Lip Augmentation With Hyaluronic Acid Fillers: A Review of Considerations and Techniques.

Lip augmentation has become a key component in addressing cosmetic concerns in dermatology practice today. In particular, hyaluronic acid (HA) fillers are increasingly used for this minimally invasive procedure. In order to achieve the optimal cosmetic and aesthetic outcome, a fundamental understanding of the relevant anatomic components is necessary: this article details lip topography, muscular and subcutaneous organization, and pertinent vascular structures of the lip, while also highlighting important changes that occur with aging. In addition to understanding the disposition of HA fillers, we also discuss specific injection techniques commonly used in practice. Finally, injection of HA fillers is not without complications; physicians must be knowledgeable of both the possibility of complications and management thereafter. This article details anatomical review, specific procedural technique, and safety considerations to be mindful of when using HA fillers for lip augmentation. J Drugs Dermatol. 2023;21(1):23-29. doi:10.36849/JDD.6304.

A Rare Case of Oral Mucosal Amelanotic Melanoma in a 77-year-old Immunocompromised Man.

Primary mucosal melanomas are rare neoplasms that occur in the mouth, esophagus, nasopharynx, larynx, and anogenital mucosa. Mucosal melanomas are rare, accounting for approximately one percent of all melanomas. Of the mucosal melanomas that occur in the head and neck, oral mucosal melanomas compose approximately 25 percent. Here, we present a case of an amelanotic oral mucosal melanoma of the mucosal lip in a 77-year-old male patient with a history of non-Hodgkin's lymphoma and multiple basal and squamous cell carcinomas. The patient presented with a pink, nonpigmented, pedunculated mass on the left superior mucosal lip. Histopathologic examination of the biopsy specimen revealed a diagnosis of a superficial spreading type of malignant melanoma with a nodular component. The patient was referred to a tertiary care center for further management. Multiple risk factors exist for developing melanoma, including immunosuppression. Lymphoproliferative disorders, such as non-Hodgkin's lymphoma, lead to inherent immunosuppression, which can be exacerbated by chemotherapy treatments. Cases of oral mucosal melanoma have a poor prognosis due to delayed diagnosis, anatomic location, and aggressive behavior. Surgical resection is first-line therapy, with regional lymph-node dissection of the neck is recommended in most cases. Radiotherapy and targeted molecular therapy, such as c-KIT inhibitors, can also be used.

Cutaneous angiosarcoma of the leg.

Angiosarcomas are malignant neoplasms arising from endothelial cells. Cutaneous angiosarcoma is the most common form, typically occurring in the setting of chronic lymphedema or previous radiation. The head and neck are the most common locations for cutaneous angiosarcoma, with rare occurrence on the trunk and extremities. Herein, we present a case of angiosarcoma on the lower extremity in an elderly man. This 71-year-old man presented with a two-year history of red-yellow discoloration of the left lower leg with subsequent development of black nodules over the past several months prior to presentation. He denied any itching, bleeding, or ulceration. Past medical history included diabetes, hypertension, and non-melanoma skin cancer. Physical examination showed erythematous, violaceous, non-blanchable papules with yellow atrophic regions and overlying black crusted nodules and plaques. Biopsies were taken and the patient was diagnosed with angiosarcoma and referred to a tertiary care center for further evaluation.

Basaloid Follicular Hamartoma: A Case Report and a Novel Cosmetic Treatment.

Introduction: Basaloid follicular hamartoma (BFH) is a rare, benign neoplasm of the hair follicle, characterized by multiple brown papules involving the face, scalp, and trunk. It is described by multiple clinical forms, and can present as localized or generalized. Diagnosis is made histologically via biopsy, which is important in order to distinguish BFH from basal cell carcinoma (BCC) or other malignant epithelial neoplasms. Correct diagnosis allows for the avoidance of unnecessary surgeries to remove benign lesions. While benign, lesions can be cosmetically unacceptable. Case Report: A 68-year-old man with a two-year history of brown, homogenous papules on his face presented to discuss treatment options. A physical examination revealed hundreds of dark brown, 1- to 3mm verrucous papules distributed throughout the face. Two punch biopsies revealed histologic features consistent with BFH. Discussion: BFHs classically present with multiple 1- to 2mm tan-to-brown-colored papules distributed on the face, scalp, neck, axilla, trunk, and pubic area. Differential diagnoses can include nevus sebaceous, lichen striatus, linear epidermal nevus, and basal cell nevus. BFH arises from a mutation in the patch gene, the same gene thought to cause nevoid BCC syndrome. Histologic examination of BFH lesions is essential to diagnosis. No standard of care exists for BFH; treatment options remain limited. This patient was treated with three rounds of pulsed dye laser (PDL) therapy and showed marked improvement in the treated areas. The authors propose PDL to be a safe, effective, and novel cosmetic treatment for BFH and potentially other adnexal tumors.

Self-reported alcohol use is an independent risk factor for head and brain injury among cyclists but does not confound helmets' protective effect.

