Jowl Improvement With Injectable Fillers: Jawline Injections Alone Versus Jawline and Cheek Injections.

BACKGROUND: Jowling is a common aesthetic complaint in aging individuals. OBJECTIVE: Injectable filler placed at the lateral jawline will improve the appearance of jowls, as defined by the Merz Aesthetic Jawline Grading Scale (MAJGS). This improvement will be independent of concomitant injection of filler into the lateral cheek. METHODS: Fifteen female subjects with grade 2 to 3 jowls on a scale of 0 to 4 were enrolled to receive either VYC-20L in the mandibular angle/ramus (Group 1) or the mandibular angle/ramus and lateral cheek (Group 2). The subjects were evaluated by a blinded cosmetic dermatologist and themselves at 4 weeks after the last injection. RESULTS: A statistically significant improvement was noted in Group 1 by all blinded reviewers and subjects. Group 2 did not reach statistical significance as evaluated by the blinded dermatologist although did by the subject's rating. The average amount of filler injected per subject was 3.36 mL for group 1 and 8.38 mL for group 2. A novel adverse event was tenderness when chewing lasting for 2 to 3 days. CONCLUSION: Injection of VYC-20L showed statistical improvement in a validated jowl scale when injected at the angle of the mandible and the mandibular ramus, independent of concomitant lateral cheek injections.

Advancing the Care of Post-Acne Scarring: Expert Insights Into New Treatment Options.

Most patients with acne have some degree of facial scarring even after their acne resolves, extending the period of psychosocial distress. Unfortunately, management of acne scars remains challenging. Many treatments for post-acne scarring including chemical peels, skin needling, laser resurfacing, surgical repair, subcision lifting, and punch elevation lifting, are limited by moderate and unpredictable results, significant morbidity, and substantial patient investments in time and money. The most recent addition to the armamentarium is tissue augmentation with soft tissue fillers, including a recently approved polymethylmethacrylate-collagen filler. Matching individual patient needs to the appropriate treatment is crucial. While many patients with acne scars have unrealistic expectations about treatment outcomes, open, honest, and realistic dialogue regarding their treatment options and concerns can facilitate realistic expectations. This article is based on a consensus discussion by the authors, who all have experience managing post-acne scarring, as well as the content of a series of live CME-accredited symposia in connection with major dermatology meetings.

J Drugs Dermatol. 2016;15(5):518-525.

New Methods for the Clinical Enhancement of Photodynamic Therapy.

The prolonged incubation time of Photodynamic Therapy (PDT) as well as the need for two treatments to achieve high efficacy have motivated physicians to experiment with treatment parameters and PDT enhancements in order to maximize results and practicality. This review explores recent published strategies including occlusion, temperature elevation, pretreatment with topical 5-FU, and microneedle or laser-assisted reduction of the stratum corneum barrier. All of these innovations improve efficacy, reduce the need for multiple treatments or both, although there are concomitant increases in post-procedure side effects.

Cheek augmentation improves feelings of facial attractiveness.

OBJECTIVE: Aesthetic fillers aim to rejuvenate the aging face, but the true end goal is to help patients feel better about their appearance. Cheek augmentation seems to elicit immediate recognition of an improved appearance. This study aims to quantify that impression. METHODS: 10 women aged 40 to 60 years were not preselected but were the first 10 women willing to undergo the study who fit the inclusion and exclusion criteria. Prior to receiving the filler, participants were asked to rate on a visual analog scale (VAS) from 1 to 6 how they felt about their appearance. Each woman received 1.0 cc of hyaluronic acid filler (Perlane, Medicis Corporation, Phoenix, AZ) into each cheek. Two weeks later they returned for photos and to complete the same VAS scale. RESULTS: Seven of ten women felt 0.5 to 2 points better about their appearance as measured by their VAS responses. CONCLUSION: Cheek augmentation improves how a woman feels about her attractiveness.

A randomized, blinded, bilateral intraindividual, vehicle-controlled trial of the use of photodynamic therapy with 5-aminolevulinic acid and blue light for the treatment of actinic keratoses of the upper extremities.

