When I started practicing dermatology 20 years ago there was only one dermal filler, bovine collagen.  It was used to enhance the lips and to fill the nasolabial fold, and occasionally to fill the frown line between the eyebrows.  How times have changed!  We have many types of fillers and the way we use them has also changed.  The emphasis is now on reinflating the mid-face.  Think of a babies chubby round cheeks and look at an aging face to understand what has been lost.  Without normal volume over the cheek bones, the mid-face flattens and the cheek skin sags.  This creates a trough under the eyelid, a roll of fat and skin above the nasolabial fold (which deepens and accentuates that fold), and creates a jowl of skin at the jawline.  By restoring that normal mid-face volume the cheek skin lifts and a more younger, natural mid-face is recreated.  I like Radiesse and Juvederm Ultra in this location for their durability.  Radiesse lasts the longest but Juvederm Ultra is softer; both are great.  I would be interested in hearing other peoples thoughts on this and if they are happy with their results.

In my practice we treat multiple skin cancers daily.  One of the challenges is to determine the best technique for each individual patient.  The best cosmetic outcome is always a critical decision point as we contemplate treatment options.  The highest cure rate is even more important, of course.  A recent article in Lancet Oncology (2008 July 9) revisited the risk of recurrence in certain squamous cell carcinomas and found that the risk of local recurrence and distant metastasis was directly related to the cancers being large, poorly differentiated (meaning a loss of normal expression of skin cell characteristics), and forming scar tissue of its own (desmoplastic).  For example, local recurrences developed overall in 3% of patients but in 12% of tumors thicker then 6 mm; recurrences were all within 6 years of surgery.  No metastases developed in tumors less then 2 mm thick, but did develop in 4% of tumors 2.1 to 6 mm and in 16% of tumors thicker then 6 mm.  Patients who had a damaged immune system had significantly more problems.  None of this is surprising, and these same characteristics have long been known for basal cell carcinomas.  Another item we consider is tumor location; these cancers on the lip, temple and genitals are usually more aggressive.  

We use this information to decide on tumor margins (narrow versus wide), the need for adjuvant treatments (imiquimod immunostimulation, radiation therapy), the need for Moh’s surgery (frozen tissue processing with horizontal sectioning), and attention to lymph node enlargement and the need for chest x-rays.  

If you are unlucky enough to develop skin cancer, consider if your physician is thinking of the worst case scenario.  There is no need to overtreat, but it is important to know when more aggressive treatments are necessary.

I recently reviewed an article in Dermatologic Surgery (2008 June; 34:S105) on the complication rates of Restylane and Perlane hyaluronic acid fillers used in the nasolabial folds and the angles of the mouth.  The investigators are well known to me (Richard Glogau in particular) and I respect their data.  What they found is that in their hands, the risk of bruising, swelling, and tenderness immediately after treatment with these agents is directly related to rapid injection, overcorrection and an injection technique called fanning.  In fanning, a single injection point is used with the needle advanced in multiple directions like a fan.  Anyway, I have found the same results in my patients and was pleased to see this data published.  Injection technique is the key to success, and if you are contemplating a dermal filler be sure and mention these items to your provider!