Combination Foam and Liquid Sclerotherapy for Lower Extremity Reticular and Telangiectatic Veins: A Single-Center Retrospective Study.

BACKGROUND: Lower extremity reticular and telangiectatic veins are of common cosmetic concern. OBJECTIVE: To retrospectively evaluate results of lower extremity sclerotherapy using a combination of foam and liquid sclerosing agents. METHODS: A retrospective chart review of sclerotherapy patients at a dermatology practice (January 2014 to April 2023) was performed. RESULTS: Eight hundred and nine patients (775 women and 34 men) with a mean age of 49.6 ± 12.2 (18-84) years underwent a mean 1.4 ± 0.7 (1-7) sessions. Multiple different sclerosing agents were used, with 0.2% sodium tetradecyl sulfate foam/liquid predominating, although 72% glycerin liquid and 0.25% to 0.5% polidocanol foam/liquid were also used. Coagula occurred in 61.0% of patients at 2 weeks and 6.4% at 3 months, whereas postsclerotherapy hyperpigmentation was seen in 5.0% and 19.1% of patients at the same time points. Both were more common after first-round treatment, each with a trend toward decreased frequency with increasing session number. Telangiectatic matting was found in 2.3% of 3-month follow-up patients. Edema, superficial venous thrombophlebitis, migraines, and ulceration were rarely seen. Significant clinical improvement was noted in 72.0% of treatments. CONCLUSION: This retrospective chart review, the largest to date of its kind, confirms the safety and efficacy of cosmetic lower extremity sclerotherapy with a combination of foam and liquid sclerosing agents.

Sclerotherapy off the Lower Extremities: A Single-Center Retrospective Study of Veins Treated on the Dorsal Hands and Chest.

BACKGROUND: Few studies have evaluated the safety and efficacy of treatment of cosmetic dorsal hand and chest/breast veins. OBJECTIVE: To retrospectively evaluate results of dorsal hand and chest vein foam sclerotherapy. MATERIALS AND METHODS: A retrospective chart review of dorsal hand and chest vein sclerotherapy patients at a dermatology practice was performed between January 2014 and April 2023. RESULTS: Fifty-five patients (54 female and 1 male patients) with a mean age of 55.8 ± 10.5 (31-83) years underwent treatment. Mean number of sessions for dorsal hand ( n = 41) and chest ( n = 14) patients were 1.5 ± 0.9 (1-5) and 1.6 ± 1.2 (1-5), respectively. Both groups were predominantly treated with 0.2% sodium tetradecyl sulfate or 0.5% polidocanol foam. Rate of coagulum formation across all sessions in the dorsal hands and chest was 15.2% and 3.0%, respectively. Vein induration, edema, postsclerotherapy hyperpigmentation, and persistent erythema were rarely seen. No patients experienced superficial venous thrombophlebitis, erosion/ulceration, telangiectatic matting, or neurologic side effects. Seventy-five percent and 63.2% of chest and hand patients, respectively, demonstrated significant clinical improvement at 3-month follow-up, although not systematically evaluated. CONCLUSION: Foam sclerotherapy of dorsal hand and chest veins with detergent sclerosing agents is safe and effective with mild, self-limited adverse events.

Prospective Study of 532-nm Picosecond Laser for the Treatment of Pigmented Lesions of the Face and Dorsal Hands.

BACKGROUND: Pigmented lesions from chronic UV photoaging are extremely common on the face and hands. OBJECTIVE: To evaluate the safety and efficacy of a 532-nm picosecond laser for these types of pigmented lesions. METHODS: This was a single-center, prospective, open-label clinical trial. Eligible subjects with pigmentation on the face and hands received 3 monthly treatments, with 1 month (1M) and 3 months (3M) follow-up. Change in investigator-graded overall facial and per lesion pigmentation and subject-graded satisfaction and pigmentation improvement was evaluated by a 5-point scale. Immediate skin response and adverse events (AEs) were evaluated post-treatment. The melanin index was measured using a mexameter. Randomized before and after photographs were graded by 3 blinded physicians for degree of pigmentation improvement. RESULTS: Twenty-five subjects (22F/3M) with Fitzpatrick skin types I-III were enrolled, with 23 subjects completing. Treatments used a 532 nm wavelength, 800 ps pulse duration, 4-6mm spot size, and 0.1 to 0.6J/cm2 fluence. Good-to-excellent clearance at 1M/3M was demonstrated in ≥95% of lesions (n = 116). Only mild treatment-related pain was reported, with transient post-treatment AEs (mean downtime of 2.1 ± 2.0 days) and no serious treatment-related AEs. Subject satisfaction (satisfied or very satisfied) was 95% at 1M and 91% at 3M. CONCLUSION: Treatment with a 532-nm picosecond laser is safe and highly effective for the treatment of the pigmented lesions of the face and dorsal hands.

