 2005: 173-175.
2. Unpublished data. Gold MH,, Tennessee Clinical Research Center, Nashville, TN.
3. Henes EM, Jackson L, Rodriquez S, Ortblad K, Akridge R. Assessing the gentleness of a sonic skin care brush for daily use. Poster Presentation American Academy of Dermatology, San Francisco, CA. 2006.
4. Akridge R, Jackson L, Rodriquez S, Henes EM, Ortblad K. Clinical efficacy of a new sonic skin care brush for facial cleansing. Poster Presentation American Academy of Dermatology, San Francisco, CA. 2006.
5. Personal communication, Pacific Bioscience Laboratories.


Plastic Surgery in Ethnic Groups on the Rise

The number of ethnic patients who chose to undergo cosmetic plastic surgery to enhance their appearance or minimize the signs of aging rose 65% from 2004 to 2005, with nearly 2.3 million procedures performed on ethnic patients in 2005, according to 2006 statistics released by the American Society of Plastic Surgeons.
Hispanics continue to lead all ethnic groups with more than 921,000 cosmetic procedures performed (a 67% increase from 2004), followed by African-Americans with 769,000 procedures (up 67% from 2004), and Asians with 437,000 procedures (up 58% from 2004). The most commonly requested minimally invasive cosmetic procedures for all three ethnic groups were Botox, injectable wrinkle fillers and chemical peels.


Botox: The Patient’s Perspective

How treatment affected self-perception about age.

To assess the effect of botulinum toxin type A (Botox Cosmetic) treatment of facial rhytids in the glabellar region, crow’s feet and multiple upper facial rhytids on patients’ age-related appearance, researchers analyzed data from five clinical studies of Botox treatment of facial rhytids.
Patients in each of the studies reported how old they thought they looked over the last 7 days using the self-perception of age (SPA) measure, a single-item scale for which patients indicate whether they feel they looked their current age, younger than their current age or older than their current age. If they reported feeling that they looked younger or older than their current age, the number of years younger or older was reported. The SPA item was analyzed as the proportion of patients reported looking younger and the mean years younger at 4 weeks post-Botox treatment. Treatment dosage and area treated included: 20 units Botox for glabellar rhytids, 12 units per side of Botox for crow’s feet or 64 units of Botox for multiple upper facial rhytids. For comparison, SPA results for patients receiving placebo for any treatment area were pooled.


Data from the 249 patients treated with Botox or placebo across the five studies found that at 4 weeks post-Botox, 39% of patients receiving 20 units for glabellar rhytids, 44.8% of patients receiving 12 units bilateral treatment for crow’s feet and 62.5% of patients receiving 64 units for multiple upper facial rhytids reported looking younger relative to their current ages. These Botox-treated patients reported they looked, on average, from 5 to 6 years younger. In comparison, 23% of patients receiving placebo reported they looked younger at 4 weeks post-treatment.

Poster Authors: Alastair Carruthers, M.D., Jean Carruthers, M.D., Sue Ellen Cox, M.D., Steven Fagien, M.D., J. Charles Finn, M.D., Jonathan W. Kowalski, Pharm.D., Nicholas Lowe, M.D., Arliene Ravelo, M.P.H., Mitchell A. Stotland, M.D., and Wm. Philip Werschler, M.D.


Banishing Cellulite

New studies shed light on what may help.

A recent study published in the August issue of Plastic and Reconstructive Surgery found that weight loss in overweight patients improved the appearance of cellulite, although for a few it actually worsened the condition.
The study examined 29 women who enrolled in medically supervised weight loss programs, including low-fat meals, liquid diets, medication and bariatric surgery. The average weight loss was 30.5 pounds with a range of 2.3 pounds to 102 pounds. Seventeen patients experienced an improvement in the appearance of their cellulite, while nine worsened.
Patients who lost larger amounts of weight and lowered their percentage of thigh fat experienced the greatest improvement in cellulite. On average, these patients had a significantly higher starting body mass index (BMI) and had more severe cellulite. Patients whose cellulite worsened started with a significantly lower BMI, lost smaller amounts of weight and had no change in percentage of thigh fat. Researchers found that skin elasticity after fast weight loss also played an important role in improving the appearance of cellulite, as cellulite worsened in those who became looser after weight loss.

