Dermatologists have been procedurally inclined since the beginning of the specialty. However, recent technological breakthroughs in minimally invasive procedural dermatology have offered a multitude of options to improve overall aesthetic appearance.
This article will provide a brief overview of the relatively least-invasive therapies available to patients today.
Soft Tissue Fillers
The most obvious and recent implosion of technology noticed today has been in the field of soft tissue fillers. The concept that senescent changes of the face are largely due to volume depletion and redistribution has been recognized as the basis for the increased use in fillers in facial rejuvenation.1,2
The FDA-approved hyaluronic acid (HA) fillers have been the cornerstone of the increase in the use of fillers with little to no downtime. This family includes: Juvéderm (Allergan), Restylane and Perlane (Medicis). The HAs do not require skin testing and rarely cause an allergic reaction. Restylane became FDA approved in 2003 for nasolabial fold augmentation, and Perlane just became FDA approved this year. Results may last between 3 and 6 months, and the duration of efficacy is directly related to the mobility of the area injected. (See Figures 1A and 1B.) Injections in the perioral area typically may be of a shorter duration, unless the patient has concomitant botulinum toxin treatments.3
The most common adverse advents are of a temporary nature including bruising, erythema, pruritus, and dyschromia. Delayed-type hypersensitivity reactions and granulomas have been reported in association with HA fillers, but these observations are in no way unique to this class of substances.4,5
Artefill recently became FDA approved as a filler for the midface region (Artes Medical). It is a suspension of polymethylmethacrylate microspheres in 3.5% bovine collagen solution. Due to the bovine source of the collagen, skin testing is required. Several sessions for correction of volume depletion are necessary. Since the product is permanent, undercorrection is encouraged, and re-injection at subsequent sessions should be spaced out to several month intervals between treatments. Artefill is not recommended for areas of thin skin, e.g., periocular skin. In the lip area, beading is a likely occurrence. Also, latent granulomatous reactions are a reported side effect of this filler.6
The aforementioned products are the most recent FDA-approved additions to the family of fillers. Moreover, novel techniques have been developed to provide aesthetically appealing results to various portions of the face.
Botox
Botulinum toxin type A is also in the forefront of minimally invasive techniques of facial rejuvenation. Botox Cosmetic (Allergan) was approved by the FDA in 2002 for the treatment of glabellar lines. Botox Cosmetic is the only botulinum toxin approved for cosmetic use in North America, but Dysport (BTX-A, Ipsen Ltd) is available in Europe and is under review for licensing by the FDA.7 The Botox-to-Dysport potency ratio is between 1:2 and 1:6.
Botox is most effective in reducing dynamic facial lines. (See Figures 2A and 2B.) The presence of a neuromuscular disorder and aminoglycoside use are both contraindications for injecting this agent.
A vial of Botox is reconstituted with preserved saline, and it is recommended to use the Becton-Dickinson Ultra-fine II short-needled 0.3-ml insulin syringe. Although the gold standard for the treatment of dynamic rhytids in the upper third of the face is botulinum toxin injection, we have seen a recent dramatic increase in its use in the midface and lower face regions. Poor technique and a poor understanding of muscle mobility in this facial area can cause severe impairment of muscular function and expression. Botox is routinely used as adjunctive therapy with soft-tissue augmentation to increase the efficacy and duration of results.3 Botox may decrease the amount of filler required to achieve the cosmetic endpoint.
Also, when Botox is used in conjunction with laser resurfacing, the cosmetic outcome is superior for the correction of rhytids than when either modality is used alone.8,9 Botox has also been in used in conjunction with eyebrow and forehead lifts to decrease the effect of the corrugator and procerus muscles. A recent study has also shown benefits of Botox in reducing scars after a facial wound.10
Lasers
Lasers have provided dermatologists with minimally invasive ways to treat a variety of skin conditions, ranging from hirsutism, dyspigmentation, vascular lesions, to acne scars and wrinkles, and perhaps even cellulite.
Fractional Photothermolysis
Although ablative laser resurfacing, such as the CO2 laser, is considered to be the main therapeutic option for treating wrinkles and acne scars, this is associated with significant and undesirable downtime. As such, many of our patients are opting for less invasive and non-ablative approaches. One such approach is fractional photothermolysis, the most recent addition to the armamentarium of non-ablative laser resurfacing.11 This new modality has allowed for the effective treatment on and off the face with an improved safety profile independent of skin type.
