Recommendations for Dermatology Office Reopening in the Era of COVID-19.

The COVID-19 pandemic, originating in Wuhan, China, has become a major public health and economic challenge for countries around the world. As of May 08, 2020, there are over 3 million COVID-19 cases, and 250,000 COVID-19- associated deaths in 215 countries. As more data is collected, updated infection control measures are continuously released and published by government, public health authorities, and physician specialty associations. Across the globe, dermatological practices have had to limit their operations to varying degrees to facilitate disease control, but as the pandemic subsides, they will broaden their operations. In light of the uncertainty surrounding safe and effective practice of medical and aesthetic dermatology in the era of COVID-19, fourteen international experts in the field contributed to recommendations for effective infection control protocols and practice management modifications. While guidance from the World Health Organization and local public health officials comes first, these recommendations are crafted as a starting point for dermatologists worldwide to commence either reopening their doors to patients or expanding available service offerings. This can help ensure that patients receive needed care in the short term and improve long term practice viability. J Drugs Dermatol. 2020;19(7):e-1-e-9. doi:10.36849/JDD.2020.5293.

Minimally Invasive Aesthetic Treatment of the Face and Neck Using Combinations of a PCL-Based Collagen Stimulator, PLLA/PLGA Suspension Sutures, and Cross-Linked Hyaluronic Acid.

BACKGROUND: Combinations of minimally invasive procedures (MIPs) are often used in aesthetic treatments and are increasingly considered as the new standard of care. Three agents with specific properties are available in this perspective: a polycaprolactone (PCL)-based collagen stimulator, a poly-L-lactic acid (PLLA)- and a poly-glycolic acid (PLGA)-based resorbable suspension suture with a 3D-cone technology, and a cross-linked hyaluronic acid (HA). OBJECTIVE: To develop the first practice guidelines on rejuvenation treatment of the face and the neck using combinations of these agents, whether associated or not with other widely used MIPs such as botulinum neurotoxins or energy-based devices. METHODS: A multi-disciplinary, multi-national board of plastic surgeons and dermatologists convened to develop guidelines using a predefined consensus method. The consensus was defined as ≥83% agreement rate between participants. RESULTS: Practice guidelines and algorithms, describing optimal procedure sequence and spacing, are proposed for the treatment of upper-, mid-, lower-face and neck, combining the PCL collagen stimulator, the PLLA/PLGA suspension sutures, and the cross-linked HA, whether associated or not with other MIPs. CONCLUSION: These new guidelines provide general support to optimal management strategies. Individual treatment plans should be adapted according to the physician's individual competence and the patient's preferences.

Validated Assessment Scales for Cellulite Dimples on the Buttocks and Thighs in Female Patients.

BACKGROUND: New treatment methods for cellulite require globally accepted scales for aesthetic research and patient evaluation. OBJECTIVE: To develop a set of grading scales for objective assessment of cellulite dimples on female buttocks and thighs and assess their reliability and validity. MATERIALS AND METHODS: Two photonumeric grading scales were created and validated for dimples in the buttocks in female patients: Cellulite Dimples-At Rest, and Cellulite Dimples-Dynamic. Sixteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. RESULTS: Overall inter-rater reliability and intra-rater reliability were both "almost perfect" (≥0.81, intraclass correlation efficient and weighted kappa) for the At Rest scale. For the Dynamic scale, inter-rater reliability and intra-rater reliability were "substantial" (0.61-0.80). There was a high correlation between the cellulite scales and body mass index, age, weight, and skin laxity assessments. CONCLUSION: Consistent outcomes between raters and by individual raters at 2 time points confirm the reliability of the cellulite dimple grading scales for buttocks and thighs in female patients and suggest they will be a valuable tool for use in research and clinical practice.

Validated Assessment Scales for Skin Laxity on the Posterior Thighs, Buttocks, Anterior Thighs, and Knees in Female Patients.

BACKGROUND: The demand for noninvasive skin-tightening body procedures is increasing. OBJECTIVE: To develop a set of grading scales for the objective assessment of skin laxity and assess their reliability and validity. MATERIALS AND METHODS: Two photonumeric grading scales were created and validated for skin laxity in female patients: Skin Laxity-Posterior Thighs/Buttocks, and Anterior Thighs/Knees. Fifteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. RESULTS: Overall inter-rater reliability according to intraclass correlation efficient (ICC) 2.1 and weighted kappa was at least "substantial" for both scales in both sessions, and "almost perfect" (≥0.81) for the Anterior Thighs and Knees scale in session 2. Intra-rater reliability was "almost perfect" for both scales (ICC 2.1) and "substantial" to "almost perfect" by weighted kappa. A correlation between the skin laxity scales and body mass index, age, weight, sun exposure, and cellulite severity was observed. CONCLUSION: The skin laxity photonumeric grading scales are valid and reliable instruments for assessing laxity on the posterior thighs and buttocks, and anterior thighs and knees. The scales will be of value for standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice.

