Survey on Resident Education for Surgical Dermatology in South Korea.

BACKGROUND: With the increasing demand for surgical procedures in dermatology, resident education in surgical dermatology has become important for delivering high-quality treatment. However, it remains unclear if a sufficient number of residency programs with quality standards exist, as there has been little research on this subject in South Korea. OBJECTIVE: To identify the status of surgical dermatology education among residents and assess dermatologists' perceptions of the subject. METHODS: A 35-question survey was developed and distributed to all resident training hospitals and local clinics listed by the Korean Society of Dermatologic Surgery. Only third- and fourth-year residents were included and board-certified specialists from training hospitals and local clinics responded to the surveys. RESULTS: Survey participants included 88 residents and 120 specialists of whom one-quarter of the residents attended regular monthly educational sessions. Most residents (93%) participated in cosmetic procedures, and many performed laser therapy. However, the opportunity for toxin or filler injection was rare, with only 12% of the residents having experience with filler injections. In response, 49% of residents and 32% of specialists said that more cosmetic training was required, whereas 28% of residents and 50% of specialists said that more training for both cosmetic and conventional surgeries was necessary. CONCLUSION: The survey demonstrated a need for more training programs in surgical dermatology during residency and a perception gap between residents and specialists. Therefore, developing educational residency programs that focus on basic dermatologic surgery principles and their applications in cosmetic procedures is essential.

Etiology of Delayed Inflammatory Reaction Induced by Hyaluronic Acid Filler.

The etiology and pathophysiology of delayed inflammatory reactions caused by hyaluronic acid fillers have not yet been elucidated. Previous studies have suggested that the etiology can be attributed to the hyaluronic acid filler itself, patient's immunological status, infection, and injection technique. Hyaluronic acid fillers are composed of high-molecular weight hyaluronic acids that are chemically cross-linked using substances such as 1,4-butanediol diglycidyl ether (BDDE). The mechanism by which BDDE cross-links the two hyaluronic acid disaccharides is still unclear and it may exist as a fully reacted cross-linker, pendant cross-linker, deactivated cross-linker, and residual cross-linker. The hyaluronic acid filler also contains impurities such as silicone oil and aluminum during the manufacturing process. Impurities can induce a foreign body reaction when the hyaluronic acid filler is injected into the body. Aseptic hyaluronic acid filler injections should be performed while considering the possibility of biofilm formation or delayed inflammatory reaction. Delayed inflammatory reactions tend to occur when patients experience flu-like illnesses; thus, the patient's immunological status plays an important role in delayed inflammatory reactions. Large-bolus hyaluronic acid filler injections can induce foreign body reactions and carry a relatively high risk of granuloma formation.

Needle-Free Jet Injection of Poly-(Lactic Acid) for Atrophic Acne Scars: Literature Review and Report of Clinical Cases.

Acne scars, particularly atrophic ones, present a persistent challenge in cosmetic medicine and surgery, requiring extended and multifaceted treatment approaches. Poly-(lactic acid) injectable fillers show promise in managing atrophic acne scars by stimulating collagen synthesis. However, the utilization of needle-free injectors for delivering poly-(lactic acid) into scars remains an area requiring further exploration. In this article, a summary of the latest advancements in needle-free jet injectors is provided, specifically highlighting the variations in jet-producing mechanisms. This summary emphasizes the differences in how these mechanisms operate, offering insights into the evolving technology behind needle-free injection systems. The literature review revealed documented cases focusing on treating atrophic acne scars using intralesional poly-(lactic acid) injections. The results of these clinical studies could be supported by separate in vitro and animal studies, elucidating the feasible pathways through which this treatment operates. However, there is limited information on the use of needle-free jet injectors for the intradermal delivery of poly-(lactic acid). Clinical cases of atrophic acne scar treatment are presented to explore this novel treatment concept, the needle-free delivery of poly-(lactic acid) using a jet pressure-based injector. The treatment demonstrated efficacy with minimal adverse effects, suggesting its potential for scar treatment. The clinical efficacy was supported by histological evidence obtained from cadaver skin, demonstrating an even distribution of injected particles in all layers of the dermis. In conclusion, we suggest that novel needle-free injectors offer advantages in precision and reduce patient discomfort, contributing to scar improvement and skin rejuvenation. Further comprehensive studies are warranted to substantiate these findings and ascertain the efficacy of this approach in scar treatment on a larger scale.

