Evaluation of an Acne Severity Grading Self-Assessment System Suitable for the Thai Population - A Pilot Study.

Background: Patient self-assessment is a potential tool in clinical practice to obtain subjective information of acne severity also in clinical trials to assess the general population in research and epidemiologic studies. The patient self-evaluation of acne severity has not yet been developed in Thailand. Objective: We aimed to validate an acne severity grading self-assessment suitable for the Thai population. Methods: A pilot study was conducted in 77 volunteers with acne lesions. We developed the Thai Global Evaluation Acne Scale (TGEA) and Thai Global Acne Grading System (TGAGS) by translating and adapting the original version. Patient self-assessment of acne severity was performed in two rounds. A training session about acne was provided to all participants lesions before starting the second round. Reliability between the self-assessment and clinician assessment of acne severity was statistically assessed. Results: For TGEA, 48.05% participants rated their acne severity corresponded with the clinicians (Cohen's kappa coefficient, kappa = 0.26). After receiving the training, 79.22% subjects responded their acne severity corresponded with the clinicians (kappa = 0.66). For TGAGS, 77.92% patients who answered their acne severity corresponded with the clinicians (kappa = 0.52). After receiving the training, 94.80% participants responded their acne severity corresponded with the clinicians (kappa = 0.89). For raw score of the TGAGS, the intraclass correlation coefficient (ICC) during the self-assessment of acne severity compared to the clinician assessments was 0.54 and it increased to 0.79 after the training. Conclusion: Due to the almost perfect reliability, we suggested that TGAGS is a reliable subjective self-assessment of acne severity suitable for the Thai population. The training is essential in enhancing the reliability of this instrument. Our study's findings can facilitate clinical practice and research studies.

Granulomatous Pigmented Purpuric Dermatosis in a Patient with (Inactive) Myasthenia Gravis: A Case Report and Review of the Literature.

Granulomatous pigmented purpuric dermatosis (GPPD) is a rare histologic variant of pigmented purpuric dermatosis (PPD) characterized by dermal histiocyte-rich interstitial infiltration with or without granuloma formation in addition to the other typical features of PPD. GPPD was previously observed more frequently to affect Asians and was reported to be associated with dyslipidemia. However, our literature search of 45 documented GPPD cases revealed an increasing prevalence in Caucasians in addition to dyslipidemia and associated autoimmune diseases. To date, etiopathogenesis of GPPD is unknown but may involve dyslipidemia, genetic and immunological factors such as autoimmune dysregulation or a sarcoidal reaction associated with C. acnes. GPPD is usually persistent and recalcitrant to treatments. We report a case of GPPD in a 57-year-old Thai woman with underlying myasthenia gravis who presented with a pruritic eruption on both lower legs. After treatment with 0.05% clobetasol propionate cream and oral colchicine, the lesion improved with marked flattening and disappeared with residual postinflammatory hyperpigmentation. We provide a literature review of the epidemiology, etiopathogenesis, concomitant comorbidities, clinical symptoms, dermatoscopic features, and treatments of GPPD.

Algorithm for Correction of Unaesthetic High Eyelid Folds.

BACKGROUND: Unaesthetic high eyelid fold is a challenging problem for plastic surgeons. Several methods have been introduced to overcome different deformities. Decision-making on how to select the most appropriate procedure for each patient with diverse underlying causes requires ample surgical experience. The authors present an algorithm as a guideline to manage this situation. METHODS: A retrospective review of planned surgical correction among 368 patients with high eyelid folds in accordance with the advocated algorithm covering 6 years was conducted, graded, and analyzed using both objective and subjective measurements. The follow-up period ranged from 1 month to 5 years (average, 7 months). RESULTS: Of 368 cases, 232 (63.05%) were classified as having an excellent result, 96 (26.08%) as good, and 40 (10.87%) as fair. No poor results, defined as failure to reduce the fold, were found using this algorithm. The crease size before surgery, ranging from 9 to 13 mm (average, 10.345 mm), was reduced to 6 to 9 mm (average, 7.324 mm). CONCLUSIONS: The authors propose an algorithm to correct high eyelid folds supported by a clinical study over 6 years. Surgical techniques and rationale behind the procedures are discussed. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

A Randomized, Double-Blind, Split-Face Study of Topical Silymarin vs 2% Hydroquinone Cream in Melasmas.

