A Double-Blind, Randomized Clinical Trial to Determine Effects of Increasing Doses and Dose-Response Relationship of IncobotulinumtoxinA in the Treatment of Glabellar Rhytids.

BACKGROUND: IncobotulinumtoxinA is an effective neuromodulator for treating glabellar rhytids. The relationship between dose and reduction in rhytid severity is well established. However, the effects of escalating doses on the treatment duration response are less understood. OBJECTIVES: The aim of this study was to assess the effects of increasing doses of incobotulinumtoxinA on the treatment duration for glabellar rhytids. METHODS: A randomized, double-blind, Phase IV study was conducted at a fully accredited, outpatient surgical facility. Subjects (31 female, 7 male) with moderate to severe glabellar rhytids were randomized to 1 of 3 incobotulinumtoxinA dose groups: 20, 60, or 100 U. Effect duration was determined by calculating the time to return to baseline for dynamic glabellar lines during maximal contraction. Follow-up was completed through 1 year, and adverse events were monitored. RESULTS: The median duration of effect was 120 days (95% confidence interval [CI] [90, 180 days]), 180 days (95% CI [180, 210 days]), and 270 days (95% CI [240, 330 days]) for the 20-, 60-, and 100-U groups, respectively. A Wald chi-square test from the Cox regression on the primary efficacy variable indicated a statistically significant effect of dose group on time to baseline (chi square = 54.63; df = 2; P < 0.001). Hazard ratios were HR = 0.21 (95% CI [0.10; 0.43] for the 60-U vs the 20-U group, and HR = 0.06 (95% CI [0.10; 0.43]) for the 100-U vs the 20-U group, indicating a statistically longer return to baseline for both the 60- and 100-U cohorts. CONCLUSIONS: There is a dose-dependent relationship between incobotulinumtoxinA and duration of effect in the glabella.

Multiphoton Microscopy of Collagen Structure in Ex Vivo Human Skin Following Electrochemical Therapy.

OBJECTIVES: Injury to healthy dermis and the dermoepidermal junction initiates a robust healing process consisting of fibrous tissue overgrowth, collagen deposition, and scar formation. The conventional management of scars and other skin injuries has largely relied upon surgical soft tissue transfer to resurface and/or replace damaged and dysmorphic tissue with new skin. However, these strategies are invasive, expensive, and may further exacerbate integumentary injury. In this study, we examine the creation of in situ redox generated pH changes in fresh human skin. We believe this process of "electrochemical therapy" (ECT) leads to changes in collagen matrix structure. Our objective is to map local tissue pH landscapes and image changes in collagen structure of non-injured skin following ECT. STUDY DESIGN: Ex vivo human study involving ECT of human skin. METHODS: Remnant fresh ex vivo human facial skin from facelift operations was enveloped in saline-soaked gauze for a maximum of 2 hours prior to ECT and imaging. ECT was performed by inserting platinum-plated needle electrodes connected to a DC power supply. Voltage (4, 5, or 6 V) and time (3, 4, or 5 minutes) were varied systematically. High frequency ultrasound (25 MHz) was performed immediately after ECT on each sample. Treated samples were also imaged using multiphoton microscopy (MPM) with second harmonic generation (SHG) to specifically visualize collagen fibers in the dermis. The pH landscapes were mapped using indicator dyes in bisected specimens and the MPM images were compared with histologic findings. RESULTS: Above 4 V and 3 minutes, a profound reduction in dermal collagen SHG signal was observed at the anode. Although there was less blunting of SHG signal seen at the cathode, a decrease in the fluorescence of the dermoepidermal junction was observed. The pH application suggests ECT spatial selectivity and a direct relationship between voltage and application time. Ultrasound demonstrated gas formation between the anode and cathode, which is consistent with ECT's mechanism of action. Importantly, these electrochemical changes occurred without disrupting dermal and epidermal histologic architecture. CONCLUSION: ECT alters tissue pH leading to dermal collagen structural change. These results offer additional insight into the translational potential of ECT to locally remodel the soft-tissue matrix. Future directions aim to expand into a skin injury model to determine if similar collagen effects are observed in vivo. ECT is incredibly inexpensive (~$5) and may be a means to treat soft tissue injuries using simple needle-based devices and DC battery power supplies. Lasers Surg. Med. © 2019 Wiley Periodicals, Inc.

The biophysical effects of localized electrochemical therapy on porcine skin.

