Hyaluronic Acid-based Fillers for Facial Rehabilitation in Inherited Neuropath.

Charcot-Marie-Tooth (CMT) disease is the most prevalent inherited neuromuscular disorder. It commonly leads to various musculoskeletal deformities, profoundly impacting the quality of life. The present case report explores the often under-recognized body image dissatisfaction in CMT, highlighting the potential benefits of a multidisciplinary approach to enhance aesthetic satisfaction. We present a case of a 54-year-old woman with CMT, who experienced chronic facial asymmetry, significantly impairing her quality of life. Seeking cosmetic enhancement, she underwent two sessions of facial treatment using hyaluronic acid-based fillers. The first session focused on correcting right mandibular hypoplasia and other facial asymmetries, whereas the second session focused on enhancing perioral aesthetics. The treatment resulted in significant aesthetic improvements, as demonstrated by high ratings in both the Physician Global Aesthetic Improvement Scale and the Subject Global Aesthetic Improvement Scale. Besides, there was a marked reduction in lip corner asymmetry, the patient's primary concern. The role of hyaluronic acid fillers in facial aesthetic enhancement is well established, and their application in the context of CMT is a promising under-investigated field, to our knowledge. This case study highlights the importance of considering body image in CMT patients and suggests that minimally invasive aesthetic procedures can be a valuable addition to the multidisciplinary care of patients with inherited neurological disorders. Despite being a single-case study, the significant improvement in the patient's aesthetic satisfaction requires further research in this field.

Dermal Thickness Increase and Aesthetic Improvement with Hybrid Product Combining Hyaluronic Acid and Calcium Hydroxyapatite: A Clinical and Sonographic Analysis.

Hyaluronic acid filler injections are regarded as the gold standard procedure for facial rejuvenation. Standing as the second most injected cosmetic filler, calcium hydroxyapatite-based fillers are also widely used worldwide. However, to our knowledge, prospective studies assessing patient satisfaction and sonographic changes in dermal thickness after a single session of a hybrid filler combining hyaluronic acid and calcium hydroxyapatite have not been previously published. Methods: This was a single-center, prospective, quasi-experimental study comprising 15 participants between 32 and 63 years of age. Each participant received a single-session treatment based on facial subcutaneous injections of HArmonyCa, a hybrid combination filler comprising hyaluronic acid and calcium hydroxyapatite. This study involved an intrapatient control design and a 120-day follow-up with clinical and sonographic assessment. For this purpose, standardized photographic images, high-frequency ultrasound evaluations, and physician- and patient-oriented overall aesthetic improvement scores were recorded at 0, 30, 90, and 120 following the procedure. Results: According to our findings, 20% of the subjects had an exceptional improvement; 20%, "very improved"; and 60%, "improved." Intrapatient sonographic comparison showed a significant increase in dermal thickness, at 90 and 120 days, only on the side treated (P < 0.001). Conclusion: In our clinical study, a single-session treatment with a hybrid product combining hyaluronic acid and calcium hydroxyapatite resulted in positive cosmetic satisfaction and increased dermal thickness.

Dermoscopic classification of melasma: Concordance study and correlation with the melanophages count.

BACKGROUND: Melasma is a common hypermelanosis characterized by symmetrical brownish macules, especially on the face. Histologic analysis demonstrates increased epidermal and dermal melanin. Dermoscopy is useful to estimate the depth of the melanin and may help in the diagnosis and classification of melasma, with therapeutic importance. OBJECTIVES: To evaluate the diagnostic concordance of dermoscopic classification of epidermal or mixed subtypes of melasma and the correlation between dermoscopic and histopathological findings. METHODS: Twenty-eight women with facial melasma, phototypes III to V, ages between 30 and 61 years were selected. Based on the evaluation of clinical and dermoscopic images, two independent observers classified melasma into epidermal or mixed subtypes. The intra and interobserver concordances were calculated. Histopathological analysis of epidermal melanin extension and maximum number of melanophages per high-power field (400×; HPF) have been assessed. Association between the melanophages count and the dermoscopic classification was evaluated. RESULTS: Intraobserver agreement was 82.1%, and between observers, from 78.6% to 89.3%, according to the Kappa index. Histopathology revealed increased intraepidermal melanin and the presence of dermal melanophages in all the samples. Ten or more melanophages/HPF was significantly associated with mixed melasma. CONCLUSIONS: Moderate to substantial concordance in the dermoscopic classification of melasma was found, and the correlation between this classification and the dermal melanophages count have been suggested. Intradermal component of every case of melasma should be considered for therapeutic and prognostic purposes.

Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures.

BACKGROUND: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region. OBJECTIVE: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments. METHODS: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m2 were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues. RESULTS: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle. CONCLUSION: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.

A vacinação contra SARS-CoV-2 afeta o efeito imediato da toxina botulínica? Primeiras impressões / Does SARS-CoV-2 vaccination affect the immediate effect of botulinum toxin? First impressions

Introdução: A infecção por SARS-CoV-2 se espalhou rapidamente pelo mundo desde sua identificação no final de 2019. Globalmente, até abril de 2021, houve mais de 150 milhões de casos confirmados de Covid-19, incluindo mais de 3 milhões de mortes. Portanto, uma corrida foi prontamente iniciada para produzir uma vacina eficaz contra o novo vírus. A injeção de toxina botulínica continua sendo o principal procedimento cosmético não cirúrgico em todo o mundo, com alto índice de eficácia e satisfação do paciente. Objetivos: Este estudo tem como objetivo analisar a associação entre a vacina SARS-CoV-2 e a resposta imediata à toxina botulínica. Materiais e Métodos: Estudo observacional, retrospectivo e multicêntrico. Os dados foram coletados entre abril e junho de 2021, e revisão de prontuários de 71 pacientes de 27 a 76 anos que foram tratados com injeção de toxina botulínica. Resultados e Conclusão: Não houve mudanças significativas no desfecho imediato dos pacientes vacinados para Covid-19 e toxina botulínica, mas é de suma importância ressaltar que são necessários acompanhamento e mais estudos para definir se a vacina Covid-19 é capaz de alterar a duração do efeito e a eficiência da toxina botulínica.

Background: The SARS-CoV-2 infection has spread worldwide rapidly since its identification at the end of 2019. Globally, until April 2021, there have been more than 150 million confirmed cases of Covid-19, including over 3 million deaths. Therefore, a race was promptly started to produce an effective vaccine against the new virus. Botulinum toxin injection remains the leading non-surgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. Aims: This study aims to analyze the association between the SARS-CoV-2 vaccine and the immediate botulinum toxin response. Materials and Methods: This was an observational, retrospective, and multicenter study. Data were collected between April and June 2021, and a medical record review of 71 patients from 27 to 76 years old treated with botulinum toxin injection. Results and Conclusion: There were no meaningful changes in the immediate outcome of patients vaccinated for Covid-19 and botulinum toxin. However, it is vital to underline that follow-up and further studies are needed to define whether the Covid-19 vaccine can alter the duration of effect and efficiency of the botulinum toxin.

Hyaluronidase: What is your fear?

BACKGROUND: The aesthetic treatment based on fillers with hyaluronic acid presents an increasing demand in the present day because it is considered a safe and minimally invasive procedure. In the management of adverse effects or more severe complications of hyaluronic acid-based fillers, hyaluronidase is the treatment of choice. AIMS: To demonstrate efficacy in reversibility and safety in the treatment of HA complications. PATIENTS/METHODS: It is a retrospective study article that reports the use of hyaluronidase in the main undesirable effects of fillers in 114 patients in a private dermatological clinic from 2015 to 2018. RESULTS: The target of the application was 51 cases of overcorrection (45%), 50 cases of Tyndall effect (44%), and 13 late nodules (11%). When we evaluated the areas where HYAL was injected, we found that the area with the most indication of the application of the product was the eyelid region (58 injections). CONCLUSION: This study concluded that HYAL is a safe and effective drug in the management of mild adverse events of HA applications with no severe side effects in our protocol of use.

