Managing the Aesthetic Patient

wide variety of therapeutic options, some challenges have arisen: designing an adequate treatment plan, electing the most suitable procedures for the patient, taking into consideration the rheological characteristics of the products, considering the amount needed to achieve a natural look, but also defining the safest way to deliver the treatment. Aging of the facial structural tissue layers occurs at a different pace and the requirements for the aesthetic approach of a 30-year-old patient are different from a 60-year-old patient. A group of twelve experts in minimally invasive injectable procedures sought to identify common changes observed in different age groups in order to help in establishing a plan of treatment for patients of different ages. The individualized aesthetic plan should consider the main pillars of the aesthetic treatment -- aging process, facial assessment, and facial anatomy, to identify and systematize common changes observed in different age groups, as well as the safest and most reproducible techniques, especially for new injectors. J Drugs Dermatol. 2019;18(1):92-102.

Complications of collagen biostimulators in Brazil: Description of products, treatments, and evolution of 55 cases.

BACKGROUND: Complications of temporary and permanent fillers have been extensively studied. However, there is a lack of comparative data regarding poly-L-lactic acid (PLLA), calcium hydroxyapatite (CaHA), and polycaprolactone (PCL) known as collagen biostimulators. AIMS: This study addressed the complications of collagen biostimulators concerning their diagnosis, type of product, treatment, and monitoring. PATIENTS/METHODS: An electronic questionnaire was sent to Brazilian dermatologic ultrasound experts to identify complications related to biostimulators. The type of biostimulator, location of application, number of vials injected, application plan, time between injection treatment and complication, injector profile, treatment, and prognosis were assessed. RESULTS: Fifty-five cases were identified, of which 49.1% were caused by PLLA-Elleva®, 23.6% by CaHA (alone or combined with hyaluronic acid), 20.0% by PLLA-Sculptra®, and 7.3% by PCL. The most affected area was the face (72.7%), with nodules being the most common clinical form (89.1%), generally occurring late (60.0%) (>1 month). Only one case was injected at an incorrect depth (musculoaponeurotic system-SMAS). Despite several treatments, including saline (45.5%), hyaluronidase (25.5%), diluted corticosteroids (23.6%), and energy-based devices (10.9%), only five cases showed complete resolution. Hyaluronidase was beneficial in complications related to fillers when there was an association of calcium hydroxyapatite with hyaluronic acid (p < 0.01). CONCLUSIONS: Complications from collagen biostimulators were more common on the face, typically manifesting about 1 month after treatment. These issues seemed to be related more to the properties of the products rather than inadequate technique. Furthermore, hyaluronidase demonstrated efficacy only in cases where there was an association with HA.

Deliberations of the Safety Task Force: Risk factors and treatment of adverse events associated with aesthetic injectables.

BACKGROUND: The growing popularity of aesthetic procedures involving fillers, biostimulators, and neurotoxins has prompted concerns about patient safety. To address these concerns, a global Safety Task Force (STF) was formed. AIMS: The inaugural STF meeting prioritized vascular compromise prevention and management, guiding clinical trial design and materials for future meetings, and collecting data from experts on current safety methods. METHODS: The STF was formed and consisted of 16 experts from nine different countries, with each possessing distinct expertise in various fields related to aesthetic injectables. Current safety data, protocols, knowledge gaps and future research priorities were discussed and voted upon. RESULTS: The establishment of a global database for tracking filler-related AEs was favored by 93% of participants. Discussions revolved around the database's scope, data standardization, and whether non-medical contributors should be included. Aspiration as a safety technique garnered support from 73% of participants. Approximately 43% of participants incorporate ultrasound in their injections, with divergent opinions on its impact and potential when used as a standard of practice versus in AE management. Most physicians on the task force incorporated cannula use for some of their injections (93%). There were varying perspectives on treatments for vascular adverse events (VAE), the primary causes, and the adoption of new protocols in the field. CONCLUSIONS: The STF meeting underscored the need for a coordinated effort to address complications related to HA fillers, including VAE management and hyaluronidase protocols. Reliable treatment endpoints were evaluated, but improved measurement methods are needed. Future meetings will focus on addressing delayed complications, furthering safety in this field.

Changes in Facial Morphology Using Poly-L-lactic Acid Application According to Vector Technique: A Case Series.

