Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck.

Background: Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited. Objective: Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment. Methods: Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference. Results: Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach. Conclusion: The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Myomodulation with Facial Fillers: A Comprehensive Technical Guide and Retrospective Case Series.

BACKGROUND: Placement of fillers in close proximity to the mimetic or sphincter muscles of the face appears to enhance or suppress muscle action in a relatively predictable way. METHODS: From June 2016 to June 2021, patients who underwent the first author's technique of myomodulation with dermal fillers to address aesthetic concerns or to manage facial spasms or synkinesis were evaluated in a retrospective case series. Additionally, the authors provide a technical guide for a whole-face approach to treatment with fillers and a conceptual map for treatment of each facial subunit with a focus on myomodulation. RESULTS: A total of 1352 patients (1108 women, 244 men; mean age, 51 years) underwent at least 1 treatment session during the 5-year study period. The treatment patterns of the study population and details of 2 representative cases are presented. CONCLUSIONS: Although not well understood mechanistically, myomodulation with injectable fillers shows promise for significant and reliable results of facial rejuvenation. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lifting supra-auricular com uso de preenchedores: nova técnica / Supra-Auricular Lifting With Fillers: New Technique

Introdução: A evolução das técnicas de preenchimento possibilitou uma abordagem tridimensional da face: deixando-se de valorizar sulcos e optando-se pela restauração volumétrica. Objetivo: Descrição de técnica inédita de volumização facial por injeção de preenchedor na região supra-auricular, com revisão detalhada da anatomia regional. Métodos: Foi conduzido estudo retrospectivo de análise de casos, em pacientes apresentando mobilidade da pele na região têmporo-parietal. A injeção de ácido hialurônico para reposição volumétrica foi feita com cânulas, utilizando-se técnicas em bólus e em leque, na região supra-auricular, limitada ântero-superiormente pela área de implantação do cabelo e inferiormente pelo trágus. Os pacientes foram avaliados clínica e fotograficamente e tiveram seus dados analisados por estatística. Resultados: Foram tratados 152 mulheres e 13 homens de 24 a 84 anos, entre julho e setembro de 2016. O volume de ácido hialurônico utilizado nos pacientes variou de 0,6 a 2,6ml. Em oito casos observou-se abaulamento local devido a hematoma durante a aplicação, controlado por compressão digital. Constatou-se melhora significativa do contorno facial. Conclusão: O uso de preenchedor na região supra-auricular permite a abordagem tridimensional e promove o rejuvenescimento estático e dinâmico de toda a face.

Introduction: The evolution of filling techniques allowed a three-dimensional approach to the face: nowadays volumetric restoration is more important than grooves. Objective: Description of an unpublished technique of facial volumization through the injection of filler in the supra-auricular region, with a detailed review of the regional anatomy. Methods: A retrospective case-control study was conducted in patients presenting skin mobility in the temporo-parietal region. The injection of Hyaluronic Acid for volumetric replacement was done using cannulae, bolus and fan techniques in the supra-auricular region, limited antero-superiorly by the area of ¿¿hair implantation and inferiorly by the tragus. The patients were evaluated clinically, photographed and had their data analyzed by statistics. Results: 152 women and 13 men aged 24 to 84 years were treated between July and September 2016. The volume of Hyaluronic Acid used in the patients ranged from 0.6 to 2.6 ml. In 8 cases local edema was observed due to hematoma during application, that was controlled by digital compression. Significant improvement of the facial contour was observed. Conclusion: The use of fillers in the supra-auricular region allows a three-dimensional approach and promotes static and dynamic rejuvenation of the entire face.

Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction.

Aspergillosis is an infection caused by saprophytic fungi of the genus Aspergillus, which typically occurs in immunosuppressed individuals, but has also been reported in immunocompetent patients. The main routes of entry are the respiratory tract, skin, cornea, and ear, and the infection may be localized or disseminated by contiguity or vascular invasion. We report a severe case of rhinosinusitis with cutaneous involvement, caused by invasive aspergillosis, in an immunocompetent user of inhaled cocaine. Invasive aspergillosis related to cocaine abuse has not yet been reported in the literature. After itraconazole treatment and surgical debridement, complete clinical remission was achieved. Nasal reconstruction with a skin graft over a silicone prosthesis resulted in a satisfactory esthetic outcome.

