Michael S. Kaminer

Clinical Effect of a Single Pulsed Dye Laser Treatment of Fresh Surgical Scars: Randomized Controlled Trial

BACKGROUND Pulsed dye laser has been used to decrease erythema and telangiectasia associated with scars, including surgical scars. There is limited evidence indicating improved surgical scar appearance if pulsed dye laser treatments are commenced immediately at the time of suture removal. OBJECTIVE To determine whether a single one-pass pulsed dye laser treatment at the time of suture removal can improve the appearance of surgical scars. METHODS Randomized controlled trial enrolling 20 patients (complete data for 17 patients) at two geographic sites, with blinded ratings of pre- and post-treatment photographs obtained at various time points. Included patients underwent elliptical excision for atypical nevi of the trunk and/or extremities, with at least one resulting scar of at least 5 cm in length or two scars of at least 2.5 cm in length. For each patient, each scar or half-scar (if a larger scar was used) was randomized to treatment or control groups. Treatment scars received a single one-pass treatment with a 595 nm pulsed dye laser (Vbeam, Candela Corporation, Wayland, MA, USA) at the time of suture removal (ie, 2 weeks after excision) at the following parameters: 7 J/cm2 fluence, 7 mm spot size, 1.5-millisecond pulse duration, and 30-millisecond spray, 20-millisecond delay of dynamic cooling. The treatment area included 1 cm on either side of the scar, and the round laser spots were overlapped 10%. Control scars were not treated with laser. RESULTS Immediate purpura was induced from the laser treatment. Six weeks after laser treatment, no significant difference was found in the clinical appearance of surgical scars treated with a single pulsed dye laser treatment on suture removal day versus those surgical scars not treated with laser. Parameters on which no significant difference was found included visibility of incision, erythema, hyperpigmentation, hypopigmentation, induration, and atrophy. Both sets of scars improved over time. CONCLUSIONS A single pulsed dye laser treatment at the time of suture removal does not appear to have a beneficial effect on clinical scar appearance. The point of minimal benefit for such laser treatments may lie somewhere between one and three treatments.

Long‐Term Efficacy of Anchored Barbed Sutures in the Face and Neck

BACKGROUND The thread lift is a minimally invasive procedure that uses barbed sutures, inserted subcutaneously, to produce lifting of ptotic tissue of the face and neck. There are currently very limited data on longevity and patient satisfaction following barbed suture lifting procedures. OBJECTIVE The purpose of this study was to assess long-term efficacy following the use of barbed sutures. MATERIALS AND METHODS A satisfaction survey was mailed to 20 patients who were a minimum of 6 months (range, 6 to 16 months) postprocedure. Physician assessment of pre- and postprocedure photographs was also performed. RESULTS At an average of 11.5 months postprocedure, patients felt that the barbed suture lift met their expectations, rating their satisfaction a 6.9 on a scale of 1 to 10. Independent physicians rated the overall improvement an average of 4.6 of 10. Higher scores were noted in Zone 1 (tear trough/malar fat pad and nasolabial folds) compared to Zone 2 (marionette lines, jowls, and jawline definition) and Zone 3 (platysmal bands and neck contour). CONCLUSION The barbed suture lift procedure provides moderate long-term and sustained improvement for facial laxity, with most improvement seen in the tear trough/malar fat pads and nasolabial folds. In this study, clinical efficacy was seen up to 16 months postprocedure.

Delayed Inflammatory Reaction to Bio-Alcamid Polyacrylamide Gel Used for Soft-Tissue Augmentation

BACKGROUND Given the recent boom of the cosmetic industry, there is a wealth of new products available to patients and physicians, including soft-tissue fillers. Bio-Alcamid polyacrylamide gel (Polymekon, Milan, Italy) is a filler that has potential to cause adverse reactions. OBSERVATIONS Two patients who had previously been treated with Bio-Alcamid outside of the United States presented with different manifestations of inflammatory responses to the product. These reactions were challenging to treat. CONCLUSIONS Despite claims of safety, Bio-Alcamid and possibly other soft-tissue fillers available worldwide have the potential to cause adverse reactions. Physicians should be aware of the various presentations and treatment options for these reactions.

Multicenter prospective cohort study of the incidence of adverse events associated with cosmetic dermatologic procedures: Lasers, energy devices, and injectable neurotoxins and fillers

IMPORTANCE Common noninvasive to minimally invasive cosmetic dermatologic procedures are widely believed to be safe given the low incidence of reported adverse events, but reliable incidence data regarding adverse event rates are unavailable to date. OBJECTIVE To assess the incidence of adverse events associated with noninvasive to minimally invasive cosmetic dermatologic procedures, including those involving laser and energy devices, as well as injectable neurotoxins and fillers. DESIGN, SETTING, AND PARTICIPANTS A multicenter prospective cohort study (March 28, 2011, to December 30, 2011) of procedures performed using laser and energy devices, as well as injectable neurotoxins and soft-tissue augmentation materials, among 8 geographically dispersed US private and institutional dermatology outpatient clinical practices focused on cosmetic dermatology, with a total of 23 dermatologists. Participants represented a consecutive sample of 20 399 cosmetic procedures. Data acquisition was for 3 months (13 weeks) per center, with staggered start dates to account for seasonal variation. EXPOSURES Web-based data collection daily at each center to record relevant procedures, by category type and subtype. Adverse events were detected by (1) initial observation by participating physicians or staff; (2) active ascertainment from patients, who were encouraged to self-report after their procedure; and (3) follow-up postprocedural phone calls to patients by staff, if appropriate. When adverse events were not observed by physicians but were suspected, follow-up visits were scheduled within 24 hours to characterize these events. Detailed information regarding each adverse event was entered into an online form. MAIN OUTCOMES AND MEASURES The main outcome was the total incidence of procedure-related adverse events (total adverse events divided by total procedures performed), as verified by clinical examination. RESULTS Forty-eight adverse events were reported, for a rate of 0.24% (95% CI, 0.18%-0.31%). Overall, 36 procedures resulted in at least 1 adverse event, for a rate of 0.18% (95% CI, 0.13%-0.25%). No serious adverse events were reported. Adverse events were infrequently associated with known risk factors. CONCLUSIONS AND RELEVANCE Noninvasive to minimally invasive cosmetic dermatologic procedures, including energy, neurotoxin, and filler procedures, are safe when performed by experienced board-certified dermatologists. Adverse events occur in less than 1% of patients, and most of these are minor and transient.

