Vince Bertucci

The evolving role of hyaluronic acid fillers for facial volume restoration and contouring: a Canadian overview

Recent advancements, including more versatile facial fillers, refined injection techniques and the adoption of a global facial approach, have contributed to improved patient outcome and increased patient satisfaction. Nine Canadian specialists (eight dermatologists, one plastic surgeon) collaborated to develop an overview on volume restoration and contouring based on published literature and their collective clinical experience. The specialists concurred that optimal results in volume restoration and contouring depend on correcting deficiencies at various layers of the facial envelope. This includes creating a foundation for deep structural support in the supraperiosteal or submuscular plane; volume repletion of subcutaneous fat compartments; and the reestablishment of dermal and subdermal support to minimize cutaneous rhytids, grooves and furrows. It was also agreed that volume restoration and contouring using a global facial approach is essential to create a natural, youthful appearance in facial aesthetics. A comprehensive non-surgical approach should therefore incorporate combining fillers such as high-viscosity, low-molecular-weight hyaluronic acid (LMWHA) for structural support and hyaluronic acid (HA) for lines, grooves and furrows with neuromodulators, lasers and energy devices.

Delineating the “Safe” Donor Area for Hair Transplanting:

Three hundred twenty-eight patients were examined and classified according to age (65–69, 70–74, 75–79, and ≥80 years) and degree of male pattern baldness Hamilton/Norwood Class I-VII. In addition, the inferior to superior height of potential temporal, parietal, and occipital donor sites containing at least eight hairs per 4-mm round circle was measured. A schematic drawing of the borders of this “safe” donor area containing permanently hair-bearing scalp with adequate hair density for transplanting is presented.

Current Concepts in the Use of Small-particle Hyaluronic Acid

Background: Soft-tissue augmentation with hyaluronic acid (HA) fillers has become one of the most popular cosmetic procedures performed. HA fillers represent safe and commonly used fillers. Several different HA fillers are available. The differences lie in the manufacturing process, allowing for tailored uses. A small-particle HA with lidocaine (SP-HAL; Restylane Silk; Galderma, Uppsala, Sweden) was approved by the US Food and Drug Administration in June 2014 but has been available for many years in Canada as Restylane Fine Lines and in Europe as Restylane Vital. Methods: Relevant articles were reviewed relating to the composition, effectiveness, and safety of SP-HAL. We also discuss the author’s extensive clinical experience in the use of this product in Canada. Results: SP-HAL has demonstrated proven benefits for lip fullness, augmentation, and treatment of perioral rhytides. Although off-label in the United States, SP-HAL is also well suited for the treatment of superficial fine lines, including periorbital, forehead, marionette, and smile lines. In addition, it has also been used in the tear trough region. A novel application for SP-HAL includes use as a skinbooster with intradermal micropuncture. In this technique, small aliquots of product are injected so as to gradually rejuvenate the skin in areas such as the face and hands. Side effects of SP-HAL were generally transient and mild. The most common side effects were swelling, tenderness, bruising, pain, and redness. Conclusion: SP-HAL is an effective and safe HA filler with varied clinical uses.

Safety and effectiveness of large gel particle hyaluronic acid with lidocaine for correction of midface volume loss.

BACKGROUND Midface volume loss and contour deficiency are often treated using soft‐tissue fillers capable of elevating and supporting facial features. OBJECTIVE To evaluate the effectiveness and safety of large gel particle hyaluronic acid with 0.3% lidocaine (LGP‐HA‐L) for the treatment of midface volume loss or contour deficiency. METHODS AND MATERIALS This 24‐week, open‐label study recruited adults aged 18 to 65 with bilateral moderate to substantial midface volume loss or contour deficiency (Medicis Midface Volume Scale (MMVS) score 3–4). The primary effectiveness measure was MMVS response (≥1‐grade improvement) 8 weeks after treatment according to evaluators blinded to injection volume. RESULTS All enrolled patients (n = 40; 85.0% female; mean ± SD age 53.1 ± 7.0 years) completed the study. Mean ± SD injected volume for both sides of the midface was 5.3 ± 2.5 mL. Week 8 MMVS response rates were 97.5% according to blinded evaluators and treating investigators and 90.0% according to patients; week 24 rates were 90.0%, 92.5%, and 82.5%, respectively. Global Aesthetic Improvement Scale response rates were 95.0% to 100.0% throughout the study. Adverse events were reported in 60.0% of patients and were mild or moderate; all resolved by study end and most within 1 week. CONCLUSION Midface volume loss or contour deficiency may be safely and effectively corrected using LGP‐HA‐L.

Hair transplantation update

Background: Since the first published description in 1959, hair transplantation has progressed tremendously. Objective: This article provides an overview of hair transplantation and a discussion of selected controversies in hair transplantation. Methods: A review of the literature was undertaken to identify current controversies. Results: Hair transplantation has been refined considerably since it was first performed. As new methods are described, controversies arise. In hair transplantation, these include use of various forms of anaesthesia, the planning of the recipient site, method of harvesting the donor area, megatransplant sessions, isolated frontal forelock transplantation, and use of lasers in hair transplantation. Conclusion: Hair transplantation is a time-tested, highly effective, permanent and natural method of improving male-pattern baldness and female alopecia. Improvements in technique continue to be developed, requiring one to keep abreast of changes in the field in order to provide patients with the best hair coverage possible while maintaining a natural appearance.