AbobotulinumtoxinA Treatment of Glabellar Lines Using a New Reconstitution and Injection Volume: Randomized, Placebo-Controlled Data.

BACKGROUND: Increasing the reconstitution and injection volumes of abobotulinumtoxinA (aboBoNT-A) could provide more options for aesthetic healthcare professionals. OBJECTIVE: To evaluate efficacy and safety of aboBoNT-A treatment of moderate-to-severe glabellar lines (GL) versus placebo, using a new reconstitution and injection volume. Methods & Materials: In this 6-month, Phase III, randomized, double-blind study, subjects 18-64 years were administered aboBoNT-A 50 U (N=224) or placebo (N=77), as five 0.1-mL-injections (10 U) in the glabellar region following reconstitution of a 300-U-vial in 3 mL. Assessments included time to onset of effect, investigator- (ILA) and subject- (SSA) assessed GL severity, subject satisfaction, aesthetic improvement and safety. The primary endpoint was composite 2-grade response at month 1 (a GL severity of none-or-mild at maximum frown and ≥2-grade improvement from baseline concurrently on both ILA and SSA). RESULTS: Median time to onset was 2 days, 34% of subjects reporting effect on day 1. At month 1, the composite 2-grade responder rate was 65.8% for aboBoNT-A versus 0% for placebo, P<0.001, 91–92% had none-or-mild GL severity, and 95–100% had a ≥1-grade GL severity improvement. A ≥1-grade improvement was sustained in 46-56% of aboBoNT-A-treated subjects up to 6 months (P<0.001 vs placebo). Aesthetic improvement and subject satisfaction were high throughout 6 months and aboBoNT-A treatment was well tolerated. CONCLUSION: Safety and efficacy of GL treatment using 0.1 mL (10 U) aboBoNT-A per injection site were demonstrated, with rapid onset and up to 6 months’ duration of effect. Severity improvement was accompanied by sustained aesthetic improvement and subject satisfaction. J Drugs Dermatol. 2021;20(9):988-995. doi:10.36849/JDD.6130.

An expert panel consensus on opioid-prescribing guidelines for dermatologic procedures.

BACKGROUND: Opioid overprescribing is a major contributor to the opioid crisis. The lack of procedure-specific guidelines contributes to the vast differences in prescribing practices. OBJECTIVE: To create opioid-prescribing consensus guidelines for common dermatologic procedures. METHODS: We used a 4-step modified Delphi method to conduct a systematic discussion among a panel of dermatologists in the fields of general dermatology, dermatologic surgery, and cosmetics/phlebology to develop opioid prescribing guidelines for some of the most common dermatologic procedural scenarios. Guidelines were developed for opioid-naive patients undergoing routine procedures. Opioid tablets were defined as oxycodone 5-mg oral equivalents. RESULTS: Postoperative pain after most uncomplicated procedures (76%) can be adequately managed with acetaminophen and/or ibuprofen. Group consensus identified no specific dermatologic scenario that routinely requires more than 15 oxycodone 5-mg oral equivalents to manage postoperative pain. Group consensus found that 23% of the procedural scenarios routinely require 1 to 10 opioid tablets, and only 1 routinely requires 1 to 15 opioid tablets. LIMITATIONS: These recommendations are based on expert consensus in lieu of quality evidence-based outcomes research. These recommendations must be individualized to accommodate patients' comorbidities. CONCLUSIONS: Procedure-specific opioid prescribing guidelines may serve as a foundation to produce effective and responsible postoperative pain management strategies after dermatologic interventions.

Efficacy and Safety of Intense Pulsed Light With a KTP/PDLlike Filter for the Treatment of Facial Telangiectasias.

