Christopher B. Zachary FRCP

Photoaging, Vascular Lesions, and Pigmentation

CBZ — Tue, 20 Jul 2010 19:11:02 +0000

The Cornerstone of Any Cosmetic Laser Practice

July 2010 Supplement

By Christopher Zachary, MBBS, FRCP

Lasers have without question revolutionized the practice of dermatology, permitting clinicians to treat conditions for which no medical therapies exist or offering results that exceed those of conventional therapeutics. From medical conditions like acne and rosacea to cosmetic rejuvenation, laser systems can address a variety of the most common presentations that bring patients to the dermatologist’s office.

Given their remarkable utility, well-designed and manufactured lasers can be a tremendous asset to dermatologists. Yet, often physicians are overwhelmed by the prospect of incorporating laser procedures into practice. Technology is costly, and there may be a tremendous sense of pressure to attract patients and, as important, provide treatment that meets their goals. There may also be a learning curve, as residency programs currently offer little training in aesthetic dermatology, and such training was virtually non-existent even 10 years ago.

Clinicians seeking to initiate or expand a laser dermatology practice must assess their own interests and skills, patient demand, and the key considerations that guide device selection and purchase.

Many dermatologists find success by focusing on medical as well as cosmetic indications, such as acne and rosacea, dyschromia, erythema, telangiectases, and fine wrinkling. With this broader approach, the clinician is able to keep her or his practice flexible. Many of the best-respected names in aesthetic medicine will tell you that a portion of their practice remains focused on traditional medical dermatology. A flexible approach may suit the clinician’s interest, and it likely reflects the level of demand for service on the local level.

Selecting a laser system can be a challenge. Key to success is to disregard the hype. Many lasers have come to the market backed with flashy campaigns to the public and the medical community, making exaggerated claims of efficacy and applicability. From a practice development standpoint, it comes down to weighing the costs—upfront and ongoing/financial and timewise—against the likely returns. It rarely makes sense for a physician to take a gamble on costly new technologies with uncertain efficacy and appeal, when tried and true systems can be acquired (often for less). Alternatively, low-priced systems can appeal to the frugal practice, but if a system is underpriced, it probably underperforms.

The initial investment in a system purchase is an important consideration, but it doesn’t account for everything. How much time do procedures take? How many patients can be treated in a period of time? Will time be wasted on set up? Will consumables and maintenance lead to costly bills?

Dermatologists establishing or growing their laser practices can benefit significantly from the wisdom of their experienced and successful colleagues. That’s what the following pages provide. Some of the best-respected minds in aesthetic dermatology share their expertise about two laser systems—Gemini® and VariLite™—from an established market leader in laser aesthetics: IRIDEX. As thousands of physicians have learned, success in laser medicine is built on a strong foundation of tried-and-true procedures using triedand- true laser systems.

Read on …..

Variability in responses to Cryolipolysis

CBZ — Mon, 21 Jun 2010 00:00:30 +0000

It is reported that 100% of cryolipolysis subjects had good outcomes following treatment with the Zeltiq device in its first major study. Further reports by serious and dependable physicians have reported similar results in all their treated patients. So why am I unable to achieve striking outcomes in all my patients on the West Coast of the USA? Not to say that I am unhappy with the overall results, for I still believe that this is currently the best device for non-invasive localized fat reduction. But as often happens, a mature look at long term outcomes can be quite revealing.

I estimate that about 70% of my patients have good results, which means that 3 out of 10 patients are unimpressed. I am surrounded by dermatology residents and fellows who call it as they see it, and they give me that quizzical look when I recount the original study outcomes, wherein every patient could see obvious improvement. We are careful to take standard digital images and we compare them diligently. True, we don’t employ the three dimensional Vector system, and neither do I perform ultrasound or MRIs on patients, but frankly if they can’t feel or see the difference, what’s the point? It’s not enough for us to be satisfied that 100% of patients have measureable improvement by U/S or MRI. Innovativel devices can be killed by hype.

So why are some investigators seeing results in all their patients, and others not. This was one of the issues discussed informally by Christine Dierickx, Henry Chan, Rox Anderson, Arielle Kauvar, and Chris Zachary in Paris recently at Les Journées Parisiennes du Laser 2010 conference, a premier meeting of French laser specialists. Henry Chan has also experienced some patients with little improvement in Hong Kong. Arielle Kauvar has noticed improvement in all her patients. We need to determine from Zeltiq users worldwide whether there are outcome differentials, and if so whether these are related to age and gender, or anatomic, geographic, ethnic, technique or other differences between our patient populations. These might then provide clues as to the cause of this disparity in outcomes.

