Mild to Moderate Dysphagia Following Very Low-dose Abobotulinumtoxin A for Platysmal Bands.

Onabotulinumtoxin A (Botox) can be a safe and successful off-label treatment of vertical platysma bands of various severities. Due to risk of the botulinum toxin diffusing to the underlying anatomic structures such as the deglutition muscles, the larynx, and the neck flexors, a maximal dose of 100 units has been suggested and there have been no known reports of untoward effects with doses less than 60 units. We present a case of mild to moderate dysphagia in a patient after very low doses of Abobutulinumtoxin (60 units, equivalent to 20 units of Onabotulinumtoxin using a 3:1 conversion ratio). We speculate that the adverse effects noted may be due to several possibilities, such as diffusion, injection technique, or intravascular injection. Thus, although botulinum toxin-A is generally considered a safe off-label treatment for vertical platysma bands, readers should still be aware of the possible side-effects even with low dose use, as supported by our case report of mild to moderate dysphagia with relatively conservative doses of Abobotulinumtoxin A.

J Drugs Dermatol. 2017;16(9):929-930.

ASDS Cosmetic Dermatologic Surgery Fellowship Milestones.

BACKGROUND: The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. OBJECTIVE: To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. METHODS: An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. RESULTS: Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. CONCLUSION: Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

Blue foot: a second case of "tattoo blow-out" pigment spread successfully treated with the QS-Nd:YAG laser.

The "tattoo blow-out" phenomenon occurs when tattoo pigments spread outside the border of a tattoo. It is thought to occur when ink is injected too deeply. A healthy 36-year-old female presented to a dermatologist with diffuse spread of tattoo pigment outside the original tattoo that occurred within one day of the placement of a professional tattoo on the dorsum of her foot. The patient was seeking treatment six weeks after the tattoo was placed because she thought the discoloration would improve or resolve on its own, but it worsened. Two punch biopsies were obtained for histology. The biopsy results confirmed granular black pigment consistent with a tattoo in the dermis and subcutaneous fat. The location of pigment was deeper than expected. Due to the success of the QS-Nd:YAG laser in a prior patient, the same treatment was recommended for this patient. The patient received nine laser sessions using the Q-switched laser at 1064 nm, 4 mm, 10 Hz, with gradually increasing energy from 4.5 to 6.0 J/cm2. The pigment outside of the original tattoo borders faded and is barely perceptible. It is important that physicians be made aware of tattoo complications so they can advise patients in regards to the associated risks.

Diagnosis and management of skin resurfacing-related complications.

The field of skin resurfacing is undergoing rapid evolution with many new technologies that have developed, providing more choices for physicians and patients. Knowing the potential adverse effects associated with each skin resurfacing modality is paramount in selecting the appropriate approach for each candidate, thereby minimizing complications and achieving optimal results.

Specific techniques for fat transfer.

At no time in the past has the field of cosmetic reconstruction paid as much attention to the contribution of volume loss to facial aging. Volume replacement can be achieved with synthetic fillers, implants, and patients' own adipose tissue. However, the results of autologous fat transfer procedures yield variable results among patients and surgeons. After many years of experience with hundreds of procedures, certain observations have become apparent that may explain some of this variability. This article discusses these observations.

Rejuvenation of the periorbital complex with autologous fat transfer: current therapy.

PURPOSE: This article examines the pathophysiology of periorbital aging and details a technique, autologous fat transfer, to restore a youthful appearance to the periorbital complex. The use of photographs taken of patients in their late teens or early 20s shows that the main changes of periorbital aging are consistent with volume loss more so than gravitational changes. This article reflects on the shortcomings of currently accepted surgical approaches to the rejuvenation of the periorbital region. PATIENTS AND METHODS: After a detailed clinical evaluation of the periorbital region including overall facial aging, brow position, and eyelid laxity, patients underwent autologous fat transfer to the periorbital region. The technique consists of autologous fat harvesting using the senior author's modification of the Coleman technique to the upper brow and lower eyelid region. RESULTS: Detailed clinical evaluations of each subject, and comparisons to a preoperative youthful photograph of each, were made at 1 week, 6 weeks, and 6 months postoperatively. These evaluations included subjective clinical estimations of overall brow fullness, brow position, and upper and lower eyelid laxity; a judgment of the appearance of the supraorbital and infraorbital rim; appearance of a short lower eyelid length, and an assessment of the subject's convex facial profile. While maintaining a natural, "nonsurgical" appearance with this approach and this technique, the patient achieved a more youthful look after autologous fat transfer. CONCLUSIONS: Although there are still indications for brow lift and blepharoplasty in certain patients, neither procedure restores a youthful, rejuvenated appearance to the periorbital complex as well as autologous fat transfer.

Repair of partial and complete earlobe clefts: a review of 21 methods.