A survey on the cosmetic use of injectable polynucleotide: The pattern of practice among Korean Dermatologists.

BACKGROUND: Skin boosters denote injectables that promote global improvement of the skin which includes skin texture, elasticity, hydration, and overall appearance. Polynucleotide (PN) products have become popular, but there is surprisingly little guidance on their use. We aimed to maximize the safety and efficacy of injectable PN by providing information on their pattern of practice among board-certified dermatologists. METHODS: A total of 235 Korean board-certified dermatologists familiar with skin boosters participated in a survey which questioned the participant's years of practice, selection of skin boosters in one's clinic, and range of lasers and light sources as well as skin care devices that are available. For those who use PN, one was asked to check all its aesthetic indications, mode of delivery, injection depth, treatment interval as well as options for combined therapy. RESULTS: Seventy-one percent of the survey participants had at least 5 years of professional experience as a board-certified dermatologist, and among the different skin boosters, 88% replied that they practiced PN injection. The top six indications for PN were fine lines on the cheek followed by infraorbital fine lines, periorbital fine lines, uneven skin texture, dry skin, and fine lines on the forehead. Many opted for a 33G needle and the serial puncture technique targeting the dermis. A total of three sessions of PN injection spaced 4 weeks apart is most often recommended. 79 percent of PN users blended PN injection with lasers and light therapy with the most popular being radiofrequency (non-invasive, needle RF) and high-intensity focused ultrasound (HIFU). CONCLUSION: PN is a skin booster which is widely practiced among Korean dermatologists. According to our survey, the best indication of PN is facial fine lines, and as such PN injection is often repeated and combined with a variety of non-surgical rejuvenation procedures. We hope our data help dermatologists better understand and utilize PN injection.

Skin aging from mechanisms to interventions: focusing on dermal aging.

Skin aging is a multifaceted process that involves intrinsic and extrinsic mechanisms that lead to various structural and physiological changes in the skin. Intrinsic aging is associated with programmed aging and cellular senescence, which are caused by endogenous oxidative stress and cellular damage. Extrinsic aging is the result of environmental factors, such as ultraviolet (UV) radiation and pollution, and leads to the production of reactive oxygen species, ultimately causing DNA damage and cellular dysfunction. In aged skin, senescent cells accumulate and contribute to the degradation of the extracellular matrix, which further contributes to the aging process. To combat the symptoms of aging, various topical agents and clinical procedures such as chemical peels, injectables, and energy-based devices have been developed. These procedures address different symptoms of aging, but to devise an effective anti-aging treatment protocol, it is essential to thoroughly understand the mechanisms of skin aging. This review provides an overview of the mechanisms of skin aging and their significance in the development of anti-aging treatments.

Cold anesthesia for pain reduction during intralesional steroid injection for nodulocystic acne.

BACKGROUND: In any dermatologic procedure, patient acceptance of treatment is heavily influenced by intraprocedural pain. Intralesional triamcinolone injections are very important in keloid scar and nodulocystic acne treatment. However, the main problem of needle-stick procedures is pain. Cryoanesthesia is ideally intended to cool only the epidermis during treatment and has advantage which did not require application time. AIMS: The aim of this study was to investigate the pain-reducing effect and safety of CryoVIVE® (newly introduced cryoanesthesia device) during triamcinolone injections for nodulocystic acne in actual clinical settings. PATIENTS/METHODS: In this two-staged, non-randomized clinical trial, a total of 64 subjects underwent intralesional triamcinolone injections for their acne lesions with cold anesthesia using CryoVIVE®. The pain intensity was assessed with Visual Analogue Scale (VAS) scores. Safety profile was also evaluated. RESULTS: The mean pain VAS scores on the lesion with and without cold anesthesia were 3.667 and 5.933, respectively (p = 0.0001). No side effects, discoloration, and scarring were observed. CONCLUSION: In conclusion, the anesthetic use of CryoVIVE® with intralesional corticosteroid injections is a practical and well-tolerated modality.

