Cutaneous Vascular Compromise and Resolution of Skin Barrier Breakdown After Dermal Filler Occlusion-Implementation of Evidence-Based Recommendations Into Real-World Clinical Practice.

BACKGROUND: Vascular occlusions that threaten skin integrity, although not an emergency like those that threaten a patient's vision, is an urgent situation. Accurately interpreting physical examination findings is paramount. The use of high-dose, pulsed hyaluronidase is the mainstay of therapy; however, adjunctive measures that may optimize clearance of an occlusion and/or skin barrier repair such as the use of image guidance and hyperbaric oxygen should be considered. OBJECTIVE: To provide a review of the literature on the treatment of vascular occlusions threatening skin barrier integrity and develop a step-wise treatment guide. MATERIALS AND METHODS: The authors searched PubMed for peer-reviewed studies, consensus statements, case series, and case reports using a variety of keywords. RESULTS: Twenty-six articles focusing on vascular occlusions threatening the skin barrier were reviewed. The authors collectively agreed on treatments to reverse vascular occlusions and restore the skin barrier. The importance of high-dose, pulsed hyaluronidase was clear. Therapies that lacked evidence such as sodium thiosulfate were also revealed. CONCLUSION: A vascular occlusion that threatens skin integrity is an urgent matter which requires accurate interpretation of physical examination findings that will help guide intervention. High-dose, pulsed hyaluronidase along with adjunctive measures performed in a step-wise manner is key to an optimal outcome.

Complications from microfocused transcutaneous ultrasound: Case series and review of the literature.

BACKGROUND AND OBJECTIVE: Microfocused ultrasound (MFUS) technology has been utilized since 2009 for improvement in mild to moderate skin and soft tissue laxity of the face and neck. Few complications have been previously reported, the majority of which include mild and transient erythema, edema, ecchymosis, and nerve paralysis. Rare yet serious potential complications of MFUS for noninvasive skin tightening of the face and neck are, however, possible. METHODS & MATERIALS: Retrospective multicenter case series of five patients from the authors' practice who developed serious adverse events directly related to MFUS with a commercially available device (Ultherapy; Merz North America, Inc., Raleigh, NC). RESULTS: Five patients developed blistering, erosion/ulceration, cutaneous, or subcutaneous tissue edema with resulting atrophy, and/or cutaneous necrosis following single sessions of MFUS. CONCLUSION: Despite their rarity, serious adverse events secondary to MFUS are nevertheless possible and may be underreported. Early management of complications includes local wound care, patient reassurance, and topical corticosteroids and/or pulsed-dye laser to mitigate inflammatory sequelae. Other cosmetic and surgical therapies should be utilized when conservative measures have failed. Lasers Surg. Med. 50:13-19, 2018. © 2017 Wiley Periodicals, Inc.

Volumizing Hyaluronic Acid Filler for Midface Volume Deficit: Results After Repeat Treatment.

BACKGROUND: Juvéderm Voluma XC (VYC-20L; hyaluronic acid gel) is approved in the United States for correction of age-related midface volume deficit (MVD). OBJECTIVE: Assess safety and effectiveness of VYC-20L after repeat treatment. METHODS: Subjects with MVD underwent optional repeat treatment 12 to 24 months after initial treatment if correction was lost or at 24 months regardless of loss of correction (n = 167). Investigators rated outcomes on the Mid-Face Volume Deficit Scale (MFVDS) and the Global Aesthetic Improvement Scale (GAIS). Subject-rated outcomes were the GAIS, overall satisfaction with facial appearance, achievement of treatment goal, and Self-Perception of Age questionnaire. Subjects recorded treatment-site responses in 30-day diaries. RESULTS: Mean injection volume for repeat treatment (3.13 mL) was approximately half the mean total injection volume for initial/touch-up treatment (6.8 mL). After repeat treatment, effectiveness was demonstrated on all investigator-rated and subject-rated measures, consistent with results observed after initial treatment. The percentage of subjects improving by ≥1 point on the MFVDS was 82.8% and 91.1% at 6 and 12 months after repeat treatment, respectively. The incidence, severity, and duration of common treatment-site responses were lower after repeat versus initial treatment. CONCLUSION: Repeat treatment with VYC-20L was well tolerated and resulted in high levels of effectiveness and subject satisfaction.

Cosmetic use of poly-l-lactic acid: a retrospective study of 130 patients.