BACKGROUND: An intense pulsed light (IPL) narrowband "KTP/PDL-like" filter (525–585 nm) may combine the tolerability of the IPL with the precision of KTP and PDL lasers. This study evaluated the impact of IPL with a KTP/PDL-like filter on telangiectasias. METHODS: This was a single-center, prospective study of 17 subjects with facial telangiectasias and skin types I–III. Three monthly treatments were performed using this specific filter, with follow-up visits at 1, 3, and 6 months. Telangiectasia improvement was assessed by the investigator and subjects using a 5-point scale. Facial photographs and safety assessments were obtained at each visit. Subject discomfort was evaluated using a visual analog scale (VAS) immediately posttreatment, and subject downtime was recorded at each subsequent visit. RESULTS: All facial telangiectasias significantly improved. At 1-month follow-up, >50% lesion clearance was noted in 97.1% of facial (n=36) and 85.7% of non-facial (n=7) lesions, with 73% of subjects satisfied or very satisfied. An increase in mean social downtime (0, 2.3, and 3 days) and VAS scores (3.5, 4.5, and 4.8) with treatments 1, 2, and 3, respectively, mirrored a stepwise increase in fluence with subsequent sessions. CONCLUSIONS: The use of a novel IPL narrowband KTP/PDL-like filter can significantly improve facial and non-facial telangiectasias with minimal downtime. J Drugs Dermatol. 2020;19(9):844-850. doi:10.36849/JDD.2020.4834.

Efficacy and safety of intense pulsed light with a KTP filter for the treatment of solar lentigines.

BACKGROUND: Optical energy-based devices, including intense pulsed light (IPL) and potassium titanyl phosphate (KTP) lasers achieve reduction of pigmented and vascular lesions in a relatively similar number of treatments. This study aimed to evaluate the efficacy and safety of an IPL with a "KTP-like" filter emitting a wavelength of 525-585 nm for the treatment of solar lentigines on the hands and face. METHODS: This was a single center, prospective, open-label clinical trial including 16 healthy Caucasian subjects (15 females, mean age, 55 years; skin types II and III) with hand and facial solar lentigines. Subjects were treated with three IPL treatment sessions with a KTP-like filter conducted at monthly intervals. Follow-up evaluations were performed 1, 3, and 6 months after the last treatment session. Overall pigmentation improvement, pigmentation clearance per lesion, adverse events, and subject tolerability to treatment were evaluated. RESULTS: Significant improvements in facial and hand pigmentation were noted at all follow-up visits (P < 0.0001). One month after the last treatment session, good to excellent outcomes were noted in 74.6% of treated facial areas and 90% of treated hand regions. Although the effect of treatment gradually declined in both treatment regions over the 6-month follow-up period, over 60% of subjects demonstrated good to excellent results at the study end. Clinical effectiveness was further confirmed by the reduction in Melanin Index (MI) following each treatment as compared to baseline. Downtime and complications were minimal. CONCLUSIONS: IPL treatment with a KTP-like filter is a well-tolerated and effective method for reducing facial and hand pigmentation. Lasers Surg. Med. 51:500-508, 2019. © 2019 Wiley Periodicals, Inc.

Cryolipolysis for Noninvasive Contouring of the Periumbilical Abdomen With a Nonvacuum Conformable-Surface Applicator.

BACKGROUND: Although most cryolipolysis treatments are performed with vacuum applicators, some patients may have areas of fibrous, nonpinchable fat or find vacuum suction to be uncomfortable. OBJECTIVE: This study evaluates a nonvacuum conformable-surface applicator for cryolipolysis of the periumbilical abdomen. METHODS/MATERIALS: Twenty subjects with periumbilical subcutaneous fat were treated with a nonvacuum cryolipolysis applicator in this prospective, single-center, open-label clinical trial. Each subject underwent a single treatment cycle with an optional second treatment 10 weeks later. Efficacy was evaluated by blinded review of digital photographs. Subject satisfaction was assessed at 10-week follow-up. RESULTS: Twenty subjects completed one treatment, of which 6 underwent the optional retreatment. Independent review demonstrated 77% correct identification of baseline photographs after one treatment, which improved to 100% after a second treatment. Patient questionnaires after one treatment revealed 50% satisfaction, with 60% willing to recommend the procedure and 60% reporting visible fat reduction. After second treatment, however, 100% were satisfied, 83% were willing to recommend, and 100% reported visible fat reduction. CONCLUSION: Cryolipolysis with a nonvacuum conformable-surface applicator is safe, effective, and well tolerated for noninvasive reduction of fibrous periumbilical abdominal fat. Efficacy and subject satisfaction is significantly greater with 2 treatments than with a single session.

