Does Increasing the Dose of Abobotulinumtoxina Impact the Duration of Effectiveness for the Treatment of Moderate to Severe Glabellar Lines?

OBJECTIVE: To evaluate the duration of effect of a single dose of 120 units of abobotulinumtoxinA for the treatment of moderate to severe glabellar lines. DESIGN: Investigator-initiated, prospective, multi-center, open-label study. MATERIAL AND METHODS: This open-label trial of thirty subjects with moderate to severe glabellar lines at maximum frown was per- formed at 2 private plastic surgery clinics. 120 units of abobotulinumtoxinA was injected in 5 equal aliquots (24 units each) into each of 5 injection sites in the glabellar complex. Investigator and subject assessments of wrinkle severity at maximum frown and repose using 4-point scales and adverse events were conducted. Follow-up was monthly for up to 11 months. RESULTS: The median duration of response for all subjects, as assessed by the investigator, was 150 days (95% CI: 120, 180). The median duration of response was 165 days (95% CI: 90, 180) for subjects with Grade 2 (Moderate) wrinkles at baseline and 75 days (95% CI: 30, 120) for subjects with Grade 3 (Severe) wrinkles at baseline. Overall, 76.7% of subjects had a duration of ≥ 120 days. At the end of study (day 300) 9/16 (53%) of subjects who were Grade 3 at baseline still rated themselves as not returning to Grade 3, demonstrating ongoing improvement. Adverse events were mild and transient. There were no events of lid or brow ptosis. CONCLUSIONS: The 120 units of abobotulinumtoxinA were significantly effective in reducing glabellar lines in subjects with Grade 2 (Moderate) wrinkles at baseline for a longer duration than the reported 85 days in the FDA Phase III randomized, placebo-controlled clinical studies using a standard 50 unit dose. Subject satisfaction was high. There was no increase in the incidence of adverse events with this higher dose. J Drugs Dermatol. 2016;15(12):1544-1549.

Midface injectable fillers: have they replaced midface surgery?

This article examines the increasing role of injectable fillers to treat midface aging and our approach to decision making regarding the use of fillers versus surgery. We discuss the volume changes of the aging midface and advocate taking an anatomic approach to correct these changes. We discuss our approach to patient selection and injection technique. Finally, we review potential complications from injectable fillers and discuss the management of complications.

An antiaging and regenerative medicine approach to optimal skin health.

The optimal health and appearance of the skin is the result of several factors: extrinsic aging (UV damage), intrinsic aging (genetics, lifestyle), and hormonal aging (primarily estrogen loss). This article intends to take an antiaging and regenerative medicine approach to the aging skin and focus on both the hormonal causes and the intrinsic causes of aging; namely, hormones, diet, and lifestyle. By taking a functional approach to the evaluation and treatment of the skin, we hope to elucidate the causation of the condition of the skin and provide targeted treatments to improve its quality. We will sequentially cover the topics of hormonal decline and the skin, understanding hormone replacement, aging and the skin, and key nutrients for youthful skin. We hope to provide a more comprehensive approach to treating the aging face and skin that will provide patients with more long-lasting and youthful results.

How to successfully incorporate antiaging and wellness into your practice: things you should know.

Antiaging medicine is the fastest growing medical specialty. It would behoove plastic surgeons to give serious consideration to extending their practices to incorporate antiaging medicine given the similarities in their patient populations, office settings, and fee-for-service practices. It is important to find a practitioner board-certified in antiaging and regenerative medicine that has done a 2-year fellowship in the specialty. Additionally, you must structure your business relationship appropriate to your needs and your practice. There are several options for the arrangement, including (1) having the antiaging physician use your office on your operative days or days off, (2) incorporating the antiaging physician as a part of your practice on a full-time or part-time basis, or (3) renting office space for the antiaging practice in your medi-spa, wellness center, or medical building. These are just some of the more common arrangements all with the ultimate goal of delineating your practice from others in your area, being a forerunner in the future of cutting-edge medical care and offering your patients the full array of aesthetic and health services.

The evolution of midface rejuvenation: combining the midface-lift and fat transfer.

