Deer Valley, Utah — Oculoplastic and facial cosmetic surgeon Richard L. Anderson, M.D., is not ready to bet the farm on light-emitting diode therapy (LED) for skin rejuvenation just yet. But he is excited about the results that he, his staff and his patients have achieved using the GentleWaves LED (Light BioScience) technology.

He is enthusiastic about the possibility of a therapy that does not "damage" the skin's surface or cause any thermal injury, but rather works below the skin, penetrating it to activate and energize cells — increasing collagen and elastin production.

"A lot of people equate LED with lasers. LED is not a laser. It is a part of a movement in the field away from lasers and into more light therapies," Dr. Anderson says.

"Before" and "after" photos of patients treated wth GentleWaves LED photomodulation.

"Another concern with CO₂ laser resurfacing is the management of patients. It was almost like having a burn unit in the office."

He says it was quite tedious and time-consuming for physicians to treat CO₂ laser patients. "Some results were pretty good, but in a lot of cases, I felt like the skin lost its life and color. There usually was a step-off line from treatment and non-treatment areas. Even with time, the skin looked washed out," he says.

Anderson has gone back to using trichloroacetic acid (TCA) peels as his staple resurfacing method. "The CO₂ laser has become a paperweight in the closet," he says.

An LED skeptic Dr. Anderson admits that, at first, he thought a device that required sitting in front of flashing lights for 35 seconds, with no pain and not even a blush, must be part of a scam. "You would think a fluorescent light would do as much," he says.

"Before" and "after" photos of patients treated wth GentleWaves LED photomodulation.

It was the first time Dr. Anderson had offered a financial guarantee to patients undergoing treatment. "I think I have a big enough practice and a good enough reputation that I was not going to jeopardize it with technology that I was uncertain about," he says, adding that he also offered the guarantee because treatments, while effective, are slow to show results. Typically, patients do not see much improvement until three months, after a series of eight to 10 treatments. He also had his own uncertainties to quell.

"Any time product, research and information are created by people who have motive for financial gain, you have to question it. I will say that there is some pretty good science by some pretty good people who have a financial interest in the instrument," he says.

Eyebrow position, symmetry and contour are of paramount importance in the evaluation of the eyelids and midface. The eyebrows dramatically influence overall facial appearance and convey the physical and emotional state of patients.

Surgeons have sought to improve eyebrow appearance through various means for decades. Coronal forehead lifts and, more recently, endoscopic elevations have received the bulk of the cosmetic attention. These techniques allow the surgeon to address the brow height and contour as well as weaken the medial brow depressors. However, these procedures have drawbacks in many situations. Coronal incisions may leave conspicuous scars, cause hair loss, elevate the hairline, and create significant scalp paresthesia. While endoscopic forehead and brow elevation causes less scarring, they may cause alopecia and paresthesia as well as elevate the hairline.

1) Intraoperative photo of the confluence of the orbital ligament and the anterior leaf of the deep galea. Note the attachment at the lateral orbital rim.

It is best to divide the discussion of brow ptosis into its lateral and medial components. The forces that cause descent of the lateral eyebrow include the weight of the eyelid and brow fat pad and the soft tissues of the temporal forehead above it. In addition, the confluence of the anterior leaf of the deep galea and the "orbital ligament"(formed by the superficial temporal fascia) and their attachment to the superolateral orbital rim tether the eyebrow and restrict it from full superior mobility. We believe this ligament is a check ligament preventing overaction of the frontalis muscle. The primary force that elevates the lateral eyebrow is contraction of the frontalis muscle. However, this is limited by the attenuation of the frontalis muscle lateral to the temporal fusion line of the skull. In addition, the brow fat pad's attachments to the lateral aspect of the supraorbital rim support the brow position in younger patients but weakens in older patients. The brow fat pad falls and puts more tension on the "orbital ligament" and anterior leaf of the galea.

2) Intraoperative photo of Stevens scissors opening the anterior leaf of the deep galea and releasing its tethering effect on the lateral brow. Note the underlying brow fat pad.

