Lucile E. White

Ultrasound tightening of facial and neck skin: A rater-blinded prospective cohort study

BACKGROUND Nonablative skin tightening technologies offer the prospect of reduction of wrinkles and skin sagging with minimal downtime, discomfort, and risk of adverse events. The excellent safety profile is mitigated by the limited efficacy of such procedures. OBJECTIVE We sought to assess the efficacy of ultrasound skin tightening for brow-lift in the context of a procedure treating the full face and neck. METHODS This was a rater-blinded, prospective cohort study at a dermatology clinic in an urban academic medical center. Subjects were medicated with topical anesthetic and then treated with an investigational focused intense ultrasound tightening device to the forehead, temples, cheeks, submental region, and side of neck using the following probes: 4 MHz, 4.5-mm focal depth; 7 MHz, 4.5-mm focal depth; and 7 MHz, 3.0-mm focal depth. Standardized photographs of front and side views were obtained at 2, 7, 28, 60, and 90 days; rating scales of pain, adverse events, physical findings, and patient satisfaction were also completed. Primary outcome measure was detection of improvement in paired comparison of pretreatment and posttreatment (day 90) photographs by 3 masked expert physician assessors, cosmetic and laser dermatologists, and plastic surgeons who were not authors. Second primary outcome measure was objective brow elevation as quantitated by a standard procedure using fixed landmarks. Secondary outcomes measure was patient satisfaction as measured by a questionnaire. RESULTS A total of 36 subjects (34 female) were enrolled, one subject dropped out, and 35 subjects were evaluated. Median age was 44 years (range 32-62). On the first primary outcome measure, 30 of 35 subjects (86%) were judged by the 3 masked experienced clinician raters to show clinically significant brow-lift 90 days after treatment (P = .00001). On the second primary outcome measure, mean value of average change in eyebrow height as assessed by measurement of photographs at 90 days was 1.7 mm. LIMITATIONS Limitations of this study include the inability to quantitatively measure lower face tightening because of the lack of fixed anatomic landmarks in this area. CONCLUSION Ultrasound appears to be a safe and effective modality for facial skin tightening. A single ultrasound treatment of the forehead produced on average brow height elevation of slightly less than 2 mm. Most treated individuals responded, commonly with accompanying transitory mild erythema and edema.

Barbed sutures: A review of the literature

Background: Despite substantial mention in the popular press, there is little in the plastic surgery or dermatology literature regarding the safety, efficacy, longevity, or complications of barbed suture suspension procedures. The authors review the literature to estimate several clinical parameters pertaining to barbed thread suspensions. Methods: The authors performed a MEDLINE search using the keywords “barbed and suture,” “thread and suspension,” “Aptos,” “Featherlift,” and “Contour Thread.” Results: The authors identified six studies that met their criteria of addressing midface elevation with barbed thread suspension. These detected some adverse events, but most of these were minor, self-limited, and of short duration. Less clear are the data on the extent of the peak correction and the longevity of effect. Objective outcome measures and long-term follow-up data were not provided in a systematic manner in the few available studies. Conclusions: Suspension of the aging face with barbed sutures offers the promise of a minimally invasive technique with diminished adverse events. The technique is in its infancy, but it has potential to be a useful and effective clinical tool as further innovations are made in the clinic and laboratory.

Accelerated resolution of laser‐induced bruising with topical 20% arnica: a rater‐blinded randomized controlled trial

Background  Dermatological procedures can result in disfiguring bruises that resolve slowly.

Comparison of Electrodesiccation and Potassium‐Titanyl‐Phosphate Laser for Treatment of Dermatosis Papulosa Nigra

BACKGROUND There is a lack of randomized split‐face studies investigating treatments for dermatosis papulosa nigra (DPN) in dark skin. OBJECTIVE To compare the efficacy, safety, and tolerability of potassium‐titanyl‐phosphate (KTP) laser with efficacy, safety, and tolerability of electrodesiccation in the treatment of DPN in subjects with Fitzpatrick skin phototypes IV to VI. METHODS Fourteen subjects with Fitzpatrick skin phototypes IV to VI were randomized to receive two KTP laser treatments 4 weeks apart to half of the face. The contralateral half received two electrodesiccation treatments 4 weeks apart. Response was evaluated by photography reviewed by blinded dermatologists at 4 weeks after the second treatment. A treatment quality questionnaire about side effects and cosmetic outcome was also administered. RESULTS Difference in improvement of DPN between the KTP side and the electrodesiccation side per each rater (p=.99, p=.54) and per raters combined (p=.50) did not reach statistical significance. There was no treatment difference for subjective effectiveness (p=.06) or subjective confidence improvement (p=.99), although there was a significant treatment difference for subjective discomfort (p=.002) in favor of KTP. Both treatments were well tolerated without significant adverse effects. CONCLUSIONS Although treatment of DPN with KTP laser and electrodesiccation are comparable in efficacy, KTP laser is preferable for patient comfort. The authors have indicated no significant interest with commercial supporters.