BACKGROUND: Hydroquinone is effective in melasma treatment, but side effects may limit its use. Silymarin cream may be a safer alternative. OBJECTIVE: To compare the efficacy of 1.4% silymarin with 2% hydroquinone for melasma treatment in Asians. METHODS: In a randomized, double-blind, split-face study of 25 patients with epidermal or mixed-type melasma, the facial sides were randomized for the application of silymarin cream on one side and hydroquinone on the contralateral side for 3 months. Results were evaluated using a colorimeter, modified Melasma Area and Severity Index (mMASI) score, and patient self-assessment. RESULTS: Twenty-three patients completed the study. Colorimetric measurements calculated as relative lightness index (RL*I) showed no statistical difference between the 2 treatments (P=0.715). Compared with baseline, both treatments showed statistically significant improvements of RL*I, with 14.56% and 12.82% improvement in silymarin and hydroquinone, respectively. Modified MASI scores decreased after both treatments but were only statistically significant on the hydroquinone side, achieving 17.97% reduction (P=0.02) vs 7.11% (P=0.32) on the silymarin side. There was no statistically significant difference of the RL*I and modified MASI between the 2 treatments (P>0.05). Patients' assessment of hydroquinone treatment showed a 69.6% good-excellent improvement with a visual analog scale (VAS) satisfaction score of 7.82, compared with silymarin showing a 73.9 % good-excellent improvement and VAS score of 7.65 (P=0.50). More adverse effects occurred with the hydroquinone. CONCLUSION: Although hydroquinone showed a better response, topical silymarin was effective in the treatment of epidermal and mixed-type melasma with fewer side effects. J Drugs Dermatol. 2022;21(12):1304-1310. doi:10.36849/JDD.6491.

Effectiveness of an epidermal growth factor-containing cream on postinflammatory hyperpigmentation after 1064-nm Q-switched neodymium-doped yttrium aluminum garnet laser treatment of acquired bilateral nevus of Ota-like macules (Hori's nevus) in Asians: A split-face, double-blinded, randomized controlled study.

BACKGROUND: Epidermal growth factor (EGF) may promote wound healing and decrease laser-induced postinflammatory hyperpigmentation (PIH). OBJECTIVES: To evaluate the effectiveness of an EGF-containing cream on PIH, post-laser erythema, and transepidermal water loss (TEWL) after 1,064-nm Q-Switched Nd: YAG laser treatment of Hori's nevus. METHODS: This is a split-face, double-blinded, randomized, controlled study conducted in 30 subjects with bilateral Hori's nevus. After laser treatment, participants were randomized to apply EGF cream on one facial side and placebo on the other side for 8 weeks. The incidence and intensity of PIH were assessed by photographs and melanin indexes (MIs) ratio at baseline, Week 2, Week 4, and Week 8. Post-laser erythema and TEWL were measured at baseline, Day 1, Day 3, and Day 7. Side effects and patient satisfaction score were evaluated. RESULTS: The incidence of PIH was 26.7% in EGF group compared to 20% in placebo. The intensity of PIH was 0.057 (0.033-0.086) and 0.045 (0.027-0.076) in EGF and placebo group, respectively. There was no significant difference in both incidence (p = 0.5) and intensity of PIH (p = 0.145). Post-laser erythema was not statistically different between groups. EGF could alleviate TEWL better than placebo but without statistical significance. Patient satisfaction score was significantly higher in EGF group compared to placebo (p < 0.001). CONCLUSIONS: The EGF-containing cream could not prevent PIH. It may reduce laser-induced skin barrier damage. Future studies in more subjects are needed.