Dallas — The lasers that first entered the medical and cosmetic arena more than 35 years ago operate in much the same way and achieve similar effects as today's lasers, according to Lars Hode, Dr.Sci., a physicist specializing in laser medicine, and president and founder of the Swedish Medical Society, Stockholm.

"It is the same mechanism behind the stimulated hair growth and accelerated wound healing reported in 1968, and the wrinkle reduction of today's methods," Dr. Hode says. He offered his historical insight in a presentation at the American Society for Laser Medicine and Surgery, here.

Studies on cell cultures, animals and humans have shown that laser light can influence several functions in cells and tissue, a complex process known as photo biostimulation. (Graphic courtesy of Lars Hode, Dr.Sci.)

Thirty years ago, a German team that tested different laser light doses on ulcers in animals found that doses of up to 10 J/cm² prompted faster healing, while doses of 20 J/cm² had a retarding effect. At the same time, Canadians found laser beams to have similar effects as needles in acupuncture, Dr. Hode says.

Five years later, lasers were shown to have a positive effect on rheumatoid arthritis. In the meantime, HeNe lasers were used more frequently in Russia for therapeutic stomatology.

Twenty years ago, European cosmeticians called their tools "soft lasers" and used them to treat acne vulgaris and facial wrinkles and scars. The lasers they used had power as low as in the milliwatt range. The effect was named skin rejuvenation.

Today, researchers know that light from many other light sources can influence biologic systems in a similar way. Also, the light emitting diodes (LED), with their relatively narrow-spectrum, high-spectral intensity but non-coherent light, show effect on wrinkles. During the past three years, flash lamp devices with very high light fluxes also have been shown to affect wrinkles. Even radio waves can be used.

"One factor they all have in common is they can all stimulate certain cell and tissue functions," Dr. Hode points out. Originally, this was called laser biostimulation, but today is given the more proper name of photobiomodulation.

During the past 10 years, CO₂ lasers and laser peels have gained popularity for treating wrinkles and acne scars. The somewhat milder Er:YAG laser was also found to improve rhytides. But this method of skin ablation is rather painful.

During the past five years, the advent of nonablative skin rejuvenation signified the ability of lasers to improve wrinkles and scars without burning or pain. The mechanism behind this is biostimulation.

More recently, within the past year, a single treatment with a pulsed dye laser has improved acne in the inflammatory phase. The reason is not that the 585 nm wavelength kills bacteria, but that biostimulation influences the local immune defense. Acne has also been successfully treated with ruby and KTP lasers by Stockholm clinicians.

Laser praise By compiling a presentation that gave a look back at the initial lasers and compared them to today's modalities, Dr. Hode hoped to encourage attendees at the meeting of the American Society for Laser Medicine and Surgery to consider laser therapy when they might not otherwise.

Los Angeles —Topical bleaching agents can safely treat post-inflammatory hyperpigmentation in darker skin types as long as treatment is conservative and monitored closely, says Pearl E. Grimes, M.D., director of the Vitiligo and Pigmentation Institute of Southern California.

Dr. Grimes says today's "designer" bleaching agents that contain hydroquinone 4 percent as an active ingredient are the gold standard for treating hyperpigmentation, but they certainly can sometimes irritate darker skin (Fitzpatrick types IV, V and VI).

"That doesn't mean you can't use these products, because you can," she says. "You have to be cognizant of the potential for irritation and just monitor patients.

Dr. Grimes

Three topical agents Dr. Grimes provided Cosmetic Surgery Times with insight into three topical agents for the treatment of hyperpigmentation in darker skin. Each contains hydroquinone and other differing active ingredients.

Rather than recommending one agent over another, she advises clinicians to become familiar with current research for each bleach, and the risk/benefit panel for each.

"Know the benefits, the side effects," she suggests. "There is efficacy with every product. You have to have experience with each one and decide, 'This is my favorite.'"

However, some cases may require a different approach.

"For severe post-inflammatory hyperpigmentation, none of these may work. You still may end up doing extemporaneous compounding of a bleach."

Tri-Luma Although the FDA has approved Tri-Luma (Galderma) as a combination bleach to treat melasma, Dr. Grimes routinely uses it off label to treat hyperpigmentation in darker skin types. Tri-Luma contains hydroquinone 4 percent, fluocinolone acetonide 0.01 percent and tretinoin 0.05 percent.

