Laser Hair Removal (Appeared in Today's Charlotte Woman -Sept. 97)
Facts and Myths
There are vast differences in these lasers
The most recent wave of laser medicine focuses on hair removal.
This is a very exciting application of laser technology, but it is important to understand that not all lasers yield equal results. Through extensive research in laser medicine, Dr. John A. Thompson and Dr. Charles J. Brown of the
Dermatologic Laser Center of Charlotte have uncovered the advances, differences, limitations and outright misrepresentations in laser applications. Drs. Brown and Thompson, who are both dermatologists, are enthusiastic about the results of
the Long Pulsed Alexandrite laser for hair removal. "So many people feel stigmatized by unwanted hair," says Dr. Brown. "It doesn't matter if it involves the face, back or bikini area: they just don't want it. Until recently,
the only way to remove unwanted hair was by electrolysis or waxing," he continues. "Now there is an excellent chance of achieving permanent hair removal with lasers." The Dermatologic Laser Center is the first in the Carolinas to
offer the most advanced laser in this promising technology. All people have hair growth cycles. "Hair follicles are in an active phase called anagen when they are producing hair," says Dr. Thompson. "After
anagen those follicles become dormant for 6 to 8 weeks; that resting phase is called telogen. The actual time between growth cycles is unique to each individual" he continues. "The laser focuses on the active follicles when
the area is treated. Because people have growth cycles, it is necessary to treat 3 to 4 times for maximum results." "It is important to know the differences in lasers and how they work," says Dr. Brown. Many laser vendors go
around renting lasers to any doctor without thoroughly understanding how or why the technology works; and it often creates a dangerous situation. "We rigorously research and study lasers and choose the best ones for our
practice. Our patient's care depends on it. Then we buy our lasers instead of renting them." There are many different lasers for hair removal, but only one with dramatic clinical results.
Yag lasers with carbon solutions have been effective in retarding hair growth and slowing follicle activity in the anagen
phase, but have been found to be relatively ineffective for long term hair removal. Ruby lasers have also been tested for hair removal and those results, while better than those seen with yag lasers, are still inconclusive. Of 13 subjects treated with a normal-mode ruby laser, at six months, only four subjects had less than 50% re-growth.
The most promising of all the laser hair removal systems is the long-pulsed alexandrite laser. It is the only device with a 20 millisecond pulse width at 755 nanometers so it can safely and effectively penetrate deeper
without the risk of any scarring or long-term side effects. This laser also differs from the others by selectively targeting the blood supply to the follicular papillae (the hair's root) in the anagen
growth phase, thus shutting down hair production. Another benefit of the alexandrite laser is that no painful waxing is necessary prior to treatment. Preliminary results are yielding 80%-100% clearance in subjects with just 3 to 4 treatments. To learn more about laser hair removal, call the Dermatologic Laser Center at 376-7546.
Reprinted from Today's Charlotte Woman Jan. 99
Shedding Light On Laser Surgery
By Sarah Woodward It's called the magic beam, and if you look around you'll see why. Lasers are everywhere: in automatic doorways and
computers, at supermarket checkouts, rock concerts, the library and the doctor's office. They're used to cut metal, detect earthquakes and guide airplanes. Already prevalent in the health care industry, new laser treatments are continually
being developed. When the first laser was built by American physicist Theodore H. Maiman in 1960, scientists said it was "a solution looking for a problem." Laser is an acronym for Light Amplification by Stimulated
Emission of Radiation. It is a device that harnesses the energy in electrons, and turns it into a concentrated beam of light. There are many lasers, and they are used to treat everything from poor vision to birth marks. Generally, laser
procedures take less time to perform, are more precise, carry less risk of complication, require less recovery time, and are less painful than standard surgeries.
What Lasers Do
According to Charles Brown, MD, of the Dermatologic Laser Center, "Each laser will emit a certain frequency or wavelength of light. One laser targets the red blood cells inside your vessels; they have a certain specificity for each other – the red blood cells and the certain wavelength. That's what makes port wine stains (caused by dilated blood capillaries) go away, whereas a carbon dioxide laser targets water in the skin, and vaporizes it. [This] leaves some thermal damage behind and that's what makes your skin make new collagen and wrinkles go away."
