Complications of soft tissue augmentation.

The wide variety of dermal fillers presently available has revolutionized treatment options for patients seeking a refreshed appearance. Soft tissue fillers include both bovine and human collagens, the hyaluronans, calcium hydroxyapatite, poly-L-lactic acid, and synthetic polymers. However, soft tissue augmentation is never risk-free, and as these procedures have increased in prevalence, complications have been more frequently reported. This article describes a range of complications resulting from dermal filler injections, reviews key case studies, and discusses possible treatment options for adverse effects. While biodegradable fillers offer the least risk for the patient, location, allergic reactions, granulomas, necrosis, and infection are all serious complications that must be considered before performing soft tissue augmentation with any approved dermal filler.

Laser treatment of pediatric vascular lesions: Port wine stains and hemangiomas.

Pediatric vascular lesions can be medically threatening and psychologically distressing to patients. This article reviews literature on the laser treatment of two common pediatric vascular lesions, port wine stains and hemangiomas. The purpose of this report was to distinguish the lesions from one another and to present the advantages, disadvantages, complications, and limitations of laser treatment for each lesion type. This review is not a comprehensive inventory but instead highlights the studies that best show promising results or the limitations of laser treatment for the lesions. Overall, port wine stain laser treatment promoted notable clearing with low side effects, whereas hemangioma laser treatment provided inconsistent benefits and severe side effects occasionally. Laser treatment of port wine stains is safe and effective, but laser treatment of hemangiomas remains controversial and is best for lesions without deeper components.

Delayed presentation of impending necrosis following soft tissue augmentation with hyaluronic acid and successful management with hyaluronidase.

Soft tissue augmentation is a key element in the successful management of facial rhytids and scars. Injection of hyaluronic acid gels into the dermis is generally well-tolerated with only minimal side effects. Injection necrosis is a rare but clinically significant side effect. We present a case of what appears to be slow swelling after injection of Juvederm (Allergan, Irvine, CA), which yielded delayed compression and vascular occlusion resulting in cutaneous necrosis. Such vascular compromise can present as delayed rather than immediately upon injection as would be the case with similarly reported cases of intra-arterial injection.

Soft tissue augmentation.

Recent additions to the soft tissue augmentation armamentarium have greatly increased the dermatologic surgeon's choices in optimizing facial contouring and the treatment of acne scars. In this article, we review the science of fillers and look at the future of dermal fillers.

Management of injected hyaluronic acid induced Tyndall effects.

BACKGROUND AND OBJECTIVES: Soft tissue augmentation represents a cosmetic procedure performed with increasing frequency. STUDY DESIGN/MATERIALS AND METHODS: Correct utilization permits precise correction of facial rhytids and scars. Novice injectors occasionally inject too superficially in tissue with the resultant appearance of discoloration secondary to the Tyndall effect. RESULTS AND CONCLUSION: In this article, we will review the Tyndall effect in the skin and management options for this growing problem in aesthetic dermatology.

Superficial skin resurfacing.

Options for both the cosmetic surgeon offering and patients seeking treatment for cutaneous aging have expanded greatly in recent years and continue to grow. Increasingly sophisticated aesthetic patients are seeking procedures to rejuvenate in record numbers,but many are unwilling to tolerate a large amount of downtime. In expert hands, ablative laser resurfacing has a long history of dramatic results for the treatment of cutaneous aging. During the last decade, there have been a growing number of reports of modalities targeting the more superficial skin structure. Such modalities offer more modest results without the downtime associated with more aggressively ablative procedures. These resurfacing techniques include the use of mechanical, chemical, and thermal forces.

Nonablative resurfacing.

In expert hands, ablative laser resurfacing has a long history of excellent results in the treatment of photodamage-induced rhytids, depressed acne scars, and other signs of cutaneous aging. Over the last decade there have been a growing number of reports in the emerging area of nonablative resurfacing. Nonablative modalities provide less impressive clinical results for rhytid reduction but have shown particular promise for the treatment of scars and superficial dyschromias. It is also ideally suited for those patients seeking a minimally invasive, greatly reduced downtime procedure.

Lasers, light, and acne.