Background: The search for nonsurgical cosmetic procedures has increased considerably in recent years. A new injection technique, using vector direction, has shown good results in improving facial aesthetics but to date has only been performed with hyaluronic acid which can be associated with a risk of vascular complications. Therefore, in clinical practice, it would be interesting to assess this technique with a liquid product already widely used in the facial region, and at the same time bring the same aesthetic benefits, but with greater durability than hyaluronic acid. Objective: To investigate the improvement of facial morphology in patients with facial flaccidity submitted to the vector technique using poly-L-lactic acid (PLLA) (Sculptra®; Galderma, Lausanne, Switzerland). Case Series: Here we report the outcomes of three cases of female patients, aged between 41 and 55 years, seeking improvement of facial flaccidity. In each patient, PLLA was applied in the posterior temporal region as a bolus, in three points, with a 2-mL injection in the upper region, 1.5mL in the midpoint, and 1.5mL at the bottom point. Each of the three patients showed an improvement in face morphology, with concomitant improvement in the support and stretching of the face and improvement in skin sagging in the upper, middle, and bottom regions. Conclusion: The vector technique with PLLA is a viable alternative for the treatment of patients with facial skin flaccidity, providing harmonious and progressive improvement in the face morphology.

Doppler Ultrasound in the Management of Vascular Complications Associated with Hyaluronic Acid Dermal Fillers.

Facial injections with hyaluronic acid (HA) dermal fillers have become increasingly common. Hyaluronic acid is currently the most frequently used dermal filler. When compared to collagen for the treatment of nasolabial folds, HA not only produces similar cosmetic results with smaller doses but also lasts longer. Our objective was to evaluate the results of 10 patients with vascular complications associated with HA fillers treated with ultrasound-guided injection of hyaluronidase (HYAL) according to the Brazilian Society of Dermatology guidelines. Admission clinical evaluation revealed that the most frequent signs were: livedo reticularis (100% of the patients), hypoesthesia (50%) and local pain (20%). Although 80% of the patients complained of local pain during HYAL injection, none of them persisted with pain after the procedure ended. The total dose of injected HYAL per patient ranged from 300 to 750 IU (mean 500 IU). Post-HYAL treatment Doppler ultrasound showed pervious facial arteries and veins in 100% of the patients.

Adverse cutaneous reactions to soft tissue fillers--a review of the histological features.

The enhanced use of exogenous substances for cosmetic and reconstructive procedures is paralleled by an increase in reports of cutaneous adverse reactions to several of these agents. Recognition of the histological features of these reactions is of importance to both dermatologists and dermatopathologists but is not always easy for several reasons. First, cost-related issues are resulting in an increasing number of these procedures being performed overseas. Thus, patients are often unsure about the exact product used. Compounding this is the fact that practitioners who perform these procedures are not forthright in divulging this information, given that improper substances may be admixed in the filler injected. Furthermore, cutaneous reactions may occur at sites distant from injected sites, secondary to migration of the filler substance and a lapse of months to years may occur prior to the development of a cutaneous reaction. Thus, a causal relationship between the procedure and the reaction is often not made. We present an overview of the histological features of adverse reactions to currently available soft tissue fillers, both in the United States and overseas, in an attempt to enhance awareness of the diversity of these reactions.

A histologic study of adverse effects of different cosmetic skin fillers.

OBJECTIVE: This study was designed to describe the histologic aspects of the cutaneous and mucosal adverse reactions to fillers used for cosmetic purposes. METHODS AND MATERIALS: Eleven specimens of adverse reactions caused by Restylane, Artecoll, Metacril, New-Fill, Aquamid, and liquid silicone were processed and stained by hematoxylin-eosin and Alcian blue and submitted to polarized light. RESULTS: Most of the reactions were foreign-body granulomas. CONCLUSIONS: The type of granuloma and the characteristics of the agent were determined, contributing to the histologic identification of the material used. In the cases involving Restylane and Aquamid, it was possible to identify the material using Alcian blue stain and by the presence of necrosis. This stain was strongly positive in Restylane and faintly positive in Aquamid, and intense necrosis was observed in Aquamid cases. In the other cases the filler material itself was recognized and identified.

