Showing papers in "Dermatologic Surgery in 2003"

A Randomized, Double-Blind, Multicenter Comparison of the Efficacy and Tolerability of Restylane Versus Zyplast for the Correction of Nasolabial Folds

Abstract: Background Bovine collagen is extensively used for facial soft tissue augmentation but provides only temporary correction and can cause hypersensitivity reactions. Hyaluronic acid derivatives potentially offer improved longevity of correction and a reduced risk of immunogenicity and hypersensitivity. Objective To compare the efficacy and safety of nonanimal stabilized hyaluronic acid gel (Restylane; Q-Med, Uppsala, Sweden) with that of bovine collagen (Zyplast) for treatment of nasolabial folds. Methods One hundred thirty-eight patients with prominent nasolabial folds were randomized to treatment with hyaluronic acid gel and bovine collagen on contralateral sides of the face. Treatments were repeated at 2-week intervals, as required, to achieve "optimal cosmetic result" (baseline). Outcomes were evaluated by a blinded investigator at 2, 4, and 6 months after baseline. Results Less injection volume was required for "optimal cosmetic result" with hyaluronic acid gel than with bovine collagen, and patients and investigators judged hyaluronic acid gel to be more effective in maintaining cosmetic correction. The investigator-based Wrinkle Severity Rating Scale and Global Aesthetic Improvement Scale assessments at 6 months after baseline indicated that hyaluronic acid gel was superior in 56.9% and 62.0% of patients, respectively, whereas bovine collagen was superior in 9.5% and 8.0% of patients, respectively. The frequency, intensity, and duration of local injection-site reactions were similar for the two products. Conclusion Nonanimal stabilized hyaluronic acid provides a more durable aesthetic improvement than bovine collagen and is well tolerated.

Evaluation of the efficacy of polidocanol in the form of foam compared with liquid form in sclerotherapy of the greater saphenous vein: initial results.

Abstract: Background. Foamed sclerosing agents have been used with enthusiasm by phlebologists for more than 5 decades. Any type of varicose veins can and has been treated with this technique. Numerous publications have stressed the advantages of foamed sclerosing agents on the basis of empiric and experimental criteria and have described various individual techniques to prepare foams. Until now, however, no comparative study for the treatment of large varicose veins with foam or liquid exists. Objective. The purpose of this first randomized, prospective, multicenter trial was to study the elimination of reflux, the rate of recanalization, and possible side effects of foam sclerotherapy (FS) compared with conventional liquid sclerotherapy for the greater saphenous vein (GSV). Methods. Eighty-eight patients were randomized into two groups: One group was treated with sclerosing foam (45 patients) and the other with sclerosing liquid (43 cases). Sclerotherapy was performed with direct puncture of the vessel under duplex guidance. The reference sclerosing agent was polidocanol in a 3% solution. The foam was prepared using the Double Syringe System (DSS) method. Only one injection of 2.0 or 2.5 mL liquid or foam was allowed, depending on the diameter of the GSV. Results were assessed according to the protocol. Results. Follow-up after 3 weeks showed 84% elimination of reflux in the GSV with DSS foam versus 40% with liquid sclerosant (P < 0.01). At 6 months, six recanalizations were found in the liquid group versus two in the foam group. After 1 year, no additional recanalization was observed with either foam or liquid. Longer term studies are underway. Side effects did not differ between both groups. Conclusion. The efficacy of sclerosing foam (DSS) compared with sclerosing liquid in therapy of the GSV is superior, a finding that had already gained empirical recognition but for which there has not been any clinical evidence to date.

Soft tissue augmentation with artecoll: 10-year history, indications, techniques, and complications.

Abstract: Most of the biologic filler materials that increase the thickness of the corium in a wrinkle line are phagocytosed within a certain time. Therefore, a lasting effect can only be achieved with nonresorbable synthetic substances. Artefill consists of 20 volume percent microspheres of polymethyl-methacrylate and 80 volume percent of bovine collagen. Beneath the crease, the microspheres with their exceptional surface smoothness stimulate fibroblasts to encapsulate each individual one of the 6-million microspheres contained in 1 mL of Artefill. Collagen is merely a carrier substance that prevents the microspheres from agglomerating during tissue ingrowth. The 20 volume percent of microspheres in Artefill provides the scaffold for the 80% volume of connective tissue deposition, a complete replacement of the injected collagen. The filler material beneath a crease acts like a splint and prevents the possibility of its further folding, thereby allowing the diminished thickness of the corium in a crease to recover. This recovery process is well known even in older patients with facial paralysis or after a stroke, whose facial wrinkles and furrows on the paralyzed side disappear over time.

A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A.

Abstract: BACKGROUNDOver the past 15 years, BTX-A has become the standard treatment for dynamic glabellar furrowing.1,2 Some individuals have resting glabellar rhytides that are sufficiently deep that they respond poorly to BTX-A alone.3,4OBJECTIVETo compare the efficacy of BTX-A combined with intradermal non

585-nm pulsed dye laser in the treatment of surgical scars starting on the suture removal day.

