Researchers studying whether botulinum neurotoxin (BoNT) A, BoNT/D and tetanus toxin (TeNT) can spread within networks of neurons to have distal effects found that indeed they do.

Specifically, they found that while the toxins act on the targeted neurons, they are also taken up, via an alternative pathway, where they are transported and released to exert effects on upstream neurons.

The result, at least in a lab dish, is long-distance effects, according to the study, epublished August 4 in Cell Reports.

According to a university press release on the study, the concern isn’t new. In 2009, the FDA added a warning in prescribing information, noting that botulinum toxin may spread from the area of injection to produce symptoms consistent with botulism, such as unexpected loss of strength or muscle weakness, swallowing and breathing difficulties that can be life-threatening.

There are also those “puzzling” results from Botox and other treatments, according to study author Ewa Bomba-Warczak, a doctoral candidate in neuroscience.

“In many cases, after an injection for a disabling spasm of neck muscles called cervical dystonia, there is no change in muscle tone but the patient finds relief and is perfectly happy. That result can’t be explained by the local effects,” Bomba-Warczak says in the release.

Dr. ChapmanIn the study, the researchers used mouse neurons in wells connected by tiny channels that allow growth of axons.

“Every time one fraction of the toxin acts locally (on the first nerve cell it contacts), another fraction acts at a distance,” says study author Edwin Chapman, Ph.D., investigator, Howard Hughes Medical Institute, and professor of neuroscience at the University of Wisconsin-Madison. “It’s unknown how far they travel, which likely depends on the dose of toxin and other factors.”

Implications for the Cosmetic Practice

Dr. FanSan Francisco-based plastic surgeon Larry Fan, M.D., says the study has no new implications for cosmetic practice.

“It is well known that botulinum toxin can spread from an injection site via passive diffusion, intraneuronal transfer or through the bloodstream. This study provides direct evidence that botulinum neurotoxin can spread distally between nerve cells,” Dr. Fan says. “Botox injection for cosmetic use remains a safe treatment. However, all patients should keep in mind that there is a small possibility of undesired effects such as temporary eyelid or eyebrow drooping.”

The study’s findings underscore the importance of the injector’s qualifications.

“A qualified injector should possess extensive knowledge of facial anatomy, aging, injection technique, botulinum pharmacology and treatment of potential complications,” Dr. Fan says. “The only injectors who consistently possess these skills and knowledge, with a few exceptions, include board-certified plastic surgeons, facial plastic surgeons and dermatologic surgeons.”

Reader Response: Letter to the Editor

NEXT: Lessons to Be Learned

Lessons to Be Learned

Miami, Fla. cosmetic surgeon John J. Martin Jr., M.D., agrees that clinically there can be spread or diffusion of the injectable fluid beyond the area of injection, but there are lessons to be learned from the study.

“… this study shows that it may also spread from cell to cell. This confirms that physicians have to be careful when injecting into areas where you don't want any spread, such as the upper eyelid,” Dr. Martin says.

Dr. Martin says that while the study release implies distant spread to remote areas, the findings confirm spread into adjacent, not remote or distant locations. 

“There have been instances of remote spread from high-dose injections. In these cases there is so much toxin being injected that there is systemic spread leading to symptoms of botulism. This is not seen with normal cosmetic doses, which all doctors should abide by,” Dr. Martin says.

Dr. FreimanMiami, Fla., plastic surgeon Jacob Freiman, M.D., has his doubts about the implications of findings like these for cosmetic practice.

“I believe this topic is being sensationalized based on a vague study that shows that the botulism toxin can propagate from one neuron to the adjacent one. So far, there has been very little bench research … and no real trials,” Dr. Freiman says. “If you look broadly at the millions of people who have gotten and will get Botox injections, you would be hard pressed to find someone who has any distant effects. At most, over-injection in one area can cause more than the just the specific target muscle to be paralyzed and the tiny muscle right next to it may also be paralyzed. This can sometimes be seen with patients who go for Botox and have a droopy upper eyelid. Eye drops can generally help resolve the issue.”

NEXT: Botox 2.0?

Botox 2.0?

Dr. ChabokiHoutan Chaboki, M.D., a facial plastic surgeon in Washington, DC, says he finds the study interesting.

