Treatment of acne in the aesthetic patient: A round table update.

BACKGROUND: The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes. AIMS: The goal of this work was to deliver a high-quality ethical and evidence-based educational program to physicians and adjunctive health care providers to advance patient care. METHODS: This paper is based on a webcam presentation with roundtable discussion by several notable experts in their field. RESULTS: A range of topical medications, injectable products, chemical peels, and energy-based devices are available for treating acne vulgaris. In most instances, these are compatible with rejuvenation procedures in the aesthetic patient. CONCLUSION: The growth of social media is raising awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. Educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.

Update: Cellulite Therapies and Optimizing Treatment Combinations.

Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.

Real-world effectiveness and safety of collagenase clostridium histolyticum-aaes injections for the treatment of thigh cellulite in women: An open-label study interim analysis.

BACKGROUND: Collagenase clostridium histolyticum-aaes (CCH-aaes) is approved in the United States for moderate-to-severe cellulite in the buttocks of adult women. AIM: Interim analysis to evaluate efficacy/safety of CCH-aaes in the treatment of thigh cellulite. METHODS: Data were analyzed from a phase 3, open-label study (REAL). Women with mild-to-moderate cellulite on both thighs (Clinician Reported Photonumeric Cellulite Severity Scale score, 2 or 3) received ≤0.84 mg (volume, 18 ml) of CCH-aaes subcutaneously, in up to 12 dimples per posterolateral thigh, in up to 3 treatment sessions (Days 1, 22, and 43). Follow-up was on Day 90 (interim cutoff). A subset of women participated in the concurrent study (PIXELS), which included high-definition photography and 3D-image scanning of treatment areas. RESULTS: Twenty-two women (44 thighs) were included in the interim analysis (mean age, 42.3 years; thighs with mild cellulite, 68.2%). Investigators reported high percentages of responders (score of "improved" or better on Investigator Global Aesthetic Improvement Scale) at Day 90 for either thigh (86.4%; primary endpoint) or both thighs (72.7%). Patient-reported bother due to cellulite was reduced at Day 90; mean change was 15.3 points (85.5% reduction) in BODY-Q Appraisal of Cellulite Scale total score (possible range, 11-44). In PIXELS analysis, Day 90 3D-image scans showed improvement from baseline in skin roughness in some of the treated thigh areas. The most commonly reported adverse events were injection-site bruising and pain (95.5% and 50.0% of patients, respectively). CONCLUSIONS: CCH-aaes treatment of mild-to-moderate thigh cellulite was effective and generally well tolerated, with markedly reduced cellulite-related bother.

Effects of hyaluronic acid filler injection for non-surgical rhinoplasty on first impressions and quality of life (FACE-Q scale).

BACKGROUND: The nose is a central visual feature of the face leading many patients wishing to improve their facial esthetic appearance to undergo rhinoplasty. Increasingly more patients are seeking non-surgical alternatives such as hyaluronic acid filler injections. These treatments have the ability to profoundly impact patients' esthetic appearance and first impressions. OBJECTIVE: To evaluate the effects of hyaluronic acid filler injection in non-surgical nasal augmentation on first impressions, quality of life, and to evaluate treatment efficacy in reducing the height of the nasal dorsal convexity. METHODS: Ten female subjects underwent small-particle hyaluronic acid filler injection into the nasal soft tissues. Photographs of the subjects were taken at baseline and post-treatment after achieving an optimal correction result. Patients reported satisfaction with outcomes using a validated patient-reported outcome measurement tool. Blinded evaluators were used to assess first impressions across specifically defined categories using the baseline and post-treatment photographs. The height of the pre and post-injection nasal dorsal convexity was compared. RESULTS: All patients experienced a statistically significant reduction in the height of their dorsal nasal convexity. There was significant improvement in patient-reported outcomes based on all measures of the FACE-Q scale. A total of 224 evaluators completed blinded assessments of first impressions. Mean first impressions in all eight categories, along with overall first impression score showed statistically significant improvement following treatment. CONCLUSION: Hyaluronic acid filler injections for non-surgical nasal reshaping are a safe and effective method to improve perceived first impressions and to improve patient-reported self-esteem and esthetic satisfaction with their nose.