In our offices, we use the LuxIR fractional handpiece on the Starlux system. This handpiece is FDA approved for repair of intrinsically aged skin and achieves dramatic results. (See Figure 3A and 3B.) Patients with mild to moderate fine lines can benefit from this treatment, as well as those with moderate acne scarring. Olive-skinned individuals who are not candidates for the CO2 laser resurfacing laser can also achieve results with this technology. A series of treatments does not denude the skin, and so patients can immediately resume daily activities. Three to six treatments at monthly increments achieves the desired endpoint, but most patients in our practice note substantial efficacy after only one treatment. Fractional photothermolysis has also become a useful adjunct to bleaching creams and chemical peels in treating melasma.12,13
Laser Hair Removal
Laser hair removal is accomplished through follicular unit destruction. The gold standard for treatment is utilizing the wavelength-specific lasers, such as the 755-nm long-pulsed alexandrite laser, on light-skinned dark-haired patients. The laser of choice in our practice for such a patient population is the Apogee by Cynosure. More recently, we have utilized the IPL systems that emit light at a range of wavelengths from 550 nm to 1200 nm. We prefer the LuxY handpiece when performing laser hair reduction in patients with Fitzpatrick skin types I to III. However, when treating a patient with a darker skin type, we prefer the LuxRS handpiece because it filters out the shorter wavelengths that can potentially burn the epidermis.
Lasers for Vascular Lesions
The flashlamp pulsed-dye lasers are efficacious in treating telangiectasias and vascular malformations. However, they tend to cause significant purpura. Because of this, we have increasingly used the Starlux LuxG handpiece to successfully treat rosacea and telangiectasias. (See Figures 4A and 4B.) For deeper vascular growths, such as port-wine stains, we do continue to use the flashlamp pulsed-dye lasers. The Starlux system also allows for the Lux1064 Nd:YAG handpiece, which can be successful used to treat small leg veins and telangiectasias without significant purpura.
Lasers for Cellulite
Some recent advances have been made in the minimally invasive treatment of cellulite. Cellulite is a common condition experienced by most post-pubertal women. It is caused by the entrapment of adipose tissue within fibrous septae that manifests clinically as dimpling of the overlying skin. A study done recently suggested a degree of efficacy of the Velasmooth (Syneron Medical) in the treatment of cellulite.14 This technology consists of a combination of radiofrequency (RF), infrared (IR) light, and a mechanical suction-based massage device. Although the improvement was marginal, the circumferential thigh measurements decreased by 0.8 cm on average, and this improvement lessened further at the 3- and the 6-month follow-up intervals.
Chemical Peels and Microdermabrasion
The use of topical retinoids and alpha-hydroxy acids have been shown to improve the aesthetic appearance of the skin and to blunt the severity of photodamaged skin.13 In our practice, the concomitant use of topical retinoids and a series of microdermabrasion treatments, with the Dermapeel system, or sequential glycolic acid chemical peels, have improved extrinsically aged skin and acne-scarred skin.
A Brief Overview
In conclusion, this is a brief overview of some recent developments and techniques in minimally invasive cosmetic procedures. This and continuing articles will review techniques for cosmetic enhancement ranging from non-invasive to fully rejuvenating surgical procedures.
Dermatologists have been procedurally inclined since the beginning of the specialty. However, recent technological breakthroughs in minimally invasive procedural dermatology have offered a multitude of options to improve overall aesthetic appearance.
This article will provide a brief overview of the relatively least-invasive therapies available to patients today.
Soft Tissue Fillers
The most obvious and recent implosion of technology noticed today has been in the field of soft tissue fillers. The concept that senescent changes of the face are largely due to volume depletion and redistribution has been recognized as the basis for the increased use in fillers in facial rejuvenation.1,2
The FDA-approved hyaluronic acid (HA) fillers have been the cornerstone of the increase in the use of fillers with little to no downtime. This family includes: Juvéderm (Allergan), Restylane and Perlane (Medicis). The HAs do not require skin testing and rarely cause an allergic reaction. Restylane became FDA approved in 2003 for nasolabial fold augmentation, and Perlane just became FDA approved this year. Results may last between 3 and 6 months, and the duration of efficacy is directly related to the mobility of the area injected. (See Figures 1A and 1B.) Injections in the perioral area typically may be of a shorter duration, unless the patient has concomitant botulinum toxin treatments.3
The most common adverse advents are of a temporary nature including bruising, erythema, pruritus, and dyschromia. Delayed-type hypersensitivity reactions and granulomas have been reported in association with HA fillers, but these observations are in no way unique to this class of substances.4,5
Artefill recently became FDA approved as a filler for the midface region (Artes Medical). It is a suspension of polymethylmethacrylate microspheres in 3.5% bovine collagen solution. Due to the bovine source of the collagen, skin testing is required. Several sessions for correction of volume depletion are necessary. Since the product is permanent, undercorrection is encouraged, and re-injection at subsequent sessions should be spaced out to several month intervals between treatments. Artefill is not recommended for areas of thin skin, e.g., periocular skin. In the lip area, beading is a likely occurrence. Also, latent granulomatous reactions are a reported side effect of this filler.6
The aforementioned products are the most recent FDA-approved additions to the family of fillers. Moreover, novel techniques have been developed to provide aesthetically appealing results to various portions of the face.
