The Lipo-laser: does it work?

We are now starting to see ads in Orlando for a new fat-melting treatment, a laser beam that melts fat after shining the beam on the the skin. Known as the "lipo-laser", or more properly, the Zerona, the manufacturer claims that its use can result in the loss of inches of fat - without surgery, injections or other invasive procedures.

The laser used in this machine, is a 635 nm wavelength diode - the very same laser that is commonly used in many hand-held battery-powered laser pointers. According to the manufacturer's website, the laser power is listed variably in different parts of the webpage, between 7.5 milliwatts and 14 milliwatts, which again is only slightly more than the typical 5 milliwatt laser pointer. (By way of comparison, most lasers used for ablative skin resurfacing treatments are in the neighborhood of 30 watts or more, or four-thousand times more powerful.) Thus, this new machine falls into the category of "low-level laser therapy".

The FDA has approved this device - in the same category as an infra-red heating lamp - according to the FDA's own 510(k) document posted on the laser manufacturer's website. N.B: it's not currently approved as a fat melter.

Neira and associates have been enthusiastically promoting the use of low level lasers to help with liposuction for several years. They claim that use of this type of laser leads to a deflation effect on the individual fat cells, resulting in the contouring effect.

This claim is certainly controversial. A study published in the Plastic and Reconstructive Surgery Journal, performed by the well-respected Plastic Surgery & laser group of Brown, Rohrich, Kenkel, Young and associates at UTSW, carefully duplicated the Neira protocol for laser fat treatment. However, they found no appreciable difference with this laser treatment, comparing the fat before and after treatment under a scanning electron microscope. Zip. Zilch. Nada. There was no effect whatsoever on the fat in the treated area, and certainly no evidence of any fat-cell deflation.

I have no personal experience with the new Zerona machine, and while I would love to have a non-invasive method to treat fat, the physics of the device make it hard to believe that the beam could possibly penetrate through the skin down to the underlying fat with enough energy to do anything.

I'll need to see better evidence from independent researchers before I can accept and recommend this treatment. To me, it seems like waving a laser pointer over the skin, and somehow expecting the fat to magically disappear. Caveat emptor.

Sunscreens: look for UV-A and UV-B protection

With the onset of ridiculously hot weather here in Orlando, it's time to talk about sunscreens. Of all the things you can do to continue having great looking skin over time, using a daily sunscreen is probably the #1 most important thing to do.

It turns out that choosing the best sunscreen is a little complicated.

While it is common knowledge that it is the ultraviolet portion of sunlight that causes sunburns, skin cancers and sun damage, most people may not realize that their sunscreen might not be blocking all the forms of ultraviolet light effectively, even if it has a high SPF number.

Let me explain. Ultraviolet light is divided into 3 main categories:
- ultraviolet A (320-400nm), which is mostly responsible for photo-aging and sun tans, but is also linked to skin cancer (UV-A)
- ultraviolet B (280-320nm), which is mostly responsible for sunburns and skin cancers (UV-B)
- ultraviolet C (<280nm), which we don't worry about too much, as it is blocked by the ozone layer

In the past, sunscreens here in the U.S. were designed to focus on protecting you from UV-B. The classic "SPF" numbers, for example, are based on how well the sunscreen blocks UV-B - but not UV-A. This helped with preventing sunburns and reducing the risk of skin cancer....but it fell short on protecting you from photo-aging, with fine wrinkles, loss of skin elasticity, and pigmentation irregularities.

We've now understand that the ideal sunscreen should give total UV protection - with both UV-A and UV-B coverage. This has been shown in clinical studies to make a huge difference in protecting the skin. The American Academy of Dermatology now recommends that the amount of protection from UV-A and UV-B be equally weighted.

How do we protect against UV-A? Well, you can either use agents which block the rays, or agents that absorb the rays. The three most commonly used ingredients for UV-A protection are:
- Titanium Oxide or Zinc Oxide (physical blocking agents)
- Parsol 1789, also known as "avobenzone"
- Mexoryl SX and XL
The latter two are chemicals that filter the UV light. Look for these in your sunscreen's ingredient list. If you don't see any of these ingredients listed, then you probably are using an older formulation, and need to get a more up-to-date product with better protection.

Mexoryl seems to be an improvement over Parsol 1789, with more efficient UV-A coverage and better photostability. Mexoryl has been available in Canada and in Europe since the early 1990's - but only was FDA approved here in the U.S. in 2006. It's available in several products, such as the Anthelios line from La Roche-Posay or the Ombrelle line from L'Oreal. These are excellent, if somewhat pricey, products. They are widely available online.

