Richard G. Glogau

Advances in facial rejuvenation: botulinum toxin type a, hyaluronic acid dermal fillers, and combination therapies--consensus recommendations.

Background: Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures, and patient demographics. Clinicians can benefit from ongoing guidance on products, tailoring treatments to individual patients, treating multiple facial areas, and using combinations of products and ways to optimize outcomes. Methods: A multidisciplinary group of aesthetic treatment experts convened to review the properties and uses of botulinum toxin type A (BoNTA) and hyaluronic acid fillers and to update consensus recommendations for facial rejuvenation using these two types of products. The group considered paradigm shifts in facial aesthetics; optimal techniques for using BoNTA and hyaluronic acid fillers alone and in combination; the influence of patient sex, ethnicity, cultural ideals, and skin color on treatment; general techniques; patient education and counseling; and emerging trends and needs in facial rejuvenation. Results: The group provided specific recommendations by facial area, focusing on relaxing musculature, restoring volume, and recontouring using BoNTA and hyaluronic acid fillers alone and in combination. For the upper face, BoNTA remains the cornerstone of treatment, with hyaluronic acid fillers used to augment results. These fillers are central to the midface because of the need to restore volume. BoNTA and hyaluronic acid in combination can improve outcomes in the lower face. Conclusions: Optimal outcomes in facial aesthetics require in-depth knowledge of facial aging and anatomy, an appreciation that rejuvenation is a three-dimensional process involving muscle control, volume restoration, and recontouring, and thorough knowledge of properties and techniques specific to each product in the armamentarium.

Botulinum A neurotoxin for axillary hyperhidrosis. No sweat Botox.

background. Axillary hyperhidrosis causes considerable emotional stress and is associated with extraordinary costs and limitations in clothing. Existing topical and surgical therapies are either ineffective or associated with unacceptable morbidity and sequelae. Botulinum A neurotoxin (Botox) has been shown to decrease sweating in normal skin and in palmar hyperhidrosis. objective. The current study was undertaken to demonstrate the utility of using Botox in the treatment of axillary hyperhidrosis. methods. Twelve patient with axillary hyperhidrosis underwent intradermal injection with 50 units of Botox in the axillary skin bilaterally. results. All patients enjoyed relatively complete anhidrosis of the axillary skin in periods ranging from 4 to 7 months. Repeat injections produced similar results. conclusion. Botulinum A neurotoxin (Botox) is an elegant and simple treatment for axillary hyperhidrosis.

The restricted cellular host range of human herpesvirus 8

DesignA selection of primary and transformed cell types were evaluated for their susceptibility to infection with human herpesvirus 8 (HHV-8)/Kaposis sarcoma- associated herpesvirus. MethodsSources of HHV-8 included Kaposis sarcoma lesion punch biopsies that were either cocultured directly with target cells or that were first cocultured with human lymphocytes to derive HHV-8-containing fluids that were inoculated onto target cells. HHV-8 was also obtained from primary effusion lymphoma-derived cell lines. Techniques to detect infection included the PCR, immunofluorescence assays and in situ hybridization. ResultsSusceptible cells included human umbilical cord blood mononuclear cells (UCMC), adult CD19 B cells, macrophages and certain endothelial cells of human and animal origin, including some that are transformed with human papilloma virus type 16 E6 and E7 genes. The infection of lymphocytes did not yield established lymphoblastoid cell lines (LCL) and virus infection persisted for only 4–7 days. However, long-term HHV-8 infection of UCMC could be achieved by coinfection with Epstein–Barr virus. HHV-8 could also infect UCMC LCL recently derived by Epstein–Barr virus transformation, but long-established LCL could not be infected with HHV-8. ConclusionsThese data provide further biological evidence in cell culture for the limited cellular host range of HHV-8 to CD19 B cells, macrophages, and certain endothelial cells.

PHYSIOLOGIC AND STRUCTURAL CHANGES ASSOCIATED WITH AGING SKIN

The spectrum of photoaging in human skin shows a recognizable progression from subtle to profound, reflecting the various anatomic and structural changes that appear with aging skin. Qualification and quantification of these changes on both the macroscopic and microscopic levels enable the physician to select and evaluate appropriate therapeutic approaches to the problem of chronic solar damage. Comparative studies remain to be done that will further refine our abilities to match the right solutions to the recognized problems.

Randomized sham-controlled trial to evaluate the safety and effectiveness of a high-intensity focused ultrasound device for noninvasive body sculpting.

Background: High-intensity focused ultrasound presents a noninvasive approach to body sculpting for nonobese patients. The purpose of this study was to evaluate the safety and effectiveness of a high-intensity focused ultrasound device for sculpting of the abdomen and flanks. Methods: Adults (aged 18 to 65 years) with subcutaneous abdominal fat greater than or equal to 2.5 cm thick who met screening criteria were randomized to receive high-intensity focused ultrasound treatment of the anterior abdomen and flanks at energy levels (a total of three passes each) of 47 J/cm2 (141 J/cm2 total), 59 J/cm2 (177 J/cm2), or 0 J/cm2 (no energy applied, sham control). The primary endpoint was change from baseline waist circumference at the iliac crest level at posttreatment week 12. Subjective aesthetic assessments included the Global Aesthetic Improvement Scale and a patient satisfaction questionnaire. Safety assessments included adverse events, laboratory values, and physical examinations. Results: For the primary endpoint, in the intent-to-treat population, statistical significance versus sham was achieved for the 59-J/cm2 (–2.44; p = 0.01) but not the 47-J/cm2 treatment group (–2.06 cm; p = 0.13). In a per-protocol population, statistical significance versus sham was achieved for both the 59-J/cm2 (–2.52 cm; p = 0.002) and the 47-J/cm2 treatment groups (–2.10 cm; p = 0.04). Investigator subjective measures of global aesthetic improvement and patient satisfaction also favored each active treatment versus sham. Adverse events included mild to moderate discomfort, bruising, and edema. Laboratory values and physical examinations were unremarkable. Conclusions: Treatment with this high-intensity focused ultrasound device reduced waist circumference and was generally well tolerated for noninvasive body sculpting. Reduction in waist circumference was statistically significant with both active treatments (per protocol). CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II. Figure. No caption available.