Conceitos atuais no uso do ácido poli-l-láctico para rejuvenescimento facial: revisão e aspectos práticos / Current concepts in the use of poly-L-lactic acid for facial rejuvenation: literature review and practical aspects

O conceito de rejuvenescimento facial abrange atualmente visão tridimensional, que reconhece como sinais de envelhecimento não só a perda da textura cutânea e as rugas de expressão, mas também as perdas volumétricas secundárias à remodelação óssea e a redistribuição da gordura facial. O objetivo do presente artigo é apresentar uma revisão da literatura sobre o ácido poli-l-láctico para rejuvenescimento facial, incluindo suas indicações, técnicas de injeção, resultados esperados e possíveis efeitos adversos.

The concept of facial rejuvenation currently includes a three-dimensional perspective, which recognizes as signs of aging not only the loss of the skin's texture and the emergence of expression wrinkles, but also the volumetric losses secondary to bone remodeling and redistribution of facial fat. This article was aimed at reviewing the literature on poly-L-lactic acid for facial rejuvenation ­ including its indications, injection techniques, expected results and possible adverse effects ­ and offer practical guidelines, based on the authors' 12-year experience with the product.

Manejo de complicações de preenchedores dérmicos / Overview and management of fillers complications

O preenchimento cutâneo figura entre os procedimentos cosméticos mais realizados. Apesar de os tratamentos estéticos possuírem perfil de segurança favorável, ocorreu um aumento nos processos jurídicos deles resultantes nos Estados Unidos. No Brasil, o número de procedimentos não cirúrgicos apresentou crescimento nos últimos anos devido não apenas ao maior número de opções de materiais para preenchimento disponíveis no mercado, mas também devido à maior quantidade de profissionais com permissão para executar esses procedimentos. O objetivo do presente estudo foi revisar a literatura, assim como delinear um guia prático para prevenção, diagnóstico e manejo das complicações secundárias ao uso de preenchedores semipermanentes e temporários.

Filler injections are among the most popular cosmetic procedures performed worldwide. Although fillers have a safety profile, there has been a rise in litigation as a result of treatments in the USA. In the Brazilian scenario, the number of non-surgical procedures has increased in the past years, mainly due to the increase of filler options available in the Brazilian market, as well as in the type of professionals allowed to perform injectable procedures. Therefore we sought to review the related literature regarding semi-permanent and temporary fillers adverse effects and outline a practical guide for complications avoidance, diagnosis and management.

A randomized and controlled trial about the use of oral isotretinoin for photoaging.

Topical retinoids are used to treat photoaging; oral isotretinoin is gold standard for acne; "off label" indications, including photoaging, have been reported with insufficient evidence of efficacy. This is a randomized controlled phase II trial with clinical and histological assessment to evaluate efficacy and safety of oral isotretinoin for photoaging. Study population was comprised of 32 menopausal or sterilized women, aged 40-55, divided in 2 groups: A (21) received 20mg isotretinoin, 3 times per week, nightly moisturizer, and daily sunscreen, for three months; B (11) just moisturizer/sunscreen. Main outcome measures were: overall clinical assessment; profilometry, corneometer and elasticity tests in periocular regions and left forearm; before/after biopsies from left forearm in patients of B and in 10 randomly selected of A. Microscopic blinded evaluation of epidermal thickness, dermal elastosis, new collagen, p53 epidermal expression was performed by quantitative digital image analysis. All data were submitted to statistical analysis. Clinical evaluation showed slight improvement; profilometry, corneometer and skin elasticity tests presented significant difference in pre/post values (P = 0.001 to 0.028), but no differences between A/B. Histological findings and p53 expression were comparable between groups before treatment (P > 0.1); microscopic analysis showed no differences between groups for most variables, after treatment. Slight but significant difference between A/B for p53 with major reduction post isotretinoin [0.66+/-0.31 vs. 0.94+/-0.34 respectively (P = 0.04) was observed. There were minor side effects and no significant laboratory test alterations. We concluded that no significant clinical, microscopic changes but p53 epidermal expression reduction were observed. The role of ultra-violet induced p53 mutation in skin carcinogenesis reinforces retinoids chemoprevention. Oral isotretinoin seemed safe but not effective to treat photoaging. Caution should be considered for women prone to pregnancy. Further controlled studies are necessary.