The Second of Two One-Year, Multicenter, Open-Label, Repeat-Dose, Phase II Safety Studies of PrabotulinumtoxinA for the Treatment of Moderate to Severe Glabellar Lines in Adult Patients.

BACKGROUND: PrabotulinumtoxinA is a 900-kDa botulinum toxin type A produced by Clostridium botulinum. OBJECTIVES: The authors sought to investigate the safety of prabotulinumtoxinA for treatment of glabellar lines. METHODS: This was a multicenter, open-label, repeat-dose, 1-year phase II safety study. Adults with moderate to severe glabellar lines at maximum frown, as independently assessed by both investigator and patient on the validated 4-point photonumeric Glabellar Line Scale (0 = no lines, 1 = mild, 2 = moderate, 3 = severe), were enrolled. On day 0, patients received an initial treatment (IT) of 20 U prabotulinumtoxinA (4 U/0.1 mL final vacuum-dried formulation injected into 5 glabellar sites). On and after day 90, patients received a repeat treatment (RT) if their Glabellar Line Scale score was ≥2 at maximum frown by investigator assessment. Safety outcomes were evaluated throughout the study. RESULTS: The 570 study patients received a median total dose of 60 U, that is, 3 treatments. Sixty-one patients (10.7%) experienced adverse events (AEs) assessed as possibly study drug related; 6.5% experienced study drug-related AEs after the IT. With each RT, progressively lower percentages of patients experienced study drug-related AEs. Eight patients (1.4%) experienced study drug-related AEs of special interest: 5 experienced eyelid ptosis (0.9%), 3 eyebrow ptosis (0.5%), 1 blepharospasm (0.2%), and 1 blurred vision (0.2%). Seven patients (1.2%) experienced serious AEs, but none were study drug related. A total of 4060 serum samples were tested for antibotulinum toxin antibodies; no seroconversion was observed. CONCLUSIONS: The safety of RTs of 20 U of prabotulinumtoxinA for moderate to severe glabellar lines was confirmed in this second phase II study based on a broad range of outcomes.

A Randomized, Single-Blind, Crossover Study Evaluating the Impact of OnabotulinumtoxinA Treatment on Mood and Appearance During the COVID-19 Pandemic.

BACKGROUND: The emergence of COVID-19 led rapidly to one of the most severe disease outbreaks in modern history. This caused many aesthetic practices to close temporarily, providing a unique opportunity to evaluate the impact of neurotoxin use in the setting of an ongoing pandemic. OBJECTIVES: The aim of this study was to examine whether administration of onabotulinumtoxinA (BOTOX Cosmetic, Allergan plc, Dublin, Ireland) to regular users synergistically amplifies the elevation in mood/happiness, self-satisfaction with appearance, and overall satisfaction in the context of the ongoing pandemic. METHODS: A randomized, single-blind, crossover study was designed to evaluate the impact of neurotoxin treatment in the upper third of the face on mood, self-satisfaction with appearance, and overall satisfaction. The placebo group crossed over to treatment after 1 month. Surveys evaluating patient happiness, self-satisfaction with appearance, and overall efficacy were completed by both groups, and again by the placebo group following crossover to treatment. RESULTS: Forty-five subjects were enrolled: 30 in the treatment group and 15 in the control/crossover group. The placebo group demonstrated no change in happiness or self-satisfaction in appearance until crossover to the treatment group. Both groups, once receiving onabotulinumtoxinA, reported increased happiness, self-satisfaction with appearance, and overall treatment satisfaction. CONCLUSIONS: OnabotulinumtoxinA treatment to the upper face in the midst of the COVID-19 pandemic was found to increase patient happiness, self-satisfaction with appearance, and overall treatment satisfaction.

Evaluation of Selfies and Filtered Selfies and Effects on First Impressions.