Using Non-Invasive Injections

For those who cannot diminish cellulite, even when at a healthy weight, collagenase enzyme injections may help, according to preliminary clinical trial study results presented at the American Society of Plastic Surgeons (ASPS) Plastic Surgery conference in October.
In the study, authored by Alexander Dagum, M.D., and Marie Badalamente, Ph.D., 10 female patients received collagenase injections in their thighs. Subjective measurements of the cellulite and photographs were taken before and after the procedure. Within 1 day, patients had a 77% decrease in the appearance of cellulite. After 6 months, results remained noticeable, with patients experiencing a 76% decrease in the appearance of cellulite. There was no significant change in the patients’ BMI or thigh measurements.
At 6 months, all patients reported they were either very or completely satisfied with their results. The only side effects, which lasted 1 to 2 weeks, were soreness, mild swelling and bruising.


Retaining Cutaneous Water: Ceramides Vs. Petrolatum Emollients

By Robert L. Buka, M.D., J.D., Leslie Storey, M.D., and Jane G. Khoury, M.D.

The best emollient has always been the subject of much debate. If you ask 10 dermatologists what is their favorite emollient, you’ll most likely get 10 different answers. However, a new class of emollients, those that are based on ceramides, may be narrowing the gap of choices on the short list of “best emollients”.
Ceramides are lipids that lie within the stratum corneum (SC), and our increased understanding of them in dermatology has led to a new class of emollients that may be more effective in restoring normal barrier function than conventional petrolatum. Ceramide-based emollients (CBEs) may re-establish the lipid balance necessary for appropriate function of the epidermis.
A primary function of the stratum corneum is to be impermeable to water. This barrier works best when a balanced lipid milieu is present between corneocytes. Specifically, a ceramide deficiency in the SC is believed to be a putative cause of this barrier’s failure.

A Closer View of Ceramides

By weight, an ideal lipid environment is composed of ceramides 47%, cholesterol 24%, fatty acids 11%, and cholesterol esters 18%. Cholesterol not only increases the chain mobility of other lipids, but also aids in the synthesis of ceramides from glucosylceramides. Ceramides and cholesterol together form a lipid crystalline state (orthorhombic) that serves as a tightly packed impermeable barrier. When levels of these important lipids decrease, the lipid lattice assumes a hexagonal state that is dangerously permeable to evaporative water loss.3

Studying the Efficacy of Ceramides

In a prospective, double-blinded, placebo-controlled trial, 10 study participants ranging in age from 18 years to 60 years were treated with both a ceramide-based emollient and a petrolatum emollient on the right and left upper extremity, respectively.
Testing was performed at a contracted, independent research laboratory without financial interest in the study’s outcome. Study technicians were given unlabeled glass containers from which to administer each tested emollient. Neither participant nor technician was informed of the study’s design or the identity of each assayed emollient. Three test sites (each site measuring 2 cm x 2 cm) were marked on the participants’ forearms. Using a Tewameter, one site was treated with a ceramide emollient, and the second site was treated with a petrolatum-based moisturizer; the third site served as an untreated control. Additional Tewameter measurements were taken at each of the test sites 30 minutes, 1, 2 and 3 hours post-application.

Summary of Results

At 30 minutes, 1, 2, and 3 hours, both ceramide and petrolatum preparations caused a decrease in TEWL in all 10 study participants. Mean scores among all 10 participants were reported. (See Table 1 above.) The comparative improvement of ceramide cream over petrolatum became statistically significant at 3 hours (p<0.05). The TEWL scores were equivalent for control and petrolatum sites after 1 hour, while scores continued to improve in ceramide-treated sites. Ceramide-treated sites revealed an overall mean decreased TEWL score of 1.8 g/cm2/hour.
Petrolatum moisturizers, though considered mainstays in the symptomatic management of xerosis, do not address the underlying SC ceramide deficiency. Our data support this observation. We hypothesize that SC rejuvenation accounts for CBEs’ superiority over petrolatum products that merely coat the SC without replenishing interstitial lipids. n

Dr. Buka (pictured at left) is at the Mount Sinai School of Medicine in the Department of Dermatology in New York City, NY. He’s also in practice at The Dermatology Group in Verona, NJ.