"Tri-Luma has become the leading topical bleaching agent for hyperpigmentation," she says. "But the worst mistake a physician can make is to keep a patient on it indefinitely, because it contains a fluorinated steroid."

A patient before and after eight weeks of treatment with Tri-Luma.

"The longer a patient stays on Tri-Luma, the greater the risk of atrophy, steroid-induced rosacea or steroid-induced telangiectasia," she explains.

Tri-Luma's quick onset of action makes it a good choice for hyperpigmentation.

EpiQuin Micro Also quick to produce results is EpiQuin Micro (SkinMedica), which contains hydroquinone 4 percent and retinol 0.15 percent in a microsponge vehicle, says Dr. Grimes.

"This is significant because treatment of post-inflammatory hyperpigmentation commonly takes several months," says Dr. Grimes, adding that EpiQuin is a good first-line therapy for mild-to-moderate cases.

She and colleagues conducted a 12-week, open-label study of EpiQuin and found it to be safe and effective. Twenty-five subjects applied the bleaching cream to their entire face once in the morning and again in the evening, with sunscreen also applied 15 minutes after the morning application.

National report — The U.S. Food and Drug Administration (FDA) has approved the injectable filler, Sculptra, for correction of lipoatrophy in people with human immunodeficiency virus (HIV) infection. Manufactured by Dermik Laboratories,the U.S.-based dermatology arm of Aventis, Sculptra becomes part of a growing armamentarium of FDA-approved fillers and injectables.

The FDA says it expedited review of the injectable poly-L-lactic acid because of its importance to people with HIV/AIDS, whose physical symptoms — hollow eyes, indentations, and sunken cheeks — often have negative psychological effects, including anxiety and depression. The product, known in Europe as New-Fill, has been shown to produce significant increases in skin thickness, adding volume to facial tissue and restoring shape in areas of the face with fat loss. It is estimated that of the 900,000 to 1 million people in the United States who are HIV-positive, some 50 percent will develop lipoatrophy. An estimated 150,000 to 350,000 patients could potentially benefit from the new treatment.

"Until now, there have been no treatments approved by the FDA specifically for (lipoatrophy)," says Marcus Conant, M.D., clinical professor, University of California, San Francisco Medical Center. "Sculptra is a well-tolerated, breakthrough treatment that can be administered during an outpatient office visit and offers long-lasting results."

Currently, Sculptra is only FDA-approved for use in patients with HIV, and is not approved for wrinkle treatment. This concerns some cosmetic surgeons, who say they applaud the use of the product for HIV patients, but wonder, over the long term, about its cost and availability for cosmetic procedures.

"Once the FDA opens up the restrictions on Sculptra, I think that it will be one of the fillers on the market that will be competitive, based on cost and usefulness," says James Carraway, M.D., of Virginia Beach, Va. "With the advent of Restylane, Perlane, non-allergic collagen and Radiance, we have a good, wide variety," he adds.

David H. McDaniel, M.D., of Norfolk, Va., is less concerned about the FDA restriction. "I think we will see off-label use of Sculptra, particularly for cases where fat grafting (due to volume) might have been used," he says.

As a condition of approval, Dermik has agreed to conduct an open-label registry study of 100 patients for five years to evaluate Sculptra's long-term safety. The study will include at least 30 females and 30 people with dark skin types. Commercial availability of Sculptra is expected in the third quarter of this year, the company says.

Virginia Beach, Va. -- James Carraway, M.D., board-certified plastic surgeon in Virginia Beach, Va., tells his new patients that he has two things to offer them. One is plastic surgery. The other is anti-aging.

"I tell them: 'The first one costs you; the second is free. But if you are only going to pick one, pick the free one because it will last you longer.' I really do tell people that because I want them to understand how important what we are offering is."

Dr. Carraway, professor and chairman of plastic surgery at Eastern Virginia Medical School, Norfolk, Va., added the anti-aging aspect to his practice and his life nine years ago, after reading the book by Barry Sears, Enter the Zone. Realizing the importance of nutrition on health, Dr. Carraway searched further into the literature and expanded his journey to include anti-aging information.

