Fillers, botulinum toxin for the Mohs surgeon

Ken K. Lee, M.D., director of dermatologic surgery and associate professor of dermatology, surgery and otolaryngology at the Oregon Health and Science University, Portland, Ore., offers his insight and basic tips and "tricks of the trade" at the American College of Mohs Micrographic Surgery and Cutaneous Oncology Meeting, here.

Low start-up costs

He claims that botulinum toxin A is a great way to get started in cosmetic treatments and is ideal in complimenting fillers. Uses for Botox (Allergan) include treatment of crow's feet and the glabella, forehead and bunny lines as well as the perioral regions. He cautions, though, that if more than one area is to be treated, the amount of Botox injected to a given area should be reduced to avoid an overtreated appearance.

Dr. Lee stresses that before starting fillers, it is important to know what each individual filler is good for, its duration and touch-up cycle, where and how deep to inject and pain level, as well as the complications.

Fillers such as collagen and Radiesse (Bioform) are good for structure and support, with collagen lasting for three months and conferring less pain, and Radiesse lasting for one to one-and-a half years, with more pain to the patient. Hyaluronic acid and Sculptra (poly-L-lactic acid, Dermik) fillers, on the other hand, are ideal for volume, with hyaluronic acid having a lasting effect for six months and Sculptra lasting for up to two years. To circumvent the issue of pain, Dr. Lee routinely uses nerve blocks and local infiltration with all his fillers.

Good to start

"When considering fillers, collagen-based fillers and hyaluronic acid fillers are a good way to get started," he tells Dermatology Times. "I generally use these two fillers for the lips. They are relatively well-tolerated with a low complication rate. The advantage is that they are relatively short-lived and so are the complications. The downside is that it does not last very long for the patient. In the end-equation though, both doctor and patient can benefit," Dr. Lee explains.

Even so, Dr. Lee says he likes using Radiesse (in the deep dermis and subcutaneous fat) because it is firm and provides a lot of support, acting as a scaffolding, pushing up wrinkles and atrophic areas. He recommends two sessions two months apart for nasolabial folds and marionette lines. This way, the effect will last one to one-and-a-half years and overcorrection can also be avoided.

When using Sculptra, it is paramount to inject into the deep dermis or subcutaneously and not superficially. The two basic treatment techniques the surgeon employs are tunneling - used in the cheeks and nasolabial folds - and Depot, used in the upper zygoma and temples.

"When I use Sculptra, I generally inject into the subcutaneous fat," Dr. Lee says. "In the periorbital region, I inject on the periosteum. In my experience, there is a higher risk of complications when you inject into the dermis. You shouldn't try to thread an individual wrinkle with Sculptra. Instead, you are wanting to expand the wrinkle with volume. Once you use Sculptra, you discover how much of the aging face is due to volume loss. It's like re-inflating a balloon. The drooping skin is lifted by volume expansion."