Overview of Deep Dermal Fillers.

Dermal fillers have become an integral part of both medical and cosmetic dermatology. Our expanding knowledge of the aging face has allowed us to shift the focus from skin-reduction lifting procedures to soft tissue augmentation. Within the past 5 years alone, nine new dermal fillers have been approved by the U.S. Food and Drug Administration for soft tissue augmentation. The rise in both the use and number of dermal fillers in recent years is a testament to their safety and efficacy. Dermal fillers can be broken down to three major types: temporary, semipermanent, and permanent. The former, which include hyaluronic acid based fillers, provide safe and effective correction but only for a limited time, typically approximately 1 to 2 years at best. This review will cover the semipermanent (poly-L-lactic acid and calcium hydroxylapatite) and permanent (polymethylmethacrylate and liquid silicone) injectable fillers. These so-called deep dermal fillers are valuable, durable tools in correcting the aging face. Given their extended duration of effect, these fillers inherently carry their own risk for potential adverse events. Thus, it is essential that clinicians have a thorough understanding of these products to best counsel, recommend, and perform soft tissue augmentation using these fillers.

The role of the cutaneous microbiome in skin cancer: lessons learned from the gut.

The human microbiome has recently gained prominence as a major factor in health and disease. Here we review the literature regarding the microbiome and cancer and suggest how the microbiome may be manipulated for improved health outcomes. The gut microbiome has been relatively well studied, and the mechanisms of how it may increase or decrease the risk of certain cancers may apply to the skin microbiome. Additionally, the gut microbiome may directly impact the risk of cancer in the skin and other organs by promoting systemic inflammation. The skin microbiome itself is as diverse as the gut microbiome, but research has just begun to unravel its influence on the host. Like the gut microbiome, it affects the risk for several diseases, including cancer. By using healthpromoting strains from the microbiome in oral or topical probiotics, it may be possible to reduce the risk of skin cancer and perhaps even increase the likelihood of successful treatment.

A novel non-invasive radiofrequency dermal heating device for skin tightening of the face and neck.

BACKGROUND: Loose, lax skin is a common cosmetic complaint. Previous non-invasive skin tightening devices had modest efficacy and were associated with pain or downtime. New technologies may allow for effective skin tightening with a series of radiofrequency (RF) treatments with no downtime. OBJECTIVE: To evaluate the efficacy and safety of a novel bipolar RF device for skin tightening. METHODS: Fifteen consecutive female patients were enrolled in the case series; 14 completed the study and were included in the analysis. The device under investigation is a novel, bipolar RF device allowing for achievement and maintenance of optimal dermal temperatures to stimulate collagen remodeling and skin tightening. Patients underwent a series of 4-6 weekly treatments. Three blinded, experienced cosmetic physicians evaluated paired pre-treatment and post-treatment photographs and determined the associated improvement, if any. RESULTS: All patients (14/14) were determined to have a clinical improvement, as the pre-treatment and post-treatment photographs were correctly identified by the evaluators. It was observed that 21% (3/14) of patients had significant improvement, 50% (7/14) had moderate improvement, and 29% (4/14) had mild improvement. No pain, side effects, or adverse events were observed. CONCLUSIONS: This novel bipolar RF device represents a safe, effective treatment option for non-invasive skin tightening.

Bilateral suborbital rash: a dermatologic manifestation of neuropsychiatric disease in a pediatric patient.

A 10-year-old girl presented with a new onset bilateral suborbital rash. Dermatologic examination revealed violaceous, non-tender, well-demarcated patches with an atypical distribution and pigmentation. After further investigation, a diagnosis of Munchausen syndrome was made and the patient was referred to her primary care provider for further management.

Finasteride associated melasma in a Caucasian male.

Melasma is an acquired hypermelanosis that typically affects sun-exposed areas on the face and presents as symmetric brownish macules and patches. It is most commonly reported in women and thought to be related to the effects of estrogen and progesterone on melanocytes. Since the advent of finasteride 1mg daily tablets for the treatment of androgenic alopecia, we have noticed an increase in the number of men presenting with melasma. Here we present one of those cases. We hypothesize this could be related to the effects of finasteride on estrogen and progesterone concentrations in the skin.

Comparison of treatment of melomental fold rhytides with cross-linked hyaluronic acid combined with onabotulinumtoxina and cross-linked hyaluronic acid alone.

