Ellen S. Marmur

Use of High-Frequency, High-Resolution Ultrasound Before Mohs Surgery

BACKGROUND Although ultrasound imaging is employed ubiquitously today, its use to examine and assess the skin is a relatively new technology. We explored the clinical application and use of high‐frequency, high‐resolution ultrasound in Mohs micrographic surgery. OBJECTIVE To evaluate the ability of ultrasound to accurately determine lesion length and width of tumor borders in order to reduce the number of surgical stages. METHODS AND MATERIALS This was an institutional review board–approved single‐center study of 26 Mohs surgery patients. Ultrasound images were taken to record lesion dimensions, and then the investigator documented clinical estimation of the first stage. Extirpation of the tumor and histological analysis were performed thereafter. RESULTS The results of 20 patients were included in the analysis. A paired‐samples t‐test revealed no significant difference between clinical and ultrasound widths (t=−1.324, p=.20). Similarly, there was no significant difference between the lengths found from clinical assessment and ultrasound (t=−1.093, p=.29). For different tumor types, there was no significant difference between clinical and ultrasound widths or lengths for basal cell carcinoma (t=−1.307, p=.23; t=−1.389, p=.20) or squamous cell cancer (t=−0.342, p=.73; t=0.427, p=.68). CONCLUSION There is a diagnostic role for high‐resolution ultrasound in Mohs surgery regarding the delineation of surgical margins, but its limitations preclude its practical adoption at this time. The ultrasound equipment was loaned to the investigators. Funding for the study was provided by Longport, Inc.

Six-Month Safety Results of Calcium Hydroxylapatite for Treatment of Nasolabial Folds in Fitzpatrick Skin Types IV to VI

BACKGROUND Recently, the cosmetic market has seen an increase in the options for treatment for people with dark skin. OBJECTIVES This study evaluates the use of calcium hydroxylapatite (CaHA), a dermal filler indicated for the correction of moderate to severe facial wrinkles and folds, including the nasolabial folds (NLFs) in individuals with dark skin. METHODS This open‐label, nonrandomized, prospective, five‐center trial enrolled 100 patients aged 18 and older with Fitzpatrick skin types IV to VI. CaHA was injected subdermally with a 25‐ to 27‐gauge needle. Participants received a range of 0.6 to 2.8 mL of CaHA and returned at 3 and 6 months to be assessed for keloid formation, hypertrophic scarring, and hyper‐ or hypopigmentation. If necessary, each subject was offered a touch‐up at the conclusion of the 6‐month visit. RESULTS No reports of keloid formation, hypertrophic scarring, hypo‐ or hyperpigmentation, or other clinically significant adverse events were recorded. CONCLUSIONS People with dark skin injected subdermally with CaHA do not show signs of keloid formation, hypertrophic scarring, or hyper‐ or hypopigmentation. Because of this safety feature, as well as other characteristics of the product already shown in clinical literature, CaHA is an attractive dermal filler in this population. BioForm Medical, Inc. provided the products and equipment for this study. Drs. Marmur and Boyd are members of the Medical Education Faculty of Bioform.

Controlled, Randomized Study of Pain Levels in Subjects Treated with Calcium Hydroxylapatite Premixed with Lidocaine for Correction of Nasolabial Folds

BACKGROUND Calcium hydroxylapatite (CaHA) has been administered after nerve block injection of anesthetic agents. OBJECTIVES This prospective, randomized, split‐face, single‐blind study (50 subjects) assessed the pain reduction, safety, and effectiveness of premixing CaHA with 2% lidocaine for the treatment of nasolabial folds (NLFs). METHODS AND MATERIALS Subjects were randomized to receive treatment with CaHA alone in one NLF (control) and with CaHA premixed with lidocaine in the other NLF (treatment). Subjects completed pain assessments using a validated visual analog scale at specified time points immediately after injection, 1 hour after injection, and 1 month later. Subjects also indicated relative pain experience and preference assessments. Investigators completed aesthetic assessments at 2 weeks and 1 month. Subjects and investigators recorded adverse events. RESULTS Subjects reported statistically significantly less pain in the treatment fold than in the control fold and expressed unanimous preference for the treatment injection over the control. Aesthetic results were essentially equivalent for both treatments. CONCLUSION Investigators concluded that CaHA premixed with lidocaine results in significant pain reduction during dermal filler injection while maintaining the aesthetic improvement of CaHA without lidocaine and demonstrating comparable local transient adverse events for treatment and control. BioForm Medical (San Mateo, CA) provided the soft tissue filler, lidocaine, and other necessary supplies used in this study. All authors are members of the Bioform Medical Education Faculty.