OBJECTIVE: To evaluate the aesthetic results in our initial group of patients treated with a combination of a midface-lift and fat transfer compared with a randomly selected group of patients who underwent a midface-lift without concurrent fat transfer by one of us. METHODS: The setting was a private, ambulatory, surgical center. The design was a comparative study between patients who did or did not receive fat transfer in addition to a midface-lift to determine if the addition of fat transfer to the midface-lift resulted in an improved aesthetic outcome. A total of 40 patients with complete photographic and medical records and a minimum of 6 months of follow-up were included in the study. Group 1 consisted of 30 patients randomly selected (from >650 potential patients) who underwent a midface-lift without fat transfer to serve as a control group. Group 2 consisted of our initial 10 patients who underwent fat transfer in addition to a midface-lift at the same setting. The degree of aesthetic improvement in 4 facial zones was assessed by 3 independent blinded evaluators. Zone 1 represents the tear trough/infraorbital rim; zone 2, the malar eminence; zone 3, the submalar region; and zone 4, the nasolabial crease. Each zone was given a rating from 0 to 2 (0 for no improvement; 1, mild improvement; and 2, marked improvement). The 2 groups were compared with 4 chi(2) tests of independence. RESULTS: Four chi(2) tests of independence were conducted to compare the findings between group 1 and group 2. One hundred twenty ratings were conducted; group 1 consisted of 90 total ratings on 30 patients and group 2 consisted of 30 total ratings on 10 patients. The first chi(2) (tear trough/infraorbital rim) test revealed a significant difference on tear trough ratings by group (chi(2)(2) = 73.59, P<.01). The second chi(2) test (malar eminence) did not reveal a significant difference on malar eminence ratings by group (chi(2)(2) = 3.10, P = .21). The third chi(2) test (submalar region) failed to reveal a significant difference on submalar region by group (chi(2)(2) = 4.01, P = .13). The final chi(2) test (nasolabial crease) revealed a significant difference on nasolabial ratings by group (chi(2)(2) = 14.28, P<.01). CONCLUSIONS: Our findings revealed a statistically significant difference between group 1 (no fat transfer) and group 2 (fat transfer) in the tear trough region (P<.01) and the nasolabial crease (P<.01). The fat transfer technique in combination with a midface-lift is a safe and effective means to provide more complete facial rejuvenation, especially in the regions of the tear trough and nasolabial crease.

Transoral approach to the superomedial parapharyngeal space.

OBJECTIVES: To present our early experience with the transoral approach to the superomedial parapharyngeal space (PPS) and describe our technique for removal of these neoplasms. STUDY DESIGN: Consecutive case series by one author (Y.D.). METHODS: Eight patients with various neoplasms of the superomedial PPS were retrospectively reviewed for type of neoplasm, size, success with the transoral approach, need for conversion to another approach, length of hospitalization, and complications. RESULTS: The transoral approach described herein safely allowed for en bloc resection of benign neoplasms with intraoperative control and exposure of the internal carotid artery. The most common pathology encountered was that of schwannoma. All patients were started on liquid diet on postoperative day 1. Average length of stay was 3.2 days (range, 2 to 5). Mean tumor size was 3.3 cm (range, 1.5 to 7 cm). No significant complications were felt to be related to the approach itself and visualization was felt to be excellent in each case without the need for conversion to a more extensive approach. CONCLUSIONS: The transoral approach safely provides access to superomedial PPS lesions with decreased morbidity compared with traditional approaches. This technique is indicated for neoplasms with benign appearance on preoperative imaging or fine needle aspiration. This approach alone may not provide adequate access for resection of malignant lesions especially those with extension intracranially or to more inferior or laterally placed lesions of the parapharyngeal space. EBM RATING: C-4.

The extended minimal incision approach to midface rejuvenation.

Recent major advancements in comprehensive facial rejuvenation have focused on management of midfacial aging. Multiple techniques have been described to treat the aging midface; the mere nature of so many approaches is evidence that no one technique has prevailed. Although the nasolabial region remains a challenge to correct, the approach described herein provides comprehensive rejuvenation of the midface, lateral brow, and jawline. The technique is performed via a minimal incision brow-lift approach and has been performed (with minor modifications) by the senior author in more than 650 patients over the past 9 years. The technique has proven to be safe, reliable, and effective.

A cost threshold analysis of ciprofloxacin-dexamethasone versus ofloxacin for acute otitis media in pediatric patients with tympanostomy tubes.

