Consensus Statement on the Use of Botulinum Neurotoxin in the Middle East.

Background: Aesthetic minimally invasive procedures have become very popular and culturally acceptable among Middle Eastern populations. Botulinum neurotoxin type A (BoNTA) is a valuable treatment modality for many cosmetic as well as therapeutic indications. The presence of BoNTA in our toolkit has revolutionized the field of aesthetic medicine to the point where it is now one of the most commonly performed cosmetic procedures worldwide. This consensus considers popular on- and off-label BoNTA indications in the Middle East. Methods: A multinational group of ten key opinion leaders, experts in facial plastic surgery and dermatology, convened the Middle East Aesthetics Consensus Group and reviewed the aesthetic applications of BoNTA. Recommendations and position statements were drafted based on the integration of the panel's clinical experience with published data, targeted to the practices implemented in the Middle Eastern and the global population. Results: Guidance statements are presented covering Middle Eastern facial characteristics and beauty ideals, BoNTA characteristics, pre-operative counselling, treatment indications and anatomical considerations, off-label and special uses including high-dose recommendations, and post-treatment advice. Throughout, an evidence-based approach to selection of products and injection techniques is provided, supplemented by the experts' advice on injections dosages and placement. Conclusion: This consensus reflects the knowledge and expertise of physicians practicing in the Middle East. The panel acknowledged the use of on-label indications and variability in the toxin formulations and immunogenicity and agreed upon a wide use of "off-label" indications.

The Lip Flip for Beautification and Rejuvenation of the Lips.

BACKGROUND: The lower third of the face, especially the lips, offer a pivotal contribution to the overall facial appearance. Hyaluronic acid fillers are widely used for lower face support and beautification. OBJECTIVE: This study presents a novel perioral rejuvenation technique. Methods: 70 females were enrolled in the study. The injection technique utilized cannula with bilateral single-entry points. Two different evaluation systems were used. RESULTS: In the upper white lip area, the distances exhibited significant shortening difference before and after treatment in both age groups (P<0.001 for all measurements). Improvement was generally higher among patients injected more than one session. In the lower white lip and chin, the agreement level by physician and patients was fair (P<0.001) while by observers and patients was moderate (P<0.001). CONCLUSIONS: The lip flip technique is a novel, safe and effective additive for perioral rejuvenation. J Drugs Dermatol. 2022;21(1):71-76. doi:10.36849/JDD.6344R1.

Global Recommendations on COVID-19 Vaccines and Soft Tissue Filler Reactions: A Survey-Based Investigation in Cooperation With the International Society for Dermatologic and Aesthetic Surgery (ISDS).

BACKGROUND: Recent reports have surfaced from the United States Food and Drug Administration hearings in December 2020 regarding the COVID-19 vaccines and study participants who developed facial and/or lip swelling after receiving the newly developed drug. Despite an incidence rate of 0.02% in the vaccine arm of the Moderna mRNA-1273 trial, concerns have been expressed about the association of adverse reactions following soft tissue filler injections and the COVID-19 vaccines. The International Society for Dermatologic and Aesthetic Surgery (ISDS) understands these concerns and has designed the following study. METHODS: A global survey was designed to capture the incidence of adverse events related to: (1) previous soft tissue filler injections, (2) soft tissue filler injections during positive testing for COVID-19, and (3) soft tissue filler injections during and after receiving any of the COVID-19 vaccines globally available. RESULTS: The information of 106 survey participants from 18 different countries was analyzed. 80.2% (n=85) never experienced any adverse reaction following their soft tissue filler injection whereas 15.1% (n=16) experienced swelling and 4.7% (n=5) experienced pain that lasted longer than two days. Of those who received at least one dose of the COVID-19 vaccine (n=78), 94.9% reported not to have experienced any adverse reaction related to their previous soft tissue filler injection, whereas 5.1% (n=4) reported to have perceived pain that lasted longer than two days. CONCLUSION: The data collected does not support the concern for an increased risk of developing adverse reactions following soft tissue filler injections associated with the COVID-19 vaccines compared to that risk associated with other previously described triggers or the default risk following soft tissue filler injections. J Drugs Dermatol. 20(4):374-378. doi:10.36849/JDD.2021.6041.

Recommendations for Dermatology Office Reopening in the Era of COVID-19.

The COVID-19 pandemic, originating in Wuhan, China, has become a major public health and economic challenge for countries around the world. As of May 08, 2020, there are over 3 million COVID-19 cases, and 250,000 COVID-19- associated deaths in 215 countries. As more data is collected, updated infection control measures are continuously released and published by government, public health authorities, and physician specialty associations. Across the globe, dermatological practices have had to limit their operations to varying degrees to facilitate disease control, but as the pandemic subsides, they will broaden their operations. In light of the uncertainty surrounding safe and effective practice of medical and aesthetic dermatology in the era of COVID-19, fourteen international experts in the field contributed to recommendations for effective infection control protocols and practice management modifications. While guidance from the World Health Organization and local public health officials comes first, these recommendations are crafted as a starting point for dermatologists worldwide to commence either reopening their doors to patients or expanding available service offerings. This can help ensure that patients receive needed care in the short term and improve long term practice viability. J Drugs Dermatol. 2020;19(7):e-1-e-9. doi:10.36849/JDD.2020.5293.

Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm.

BACKGROUND AND OBJECTIVES: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose. MATERIALS AND METHODS: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists. RESULTS: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement. CONCLUSION: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.

Consensus Opinions on Facial Beauty and Implications for Aesthetic Treatment in Middle Eastern Women.