“The doses for cosmetic uses are generally much smaller than other medical uses for botulinum toxin,” Dr. Chaboki says. “Anecdotal evidence among plastic surgeons hasn't shown a clinical effect of this possible neuron-to-neuron transfer of the toxin beyond the injection site. Injecting muscle for forehead wrinkles hasn't affected smiling muscles, for example. It does, however, encourage drug manufacturers to develop a newer, modified version of botulinum toxin that doesn't travel. Botox 2.0.”

Dr. WienerChicago plastic surgeon Gregory Wiener, M.D., says he thinks the study is informative and welcomes any increase in the safety profile of the products he uses.

“However, after 17 years of using Botox for cosmetic applications, I can say that clinically we just don’t see the effect spreading to adjacent (much less distant) areas,” Dr. Wiener says. “As long as the Botox dose is appropriate, the fluid used to reconstitute and deliver the Botox kept to a minimum and the injection techniques are low pressure and focused, it is extremely rare to see unwanted effects in surrounding areas,” Dr. Wiener says.

NEXT: Avoiding Unwanted Effects

Avoiding Unwanted Effects

Dr. Martin says that to avoid spread cosmetic surgeons should not use a highly-diluted preparation of the toxin or a high-dosage and only inject into areas that they want to paralyze.

“Some local diffusion is expected, so they should be careful when injecting into certain areas that are known to be sensitive (such as around the upper lid to elevate the brow) and air on the side of being conservative with dosages,” he says. “You can always add more once the solution has settled, but the same can’t be said the other way around.”

Dr. Wiener tailors injection techniques and Botox doses to each patient, but considers such things as strength of the muscular contraction and thickness of the skin and tissues.

“If these types of guidelines are not followed, there may be a higher incidence of unwanted effects (as in personnel with less training and experience),” Dr. Wiener says. “And in some cases, when larger doses and higher numbers of injections are done, such as treating hyperhidrosis (excessive sweating), there is more potential for unwanted effects. In these instances, a more focused Botox would be appropriate."

In some types of injections, like the forehead and crow’s feet, injectors actually want a small amount of diffusion and spreading of the effects in order to block these large, flat muscles over a wider area, Dr. Wiener says.

“A Botox with more focused effect in this situation may take additional injections for adequate treatment," Dr. Wiener says.

Dr. MoellekenIt’s important that the injector be familiar with not only the anatomy, but also the volume of distribution of the various botulinum preparations. The injector needs to perform an appropriate history and physical prior to treatment. He or she needs to know how to treat complications should they occur, according to Brent Moelleken, M.D., Beverly Hills plastic surgeon and associate clinical professor of plastic surgery at UCLA.

“A medi-spa is not the place to have a complication from errant botulinum toxin injection,” Dr. Moelleken says.

Dr. Moelleken says he injects botulinum toxin only in an office setting for that reason and disagrees with the commoditization of botulinum toxin with advertisements on billboards and buses. 

“While in the proper hands botulinum toxin is quite safe, complications can and do occur, up to and including death," Dr. Moelleken says.

Besides being effective in treating rhytides, Botox and other botulinum neurotoxin (BoNT) are also efficacious for seven non-cosmetic indications, according to a review in the August issue of Plastic and Reconstructive Surgery.

Migraines, upper limb spasticity, neuropathic pain, facial dystonias, facial nerve palsy and aberrant regeneration, hand tremor and palmer hyperhidrosis all benefited from BoNT, with high-quality evidence to support good responses.

“Neuropathic pain and hand tremor are two less known uses for BoNT and may be a surprise to some clinicians,” lead author Marie E. Noland, M.D., senior plastic surgery resident physician at Dalhousie University in Halifax, Nova Scotia, Canada, tells Cosmetic Surgery Times. 

Dr. Noland says that BoNT’s versatility is effective at multiple sites in the body, “including but not limited to the neuromuscular junction, the ubiquitous relay center between all nerves and muscles, making almost any location in the body a possibility for targeted therapy.”

Related: Botox, Dysport, Xeomin not interchangable

Additionally, with the drug being delivered in such small volumes, “precise and focused injections are possible with relative ease of use and limited spread to unwanted areas,” Dr. Noland notes. “Its dose-dependent nature allows preservation of muscle function while targeting unwanted conditions.”

BoNT’s high-safety profile and impermanence also “makes it possible to experiment in different clinical settings,” Dr. Noland says.

