Improved Patient Satisfaction With Skin After Treatment of Cheek Skin Roughness and Fine Lines With VYC-12L: Participant-Reported Outcomes From a Prospective, Randomized Study.

BACKGROUND: VYC-12L is a hyaluronic acid filler to improve skin quality. A prospective study showed safety and effectiveness of VYC-12L for improving cheek skin smoothness and fine lines. OBJECTIVES: To report participant-reported outcomes, subgroup analyses, and physician experience from the prospective study. METHODS: Adults with moderate to severe Allergan Cheek Skin Smoothness (ACSS) scale scores were randomized 2:1 to VYC-12L or control (no treatment with optional treatment). Participant assessments included FACE-Q Satisfaction With Skin, FACE-Q Appraisal of Lines, natural look and feel, the Global Aesthetic Improvement Scale (GAIS), and safety. Subgroup analyses examined ACSS responder rate (≥1-grade improvement from baseline to 1 month). RESULTS: FACE-Q Satisfaction With Skin overall mean scores improved from baseline to 1 month posttreatment by 32.0 and 1.4 in the VYC-12L and control groups, respectively. FACE-Q Appraisal of Lines overall mean scores improved from baseline to 1 month posttreatment by 23.3 and 0.4 in VYC-12L and control, respectively. Treated participants had high median scores (≥9.0) of natural look and feel of their cheek skin. GAIS responder rate was high at Month 1 (85.5%; 95% CI, 79.3%-91.7%) and through Month 6 (83.1%; 95% CI, 76.5%-89.7%). Mean participant-rated pain scores were low (<3). The most common injection site reactions were redness, swelling, and lumps/bumps; most resolved within 3 days. Subgroup analyses showed significant differences in ACSS responder rate between VYC-12L and control groups 1 month posttreatment. Physician injectors reported that VYC-12L was easily injected at the superficial skin and integrated quickly. CONCLUSIONS: VYC-12L treatment produced significant improvements in satisfaction with skin and cheek skin smoothness, as measured by participant-reported outcome measures.

Jowl Reduction With Deoxycholic Acid.

BACKGROUND: The study proposes a novel protocol for targeting the jowls using deoxycholic acid (DCA) injections, with emphasis on safety and feasibility of the procedure. METHODS: This prospective study was conducted at a cosmetic practice between June 2016 and May 2017. Twelve consecutive patients seeking reduction/improvement in mild/moderate jowl fat were injected with DCA subcutaneously in a predefined circular area 1.0 cm above the mandibular border. Treatment response was assessed using physician-evaluated Global Aesthetic Improvement Scale (GAIS) and Subject GAIS. RESULTS: Twelve patients (11 women and 1 man) with mild (n = 8) or moderate (n = 4) jowls were treated. After the first treatment, GAIS responses for 24 jowls showed 5 jowls with vast improvement, 15 with moderate improvement, and 4 with no change. After the second session for 5 jowls in 3 patients, GAIS responses showed vast improvement in 4 jowls and moderate improvement in 1. Adverse events included induration (n = 4), bruising (n = 6), numbness (n = 2), pain (n = 5), redness (n = 3), edema (n = 9), and dysphagia (n = 1). CONCLUSION: Results of this early experience showed that DCA injections were safe and effective for nonsurgical jowl reduction.

Rehabilitation of the Dysmorphic Lower Eyelid From Hyaluronic Acid Filler: What to Do After a Good Periocular Treatment Goes Bad.