Laser Treatments For Skin Problems
Some
dermatological problems are more receptive to treatment than others. Brown says lasers work best on wrinkles, lipstick lines and roseacea (red cheeks and neck), though he and his partner, John Thompson, Jr., MD, also remove hair, tattoos,
spider veins, non – vericose leg veins (varicose veins must be injected or surgically removed), age spots, acne scars and hemangiomas (benign tumors made of blood vessels). Most healthy people make good candidates for laser procedures. The
exception is people who smoke; they don't heal as well. A preliminary consultation is required, during which patients are shown "before" and "after" photos. "I want people to know what they'll look like two days
after, one week after, two months after, so they know exactly what they're in for," says Brown. Most dermatological treatments, with the exception of hemangiomas and port wine stains, are considered cosmetic and thus
not covered by insurance, so cost can be a drawback. But Brown says, "The benefits people get psychologically are immeasurable." As for the more measurable factor of cost, Brown declined to give specifics. Several other dermatologic centers
also said general estimates can be misleading because much depends on the patient's particular condition. Many centers offer a free consultation, or deduct the fee from the cost of the procedure. Many also offer payment plans.
Facial Resurfacing
Facial treatments involve a
preparatory skin care program of antibiotics and Vitamin C administered over the course of two weeks. Once ready for surgery, wrinkles, lipstick lines and acne scars are treated with two lasers: a carbon dioxide and an Erbium laser, which has
become the "gold standard" says Brown. "If you use the carbon dioxide laser alone, you do a lot of thermal damage, which makes people red for quire a long time after they are healed." Erbium reduces the recovery time by half.
Treatment of wrinkles and lipstick lines are consistently successful, but acne scars are less predictable. "[Improvement] depends on the type of acne scar," Brown says. Patients who have been treated for acne with Acutane
must wait a year before their skin can be resurfaced. Most skin procedures take about an hour and can cost anywhere from $700 to $3,000. Either an intravenous anesthesia or a local anesthesia around the mouth or the
eyes may be used. Following surgery, patients will be " completely raw" says Thompson, and they cannot wear makeup for seven to 10 days. Their skin will continue to be red for about three months, and recovery is monitored with several
follow-up visits.
Hair Removal
Lasers used
in hair removal have a specificity for melanin (which colors hair and skin), so ideal candidates for hair removal have dark hair and light skin. For them, a long-pulse, Alexandrite (crystal) laser is usually used. Melanin in the hair follicle
absorbs the laser and disables the follicle. With darker skin, there is the risk that the skin will absorb the laser and result in blistering. To prevent that, a milder laser called a Medlite laser is used, but it can be somewhat less
effective. Hair removal costs about $300 and generally takes less than a half-hour. Anesthetics are rarely used, and Brown says, "We often do it the same day s the consultation." Patients may feel a slight burning
sensation, and after the treatment the area may be pink and feel like it's mildly sunburned for a day or so.
Roseacea
Roseacea is a condition in which blood vessels in the neck and cheeks become flushed due to heat or consumption of an alcoholic drink. "[Treating] red cheeks takes about 20 to 30 minutes," Brown says. "You can get up off the table and go right home." A pulse-dye laser is used and no anesthesia is required. Says Brown, "It stings a bit, but it tends to give people very good results." The treated area will be purple for about a week, because the procedures causes some bruising of the tissue, but patients can conceal it to some degree with makeup. Expect to spend about $1,000 per area (cheeks or neck) or $1800 for two areas.
Tattoo Removal
Getting a tattoo is one thing. Having it removed is something else. "You're blasting the pigment into tiny pieces and then your body has to remove the pigment," Brown says. "There's no scarring, [but it takes] multiple treatments. We treat tattoos every two months and it takes eight to 10 treatments for [the removal of] a professional tattoo." Cost depends on the size and nature of the tattoo, but plan to spend around $1,000. Patients may experience some mild soreness the day of treatment.
Spider Veins, Hemangiomas And Port Wine Stains
Facial spider veins, hemangiomas and port wine stains can be treated with a pulse-dye laser that doesn't scar and can be safely used on infants. Some blemishes can be removed in 15 minutes, while more severe conditions may require several treatments. Generally, six to eight weeks should elapse between treatments. Treated areas will appear bruised and purplish, but areas treated for veins are fairly easy to conceal with makeup, and clear up in one to two weeks. For larger, spider veins on legs, healing is much slower and sometimes the veins will appear brownish for up to several months.
