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.

Anatomical Proposal for Botulinum Neurotoxin Injection for Horizontal Forehead Lines.

SUMMARY: The frontalis muscle is situated across the forehead and is a representative target muscle for botulinum neurotoxin (BoNT) injections aimed at treating horizontal wrinkles in this region. However, a lack of anatomical information regarding the shape and thickness of the frontalis may lead to unexpected adverse effects, such as ptosis and samurai eyebrows, caused by the lack of detail on anatomical variation. Achieving the maximum effect using the minimal amount of BoNT requires a precise injection into the frontalis muscle. The anatomical factors associated with BoNT injection into the frontalis muscle have been reviewed in the current study. Up-to-date understanding of the localization of the BoNT injection point according to an updated understanding of the anatomy leads to more accurate localization of the injection point into the frontalis muscle. Optimal injection sites have been provided for the frontalis muscle, and the injection method has been recommended. The authors suggest optimal injection sites according to the external anatomical landmarks of the forehead. Furthermore, these proposals could aid in a more precise procedure that avoids the deleterious effects of BoNT.

Guidelines for Botulinum Neurotoxin Injection for Facial Contouring.

SUMMARY: The hypertrophied temporalis and masseter muscles give a muscular shaped and bulky contour to the face. Botulinum neurotoxin injection methods are commonly used for facial contouring; however, adverse effects have been reported owing to a lack of delicate anatomical information. The anatomical considerations when injecting botulinum neurotoxin into the temporalis and masseter muscles were reviewed in the present study. Current knowledge on the localization of the botulinum neurotoxin injection point with more recent anatomical dissection and modified Sihler staining procedures was assessed. The authors found that, for the muscles, the injection point can be more precisely demarcated. Optimal injection sites are presented for the temporalis and masseter muscles, and the injection technique is suggested. The authors propose the optimal injection sites in relation to external anatomical landmarks for the frequently injected muscles of the face to facilitate the efficiency of botulinum neurotoxin injections. In addition, these guidelines would aid in more precise practice without the adverse effects of botulinum neurotoxin.

A novel needle-free microjet drug injector using Er:YAG LASER: A completely new concept of transdermal drug delivery system.

The skin barrier effectively inhibits the penetration of substances; therefore, drug delivery, especially the delivery of drugs that are hydrophilic, through the skin, is challenging. Objectives: Physicians in the esthetic field now use the transdermal drug delivery system to attempt to deliver esthetic materials, such as hyaluronic acid and poly-DL-lactic acid into the skin. Conventionally, esthetic physicians manually injected these materials using needle syringes into the dermis layer. However, the injection is often irregular, imprecise, slow, and painful. Injector devices have been developed to overcome these limitations. A total of five Korean cadavers (that of three men and two women with a mean age of 69.2 years; range, 60-73 years) underwent laser injection. We used a device called Er:YAG LASER to create the pressure needed for microjet delivery to the skin of the cadaver. Discussion: In this study, the first LASER pressure-based, needle-free microjet injector was used to deliver drugs effectively into the dermis of a cadaver. This study showed that a novel needle-free microjet injector using Er:YAG LASER can introduce beneficial, liquid, esthetic drugs into the papillary dermal layer (depth of 300um) with minimal epidermal damage.

Intramuscular Neural Arborization of the Latissimus Dorsi Muscle: Application of Botulinum Neurotoxin Injection in Flap Reconstruction.

Postoperative pain after breast reconstruction surgery with the latissimus dorsi flap is a common occurrence. Botulinum neurotoxin (BoNT) injection during surgery is effective in reducing postoperative pain. This study aimed to determine the most appropriate locations for BoNT injection. A modified Sihler's method was performed on the latissimus dorsi muscles in 16 specimens. Intramuscular nerve arborization was noted under the landmark of the medial side surgical neck of the humerus to the line crossing the spinous process of T5 and the middle of the iliac crest. The latissimus dorsi muscles were divided into medial, middle, and lateral segments with 10 transverse divisions to give 10 sections (each 10%). Intramuscular nerve arborization of the latissimus dorsi muscle was the largest from the medial and lateral part of the muscle ranging from 40 to 60%, middle part from 30 to 60% and medial, middle and lateral part from 70 to 90%. The nerve entry points were at the medial and lateral part with 20-40% regarding the medial side of surgical neck of the humerus to the line crossing spinous process of T5 to the middle of iliac crest. These outcomes propose that an injection of BoNT into the latissimus dorsi muscles should be administered into specific zones.