Determination of Hyaluronic Acid Dermal Filler Impurities Using SEM/EDS Analysis.

Although hyaluronic acid (HA) filler injections are associated with various non-vascular inflammatory complications, the underlying mode of action remains unclear. The hyaluronic acid filler may not be sufficiently pure, leading to an immune response. The present study attempted to identify any impurities in hyaluronic acid fillers available on the market. Particles were counted after degrading hyaluronic acid filler with hyaluronidase. Particulate matter was subsequently observed using scanning electron microscopy, and the particle components were evaluated using energy-dispersive X-ray spectroscopy. Different quantities of impurity particles (>10 and 25 µm) were detected microscopically. Silicon and aluminum isotopes were also detected. Hyaluronic acid fillers were contaminated with these particles. The degree of contamination varied substantially among the tested filler products. These contaminant particles may evoke reactions in the patient's body. Clinicians should be aware of this source of possible contamination and its effects.

Lip Lifting Efficacy of Hyaluronic Acid Filler Injections: A Quantitative Assessment Using 3-Dimensional Photography.

The study aimed to compare the volume enhancement and the lifting capacity of two different hyaluronic acid gels for lip injection. Thirty-six Korean female patients were randomized into two groups according to the cross-linking degree of the hyaluronic acid filler injected. Using a fixed injection protocol, patients were injected with 1 mL of hyaluronic acid filler in the lips and followed up at four and 12 weeks after injection. Lip volume, lip projection, and columella-labial angle were measured using a 3-dimensional imaging system at each time point. Follow-up values were compared with baseline. Compared with pre-treatment values, there was a statistically significant increase in mean lip volume and lip projection at four and 12 weeks after injection, with no significant differences between the two groups. Lips injected with hyaluronic acid filler of intermediate cross-link density resulted in more acute angles than lips injected with lightly cross-linked hyaluronic acid. The difference was statistically significant at each follow-up time point. No serious complications were observed throughout the study period. Our results imply that in patients who want a prominent upper lip lift, lip injections using hyaluronic acid fillers with intermediate cross-linking density can be a good option due to their lift capacity. The degree of cross-linking may not be a significant determinant of simple lip volume augmentation when other variables are constant.

An Update on the Cosmetic Use of Botulinum Toxin: The Pattern of Practice among Korean Dermatologists.

The efficacy and safety of botulinum toxin injection have made it a popular aesthetic procedure worldwide. A cross-sectional survey was performed in order to determine the pattern of type A botulinum toxin injections in cosmetic practice, for which an 18-item questionnaire was distributed to dermatologists. A total of 469 Korean board-certified dermatologists participated in the survey, with the following results: the main candidates for type A botulinum toxin injection were individuals in their 40-50 years (46.1%), followed by those in their 20-30 years (33.4%), and people over 60 years of age (20.5%). Overall, the upper face (the glabella, forehead, and crow's line, in decreasing order) was the most favored area of injection (51%). In contrast, body contouring (i.e., shoulder, calf) and treatment for benign masseter hypertrophy were significantly more popular in the 20-30 years age group than their older counterparts. For wrinkle effacement, the most preferred dilution was 100 units/2.5 mL with isotonic sodium chloride injection (51.2%), and the most often used interval was six months (43.6%). About half (46.3%) of the dermatologists reported the experience of clinical cases which were suspicious of botulinum toxin resistance. Despite this, regarding the choice of the product, type A botulinum toxin products with greater cost-effectiveness were favored over products with a lower risk of antibody formation. Other than its cosmetic usage, botulinum toxin is applied for a variety of skin conditions. Further studies are suggested in order to identify the practice pattern of type A botulinum toxin for therapeutic uses in dermatology, such as hyperhidrosis and rosacea.