Famous sun tanning myths:

"It's a cloudy day - I don't need sunscreen."

"The SPF in my makeup/moisturizer will protect me from sun damage."

"Once I apply sunscreen, I'm good for hours."

"I can't get skin cancer/photo-damage if I just use a tanning bed."

"I need to get a good base tan before I go on vacation, so I don't burn."


Now, there are many good self-tanning products - so you can fake the sun-kissed look, without exposing yourself to the aging effects of tanning.

On-line photo morphing for plastic surgery - is it any good?

There are a few websites that claim to simulate the effects of plastic surgery on a photo that you can upload to the site. Others have adjustable 3-D renderings of models, where you can adjust their appearance by moving slider-type controls, to more closely mimic your own appearance.

I've looked at a couple of these, and yes, they are fun to play with. You can check them for yourself: lookingyourbest.com, reshapr.com, and liftmagic.com

Unfortunately, they are quite limited with what they can do, and how realistically it corresponds to what surgeons can achieve in the operating room. I found the programs worked acceptably well when modelling the effect of wrinkle smoothing ("airbrushing") lines and wrinkles. But I thought they fell short when modelling the much more complicated effects of rhinoplasty, blepharoplasty or facelift surgery. For example, the rhinoplasty simulator shows only a generic narrowing of the width of the nose on the front view, or reduction of a hump on the nose on the side view. There's no way to simulate nasal tip surgery.

The breast augmentation program at lookinyourbest.com claims to show the effect of certain size and shapes of breast implants. While this site does give potential patients some education about the difference between high profile and moderate profile implants, I felt that the results pictured did not look like what the real result would be with an implant of the stated size or shape.

So, use these websites for fun - but they are not very representative of what your post-operative appearance will look like at all.

Obesity and Pancreatic Cancer

Pancreatic cancer is the fourth leading cause of cancer-related death for both men and women in the U.S. An interesting new study, published this week in the Journal of the American Medical Association has found that, not only is obesity linked to the risk of developing this fatal disease, but that obesity in early adulthood in particular makes you significantly more likely to develop the disease, compared to gaining weight later in life.

The researchers from M.D. Anderson Cancer Center found that obese youths between the age of 14 and 19 years old had a 60 percent higher chance of developing pancreatic cancer than their less overweight peers.

Obese individuals between the age of 20 and 40 were two to three times more likely to develop pancreatic cancer. Interestingly, the risk levelled off for those who gained the weight in their 40s and 50s.

The study also found that obese or overweight individuals were more likely to develop pancreatic cancer earlier on their lives.

Since the medical and surgical treatments for cancer of the pancreas are so very limited, this data adds yet another argument to the need to combat the obesity epidemic here in the United States. Go to the gym and do your bit for cancer prevention!

Dysport - now here

Dysport - the recently approved competitor to Botox Cosmetic - is now being shipped to U.S. physicians. We have both products in our office now, and are testing Dysport, seeing how it compares to Botox, the market leader. So far, there are some subtle differences, but both seem to work well in relaxing dynamic wrinkles of the face.

It will take a little education for patients to get used to the fact that the drug doses are measured differently. Botox units are not the same as Dysport units, even though they sound similar. It's a bit like measuring someone's height in feet, compared to measuring it in yards. Same height, just different numbers. Dysport comes in a 300 unit bottle, Botox comes in a 100 unit bottle - but the clinical effect is approximately the same, as far as we can see, with a 3:1 ratio.

Dysport is priced so that it is a little less expensive than Botox (at the 3:1 conversion ratio), so patients who wish to save a little money while they are fighting their wrinkles may want to give Dysport a try.

When Bad Lips Happen to Good People

One of the hallmarks of unfortunate plastic surgery in many celebrity photos is the overdone lip augmentation. The lips in these photos generally appear overstuffed, like two tubes, or two sausages lying side by side.

The real reason that these results are bad is that the idea of creating a beautiful normal lip has gone out the window! Real lips have many subtle features in their shapes - and beautiful lips maintain these features. Unskilled practitioners just "pump in" fillers without regard for the details of the anatomy. Skilled practitioners shape and enhance the underlying forms.

For example, the upper lip and lower lip are not the same size. Usually, the lower lip is about twice the height of the upper lip. It's important to maintain this 2:1 ratio when enhancing lips. If the lips are made to be the same size, this will make the upper lip appear excessively large, which is not desirable.

Secondly, lips have subsections or segments to them. The upper lip has three segments, the lower lip has two. It's important to recognize these segments and maintain their individual shapes when performing lip enhancement with fillers. For example, since the lower lip should have two symmetric halves, with a slight depression in between - the plan for the filler treatment should be designed this way too.