The international review identified rhytides and the seven non-cosmetic indications treated by plastic surgeons. And although the evidence is strongest for the minimally invasive treatment of rhytides, botulinum neurotoxin is also effective for dystonias, such as tics caused by benign essential blepharospasm.

Two studies have also concluded that Botox can reduce hand tremors in patients with essential tremor, although hand function may not improve. BoNT also shows promise for treatment of muscle spasticity in children with cerebral palsy.

In addition, based on three large studies, Botox has been approved for treatment of chronic migraine headaches.

Neuropathic pain, for which there are few effective treatments, can also be remedied with BoNT, including pain caused by diabetes and surgical nerve damage.

Using kaolin-impregnated gauze offers limited benefit for blepharoplasty patients. The mineral, which has been shown to help control hemorrhage when combined with gauze and applied to wounds, showed no quantifiable change in intraoperative hemostasis among cosmetic eyelid surgery patients. Postoperatively, the limited positive effects on lid edema and ecchymosis were noted in the later healing stages by surgeons but not by patients, according to a new study.

Investigators reported on a prospective, randomized, double-blind study of 46 eyelid surgery patients. After making skin incisions, they placed kaolin-impregnated gauze in one eyelid wound bed and cotton gauze in the other.

They removed the gauze and took postoperative pictures on days one, four and seven. Blinded observers graded the photos for edema and ecchymosis, and patients completed a survey at each visit, asking them which side had more bruising, swelling and pain.

Researchers noted no notable difference in the number of intraoperative bleeding sites for kaolin compared to plain gauze. The blinded observers didn’t see differences in postoperative edema between lids photographed.

Related: IPL reduces post-bleph bruise

But while they didn’t see immediate effects from the treated gauze, there appeared to be limited postoperative benefit — a statistically significant difference in ecchymosis at days four and seven. Patients, however, didn’t note this or any differences in perceived edema, ecchymosis or pain between the lids.

While this study doesn’t show a clear benefit associated with using kaolin-impregnated gauze for blepharoplasty patients, considering the time and cost, other research suggests the gauze might be of more benefit with repeated applications, according to the authors.

Cherry Hill, N.J., plastic surgeon Steven L. Davis, M.D., does not use kaolin-impregnated gauze for eyelid surgery patients.

“…the additional cost does not seem beneficial,” he says. “I use 1% lidocaine with epinephrine on a gauze topically after incision.”

A user survey asking nine plastic surgery physicians and residents about the applications of Google Glass in the operating room reveals the Glass is comfortable and satisfying to wear during surgery, but there are weaknesses, including a tendency for the device to be distracting.

Researchers surveyed residents and attending physicians in the department of plastic surgery at MedStar Georgetown University Hospital, Washington, DC, from January to July 2015, asking about the technology’s ease of use, quality of images, gaze disruption and distraction during surgery. The results were published July 2016 in Plastic and Reconstructive Surgery.

Among the potential benefits of Google Glass in surgery is that it allows users to capture intraoperative images, without using their hands and, instead, by using their voices or winking. Concerns with the technology include the potential for operator distraction and gaze disruption.

Google Glass Explorer (the program to test the device) removed the technology from the consumer market January 2015, during the study in plastic surgery. Despite that, the study’s authors write that Google Glass continues to rise in popularity in medicine and other professional fields.

Dr. SinkinStudy author Jeremy C. Sinkin, M.D., who was chief resident in plastic and reconstructive surgery at Georgetown University Hospital during the study and now is a fellow in reconstructive microsurgery at Memorial Sloan Kettering Cancer Center in New York City, tells Cosmetic Surgery Times that the study’s goal was to assess surgeon comfort using Google Glass in the OR for some of its more basic functions.

“The device is a unique piece of technology that may have the potential to become fully integrated into a surgical practice in the future, but prior to its widespread adoption, we wanted to get feedback from other plastic surgeons,” Dr. Sinkin says. “Specifically, we asked surgeons to wear the device for the length of their surgeries and take pictures [and] videos throughout. [We] then surveyed the surgeons on ease of use [and] comfort and satisfaction with picture quality, etc.”

NEXT: How Google Glass Scored

How Google Glass Scored

On a scale of 1 (very poor) to 5 (excellent), users rated Google Glass features.On a scale of one (very poor) to five (excellent) users ranked the device’s average ease of image capture by means of voice activated control an average 3.11, or good. They gave a similar rating, at an average 3.22, for video capture by means of voice-activated control.

