Efficacy and safety of and patient satisfaction with injectable hyaluronic acid with 0.3% lidocaine hydrochloride for the treatment of superficial perioral lines or superficial lateral canthal lines.

BACKGROUND: It is commonly requested that perioral and lateral canthal rhytides, which result from extrinsic and intrinsic factors, be rejuvenated. OBJECTIVE: To valuate the safety and efficacy of and patient satisfaction with injectable hyaluronic acid (HA) with 0.3% lidocaine hydrochloride in reducing superficial, vertical perioral wrinkles and superficial, horizontal, lateral canthal rhytides. MATERIALS AND METHODS: This was a two-center, evaluator-masked, 180-day study in which 40 patients with moderate to severe superficial, vertical perioral lines or superficial, horizontal, lateral canthal lines were treated at their baseline visit with up to three 0.9-mL syringes of HA (5.5 mg/mL) with 0.3% lidocaine hydrochloride. The investigator and a blinded evaluator assessed patients 7 days after treatment and then every 30 days after the initial treatment session for 180 days. RESULTS: Subjects experienced statistically significant improvement in their superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines and maintained those results for 180 and 120 days, respectively. Three patients experienced delayed-onset periocular nodule formation associated with swelling and erythema at sites of injection, which were histologically consistent with a granulomatous reaction to the product. CONCLUSION: Injectable HA with a particle size of 350 µm was efficacious and resulted in high patient improvement scores in improving moderate to severe superficial, vertical perioral lines and superficial, horizontal, lateral canthal lines. Three of the 40 enrolled patients demonstrated granuloma formation.

Facial filler and neurotoxin complications.

Botulinum neuromodulators and injectable dermal fillers have become part of the armamentarium in the treatment of facial aging. Their successful use requires a fundamental knowledge of anatomy and physiology and a sound understanding of their risks and complications. Although neuromodulators and fillers continue to demonstrate a strong record of safety, several notable risks exist.

Neuromodulators: available agents, physiology, and anatomy.

Neuromodulators have risen to the forefront of aesthetic medicine. By reversibly relaxing target muscles, neuromodulators exhibit their effect by softening hyperfunctional lines. An understanding of their physiology, relevant facial anatomy, and current agents is imperative for a successful aesthetic practice.

Prospective evaluation of endoscopic approaches to the thyroid compartment.

OBJECTIVE: To compare a number of endoscopic approaches to the thyroid compartment. DESIGN: Prospective, nonrandomized, experimental investigation in a porcine model. METHODS: We performed a consecutive series of 13 endoscopic thyroidectomies using 5 distinct approaches. The procedures differed by the direction of the approach, incision placement, and use of facilitative maneuvers. The parameters assessed included procedure duration, estimated blood loss, heart rate, blood pressure, temperature, oxygen saturation, and arterial blood gas levels. The thyroid specimens were weighed and examined histologically. RESULTS: Four of the endoscopic approaches were successfully used for resection of the thyroid (12 of 13 animals). The mean operative times were as follows: superior approach (n = 4), 47 +/- 14.6 minutes; lateral axillary approach (n = 4), 67 +/- 11.8 minutes; and superficial axillary (n = 3), 67.7 +/- 22.3 minutes. The one axillary approach took 84 minutes. The precordial approach (n = 1) lasted 47 minutes and then required open conversion. The overall median estimated blood loss was 0 (range 0-100) mL. The mean change in blood pressure and pH from the beginning to the end of the procedure was -0.5 +/- 24.1 mm Hg and 0.16 +/- 0.07, respectively. The thyroid glands weighed 4.3 +/- 0.9 g and had normal glandular architecture with no evidence of significant tissue trauma or thermal injury. There were no cases of pneumothorax, subcutaneous emphysema, or air embolism. CONCLUSION: A number of approaches to the thyroid compartment are conceivable. The superior approach proved to be the fastest and easiest, whereas the lateral axillary and superficial axillary were the best approaches from a cosmetic and clinical standpoint.

Split-face double-blind study comparing the onset of action of onabotulinumtoxinA and abobotulinumtoxinA.