The efficacy and safety of a combined multipolar radiofrequency with pulsed electromagnetic field technology for the treatment of vaginal laxity: a double-blinded, randomized, sham-controlled trial.

Non-invasive vaginal rejuvenation with radiofrequency (RF) and lasers devices have gained popularity, but well-designed studies confirming their effectiveness are lacking. The aim of this study was to compare the efficacy and safety of a multipolar RF and pulsed electromagnetic field-based device (PEMF) versus sham for vaginal laxity. Thirty-two premenopausal females with ≥ 1 vaginal delivery and self-reported vaginal laxity were randomized into 2 groups: active (RF + PEMF) and sham. Both groups received 3 vaginal treatments at 3-week interval. The Vaginal Laxity Questionnaire (VLQ), perineometer measurements, and Brink score were conducted at baseline, 4, and 12 weeks after treatments. Pre and post-treatment vaginal histology, Female Sexual Function Index (FSFI), subjects' satisfaction, pain, and adverse events were assessed. The active group VLQ scores increased and were significantly better than the sham group (p < 0.001). At the final follow-up, 50% of the active group reported no vaginal laxity (VLQ > 4) versus 12% in the sham group (p = 0.054). In the active group, all domains of perineometer measurements and Brink scores (p < 0.001), FSFI scores (p < 0.05), and patients' satisfaction (p < 0.001) were significantly increased and higher in the active group. Mild adverse effects including pain and burning sensation were not different between groups except for itch which was significantly higher in the sham arm (p = 0.014). Histology after RF + PEMF treatments demonstrated neocollagenesis, neoelastogenesis, and neoangiogenesis. In conclusion, combination RF + PEMF therapy was safe, improved vaginal laxity, strengthened pelvic floor muscles, and improved female sexual function for at least 12-week post-procedures with confirmed histological improvements. This study was registered on the Thai Clinical Trials Registry, TCTR20200803002 on 2020-07-30 "retrospectively registered."

Mesh Suspension Thread for Facial Rejuvenation.

BACKGROUND: Thread lifting was first described in the early twentieth century, but for many years it remained a relatively debatable technique due to the unreliability of the long-term results. Very few papers described the long-term follow-up of the patients. Until now there has been no ideal thread that can demonstrate the long-lasting results. METHOD: A long-term study of mesh suspension thread in Bhumibol Adulyadej Hospital and Bangkok Skin-Plastic Surgery Center was conducted during February 2016 to December 2018. In all, 21 patients, 20 females and one male, were treated. The follow-up period ranged from 6 months to 2 years. The results were evaluated by both patients themselves and an independent investigator using the Global Aesthetic Improvement Scale (GAIS), Modified Fitzpatrick Wrinkle Scale and Marionette Lines Grading Scale at 6 months, 1 year and 2 years. RESULTS: No serious complications were involved in all cases. The most frequent complaint was mild to moderate pain at the temporal area at the night of surgery that gradually improved in a few days. The improved result could be maintained up to 1 year among 14 patients (66.6%) and 2 years among eight patients (38%). The follow-up period up to 2 years showed a favorable result. Most cases received the same GAIS scores by patients and those of the investigator. Some patients rated their outcome higher than the investigator. No obvious contradiction in the scores was observed between both groups. CONCLUSION: We performed a long-term clinical study to validate the efficacy of mesh suspension thread. The result showed that this novel thread could provide a long-lasting result up to 2 years. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Bullous Pemphigoid Associated with Acquired Hemophilia A: A Case Report and Review of the Literature.