Average ease of using the wink feature was poor, at 1.89. Users also reported difficulty with intraoperative image review, rating the feature 2.56.

They rated quality of image at an average 3.89, and quality of video, at 3.67.

One-third of users reported the device distracted them from surgery; yet, on average, operators were required to “sometimes” remove their gaze from the surgical field when taking pictures. Users had to shift their gaze to the display screen to focus the camera on the intended target, the authors write.

Overall, they rated the comfort of wearing Google Glass an average 4.56. Overall satisfaction was an average 3.78.

NEXT: A Promising Technology

A Promising Technology

Despite the weaknesses, the overall survey results suggest plastic surgeons believe Google Glass is a promising device for use in the OR during plastic and reconstructive surgery.

Dr. Sinkin, says he does not use Google Glass regularly in practice and sees it as a work in progress.

“There are many potential strengths of using a hands-free, head-mounted, voice-activated computer with viewing screen in the operating room, including obtaining pictures [and] videos of the surgical field, or reviewing patient data without breaking sterility,” he says. “There is also the potential benefit of tele-consulting with a colleague during surgery to show particular pathology or ask questions, without stepping away from the operating table, or needing a fellow surgeon to come to the OR to take a look. In plastic surgery, we rely heavily on photographs and pictures for documenting patient outcome, and Google Glass has the potential to integrate into that role.”

On the flip side, Dr. Sinkin says, protecting patient privacy is of the utmost importance.

“The question of encryption/security needs to be addressed prior to widespread use in the medical field. In addition, we found that the camera did not always line up with where we, as surgeons, were looking. Picture quality in the OR may benefit from a hardware adjustment that allows the camera to be adjustable up [or] down,” Dr. Sinkin says.

NEXT: The Future of Google Glass

The Future of Google Glass

Dr. NiamtuJoe Niamtu, III, D.M.D., an oral and maxillofacial surgeon with a practice limited to cosmetic facial surgery in Richmond, Va., was among the early testers of the technology and commented on its use in cosmetic surgery in 2014 for Cosmetic Surgery Times.

“In some respects, the Glass was a technology without a use. You had this cool, futuristic device that could do a bunch of neat stuff, but really not supporting apps that could make it practical and useful for medicine and surgery,” Dr. Niamtu says. “It certainly got a lot of attention, but in my opinion, sort of fell by the wayside …. Don’t get me wrong, it will be back! And I believe when it does return you will see numerous supporting apps that will make Glass.2 much more useful.”

Dr. Niamtu says he envisions Google Glass applications that would allow seamless integration into electronic medical records, for example.

“I remember people laughing when the iPad was first released saying it was neat technology that had no use,” he says.

Like the Apple technology, Google Glass is a device whose time has not yet come, but will come, Dr. Niamtu says. 

A new study suggests that once weekly treatment of low-level laser therapy (LLLT) for six weeks might be more effective than three treatments weekly for two weeks, for noninvasive body contouring of the waist, hips and thighs.

The six-week protocol offers a more convenient treatment plan, which, could increase patient satisfaction, according to the authors.

Related: Strong growth predicted for body contouring market

Researchers at two dermatology practices studied 54 healthy adults with body mass indexes of 25 to 40 kg/m2, who had one weekly LLLT procedure for six consecutive weeks. In the study, which was sponsored by Erchonia Corporation, the researchers used Erchonia’s Zerona 6-Headed Scanner (EZ6) device with six 17 mW, 635 nm red diodes, to contour patients’ waists, hips, thighs and upper abdomens.

They treated patients’ backs and fronts for 30 minutes each, or a total 60 minutes, and repeated that approach weekly for six weeks.

Measuring the treated body area circumference weekly, the researchers defined study success as a 4.5-inch average decrease in combined body circumference. They used the minimum mean decrease of 4.5-inches because the FDA had determined that to be statistically significant and clinically meaningful, based on prior LLLT studies.

In this study, they found a mean decrease at six weeks of 5.4 inches; 81% of patients said they were satisfied or very satisfied with their results.

The new study confirms and demonstrates LLLT’s effectiveness for reducing circumference of the bilateral thighs, hips and waist. It also shows significant reductions in upper abdomen circumference, which decreased a mean 5.4 inches, according to the study.

Among the limitations of the study is its small size and open-label design, according to the authors. 