Abstract: Background The optimal time frame to improve the quality and cosmetic appearance of scars by laser therapy has not been clearly elucidated by prior controlled clinical trials. Objective To determine the efficacy of the 585-nm pulsed dye laser (PDL) in the treatment of surgical scars starting on the day of suture removal. Methods Eleven patients (skin types I-IV) with 12 postoperative linear scars that were greater than 2 cm were treated three times on monthly intervals with the 585-nm PDL (450 micro s, 10-mm spot size, 3.5 J/cm2 with 10% overlap) on one scar half, whereas the other half received no treatment. Scars were later evaluated by a blinded examiner using the Vancouver Scar Scale (VSS) for pigmentation, vascularity, pliability, and height. Scars were then blindly examined for cosmetic appearance using a visual analog scale. Results One month after the last treatment, final scar analysis by the blinded examiner revealed a significant difference between treated and untreated sites, with the treated halves scoring better in all scar parameters in the VSS and in cosmetic appearance. The treated halves demonstrated an overall average improvement in the VSS between the first treatment score and the final score of 54% versus 10% in the controls (P=0.0002). The cosmetic appearance score (0=worst; 10=best) at final assessment was significantly better for the treated scars, scoring 7.3 versus the averaged control score of 5.2 (P=0.016). Conclusion The 585-nm PDL is effective and safe in improving the quality and cosmetic appearance of surgical scars in skin types I-IV starting on the day of suture removal.

A wound-isolated Pseudomonas aeruginosa grows a biofilm in vitro within 10 hours and is visualized by light microscopy.

Abstract: Background. In chronic wounds, biofilms probably play a vital role in protecting bacteria from host defenses and antimicrobial medications by creating a barrier of exopolysaccharide that is difficult for the immune system and antibiotics to penetrate. A biofilm consists of an exopolysaccharide matrix that is produced and secreted by certain species of bacteria. Objective. The purpose of this study was to visualize and time the progressing growth of a biofilm by a wound-isolated Pseudomonas aeruginosa. Methods. P. aeruginosa that was initially isolated from a human burn wound was allowed to grow a biofilm in vitro. We used a modified Congo red staining technique to demonstrate the sequential development of a mature biofilm as examined by light microscopy. Results. We show that the exopolysaccharide of the developing biofilm is visible in just 5 hours after inoculation and has the characteristics of a mature biofilm by 10 hours. Conclusion. The rapidity of biofilm growth suggests that bacteria in wounds possess the capacity of producing this shield against antibiotics and immune effector cells early in the infection process. Therefore, efforts to prevent or slow the proliferation of bacteria and biofilms should occur soon after a wound is created. Additionally, this staining technique can be used to demonstrate the ability of agents to slow biofilm growth or to interrupt formed biofilm and may be useful in future studies of chronically infected wounds.

Laser scar revision: comparison study of 585-nm pulsed dye laser with and without intralesional corticosteroids.

Abstract: BACKGROUND. Hypertrophic scars affect 1.5% to 4.5% of the general population and remain notoriously difficult to eradicate because of the high recurrence rates and the incidence of side effects associated with treatment. Pulsed dye laser (PDL) treatment and intralesional corticosteroids have individually been reported to be effective in reducing hypertrophic scar bulk and symptoms. OBJECTIVE. To determine whether combination PDL and intralesional corticosteroid treatment produces better hypertrophic scar improvement than PDL treatment alone. METHODS. Bilateral hypertrophic inframammary scars in 22 females were randomly assigned to receive treatment with 585nm PDL alone or in combination with intralesional corticosteroid. Clinical evaluations and scar pliability scores were determined before each of the two treatment sessions and 6 weeks after the final treatment. Histologic evaluation of skin biopsies obtained before and after treatment was performed in four patients. RESULTS. All scars showed clinical improvement with increased pliability and decreased symptoms (pruritus) after each of the two treatments. Clinical improvement scores were not significantly better with the concomitant use of corticosteroids. Side effects were limited to mild purpura and transient hyperpigmentation. Decreased sclerosis was seen in scars after PDL treatment (with or without concomitant corticosteroids). CONCLUSIONS. Treatment of hypertrophic inframammary scars with 585-nm PDL irradiation alone effected substantial clinical and histologic improvement. The adjunctive use of intralesional corticosteroids did not significantly enhance clinical outcome except in those scars that were most symptomatic.

Single-pass carbon dioxide versus multiple-pass Er:YAG laser skin resurfacing: a comparison of postoperative wound healing and side-effect rates.

Abstract: BACKGROUND. Ablative laser skin resurfacing with carbon dioxide (CO2) and erbium:yttrium-aluminum-garnet (Er:YAG) lasers has been popularized in recent years and their side effects individually reported. No prior study, however, has directly compared the relative healing times and complications rates between the two different systems. OBJECTIVE. To evaluate and compare postoperative wound healing and short- and long-term side effects of single-pass CO2 and multiple-pass, long-pulsed Er:YAG laser skin resurfacing for the treatment of facial photodamage and atrophic scars. METHODS. A retrospective chart review and analysis of sequential clinical photographs were performed in 100 consecutive patients who underwent laser skin resurfacing with single-pass CO2 (Ultrapulse 5000; Coherent, Palo Alto, CA, N 5 50) or multiple-pass, long-pulsed Er:YAG laser resurfacing (Contour; Sciton, Palo Alto, CA, N 5 50). All laser procedures were performed by a single operator for the amelioration of facial rhytides or atrophic scars. The rate of re-epithelialization, duration of erythema, and presence of complications were tabulated. RESULTS. The average time to re-epithelialization was 5.5 days with single-pass CO2 and 5.1 days with long-pulsed Er:YAG laser resurfacing. Postoperative erythema was observed in all patients, lasting an average of 4.5 weeks after single-pass CO2 laser treatment and 3.6 weeks after long-pulsed Er:YAG laser treatment. Hyperpigmentation was seen in 46% of the patients treated with single-pass CO2 and 42% of the patients treated with the long-pulsed Er:YAG laser (average duration of 12.7 and 11.4 weeks, respectively). No incidences of hypopigmentation or scarring were observed. CONCLUSION. Skin resurfacing with single-pass CO2 or multiple-pass long-pulsed Er:YAG laser techniques yielded comparable postoperative healing times and complication profiles.