LPIR Laser Answers Hair Removal D emands
(While this article is dated, it still supports the best technology in use today. We have
now treated over 4000 patients with excellent permanent hair reduction.)
Although
the laser-based hair-removal field still remains in an early stage of development, hundreds of medical practices, aestheticians, and health spas already offer this service to consumers. In many ways, these early adopters of lasers have
been involved in a widespread test of new technology and public attitudes towards alternative modes of long-term hair removal. The first laser available to these users was the Nd:YAG, which originally required the additional application
of a carbon lotion initiator. Ruby lasers followed the YAG, and marketers naturally made strong claims, that this technology was better. Nevertheless, no definitive scientific studies were published to help laser buyers make
an informed decision. Rather, aesthetic practices had to find users of these lasers and try to get honest answers about efficacy. And since very little has been done in the way of long-term laser comparison studies, anecdotal
reports from users remains the main source of information at this time. GRADUALLY, as users gained experience with the first generation of hair removal lasers, we began to hear more details about the clinical and functional
limitations of these devices. In some cases, the first lasers shipped to customers were prototypes rushed out into the field in response to market demand. This led to reliability problems, frequent laser downtime, and disgruntled
customer. Still, practices with these crippled lasers realized that there is a strong consumer interest in long-term hair removal---along with a definite willingness to pay for this convenience. So these pioneers persevered through
the technical difficulties while they waited for superior technology to emerge. OVER THE PAST
three years, laser pioneers explored the optimum treatment parameters and patient selection criteria for hair removal treatments. They quickly realized that skin types are a critical factor, as well as laser power settings. The more conservative users tested skin patches and avoided suntanned or dark skin types, while others pushed the limits in a cavalier fashion --- causing skin burns and much patient dissatisfaction. Laser users soon recognized a perfect patient profile, defined as a light-skinned Caucasian with dark hair color. Yet from a market development standpoint, this patient selection criteria places severe limitations on a practice.
INTELLECTUAL BREAKTHROUGH Enter Dr. Horace Furumoto, a laser physicist that founded one of the first medical laser companies and designed the pulsed dye laser commonly used now for dermatology applications throughout the
world. Currently CEO of Cynosure in Chelmsford, MA, Dr. Furumoto started working with the 755-nm (near-infrared) wavelength in 1994 for an industrial application. This R&D project led to a prototype Alexandrite LPIR (long-pulse
infrared laser). In 1995, this Alexandrite laser was placed in the clinic of dermatologist David McDaniel, M.D. in Virginia Beach, VA to test it for leg vein treatments. However, by 1996 the dominant interest in the market at that time
was hair removal, which Dr. Furumoto realized would require even longer pulses {See New Technology section in this issue}. So he started to redesign the LPIR laser for hair removal in the summer of 1996. DR. FURUMOTO
likes to tell the story of an incident that finally convinced him that the Alexandrite laser had a bright future for hair removal. "I thought that we were so far behind the ruby lasers, which were already on the market at that time, that we couldn't catch up. Then one of our Asian distributors brought some of their doctors over to visit. These doctors treated themselves with the ruby laser for hair removal, and burned their skin at a low energy setting (20 J/cm ). They subsequently went to visit Dr. McDaniel where they obtained hair removal at 20 J/cm without any skin damage. This convinced both them and myself that we had a better technology then the ruby laser, even though that system had been under development for much longer. And we also don't need the patented chilled water-cooled handpiece that they use for cooling the epidermis."
CYNOSURE
subsequently finished the PhotoGenica LPIR commercial design, put this laser into production, and shipped 40 units in the first six months of 1997. The original FDA approval for the LPIR system only covered vascular applications. In August 1997, however, the FDA granted marketing clearance for the device in hair removal. Most of the early units were upgraded with some design enhancements, and customers continue to use them on a daily basis. And as word spread in the medical community regarding the clear advantages of LPIR technology versus ruby lasers, Cynosure was soon faced with a production backlog. This year, which represents the first full year of LPIR production, saw the delivery of about 150 units to customers. Based on the current volume of sales, and as production capacity increases, Cynosure expects to more than double this amount in 1998.