Benjamin Button Effect: Recognizable Rejuvenation.

The "Benjamin Button" effect inspired by the popular motion picture, is used to describe the goal of achieving a clearly younger and more attractive, yet still natural appearance utilizing noninvasive and minimally invasive therapies and procedures. Due to high patient demand for enhancement and rejuvenation of the face and body with minimal downtime, there is an ever-increasing number of companies developing products and devices, variety of indications, and field of practitioners offering them. Each option, including topicals, injectables, and devices, promises near magical results. Despite that, a brief review of online discussions and media resources reveals both patients complaining of inadequate results and celebrities with extreme appearances. For clinical practitioners, it is critical to understand the art, science, and economics of noninvasive rejuvenation in order to properly evaluate potential patients, set appropriate expectations, develop, and provide an effective noninvasive rejuvenation plan to achieve a true "Benjamin Button" effect for patients.

J Drugs Dermatol. 2017;16(6 Suppl):s74-76.

First Consensus on Primary Prevention and Early Intervention in Aesthetic Medicine.

BACKGROUND: Facial aging is a complex interplay of extrinsic and intrinsic factors leading to progressive changes in the skin, subcutaneous tissue, and bone. Clinical experience suggests that early aesthetic intervention may slow the signs of aging, but treatment in the absence of symptoms or with minimal signs of aging has not yet been properly addressed. OBJECTIVES: To provide treatment recommendations for primary prevention and early intervention in individuals with no or minimal signs of aging. METHODS: Fourteen specialists in aesthetic medicine convened over a full-day meeting under the guidance of a certified moderator. RESULTS: Tailored treatment recommendations have been provided for prevention and early intervention of fine wrinkles, static lines and folds, irregular pigmentation, laxity, and subcutaneous volume loss by protecting the epidermis, stimulating neocollagenesis, reducing hyperkinetic musculature, and reinforcing supporting structures. CONCLUSION: Preventive measures and early therapeutic interventions that may alter the course of facial aging were defined. Further studies are needed to support these recommendations with the best possible evidence.

J Drugs Dermatol. 2017;16(9):846-854.

Communication Concepts for Prevention and Early Intervention in Aesthetic Medicine: Consensus and Literature Review.

BACKGROUND: Communication concepts relating to prevention and early intervention (P&E) within aesthetic medicine are poorly understood and highly underexplored. However, effective communication is a key criterion for successful outcomes. OBJECTIVES: To introduce the framework for P&E communication strategies within a younger population and explore the barriers that may be encountered. METHODS: A literature review on P&E communication strategies in aesthetic medicine and related topics of interest was conducted and used to construct a working framework that may be applied in clinical practice. RESULTS: Examination of existing literature revealed a need for a more structured communication framework for P&E encompassing up-to-date evidence-based learning and educational marketing that is tailored to individual needs and target populations. Message framing-the way in which a message is presented-is an important consideration in the dissemination of information to promote changes in health behaviour. A structured consultation is key to optimising patient engagement and ensures a tailored approach to understanding and catering to the specific needs of each patient. CONCLUSION: This is the first paper to discuss the communication concepts behind P&E within aesthetic medicine and paves the way for further research and focus in this significant field.

J Drugs Dermatol. 2017;16(9):859-864.

Aging Gracefully.