Acquired hemophilia A (AHA) is a rare autoimmune disorder with high morbidity and mortality. It results from the development of circulating autoantibodies against factor VIII. AHA can be seen in association with autoimmune vesiculobullous diseases, autoimmune diseases, malignancy, pregnancy, and medications. We report a 68-year-old Thai woman diagnosed and treated for bullous pemphigoid (BP) for 11 months who recently presented with a 3-day history of extensive hemorrhagic bullae and large intra-oral buccal hematoma. Laboratory investigations confirmed a prolonged activated partial thromboplastin time, a low factor VIII level, a high factor VIII inhibitor level, and elevated anti-BPAG180 and anti-BPAG230 titers, confirming the diagnosis of BP associated with AHA. Immunosuppressive therapy with systemic corticosteroids and cyclophosphamide combined with bypassing agents for bleeding control resulted in significant clinical improvement and subsequent negative antibody levels. There was no recurrence after a 7-month follow-up period. Due to life-threatening bleeding in severe AHA cases, early diagnosis and effective treatment in this condition are essential.

Serum Sickness after Equine Rabies Immunoglobulin in Identical Male Twins: Two Case Reports.

We, hereby, report two cases of serum sickness in adult male identical twins who had received equine rabies immunoglobulin as a postexposure rabies treatment after cat scratches. The younger brother developed low-grade fever, polyarthritis, and multiple erythematous maculopapular eruptions, whereas low-grade fever and urticaria-like eruptions were detected in the elder brother. Both patients received a 7-day course of low-dose prednisolone and achieved good responses without recurrent attacks.

Thyroid Autoimmunity and Autoimmunity in Chronic Spontaneous Urticaria Linked to Disease Severity, Therapeutic Response, and Time to Remission in Patients with Chronic Spontaneous Urticaria.

BACKGROUND: Chronic spontaneous urticaria (CSU) is autoimmune in nature and associated with thyroid autoimmunity (TA), but evidence on autoimmunity in relation to CSU progression and prognosis is limited. We evaluated whether TA and autoimmunity in CSU are correlated with disease severity, therapeutic response, and time to remission and establish an association between CSU characteristics linked to thyroid autoantibody. METHODS: Medical records of patients diagnosed with urticaria attending outpatient dermatology clinic at a university-based hospital from 2013 to 2017 were retrospectively reviewed. Data on the clinical characteristics, laboratory investigations particularly thyroid antibody titers, autologous serum skin test (ASST) and autologous plasma skin test (APST) results and their link to disease severity, treatments, and time to remission of CSU patients were analyzed. RESULTS: Of 1,096 patients with urticaria, 60.2% had CSU. Three-hundred patients fulfilled the inclusion criteria for CSU with complete thyroid antibody testing. Positive TA was significantly associated with female gender and age > 35 years (p = 0.008). Antithyroid peroxidase (anti-TPO)-positive patients suffered from CSU longer than 12 and 18 months compared to anti-TPO-negative patients (100.0% vs. 82.6%, p = 0.042, and 100.0% vs. 75.9% p = 0.020, respectively). The presence of urticarial attacks > 4 days/week was significantly seen in ASST and APST-positive patients compared to those without (84.6% vs. 61.3%, p = 0.011, and 85.3% vs. 61.8%, p = 0.006, respectively). Positive APST patients were more difficult to treat than those with negative results (61.2% vs. 37.8%, p = 0.017). CONCLUSIONS: Antithyroid peroxidase is a predictor of time to remission, while autologous skin testing is linked to disease severity (ASST and APST) and therapeutic response (APST) in CSU patients.

The study of histological changes of the arterial vascular structure after hyaluronidase exposure.