Botox
Botulinum toxin type A is also in the forefront of minimally invasive techniques of facial rejuvenation. Botox Cosmetic (Allergan) was approved by the FDA in 2002 for the treatment of glabellar lines. Botox Cosmetic is the only botulinum toxin approved for cosmetic use in North America, but Dysport (BTX-A, Ipsen Ltd) is available in Europe and is under review for licensing by the FDA.7 The Botox-to-Dysport potency ratio is between 1:2 and 1:6.
Botox is most effective in reducing dynamic facial lines. (See Figures 2A and 2B.) The presence of a neuromuscular disorder and aminoglycoside use are both contraindications for injecting this agent.
A vial of Botox is reconstituted with preserved saline, and it is recommended to use the Becton-Dickinson Ultra-fine II short-needled 0.3-ml insulin syringe. Although the gold standard for the treatment of dynamic rhytids in the upper third of the face is botulinum toxin injection, we have seen a recent dramatic increase in its use in the midface and lower face regions. Poor technique and a poor understanding of muscle mobility in this facial area can cause severe impairment of muscular function and expression. Botox is routinely used as adjunctive therapy with soft-tissue augmentation to increase the efficacy and duration of results.3 Botox may decrease the amount of filler required to achieve the cosmetic endpoint.
Also, when Botox is used in conjunction with laser resurfacing, the cosmetic outcome is superior for the correction of rhytids than when either modality is used alone.8,9 Botox has also been in used in conjunction with eyebrow and forehead lifts to decrease the effect of the corrugator and procerus muscles. A recent study has also shown benefits of Botox in reducing scars after a facial wound.10
Lasers
Lasers have provided dermatologists with minimally invasive ways to treat a variety of skin conditions, ranging from hirsutism, dyspigmentation, vascular lesions, to acne scars and wrinkles, and perhaps even cellulite.
Fractional Photothermolysis
Although ablative laser resurfacing, such as the CO2 laser, is considered to be the main therapeutic option for treating wrinkles and acne scars, this is associated with significant and undesirable downtime. As such, many of our patients are opting for less invasive and non-ablative approaches. One such approach is fractional photothermolysis, the most recent addition to the armamentarium of non-ablative laser resurfacing.11 This new modality has allowed for the effective treatment on and off the face with an improved safety profile independent of skin type.
In our offices, we use the LuxIR fractional handpiece on the Starlux system. This handpiece is FDA approved for repair of intrinsically aged skin and achieves dramatic results. (See Figure 3A and 3B.) Patients with mild to moderate fine lines can benefit from this treatment, as well as those with moderate acne scarring. Olive-skinned individuals who are not candidates for the CO2 laser resurfacing laser can also achieve results with this technology. A series of treatments does not denude the skin, and so patients can immediately resume daily activities. Three to six treatments at monthly increments achieves the desired endpoint, but most patients in our practice note substantial efficacy after only one treatment. Fractional photothermolysis has also become a useful adjunct to bleaching creams and chemical peels in treating melasma.12,13
Laser Hair Removal
Laser hair removal is accomplished through follicular unit destruction. The gold standard for treatment is utilizing the wavelength-specific lasers, such as the 755-nm long-pulsed alexandrite laser, on light-skinned dark-haired patients. The laser of choice in our practice for such a patient population is the Apogee by Cynosure. More recently, we have utilized the IPL systems that emit light at a range of wavelengths from 550 nm to 1200 nm. We prefer the LuxY handpiece when performing laser hair reduction in patients with Fitzpatrick skin types I to III. However, when treating a patient with a darker skin type, we prefer the LuxRS handpiece because it filters out the shorter wavelengths that can potentially burn the epidermis.
Lasers for Vascular Lesions
The flashlamp pulsed-dye lasers are efficacious in treating telangiectasias and vascular malformations. However, they tend to cause significant purpura. Because of this, we have increasingly used the Starlux LuxG handpiece to successfully treat rosacea and telangiectasias. (See Figures 4A and 4B.) For deeper vascular growths, such as port-wine stains, we do continue to use the flashlamp pulsed-dye lasers. The Starlux system also allows for the Lux1064 Nd:YAG handpiece, which can be successful used to treat small leg veins and telangiectasias without significant purpura.
