Corey S. Maas

Temporal brow lift using botulinum toxin A.

The objective of this study was to determine whether brow elevation occurs as a result of paralysis of brow depressors after botulinum toxin A injection. The study’s design was a prospective case series with pretreatment and posttreatment outcome evaluation with statistical analysis at a university-based division of facial plastic surgery private clinic. Twenty-two patients of a consecutive sample desiring a cosmetic enhancement underwent injection of botulinum toxin A directed to brow depressors. Injections consisted of 7 to 10 units of botulinum toxin A (Botox, Allergan, Irvine, Calif.) into selected brow depressor muscle (lateral orbicularis oculi) bilaterally. No patients withdrew for adverse effects. All patients were evaluated 2 weeks after treatment. The outcomes were measured by change in brow elevation along vertical axis extending from both midpupil and lateral canthus to the caudal row of brow hairs with eyes at neutral gaze and the head at Frankfort plane. Preintervention and postintervention brow height was measured by the primary clinical investigator. The average brow elevation from the midpupil observed after selected injection of brow depressors with botulinum toxin A was 1.02 mm (p = 0.038). The average brow elevation from the lateral canthus observed after selected injection of brow depressors with botulinum toxin A was 4.83 mm (p < 0.0001). Significant temporal brow elevation occurs as the result of paralysis of brow depressors by using botulinum toxin A injection. This procedure may be considered an alternative to surgical brow elevation.

The predictive efficacy of the Müller maneuver in uvulopalatopharyngoplasty

Flexible pharyngoscopy with the Müller maneuver has been proposed as a method for selection of uvulopalatopharyngoplasty candidates. In this prospective study, its predictive efficacy has been evaluated in 24 consecutive obstructive sleep apnea patients undergoing uvulopalatopharyngoplasty. FPMM enabled us to accurately predict the uvulopalatopharyngoplasty outcome in 12 of the 24 patients (50%).

Complications of Inject able Synthetic Polymers in Facial Augmentation

BACKGROUND. Inject able synthetic materials have been used for augmentation of soft tissue defects, correction of wrinkles, and augmentation of facial features such as the nasal dorsum. Success has been limited by inflammatory reactions, material migration, and the difficulty of removal should complications occur. OBJECTIVE. To evaluate complications resulting from soft tissue augmentation with injectable allopathic materials. METHODS. Retrospective review of seven cases. Clinical history, treatment, histapathologic findings, and outcomes are assessed. RESULTS. Inflammatory reaction and tissue damage were refractory to antibiotics and steroids, and surgery was required to remove the foreign material. Histologic examination revealed giant cell foreign body reaction in all cases. CONCLUSION. Inject able synthetic polymers can produce significant complications including deformity and inflammatory tissue destruction, the control of which is complicated by the difficulty of removing the materials. Removable tissue fillers, such as e‐PTFE, or natural materials such as collagen, autologous, fat, or Alloderm, should be considered instead.

Twelve-month persistency of a novel ribose-cross-linked collagen dermal filler.

BACKGROUND The porcine collagen–derived dermal filler Dermicol-P35 (Evolence, Colbar LifeScience Ltd, Herzliya, Israel) has low immunogenicity and the potential to provide a long-lasting corrective response for soft-tissue contour deficiencies and deformities. OBJECTIVE The objective was to assess the persistence of the corrective response with Dermicol-P35 up to 12 months after obtaining an optimal cosmetic result (OCR) in a randomized, multicenter study comparing the efficacy and safety of Dermicol-P35 with the hyaluronic acid (HA) filler Restylane (Medicis Pharmaceutical Co.). METHODS & MATERIALS Subjects with moderate to deep nasolabial wrinkles (n=149) were randomized to injections of either Dermicol-P35 or HA on one side of the face and the alternative preparation on the contralateral side. If necessary, one touch-up injection could be given after 2 weeks to obtain an OCR. RESULTS Although the mean Modified Fitzpatrick Wrinkle Scale score increased gradually after achieving the OCR with Dermicol-P35, 95.3 and 76.5% of subjects, respectively, met the criteria for persistence of the corrective response after 9 and 12 months. Persistency rates were similar regardless of the requirement for a touch-up injection at Week 2. No unexpected, severe, or serious injection-related adverse events were experienced. CONCLUSION The effectiveness of Dermicol-P35 appears to be maintained for up to 1 year after achieving an OCR, both for touch-up and for non–touch-up subjects.