Recommendations and Treatment Options for Nodules and Other Filler Complications

&NA; The authors have indicated no significant interest with commercial supporters in regards to this article.

Effect of Injection Techniques on the Rate of Local Adverse Events in Patients Implanted with Nonanimal Hyaluronic Acid Gel Dermal Fillers

BACKGROUND One question associated with dermal fillers is whether the rate and variability of local adverse events following treatment are related to injection technique and needle trauma or to the intrinsic chemical composition. OBJECTIVE The objective was to determine if there is a relationship between dermal filler injection technique and the incidence of local adverse events. METHODS AND MATERIALS A prospective, blinded, controlled study enrolled 283 patients who were randomized to receive midface volume correction of the nasolabial folds and oral commissures with the nonanimal-stabilized hyaluronic acid (NASHA) gel filler Restylane or Perlane (Medicis Pharmaceutical Corp.). Data were collected on multiple injection technique variables to assess adverse events. RESULTS Injection techniques that increase the dissection of the subepidermal plane (e.g., fanlike needle use, rapid injection, rapid flow rates, and higher volumes) increased the incidence of local adverse events. Injection techniques that increase epidermal damage or subcutaneous exposure (e.g., multiple punctures or deep subcutaneous injection) had no effect on adverse events. Furthermore, single injection correction, depth of injection, and NASHA product injected had no effect on local adverse events. CONCLUSIONS Local adverse events following injection with the NASHA gel fillers used in this study were related to investigator technique and not to differences in the intrinsic properties of the NASHA agents.

6-Thioguanine treatment of psoriasis: Experience in 81 patients

BACKGROUND Despite recent innovations a considerable number of patients with psoriasis cannot be successfully treated by current therapies. OBJECTIVE Our purpose was to summarize our 18-year experience with the antimetabolite 6-thioguanine in the management of patients with psoriasis. METHODS We retrospectively studied 81 patients who were treated with 6-thioguanine. A variety of schedules were used to find the optimal schedule. Forty-eight percent of the patients either had been treated with methotrexate or were excluded from receiving methotrexate because of liver or kidney disease. RESULTS Forty-nine percent of patients with plaques were effectively maintained with 6-thioguanine for a median of 33 months. Four of five patients with palmoplantar pustular psoriasis experienced substantial benefit. The most common side effect was myelosuppression. CONCLUSION 6-Thioguanine is an effective therapy for psoriasis and should be considered for patients who have failed to respond to other systemic agents.

Treating glabellar lines with botulinum toxin type A-hemagglutinin complex: a review of the science, the clinical data, and patient satisfaction.

Botulinum toxin type A treatment is the foundation of minimally invasive aesthetic facial procedures. Clinicians and their patients recognize the important role, both negative and positive, that facial expression, particularly the glabellar frown lines, plays in self-perception, emotional well-being, and perception by others. This article provides up-to-date information on fundamental properties and mechanisms of action of the major approved formulations of botulinum toxin type A, summarizes recent changes in naming conventions (nonproprietary names) mandated by the United States Food and Drug Administration, and describes the reasons for these changes. The request for these changes provides recognition that formulations of botulinum toxins (eg, onabotulinumtoxinA and abobotulinumtoxinA) are not interchangeable and that dosing recommendations cannot be based on any one single conversion ratio. The extensive safety, tolerability, and efficacy data are summarized in detail, including the patient-reported outcomes that contribute to overall patient satisfaction and probability treatment continuation. Based on this in-depth review, the authors conclude that botulinum toxin type A treatment remains a cornerstone of facial aesthetic treatments, and clinicians must realize that techniques and dosing from one formulation cannot be applied to others, that each patient should undergo a full aesthetic evaluation, and that products and procedures must be selected in the context of individual needs and goals.

A review of the metabolism of 1,4-butanediol diglycidyl ether-crosslinked hyaluronic acid dermal fillers.

BACKGROUND Cosmetic procedures are growing ever more common, and the use of soft tissue fillers is increasing. Practicing physicians need to be aware of the biological behavior of these products in tissue to enable them to respond to any safety concerns that their patients raise. OBJECTIVES To provide an overview of the metabolism of 1,4‐butanediol diglycidyl ether (BDDE)‐crosslinked hyaluronic acid (HA) dermal fillers and to examine the safety of the resulting byproducts. METHODS A review of available evidence was conducted. RESULTS After reaction with HA, the epoxide groups of BDDE are neutralized, and only trace amounts of unreacted BDDE remain in the product (<2 parts per million). When crosslinked HA, uncrosslinked HA, and unreacted BDDE degrade, they break down into harmless byproducts or into byproducts that are identical to substances already found in the skin. CONCLUSION Clinical and biocompatibility data from longer than 15 years support the favorable clinical safety profile of BDDE‐crosslinked HA and its degradation products. Given the strength of the empirical evidence, physicians should be confident in offering these products to their patients.