OBJECTIVE: To report and discuss the outcome of a prospective, internally controlled, randomized, double-blind, split-face study comparing the onset of action of 2 commercially available botulinum neuromodulators. METHODS: Ninety individuals with moderate-to-severe lateral orbital rhytids were treated with onabotulinumtoxinA, 10 U, and abobotulinumtoxinA, 30 U, for the treatment of lateral orbital rhytids. Participants were assessed live with a validated 5-point photographic scale before treatment and on days 2, 4, and 6 after treatment. Photographs were taken at each encounter. Statistical analysis was applied to evaluate for any significant difference in onset of action between the 2 products. RESULTS: AbobotulinumtoxinA and onabotulinumtoxinA demonstrated statistically significant change from baseline at day 2 in the treatment of lateral orbital rhytids at maximal contraction and rest when evaluated independently by investigator and participant (P.001). Also at day 2, the improvement with abobotulinumtoxinA was better than that with onabotulinumtoxinA for the primary end point of maximal contraction graded by the investigator, although this did not reach statistical significance (P=.21); by day 4, the greater improvement achieved with abobotulinumtoxinA reached statistical significance (P=.02) and remained superior at day 6 (P=.02). The primary findings were strengthened by similar results in the secondary end points of patient self-grade at maximal contraction and at rest and of investigator grade at rest. CONCLUSIONS: In conclusion, both abobotulinumtoxinA and onabotulinumtoxinA achieved statistically significant onset of action at day 2. This improvement was seen in all end points, with abobotulinumtoxinA demonstrating a trend toward greater improvement than onabotulinumtoxinA at day 2 and a statistically significant greater improvement at days 4 and 6 when looking at maximal contraction.

An internally controlled, double-blind comparison of the efficacy of onabotulinumtoxinA and abobotulinumtoxinA.

OBJECTIVE: To compare 2 commercially available botulinum neuromodulators in a randomized, double-blind, split-face study. METHODS: Ninety patients were treated with 10 U of onabotulinumtoxinA and 30 U of abobotulinumtoxinA for the treatment of lateral orbital rhytids. Patients were assessed live with a validated 5-point photographic scale prior to treatment and at 30 days. Patients were also photographed at each visit. RESULTS: AbobotulinumtoxinA demonstrated a statistically significant advantage compared with onabotulinumtoxinA in the treatment of lateral orbital rhytids at maximal contraction, as evaluated independently by the investigator (P = .01) and patient (P = .03). AbobotulinumtoxinA was also favored by the patient over onabotulinumtoxinA 67% of the time. While abobotulinumtoxinA seemed to treat lateral orbital rhytids better at rest, as evidenced by the data and photographs, this difference was not statistically significant (P = .42). CONCLUSIONS: AbobotulinumtoxinA offers superior efficacy in the treatment of lateral orbital rhytids compared with onabotulinumtoxinA. Further studies are needed to compare the 2 products in different muscle groups and for other indications.

Pre-donation assessment of kidneys by magnetic resonance angiography and venography: accuracy and impact on outcomes.

Reports on the accuracy of magnetic resonance angiography (MRA) and magnetic resonance venography (MRV) in evaluating living donor renovasculature employ few patients or omit the consequences of inaccurate scans. We retrospectively compared intraoperative findings to MRA/MRV scans in 146 donor-recipient pairs. For detecting accessory arteries and early branching, MRA sensitivity was 57.6%, specificity 96.5%, false positive rate 3.5%, false negative rate 42.4%, positive predictive value 82.6%, negative predictive value 88.6% and overall accuracy 87.7%. By excluding clinically inconsequential accessory arteries, MRA sensitivity rose to 73.1%, specificity to 96.7% and overall accuracy to 92.5%. For MRVs, sensitivity was 56.2%, specificity 99%, false positive rate 1%, false negative rate 43.8%, positive predictive value 90%, negative predictive value 94.8% and accuracy 94.5%. Inaccurate scans were associated with prolonged donor and recipient operations and more frequently reconstructed arteries, but did not affect clinical outcomes. Because most missed accessory arteries are inconsequential, MRA is a useful, less invasive method for defining donor renovascular anatomy.