Cosmetic dermatologists have never before had so many unique options for facial rejuvenation. From topical creams to fractional ablative resurfacing, supplemented by an incredible range of interventions from injectables to minimally-invasive devices, the practitioner now chooses from a wide range of never before available treatments. It is from this middle of the pack that most patients will receive one or a combination of treatments. Deciding what interventions to offer and how to combine treatments can be a challenge and is dependent on the needs of the specific patient and the resources of the practice.

One of the reasons I started Cosmetic Surgery Forum two years ago was to afford practitioners the ability to discourse on all pertinent topics, structured within a CME environment. All too often, marketing seminars, with the attendant restriction to 'on-label' discussions, pervades our learning environments. Given the fact that most dermatologists and cosmetic surgeons practice in a completely different manner than the 'on-label' indications, I felt it was important to provide an opportunity to discuss these differences in practice, ranging from the subtle to the extreme.

At the Cosmetic Surgery Forum in Las Vegas in December, leading cosmetic surgeons shared their insights on rejuvenation techniques and procedures, frequently debating amongst themselves, with input from the audience and panel. Following are reports on some of the many discussions that occurred during the second Cosmetic Surgery Forum.

Understand Facial Aging
The secret of success in applying cosmetic facial rejuvenation techniques lies in understanding the processes of facial aging, said Gregory A. Buford, MD, Founder and Medical Director of Beauty by Buford in Denver. The appearance of facial aging involves the skin and underlying structures, including bone and fat, he explained. He described three basic phases of progression in each domain.

Age-induced changes to the skin typically begin with pigmentary alterations and the formation of brown spots and dyschromia. With time, collagen loss becomes evident, coinciding with the formation of lines and wrinkles. Finally, overall thinning of the skin can be seen.

Volume loss to fat pads is the first sign of aging. This is followed by localized “deflation” that eventually leads to a flattening of the mid-face.

As an individual ages, changes in bony structures may produce the appearance either of an increase in volume in some areas or a loss of it in others. Eventually, as bone changes take place, the structure of the face will change, leading to widening of the jawline and an inversion of the up-side down pyramid structure of the youthful face.

Given these various changes, the best approach to rejuvenation has changed recently, now frequently involving the combined use of lasers/light devices and injectables, with less emphasis on the face-lift as a 'cure all'. Energy-based devices largely affect the skin, working to improve pigmentation, smooth lines and wrinkles, while tightening sagging skin, and to some degree reducing unwanted fat deposits. However, to rebalance the structural changes that take place due to volume loss and bone changes requires the use of dermal fillers and neurotoxins.

Dr. Buford reported that he frequently uses fractional CO2 resurfacing (Active/Deep FX, Lumenis) in combination with the neurotoxins and fillers he feels are best suited to the patient's aesthetic needs and concerns.

Consider Non-invasive “Lifting”
Many patients in search of rejuvenation procedures seek a “lifting” of sagging facial skin. Surgical facelifts obviously provide such benefit, but they require invasive surgery, are associated with significant downtime, are expensive, and often provide a result that is too dramatic or “artificial.” Therefore, subtle lifting has emerged as the goal of many clinicians. According to Curt Samlaska, MD of Academic Dermatology in Henderson, NV, the only energy-based technology FDA cleared for non-invasive lift (brow lift, September 2009), is Ulthera, which provides notable but natural-looking improvements when properly applied.

Ulthera uses micro-focused ultrasound energy to provide a tissue tightening and lifting effect. Optimal correction may require several treatments over time. When patients have reasonable expectations for the number of treatments and treatment guidelines, response and satisfaction rates are high, Dr. Samlaska said. Treatment is safe for all skin types with no risk of pigmentary alteration, based on his data.

The dual modality ultrasound system allows the operator to visualize structures below the skin's surface (to 8mm depth) while precisely delivering energy that converges at target points, known as “thermal coagulation points.” Thermal energy is deposited at these coagulation points, affecting local tissues. The size and depth of the points depends on the frequency and power settings selected by the operator.

Use of thermal coagulation points spares designated areas of tissue to encourage and speed healing.

The Ulthera System has not been evaluated for application over mechanical implants, dermal fillers, implanted electrical devices, or metal stents and is not recommended for use over these materials in the face and neck area. Additionally, use directly on keloids has not been studied and should be avoided, Dr. Samlaska noted.

Optimize Non-ablative Treatments
Significant rejuvenation effects are possible with ablative resurfacing devices, such as CO2 and erbium systems; however, these devices are associated with significant downtime and potential adverse events. Nonablative devices have provided much more modest results, with the degree of success sometimes linked to operator skill and patient expectations/education prior to the procedure. Optimal results and minimal downtime from non-ablative devices may be possible through the combined use of nonablative fractionated lasers (such as Fraxel re:store) and radiofrequency tightening devices (Thermage), suggested Heidi A. Waldorf, MD, Director of Laser and Cosmetic Dermatology and Associate Clinical Professor in the Department of Dermatology at Mount Sinai Hospital in New York City who practices at Waldorf Dermatology & Laser Associates in Nanuet, NY.