BACKGROUND: Chronic, long-lasting edema accompanied by the Tyndall effect as a delayed reaction to hyaluronic acid (HA) filler injection seems to occur exclusively in the eyelids. OBJECTIVES: The authors sought to present a treatment algorithm for management of patients with chronic lower eyelid edema as a delayed complication of HA filler injection. METHODS: Retrospective study including 61 patients with delayed-onset chronic periocular edema following uneventful HA filler injection in the lower eyelids or cheeks. All patients underwent hyaluronidase enzyme dissolution followed by secondary treatment. Three retreatment options were presented: (1) observation, (2) secondary treatment with HA filler, and (3) lower eyelid blepharoplasty. RESULTS: All patients underwent filler dissolution using hyaluronidase. The mean age was 48 years and 97% of the patients were female. Single treatment was effective in 92% of patients with 8% requiring another hyaluronidase injection to completely eradicate residual edema. Six patients (10%) were satisfied after hyaluronidase only and 6 patients (10%) underwent lower eyelid blepharoplasty. Secondary treatment with HA filler was performed in 48 patients (80%). All were satisfied with final results without further edema in the follow-up period. CONCLUSIONS: Delayed-onset chronic lower eyelid edema is a frequent HA-related complication and cause of concern when considering periocular HA treatment. Previous treatment has been limited to either hyaluronidase only or blepharoplasty as a secondary solution after hyaluronidase, with only a minority of patients satisfied. Hyaluronidase, shortly followed by HA filler retreatment, is a safe and effective solution.

Patient Satisfaction Following Treatment With Microfocused Ultrasound With Visualization: Results of a Retrospective Cross-Sectional Survey

Background: A device that uses microfocused ultrasound with visualization (MFU-V) is cleared in the United States and European Union as a noninvasive procedure that lifts and tightens the skin (Ultherapy® System; Merz North America, Raleigh, NC, USA). The objective of this patient survey was to obtain more in-depth information on patient satisfaction during the MFU-V treatment procedure and satisfaction with their aesthetic results. Methods: Survey participants had received MFU-V treatment and completed at least 6 months of follow-up. A hyperlink to an online survey was distributed via email and respondents completed the survey anonymously. The satisfaction survey consisted of 13 questions related to the treatment process and post-treatment outcomes. A validated Age Appraisal Visual Analog Scale was also included to evaluate patient pre- and post-treatment self-assessments of their age. Results: The survey was completed by 52 patients, and the majority of surveyed patients received treatment on the lower face (100%) and submentum (92.3%). Many patients (41%) reported their treatment outcome met or exceeded their expectation. About one-half of patients (n=27; 52%) needed a follow-up appointment with photos to be able see post-treatment changes. Following MFU-V treatment, 50% believed they looked 1 to 15 years younger. Most (73%) would recommend MFU-V to others. Conclusion: About half of patients undergoing MFU-V were Very Satisfied or Satisfied with their results and a large number reported their treatment outcome met or exceeded their expectations. The number of follow-up appointments appeared to be related to patient satisfaction. Treatment with MFU-V is very well tolerated. J Drugs Dermatol. 2019;18(1):75-79.

Understanding the Female Hispanic and Latino American Facial Aesthetic Patient

Background: Among the growing aesthetic patient population, Hispanic/Latinos represent the largest proportion of non-Caucasians patients. While treatment of Caucasian facial aging patterns are well documented, far less information describes the aesthetic needs of the Hispanic/Latino patient. Objective: An online study was designed to survey facial aesthetic concerns, treatment priorities, and future treatment considerations among a US-based population of Hispanic/Latino American women. Materials and Methods: A total of 401 participants ages 30 to 65 years reported their attitudes toward facial aging, current facial conditions, most bothersome facial areas, areas most/least likely to be treated first, awareness of treatment options and their consideration rates, and motives and barriers that factor into consideration of injectable treatments. Results: Most participants wanted to look good for their age and treatment interests reflected predominant conditions: facial wrinkles, periorbital signs of aging, and uneven skin tone. Most bothersome facial areas included the submental area, periorbital area, and forehead, which were also among the areas most-likely to treat first. The majority of participants would consider injectables. Cost and safety/side effects were cited as frequent concerns. Conclusion: An understanding of the facial aesthetic concerns and treatment priorities specific to Hispanic/Latino women will enhance the practitioner's patient-centric treatment approach. J Drugs Dermatol. 2019;18(7):623-632.

Durability, Behavior, and Tolerability of 5 Hyaluronidase Products.