BACKGROUND: Poly-l-lactic acid (PLLA) is an effective treatment for patients seeking to correct volume loss due to aging. Although the Food and Drug Administration has approved PLLA for use in people with the human immunodeficiency virus (HIV), it is well-suited for patients seeking cosmetic treatment. OBJECTIVE: To evaluate the efficacy and incidence of adverse events of HIV-negative patients treated with PLLA for volume restoration. MATERIALS AND METHODS: This is a retrospective, single-center study of 130 HIV-negative patients treated with PLLA from 2003 to 2008. Patient satisfaction and incidence of adverse reactions were evaluated. RESULTS: The most common reaction to PLLA treatment was the formation of nodules (8.5%). Almost all of the nodules were palpable; only one was visible. Treatment areas with the highest incidence of post-treatment nodules were the hands (12.5%) and cheeks (7.2%). Overall, patients were satisfied, with 55% having good to excellent correction; 75% of patients with five or more treatments rated their correction as good to excellent. Sixty-eight percent of all patients would repeat the procedure again. CONCLUSION: PLLA is a safe, biodegradable volumizer used to reverse the signs of aging by gradually correcting volume loss. Patients should be aware of possible adverse reactions during the course of treatment. Nodule formation is low, with most patients having good to excellent correction.

Autologous fat transfer: an in-depth look at varying concepts and techniques.

Fat augmentation is safe, relatively inexpensive, and readily available. Now that cosmetic surgeons are recognizing that facial aging is not simply due to gravity but also to atrophy of tissues, the use of fat for volume restoration is becoming even more popular. Newer techniques of Lipostructure, facial fat rebalancing, and fat autograft muscle injection (FAMI) are targeted to achieve true full-face three-dimensional rejuvenation; however, practical means of objectively measuring outcome are lacking. Basic questions remain regarding the optimal harvesting site, processing technique, and most effective injection technique. Scientific research is emerging th address these issues.

Laser and light therapies for acne rosacea.

Acne rosacea is a multifactorial, somewhat mercurial disorder that can be a challenge to control with standard pharmacologic agents. Laser and light sources have been increasingly utilized, particularly for control of the generalized erythema, flushing, and telangiectasia of rosacea. This paper will review the clinical studies presented in the literature specifically treating patients with rosacea. Long-pulsed dye lasers and intense pulsed light devices can offer patients effective treatment without the purpura of short-pulsed dye lasers. Long-term efficacy has not been studied but maintenance therapy may be necessary to control the vascular manifestations of this disease.

Rejuvenation of the aging hand.

This article reviews aging of the hand and the treatment options for cosmetic rejuvenation. Options available for cutaneous rejuvenation include microdermabrasion, chemical peeling, intense light sources, and laser therapy, including pigment lasers, ablative resurfacing, and noninvasive rejuvenation. Protuberant veins of the aging hand can be treated effectively with sclerotherapy. The soft tissue atrophy of the aging hand is best treated with fat augmentation. The article concludes with a mention of new fillers that are just beginning to be used for soft tissue atrophy of the hand.

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.

Enhancement of the results of neck liposuction with the FAMI technique.

Submental liposuction is an excellent procedure for improving the aging neck by reducing the cervicomental angle and increasing the definition of the mandibular border. However, it does not address the loss of volume of the chin and perioral areas caused by atrophy of hard and soft tissues. In this study, thirty patients underwent concomitant submental tumescent liposuction and fat augmentation with the FAMI (fat autograft muscle injection) technique in order to assess short-term results and complications associated with these two relatively noninvasive procedures. All patients had improvement in the cervicomental border, a smoother mandibular border, and a more proportioned chin following 3-5 days of swelling. Patients followed for 6 months to one year had long term retention of fat. There were no significant complications. In this preliminary series, submental tumescent liposuction with FAMI provided enhanced aesthetic results with little downtime and minimal complications.

Fat transplantation using fresh versus frozen fat: a side-by-side two-hand comparison pilot study.

BACKGROUND: Autologous fat in both fresh and frozen forms has been used for many years as a filler for various dermatologic conditions. However, it is not clear whether fat that has been frozen survives as well as, and gives aesthetic results similar to, fresh fat. The efficacy of frozen fat has been debated in the literature. OBJECTIVE: To evaluate the clinical aesthetic appearance and longevity of fresh fat versus frozen fat in a side-by-side two-hand comparison in the same patient. METHODS: Ten patients underwent fat augmentation on their hands, utilizing 10 cc of fresh fat in one hand and 10 cc of frozen fat in the contralateral hand within 17 days of fresh fat placement. Follow-up evaluation was conducted at 1, 3, and 5 months in a randomized, double-blind comparison study. Physician-determined aesthetic preference, prominence of veins, and depth of metacarpal spaces were evaluated. Photographs were taken of both hands during each patient follow-up visit. RESULTS: All three areas of physician-assessed gradation: aesthetics, vein prominence, and depth of metacarpal space were superior for the hand injected with frozen fat at 1-, 3-, and 5-month follow-up visits. CONCLUSIONS: This pilot study supports the use of autologous frozen fat for equivalent to improved results regarding longevity and aesthetic appearance versus fresh fat at 1, 3, and 5 months for fat augmentation of aging hands.

Fat autograft muscle injection (FAMI): new technique for facial volume restoration.