Acne vulgaris is a highly prevalent disease with significant potential for physical and emotional scarring. Acne lesions have long been noted to improve after exposure to sunlight. This improvement may be secondary to activation of endogenous porphyrins produced by Propionibacterium acnes. Recently, several investigators have presented studies in which light of particular wavelengths has been used to treat acne vulgaris. In this article, we review the results of these studies as we look to the future of light-based acne treatment.

Severe cutaneous reactions associated with the use of human immunodeficiency virus medications.

Patients infected with human immunodeficiency virus are highly susceptible to adverse dermatological reactions to specific medications. Severe cutaneous conditions such as Stevens-Johnson syndrome and toxic epidermal necrolysis are associated with high morbidity and, notably for toxic epidermal necrolysis, high mortality. Although overall mortality from human immunodeficiency virus has dramatically declined owing to highly active antiretroviral therapy, these antiretroviral regimens have been associated with a wide spectrum of severe cutaneous reactions. We reviewed case reports and clinical trials in the English literature on Medline (1966 to 2001) and Aidsline (1980 to 2000) to determine the prevalence of Stevens-Johnson syndrome and toxic epidermal necrolysis attributable to the current FDA approved antiretroviral medications. We identified a total of approximately 50 patients who had Stevens-Johnson syndrome and/or toxic epidermal necrolysis associated with the use of 5 antiretroviral medications: 2 nucleoside reverse transcriptase inhibitors, zidovudine (2 patients) and didanosine (1 patient); 1 non-nucleoside reverse transcriptase inhibitor, nevirapine (42 patients); and 2 protease inhibitors, indinavir (1 patient) and amprenavir (an unspecified number within the 1% of over 1400 patients experiencing severe life-threatening reactions). Of the reports that specified the onset time of adverse reaction after initiation of treatment, 86% (19/22) of patients experienced reactions within 4 weeks. Ten of the approximately 50 patients were diagnosed with Stevens-Johnson syndrome or toxic epidermal necrolysis, due to specific antiretroviral medication, or a combination of medications identified by either resolution upon withdrawal, consistent biopsy findings or a positive rechallenge. The remainder of the identified patients were reported in articles lacking data regarding drug administration, reaction history or other details.

Cutaneous tuberculosis: diagnosis and treatment.

As we move into the 21st century, cutaneous tuberculosis has re-emerged in areas with a high incidence of HIV infection and multi-drug resistant pulmonary tuberculosis. Mycobacterium tuberculosis, Mycobacterium bovis, and the BCG vaccine cause tuberculosis involving the skin. True cutaneous tuberculosis lesions can be acquired either exogenously or endogenously, show a wide spectrum of morphology and M. tuberculosis can be diagnosed by acid-fast bacilli (AFB) stains, culture or polymerase chain reaction (PCR). These lesions include tuberculous chancre, tuberculosis verrucosa cutis, lupus vulgaris, scrofuloderma, orificial tuberculosis, miliary tuberculosis, metastatic tuberculosis abscess and most cases of papulonecrotic tuberculid. The tuberculids, like cutaneous tuberculosis, show a wide spectrum of morphology but M. tuberculosis is not identified by AFB stains, culture or PCR. These lesions include lichen scrofulosorum, nodular tuberculid, most cases of nodular granulomatous phlebitis, most cases of erythema induratum of Bazin and some cases of papulonecrotic tuberculid. Diagnosis of cutaneous tuberculosis is challenging and requires the correlation of clinical findings with diagnostic testing; in addition to traditional AFB smears and cultures, there has been increased utilization of PCR because of its rapidity, sensitivity and specificity. Since most cases of cutaneous tuberculosis are a manifestation of systemic involvement, and the bacillary load in cutaneous tuberculosis is usually less than in pulmonary tuberculosis, treatment regimens are similar to that of tuberculosis in general. In the immunocompromised, such as an HIV infected patient with disseminated miliary tuberculosis, rapid diagnosis and prompt initiation of treatment are paramount. Unfortunately, despite even the most aggressive efforts, the prognosis in these individuals is poor when multi-drug resistant mycobacterium are present. An increased awareness of the re-emergence of cutaneous tuberculosis will allow for the proper diagnosis and management of this increasingly common skin disorder.