Anatomical locations of the motor endplates of sartorius muscle for botulinum toxin injections in treatment of muscle spasticity.

PURPOSE: This study aimed to detect the idyllic locations for botulinum neurotoxin injection by analyzing the intramuscular neural distributions of the sartorius muscles. METHODS: An altered Sihler's staining was conducted on sartorius muscles (15 specimens). The nerve entry points and intramuscular arborization areas were measured as a percentage of the total distance from the most prominent point of the anterior superior iliac spine (0%) to the medial femoral epicondyle (100%). RESULTS: Intramuscular neural distribution were densely detected at 20-40% and 60-80% for the sartorius muscles. The result suggests that the treatment of sartorius muscle spasticity requires botulinum neurotoxin injections in particular locations. CONCLUSIONS: These locations, corresponding to the locations of maximum arborization, are suggested as the most suggestive points for botulinum neurotoxin injection.

Application of Botulinum Neurotoxin Injections in TRAM Flap for Breast Reconstruction: Intramuscular Neural Arborization of the Rectus Abdominis Muscle.

Breast reconstruction after mastectomy is commonly performed using transverse rectus abdominis myocutaneous (TRAM) flap. Previous studies have demonstrated that botulinum neurotoxin injections in TRAM flap surgeries lower the risk of necrosis and allow further expansion of arterial cross-sectional diameters. The study was designed to determine the ideal injection points for botulinum neurotoxin injection by exploring the arborization patterns of the intramuscular nerves of the rectus abdominis muscle. A modified Sihler's method was performed on 16 rectus abdominis muscle specimens. Arborization of the intramuscular nerves was determined based on the most prominent point of the xyphoid process to the pubic crest. All 16 rectus abdominis muscle specimens were divided into four muscle bellies by the tendinous portion. The arborized portions of the muscles were located on the 5-15%, 25-35%, 45-55%, and 70-80% sections of the 1st, 2nd, 3rd, and 4th muscle bellies, respectively. The tendinous portion was located at the 15-20%, 35-40%, 55-60%, and 90-100% sections. These results suggest that botulinum neurotoxin injections into the rectus abdominis muscles should be performed in specific sections.

Guidelines for botulinum neurotoxin injections in piriformis syndrome.

BACKGROUND: The piriformis muscle is normally involved in piriformis syndrome and can be treated with botulinum neurotoxin using several different injection methods. However, definitive injection guidelines for the muscle have not been reported previously. AIMS: This study aimed to determine the ideal area for injections based on the intramuscular nerve distribution as obtained using a modified Sihler's staining technique. MATERIALS AND METHODS: A modified Sihler's method was applied to the piriformis muscle in 15 specimens. The intramuscular arborization areas were identified based on two anatomical landmarks: (a) the lateral border of the sacrum bone and (b) the greater trochanter. RESULTS: The nerve entry point for both piriformis muscles was found in the area between the lateral border of the sacrum and one-fifth of the distance toward the greater trochanter. The intramuscular nerve distribution for the piriformis muscle had the largest arborization patterns between one-fifth and two-fifths of the distance from the sacrum to the greater trochanter. The piriformis muscle was tendinous from two-fifths of the distance to the greater trochanter. DISCUSSION: This study has yielded suggested optimal injection locations for the piriformis muscle relative to external anatomical landmarks. CONCLUSION: Clinicians can use these guidelines to ensure the effectiveness of not only botulinum neurotoxin injections but also other agents such as steroids, anesthetics, and normal saline. These guidelines will also help to avoid adverse outcomes of injection treatments.

Comparison between Conventional Blind Injections and Ultrasound-Guided Injections of Botulinum Toxin Type A into the Masseter: A Clinical Trial.