BACKGROUND/OBJECTIVE: Actinic keratoses (AKs) on the upper extremities are difficult to treat. This study compares the efficacy and tolerability of photodynamic therapy (PDT) using 20% 5-aminolevulinic acid solution (ALA) and blue light versus ALA vehicle and blue light for the treatment of AKs of the dorsal hand and forearm. METHODS: Subjects were treated twice at an eight-week interval by ALA with blue light on one hand and forearm and with ALA vehicle and blue light on the contralateral hand and forearm. ALA incubation time was two hours under occlusion. Efficacy and tolerability were compared. RESULTS: The mean lesion count reductions (58.4 ± 22.2% and 24.8 ± s20.6% four weeks after the second treatment for the ALA and vehicle-treated sides, respectively) differed significantly (P=0.0004). Eleven of 15 subjects (73%) in the ALA-treated side achieved at least 50 percent reduction in lesion count compared to only two subjects (13%) in the vehicle-treated side four weeks after the second treatment. The difference was significant (P=0.0143). Photodamage grade reduction was also significant (P=0.0309) after the second treatment. Subject satisfaction was moderate to very satisfied (86.7%) on the ALA-treated side. Transient adverse events were significantly greater on the ALA-treated side for erythema (P=0.0011), edema (P=0.0199) and stinging and burning (P=0.0016) 48 hours after the first treatment. CONCLUSIONS: Two sessions of PDT using ALA with blue light is a moderately effective, well-tolerated treatment of actinic keratoses of the dorsal hand and forearm.

Effect of multisyringe hyaluronic acid facial rejuvenation on perceived age.

BACKGROUND: The objective of aesthetic treatments is to create a more youthful appearance. Most injectable fillers are indicated for the reduction of nasolabial folds, but the current aesthetic movement is toward volume replacement in multiple areas, known as global fillers or liquid face-lift. OBJECTIVES: To quantify the degree of perceived age reduction from multisyringe hyaluronic acid treatment. MATERIALS AND METHODS: Ten women were treated with 6 to 8 mL of hyaluronic acid. Exclusion criteria were no laser for 6 months and no hyaluronic acid fillers for 6 months or semipermanent fillers for 1 year. High-resolution photographs were taken in identical lighting and position before and 2 and 4 weeks after treatment. Three blinded dermatologists rated patients' ages before and after from photographs. RESULTS: The dermatologists reported an average of 6.1 to 7.3 years of reduction in apparent age at 2 and 4 weeks, respectively. The patients perceived a decrease in apparent age of 7.8 and 9 years. CONCLUSION: Multisyringe injection of hyaluronic acid filler into the aging face results in a reduction of apparent age from 6.1 to 9 years after 2 to 4 weeks. Full-face correction with hyaluronic acid is an important procedure in the armamentarium of anti-aging techniques.

Treatment of 2,453 acne vulgaris patients aged 12-17 years with the fixed-dose adapalene-benzoyl peroxide combination topical gel: efficacy and safety.

Acne vulgaris is a common disease in adolescents, and early treatment may minimize its physical and psychological effects. A fixed-dose combination gel of adapalene 0.1% and benzoyl peroxide 2.5% (adapalene-BPO) is efficacious and safe in the treatment of acne patients aged 12 years or older, as demonstrated in three randomized and controlled studies. The current study is a subgroup analysis of the efficacy and safety of adapalene-BPO among 2,453 patients aged 12-17 years. After 12 weeks of treatment, significantly more patients in the adapalene-BPO group were "clear" or "almost clear" (30.9%, P < 0.001) compared to the monotherapies and vehicle. The percentage reduction from baseline in total, inflammatory and non-inflammatory lesions was 56, 63 and 54.5 percent in the adapalene-BPO group, respectively, significantly higher than in the monotherapy groups and vehicle (all P < 0.001). Significantly earlier onset of effect was observed at week 1. Adapalene-BPO was also well tolerated, with the mean scores of dryness, erythema, scaling and stinging/burning less than 1 (mild) at all study visits. Overall, the adapalene-BPO combination gel provides significantly greater and synergistic efficacy and a fast onset of action compared to the monotherapies and vehicle in young acne patients aged 12-17 years.

Sublative rejuvenation: experience with a new fractional radiofrequency system for skin rejuvenation and repair.