Nonablative Radiofrequency for Active Acne Vulgaris: The use of Deep Dermal Heat in the Treatment of Moderate to Severe Active Acne Vulgaris (Thermotherapy): A Report of 22 Patients

Abstract: Background Acne vulgaris is an exceedingly common condition in adolescence and may extend into adult life in some individuals. Even though this condition is at times minimized, it has been found to have a profound impact in the quality of life of many affected individuals. Acne scarring can be even more of a source of psychological and social problems than active acne is, and when inadequately treated, the latter can lead to the former. Moderate and severe acne vulgaris usually require a regimen of systemic and/or topical medications, which are given for several months or even years and frequently require multiple visits to the physician office, the laboratory, etc. This results in loss of time at school and considerable expense. Side effects from medications and the frequent need to use alternative drugs when there is no response to medical treatment are possible. Objective To evaluate the role of a novel medical device that uses radiofrequency as a source of energy to produce volumetric tissue heating, while sparing the epidermis, allowing for a procedure with no down time and no postoperative care required. Methods Twenty-two patients, 10 women and 12 men, ranging in age from 16 to 28, with moderate to severe, scarring, cystic, active, acne vulgaris participated. Only nine of these patients were on concomitant medical treatment such as oral antibiotics or topical agents. All 22 patients were treated with a new nonablative radiofrequency unit, which delivers a concomitant spray of cryogen for epidermal sparing. One session was done in 20 patients and two sessions in 2 patients. The average fluence per energy delivery was 72 J/cm2. Follow-up ranged from 1 to 8 months. Patient questionnaires and active acne lesion counts were used to evaluate the response to treatment. Results Excellent response was seen in 82% (n=18). Modest response was seen in 9% (n=2), and no response was seen in 9% (n=2); t-test on active lesion counts before treatment and after treatment was less than 0.009004. No side effects were identified on any of these patients. No down time from the procedure was seen. Only topical anesthesia, ELA-Max 5% (Ferndale Labs, Ferndale, MI) was used; 59% of patients were on no acne medication before, during, or after the procedure. Conclusions Nonablative radiofrequency appears to be a new safe and effective treatment alternative for moderate to severe acne vulgaris. Further research is in progress to evaluate this treatment modality in a larger number of patients.

“Functional” Surgery in Subungual Melanoma

Abstract: BACKGROUND Subungual melanomas represent approximately 2% to 3% of cutaneous melanomas in White populations. Complete or partial amputation proximal to the distal interphalangeal joint of the digits has been suggested. Recently, we introduced for acral melanomas, similar to lentigo maligna melanoma, limited excision and complete histology of excisional margins (three-dimensional histology). OBJECTIVE To evaluate the prognostic relevance of clinical parameters and different surgical management in patients with subungual melanoma. STUDY DESIGN From 1980 to 1999, subungual melanoma was diagnosed in 62 of 3,960 stage I and II melanoma patients (1.6%) of the melanoma registry of the Department of Dermatology (University of Tuebingen). A retrospective comparative analysis of two treatment groups was performed: Thirty-one patients had an amputation in or proximal to the distal interphalangeal joint (median follow-up of 55 months), and 31 patients had “functional” surgery with local excision of the tumor and only partial resection of the distal phalanx (median follow-up of 54 months). RESULTS In the univariate analysis, the level of invasion (P=0.0059), ulceration (P=0.0024), and tumor thickness (P=0.0004) were significant prognostic factors for recurrence-free survival but not for survival. In a multivariate analysis, only lower tumor thickness and a reduced level of amputation were independent significant prognostic parameters for recurrence-free survival (P=0.035 and P=0.0069). Patients with an amputation in or proximal to the distal interphalangeal joint did not fare better than patients with less radical “functional” surgery. CONCLUSION Limited excision with partial resection of the distal phalanx only and three-dimensional histology to assure tumor-free resection margins give better cosmetic and functional results and do not negatively affect the prognosis of patients with subungual melanoma.