A Retrospective Study Supporting the Importance of Individualizing the Dose of Botulinum Toxin According to the Age.

BACKGROUND: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide with a high rate of efficacy and patient satisfaction. OBJECTIVE: This study aims to demonstrate the importance of individualization of botulinum toxin doses to treat the upper face according to the age of the patients, considering the muscles particularities and the specificities of each face area. MATERIALS AND METHODS: A retrospective study with 389 female patients treated with botulinum toxin type A in the upper third of the face (forehead, glabellar, and periorbital lines). Statistical analysis of the data was performed. RESULTS: The mean age was 47.49 years old and the median total dose of botulinum toxin type A was 53.76 units, whereas the median dose in the glabella was 26.28 U, the mean forehead dose was 12.23 U, and in the periorbital area was 14.79 U, adding both sides. It is possible to observe that the doses are negatively correlated with age, except in the periorbital area, where an increase in the dose was observed. CONCLUSION: It is important to highlight that although there is consensus on pre-established dose suggestions, the treatment should be individualized, respecting the individual characteristics of each patient.

Supraperiosteal application of hyaluronic acid with cannula: Is it possible?

INTRODUCTION: The aging process occurs in all anatomical layers of the face; therefore, rejuvenation should not be limited to the dermic signs of aging (Aesthet Surg J. 2018;38:73) The treatment with fillers in strategic points can reconstruct young anatomy, providing natural results (Aesthet Surg J. 2018;38:73). There are two instruments used for facial application of hyaluronic acid: cannula and needle. Both of them have advantages and disadvantages. OBJECTIVE: In this study, we aim to compare the limitations of application with cannula by cutaneous ultrasound when compared to the needle by ultrasound, since some injectors suggest that one of the disadvantages would be the inability to reach certain application plans (periosteum). MATERIALS AND METHODS: A 52-year-old female patient was treated with 22 mg/ml hyaluronic acid (Juvéderm® Voluma), guided by high-frequency ultrasound (LogicE device, Logic brand (GE Healthcare), with high-frequency linear probe (L8-L18i-RS). The left hemiface was treated with a 27G needle and the right hemiface with a 5 cm 22G cannula (SoftFil®). CONCLUSION: This study proved that, in the malar/zygomatic and the chin region, it is possible the cannula and needle reached the supraperiosteal region. In the temporal region, the cannula did not reach the supraperiosteal plane.

Ultrasound-guided poly-l-lactic acid nodule excision: The importance of the injector ultrasonographic experience.

The possibilities for facial and body treatments are wide, but when it comes to treatment for the cervical region, the options are more restricted and among them, the use of poly-l-lactic acid (PLLA) stands out. PLLA is used for collagen biostimulation and improvement of skin turgor with good results; however this procedure is not free of complications, and for the treatment of these, a correct diagnosis is essential. As it is esthetic medicine, the guarantee of results requires that complications are not tolerated, and thus, any resource that enriches the diagnostic and therapeutic arsenal is of great value. The objective of this study is to report the diagnosis of a PLLA nodule with the help of high-frequency ultrasound, establishing a clinical, radiological, and histopathological correlation, in a patient submitted to PLLA injection for esthetic improvement of the cervical region. We present a case in a female patient presenting a nodule in the cervical region after the application of PLLA, where we performed the excision guided by high-frequency ultrasound. Mastering the diagnostic technique with high-frequency ultrasound can play a valuable role in indicating early surgical exeresis, also contributing to complete patient care. It allows the application of the product, monitoring, diagnosis of the complication, and treatment to be carried out dynamically and precisely by the injector.

Safety in immediate reconstitution of poly-l-lactic acid for facial biostimulation treatment.

