Creation and Validation of a Photonumeric Scale for Assessment of Infraorbital Hollows.

BACKGROUND: Validated clinical scales are needed to assess aesthetic improvement of the infraorbital hollows (IOHs) after treatment with dermal fillers. OBJECTIVE: To develop an IOHs scale and establish its reliability and sensitivity for grading subjects in clinical trials or routine practice. METHODS AND MATERIALS: The Teoxane IOHs Scale (TIOHS), a 5-grade photonumeric scale, was developed based on real-subject photographs and validated through photographic and live subjects' evaluation. RESULTS: Clinician intra- and inter-rater agreements during the TIOHS validation were excellent. The mean intrarater-weighted Kappa score between the 2 sessions of photographic validation was 0.92, while inter-rater interclass correlation coefficient (ICC) was 0.92 for the combined sessions. The average intrarater-weighted Kappa score and inter-rater ICC for the live validation reached 0.80 and 0.76, respectively. In addition, evaluators identified clinically significant differences between photographs of subjects presenting a 1-grade or 2-grade difference in 82% and 86% of cases, respectively. CONCLUSION: The intrarater Kappa scores and inter-rater ICCs met their predetermined acceptance criteria of >0.70. The TIOHS is a repeatable and reproducible clinician-reported outcome for health care providers to classify IOHs in clinical trials and routine patient care. A 1-grade difference on the TIOHS can detect a clinically meaningful difference in infraorbital hollowing.

Creation and validation of a photonumeric scale for assessment of lip fullness.

BACKGROUND: Validated, objective clinical scales are needed to assess aesthetic improvement of the lips after augmentation with dermal fillers. OBJECTIVE: To develop a lip fullness rating scale and establish its reliability for grading subjects in clinical trials or routine practice, and sensitivity for detecting clinically meaningful changes. METHODS: The Teoxane Lip Fullness Scale (TLFS), a proprietary, 5-grade photonumeric scale, was developed by clinical experts based on real subject photographs and was validated through both photographic and live subjects' evaluation. RESULTS: Clinician intra- and inter-rater agreement for the TLFS was substantial to almost perfect. Mean intra-rater weighted Kappa score between the two rounds of photographic validation was 0.92, and inter-rater agreement was substantial with an ICC of 0.93 for the combined rounds. Average intra-rater weighted Kappa score and inter-rater ICC for the live validation were equally high, reaching 0.91 and 0.89 respectively. Additionally, evaluators identified clinically significant differences between photographs of subjects presenting a 1-grade or 2-grade difference on the scale in 90% and 98% of cases, respectively. CONCLUSIONS: The intra-rater Kappa scores and inter-rater ICC met their pre-determined acceptance criteria of >0.70 in the photographic and live validation. The TLFS was shown to be a repeatable and reproducible Clinician Reported Outcome (Clin-RO) for healthcare providers to classify lip fullness both in clinical trials and in routine patient care. A 1-grade difference on the TLFS can detect a clinically meaningful difference in lip fullness.

Xenografts in the post-operative wound management of interpolation flaps.

INTRODUCTION: Safeguarding the integrity of the donor site during the initial suspension phase of an interpolation flap is difficult. There are a variety of approaches and no consensus on post-operative management of the donor site or pedicle following the creation of the flap. The use of xenografts at the donor site of postauricular interpolation flaps simplifies post-operative wound care and prevents infection, desiccation of tissue, reduces pain, and assists with hemostasis. METHODS: A porcine acellular dermal skin substitute can be utilized for the purpose of care-free interpolation flap wound care. First, the flap is designed and raised using standard surgical technique. The porcine xenograft is then sutured into the donor site and to the exposed subcutaneous side of the flap pedicle using nylon suture material. The flap then is interpolated and sutured into the surgical defect of the auricle. Silicone gel is applied to the surface of the xenograft. A pressure dressing is then placed over the surgical site. RESULTS: A total of 4 patients had postauricular interpolation flaps to the ipsilateral helix. All four patients had a xenograft placed at the donor site and flap pedicle at the time of the flap creation and suspension. No infections and no incidence of post-operative bleeding requiring intervention were noted. CONCLUSION: Utilizing a dermal skin substitute as a biological dressing for an interpolation flap prior to division and inset of the flap provides a useful alternative to traditional wound care during this interim period.