Endovenous Laser Treatment of the Small Saphenous Vein with a 980‐nm Diode Laser: Early Results

Abstract: BACKGROUND Whereas numerous studies have been conducted regarding the outcome of the treatment of the great saphenous vein, few studies have been conducted on the small saphenous vein (SSV), especially concerning endovenous laser treatment. OBJECTIVE The objective was to evaluate the safety and efficacy of the 980-nm diode laser for the treatment of SSV reflux caused by saphenopopliteal junction (SPJ) incompetence. MATERIALS AND METHODS From October 2003 to April 2006, 390 SSVs in 344 subjects with varicose veins were treated with 980-nm diode laser energy delivered percutaneously into the SSV. Tumescent anesthesia (70-220 mL of 0.1% lidocaine) was delivered perivenously under ultrasound (US) guidance. The patients were evaluated clinically and with duplex US at 1 week, 1 month, 3 months, 6 months, 1 year, and thereafter to assess the efficacy of the treatment and the adverse reactions of the patients to it. RESULTS Successful occlusion of the SSV, defined as the absence of flow on color Doppler imaging, was noted in 389 of the 390 SSVs (99.7%) after the initial treatment. The remaining 1 SSV was closed after the repeat treatment. Of 108 SSVs, 102 (94.4%) remained closed throughout the 12th-month follow-up. Bruising and tightness along the course of the treated vein was present in almost all the patients, but these disappeared in 1 to 2 weeks. Seven patients (2%) noted localized skin paresthesia, but there were no major complications like skin burns and deep vein thrombosis. CONCLUSION Taking into account the high failure rates of incompetent SSV surgery and the anatomic complexity of SPJ, the endovenous 980-nm diode laser surgery is a safe and effective, cosmetically preferential procedure while a long-term follow-up is being awaited.

The Medical Face Lift: A Noninvasive, Nonsurgical Approach to Tissue Tightening in Facial Skin Using Nonablative Radiofrequency

Abstract: BACKGROUND. Traditional surgical rhytidectomy is aimed at correcting facial skin that is sagging, which is caused by excessive skin laxity as a result of photoaging. Operating room facilities, general anesthesia, and a skilled surgeon are needed. The patient has recuperation time, which may be prolonged if complications arise. Incision lines are where they could be easily camouflaged or where they blend with natural lines. Nevertheless, healing of surgical wounds and concurrent scars are seen in all patients. OBJECTIVE To evaluate the function of a novel technology that tightens tissue, using energy in the radiofrequency segment of the electromagnetic spectrum to produce internal heat within the skin. METHODS Fifteen patients had one treatment session under topical anesthesia and without sedation. Ages ranged from 41 to 68 years. The total treatment time lasted 40 minutes or less. A new radiofrequency unit with concurrent delivery of a cryogen spray to spare the epidermis from burning was used. Pain was used as a clinical indicator of maximum tolerable energy delivered. No postoperative care was needed. RESULTS All patients experienced minimal discomfort and were able to return to their normal activities right away. One patient did not respond to this treatment. For all of the others, visible results appeared approximately 12 weeks after the treatment session. In one patient, however, the results started at only 1 week after treatment. Four independent physicians outside of the study reviewed standardized photographs to evaluate results. The patients were followed for 6 to 14 months. CONCLUSION Fourteen of 15 patients obtained cosmetic improvement from facial skin tightening induced by a novel nonlaser, nonablative, noninvasive source. Nonablative radiofrequency is a safe and effective method to achieve tissue tightening of the face to correct excessive sagging from photoaging. Patients had visible results as early as 1 week and generally within 3 months after the procedure without wounding or scarring.

Botulinum toxin type A treatment for contouring of the lower face.

Abstract: Forty-five patients consented to the study andreceived a contouring procedure of the lower face fromNovember 2001 to April 2002. Twenty five to 30 U of Botoxper side was injected at five to six points into the prominentportions of the mandibular angle. Serial measurements weremade of the thickness of the masseter muscle by ultrasound andCT before the injections and at 1 and 3 months thereafter. Aquantitative analysis for the masseter thickness changes wasperformed on just one patient who underwent all ultrasoundand CT scans. Statistical analysis of the masseter thicknesschange was by two-way and multiple comparison analysis. Toevaluate clinical long-term effects, the patient’s satisfaction withthe procedure and any side effects after injections weremonitored during 4 to 10 months of follow-up.

Chondroid syringoma: a diagnosis more frequent than expected.

Abstract: BACKGROUND Chondroid syringoma or mixed tumor of the skin is a rare subcutaneous tumor that may be confused with various skin lesions. OBJECTIVE To elucidate the incidence of condroid syringomas among skin lesions that were excised under local anesthesia. METHODS The histopathologic diagnosis of 16,200 skin lesions that had been operated between 1986 and 2002 were retrospectively evaluated. The cases with condroid syringoma were histopathologically re-examined, and confirmed cases were further analyzed for preoperative diagnosis, age, gender, and lesion location. RESULTS Sixteen patients were found to have histopathologic diagnosis of chondroid syringoma constituting 0.098% of the excised skin lesions in this series. All of these 16 cases were misdiagnosed preoperatively. The typical presentation was a solitary skin lesion located in the head and neck region in a middle-aged male patient. CONCLUSION In the evaluation of a middle-aged male patient with a small subcutaneous nodule in the head and neck region, chondroid syringoma should be also taken into consideration for differential diagnosis. For such a lesion, excisional biopsy without destroying aesthetic and functional structures is the preferred diagnostic approach.

Comparison of mohs micrographic surgery and wide excision for extramammary Paget's disease.