BACKGROUND: Hyaluronic acid (HA) dermal fillers are commonly used in cosmetic dermatology. Due to differences in their physical characteristics, HA fillers demonstrate different sensitivity to degradation by hyaluronidase (Hase) because of HA concentration and differences in cross-linking. Similarly, there are differences in the activity of Hase products depending on source and concentration. OBJECTIVE: The primary objective was to demonstrate the differences in potency and activity of 5 Hase products when used to degrade 5 different HA products using a human in vivo model. MATERIALS AND METHODS: The study subject was a healthy, consenting adult woman scheduled to undergo abdominoplasty. Skin to be excised was injected with 0.1 to 0.2 mL of each filler (10 injections each) leaving a visible lump. Immediately afterward, the HA lumps were injected with 4 IU of each Hase product every 2 minutes until the HA lumps were no longer visible or palpable. This procedure was repeated after 30 days. Injected tissues were excised after abdominoplasty for histological analysis. RESULTS: The 5 Hase products displayed a wide range of doses and times required to completely degrade the 5 HA products ranging from <2 to >16 minutes. CONCLUSION: Cosmetic practitioners should familiarize themselves with differences in HA and Hase products.

Evaluation of Men's Trends and Experiences in Aesthetic Treatment.

Men's interest and participation in cosmetic procedures has increased in recent years; however, the factors that motivate or discourage men from undergoing these procedures is not well understood. To evaluate which factors impact men's decisions towards cosmetic procedures, an observational, single-site, cross-sectional study utilizing a voluntary questionnaire was executed in a target population size of 209 men ≥21 years old who visited the study site from 2015 to 2017. A majority of the male respondents incorporate a basic skincare regimen into their daily routine (90%), have had experience with neurotoxin treatments (54%), and expressed interest in either neurotoxin or dermal filler treatments (77% and 83%, respectively). The main motivating reason to undergo a cosmetic procedure was pursuit of a youthful appearance and the main discouraging reasons were cost and time for appointments or recovery. This study suggests that a majority of our male patients have either embraced or are interested in cosmetic treatments, but the cost and time play a big role in their decision. As cosmetic providers, we should reflect a commitment to the male population through marketing efforts and offerings to increase participation in minimally invasive aesthetic procedures. J Drugs Dermatol. 2018;17(9):941-946.

Periorbital Changes associated with Topical Prostaglandins Analogues in a Hispanic Population.

OBJECTIVE: To describe the prevalent side effects of prostaglandin analogues (PA) in a Hispanic population and their effect on quality of life (QOL). PATIENTS AND METHODS: This is a cross-sectional study conducted in a tertiary medical facility in which patients were evaluated in a single visit. Total of 14 participants in the study, 10 women and 4 men. Ages ranged from 26-78 years old. Subjects underwent a single full Oculoplastic evaluation by two physicians; one was blinded on patient medical history and assessed for PA side effects. After evaluation, each study subject was asked to answer a self reported QOL questionnaire. RESULTS: Study participants had used or were currently using Bimatoprost (28.6%), Latanoprost (50%) or Travoprost (21.4%). After evaluate periorbital changes, 2 patients (14.3%) had ptosis, 2 (14.3%) had periorbital skin hyperpigmentation, 11 (78.6%) had periorbital fat show, 11 (78.6%) had eyelash elongation, 1 (7.1%) had injected conjunctiva, 5 (35.7%) had iris hyperpigmentation. 10 (71.4%) noted changes in the size/shape of their eyes. The questionnaire show that 10 (71.4%) disliked how their eyes looked. 9 (62.4%) reported dry eyes, 3 (21.4%) noted increased need to blink, 5 (35.7%) reported foreign body sensation, 7 (50%) reported burning sensation, 2 (14.2%) reported secretions and 3 (21.4%) reported sticky eyes. Mean QOL was 3.50, 2.14, and 2.00 in the Bimatroprost, Latanoprost, and Travoprost users respectively. CONCLUSION: QOL questionnaire showed that Bimatoprost side effects had the most negative impact in QOL, followed by the Latanoprost and Travoprost groups.

Injection-related Visual Compromise.