COMPANY BACKGROUND Cynosure was founded in 1991 by Horace Furumoto, Ph.D. and several colleagues who had previously worked with him at Candela Laser Corp.a company that he had also co-founded back in 1970. A
privately held company, Cynosure currently generates an estimated $30 million in annualized revenues with about 115 employees. This company has an installed base of over 600 aesthetic lasers for applications including: hair
removal; leg vein treatment; pigmented lesions; and vascular lesions. Last year, Inc. magazine named Cynosure as one of the fastest growing private companies in America. HOW THERMOKINETIC SELECTIVITY REMOVES HAIR The well-known principle of selective photothermolysis, as defined by Rox Anderson, M.D., involves destruction of target tissue through careful selection of wavelength, energy, and pulse length based on the thermal relaxation time
of the target cells. This concept works quite well for vascular lesions, where the target chromophores in blood are different from those in the intervening epidermis. However, using this approach can become problematic when
the target has the same chromophore as surrounding tissue (e.g. hair follicles and melanin in the epidermis). In his recent technical article on the subject {Derm Magazine, October 1997}, Dr. Marco Fuchs in Germany gives a
superb explanation of the new concept which makes the LPIR laser effective for hair removal: "The LPIR laser exploits the principle of Thermokinetic Selectivity (TKS). Because of the unfavorable volume-to-surface area ratio, target
structures of large volume (e.g.hair) are not as capable of radiating the absorbed laser energy (heat) through their relatively small surface area (and transmitting it onward into the surroundings) as small volume structures of the same
chromophore are capable of doing. After an appropriate time of exposure (pulse length), this results in a heating of the target hair shaft, followed by thermal destruction of the directly neighboring structures (papilla, germinative cell
layer, bulge area). Therefore, the duration of the laser pulse must logically be selected to lie above the thermal relaxation time of the epidermis and below the thermal relaxation time of the target cells. Hence, it follows that a
pulse duration of 10 40 milliseconds should prove ideal to damage the hair follicle without causing harm to the epidermis {See Figures 1-3}. Therefore, the long-pulse LPIR laser with pulse lengths of 20 milliseconds fulfills the
conditions for Thermokinetic Selectivity." PHOTOGENICA LPIR USERS OPTIMIZE TREATMENTS The rapidly growing installed base of PhotoGenica LPIR users is learning how to select patients, test skin patches prior to treatment,
and generally optimize their clinical results. Vic Narakur, M.D., who is assistant professor for laser and MOHS surgery in the Department of Dermatology at the University of California, Davis, has used the LPIR laser for hair removal on
over 100 patients since January 1997. The most predictable results for this researcher have been with patients that have the combination of Type I or Type II skin color, along with dark hair. But prior to treating any patient, Dr.
Narakur treats a 1 cm test patch of skin in the area where the patient wants hair removal, and then waits six weeks before deciding to attempt hair removal on the entire region. ON THE DAY of treatment, EMLA cream is applied to the
skin 30 minutes prior to the procedure after the area to be treated is shaved. A cold gel (aloe vera) is applied to the skin, and the laser output energy parameters are then pre-set, according to skin color. For dark skin types,
Dr. Narakur prefers to use a setting of 8 10 Joules; for medium color, 10 14 Joules; and 14 18 Joules for light skin types. Pulse length is always set at the maximum, which is 20 milliseconds. He then waits three
months between treatments. When asked about the permanence of hair removal, Dr. Narakur confirms what all experienced laser users have come to understand. "You need at least a one-year follow up study with each patient to
determine if the hair loss is long-term." A SCIENTIFIC PAPER published by Dr. Narakur in Cosmetic Dermatology, June 1997, attempts to explain the LPIR laser's ability to remove hair. "The Alexandrite wavelength
of 755-nm has considerable affinity for melanin. By carefully matching laser pulse duration and energy input to the diameter of the desired target, the long-pulse Alexandrite laser hears the large target enough to destroy it, while only
warming smaller targets and leaving them unaffected: Dr. Narakur is essentially describing the LPIR laser's mechanism of Thermokinetic Selectivity (TKS). GERMAN EXPERIENCE
Dr. Marco Fuchs articulated his clinical experience with PhotoGenica LPIR in a recent German language article in Derm Magazine, October 1997. After giving a scientific explanation of TKS, this dermatologist discussed his method of
treating patients with this device. He used the LPIR laser for hair removal on nearly every part of the body, but only found the need for pretreatment with EMLA cream on the upper lip. In order to cool the epidermis and
reduce the frequently reported prickly sensations experienced during treatment, ice cooled sonography gel was uniformly applied at a thickness of approximately 1 millimeter. All patients were treated with an energy fluence between 18 and
30 J/cm , at a pulse length of 20 milliseconds. Postoperatively, some of these patients experienced erythema in the treated area which lasted from 3 to 24 hours. However, Dr. Fuchs noted no blistering or severe pain that his patients
had experienced when he treated them previously with the Ruby laser, which had a pulse length of 1 millisecond, less depth of penetration in the skin, and required higher fluence levels. EACH PATIENT
initially received only one treatment, where the laserbeam was applied to the entire area and the patient returned for followup evaluations at 2 and 14 days postop. Most treatments in the facial area required 1 or 2 sessions, with an interval of six weeks before the second procedure. Histological examinations performed up to six months later appear to confirm that most hair follicles in the facial areas were destroyed.
