Drmatologists agree that cellulite may be one of the most vexing cosmetic problems.

Appearing like cottage cheese dimpling in the thighs, hips and buttocks, cellulite seems to be the one beauty battle that is hard-fought, but never quite won.

Dr. Draelos

Some contain caffeine; others have different ingredients — but what they share is the ability to temporarily either dehydrate the skin or plump it up, reducing the visibility of dimpling. Newer products such as Ahava's Pure Spa Body Mud Mask are designed specifically for this purpose and can leave skin looking improved, but ultimately, the problem still lurks under the surface.

Numerous devices have been developed over the years to massage away this condition, which in appearance can resemble golf balls under the skin, but none has been able to produce permanent effects. The most efficacious of the bunch is technology used with the Endermologie system.

Endermologie is the brand name for a type of roller massage therapy that has been clinically proven to reduce the signs of cellulite. According to manufacturer LPG Wellness, the system's technology is the first noninvasive device approved by the Food and Drug Administration specifically for this purpose. It uses mechanical rollers and regulated suction to create symmetrical skin folds, temporarily stimulating circulation to the area.

Each Endermologie treatment lasts 30 to 45 minutes, and patients typically need a dozen or more treatments for visible results. After the desired effect is achieved, the patient needs to maintain the effects of the cellulite treatment with additional Endermologie sessions at less-frequent intervals.

Liposuction can also be used to help improve the appearance of cellulite. But it too, has limitations, depending on the surface area of the problem. It is virtually impossible to remove cellulite completely with liposuction. If this is the technique you decide to try, make sure you choose a highly trained physician to avoid developing skin with with a bumpy, uneven appearance.

So what can you do? According to North Carolina dermatologist Zoe D. Draelos, M.D., you can ignore the myths that abound about cellulite and stick to basics, because basics help.

"A good, healthy diet that reduces fat will help. The less fat you have, the less likely it is to spill through the web of fibrous tissue that separates the skin from underlying layers of fat and muscle. Exercise that helps to burn fat may help minimize cellulite's dimpled effect," she says.

Forget about drinking more water or spending hundreds of dollars on creams that claim they can remove cellulite permanently. There simply isn't a quick cure. What you can do is discuss your options with a cosmetic dermatologist or dermasurgeon.

Dr. Gold

FIRST THINGS FIRST As president of Trent and Company, a New Yorkbased public relations (PR) firm specializing in medical spas and healthy lifestyles, Ms. Trent tell s Ccoossmmeetticc SSuurrggeerryy TTimmeess that she urges her clients to do some self-reflection: "What makes one's medical spa practice special? Is it the trendiest? Does it provide the best results?"

Only after the formation of that desired end-image and message does she recommend employing the following PR tools and strategies to successfully disseminate it:

AN EFFECTIVE SPOKESPERSON "You wouldn't go into a trial without getting training from an attorney," says Ms. Trent. Nor should you enter a media interview without learning through mock interviews how to be succinct, organized and engaging, she says. Tips here include limiting focus to only three main points, smiling and being "absolutely honest" if you can't answer a question on the spot.

FREEBIES "It's very useful to make sure that media representatives come to one's medical spa to get treatments," she adds. And when they show up, she says, "Treat them like rock stars. If they write an article or do a television segment, your phone is going to ring."

A PR CASE STUDY When Juva Skin & Laser Center launched about seven years ago, "Not only did we invite media, but we al so invited local physicians of other specialties because they can be another great referral source," reveals Angela Caponi, Juva's chief operating officer and co-founder of the Medical Spa Society.

"Many people have lasers now, so one must be more innovative" in separating oneself from competitors, adds Michael H. Gold, M.D. Other necessities include a marketing plan and perhaps a PR agency, he says.

"One doesn't want to come out in the newspaper and say, 'Botox special — one dollar a unit.' That's not going to [help] in the long run. One needs high-class, high-profile advertising," particularly in the beginning, plus internal advertising as one's client base grows, he says.

At Juva, "We're very big into branding our name," says Ms. Caponi. "Juva's name is all over when one walks into the Center," even on candy wrappers and bottled water, she says.

GOING MULTIMEDIA In keeping with these efforts, the medical spa publishes a quarterly newsletter for its 40,000 patients, highlighting happenings such as research studies or equipment additions. "It's quite costly to do," Ms. Caponi says, "but many of our vendors have put ads in our newsletter" to help offset the expense.