OBJECTIVE: The aim of this study was to determine the cost-effectiveness hreshold of a ciprofloxacin 0.3% and dexamethasone 0.1% (CD) otic suspension relative to olfloxacin otic solution (OFX) for the treatment of acute otitis media in pediatric patients with tympanostomy tubes (AOMT). METHODS: This study used a decision-analytic model to simulate the costs and consequences of the ototopical treatment of AOMT. The AOMT model consisted of 3 tiers of antimicrobial therapy. Each successive tier represented the repeat treatment of clinical failures from the preceding tier. Patients were modeled for treatment until cured or until third-tier therapy was complete, at which time patients were considered cured. First-tier therapy modeled a comparison of CD and OFX using efficacy rates taken from a randomized clinical trial with a population of 599 patients. Second-tier therapy modeled the use of amoxicillin and clavulanic acid using an efficacy rate taken from the medical literature. Third-tier therapy was modeled as being pathogen specific and could follow 1 of 3 possible clinical pathways: (1) PO fluconazole, (2) IM ceftriaxone, or (3) IV antibiotics administered in a hospital setting. Third-tier therapeutic pathway probabilities were based on the microbiologic spectrum of the treatment failures from the clinical trial. Cost information (in year-2003 US dollars) was taken from accepted cost reference sources and presented from the perspective of a third-party payer. The economic outcome of interest was the cost-effectiveness threshold of CD relative to OFX. RESULTS: Given the model parameters, CD had a cost-effectiveness threshold value of 4.5 times the wholesale acquisition cost of OFX. Based on actual cost, first-tier CD therapy was more cost-effective than OFX up to a threshold price of US 152.64 dollars. CONCLUSION: In this decision-analytic model, CD was more cost-effective than OFX for AOMT therapy in pediatric patients up to a threshold price of 4.5 times the price of OFX.

New techniques for management of the crooked nose.

The crooked or twisted nose results from a complex deformity of the bony pyramid, the upper and lower cartilaginous vaults, and the septum and causes functional and aesthetic problems. The forces of scar contracture coupled with long-standing cartilage deformation may make the crooked nose resistant to conventional surgical intervention. The middle vault of the nose may exhibit deformities that are due to atrophy, deviations, and skewing in relationship to the other regions of the nose. We report a series of 79 cases of significantly crooked noses to highlight 5 techniques not widely discussed in the facial plastic surgery literature.

Extended orbitozygomatic approach to the skull base to improve access to the cavernous sinus and optic chiasm.

BACKGROUND: The orbitozygomatic approach to the skull base has evolved over the past century, with a surge in development during the past 20 years. We describe an extension of this technique involving removal of the most inferior portion of the temporal bone to the level of the internal carotid artery as it enters the carotid canal, to further facilitate exposure of tumors in this region. METHODS AND MATERIALS: We performed the extended orbitozygomatic approach in a series of 17 patients with a variety of neoplastic lesions. Our case series was reviewed in a retrospective fashion, and our surgical approach is described. The approach is performed safely and effectively by using the spine of the sphenoid and middle meningeal artery as landmarks and then resecting the temporal bone from the temporal craniotomy site to the carotid canal. RESULTS: The extended orbitozygomatic approach has been performed at our institution over the past 6 years and has provided significantly improved access to this region of the skull base, facilitating tumor extirpation in our patient population without an increase in complications. CONCLUSIONS: The extended orbitozygomatic approach further improves exposure and facilitates surgical dissection in patients with neoplasms of the cavernous sinus, sellar region, interpeduncular region, and upper clivus. The improved access without an increase in complications supports the inclusion of the extended orbitozygomatic approach in the armamentarium of the skull base surgeon.

Nasal reconstruction in surgery of the anterior skull base.