BACKGROUND: Minimally-invasive methods to treat scars address a common pathway of altering collagen structure, leading to collagen remodeling. OBJECTIVE: In this study, we employed in situ redox chemistry to create focal pH gradients in skin, altering dermal collagen, in a process we refer to as electrochemical therapy (ECT). The effects of ECT to induce biochemical and structural changes in ex vivo porcine skin were examined. METHODS: During ECT, two platinum electrodes were inserted into fresh porcine skin, and following saline injection, an electrical potential was applied. pH mapping, high frequency ultrasonography, and two photon excitation microscopy and second harmonic generation (SHG) microscopy were used to evaluate treatment effects. Findings were correlated with histology. RESULTS: Following ECT, pH mapping depicted acid and base production at anode and cathode sites respectively, with increasing voltage and application time. Gas formation during ECT was observed with ultrasonography. Anode sites showed significant loss of SHG signal, while cathode sites showed disorganized collagen structure with fewer fibrils emitting an attainable signal. Histologically, collagen denaturation at both sites was confirmed. CONCLUSION: We demonstrated the production of in situ acid and base in skin occurring via ECT. The effects chemically and precisely alter collagen structure through denaturation, giving insight on the potential of ECT as a simple, low-cost, and minimally-invasive means to remodel skin and treat scars.

The evolution of RecD outside of the RecBCD complex.

The common understanding of the function of RecD, as derived predominantly from studies in Escherichia coli, is that RecD is one of three enzymes in the RecBCD double-stranded break repair DNA recombination complex. However, comparative genomics has revealed that many organisms possess a recD gene even though the other members of the complex, recB and recC, are not present. Further, bioinformatic analyses have shown that there is substantial sequence dissimilarity between recD genes associated with recB and recC (recD1), and those that are not associated with recBC (recD2). Deinococcus radiodurans, known for its extraordinary DNA repair capability, is one such organism that does not possess either recB or recC, and yet does possess a recD gene. The recD of D. radiodurans was deleted and this mutant was shown to have a capacity to repair double-stranded DNA breaks equivalent to wild-type. The phylogenetic history of recD was studied using a dataset of 120 recD genes from 91 fully sequenced species. The analysis focused upon the role of gene duplication and functional genomic context in the evolution of recD2, which appears to have undergone numerous independent events resulting in duplicate recD2 genes. The role of RecD as part of the RecBCD complex appears to have a divergence from an earlier ancestral RecD function still preserved in many species including D. radiodurans.

Autologous Fat Harvest and Preparation for Optimal Predictable Outcomes.

Best practices in fat transfer to the face focus on tissue harvest and processing techniques. This article discusses the role of adipose-derived mesenchymal stem cells (MSCs) in mitigating tissue loss in grafting. Discrepancies among common practice and recent study results have propagated uncertainty with long-term results. Fortunately, recent increases in the understanding of these MSCs are leading providers to identify statistically more favorable tissue donor sites, harvest technique, and preparation methods to increase their concentration in transferred tissue. Future studies are needed to support or confound the long-term effects of MSC transfer on facial fat grafting.

Categorization and Analysis of Nasal Base Shapes Using a Parametric Model.

IMPORTANCE: Nasal base view is important for rhinoplasty analysis. Although some descriptors of nasal base shape exist, they are largely subjective and qualitative. OBJECTIVE: To evaluate a parametric model of nasal base shape and compare it with categorization by surgeons to create an objective classification system for clinical evaluation and communication. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort review of deidentified photographs of 420 patients evaluated for possible facial plastic surgery at a tertiary care academic medical center between January 2013 and June 2017. The nasal bases were classified into 6 shape categories (equilateral, boxy, cloverleaf, flat, round, and narrow) via visual inspection. The contour of each nasal base was traced using MATLAB software (MathWorks Inc). The software then performed a curve fit to the parametric model with output of values for 5 parameters: projection-to-width ratio, the anterior-posterior positioning of the tip bulk, symmetry, degree of lateral recurvature of the nasal base, and size. The differences among shape categories for each parameter were analyzed using 1-way analysis of variance. Pairwise comparisons were then performed to ascertain how the various shapes differed. Finally, a multinomial logistic regression model was used to predict nasal base shape using parameter values. Data were analyzed between April 2017 and January 2018. MAIN OUTCOMES AND MEASURES: An algorithm that categorized nasal base shapes into 6 categories. RESULTS: The 420 nasal base photographs of patients evaluated for possible plastic surgery were categorized into 1 of 6 categories; 305 photographs were readily classified, and the remaining 115 were termed unclassified and were categorized. For both the classified and unclassified nasal base groups, there were statistically significant differences between projection-to-width ratio (classified, F5,299 = 21.51; unclassified, F4,100 = 10.59; P < .001), the anterior-posterior positioning of the tip bulk (classified, F5,299 = 3.76; P = .003; unclassified, F4,110 = 4.54; P = .002), and degree of lateral recurvature of the nasal base (classified, F5,299 = 24.14; unclassified, F4,100 = 7.21; P < .001). A multinomial logistic regression model categorization was concordant with surgeon categorization in 201 of 305 (65.9%) cases of classified nasal bases and 38 of 115 (33.0%) unclassified nasal bases. CONCLUSIONS AND RELEVANCE: The parametric model may provide an objective and numerical approach to analyzing nasal base shape. LEVEL OF EVIDENCE: NA.