Tratamiento exitoso con gel de silicona de heridas que no cicatrizan en el cuero cabelludo / Successful silicone gel treatment of wounds that do not heal on the scalp

La silicona podría tener propiedades ideales para estimular la cicatrización de heridas abiertas. Se presentan cuatro casos de heridas en el cuero cabelludo que no cicatrizaban y en todas se observaba tejido de granulación abundante y falta de migración epidérmica. La aplicación de un gel a base de silicona (Stratamed, Stratpharma, Basilea, Suiza), que forma una película directamente sobre la herida, a modo de monoterapia se asoció con una mejor cicatrización de la herida

The silicone could have ideal properties to stimulate the healing of open wounds. We present four cases of wounds on the scalp that did not heal and in all of them there was abundant granulation tissue and lack of epidermal migration. The application as a monotherapy of a silicone-based gel (Stratamed, Stratpharma, Basel, Switzerland), which forms a film directly on the wound, was associated with better wound healing

What's New in Cosmetic Dermatology.

Topical silicone gel is more beneficial than petrolatum-based products as an all-purpose wound dressing for granulating and sutured wounds, regardless of cause. Vaginal laser rejuvenation is effective in relieving genitourinary syndrome of menopause, stress urinary incontinence, vaginal relaxation syndrome, and related vulvar disorders. New cosmetic indications in the upper face for onabotulinumtoxinA have been approved by the Food and Drug Administration, whereas off-label treatments in the lower face increase in popularity. Clinical trials of uncomplexed daxibotulinumtoxinA demonstrate safety and efficacy lasting more than 6 months.

Travel as a teaching and learning tool.

Throughout history, physicians have traveled extensively to acquire new knowledge or to learn the latest therapeutic techniques from colleagues and academicians. This "wanderlust" persists in many who want to understand the world around them and learn from others, physicians or nonphysicians. Before the era of instantaneous online telecommunication, dermatologists would enhance their education by traveling abroad to learn from world-renowned experts in Europe and elsewhere and return with a treasure trove of knowledge and new skills. With the Internet, webinars, and teledermatology, the attraction for travel has diminished, mainly due to our ever-increasing demanding world of obligations; however, face-to-face interaction with colleagues of a different culture and educational background still has an inexorable educational value. To facilitate such endeavors, many insightful educators have taken the opportunity to establish several international societies and academies, where on-site educational activities can take place. Currently, a few of the more active and popular dermatologic organizations that are conducting meetings around the world are the International League of Dermatologic Societies; International Society of Dermatology; North American Clinical Dermatologic Society; International Society of Dermatologic Surgery; International Academy of Cosmetic Dermatology; and European Society of Cosmetic and Aesthetic Dermatology, all of which exemplify "travel as a teaching tool."

Adverse events associated with mohs micrographic surgery: multicenter prospective cohort study of 20,821 cases at 23 centers.

IMPORTANCE: Detailed information regarding perioperative risk and adverse events associated with Mohs micrographic surgery (MMS) can guide clinical management. Much of the data regarding complications of MMS are anecdotal or report findings from single centers or single events. OBJECTIVES: To quantify adverse events associated with MMS and detect differences relevant to safety. DESIGN, SETTING, AND PARTICIPANTS: Multicenter prospective inception cohort study of 21 private and 2 institutional US ambulatory referral centers for MMS. Participants were a consecutive sample of patients presenting with MMS for 35 weeks at each center, with staggered start times. EXPOSURE: Mohs micrographic surgery. MAIN OUTCOMES AND MEASURES Intraoperative and postoperative minor and serious adverse events. RESULTS: Among 20 821 MMS procedures, 149 adverse events (0.72%), including 4 serious events (0.02%), and no deaths were reported. Common adverse events reported were infections (61.1%), dehiscence and partial or full necrosis (20.1%), and bleeding and hematoma (15.4%). Most bleeding and wound-healing complications occurred in patients receiving anticoagulation therapy. Use of some antiseptics and antibiotics and sterile gloves during MMS were associated with modest reduction of risk for adverse events. CONCLUSIONS AND RELEVANCE: Mohs micrographic surgery is safe, with a very low rate of adverse events, an exceedingly low rate of serious adverse events, and an undetectable mortality rate. Common complications include infections, followed by impaired wound healing and bleeding. Bleeding and wound-healing issues are often associated with preexisting anticoagulation therapy, which is nonetheless managed safely during MMS. We are not certain whether the small effects seen with the use of sterile gloves and antiseptics and antibiotics are clinically significant and whether wide-scale practice changes would be cost-effective given the small risk reductions.