The aim of the study was to propose a more efficient and safer botulinum toxin type A (BoNT-A) injection method for the masseter by comparing the conventional blind injection and a novel ultrasonography (US)-guided injection technique in a clinical trial. The 40 masseters from 20 healthy young Korean volunteers (10 males and 10 females with a mean age of 25.6 years) were included in this prospective clinical trial. The BoNT-A (24 U) was injected into the masseter of each volunteer using the conventional blind and US-guided injection techniques on the left and right sides, respectively, and analyzed by US and three-dimensional (3D) facial scanning. One case of PMB (paradoxical masseteric bulging) was observed on the side where a conventional blind injection was performed, which disappeared after the compensational injection. The reduction in the thickness of the masseter in the resting state differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 12.38 ± 7.59% and 17.98 ± 9.65%, respectively (t(19) = 3.059, p = 0.007). The reduction in the facial contour also differed significantly at 1 month after the injection between the conventional blind injection group and the US-guided injection group by 1.95 ± 0.74 mm and 2.22 ± 0.84 mm, respectively (t(19) = 2.908, p = 0.009). The results of the study showed that the US-guided injection method that considers the deep inferior tendon by visualizing the masseter can prevent the PMB that can occur during a blind injection, and is also more effective.

A Randomized, Active-Controlled, 52-Week Study of Hyaluronic Acid Fillers for Anteromedial Malar Region Augmentation.

BACKGROUND: Hyaluronic acid (HA) fillers for volume augmentation in the anteromedial malar region of Asians have been popular for many years. However, studies on their long-term effectiveness are lacking. This study aimed to evaluate the effectiveness and safety of HA fillers injected into the anteromedial malar region for volume augmentation for up to 52 weeks. METHODS: Each anteromedial malar region of the subjects was treated with YVOIRE Contour (YVOC) in one side and Restylane Sub-Q (RESS) in the other and followed up at weeks 2, 14, 26, and 52. The volume using the mid-face aesthetic scale (MFAS) ranging from 0 (full) to 4 (very severely sunken) and the subject's satisfaction and adverse events were evaluated. RESULTS: Total 83 subjects were randomized and treated with YVOC and RESS. The LS means (standard error) of MFAS score in the YVOC and RESS groups were both 2.56 (0.05) at baseline, 1.32 (0.07) and 1.39 (0.07) at week 26, and 1.84 (0.10) and 1.89 (0.10) at week 52, respectively. The difference in the LS mean of MFAS score between the groups at week 26 was 0.07 (95% confidence interval, 0.01-0.12), showing the non-inferiority of YVOC to RESS. About 70% of subjects were still satisfied with the results at week 52. No specific safety concern was detected. CONCLUSIONS: The HA fillers injected for the anteromedial malar augmentation maintained the volume well for up to 52 weeks. Additionally, both YVOC and RESS show similar effectiveness and safety profiles.

Validated Assessment Scales for the Female Asian Calf.

BACKGROUND: Clinical photonumeric scales have been developed and validated to objectively measure the effectiveness of aesthetic treatments in specific anatomical areas; however, these are based on the typical features of Caucasian patients. No clinical scale for Asian calf appearance currently exists. OBJECTIVE: To develop and validate a calf assessment scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed calf images of female Asian subjects (N = 35) viewed from behind with feet flat on the floor (at rest) and on tiptoes (dynamic). Images were rated from 0 (very slim, linear profile) to 4 (very severe convex profile). RESULTS: Inter-rater and intra-rater reliability were "substantial" (≥0.6, intraclass correlation coefficient [ICC] and weighted kappa) for the calf-at rest, calf-dynamic, and calf summary score. Reliability was "substantial" for calf-at rest and calf-dynamic (≥0.6, ICC and weighted kappa) and "almost perfect" (0.85) for the calf summary score. BMI and calf circumference were highly correlated with scale ratings, and calf circumference was a significant predictor. CONCLUSION: This new photonumeric assessment scale has value for assessing the female Asian calf, providing a standardized measure of calf appearance in clinical practice and clinical research settings.