Juva management then tracks its newsletter's impact by offering discounts for patients who bring it to the spa. Computer software likewise tabulates how many new patients the newsletter attracts, she says.

And soon, Juva will provide all new patients with a take-home DVD covering topics including doctor bios, accreditation and press coverage.

"This way," Ms. Caponi states, "the next time they come in, they can ask questions based on that." The DVDs cost relatively little, especially in bulk, she adds.

Patient shown pre-operatively.

After performing a series of rhinoplasty procedures on African-American patients, Oleh Slupchynskyj, M.D., was struck by the similarity between implants he had carved to correct a low bridge and deep frontal angle in these patients. In early 2006, he patented the Silastic (S-) implant.

"There isn't any other implant on the market like this one," Dr. Slupchynskyj, director of the Aesthetic Facial Surgery Institute of New York, tells Cosmetic Surgery Times . "Certainly, the nasal frontal angle can be augmented by the insertion of a piece of Gore-tex or cartilage grafting. However, the S-implant is the only implant that addresses the nasal frontal angle in addition to addressing the height of the dorsum."

Patient shown pre-operatively with "S" nasofrontal implant.

S-implant rhinoplasty patient shown 3 months post-operatively.

In addition to African-American patients, the S-implant may be suitable for rhinoplasty in patients of other ethnicities if augmentation of the nasal frontal angle is an issue.

A QUESTION OF SATISFACTION Dr. Slupchynskyj conducted a retrospective review via questionnaire of 47 African-American patients who had been treated with rhinoplasty using the S-implant.

The questionnaire covered patient satisfaction, subjective evaluation of ethnic changes, and changes in self-esteem. Compared with an overall revision rate of approximately 1 percent to 2 percent for rhinoplasty on a national level, patients in this study indicated a 0.05-percent rate of revision. In addition, results showed a significant increase in self-esteem. According to Dr. Slupchynskyj, the analysis demonstrates that these African-American patients sought not to change their ethnicity, but to achieve facial harmony.

Results of this study were presented at the recent meeting of the American Academy of Cosmetic Surgery.

Dr. Slupchynskyj

Typically, explains Dr. Slupchynskyj, these patients are looking for augmentation of the dorsum, narrowing of the nostrils, and refinement of the nose tip. Dr. Slupchynskyj, who is double board certified by the American Board of Facial Plastic Surgery and the American Board of Otolaryngology, speculates that black patients in search of a rhinoplasty may encounter some difficulty finding a surgeon who feels comfortable taking on the task. Lack of training, the complexity of the surgery, and a substantial time commitment are all inhibitory factors.

Dr. Fields

"When a doctor considers selling a line, he or she and the staff should be on it, and they should make sure it works," Kathy A. Fields, M.D., San Francisco-based dermatologist and assistant clinical professor at University of California, San Francisco, tells Cosmetic Surgery Times .

According to Dr. Fields, physicians typically acquire cosmeceuticals in one of three ways: they purchase and sell ready-made products under the products' established name; they purchase ready-made and tested products and market them under private labels that bear the physician's or practice name; or they create the formulas themselves.

Years ago, there was little competition and the chemicals were reasonably priced. Since the medspa boom, however, the market has become saturated with new cosmeceuticals and the innovative, high-profile chemicals, such as peptides, can be cost prohibitive.

For product formulation, physicians need to have a chemist on board. And they need to own their own formula, she says. But purchasing strategic chemicals, such as the newer antioxidants or peptides, can be extremely expensive, costing thousands of dollars a gram. Large orders of the ingredients can help to bring costs down, she notes.

"It takes years, a lot of money, time and effort to create a formula, get it stable, and do the clinical studies that are necessary by the [U.S. Food and Drug Administration]. You have to do antimicrobial, stability, heat and light testing, and really work that formula through," Dr. Fields says.

THE BETTER MOUSETRAP Dr. Fields, who is co-inventor of ProActive Solution, advises that physicians who go the route of developing their own formulas should be very confident that what they have to offer fills an unmet need. She helped develop her benzoyl peroxide acne solution 14 years ago when the available products were not working, she says.

"If you can do it better and can think it through — whether it is psoriasis, acne, antiaging — then, it is worth the time to find the right chemist and develop a very unique system," Dr. Fields says. But she adds that developing the product is only part of the expense and effort. Other considerations include marketing, packaging and distributing.