Long-term Safety and Efficacy of a New Botulinum Toxin Type A in Treating Glabellar Lines

OBJECTIVE To evaluate the long-term safety of repeated administrations of a new botulinum toxin type A (Reloxin; Medicis Pharmaceutical Corp, Scottsdale, Arizona) in the treatment of moderate to severe glabellar lines. METHODS Open-label assessment of 1200 patients receiving as many as 5 treatments of Reloxin over a 13-month period. The product was diluted in 2.5-mL sterile physiologic saline solution, 0.9%, without preservative to a concentration of 50 U of Reloxin per 0.25 mL of solution. Investigators injected 0.05 mL of the solution (10 U each) into each of 5 injection sites in the glabellar area on day 0 of each treatment cycle. There was a minimum 85-day gap between treatments. Postinjection clinical evaluation was performed on days 14 and 30 and monthly thereafter until retreatment, study completion, or early termination. The patients were telephoned on day 7 to check for adverse events (AEs) and concomitant medications, and patient diaries were used to document the onset of treatment effect. RESULTS The majority (72%) of treatment-emergent AEs were considered unlikely or not related to study treatment. Probably or possibly related treatment-emergent AEs occurred in 36% of patients. The most frequently occurring related AEs were injection site disorders (18%), nervous system disorders (14% and 12% headache), and eye disorders (9%). Related AEs around the injection site or eyes were usually reported by day 7 and then resolved. Reported ptosis does not differentiate between brow ptosis and eyelid ptosis. A total of 45 patients had a total of 55 instances of ptosis across all cycles, with most episodes lasting less than 3 weeks. The rates of ptosis decreased during successive cycles from 2.4% in cycle 1 to 0.6% in cycle 5. The proportion of patients reporting an onset of response by day 7 ranged from 93% to 95%. By investigator assessment, the response rate (patients reporting none or mild glabellar line severity scale scores on day 30) ranged from 80% to 91% during cycles 1 to 5. CONCLUSIONS There was no evidence of cumulative AEs or tachyphylaxis with multiple Reloxin treatments over a period of 13 months. The treatments were well tolerated. The rates of ptosis decreased over successive cycles, and the proportion of responders by day 7 ranged from 93% to 95%.

A validated lip fullness grading scale.

OBJECTIVES To develop the Lip Fullness Grading Scale for objective quantification of lip volume for a reliable assessment and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify fullness of upper and lower lip separately. Nine experts rated photographs of 35 subjects, twice, separately for upper and lower lip. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS Agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the fullness of the upper and lower lip for which patients commonly seek correction. This scale is well stratified, with low intra- and interrater variability.

A validated grading scale for crow's feet.

OBJECTIVE To develop the Crows Feet Grading Scale for objective quantification of the severity of lateral canthal lines and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of lateral canthal lines at rest and at maximum contracture of the orbicularis oculi. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect crows feet in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was significantly high. Furthermore, the test–retest correlation coefficients were high for each expert after an overnight interval, demonstrating low inter- and intraevaluator variability. CONCLUSION The 5-point photonumeric scale generated spans the severity of the type of crows feet for which patients most commonly seek correction. The scale is well stratified for consistent rating.

Botulinum toxin type B (MyoBloc) in the management of hyperkinetic facial lines

OBJECTIVE: Our goal was to evaluate the safety and efficacy of botulinum toxin type B (BTX-B) in the management of hyperfunctional facial lines. STUDY DESIGN AND SETTING: Twenty-four patients from an academic faculty practice were treated with 400 to 800 units BTX-B in the corrugator, orbicularis oculi, or frontalis. Patients were evaluated with the Wrinkle Improvement Score (WIS) and Rated Numeric Kinetic Line Scale (RNKLS) and questioned about side effects and pain. Evaluations were made at 1, 2, 4, 8, and 12 weeks. RESULTS: Onset of effect was within 72 hours. WIS and RNKLS for all sites were statistically better after treatment, with the effect lasting 8 weeks. In general, patients noted a moderate improvement (grade 2) on WIS and a 2-point improvement on RNKLS. Injection was more painful than that of BTX-A. There were no complications. CONCLUSION: BTX-B is a safe and effective technique to eliminate wrinkles. Further studies are needed to elucidate dosage and duration. SIGNIFICANCE: BTX-B is stable for prolonged periods of time, requires no preparation before use, and is antigenetically distinct from BTX-A.

A validated grading scale for forehead lines.

BACKGROUND As with other facial wrinkles, the gradual loss and disorganization of collagen fibers and elastin, connective tissues that provide underlying support for skin, cause horizontal forehead rhytides in large part. OBJECTIVES To develop the Forehead Lines Grading Scale for objective quantification of horizontal forehead rhytides at rest and with expression and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS The Forehead Lines Grading Scale is a 5-point photonumeric rating scale that was developed to objectively quantify resting (static) and hyperkinetic (dynamic) forehead lines. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was highly significant. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of forehead lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

A Validated Grading Scale for Marionette Lines

BACKGROUND Melomental folds, or marionette lines, are one of the consequences of facial aging. The curvilinear wrinkles formed because of facial movements and the aging process extend downward from the oral commissures. OBJECTIVES To develop the Marionette Lines Grading Scale for objective quantification of the severity of melomental folds and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of melomental folds. Nine experts rated photographs of 35 subjects, twice, with regard to marionette lines in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of marionette lines for which patients commonly seek correction. The scale is well stratified for consistent rating.