The Skin Microbiome in Atopic Dermatitis and Its Relationship to Emollients

Background: Human-associated bacterial communities on the skin, skin microbiome, likely play a central role in development of immunity and protection from pathogens. In atopic patients, the skin bacterial diversity is smaller than in healthy subjects. Objective: To review treatment strategies for atopic dermatitis in Canada, taking the skin microbiome concept into account. Methods: An expert panel of 8 Canadian dermatologists explored the role of skin microbiome in clinical dermatology, specifically looking at atopic dermatitis. Results: The panel reached consensus on the following: (1) In atopic patients, the skin microbiome of lesional atopic skin is different from nonlesional skin in adjacent areas. (2) Worsening atopic dermatitis and smaller bacterial diversity are strongly associated. (3) Application of emollients containing antioxidant and antibacterial components may increase microbiome diversity in atopic skin. Conclusion: The skin microbiome may be the next frontier in preventive health and may impact the approach to atopic dermatitis treatment.

Adverse Reactions to Injectable Fillers

As the use of fillers becomes increasingly more common and the skill level of those injecting is so varied, adverse events can be expected to increase as well. Avoiding complications is always the best measure, and with appropriate training and injection techniques, many complications can be avoided. However, adverse events can occur in the best of hands, and early detection and treatment may eliminate or minimize sequelae. This article is an effort to help in that endeavor.

Injectable DaxibotulinumtoxinA for the Treatment of Glabellar Lines: A Phase 2, Randomized, Dose-Ranging, Double-Blind, Multicenter Comparison With OnabotulinumtoxinA and Placebo

BACKGROUND Injectable daxibotulinumtoxinA (RT002) is an investigational botulinum toxin Type A in clinical development. It is formulated with a proprietary peptide and offers the potential of a longer acting neurotoxin therapy. OBJECTIVE To compare the safety, efficacy, and duration of response of daxibotulinumtoxinA with onabotulinumtoxinA and placebo [www.clinicaltrials.gov NCT02303002]. METHODS In this Phase 2, randomized, dose-ranging, parallel-group, double-blind, multicenter study, subjects with moderate or severe glabellar lines at maximum frown were randomly assigned to 20U, 40U, or 60U daxibotulinumtoxinA, 20U onabotulinumtoxinA, or placebo. Glabellar line severity was evaluated by investigators and subjects at least every 4 weeks, for at least 24 weeks. RESULTS Overall, 268 subjects enrolled. Statistical and clinical superiority were observed for 40U and 60U daxibotulinumtoxinA over 20U onabotulinumtoxinA for a range of efficacy outcomes despite the study not being powered to detect statistically significant differences between these active treatment groups. CONCLUSION The 40U dose of daxibotulinumtoxinA was well tolerated (e.g., absence of ptosis) and had the most favorable risk: benefit profile. Compared with 20U onabotulinumtoxinA, it exhibited a significantly greater response rate and a significantly longer duration of response (median of 24 weeks vs 19 weeks; p = .030).

Abstract: Subjective and Objective Facial Dynamics Using Dermal Fillers Formulated for Facial Movement Adaptation

METHODS: An open-label, non-comparative 12 week prospective study conducted in 4 U.S. centers evaluated the safety and effectiveness of SPHAL in conjunction with a blunt-tipped cannula. Adverse events (AEs) were collected throughout the study. Subjects reported predefined, expected post-treatment injection site reactions during the first 2 weeks post-treatment via diary. Effectiveness assessments at 4 and 12 weeks post-treatment included treating invesitgatorand subject-reported Global Aesthetic Improvement Sclae (GAIS) scores and treating investigator-reported evaluations using the Medicis Lip Fullness Scale (MLFS).1

Comparing Injectable DaxibotulinumtoxinA and OnabotulinumtoxinA in Moderate and Severe Glabellar Lines: Additional Analyses From a Phase 2, Randomized, Dose-Ranging, Double-Blind, Multicenter Study

BACKGROUND Injectable daxibotulinumtoxinA (RT002) is an investigational botulinum toxin Type A. Published Phase 2 data show that, compared with 20U onabotulinumtoxinA, 40U daxibotulinumtoxinA is associated with a significantly greater response rate and significantly longer duration of response (median 24 weeks), and appears generally safe and well tolerated (www.clinicaltrials.gov NCT02303002). OBJECTIVE To evaluate whether these efficacy and safety findings are influenced by baseline glabellar line severity. MATERIALS AND METHODS In the Phase 2, randomized, dose-ranging, parallel-group, double-blind, multicenter study, subjects with moderate or severe glabellar lines at maximum frown were randomly assigned to 20U, 40U, or 60U daxibotulinumtoxinA, 20U onabotulinumtoxinA, or placebo. Efficacy was evaluated by investigators for ≥24 weeks. RESULTS Data from the per protocol population (n = 191) stratified by baseline glabellar line severity (125 moderate, 66 severe) suggest that the clinical advantage of 40U daxibotulinumtoxinA over 20U onabotulinumtoxinA is maintained for a range of efficacy outcomes regardless of whether glabellar lines are moderate or severe at baseline. Statistical evaluations were not completed due to the limited size of each subgroup. CONCLUSION 40U daxibotulinumtoxinA appears to offer a clinical efficacy advantage over 20U onabotulinumtoxinA in both moderate and severe glabellar lines—with a greater advantage observed in severe glabellar lines.