Functional Outcomes, Quantitative Morphometry, and Aesthetic Analysis of Articulated Alar Rim Grafts in Septorhinoplasty.

IMPORTANCE: The design, use, and indications for the articulated alar rim graft (AARG) and the functional and aesthetic improvements that can be achieved have not been fully characterized. OBJECTIVE: To analyze the functional and aesthetic outcomes of AARG placement on nasal airway function, nasal base shape change, and appearance. DESIGN, SETTING, AND PARTICIPANTS: A case series study of patients who underwent septorhinoplasty with placement of AARG at University of California, Irvine Medical Center, from 2015 to 2018 was carried out. Surgical data recorded included stage of rhinoplasty (primary vs revision), use of spreader grafts, rim grafts (and dimensions), caudal septal extension graft (CSEG), lateral crural tensioning (LCT), and turbinate reductions. MAIN OUTCOMES AND MEASURES: Preoperative and postoperative Nasal Obstruction Symptom Evaluation Survey (NOSE) surveys were analyzed and correlated with AARG geometry, use of CSEG, and the LCT maneuver. Preoperative and postoperative alar base views were evaluated by fitting base shape to a parametric numerical model to categorize each to 1 of 6 shape categories. Blinded reviewers rated alar furrow severity and the alar ridge presence using a Likert scale for both preoperative and postoperative images to subjectively gauge aesthetic outcomes. RESULTS: Overall, 90 patients with both preoperative and postoperative NOSE scores who underwent septorhinoplasty and placement of an AARG were included. Of the 90 patients, 60 were women (mean age, 38.2 years). Patient NOSE scores (70.4 preoperatively to 25.1 postoperatively) significantly improved from preoperation to postoperation (P < .001), regardless of AARG size, CSEG, or LCT. Alar base shape parametric analysis showed preoperative to postoperative improvements were significant for anterior-to-posterior ratio mass distribution (95% CI, -0.16 to 0.02; P = .05) and vertical projection-to-horizontal base width ratio (95% CI, 0.01-0.32; P = .02) in flat noses and cloverleafing for narrow noses (95% CI, -0.05 to -0.01; P = .001); enhancement approached significance for reduction in lateral scalloping in cloverleaf noses (P = .06). Aesthetic analysis showed that there was a statistically significant improvement for the alar furrow (95% CI, -0.68 to -0.29 for rater 1; -0.54 to -0.27 for rater 2; and -0.59 to -0.27 for rater 3; P < .001) for all raters and for the alar ridge (95% CI, 0.16-0.48; P < .001) for 1 rater. CONCLUSIONS AND RELEVANCE: To our knowledge, this is the first study to demonstrate that AARG use is associated with statistically significant improvement in NOSE scores. Placement of AARGs may improve posterior mass ratios in flat noses and lateral cloverleafing in narrow noses as suggested by quantitative shape change parameter analysis. The placement of AARGs was associated with aesthetic and functional enhancement in the cloverleaf deformity, which is associated with a prominent alar furrow, and often external nasal valve collapse. Patient selection is key when placing AARGs. LEVEL OF EVIDENCE: NA.

Quantitative Analysis and Classification of the Nasal Base Using a Parametric Model.