Poly-L-lactic acid is presented as freeze-dried preparation of 150 mg per vial and, according to consensus, the recommendation on your preparation is hydrate in sterile water for injection (SWFI) or bacteriostatic water at room temperature for ≥24 hours. (J Drugs Dermatol; 2014;13:s44) However, in these long periods of hydration, it is time-consuming and costly for the physicians. To demonstrate the safeness of immediate reconstitution of facial biostimulation treatment with PLLA. A clinical prospective study with 26 Latin American female patients, aged between 27 and 80 years, complaining of facial laxity of treated with immediate PLLA reconstitution. One PLLA vial was injected per session in 12 mL total dilution. All patients had their pictures taken before and after the treatment in Photo Analysis Program Vectra 3D (Canfield® ). A follow-up 90 days was performed. The total of 58 facial applications of PLLA was reported in female patients with a mean age 52.62 (±13.46) years. Pain was reported in 17 injections (29.31%) and ecchymosis in 6 (10.34%). Also, 2 patients (3.44%) developed a nodule. None of the patients presented significant bruising, edema, or papules formation. Despite the literature declare that a longer hydration times (up to 48 hours) have been shown to reduce the risk of nodule formation (Aesthet Surg J; 2011;31:95), our study demonstrated the safeness of injection with immediate reconstitution and a very low adverse events rate. Immediate PLLA reconstitution is a great asset for physicians, injections in account of being less laborious, less time-consuming, and reducing product loss for the injector.

Effect of the aging process on columella-labial, naso-mental and facial angles and how to apply it in clinical practice.

BACKGROUD: Aging is the result of the interplay of changes occurring in the facial skeleton, ligaments, muscles, adipose tissue, and skin (1), and these changes befall each mentioned structure at a different pace, start in each individual at a different age, and differ between ethnic background. (4) It changes directly the measurements of the face angles, making the face more concave and flattened aspect, while the young face presents a more convex and rounded aspect. Female skulls had an increase in all transverse facial widths and depth of the middle face with increasing age. Therefore, aging is consequence of progressive changes through intrinsic and extrinsic factors (5) and different methods can be used to assess and diagnose these changes. AIMS: The aim of the study is to evaluate facial angles and their aging changes. METHODS: A retrospective study was performed with a total of 1213 Caucasian female patients in the author's private clinic. The angles evaluate age-related changes were analyzed: facial, naso-mental, and columella-labial angle. Photograph analysis program Vectra 3D (Canfield) was used to perform the anthropometric assessment of the angles, and after data collection, the analysis was performed statistics. RESULTS AND CONCLUSION: We could conclude angles analyzed change with age, while two angles increase (naso-mental and facial angle), the other decreases (columella-labial angle). The study reinforces the principle of an objective clinical anthropometric assessment of facial angles as a relevant guide for a more appropriate treatment plan for the doctor to perform aesthetic procedures in order to restore a youthful face.

Use of Hyaluronic Acid Fillers to Correct Scleral Show: A Review of Technique.

Generally, the shape of women's eyes are distinctly different in intercatal height from that in men. Ideally, in a woman, the lateral intercostal point is positioned above the medial intercostal point, which gives the eyes a cat-like appearance that culturally suggests youth and health. Because of aging and/or physiological changes, this area can be altered with the inversion of the lateral intercantal line lower than the medial intercantal line, producing a tired and/or sad looking appearance. Hyaluronic acid is a quick and safe method of elevating the lateral intercantal area of the eye. This article describes a technique for using hyaluronic acid for the treatment of scleral show.

Evaluation and Proportion in Nasal Filling with Hyaluronic Acid.

The nose is an essential feature when considering the aesthetic appeal of the face. As aesthetic preferences vary from person to person, the concept of the "ideal" nose must be applied on a case-by-case basis, with respect to the classical patterns of anthropometry, sex, ethnic group, and psychosocial factors. Interest in less invasive procedures for nasal correction has increased considerably, among which is the emerging use of hyaluronic acid for nonsurgical rhinoplasty. In this article, the authors present an objective review of the anatomy of the nasal region, the evaluation and indications of nasal filling with hyaluronic acid, a description of the technique, and brief discussion of associated complications.

