William P. Coleman, III, M.D.There are five controversies rattling today’s dermatology community, causing some dermatologists to think twice about commonly used products, services and procedures, according to William P. Coleman, III, M.D., editor in chief of Dermatologic Surgery, clinical professor of dermatology and adjunct professor of surgery (plastic surgery) at Tulane University Health Sciences Center, New Orleans.
Dr. Coleman was co-moderator of a session on dermatologic controversies at the October 2015 American Society of Dermatologic Surgery (ASDS) annual meeting in Chicago. He shared the controversies and other dermatology experts weighed in with their thoughts.
#1: Filler Fact or Fiction?
“One of the most powerful controversies in cosmetic dermatologic surgery is whether non-dissolvable fillers are safe. As more fillers are used to volumize, there is concern that vascular occlusion is becoming more common,” Dr. Coleman says. “In some cases, this may lead to skin necrosis, but in rare cases causes blindness. Hyaluronidase can be used to dissolve hyaluronic acid (HA) fillers, but has much less effect on non-HA fillers. HA fillers can also be dissolved to correct unintended asymmetries or overcorrection so they are inherently safer.”
Derms speak up
Derek H. Jones, M.D.FDA-approved non-dissolvable fillers are, for the most part, safe when used on-label. But adverse events do and will occur in a minority of patients, according to Derek H. Jones, M.D., clinical associate professor of dermatology, University of California, Los Angeles, and founder and director, Skin Care and Laser Physicians of Beverly Hills.
“In areas at high-risk of problems, such as the lid cheek junction or tear trough, only HA fillers should be used as they are dissolvable,” Dr. Jones says.
Jeremy B. Green, M.D.Non-dissolvable fillers are safe and play and important role in clinical dermatology practice, according to Jeremy B. Green, M.D., a Coral Gables, Fla. Dermatologist.
“It is reassuring to have the ability to dissolve hyaluronic acid (HA) fillers, and it gives first-time filler patients a level of comfort that the product can be reversed if they are not happy with the appearance. This fear is usually rooted in the overfilled celebrity stereotype. Nonreversible volumizers, like calcium hydroxylapatite (CaHA Radiesse) and poly lactic acid (PLLA Sculptra), are an indispensable part of our aesthetic toolbox and should not be feared because they are 'irreversible,'” Dr. Green says. “I have a subset of patients, they tend to be active, fit people who seem to metabolize HA fillers quite quickly. With these folks, volumizing with CaHA or PLLA offers long-lasting natural results. Injecting with cannulas and having an intimate knowledge of facial anatomy can also mitigate the risk of intravascular injection.”
#2: Big Fat Debate
“As more non-invasive technologies are rolled out for reduction of fat, there is a sense by some that these techniques have replaced liposuction. In fact, none can achieve the results of liposuction and may actually cost more and sometimes have side effects, such as skin laxity and depressions,” Dr. Coleman says. “There is a tendency for those physicians who do not perform liposuction to ignore this and not give their patients a full range of options. Local anesthesia liposuction also gives much more rapid results with only one treatment, and patients are able to resume normal activities within 24 hours. In addition, the fat removed can be re-injected elsewhere on the body in the ultimate in medical re-cycling.”
Derms speak up
Bruce Katz, M.D.Bruce Katz, M.D., director of the Juva Skin and Laser Center in Midtown Manhattan, says he buys into the controversy in part: noninvasive options do not rival liposuction.
“They’re not as effective. They certainly do not remove as much fat as liposuction does, but they work,” Dr. Katz says. “I wouldn’t agree with the statement that they have more side effects. They may cost more, but they don’t have more side effects than liposuction. Liposuction is very safe. But they both are very safe. The newest one is Sculpsure [Cynosure], which probably has the best combination of benefits, and that is to treat four areas in only 25 minutes. That’s a major advance compared to the old technologies."
The bottom line, however, is that noninvasive options do not remove as much fat as liposuction, according to Dr. Katz.
#3: Solving Cellulite
“Dermatologic surgeons have struggled in finding effective treatments for cellulite. Perhaps no condition has had more ineffective therapies promoted for its treatment. Physicians remain skeptical of any new treatment for this condition,” Dr. Coleman says. “Recently, various energy-based devices have been proposed to treat cellulite, including a novel laser fiber for subcutaneous release of fibrous bands, which pull the skin in. Although this should theoretically give excellent results, patient responses have been variable. The newest treatment for cellulite, Cellfina [Ulthera], uses a small blade to lyse the bands. The disposable device includes a motorized housing which powers the blade. The treated tissue is fixed by suction so that a precise lysis of the bands can be performed. The results are typically very good and last for years.”
Derm speaks up
There are probably two cellulite treatments available today that have been shown to be most effective, according to Dr. Katz.
