Stackable Medical-Grade Skincare for the Cosmetic Medicine Patient: A Long-Term Pilot Assessment.

Background: Multiple intrinsic and extrinsic factors influence aging and lead to visible changes in the skin, including dryness, fine lines and wrinkles, loss of elasticity, surface roughness, uneven pigmentation, and loss of luminosity. Although it is well established that a single combination of topicals can address multiple signs of skin aging, it is common for patients' at-home skin treatment routines to include multiple different topicals with different active ingredients. The layering of active ingredients can cause skin irritation, and lead to noncompliance with a consistent routine. Further, multiple active ingredients may exacerbate irritation from in-office aesthetic treatments. Objectives: To assess the long-term efficacy, safety, tolerability, and patient adherence to a Stackable Treatment topical routine consisting of 4 complementary topical formulations. Methods: This study examined a daily topical routine (Stackable Treatment routine) consisting of 4 topical formulas with different active ingredients, and evaluated the routine's safety, tolerability, and efficacy in a composite of in-office treatment patients who applied the routine for a minimum of 1 year. Results: Of the 14 patients, 0 experienced adverse reactions. Improvements to multiple skin parameters were observed, including improvements to skin hydration, surface texture, pigmentation, vasculature, and the appearance of scars. The majority of patients continue to use the Stackable Treatment routine after the study's conclusion. Conclusions: The combination of low incidence of irritation, high patient satisfaction, and overall efficacy of the routine indicates the Stackable Treatment routine may be well suited as a foundational skin care regimen that can complement in-office aesthetic treatments.

A Single-Center Study Evaluating the Effects of a Topical Serum Combining Postbiotics, Peptides, and Botanical Extracts on Skin.

Background: Aging, influenced by intrinsic and extrinsic factors, leads to visible skin changes such as dryness, surface roughness, and loss of luminosity. Proper skin care can mitigate some of these effects, with topical combination products offering support through complementary mechanisms. Objectives: To test efficacy and safety of GSYBS-7 (Goop Beauty Youth-Boost Peptide Serum; Goop Inc., Santa Monica, CA), a topical postbiotic and botanical combination serum, used twice daily on facial skin for 6 weeks. Methods: In this 19-patient pilot study, the primary efficacy measure was improvement on the Global Ranking Scale (GRS) at 42 days. A 12-point patient satisfaction survey and the serum's effect on healing after ablative laser treatment served as secondary and exploratory measures, respectively. Results: Statistically significant improvements in all GRS domains were observed as early as day 7 with ongoing improvement up to day 42. A >1-point improvement was observed for dehydration (1.8; 95% CI, 1.5-2.2), visible pores (1.6; 95% CI, 1.3-2.0), surface roughness (1.6; 95% CI, 1.3-1.9), imbalance (1.3; 95% CI, .9-1.7), static wrinkles (1.3; 95% CI, .9-1.6), pigmentation (1.3; 95% CI, 1.0-1.5), and vasculature (1.2; 95% CI, .8-1.5). Independent photographic review and patient satisfaction surveys corroborated these findings. At day 42, 94.4% of patients were very satisfied with the results, and 88.9% would recommend GSYBS-7 to family and friends. No adverse events were reported, and 100% of patients indicated that GSYBS-7 was gentle enough for everyday use. Conclusions: GSYBS-7 appears to be an effective and well-tolerated combination topical for the management of age-related and environment-induced skin changes.

Facelift Patients Receiving Intraoperative Administration of a Self-assembling Hemostat Agent Experienced Minimal Bruising and No Acute Hematomas: A Pilot Study.

Background: Hematomas are consistently cited as the most common complication of facelift surgery, with reported incidence rates ranging from 1% to 9% despite preventative measures. A self-assembling RADA16 peptide solution (PuraSinus, 3-D Matrix, Newton, MA) designed to aid in wound healing, adhesion prevention, and bleeding control has demonstrated hemostatic control of intra- and postoperative bleeding associated with various surgical procedures, including nasal and sinus surgery. Objectives: To report surgical experience using novel application of RADA16 hemostatic agent in facelift procedures. Methods: Through exploring incorporation of RADA16 hemostatic agent into standard of care, 15 higher-risk facelift patients were treated intraoperatively between December 2020 and July 2021. Postoperative follow-up was on post-procedure day 1 and 3 and at approximately one week. During follow-up, potential complications were assessed subjectively, including hematoma, swelling, and bruising; postoperative observations recorded; and photographs taken. Results: Among facelift patients receiving intraoperative RADA16 hemostatic agent there were no hematomas or protracted ecchymosis events. The only significant complication was one patient admitted for intravenous hydration due to post-operative nausea and vomiting. All patients had minimal bruising or a dramatic absence of bruising and experienced no hemorrhage or hematoma. Through surgical experience, technique for RADA16 hemostatic agent placement was optimized and procedural details are provided. Conclusions: Intraoperative administration of topical RADA16 hemostatic agent appears to deter acute hematoma and hemorrhage formation and early experience suggests that RADA16 hemostatic agent may also attenuate post-operative bruising in facelift patients. These observations warrant further investigation in a larger randomized controlled study.

