Lasers for the treatment of eyebrow microblading and cosmetic tattoo pigment: a review of the literature.

We aim to discuss the use of laser for the treatment of eyebrow microblading and cosmetic tattoo complications through a review of the literature. Our research question is whether quality-switched or picosecond laser is superior for the removal of eyebrow tattoos. This structured review was conducted using a PubMed search using the search terms "laser tattoo removal" AND "cosmetic tattoo" AND "eyebrow" with the article type filtered to "case reports," "clinical trial," and "randomized controlled trial" ranging from dates 1994-2023. All case reports or series evaluating the effect of laser on eyebrow cosmetic tattooing pigment were included. We summarize the results of 11 studies evaluating the use of laser for cosmetic tattoo removal, with 129 patients treated specifically for eyebrow pigment. Most studies (8/11) report Fitzpatrick skin type or race. Seven studies utilize quality-switched (QS) neodymium-doped yttrium aluminum garnet (Nd:YAG), alexandrite or ruby, three used picosecond (PS) Nd:YAG or alexandrite, and three used carbon dioxide (CO2) laser. We report laser energy, spot size, and pulse duration, as well as treatment outcomes and adverse events. Historically, methods of pigment removal included dermabrasion, cryosurgery, electrosurgery, radiofrequency, infrared light, intense pulsed light, and surgical excision; however, these methods often led to poor cosmetic outcomes including scarring and further dyspigmentation. QS laser treatments provided superior cosmetic outcomes and thus were considered the gold standard treatment option for pigment removal. However, the advent of PS lasers has challenged this given their increased selectivity, lower fluence requirements, and reduction in surrounding thermal damage. Our review demonstrates that PS Nd:YAG is quicker and more effective that QS Nd:YAG in the treatment of eyebrow tattoos. Additionally, the paradoxical darkening seen with QS lasers is less common with PS lasers. We also demonstrate that CO2 laser may be a helpful adjunct to QS or PS laser. This review focuses on Fitzpatrick skin type and race, providing a unique perspective on the use of laser treatment in skin of color, which often poses an additional treatment challenge.

Actinic Keratosis Color and Its Associations: A Retrospective Photographic, Dermoscopic, and Histologic Evaluation.

BACKGROUND AND OBJECTIVE: Actinic keratoses (AKs) have been described with varying color and morphology; however, no reports have demonstrated associations between color, vasculature, and inflammation. In this retrospective study, we analyze the clinical, dermoscopic, and histopathologic features of AKs to elucidate this relationship. METHODS: A retrospective search for patients diagnosed with AK between January 2018 and October 2019 was performed. Clinical and dermoscopic photographs and pathology slides for all included subjects were reviewed. RESULTS: Forty-nine images and histopathology slides were analyzed. Dermoscopy of white AKs demonstrated scale and absence of erythema with corresponding absence of inflammation on histopathology. Dermoscopy of brown AKs revealed pseudonetwork, absent scale, and a variable vessel pattern with pigment incontinence and absence of inflammation on histopathology. Red AKs had a distinct polymorphous vessel pattern and presence of erythema on dermoscopy. On histopathology, about half of samples showed increased vascularity and variable inflammation. Pink AK dermoscopy revealed a presence of erythema with corresponding presence of inflammation on histopathology. CONCLUSION: This report adds to our understanding of AKs and confirms that, in general, the pinker or redder the AK, the more prominent the inflammatory infiltrate and vasculature, respectively. Dermatologists should continue to use their diagnostic skills to successfully diagnose and triage AKs.

Needle Manufacturing, Quality Control, and Optimization for Patient Comfort.

