Pinch Anatomy of Forehead: An Injection Guide for Forehead Filler Treatment.

Filler injections have become very popular in recent years, and injectors globally use them for facial shaping and reversing age-related changes. Detailed knowledge about important vessels' and tissue planes' anatomy is essential for injectors. While giving the filler injections, injectors tend to gently pinch or pull the tissue fold with the nondominant hand during the procedure. The deformational forces cause some changes in the anatomy of tissue layers held in a pinch. During the pinch and "pinch and pull" maneuver, the crucial vessels in the area can get pulled up in the tissue layers in a pinch or stay in their position unaffected depending on the force applied. The "pinch and pull" maneuver also increases the tissue space for injections by moving the mobile tissue layers away from the fixed ones. The injector can use knowledge of the "'pinch anatomy" in the forehead to avoid important arteries and place filler in the correct plane. With the understanding of the anatomical changes occurring during the pinched state of tissue layers, filler injection can be performed in the right and safer tissue plane in the forehead. This study reflects level of evidence V.

Facial Aesthetic Priorities and Concerns: A Physician and Patient Perception Global Survey.

BACKGROUND: Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed. OBJECTIVES: The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries. METHODS: This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care. RESULTS: A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow's feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes. CONCLUSIONS: This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

Multi-Dimensional Aesthetic Scan Assessment (MD ASA™): Initial experience with a novel consultation, facial assessment, and treatment planning tool.

BACKGROUND: Comprehensive patient assessment and planning are central to esthetic treatment with injectables. MD ASA™ (Multi-Dimensional Aesthetic Scan Assessment) is a novel tool developed for this purpose. AIMS: To describe the MD ASA technique and present its preliminary application. METHODS: MD ASA breaks down the face into five hierarchies (H1-H5). H1 shifts patients' focus from "distractions" (individual lines and folds) toward the overall messages their face portrays, based on eight Emotional Attributes: four negative (tired, sad, angry, and saggy); four positive (youthful, attractive, contoured, and feminine/masculine). Three priority Emotional Attributes are selected for each patient. This is followed by a process of narrowing down through facial thirds (H2), periorbital and perioral dynamics (H3), facial units (H4), and subunits (H5), to arrive at a final assessment. Based on the key facial signs identified, this can be translated into MD Codes equations and thus a treatment formula. A retrospective analysis was performed based on 12 female patients injected by expert clinicians at an educational event. All patients were selected for, and treated using, a single MD Codes formula derived from a common MD ASA work-up. RESULTS: There were substantial differences between patients and clinicians in their views of which anatomical areas needed treatment-but good alignment on priority Emotional Attributes. Patients were treated only for three negative Emotional Attributes, but improvements were observed across all eight attributes. CONCLUSIONS: MD ASA provides a practical method for translating facial messages into actionable injectable treatment plans and facilitates greater patient-clinician alignment. Prospective studies are warranted.

Pinch anatomy: An injection guide for temple filler injections.

Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age-related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane.

COVID-19 Pandemic: Consensus guidelines for preferred practices in an aesthetic clinic.

Strict infection control measures in response to the current COVID-19 pandemic are expected to remain for an extended period. In aesthetic clinics, most procedures are provided on one to one basis by the physician or therapist. In such a scenario, guidelines detailing the infection control measures for aesthetic clinics are of particular importance. An online meeting of an international group of experts in the field of aesthetic medicine, with experience in administration of an aesthetic clinic, was convened. The meeting aimed to provide a set of consensus guidelines to protect clinic staff and patients from SARS-CoV-2 infection. Consensus guidelines for "preferred practices" were provided for scheduling of patients, patient evaluation and triaging, and for safety precautions about the different procedures. Procedures were categorized into low-risk, moderate risk, and high-risk based on the likelihood of transmission of SARS-CoV-2 virus from the patient to the treating physician or therapist. While not intended to be complete or exhaustive, these guidelines provide sound infection control measures for aesthetic practices. Since guidelines regarding safety measures and use of PPEs may vary from country to country, the local guidelines should also be followed to prevent COVID-19 infection in aesthetic clinics.

Soft-tissue Filler-associated Blindness: A Systematic Review of Case Reports and Case Series.