Invasive aspergillosis in a user of inhaled cocaine: rhinosinusitis with bone and cartilage destruction

Aspergillosis is an infection caused by saprophytic fungi of the genus Aspergillus, which typically occurs in immunosuppressed individuals, but has also been reported in immunocompetent patients. The main routes of entry are the respiratory tract, skin, cornea, and ear, and the infection may be localized or disseminated by contiguity or vascular invasion. We report a severe case of rhinosinusitis with cutaneous involvement, caused by invasive aspergillosis, in an immunocompetent user of inhaled cocaine. Invasive aspergillosis related to cocaine abuse has not yet been reported in the literature. After itraconazole treatment and surgical debridement, complete clinical remission was achieved. Nasal reconstruction with a skin graft over a silicone prosthesis resulted in a satisfactory esthetic outcome.

Ácido Poli-L-láctico na região medial dos braços / Poly-L-lactic acid in the rejuvenation of the medial and anterior arms

O ácido poli-L-láctico é poliéster alifático, polímero do ácido láctico. É substância biocompatível, completamente absorvível e imunologicamente inerte. Sua ação baseia-se no incremento do tecido dérmico através do estímulo à produção de colágeno. A aplicação dessa substância na face já é bastante conhecida, porém há poucas publicações sobre seu uso extrafacial. Descreve-se técnica de rejuvenescimento da região medial e anterior dos braços através da aplicação do ácido poli-L-láctico na derme profunda.

Poly-L-lactic acid is an aliphatic polyester, a lactic acid polymer. It is a biocompatible, fully absorbable and immunologically inert substance. Its action mechanism is based on the increase of dermal tissue by stimulating collagen production. The application of this substance in the face is well known, however there are few publications on its use in other areas of the body. This article describes for the use of poly-L-lactic acid in the deep dermis to rejuvenate the medial and anterior region of the arms.

Preenchimento dos sulcos orbital inferior e naso-jugal com ácido hialurônico de baixa concentração: uma nova técnica de aplicação / Filling of the orbital inferior area and nasojugal groove with low concentration hyaluronic acid: a new application technique

As técnicas não-cirúrgicas utilizadas para o rejuvenescimento da região orbicular tem gerado discussões, pricipalmente as injeções de ácido hialurônico para a correção de depressões locais. Apesar das técnicas descritas e produtos utilizados trazerem bons resultados, ainda estão associadas a alterações da cor, irregularidades na superfície cutânea, edema local e tempo de recuperação. Na tentativa de amenizar esses efeitos indesejaveis, 30 pacientes foram tratados com ácido hialurônico de baixa concentração, com a deposição lenta e seqüencial de pequenas gotas lembrando um rosário,em plano superficial,. Esta técnica trouxe bons resultados estéticos, facilidade na aplicação, e menor risco de complicações e efeitos indesejados.

Non-surgical techniques used in the rejuvenation of the periorbital region, notably regarding injections of hyaluronic acid for the correction of depressed areas. However, in spite of the good results brought by these described techniques and products, there are still complications linked to their use, such as color alterations, irregularities in the surface of the skin, local edema, and long time of recovery. In an attempt to abate those undesirable effects, thirty patients were treated with a filler of low hyaluronic acid concentration, slowly and sequentially depositing small drops in a superficial plane, reminding a string of beads, with the subsequent application of digital pressure. This technique of easy application, has presented good aesthetical results and lower risk of undesirable effects and complications.

Manifestações cutâneas em indivíduos infectados pelo HIV após 10 anos da introdução da terapia anti-retroviral potente: experiência de três centros de atendimento dermatológicos no Rio de Janeiro / Skin disorders in HIV-infected individuals after 10 years the emergence of highly active anti-retroviral therapy: three centers experience service in Rio de Janeiro