At the Annual Meeting of the American Academy of Dermatology in 2016, I directed the symposium entitled 'Aging Gracefully' for the second time. The symposium's primary learning objective was to give the audience a framework for managing aesthetic patients. In the last decade, there has been a significant increase in the options for and availability of noninvasive and minimally invasive rejuvenation. With that has been an associated surge in interest by physicians and patients. And, as the number of procedures across the globe increases, so too do the number of aesthetically poor outcomes. Most come from practitioners doing paint-by-numbers treatment. As experts in skin biology and treatment, dermatologists should practice the highest-level cosmetic as well as general dermatology. The faculty presented information to aid practitioners how best to approach patients and formulate a cosmetic plan. The faculty discussed important considerations based on patient gender, age, and skin type. Updated information on the science of cosmeceuticals and the benefits of early noninvasive intervention was presented as were next generation devices and alternatives to standard therapies. The faculty have kindly condensed their AAD presentations for this supplement. I thank L'Oréal and the Journal of Drugs in Dermatology for giving us the opportunity to present this information to a wider audience in this e-supplement. Heidi A. Waldorf MD Director of Laser & Cosmetic Dermatology, The Mount Sinai Hospital, New York, NY Icahn School of Medicine of Mount Sinai, New York, NY Waldorf Dermatology Aesthetics, Nanuet, NY

Is There a Role for Arnica and Bromelain in Prevention of Post-Procedure Ecchymosis or Edema? A Systematic Review of the Literature.

BACKGROUND: The management of postprocedure skin care is of significant interest to dermatologists and other physicians. Ecchymosis and edema are common temporary postprocedure unwanted effects. Two botanically-derived products, arnica and bromelain, are used internationally by physicians to limit ecchymosis and edema that occur secondary to cosmetic, laser, and surgical skin procedures. OBJECTIVE: The authors review the published literature and provide evidence-based recommendations on arnica and bromelain for prevention and treatment of postprocedure ecchymosis and edema. METHODS AND MATERIALS: A search of the computerized bibliographic databases Medline, EMBASE, Scopus, and CINAHL was performed on March 23, 2015. The key terms used were "arnica," and "bromelain." RESULTS: This review contains clinical trials that evaluated prevention and/or treatment of postprocedure ecchymosis or edema with oral arnica (11), topical arnica (2), and oral bromelain (7). No studies on topical bromelain were found. Clinical trials on arnica and bromelain have demonstrated mixed results. Some randomized controlled trials reported improvement postprocedure with arnica (4/13) and bromelain (5/7). CONCLUSION: Based upon published studies, there is insufficient data to support use of arnica and bromelain post procedure, and the authors recommend additional research to determine the efficacy and safety of arnica and bromelain to prevent and/or treat ecchymosis and edema in patients.

Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers.

The use of injectable fillers enables facial sculpting through treatment of volume depletion and modeling of facial contours. Injectable fillers are among the most frequently performed minimally invasive cosmetic procedures.However, treatment of the lower third of the face can be challenging and requires expertise in facial anatomy. In this article, the authors provide a comprehensive review of the anatomy of the lower third of the face, highlighting danger zones. In addition, the authors describe their preferred approach and detailed technique used in the treatment of each specific area, namely the jawline, prejowl sulcus, melomental folds, and lips.

The Safety and Efficacy of a Sustainable Marine Extract for the Treatment of Thinning Hair: A Summary of New Clinical Research and Results from a Panel Discussion on the Problem of Thinning Hair and Current Treatments.

Alopecia and thinning hair are highly prevalent conditions affecting a large proportion of men and women. Diffused hair loss is often more difficult to diagnose in women, mostly due to over-reliance on the assumption of hormonal influences, and it is commonly treated with a multi-therapy approach. Clinical studies have demonstrated the effectiveness of a nutraceutical supplement to provide essential nutrients that aid in stimulating existing hair growth and reducing hair shedding. The supplement Viviscal® contains a proprietary blend of proteins, lipids, and glycosaminoglycans derived from sustainable marine sources. We present here a summary of studies that have examined the safety and efficacy of this nutraceutical; as well as discussions on hair loss and current therapies from a recently convened expert panel in dermatology and plastic surgery.

Review of key Belotero Balance safety and efficacy trials.

Belotero Balance is a novel highly cross-linked hyaluronic acid that uses cohesive polydensified matrix technology to achieve cohesive gel; improved adaptation by the dermis; and a soft, smooth fill. Several studies have now compared Belotero Balance to bovine collagen and other hyaluronic acids. Two pivotal studies demonstrated the noninferiority and superiority of Belotero Balance to bovine collagen. In the first study, more than half of the patients maintained optimal correction at 6 months on the Belotero-treated side of the face. The second of those two studies followed patients to week 96 and demonstrated that the effects of Belotero Balance in this long-term, open-label study persisted in the majority of subjects without repeated treatment for at least one interval of 48 weeks. The filler was well tolerated, with only one of 34 total adverse events (injection-site bruising) considered to be related to the study device. A third study compared the safety and efficacy of other hyaluronic acids (i.e., Juvéderm and Restylane) with Belotero Balance. In this study, the safety profiles of all three hyaluronic acids were generally favorable, with site-specific adverse events mild to moderate and comparable across each hyaluronic acid. Aesthetic results were also similar, although Belotero Balance resulted in greater evenness than Restylane at 4 weeks by one indicator used in the study. Finally, a 5-year retrospective safety review of 317 patients treated with Belotero Balance over a 5-year period revealed no severe adverse events in any patients, including the absence of persistent nodules or granulomas.