Several laser-based ablative resurfacing and nonablative rejuvenation technologies offer non-surgical options for improving the appearance of the skin. Although efficacy and good safety profiles have been demonstrated, limitations do exist with these systems. A more recent technology has been developed that employs fractionated bipolar radiofrequency (RF) energy. Referred to as "sublative rejuvenation," the treatment improves skin appearance while addressing some of the limitations of both ablative resurfacing and nonablative skin rejuvenation. This article describes the technology and reports on the authors' experience with it in clinical practice. Unlike fractional ablative laser treatments, which can disrupt 10-70% of the epidermis and most of the effect is in the epidermis, the sublative rejuvenation technique impacts only up to 5% of the epidermis and most of the effect is in the dermis. As a result, healing is rapid and downtime is minimal. The treatment is appropriate for all skin types and is an effective alternative for patients with darker skin who may be at risk for hyperpigmentation from laser treatments.

Skin rejuvenation and wrinkle reduction using a fractional radiofrequency system.

INTRODUCTION: Skin resurfacing has evolved rapidly over the past 15 years from ablative techniques to nonablative methods and most recently fractional ablative resurfacing. The purposes of this study were to analyze the degree of tissue ablation, coagulation, and heating; and to evaluate the clinical efficacy and safety of a fractional radiofrequency (RF) device, for the treatment of wrinkles with fractional skin ablation and coagulation. MATERIAL AND METHODS: Individuals scheduled for abdominoplasty received fractional RF treatment to the abdomen area, using different tips at varying energy densities and coverage rates. Biopsies were performed ex vivo following abdominoplasty and tissue samples were routinely processed and stained, using hematoxylin and eosin). Another group of subjects received 3 facial treatments, scheduled at 3 to 4 week intervals. Clinical improvement and response to therapy were evaluated with standardized photography and clinical assessment by the subjects and investigators. RESULTS: Histological findings immediately posttreatment revealed demarcated zones of ablation/coagulation/necrosis and subnecrosis up to a depth of 450 microm. Higher energy levels generated deeper effects. We noticed a tunable balance between ablation and coagulation/necrosis. These effects were coverage mode and energy density dependent. Subjects undergoing facial treatment had minimal pain, no permanent side effects, or significant downtime. Investigators' assessment for improvement in skin texture correlated with subjects' evaluation and was greater than 40% for approximately 50% of subjects. Eighty percent of the subjects were satisfied with the results. Higher energy levels and lower coverage rates produced better aesthetic results along with less pain. CONCLUSION: The clinical observations and histological findings suggest that fractionated ablative skin resurfacing using a fractional radiofrequency device resulted in a safe, tolerable and effective improvement in skin texture and reduction of wrinkles. The depth of tissue ablation, coagulation and necrosis and the relative proportions of these phenomena were found to be controllable and could be modulated to optimize treatment of variable dermatologic conditions.

The Treatment of Acne Scars, a 30-Year Journey.

Over the past 30 years, the treatment of acne scars has undergone changes that have been significantly influenced by the concurrent development of new devices. The advent of fractional resurfacing lasers was a watershed moment for acne scarring therapy. The author recounts a career history of considerations of acne scarring treatments as well as the literature supporting the experiences causing changes in practice. Fractional ablative and nonablative lasers, sublative radiofrequency, picosecond lasers, microneedling with and without radiofrequency and fillers are the bulk of the treatments covered, along with a discussion of combination therapy. A practical algorithm for acne scarring for selection of treatment modalities is presented.

Stem Cells in Dermatology and Anti-aging Care of the Skin.

Multipotent stem cells have paved the way for new applications and deeper understanding in regenerative medicine and the pathophysiology of aging. During skin aging, cumulative photodamage, exhaustion of endogenous stem cell populations, mechanical stress, and increased fibrosis lead to skin with decreased epidermal thickness and compromised dermal integrity. Specific stem cells in the hair follicle create new keratinocytes after activation by defensin peptides, released by neutrophils during wounding. Studies pertaining to defensin peptides' efficacy on skin aging have been published, highlighting their potential as a new therapy for skin rejuvenation.

Photodynamic therapy: other uses.