Abstract: Background. Extramammary Paget's disease is a rare cutaneous adenocarcinoma that occurs in an apocrine gland distribution mainly in the anogenital region. Objective. To formulate treatment recommendations for this rare disease, we examined clinical and follow-up data of patients with it. Methods. A retrospective review is given about the treatment and outcome for 95 patients at Mayo Clinic, Rochester, Minnesota, and Scottsdale, Arizona, between 1976 and 2001. The literature regarding diagnosis and treatment of this disease is also reviewed. Results. Of the 95 patients, 86 had primary disease and 9 had recurrent disease. At mean follow-up (wide excision, 65 months; Mohs surgery, 24 months), disease had recurred in 18 of 83 (22%) who underwent standard wide excision, compared with recurrence in 1 of 12 (8%) who had the Mohs micrographic excision. Conclusion. Mohs micrographic surgery compares favorably with wide excision. Intraoperative immunostaining with cytokeratin 7 is helpful in delineating disease, as are preoperative scouting biopsies and photodynamic diagnosis.

Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation.

Abstract: Background. HYALURONIC ACID (HA) (Restylane and Hylaform) is becoming more widely used for cosmetic procedures such as lip augmentation and treatment of facial skin lines, as other products, mainly bovine collagen, have proved allergenic in many patients. Objective. To report a case of a 48-year-old woman who developed discrete nodules in the lips after HA injection for lip augmentation. The histologic analysis revealed the presence of a granulomatous reaction surrounding a blue amorphous material with the tinctorial features of HA. Conclusion. To our knowledge, this is the third case of granulomatous body reaction against this substance, which was allegedly inert in humans. Although rare, this reaction can have important aesthetic implications, and the patients should be informed about their risks.

Multicenter, double-blind study of the efficacy of injections with botulinum toxin type A reconstituted up to six consecutive weeks before application.

Abstract: Background. It is recommended that botulinum toxin be used immediately or within 2 weeks after its reconstitution because its efficacy might be compromised by prolonged storage. Objectives. To evaluate the efficacy of botulinum toxin type A (BTX-A) reconstituted over 6 consecutive weeks for the treatment of glabellar frown lines. Methods. Four vials of BTX-A were reconstituted each of 7 days over a period of 6 weeks, totaling 28 vials, corresponding to seven reconstitution dates. During this period, the BTX-A was stored according to the manufacturer's instructions. On the day after the last reconstitution, all of the reconstituted vials were injected in patients from four dermatologic centers taking part in this study. A total of 88 patients were treated on the same day and were followed every 2 weeks for 4 months. All patients were photographed at all stages. A number of professionals assessed the efficacy of reconstituted BTX-A based on the reduction of the maximum frowning capacity of the treated muscles. Results. Of the 88 patients who were selected, 3 were excluded. Three forms of evaluation were applied, and no statistically significant differences were found in the results presented. Conclusion. BTX-A may be applied up to 6 weeks after reconstitution without losing its effectiveness. Other factors, which are probably individual, may influence the response to BTX-A injections.

Endovenous Laser Surgery of the Incompetent Greater Saphenous Vein With a 980‐nm Diode Laser

Abstract: BACKGROUND. In recent years, the minimal endoluminal invasive alternatives against surgical ligation and stripping for the treatment of incompetent greater saphenous vein (GSV) have been explored. Endovenous laser surgery is one of these endoluminal alternatives, and its clinical results are being reported at up to 3 years. OBJECTIVE. To evaluate the safety and efficacy of a 980-nm diode laser for the elimination of the incompetent GSV. METHOD. Fifteen limbs in 12 patients with incompetent GSV were treated via an endovenous route with a 980-nm laser under local anesthesia in an outpatient setting. The effects were evaluated clinically along with duplex ultrasound at 1, 4, and 12 weeks after the treatment to determine efficacy and possible complications. RESULTS. Complete occlusion and retraction of treated GSV in all patients were observed during the 12 weeks of the postoperative period. There have been no significant complications to be concerned. CONCLUSION. The endovenous 980-nm diode laser surgery is a relatively simple, safe, office-based procedure that is expected to promise favorable results while a long-term follow-up is awaited.

Effects of Botulinum Toxin Type A on Bilateral Masseteric Hypertrophy Evaluated With Computed Tomographic Measurement

Abstract: BACKGROUND. A paucity of reports exist on the use of botulinum toxin type A injections as an alternative noninvasive treatment for masseteric hypertrophy. OBJECTIVE. To evaluate the effects of botulinum toxin type A on masseteric hypertrophy using computed tomography. METHODS. Percutaneous intramuscular injections of botulinum toxin type A of 30 U per side was carried out in 11 subjects with masseteric hypertrophy. The changes in the masseteric muscle volume before and 12 weeks after injection were evaluated using computed tomography. The changes in the lower facial contours on the photographs were evaluated as excellent, good, fair, and no changes. RESULTS. Nine of the 11 subjects showed a mean reduction of approximately 22% in the masseteric muscle volume. The maximum reduction was 35.4% (range, 8.1% to 35.4%). Nine subjects showed aesthetically good results with a grade of good or excellent at 12 weeks after treatment. CONCLUSION. Botulinum toxin injections are a noninvasive alternative method for treating masseteric hypertrophy.

Aesthetic botulinum A toxin in the mid and lower face and neck.

