Although it’s in its early stages of development, a new technique using “guided” ultrasound shows much promise as a future noninvasive skin-tightening approach.

“Ultrasound technology used for skin tightening is still in its fledgling stages and there is still significant room for improvement and development of the technology for this indication. However, there are intrinsic elements of ultrasound technology that render it particularly appropriate for skin tightening, and therefore, this treatment modality could eventually pan out to be very effective here,” says Murad Alam, M.D., associate professor of dermatology, otolaryngology and surgery and chief of cutaneous and aesthetic surgery, Feinberg School of Medicine, Northwestern University, Chicago.

Ultrasound can be delivered arbitrarily deep into the skin and subcutaneous tissue and can reach target areas without causing any significant injury to the surface of the skin, unlike other forms of energy used in dermatology. These include lasers, particularly infrared devices ranging from 1,100 nm to 1,800 nm, as well as mono-, bi- and unipolar RF devices.

With further evolution and development of ultrasound technology, “guided” ultrasound treatments could better differentiate and more precisely target specific structures in the dermis and subcutaneous tissue, resulting in more consistent treatments with more predictable cosmetic outcomes.

U/S study

The Ulthera System (Ulthera) is a noninvasive ultrasound device designed for full-face and neck skin-tightening treatments and is currently the only device of its kind approved by the FDA for a lift indication.

The study assessment included 35 patients who received a single Ulthera treatment to the forehead, temples, cheeks, submental region and side of the neck using varying ultrasound probes at different depths.

Results showed that 30 of 35 patients (86 percent) demonstrated a clinically significant brow lift three months after treatment. Compared to baseline, 83 percent of patients could achieve an average brow height elevation ranging from 1.7 mm to 1.9 mm lasting three month post-treatment.

Adverse events following the treatment were minimal and included slight erythema and edema which resolved in 78 percent of patients by day-two follow-up visit and in all patients by day-seven post-treatment.

Skin tightening is believed to be associated with contraction of the fibrous septae that engulf the fat cells in the deep subcutaneous tissue. When performing a facelift, the SMAS, which lies below the level of the fibrous septae and the subcutaneous tissue, is plicated, resulting in a lifting effect of the sagging facial skin. Thermal energy in the form of ultrasound delivered to the SMAS could potentially also effect a contraction of these tissues.

Developments that this technology would need to undergo include the development of various probes of different depths and sizes and varying energies. These more sophisticated probes would allow physicians to apply ultrasound energy at different levels in the skin and subcutis and achieve more reliable and consistent cosmetic results.

According AACS, based here, more than 17 million cosmetic surgery procedures were performed in the United States in 2009, more than has ever been reported before — and especially significant considering the economic downturn.

The rise in cosmetic surgeries is primarily due to the baby boomer generation’s desire to preserve their youth and to elective cosmetic surgery financing being more available than ever, according to the academy.

The survey notes that the invasive procedures that have increased in number the most over the past five years are blepharoplasty, abdominoplasty and rhinoplasty. Among less-invasive procedures, laser resurfacing, chemical peels and filler procedures have increased the most.

For AACS members, rhinoplasty surgeries jumped from 12,460 in 2008 to 21,730 in 2009, a 74 percent increase. Facelifts were also up this year, from 20,478 in 2008 to 34,455 in 2009, a 44 percent spike.

The Food and Drug Administration (FDA) on Jan. 29 approved Restylane-L for implantation into the mid- to deep dermis and Perlane-L for implantation into the deep dermis to superficial subcutis. Both fillers are intended for the correction of moderate to severe facial wrinkles, such as nasolabial folds.

GlobeNewswire quotes Medicis Chairman and CEO Jonah Shacknai as saying, “We are pleased to be shipping Restylane-L and Perlane-L just two weeks after announcing FDA approval. Restylane is the first and only hyaluronic acid dermal filler approved to last up to 18 months with one repeat treatment.

The 23-center study involved 1,008 patients with no recent history of nasolabial fold correction. Patients received an initial treatment with Artefill, and up to two touch-ups after 30 and 60 days, until full correction was achieved.

Potential adverse events (AE) and satisfaction data are reported by all patients at two, six, 12, 18, 24, 36, 48 and 60 months to assess any adverse events, patient satisfaction and changes in health. Potential subject-reported AEs were followed up, and changes thought to be granulomas were biopsied and confirmed or ruled out by histology. All study patients will complete a final in-office visit at 60 months.

Poly-L-lactic acid is marketed as Sculptra in the US and New Fill in the UK.

