BBI Contributing Editor
Two October meetings, one in the U.S. and the other in Europe, provided interesting windows on where aesthetic dermatologic surgery is today and is headed in the near future.
The annual meeting of the European Academy of Dermatology & Venereology in Barcelona, Spain, was attended by several thousand dermatologists and facilitated the introduction of numerous new aesthetic technologies. Many of these devices and procedures are not available yet in the U.S., so the meeting served as a tremendously valuable preview arena.
This show was also populated by a stellar cast of European dermatology opinion leaders who participated in the scientific program. Aesthetic laser pioneers such as Drs. Mario Trelles, Jean Luc Levy and Christine Dierickx continue to set the pace in Europe in terms of leading-edge research projects.
European procedure and product preferences among physicians are significantly different from the U.S., with a strong emphasis on using pulsed light devices for epilation and erbium lasers for resurfacing vs. nonablative wrinkle treatment technologies. There also is a greater emphasis on medically oriented light-based treatments such as psoriasis, vitiligo and skin cancer.
At least 10 different pulsed light devices were offered in the EADV exhibit hall, including some brands that are privately labeled for the European market or even specific countries. Danish Dermatologic Development (DDD; Horsholm, Denmark) showed a new design of its popular Ellipse pulsed light system, which covers all major applications such as hair removal, vascular/pigmented lesions and photorejuvenation via a variety of treatment attachments. DDD has a large installed base of systems internationally, but it is blocked from entry to the U.S. due to patent issues.
Other pulsed-light devices at the show included the Lovely line of devices manufactured by Israel's IM2. These products are priced from $25,000 up to $70,000 and feature a unique technology that controls the pulse energy.
Syneron (Yokneam, Israel) offers a full range of treatments with its ELOS technology-based product line, which includes Aurora and Polaris. Also shown were the NovaLight from Ultramed in Switzerland and some very interesting phototherapy systems from CureLight (Or Akiva, Israel). This is the company that manufactures the ClearLight acne treatment system for Lumenis (Yokneam, Israel). However, outside of the U.S., CureLight offers the same ClearLight system at a much lower price (EUR 25,000) directly to customers, as well as the reduced energy output iClear (EUR 15,000) for acne and MultiClear device for treating conditions such as psoriasis and vitiligo.
Galderma (Lausanne, Switzerland), which has invested heavily in the development and commercialization of photodynamic therapy, had a strong presence at the EADV. This company is the exclusive global distributor (with the exception of a few Nordic countries) for PhotoCure's (Oslo, Norway) Metvix photosensitizer. Metvix currently has regulatory approval for sale in Germany, Austria and the UK, while the other European countries are pending. However, insurance reimbursement has not yet been finalized. Thus, use of this product has been very limited due to the cost, which ranges from $300 to $500 per two-gram dose. Galderma also supplies the Aktilite LED light source for activation of the Metvix drug.
Undoubtedly, the most interesting new technology to debut at the EADV was the ClearTouch Lite device from Radiancy (Orangeburg, New York/Yavne, Israel), which is the first light-based acne treatment system for home use. Zion Azar, president and chief executive officer of the company, said ClearTouch Lite is "the first in a line of LHE (Light Heat Energy) based skincare products for the home."
This product is packaged for the consumer in an Acne Clearance Kit and provides "a comprehensive system of acne care for patients to use safely and effectively on their own as part of a professional treatment plan," Azar said. The kit, priced at less than $500, includes a resusable light device and a select line of ProCare Dead Sea mineral cosmeceuticals.
New-product 'explosion' at ASDS
Seldom has there been an explosion of new drugs, devices and treatment modalities in the field of cosmetic skin surgery as was presented at the annual scientific meeting of the American Society for Dermatologic Surgery (ASDS; Rolling Meadows, Illinois) in New Orleans, Louisiana. The meeting attracted nearly 1,000 attendees for mini-courses and focus sessions on breakthrough research and clinical advances in dermatologic surgery. Among the topics creating buzz were new wrinkle fillers, new applications for Botox, non-ablative technologies for skin rejuvenation and innovative endovenous techniques for leg veins.