Abstract: Background. Botulinum toxin type A (Botox formulation) is used extensively for smoothing hyperkinetic lines in the upper face. The use of botulinum toxin for aesthetic indications in the mid and lower face and neck is now becoming increasingly popular. Objective. To review our current approaches to botulinum toxin treatment for cosmetic indications in the mid and lower face and neck. Methods. Procedures and outcomes are described for the primary and adjunctive use of botulinum toxin. Results. Cosmetic treatment with botulinum toxin successfully changes the contour of the palebral aperture; smoothes lines, including “bunny” lines, perioral rhytides, and horizontal neck lines; softens creases, including the mental crease and melomental folds; and alleviates facial asymmetry and nasal flare. The doses of botulinum toxin used in the mid and lower face are generally lower than those used in the upper face. Caution must be used in injecting botulinum toxin in the perioral area to avoid an incompetent mouth. Conclusion. Botulinum toxin treatment is valuable for aesthetic improvements in the mid and lower face and neck. In some areas, particularly the perioral region, the use of botulinum toxin in combination with other therapeutic modalities provides optimal results.

Combined Ultrapulse CO2 Laser and Q‐Switched Alexandrite Laser Compared with Q‐Switched Alexandrite Laser Alone for Refractory Melasma: Split‐Face Design

Abstract: Background. Melasma is common and can cause major psychological impact. To date, the mainstay of treatment, including various hypopigmenting agents and chemical peels, is ineffective and can cause adverse effects. Laser is a new approach and is yet to be explored for its efficacy and safety. Objective. To compare combined Ultrapulse CO2 laser and Q-switched alexandrite laser (QSAL) with QSAL alone in the treatment of refractory melasma. Methods. Six Thai females were treated with combined Ultrapulse CO2 laser and QSAL on one side of the face and QSAL alone on the other side. The outcome was evaluated periodically for up to 6 months using the modified Melasma Area and Severity Index score and the modified Melasma Area and Melanin Index score. Results. The side with combination treatment had a statistically significant reduction of both scores. On the QSAL side, the score reduction was not significant. Two cases developed severe postinflammatory hyperpigmentation and were effectively treated with bleaching agents. Transient hypopigmentation and contact dermatitis were observed with the combination treatment side. Conclusions. Combined Ultrapulse CO2 laser and QSAL showed a better result than QSAL alone but was associated with more frequent adverse effects. Long-term follow-up and a larger number of cases are required to determine its efficacy and safety for refractory melasma.

Salicylic acid peels for the treatment of acne vulgaris in Asian patients.

Abstract: Background. Salicylic acid peels have been introduced as a useful modality in acne treatment. Few studies have examined its efficacy and safety, especially in darker skin. Objective. To assess the efficacy and safety of salicylic acid peels as a treatment for acne vulgaris in Asian patients. Methods. Thirty-five Korean patients with facial acne were treated with 30% salicylic acid peels biweekly for 12 weeks. Lesion counts and Dr. Cunliffe's score were assessed by a blinded evaluator. Safety assessments and patient's evaluations were also recorded. Results. Both inflammatory and noninflammatory acne lesion counts were decreased in proportion to the duration of treatment. Dr. Cunliffe's acne grade was statistically significantly decreased after treatment. The side effects were tolerable in most cases, and all patients were pleased with their peel results. Stratum corneum hydration, skin surface lipid, skin pH, and transepidermal water loss were unchanged from baseline levels. Conclusion. Salicylic acid peels are an effective and safe therapy for acne vulgaris in Asian patients.

Social implications of hyperfunctional facial lines.

Abstract: The face is the focus of human interactions, and facial appearance profoundly affects self-esteem. Facial appearance is not only a compilation of the dimensions of the primary morphologic features but is also a direct result of the emotional expressions exhibited on the face. Facial expressions are central in the communication of emotions, as well as in signaling characteristics such as age. The repeated expression of emotions produces hyperfunctional facial lines, and the presence of these lines when the face is at repose may give an erroneous impression of emotions or personality characteristics. These lines are also perceived as a sign of aging. Treatment of hyperfunctional facial lines is beneficial for patients who believe that their faces are not communicating their emotions properly, who want to delay the outward appearance of aging, or who simply want to look their best.

