Brian Biesman

Treatment of Hyaluronic Acid Filler–Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

Clinical evaluation of a single-wavelength fractional laser and a novel multi-wavelength fractional laser in the treatment of photodamaged skin†

Nonablative fractional lasers are well recognized for rejuvenating photoaged skin. We previously reported favorable outcomes with short follow‐up after the use of 1,440‐nm Nd:YAG laser energy used alone or in combination with a 1,320‐nm laser to effect rejuvenation and wrinkle reduction. We now report longer follow‐up data.

Assessment of Botulinum Toxin Aesthetic Outcomes: Clinical Study vs Real-World Practice.

Thirty years ago, few of us could have envisioned today’s practice of aesthetic medicine. Led by botulinum toxin type A (BoNTA), innovation in facial injectables has revolutionized our practices. New technologies are poised to further expand aesthetic treatment opportunities in the near future. To fuel continued progress, regulatory bodies must accurately reflect the knowledge and best practices shaped from the research and experience of the past 3 decades. Aesthetic medicine is unique; clinical success is inextricably linked to patient perception and preference. Whereas eradication of acne lesions or squamous cell carcinomas is easily quantified in medical dermatology, optimal outcomes in aesthetic medicine are not as objectively defined. Early usage of aesthetic BoNTA focused on immobilizing the muscles responsible for hyperdynamic lines. This approach dramatically reduced targeted lines yet precipitated a host of poor aesthetic outcomes, most notably the compromise of facial expressiveness. Contemporary aesthetic treatment approaches are more refined, and our dosing recommendations have trended downward to retain a balanced, natural look while diminishing unwanted lines. In August 2014, The US Food and Drug Administration (FDA) issued the draft guidance Upper Facial Lines: Developing Botulinum Toxin Drug Products.1 Although we applaud this document as a good initial step in establishing high standards for aesthetic BoNTA development, aspects of the guidance highlight fundamental misunderstandings of best practices in aesthetic medicine. Specifically, the Efficacy Endpoints section states, in part: • “Measurements at maximum contraction should be used to assess the efficacy of botulinum toxin drug products to demonstrate the paralytic effect. . . ”1(p7) • “Success should be defined as . . . a two-grade improvement from the baseline, on both the IA [investigator’s assessment] and the SSA [subject’s self-assessment] scales concurrently, to ensure clinical significance.”1(p8) Taken at face value, these measures may seem to be clear-cut methods of evaluating efficacy. In reality, these requirements can foster an approach that increases the risk for overtreatment and poorly reflects contemporary aesthetic practice. The guidance seems to presume that all muscle action associated with facial lines is undesirable. Yet, although muscular contraction creates lines that patients want diminished, it also enables the facial expressions they wish to keep. Facial appearance and emotive ability have important social implications and lay the foundation for social judgments about age and personality characteristics.2 Each facial feature uniquely contributes to the whole, and no single treatment or assessment approach should be applied universally.

Caution in the Use of Soft Tissue Injectable Fillers in the Tear Trough Region

I read with interest the article “Correction of Tear Trough Deformity With Novel Porcine Collagen Dermal Filler (Dermicol-P35),” which appeared in the May/June 2009 Supplement to Aesthetic Surgery Journal .1 I would like to congratulate the author, Dr. David Goldberg, on his successful use of this product in a challenging application. In his article, Dr. Goldberg reports excellent clinical results in 10/10 patients who received Dermicol-P35 injections in the tear trough region. I write this note from the perspective of an oculofacial plastic surgeon who has approximately …

Evaluation of a hot-wire hair removal device compared to razor shaving

We describe a blinded, controlled, prospective clinical study of a hot‐wire device promoted for hair removal and the reduction or delay of hair regrowth (no!no!, Radiancy, Inc., Orangeburg, NY) compared to a shaving control.