BACKGROUND: Head and brain injury accounts for most morbidity and mortality related to bicycle accidents, much of which can be mitigated by helmet use; but other factors, such as alcohol use and type of accident, also correlate with injury. OBJECTIVE: To examine the correlation between alcohol use, helmet use, riding environment, and rider characteristics, with the presence of head and severity of brain injury in a group of bicycle riders presenting to a regional trauma center after an accident. METHODS: Data were collected at the bedside and from the medical records for all bicycle accident victims presenting during a 2 ½-year period to a regional trauma center. Data were analyzed in Stata version 10 (StataCorp LP, College Station, TX) using chi-squared, analysis of variance, Kruskal-Wallis, or Wilcoxon rank-sum where appropriate. RESULTS: There were 427 patients enrolled, of which 82% were male, with a median age of 31 years. Two factors correlated with presence of head injury and severity of brain injury among bicycle riders presenting to the emergency department (ED) after an accident. For any head or brain injury, the odds ratios for helmet use and alcohol use were 0.5 (95% confidence interval [CI] 0.32-0.78) and 2.68 (95% CI 1.66-4.33). Of accidents presenting to the ED, helmeted riders were less likely to sustain a head or brain injury, and riders who reported alcohol use were more likely to sustain a head or brain injury. CONCLUSIONS: Helmet use was protective for head or brain injury in non-drinking cyclists, but had a confounding effect in drinking riders.

Risk factors associated with early reintubation in trauma patients: a prospective observational study.

BACKGROUND: After mechanical ventilation, extubation failure is associated with poor outcomes and prolonged hospital and intensive care unit (ICU) stays. We hypothesize that specific and unique risk factors exist for failed extubation in trauma patients. The purpose of this study was to identify the risk factors in trauma patients. METHODS: We performed an 18-month (January 2008-June 2009) prospective, cohort study of all adult (8 years or older) trauma patients admitted to the ICU who required mechanical ventilation. Failure of extubation was defined as reintubation within 24 hours of extubation. Patients who failed extubation (failed group) were compared with those who were successfully extubated (successful group) to identify independent risk factors for failed extubation. RESULTS: A total of 276 patients were 38 years old, 76% male, 84% sustained blunt trauma, with an mean Injury Severity Score = 21, Glasgow Coma Scale (GCS) score = 7, and systolic blood pressure = 125 mm Hg. Indications for initial intubation included airway (4%), breathing (13%), circulation (2%), and neurologic disability (81%). A total of 17 patients (6%) failed extubation and failures occurred a mean of 15 hours after extubation. Independent risk factors to fail extubation included spine fracture, airway intubation, GCS at extubation, and delirium tremens. Patients who failed extubation spent more days in the ICU (11 vs. 6, p = 0.006) and hospital (19 vs. 11, p = 0.002). Mortality was 6% (n = 1) in the failed group and 0.4% (n = 1) in the successful extubation group. CONCLUSIONS: Independent risk factors for trauma patients to fail extubation include spine fracture, initial intubation for airway, GCS at extubation, and delirium tremens. Trauma patients with these four risk factors should be observed for 24 hours after extubation, because the mean time to failure was 15 hours. In addition, increased complications, extended need for mechanical ventilation, and prolonged ICU and hospital stays should be expected for trauma patients who fail extubation.

Barriers to obtaining family consent for potential organ donors.

BACKGROUND: Our country suffers from a chronic shortage of organ donors, and the list of individuals in desperate need of life-saving organ transplants is growing every year. Family consent represents an important limiting factor for successful donation. We hypothesize that specific barriers to obtaining family consent can be identified and improved upon to increase organ donation consent rates. The purpose of this study was to compare families who declined organ donation to those who granted consent, specifically to identify barriers to family consent for successful organ donation. METHODS: We performed a 4-year (2004-2007) retrospective study of potential organ donors covered by our regional organ procurement organization (OPO). Variables collected included age, gender, race, cause of brain death (trauma vs. medical) of the potential organ donor, and elapsed time from declaration of brain death to family approach by OPO. Potential organ donors whose family declined organ donation (DECLINE group) were compared with potential organ donors whose family consented to organ donation (CONSENT group). Groups were compared using univariate and multivariate analysis. RESULTS: There were a total of 827 potential organ donors during the 4-year period within our OPO region. Overall, 471 families (57%) consented to organ donation, whereas 356 families (43%) declined. Although there was no difference in male gender between the DECLINE and CONSENT groups (59% vs. 53%, p = 0.12), the DECLINE group had more medical brain deaths (73% vs. 58%, p < 0.001), more potential donors aged 50 years or older (43% vs. 34%, p < 0.001), as well as more potential organ donors of Hispanic (67% vs. 43%, p < 0.001) and African American (10% vs. 4%, p < 0.001) descent. In addition, time from declaration of brain death to family approach by OPO was longer for the DECLINE group (350 minutes vs. 112 minutes, p = 0.001). Logistic regression identified race, older age, and death from a medical cause as independent risk factors for failure of obtaining consent. CONCLUSION: Several barriers exist to family consent for successful organ donation. Family members of minority populations, medical brain deaths, and older potential donors more often decline consent for organ donation. Family education and resource utilization toward these specific populations of potential organ donors may help to improve organ donation consent rates. In addition, delayed family approach by OPO seems to be associated with decreased consent rates. System improvements to expedite family approach by OPO may likewise lead to improved consent rates.