Utility of Preinjection Aspiration for Hyaluronic Fillers: A Novel In Vivo Human Evaluation.

BACKGROUND: Hyaluronic acid (HA) fillers have increased in popularity. While complications are rare, practitioners should focus on their prevention. Preinjection aspiration remains controversial as an effective safety checkpoint. OBJECTIVES: Our study investigated the utility of preinjection aspiration as a safety checkpoint for HA fillers through comparison of physiochemical and rheological properties in a novel in vivo human model. METHODS: An in vivo human model consisted of a cannula inserted into a peripheral vein. Preinjection aspiration was evaluated using syringes of 10 commonly used HA fillers. The time required to visualize a flash was recorded. RESULTS: Using a multivariable regression model, needle gauge, HA concentration, elastic modulus (G'), viscous modulus (G″), and complex modulus (G*) had significant relationships with time to flash, whereas pullback volume did not. However, when comparing pullback volume using a more appropriate paired analysis, 0.5 cc pullback volume had a significantly decreased time to flash than 0.2 cc. CONCLUSIONS: Preinjection aspiration for HA fillers has utility as a safety checkpoint. The times to visualize flashback decreased when using a human peripheral vein model compared to a previous in vitro model, suggesting that there may be real-time clinical utility of preinjection aspiration. Waiting times to visualize flashback may be affected by physiochemical and rheological properties. Additional studies would help to validate our results.

In Vitro Evaluation of Preinjection Aspiration for Hyaluronic Fillers as a Safety Checkpoint.

BACKGROUND: Hyaluronic acid (HA) fillers have increased in popularity. Although complications are rare, knowledge regarding their prevention and management are crucial. The utility of preinjection aspiration has become controversial. OBJECTIVE: Our study investigated the utility of preinjection aspiration as a safety checkpoint for HA fillers through comparison of physiochemical and rheological properties in an in vitro model. MATERIALS AND METHODS: Whole blood was drawn from vacutainers using syringes containing 10 commonly used HA fillers. Each HA filler was examined with the plunger pulled back at volumes of 0.2 and 0.5 cc. The time required to visualize a flash was recorded. Data were compared using physiochemical and rheological properties, pullback volumes, and needle gauges. RESULTS: Using a multivariable regression model, HA concentration, elastic modulus (G'), viscous modulus (G″), and complex modulus (G*) had significant relationships with time to flash, whereas needle gauge and pullback volume did not. However, when comparing pullback volume using an appropriate paired analysis, 0.5 cc pullback volume had a significantly decreased mean time to flash than 0.2 cc. CONCLUSION: Preinjection aspiration may have utility as a safety checkpoint for HA fillers. Practitioners may have to adjust pullback volume and waiting time to visualize the flash based on physiochemical and rheological properties.

Cadaveric simulation for improving surgical training in dermatology.

Simulation models are rapidly changing medical education, especially the training of dermatology residents. Various models are available, including cadaveric simulations. Our study evaluates the impact of a cadaveric simulation on the training of dermatology residents. Over a period of three years, cadaveric simulation was shown to increase the surgical knowledge of residents. Residents were more confident in their knowledge of surgical anatomy and also surgical skills. Cadaveric simulation may offer a positive impact on resident training in dermatology.

Buccal Fat Pad Reduction With Intraoperative Fat Transfer to the Temple.

There is now a growing trend for buccal fat pad reduction in patients who desire a decrease in midface and lower face volume, refinement, sculpting, or enhancement of facial features. The buccal fat pad is connected to the temporal fat, and therefore buccal fat pad reduction can result in volume depletion of the temporal fossae. In addition, most patients undergoing this procedure already have pre-existing temporal volume depletion due to aging. We describe a technique in which we remove part of the buccal fat pad and transfer the fat to the temple to achieve aesthetically pleasing facial contouring.

Analyzing Controversies in Management and Surveillance of Early-Stage Melanoma.

The incidence of cutaneous melanoma continues to rise dramatically worldwide, presenting a significant burden to the healthcare system. Despite this, there is still controversy in the guidelines regarding follow-up surveillance for patients with thin melanoma. Since there are no randomized clinical trials to support evidence-based guidelines for follow-up surveillance, dermatologic and oncologic organizations have developed their own recommendations based on expert opinion. However, these recommendations differ widely and are often vague, resulting in considerable variability in the management of early-stage melanoma among clinicians. The benefits of frequent follow-up visits are early detection of recurrent lesions, lower cost of early-stage melanoma compared to that of late-stage melanoma, decreased need for sentinel lymph node biopsy and adjuvant therapies, and the opportunity to educate patients on self-examination and sun protection. However, the high cost of screening and potential increased rates of biopsy, as well as over-imaging and overtreating, pose serious concerns about this approach. While more rigorous research is needed to resolve this controversy, currently clinicians should follow a relatively universal recommendation to tailor the follow-up regimen based on the patient's relative risk of recurrence and comfort.

Scleromyxedema in a patient with thyroid disease: an atypical case or a case for revised criteria?

Lichen myxedematosus (LM), commonly referred to as papular mucinosis, is a rare papular eruption defined by mucin deposition in the dermis. Scleromyxedema (SM) is a generalized papular and sclerodermoid form of LM. It is a progressive disease of unknown etiology with systemic manifestations that cause serious morbidity and mortality. Current criteria list thyroid dysfunction as an exclusion for the diagnosis of SM. Cases of LM associated with thyroid dysfunction have been defined as atypical. We describe a patient with uncontrolled hypothyroidism due to Hashimoto thyroiditis who subsequently developed a diffuse papular eruption with systemic signs and symptoms attributable to SM. Diagnostic workup, including laboratory studies and histologic specimens from the skin and muscle, were consistent with SM. Furthermore, our patient responded clinically to intravenous immunoglobulin (IVIg) and lenalidomide. We discuss the diagnostic criteria, differential diagnoses, and diagnostic challenges associated with LM in association with thyroid dysfunction. We propose that the presence of thyroid disease should not preclude the diagnosis of SM. Finally, we add to the case reports and series of successful treatments of SM with IVIg and lenalidomide.

Preinjection aspiration for injectable fillers in aesthetic dermatology: Trust or bust?

In recent years, the utility of preinjection aspiration for injectable fillers as a safety checkpoint has been debated. It is a clinical technique that has become controversial in both the literature and at national aesthetic conferences. Many consensus papers and anecdotal reports have been divided on how helpful preinjection aspiration is in reducing adverse events and subsequently increasing patient safety. Here, we summarize the prominent studies in the literature and offer an evaluation and insights.

Business administration training for dermatology residents: preparing for the business of medicine.

Previous studies have evidenced the lack of practice management and business training components in the residency curriculum, and that satisfaction with this training, when provided, was low. Whether considered good or bad, medicine has been moving increasingly toward becoming more business centric. Dermatology represents a unique field, because most residents choose to pursue private practice, where competent business skills are helpful to running a successful clinic. Our study examines the current state of business administration training for dermatology residents in Accreditation Council for Graduate Medical Education-approved programs as of 2017 to 2018. Our results show that residents both value and desire business administration training; however, the current training provided is considered to be insufficient and inadequate. Promoting and encouraging the teaching of business administration skills, while still balancing core competencies, may help to prepare residents in navigating the future of our field.