A Validated Assessment Scale for Asian Chin Projection.

BACKGROUND: As the number of different aesthetic treatments increase, numerous photonumeric assessment scales have been developed and validated to measure the effectiveness of these new treatments and techniques. Photonumeric rating scales have been developed to objectively assess improvements in anatomical areas; however, these have been based on the features of Caucasian patients. OBJECTIVE: To develop and validate a Chin Projection Scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial views of 50 Asian subjects and also estimated their age and the aesthetic treatment effort required for each subject. Chin projection was rated on a scale from 0 (optimal) to 4 (very severely receding). RESULTS: Inter-rater reliability was 0.80 (substantial) for Validation Session 1 and 0.83 (almost perfect) for Validation Session 2. The results for Estimated Age and Estimated Treatment Effort were essentially the same. CONCLUSION: This study demonstrated the validity of the first photonumeric assessment scale for assessing the appearance of the female Asian chin. This new scale will provide a standardized measure of chin projection for Asian patients in clinical practice and clinical research settings.

Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead.

BACKGROUND: As the number of aesthetic treatments has grown, so have the number of photonumeric assessment scales used to compare the effectiveness of these aesthetic treatments in specific anatomical areas; however, these are primarily based on Caucasian features. OBJECTIVE: To assess the validity of the first aesthetic scale for assessing the slope of the Asian forehead. A secondary objective was to correlate this scale with subject demographics and baseline characteristics. METHODS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial images of female (n = 28; 56.0%) and male (n = 22; 44%) subjects. For each subject, the severity of forehead sloping was graded from 0 (convex forehead, optimal forehead volume) to 4 (concave forehead, very severe sloping). Raters also assessed the age of each subject and the estimated aesthetic treatment effort required to treat each subject. RESULTS: Inter-rater reliability was "substantial" with scores of 0.67 and 0.68 for the first and second validation sessions, indicating high reliability. BMI showed the highest correlation with the scale and was a significant predictor in the final regression model. CONCLUSION: This photonumeric assessment scale will be useful for assessing the slope of the Asian forehead in both clinical and research settings.

Combined aesthetic interventions for prevention of facial ageing, and restoration and beautification of face and body.

The Merz Institute of Advanced Aesthetics Expert Summit was held in Prague, Czech Republic, from 19-20 November 2016. The meeting had a distinct advisory board character and invited aesthetic practitioners from all over the world to hear an international faculty present a range of keynote lectures and conduct live injection sessions with an emphasis on recent developments in combination aesthetic interventions for face and body rejuvenation and beautification. Aging is associated with changes in bones, muscles, ligaments, adipose tissue, and skin and, moreover, involves interactions among these tissue types. To achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected, which generally involves treatment with more than a single agent or technology. Presentations described innovative treatment algorithms for the face and body and focused on patients' desires for natural-looking rejuvenation and how this requires a three-dimensional approach combining products that relax the musculature, volumize, and re-drape the skin. Besides treating the aging face, these procedures are increasingly used to enhance facial features as well as to delay facial aging in younger patients. The presentations covered patients from different ethnicities as well as the treatment of non-facial areas, with a particular focus on the use of Ultherapy® for skin lifting and tightening, and new aesthetic procedures such as Cellfina® and diluted Radiesse®. The current report provides a summary of key presentations from the meeting.

PAN-ASIAN CONSENSUS-Key Recommendations for Adapting the World Congress of Dermatology Consensus on Combination Treatment with Injectable Fillers, Toxins, and Ultrasound Devices in Asian Patients.