INTRODUCTION: There is an increasing rise of cosmetic injectables. We sought to understand the manufacturing, quality control process, and needle selection of hypodermic needles for fillers. OBJECTIVE: To understand the process of manufacturing and quality control of hypodermic needles and the relevance to an aesthetic clinician. METHODS: We conducted a search of the internet and contacted medical device companies to understand the manufacturing process. We then collaborated with the Executive director of global pharmaceutical technology from Abbvie as well as the packaging and device engineer at Galderma and summarized our findings. Finally, we reviewed the literature and summarized existing recommendations on techniques to minimize pain related to injection. RESULTS: Hypodermic needles undergo an extensive manufacturing and regulatory process. Many considerations are taken into account in needle manufacturing as well as the selection process with commercially available hyaluronic acid filler products. Needle manufacturers are held to universal standards though the International Organization for Standardization (ISO). Filler companies perform their own testing to evaluate suitability of needles for their product including leakage force, penetration force, extrusion force, etc. Finally, parameters such as needle length, needle diameter, and wall thickness are considered for selection of needle/hub with individual filler viscosity. CONCLUSION: There is extensive consideration that goes into needle manufacturing, quality control, and optimization for hyaluronic acid filler. Understanding the technical process helps inform the clinician and guide patient care for maximum comfort. J Drugs Dermatol. 2021;20(1):44-48. doi:10.36849/JDD.5591.

The Unhappy Cosmetic Patient: Lessons From Unfavorable Online Reviews of Minimally and Noninvasive Cosmetic Procedures.

BACKGROUND: The number of patients receiving minimally and noninvasive cosmetic procedures is increasing. Often, patients turn to online review forums to gain and share advice regarding cosmetic procedures. Understanding and discussing patient-reported outcome data can help align physician and patient expectations and ultimately help improve the patient experience. OBJECTIVE: To determine the most common reasons patients are dissatisfied with a selection of minimally and noninvasive cosmetic procedures. MATERIALS AND METHODS: Negative patient reviews from the RealSelf.com website were analyzed, and the reason for patient discontent was recorded for the following treatments: tissue stabilized-guided subscision, cryolipolysis, electromagnetic therapy, deoxycholic acid injections, energy-induced thermolysis, radio thermoplasty, threadlifts, and ultrasound therapy. RESULTS: One thousand two hundred four reviews were included in analysis. For all treatments analyzed, the most common reason for patient dissatisfaction was ineffectiveness (n = 782, 65.0%), followed by complications (n = 301, 25.0%). The most common complications were as follows: lumps for tissue stabilized-guided subscision (n = 6, 50.0%), treated area enlargement for cryolipolysis (n = 23, 22.1%), swelling for deoxycholic acid injections (n = 9, 47.4%), numbness for energy-induced thermolysis (n = 6, 35.3%), fat loss for radio thermoplasty (n = 26, 53.1%) and ultrasound therapy (n = 32, 48.5%), and indentations for threadlifts (n = 10, 30.3%). CONCLUSION: Ineffectiveness and complications were the most common reasons for dissatisfaction among all treatments analyzed. Patient-reported outcome data may offer insight into how physicians can improve their patient's satisfaction with cosmetic procedures.

Setting appropriate pain expectations: Lessons learned from a clinical trial.

OBJECTIVE: This retrospective study compares subject-reported pain levels and expectations set forth by industry and treating physicians during a clinical trial of an energy based device. The physiologic and emotional aspects of pain expectations are discussed and recommendations are made for strategic patient counseling. MATERIALS AND METHODS: Average and mode pain scores were collected from the records of a previously conducted clinical trial investigating a radiofrequency microneedling device at three different settings. The trial protocol and device manual were reviewed to ascertain language regarding procedural pain. Treating physicians were asked how they learned about procedural pain and how they described it to subjects. Subject-reported pain scores and verbal pain descriptors from the device manual and trial protocol were translated onto validated pain scales, the Numerical Rating Scale (NRS), and the Verbal Rating Scale (VRS), for comparison. RESULTS: A total of 90 procedural pain scores were collected from 30 subject charts. The average procedural pain scores for three different device settings were 5.3, 6.7, and 4.6 out of 10 and the mode pain score was 6 out of 10. This translated to a 5-6 and 7-8 on the NRS, respectively and classification as "painful but bearable" and "considerable pain" on the VRS. Industry sourced pain levels translated to a 2-4 on the NRS and classification as "little pain" on the VRS. CONCLUSION: Subject-reported pain scores were higher than those set forth by industry materials and personnel. Physicians should be wary of manufacturer materials or anecdotal evidence that might mislead patients and cause undue physiological or emotional stress. Lasers Surg. Med. 9999:XX-XX, 2018. © 2018 Wiley Periodicals, Inc.