In terms of fillers, Restylane has received considerable notoriety in the media recently. To clarify its role in soft tissue augmentation, Rhoda Narins, MD, director of the Dermatologic Surgery and Laser Center (White Plains, New York), led off the Fillers Course with a clinical update on Restylane hyaluronic acid gel in the U.S. "The efficacy of injectable filler substances is based on volume and longevity," Narins said. "Since non-animal stabilized hyaluronic acid (NASHA) binds to water and provides volume correction, Restylane is poised to do for the lower half of the face what Botox did for the upper face."
According to Narins, the key advantages of NASHA include no allergy testing for same-day treatment, enhanced safety with no transmission of disease, increased longevity with smooth, natural-looking results, and different forms for different tissues. When compared to Zyplast collagen, "our study found that Resytlane lasted longer, less injection volume was required for optimal cosmetic results and immediate side effects were similar for the two products," she said.
In contrast to permanent fillers, "Restylane is forgiving, and no long-term complications have been reported," Narins added. "With these documented benefits, I believe Restylane should be considered the new standard in injectable filler materials."
David Orentreich, MD, assistant clinical professor in the department of dermatology at Mt. Sinai School of Medicine (New York), presented his microdroplet serial puncture technique for silicone as a facial filler, noting that Silikon 1000 is FDA-cleared only as a retinal tamponade, while SilSkin is pending FDA approval for cosmetic use.
"The serial puncture microdroplet technique with attention to bevel placement is mandatory for safe and effective results using silicone," Orentreich said. "I begin with monthly treatments and then increase the treatment interval to every two to four months, every six months, and once a year as you approach the end point." He likened his technique to planting seeds of silicone under the target area that grow with collagen augmentation.
In addition to the perioral area, Orentreich favors silicone for HIV-related facial wasting, crow's feet and forehead creases not responsive to Botox and small depressions post-rhinoplasty. As a rule, for increasing overall total volume, he told colleagues to increase the number of injection puncture sites rather than increasing the microdroplet size. He also suggested applying pressure to reduce bruising after treatment.
Orentreich offered colleagues the following technique tips to achieve optimal effect: mark with a Sharpie; inject with the syringe only half full for better control, force and comfort; inject just under the dermis with a release and inject movement; stay aware of the bevel so the axis of the syringe is parallel to the axis of the target area; avoid resting your thumb on the plunger; and do not use the fanning approach.
In a presentation on "CosmoDerm/CosmoPlast in Restoration Therapy," Richard Glogau, MD, of San Francisco, California, noted that rejuvenation of the lower face requires combination therapy and "no single agent can do it all." He identified four treatment targets: the shape and volume of lips; lateral support of the mouth; marionette lines; and nasolabial folds. Glogau said he prefers CosmoPlast to outline and sharpen the border of the lips and uses CosmoDerm to fill in the contour and volume of the lips. His technique relies on Restylane to build body, balance the upper and lower volume around the mouth and generally support the mouth at the lateral corners.
Glogau uses Perlane in the deeper nasolabial folds to maximize its more robust effect. Challenging the "wash and wear" view of the hyaluronic acids, he remarked that "these fillers need a day or two to settle down and are not 'camera-ready' that evening. I also like to combine and layer the fillers to enhance volume correction, obtain longer lasting cumulative results and soften the overall look."
Expanding on the "combine and layer" approach was Fredric Brandt, MD, a cosmetic dermatologist in private practice in Miami, Florida, and New York, who delivered an overview of his technique for utilizing the new collagens and the NASHA product line: CosmoDerm and ComsoPlast; Restylane, Restylane Fine and Perlane, respectively.
Brandt injects CosmoDerm into the upper dermis using a serial puncture technique with over-correction; for CosmoPlast, he targets the mid dermis using a serial puncture technique with no over-correction. In the lips, he prefers ComsoPlast for the vermillion border and CosmoDerm for the mucosa and vertical lip lines above and below. "I flow CosmoDerm across the lips to essentially resurface the upper lip area."
For nasolabial folds, Brandt said, "I often layer the CosmoDerm over the CosmoPlast with the degree of overcorrection dependent on the defect." Another popular combination is CosmoDerm overlaid with Restylane or Perlane to erase fine rhytids and restore bulk and volume. Above the eyebrows, he does not use CosmoPlast, only CosmoDerm to avoid arterial occlusion.
When Restylane is used on the lips, he advocates a retrograde injection technique since "I would rather get a bruise than an occlusion. In general, I consider the Restylane family for facial contouring and the new collagens for superficial wrinkles and depressions," Brandt said.