IMPORTANCE: The nasal base view is often overlooked in rhinoplasty analysis and, unlike lateral and frontal views, lacks detailed quantitative analysis and descriptors. While shape-category analysis of the nasal base is well established, these descriptive methods remain subjective and do not facilitate quantitative analysis. OBJECTIVE: To establish a simple and quantitative classification scheme using a multiple-parameter numerical model for analyzing and describing the shape of the nasal base. DESIGN, SETTING, AND PARTICIPANTS: Deidentified photographs of the nasal base view were analyzed without knowledge of patients' pathology or medical history. Each nose was classified into 1 of 6 categories derived from literature (equilateral, narrow, flat, cloverleaf, boxy, and round). Finite parametric modeling was performed on each nose, and the correlations between the resulting parameters and the 6 categories were analyzed. Photographs for this study were acquired from the practice of a single facial plastic surgeon (B.J.F.W.) at a tertiary care academic medical center. One hundred twenty-one consecutive patients who had nasal base view photographs taken were included in the study. MAIN OUTCOMES AND MEASURES: All of the 121 images were classified into 1 of the 6 categories by 1 reviewer (C.H.B.). The contour of each nasal base was curve fit to a 5-parameter numerical model. The 5 parameters controlled base size, deviation from the midline, projection-to-width ratio, degree of nasal alar recurvature, and anterior-posterior positioning of nasal base bulk. A numerical value for each nasal base shape type was predicted by the parametric model. RESULTS: In 121 patient photographs, the parametric model generated shapes that accurately matched the tracing of the actual nasal base contours with an average correlation coefficient of greater than 0.98. This finding indicates close approximation of the nasal base shape with the curve fit constructed by the PM. Parameters b (projection-to-width ratio) and e (roundedness) were shown to have significant differences among the groups (F statistic, 8.88; P < .001 and F statistic, 13.05; P < .001, respectively). These two curve-fit parameters alone could be used to classify nasal shape into 1 of the 6 clinically determined base geometries. CONCLUSIONS AND RELEVANCE: A numerical approach to classify nasal base shape was developed using a 5-parameter model and tested against subjective analysis. This model may aid in the advancement of algorithm-driven objective nasal analysis techniques, preoperative modeling, intraoperative guidance, and surgical outcome measures beyond using Likert scales. LEVEL OF EVIDENCE: NA.

Solid Variant of Aneurysmal Bone Cyst of the Temporal Bone.

OBJECTIVES: Aneurysmal bone cysts (ABC) are benign, rapidly growing osteolytic lesions. Solid variant of ABC (SVABC) is a rare subtype of ABC that has not been reported in the temporal bone. METHODS: We report the case of a 6-year-old boy presenting with a slowly enlarging bony protuberance over the right zygomatic/malar eminence region. Computed tomography and magnetic resonance imaging demonstrated a 2.6 × 5.8 × 5.1 cm temporal bone mass involving the right mastoid, petrous, and temporal squamosal calvarium, with extradural intracranial extension to the middle cranial fossa. RESULTS: The patient underwent preoperative embolization of feeder arteries followed by combined neurosurgical and neurotologic resection. Histopathology revealed characteristic ABC features with interspersed areas of intralesional osteoid formation. CONCLUSION: Solid variant of ABCs are rare lesions of the skull base that present a diagnostic challenge given their unique radiographic and histologic features. Thorough cytogenetic evaluation is warranted to rule out potential malignant secondary causes. Early surgical resection is essential due to the risk of intracranial extension. This is the first report of ABC of any type with concurrent involvement of the squamous, mastoid, and petrous portions of the temporal bone and the first report of SVABC of the temporal bone.

Unique Clinical Aspects of Nasal Scarring.

Various methods are available for refining scars of the external nose and optimal scar revision frequently requires the utilization of multiple techniques. Differing anatomy of nasal subunits and their underlying structural framework limit surgical options in nasal scar revision compared with other areas of the face. An understanding of a variety of laser technologies and their specific applications can vastly aid in fine, controlled scar revision. Achieving optimal scar reduction regularly requires multiple stages of intervention, close follow-up, and repeat procedures.

Overview of Facial Plastic Surgery and Current Developments.