Evolution of the Picosecond Laser: A Review of Literature.

BACKGROUND: Picosecond pulse duration lasers (PS) have altered the field of dermatology. PS were initially used in tattoo removal, to optimize efficacy and reduce side effects with nanosecond domain lasers. More recently, they have been demonstrated to be effective in the treatment of pigmentary disorders, acne scarring, and photoaging. OBJECTIVE: In this article, we critically analyze the published data on the many uses of picosecond lasers in dermatology. MATERIALS AND METHODS: A systematic review of PubMed was conducted using the following search terms: "picosecond," "picosecond laser," "picosecond laser dermatology," "picosecond laser pigment/pigmentation," and "picosecond laser tattoo removal." Articles ranged from 1988 until 2017. RESULTS: Forty-one articles were identified, and 27 met inclusion criteria for review. Indications for the PS included a variety of dermatologic applications include tattoo removal, benign pigmented lesions/pigmentary disorders, acne scarring, and photoaging. Most studies demonstrated safe and effective treatment. CONCLUSION: The development of the picosecond pulse duration is a breakthrough innovation in laser technology, changing the scope of laser treatment. Encouraging findings in tattoo pigment clearance spurred the use of PS in a wider array of dermatologic issues. The increasingly positive results and low incidence of adverse effects further substantiates PS efficacy for a variety of dermatologic uses.

Safety of Laser-Assisted Delivery of Topical Poly-L-Lactic Acid in the Treatment of Upper Lip Rhytides: A Prospective, Rater-Blinded Study.

BACKGROUND: Perioral rhytides are a common complaint among dermatologic patients and can be notoriously stubborn and resistant to therapy. OBJECTIVE: We aimed to assess the safety of fractional ablative laser-assisted delivery of topical poly-L-lactic acid (PLLA) suspension in the treatment of upper cutaneous lip rhytides. MATERIALS AND METHODS: Prospective, single-arm, rater-blinded trial. Ten subjects with moderate to severe upper lip rhytides underwent 3 bimonthly treatments of low-density fractional carbon dioxide laser followed by topical application of PLLA suspension. Wrinkle severity before and after treatment was analyzed using computer-generated analyses. Blinded raters and subjects assessed improvement of wrinkles after treatment using the Global Aesthetic Improvement Scale (GAIS) (scores ranging from -3 to 3). Adverse events were recorded at each visit. RESULTS: Treatments were well tolerated. Other than expected post-laser erythema, no unanticipated adverse events were noted. After 3 treatments, the severity of upper lip wrinkles decreased by an average of 47% (p < .05) as calculated by computer-generated image analyses. Blinded raters and subjects rated wrinkles as much improved after 3 treatments (score of 2 on the GAIS). CONCLUSION: Laser-assisted delivery of PLLA is a safe and possibly effective treatment for upper lip rhytides.

Delayed-Onset Nodules to Differentially Crosslinked Hyaluronic Acids: Comparative Incidence and Risk Assessment.