Uso de hialuronidase em complicações causadas por ácido hialurônico para volumização da face: relato de caso / The use of hyaluronidase in complications caused by hyaluronic acid for volumization of the face: a case report

O uso do ácido hialurônico (AH) injetável no preenchimento de rugas e volumização facial está consagrado na prática dermatológica. O manejo de suas complicações, embora raras, deve ser do conhecimento do dermatologista. No uso dos preenchedores de aplicação mais profunda, a formação de nódulos pode ocorrer, e a conduta é similar à utilizada para preenchedores mais superficiais e menos viscosos. O uso da cânula mais fina possivelmente reduz esse risco, sobretudo em áreas de derme mais fina.

The use of injectable hyaluronic acid (HA) in wrinkle filling and facial volumization is well established in the dermatological practice. While complications are rare, techniques for their management should be known by the dermatologist. Nodules may occur with the use of deeper application fillers, and the treatment is similar to that used for the more superficial and less viscous fillers. The use of a thinner cannula may reduce this risk, especially in areas where the dermis is thinner.

Tratamento de queloide: comparação entre infiltrações intralesionais com 5-fluorouracil, corticosteroide e 5-fluorouracil associado a corticosteroide / Keloid treatment: comparative intralesional injections of 5-fluorouracil, corticosteroid and 5-fluorouracil combined with corticosteroid

O queloide representa proliferação fibrosa exagerada da pele após injúria. É considerado de difícil tratamento, com baixa eficácia de medidas isoladas, demandando, na maioria dos casos, combinações de técnicas. Descreve-se caso de cicatriz queloidiana na região pubiana em incisão cirúrgica de miomiectomia. A cicatriz foi dividida em três partes tratadas com infiltração intralesional de 5-fluorouracil, corticosteroide e 5-fluorouracil associado a corticosteroide

Estudo comparativo da aplicação de CRMDex® em igual volume em uma versus duas sessões para correção dos sulcos nasogenianos / CRMDex® in the treatment of nasolabial folds: a comparative study of same applied in one versus two sessions

Introdução: O interesse por procedimentos minimamente invasivos para o rejuvenescimento facial proporcionou o desenvolvimento da técnica de preenchimento cutâneo para rugas e sulcos.O ácido hialurônico é um dos preenchedores mais populares, considerado menos imunogênico e mais seguro.Objetivos: avaliar e comparar a eficácia, segurança e duração do efeito da aplicação do preenchedor CRMDex® nos sulcos nasogenianos, em sessão única e em duas sessões. Métodos: ensaio clínico, aberto, com randomização dos sulcos nasogenianos e comparativo entre duas técnicas.Trinta mulheres, de 30 e 60 anos de idade, com acentuação simé-trica dos sulcos nasogenianos de grau leve a moderado foram submetidas à aplicação intradémica de CRMDex®.Três dermatologistas independentes avaliaram a eficácia utilizando a escala Wrinkles Severity Rating Scaling.Resultados: o tratamento realizado em duas sessões não se diferenciou do realizado em uma sessão, pois ambos proporcionaram diminuição de pelo menos um grau na escala Wrinkles Severity Rating Scaling com similar duração do efeito preenchedor. Os efeitos adversos locais mais frequentes (dor, eritema e edema) ocorreram durante a injeção emelhoraram espontaneamente. Conclusões: não houve otimização da resposta terapêutica com a injeção de volumes menores por sessão. Parece que volumes maiores podem aumentar o risco de efeitos adversos locais.

Avaliação da segurança e eficácia de novo preenchedor à base de ácido hialurônico no tratamento dos sulcos nasolabiais e contorno dos lábios / Safety and efficacy evaluation of a new hyaluronic acid based filler in the treatment of nasolabial folds and lips outline

Introdução: o uso da técnica de preenchimento cutâneo vem crescendo nos últimos anos. O ácido hialurônico é um dos preenchedores dérmicos temporários mais usados na correção de rugas, linhas e sulcos faciais por ser seguro e eficaz. Objetivo: avaliar a eficácia e segurança do produto Perfectha®, novo preenchedor à base de ácido hialurônico, para a correção dos sulcos nasolabiais e contorno dos lábios. Métodos: estudo aberto, multicêntrico, não randomizado, não controlado, incluindo 87 mulheres saudáveis.A avaliação da eficácia foi realizada através das escalas de melhora estética global (Global Aesthetic Improvement Scale - GAIS) e da classificação de gravidade das rugas (Wrinkle Severity Rating Scale - WSRS). A segurança foi avaliada por observação e relato de eventos adversos. Resultados: uma semana após a aplicação do preenchedor, foi observada melhora nos sulcos nasolabiais de 86% das mulheres e nos lábios de 89% delas. Reação inflamatória, transitória, leve ou moderada e equimoses ocorreram em 15% e 9% das pacientes, respectivamente, sobretudo nos sulcos nasolabiais. Duas pacientes apresentaram herpes simples labial após o tratamento dos lábios. Os bons resultados se mantiveram em 76% e 57% das mulheres, nos sulcos nasolabiais e em 72% e 45% delas nos lábios, após três e seis meses, respectivamente. Conclusão: o preenchedor Perfectha® mostrou-se eficaz e seguro para essas indicações.