Treatment of vascular lesions located in the lip and in the oral cavity with Nd:YAG laser.

Vascular lesions such as hemangiomas can be found in the oral cavity. Some therapeutic modalities can be used in the treatment of these lesions and Nd:YAG 1064 nm long pulse laser shows good results with easy application, fewer complications and satisfactory results. This study describes the technique and outcome of a case of hemangioma located on the tongue treated with Nd:YAG laser.

Erupção medicamentosa fixa na face associada a dipirona: correlação dos achados clínicos, histopatológicos e dermatoscópicos / Fixed drug eruption on the face associated with dipyrone: correlation of clinical, histopathological and dermatoscopic findings

As reações adversas associadas aos fármacos com manifestações cutâneas não são raras, expressando-se com múltiplos aspectos clínicos, podendo gerar morbidade significativa. A erupção medicamentosa fixa é uma reação adversa comum, com envolvimento cutâneo, associada ao uso de inúmeros medicamentos. A dipirona é fármaco com efeitos analgésicos e antitérmicos amplamente utilizada no Brasil, porém, sabe-se que é uma substância potencialmente desencadeadora de reações adversas, e a erupção medicamentosa fixa entre elas. Relata-se um caso de erupção medicamentosa fixa relacionada ao uso da dipirona, com apresentação clínica singular e correlacionam-se os achados clínicos, histopatológicos e dermatoscópicos encontrados.

Adverse reactions associated with drugs presenting cutaneous manifestations are among the most common, expressing itself with multiple clinical aspects and causing significant morbidity. The fixed drug eruption (FDE) is a common adverse reaction with cutaneous involvement and is associated with the use of numerous drugs. Dipyrone is a drug with analgesic and antipyretic effects prescribed widely used in Brazil, however, it is known for its potential to triggering adverse reactions, including the FDE. This report shows an EMF case related to the use of dipyrone, with unique clinical presentation and correlate the clinical, histopathological and dermatoscopic found.

Tratamento cirúrgico seriado de múltiplos granulomas por PMMA / Surgical approach to multiple foreign body granulomas (PMMA)

Substâncias para preenchimento têm sido muito utilizadas nos últimos anos em procedimentos estéticos e para correção de lipodistrofias em pacientes HIV-positivos. O granuloma de corpo estranho pode ser secundário à aplicação de produtos absorvíveis/temporários e mais frequentemente aos preenchedores inabsorvíveis/permanentes. Não é possível prever a formação desses granulomas que podem ocorrer independentemente da técnica utilizada. Neste artigo descreve-se o tratamento cirúrgico de uma paciente com múltiplos granulomas causados por preenchimento intradérmico prévio de PMMA na face, com resposta pobre a tratamentos conservadores, e com grave comprometimento psicossocial devido a essa complicação inestética e deformante.

Injectable fillers have long been used for cosmetic purposes and in HIV induced lipodystrophy patients. A foreign body granuloma may be a side effect of the application of absorbable products/temporary and most often the nonabsorbable/permanent fillers. It is not possible to predict the formation of these granulomas, and it may occur regardless of the application technique. In this article we describe the surgical treatment of a patient with multiple granulomas caused by intradermal injection of PMMA in the face, with poor response to conservative treatments, and severe psychosocial impairment due to this unsightly and disfiguring complication.

Siliconoma: Report of Two Cases.

UNLABELLED: Injectable silicone has been used illegally for more than 60 years. Siliconoma is the term used to describe a foreign body reaction in the human body caused by the presence of silicone. The aim of this study is to report two cases of patients who underwent application of large volumes of injectable silicone with non-medical and unqualified professionals, which led to serious complications sometime after the procedure. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Oral isotretinoin in photoaging: objective histological evidence of efficacy and durability.