BACKGROUND: Robust and long-term data on true incidence of delayed-onset nodules and immune tolerance of hyaluronic acid (HA) fillers are lacking. OBJECTIVE: To characterize the incidence of delayed nodules in Vycross (VYC) HA fillers compared with previously reported FDA and non-FDA data of all HA fillers. METHODS AND MATERIALS: The incidence of delayed nodules in all patients who had received VYC fillers in a 12-month period was assessed through a retrospective chart review. Nodule incidence for currently approved nonanimal-stabilized hyaluronic acid (NASHA) fillers was assessed using the FDA Summary of Safety and Effectiveness Data. RESULTS: Overall, 1,029 patients received 1,250 VYC filler treatments. Five patients developed delayed nodules to VOB, with an incidence of 1.0% per patient and 0.8% per syringe. No nodules were observed in patients who received VLR or VOL. All nodules were treated successfully using a combination of intralesional triamcinolone and hyaluronidase. Compared with other currently approved NASHA fillers, VOB is associated with a higher incidence of nodule formation. CONCLUSION: The introduction of VYC HAs has introduced a new variable that may be changing the immune tolerance of these substances, resulting in a higher incidence of delayed nodules than previously expected.

Challenges to laser-assisted drug delivery: Applying theory to clinical practice.

BACKGROUND: The percutaneous penetration of topically applied compounds can be enhanced using external chemical or physical sources and thus laser-assisted drug delivery is a burgeoning area of interest within the field of dermatology. OBJECTIVES: This article briefly discusses the mechanism of laser-assisted drug delivery and expands upon the challenges and safety issues that may arise in the clinical implementation of this modality. RESULTS: The existing literature demonstrates that investigators and clinicians in dermatology have successfully delivered anti-inflammatory, anti-neoplastic, and anti-oxidative medications transdermally for the treatment of a variety of conditions including scarring, photoageing, and cutaneous neoplasia. Despite growth of the field, much remains to be learned about the applicability of laser-assisted drug delivery in humans, and practitioners are faced with new safety concerns that may be associated with this treatment modality. CONCLUSIONS: Challenges in laser assisted drug delivery include unpredictability of dosing and response to therapy, possibility of inducing local and systemic reactions, and variability in treatment regimens. Lasers Surg. Med. 50:20-27, 2018. © 2017 Wiley Periodicals, Inc.

Filler Nodules: Inflammatory or Infectious? A Review of Biofilms and Their Implications on Clinical Practice.

BACKGROUND: The numbers of minimally invasive cosmetic procedures performed in the United States have steadily increased each year. Concurrently, the rates of filler complications have also increased. Delayed filler reactions and granulomas have recently been attributed to biofilm infections. OBJECTIVE: The biology and pathogenesis of biofilms, and their diagnosis, treatment, and prevention will be discussed. METHODS: The relevant and recent literature on delayed filler reactions and biofilms was reviewed. RESULTS: Increasing evidence implicates biofilm infections in the pathogenesis of delayed filler reactions. Therapeutic and preventative measures can be taken to minimize the occurrence of these potentially devastating consequences of dermal fillers. CONCLUSION: Awareness of biofilm infections is key in the assessment of filler reactions in order to ensure timely and accurate diagnosis and treatment.

Nodule Formation Following Treatment With Hyaluronic Acid Fillers: A Report of Two Challenging Cases.

Nodule formation can be a potentially disfiguring adverse event of soft tissue fillers. Limited treatment consensus exists regarding the optimal approach for addressing recurrent and persistent nodules. Here we describe two challenging cases of nodules that developed following injection with Restylane and Juvéderm Voluma. We review suspected pathophysiology and discuss our treatment approach. J Drugs Dermatol. 2018;17(5):580-581.

Laser Safety in Isotretinoin Use: A Survey of Expert Opinion and Practice.