Clinical application and assessment of Belotero: a roundtable discussion.

In this final article for the Supplement, the authors address the physical and aesthetic characteristics of the latest hyaluronic acid, Belotero Balance. Topics include unique characteristics of the hyaluronic acid, aesthetic indications, administration techniques, adverse events, and differences between Belotero and other hyaluronic acids. The article closes with a brief discussion about nomenclature of hyaluronic acid products.

A review of AbobotulinumtoxinA (Dysport).

AbobotulinumtoxinA was approved by the US Food and Drug Administration in 2009 as the second botulinum neurotoxin type A (BoNTA) for use in facial aesthetics. This article provides an overview of abobotulinumtoxinA's applications and indications as well as safety and efficacy data. AbobotulinumtoxinA is generally well tolerated. Adverse events from abobotulinumtoxinA are similar to those reported with other BoNTA products. Clinical applications of the product are also discussed in this article. Information on handling, storage, and dosing is provided.

IncobotulinumtoxinA (Xeomin): background, mechanism of action, and manufacturing.

IncobotulinumtoxinA is the third botulinum neurotoxin type A (BoNTA) to be approved for aesthetic use in the United States. This article introduces the new product with an overview of clinical applications and a discussion of the neurotoxin's molecular structure. The role and clinical relevance of complexing proteins in BoNTA products are discussed. Finally, incobotulinumtoxinA's mechanism of action is described.

IncobotulinumtoxinA in clinical literature.

IncobotulinumtoxinA is the third neurotoxin type A to be approved for aesthetic use in the United States. Because incobotulinumtoxinA has been in use in Europe for some time, the clinical literature is fairly replete with references to its properties and characteristics, as well as its safety and efficacy. In North America, 2 pivotal trials, referred to as GL-1 and GL-2, investigated the safety and efficacy of incobotulinumtoxinA in the glabellar region; both are currently in press with another journal. Other published studies of incobotulinumtoxinA are also described in depth in this article, including reports on aesthetic indications, diffusion, therapeutic indications, and studies pertaining to the preclinical and clinical pharmacology of incobotulinumtoxinA. Topics addressed include potency variability, mean concentration, stability and dissociation, and endopeptide immunoassay.

Consensus panel's assessment and recommendations on the use of 3 botulinum toxin type A products in facial aesthetics.

In this summary article, the authors discuss the characteristics of abobotulinumtoxinA, incobotulinumtoxinA, and onabotulinumtoxinA. With 3 neuromodulators available in the US market, comparisons between and among products will invariably be made, so arguments for the most effective facial aesthetic uses of each neuromodulator are presented. Topics addressed in this article include patient expectations, toxin reconstitution and preparation, patient positioning, differences among products, the role of complexing proteins, and dosing and injection strategies. Recommendations are also provided by treatment area.

A review of onabotulinumtoxinA (Botox).

OnabotulinumtoxinA was introduced to the US market in 2002 as the first botulinum toxin type A (BoNTA) approved for facial aesthetics. This article provides an overview of onabotulinumtoxinA's uses and indications as well as safety and efficacy data. As with other BoNTA products, onabotulinumtoxinA is generally well tolerated. Consideration is also given to clinical applications of the product. Information on handling, storage, and dosing is provided.

The basic science of dermal fillers: past and present Part I: background and mechanisms of action.

Dermal fillers have provided a safe and effective means for aesthetic soft tissue augmentation, and have experienced a dramatic increase in popularity during the past 10 years. Much focus has been placed upon filler technique and patient outcomes. However, there is a relative lack of literature reviewing the basic science of dermal fillers, which is vital to a physician's understanding of how each product behaves in vivo. Part I of this article reviews the basic science and evolution of both historical and contemporary dermal fillers; Part II examines their adverse effects. We endeavor to provide the physician with a practical approach to choosing products that maximize both aesthetic outcome and safety.