Lasers for Cellulite
Some recent advances have been made in the minimally invasive treatment of cellulite. Cellulite is a common condition experienced by most post-pubertal women. It is caused by the entrapment of adipose tissue within fibrous septae that manifests clinically as dimpling of the overlying skin. A study done recently suggested a degree of efficacy of the Velasmooth (Syneron Medical) in the treatment of cellulite.14 This technology consists of a combination of radiofrequency (RF), infrared (IR) light, and a mechanical suction-based massage device. Although the improvement was marginal, the circumferential thigh measurements decreased by 0.8 cm on average, and this improvement lessened further at the 3- and the 6-month follow-up intervals.
Chemical Peels and Microdermabrasion
The use of topical retinoids and alpha-hydroxy acids have been shown to improve the aesthetic appearance of the skin and to blunt the severity of photodamaged skin.13 In our practice, the concomitant use of topical retinoids and a series of microdermabrasion treatments, with the Dermapeel system, or sequential glycolic acid chemical peels, have improved extrinsically aged skin and acne-scarred skin.
A Brief Overview
In conclusion, this is a brief overview of some recent developments and techniques in minimally invasive cosmetic procedures. This and continuing articles will review techniques for cosmetic enhancement ranging from non-invasive to fully rejuvenating surgical procedures.
Dermatologists have been procedurally inclined since the beginning of the specialty. However, recent technological breakthroughs in minimally invasive procedural dermatology have offered a multitude of options to improve overall aesthetic appearance.
This article will provide a brief overview of the relatively least-invasive therapies available to patients today.
Soft Tissue Fillers
The most obvious and recent implosion of technology noticed today has been in the field of soft tissue fillers. The concept that senescent changes of the face are largely due to volume depletion and redistribution has been recognized as the basis for the increased use in fillers in facial rejuvenation.1,2
The FDA-approved hyaluronic acid (HA) fillers have been the cornerstone of the increase in the use of fillers with little to no downtime. This family includes: Juvéderm (Allergan), Restylane and Perlane (Medicis). The HAs do not require skin testing and rarely cause an allergic reaction. Restylane became FDA approved in 2003 for nasolabial fold augmentation, and Perlane just became FDA approved this year. Results may last between 3 and 6 months, and the duration of efficacy is directly related to the mobility of the area injected. (See Figures 1A and 1B.) Injections in the perioral area typically may be of a shorter duration, unless the patient has concomitant botulinum toxin treatments.3
The most common adverse advents are of a temporary nature including bruising, erythema, pruritus, and dyschromia. Delayed-type hypersensitivity reactions and granulomas have been reported in association with HA fillers, but these observations are in no way unique to this class of substances.4,5
Artefill recently became FDA approved as a filler for the midface region (Artes Medical). It is a suspension of polymethylmethacrylate microspheres in 3.5% bovine collagen solution. Due to the bovine source of the collagen, skin testing is required. Several sessions for correction of volume depletion are necessary. Since the product is permanent, undercorrection is encouraged, and re-injection at subsequent sessions should be spaced out to several month intervals between treatments. Artefill is not recommended for areas of thin skin, e.g., periocular skin. In the lip area, beading is a likely occurrence. Also, latent granulomatous reactions are a reported side effect of this filler.6
The aforementioned products are the most recent FDA-approved additions to the family of fillers. Moreover, novel techniques have been developed to provide aesthetically appealing results to various portions of the face.
Botox
Botulinum toxin type A is also in the forefront of minimally invasive techniques of facial rejuvenation. Botox Cosmetic (Allergan) was approved by the FDA in 2002 for the treatment of glabellar lines. Botox Cosmetic is the only botulinum toxin approved for cosmetic use in North America, but Dysport (BTX-A, Ipsen Ltd) is available in Europe and is under review for licensing by the FDA.7 The Botox-to-Dysport potency ratio is between 1:2 and 1:6.
Botox is most effective in reducing dynamic facial lines. (See Figures 2A and 2B.) The presence of a neuromuscular disorder and aminoglycoside use are both contraindications for injecting this agent.