BACKGROUND: Partially or completely spilt earlobes are a common reason for patient presentation to the cosmetic surgeon. METHODS: In this article, we review the different techniques of repairing both partial and complete cleft earlobes. RESULTS: We review and illustrate 4 methods to repair a partial cleft earlobe and 17 methods to correct a complete cleft earlobe. In addition, preoperative, intraoperative, and follow-up photographs are shown on several examples. CONCLUSIONS: Earlobe clefts may be repaired by various techniques. While advantages and disadvantages exist for each method, the surgeon should be familiar with categorizing the cleft, choosing a repair, and deciding whether to repierce the earlobe intra- or postoperatively.

Autologous fat augmentation: a perfect fit in new and emerging technologies.

The focus of recent cosmetic surgery is on the replacement of lost facial volume. Much of aging is a complex set of changes, including bone loss, muscle atrophy, and subcutaneous loss. For this reason, autologous fat augmentation is the perfect fit in the realm of new and emerging technologies. Although not necessarily a "new" technology, many advances have been made in the harvesting and infiltration of the fat, yielding much more consistent and long-lasting results. It also has the closest attributes of the "ideal filler."

Autologous fat transfer for periorbital rejuvenation: indications, technique, and complications.

BACKGROUND: The periorbital region is one of the first facial regions to show signs of aging. Traditional surgical approaches consisted of lifting and excisional procedures including brow lifts and blepharoplasties. Suboptimal results, however, have led surgeons to reassess their approach to the periorbita to address volume loss. OBJECTIVE: In this article, we review the shortcomings of brow lifting and blepharoplasty procedures and discuss the volume loss that occurs with aging. We present our approach of rejuvenating the periorbital region through volume restoration using autologous fat transplantation. MATERIALS AND METHODS: A review of fat transfer technique for the periorbital region is presented. RESULTS: Before and after photos are presented demonstrating periorbital rejuvenation. CONCLUSION: Surgeons performing cosmetic surgery should reconsider their approach to the periorbital region and enhance their results through autologous fat transplantation.

Histologic comparison of autologous fat processing methods.

PURPOSE: To perform a quantitative analysis of adipocyte viability after fat processing during autologous fat transfer, comparing the processing methods of washing, centrifuging, and sedimentation. METHODS: An experimental study was conducted in which 24 fat samples were obtained after processing from 22 patients undergoing autologous fat transfer. Histologic analysis of periodic acid-Schiff-stained specimens was then performed. RESULTS: Cell counts per high-powered field of intact adipocytes and nucleated adipocytes and adipocyte cross-sectional area were significantly greater in samples processed by sedimentation, compared with those by centrifuging or washing. CONCLUSIONS: Of the various processing techniques currently used during autologous fat transfer, sedimentation appears to yield a higher proportion of viable adipocytes than does washing or centrifuging.

Autologous fat augmentation for addressing facial volume loss.

Autologous fat augmentation is in vogue again. The realization that traditional cosmetic surgery has often failed to achieve a truly rejuvenated look has refocused attention on volume replacement. Autologous fat is truly the ideal filler, being available in relative abundance, nonimmunogenic, a living tissue, and able to take on the properties of the area into which it is infiltrated. This article describes the author's technique that has been used on more that 200 patients over a 4-year period.

Subcision and 1320-nm Nd:YAG nonablative laser resurfacing for the treatment of acne scars: a simultaneous split-face single patient trial.

BACKGROUND: Many methods have been proposed for the treatment of acne scars with variable cosmetic results. Subcision has been successfully used, although complications often include a hyperpigmented and hypertrophic wound healing response. Nonablative skin resurfacing with a 1320-nm Nd:YAG laser has also been proposed; however, the results are generally inferior to those of more invasive modalities. OBJECTIVE: The objective was to improve on the results of 1320-nm Nd:YAG nonablative laser resurfacing by combining this treatment of acne scars with needle subcision. METHODS: A split-face trial was conducted in a patient with severe rolling and boxcar acne scars. One side of the face was treated with two sessions of subcision alone, spaced 6 weeks apart, whereas the other side was treated with two sessions of subcision spaced 6 weeks apart and 1320-nm Nd:YAG laser sessions every 2 weeks starting after the first subcision. At the conclusion of the split-face trial, the unlasered side was then treated with six biweekly sessions of 1320-nm Nd:YAG. RESULTS: Although the use of subcision resulted in an improvement of the patient's acne scars, the combination of subcision and nonablative laser resurfacing was superior in topography, pigmentation, and overall appearance of the acne scars. CONCLUSION: This case illustrates that dual treatment with subcision and 1320-nm Nd:YAG nonablative laser resurfacing is a well-tolerated and highly effective regimen for the improvement of facial acne scars, compared to subcision alone.