The global market for hyaluronic acid (HA)-based dermal fillers has experienced substantial growth, providing patients with an effective nonsurgical cosmetic option. According to the global market report, the HA dermal fillers market size is expected to grow to $8.5 billion in 2027 at an annual growth rate (CAGR) of 8.9%. However, despite their popularity, HA injections are not free of complications. Vascular occlusion, particularly involving the central retinal artery, represents a significant risk. This case report presents a 60-year-old woman who presented with binocular vertical diplopia after HA filler injection in the right tear trough area. Upon evaluation, the patient exhibited right hypertropia, suggesting right inferior rectus paresis due to vascular injury of the infraorbital artery. Prompt management with hyaluronidase and oral steroids resulted in the resolution of double vision. This case highlights the importance of recognizing potential complications during HA filler injections and emphasizes the need for early intervention to minimize adverse effects.

Aesthetic considerations when treating the Latin American patient: Thriving in diversity international roundtable series.

BACKGROUND: The Hispanic/Latin American population is the fastest growing non-Caucasian group in the United States. Within this group, demand for aesthetic procedures is on the rise. High ethnic variability among these patients influences treatment approaches and patient priorities. Understanding these ethnic differences is central to providing optimal care. AIMS: To discuss similarities and differences in anatomy and treatment preferences of Hispanic/Latin American patients both within the United States and internationally and explore how these differences may influence or inform aesthetic practices. PATIENTS/METHODS: In support of clinicians who wish to serve a diverse patient population, a 6-part, international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021 to May 16, 2022. In this roundtable, held in Medellin, Columbia, expert clinicians from across Latin America and the United States were invited to contribute and share best practices. RESULTS: The results of the second roundtable in the series, the Latin American Patient, are described here. A special emphasis is placed on procedures that address the most commonly encountered concerns in these patients. CONCLUSIONS: Hispanic and Latino patients represent a broad demographic with unique anatomical features, aesthetic preferences, and treatment priorities. Clinicians should consider these differences when treating this patient population.

Xanthogranuloma of the Eyelid: A Case Report.

We report on the case of a Hispanic woman with necrobiotic xanthogranuloma (NBX) whose disease was managed based on her symptoms. She underwent a diagnostic and debulking surgical intervention and surveillance for hematologic malignancy. This 56-year-old patient presented with a six-year history of enlarging masses and swelling around her eyes, with intermittent inflammation, associated pain, and occasional redness. Her past medical history was remarkable for asthma and nasal polyps. Upon external examination, she had severe fullness of the upper lids with yellow plaques and palpable masses along them, nontender palpation, the absence of visible erythema, and blepharoptosis in both eyes. The patient presented with bilateral visual field constriction due to mechanical obstruction. An orbital computed tomography scan revealed a dense diffuse lesion involving the pre- and postseptal tissues and invading the orbit of the right eye. A facial magnetic resonance imaging scan revealed infiltration of the postseptal spaces within both orbits. A skin and soft tissue biopsy from the bilateral periorbital regions of both eyes confirmed the diagnosis of NBX. A workup for underlying hematologic malignancies, including plasma cell dyscrasias and lymphoproliferative disorders, was unremarkable. The patient underwent diagnostic and debulking surgery in an attempt to improve her visual function. Subsequently, she was scheduled for ongoing monitoring of her disease progression.

A Retrospective Review of the Safety and Efficacy of Low-dose Triamcinolone Mixed with Hyaluronic Acid Fillers to Reduce Post-injection Infraorbital Swelling.

Objective: This retrospective review assesses the efficacy and safety of low-dose triamcinolone (1mg/cc) added to hyaluronic acid fillers to decrease swelling after infraorbital injection. Methods: This retrospective analysis includes 447 patients who underwent 706 infraorbital hyaluronic acid filler treatments from April 2013 to March 2020 by a single injector. Short-term post-procedural swelling (≤2 weeks) was assessed through follow-up phone calls, which were documented in patient charts. The effect of triamcinolone, filler type, volume, and patient characteristics on the rate of post-procedure swelling were analyzed. Results: Swelling after infraorbital hyaluronic acid filler occurred in over half of the patients (51%, 103/202), but significantly decreased (23%, 29/124) when 1mg/cc of triamcinolone was mixed with the filler (x2[1, N=326]=24.296, p<0.00001). The incidence of swelling was directly correlated with the amount of hyaluronic acid filler injected (37% ≤ 0.55cc, 51% 0.56-1cc, and 60% >1cc) [x2[1, N=95]=3.9231, p=.048]. There was no significant difference in patient age, sex, Fitzpatrick skin type, or history of allergies on incidence of post-procedure swelling. Adverse events were limited to expected injection-site reactions, and there were no reports of hypopigmentation or atrophy from the addition of triamcinolone. Limitations: This is a retrospective study that used patient reporting for short-term post procedure swelling. Conclusion: This is the first retrospective study showing the safety and efficacy of a novel technique adding low-dose triamcinolone (1mg/cc) to hyaluronic acid filler to reduce post-procedure swelling within the first few weeks following infraorbital injection. Additionally, using lower volumes is also effective at reducing post-procedure swelling. Larger, randomized, controlled trials are needed to support our findings.