COMPARISON STUDY Suzanne Kilmer, M.D. of the Laser & Skin surgery Center in Sacramento, CA has been using the LPIR laser for six months. During that time, she treated approximately 100 patients,
setting the energy fluence at 15 J/cm2 for darker skin types, or at 18 J/cm2
for light skin. Summarizing her experience so far, Dr. Kilmer said LPIR "works well for most patients, but sometimes we see complete hair regrowth which is unpredictable. We need to learn more about the physiology of hair growth to choose better treatment intervals, timing, and other factors." Dr. Kilmer has conducted some of the best scientific studies of laser-based hair removal, and she is currently in the midst of a clinical trial comparing the Ruby laser, Q-switched YAG, and Alexandrite laser.
Other LPIR laser users we contacted for this report were very positive about their clinical experiences with this system. For instance, Coyle Connolly, D.O. and Lawrence Paolini, D.O. of Cape May Courthouse, NJ have treated
more than 50 patients so far, typically using an energy setting of 20-27 J/cm2 . Most of these patients did not require EMLA cream as an anesthetic, and have reported permanent long-term hair reduction.
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Dermatologists Continue to Pioneer Laser Treatments
(Charlotte Observer) What do two
Charlotte dermatologists find most fascinating about their chosen field of study? In one word---"people" You might expect such an answer from psychologists, who study the human psyche, but coming from dermatologists, who study the body's
largest organ---the skin, the response is a bit surprising. John A. Thompson, Jr., M.D. and Charles J. Brown, M.D. partners at the Dermatologic Laser Center, say that the interaction with patients keeps their jobs gratifying although the
rapidly changing technology in laser dermatology is stimulating because it continues to offer new effective treatments for patients. "These exciting advances in laser dermatology," says Dr. Thompson, "offer patients many procedures
with short or no recovery periods that otherwise would be impossible given the busy schedules people have today."
With a CoolTouch
By Lee Preece
Look Younger in a Matter of Minutes One of the latest breakthroughs in laser dermatology is the CoolTouch
laser. "The CoolTouch treatment takes anti-aging technology to a new level with its uniquely gentle and effective approach. It is specifically designed to be safe for every skin type," said Dr. Brown. The CoolTouch process
eliminates the recovery period following laser resurfacing and lets patients enjoy the benefits of a laser facial treatment without the cosmetic downtime. No injections. No lingering redness. No tenderness. Just
smoother, younger looking skin. The treatment is done using a protective cryogen spray which cools the skin and allows the laser to penetrate deeper in the dermis. According to Dr. Thompson, "The cooling protects the sensitive surface
skin layer and nerve endings, while the laser stimulates the fibroblasts deep in the dermis where new collagen, the foundation of your skin, is generated. " After just two or three treatments, patients see their skin becoming smoother
and the signs of aging beginning to fade away. The process is most effective on the fine lines around the eyes and mouth, where the tissue has become less elastic, however the CoolTouch laser can be used anywhere. Treatments take only
15-30 minutes, and patients can continue their normal activities immediately. In clinical studies, after a series of 3 to 6 treatments, patients saw remarkable resolution of fine lines and wrinkles. Combined with a healthy lifestyle and
the skin care program your dermatologist recommends, CoolTouch Laser Treatments can lead to younger looking skin, and help reveal a beautiful and confident new you.