Physicians and researchers participating in the study randomly assigned 233 healthy patients (mostly Caucasian women) with nasolabial fold wrinkles to injection with human collagen or PLLA.

The researchers found that patients treated with PLLA had significant wrinkle correction as assessed by the Wrinkle Assessment Scale. The improvements with PLLA were significantly better than with collagen from three to 13 months after the last treatment, and the benefits of PLLA were still observed 25 months after the last treatment.

Facelifts rose 44 percent from 2008 to 2009 in procedures by AACS members, totaling
34,455 in ’09. Blepharoplasty procedures went up 42 percent, from 42,602 to 60,507.
Similarly, non-invasive anti-aging procedures such as Botox (up 157 percent) and fillers
(up 245 percent) rose exponentially.

In procedures performed by AACS members, the average age of facelift patients is 54.1
years. The average age for blepharoplasty is 52.3 years. In addition, the average age of
patients receiving Botox is 46.6 and fillers is 46.8.

The FDA has approved Asclera for the treatment of spider veins (tiny varicose veins less than 1 millimeter in diameter) and reticular veins (those that are 1 to 3 millimeters in diameter). Asclera works by damaging the cell lining of blood vessels which closes the vessel.

Common adverse reactions to Asclera include leakage and collection of blood from damaged blood vessels at the injection site (hematoma), bruising, irritation, discoloration, and pain at the injection site.

Sclerotherapy, laser and intense-pulsed-light therapy, radiofrequency (RF) or laser ablation, and ambulatory phlebectomy are the modern techniques used to ablate varicosities.

Use of Asclera joins hypertonic saline, hypertonic glucose, sodium morrhuate, and sodium tetradecyl sulfate as an option for sclerotherapy of spider veins.

Ensuring the patient is properly educated about the procedure and its possible outcomes are also essential in preventing dissatisfaction, but this seems to be a weak area for some cosmetic surgeons.  Information must be presented in terms the patient understands and be reinforced with additional resources (for example, online information or written literature), keeping in mind that patients will retain only a small percentage of the verbal information they receive in the office.

Patients who have decided on surgery are also given the consent form in advance, not on the day of the procedure, so they have time to read it and develop questions.

These are just some of the items that can performed during the consultation to help facilitate better understand between the patient and the surgeon.

As of January 1, 2010, the much publicized “Donda West Law” is in effect in California.

The law, named after rap artist Kanye West’s mother, who died a day after cosmetic surgery in 2007, prohibits doctors from performing elective cosmetic surgery without a physical examination and clearance from a medical professional.

The law requires an “appropriate” physical exam within 30 days before a procedure and “written clearance” from a doctor, nurse practitioner or physician’s assistant before cosmetic surgery is performed.

The law will change little, since reputable cosmetic surgeons have always obtained a patient’s medical history and made sure the patient has had a physical exam before a procedure, says Terry Zimmerman, M.D., F.A.C.S., head of the Greater Sacramento Plastic Surgical Society.

According to UPI, autopsy results showed Donda West died of pre-existing coronary artery disease and “multiple post-operative factors” a day after she had undergone an abdominal tuck, breast surgery and liposuction. The surgeon who operated on West surrendered his medical license in April.

The study, conducted by researchers at the New York University School of Medicine, suggests that polyacrylamide hydrogel was as effective as HA at six months on the widely validated Wrinkle Assessment Scale (WAS), the study’s primary endpoint. Efficacy was maintained at the 12-month follow-up evaluation.

Medical News Today quotes Rhoda Narins, M.D., clinical professor of dermatology at NYU School of Medicine, as saying, “Our results demonstrate that polyacrylamide hydrogel shows strong potential as a permanent soft tissue filler,” adding that because polyacrylamide hydrogel is non-biodegradable and does not migrate, it is expected that efficacy will continue over a longer period than with HA. Dr. Narins and colleagues compared the efficacy and safety of polyacrylamide hydrogel to HA in 315 men and women who presented for bilateral soft tissue augmentation of the nasal labial folds and had a WAS of 3 or 4. The primary efficacy measure was the mean change in WAS scores at six months. The study found that the average WAS improvement at six months in the polyacrylamide hydrogel group was 1.8 points, as compared with 2.0 in the HA group.

Study results also suggest a benefit for polyacrylamide hydrogel beyond its favorable safety and efficacy: Because the filler is non-biodegradable and not resorbed, the patient does not require periodic re-injections. The study’s authors emphasize that while the study results are promising for use of polyacrylamide hydrogel, longer follow-up is needed to establish whether favorable one-year results hold up over a longer period of time.