"I never have advertised, and I'm booked for cosmetic cases six months in advance -- even in a small city like Virginia Beach. Every patient has been referred by another," he says. "It has changed my whole practice because I get healthy people in now, and patients always want to bring their friends to share the information about better aging and plastic surgery."

Long-term benefits Many cosmetic surgeons will cringe with the time and effort Dr. Carraway puts into the anti-aging side of his practice. But the physician insists there is no other way to approach the plastic surgery patient. The practice philosophy is not just about cosmetic surgery. It also is about how to keep patients aging better — not just so that they look better with a quick operation but how to teach them to age so that they will look and feel better 10, 15, and 20 years in the future, he says.

Patients who book consultations are sent information and educational packets. In each is an extensive questionnaire, wellness information, tips and resources.

Dr. Carraway's questionnaire is more than a medical history. The eight-page piece asks intricate details about a person's lifestyle, including: How many meals do you eat in a day? What kinds of snacks do you eat? What is your body weight now and what was it five years ago? How much exercise are you doing? It also quizzes people about their exercise ability, anxiety, appearance of aging, sexual drive, sexual function and more.

Potential patients send these in before they come in for the consultation, so that Dr. Carraway can review them and discuss, at length, where these people can adopt healthier lifestyles.

Tips for a healthy future The new patient folder features steps that patients can take for anti-aging and wellness. Dr. Carraway and his staff recommend regular medical checkups or executive physicals and suggest patients look into extensive cardiovascular testing, total body scans, growth hormone and other hormone level checkups.

The packet makes recommendations about ideal balances of carbohydrates, proteins, fats and nutrients. Patients learn about the numbers of fruits and vegetables they should eat, as well as what kinds of fats and amounts of carbohydrates they should consume.

"We also give them an appointment with our nutritional counselor. We have a Zone-trained, master's level nutritional counselor and trainer. We pay her salary so that she can be available for people," Dr. Carraway says.

There is a sheet of information on white carbohydrates, including myths and truths. In addition to learning the negative sides of eating flour and sugar, Dr. Carraway's packet features a list of foods to eat and avoid. Examples of low-glycemic carbohydrates to eat are: green vegetables, high- fiber whole-grain cereals, whole-grain breads, small potatoes with the skins on, semolina pasta, brown rice, high-protein pasta, fresh fruits, nuts, dried beans, small amounts of sweet potatoes and plain yogurt. Foods to avoid would be mashed potatoes, white bread, regular pasta, quick oatmeal, bagels, muffins, doughnuts, cakes, candies, breakfast cereals, white or polished rice, cooked carrots and bananas.

National report — Breast reduction surgery may play an important role in the primary prevention of breast cancer, according to results of a recent review of data on more than 70,000 women published in Plastic and Reconstructive Surgery (2004; 113: 2104).

Reduction mammoplasty appears to lower risk of breast cancer by 50 percent to 70 percent, according to the review, which included evidence from cohort and case-control studies conducted in the United States, Canada, Denmark and Sweden. Individually, all six studies showed a reduction in breast cancer risk in women who received the procedure.

By comparison, clinical studies suggest prophylactic bilateral mastectomy lowers breast cancer risk in high-risk women by 90 percent or more. However, this procedure is disfiguring and potentially psychologically damaging, and thus an unacceptable option for most women.

"This study pretty convincingly shows that reduction mammoplasty reduces risk of breast cancer," says Dr. Young, chair of the American Society of Plastic Surgeons (ASPS) Committee on Emerging Trends. "When you go through the literature, this reduction in risk is an obvious plus."

This news should be shared with two types of patients, according to Dr. Young.

The first group includes women at high risk of breast cancer who don't want prophylactic mastectomy. American Cancer Society statistics suggest the average woman has a one-in-eight risk of developing breast cancer in her lifetime. However, women with a strong family history of breast cancer may be at increased risk; in one study, researchers found a definable hereditary component in about 25 percent of women who developed breast cancer before age 42. A small number of women (about 0.1 percent) are carriers of BRCA1 and BRCA2, markers of predisposition to developing breast cancer early in life.