While musing over lunch, no doubt thinking ‘we are what we eat’, Rox Anderson suggested that the Californian diet was probably lower in saturated and trans fats, and that their fat might ‘freeze’ differently, whereas the East Coasters who enjoy more Philly cheese steak sandwiches might have longer fatty acid chain adipose tissue, with a more responsive outcome. While humorous, this thought has merit, and would be easy to study, even retrospectively.

Also discussed was the question of painful responses. Two patients with prolonged and severe pain post-Zeltiq were previously reported in this Blog. At the time they seemed to be absolute outliers. However, it is clear that there have been a very small number of similar but less extreme painful responses, lasting several weeks. The cause of this painful response is not understood, but could be related to the acute panniculitis itself, or possibly a vascular event, an acute neuritis, or some other noxious stimulus to the fat, the underlying fascia, or possibly the underlying muscle. Rox reminded us that the glomus cell is involved in the control of vascular shunting in a cold environment, and that these shunts can be associated with significant pain. Given that the Zeltiq suction device effectively shuts off the vascular supply to the affected skin and subcutaneous tissue for 60 minutes, one could predict hypoxic tissue responses, despite the protective nature of the cooling.

The normal sequelae of numbness, a modest burning sensation, and other paresthesias are commonplace for several weeks or months. All patients should be informed about these. Further, these side effects might be used therapeutically in order to control chronic cutaneous pain syndromes, such as post herpetic neuralgia.

CME Courses: compromised relationships and Payola

CBZ — Tue, 15 Jun 2010 04:41:32 +0000

I am becoming increasingly concerned about over-regulation of CME programs, so much so that I would prefer to be associated with non-CME programs if they have equivalent educational goals and less interference from overzealous regulators. However, we have in our midst those who would provide CME events and then flout these regulations at the same time. We can’t play both sides of this game.

The issues are twofold, and both are pernicious. Device companies are being squeezed by organizers of certain CME meetings in a pay now and pay later ruse. Companies sign up months in advance to exhibit at a cost of $5-10K. Then they receive a call one to two weeks prior to the actual meeting and are invited to pay another $5-10K to have their device discussed at the podium. No pay … no play. I have know speakers disinvited from talking about a certain generic technology ‘because their sponsor refused to pay up’ in this double squeeze play, and ‘thus their talk would no longer be needed’. Further, new talks are susbstituted by inferior product-specific presentations merely because company ‘B’ agreed to pay up. Clearly this is flouting CME regulations, and more importantly, is an unhealthy manipulation of power and trust.

It might seem very Pollyannaish of me to hold these sentiments, but there you have it.

Conversely, I would hold the somewhat controversial view that product specific presentations are absolutely appropriate, if billed as such. The increasingly popular trend is for meetings to include technology exhibits or forums as side shows that are well funded and are represented as being exactly what they are, namely product specific promotional information sessions. Much akin to separation of church from state, there is clear separation from the main scientific sessions, and this is fine as far as I am concerned.

As a Medical Director of the SDEF meetings, I am aware that we used to do things differently in the old days ….. But now, all the CME scientific sessions need to be free of commercial bias. The meeting attendees are not always well informed enough to know when they are being snowed. Maintaining an even keel can be difficult, but common sense allows an impartial moderator to steer the content in a straightforward and candid manner. The integrity of a meeting is often based on the integrity of the session moderators, and has little to do with a boatload of CME regulations.

No amount of regulation will prevent the type of unethical end-run that some CME conference organizers are using to line their pockets at the expense of truth. So this is really a call for moderation, and for achieving a balance, for if we do not get it right, then we will reap the consequences.

Severe Pain Unusual Response Following Cryolipolysis

CBZ — Wed, 02 Jun 2010 06:19:00 +0000

Cryolipolysis is recognized as the most successful non-invasive treatment of localized fatty deposits currently available. To date, this treatment is said to be associated only with a mild burning sensation and some numbness, both of which are transient. Indeed, the great majority of patients have very minimal sequelae, little or no downtime, and predictable results. I am reporting in this blog that, in two cases, pain has been described by patients to be severe and persistent, for at least several weeks.

While these cases are being investigated, this report is being released to alert treating physicians about the very uncommon possibility that in the immediate post-cryolipolysis period, painful symptoms in the areas treated can be enough to require narcotics, anti-inflammatories, and possibly steroid treatment. Ironically, should such treatments be necessary, they will likely limit the benefits of the cryolipolysis undertaken.

The cause of symptoms in these cases is as yet unknown. It could be related to inflammatory changes within the fascia, the nerves, or the fat itself. This does not appear to be ischemic. There was no associated purpura or sign of superficial skin freeze artifact. In one case at a 2 month follow up visit, the abdominal contour improvement was quite significant, as noted by the patient and as evidenced photographically, and the appearance of the skin was entirely normal. This patient had not received any steroids, anti-inflammatories, or antibiotics.