BACKGROUND: The off-label use of oral isotretinoin in photoaging is a therapeutic tool that has been used by dermatologists. There are few studies to corroborate its effectiveness and durability. OBJECTIVES: To assess, both clinically and histologically, the changes caused by the use of oral isotretinoin in skin photoaging as well as the duration of the effects. METHODS: 20 female patients, aged 45-50 years, with phototypes II-VI, none of whom had experienced menopause, were treated with 20mg oral isotretinoin, 3 days a week, for 12 weeks. They underwent clinical analysis and skin biopsies in the pre-auricular region, while histologic cuts enabled assessment of the solar elastosis level and morphologic analysis. RESULTS: Clinically, patients, as well as the researching and the assessor physicians, noticed improvement in skin quality. One patient presented severe solar elastosis, 11 manifested the moderate form, while 8 presented the discreet type. According to histological analysis, 65% of the patients revealed alteration in the distribution and thickness of the elastic fibers, which can be interpreted as a histological improvement, while 60% showed an increase in collagen density. We observed an increase in collagen density, from 51.2% to 57.4%, (p=0.004). At the end of the 12-week follow-up period, this density decreased to 54.7% (p=0.050). There was an increase in the density of elastic fibers, from 26.5% to 31.3%, (p=0.02), which had dropped to 27.5% at the end of the 12-week follow-up period. CONCLUSIONS: The study confirmed the role of oral isotretinoin in remodeling the extracellular matrix against photoaging, as well as its durability after 12 weeks, especially when we consider collagen fibers.

Oral isotretinoin in photoaging: objective histological evidence of efficacy and durability

AbstractBACKGROUND:The off-label use of oral isotretinoin in photoaging is a therapeutic tool that has been used by dermatologists. There are few studies to corroborate its effectiveness and durability.OBJECTIVES:To assess, both clinically and histologically, the changes caused by the use of oral isotretinoin in skin photoaging as well as the duration of the effects.METHODS:20 female patients, aged 45-50 years, with phototypes II-VI, none of whom had experienced menopause, were treated with 20mg oral isotretinoin, 3 days a week, for 12 weeks. They underwent clinical analysis and skin biopsies in the pre-auricular region, while histologic cuts enabled assessment of the solar elastosis level and morphologic analysis.RESULTS:Clinically, patients, as well as the researching and the assessor physicians, noticed improvement in skin quality. One patient presented severe solar elastosis, 11 manifested the moderate form, while 8 presented the discreet type. According to histological analysis, 65% of the patients revealed alteration in the distribution and thickness of the elastic fibers, which can be interpreted as a histological improvement, while 60% showed an increase in collagen density. We observed an increase in collagen density, from 51.2% to 57.4%, (p=0.004). At the end of the 12-week follow-up period, this density decreased to 54.7% (p=0.050). There was an increase in the density of elastic fibers, from 26.5% to 31.3%, (p=0.02), which had dropped to 27.5% at the end of the 12-week follow-up period.CONCLUSIONS:The study confirmed the role of oral isotretinoin in remodeling the extracellular matrix against photoaging, as well as its durability after 12 weeks, especially when we consider collagen fibers.

Comprehensive Treatment of Periorbital Region with Hyaluronic Acid.

The periorbital subunit is one of the first facial regions to show signs of aging, primarily due to volume depletion of the soft tissue and bony resorption. Surgical and office-based nonsurgical procedures form an important basis for periorbital rejuvenation. It is important to make a detailed clinical evaluation of the patient to indicate the most appropriate procedure to be performed. With the objective of showing a nonsurgical procedure for the rejuvenation of the periorbital area, the authors describe a technique of applying fillers in the upper and lower periorbital regions, paying attention to the anatomy of this facial region and the type of product to be used besides the expected results of the procedure and its possible adverse effects and complications. The nonsurgical rejuvenation of the periorbicular region with hyaluronic acid is a new and innovative technique. In the opinion of the authors, it is a great aesthetic impact area and consequently brings high satisfaction to patients.