Facial skin rejuvenation: ablative laser resurfacing, chemical peels, or photodynamic therapy? Facts and controversies.

Patients and cosmetic surgeons continue to develop innovative devices and techniques in search of the elusive fountain of youth. Our efforts in the past decade can be distilled to three primary approaches: refinement of existing technologies (ablative lasers); refinement of tried-and-true techniques (chemical peeling); and innovative use of new technologies (photorejuvenation). In this contribution, the authors discuss how these three approaches are used to achieve facial skin rejuvenation. Specifically, the authors compare and contrast the clinical benefits and disadvantages of the ablative fractionated and unfractionated carbon dioxide resurfacing lasers, medium-depth and deep chemical peeling, and the combination of photodynamic therapy with intense-pulsed light.

Antimicrobials in dermatologic surgery: facts and controversies.

The two main uses of antimicrobials in dermatologic surgery include prophylaxis for bacteremia and prevention of localized surgical skin infection (LSSI). Bacteremia can result in hematogenous surgical infections such as infective endocarditis and prosthetic joint infection. Comprehensive guidelines from the American Heart Society (AHA), American Dental Association (ADA), and the American Academy of Orthopedic Surgeons (AAOS) have significantly reduced the number of patients in which prophylaxis is indicated for hematogenous surgical infection. The use of antimicrobials for localized surgical skin infection in dermatology is controversial. Although the overall trend in the literature supports the decreased use of antimicrobials in dermatologic surgery as a whole, it is important to know which situations still warrant antibiotics. This contribution will address the updated guidelines of the AHA, ADA, and AAOS, evidence-based techniques to decrease localized surgical skin infections, and situations in which antibiotics should be considered during dermatologic surgery.

Asymmetrical smiles corrected by botulinum toxin serotype A.

OBJECTIVE: The objective was to identify the cause of an asymmetrical smile and to ascertain whether or not it would be correctable by injections of Botulinum toxin A (BTX-A). METHODS: Five patients with asymmetrical smiles were identified and found to lower one side of their lower lip in an exaggerated fashion when smiling or laughing. After close observation, it was determined that the ipsilateral depressor labii inferioris of the lower lip was hyperkinetic and retracted that side of the lips lower than its contralateral side when smiling or laughing. Injections of low-volume and low-dose BTX-A (BOTOX, Allergan, Inc.) were placed into the depressor labii inferioris on the side where the lower lip retracted the lowest. RESULTS: All of the five patients with asymmetrical smiles presented with unilateral hyperkinetic depressor labii inferioris and responded to injections of BOTOX. Their lower lips became level and their smiles were symmetrical within 1 week of the BOTOX treatments. Their lip symmetry lasted for at least 6 months after their initial treatment. With each additional treatment, the duration of BOTOX lasted even longer, averaging approximately 7 months. CONCLUSION: BOTOX is an effective, safe, and long-lasting treatment for lower lip asymmetries caused by a hyperkinetic depressor labii inferioris.

Cosmetic aspects of pregnancy.

There are a vast number of changes to the female body that occur during pregnancy, to which any pregnant woman will attest. The changes, although considered, for the most part, physiological and not pathological, are quite distressing to many women. This chapter serves to review those changes and comment on their physiological origins. Most of these changes can be definitively or inferentially linked to the dramatic hormonal changes that take place to support a pregnancy. Comments are also made about treatment as they pertain to pregnant women. In addition, a brief discussion about performing cosmetic procedures during pregnancy is included.