BACKGROUND. The demand for minimally invasive aesthetic procedures has driven requests by physicians for guidance on their use in Asian patients, who have unique cultural preferences, social trends, and anatomy. However, few guidelines exist, particularly on combination treatment strategies for different facial shapes or indications such as the modification of face shapes to the "oval ideal."Physicians must, therefore, apply Caucasian patient-optimized guidelines to their Asian patients. METHODS. Eleven specialists developed a consensus on the use of botulinum toxin A (BoNT-A), calcium hydroxylapatite (CaHA) and hyaluronic acid (HA) fillers, and microfocused ultrasound with visualization (MFU-V) devices in Asian patients on upper-, middle-, and lower-face indications, including strategies to modify different facial shapes to the oval shape. Approval from 70 to 90 percent of all participants led to moderate consensus, while 90 percent agreement denoted a strong consensus. RESULTS. For early intervention/enhancement and restoration, most combination strategies are similar between Asian and Caucasian patients. Compared to Caucasian patients, however, beautification is a more common focus in Asian patients. The "ideal" oval facial shape can be created using different interventions depending on the patient's baseline characteristics. CONCLUSIONS. Although treatments and treatment sequences for early intervention/enhancement and restoration for beautification in Asian patients are similar to those in Caucasian patients, different treatment strategies may be required.

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.

Efficacy and Safety of IncobotulinumtoxinA in Asian Subjects: A Pooled Analysis of Clinical Trials in the Treatment of Glabellar Frown Lines.

BACKGROUND: Owing to differences in facial anatomy and cultural beauty ideals, dose adaptations are often necessary when administering botulinum toxin type A to Asians and non-Asians. OBJECTIVE: To assess potential differences in the efficacy and safety of incobotulinumtoxinA in Asian and non-Asians.
METHODS: Efficacy data were pooled from several Phase II/III trials that used 20 U incobotulinumtoxinA to treat glabellar frown lines in Asian subjects. The variable of interest was investigator-assessed improvement in scores on the 4-point Facial Wrinkle Scale from baseline to days 30, 60, 90, and 120. Subjects with a 1-point improvement were considered 'responders'. Data were also assessed for treatment-emergent adverse events, treatment-emergent serious adverse events, and adverse events of special interest among a pool of incobotulinumtoxinA safety studies.
RESULTS: Four trials were pooled, comprising 19 Asian and 563 non-Asian subjects. At maximum frown on day 30, 100% of Asians and 87% of non-Asians were responders; by day 120, values were 37% and 40%, respectively. At rest on day 30, 63% of Asians and 56% of non-Asians were responders. Corresponding values for day 120 were 11% and 25%. The mean change in score on the Facial Wrinkle Scale from baseline over time was similar in both groups. Very few adverse events occurred. Overall, treatment-emergent adverse events were lower amongst Asians than non-Asians.
CONCLUSIONS: Compared with non-Asians, a trend towards slightly higher responses was observed in Asians at maximum frown. There were no clinically relevant differences in the safety of incobotulinumtoxinA when administered to Asian and non-Asian subjects.

J Drugs Dermatol. 2016;15(9):1084-1087.

Filler Rhinoplasty Evaluated by Anthropometric Analysis.

BACKGROUND: There are no reports of objectively evaluating the efficacy of filler rhinoplasty by anthropometric techniques. OBJECTIVE: To objectively demonstrate the effectiveness of filler rhinoplasty by anthropometric analysis. MATERIALS AND METHODS: A total of 242 patients who revisited the clinic within 2 months of undergoing hyaluronic acid filler rhinoplasty were analyzed based on the injection site, injected volume, and the change in anthropometry. RESULTS: Among the 242 patients, 112 (46.3%) were in the nasal dorsum augmentation group, 8 (3.3%) were in the tip rotation group, and 122 (50.4%) were in the whole nose augmentation group. Average injection volume was 1 ± 0.4 mL for nasal dorsum and 0.9 ± 0.3 mL for tip rotation, whereas 1.6 ± 0.5 mL was used for whole nose augmentation. On follow-up, the radix height, nasofrontal angle, and nasolabial angle (NLA) had increased by 78.3%, 5.7 ± 4.1°, and 9.4 ± 4.5°, respectively, whereas the modified nasofacial angle had decreased by 1.9 ± 2.9°. Three cases (1.2%) of vascular complications were encountered. CONCLUSION: Filler rhinoplasty is a simple and effective treatment modality producing outcomes comparable with surgical augmentation rhinoplasty. Among various anthropometric measurements, the nasal radix height was the most useful for evaluating dorsum augmentation, whereas the NLA was the best for nasal tip rotation.

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.