BACKGROUND: Reports of poor wound healing in the setting of isotretinoin treatment have created a conservative standard of care in which laser and phototherapy treatment of patients receiving isotretinoin is relatively contraindicated. OBJECTIVE: A survey of 220 nationally recognized experts in cutaneous laser surgery was conducted to evaluate physician experience and opinion pertaining to laser and light procedures in patients treated with isotretinoin, including perceived risk and actual complications. RESULTS: There was a 42% response rate. Seventy-six percent of respondents have never seen in their own clinical practices any cases of complications arising in patients treated with laser while receiving isotretinoin or within 6 months of completing a course of therapy. Almost half of respondents have treated patients in this subpopulation with laser, although only a small minority have done so with ablative devices. Common concerns among respondents regarding isotretinoin patients are the risks of poor wound healing and scarring, but the most often reported concern is medicolegal risk (74%). CONCLUSION: It would seem that the risk of performing laser procedures on patients receiving isotretinoin or having recently completed a course, as estimated and observed by cutaneous laser experts, is lower than the currently perceived risk among the general medical community.

ASDS Guidelines Task Force: Consensus Recommendations Regarding the Safety of Lasers, Dermabrasion, Chemical Peels, Energy Devices, and Skin Surgery During and After Isotretinoin Use.

BACKGROUND: Currently, the isotretinoin (13-cis-retinoic acid) package insert contains language advising the discontinuation of isotretinoin for 6 months before performing cosmetic procedures, including waxing, dermabrasion, chemical peels, laser procedures, or incisional and excisional cold-steel surgery. It is common practice to follow this standard because of concerns regarding reports of sporadic adverse events and increased risk of scarring. OBJECTIVE: To develop expert consensus regarding the safety of skin procedures, including resurfacing, energy device treatments, and incisional and excisional procedures, in the setting of concurrent or recent isotretinoin use. MATERIALS AND METHODS: The American Society for Dermatologic Surgery authorized a task force of content experts to review the evidence and provide guidance. First, data were extracted from the literature. This was followed by a clinical question review, a consensus Delphi process, and validation of the results by peer review. RESULTS: The task force concluded that there is insufficient evidence to justify delaying treatment with superficial chemical peels and nonablative lasers, including hair removal lasers and lights, vascular lasers, and nonablative fractional devices for patients currently or recently exposed to isotretinoin. Superficial and focal dermabrasion may also be safe when performed by a well-trained clinician.

Laser advances in the treatment of burn and traumatic scars.

The realm of scar management is constantly changing. Many factors need to be considered when developing a comprehensive treatment plan, including the nature of the scar and the patient. Scar characteristics can be divided by color, scar type and thickness, and body location. Topical and intralesional agents and light- and laserbased treatments can be used to revitalize and restore damaged skin in atrophic and hypertrophic scars. The most commonly used lasers are the pulsed-dye laser (PDL) and fractional lasers. Ideally, a combination approach using topical and intralesional medications along with pulsed-dye laser and a fractional laser should be considered in all patients wishing to undergo treatment of their hypertrophic and atrophic scars. Keloidal scars tend to be resistant to standard therapy so other modalities should be considered.

ASDS Cosmetic Dermatologic Surgery Fellowship Milestones.

BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

No Difference in Psychotropic Medication Use in Cosmetic and General Dermatology Patients.

BACKGROUND: Patients presenting for appearance-related concerns are often perceived as being more difficult (ie, more needy, more difficult to satisfy) than patients presenting for medical dermatologic problems. While the reasons for this perception are many, some hypothesize that this may be related to a higher rate of anxiety, depression, or body image issues among these patients.
OBJECTIVE: To determine the prevalence of psychotropic medication use in cosmetic dermatology patients compared to the prevalence of such medication use in general dermatology patients.
METHODS & MATERIALS: The study was a retrospective chart review of female patients, 18 or older, new to a private practice. Exclusion criteria included dermatologic disorders with known psychosocial comorbidity. Psychotropic medication use was recorded.
RESULTS: The percentage of subjects in the medical group (n=156) who reported using psychotropic medications was 22.2% compared to 26.8% in the cosmetic group (n=154; P=0.09).
CONCLUSION: The prevalence of psychotropic medication use among all dermatology patients in our practice was relatively high, but there was no statistically significant difference in the rate of psychotropic medication use in cosmetic dermatology patients compared to general dermatology patients.

J Drugs Dermatol. 2016;15(7):858-861.