No Recovery period
It's Your Skin – See A Dermatologist Doctor Profiles
Dr. Thompson is a native of Texas. After graduating from Georgetown University and Bowman Gray School of Medicine (currently Wake Forest School of Medicine), he completed his dermatology
residency at UNC-Chapel Hill. Thompson chose dermatology because of the breadth of the field. "Dermatology draws on internal medicine, surgery, immunology and dermatopathology," he says. Brown, his medical partner, echoes
this sentiment and says he finds the scope of the specialty unique. "Skin diseases really profoundly affect people's self-esteem," says Dr. Brown. "Your skin is always on display for the entire world. Think of the
consequences of severe acne on a teenager or the impact of psoriasis on any patient. I see people of all ages with severe eczema who must cope on a daily basis with skin that is not visually normal." Dr. Thompson insists that
listening and talking with patients about their skin problems can be enlightening for both doctor and patient. "Oftentimes it requires sleuthwork to ferret out the cause of a rash," he says. Likewise he finds it vital to spend time with
acne patients to make sure they understand what is causing their acne and how to get the best results from their medicines. Of course, one of the most potentially devastating diseases dermatologists deal with is skin
cancer. Caused by a combination of genetic factors and excessive sun exposure, especially blistering sunburns, the incidence of skin cancer is increasing at an alarming rate. Both Thompson and Brown treated patients with melanoma
this past year. "Whereas this most serious form of skin cancer used to be relatively uncommon, we now routinely see several patients a year with melanoma," says Thompson. "If we catch it early there is a good prognosis for the
patient. We stress that people examine their skin on a regular basis for unusual or changing moles and see a doctor if any doubt exists." Fortunately ongoing research and technological advances are revolutionizing
the treatment of skin disease. The emergence of lasers to treat conditions as diverse as birthmarks and facial wrinkles has added a new dimension to dermatology's therapeutic tools. Thompson and Brown were the first dermatologists
in the Charlotte region to use lasers and currently devote a most of their practice to laser surgery. Lasers can now remove hair, tattoos, wrinkles, acne scars, age spots, treat red faces and rednecks, and oftentimes remove unsightly skin
growths with no scarring. Thompson has traveled throughout the world, including New Zealand, Australia, and the former Soviet Union, lecturing with the North American Clinical Dermatological Society. These medical
conferences provide opportunities to learn how medicine is practiced in other countries as well. Brown, too, is an experienced traveler and finds foreign languages challenging. A North Carolina native, he attended the
North Carolina School of the Arts as a musician and graduated from Oberlin College with degrees in both music and German. He then spent two years teaching music in a public school in Iceland where he also directed town and school
choirs. He then attended Yale University where he completed a master's degree in music. After graduation, however, Brown answered a challenge that he had been mulling for years---medical school. While at Yale he completed
pre-med courses and then returned home for medical school at UNC. He joined the practice of Charlotte Dermatology in 1992 and teamed up with Dr. Thompson in 1996. Although his medical practice is demanding, Brown still
travels as time permits. This past year, while in Turkey, he came across a boy with a severe birthmark on his face. "I realized that he would probably never get treatment for it in Turkey," he says, "so we decided to bring him
over. We plan to treat him every two to three months for a couple of years, so this involves a lot of travel preparations for him." Dr. Brown hopes that a new laser can significantly lighten the port-wine mark that covers half of this boy's
face. Both Brown and Thompson say they are lucky because they get to treat patients of all ages. And they are able to develop long-term relationships with their patients, many of whom they begin seeing as children.
In an era when most doctors have to see so many patients in a day, Drs. Thompson and Brown still try their best to answer their patients' questions. "Dr. Thompson spends so much time with his patients that he is always behind schedule,"
Brown jokes.
The Latest Advances In Laser Medicine
Shedding Light On Laser Surgery
Laser Hair Removal - Facts & Myths
Permanent Hair Reductionr Answers Hair Removal Demands
Dermatologists Continue To Pioneer Laser Medicine
LINKS
Restylane - Long term wrinkle filling agent
Candela Corporation - Developers of the Vbeam & IPL
Continuum Biomedical - Developers of the Medlite IV for Tattoos and Age Spots
Derma Genesis - Developers of the DermaPeel microdermabrator
SilkPeel - Dermalinfusion for fine lines, sun damage, acne and more!
Sculptra - Restoration and correction of facial fat loss (liopatrophy)