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“The first is Cellulaze, which is a laser treatment. And this treatment actually addresses the three components of cellulite. If you look at cellulite, there are changes in the skin, we call the hills and valleys. The hills are the areas where fat is pushing out or are herniated through the dermis, and the valleys are where the fibrous bands pull down and cause these depressions. And the third issue is the laxity of the dermis, in general, that allows the other two issues to occur. Cellulaze [Cynosure] works by going under the skin … and that addresses all three of those components of cellulite,” Dr. Katz says. “The newest one is called Cellfina, which is actually basically a variation on subcision…. So, Cellfina works, but it doesn’t address the other two issues—the raised areas or laxity of the dermis. It only treats the little depressions or valleys.”
Manual subcision, which requires no expensive technology, also works to treat the depressions, according to Dr. Katz.
#4: Ablative versus Nonablative
“Although dermatologists have used ablative methods for smoothing acne scars for well over one hundred years, some now say non-ablative approaches may produce similar results with less downtime and fewer side effects. Dermabrasion, deep chemical peeling, and laser resurfacing have been the go-to approaches for acne scars, removing skin to the mid to lower dermis and allowing re-epithelialization to produce smoother skin. Now a number of non-ablative technologies may produce equal results,” Dr. Coleman says. “[Among those, the] 1,540ânm erbium-doped diode fractional lasers used in a maximum dose of 100 mJ in six serial sessions have been shown to produce significant improvement in all but deep atrophic acne scars. Fractional radiofrequency microneedle devices have also been shown to produce demonstrable improvement. Recently, the 755-nm alexandrite picosecond laser has been used successfully in acne scars with the added benefit of improvement in post inflammatory hyperpigmentation.”
Derms speak up
Jennifer Chwalek, M.D.Dermatologist Jennifer Chwalek, M.D., clinical instructor at Mount Sinai Medical Center, says she agrees that nonablative technologies can produce very good results. In many cases, she says, those results may be similar to or even approach ablative technology (but requiring more treatments).
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“All of the technologies [Dr. Coleman noted] may be used successfully to treat acne scars, but when it comes to deciding the right modality for a patient, the type of scar, severity of scars and patient's lifestyle (specifically the possible downtime associated with some treatments) need to be considered,” Dr. Chwalek says.
Roy G. Geronemus, M.D.There’s room and need for all options, according to Roy G. Geronemus, M.D., director of the Laser & Skin Surgery of New York and clinical professor of dermatology, New York University Medical Center.
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“The dermatologist’s toolbox for the treatment of acne scars has grown over the past decade. Many lasers and radiofrequency devices (nonablative and ablative) can effectively improve acne scars with certain advantages provided by the various devices,” Dr. Geronemus says. “The optimal outcome for each individual patient varies based upon matching the benefits and downtime of each device with many clinical variables. These variables include the benefit of each device for certain types of acne scars, the ability to treat darker skin phototypes and the tolerance for downtime and multiple treatments, if needed.”
#5: Comparing Neurotoxins
“Although Botox was been the only neurotoxin available in the U.S. until the last few years, the introduction of Dysport and Xeomin has stirred up arguments about the variable potency of each. Although they are classified as different toxins, they appear to have more in common than not,” Dr. Coleman says. “A number of scientific studies have set out to determine whether or not they can be used clinically to achieve the same results and longevity. A recent study published in Dermatologic Surgery determined that Botox and Xeomin were quite comparable. Because of the large markets involved, we can expect that the three manufacturers will continue to debate the potency and longevity of their competitors.”1
Derms speak up
The recent publication comparing Botox and Xeomin head to head proves that in the glabella, Xeomin and Botox perform equally within bounds of statistical significance, according to Dr. Jones.
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“However, there will be patients or practitioners who favor one product over another for a variety of reasons,” Dr. Jones says.
Dr. Green says he agrees with Dr. Coleman’s take on the controversy.
“I find in clinical practice that the three toxins behave quite similarly. The most dissimilar characteristic is the name recognition that Botox continues to enjoy as the 'first kid on the block,'” Dr. Green says.
Dr. Coleman is a clinical trial investigator for Merz, Allergan and Syneron.
Dr. Jones is an Investigator, consultant and/or speaker for Allergan, Galderma and Merz.
Dr. Green is on the advisory board for Allergan, Merz, Galderma, is a researcher for Allergan, Merz, Galderma, and is on the speakers’ bureau for Allergan and Merz.
Dr. Katz did the FDA trials for Cellulaze.
Dr. Chwalek has no disclosures.
Dr. Geronemus is an investigator for Cynosure and performed the clinical trials on the PicoSure.
1. Kane MA, Gold MH, Coleman WP, et al. A Randomized, Double-Blind Trial to Investigate the Equivalence of IncobotulinumtoxinA and OnabotulinumtoxinA for Glabellar Frown Lines. Dermatol Surg. 2015;41(11):1310-9.