Syneron Medical announced in mid-July FDA clearance of its noninvasive UltraShape Power device for fat reduction around the abdomen.

According to press materials for the device, while ultrasound measurement reveals cryolipolysis reduces fat thickness by 22% and the 1060 nm laser by 24%, UltraShape Power reduces abdominal fat layer thickness by 32%.

The device, which uses pulsed mechanical ultrasound energy to seek and destroy fat, features the USculpt transducer, which delivers 20% more energy than its predecessor.

“The device's unique deployment of higher acoustic energy via its new transducer allows for the precise targeting of small and large pockets of fat with minimal increase in tissue temperature, resulting in a comfortable treatment experience," according to Suzanne Kilmer, M.D., founding director of the Laser & Skin Surgery Center of Northern California, in a Syneron press release.

The result is a system that offers customizable treatments, according to Alix Charles, M.D., clinical trial investigator.

"The clinical studies show a pain score of less than one out of a ten point scale, and my patients have experienced similar comfort levels," Dr. Charles says in the release.

Full abdominal fat reduction treatment with the device can be done in close to 30 minutes, according to the release.

Beverly Hills, Calif., dermatologic surgeon Jason Emer, M.D., tells Cosmetic Surgery Times that it’s too early to tell how UltraShape Power will compare to other noninvasive fat reduction devices.

“I… feel UltraShape is great for people who are already thin, without much pinchable fat, who have small problem areas or irregularities,” Dr. Emer says. “The numbers on the study show a small percentage difference, so it will be hard to say how this will measure up in real practice. Although UltraShape has the advantage of being able to treat any size and shape of an area and is virtually painless…, it still takes a number of treatments to see the ultimate outcome, as compared to SculpSure [Cynosure] or CoolSculpting [Zeltiq], which show a large improvement in a single treatment.”

Dr. Emer says he hasn’t used the upgraded power feature yet, but is excited to try it for high-definition sculpting of the abdominal muscles.

“Ultimately, with all these treatments, you need to educate patients on long-term diet and exercise, and integrating these treatments into their daily lifestyles,” he says.

Disclosure: Dr. Emer is a consultant/luminary for Syneron-Candela and BTL Aesthetics.

The body contouring market is expected to achieve a compound annual growth rate of 7.9% between 2015 and 2022, according to a report from research and consulting firm GlobalData. This represents an annual increase from $671.8 million to over $1.1 billion.

The report, which was generated by Brigitte Babin, a medical device analyst specializing in general surgery at GlobalData, notes that the body contouring market encompasses both noninvasive and minimally invasive fat reduction procedures like lipolysis and cryolipolysis.

“There are several drivers contributing to the strong growth of the body contouring devices market,” Babin tells Cosmetic Surgery Times. “One key driver is the rising popularity of nonsurgical options, leading to the very fast market growth of a relatively new technology. There are also two groups that have created significant growth in the market: an increase in the number of men seeking treatments and an aging baby boomer population also seeking body contouring. This later group is often looking for procedures, such as skin tightening, to combat the effects of aging.”

Related: 3 Hot nonsurgical devices

The 15 major markets of growth for body contouring are the United States, France, Germany, Italy, Spain, the United Kingdom, Japan, China, India, Brazil, Australia, Canada, Mexico, Russia and South Korea.

Besides advancements in the accessibility and quality of nonsurgical procedures, rising obesity rates will be a driver of demand as well. Babin says people continue their quest for easier alternatives to diet and exercise to reduce body fat content.

This escalating trend of a “quick fix” is also propelling growth in the noninvasive body contouring market. However, Babin points out that the noninvasive segment is not in direct competition with invasive or minimally invasive procedures because many patients will not consider any type of invasive fat reduction or body contouring, due to unnecessary surgery concerns, complications and financial barriers.

Between 2012 and 2015, there was an annual increase of 22.6% in the number of U.S. men who scheduled noninvasive body contouring treatments. In 2015 alone, 16.7% of nonsurgical fat reduction procedures were performed on American men, mirroring trends seen in other countries.

A pair of Beverly Hills plastic surgeons has a simple message for women with breast cancer who seek mastectomies and reconstruction: Expect more. 

Dr. CassilethLisa B. Cassileth, M.D., FACS, and her partner Kelly Killeen, M.D., tell their breast reconstruction patients that it’s often possible to spare their nipples and avoid devastating scarring. It’s all thanks, they say, to their partnerships with top breast surgeons and a strong focus on aesthetics.