Combined Treatment of Monopolar and Bipolar Radiofrequency Increases Skin Elasticity by Decreasing the Accumulation of Advanced Glycated End Products in Aged Animal Skin.

It is well known that skin aging is related to the destruction of collagen and elastin fibers by metalloproteinases (MMPs). Aged fibroblasts have a decreased ability to synthesize collagen and elastin. Nuclear factor erythroid 2-related factor 2 (NRF2) involves glyoxalase (GLO) activation, which inhibits the production of advanced glycated end products (AGE) and the expression of its receptor (RAGE). RAGE increases nuclear transcription factor-kappa B (NF-κB), which upregulates MMPs and decreases skin elasticity. NRF2 also decreases M1 macrophages, which secrete tumor necrosis factor-alpha (TNF-α), thereby decreasing AGE production. It is well known that radiofrequency (RF) decreases skin elasticity by increasing collagen synthesis. We evaluated whether RF increases skin elasticity via NRF2/GLO and whether they decrease AGE and RAGE expression in aged animal skin. We also compared the effects of RF based on the modes (monopolar or bipolar) or the combination used. In aged skin, NRF2, GLO-1, and M2 macrophage expression was decreased, and their expression increased when RF was applied. M1 and TNF-α demonstrated increased expression in the aged skin and decreased expression after RF application. AGE accumulation and RAGE, NF-κB, and MMP2/3/9 expression were increased in the aged skin, and they were decreased by RF. The papillary and reticular fibroblast markers showed decreased expression in young skin and increased expression in aged skin. The densities of collagen and elastin fiber in the aged skin were low, and they were increased by RF. In conclusion, RF leads to increased collagen and elastin fibers by increasing NRF2/GLO-1 and modulating M1/M2 polarization, which leads to decreased AGE and RAGE and, consequently, decreased NF-κB, which eventually slows collagen and elastin destruction. RF also leads to increased collagen and elastin fiber synthesis by increasing papillary and reticular fibroblast expression.

Revisiting the Role of Local Cryotherapy for Acne Treatment: A Review and Update.

Acne vulgaris is a well-recognized condition among adolescents and adults that adversely affects their quality of life. Local cryotherapy has long been reported to be effective in treating acne vulgaris, inducing a more rapid involution of acne than topical medications. However, the use of cryotherapy has been limited for acne treatment due to several drawbacks, including procedural pain and pigmentary alterations. Currently, newer cryotherapy devices are gaining attention in dermatology due to their ability to monitor and precisely control the target temperature. In this narrative review, a brief history and the latest update on acne cryotherapy will be presented. Additionally, a special emphasis is placed on the role of cryotherapy, alone or in combination with intralesional steroid injections for nodulocystic acne.

Botulinum Neurotoxin Type A in the Treatment of Facial Seborrhea and Acne: Evidence and a Proposed Mechanism.

Intradermal injection of botulinum neurotoxin is a frequently performed procedure in aesthetic dermatology to improve facial skin tone, texture, fine wrinkles, and enlarged pores. In practice, botulinum neurotoxin type A is also used to reduce skin oiliness of the face. There is increasing evidence that acetylcholine plays specific roles in sebum production, suggesting that botulinum neurotoxin type A may reduce sebum production by interfering with cholinergic transmission between sebaceous glands and autonomic nerve terminals. Botulinum neurotoxins can also inhibit several pathogenetic components of acne development, suggesting that botulinum neurotoxins can be used as a safe and effective treatment modality for acne and other skin disorders related to overactivity of sebaceous glands. This review aims to explore the current evidence behind the treatment of facial seborrhea and acne with botulinum neurotoxin type A.

A comparison of the safety, efficacy, and longevity of two different hyaluronic acid fillers in filler rhinoplasty: A multicenter study.