Full information about the second case is still pending, but given the similar stormy nature of both post operative periods, is referrenced in this blog.

Cryolipolysis remains a safe, comfortable and effective treatment in the great majority of treated patients. It should be noted that many established treatments can be associated with idiosyncratic responses, and such problems should not dissuade us from using this reliable non-invasive technology.

We should collect data on similar cases, investigate their cause further, and hopefully assist in their avoidance for the future.

CME Requirements are Negatively Impacting Education

UberZooTu — Mon, 31 May 2010 23:55:02 +0000

“The increasingly onerous CME requirements have reached the point at which many educators are heartily fed up and unwilling to comply”, said Dr Christopher Zachary, professor and chair of the department of dermatology at University of California, Irvine yesterday at the Florida Derm Society annual meeting in Naples. “You can push them so far …. and then it becomes counter-productive”. Roy Geronemus MD agrees, “these regulations negatively impact our ability to bring new research and the latest data to our academic meetings” he stated in a personal communication at the ASLMS meeting earlier in the year. Some of the complaints heard in the corridors of academic meetings are as follows:

The CME staff are so confused about what is acceptable that presentations are often changed by them without permission, often at the last minute and without informing the speakers.

Device (and drug) names are removed from PowerPoint slides leaving the audience without any basis upon which to understand the difference between one device or another.

Eyes and periorbital regions are covered in photographs, despite signed use agreements, even in cases depicting pre and post eyelid surgery.

Requirement for talks to be submitted weeks or months before the meetings …. (is anyone really that organized?)

“The pendulum has swung too far”, said Dr Zachary. “It’s time for reason to set in”. If doctors can’t tell the difference between science and a sales job, then our medical schools have failed to educate them appropriately”.

Delegation of Laser Services can be Problematical

UberZooTu — Sun, 30 May 2010 15:33:36 +0000

Dr Christopher Zachary, guest speaker at the 2010 annual meeting of the Florida Society of Dermatology and Dermatologic Surgery, expressed concern that some physicians are trivializing the potential complications associated with laser surgery by delegating all such procedures to nursing or other staff instead of performing the surgery themselves. “Any device that can induce serious benefits can also be asssoicated with serious complications”, said Dr Zachary. “I have no problem with properly trained staff using these devices under the supervision of a trained physician ….. but I have seen enough complications from unsupervised situations that it’s time to review the licensing requirements in this regard. I believe patients really need to know that those who will be treating them are appropriately trained, and that there is adequate supervision”. He went on to say that the supervising physicians can’t simply be ‘caretaker supervisors’; they have to be experts in the use of these devices, fully able to advise, support, and review the patients before, during and after the procedure.

Other problems to be avoided include the development of bulk heating by poor scanning techniques. “It is critical that the spatial separation of fractionated laser pulses is not lost by overlapping the scan or stamp patterns”. Bulk heating can and will lead to full thickness loss of skin leading to significant scarring.

Rox Anderson Sheds Light on Future

CBZ — Sun, 30 May 2010 14:58:25 +0000

Rox Anderson’s vision of the future of laser surgery was presented here in Naples, Florida, at the 2010 annual meeting of the Florida Society of Dermatology and Dermatologic Surgery. He would like to cure acne …. for good! The best hope in this regard would be the use of photodynamic therapy. ALA or methyl-ALA is absorbed preferentially by the sebaceous glands in the skin. ALA 20% with three hours under occlusion allows better uptake than the more usual 60 minutes application. Red light at 635 nm is probably the optimal wavelength over a prolonged period. Short contact (<60 minutes) is not going to do it. Blue light is probably not optimal for this technique, (but can by itself reduce P Acnes numbers in the skin.) These patients are going to have quite an aggressive response, but it should be worth it in the end. Remember that cooling and bright light reduce the PDT process, so incubate your patients in a warm dark location “just like mushrooms”.

“Low level light (LLL) is going to be used by most of us in ten years when we can work out how best to manipulate it”. It’s all related to mitochondrial absorption of light. The cytochrome (cell color) absorption of specific wavelengths (630, 670, 810, 900 nm) can control oxygenation of tissue by affecting the nitric oxide (NO) switch. Stress caused by surgery or other injury induces copious amounts of NO, which competes with oxygen tissue binding sites. LLL pulls NO off these key binding sites which allows greater tissue oxygenation (read more by Harvey Whelan and Uri Oron. This is likely to help all ischemic tissue states, and has even been found to have a significant beneficial effect on acute stroke patients. The exception that both Dr Anderson and Dr Matt Avram stated was that they had a hard time believing the claims made by Zerona that inches could be lost with the use of this device.