"Creating a formula today can cost more than $100,000 and just selling it in your office is impossibly prohibitive. If you are going to market to the masses, you have to get your message above that of the competition, which is hard to do," she says. And not everything pans out, notes Dr. Fields. Even great ideas fizzle.

"Prevage (Allergan) was a great idea; we have heard about the science forever." But, she recalls, its uptake in the market was stalled due to the skin irritation some patients experienced.

The prohibitive cost and risk of proprietary product development lead many physicians down the private label road. In this business model, companies that can afford to study expensive chemicals are willing to put physicians' names on the product labels — for a price. Sometimes, such companies offer practices unique formulations.

"These companies, for example, will already have a benzoyl peroxide formula. Physicians can private label the products they like or sell them in the office as is," she explains.

Ethically, Dr. Fields notes, physicians who put their names on existing products should not claim to have developed the products. In her experience, patients are most concerned about whether their physicians really believe in what they are selling — not whether the doctor has developed it.

Sometimes, it does not pay to change the name. Some products have been marketed and have developed reputations and followings, so keeping the name of the product offers a marketing benefit.

WOBURN, MASS. German researchers have, for the first time, used an innovative, non-invasive laser technique to evaluate levels of collagen and elastin in the skin in real time. The technique could eventually be useful in studying skin diseases involving the collagen structure, such as scleroderma or chronic complications of graft-versus-host disease. In addition, it could be useful in testing the efficacy of anti-aging cosmetic products that are designed to address collagen levels.

The study, published in a recent issue of Optics Letters, used in vivo multiphoton laser tomography to measure two-photon excited autofluorescence (AF), and second harmonic generation (SHG) to examine the extracellular matrix components of collagen and elastin.

Under the ultra-brief pulses of laser infrared light, the tissues are stimulated to emit light at shorter wavelengths – for collagen, the light is blue, and for elastin, it is green.

Working with Germany-based laser company JenLab GmbH, researchers with Friedrich Schiller University applied Lin's technique directly to the forearms of 18 patients, obtaining tiny swaths of collagen and elastin's fibrous matrices measuring just one-fifth of a millimeter wide.

Substantial variations were found, not only from one patient to another, but from one part of a patient's forearm to another. Some similarities clearly emerged, however, including the fact that the collagen/elastin ratio was dependent upon the patient's age, and women's skin was observed as losing collagen at faster rates than men's (Opt Lett. 2006 Oct 1;31(19):2879-2881).

GENDER ACCELERATOR The researchers speculate that the fluctuating hormone levels in women may explain the more rapid aging that was observed.

"As these differences are most notably present beyond the reproductive phase, a connection to decreasing sex hormone levels in the context of menopause is plausible," they wrote. "This is consistent with numerous studies that have shown anti-aging effects of estrogen and progesterone."

They caution, however that, with such a small study, the findings can only be considered preliminary.

"[The finding on women's skin aging faster] was definitely a surprise, but since the sample is very small and the variance is very high, we tried not to emphasize that finding," Dr. Johannes Koehler, M.D., tells Cosmetic Surgery Times .

"It was a minor finding with a new technique that should not be overestimated, but we are preparing a new study to [further] investigate," said Dr. Koehler, a dermatologist at Friedrich Schiller University and a co-author of the Optics Letters paper.

MATRIX STATE The laser technique holds promise for its ability to give precise measurements of collagen and elastin non-invasively, while previous techniques required extracting tissue from live patients and gave only a qualitative assessment of the state of the matrix.

Importantly, the new method makes it possible to monitor variations in the exact same spot as aging progresses — a process not possible using the previous method.

Dr. Hirsch

However, the technology does not yet represent a clinical home run, says Ranella J. Hirsch, M.D. Her take home message is, "Stay tuned for more clinical data before making a final judgment."

LITTLE DRAMA "There is no question from the in vitro and histological studies that this treatment using low-level illumination has biological effects and induces positive changes," says Dr. Hirsch, vice president of the American Society of Cosmetic Dermatology and Aesthetic Surgery and a private practitioner in Cambridge, Mass.

SHEDDING LIGHT The LED device uses an array of elements to deliver non-coherent light at a wavelength of 590-nm. It induces its effects by modulating the activity of cells in the skin.

"This mechanism contrasts with that of lasers and intense pulsed light devices that reverse signs of photoaging, either through ablative effects or by inducing a photothermal reaction. LED treatment involves delivery of very low energy light that results in a biomodulatory effect unrelated to heat generation," Dr. Hirsch explains.