A Single-Center Study Evaluating the Effects of a Novel Retinol and Cannabidiol Combination Topical on Facial Skin.

Background: While retinol is known to reduce the appearance of fine lines and wrinkles, it is associated with irritating effects. However, when combined with water soluble cannabidiol (CBD; CR Topical), CBD may act to reduce oxidative stress and inflammation, mitigating irritation from retinol and further improving the skin's appearance through independent anti-aging mechanisms. Objectives: To assess the efficacy and tolerability of CR-Topical for improving facial skin. Methods: In this prospective, single-center pilot study, 9 female patients and one male patient aged 20 to 53 years who presented with facial skin imperfections (visible pores, dehydration, roughness, and/or static/dynamic wrinkles) applied CR-Topical to the entire face once daily for 42 days. Outcomes were measured on days 1, 21, and 42 using the Global Ranking Scale (GRS) with Comprehensive Skin Analysis by the patient and senior investigator as well as by a blinded reviewer (board-certified plastic surgeon). Dynamic videos and static imagery were taken before and after treatment, and patient satisfaction surveys were completed. Results: Global improvement across all 13 domains was observed, with the greatest mean differences for visible pores (2.0; 95% CI, 1.5-2.5), dehydration (2.0; 95% CI, 1.4-2.6), surface roughness (1.8; 95% CI, 1.2-2.4), static wrinkles (1.8; 95% CI, 1.1-2.5), and dynamic wrinkles (1.6; 95% CI, 0.8-2.3). Patient satisfaction (100%) and willingness to recommend the product to others (90%) were high, and tolerability of CR-Topical was excellent. Conclusions: CR-Topical is effective at improving global skin quality, including static and dynamic wrinkles. This study also used 4-dimensional analysis in the evaluation, a novel and developing method.

High-Dose Neuromodulators: A Roundtable on Making Sense of the Data in Real-World Clinical Practice.

BACKGROUND: For aesthetic treatment with botulinum neurotoxin type A (BoNTA), interest in maximizing treatment duration and efficacy has prompted study of doses higher than those used in registration studies. As data emerge, it is important that physicians understand how to apply study findings to their own practice so that patient demand is satisfied. OBJECTIVES: To bring together leading experts in neuromodulators for a roundtable discussion on the implications of high-dose BoNTA studies for patient care. METHODS: The authors reviewed and discussed recent data from high-dose BoNTA studies for abobotulinum toxin A, incobotulinum toxin A, and Oonobotulinumtoxin A. RESULTS: Discussion focused on the challenges of data interpretation and extrapolation of study findings for real-world patient care. The authors participated in a candid discussion of whether the observed improvements in treatment duration and patient satisfaction warrant treatment with high-dose regimens delivered as high-concentration injections. Safety was also discussed, as well as economic considerations for both practices and patients. Of note, for BoNTA products, the registration dose, when administered in a smaller total volume, appears to give rise to more durable results than those observed in pivotal trials, implicating product concentration as an important consideration. Importantly, at higher doses, extended duration of effect does not appear to be at the expense of natural-looking results. CONCLUSIONS: While the authors provide considerations for the development of individual clinical practice, there is no one-size-fits-all recommendation. It may be that "high-dose" BoNTA is in reality the optimal dose; however, important economic considerations may prevent rapid uptake for all patients.

Evaluation of Physicochemical Properties Following Syringe-to-Syringe Mixing of Hyaluronic Acid Dermal Fillers.

BACKGROUND: Historically, soft-tissue hyaluronic acid (HA) fillers have been mixed with agents to reduce pain or alter physicochemical properties. OBJECTIVE: Evaluate the impact of dilution and mixing on HA filler physicochemical properties. MATERIALS AND METHODS: Crosslinked HA filler (VYC-20L, 20 mg/mL) was diluted to 15 mg/mL using saline through 5 or 10 passes between 2 syringes connected using a luer connector. Extrusion force, rheological properties, and microscopic appearance were assessed. Undiluted VYC-15L (15 mg/mL) served as the control. RESULTS: Average extrusion force was higher for diluted VYC-20L versus the control, with an increase in slope for gel diluted using 5 passes (0.65) and 10 passes (0.52) versus the control (<0.1). For diluted samples mixed with 5 or 10 passes, the rheological profile was different between the 2 halves of the syringe, with the second half more elastic than the first half, compared with the consistent profile of undiluted samples. Microscopically, diluted VYC-20L samples seemed more liquid near the luer and more particulate near the piston compared with the control, which was smooth throughout. CONCLUSION: In addition to potentially introducing contamination, diluting or mixing soft-tissue HA fillers yields a heterogeneous product with physicochemical characteristics that vary substantially throughout the syringe.

