Kenneth Beer

Comparison of the Rheological Properties of Viscosity and Elasticity in Two Categories of Soft Tissue Fillers: Calcium Hydroxylapatite and Hyaluronic Acid

BACKGROUND Two types of soft tissue filler that are in common use are those formulated primarily with calcium hydroxylapatite (CaHA) and those with cross‐linked hyaluronic acid (cross‐linked HA). OBJECTIVE To provide physicians with a scientific rationale for determining which soft tissue fillers are most appropriate for volume replacement. MATERIALS Six cross‐linked HA soft tissue fillers (Restylane and Perlane from Medicis, Scottsdale, AZ; Restylane SubQ from Q‐Med, Uppsala, Sweden; and Juvéderm Ultra, Juvéderm Ultra Plus, and Juvéderm Voluma from Allergan, Pringy, France) and a soft tissue filler consisting of CaHA microspheres in a carrier gel containing carboxymethyl cellulose (Radiesse, BioForm Medical, Inc., San Mateo, CA). METHODS The viscosity and elasticity of each filler gel were quantified according to deformation oscillation measurements conducted using a Thermo Haake RS600 Rheometer (Newington, NH) using a plate and plate geometry with a 1.2‐mm gap. All measurements were performed using a 35‐mm titanium sensor at 30°C. Oscillation measurements were taken at 5 pascal tau (&tgr;) over a frequency range of 0.1 to 10 Hz (interpolated at 0.7 Hz). Researchers chose the 0.7‐Hz frequency because it elicited the most reproducible results and was considered physiologically relevant for stresses that are common to the skin. RESULTS The rheological measurements in this study support the concept that soft tissue fillers that are currently used can be divided into three groups. CONCLUSION Rheological evaluation enables the clinician to objectively classify soft tissue fillers, to select specific filler products based on scientific principles, and to reliably predict how these products will perform—lifting, supporting, and sculpting—after they are appropriately injected. Drs. Beer and Sundaram are members of the Medical Education Faculty for BioForm Medical. They have received compensation from the company for presentations about Radiesse to the medical community. Authors Voigts and Meland are employees in Research and Development at BioForm Medical, Inc. BioForm Medical provided the logistical and financial support for execution of this study. Unless stated otherwise, all of the dermal fillers discussed in this article were purchased from commercial sources.

Dermal Fillers and Combinations of Fillers for Facial Rejuvenation

Until recently, the use of dermal fillers was limited in the United States by the small number of products approved by the Food and Drug Administration. The products now approved for use in the United States have opened up the range of possibilities for combinations of products that are synergistic in their effects. Combinations of products may be discussed in temporal or anatomic relationships. Temporal combinations refer to the use of different fillers at different times, whereas anatomic combinations refer to the use of different fillers in different parts of the face. Before discussing how the various fillers may be used in combination, it is worthwhile to consider their use in isolation. Soft-tissue augmentation products under consideration in the present article include the hyaluronic acids (HA), poly L lactic acid (PLLA), calcium hydroxylapatite (CAHA), porcine collagen, and silicone.

Overview of facial aging.

Facial aging is a multidimensional, multifactorial process. The aging face has traditionally been treated by each specialty in a different manner. However, by understanding the process from the perspective of different specialties, each physician may better treat the spectrum of facial aging. Whether or not the facial plastic surgeon injects products to restore volume, uses lasers to resurface the epidermis and dermis, incorporates cosmeceuticals to enhance and maintain improvements in the skin integrity and appearance, or relaxes muscles with botulinum toxins, he or she can best advise patients and address facial aging by having a functional understanding of these various modalities. With this knowledge, the facial plastic surgeon can parse the component of facial aging that enables him or her to correct each with the appropriate treatment.

Relationship between delayed reactions to dermal fillers and biofilms: facts and considerations.

BACKGROUND Delayed reactions associated with dermal fillers have often been attributed to hypersensitivity reactions; however, the evolving literature suggests that biofilms may represent an underrecognized cause and a difficult diagnosis to establish. As implanted devices become more popular, biofilms present an increasing risk to patients. OBJECTIVE The mechanism of action for biofilm formation, diagnostic challenges, and methods to recognize biofilms will be reviewed. These are increasingly important for physicians who implant these devices and for those who see patients with implanted devices. METHODS We review the relevant literature and explore some of these issues. CONCLUSION Preventative measures may decrease delayed reactions and biofilm formation after injection of dermal fillers. Infection through biofilms should be considered and carefully evaluated to ensure timely treatment.

Treatment of eyebrow hypotrichosis using bimatoprost: a randomized, double-blind, vehicle-controlled pilot study.