Complications, Adverse Reactions, and Insights With the Use of Botulinum Toxin

Abstract: EXOTOXINS OF the anaerobic spore-forming bacterium Clostridium Botulinum, botulinum toxins (BTX) are the causative agents of the severe food-borne illness botulism. The lethal dose of these agents is approximating 10 9 g/kg body weight, and these neurotoxins are the most toxic naturally occurring substances. The bacterium C. Botulinum has eight serotypes (A, B, C a, C b, D, E, F, and G) that produce seven serologically distinct neurotoxins. Of these, types A, B, and E are most commonly associated with botulism in humans. The different serotypes are structurally and functionally similar; however, specific differences in neuronal acceptor binding sites, intracellular enzymatic sites, and species sensitivities suggest that each serotype is its own unique pharmacologic entity. Neutralizing antibodies developed against one serotype have not been reported to block the biologic activity of another serotype. BTXs exist in their native states as large protein complexes consisting of the neurotoxin moiety (approximately 150 kDa) and one or more nontoxic proteins that function to protect the toxin molecule and may or may not have hemagglutinin activity. Stabilized through noncovalent bonds, nontoxic proteins account for up to 70% of the total mass. BTX-B associates with the nontoxic proteins to form a complex with a total molecular weight of approximately 700 kDa, whereas the BTX-A complex is estimated to be approximately 900 kDa. These large BTX complexes are most stable in the pH range of 5 to 7. At pH values above 7, the protein subunits may dissociate. Although the intracellular targets of the toxins are variable, they all ultimately prevent release of acetylcholine at the neuromuscular junction of striated muscles and thus produce chemical denervation and paralysis of the muscles. This chemical denervation, which is effective for both striated muscle and eccrine glands, is the most studied mode of action of these agents. Pharmacologic and morphologic studies suggest that the toxin enters the nerve endings via endocytosis and inhibits the release of the vesiclebound acetylcholine within the nerve terminal itself. The toxin is rapidly (within 90 minutes) and irreversibly bound to the presynaptic neuron at the neuromuscular junction. The BTX is internalized and then acts on a zinc-dependent endoprotease to disrupt some of the peptides necessary for acetylcholine release. This action may not be complete for 2 weeks and effectively disrupts the affected neuromuscular junction, causing muscular paralysis. There is an ongoing turnover of neuromuscular junctions, however, that is enhanced by toxin exposure. Muscular function begins to return at approximately 3 months and is usually complete by 6 months. The return of muscular function is due to sprout formation, but the original neuromuscular endplate is eventually totally restored. Paralytic activity in the mouse is the mode of measuring the potency of this toxin. One unit is that amount of the toxin that kills 50% (LD50) of a standardized mouse model when injected intraperitoneally. This is affected by many factors such as the strain of mouse and housing conditions. Specific potency can be reduced by the presence of contaminating proteins or inactive, aggregated toxins (toxoid) that may have been carried through in the purification procedures. These molecules may increase the risk for antibody formation. Indeed, an excess of toxoid was considered very early on to be one of the great worries in preparing the agent. It was the goal to produce toxin with as little toxoid as possible. The therapeutic activity of BTX most understood at this time is the peripheral blockade of neuromuscular activity through inhibition of acetylcholine release that causes both muscular weakness and inhibition of eccrine function. Nevertheless, numerous other modes of action are being studied, such as its ability to affect afferent pain signals as well as the communication receptors on peripheral muscle spindles. Some evidence exists that suggests that central reorganization occurs after large amounts of BTX are used peripherally. Nevertheless, there has been no evidence to suggest any permanent degeneration or atrophy of muscles in those patients treated for dystonic or spastic disorders who have been injected

Treatment of striae rubra and striae alba with the 585-nm pulsed-dye laser.

Abstract: BACKGROUND The treatment of striae distensae has recently been reported with various lasers such as the 585-nm pulsed dye laser. At lower fluences (2.0 to 4.0 J/cm2), this laser has been purported to increase the amount of collagen in the extracellular matrix. OBJECTIVE To determine whether the 585-nm pulsed dye laser is effective in both striae rubra and striae alba after two treatments and, in addition, to determine whether there is a net effect on collagen density in treated samples. METHODS Twenty patients (skin types II to VI) with either striae rubra (9) or striae alba (11) were treated at baseline and at week 6. The total length of the study was 12 weeks. Untreated striae on the same patient were used as control subjects. Striae clinical parameters such as color and area were measured before the first and after the last treatment by an independent examiner using a visual analog scale. A hydroxyproline assay was used to measure collagen changes in two of the striae quantitatively. RESULTS The 585 nm had a moderate beneficial effect in reducing the degree of erythema in striae rubra. There was no apparent clinical change on striae alba. Total collagen per gram of dry weight of sampled tissue increased in striae treated with pulsed dye laser versus control subjects. CONCLUSION We recommend the use of the 585-nm pulsed dye laser for striae rubra in patients skin types II to IV. Extreme caution or avoidance should be observed in pulsed dye laser treatments for patients with phototypes V to VI even with the use of low fluences. Tissue collagen changes measured may be an early change, which precedes significant clinical improvement.

A Prospective, Double-Blind, Randomized, Parallel- Group, Dose-Ranging Study of Botulinum Toxin Type A in Female Subjects With Horizontal Forehead Rhytides

Abstract: Background. Botulinum toxin type A is used cosmetically to improve facial lines, but it has not been thoroughly investigated for the treatment of horizontal forehead rhytides. Objective. To compare the efficacy and safety of three doses of botulinum toxin type A in females with horizontal forehead rhytides and to establish whether the response rate and the duration of response are dose dependent. Methods. Fifty-nine female patients with horizontal forehead rhytides scoring 2 (moderate) or 3 (severe) on the facial wrinkle scale (FWS) were randomly assigned to receive 16, 32, or 48 U of botulinum toxin type A (Botox, Botox Cosmetic; Allergan, Irvine, CA), which was administered to eight injection sites. Half of the dose was administered to the brow depressors and the other half to the elevators. Wrinkle severity was assessed by the investigator and patient using the FWS at baseline, at Weeks 2 and 4, and then every 4 weeks for 48 weeks. Results. Improvements in horizontal rhytides were observed in all dosage groups. Significant dose–response trends were observed for rate of improvement at maximum brow elevation (53% in the 48-U group vs. 15% in the 16-U group at 16 weeks) and rate of relapse to baseline (35% in the 48-U group vs. 75% in the 16-U group at 16 weeks) by a trained observer. Conclusion. Higher botulinum toxin type A doses resulted in greater efficacy and longer duration of effect in the reduction of horizontal rhytides.

Treatment of facial rhytides with a nonablative 1,450-nm diode laser: a controlled clinical and histologic study.

