Peer to Peer
Breadth of clinical practice
Put to our panel are questions on photodynamic therapy, the use of botulinum toxins, and how an informed receptionist can help the bottom line
Our panel this session comprises:
Dr Timothy Flynn, a clinical professor, department of dermatology, University of North Carolina at Chapel Hill; Dr Jean Carruthers, a clinical professor at the department of ophthalmology and visual sciences at the University of British Columbia in Vancouver, where she specialises in aesthetic medicine and facial cosmetic surgery; Dr Koenraad De Boulle, a dermatologist and director of Aalst Dermatology clinic, a private dermatology clinic in Aalst, Belgium; and Dr Russell Emerson, a consultant dermatologist and dermatological surgeon who runs the Hove Skin Clinic in East Sussex.
Q - Any improvement with sebaceous hyperplasia? It’s in the literature that you can use amino levulinic acid (ALA) and intense pulsed light (IPL) to shrink some sebaceous hyperplasia. I’ve never really seen it work.
Dr Russell Emerson: No, I don’t think that works. Sebaceous hyperplasia is dermal. It’s deep; it has deposits. It is hard to believe that it will shrink off considerably. If you treat people with Roaccutane, which really shrinks sebaceous activity, you still have to remove the existing sebaceous hyperplasia lesions.
Q - How many units of Botox do you use for masseteric hypertrophy?
Dr Jean Carruthers: I treat a lot of masseteric hypertrophy and I usually start off with about 15 to 20 units in the posterior masseter and see them back. If you put too much in at the beginning you can have a functional change in how they chew. I just think it’s kinder to see them back and see what works for them, because aesthetically they might be happy with what you’ve done with, say, 30 units.
Q - What about longevity?
Dr Jean Carruthers: You get a good six months. Quite a number have tight pterygoids, and you can tell they have tight pterygoids because they get pain—sometimes it’s a trigger from migraine—and they can’t open their mouth, and can’t move their jaw from side to side. You get them to open their mouths as wide as you can. I usually put about 5-10 units at each of their internal pterygoids from the inter oral root. The pain goes away, the mouth opens and moves. Now they can eat corn on the cob which they couldn’t get their mouths open to do before. Just treating the masseter isn’t enough.
Q - For the temporomandibular joint, a specialist I worked with specialised used to puncture the internal pterygoid to sort out the problems. Is the toxin necessary?
Dr Jean Carruthers: Puncturing on its own may not last long before it needs to be repeated. If you add the toxin with the puncturing you get a good six months.
Q - Dr Flynn, you showed in a graph from a paper by Dr Nick Lowe that the response rate of his patients was shorter with Dysport than with Botox. Were you suggesting that was because the dilution used was 1:2.5?
Dr Timothy Flynn: The 50-unit dose of Dysport for the glabella was what we selected. But in Dr Lowe’s study he put 20 units of Botox into the glabella and 50 units of Dysport, which is the same ratio of 1:10.5. He did find in this study, which didn’t have a huge number of patients, that the Dysport people fell off a little faster. Now it would be interesting to compare that in a different dose ratio, maybe 1:3, or perhaps just try it on a larger number of patients.
Q - As regards the lip injections, that seemed quite deep. Were you one-third, or one-half the depth of the needle. Does it make much of a difference?
Dr Koenraad de Boulle: As a rule of thumb, if you are just below the bevel of the needle, it’s okay. Don’t forget the spread of a product is not in a two dimensional plane; it is three dimensional, so you have like half a sphere. So this point about being .1mm too high or too deep does not make that much of a difference unless you have to be exactly because of a three dimensional spread of the product.
Q - How can front-line staff best help answer questions from customers and prospects?
Dr Jean Carruthers: It will really help your practice if your staff are users of products—especially the receptionist, as she answers the phone. "Hello. I just saw this ad about this product that grows eyelashes. Have you guys heard about that?" "Yes, I’ve been using it for nine months, and it’s really effective." We book a lot of younger patients this way, and when they come into the office they learn about the other things that are available.
Q - What do you think about the e-bay Botox do it yourself kits marketed direct to consumers?
Dr Jean Carruthers: This is web-based advertising. A money order is posted to an address somewhere in Georgia and a little bottle of "juice" arrives with a little map of where you inject it on the face. It’s quite curious how the website is up one day and down the next. I would ask what are they selling? There are many neurotoxins around. In the "upfront world" we know what’s in the vial.