OBJECTIVES: We sought to evaluate the effectiveness of a number of surgical maneuvers in nasal reconstruction of a diverse population of patients undergoing skull base surgery. Study design We conducted a retrospective review of a cohort of patients undergoing nasal reconstruction during surgery of the anterior skull base and craniovertebral junction. METHODS: All patients undergoing skull base surgery and nasal reconstruction by the senior author (Y.D.) with a minimum follow-up of 12 months from 1997 to 2001 were evaluated. Preoperative and postoperative photographs and clinical evaluation were examined in detail with particular attention focused on the nasal complex. RESULTS: A total of 47 patients were evaluated for this study, including those who had undergone anterior craniofacial resections (n = 14), Le Fort osteotomies (n = 5), subcranial approaches (n = 10), maxillotomies (n = 8), and midfacial disassemblies (n = 10). Primary calvarial bone graft reconstruction of the anterior craniofacial group was facilitated with the use of positioning plates and resuspension of the upper lateral cartilages when available. In contradistinction to secondary bone grafting, dorsal grafts in this group extended to the native nasal bone length. A small overlay bone graft was thought to be necessary when the nasal root was osteotomized in conjunction with the orbital and/or maxillary segments to maintain dorsal height in the long term. Le Fort osteotomy patients require refixation of the septum to the anterior nasal spine region for stability. CONCLUSIONS: Use of the techniques outlined in this article appears to be associated with gratifying long-term nasal form in reconstruction of the anterior skull base.

Metastatic neuroendocrine tumors of the parotid gland.

OBJECTIVES: To present 2 cases of neuroendocrine tumors of the parotid gland and to review the clinical presentation, histopathologic, and immunohistochemical findings and treatment of these rare tumors. STUDY DESIGN: Case series. METHODS: This study reviews 2 patients who both presented with firm masses in the parotid gland diagnosed as neuroendocrine carcinoma by histopathologic and immunohistochemical examination. The evaluation, diagnosis, and treatment are discussed. RESULTS: Both patients underwent complete tumor extirpation via a total or subtotal parotidectomy. Both patients received postoperative radiation therapy and chemotherapy. CONCLUSIONS: Neuroendocrine tumors of the parotid gland are uncommon lesions; however, they have a favorable prognosis as compared to their pulmonary counterparts with early diagnosis and aggressive treatment. Diagnosis is based on the immunohistochemical characteristics of the tumor. Appropriate treatment includes complete surgical excision with postoperative radiation therapy to the parotid bed with the addition of postoperative chemotherapy in patients suspected to have metastatic disease.

Temporal bone chondroblastomas.

OBJECTIVES: To review temporal bone chondroblastomas in regards to their presentation, radiographic findings, histopathology, and treatment.Study design Case report and literature review. METHODS: A case report of a 38-year-old man is reviewed who presented with left-sided mixed hearing loss, otalgia, otorrhea, and a left external auditory canal mass. A computed tomography scan revealed a 6-cm mass involving the petrous and squamous portions of the left temporal bone. CONCLUSIONS: Temporal bone chondroblastomas are extremely rare osseous tumors with only 35 cases previously reported in the literature. Presenting symptomatology and pathology may be confused with more common lesions seen in the temporal bone. Diagnostic radiology, including computed tomography and/or magnetic resonance imaging, as well as immunohistochemical staining with S-100 protein may assist in making the diagnosis. Treatment is complete surgical excision with preservation of vital neurovascular structures.

Lipotransfer as an adjunct in head and neck reconstruction.

OBJECTIVES: To present our technique of lipotransfer and to evaluate a single center's experience in the use of lipotransfer as an adjunct to head and neck reconstruction. STUDY DESIGN: A retrospective review of all patients undergoing lipotransfer over a 5-year period by the senior author was undertaken. A total of 23 patients with a minimum follow-up of 1 year were available for analysis. METHODS: Patient records were retrospectively reviewed to assess functional (in the case of palate augmentation) and esthetic outcomes. RESULTS: Twenty-three patients undergoing lipotransfer as part of their reconstructive effort included (1) eight patients undergoing temporal fossa augmentation following temporalis muscle flap reconstruction for extirpative skull base surgery, (2) six patients undergoing facial defect augmentation following traumatic atrophy, (3) three patients undergoing palatal augmentation for correction of velopharyngeal insufficiency, and (4) six patients undergoing soft tissue augmentation following flap reconstruction of the face. Twenty of the 23 patients had excellent maintenance of graft volume. An adequately vascularized recipient bed appears to be an important factor in determining ultimate graft survival using our technique. CONCLUSIONS: Lipotransfer of the head and neck represents a simple, effective adjunctive technique providing for large amounts of readily available, well-tolerated soft tissue filler material. Patient selection is important, specifically in regard to determining that there is adequate vascularity of the recipient bed.