Abstract: OBJECTIVE. To evaluate the safety and effectiveness of a nonablative 1,450-nm midinfrared diode laser in the treatment of facial rhytides. METHODS. Twenty-five patients (skin phototypes I‐III) with mild-to-moderate perioral or periorbital rhytides received four successive treatments at 3- to 4-week intervals with a 1,450-nm diode laser (SmoothBeam; Candela Corp., Wayland, MA). Symmetrical matched areas were left untreated to serve as controls. Patients were evaluated with digital photography at each treatment session and at 1, 3, 6, and 12 months after the final laser treatment. Skin biopsies were obtained from treatment and control facial sites for histologic evaluation before treatment, immediately after the first treatment, and 3, 6, and 12 months after the fourth treatment. Patient satisfaction scores were obtained at each follow-up visit. RESULTS. Mild to moderate improvement in treated facial rhytides was observed in all patients. Increased dermal collagen was seen 6 months after four successive treatments. Patient satisfaction scores paralleled the photographic and histopathologic changes seen. Side effects were limited to transient erythema, edema, and postinflammatory hyperpigmentation. CONCLUSION. The nonablative 1,450-nm diode laser is safe and effective for the treatment of mild-to-moderate facial rhytides.

Laser Dopplers to determine cutaneous blood flow

Abstract: BACKGROUND Laser Dopplers can be useful in determining the relative amount of blood flowing through superficial skin. These instruments may be useful in assessing blood flow in healing wounds, flaps, and grafts. OBJECTIVE To review the theory and types of laser Dopplers available. METHODS This work includes a review of the literature. RESULTS Laser Dopplers potentially have a broad range of applications in dermatologic surgery and dermatology. Because laser Dopplers can quantify blood flow, the course of wound healing over time can be studied; however, for predicting viability of skin flaps and grafts, laser Dopplers have not been able to supplant clinical assessment. CONCLUSION Laser Dopplers provide an additional means of assessing superficial blood flow in the skin. This blood flow, which can be quantified, may be useful in studying wound and flap and graft healing.

Utility of sentinel lymphadenectomy in the management of patients with high-risk cutaneous squamous cell carcinoma.

Abstract: BACKGROUND High-risk cutaneous squamous cell carcinoma (SCC) is an aggressive tumor with a significant rate of metastasis, especially nodal, and deaths yearly. Sentinel lymphadenectomy may be a valuable adjunct in the treatment of patients with cutaneous SCC at high risk for metastases with a clinical N0 status. OBJECTIVE To report the clinical and pathologic features in nine patients who underwent this procedure at a tertiary-care cancer center. METHODS Since 1995, a total of nine patients from the Cutaneous Oncology Program at the H. Lee Moffitt Cancer Center received preoperative lymphoscintigraphy and sentinel lymphadenectomy for high-risk cutaneous SCC with a clinical N0 status. RESULTS Histologically positive nodes were found in 4 of 9 cases (44%). Two of the four patients with positive sentinel nodes died of metastatic disease within 2 years. All five patients with negative sentinel nodes are alive and well at a median follow-up of 8 months (mean of 13 months). Preoperative lymphoscintigraphy and sentinel lymphadenectomy were well tolerated by all patients. CONCLUSION In this small series of predominantly trunk and extremity high-risk SCCs, sentinel lymph node biopsy was technically feasible with low morbidity. Sentinel lymphadenectomy may prove to have an important role in the management of high-risk cutaneous SCC with a clinical N0 status.

Comparison of botulinum toxin types A and B: a bilateral and double-blind randomized evaluation in the treatment of canthal rhytides.

Abstract: BACKGROUND The obligate bacterium Clostridium botulinum produces exotoxins (A, B, C-1, C-2, D, E, F, G) that are serologically and antigenically distinct. All serotypes have similar neurotoxic properties resulting in flaccid muscle paralysis. Types A and B are commercially available and are used widely for the reduction of dynamic facial rhytides. Although extensive information is known about type A, type B has recently become available; however, there is a limited clinical familiarity. Some of the remaining unknown distinctions between the two subtypes are the extent of toxin diffusion from the site of injection, the onset of action, the dose equivalency, and the duration of effect. OBJECTIVE The purpose of this preliminary double-blind study was to compare the duration of muscle paralysis and rhytid reduction of botulinum toxin types A and B. Additional relevant information was obtained, all of which can be useful in toxin selection. METHOD Ten women, ages 28 through 60, voluntarily consented to undergo a double-blind trial and were randomly assigned to have botulinum toxin type A injected into one set of lateral canthal rhytides and toxin type B into the contralateral periocular region. Based on dose-ranging investigations performed in patients with cervical dystonia, participants received treatment at the lowest reported effective ratio of 1:50 (1 U of toxin type A to 50 U of toxin type B). Three injections of 5 U of type A (total 15 U) and three injections of 250 U of undiluted type B (total 750 U) were injected into the lateral fibers of the orbicularis oculi muscle. RESULTS Patients were evaluated at 7, 30, 60, and 90 days. Findings were compared by the treating physician, patient self-assessment, and photographic images. CONCLUSION All patients noted rapid and satisfactory reduction in the rhytides in both periocular areas. However, upon unblinding of the solutions at the same volumes with a 1:50 ratio, type B toxin was found to be associated with slightly more discomfort upon injection, quicker onset of action, a sensation of “tightness” of the treated area, and a briefer duration of muscle paralysis.