Association Between Number of Stages in Mohs Micrographic Surgery and Surgeon-, Patient-, and Tumor-Specific Features: A Cross-Sectional Study of Practice Patterns of 20 Early- and Mid-Career Mohs Surgeons

OBJECTIVE To determine the number of Mohs micrographic surgery (MMS) stages per tumor taken by early‐ to mid‐career Mohs surgeons and to assess other factors affecting number of stages. METHODS Statistical analysis of MMS logs of 20 representative early‐ to mid‐career surgeons. RESULTS There was no difference in stages when surgeons were divided into two categories based on whether they had more than 500 cases per year or more than 5 years of experience. Similarly, when surgeons were categorized according to geographic location, there was no difference in number of stages. Anatomic location was associated with the number of stages (analysis of variance, p<.001), with the greatest number of stages for nose (2.01) and ear (2.06) lesions and the fewest for neck (1.47), back and shoulder (1.47), and lower extremity (1.33) lesions. Basal cell carcinomas required 1.92 stages (median 2.00), compared with 1.66 (median 1.00) for squamous cell carcinoma (p<.001). CONCLUSIONS Early‐ and mid‐career Mohs surgeons appear to remove tumors with similar numbers of stages regardless of their experience, case volume, or geographic location. Number of stages varies with anatomic location and tumor type. &NA; The authors have indicated no significant interest with commercial supporters.

Association Between Type of Reconstruction After Mohs Micrographic Surgery and Surgeon-, Patient-, and Tumor-Specific Features: A Cross-Sectional Study

BACKGROUND There are few data to indicate whether the type of final wound defect is associated with the type of post‐Mohs repair. OBJECTIVE To determine the methods of reconstruction that Mohs surgeons typically select and, secondarily, to assess the association between the method and the number of stages, tumor type, anatomic location, and patient and surgeon characteristics. METHODS Statistical analysis of procedure logs of 20 representative young to mid‐career Mohs surgeons. RESULTS The number of stages associated with various repairs were different (analysis of variance, p < .001.). Linear repairs, associated with the fewest stages (1.5), were used most commonly (43–55% of defects). Primary repairs were used for 20.2% to 35.3% of defects of the nose, eyelids, ears, and lips. Local flaps were performed typically after two stages of Mohs surgery (range 1.98–2.06). Referral for repair and skin grafts were associated with cases with more stages (2.16 and 2.17 stages, respectively). Experienced surgeons were nominally more likely perform flaps than grafts. Regression analyses did not indicate any association between patient sex and closure type (p = .99) or practice location and closure type (p = .99). CONCLUSIONS Most post‐Mohs closures are linear repairs, with more bilayered linear repairs more likely at certain anatomic sites and after a larger number of stages.

Comparison of Treatment of Cherry Angiomata With Pulsed-Dye Laser, Potassium Titanyl Phosphate Laser, and Electrodesiccation A Randomized Controlled Trial

OBJECTIVE To assess the comparative efficacy of energy treatments in resolving cherry angiomata. DESIGN Rater-blinded randomized controlled trial. SETTING Outpatient dermatology clinic in an urban referral academic medical center. PARTICIPANTS Fifteen healthy adults aged 21 to 65 years were enrolled. Two eligible individuals who were approached declined to participate, and no one enrolled was withdrawn for adverse effects. INTERVENTIONS For each participant, 3 areas on the torso were demarcated such that each area contained 4 cherry angiomata. Each area was then randomly assigned to receive 1 of the 3 treatments: pulsed-dye laser (PDL) (595 nm), potassium titanyl phosphate (KTP) laser (532 nm), or electrodesiccation. Two treatments spaced 2 weeks apart were delivered to each area. MAIN OUTCOME MEASURES Standardized photographs from before treatment and 3 months after the last treatment were evaluated for color and texture on visual analog scales. RESULTS Mean change in color was a significant improvement of 7.77 (P<.001), but there was no significant difference across treatment arms (P=.19). Mean change in texture was a significant improvement of 6.23 (P<.001), and the degree of textural change also differed across treatments (P<.001). In pairwise comparisons, cherry angiomata treated with electrodesiccation were significantly less improved than were those receiving KTP laser (P=.003) and those treated with PDL (P=.001). The effects of KTP laser and PDL on texture were not different (P=.50). CONCLUSIONS Cherry angiomata can be effectively treated with electrodesiccation and with laser. Laser, especially PDL, may minimize the likelihood of treatment-associated textural change. Trial Registration clinicaltrials.gov Identifier: NCT00509977.

Treatment of neck laxity with therapeutic ultrasound

Ultrasound represents sound waves above the capacity for human hearing (16 kHz). Generally, the ultrasound used in clinical practice utilizes a spectrum of frequencies between 1 and 20 MHz. When applied diffusely, these waves have broad applicability as a diagnostic imaging modality.