BACKGROUND: Selfies and filtered selfies are becoming more prevalent throughout society and in the facial plastic surgery clinic. The term "Snapchat dysmorphia" has been used to describe patients seeking procedures to look like their selfie or filtered selfie. This is particularly frequent in the Millennial population, aged 22 to 37 years. OBJECTIVES: The authors sought to determine the effects on first impression from different photograph types: selfies, filtered selfies, a rear-facing smartphone camera, and a digital camera (DC). We hypothesize that the DC photographs will have the highest rated first impressions among evaluators despite the popularity of selfies and filtered selfies. METHODS: This study included 240 evaluators and 4 patients each completing the 4 different photograph types. The evaluators completed a survey rating first impression on various measures of success for each photograph type. RESULTS: A total of 960 first impressions were recorded for each of the 8 subscales, yielding 7680 individual assessments of first impression. The DC photograph was found to have the highest first impression scores among the 4 photograph types. There was no statistical difference between selfies and filtered selfies. The rear-facing smartphone camera received the lowest first impression scores. CONCLUSIONS: Our findings indicate that the standard DC photograph taken during a preoperative consultation has higher first impressions than selfies or filtered selfies. Although "Snapchat dysmorphia" may continue to be a growing trend in the near future, our findings provide important information to discuss with patients in the preoperative visit to set realistic expectations.

Blinded Evaluation of Hyaluronic Acid Hand Filler Injections and Effects on First Impressions.

BACKGROUND: The hands are the second most common body part visible after the face. In the aging hand, the dorsum loses volume, becomes uneven, veins become more prominent, and there is an increase in spots and wrinkles. OBJECTIVE: To determine the effects of large-particle hyaluronic acid filler injection into the dorsal hand on first impressions. MATERIALS AND METHODS: Ten subjects underwent filler injections in the bilateral dorsal hands with large-particle hyaluronic acid filler. Photographs of the hands were taken at baseline and 2 weeks after the optimal correction result. A survey to evaluate first impressions was then completed by blinded evaluators on defined categories of perception. RESULTS: A total of 209 evaluators completed the first impression questionnaire. Overall, 10,032 individual assessments of first impressions were completed. There was a significant improvement in mean first impressions in all categories of perception and overall first impression scores. CONCLUSION: Cosmetic treatments to the hands is a growing field with the use of hyaluronic acid fillers to restore volume, decrease wrinkles, and improve the appearance of prominent veins. This study revealed an improvement in first impression scores in all categories following treatment with large-particle hyaluronic acid filler to the dorsal hands.

The perception bias of aesthetic providers.

Since there is no universal standard of beauty, each aesthetic provider's definition may shape his/her practice of aesthetic procedures. Beauty and attractiveness are commonly defined by both mathematical and cultural influences and are shaped by our surroundings and what is most familiar to us. Therefore, we thoroughly explored the literature to better elucidate these variables and biases that affect the perception of beauty, in order to better provide appropriate and customized aesthetic procedures that preserve each individuals' own unique beauty. Understanding how each provider's own bias and aesthetic preferences differs from that of his/her patients may go a long way to improving communication in the consultation process and patient satisfaction with the outcomes achieved. We know that clinicians many times superimpose their biases onto their patients, so it is important that each practitioner accounts for bias in aesthetic medicine when consulting with patients and colleagues.

The use of radiofrequency-assisted lipolysis with radiofrequency microneedling in premature jowl and neck laxity following facialplasty.

BACKGROUND: A subset of facelift patients have premature redevelopment of skin laxity in the lower face and neck. Many patients seek alternatives to revision facelifts to avoid high risks and costs. Radiofrequency-assisted lipolysis (RFAL) with Radiofrequency (RF) microneedling may be alternative minimally invasive options. OBJECTIVE/AIM: To evaluate the efficacy of radiofrequency energy devices for treatment of premature jowl and neck skin laxity following facialplasty. METHODS: This is a single-center, prospective study of patients seeking treatment for jowl and neck skin laxity 1-5 years following facialplasty. Treatment was performed with the InMode radiofrequency AccuTite® and Morpheus8® systems. Study duration was 12 months with 6 months of follow-up. Endpoints included improvement in skin tightening assessed by blinded investigators, and investigator and subject assessment of skin appearance. Subjects also rated satisfaction with treatment and pain levels. RESULTS: The study protocol was completed by nine patients. Based on investigator evaluations, 33% had marked improvement at 3 months, which increased to 55% at 6-month postprocedure. Patient-reported improvement was "markedly improved" in 67%, "moderate improvement" in 11%, and "slight improvement" in 22% at 3 months. Overall patient satisfaction was rated as "very satisfied" by 33% and "satisfied" by 67% at 3 months. There were no adverse events reported. CONCLUSION: The results of this study provide supporting evidence that RFAL technology can provide a safe, minimally invasive, and effective treatment for skin laxity in the jowls and neck in patients who desire further correction after undergoing primary facelift.