REGISTRATION TRIAL The study that resulted in FDA approval of LED treatment was a multicenter trial enrolling 90 patients with a range of skin changes associated with photoaging.

They underwent full face treatment twice a week for four weeks and were followed photographically for up to 12 months with serial evaluations.

Subsequent studies included computerized optical digital profilometry, and histology using immunofluorescent stains for changes in collagen synthesis and degradation. These in vitro studies showed increases in collagen content in the papillary dermis with evidence of increased collagen I density and a reduction in matrix metalloproteinases that are responsible for collagen degradation.

SAFE BUT PROTRACTED "This technique has some advantages in that it is quick, easy and safe for all skin types. However, it does involve a series of eight sessions, it is not inexpensive, and thus is a hard sell to the cosmetic surgery candidate who is seeking noticeable improvement of facial aging. It may have a role for those seeking more modest improvements or maintenance therapy after more aggressive procedures," Dr. Hirsch says.

COMING TO LIGHT Meanwhile, clinician-investigators have been exploring additional applications of LED treatment.

Their anecdotal reports indicate it may have a role for modulating the immune response to shorten the duration of sunburn and for hastening wound healing.

"These reports are intriguing and will be of interest to follow going forward." Dr. Hirsch concludes.

Disclosure
Dr. Hirsch reports no financial interests related to this article.

Reference

Weiss RA, Weiss MA, Geronemus RG, McDaniel DH. A novel non-thermal non-ablative full panel LED photomodulation device for reversal of photoaging: digital microscopic and clinical results in various skin types.J Drugs Dermatol. 2004 Nov-Dec;3(6):605-10.

Everyone, from beauty editors to your best friends, seems to be talking about them.

Even your mother is contemplating getting them. What's the big buzz about? It's about injectable fillers. It seems everyone is considering them. Are they right for you?

According to Metairie, La., dermatologist Patricia Farris, M.D., "Facial fillers serve two purposes in helping people achieve a younger, more toned look. They help fill in individual lines and wrinkles, and they can help add volume and contour to areas that have lost that youthful 'fullness.'"

PLUMP IT UP Dr. Farris explains that fillers such as collagen and hyaluronic acid, which go by names such as Restylane, Juvéderm and Hylaform, are excellent when used for individual lines and wrinkles, but are not the fillers of choice when it comes to replenishing lost volume.

This lack of volume can often be seen in the cheeks. Restylane, which lasts about three to four months, is also an excellent choice for helping to fill out lips that have gotten thinner with age.

Adding volume back to sunken cheeks is of real benefit to some women, helping them to regain a more youthful look.

"We now recognize that as you age your face loses fat, causing it to look hollow in certain areas," Dr. Farris says. "I refer to the 'cone of youth' when talking to patients. If you can imagine a triangle with its base stretched over the cheeks, tapering down at the chin in young people, you have what typically defines faces in the teens, 20s and 30s. As you age, you develop an inverted cone where the volume has sunk to the jowls and the upper face becomes thinner and sometimes hollow in appearance."

This inverted cone of youth is the way the face ages. Many doctors now use a filler called Sculptra off label to restore facial volume. It adds back a lot of the volume that makes the face look younger and more vital. The only downside to this, Dr. Farris explains, is that it requires multiple treatments and touch-ups — usually three to six treatments at monthly intervals. The effects, however can last about 18 months to two years.

JUST ON THE MARKET New to the filler market are Juvéderm Ultra and Juvéderm Ultra Plus, which are hyaluronic acid fillers.

Both were approved by the Food and Drug Administration in June 2006. Juvéderm Ultra is a formulation that provides more versatility in contouring and volumizing facial wrinkles and folds. Juvéderm Ultra Plus is a more robust formulation for volumizing and correction of deeper folds and wrinkles. Both contain the highest concentration of non-animal hyaluronic acid of any dermal filler now available. Sustained results last up to six months or longer.

Another new filler to discuss with your dermatologist is Radiesse. Radiesse is an innovative filler made from calcium hydroxylapatite particles. When injected into the skin, these particles act as both a filler and a stimulator, meaning this filler restores volume and also stimulates the production of collagen. Radiesse is longer-lasting than most fillers and will show improvement for up to one year.

Whichever route you choose, make sure you find a qualified doctor — one who is trained in the technique for the selected filler (dermatologists often have to be trained by the drug manufacturer, as each filler requires using specific injection techniques). Don't be afraid to ask questions. The more you know, the better you will be equipped to make a decision that produces the best results.