BACKGROUND: Hyaluronic acid (HA) filler injection is commonly used for soft tissue augmentation. Uncommon but serious complication from filler injection is vascular occlusion. Hyaluronidase enzyme can be used to dissolve HA filler. Evidence demonstrates that hyaluronidase can penetrate through vessel wall after incubation. However, studies regarding effects of hyaluronidase on vessel wall after intraluminal injection are limited. The objective of this study is to evaluate histological changes of postmortem arteries after intravascular injection of hyaluronidase enzyme. METHODS: This was an ex vivo experiment including arterial specimens from four cadavers which recently deceased within 24 hours. All vessels were examined at baseline and then were divided into two groups. The first was the control group treated with normal saline and the second hyaluronidase-treated group was intra-luminally injected with hyaluronidase enzyme (1500 IU/mL). Gross and histological examination was performed at baseline, 30-minutes and 4 hours after. RESULTS: Gross examination of vessels revealed no significant difference at baseline, 30 minutes and 4 hours after injection in both groups. Histological examinations at baseline and 30 minutes after injection revealed viable endothelial cells in both experimental and NSS-control group. At 4 hours after hyaluronidase injection, two of the four arterial specimens had degeneration of endothelial cell, and one artery showed separation of tunica intima from tunica media. CONCLUSION: There were endothelial injuries in the arterial specimens after intravascular concentrated hyaluronidase injection.

Prevalence of polycystic ovary syndrome in Thai University adolescents.

Polycystic ovarian syndrome (PCOS) is a common and complex condition characterized by endocrine features and influenced by genetic and environmental factors. In Southeast Asia and Thailand, the prevalence of PCOS is unknown. The aim of this study was to estimate the prevalence of and determine factors associated with PCOS in Thai adolescents. We administered a validated questionnaire to 600 university female participants aged 17-19 years from Mahidol University in Bangkok. Of these, 548 (91.33%) responded and agreed to participate. Two-hundred and seventy-nine girls (50.91%) were identified as likely having PCOS and defined as 'probable cases'. Of those 279 participants, 248 (88.88%) were evaluated further for PCOS using the Rotterdam criteria. A complete history was taken, and a physical examination including trans-abdominal ultrasound was performed. Blood chemistry tests were performed to exclude similar conditions and to investigate potential co-morbidities. The prevalence of PCOS in Thai adolescents was found to be 5.29%. After multivariate analyses, moderate acne was the strongest risk factor for PCOS. The odd ratios (95% confidence interval) for the presence of mild acne, moderate acne, and oligo- or amenorrhea in participants with PCOS were 2.83 (1.01-7.90; p = .47), 31.69 (10.07-99.67; p < .001), and 5.89 (2.42-14.37; p < .001), respectively.

Dapsone-induced severe cutaneous adverse drug reactions are strongly linked with HLA-B*13: 01 allele in the Thai population.

OBJECTIVES: A previous publication in Chinese leprosy patients showed that the HLA-B*13:01 allele is a strong genetic marker for dapsone-induced drug hypersensitivity reactions, however there are no data describing whether HLA-B*13:01 is a valid marker for prediction of dapsone-induced drug hypersensitivity reactions in other ethnicities or nonleprosy patients. The aim of this study is to investigate whether there is an association between HLA genotypes and dapsone-induced severe cutaneous adverse reactions (SCARs) in Thai nonleprosy patients. PATIENTS AND METHODS: HLA-B genotypes of 15 patients with dapsone-induced SCARs (11 drug reaction with eosinophilia and systemic symptoms, 4 Stevens-Johnson syndrome/toxic epidermal necrolysis), 29 control patients, and 986 subjects from the general Thai population were determined by the reverse PCR sequence-specific oligonucleotides probe. RESULTS: The HLA-B*13:01 allele was significantly associated with dapsone-induced SCARs compared with dapsone-tolerant controls (odds ratio: 54.00, 95% confidence interval: 7.96-366.16, P=0.0001) and the general population (odds ratio: 26.11, 95% confidence interval: 7.27-93.75, P=0.0001). In addition, HLA-B*13:01 associated with dapsone-induced SJS-TEN (OR: 40.50, 95% confidence interval: 2.78-591.01, P=0.0070) and DRESS (OR: 60.75, 95% confidence interval: 7.44-496.18, P=0.0001). CONCLUSION: This study demonstrated an association between HLA-B*13:01 and dapsone-induced SCARs including Stevens-Johnson syndrome/toxic epidermal necrolysis and drug reaction with eosinophilia and systemic symptoms in nonleprosy patients. Moreover, these results suggest that the HLA-B*13:01 allele may be a useful genetic marker for prediction of dapsone-induced SCARs in Thai and Han-Chinese populations.