BACKGROUND: Hyaluronic acid and onabotulinumtoxinA combination therapy has been shown to have greater clinical effectiveness than hyaluronic acid alone for glabellar furrowing, but this is not well documented for melomental fold rhytides. OBJECTIVE: To compare the efficacy of intradermal cross-linked hyaluronic acid (HA) and onabotulinumtoxinA combination therapy with the efficacy of cross-linked HA monotherapy in patients with melomental fold rhytides. METHODS AND MATERIALS: Twenty-two patients received combination therapy to a melomental fold area while also receiving cross-linked HA and a placebo saline injection to the contralateral side. Blinded physician evaluators and patient self-evaluators clinically and photographically assessed responses during standard intervals over 12 months. RESULTS: The melomental folds treated with combination therapy had significantly greater aesthetic improvement than the monotherapy-treated side at 2 weeks and 1 month upon physician photographic review. Furthermore, the median time for return to pretreatment rhytides was 6.5 weeks longer in the combination therapy side. Patient assessment also revealed improvement over baseline for the combination therapy at 1 month. CONCLUSION: Cross-linked HA and onabotulinumtoxinA combination therapy to melomental fold rhytides may provide better overall aesthetic results and longer duration of aesthetic improvement than cross-linked HA monotherapy.

Clinical and pathological features of posttransplantation lymphoproliferative disorders presenting with skin involvement in 4 patients.

BACKGROUND: Posttransplantation lymphoproliferative disorders (PTLDs) are lymphoid proliferations that can develop in recipients of solid organ or allogeneic bone marrow transplants. They are clinically and pathologically heterogeneous and range from polyclonal hyperplastic lesions to malignant lymphomas. Although extranodal involvement in PTLD is common, cutaneous presentation is rare, with only 19 cases reported previously. OBSERVATIONS: We describe 4 patients with cutaneous presentations of PTLD. All patients had relatively late-onset PTLD (>1 year after transplantation) with a median of 8 years from organ allograft to tumor diagnosis. The extent, number, and anatomic location of skin lesions varied from a localized patch to widespread nodules. None of the patients exhibited systemic symptoms at the time of PTLD diagnosis. Pathological findings ranged from plasmacytic hyperplasia to monomorphic PTLD. In situ hybridization detected Epstein-Barr virus messenger RNA in all 3 cases with evaluable tissue. All patients underwent reduction in immunosuppressive therapy and received other individualized treatments. Median follow-up was 2.5 years. At the most recent follow-up, 3 patients were in complete remission and 1 had residual disease. CONCLUSIONS: In this study, PTLD lesions presenting in the skin responded to therapy. Despite their relatively late occurrence after transplantation, most of these cases were positive for Epstein-Barr virus. As observed with other cutaneous lymphomas, the PTLDs with predominant skin involvement had a relatively favorable outcome.

Therapeutic lymphangiogenesis with human recombinant VEGF-C.

Chronic regional impairments of the lymphatic circulation often lead to striking architectural abnormalities in the lymphedematous tissues. Lymphedema is a common, disabling disease that currently lacks a cure. Vascular endothelial growth factors C and D mediate lymphangiogenesis through the VEGFR-3 receptor on lymphatic endothelia. The purpose of this study was to investigate the therapeutic potential for lymphangiogenesis with VEGF-C. We developed a rabbit ear model to simulate human chronic postsurgical lymphatic insufficiency. Successful, sustained surgical ablation of the ear lymphatics was confirmed by water displacement volumetry. After complete healing, the experimental animals (n=8) received a single, s.c. 100 microg dose of VEGF-C in the operated ear; controls (n=8) received normal saline. Radionuclide lymphoscintigraphy was performed to quantitate lymphatic function. Immunohistochemistry (IHC) was performed 7-8 days following treatment. After VEGF-C, there was a quantifiable amelioration of lymphatic function. IHC confirmed a significant increase in lymphatic vascularity, along with reversal of the intense tissue hypercellularity of untreated lymphedema. This study confirms the capacity of a single dose of VEGF-C to induce therapeutic lymphangiogenesis in acquired lymphedema. In addition to improving lymphatic function and vascularity, VEGF-C can apparently reverse the abnormalities in tissue architecture that accompany chronic lymphatic insufficiency.