Mathew M. Avram

Cellulite: a review of its physiology and treatment

Cellulite affects 85–98% of post‐pubertal females of all races. While not a pathologic condition, it remains an issue of cosmetic concern to a great number of individuals. Despite its high prevalence, there have been few scientific investigations into the physiology of cellulite. There have only been a few dozen peer‐reviewed articles devoted to cellulite in the medical literature in the past 30 years. There is no definitive explanation for its presentation. This greatly complicates the ability to treat or improve it. The four leading hypotheses that purport to explain the physiology of cellulite include: sexually dimorphic skin architecture, altered connective tissue septae, vascular changes and inflammatory factors. Treatment modalities can be divided into four main categories: attenuation of aggravating factors, physical and mechanical methods, pharmacological agents and laser. There are no truly effective treatments for cellulite.

Prealbumin is the best nutritional predictor of survival in hemodialysis and peritoneal dialysis

Patients undergoing dialytic therapy for end-stage renal disease (ESRD) have greater morbidity and mortality than age-matched individuals with similar demographics in the general population. Risk factors for early death during treatment for ESRD include advanced age, diabetes, hypertension, and malnutrition. We questioned whether the level of serum prealbumin at the start of uremia therapy might serve as a marker of subsequent survival in patients treated with maintenance hemodialysis (HD) and peritoneal dialysis (PD). Study cohorts included 111 HD and 78 PD patients followed for up to 5 years. Selected demographic characteristics and biochemical variables were tested for correlation with survival in each cohort. Variables evaluated included age, race, gender, diabetic status, and serum concentrations of albumin, creatinine, cholesterol, and prealbumin. For comparison, expected survival was calculated with Cox proportional hazards analysis, which accounts for confounding variables. We found that a higher relative risk (RR) of death in HD patients correlated with older age, the diagnosis of diabetes, and a serum prealbumin < 30 mg/dL. In PD patients, older age and the presence of diabetes correlated with a higher RR of death than in the standard population. When nutritional variables were analyzed separately, prealbumin < 30 mg/dL was the strongest variable that predicted mortality in HD patients (RR = 2.64, P = 0.002) and also predicted increased risk of mortality in PD patients (RR = 1.8, P = 0.035). Observed and expected survival was significantly higher in patients with enrollment prealbumin greater than 30 mg/dL in both HD and PD. The serum prealbumin level correlated significantly with other measures of nutrition, including serum albumin, serum creatinine, and serum cholesterol, in both HD and PD patients. Among tested markers of nutritional status, prealbumin level appears to be the single best nutritional predictor of survival in ESRD patients.

Cryolipolysis™ for subcutaneous fat layer reduction†

Cryolipolysis is a unique non‐invasive method for the selective reduction of fat cells with controlled, localized cooling. It is important, therefore, to understand the potential efficacy and safety of this new procedure for fat layer reduction.

Consensus Recommendations on the Use of an Erbium‐Doped 1,550‐nm Fractionated Laser and Its Applications in Dermatologic Laser Surgery

BACKGROUND Nonablative fractional photothermolysis has revolutionized the way we treat a number of common skin conditions with laser technology. OBJECTIVE A comprehensive guide is needed for clinicians using this technology to treat specific skin conditions in various skin types. MATERIALS AND METHODS Recommendations were made from a recent round table discussion among experienced physicians and a review of recent literature findings. RESULTS Optimal laser parameters are dependent on patient skin type and condition. We recommended guidelines for the successful treatment of several common skin conditions on and off the face using nonablative fractional photothermolysis. Specific conditions were dyschromia, rhytides, acne scars, surgical scars, melasma, and striae distensae. CONCLUSIONS We developed reproducible guidelines to most effectively treat a variety of skin types and conditions using nonablative fractional photothermolysis. Future large, multicenter trials are indicated for further optimization of treatment parameters. Reliant Technologies paid travel expenses and honorariums to all authors.

Laser hair removal.

The extended theory of selective photothermolysis enables the laser surgeon to target and destroy hair follicles, thereby leading to hair removal. Today, laser hair removal (LHR) is the most commonly requested cosmetic procedure in the world and is routinely performed by dermatologists, other physicians, and non‐physician personnel with variable efficacy. The ideal candidate for LHR is fair skinned with dark terminal hair; however, LHR can today be successfully performed in all skin types. Knowledge of hair follicle anatomy and physiology, proper patient selection and preoperative preparation, principles of laser safety, familiarity with the various laser/light devices, and a thorough understanding of laser–tissue interactions are vital to optimizing treatment efficacy while minimizing complications and side effects.

