Lauren Levy

Complications of minimally invasive cosmetic procedures: prevention and management.

Over the past decade, facial rejuvenation procedures to circumvent traditional surgery have become increasingly popular. Office-based, minimally invasive procedures can promote a youthful appearance with minimal downtime and low risk of complications. Injectable botulinum toxin (BoNT), soft-tissue fillers, and chemical peels are among the most popular non-invasive rejuvenation procedures, and each has unique applications for improving facial aesthetics. Despite the simplicity and reliability of office-based procedures, complications can occur even with an astute and experienced injector. The goal of any procedure is to perform it properly and safely; thus, early recognition of complications when they do occur is paramount in dictating prevention of long-term sequelae. The most common complications from BoNT and soft-tissue filler injection are bruising, erythema and pain. With chemical peels, it is not uncommon to have erythema, irritation and burning. Fortunately, these side effects are normally transient and have simple remedies. More serious complications include muscle paralysis from BoNT, granuloma formation from soft-tissue filler placement and scarring from chemical peels. Thankfully, these complications are rare and can be avoided with excellent procedure technique, knowledge of facial anatomy, proper patient selection, and appropriate pre- and post-skin care. This article reviews complications of office-based, minimally invasive procedures, with emphasis on prevention and management. Practitioners providing these treatments should be well versed in this subject matter in order to deliver the highest quality care.

Female pattern alopecia: current perspectives

Hair loss is a commonly encountered problem in clinical practice, with men presenting with a distinctive pattern involving hairline recession and vertex balding (Norwood-Hamilton classification) and women exhibiting diffuse hair thinning over the crown (increased part width) and sparing of the frontal hairline (Ludwig classification). Female pattern hair loss has a strikingly overwhelming psychological effect; thus, successful treatments are necessary. Difficulty lies in successful treatment interventions, as only two medications – minoxidil and finasteride – are approved for the treatment of androgenetic alopecia, and these medications offer mediocre results, lack of a permanent cure, and potential complications. Hair transplantation is the only current successful permanent option, and it requires surgical procedures. Several other medical options, such as antiandrogens (eg, spironolactone, oral contraceptives, cyproterone, flutamide, dutasteride), prostaglandin analogs (eg, bimatoprost, latanoprost), and ketoconazole are reported to be beneficial. Laser and light therapies have also become popular despite the lack of a profound benefit. Management of expectations is crucial, and the aim of therapy, given the current therapeutic options, is to slow or stop disease progression with contentment despite patient expectations of permanent hair regrowth. This article reviews current perspectives on therapeutic options for female pattern hair loss.

Emotional benefit of cosmetic camouflage in the treatment of facial skin conditions: personal experience and review

Background Recent studies highlighting the psychological benefits of medical treatment for dermatological skin conditions have demonstrated a clear role for medical therapy in psychological health. Skin conditions, particularly those that are overtly visible, such as those located on the face, neck, and hands, often have a profound effect on the daily functioning of those affected. The literature documents significant emotional benefits using medical therapy in conditions such as acne, psoriasis, vitiligo, and rosacea, but there is little evidence documenting similar results with the use of cosmetic camouflage. Here we present a review highlighting the practical use of cosmetic camouflage makeup in patients with facial skin conditions and review its implications for psychological health. Methods A search of the Medline and Scopus databases was performed to identify articles documenting the emotional benefit of cosmetic camouflage. Results Cosmetic camouflage provides a significant emotional benefit for patients with facial skin conditions, and this is substantiated by a literature review and personal experience. More clinical studies are needed to assess and validate the findings reported here. Conclusion Patients with visible skin conditions have increased rates of depression, anxiety, and decreased self-esteem. It is prudent for us to consider therapies that can offer rapid and dramatic results, such as cosmetic camouflage.

Optical imaging with a high-resolution microendoscope to identify cholesteatoma of the middle ear.

High‐resolution optical imaging is an imaging modality that allows visualization of structural changes in epithelial tissue in real time. Our prior studies using contrast‐enhanced microendoscopy to image squamous cell carcinoma in the head and neck demonstrated that the contrast agent, proflavine, has high affinity for keratinized tissue. Thus, high‐resolution microendoscopy with proflavine provides a potential mechanism to identify ectopic keratin production, such as that associated with cholesteatoma formation, and distinguish between uninvolved mucosa and residual keratin at the time of surgery.

Biologics in the treatment of psoriasis and emerging new therapies in the pipeline

Correspondence: Jason J Emer Mount Sinai School of Medicine, Department of Dermatology, 5 East 98th Street, 5th Floor, New York, NY 10029, USA Tel +1 212 659 9530 Fax +1 212 348 7434 Email Jason.emermd@gmail.com Abstract: Elucidation of the immunopathogenesis of psoriasis has led to the discovery of novel biologic agents for the treatment of moderate-to-severe plaque psoriasis. There are currently five biologic agents approved by the US Food and Drug Administration for psoriasis which have proven to be quite efficacious in clinical trials and in post-marketing and clinical experience. As more details are uncovered about the immunologic pathways involved in initiation and maintenance of this disease, there will be an increasing development and marketing of novel therapeutics. It is crucial to understand the immunopathogenesis of psoriasis and the mechanisms of these novel agents in order to to treat the psoriatic population effectively and mitigate disease burden. This article reviews the currently approved biologics for the treatment of psoriasis, with emphasis on efficacy and safety. There are countless therapies currently in the research pipeline, with mechanisms ranging from receptor antagonism to signal transduction pathway inhibition. The initial trials and future studies involving these new agents are also reviewed. As therapeutics escalate through the research pipeline, the management and treatment of psoriasis will likely become more manageable for practitioners and patients.