Nevirapine patch testing in Thai human immunodeficiency virus infected patients with nevirapine drug hypersensitivity.

BACKGROUND: Antiretroviral drug hypersensitivity in HIV patients is common. Publications have shown that Abacavir (ABC) patch testing is useful in confirming ABC hypersensitivity in 24-50% of cases with a 100% sensitivity of HLA-B*5701 in patch test positive cases. However, Nevirapine (NVP) patch testing has not been reported. OBJECTIVES: (1) To evaluate the usefulness and safety of NVP patch testing in Thai HIV patients with NVP hypersensitivity. (2) To assess the correlation of positive patch tests with HLA-B*3505. PATIENTS AND METHODS: Patients were classified into two groups: (1) study group of 20 HIV NVP hypersensitivity patients and (2) control group of 15 volunteers without NVP hypersensitivity. Both groups were patch tested with purified and commercialized form of NVP in various vehicles. RESULTS: Two HIV patients with NVP hypersensitivity were patch test positive. All controls tested negative. Three HIV patients were positive for HLA-B*3505 and the two patients with positive patch testing were both HLA-B*3505 positive. CONCLUSIONS: NVP patch testing in Thai HIV patients is safe and can be used to help confirm the association between NVP and hypersensitivity skin reactions. NVP patch test results significantly correlated with HLA-B*3505. The sensitivity of HLA-B*3505 for positive patch test was 100%.

Secondary Blepharoplasty: Correction of the High Fold.

BACKGROUND: Blepharoplasty is a common aesthetic surgery performed worldwide. In Asians, too high eyelid folds after blepharoplasty cause an unsatisfactory aesthetic outcome that is difficult to correct. In this article, the authors propose surgical techniques to correct the high eyelid fold after blepharoplasty. METHODS: During a 4-year period, 213 secondary blepharoplasties were performed to correct high folds. Postoperative results were reviewed, graded, and analyzed. RESULTS: Of 213 cases of secondary blepharoplasty to correct the high eyelid fold, almost all could achieve reduction of the fold size (98.59 %). One hundred and nine cases (51.17 %), 69 cases (32.40 %), and 32 cases (15.02 %) were classified as excellent, good, and fair results, respectively. Only three cases (1.41 %) were classified as poor results. CONCLUSION: Secondary blepharoplasty to correct a high fold is a challenging procedure for aesthetic surgeons. Surgeons performing this operation need to have a thorough understanding of eyelid anatomy and its dynamics together with familiarity with secondary blepharoplasty to avoid any further injury to the levator muscle. The key points of this surgery are levator advancement and intervening between the levator aponeurosis and the overlying skin by in situ tissue or fat grafting. LEVEL OF EVIDENCE V: This journal requires the authors to assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors. www.springer.com/00266 .

Clinical practice guideline for diagnosis and management of urticaria.

Urticaria is a common skin condition that can compromise quality of life and may affect individual performance at work or school. Remission is common in majority of patients with acute spontaneous urticaria (ASU); however, in chronic cases, less than 50% had remission. Angioedema either alone or with urticaria is associated with a much lower remission rate. Proper investigation and treatment is thus required. This guideline, a joint development of the Dermatological Society of Thailand, the Allergy, Asthma, and Immunology Association of Thailand and the Pediatric Dermatological Society of Thailand, is graded and recommended based on published evidence and expert opinion. With simple algorithms, it is aimed to help guiding both adult and pediatric physicians to better managing patients who have urticaria with/without angioedema. Like other recent guideline, urticaria is classified into spontaneous versus inducible types. Patients present with angioedema or angioedema alone, drug association should be excluded, acetyl esterase inhibitors (ACEIs) and non-steroidal anti-inflammatory drugs (NSAIDs) in particular. Routine laboratory investigation is not cost-effective in chronic spontaneous urticaria (CSU), unless patients have clinical suggesting autoimmune diseases. Non-sedating H1-antihistamine is the first-line treatment for 2-4 weeks; if urticaria was not controlled, increasing the dose up to 4 times is recommended. Sedating first-generation antihistamines have not been proven more advantage than non-sedating antihistamines. The only strong evidence-based alternative regimen for CSU is an anti-IgE: omalizumab; due to very high cost it however might not be accessible in low-middle income countries. Non-pharmacotherapeutic means to minimize hyper-responsive skin are also important and recommended, such as prevention skin from drying, avoidance of hot shower, scrubbing, and excessive sun exposure.