Dr. Storey is with Loma Linda University Medical Center in Loma Linda, CA.

Dr. Khoury (pictured at left) is completing a cosmetic dermatology fellowship through the American Academy of Cosmetic Surgery at Dermatology/ Cosmetic Laser Associates of La Jolla, Inc.

Disclosure: Dr. Buka is developing a ceramide-based product. The study was sponsored by Bobby and Me, Inc. Drs. Khoury and Storey have no relevant disclosures.

1. DiNardo A, Wertz P, Giannetti A, Seidenari. Ceramide and cholesterol
composition of the skin of patients with atopic dermatitis.
Acta Derm Venereol. 1998;78:27-30.
2. Rawlings AV. Trends in stratum corneum research and the management
of dry skin conditions. Inter J Cosm Sci. 2003;25:63-95 (2003).
3. Moore DJ, Rerek ME, Mendelsohn R. Role of ceramides 2 and 5 in the structure of the stratum corneum lipid barrier. Inter J Cosm Sci. 1999; 21L:353-368.


The Effects of Plastic Surgery

Beyond looks, how cosmetic surgery can improve moods.

A significant number of patients stopped taking antidepressant medications after undergoing plastic surgery, according to a study presented at the American Society of Plastic Surgeons (ASPS) Plastic Surgery 2006 conference this month.
In the study, led by Bruce Freedman, M.D., 362 patients had cosmetic plastic surgery and 17% (61 patients) were taking antidepressants. Six months after surgery, that number dropped to 31% or 42 patients still taking antidepressants. In addition, 98% of patients said the surgery had markedly improved their self-esteem.
All of the patients, who were primarily middle-aged women, had an invasive cosmetic plastic surgery procedure, such as a facelift, tummy tuck or breast augmentation. The authors did not identify any other major life changes that may have affected patients’ use of antidepressants.
“Plastic surgery patients are taking a proactive approach in making themselves happier by improving something that has truly bothered them,” says Dr. Freedman in an ASPS release. “ While we are not saying that cosmetic plastic surgery alone is responsible for the drop in patients needing antidepressants, it surely is an important factor.


An Alternative to Liposuction

There may be a safer and more convenient alternative to liposuction, according to a recent report in the Aesthetic Buyers Guide. The 1064 nm Smartlipo Nd:YAG pulsed laser system from Deka (Calenzano, Italy) removes fat from areas typically unsuitable for traditional liposuction with only the need for tumescent anesthesia. This procedure, known as Laserlipolisi, breaks down subcutaneous adipocytes so that the liquid fat can be removed through low-pressure suction or by the body itself. There is little to no loss of blood with this procedure. Areas such as the face, submentum, ankle and calf can be treated with this procedure.


MRSA Skin Infections and Tattoo Recipients

Community-associated methicillin-resistant Staphylococcus aureus (CA-MRSA) infections have emerged in some groups of tattoo recipients. Six unlinked clusters of skin and soft tissue infections caused by CA-MRSA among 44 recipients of tattoos from 13 unlicensed tattooists in three states (Ohio, Kentucky and Vermont) were reported in the July 26 issue of the Journal of the American Medical Association. Use of nonsterile equipment and suboptimal infection-control practices were identified as potential causes of the infections.


Treatments with New HA-Based Fillers

The safety and efficacy of repeat treatment.