High-Resolution Optical Imaging of Benign and Malignant Mucosa in the Upper Aerodigestive Tract: An Atlas for Image-Guided Surgery

BACKGROUND High-resolution optical imaging provides real-time visualization of mucosa in the upper aerodigestive tract (UADT) which allows non-invasive discrimination of benign and neoplastic epithelium. The high-resolution microendoscope (HRME) utilizes a fiberoptic probe in conjunction with a tissue contrast agent to display nuclei and cellular architecture. This technology has broad potential applications to intraoperative margin detection and early cancer detection. METHODS Our group has created an extensive image collection of both neoplastic and normal epithelium of the UADT. Here, we present and describe imaging characteristics of benign, dysplastic, and malignant mucosa in the oral cavity, oropharynx, larynx, and esophagus. RESULTS There are differences in the nuclear organization and overall tissue architecture of benign and malignant mucosa which correlate with histopathologic diagnosis. Different anatomic subsites also display unique imaging characteristics. CONCLUSION HRME allows discrimination between benign and neoplastic mucosa, and familiarity with the characteristics of each subsite facilitates correct diagnosis.

Comparison of high-resolution microendoscope images and histopathological sections in ex vivo middle ear cholesteatomas and surrounding tissue

Objective: To investigate the concordance between optical images obtained with high-resolution microendoscopy (HRME) and conventional histopathology for ex vivo cholesteatoma specimens and surrounding middle ear epithelium. Methods: After resection of cholesteatoma and surrounding middle ear epithelium from surgical patients, tissues were stained with a contrast agent, proflavine, and the HRME fiberoptic scope was placed directly on each tissue specimen. 4- 10 short movie clips were recorded for both the cholesteatoma and surrounding middle ear epithelium specimens. The imaged areas were sent for standard histopathology, and the stained specimens were correlated with the HRME images. IRB approval was obtained, and each patient was consented for the study. Results: Ten cholesteatoma specimens and 9 middle ear specimens were collected from 10 patients. In each case, cholesteatoma was easily discriminated from normal middle ear epithelium by its hyperfluorescence and loss of cellular detail. Qualitative analysis for concordance between HRME images and histological images from the same surgical specimen yielded a strong correlation between imaging modalities. Conclusions: Keratinizing cholesteatoma and surrounding middle ear epithelium have distinct imaging characteristics. Loss of cellular detail and hyperfluorescence with proflavine are the hallmark characteristics of cholesteatoma which allow for differentiation from normal middle ear epithelium. Real-time optical imaging can potentially improve the results of otologic surgery by allowing for extirpation of cholesteatomas while eliminating residual disease. We anticipate performing an in vivo study to test this hypothesis.

High-Resolution Microendoscope Images of Middle Ear Cholesteatoma and Surrounding Tissue Evaluation of Interobserver Concordance

Objective Investigate how accurately otolaryngologists could differentiate between images obtained with high-resolution microendoscopy (HRME) of ex vivo cholesteatoma specimens and surrounding middle ear epithelium. Study Design HRME images of surgically resected cholesteatoma and middle ear epithelium were obtained and otolaryngologists classified these images. Setting Tertiary medical center. Subjects and Methods Resected cholesteatoma and middle ear epithelium were stained with a contrast agent, proflavine, and HRME images were captured. Specimens were sent for standard histopathology and compared with HRME images. Quality-controlled images were used to assemble a training set. After viewing training images, otolaryngologists without prior cholesteatoma HRME experience reviewed and classified test images. Results Ten cholesteatoma and 9 middle ear specimens were collected, of which 17 representative cholesteatoma and 19 middle ear epithelium images were extracted for a testing set. Qualitative analysis for concordance between HRME images and histological images yielded a strong correlation between modalities. The mean accuracy of all reviewers in correctly identifying images was 95% (95% confidence interval [CI], 92%-98%). The sensitivity to correctly detect cholesteatoma images was 98% (95% CI, 93%-100%), and the specificity was 92% (95% CI, 87%-97%). The Fleiss kappa interrater reliability score was 0.83, (95% CI, 0.77-0.89). Conclusions Medical professionals can quickly be trained to accurately distinguish between HRME images of cholesteatoma and normal middle ear epithelium, both of which have distinct imaging characteristics. Real-time HRME optical imaging can potentially improve the results of otologic surgery by allowing for extirpation of cholesteatomas while eliminating residual disease.

Treatment of Psoriasis during Pregnancy

Data on pregnant or lactating women with psoriasis are limited, in part because of the ethical ramifications of placing pregnant women in clinical trials. This article reviews topical and systemic treatment options for women with psoriasis who are pregnant or nursing. Caution is advised both when prescribing treatments with known risks to the fetus and when prescribing treatments for which data are lacking.

Ex vivo high resolution imaging with a miniaturized microendoscope to discriminate between benign and malignant mucosa in the upper aerodigestive tract.

•Continued refinement of this optical imaging technology may lead to improved ability to accurately determine optical margins, facilitate the sparing of uninvolved normal tissue, and find application to novel technological platforms, such as robotic surgery. Figure 1. High Resolution Microendoscope (HRME). The device consists of a fiber-optic bundle which can deliver high resolution narrow field images of tissue morphology. The image is magnified by a microscope objective. Surface staining with a nuclear dye is required to display the morphology of the epithelial nuclei.