BACKGROUND: Restoration of depleted facial volume is becoming increasingly recognized by cosmetic surgeons as a necessary component of facial rejuvenation. Autologous fat has been used for years, but asymmetry and transient duration have been problematic. OBJECTIVE: To describe a new procedure called fat autograft muscle injection (FAMI), which is designed to maximize the survival of the adipocyte by placement within the muscles of facial expression. METHODS: The technique involves gentle harvesting of fat and centrifugation for 3 minutes. Fat is transferred to 1 cc syringes and attached to one of nine different cannulas shaped to conform to musculoskeletal contours. The muscle is injected with 1 to 3 cc of fat in a retrograde fashion from the insertion to origin or vice versa. Each syringe is emptied in one to three passes. The full face or regions of the face may be treated. RESULTS: FAMI offers soft, natural rejuvenation of depleted facial volume.

Lipoaugmentation for aging hands: a comparison of the longevity and aesthetic results of centrifuged versus noncentrifuged fat.

BACKGROUND: Fat augmentation has long been utilized by cosmetic surgeons for volume restoration of the face and hands. However, it is not clear which methods of fat preparation optimize survival and aesthetic results. The need for centrifugation of the fat prior to augmentation has been debated in the literature. OBJECTIVE: To evaluate the long-term efficacy of fat transplantation to the hands using centrifuged versus noncentrifuged fat. METHODS: Fourteen patients underwent fat augmentation to the hands utilizing 10 ml of centrifuged fat in one hand and 10 ml of noncentrifuged fat in the contralateral hand in a randomized, double-blind comparison study. Evaluation intervals were at 1, 3, and 5 months at which time aesthetic results, vein prominence, and depth of metacarpal space were evaluated. RESULTS: At 1 month the subjective and objective preference was the hand with the noncentrifuged fat in 75% of patients, even though vein prominence and depth of metacarpal space were higher in that group. By 3 months the preferred result was centrifuged fat in 62.5% of patients; 25% had equal results and 12.5% preferred the noncentrifuged fat. By 5 months the subjective and objective preference was for the centrifuged fat in 100% of patients. This preference was supported by a lower score in vein prominence and depth of metacarpal space in that group. CONCLUSION: This preliminary study supports the use of centrifuged fat compared to noncentrifuged fat for longevity and improved aesthetic results at 3 and 5 months for fat augmentation of the aging hands.

Facial volume restoration with the fat autograft muscle injection technique.

BACKGROUND: Fat augmentation of the aging face has been a popular cosmetic procedure for decades. Many consider fat the ideal filler because it is natural, nonallergenic, and readily available. However, longevity and symmetry of the fat graft have been unpredictable. In addition, when large volumes are injected for panfacial correction, prolonged edema for months may result. OBJECTIVE: Roger E. Amar has developed a new technique that is known as fat autograft muscle injection (F.A.M.I.) for fat augmentation. We present our experience in 100 patients who underwent this new method. METHODS: One hundred patients underwent the F.A.M.I. procedure in which fat was injected within the muscles of facial expression. The fat was harvested in an atraumatic and sterile manner. Centrifuged fat was then injected with specific blunt-tipped cannulae for different muscle groups. The majority of patients underwent a partial- versus full-face procedure. RESULTS: Patients were injected with volumes ranging from 3 to 63 cc of centrifuged fat in a single session. There were no complications, and downtime was 5 to 7 days. Patient satisfaction was high. Patients were followed postoperatively for 3 to 6 months. CONCLUSIONS: Facial volume restoration with the F.A.M.I. technique is an artistic and systematic approach for facial volume restoration. It offers the potential for symmetric, long-term results.

Diamond laser scalpel vs. steel scalpel: a side by side comparison of cutaneous wound healing.

BACKGROUND AND OBJECTIVES: To compare the cutaneous wound healing using the diamond laser scalpel with wound healing using a steel scalpel and electrocoagulation for hemostasis. STUDY DESIGN/MATERIALS AND METHODS: A prospective and randomized, comparative trial was conducted on eighteen patients. Fusiform excisions were performed using the diamond laser scalpel on one half of each excision and a steel scalpel with electrocoagulation for hemostasis on the other half. The Clinicon SureBlade diamond laser scalpel was used with the Luxar CO(2) attachment at the 6-8-W settings. Blinded assessment of adverse events and photographs were taken at 1 day, 7-10 days, 4 weeks, and 8-12 weeks. The final scar was evaluated at 8-12 weeks for cosmetic outcome and three physicians blinded to the method of excision evaluated photographs of the wounds. Histologic evaluation was performed on all excisions for collateral thermal damage. RESULTS: Investigator assessment showed no statistically significant differences between the diamond laser scalpel side and the steel scalpel side with respect to bleeding, bruising, swelling, pain, dehiscence, or final scar appearance. The mean residual thermal damage was 350.3 microm (95% CI +/- 37 microm, P < 0.001). The diamond laser scalpel scored higher on intra-operative coagulation (P = 0.20) although these differences were not statistically significant. CONCLUSIONS: The cosmetic outcomes of cutaneous excisions performed with the diamond laser scalpel are equivalent to excisions performed with steel scalpels with electrocoagulation for hemostasis.