A pele é um dos órgãos mais acometidos na infecção pelo Vírus da Imunodeficiência Humana (HIV) , podendo as manifestações cutâneas serem o sinal mais precoce e/ou marcador de progressão da infecção. A história natural do HIV modificou-se na era da terapia anti-retroviral, principalmente após 1996 com a introdução terapia anti-retroviral potente, resultando no declínio das infecções oportunísticas, melhora na qualidade de vida e aumento na sobrevida. Porém, propiciou o desenvolvimento de novas entidades clínicas, como a lipodistrofia e a síndrome inflamatória de reconstituição imunológica. Com o objetivo de verificar a atual prevalência das afecções cutâneas nos pacientes infectados pelo HIV, foi realizado um estudo descritivo, prospectivo, em 281 pacientes atendidos em três ambulatórios de dermatologia no município do Rio de Janeiro. No estudo, foram encontradas mudanças nas frequências das dermatoses descritas antes da introdução da terapia anti-retroviral pontente (HAART) com, diminuição da quantidade de doenças por pacientes, das infecções oportunísticas e neoplasias cutâneas, além de apresentações pouco exuberantes, demonstrado assim, grande mudança no padrão do acometimento cutâneo com o uso contínuo e prolongado da HAART. A lipodistrofia, normalmente excluída dos trabalhos de prevalência de dermatoses nos pacientes portadores de HIV, mostrou-se uma das principais queixas e a manifestação mais frequente, estando presente em 51,9 por cento dos pacientes. Após a lipodistrofia, as dermatoses mais frequentes foram: dermatite seborréica, onicomicose, infecção pelo HPV, erupção pápulo-pruriginosa, xerose cutânea, candidíase, farmacodermia, infecção pelo vírus da herpes e prurido. Desse modo, as doenças cutâneas, que antigamente eram apenas marcadores de imunodepressão, hoje também são marcadoras da infecção crônica pelo HIV associada ao uso dos anti-retrovirais.

Skin is one of the most affected organs in HIV infection. Skin disorders can be the first sign or a marker of progression of HIV disease. HIV natural history was modified by the anti-retroviral era, especially after the highly active anti-retroviral therapy (HAART), resulting in a decline of opportunistic infection, improve of quality of life and surviving.Beside this, leaded to the development of new clinical entities, as such as lipodystrophy and immune reconstitution inflammatory syndrome.Aim of this study was verify and describe the prevalence of cutaneous disorders in HIV infected patients, through a prospective study with 281 patients followed in three dermatology ambulatories’ in the city of Rio de Janeiro. In this study we found changes in the frequency of skin disease from previews publications, with diminishing of the occurrence of opportunistic infections and skin cancers per patient, with character less exuberant of these dermatitis, showing the big change in thepattern of the skin involvement with the long term and continuous use of HAART. Lipodystrophy usually excluded on the prevalence studies, showed to be the principal complain and most frequent skin disorder, presenting in 51,9 percent of the patients. Beside lipodystrophy the most common skin diseases were: seborreic dermatitis, onicomycosis, HPVinfection, papular and pruritic eruption, xerosis cutis, candidiasis, pharmacodermia, HSV infection, e itching. In resume, cutaneous manifestations that used to be just markers of immunesupression,today are markers of HIV chronic infection associated with the use on anti-retrovirals.

Colagenoma eruptivo em paciente HIV+ / Eruptive collagenoma in an HIV-positive patient

Colagenomas são hamartomas do tecido conjuntivo gerados por aumento anormal do colágeno dérmico. O colagenoma eruptivo caracteriza-se por pequenos nódulos duros, assintomáticos, sem relato de trauma ou processo inflamatório prévios. Descreve-se caso de paciente do sexo masculino, de 28 anos, que há 10 anos notou surgimento espontâneo de lesões papulosas no tronco, nos membros superiores e abdômen, e há três anos descobriu ser soropositivo para HIV. O diagnóstico diferencial, a classificação da doença como entidade própria e a associação casual com o HIV são discutidos, bem como a necessidade da realização da coloração vermelho Picrosirius/luz polarizada para confirmação diagnóstica dos colagenomas.

Collagenomas are connective tissue nevi predominantly composed of excessive dense and coarse collagen in the dermis. Eruptive collagenoma is a rare disorder occurring in young adults as asymptomatic dermal nodules, with no previous history of injury or inflammation and usually localized on the back. We describe the case of a 28-year-old male patient who was examined for numerous asymptomatic little nodules on the trunk and upper arms, which appeared ten years ago with no previous inflammation or injury. Three years ago the patient was diagnosed HIV-positive. Differential diagnoses, classification of the disease as an autonomous entity, its casual association with HIV, as well as the real need for picrosirius red staining to confirm diagnosis of collagenoma are discussed.