A new family of non-animal hyaluronic-acid (HA)-based fillers was recently FDA-approved. These next-generation HA fillers use advanced Hylacross technology, offering the highest amount of crosslinked HA of any dermal filler currently available in the United States.
Results from a multi-center, double-blind, randomized, within-subject, controlled, pivotal study demonstrated the long-lasting clinical improvement obtained with the new HA fillers. A multi-center, open-label, follow-up study was conducted to examine the safety and efficacy of the new fillers.
To be included in the follow-up study, patients had to have completed the 24-week follow-up period in the pivotal study, which was a split-face study with patients receiving one of three related HA fillers (J30, J24HV or J30HV) in one nasolabial fold and crosslinked bovine collagen filler in the other. Up to three treatments were allowed over a 4-week period (initial treatment plus up to two touch-ups about 2 weeks apart) to achieve optimal correction of the nasolabial folds. Patients from five of the original 11 investigational sites were invited to participate if their preferred product at the end of the trail was the HA filler and they chose to undergo repeat treatment within 24 to 36 weeks (+/- 2 weeks).
Patients were treated in both nasolabial folds using the same HA filler (J30, J24HVor J30HV) they were assigned in the pivotal study, with no limit on the volume injected. Treatment was provided in one session at 24 to 36 weeks after the last treatment in the pivotal study. Investigators were instructed to achieve full correction but not to overcorrect. Patients could not have had any cosmetic procedure or tissue augmentation at the nasolabial fold injection site in the 30 days prior to repeat treatment through the end of the study.
Patient follow-up visits occurred at weeks 4, 12 and 24 post-treatment and investigators assessed the nasolabial fold severity using the five-point wrinkle assessment scale (WAS) (0 = none (no wrinkle), 1 = mild (shallow, just perceptible wrinkle),
2 = moderate (moderately deep wrinkle), 3 = severe (deep wrinkle, well-defined edges but not overlapping), 4 = extreme (very deep wrinkle, redundant fold with overlapping skin) together with a validated photographic guide. Patients evaluated nasolabial fold severity using a five-point WAS without photographs and were also asked to report any unusual signs or symptoms.


• The volume of HA filler required to achieve full correction at repeat treatment was significantly less than the volume required at pivotal trial treatments 24 to 36 weeks earlier (p<0.001).
• Clinically significant improvement from baseline was achieved after initial and repeat treatment. Improvement from baseline tended to be greater after repeat treatment than after initial treatment.
• The mean nasolabial fold severity score was improved by more than 1 point relative to pre-study baseline 24 weeks after both initial and repeat treatments, according to both investigator and patient assessments.
• At 24 weeks after repeat treatment, 100% of patients maintained a clinically significant improvement.
• No serious or unanticipated adverse events were reported with any of the fillers.

Poster Authors: Stacy R. Smith, M.D., Derek Jones, M.D., Jane A. Thomas, A.A.S., C.C.R.A., Diane K. Murphy, M.B.A., and Patricia S. Walker, M.D., Ph.D.

Sparking Interest in Your Medical Spa

In the Summer 2006 issue of the newsletter for Advanced Dermatology, SKINQRI and skinfo, leading dermatologist Amy Forman Taub, M.D., offered an idea that might help your medical spa attract new customers or allow you to thank current patients. In celebration of support for Advanced Dermatology, skinfo and SKINQRI, Dr. Taub and the staff hosted an open house this month with complimentary drinks and hors d’oeuvres. Everyone attending had a chance to spin the Wheel of Rejuvenation — with prizes ranging from free skincare products to cosmetic consultations to Botox or injectable filler injections and much more.


Attracting Male Cosmetic Patients

In the La Jolla Spa MD’s October newsletter, Monthly Injections, Heather Endicott, M.S.N., F.N.P.-C., says that male customers have increased 40% since 2005. The treatment most commonly requested by her male customers is the “White Collar Special”, which is laser hair removal for the nape and front of the neck to eliminate the irritation of men’s collars rubbing against their freshly shaven skin.


Can Fillers Hide Health Risks?

In an effort to alleviate a perceived “sickly” appearance, many human immunodeficiency virus (HIV) patients have turned to dermatologic surgeons for injections of calcium hydroxyl apatite (CaHA), recently FDA approved to treat nasolabial folds and facial lipoatrophy. While this procedure fills in these patients’ concave cheek areas and gives them full, healthy looking faces, some experts theorize that the filler substance used may interfere with subsequent X-rays — a tool often used to monitor for cancerous tumors associated with HIV.
To evaluate this theory, Alastair Carruthers, M.D., evaluated 58 patients, 28 of whom had been injected 12 months previously with CaHA for HIV-associated facial lipoatrophy. All patients enrolled had pre-treatment sinus X-rays and facial CAT scans performed. They were then injected with CaHA to achieve optimum cosmetic improvement and the radiological studies were repeated 1 week later. The results were very promising, showing that cosmetic use of this filler will not interfere with subsequent radiological studies. Dr. Carruthers will present his findings at the American Society for Dermatologic Surgery Annual Meeting at the end of this month.




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