Complications from microfocused transcutaneous ultrasound: Case series and review of the literature.

BACKGROUND AND OBJECTIVE: Microfocused ultrasound (MFUS) technology has been utilized since 2009 for improvement in mild to moderate skin and soft tissue laxity of the face and neck. Few complications have been previously reported, the majority of which include mild and transient erythema, edema, ecchymosis, and nerve paralysis. Rare yet serious potential complications of MFUS for noninvasive skin tightening of the face and neck are, however, possible. METHODS & MATERIALS: Retrospective multicenter case series of five patients from the authors' practice who developed serious adverse events directly related to MFUS with a commercially available device (Ultherapy; Merz North America, Inc., Raleigh, NC). RESULTS: Five patients developed blistering, erosion/ulceration, cutaneous, or subcutaneous tissue edema with resulting atrophy, and/or cutaneous necrosis following single sessions of MFUS. CONCLUSION: Despite their rarity, serious adverse events secondary to MFUS are nevertheless possible and may be underreported. Early management of complications includes local wound care, patient reassurance, and topical corticosteroids and/or pulsed-dye laser to mitigate inflammatory sequelae. Other cosmetic and surgical therapies should be utilized when conservative measures have failed. Lasers Surg. Med. 50:13-19, 2018. © 2017 Wiley Periodicals, Inc.

Calcium Hydroxylapatite Dermal Filler for Treatment of Dorsal Hand Volume Loss: Results From a 12-Month, Multicenter, Randomized, Blinded Trial.

BACKGROUND: Calcium hydroxylapatite (CaHA) microspheres suspended in a carrier gel is an opaque dermal filler that has been used to provide immediate volume correction in the dorsal hands. OBJECTIVE: To assess the safety and effectiveness of CaHA for the correction of volume loss in the hands up to 12 months. MATERIALS AND METHODS: This multicenter, controlled, single-blind study (NCT01832090) included 114 subjects randomized 3:1 to CaHA treatment and untreated control groups. Effectiveness was assessed by blinded investigators using the validated Merz Hand Grading Scale (MHGS). Subject-reported improvement was assessed using the Global Aesthetic Improvement Scale. Effects of treatment on hand function were also assessed. RESULTS: A total of 75% of subjects achieved ≥1-point improvement on the MHGS (p < .0001) at 3 months (primary end point); this response was generally maintained through 12 months. Proportions of subjects reporting improvement ranged from 98% (3 months) to 86% (12 months). There were no clinically significant differences between control and CaHA-treated subjects in any hand function measure. Adverse events were generally expected, minor, short-lived, injection-related, and similar to those observed in previous CaHA clinical studies. CONCLUSION: Treatment with CaHA results in significant improvement in the appearance of the dorsal hand and is well tolerated.

A Retrospective Study of Multiple Sequential Light and Laser Sources to Activate Aminolevulinic Acid in the Treatment of Acne Vulgaris.

Reports of the sequential use of multiple light and laser sources for topical 5-aminolevulinic acid (ALA) activation in photodynamic therapy (PDT) of inflammatory acne vulgaris are lacking. The authors sought to retrospectively compare field-directed ALA-PDT with blue light only, blue light + pulsed dye laser (PDL), blue light + intense pulsed light (IPL), blue light + PDL + IPL, or blue light + red light + PDL + IPL for inflammatory acne of the face or upper trunk. Results showed a trend toward greater patient-reported improvement with comparable tolerability using multiple, sequential light sources in ALA-PDT for acne vulgaris, albeit not statistically significant. The addition of red light, however, did not improve outcomes. The disparate numbers of patients between treatment arms and high potential for recall bias limit this single-center retrospective study.

Treatment of facial photodamage and rhytides using a novel 1,565 nm non-ablative fractional erbium-doped fiber laser.