Nonablative fractionated lasers—associated with just two to three days of postoperative swelling and about five days of peeling—provide resurfacing benefits, while radiofrequency devices—which have no downtime—producing tightening. Furthermore, these devices can be used also to treat the neck, chest, and arms, eliminating any demarcation lines or mismatched areas of coloration that have been limitations of ablative devices.

Achieving good cosmetic results and assuring patient satisfaction depends on setting realistic patient expectations, Dr. Waldorf said. Nonablative resurfacing generally does not generate a sufficient effect with just a single session; multiple treatments are necessary over time. Furthermore, patients should understand that radiofrequency tightening is not equivalent to a surgical facelift. Patients and practitioners, therefore, should develop a “building plan” at the start of therapy, Dr. Waldorf says.

“Clean–up” treatments following the combined nonablative procedures may include a vascular laser to address erythema or a pigment laser for discreet pigmented lesions. Fillers and/or neurotoxins can be included in the treatment regimen to improve specific areas, and cosmeceuticals should be used to help maintain effects and continue to improve the appearance of skin.

Finally, Dr. Waldorf advised all in attendance to “Know your population” when selecting devices, suggesting that clinicians must consider what types of treatments patients may desire, what types of results they may anticipate, and the degree of downtime and speed of improvement they may be willing to tolerate.

Update on Topical Interventions
Two popular topical product ingredients continue to generate interest among patients and cosmetic dermatologists.
1.) The regulatory status of hydroquinone, the skin lightening drug formulated into prescription and over-the-counter formulations, remains uncertain, Jeannette Graf, MD reported. Grandfathered as safe and effective medication since 1963, the early 1980s saw hydroquinone concentrations from 0.5-2% classified as “Generally Rated As Safe and Effective” or GRASE by FDA. However, in 2006 FDA proposed re-classifying hydroquinone, thus eliminating OTC use in the US.

Hydroquinone was banned in the EU in 2001 due to concerns about the development of exogenous ochronosis; however, Dr. Graf said, data show about 30 incidences, not all of which are biopsy proven, of exogenous ochronosis reported in North America, despite widespread use of topical hydroquinone. According to Dr. Graf, there are no reports of human malignancy associated with hydroquinone use while it was in widespread use in the 1920s by the photographic/film industry.

There are also a few worldwide reports of cutaneous annular sarcoidosis developing on a background of exogenous ochronosis. Most of these didn't have biopsy prior to the application of HQ, so it is difficult to say whether the initial treatment was mistakenly applied to an area of sarcoidosis or not. Risk of ochronosis is thought to be associated with prolonged use of topical hydroquinone and is more common in patients with darker skin types, but there are many contradictions in reports and it is unclear whether all supposed preparations of HQ are purely HQ or contain other ingredients/impurities.

2.) Topical retinoids, which have been shown to prevent UV-induced collagen degradation, continue to be cornerstones of many topical antiaging regimens. UV exposure incites AP-1 induction, which mediates the formation of collagenase and gelatinase, Leon Kircik, MD, explained. Retinoids are shown to block AP-1, thus stopping the UVinduced degradation process. Currently, four derivatives of vitamin A are used in prescription and OTC skincare products:

• Retinol. Pure Vitamin A converts in part to tretinoin. It has been shown to repair photodamage independent of this conversion.
• Retinyl Palmitate. This artificially stabilized Vitamin A must be converted to retinol to be effective. Despite environmental watchdog industry concerns about this ingredient in sunscreens, Dr. Kircik feels it is safe and perhaps a cancer prevention strategy.
• Retinaldehyde. Likely the form of vitamin A that is closest to tretinoin in conversion process, it has been shown to be as irritating as tretinoin, though not as effective.
• Tretinoin. The biologically active form of Vitamin A binds to the nuclear retinoid R and X receptors.

Evidence continues to suggest that the efficacy of retinol, which is not associated with significant irritation, depends on the influence of the vehicle formulation on penetration and bioavailability, Dr. Kircik said. For example, he noted that emulsified retinol has low bioavailability. Furthermore, ingredients in a formulation may increase irritation. By contrast, he noted that a novel formulation of retinol in suspension (Retriderm, Biopelle) offers good bioavailability and incorporates ingredients intended to reduce transepidermal water loss and to enhance barrier function and repair. The new formulation has shown clinical effects similar to prescription tretinoin, he said.