“Women often feel they can’t be naked after a mastectomy, that they feel asexual: ‘I’ve had this happen to me and I’ll move on, but I’ll never be able to be naked again or have anyone see me naked again,’” says Dr. Cassileth, the clinical chief of the Division of Plastic Surgery at Cedars-Sinai Medical Center and an assistant clinical professor at UCLA.

The reality, she believes, is the exact opposite. In fact, women can often even get the breasts they always wanted.

Dr. Cassileth puts it this way when she talks to breast cancer patients: “Sorry to be so superficial, but my job is to make you hot.”

Dr. KilleenIn July, the two surgeons became a hit on the Internet bulletin board Reddit when they took part in an AUA — Ask Us Anything — titled “We are two female Beverly Hills plastic surgeons, sick of seeing crappy breast reconstruction — huge scars, no nipples, ugly results. There are better options!” Their discussion drew more than 2,100 comments.

Cosmetic Surgery Times reached out to the surgeons and asked them to describe their approach to mastectomy and breast reconstruction.

Q: What does the public misunderstand about breast reconstruction after breast cancer?

Dr. Cassileth: The reality is that women have no idea about it. Maybe their mothers or someone they know had a mastectomy, but it’s a taboo subject. You may never be told that you have this big cut across your chest. Then they look online, and the pictures can be really horrific. These women come into my office, and they’re shell-shocked. They just want to get this done.

Q: How have surgeons typically looked at the nipple in mastectomies and reconstructions?

Dr. Killeen: Traditionally, cancer surgeons considered the nipple to be part of the breast tissue, and it was removed. In fact, the nipple can be safely left behind in most patients. This leads to superior cosmetic outcomes, and women feel psychologically better keeping their nipple. Unfortunately, a lot of the country has been slow to adopt this as the standard of care.

Q: Why do you think nipple-sparing surgeries are so uncommon?

Dr. Cassileth: The majority of surgeons I’ve worked with don’t know how to do that. That’s why I’ve reversed the flow so we only work with breast surgeons who are fabulous.

Q: So you choose the breast surgeon instead of a breast surgeon choosing you?

Dr. Cassileth: I’m driving the consult back to the general surgeon, not the other way around. I’m first, and they’re second.

NEXT: Reducing Complication Rates

Q: What does your approach mean for the risk of mastectomy flap necrosis, a common complication of breast reconstruction?

Dr. Cassileth: The published complication rate is 15%. I’ve seen an average of 30% among surgeons, and one surgeon reached 55%. They want to do a good job, but they’re not fully aware, it doesn’t hit them like it hits us. All we care about is the aesthetic. When we choose the general surgeon, we keep statistics on every single one of our patients. We’re under 1%. I had one surgeon get up to 2%, and I said this will never happen again.

Q: You perform breast reconstruction at the same time as the mastectomy instead of separating the procedures. What does that accomplish?

Dr. Killeen: Traditionally, a lot of surgeons don’t pay as much attention to creating a perfect pocket. They don’t think they have to get it right the first time, since can be fixed when the patient comes back to get an implant later.

When you get the implant in on the first go, you have to treat that reconstruction with respect. You aren’t coming back another time.

NEXT: How Men Deal With Breast Reconstruction

Q: In the Reddit Q&A, you mention something surprising about how many men deal with the breast reconstruction of their loved ones. Can you tell that story?

Dr. Cassileth: When you give a man an implant to hold, they close their eyes and massage it: What does that feel like? I like it when they do that. They’re really committing. They’re fully committed that this will be their wife’s boob.

Q: How can men support the women in their lives when they undergo these procedures?

Dr. Cassileth: The woman’s facing this idea that they’ll somehow be maimed or damaged.  They’re inhibited by the idea that their husbands are judging them. If the husband weights in too heavily, even if he’s trying to be helpful, women will often take that as a criticism of themselves. They’ll feel more nervous and insecure about their reconstruction. Men who say “I love you, I don’t care about what you look like” — even if they’re lying — help women to feel unconditional love. 

A new study suggests brachioplasty complication rates are lower than previously reported. The most common major complications from the popular surgery to correct upper arm ptosis are hematoma and infection, according to the study published online May 23, 2016 in the Aesthetic Surgery Journal.