Cryolipolysis for Reduction of Excess Adipose Tissue

Controlled cold exposure has long been reported to be a cause of panniculitis in cases such as popsicle panniculitis. Cryolipolysis is a new technology that uses cold exposure, or energy extraction, to result in localized panniculitis and modulation of fat. Presently, the Zeltiq cryolipolysis device is FDA cleared for skin cooling, as well as various other indications, but not for lipolysis. There is, however, a pending premarket notification for noninvasive fat layer reduction. Initial animal and human studies have demonstrated significant reductions in the superficial fat layer thickness, ranging from 20% to 80%, following a single cryolipolysis treatment. The decrease in fat thickness occurs gradually over the first 3 months following treatment, and is most pronounced in patients with limited, discrete fat bulges. Erythema of the skin, bruising, and temporary numbness at the treatment site are commonly observed following treatment with the device, though these effects largely resolve in approximately 1 week. To date, there have been no reports of scarring, ulceration, or alterations in blood lipid or liver function profiles. Cryolipolysis is a new, noninvasive treatment option that may be of benefit in the treatment of excess adipose tissue.

Paradoxical adipose hyperplasia after cryolipolysis.

IMPORTANCE Cryolipolysis is the noninvasive reduction of fat with localized cutaneous cooling. Since initial introduction, over 650,000 cryolipolysis treatment cycles have been performed worldwide. We present a previously unreported, rare adverse effect following cryolipolysis: paradoxical adipose hyperplasia. OBSERVATIONS A man in his 40s underwent a single cycle of cryolipolysis to his abdomen. Three months following his treatment, a gradual enlargement of the treatment area was noted. This enlargement was a large, well-demarcated subcutaneous mass, slightly tender to palpation. Imaging studies revealed accumulation of adipose tissue with normal signal intensity within the treatment area. CONCLUSIONS AND RELEVANCE Paradoxical adipose hyperplasia is a rare, previously unreported adverse effect of cryolipolysis with an incidence of 0.0051%. No single unifying risk factor has been identified. The phenomenon seems to be more common in male patients undergoing cryolipolysis. At this time, there is no evidence of spontaneous resolution. Further studies are needed to characterize the pathogenesis and histologic findings of this rare adverse event.

Cellulite: Is there a role for injectables?

Background. Cellulite describes the cutaneous dimpling of the thighs, buttocks, and hips that is seen predominately in women. Current evidence suggests that structural differences in fat architecture between the sexes account for its appearance. Mesotherapy, a method of delivering medication locally with the use of numerous cutaneous injections, has recently become a popular method to purportedly treat the condition. Methods. An overview of cellulite and adipocyte physiology, with a literature review and appraisal of compounds commonly used in mesotherapy. Results. Experimental studies using individual mesotherapy ingredients for other conditions suggest a number of mechanisms, including lipolysis, disrupting connective tissue and augmenting circulation, which may theoretically improve cellulite. Peer‐reviewed studies have not evaluated whether these effects translate clinically. Conclusions. Until further studies are performed, patients considering mesotherapy for cellulite must be aware that the substances currently being injected to treat this cosmetically disturbing, but medically benign, condition have not been thoroughly evaluated for safety or efficacy.

Three-dimensional volumetric quantification of fat loss following cryolipolysis

Cryolipolysis is a noninvasive and well‐tolerated treatment for reduction of localized subcutaneous fat. Although several studies demonstrate the safety and efficacy of this procedure, volumetric fat reduction from this treatment has not been quantified. This prospective study investigated the change in volume of fat after cryolipolysis treatment using three‐dimensional (3D) photography.

Treatment of tattoo allergy with ablative fractional resurfacing: A novel paradigm for tattoo removal

BACKGROUND Q-switched lasers are the gold standard for tattoo treatment. Allergic tattoo reactions present a treatment dilemma. We present the application of ablative fractional resurfacing (AFR) as a novel method for tattoo removal. OBJECTIVE We describe two patients with tattoo allergies, referred to us for treatment. METHODS AFR was used in a series of treatments to remove the allergic-ink portion of a multicolored tattoo on the upper extremity of a 52-year-old man. In a 31-year-old woman with a red and black tattoo on her lower extremity, AFR was combined with a Q-switched neodymium:yttrium-aluminum-garnet laser. RESULTS After a series of treatments, both patients experienced significant to complete removal of the offending tattoo inks with substantial or complete resolution of their symptoms. LIMITATIONS This uncontrolled observational series is based on two patients. CONCLUSIONS AFR appears to be safe and effective for removal of allergic tattoos. AFR can be combined with other treatments such as Q-switched lasers. The potential for a series of AFR treatments to remove tattoos, including allergic tattoos and inks of any color, merits further study.