Tazorac

Chicago -- Patients seeking full facial rejuvenation can now choose from an unprecedented array of nonsurgical options, according to William P. Werschler, M.D.

"There are finally enough tools available that one can discuss nonsurgical facial rejuvenation comprehensively," says Dr. Werschler, assistant clinical professor of medicine and dermatology, University of Washington School of Medicine. "It used to be that we essentially broke the face up into parts. We said, 'We can treat forehead lines and frown lines with botulinum toxin A (Botox Cosmetic, Allergan). Or we can inject collagen into the lips to make the lips fuller and smooth out the lines around the mouth."

However, he says, "We really didn't have a recipe that was nonsurgical all the way around. In the last few years, though, we've had Sculptra (poly-L-lactic acid, Dermik), Restylane (hyaluronic acid, Q-Med Laboratories) and ThermaCool[TM] (Thermage Inc.) approved. Combining those with other treatments we have, we now possess a package that allows one to approach total facial restoration nonsurgically."

According to Dr. Werschler, today's nonsurgical approach to total facial restoration or rejuvenation encompasses the following elements:

* Botulinum toxin for the upper face.

* Poly-L-lactic acid for the midface. "Though it's not a dermal filler like Restylane or collagen," Dr. Werschler says, "Sculptra adds volume back and helps to restore the youthful convexity of the face. Restoring volume can also be done with surgical implants, fat transfers and some types of lifting that basically reposition the cheek. But, essentially, today, in the concept of non-surgical facial restoration for the midface, one is going to be using Sculptra."

* Hyaluronic acids for the perioral region and lower face. "Principally," he says, "Restylane is used around the mouth, for augmenting the tips, treating smokers' lines, lifting the nasolabial folds and addressing marionette lines that emanate downward from the corner of the mouth."

* Resurfacing the skin. Dr. Werschler says, "This procedure helps alleviate photodamage, as well as pigmentary and textural changes. In a patient whose skin has been relatively well-protected from the sun, one might use something as simple as retin-A (tretinoin, Ortho Dermatological) or one of the other anti-aging creams. Most people, however, probably require chemical peels, intense pulsedlight (IPL) or photodynamic (PDL) treatments. For people with extensively damaged skin, one must perhaps use laser resurfacing. Also, tucked into the concept of tightening and smoothing the skin is Thermage[R]."

* Maintenance. "At minimum," he says, "this phase includes a sunscreen every morning. And for most people, it will include some kind of exfoliating agent at night. That may be retin-A, Renova (OrthoNeutrogena), Tazorac (tazarotene, Allergan) or glycolic acid. The list goes on. It's going to be somewhat unique to the needs, desires and tolerances of the individual."

Assessing patient needs

Assessing and consulting with patients, Dr. Werschler adds, begins with looking at what's gone wrong over time.

"In the upper face," he says, "with botulinum toxin, one is mainly treating muscle movement and associated pleating of the skin with muscle folding. But around the mouth, lines can form because the skin is attached directly to the muscle. It's one of the few areas on the body where that's the case. So one tends to see unique spokes in a wheel formation around the mouth. And with age, we tend to lose volume in our lips. And as the upper lip loses volume, it tends to elongate somewhat and roll inward. Therefore, we lose the sharp Cupid's bow and red hue of the lip."

In the mid-cheek, Dr. Werschler adds, "The fat redistributes itself. We get some thinning of the tissue, and the cheeks begin to hollow and sag. So one must lift and reposition the cheek. One does that basically with Sculptra, which thickens the tissue."

To treat droopy mouth corners, he says, "We bolster the corners of the mouth and try to upturn them a little bit. Consider a child's smile--the corners of the mouth are upturned; the Cupid's bow is very distinct; and the vermilion is very prominent."

Deciding on treatment

Deciding on a course of treatment usually involves weighing the strengths and weaknesses of fillers in various categories, Dr. Werschler adds.

"Sculptra is not truly a filler" he says. "It's a catalyst that stimulates neo-collagenesis. The new collagen thickens the skin, making it a younger, fuller and more elastic tissue" that helps to lift and resuspend the midface. Such improvements, he adds, can last two years and longer.

The hyaluronic acid category includes Restylane, Hylaform (Inamed) and Captique (Genzyme Corp.).

"Hyaluronic acids don't require pretreatment skin testing," Dr. Werschler says. "They're very safe and effective, and last anywhere from three to six months or more."

Radiesse (calcium hydroxyapatite, BioForm), on the other hand, remains soft when injected into soft tissue, Dr. Werschler says.

"It lasts a year, maybe a little longer," he says. "It's used principally to augment the nasolabial folds. It's a lovely product, but it hasn't done quite as well in the marketplace as Restylane, probably because Restylane has more name recognition. And some people are somewhat afraid of injecting calcium into the skin, thinking it might harden. That doesn't really happen" outside of the lips, where plastic surgeons now generally avoid using this material because it can cause granulomas.

With collagen products such as CosmoDerm and CosmoPlast (Inamed), Dr. Werschler says, "The principal drawback is longevity. Patients hope it's going to last for three to six months, but it doesn't. A lot of those people have converted to Restylane."

Among hyaluronic acid products, he adds, "Hylaform and Captique (Inamed) are very similar to Restylane, but they don't last as long."

Products on the horizon, Dr. Werschler says, include Restylane Touch (formerly Hylaform FineLine) and Perlane (both made by Q-Med Laboratories).

"Perlane is a little bit thicker and heavier than Restylane. It's supposed to last six to nine months," he says.

Similarly, he says Sub-Q (formerly Macrolane, Q-Med Laboratories), not yet approved by the Food and Drug Administration, consists of very large hyaluronic acid particles and is designed for deep injection.

Products now undergoing phase 3 trials include Juvederm HV-24 and HV-30 (hyaluronic acid, Inamed/ Corneal Group).

"They are direct competitors to the Restylane and Perlane franchise," Dr. Werschler says. "In some ways, Juvederm might be a little bit better than Restylane and Perlane. It is said to flow more easily into the tissue, and maybe Juvederm lasts a bit longer and has a softer feel, although (these observations) come from anecdotal comments by injectors in Europe and Canada."

Another product on the horizon is Bioinblue (polyvinylalcohol, Polymekon Research) that Dr. Werschler says is soft, natural and well-tolerated in the lips.

JOHN JESITUS

STAFF CORRESPONDENT

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