Top Doctors 2003

Meet the Bay Area doctors other doctors call when they're stumped by a diagnosis or need help for a patient facing a rare cancer or dicey surgery.

In 1991, a Boston company called Best Doctors asked some of the nation's leading physicians – teaching heads at universities and the like – to identify the doctors they trusted most in several dozen different specialists; the ones they picked then evaluated each other and nominated some more. So began the company's database of physicians reviews, which Best Doctors analyzes and boils down to a rolling list of 30,000 high-rated healers.

This month we excerpt the current local Best Doctors list. You aren't likely to find your primary doctor here; most of those named are specialists. You'll also see no sign of doctors over whom patients don't have much say (anesthesiologists) or those whose names we plan to publish later (general pediatricians). And certainly without objective ratings by patients, too – the Holy Grail of consumer research – no list can include every great doctor in the Bay Area. But if you or a loved one needs medical help, this is one reliable place to begin your search. Of those on the Best Doctors list, almost half take the time every year to evaluate the colleagues they know. That means, says Chris Greame of Best Doctors, the company may have 100 ratings on file to determine whether a heart surgeon makes the list, whereas for specialists in rare diseases, who travel in narrower medical circles, it may rely on a dozen. When doctors are judged to be no longer at their prime or their practice winds down, they drop off the list; meanwhile, new names come on. For more information, click on www.bestdoctors.com.

Botox's Best Bets

Chicago – Experience using botulinum toxin type A (Botox, Botox Cosmetic) over the past few years has taught dermatologists that its utility is not equivalent across its range of potential applications, Richard G. Glogau, M.D. said.

Speaking at the annual meeting of the American Society for Dermatologic Surgery, Dr. Glogau, clinical professor of dermatology, University of California at San Francisco, presented a Top 10 list of his personal prejudices on the best uses for the agent. His rankings, based on review of treatment efficacy, reproducibility, and "hassle" areas follows, in descending order:

1. Glabellar Frown Lines

This sole approved indication for Botox Cosmetic achieved top billing based on its technical simplicity, relatively low cost, high efficacy, and reproducibility. Dr. Glogau noted the injections are easy to perform, and it is possible to achieve uniform responses and consistently happy patients using a relatively low-dose of the toxin. "This is a procedure that can be easily taught and yields safe and reproducible results independent of the treating physician. Therefore, for doctors interested in incorporating botulinum toxin into their practice, treatment of glabellar frown lines is a good place to begin," he said.

He added that the popularity for the procedure among patients has less to do with wrinkle reduction and more to do with its impact on their interpersonal relationships. "Brow position has an enormous influence on nonverbal communication. Patients who receive botulinum toxin treatment for glabellar frown lines benefit with positive reinforcement when they interact with others, and I believe that consequence is the true driving force behind the popularity of Botox Cosmetic," Dr. Glogau said.

2. Horizontal Forehead Lines

Horizontal forehead liens achieved the No. 2 position, followed in order by two other uses in the upper third of the face. As is the case when treating the glabellar lines, delivering the intramuscular injections for improving the forehead lines is also straightforward, can be performed with predictably good results, and is relatively low cost considering the required dose.

3. Crow's Feet

Dr. Glogau ranked injection around the crow's feet a notch lower than the forehead line treatment, recognizing botulinum toxin is best used for crow's feet as an adjunct to resurfacing. "I credit Dr. Jean Carruthers and Dr. Tina Alster for pointing out to us that there can be a tremendous improvement in laser resurfacing of these periorbital wrinkles if botulinum toxin is used to immobilize the skin during the postoperative healing period. With use of this dual approach, however, it is possible to achieve highly reproducible results," Dr. Glogau said.

4. Infraorbital Horizontal Creases

Although botulinum toxin is highly effective in improving the appearance of those wrinkles, a "basic factor" comes into play in the treatment of infraorbital horizontal creases. At least 8 percent to 10 percent of patients develop transient lymphedema of the lower lid secondary to temporary loss of the pumping action of the orbicularis muscle, Dr. Glogau said. "Excluding individuals with medical contraindications, almost any patient with glabellar frown lines is a candidate for botulinum toxin treatment. However, older patients with infraorbital horizontal creases should not be injected with botulinum toxin if they have poor tarsal tone. So, be sure to screen for appropriate patients by performing snap test and warn those who are going to be treated about the potential for puffiness of the lower lid that can last for a few weeks until alternatively lymphatic drainage channels are established," he said.

5. Platysmal Bands, Horizontal Neck Creases

Treatment of these problems in the neck was recognized as having the potential to reproducibly yield a high cosmetic benefit, but the overall downside of injections at this anatomic location is an increased potential for bruising compared with treatment in the upper third of the face. Treatment of the platysmal bands also involves a higher dose relative to the previous indications, thus raising cost of the intervention.

6. Marionette Lines

Although a relatively low dose of botulinum toxin is required for treating these folds, the best efficacy is achieved when the toxin injection is combined with filler agents. In addition, achieving a predictable result is not always easy as there is a significant risk for causing problematic asymmetry. "When you hit the bulls-eye, you can provide patients with a very high esthetic effect with little expense, and this can be a great place to use botulinum toxin. However, asymmetry is a bigger problem when treating the lower face and even minute irregularities that develop in the smile or movements of the mouth are readily perceived by patients," said Dr. Glogau.

7. Axillary Hyperhidrosis

Dr. Glogau characterized treatment of excessive axillary sweating as being technically easy and resulting in reproducibly good outcomes with very satisfied patients. Expense was its biggest limitation. "Botulinum toxin treatment for axillary hyperhidrosis is a snap to do and one can hit home runs fairly consistently. However, the required dosage is fairly high, making the treatment costly. In fact, I think a lot more patients would take advantage of this very effective modality if it weren't for its cost," Dr. Glogau said.

8. Palmer Hyperhidrosis

Palmar Hyperhidrosis was ranked lower than axillary treatment because it is a more time consuming procedure, requires facility in administering wrist blocks for anesthesia, and is associated with a shorter duration of activity. Nevertheless, it is possible to achieve good outcomes with high patient satisfaction, Dr. Glogau said.

9. Migraine Headaches

Results achieved using botulinum toxin to treat migraine headaches can be very rewarding. However, the procedure requires use of about $800 to $1000 of drug and does not seem to work in about one-third of patients.

10. Perioral Rhytides

Two main objections accounted for Dr. Glogau's relatively low ranking of this potential use for botulinum toxin. He explained that the injection changes the conformation of the border between the skin and the vermilion. Therefore, the benefit of rhytid reduction is achieved at the expense of producing a flattened vermilion border. In addition, as when treating the marionette lines, production of asymmetry is a concern. "A sharp vermilion border is critical to the appearance of a younger lip, and so as to avoid trading one problem for another, botulinum toxin treatment for perioral rhytides should be combined with filler injections. Nevertheless, it is very easy to produce asymmetry in the upper lip, and my advice is to perform this treatment only in patients who have been satisfied in several previous visits with botulinum toxin injections for other indications," he said.

Botox and Botox Cosmetic are products of Allergen. Dr. Glogau is a consultant to the company.