The other group is "women who want to have a reduction mammoplasty, but have the general one-in-eight risk of breast cancer," he adds. "Besides the benefit in relief from macromastia, there is a reduction in risk of breast cancer, and that's never really been promoted as an issue. It's a common procedure, and I don't think women are aware of that benefit."

Reduction prevalence Reduction mammoplasty is one of the most common breast procedures that U.S. plastic surgeons perform. In 2002, members of the ASPS performed almost 100,000 breast reduction surgeries, a remarkable increase of 150 percent over the past 10 years. Reasons for that increase may include better public awareness, increased insurance coverage and a large increase in obesity in the population, according to Dennis P. Orgill, M.D., Ph.D.

The available data should "make some patients and surgeons feel more comfortable about breast reduction surgery,"says Dr. Orgill, associate chief of plastic surgery, Brigham and Women's Hospital, Harvard Medical School, Boston.

"Often, patients ask if breast reduction surgery will raise or lower risk (of breast cancer)," says Dr. Orgill, who co-authored an editorial in the same issue of Plastic and Reconstructive Surgery. "Certainly there is a trend in these articles, though not proven, that the procedure would lower the risk."

The literature review Dr. Young and colleagues published was based on two large cohort studies from Canada and Sweden, including about 30,000 women each, and four smaller cohort or case-control studies ranging in size from 559 to 7,720 patients.

Research study The large Canadian study included about 28,000 women who had undergone bilateral breast reduction surgery between 1979 and 1992. With an average follow-up of 6.5 years, investigators observed 101 out of an expected 165.8 breast cancers. The standardized incidence ratio was 0.61 (95 percent CI, 0.50-0.74). The large Swedish study included almost 32,000 women undergoing breast reduction between 1965 and 1993; in this cohort, the standardized incidence ratio was 0.7 (95 percent CI, 0.6-0.8).

National Report — As the cosmetic revolution continues to sweep across the country, health plans are beginning to acknowledge that millions of Americans — many of whom are managed care patients — want smoother skin and sculpted waistlines. With 8.3 million women and men undergoing some form of cosmetic surgery in 2003, health plans are taking a closer look at this growing trend to better serve their members.

A small handful of health plans have ventured into this uncharted territory and are offering their members new cosmetic services that would have been unheard of five years ago. Two Blue Cross and Blue Shield plans are providing customers with discounted cosmetic services to a network of physicians, and Kaiser Permanente, making the boldest move in the industry, has opened new cosmetic centers throughout northern California that offer everything from chemical peels to facelifts for members - and non-members.

Cosmetic procedures are not the only non-traditional benefits being offered by health plans. Many insurers now routinely cover chiropractic care, and alternative medicine is quickly becoming a covered benefit. Other health plans are starting to offer discounts on LASIK surgery, gym memberships and subscriptions to health magazines.

For now, health plans are cautiously entering the prosperous field of cosmetic services - an area of medicine that has been shunned by insurers for decades. But with demand for cosmetic procedures skyrocketing, health plans are taking another look at this growing market.

"Managed care organizations are doing this to be more member friendly," comments Ms. Burgess, formerly with U.S. Healthcare. "Health plans have a vested interest in doing this because they want to direct members to qualified doctors to prevent unsatisfactory procedures."

Ms. Burgess adds that many health plans are unknowingly paying for complications resulting from cosmetic surgery. As an example, she explains what happens when a rhinoplasty is unsuccessful. "If a CPT code comes through as a nasal valve collapse, the doctor or patient will probably not say it was the result of poor cosmetic surgery. It's just going to come through as a reconstructive cost to the company. If health plans can direct people to good-quality doctors to begin with, they will minimize the cost of corrective surgeries."

Cosmetic ventures One of the earliest experiments to offer discounts on cosmetic services failed, however. UnitedHealthcare of Georgia offered discounts to members under a pilot project started in 1999. Plan administrators decided to reduce complications by developing a network of nearly 20 cosmetic surgeons who met certain quality standards. Under the program, United's members received discounted consultation visits to Burgess' company, which provides advice and guides people to a network of cosmetic surgeons and dermatologists who meet national quality standards.