Commentary: Treatment of Venous Infraorbital Dark Circles Using a Long-Pulsed 1,064-nm Neodymium-Doped Yttrium Aluminum Garnet Laser

The article by Ma and colleagues 1 describes the use of long-pulse 1,064-nm laser energy to address a common yet challenging clinical concern that lacks a well-established solution. The question that must be addressed is whether use of long-pulsed 1,064-nm lasers around the eyes is safe. The authors treated 26 subjects one to three times and took the precautions of using corneoscleral shields, pulling the infraorbital skin away from the orbit, and directing the laser away from the eye. The only adverse events reported were moderate pain, transient mild erythema, and development of a blister in one subject. The authors did not specifically evaluate their subjects for ocular side effects or injury. Neodymium-doped yttrium aluminum garnet (Nd:YAG) 1,064-nm lasers have been used for many years to deliberately cause controlled injury to intraocular structures for the treatment of end-stage glaucoma. Numerous ocular complications, including macular holes, uveitis, and pupillary abnormalities, have been reported after the use of Nd:YAG lasers for military and aesthetic applications. Although I applaud the authors’ novel approach to a challenging clinical problem, in the absence of baseline and post-treatment comprehensive ophthalmic examinations, I do not believe that it is appropriate to conclude that the technique described in this study is safe or that the experimental methods adequately establish the safety of this technique from an ocular perspective. References

Wrinkles and Acne Scars: Technology-Based Treatment of Periorbital Wrinkles

Although many energy-based devices offer well-documented benefits in treating facial rhytids, less comprehensive study exists to support their safety and efficacy within the orbital rim. Choose ocular safety devices appropriate to the therapy. These include plastic eye shields for radiofrequency treatments and metal eye shields for laser resurfacing. To determine the optimal treatment, consider the anatomic basis for the patient’s periorbital rhytids: photodamage, volume loss, frequent use of the underlying musculature, or a combination of the three. Understand the primary indications and limitations of each of the major treatment options that are safe and efficacious for use in the periorbital region. Multiple treatment approaches are often required to optimize cosmetic results in the periocular area. These may include dermal fillers, chemical peels, neurotoxins, or blepharoplasty in addition to lasers or other energy-based devices. Surgery is indicated for individuals with excessive periorbital laxity or skin redundancy, which cannot be treated effectively with laser and energy treatments alone.

Technologiebasierte Behandlung periorbitaler Fältchen

Obwohl viele energiebasierte Gerate nachweisbare Vorteile bei der Behandlung von Gesichtsfaltchen bieten, gibt es nur wenige umfangreiche Studien, die die Sicherheit und Wirksamkeit ihrer Anwendung in der Periorbitalregion belegen. Je nach Therapieart muss ein geeigneter Augenschutz gewahlt werden. Dazu zahlen Augenschalen aus Plastik bei Radiofrequenzbehandlungen sowie Augenschalen aus Metall beim Laserresurfacing. Um die optimale Behandlung festzulegen, mussen die physiologischen Ursachen der periorbitalen Falten des Patienten sorgfaltig bedacht werden: UV-bedingte Hautalterung, Volumenverlust, haufige Aktivitat der darunterliegenden Muskulatur (dynamische Falten) oder eine Kombination dieser 3 Faktoren. Fundiertes Wissen uber die primaren Indikationen und die Grenzen aller wesentlichen Behandlungsoptionen, die bei der periorbitalen Anwendung als sicher und wirksam gelten, ist unerlasslich. Oft sind mehrere Behandlungsansatze notig, um die kosmetischen Ergebnisse an der periokularen Haut zu optimieren. Dazu zahlen neben Lasern und anderen energiebasierten Geraten dermale Fullstoffe, chemische Peelings, Neurotoxine oder Blepharoplastik. Ein chirurgischer Eingriff ist bei Patienten indiziert, bei denen ein ausgepragter periorbitaler Elastizitatsverlust oder ein Hautuberschuss vorliegt, der mit Laser- und anderen licht-/energiebasierten Behandlungen allein nicht effektiv behandelt werden kann.