Researchers conducted a prospective, multicenter database study on the incidence of major complications and risk factors from brachioplasty using data from 2,294 brachioplasty patients in the CosmetAssure database. CosmetAssure is a Birmingham, Ala.-based complications insurance company.

They looked specifically for major complications, which the researchers defined as one requiring an emergency room visit, hospital admission or reoperation within 30 days of surgery.

They found brachioplasty patients represented 1.8% of the 129,007 patients enrolled in the CosmetAssure database. Major complications occurred in 3.4% of the brachioplasty patients studied. Infection represented 1.7% and hematoma 1.1% of those cases, according to the study.

Patients who had combined procedures were more likely to suffer a major complication, at a rate of 4.4%, versus the 1.3% major complication rate when brachioplasty alone was performed. Another independent risk factor for complications was having a BMI of 30 kg/m2 or more. Men were more likely than women to experience hematoma formation.

These rates are lower than previously reported, the authors write.

Related: Variations in brachioplasty allow tailoring of technique to suit patient need

In June 2006, researchers reported in Plastic and Reconstructive Surgery on a retrospective review and cadaveric study of brachioplasty procedures performed at Mayo Clinic over a 16-year period.

Looking at an average follow up of 50 months, the researchers found the revision rate was 12.5% and the overall complication rate was 25% (although 95% of the complications were considered minor). The complications — none of which required surgical correction — were seroma, hypertrophic scarring, cellulitis, wound dehiscence, subcutaneous abscess and nerve injury, according to the study.

These researchers classified nerve injuries as major complications, reporting that two patients, or 5%, developed injury to the medial antebrachial cutaneous nerve.

In a later study published in Plastic and Reconstructive Surgery, published in April 2013, researchers conducted a multi-practice review of brachioplasty outcomes. They found that among 96 patients, 17.7% had major complications and 44.8 percent had minor complications. The revision rate in that cohort was 22.9%, with the most common reason being residual contour deformity. Unlike the new study in Aesthetic Surgery Journal, these researchers did not find an association between a higher complication rate and additional procedures performed at the time of brachioplasty.

Noninvasive skin tightening is in demand. But there are many such devices and finding the best fit for a practice can be challenging.

Dr. GoldMichael H. Gold, M.D., medical director of Gold Skin Care Center and the Tennessee Clinical Research Center in Nashville, Tenn., says his practice has offered skin tightening since it first came to market.

“The numbers don’t lie. Outside of neurotoxins and fillers, skin tightening is one of the most sought-after cosmetic noninvasive treatments out there,” Dr. Gold tells Cosmetic Surgery Times. “I do think that one needs to be honest with your patients. These devices work over time and multiple sessions may be needed for success. Maintenance… may be needed, as well.

Dr. DiBernardoBarry DiBernardo, M.D., director of New Jersey Plastic Surgery, in Montclair, N.J., says that he added skin tightening devices to his practice because patients want tighter, smoother skin, without having to go through with big surgeries or long recoveries.

“Noninvasive and invasive fat removal is very popular today, but if that fat is removed and there is loose skin, it is not a becoming result. Thus, the importance of skin tightening today,” says Dr. DiBernardo.

Dr. RobbSkin tightening devices have come a long way but questions remain, says Chris Robb M.D., Ph.D., cofounder of the Skin and Allergy Center in Spring Hill, Tenn. 

“The molecular mechanisms that lead to skin tightening are not entirely understood, so the effectiveness of any given device is still being worked out. That makes a direct device-by-device comparison very difficult,” Dr. Robb says. “Finally, some patients respond to this kind of treatment and some do not. Experience will guide who you select and make for a happy customer base.”

In This Article:

Device Search 101

My Top Device Picks

3 Steps to Buying the Right Device

NEXT: Device Search 101

Device Search 101

First and foremost, cosmetic physicians should look for a device that achieves true skin tightening, according to Dr. DiBernardo.

“Skin tightening has always been a mystery as a sole treatment,” Dr. DiBernardo says. “For years, we ‘tightened’ skin surgically by excising excess and pulling the remainder. But was that true tightening or just pulling?”

The answer lies in what makes skin tight. The two components to consider are plumpness and elasticity, or the lack of laxity, according to the plastic surgeon.