BACKGROUND: With the increase in the use of soft-tissue fillers worldwide, there has been a rise in the serious adverse events such as vascular compromise and blindness. This article aims to review the role of fillers in causing blindness and the association between hyaluronic acid (HA) filler and blindness. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to report this review. RESULTS: A total of 190 cases of blindness due to soft-tissue fillers were identified, of which 90 (47%) cases were attributed to autologous fat alone, and 53 (28%) cases were caused by HA. The rest of the cases were attributed to collagen, calcium hydroxylapatite, and other fillers. CONCLUSIONS: Autologous fat was the most common filler associated with blindness despite HA fillers being the most commonly used across the globe. However, the blindness caused by other soft-tissue fillers like collagen and calcium hydroxylapatite was represented. It was also evident through the review that the treatment of HA-related blindness was likely to have better outcomes compared with other fillers due to hyaluronidase use.

Consensus Recommendations for Treatment Strategies in Indians Using Botulinum Toxin and Hyaluronic Acid Fillers.

BACKGROUND: Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment. METHODS: The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience. RESULTS: The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20-40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women. CONCLUSIONS: These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.

Elastophagocytosis in extragenital lichen sclerosus.

BACKGROUND: Elastophagocytosis, or elastic fiber phagocytosis by multinucleate macrophages, has been observed in different skin conditions that may or may not occur on sun-exposed skin. Although loss of elastic fibers has been well documented in the homogenized papillary dermal zone in lichen sclerosus (LS), elastophagocytosis, to the best of our knowledge, has never been observed. METHODS: We encountered striking elastophagocytosis in a case of extragenital LS which prompted us to review all cases of LS diagnosed at the Skin Pathology Laboratory at Boston University over a 2-year period to assess for the presence of elastophagocytosis. RESULTS: In 7 of 35 patients diagnosed with LS (20%), we found prominent elastophagocytosis to be present either immediately below or at the junction of the homogenized collagen and the normal underlying reticular dermis. Interestingly, all the cases in which elastophagocytosis was observed were in extragenital locations. CONCLUSION: Elastophagocytosis was observed in 20% of LS cases, all of which were extragenital. We hypothesize that elastophagocytosis in LS, especially in extragenital sites, may not be an epiphenomenon but rather represents a contributing factor to elastic fiber loss in the hyalinized papillary dermal collagen that typifies this disease.

Does pulse stacking improve the results of treatment with variable-pulse pulsed-dye lasers?

BACKGROUND: It has been suggested that multiple stacked pulses of lower fluence may have a similar effect on targets as a single pulse of higher fluence. When treating vascular lesions, increasing the fluence beyond a certain point will increase the risk of purpura given a constant pulse duration. Stacking pulses of lower fluence may have the advantage of heating vessels to a critical temperature without creating purpura. OBJECTIVE: To determine whether stacking low-fluence pulses of a variable-pulse pulsed-dye laser would improve clinical results without significantly increasing side and adverse effects. METHODS: Twenty-five patients between the ages of 18 and 65 years with facial telangiectasia and skin types I-IV were enrolled in the study. For each subject, the cheek or nasal ala areas on either side of the facial midline with similar telangiectasia density ratings were randomized to single pulse and multiple stacked pulse groups. One side of the cheek or nasal ala was treated with single nonoverlapping pulses with the Candela Vbeam 595-nm pulsed-dye laser. The opposite side of the cheek or nose was treated with the same parameters but with three or four pulses stacked on top of each other at a 1.5-Hz repetition rate. Patients were asked to rate the pain of the procedure on each side on a 0 to 3 scale. Investigators rated the erythema and edema after the procedure as well as vessel clearing and overall telangiectasia density scale at 1 and 6 weeks after the procedure. RESULTS: Twenty-three patients completed the study. The mean pain rating was 1.58 for the pulse stacked side and 1.38 for the single-pass side. The mean erythema score after the procedure was 1.17 for the pulsed stacked side and 1.09 for the single pulsed side. The mean vessel clearing 1 week after the treatment was 74.3% for the pulse stacked side and 58.5% for the single pulsed side. The mean vessel clearing 6 weeks after the treatment was 87.6% for the pulse stacked side and 67.4% for the single pulsed side. The mean telangiectasia density scale score before treatment was 2.67 for the pulse stacked side and 2.59 for the single pulsed side. At 1 week after treatment, the mean telangiectasia density scale score was 1.06 for the pulsed stacked side and 1.5 for the single pulsed side. At 6 weeks after treatment, the mean telangiectasia density scale score was 0.72 for the pulsed stacked side and 1.30 for the single pulsed side. No patients experienced purpura in either group, and there were no cases of hyperpigmentation, hypopigmentation, or scar formation. One patient experienced significant edema on the side of the cheeks treated with pulse stacking. CONCLUSIONS: Treating superficial facial telangiectasia with a pulse stacking technique may improve clinical results without significantly increasing adverse effects.