Mainstream uses for photodynamic therapy (PDT) in dermatology include nonmelanoma skin cancer and its precursors, acne vulgaris, photorejuvenation, and hidradenitis suppurativa. Many other dermatologic entities have been treated with PDT, including psoriasis, lichen planus, lichen sclerosus, scleroderma, cutaneous T cell lymphoma, alopecia areata, verruca vulgaris, Darier's disease and tinea infections. Nondermatologic applications include anal and vulva carcinoma, palliation of metastatic breast cancer to skin, Barrett's esophagus, and macular degeneration of the retina. PDT also has found to be useful in immunologic and inflammatory disorders, neoplasias other than skin cancer, and infections. The ability of this treatment to hone in on dysplastic epithelial and endothelial cells while retaining viability of surrounding tissue is its key feature because this leads to specific tumor destruction with cosmesis and function of the target organ intact.

A comparison of intense pulsed light, combination radiofrequency and intense pulsed light, and blue light in photodynamic therapy for acne vulgaris.

BACKGROUND: Photodynamic therapy (PDT) with 5-aminolevulinic acid (ALA) is an emerging modality for the treatment of acne vulgaris. However, optimal therapeutic protocols have not been established. OBJECTIVES: To compare the efficacies of 3 different light sources for activating ALA-induced protoporphyrin IX for the treatment of acne vulgaris. METHODS: Twenty-two patients with moderate to severe acne vulgaris were randomly assigned to receive ALA-PDT with photoactivation by intense pulsed light (IPL, 600-850 nm), a combination of IPL (580-980 nm) and bipolar radiofrequency (RF) energies, or blue light (417 nm). Each patient received 3 ALA-PDT sessions at 2-week intervals. Follow-up evaluations were conducted 1 and 3 months after the final treatment. RESULTS: At 1 month and 3 months, median lesion count reduction percentages were highest with IPL activation and lowest with blue light activation, although the differences did not reach statistical significance. At 1 month and 3 months, median investigator-assessed improvements were highest with IPL activation and lowest with blue light activation. The variability of responses was significantly smaller with IPL activation than with either RF-IPL or blue light activation. CONCLUSION: ALA-PDT with activation by IPL appears to provide greater, longer-lasting, and more consistent improvement than either RF-IPL or blue light activation in the treatment of moderate to severe acne vulgaris.

Evaluation of a nonsurgical, muscle-stimulating system to elevate soft tissues of the face and neck.

Non-invasive procedures for tissue tightening and elevation are new frontiers in dermasurgery. Current methods for achieving a "nonsurgical face-lift" include radiofrequency and infrared light devices which disrupt non-covalent collagen bonds and stimulate collagen production. This study evaluated a novel treatment protocol designed to achieve a nonsurgical face-lift with electrical stimulation of muscle. Thirty-five women were treated with the Pan G Lift (Pan Germinal Systems, Clearwater, Florida) to enhance skin and induce soft-tissue lifting via hypertrophy of the facial musculature. The protocol consists of biweekly treatments for 10 weeks followed by monthly maintenance treatments. Results were evaluated by both the investigating physician and patients for up to 12 months. Estimates of percentage improvement were based on a scale of 1 to 4 (1 = 0%-25% [mild]; 2 = 26%-50% [moderate]; 3 = 51%-75% [good]; and 4 = 76%-100% [marked]). After 10 weeks (20 treatments), the median lifting improvement scores as assessed by patients and physician were the following: cheeks-2.0 and 2.0, jowls-2.0 and 2.0, and texture-2.0 and 2.0, respectively. Physician-evaluated eye lift and neck lift showed similar improvement. At 12 months (32 treatments), lifting and skin texture changes (assessed by patients and physician) reached 3.0 to 4.0, respectively, while physician-evaluated eye lift and neck lift achieved at least a 3.0 at 20 and 26 treatments. At one year (32 treatments), neck lift reached a 4.0. There was no downtime and no complications occurred. The non-invasive, muscle-stimulating Pan G Lift is a novel procedure that yields significant 3-dimensional improvements of the face and neck (nonsurgical face-lift), which demonstrates progressive improvement with continued monthly treatments over time.

Multicenter clinical perspectives on a broadband infrared light device for skin tightening.