The central portion of the upper lip and the adjoining skin is particularly unique, with features known as "cupid's bow" and the "philtral columns". A well done lip augmentation preserves and enhances these normal contours, rather than obliterating them through excessive filling. Plastic surgeons have a unique understanding of the anatomy of the lip, as the surgical repairs for children with congenital cleft lip problems also require the restoration of these same anatomic features with careful attention to subtle anatomic details.

In addition to enhancing the outline of the lips, adding volume to the lips is also helpful to restore a loss of lip fullness that happens with aging, or to enhance the look of lips that were naturally thin. Once again, respect for the segmental lip anatomy is key to getting a good result. So is restraint.

Excessively sized "pillow lips" will not look attractive, no matter how you do them. Sometimes patients get carried away with their desires for lip fullness... and the results may look peculiar. In these cases, a responsible physician will have to tell the patient, "No - that won't look good."

The bottom line:
1. Careful communication about the desired result with your practitioner is essential.
2. Start small / be conservative at first, using a more subtle approach.
3. Avoid long-lasting or permanent fillers, such as silicone, radiesse or artefill, in the lip. If there is an unsatisfactory result, you could be stuck with it. The options for correcting lumpy looking permanent fillers are very limited.
4. Look at lots of before and after photos when evaluating the previous results of your practitioner. Your injection specialist should have a light touch and an artistic eye. If you see some of the problems we've discussed here, go elesewhere!

Happy Father's Day!

Counterfeit Botox

As we've discussed earlier, Botox injections are the most popular cosmetic procedure overall in the U.S. But Botox is expensive - and Allergan, the manufacturer, has been steadily raising their prices each year.

This has created a black market for Botox, with counterfeit and imitation Botox knock-offs. These imitations are not FDA-approved, and vary widely in their potency, quality, and source. But they certainly are cheap....

Many of these imitators originate in China. Brand names such as BTX-A, Botutox, Estetox-A, Refinex, Novotox, Canitox, QuickStar and Linurase are commonly seen knock-offs.

A recent review of these products showed their potency varied widely: from zero potency (no effect at all) to 5 x the indicated potency (way too much).

Counterfeit Dysport is also beginning to show up as well.

Allergan has put holographic stickers on the bottle, in an effort to deter counterfeiting.

If the Botox price quoted appears unusually low, watch out for:
- over-dilution (watered-down) with fewer units of Botox per syringe,
- use of grey-market / black market Botox imitators

If the price seems "too good to be true", ask to see the official Botox hologram.

Can Botox be purchased from Canada? According to U.S. Federal regulations, physicians or corporations can not legally import large quantities of Botox (or any other medication) from anywhere, even if the Botox product was legitimately made by Allergan. Cross-border drug importation is a BIG DEAL to the FDA, who frowns on this practice. Despite this, there are some people that take the legal risk of Federal-level drug importation & trafficking prosecution, in order to save a few dollars of expense.

Caveat emptor.

FDA approves "12 month" indication for Evolence

This week, the FDA approved a labelling change for the collagen-based filler Evolence, permitting what is known as a "12 month indication". In simple terms, this means the FDA was satisfied that the product has a significant effect on correcting moderate to deep facial wrinkles or nasolabial folds for 12 months. The original label indication was for six-month duration.

Evolence is the first collagen-based filler to get this "12 month indication", and you can bet that it will be featured extensively in future marketing.

What is not yet clear to me, however, is whether Evolence really performs significantly better than some of the other available filler agents (which currently have the older "6 month" label from the FDA) at 12 months after injection. There is data, for example, that Restylane also has significantly lasting effects well beyond their 6 month label.

I expect Allergan and Medicis (makers of Juvederm and Restylane respectively) will be submitting their data to the FDA, hoping for a similar 12-month approval, if only for competitive marketing purposes.

Mederma - does it work?

Mederma is a non-prescription cream, which has been used for years to help improve scar healing. Its main active ingredient is an onion extract - derived from a particular type of onion - called allium cepa, which is rich in the bioflavinoid compund known as quercetin.

Recently, I reviewed the published studies on this product: and the results, quite honestly, are mixed. Some studies show little or no benefit on scar healing, while others report positive results. Here's a few summaries for you to look at.

Doesn't work:

1. Chung and associates, from the famed Beth Israel hospital in Boston, did a propsective double-blinded study, comparing the effects of the onion extract versus petrolatum gel (vaseline) on fresh surgical incisions. Each product was applied three times daily for 8 weeks. Results were rated at 2, 8, 12 weeks by non-biased evaluators for cosmetic appearance, redness and thickness. Result: no significant difference.