A Five-Patient Satisfaction Pilot Study of Calcium Hydroxylapatite Injection for Treatment of Aging Hands

BACKGROUND The process of skin aging is not limited to the face but involves every part of the body, including the hands. A common manifestation of aging of the hands is the loss of volume, which occurs as the skin loses its subcutaneous fat. Injectable dermal fillers have surfaced as a popular method to address such deficiencies. OBJECTIVES To report the use of calcium hydroxylapatite (CaHA) to address lost volume. METHODS Five female subjects with soft tissue deficiency of the dorsa of the hands were enrolled at Mount Sinai Medical Center. A solution of CaHA with 2% lidocaine in amounts of 0.3 to 1.0 mL was injected interdigitally at each of three to five insertion sites; the sites were massaged and molded up to three times to ensure an optimal cosmetic end point. Subjects were seen for a follow‐up visit after 1, 4, 16, and 24 weeks. RESULTS With a single injection, all subjects reached their correction goals without requiring any touch‐ups. At the 24‐week visit, the subjects retained the filling effect, with no adverse events and high patient satisfaction. CONCLUSION CaHA, a new, easily injectable, safe dermal filler, has emerged as an excellent option for soft tissue augmentation in aging hands. BioForm Medical, Inc. provided the products and equipment for this study. Drs. Marmur and Boyd are members of the Medical Education Faculty of Bioform.

Nitroglycerin: A Review of Its Use in the Treatment of Vascular Occlusion After Soft Tissue Augmentation

BACKGROUND Skin necrosis after soft tissue augmentation with dermal fillers is a rare but potentially severe complication. Nitroglycerin paste may be an important treatment option for dermal and epidermal ischemia in cosmetic surgery. OBJECTIVES To summarize the knowledge about nitroglycerin paste in cosmetic surgery and to understand its current use in the treatment of vascular compromise after soft tissue augmentation. To review the mechanism of action of nitroglycerin, examine its utility in the dermal vasculature in the setting of dermal filler‐induced ischemia, and describe the facial anatomy danger zones in order to avoid vascular injury. METHODS A literature review was conducted to examine the mechanism of action of nitroglycerin, and a treatment algorithm was proposed from clinical observations to define strategies for impending facial necrosis after filler injection. RESULTS AND CONCLUSIONS Our experience with nitroglycerin paste and our review of the medical literature supports the use of nitroglycerin paste on the skin to help improve flow in the dermal vasculature because of its vasodilatory effect on small‐caliber arterioles.

The five D's of botulinum toxin: Doses, dilution, diffusion, duration and dogma

The purpose of this review is to update cosmetic dermatologists and surgeons on the latest information about botulinum toxin injections for the treatment of the face and neck and to provide a practical guide to effective and safe technique. We review indications, recommended doses and dilutions, storage recommendations and injection techniques.

Dermatological Complications of Diabetes Mellitus; Allergy to Insulin and Oral Agents

Long-standing diabetes and/or lack of tight glucose control over time may result in the development of complications affecting many organ systems including the skin. Due to the metabolic nature of the skin, fluctuations in glucose and insulin levels may result in skin changes. In many patients, the first presentation of diabetes may be in the form of skin changes. Therefore, recognition of skin manifestations of diabetes mellitus is an important aspect of the physical examination. Most cutaneous manifestations of diabetes are attributed either to chronic degenerative changes or to metabolic derangement.

The use of natural ingredients in innovative Korean cosmeceuticals

The cosmeceutical industry is an ever‐growing and in demand market, especially in Asia. Korea has been on the forefront of creating the newest generation and most innovative cosmeceuticals products including ingredients such as snail secretions, starfish powder, botanical extracts, green tea, and red ginseng. Given their increasing prevalence in the cosmeceutical industry, scientists have been conducting investigations into these extracts and their properties.

Energy-Based Devices in Male Skin Rejuvenation

Men seek cosmetic procedures for vastly different reasons than women. Men often seek discrete cosmetic services with little downtime. Male skin structure generally differs from female skin structure. Dermatologists should consider subtle differences in the psyche of the male cosmetic patient.

A review of available laser and intense light source home devices: A dermatologist's perspective

Home optical devices are becoming an increasingly popular treatment modality sought out by patients for dermatologic pathologies such as acne, hair removal and anti‐aging, as these devices are a low‐cost and convenient therapy choice.