Timothy Corcoran Flynn

Dry skin and moisturizers.

Almost every person will experience dry skin during his or her lifetime.1 Many people experience occasional episodes, but some have a chronic problem with xerosis that is irritating and troublesome. In people with an atopic diathesis, dry skin can progress to eczema. Moisturizers are the mainstay of treatment for dry skin, daily maintenance of normal skin, and adjunctive therapy for many skin diseases.2 This chapter will discuss dryness of the skin and moisturization.

Noninferiority of IncobotulinumtoxinA, Free from Complexing Proteins, Compared with Another Botulinum Toxin Type A in the Treatment of Glabellar Frown Lines

BACKGROUND Use of botulinum toxin for esthetic purposes has rapidly expanded over the last 20 years. IncobotulinumtoxinA, also known as NT 201, is a new botulinum toxin type A (150 kDa) that is free from complexing proteins. OBJECTIVES A prospective, multicenter, randomized, rater‐ and patient‐blind, international Phase III trial to investigate the noninferiority of incobotulinumtoxinA to another botulinum toxin type A, onabotulinumtoxinA, in the treatment of glabellar frown lines. METHODS A total of 381 patients were randomized in a 3:1 (incobotulinumtoxinA:onabotulinumtoxinA) ratio to receive 24 U incobotulinumtoxinA of or onabotulinumtoxinA. Efficacy end points included the percentage of responders (patients with an improvement of ≥1 point on a 4‐point facial wrinkle scale) at maximum frown at weeks 4 and 12 as assessed by the investigators, and a panel of independent raters based on standardized digital photographs. RESULTS Four weeks after injection, response rates at maximum frown were 96.4% in the incobotulinumtoxinA group and 95.7% in the onabotulinumtoxinA group as assessed by independent raters. Analysis of the data confirmed the noninferiority of incobotulinumtoxinA. Response rates at rest were lower for both products. The rate of adverse events was low. CONCLUSION IncobotulinumtoxinA is equally as effective as onabotulinumtoxinA in the treatment of glabellar frown lines. Both preparations were well tolerated. This study was funded by Merz Pharmaceuticals GmbH. Editorial assistance was provided by Ogilvy 4D, Oxford, UK.

Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers.

BACKGROUND Hyaluronic acid (HA) gels have been used as filler material in the aesthetic field. Although the native HA molecule is without specificity of species and organs, synthetic cross‐linked gels have differences in chemical composition and three‐dimensional structure. Different technologies are employed in cross‐linking, and the products have varying rheological properties. OBJECTIVE To determine whether the gels with differing chemical composition have differing histologic behavior when injected into human skin to determine if the histology changes after 14 days of implantation. MATERIALS AND METHODS Human volunteers consented to having controlled placement of HA intradermally into forearm or buttock skin. The trials were conducted in a single clinic in association with the Hôpitaux Universitaires de Genève, Geneva, Switzerland. The biopsies were taken immediately after implantation of the product and at day 14. Standard paraffin sections were prepared and stained with hematoxylin and eosin and Alcian blue and examined by an independent pathologist. RESULTS Results show that each type of HA has a predictable histologic behavior in the skin. Biphasic gel has demonstrated deposition in big pools, often deep in the reticular dermis. The pools compress the collagen fibers. The papillary dermis and superficial reticular dermis are free of HA. Monophasic monodensified gels show large pools of hyaluronans throughout all the thickness of the reticular dermis. This material breaks up the collagen fibers of most of the dermal plane. The papillary dermis is free of exogenous hyaluronans. Monophasic polydensified cohesive gel penetrates into the dermis in a diffuse, evenly distributed manner, except in the papillary dermis, which remains free of exogenous material. CONCLUSION The different types of cross‐linked HA have different behaviors in the dermis immediately after their injection. The patterns are consistent between patients and are predictable. These histologic patterns do not change when biopsies are examined at 2 weeks. Dr. Flynn serves as a researcher for Merz.

Validated Assessment Scales for the Lower Face

Background Aging in the lower face leads to lines, wrinkles, depression of the corners of the mouth, and changes in lip volume and lip shape, with increased sagging of the skin of the jawline. Refined, easy‐to‐use, validated, objective standards assessing the severity of these changes are required in clinical research and practice. Objective To establish the reliability of eight lower face scales assessing nasolabial folds, marionette lines, upper and lower lip fullness, lip wrinkles (at rest and dynamic), the oral commissure and jawline, aesthetic areas, and the lower face unit. Methods and Materials Four 5‐point rating scales were developed to objectively assess upper and lower lip wrinkles, oral commissures, and the jawline. Twelve experts rated identical lower face photographs of 50 subjects in two separate rating cycles using eight 5‐point scales. Inter‐ and intrarater reliability of responses was assessed. Results Interrater reliability was substantial or almost perfect for all lower face scales, aesthetic areas, and the lower face unit. Intrarater reliability was high for all scales, areas and the lower face unit. Conclusion Our rating scales are reliable tools for valid and reproducible assessment of the aging process in lower face areas.

A validated lip fullness grading scale.