Surgical Dermatology: Advances in Current Practice

Surgical Dermatology: Advances in Current Practice is an excellent text that certainly lives up to its title. It is a collection of 51 chapters covering basic clinical and surgical concepts, cutaneous oncology, lasers, reconstructive surgery, and cosmetic surgery. The chapters are written by many familiar names in dermatologic surgery and include facts as well as opinions and pearls not easily found in other texts. While this book should not be considered a comprehensive reference text, the authors clearly state in the preface that it is not intended to be one. Rather, its purpose is to present what the authors feel are the most important developments in dermatologic surgery in the past few years. The reader is referred to a general dermatologic surgery reference text if in search of basic information. What this book succeeds in doing is presenting a vast array of new ideas and surgical therapies in a concise

Therapeutic approaches to cellulite.

Cellulite is a condition that affects the vast majority of women. Although it is of no danger to ones overall health, cellulite can be psychosocially debilitating. Consequently, much research has been devoted to understanding cellulite and its etiopathogenesis. With additional insights into the underlying causes of its clinical presentation, therapeutic modalities have been developed that offer hope to cellulite sufferers. This review examines evidence for topical treatments, noninvasive energy-based devices, and recently developed minimally invasive interventions that may finally provide a solution.

A Multicenter Pivotal Study to Evaluate Tissue Stabilized—guided Subcision Using the Cellfina Device for the Treatment of Cellulite With 3-year Follow-up

BACKGROUND Cellulite is a common female cosmetic concern for which no single treatment option had been proven effective over the long term. A novel tissue stabilized-guided subsicion system (TS-GS system) has demonstrated significant reduction in the appearance of cellulite after treatment. OBJECTIVE The objective of this extended follow-up period was to assess the effectiveness of TS-GS out to 3 years after initial treatment. PATIENTS AND METHODS After completing an open-label, multicenter, pivotal study, 45 subjects were followed for an extended period of up to 3 years after receiving a single treatment using the TS-GS system. Treatment areas were photographed prior to the procedure and at multiple time points post-treatment throughout the 3 years. In this open-label study, subjects served as their own controls. Effectiveness was assessed based on blinded independent physician panel assessments of improvement from baseline using a cellulite severity scale. Subject aesthetic improvement and patient-reported satisfaction were also collected. RESULTS The results of this trial supported Food and Drug Administration clearance of the device for the long-term reduction in the appearance of cellulite following TS-GS. CONCLUSION These data further demonstrate the safety and efficacy of this treatment with no reduction in treatment benefits out to 3 years.

A Randomized, Controlled Trial of Four Ablative Fractionated Lasers for Photoaging: A Quadrant Study

BACKGROUND Fractionated technology has revolutionized laser therapy. With the success of initial devices, several fractionated lasers have appeared on the market. Claims of superiority have made device choice difficult for physicians and patients. MATERIALS AND METHODS Twelve subjects were treated with fractionated ablative lasers (10,600‐nm carbon dioxide and 2790‐nm yttrium scandium gallium garnet) in this institutional review board–approved trial. Each face was divided into four quadrants, and each quadrant was randomly treated using one of four lasers. Clinical experience was used to optimize settings. Two patients submitted biopsies from each quadrant immediately after treatment. Patients and blinded investigators assessed pain during treatment and post‐treatment improvement in photoaging (measured by rhytides, lentigines, texture, and pore size) using a five‐point scale. RESULTS All devices resulted in statistical improvement in photoaging in all patients, but no device was statistically significantly superior. No statistically significant difference was found in pain scores. All patients reported satisfaction 1 month after treatment. Three patients experienced adverse reactions. Histologically, there were no statistically significant differences between devices. CONCLUSIONS Fractionated ablative lasers reliably result in improvement in photoaging. Despite marketing claims, no statistically significant differences were found in outcomes, pain during treatment, or histologic findings. Even with experienced users, significant adverse reactions are possible.

Use of hyaluronidase in patients with bee allergy.

The use of hyaluronidase in patients with a known bee allergy has not been studied and remains a confusing area in clinical practice. The risk of severe systemic reaction in adults stung by Hymenoptera species is approximately 3.0%, and deaths related to stings are approximately 30 to 40 yearly in the United States. Composition of bee venom is complex, consisting of numerous antigenic compounds. Many of these compounds cross-react with other Hymenoptera species, making clinical diagnosis of a specific bee allergy difficult. Before immediately eliminating the potential use of hyaluronidase in a patient who acknowledges a bee allergy, the practitioner should delve deeper into the history to more clearly determine the safety of hyaluronidase in such patients.

Cellulite: a review of pathogenesis-directed therapy

Cellulite is a condition that affects the majority of postpubertal women and can negatively impact quality of life. This review discusses several proposed pathophysiologies of cellulite, and examines treatment options that have been utilized, focusing on the etiologic factor targeted by the therapies. This approach aims to help clarify the pathogenesis of cellulite and provide a road map for developing effective treatment paradigms for patients.