Once again, cosmetic procedures are on the rise.The American Society for Dermatologic Surgery reports that in 2003 cosmetic procedures were up by 11%. This month, we bring our Cosmetic Dermatology Update to provide you with a sampling of emerging procedures and research highlights.

How Does Botox Measure Up to the Topical Wrinkle Creams?
The first ever study to gauge the effectiveness of botulinum toxin type A Botox Cosmetic) against three over-the-counter wrinkle creams placed Botox as the clear winner.
Results of the study, which was conducted by Kenneth Beer, M.D., a dermatologist in private practice in West Palm Beach, FL, and an instructor at the University of Miami, were released at this month’s annual meeting of the American Society for Dermatologic Surgery.

Do the Claims Have “legs” to stand on?
Dr. Beer decided to put to the test the claims of several OTC wrinkle creams that say they’re as effective and as safe as Botox Cosmetic. To date, no comparative data exist to maintain the validity of these claims, and Dr. Beer wanted physicians to have study data to discuss with patients and consumers to help answer questions and help patients make more informed choices.
The creams Dr. Beer evaluated include HydroDerm, StriVectin-SD and Wrinkle Relax and compared their safety and effectiveness to Botox Cosmetic in a randomized, investigator-masked, 12-week parallel study of 77 women.
Patients were randomized into one of five treatment groups, Botox Cosmetic injection, placebo injection with 0.9% saline, HydroDerm, StriVectin-SD and Wrinkle Relax.

Patients received baseline evaluations and follow-up visits were conducted at 4, 8 and 12 weeks.
The patients in the Botox group received five injections of 0.1 ml each: two in each corrugator muscle and one in the procerus muscle. Patients in the groups using the topical creams were instructed how to properly use the creams, which were applied daily.
Results were measured by blinded evaluation of glabellar line severity and overall change.
At 4 weeks, more than 86% of those treated with Botox had a 50% or greater improvement in wrinkle severity per the Patient Global Assessment of Improvement Scale. Patients in the placebo or cream groups had less than 50% improvement in wrinkles.
At weeks 8 and 12 results remained the same with the Botox group experiencing the greatest improvement and no greater improvements noted in the other study groups.
Another study on Botox, the first long-term safety data available on this drug, was conducted by Drs. Alastair and Jean Carruthers. These doctors reported on data from 853 treatment sessions over time periods as long as 9 years. They found no adverse events in 99% of treatments, and no serious or severe adverse events in the remaining 1% of patients.

Inhibiting Hair Re-Growth with Eflornithine Cream
By Stacy R. Smith, M.D., and Daniel J. Piacquadio, M.D.

Unwanted facial hair is a common problem among women, and one that can have devastating psychosocial consequences.

Photo-epilation (laser or intense pulsed light) has emerged as a leading treatment modality for excess female facial hair and can be used to achieve long-term suspension of hair growth. However, multiple treatments are needed, and even then, treatment is effective in removing or fully inhibiting 50% to 90% of terminal hairs.
This approach can also be expensive and occasionally result in side effects (pigmentation, etc.). It also requires maintenance therapy, which can have challenges with compliance.
Eflornithine hydrochloride cream 13.9% (Vaniqa), an FDA-approved prescription product, is another therapeutic option for reducing unwanted facial hair in women and has been shown to reduce hair growth in more than half of the patients who use it.
An irreversible inhibitor of ornithine decarboxylase, eflornithine has been shown to lead to inhibition of cell division and synthetic functions associated with hair growth.

Comparing each modality
A randomized, double-blind, vehicle-controlled, bilateral split-face study design was performed to compare the safety and efficacy of laser therapy plus twice-daily application of eflornithine cream versus laser therapy plus vehicle cream in the management of unwanted facial hair growth in women.
The study was conducted at two investigational sites with one of two different types of lasers (1064 nm nd: YAG laser with contact cooling (Laserscope) or 755 nm alexandrite laser (Candela) with a cryogen spray cooling. Patients underwent two treatments at weeks 2 and 10.
A total of 64 female patients, Fitzpatrick skin types I to IV, with presence of bilaterally symmetric facial hirsutism (black/brown hair color) of the lip and chin were enrolled and treated for 34 weeks. Operating parameters for the laser were determined individually for each patient with the goal of using the maximum fluence that would be safely tolerated.
Here’s a look at the findings:
• Based on Physician Global Scores, statistically significant differences favoring combination with eflornithine cream were noted consistently between weeks 6 and 22.
• Patients clearly preferred combination therapy 4:1 over the laser alone throughout most of the study including the last visit at week 34. This strong preference underscores an advantage for physician administered hair removal where combination therapy can be used.
• Combination therapy offers the advantage of working on velus as well as terminal hair.
• There was no difference in outcome for the two types of lasers evaluated
in this trial. This would imply but not confirm results with other forms of photo-epilation would be similar.
• The safety data provide no evidence of an increased risk for adverse events associated with concomitant treatment with eflornithine cream and laser photo-epilation.

Drs. Smith and Piacquadio are in private practice in San Diego, CA.