2. Jackson and Shelton, from MD Anderson Cancer Center in Houston, looked at surgical scars resulting from skin cancer removal with the Moh's technique. Again, an ointment was applied three times daily for one month, and the results were compared. They found no benefit in the pre-treatment versus post-treatment levels of scar redness or itchiness with the onion extract, and actually found that the petrolatum group had less redness.

3. In an animal model, wound-healing guru and plastic surgeon Tom Mustoe and associates looked at the effect of Mederma on hypertrophic scarring. They found no significant reduction in scar redness, scar elevation or scar volume. They did see some changes in collagen organization when the scar tissue was examined under the microscope.


Does work:

1. A study by Draelos examined the effect of Mederma on the appearance of surgical scars from the removal of skin lesions using the superficial shave technique, versus no additional treatment. She found that the Mederma treatment was statistically better than no treatment, improving scar softness, redness, texture and overall appearance.

2. Another study compared the effectiveness of onion extract versus silicone sheeting or silicone sheeting together with onion extract on hypertrophic and keloid scars. After 6 months of treatment, they found the combination treatment worked the best. The onion extract by itself seemed to improve scar color, but did not change scar height or itching of the scar.


Bottom line:

Using Mederma is certainly better than doing nothing for your scar. It's inexpensive, widely available, and well tolerated. It encourages people to do scar massage - which is also helpful to help scars become softer and more pliable.

However, I think there are other more scientifically-convincing products available for scar therapy. I usually recommend one of the many forms of topical silicone products for my patients, in addition to scar massage, sun avoidance, and if needed, IPL or kenalog treatments.

Ripples and breast augmentation

One of the frustrating problems that can sometimes occur after breast implant surgery is known as "rippling" - an irregular wavy look or feel to the breast. This is caused by a combination of factors, related to the physical properties of the implant, the patient's own soft tissue and how it may have changed over time, and the choice of implant pocket design ("over vs. under").

Plastic surgeons generally divide these problems into 2 main categories, based on why they've happened.
1. Shell rippling
2. Traction rippling

Shell rippling is the most common problem of this kind I see, and is the topic for today. (I'll discuss traction ripples in a later blog.) The classic scenario is with a subglandular ("over") saline-filled implant in a slender woman who doesn't have very much tissue coverage over the implant. Typically, the breasts looked OK for a period of time, and then, ripples started to show up later.

The usual way to improve this situation is to operate, and get more tissue coverage over the implant, by converting it to a sub-pectoral position. This move significantly improves ripples in the upper portion of the breast - which is the area most exposed by low neckline fashions. The other solution is to change the saline implant to a silicone gel implant, which has been shown in studies to have a ripple rate of approximately 1%, as opposed to the ripple rate of saline implants, at about 10%. I usually prefer to use both methods - getting muscle coverage over a gel implant. It works well to fix this problem.

Shell ripples occur for several reasons: they have to do with the tendency of the elastomeric implant shell to want to fold in on itself, the amount of fill in the implant, the viscosity of the fill material in the implant, and the pressure applied by the surrounding soft tissue. They are disguised by the amount of soft tissue thickness over the implant. Often, with the passage of time, there is thinning out of the breast tissue adjacent to the implant, and implants that were adequately covered early post-op may become more obviously rippled over time.

Saline implants, having the lowest viscosity filler, will ripple the most. Currently available silicone gel implants, having a moderate viscosity filler, ripple a lot less. The "form stable" gummy bear implants, with their high viscosity silicone filler, should ripple even less than the current generation of gel implants. Early data from Europe seems to support this concept.

Women interested in saline implants often ask about the concept of "over-filling", which is just adding more saline solution in the implant bag, beyond the manufacturer's recommended range. There are pro's and con's to this approach. Certainly, more fluid will reduce some of the emptiness and collapse of the implant shell seen when the saline implant is in the vertical position. It also makes the implant larger, rounder, less natural looking, and a little more firm. It also potentially voids the manufacturer's warranty. If you over-do the over-filling, you start to see a new type of wrinkling - tension bands around the equator of the implant. So overfilling is only partially helpful- and as we've discussed, it only addresses one of the multiple factors that are involved with ripple formation.

The soft tissue pocket is also important. If there is a significant amount of capsular contracture, the soft tissue envelope may actually distort the shape of the implant, and cause it to fold on itself. This can cause a knuckle-like point to occur in the implant, which patients may be able to feel through the skin. Implant folds can lead to early implant failure. So, when you are fixing ripple issues, any capsule issues will need to be addressed surgically as well.