OBJECTIVES To develop the Lip Fullness Grading Scale for objective quantification of lip volume for a reliable assessment and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify fullness of upper and lower lip separately. Nine experts rated photographs of 35 subjects, twice, separately for upper and lower lip. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS Agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the fullness of the upper and lower lip for which patients commonly seek correction. This scale is well stratified, with low intra- and interrater variability.

A validated grading scale for crow's feet.

OBJECTIVE To develop the Crows Feet Grading Scale for objective quantification of the severity of lateral canthal lines and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of lateral canthal lines at rest and at maximum contracture of the orbicularis oculi. Nine experts rated photographs of 35 subjects, twice, with regard to the aspect crows feet in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was significantly high. Furthermore, the test–retest correlation coefficients were high for each expert after an overnight interval, demonstrating low inter- and intraevaluator variability. CONCLUSION The 5-point photonumeric scale generated spans the severity of the type of crows feet for which patients most commonly seek correction. The scale is well stratified for consistent rating.

A validated grading scale for forehead lines.

BACKGROUND As with other facial wrinkles, the gradual loss and disorganization of collagen fibers and elastin, connective tissues that provide underlying support for skin, cause horizontal forehead rhytides in large part. OBJECTIVES To develop the Forehead Lines Grading Scale for objective quantification of horizontal forehead rhytides at rest and with expression and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS The Forehead Lines Grading Scale is a 5-point photonumeric rating scale that was developed to objectively quantify resting (static) and hyperkinetic (dynamic) forehead lines. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was highly significant. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of forehead lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

A Validated Grading Scale for Marionette Lines

BACKGROUND Melomental folds, or marionette lines, are one of the consequences of facial aging. The curvilinear wrinkles formed because of facial movements and the aging process extend downward from the oral commissures. OBJECTIVES To develop the Marionette Lines Grading Scale for objective quantification of the severity of melomental folds and to establish the reliability of this photonumeric scale for clinical research and practice. MATERIALS AND METHODS A 5-point photonumeric rating scale was developed to objectively quantify the severity of melomental folds. Nine experts rated photographs of 35 subjects, twice, with regard to marionette lines in comparison with morphed images. Inter- and intrarater variability was assessed by computing intraclass correlation coefficients. RESULTS The agreement between the experts was high. Bubble plots (bivariate scatter plots) demonstrated linearity in judgment by the experts. CONCLUSION The 5-point photonumeric scale generated spans the severity of marionette lines for which patients commonly seek correction. The scale is well stratified for consistent rating.

Validated Assessment Scales for the Mid Face

Background The improvement of aesthetic treatment options for age‐related mid face changes, such as volume loss, and the increase in patient expectations necessitates the development of more‐complex and globally accepted assessment tools. Objective To develop three grading scales for objective assessment of the infraorbital hollow and upper and lower cheek fullness and to establish the reliability of these scales for clinical research and practice. Methods and Materials Three 5‐point rating scales were developed to assess infraorbital hollow and upper and lower cheek fullness objectively. Twelve experts rated identical mid face photographs of 50 subjects in two separate rating cycles using the mid face scales. Test responses of raters were analyzed to assess intra‐ and interrater reliability. Results Interrater reliability was substantial for the infraorbital hollow, upper cheek fullness, and lower cheek fullness scales. Intrarater reliability was high for all three scales. Both of the cheek fullness scales yielded higher reliabilities when three rather than two views were used to assess the volume changes of the cheek. Conclusion The mid face scales are reliable tools for valid and reproducible assessment of age‐related mid face changes.

What do applicants look for when selecting internal medicine residency programs? - A comparison of rating scale and open-ended responses

Objective: To develop reliable scale measures of factors most important to applicants when they select internal medicine residencies and to assess their validity by comparing scores from these measures with responses to open-ended questions.Design: All 353 applicants ranked by the University of North Carolina at Chapel Hill (UNC-CH) for the 1988 National Residency Match Program received a questionnaire after submitting their match lists. First, they listed the three most important factors considered in ranking residency programs and starred the single most important factor out of the three. Then, they rated 41 items on a five-point Liken scale ranging from 1 (not important) to 5 (extremely important).Setting: Categorical internal medicine residency program at an academic medical center.Measurements and main results: 315 (8896) applicants responded to the survey. Three reliable scales, Interpersonal Issues (7 items, alpha=0.78), Reputation (5 items, alpha=0.77), and Work Issues (11 items, alpha=0.89), were developed using exploratory factor analysis of applicants’ responses to the 41 items. Applicants felt interpersonal issues were very important (mean score=4.2±0.5), academic reputation was important (3.3±0.8), and work issues were less important (2.8±0.7). The differences between these scores were significant (F=3.76, p<0.05). The ratings for the top five items not in these scales also indicated that education and location -were very important. These results were corroborated by applicants’ responses to the open-ended request to list the three most important factors in ranking residencies.Conclusion: These findings suggest that work issues are important, but greater emphasis is placed on interpersonal issues, education, location, and a program’s reputation when applicants select residency programs. Furthermore, this study provides evidence supporting the reliability and validity of the three scales.