Modalities for skin tightening include radiofrequency (RF) energy, lasers, and combination RF and diode lasers. A new broadband infrared light device (BILD) (Titan, Cutera, Inc, Brisbane, CA) targets water to achieve dermal heating and collagen remodeling for skin tightening. Although thousands of procedures have been performed worldwide with this device, only one article (to the author's knowledge) describing its performance in skin tightening has been published. Three US dermatologists report their experience with and provide their perspective on facial skin tightening with the BILD system. As early adopters, they each have 12 to 18 months experience with this system. One author (A.F.T.) treated 42 patients twice at 1-month intervals over 18 months. The mean improvement score was 1.83 (scale 0 to 4, with 4 denoting maximum improvement) with an average follow-up time of 3.7 months. More than 90% of treated patients showed visible improvement. No complications were observed and patient satisfaction was high. This paper presents the general consensus of the authors on patient selection and treatment protocol, their modifications of the manufacturer's treatment protocol, and the outcomes of 42 patients treated by one author (A.F.T.). The observations were gathered separately and turned out to be very similar. The recommendations are presented to help practitioners achieve consistently good results and avoid complications with the BILD procedure.

Photodynamic therapy in dermatology: history and horizons.

Photodynamic therapy (PDT) uses a photosensitizer, light, and molecular oxygen to selectively kill cells. When localized in the target tissue, the photosensitizer is activated by light to produce oxygen intermediates that destroy target tissue cells. The easy access of skin to light-based therapy has led dermatologists to apply PDT to cutaneous disorders. In dermatology, PDT has been most successful in treating actinic keratoses, basal cell carcinoma, and Bowen's disease. The introduction of aminolevulinic acid, which does not make patients susceptible to phototoxicity for extended periods, has reduced morbidity associated with PDT. This has led to new interest in PDT not only for nonmelanoma skin cancer and premalignant lesions but also in the treatment of acne and as an adjuvant to photorejuvenation procedures. This review examines the historical roots of PDT and the research evaluating different light and laser sources as well as reports on new horizons for PDT in dermatology.

Photodynamic therapy for the treatment of acne: a pilot study.

Photodynamic therapy (PDT) with use of topical 5-aminolevulinic acid (ALA, Levulan Kerastick, Dusa Pharmaceuticals, Inc., Wilmington, MA) photosensitizing agent is a new modality for the treatment of acne. Eighteen patients (aged 15 to 63) with moderate to severe inflammatory acne received ALA-PDT. ALA remained in contact with skin for 15 to 30 minutes before exposure to blue light (ClearLight [Lumenis] or BLU-U [Dusa Pharmaceuticals, Inc.]) or the Aurora DSR (Syneron Medical Ltd.), which uses Electro-Optical Synergy (ELOS), a unique combination of optical and radiofrequency (RF) energy. Patients received two to four ALA-PDT treatments over four to eight weeks or two cycles of ALA-PDT (weeks 2, 4) preceded by salicylic acid peel (weeks 1, 3) over four weeks. The average follow-up time was four months. On a scale of 0.0 to 4.0, the average acne grade improvement was 1.75. Among the 12 patients who said their acne had improved, 11 had at least 50% improvement and five had more than 75% improvement. Adverse effects were limited to erythema and peeling for up to five days after treatment and one episode of impetiginization of the affected area. Patients with moderate to severe acne can achieve durable improvement with short-contact ALA-PDT.

Treatment of rosacea with intense pulsed light.

Rosacea is a chronic disease that affects millions of men and women. Topical and oral antibiotics are effective, yet often leave individuals with treatment plateau associated erythema and persistent flushing. We investigated the use of intense pulsed light for treatment of the redness, flushing, and breakouts associated with rosacea. Thirty-two consecutive patients of Fitzpatrick skin types I-III underwent 1 to 7 treatments with intense pulsed light. Patients were assessed clinically and photographically. In addition, patients completed a detailed questionnaire regarding their response to treatment. Following treatment, eighty-three percent of patients had reduced redness, 75% noted reduced flushing and improved skin texture, and 64% noted fewer acneiform breakouts. Complications were minimal and transitory. It appears that intense pulsed light is an effective treatment for the signs and symptoms of rosacea and represents a new category of therapeutic options for the rosacea patient.