A Novel Technique of Supra Superficial Musculoaponeurotic System Hyaluronic Acid Injection for Lower Face Lifting.

BACKGROUND: Various methods attempting to correct sagging of the lower face focus mainly on manipulation of the superficial musculoaponeurotic System. Each technique has its own limitation. The authors propose a relatively simple, conservative method utilizing hyaluronic acid injection just above the superficial musculoaponeurotic System. OBJECTIVE: To address a novel hyaluronic injection technique to lift the lower face. METHODS: Details of the injection techniques are described. The Position of the hyaluronic acid injected and the effect of hyaluronic acid on the superficial musculoaponeurotic System were confirmed by ultrasonography in one of the cases. RESULTS: Sonogram images demonstrated the location of the injected hyaluronic acid and pressure effect of hyaluronic acid on the superficial musculoaponeurotic System, confirming the ability to manipulate the superficial musculoaponeurotic System by this injection technique. The lifting result of this Single injection technique was immediately visible and maintained for at least 26 weeks. CONCLUSION: This is a less invasive, reproducible method that provides a sustained face lifting result. The authors propose the term "supraSMAS lift" for this novel injection technique.

The possible role of contact sensitization to fragrances and preservatives in poikiloderma of civatte.

Numerous mechanisms have been postulated to play an important role in the pathogenesis of poikiloderma of Civatte (PC), including chronic exposure to ultraviolet radiation, menopause-related hormonal changes, contact hypersensitivity and genetic predisposition. Herein, we report a case of contact sensitization to fragrances and commonly used preservatives, methylchloroisothiazolinone and methylisothiazolinone, also widely known as Kathon CG, in a post-menopausal woman with PC, who denied excessive sun exposure and a family history. After abstaining from the use of her personal care products containing the documented allergens, not only the itching and burning symptoms, but also the cutaneous changes appeared to improve partially. This report underlines the possible influence of contact hypersensitivity in the pathogenesis of PC.

The periosteal pulley technique for orbital fat realignment and correction of nasojugal groove in lower lid blepharoplasty.

BACKGROUND: Removal of orbital fat in lower lid blepharoplasty has been widely replaced by fat realignment over the orbital rim. However, incomplete correction or recurrence of fat bulging is still common compared to a simple fat removal procedure due to improper transfer and fixation of fat over the orbital rim. The authors present a novel technique of orbital fat transfer under the periosteal strip to secure the fat along the orbital rim and prevent recurrence of fat bulging from reherniation. METHODS: Of the patients who underwent lower blepharoplasties using the periosteal pulley technique during January 2010 to September 2012, 115 were included in this prospective uncontrolled clinical trial. There were 107 females and eight males. The follow-up period ranged from 6 months to 2 years (average 1 year). The results on the last follow-up were categorised into four grades: excellent, good, fair and poor. RESULT: Of the 115 patients, 10, 81 and 24 patients achieved excellent, good and fair results, respectively. We have three cases of temporary lower lid retraction or ectropion that developed 1 month after surgery and were resolved within 3-4 months. No revision surgery is needed. CONCLUSION: We propose the periosteal pulley technique as an alternative way of orbital fat transfer in lower lid blepharoplasty. This technique can provide a secure fixation of fat that not only corrects the nasojugal groove but also prevents further herniation of the remaining fat.