Optimizing Liposuction
Liposuction is a tried-and-true procedure, explains Dr. Rhoda Narins, President-Elect of the American Society for Dermatologic Surgery. She offers the following advice for the best results:

• Certain areas of the body should undergo liposuction at the same time. If someone has not only upper and lower abdomen fat but fat on the waist, hips and around the back, it’s better to do all of those areas in the same sitting because when the skin pulls back, results are optimized.
• When a patient has a “violin deformity,” or fat on the hips, outer thighs and buttocks, it’s best to perform liposuction on all these areas at once.
• Consider performing some of the newer techniques in conjunction with liposuction. Dr. Narins performs Thermage along with liposuction of the abdomen, neck and arms. She cautions, however, that Thermage should be done before the tumescent fluid is injected because the tumescent fluid changes the impedence of the radiofrequency.

Dr. Narins authored Safe Liposuction and Fat Transfer (Marcel Dekker, 2003) and Body Contouring: The New Art of Liposculpture (Indiana Cooper Publishing Group, 2004).

The Next “Hot” Cosmetic Procedure
According to the American Society for Aesthetic Plastic Surgery, “the hand lift” will soon be one of the top most requested procedures.

The new surgical procedure called micro-lipo helps to create fuller hands to minimize the “veiny, thin” look.
The procedure usually entails transplanting fat cells from another part of the patient’s body, usually the abdomen, and immediately injecting them into the hands.
Two or three injections are usually necessary. Treatments typically begin at $2,000.
Since each patient’s results will vary, some patients may return for touch-ups after 7 to 10 years.
This procedure is often being used in conjunction with laser resurfacing of the hands to remove lentigines.

New Vein Treatment Cleared by FDA
When it comes to varicose veins, up to 55% of women and 45% of men are plagued by these often painful abnormally swollen vessels. Presently, non-surgical treatments available for varicose veins include radiofrequency, sclerotherpy and laser treatments.
Recently, another treatment for these enlarged blood vessels was approved by FDA when it gave the green light to the first mid-infrared 1320-nm laser available for treatment of the greater saphenous vein. The CoolTouch CTEV targets water as the chromophore, resulting in a shorter absorption length compared to diode lasers.

According to CoolTouch CTEV literature, “the 1320 nm coagulates the endothelium and stops at the vessel wall.” The absorption length is 300 to 500 microns in tissue.
In one study, authored by Robert Weiss, M.D., and Girish Munavelli, M.D., M.H.S., three types of saphenous vein treatments were compared: the 810 nm and 1320 wavelengths and radiofrequency.
Using the different modalities, researchers proceeded as follows:
• 36 saphenous veins were treated with the 810 nm wavelength, using manual pullback. (Pullback time averaged 3 minutes.)
• 42 saphenous veins were treated with the 1320 wavelength, utilizing a motorized pullback at a rate of 1 mm/sec. (Pullback time averaged 5.21 minutes.)
• 174 saphenous veins were treated with radiofrequency, using fast pullback with 90 degrees Celsius as a target temperature (7.14 minutes was the average time of pullback).

Treatment results were evaluated with Duplex ultrasound at 1 day, 1 month, 6 months and 1 year.
Treatment success at 1 year with the 810 nm was 86%, but the side effects with this modality were greatest.
In patients who underwent radiofrequency, the success rate was 95% at 1 year and significant pain and bruising were not noted at all.
The 1320 nm also had no noted side effects and the success rate was similar to radiofrequency.

Could a Finding in Mice Play a Role in Treating Baldness?
Deep inside the hair follicles of one of the members of the family Muridae, or mouse, researchers have discovered cells that have the ability to generate both epidermis and hair in vitro.
This discovery was reported in the September issue of the journal Cell. In the article that describes this finding, researchers report on discovering adult stem cells that are immature master cells and have the ability to change their type to a certain degree, reported Reuters.
Researchers located and isolated the cells by finding a difference in the surface of the skin stem cells — the first time stem cells have been isolated from the hair follicle this way. Next, after the stem cells multiplied in laboratory dishes, the cells were grafted onto the backs of bald mice.
The result? Tufts of hair and skin, with sebaceous glands, grew.
To date, this is the first time scientists have been able to grow both skin and hair from a single skin stem cell.
Not only does this finding have the potential for treating baldness and regenerating the skin of burn victims, but researchers were excited to discover that these cells behaved as “true stem cells” — they were able to self-renew and were multipotent — offering new hope that not all stem cells must be harvested from embryos in order for them to take on the characteristics of any type of cell.
Researchers are quite hopeful that they will be able to identify these same cells in human hair follicles. In addition, researchers also want to know if these stem cells have the ability to generate cells other than skin or hair cells.

Who Is Performing Cosmetic Procedures on Patients?
A recent survey conducted by the American Society for Dermatologic Surgery of its members reported that 41% of ASDS physicians reported a rise in the number of patients seeking treatment to reverse cosmetic damage caused by untrained non-physicians. Adverse events such as second- and third-degree burns, permanent nerve damage and scarring were among the negative results reported by ASDS members. As the popularity of procedures increases, this number will likely rise.

A Harris Interactive/Wall Street Journal Online Health Care Poll of 2,719 U.S. adults, 14% of whom reported undergoing a cosmetic procedure, gives insight into who is performing some of these procedures. See the chart below for specifics.