“If we know what makes skin tight, then we can explore devices able to reproduce the condition of tightness in aging skin,” Dr. DiBernardo says. “Originally, the work was done with lasers and more recently with radiofrequency devices. If we can control the heat to 47 degrees centigrade and measure it, this will enable fibroblasts to make more collagen and elastin, which can then be measured and seen as tighter, thicker skin.”

The optimal skin tightening device should (a) emit an energy form to achieve a temperature rise in skin, (b) measure that temperature and (c) for safety, monitor the temperature and shut off when needed to prevent injury, according to Dr. DiBernardo.

NEXT: My Top Device Picks

My Top Device Picks

Dr. DiBernardo has two devices: the Smartlipo TriPlex (Cynosure), which is a laser delivered through a 1 mm fiber to breakup fat and tighten skin. The device monitors temperature with its ThermaGuide.

“This device, using these mechanisms, can treat body skin and fat, and also cellulite…,” Dr. DiBernardo says.

He also uses the ThermiRF (Thermi), which emits radiofrequency energy through a 1 mm probe. The device offers deep tissue and surface temperature settings via its thermal camera. It also stops energy emission once the “set temp” is reached, leading to a high degree of safety and efficacy, he says.

“This has been used in all areas of the body and breasts,” Dr. DiBernardo says.

Dr. Robb says he performs skin tightening with broad band light from Sciton, external radiofrequency and radiofrequency microneedling from Infini (Lutronic).  

“And we have treated literally every part of the dermis that can have laxity. The areas that best respond are the lower eyelids, neck, abdomen, knees and labia,” Dr. Robb says. “We use the Sciton BBL (Skin Tyte II) the most. It's pain free and effective. We've also had very good experience with Infini and the results are very impressive.”

Dr. PoznerBoca Raton, Fla., plastic surgeon Jason Pozner, M.D., says his practice does quite a bit of skin tightening, and he gives a thumbs up to Infini by Lutronic among other devices.

Among the better devices on the market that head from the outside in, according to Dr. Pozner, are radiofrequency devices, like Thermi 250, VelaShape or long-pulse IPL devices, including Sciton’s SkinTyte. He also looks at the devices that heat from the inside-out. Winners in that category, he says, include the radiofrequency device ThermiTight, Precision TX laser by Cynosure and ProLipo by Sciton.

“Other devices cause a burn zone in the skin. These are either Ulthera (ultrasound) or microneedle radiofrequency, like Lutronic Infini,” Dr. Pozner says.

Dr. Gold uses many of the devices because he works with companies in the space and does research on the associated skin tightening devices.

“My favorites — in no particular order — are the Venus Legacy, EndyMed 3deep, Alma Accent (now called the V-shape), Invasix Inmode system, BTL Exelis and Syneron VelaShape,” Dr. Gold says.

NEXT: 3 Steps to Buying the Right Device

3 Steps to Buying the Right Device

Dr. DiBernardo says he goes through these three steps before purchasing expensive devices:

1. He makes sense of the physics and biophysics of the device.
2. He needs to see very clear before and after photographs that are standardized and consistent from that technique.
3. He needs to understand all the finances, including the costs to purchase and run a device, the return on investment in the procedure’s pricing and potential demand.

“If those three items are achieved, you will have made a wise investment for the practice and a terrific treatment for your patients,” Dr. DiBernardo says.

It’s important to ask the companies to show you evidence that the devices work, including peer-reviewed studies. And beware of promotional literature that poses as credible studies, according to Dr. Gold.

“Many laser companies like making white papers which in essence is a promotional piece and not scrutinized as a peer-reviewed paper,” Dr. Gold says. “One also wants to look to see how long the company has been in business, and what they have done to enhance the industry.”

Skin tightening device purchases make sense for cosmetic practices that are already doing the fundamentals, according to Dr. Robb.

“I wouldn't add one unless you already owned an IPL, for example. But if you have an established patient population, this is a good move,” he says. “I would focus my homework on market demand (in office questionnaires, etc), local pricing and competition. It's easier to brand yourself if your device is unique but also effective — not just one or the other.”

Skin tightening devices have come a long way but questions remain and patients should be educated about realistic expectations, says Dr. Robb. 

“The molecular mechanisms that lead to skin tightening are not entirely understood, so the effectiveness of any given device is still being worked out. That makes a direct device-by-device comparison very difficult,” he says. “Finally, some patients respond to this kind of treatment and some do not. Experience will guide who you select and make for a happy customer base.”