Eyelid and Periorbital Dermal Fillers: Products, Techniques, and Outcomes.

A retrospective observational case study and a literature review were conducted to evaluate how anatomic findings, especially those related to the periorbital zone, serve as a guiding compass for injectable implants. Treatment techniques and product selection will be discussed for patients with negative vector, shallow orbit, and deep set eyes. Versatility of injectables will be demonstrated on patients with peanut face, iatrogenically altered anatomy (after surgery), and trauma.

Technical Considerations for Filler and Neuromodulator Refinements.

Background: The toolbox for cosmetic practitioners is growing at an unprecedented rate. There are novel products every year and expanding off-label indications for neurotoxin and soft-tissue filler applications. Consequently, aesthetic physicians are increasingly challenged by the task of selecting the most appropriate products and techniques to achieve optimal patient outcomes. Methods: We employed a PubMed literature search of facial injectables from the past 10 years (2005-2015), with emphasis on those articles embracing evidence-based medicine. We evaluated the scientific background of every product and the physicochemical properties that make each one ideal for specific indications. The 2 senior authors provide commentary regarding their clinical experience with specific technical refinements of neuromodulators and soft-tissue fillers. Results: Neurotoxins and fillers are characterized by unique physical characteristics that distinguish each product. This results in subtle but important differences in their clinical applications. Specific indications and recommendations for the use of the various neurotoxins and soft-tissue fillers are reviewed. The discussion highlights refinements in combination treatments and product physical modifications, according to specific treatment zones. Conclusions: The field of facial aesthetics has evolved dramatically, mostly secondary to our increased understanding of 3-dimensional structural volume restoration. Our work reviews Food and Drug Administration-approved injectables. In addition, we describe how to modify products to fulfill specific indications such as treatment of the mid face, décolletage, hands, and periorbital regions. Although we cannot directly evaluate the duration or exact physical properties of blended products, we argue that "product customization" is safe and provides natural results with excellent patient outcomes.

Ethnic and Gender Considerations in the Use of Facial Injectables: Latino Patients.

BACKGROUND: Globalization marks an important change in the world's perception of elective procedures: patients are becoming consumers and cosmetic procedures are being viewed as commodities. The quest to achieve and preserve a youthful appearance has no geographic boundaries or ethnic limitations. Cosmetic injectables have become an increasingly popular treatment option designed to improve and preserve facial appearance. Hispanic (Latino) patients are one of the rapidly increasing ethnic groups worldwide, seeking injectable treatments. METHODS: The author evaluated the trends in the use of injectables in his practice, mainly in Hispanic (Latino) patients, during one of the year's busiest seasons, specifically December 2014. RESULTS: The results reflect Latino patients' behavior toward injectables and how a high-volume injector addresses the needs of patients, taking into consideration ethnic characteristics and socioeconomic factors in balance with the provider plan for cosmetic improvement or facial restoration. CONCLUSIONS: The author's Latino-Hispanic patients have embraced the concept of "less invasive" facial rejuvenation, and in his experience, he has found that their goal is to achieve precise results in a natural manner. Ethnicity does not play a role in patients' behavior toward cosmetic procedures. This "behavior" tends to be related more to the socioeconomic status and/or the level of education, rather than ethnicity, which move the patient toward specific procedures.