BACKGROUND The Food and Drug Administration has approved bimatoprost ophthalmic solution (0.03%) for the treatment of eyelash hypotrichosis. Previous reports of its efficacy in eyebrow hypotrichosis are anecdotal. OBJECTIVE To assess the efficacy and safety of bimatoprost 0.03% ophthalmic solution applied to the eyebrows in a randomized, double‐blind, vehicle‐controlled study. METHODS Subjects (n = 20) with mild to moderate eyebrow hypotrichosis enrolled in the study. One group (Bim) applied bimatoprost to each eyebrow daily for 9 months, and another applied vehicle nightly to each eyebrow for 5 months. Subjects in the latter group were re‐randomized to apply bimatoprost (Veh‐Bim Group) or vehicle (Veh Group) daily to each eyebrow for 4 months. The primary end point was investigator‐assessed eyebrow appearance; secondary end points were subject‐reported outcomes. RESULTS Investigator assessments showed significant improvements from baseline to 6 (p = .002) and 7 (p = .005) months for the eyebrows treated with bimatoprost. p‐Values for the Veh‐Bim and Veh groups were not significant at any time point. End‐of‐study subject satisfaction with eyebrow fullness or thickness and darkness or color was greater in the Bim group than in the Veh group. Adverse effects were not observed. CONCLUSION Bimatoprost 0.03% ophthalmic solution applied daily for 9 months improves the appearance of eyebrows noticeably more than vehicle, without side effects.

Clinicopathologic correlation of delayed-onset periorbital poly-L-lactic acid nodules.

&NA; The author has indicated no significant interest with commercial supporters.

Cosmeceuticals for Rejuvenation

Facial plastic surgeons are frequently called upon to enhance the appearance of their patients. Typically, this involves surgery of the face or neck. Increasingly, this may also require the use of injectables such as botulinum toxins, fillers, and volumizers. Lasers and light sources are used to enhance the appearance of the surface of the skin. Each of these modalities will help to improve the patient but are limited by the fact that they require the patient to be treated in the office. With the advent of effective topical agents, patients are increasingly able to improve their appearance with the use of prescription and nonprescription topical products. It is incumbent upon the facial plastic surgeon to have an understanding of these topical agents so that they can assist the patient in deciding what does and does not make sense. In addition, many cosmetic physicians will dispense these products in their office, and it behooves them to understand the various products available and what will likely be produced in the future.

Delayed Complications from Thread-Lifting: Report of a Case, Discussion of Treatment Options, and Consideration of Implications for Future Technology

The use of minimally invasive surgical techniques to reverse facial ptosis has a significant attraction for physician and patient alike. To the patient, this procedure holds the potential to provide results that, while not the same as a traditional face-lift, provide some of the benefits of this surgery. For the physician, the procedures offer an opportunity to provide dramatic results in less time and with less liability. A great deal of initial enthusiasm was generated by published reports with the APTOS threads. These reports included one that stated that ‘‘Lifting facial tissues using APTOS threads is simple, constructive and time saving.’’ The same publication continues to state that ‘‘It avoids scars and the need for implants.’’ Another publication also advocated the use of threads as a replacement for traditional surgical interventions because the threads not only had minimal complications but also had high patient satisfaction. However, there have been complications associated with the various thread-lift procedures that include nerve damage and scarring. This report documents a case of delayed thread migration to the surface of the skin and discusses one approach to remove the threads.

Skin Cooling Provides Minimal Relief of Patient Discomfort During Periocular Botulinum Toxin Type A Injection

When multiple injections of botulinum toxin type A are necessary, pain may become intense enough to interrupt the treatment session. This is particularly true when the lateral orbital areas are injected. The results of this study show that cooling the periorbital area with the cooling device does not significantly reduce pain associated with injection of botulinum toxin type A or increase the likelihood of patients returning for repeat treatment.

An open-label trial examining the efficacy and safety of a pre- and postprocedure topical five-product system (Clinique Medical Optimizing Regimen) specifically formulated to complement laser/light-based facial cosmetic procedures

Abstract Background: Specialized skin care regimens may help to minimize adverse events (AEs) following non-ablative facial procedures. Methods: A 14-week, open-label, three-center study evaluated the efficacy and safety of a topical five-product system (Clinique Medical Optimizing Regimen; Allergan, Inc., Irvine, CA, USA) for minimizing localized AEs during two 6-week procedure cycles with fractionated laser (FL) or intense pulsed light (IPL). The skin care regimen consisted of a 2-week preprocedure phase, a 1-week postprocedure phase, and a 3-week maintenance phase. Investigators and patients rated the presence and severity of erythema, itching, stinging/burning, edema, pain, pruritus, swelling, crusts/erosion, and photodamage. Results: Two days after the FL/IPL treatment (IPL: n = 27; FL: n = 21), most assessments, including erythema, were near baseline values; at 4 weeks postprocedure, all investigator scores were comparable to baseline. Patients missed work or avoided social situations a mean of only 0.8 days. Mean subject ratings for itching, stinging/burning, pain, swelling, and redness for 2 weeks postprocedure were ‘none’ to ‘mild’. Treatment-related AEs (acne, facial rash) occurred in four patients. All investigators stated they would recommend this topical over-the-counter regimen again in conjunction with non-ablative FL/IPL treatments. Conclusions: This topical five-product skin care system was safe and effective in conjunction with non-ablative FL/IPL procedures.