Attitudes Toward Submental Fat Among Adults in the United States.

BACKGROUND: Excess submental fat (SMF) can cause submental fullness resulting in negative perceptions of individuals. However, the impact of SMF on perceptions of social traits has not been well studied. OBJECTIVE: To characterize the impact of SMF on external value judgments in adults in the United States. METHODS: Respondents completed an online survey in which they reacted to statements about individuals with varying grades of SMF. Attributes were rated on a scale from 0 to 100 with higher scores for more positive attributes. RESULTS: Similar proportions of respondents (N = 1996) indicated that women and men with double chins were less attractive than those without (91% and 90%, respectively). A double chin was more likely to be noticed on a woman than on a man (78% of respondents). With increasing SMF, individuals were perceived as significantly less likeable, intelligent, happy, active, and easygoing. Those with greater amounts of SMF were rated as significantly less attractive than those with less SMF. For all attributes, male respondents rated all individuals lower than female respondents did. CONCLUSION: Results from this study provide further evidence of negative perceptions of individuals with SMF. Aesthetics of the submental area, especially SMF, likely impact the overall assessment of attractiveness and social attributes.

How to Leverage Social Media in Private Practice.

Social media has become a rising popular online medium for facilitating the exchange of information and ideas for the purpose of education and networking, especially in the realm of plastic surgeon. It is important for facial plastic surgeons in private practice to recognize the influence of and engagement in social media, particularly among younger adults given the ongoing movement of cosmetic patients seeking facial rejuvenation treatments at an earlier age. This article discusses the most recent trends in social media and facial plastic surgery as well as the benefits and challenges of social media in private practice.

The role of a shelf-ready, human-derived, soft tissue injectable adipose matrix for facial volume correction.

BACKGROUND: Synthetic soft tissue fillers frequently used to restore facial volume do not provide a regenerative framework, limiting their sustained efficacy. Autologous fat transfer for facial rejuvenation supports tissue regeneration but has unpredictable outcomes depending on the quality of harvesting, processing, and implantation. AIMS: Exploration of the pros and cons of available tissue fillers and the role of an injectable Allograft Adipose Matrix (AAM) for facial rejuvenation. METHODS: The results of a literature review conducted by two clinicians with extensive experience in this field were discussed by a panel of dermatologists and surgeons who regularly treat patients with signs and symptoms of facial aging. A manuscript was prepared and reviewed by the panel taking into account the evidence and their clinical experience treating patients for facial rejuvenation. RESULTS: Facial rejuvenation needs to address the volume deficiency and repositioning of ptotic soft tissues. Frequently used synthetic fillers are suitable candidates for improving the facial appearance of fine lines and for molding. A better understanding of facial volume loss has allowed the use of adipose fat cells for facial rejuvenation. The injectable AAM is readily available and provides a regenerative framework for sustainable results. Prospective clinical and randomized studies support the effective and safe use of AAM for facial rejuvenation. CONCLUSION: AAM may offer an alternative to synthetic fillers and autologous fat implantation in the face without the cumbersome process of fat harvesting and processing. More robust studies are to confirm the positive results obtained in smaller studies using the soft tissue bio stimulatory injectable.

Perception of Beauty in the Visually Blind: A Pilot Observational Study.