Can patients treat themselves with a small novel light based hair removal system?

BACKGROUND AND OBJECTIVES: This study was designed to evaluate the safety and effectiveness of a small, low energy light based system for hair removal, when used by non-healthcare professionals ("patients") for self treatment in home-like environment following instructions and guidance provided by a physician. STUDY DESIGN/MATERIALS AND METHODS: A total of 73 patients between the ages of 19 and 54 years with skin types I through IV were enrolled in the study out of which 67 completed the study. Two treatment sites were chosen from among the arms, axilla, legs, bikini, back, belly, chest or face. The hair on the sites was trimmed and photographed. Each patient performed two self-treatments, using the hair removal device on their designated body sites, under the Investigator's direction. The first self-treatment was performed at the Investigator's office by the patient while the second self-treatment was performed 4 weeks later at a hotel room, simulating the home environment. Follow-up visits to evaluate the safety and efficacy of the treatments were performed 2 and 12 weeks following the last self-treatment. RESULTS: The mean hair reduction was 33.6%, 4 weeks after the first self-treatment, 44.3%, 2 weeks following the last self-treatment, and 32.3%, 12 weeks following the last treatment. All the noted side effects were mild and transient. Transient erythema was noted in 47.5% of the patients. Other transient side effects reported include edema (5%), hyperpigmentation (4.75%), crusting (2.35%), hypopigmentation (1.55%), and blistering (1.4%). All noted side effects were resolved by the 12-week follow-up visit. CONCLUSIONS: With adequate training and instruction, patients may administer self-treatments for hair removal with this small light based unit in a safe and effective manner.

The periodic acid-Schiff stain in diagnosing tinea: should it be used routinely in inflammatory skin diseases?

BACKGROUND: The clinical presentation of tinea is usually, but not always, characteristic. The purpose of this study was to determine whether the routine use of the periodic acid-Schiff (PAS) stain in inflammatory skin disorders is requisite for identifying clinically undiagnosed tinea cases and to ascertain whether there are histopathologic clues that suggest the diagnosis of a dermatophyte infection. METHODS: Hematoxylin and eosin (H&E)-stained slides from 60 PAS-positive tinea cases were examined histologically by two observers. One observer, aware of the diagnosis of tinea, searched for hyphal elements and also recorded in detail epidermal, dermal, and follicular changes. The second observer, not aware of the diagnosis beforehand, reviewed the same slides, together with randomly mixed slides from 21 non-tinea cases, recording the same parameters as the first reviewer. RESULTS: Of the 60 cases of tinea, only 45% were diagnosed clinically. Histologic examination of H&E sections by the two observers disclosed the presence of hyphal elements in 68 and 45%, respectively. No significant histologic differences, except for the presence of hyphae, were observed between tinea and non-tinea cases. CONCLUSIONS: The finding that only 57% of PAS-positive cases of tinea showed hyphal elements on H&E examination alone, together with no other differentiable histologic characteristics, lends strong support for the routine use of PAS-staining for inflammatory skin disorders.

Granuloma faciale successfully treated with long-pulsed tunable dye laser.

BACKGROUND: Granuloma faciale has been treated in the past with different modalities but the majority have had the risk of scarring. OBJECTIVE: Based on the principle of selective photothermolysis, we considered using the newer long-pulsed tunable dye laser for the treatment of granuloma faciale to target the vessels and minimize scarring. METHODS: Confirmation of the diagnosis by a punch biopsy of the lesion was followed by three treatments on separate occasions 6 weeks apart with the long-pulsed tunable dye laser. RESULTS: There was significant flattening of the lesions after two treatments, with complete clearing after the third. No scarring was detectable and there was no recurrence in the 9-month follow-up. CONCLUSION: We conclude that granuloma faciale may be successfully treated with the long-pulsed tunable dye laser with minimal risk of scarring, especially in cosmetically sensitive areas.