A vial of Botox is reconstituted with preserved saline, and it is recommended to use the Becton-Dickinson Ultra-fine II short-needled 0.3-ml insulin syringe. Although the gold standard for the treatment of dynamic rhytids in the upper third of the face is botulinum toxin injection, we have seen a recent dramatic increase in its use in the midface and lower face regions. Poor technique and a poor understanding of muscle mobility in this facial area can cause severe impairment of muscular function and expression. Botox is routinely used as adjunctive therapy with soft-tissue augmentation to increase the efficacy and duration of results.3 Botox may decrease the amount of filler required to achieve the cosmetic endpoint.
Also, when Botox is used in conjunction with laser resurfacing, the cosmetic outcome is superior for the correction of rhytids than when either modality is used alone.8,9 Botox has also been in used in conjunction with eyebrow and forehead lifts to decrease the effect of the corrugator and procerus muscles. A recent study has also shown benefits of Botox in reducing scars after a facial wound.10
Lasers
Lasers have provided dermatologists with minimally invasive ways to treat a variety of skin conditions, ranging from hirsutism, dyspigmentation, vascular lesions, to acne scars and wrinkles, and perhaps even cellulite.
Fractional Photothermolysis
Although ablative laser resurfacing, such as the CO2 laser, is considered to be the main therapeutic option for treating wrinkles and acne scars, this is associated with significant and undesirable downtime. As such, many of our patients are opting for less invasive and non-ablative approaches. One such approach is fractional photothermolysis, the most recent addition to the armamentarium of non-ablative laser resurfacing.11 This new modality has allowed for the effective treatment on and off the face with an improved safety profile independent of skin type.
In our offices, we use the LuxIR fractional handpiece on the Starlux system. This handpiece is FDA approved for repair of intrinsically aged skin and achieves dramatic results. (See Figure 3A and 3B.) Patients with mild to moderate fine lines can benefit from this treatment, as well as those with moderate acne scarring. Olive-skinned individuals who are not candidates for the CO2 laser resurfacing laser can also achieve results with this technology. A series of treatments does not denude the skin, and so patients can immediately resume daily activities. Three to six treatments at monthly increments achieves the desired endpoint, but most patients in our practice note substantial efficacy after only one treatment. Fractional photothermolysis has also become a useful adjunct to bleaching creams and chemical peels in treating melasma.12,13
Laser Hair Removal
Laser hair removal is accomplished through follicular unit destruction. The gold standard for treatment is utilizing the wavelength-specific lasers, such as the 755-nm long-pulsed alexandrite laser, on light-skinned dark-haired patients. The laser of choice in our practice for such a patient population is the Apogee by Cynosure. More recently, we have utilized the IPL systems that emit light at a range of wavelengths from 550 nm to 1200 nm. We prefer the LuxY handpiece when performing laser hair reduction in patients with Fitzpatrick skin types I to III. However, when treating a patient with a darker skin type, we prefer the LuxRS handpiece because it filters out the shorter wavelengths that can potentially burn the epidermis.
Lasers for Vascular Lesions
The flashlamp pulsed-dye lasers are efficacious in treating telangiectasias and vascular malformations. However, they tend to cause significant purpura. Because of this, we have increasingly used the Starlux LuxG handpiece to successfully treat rosacea and telangiectasias. (See Figures 4A and 4B.) For deeper vascular growths, such as port-wine stains, we do continue to use the flashlamp pulsed-dye lasers. The Starlux system also allows for the Lux1064 Nd:YAG handpiece, which can be successful used to treat small leg veins and telangiectasias without significant purpura.
Lasers for Cellulite
Some recent advances have been made in the minimally invasive treatment of cellulite. Cellulite is a common condition experienced by most post-pubertal women. It is caused by the entrapment of adipose tissue within fibrous septae that manifests clinically as dimpling of the overlying skin. A study done recently suggested a degree of efficacy of the Velasmooth (Syneron Medical) in the treatment of cellulite.14 This technology consists of a combination of radiofrequency (RF), infrared (IR) light, and a mechanical suction-based massage device. Although the improvement was marginal, the circumferential thigh measurements decreased by 0.8 cm on average, and this improvement lessened further at the 3- and the 6-month follow-up intervals.
Chemical Peels and Microdermabrasion
The use of topical retinoids and alpha-hydroxy acids have been shown to improve the aesthetic appearance of the skin and to blunt the severity of photodamaged skin.13 In our practice, the concomitant use of topical retinoids and a series of microdermabrasion treatments, with the Dermapeel system, or sequential glycolic acid chemical peels, have improved extrinsically aged skin and acne-scarred skin.
A Brief Overview
In conclusion, this is a brief overview of some recent developments and techniques in minimally invasive cosmetic procedures. This and continuing articles will review techniques for cosmetic enhancement ranging from non-invasive to fully rejuvenating surgical procedures.