Nonsurgical Tissue Repositioning: Analysis of Long-Term Results and Patient Satisfaction From 100 Absorbable Suture Suspension Cases.

BACKGROUND: Absorbable suspension sutures are the only nonsurgical modality approved for tissue repositioning. OBJECTIVES: To quantitate patient perceptions of treatment at 24 months and determine the impact of age and prior surgical procedures on perceptions of efficacy, treatment longevity, and overall satisfaction. In addition, the authors sought to describe the impact of treatment with absorbable suspension sutures on the likelihood a patient will undergo future surgical procedures. METHODS: The first 100 treated patients who underwent treatment with absorbable suspension sutures, by the senior author, were critically evaluated. Subjects completed surveys 24 months following initial treatment. RESULTS: Of the initial 100 patients, complete records were available for 80 patients (age 39-86). Eighteen (22.5%) received a second treatment with absorbable suspension sutures and average time to second treatment was 23.4 months (range 13-37 months). Overall satisfaction was affected by age, 100% of patients ≤ 50 vs. 60% of patients > 50 (P = 0.026). Prior surgery appeared to be a factor in patient perception of efficacy: 82.6% of patients with no prior surgery indicated that absorbable suspension sutures were effective vs. 45.5% of patients with a prior surgical procedure (P = 0.0286). Just under one third of pretreatment surgical patients underwent surgery following treatment while 25% of surgery naïve patients went on to have surgery. Importantly, satisfaction with the initial procedure does not preclude later surgery. CONCLUSIONS: Treatment with absorbable suspension sutures is associated with high satisfaction through 24 months and does deter patients from surgery. The combination of lift and volumization results in 4-dimensional rejuvenation that includes rejuvenation of dynamic expression.

Cryolipolysis: Clinical Best Practices and Other Nonclinical Considerations.

Cryolipolysis is a nonsurgical body contouring procedure that involves cooling of fat cells to induce lipolysis while sparing surrounding structures. Plastic surgery practices are increasingly incorporating noninvasive aesthetic procedures (eg, cryolipolysis, fillers, radiofrequency, ultrasound) to offer their patients a wider range of aesthetic treatment options. Here, we report insights from 8 plastic surgeons with regard to cryolipolysis best practices from a clinical perspective and the impact of integrating this noninvasive body contouring procedure into a plastic surgery practice. The authors prefer cryolipolysis over liposuction for patients who are not amenable to surgery or those who desire to avoid downtime, also taking into consideration body mass index, skin laxity, comorbidities, and risk of contour irregularities. Patient counseling is critical for setting realistic expectations regarding outcomes and should focus on the efficacy of cryolipolysis, individual variability in results, potential side effects, time course of treatment response, and the need for multiple treatment cycles. Strategies for reaching new patients and expanding services among current cryolipolysis patients are discussed.

Practical Guidance for Optimizing Patient Comfort During Microfocused Ultrasound with Visualization and Improving Patient Satisfaction.

BACKGROUND: Microfocused ultrasound with visualization (MFU-V; Ultherapy®) is an effective method for correction of skin laxity through lifting and tightening skin on the face, neck, and décolleté as well as on other parts of the body such as the knees, arms, and abdomen. In addition to being a noninvasive modality for tissue tightening, MFU-V has a biological effect on tissue, rejuvenating the skin through stimulation of elastogenesis and neocollagenesis. MFU-V is also commonly combined with other interventions such as fillers, neuromodulators, and absorbable suspension sutures. OBJECTIVES: The aim of this study was to share the extensive experience of the authors in optimizing comfort for their MFU-V patients in order to provide guidance to the broader community surrounding optimal patient comfort with this procedure. METHODS: The authors discuss their approaches to patient comfort and satisfaction. Elements of each approach include patient selection, pharmacologic and nonpharmacologic comfort measures, and how prioritization of patient comfort affects both their individual patients and practices. RESULTS: The authors share their approaches for optimizing patient comfort during the procedure and provide an overview of both pharmacologic and nonpharmacologic measures that can be adopted to support patient comfort and satisfaction. The similarities and differences of each approach are discussed. CONCLUSIONS: In addition to diligent patient selection, the authors find that attention to patient comfort is directly related to satisfaction and appears to be a primary factor in patients' decisions to return for additional treatments.

