Current status of surgery in dermatology.

An article titled "Current issues in dermatologic office-based surgery" was published in the JAAD in October 1999 (volume 41, issue 4, pp. 624-634). The article was developed by the Joint American Academy of Dermatology/American Society for Dermatologic Surgery Liaison Committee. A number of subjects were addressed in the article including surgical training program requirements for dermatology residents and selected advances in dermatologic surgery that had been pioneered by dermatologists. The article concluded with sections on credentialing, privileging, and accreditation of office-based surgical facilities. Much has changed since 1999, including more stringent requirements for surgical training during dermatology residency, and the establishment of 57 accredited Procedural Dermatology Fellowship Training Programs. All of these changes have been overseen and approved by the Residency Review Committee for Dermatology and the Accreditation Committee for Graduate Medical Education. The fertile academic environment of academic training programs with interaction between established dermatologic surgeons and fellows, as well as the inquisitive nature of many of our colleagues, has led to the numerous major advances in dermatologic surgery, which are described herein.

Dermal fillers do not induce upregulation of NLRP3 inflammasomes or expression of inflammatory cytokines in granulomas.

BACKGROUND: Filling materials have increasingly been used in aesthetics over the last decades. Understanding the pathophysiology of granuloma formation as a very relevant unwanted side effect of filler application may be essential to help avoid these adverse events. AIMS: Our aim was to investigate the role of the inflammasome in the formation of filler granuloma, as a central column of the innate immune response. METHODS: RPMI 1640 medium was used for growth of THP-1 cells and the induction of THP-1 macrophages. Sonication was applied in order to crush the acrylic particles of the filler. ELISA was the method of analysis for the specific cytokines. Biopsy specimens of filler granuloma were analyzed by various immunohistochemical methods. GraphPad Prism 5 software was used for the statistical data analysis. RESULTS: Neither was the sensor NALP3 overexpressed, nor could an elevated expression of cleaved IL-1ß, IL-18, or IFN-γ be detected. Furthermore, no increased expression of IL-8 or IL-1ß was detectable in vitro. CONCLUSION: No increased inflammasome activation could be observed; however, filler granulomas were infiltrated with granulocytes and macrophages. Therefore, we speculate that an unspecific immune response might be the key player in the formation of filler granuloma.

Electron microscopic documentation of late changes in permanent fillers and clinical management of granulomas in affected patients.

BACKGROUND: The manufacturers of permanent injectable fillers claim that their products are widely inert, biocompatible, atoxic, and nonimmunogenic. There are polymer gels without microparticles on the market and combination products that use collagen suspension or a hyaluronic acid gel as a vector to which polymer microspheres or polygonal particles are added. The filling effect of the polymer gels is based on the volume injected and, for the combination gels, partly on the volume injected and partly on the intended host foreign-body reaction to the microparticles. Foreign body reactions that are seen as inflammatory, sometimes disfiguring, nodules may develop years later at the injection sites. OBJECTIVES: Permanent fillers differ with respect to composition and chemical and biological characteristics. There have been reports that intend to explain how host tissue reacts with different permanent fillers and how adverse reactions differ depending on the filler used. The changes that some of the permanent fillers undergo during years of residence in human tissue have not been included in this discussion. These structural changes may be one of the reasons why adverse reactions to permanent fillers occur clinically with a delay of several years. METHODS: In a series of 10 patients who had been injected with a permanent filler of hydroxymethylmethacrylate and ethylmethacrylate (40%) in hyaluronic acid gel (60%) and had developed adverse reactions with inflammatory nodules after variable time elapsed, biopsies could be obtained for histologic and electron microscopic examinations. RESULTS: After 2 years in all specimens, changes of degradation of the filler material could be detected. Bacteria were not found in any of the specimen. In 40% of the particles, the size of the particles did not correspond to the size declared by the manufacturer (45-65 microm) and was smaller, thus being more susceptible to phagocytosis. CONCLUSIONS: Inflammatory nodules due to adverse reactions to permanent fillers containing microparticles with a hydrophobic surface were treated with good results with a regimen of allopurinol and intralesional injections with a mixture of fluorouracil and low-dose triamcinolon.

An overview of the cosmetic treatment of facial muscles with a new botulinum toxin.

Botulinum toxin (BTX) is used nowadays in a much more differentiated way with a much more individualized approach to the cosmetic treatment of patients. To the well known areas of the upper face new indications in the mid and lower face have been added. Microinjection techniques are increasingly used besides the classic intramuscular injection technique. BTX injections of the mid and lower face require small and smallest dosages. The perioral muscles act in concert to achieve the extraordinarily complex movements that control facial expressions, eating, and speech. As the mouth has horizontal as well as vertical movements, paralysis of these perioral muscles has a greater effect on facial function and appearance than does paralysis of muscles of the upper face, which move primarily in vertical direction. It is essential that BTX injections should achieve the desired cosmetic result with the minimum dose without any functional discomfort. In this paper the three-year clinical experience with average dosages for an optimal outcome in the treatment of facial muscles with a newly developed botulinum toxin type A (Xeomin) free from complexing proteins is presented.

Decrease of reported adverse events to injectable polylactic acid after recommending an increased dilution: 8-year results from the Injectable Filler Safety study.

BACKGROUND: Injectable fillers are widely used in aesthetic medicine. Polylactic acid (PLA) is a semipermanent filler that needs to be diluted with sterile water before injection. PLA has been associated with an increased risk of adverse reactions, specifically nodule formation. OBJECTIVE: To describe adverse reactions to PLA and potential risk factors based on a partly population-based registry over an 8-year period. METHODS: The Berlin registry is a partially population-based registry where dermatologists, plastic surgeons, and other specialists are contacted regularly and asked to report patients with adverse events to injectable fillers substances. Additional patients were derived from private practices outside of Berlin. The patients were assessed with a standardized questionnaire. The results were mainly analyzed by descriptive measures. RESULTS: Twenty-two patients (age, 47.82 +/- 12.65 years) with adverse reactions to PLA were included. The most frequent adverse reaction was nodule formation found in all patients. In 13 (59.1%) of the cases, nodule formation was considered to be severe. Nodules appeared after a mean latency period of 6.00 +/- 5.84 months. The duration of the adverse reactions until the interview was 14.32 +/- 10.13 months. The frequency of patients with adverse events to PLA was found to decrease after new recommendations concerning the dilution of the product were launched. CONCLUSION: PLA is an injectable filler substance that may cause subcutaneous nodules in treated patients. Our data support a decreased risk of adverse reactions with an increased dilution. However, nodule formation still appears to be a characteristic feature of PLA.