While United never supported the program with an extensive marketing campaign, word still spread quickly to members. But after a few months, the program lost support when executive leadership changed hands at the company.

Undeterred by UnitedHealthcare's failed attempt, BlueCross and BlueShield of North Carolina kicked off a program in October 2001 to provide discounted cosmetic services. Eight cosmetic surgery practices participate in the network, and more than 2,200 members have called a toll-free referral line since the program's inception. The practices offer a flat 15 percent discount on surgery costs; anesthesia and facility expenses are billed at the full amount.

Another experiment with discounted cosmetic services provided by BlueCross and BlueShield of South Carolina enlists two established cosmetic surgery practices to provide discounted cosmetic procedures to its 1.4 million members. The discounts will average about 20 percent for eight common procedures.

BlueCross BlueShield of South Carolina also signed up Charleston Plastic Surgery, headed by Tracy Harvey, M.D., and Richard Hagerty, M.D. The health plan has not determined how many other practices it might add, comments Rick Gallion, director of complementary health care.

New Haven, Conn. — New fillers for facial lines, wrinkles and creases have exploded on the scene in recent months in sharp contrast to the situation in February 2003, when the U.S. Food and Drug Administration had approved only one filler — bovine collagen (Zyplast and Zyderm), provided by only one company in this country (Inamed).

New fillers, which include hyaluronic acid products previously approved in Europe and Canada, provide significant improvement of age-related facial lines and creases and offer malleable products with long-lasting results. The availability of several types of products also offers the opportunity to use several fillers in one procedure, says Jeffrey Dover, M.D., associate clinical professor of dermatology, Yale University School of Medicine, New Haven, Conn.

Successful fillers of the future will include long-term, short-term and medium-term fillers — and patients and doctors will choose which of those they would like to use alone or in some combination, Dr. Dover says. For example, long-lasting fillers such as fat, Perlane, Radiance, or Artefill may become fillers of choice for the nasolabial fold, while a shorter term filler might be used in the lips.

Recently approved products Fillers have come a long way since they have joined ranks with bovine collagen, offering particular advantages.

Human collagen (Cosmoplast, Cosmoderm) was a step up in many ways — a clean, safe alternative to bovine collagen that did not require any skin tests. Collagen, either bovine or human, rarely causes swelling, Dr. Dover says.

"Collagen is fantastic ... if the patient wants to look great that night," he says.

Immediate results are the main advantage of human collagen, despite it being more expensive than bovine collagen and not as long lasting as some newer filling agents.

Europe has seen the development of many non-collagen-based fillers.

"Probably the most exciting so far is hyaluronic acid," Dr. Dover says.

Restylane, an FDA-approved productmanufactured by Q-Med and licensed by Medicis, uses non-animal-based hyaluronic acid. The two other NASHA products are Restylane Fine Lines and Perlane, neither of which is FDA approved. The difference between the three products is the size of the particles, with Perlane having the largest particles followed by Restylane, and then Restylane Fine Lines, says Dr. Dover.

"The bigger the particle, the longer it lasts," Dr. Dover says.

Hylaform (Inamed), a hyaluronic acid product FDA approved in April 2004, is derived from cock's comb. Allergic reactions are extremely rare with any type of hyaluronic acid product, Dr. Dover says, and skin tests are not required.

The advantages for these products include no delay in receivingtreatments and they last much longer than collagen — perhaps as much as one and a half to two times as long.

"Instead of three to four months with collagen, Restylane provides approximately six months and Perlane, six to eight months," according to Dr. Dover.

Another significant advantage is that hyaluronic acid products are very malleable — they remain soft and compressible for months after treatment. Restylane and Perlane, for example, can be compressed and the product is malleable even three or four months later, Dr. Dover says. If lumps do form, they can be removed with pressure and molding.

The one disadvantage of hyaluronic acid is that because water is drawn to the molecule, it tends to cause almost immediate swelling, which can last one to three days after treatment, Dr. Dover says. It is especially noticeable in lips, less so in the nasolabial fold, he says.