Facial plastic surgery is a multidisciplinary specialty largely driven by otolaryngology but includes oral maxillary surgery, dermatology, ophthalmology, and plastic surgery. It encompasses both reconstructive and cosmetic components. The scope of practice for facial plastic surgeons in the United States may include rhinoplasty, browlifts, blepharoplasty, facelifts, microvascular reconstruction of the head and neck, craniomaxillofacial trauma reconstruction, and correction of defects in the face after skin cancer resection. Facial plastic surgery also encompasses the use of injectable fillers, neural modulators (e.g., BOTOX Cosmetic, Allergan Pharmaceuticals, Westport, Ireland), lasers, and other devices aimed at rejuvenating skin. Facial plastic surgery is a constantly evolving field with continuing innovative advances in surgical techniques and cosmetic adjunctive technologies. This article aims to give an overview of the various procedures that encompass the field of facial plastic surgery and to highlight the recent advances and trends in procedures and surgical techniques.

Prolonged proteasome inhibition cyclically upregulates Oct3/4 and Nanog gene expression, but reduces induced pluripotent stem cell colony formation.

There is ample evidence that the ubiquitin-proteasome system is an important regulator of transcription and its activity is necessary for maintaining pluripotency and promoting cellular reprogramming. Moreover, proteasome activity contributes to maintaining the open chromatin structure found in pluripotent stem cells, acting as a transcriptional inhibitor at specific gene loci generally associated with differentiation. The current study was designed to understand further the role of proteasome inhibition in reprogramming and its ability to modulate endogenous expression of pluripotency-related genes and induced pluripotent stem cells (iPSCs) colony formation. Herein, we demonstrate that acute combinatorial treatment with the proteasome inhibitors MG101 or MG132 and the histone deacetylase (HDAC) inhibitor valproic acid (VPA) increases gene expression of the pluripotency marker Oct3/4, and that MG101 alone is as effective as VPA in the induction of Oct3/4 mRNA expression in fibroblasts. Prolonged proteasome inhibition cyclically upregulates gene expression of Oct3/4 and Nanog, but reduces colony formation in the presence of the iPSC induction cocktail. In conclusion, our results demonstrate that the 26S proteasome is an essential modulator in the reprogramming process. Its inhibition enhances expression of pluripotency-related genes; however, efficient colony formation requires proteasome activity. Therefore, discovery of small molecules that increase proteasome activity might lead to more efficient cell reprogramming and generation of pluripotent cells.

Silencing histone deacetylase-specific isoforms enhances expression of pluripotency genes in bovine fibroblasts.

Histone deacetylases (HDACs) catalyze deacetylation of histones that results in altered transcriptional activity. Inhibitors of HDACs have been shown to induce transcriptional changes that contribute positively to reprogramming somatic cells either by nuclear transfer or inducing a pluripotent state. However, the exact molecular mechanisms whereby HDAC inhibitors function and the specificity of the HDAC isoforms in cell reprogramming are not yet fully understood. Herein, we report the ability of individual isoform-specific HDACs to modulate endogenous expression of pluripotency-associated genes in bovine somatic cells. This in vitro study showed that a transient selective depletion of HDACs resulted in elevated mRNA levels of Oct-4, Sox2, and Nanog. In particular, we found that inhibition of specific HDAC isoforms using small interfering (si) RNA significantly increased expression of Nanog, a key factor required for totipotency induced by somatic cell nuclear transfer and for maintaining pluripotency in embryonic and induced pluripotent stem cells. Our study suggests that this gene might be the most susceptible to HDAC activity inhibition. Moreover, a regulatory role of the class III HDAC, SIRT3, on an Oct4-Sox2-Nanog transcriptional network was revealed. We observed the upregulation of pluripotency-related genes by depletion of SIRT3. SIRT3 is localized to mitochondria and is associated with energy metabolism processes, suggesting metabolic changes may be linked to reprogramming in bovine fibroblasts. In conclusion, we show that targeting selective HDACs can potentially be useful to enhance reprogramming and that sirtuins may play a pivotal role in somatic cell reprogramming by upregulating an Oct4-Sox2-Nanog transcriptional network. Dedifferentiating donor somatic cells by upregulating developmentally important genes through specific knockdown of epigenetic targets, in particular HDACs, may provide a path to improving livestock cloning and the in vitro production of pluripotent cells.

Screening for epigenetic target genes that enhance reprogramming using lentiviral-delivered shRNA.

Small molecules will need to be identified and/or developed that target protein classes limiting reprogramming efficiency. A specific class of proteins includes epigenetic regulators that silence, or minimize expression, of pluripotency genes in differentiated cells. To better understand the role of specific epigenetic modulators in reprogramming, we have used shRNA delivered by lentivirus to assess the significance of individual epi-proteins in reprogramming pluripotent gene expression.