Take home message: ripples are related to the combination of thin soft tissue coverage, combined with the engineering limitations of the current generation of breast implant devices. If you are slender up top, and can feel or see your ribs on the side of your rib cage, you should give some thought to sub-pectoral implant placement of a gel implant, if you want to do everything currently possible to minimize your risk of ripple issues post-op.

For some ultra-skinny women, even sub-pectoral gel implants will have some ripples. While weight gain would help, very few women want to hear that they should gain a few pounds! Here, our treatment options are limited - placement of a layer of alloderm or strattice (very expensive), fat grafting to the breast (technically difficult), or perhaps injections of commercially available fillers. It remains to be seen whether the new generation of form-stable breast implants will be a good answer or not for this group of patients.

When Lawn Mowers Attack

I was astounded to learn that each year, 16,000 children are seriously injured by lawn mowers here in the U.S. each year.

Since June is National Safety Month, the American Society of Plastic Surgeons (ASPS) is doing its part to remind people about this commonplace hazard.

Of course, lawn mowers don’t "attack" on their own. Most injuries - such as severed fingers and toes, limb amputations, broken bones, burns and eye injuries - can be prevented by following a few simple safety tips, as suggested by the ASPS:

- Children should be 12-years-old before they operate any type of lawn mower, and 16-years-old for a ride-on mower.

- Children should never be passengers on ride-on mowers, even though it may look cute.

- Pick up stones, toys and debris from the lawn to prevent injuries from flying objects.

Don't let your young child become one of the 16,000.

Are you the typical Botox & Filler patient?

Here's an interesting press release from ASAPS (American Society for Aesthetic Plastic Surgery), discussing a new survey in which Botox Cosmetic and fillers like Restylane and Juvederm were now "mainstream" topics of discussion amongst patients, and not any big "secret". This matches with our experience - our female patients openly discuss their treatments, much like they were sharing make-up tips! What I find interesting in this survey is that 7 of 10 Botox users also have HA fillers done.


Survey Shows Majority of Respondents Openly Discuss Use of BOTOX® Cosmetic and Hyaluronic Acid Dermal Fillers

NEW YORK, NY (June 1, 2009) — Despite what some may think, people aren’t hiding their use of BOTOX® Cosmetic and hyaluronic acid dermal fillers. In fact, according to survey statistics released today by The Aesthetic Surgery Education & Research Foundation (ASERF), the research arm of the American Society for Aesthetic Plastic Surgery (ASAPS), nearly nine out of 10 respondents (87 percent) openly discuss their BOTOX® Cosmetic and hyaluronic acid dermal filler treatments with others, with seven out of ten (70 percent) receiving support from the people they told.

“In a similar survey issued four years ago, we dispelled the myth that Hollywood and corporate wives were the typical BOTOX® Cosmetic patient,” says ASERF President Laurie Casas, MD, a plastic surgeon practicing in suburban Chicago. “Now, demographic and perception data trends show us that aesthetic injectable treatments have continued to evolve into mainstream and accepted options for the everyday woman.”

Survey results found that the typical aesthetic injectable patient is a married, working mother between 41-55 years of age with a household income of under $100,000. The survey also found that women receiving aesthetic injectable treatments are health-conscious and philanthropy minded, with the majority incorporating exercise (95 percent) and healthy eating habits (78 percent) into their lives, and many volunteering with charitable organizations that matter to them (32 percent). In addition, nearly seven out of 10 respondents believe that BOTOX® Cosmetic (72 percent) and hyaluronic acid dermal fillers (65 percent) are important parts of their aesthetic routine.

“Interestingly, among BOTOX® Cosmetic patients, nearly seven out of 10 respondents also received treatment with hyaluronic acid fillers with the majority of respondents being treated with JUVÉDERM®,” says Dr. Casas. “Most people have great success with BOTOX® Cosmetic and dermal fillers; however, we need to make patients aware that even though injectables are not ‘surgery,’ their administration is a medical procedure with risks that depend on the training and experience of the clinician, the clinical setting and the technique used.”

Additional findings of the survey found that 72 percent of respondents received BOTOX® Cosmetic injections to treat their glabellar lines – the frown lines in between the brows, while 63 percent of those surveyed received hyaluronic acid dermal filler injections to treat their nasolabial folds – also known as the “parentheses” – the lines around the nose and mouth. A few of the most frequently cited reasons to receive treatment with BOTOX® Cosmetic was “to look more relaxed, less stressed” while patients reported choosing treatment with hyaluronic acid dermal fillers to “look more rejuvenated.”