Filler rhinoplasty is a popular procedure in Asia, and it is of great importance to understand the clinical efficacy and durability of the different filler products that serve this purpose. Here, we aimed to evaluate and compare the safety, efficacy, and longevity of two different hyaluronic acid (HA) fillers in improving the nasal profile in Asians. A multicenter comparative trial was performed for 48 weeks after a single injection of a popular monophasic monodensified, and a newly developed biphasic HA filler. Assessments including patient satisfaction and three-dimensional (3D) imaging analysis were performed before, immediately after, 2 weeks, 12 weeks, 24 weeks, and 48 weeks after filler rhinoplasty. Twenty-eight Korean women underwent structured rhinoplasty were divided into monophasic monodensified (n = 14) and biphasic (n = 14) groups. There were significant changes in the facial profile following filler rhinoplasty throughout the study period. Overall, an increase of 1.75 mm in nose height, increase of 3.66° in the nasofrontal angle and 2.77° in the nasolabial angle, and radix elevation of 1.24 mm was noted at week 48 which was statistically different from the baseline values (P < .05). Between the different filler types, statistical difference was only noted in radix elevation (per milliliter of filler material) immediately after filler injection. No serious adverse event occurred during treatment or follow-up. Nonsurgical rhinoplasty with the specific HA filler products led to significant changes in the facial profile which persisted for 48 weeks. Overall, the clinical efficacy and safety were comparable between the two filler types except for radix elevation which was more prominent with C-C immediately after filler injection. J-V was superior to C-C in maintaining the radix elevation long term.

Acquired Partial Lipodystrophy (Barraquer-Simons Syndrome): Early Cosmetic Intervention with Autologous Fat.

Barraquer-Simons syndrome is a rare acquired lipodystrophy characterized by gradually symmetric subcutaneous fat loss in a craniocaudal distribution, often associated with hypocomplementemia and nephropathies. Facial cosmetic treatment in this disorder has not been fully described in the literature. We present a patient with Barraquer-Simons syndrome with emphasis on early cosmetic intervention with autologous fat grafting and its long-term efficacy. At the follow-up 37 months after the last fat grafting, preservation of the grafted fat was noted while lipodystrophy progressed in the trunk regions. Autologous fat grafting is suggested for the correction of facial dysmorphism in this type of lipodystrophy.

Early Changes in Facial Profile Following Structured Filler Rhinoplasty: An Anthropometric Analysis Using a 3-Dimensional Imaging System.

BACKGROUND: Quantitative measurements are important for objective evaluation of postprocedural outcomes. Three-dimensional (3D) imaging is known as an objective, accurate, and reliable system for quantifying the soft tissue dimensions of the face. OBJECTIVE: To compare the preprocedural and acute postprocedural nasofrontal, nasofacial, nasolabial, and nasomental angles, early changes in the height and length of the nose, and nasal volume using a 3D surface imaging with a light-emitting diode. METHODS: The 3D imaging analysis of 40 Korean women who underwent structured nonsurgical rhinoplasty was conducted. The 3D assessment was performed before, immediately after, 1 day, and 2 weeks after filler rhinoplasty with a Morpheus 3D scanner (Morpheus Co., Seoul, Korea). RESULTS: There were significant early changes in facial profile following nonsurgical rhinoplasty with a hyaluronic acid filler. An average increase of 6.03° in the nasofrontal angle, an increase of 3.79° in the nasolabial angle, increase of 0.88° in the nasomental angle, and a reduction of 0.83° in the nasofacial angle was observed at 2 weeks of follow-up. Increment in nasal volume and nose height was also found after 2 weeks. Side effects, such as hematoma, nodules, and skin necrosis, were not observed. CONCLUSION: The 3D surface imaging quantitatively demonstrated the early changes in facial profile after structured filler rhinoplasty. The study results describe significant acute spatial changes in nose shape following treatment.

Consensus Recommendations for Combined Aesthetic Interventions Using Botulinum Toxin, Fillers, and Microfocused Ultrasound in the Neck, Décolletage, Hands, and Other Areas of the Body.