BACKGROUND: Blind individuals have demonstrated the ability to detect danger and facial expressions without conscious awareness of visual stimuli. These embodied sensations are believed to be the result of primitive neural networks refined by evolutionary adaptations. We postulate that similar embodied sensations may have evolved to allow blind individuals to perceive beauty. OBJECTIVE: To determine whether the visually blind can detect physical beauty. PATIENTS AND METHODS: This observational study consisted of 8 blind and 10 nonblind test subjects and 6 models that were categorized into predetermined beauty categories. Test subjects were individually asked to rate 6 models on a 1 to 10 numerical beauty scale. This process was repeated in both groups while blindfolded (masked). All groups' mean model beauty scores underwent multivariate and univariate analysis. RESULTS: All groups rated preselected (greater than 8) more beautiful models, higher except for the masked, nonblind group. Intraclass correlation was good in the blind raters with a score of 0.751, whereas poor in the nonblind masked raters with a score of 0.458. CONCLUSION: This is the first pilot study demonstrating with supporting evidence that blind individuals can detect beauty and supports that beauty may rely on primal forms of messaging that are subconsciously appreciated.

Premaxillary Injection for Perioral Rejuvenation and Lip Enhancement.

BACKGROUND: This is the first study to evaluate the effect of premaxillary filler injection on nasal tip projection, upper lip projection, and upper lip vermilion height. OBJECTIVES: The primary objective of this study was to analyze the change in nasal tip projection (measured by the Goode ratio) and the change in upper lip projection (measured by the Z angle) following premaxillary hyaluronic acid injection. A secondary objective was to measure the change in upper lip vermilion height. We hypothesized that treated subjects will show an increase in nasal tip projection, upper lip projection, and upper lip vermilion height. METHODS: Twenty volunteer patients with signs of perioral aging or poor upper lip projection were enrolled in this prospective cohort study and underwent premaxillary hyaluronic acid filler injection between November 2017 and June 2018. Nasal tip projection, upper lip projection, and upper lip vermilion height were assessed from baseline and posttreatment photographs based on the Goode ratio, Z angle, and lip vermilion height ratio, respectively. RESULTS: No significant change was noted between pre- and posttreatment Goode ratio measurements (P = 0.841). There was a significant decrease in Z angle and therefore significant increase in upper lip projection with treatment (P < 0.001). The lip vermilion height ratio demonstrated a trend of increased upper lip vermilion height but this did not achieve statistical significance (P = 0.561). CONCLUSIONS: Premaxillary filler treatment resulted in a significant increase in upper lip projection. Premaxillary filler injection when performed in a safe manner is a valuable treatment option for perioral rejuvenation.

Are Cosmetic Procedures Comparable to Antidepressive Medication for Quality-of-Life Improvements? A Systematic Review and Controlled Meta-Analysis.

Cosmetic procedures, especially cosmetic minimally invasive treatments, are rising in popularity, despite societal perception that these procedures may not improve patient health. The purpose of this study was to conduct a systematic review and controlled meta-analysis to compare the effects of cosmetic procedures and antidepressant treatment on health-related quality-of-life improvement. The PubMed database was queried in two independent searches to identify peer-reviewed cosmetic and antidepressant articles published between 1996 and 2017 that prospectively assessed the impact of the treatment on quality of life. All results were screened using defined exclusion and inclusion criteria and data were extracted using a standardized protocol. The meta-analysis was performed using a random-effects model. Five of 2,788 cosmetic studies and eight of 2,312 antidepressant studies met all inclusion criteria and utilized the 36-Item Short Form Health Survey (SF-36) measure. Except for the physical functioning scale, when compared with the cosmetic studies, antidepressant studies had significantly lower median baseline and post-treatment follow-up scale scores with larger median score improvement (p < 0.05). Positive effect sizes following treatment were observed for all eight SF-36 scales (range: 0.32-1.16; p < 0.05). This meta-analysis provides evidence that cosmetic procedures objectively improve a patient's health-related quality of life. While antidepressant studies exhibited greater SF-36 score improvement except for the physical functioning scale, both treatment groups demonstrated the greatest improvement in mental health and role emotional scales. As previously suggested, a disconnect exists between score improvement and clinical improvement due to baseline severity, ceiling effect, and regression to the mean effects.