Introduction: The use of dermal filling techniques for soft tissue augmentation has greatly increased in recent years.Hyaluronic acid is one of the most used temporary dermal fillers in the treatment of facial wrinkles, furrows, and folds due to its effectiveness and safety. Objective: To evaluate the efficacy and safety of Perfectha®, a new hyaluronic acid filler, for nasolabial folds and lip correction. Methods: Open, multicenter study comprising 87 women. Efficacy was evaluated by the Global Aesthetic Improvement Scale and the Wrinkle Severity Rating Scale. Safety was evaluated through observation and the reporting of side effects. Results: One week after the injection of the filler, improvement in nasolabial folds and lips was observed in 86% and 89% of the women, respectively. Mild or moderate transient inflammatory reaction and ecchymoses occurred in 15% and 9% of patients, respectively, mainly in nasolabial folds. Two patients presented labial herpes simplex after treatment of the lips.The good results were maintained in 76% and 57% of women for nasolabial folds and in 72% and 45% of women for lips after 3 and 6 months, respectively. Conclusion: Perfectha® was effective and safe for these indications.

Tratamento do líquen plano pigmentoso com luz intensa pulsada / Treatment of lichen planus pigmentosum with intense pulsed light

Trata-se do relato de um caso de líquen plano pigmentoso,associado ao líquen plano clássico, tratado com luz intensa pulsada. A tecnologia da luz intensa pulsada tem sido utilizada com êxito na remoção de várias lesões cutâneas pigmentadas benignas e, no caso raro aqui abordado, provou sua efetividade.

This a case report of lichen planus pigmentosus associated with classical lichen planus treated with intense pulsed light. Intense pulsed light technology has been used successfully for removal of various benign pigmented skin lesions and, in this rare case, it has proved its effectiveness.

Preenchimentos faciais - parte um / Dermal fillers - part one

Nos últimos anos, presenciamos o aparecimento de grande variedade de preenchimentos dérmicos. Eles permitiram que aumentasse nossa variedade de escolha, nunca tida antes. Neste artigo abordaremos algumas novas opções de preenchedores.

Hiperandrogenismo e pele: síndrome do ovário policístico e resistência periférica à insulina / Hyperandrogenism and skin: polycystic ovary syndrome and peripheral insulin resistance

A síndrome do ovário policístico é distúrbio endócrino feminino, extremamente comum na idade reprodutiva. Caracteriza-se por anormalidades menstruais, hiperandrogenismo e/ou hiperandrogenemia. A principal alteração na fisiopatologia é desconhecida. Entretanto, parece que a resistência à insulina, o hiperandrogenismo e a alteração na dinâmica das gonadotropinas são os mais importantes mecanismos fisiopatológicos envolvidos. As características clínicas mais freqüentes da síndrome do ovário policístico estão relacionadas com a unidade pilossebácea, como hirsutismo, acne, seborréia e alopecia. Desse modo, o dermatologista pode ser responsável pelo diagnóstico precoce da síndrome, evitando o retardo na instituição de medidas terapêutico-preventivas. Atualmente, as drogas recomendadas para as manifestações cutâneas da síndrome do ovário policístico são os contraceptivos orais conjugados, antiandrógenos e sensibilizantes de insulina e, além disso, é geralmente recomendada a modificação no estilo de vida. Trata-se de artigo de revisão sobre diagnóstico, fisiopatologia e tratamento da síndrome do ovário policístico. Os autores enfatizam que o conhecimento da fisiopatologia dessa síndrome, principalmente pelos dermatologistas, é fundamental para seu tratamento preventivo, nas diferentes fases da vida da mulher.