BACKGROUND: Middle Eastern women worldwide increasingly seek aesthetic treatment to enhance their beauty and improve self-esteem, but literature describing standards of beauty across the Middle East are scarce. Knowledge of facial anthropometry and Middle Eastern subregional beauty preferences and aesthetic weaknesses are key to develop an effective facial enhancement strategy that does not jeopardize ethnic identity or facial harmony. METHODS: Dermatologists and plastic surgeons from 8 Middle Eastern countries who had 7.5-25 (mean 13.5) years of experience in aesthetic medicine examined female Middle Eastern beauty in 4 geographic subregions: the Gulf (comprising Bahrain, Kuwait, Saudi Arabia, and the United Arab Emirates), Iran, Lebanon, and Egypt. They developed consensus opinions regarding facial beauty, aesthetic deficiencies, and injectable treatment solutions. RESULTS: Facial anthropometry differs between Middle Eastern and Western women, and also within the region. Although subregional differences are seen, beauty is generally recognized by an oval or round face; temple fullness; pronounced, elevated, arched eyebrows; large almond-shaped eyes; well-defined, laterally full cheeks; a small, straight nose; full lips; a well-defined jawline; and a prominent, pointed chin. The relative prominence of the nose necessitates attention to the lips and the shape and projection of the chin. Aging is often accompanied by midface sagging that leads to increased heaviness in the lower facial third. CONCLUSIONS: Middle Eastern beauty is characterized by striking eyes, defined cheeks, and full lips. These consensus opinions inform aesthetic practitioners who treat Middle Eastern women worldwide about their aesthetic ideals and the implications for treatment.

Treating the Lips and Its Anatomical Correlate in Respect to Vascular Compromise.

Treating the lips to increase facial attractiveness and youthfulness is challenging when trying to consider ethnic differences in an increasingly more diverse society. Multiple injection techniques are currently available for treating lip contour and volume, but a validation in the cadaveric model under the aspects of safety has not been performed yet. The injection techniques presented in this study are based on the experience and personal selection of the authors. The authors have assessed, treated, and evaluated for more than 20 years patients from the Middle East and Central Europe. Cadaveric verification was performed for each of the presented techniques to identify the positioning of the injected product inside the lips and its relation to the superior/inferior labial arteries. The results of the anatomic analyses revealed that in 58.3% of the performed injections, the product was placed close to the superior/inferior labial arteries. In 60.0% of the cases, applications using a needle placed the injected product in endangered locations, whereas 57.1% of the cases using cannulas placed the product in endangered locations (i.e., in the vicinity of the superior/inferior labial arteries). This anatomic study revealed that injected material into the lips is frequently placed in close proximity to labial arteries representing a high risk for intra-arterial applications, leading to tissue loss (necrosis) and potential end-arterial embolism (potential blindness). Nevertheless, treatment of the lips should be a multistep approach focusing first on the far (upper and middle face) and close (labiomandibular and labiomental) perioral regions.

Efficacy of Low-Fluence Nd:YAG 1064 nm Laser for the Treatment of Post-Inflammatory Hyperpigmentation in the Axillary Area.

OBJECTIVE: Post-inflammatory hyperpigmentation results in aesthetically unpleasant discoloration of the skin in the affected area. The efficacy of low-fluence Q-switched 1064-nm Nd:YAG laser has so far not been evaluated for the treatment of the axilla. This observational study was designed to evaluate whether the application of the laser treatment can satisfactorily reduce axillary hyperpigmentation. MATERIAL AND METHODS: 17 females (mean age, 34.27 ± 9.24; range, 19-48) were treated in a single center between 2014 and 2016 for post-inflammatory hyperpigmentation of the axillary area. One treatment session was done every 2 weeks. Pairwise pre- / post-treatment assessment was graded by the practitioner, the patient, and an independent non-medical observer for consistency using a standardized grading scale. RESULTS: Post-treatment evaluation revealed an improvement score of 4 ± 0.44; range, 4-5 (good improvement) with a variance of 0.19 after the treatment. The scoring of the practitioner rs= 0.31 correlated higher with the patient-related outcome than with the scoring of the independent non-medical observer rs= 0.17. The minimum number of sessions needed for an excellent patient-evaluated improvement was 3, but an increased number of sessions was not significantly correlated with the outcome. The results of the treatment lasted for at least 6 months after the last session. CONCLUSION: A low-fluence Q-switched 1064-nm Nd:YAG laser provided safe and effective treatment for post-inflammatory hyperpigmentation in the axillary area, with good-to-excellent improvement after a minimum of 3 sessions.

J Drugs Dermatol. 2017;16(11):1118-1123.

A clinical and epidemiological study of lichen planus among Egyptians of al-Minya province.

BACKGROUND: Lichen planus (LP) is a papulosquamous disease that affects skin and mucous membranes. It may also affect hair and nails. From the middle east, studies concerning its prevalence and clinical characteristics are few. This study presents the clinical and epidemiological pattern of LP among the Egyptian people. We analyzed the clinical and epidemiological data obtained from 50 LP patients who attended the dermatology outpatient clinic of al-Minya University Hospital, al-Minya, Egypt over a 1-year period. Lichen planus was present in 0.28 percent of the patients (females 44%, males 56%). The age range was 10-65 years; the majority fall in the 21-50 age group. Presentations include actinic LP (36%), classic LP (30%), hypertrophic LP (12%), guttate LP (6%), atrophic LP (4%), follicular LP (4%), and isolated oral LP (8%). Pruritus was the chief complaint of 50 percent of these patients. In 56 percent of patients, limbs were the initial site of onset.