BACKGROUND: The popularity of aesthetic procedures in the face has led to greater disparity between treated areas and those that still show evidence of true age. Although many areas of the body often require multiple treatment procedures for optimal rejuvenation, combination therapy for specific areas is not yet well defined. OBJECTIVE: To develop recommendations for the optimal combination and ideal sequence of botulinum toxin (BoNT), hyaluronic acid, calcium hydroxylapatite (CaHA), and microfocused ultrasound with visualization in nonfacial areas across all skin phototypes. METHODS: Fifteen specialists convened under the guidance of a certified moderator. Consensus was defined as approval from 75% to 94% of all participants, whereas agreement of ≥95% denoted a strong consensus. RESULTS: Recommendations have been provided for the neck, décolletage, and hands and include the timing and sequence of specific procedures when used concurrently or over several treatment sessions. Position statements are offered in lieu of consensus for the upper arms, abdomen, buttocks, and knees. CONCLUSION: Nonfacial rejuvenation often requires multiple procedures for optimal results in individuals with significant age-related changes. Further clinical studies are recommended to raise awareness of non-facial indications and provide clinicians with the best evidence for best treatment practices.

Consensus Recommendations for Combined Aesthetic Interventions in the Face Using Botulinum Toxin, Fillers, and Energy-Based Devices.

BACKGROUND: The aging process is a complex interplay of intrinsic and extrinsic factors across multiple layers of the face. Accordingly, combining aesthetic interventions targeting different manifestations of aging often leads to better results than single modalities alone. However, no guidelines for a pan-facial approach using multiple interventions have been published to date. OBJECTIVE: To develop consensus recommendations for the optimal combination and ideal sequence of botulinum toxin (BoNT), hyaluronic acid, calcium hydroxylapatite, and microfocused ultrasound with visualization (MFU-V) in persons of all Fitzpatrick skin types. METHODS AND MATERIALS: Fifteen specialists convened under the guidance of a certified moderator. Consensus was defined as approval from 75% to 94% of all participants, whereas agreement of ≥95% denoted a strong consensus. RESULTS: Optimal aesthetic treatment of the face begins with a thorough patient assessment and an individualized treatment plan. Spacing consecutive treatments 1 to 2 weeks apart allows for resolution of side effects and/or to assess results. For same-day treatments, BoNT and fillers may be performed together in either sequence, whereas MFU-V is recommended before injectable agents. CONCLUSION: Expert consensus supports a combination approach using multiple modalities in specific sequence for the safe and effective treatment of the aging face.

Long-chain polynucleotide filler for skin rejuvenation: efficacy and complications in five patients.

Aging well has become the new target of preventative medicine, and aesthetic dermatology can contribute to this request. The polynucleotide (PN) containing products not only fill the space, but improve tissue regeneration, resulting in more natural tissue regeneration. Five Korean women received four times injections of long-chain PN filler in two-week intervals for skin rejuvenation. About 0.05 mL of material was injected in 40 points of one-side cheek. The pore and skin thickness were markedly improved in the patients in their 30s, whereas skin tone, melanin, wrinkles, and sagging were noticeably improved for patients in their 40s. There are no serious side effects. In conclusion, intradermal long-chain PN filler injection seems to be an effective and safe treatment for skin rejuvenation.

Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers.

BACKGROUND: Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications. METHODS: Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers. RESULTS: The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply. CONCLUSION: The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations. CLINCIAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Successful treatment of angioma serpiginosum using a novel 532 nm potassium titanyl phosphate (KTP) laser.

Angioma serpiginosum (AS) is a rare, benign, vascular disorder comprising non-blanchable punctate red to purple lesions in a gyrate or serpiginous configuration. We report a case of a 38-year-old woman with a red colored eruption on her chest which was present since puberty. A novel 532 nm potassium-titanyl phosphate (KTP) laser (Excel V, Cutera Inc., Brisbane, CA, USA) was applied which resulted in near complete resolution after two sessions of treatment.