Efficacy, Patient-Reported Outcomes, and Safety for Millennial Subjects Treated With OnabotulinumtoxinA for Moderate to Severe Horizontal Forehead Lines.

BACKGROUND: Millennials (aged 18-34 years) represent a growing segment of the facial aesthetic market. OBJECTIVE: To evaluate investigator-assessed efficacy, patient-reported outcomes (PROs), and safety for millennials versus subjects aged at least 35 years after onabotulinumtoxinA treatment of forehead lines (FHL) across 2 phase 3 studies. METHODS: Eligible subjects with moderate to severe FHL received onabotulinumtoxinA (FHL: 20 U; glabellar lines: 20 U, with/without 24 U in crow's feet line regions) or placebo. All findings were pooled by the age group. RESULTS: Millennials composed 15% of subjects (176/1,178). Day 30 responder rates of at least 1-grade Facial Wrinkle Scale improvement in FHL severity for millennials versus subjects aged 35 years and older were 100% versus 97.8% at maximum eyebrow elevation and 78.4% versus 83.5% at rest, respectively. Responder rates were significantly greater with onabotulinumtoxinA than placebo (p ≤ .015) for both groups through Day 180. Similar trends were observed for achieving none/mild severity. Both age groups reported high satisfaction rates and improved psychological impacts with onabotulinumtoxinA treatment. No new safety signals were detected. CONCLUSION: OnabotulinumtoxinA treatment was well tolerated, and both age groups experienced significant improvements in FHL severity, high satisfaction, and improved psychological impacts after treatment. Millennials reported numerically greater improvements.

Myths and Knowledge Gaps in the Aesthetic Treatment of Patients With Skin of Color

Background: Misperceptions about facial aesthetic treatments in individuals with skin of color (SOC) may influence treatment selection. Objective: We aimed to identify knowledge gaps and myths concerning facial aesthetic treatment in individuals with SOC. Methods: A PubMed search identified articles concerning patients with SOC receiving facial aesthetic treatments. The experience of experts in aesthetic treatment of patients with SOC was also considered. Results: Knowledge gaps included not seeking injectable filler treatment of lips, risk of developing keloids with injectable filler treatment, risk of hyperpigmentation precluding surgical procedures and nonsurgical injectable filler treatment, melasma being a minor cosmetic concern with limited treatments, and racial/ethnic groups being homogeneous with respect to facial characteristics and aesthetic concerns. Dispelled myths included perceptions that: individuals with SOC do not need sunscreen; dermal fillers and neuromodulators are not necessary or useful for patients with darker skin; laser treatments cannot be used on darker skin; facial products are unnecessary; and only medical providers with SOC can understand how to treat patients with SOC. Conclusions: Knowledge gaps and myths concerning facial aesthetic treatment in individuals with SOC exist. These patients may undergo various facial aesthetic procedures safely and effectively, as long as nuances in treatment approaches are recognized. J Drugs Dermatol. 2019;18(7):616-622.

Lip and Perioral Enhancement With Hyaluronic Acid Dermal Fillers in Individuals With Skin of Color.

BACKGROUND: Individuals with skin of color are underrepresented in studies of lip and perioral enhancement. OBJECTIVE: To examine the effectiveness and safety of hyaluronic acid (HA) dermal filler treatment for lip and perioral enhancement in subjects with skin of color. METHODS: Data were pooled from subjects with Fitzpatrick skin phototypes IV, V, or VI in 2 pivotal studies of HA dermal fillers. Photonumeric scales were used to assess lip fullness (5-point scale) and perioral lines and oral commissures severity (each 4-point scales). Safety was assessed by injection site responses recorded in patient diaries and adverse events (AEs). RESULTS: The cohort comprised 72 subjects (median age: 49.5 years; 95.8% female). Mean lip fullness improved from baseline by 1.1 points at 3 months after treatment; 85.0% of subjects were responders (≥1-point improvement). Of subjects treated for perioral lines (n = 12) and oral commissures (n = 56), 90.9% and 46.4%, respectively, were responders. Injection site responses were generally mild or moderate in severity, resolved within 2 weeks, and were consistent with those expected for HA dermal filler treatment. The most common AEs were injection site mass (19.4%) and bruising (12.5%). CONCLUSION: Lip and perioral enhancement with HA dermal fillers is effective and safe in subjects with skin of color.

Expert Consensus on Achieving Optimal Outcomes With Absorbable Suspension Suture Technology for Tissue Repositioning and Facial Recontouring.

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.