BACKGROUND AND OBJECTIVE: Non-ablative fractional lasers (NAFL) generate microscopic non-contiguous columns of thermal injury in the dermis, resulting in collagen remodeling. This manuscript details our experience with a novel 1,565 nm scanned, erbium-doped fiber NAFL for the treatment of facial photodamage. STUDY DESIGN/MATERIALS AND METHODS: A prospective, open-label clinical trial was conducted at two clinical sites in the United States on 16 female subjects with a mean age of 49.6 years, Fitzpatrick skin types II to IV, and a baseline Fitzpatrick-Goldman Wrinkle and Elastosis Score (FGWES) of 3-6. Each subject received three treatments at 4-5 week intervals with follow-up assessments at 1, 3, and 6 months after the last treatment. RESULTS: The mean FGWES demonstrated a statistically significant decrease from baseline both at 3 months (-0.58 ± 0.23, P = 0.02) and 6 months (-0.66 ± 0.22, P = 0.008) after the last treatment. Fifty percent (95%CI [24.21%, 68.49%]) of subjects showed a significant (at least 1 grade) improvement in FGWES from baseline at 3-month follow-up. At least 72% of subjects perceived the results as "moderate" to "very good" at 3 months post-treatment, with comparable satisfaction rates. Treatments were not associated with a high level of pain or discomfort and typical downtime was less than 2 days. No unexpected adverse events or serious adverse events were reported. CONCLUSION: The 1,565 nm erbium-doped scanned NAFL is an effective treatment for facial wrinkles with a favorable recovery and side effect profile.

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.

Delayed granulomatous reactions to facial cosmetic injections of polymethylmethacrylate microspheres and liquid injectable silicone: A case series.

Polymethylmethacrylate microsphere (PMMA) and liquid injectable silicone (LIS) fillers are non-biodegradable, synthetic polymers utilized for long-term soft-tissue augmentation. Delayed granulomatous reactions to permanent fillers are a rare yet significant event that can occur months to years post procedure and are often refractory to treatment and associated with significant cosmetic morbidity. We report a case series of 4 patients who developed granulomatous reactions to PMMA or LIS, 15 months to 5 years post injection. The etiology of granulomatous reactions to permanent fillers is still poorly understood, with foreign-body reactions and/or biofilms purported to play a role. Real-time biochemical analysis with polymerase chain reaction should be performed when the index of suspicion for the presence of a biofilm is high.

A review of the aesthetic treatment of abdominal subcutaneous adipose tissue: background, implications, and therapeutic options.

BACKGROUND: The demand for aesthetic body sculpting procedures has expanded precipitously in recent years. Subcutaneous adipose tissue (SAT) deposits of the central abdomen are especially common areas of concern for both males and females. OBJECTIVE: To review the available literature regarding the underlying pathophysiology of subcutaneous fat accumulation in the abdominal area and available treatment options. METHODS: A MEDLINE and Google Scholar search was performed accordingly. RESULTS: The preferential accumulation of SAT in the central abdomen is attributable to the reduced lipolytic sensitivity of its adipocytes. A number of therapeutic options are available for the treatment of central abdominal adiposity. Cryolipolysis, high-intensity focused ultrasound, nonthermal ultrasound, radiofrequency, and injection adipolysis lead to adipocyte destruction through multiple different mechanisms. Nonablative modalities such as injection lipolysis mobilize fat stores from viable adipocytes, although its effects may be curtailed in obese patients. Liposuction through tumescent technique, however, mechanically extricates SAT. CONCLUSION: Although tumescent liposuction remains the gold standard for SAT removal, less invasive ablative and nonablative options for targeting localized deposits of adipose tissue now permeate the aesthetic marketplace. Limited results associated with these modalities mandate multiple sessions or combination treatment paradigms.

Foam sclerotherapy for reticular veins of the chest: a retrospective review of efficacy and safety.

BACKGROUND: No study has evaluated the use of foam sclerotherapy in treating clinically conspicuous reticular chest veins. OBJECTIVE: This retrospective study evaluates patient-rated efficacy, safety, and satisfaction after foam sclerotherapy for reticular veins of the chest. MATERIALS AND METHODS: A telephone-based questionnaire was used for patient self-assessment of overall improvement, satisfaction, and adverse events. All patients had been treated with 0.25% to 0.50% sodium tetradecyl sulfate (STS) foam using room air (1:4 ratio). The mean length of follow-up was 3.7 years. RESULTS: Twelve of 23 patients were successfully contacted, with a total of 14 treatment sessions. Overall, patients reported scores of 2.4 ± 0.8 for overall improvement (0 = none, 1 = mild, 2 = moderate, and 3 = complete resolution) and 1.75 ± 0.6 for satisfaction with results (0 = not satisfied at all, 1 = mildly satisfied, and 2 = very satisfied), with minor treatment-related adverse events. CONCLUSION: Foam sclerotherapy with STS is effective for management of reticular veins of the chest with an excellent safety profile and high long-term patient satisfaction.