Fractionation of Laser Energy

Rox Anderson MD discussed the microscopic effects of fractionated laser surgery at the FSDDS meeting in Naples, FL, Sunday 31^st May. Each area of injury is like a tiny murder, which is pretty innocuous on the grand scale of things, and induces new healing, new collagen. The maximum depth for the non ablative devices is about 1.2 mm “we’re not going to get much deeper than that’, said Anderson. They also do a pretty good job with fine superficial telangiectases and for atrophic skin conditions. ‘Don’t be in a hurry, because some of these great results take 5 or 6 treatments’.

He reminded us of Dr Jil Waibel’s work who has induced remodeling of scars on a microscopic scale, which has made very significant changes to hypertrophic scars after burns and surgery. Also, Chad Hivnor MD USAF, who has been treating shrapnel scars on the men and women coming back from the Afghan and Iraq wars. Fractionated ablative surgery has been found to be very useful in reducing both hypertrophic and atrophic scars.

Combination use of fractionated ablative lasers with Methyl-ALA (porphyrin precursor) indicates 10-100 times more agent gets into the deeper skin than would otherwise. There is a very fast uptake of any molecule, which will also include bugs ….. “there’s a ying and yang for everything”. Massaging the topical agent makes no difference in its uptake.

Scarring can occur if the technique and parameters are incorrect, as evidenced by the work by Matt Avram and Christopher Zachary published in separate articles last year.

Circumferential Measurements are Essentially Unreliable.

CBZ — Tue, 18 May 2010 19:55:21 +0000

One look at the inaccurate and misleading claims related to the use of Zerona, the too-good-to-be-true fat busting device, and other claims with related devices, led a team of investigators to develop and utilize a mathematic geometric model that can reliably be used by clinicians and device engineers alike. Hailed by Mat Avram and others as one of the most significant presentations at the annual ASLMS meeting in Phoenix, the authors studied a faux fat model with circumference, ultrasound and micrometer measurements to understand these issues better. Mathematically, if the fat is reduced by ‘X’ mm, then the circumference reduction will be 2.1 times ‘X’. Thus a device that reduces abdominal fat by 0.5 cm will cause a predicted abdominal circumference reduction of just over 1cm. The claims of 4 independent studies of these types of devices, published in reputable journals, were, in 3 out of 4 cases, found to be mathematically impossible and exaggerated the maximum possible average girth reduction by a factor of 5 times.

It’s impossible for a potential client, be they a prospective patient or purchaser of these devices, to make a serious and clear decision about the ‘right’ device, when these studies, vetted and stamped with the approval of the Journal editors and reviewers, are so clearly full of nonsense. Dr Christopher Zachary, Professor and Chair of UC Irvine’s department of dermatology, together with John Allison PhD and Nazanin Saedi MD, made this presentation to the Dermatology/Plastic section of the American Society for Laser Medicine and Surgery’s annual meeting in Phoenix.

UC Irvine makes its mark at ASLMS

CBZ — Tue, 18 May 2010 19:24:54 +0000

The University of California, Irvine was made its mark at this year’s ASLMS annual meeting Phoenix. With one of the strongest group of scientific / clinical presentations and posters, UCI is recognized the world over for its brilliant science in the laser world. The members of the Beckman Laser Institute, School of Bioengineering, Department of Dermatology and other groups all had major contributions to the meeting. “Harnessing the brains and brawn in a collaborative effort is the key to success” said Dr Christopher B Zachary FRCP, Professor and Chair of the Department of Dermatology. “Coming up with the right questions leads our amazing laser engineers to design intelligent systems”.

Hack ‘n Smack for Melanoma

CBZ — Tue, 27 Apr 2010 04:07:18 +0000

Joe Pesci studies the green

University of California, Irvine, Department of Dermatology resident Naz Saedi MD was on hand for the early show on KTLA Channel 5, to promote the 7th Annual Hack ‘n Smack golf tournament in aid of melanoma research.

5:00AM KTLA HacknSmack for Melanoma

6:00 AM KTLA HacknSmack for Melanoma

Dennis Haysburt takes the wheel ....

The 7th Annual Hack ‘n Smack golf tournament in aid of melanoma research continues to gather great support from golfing enthusiasts and the media. At the beautiful El Caballero Golf Club in Tarzanna, where this tournament has enjoyed incredible hospitality from the management, Kevin West has again pulled off an incredibly fun and dynamic day with a great bunch of Holywood stars and sponsors.