The Surgical Anatomy and the Deep Plane Thread Lift of the Buccal Fat Pad.

BACKGROUND: Management of facial rejuvenation by the thread lift procedure has evolved over the past few years. The role of deep plane thread lift for buccal fat pad reposition was advocated. However, there are concerns about the risks and the feasibility of the deep plane thread lift. This study was designed to determine whether the deep plane thread lift could achieve effective aesthetic results and to investigate the possible risks of critical tissue injury through cadaveric studies. METHODS: Twelve fresh frozen cephalic specimens of 8 male and 4 female Asian body donors (mean age, 63.3 ± 8.0 years) were investigated. The deep plane thread lifts for reposition of the buccal fat pads were performed for all the left hemifaces. Cadaveric dissections were performed to investigate the moving distance of the buccal fat pad and to examine the surrounding tissue of the passage of the deep plane thread lift. RESULTS: The average moving distance of the buccal fat pads after the deep plane thread lift was 3.73 cm. The difference in moving distance of buccal fat pads between bilateral sides was statistically significant (P < 0.001). No injuries of the critical vessels or nerves were found after cadaveric dissection. The passage of the deep plane thread lift was evaluated. CONCLUSION: The deep plane thread lift for reposition of the buccal fat pad is a safe, effective, and practical method.

Minimally invasive approaches to axillary osmidrosis treatment: A comparison between superficial liposuction with automatic shaver curettage, subcutaneous laser treatment, and microwave-based therapy with a modified technique.

BACKGROUND: Minimally invasive techniques, including superficial liposuction with automatic shaver curettage (LC), subcutaneous laser treatment, and microwave-based therapy have been developed to treat osmidrosis. Few studies have compared these three techniques in relation to clinical efficacy, life quality improvement, and downtime. AIMS: We aim to evaluate clinical results and life quality improvement, in addition to downtime and complications, between these three techniques. PATIENTS/METHODS: Clinical records of patients treated with these three minimally invasive techniques for axillary osmidrosis were retrospectively reviewed. Hyperhidrosis disease severity scale, Dermatology Life of Quality Index, clinical improvement, complication, and recurrence were assessed. RESULTS: Among 403 patients, 168 received microwave-based therapy, 119 received subcutaneous laser treatment, and 116 received LC. All treatments showed significant improvements (P < 0.001) in HDSS, DLQI and clinical result after 3 and 12 months comparing to the baseline. But the improvements of subcutaneous laser were significantly inferior to microwave-base therapy and LC. Patients who received LC had a significantly longer downtime (P < 0.001) than those who received other treatments. The recurrence rate was significantly higher in the subcutaneous laser treatment group, and the microwave-based therapy group exhibited a longer recurrence duration (P < 0.001). LC group presented higher complication rate than other treatments. CONCLUSION: Comparing to other treatments, microwave-based therapy was effective in treating osmidrosis with minimal downtime, recurrence, and complications. It could be a durable and effective therapeutic modality for osmidrosis and is less operator-dependent. It may be considered as a first-line treatment for axillary osmidrosis.

Risk assessment of excess drug and sunscreen absorption via skin with ablative fractional laser resurfacing : optimization of the applied dose for postoperative care.

The ablative fractional laser is a new modality used for surgical resurfacing. It is expected that laser treatment can generally deliver drugs into and across the skin, which is toxicologically relevant. The aim of this study was to establish skin absorption characteristics of antibiotics, sunscreens, and macromolecules via laser-treated skin and during postoperative periods. Nude mice were employed as the animal model. The skin received a single irradiation of a fractional CO2 laser, using fluences of 4-10 mJ with spot densities of 100-400 spots/cm(2). In vitro skin permeation using Franz cells was performed. Levels of skin water loss and erythema were evaluated, and histological examinations with staining by hematoxylin and eosin, cyclooxygenase-2, and claudin-1 were carried out. Significant signs of erythema, edema, and scaling of the skin treated with the fractional laser were evident. Inflammatory infiltration and a reduction in tight junctions were also observed. Laser treatment at 6 mJ increased tetracycline and tretinoin fluxes by 70- and 9-fold, respectively. A higher fluence resulted in a greater tetracycline flux, but lower skin deposition. On the other hand, tretinoin skin deposition increased following an increase in the laser fluence. The fractional laser exhibited a negligible effect on modulating oxybenzone absorption. Dextrans with molecular weights of 4 and 10 kDa showed increased fluxes from 0.05 to 11.05 and 38.54 µg/cm(2)/h, respectively. The optimized drug dose for skin treated with the fractional laser was 1/70-1/60 of the regular dose. The skin histology and drug absorption had recovered to a normal status within 2-3 days. Our findings provide the first report on risk assessment of excessive skin absorption after fractional laser resurfacing.

Skin permeation of small-molecule drugs, macromolecules, and nanoparticles mediated by a fractional carbon dioxide laser: the role of hair follicles.

PURPOSE: To evaluate skin permeation enhancement mediated by fractional laser for different permeants, including hydroquinone, imiquimod, fluorescein isothiocyanate-labeled dextran (FD), and quantum dots. METHODS: Skin received a single irradiation of a fractional CO(2) laser, using fluence of 2 or 4 mJ with densities of 100 ∼ 400 spots/cm(2). In vitro and in vivo skin penetration experiments were performed. Fluorescence and confocal microscopies for imaging delivery pathways were used. RESULTS: The laser enhanced flux of small-molecule drugs 2 ∼ 5-fold compared to intact skin. A laser fluence of 4 mJ with a 400-spot/cm(2) density promoted FD flux at 20 and 40 kDa from 0 (passive transport) to 0.72 and 0.43 nmol/cm(2)/h, respectively. Microscopic images demonstrated a significant increase in fluorescence accumulation and penetration depth of macromolecules and nanoparticles after laser exposure. Predominant routes for laser-assisted delivery may be intercellular and follicular transport. CO(2) laser irradiation produced 13-fold enhancement in follicular deposition of imiquimod. Laser-mediated follicular transport could deliver permeants to deeper strata. Skin barrier function as determined by transepidermal water loss completely recovered by 12 h after irradiation, much faster than conventional laser treatment (4 days). CONCLUSIONS: Fractional laser could selectively enhance permeant targeting to follicles such as imiquimod and FD but not hydroquinone, indicating the importance of selecting feasible drugs for laser-assisted follicle delivery.

Laser-assisted topical drug delivery by using a low-fluence fractional laser: imiquimod and macromolecules.

The aim of this study was to evaluate the ability of a low-fluence fractional erbium:yttrim-aluminum-garnet (Er:YAG) laser, with a wavelength of 2940 nm, for enhancing and controlling the skin permeation of imiquimod and macromolecules such as polypeptides and fluorescein isothiocyanate (FITC)-labeled dextran (FD). The in vitro permeation has been determined using a Franz diffusion cell, with porcine skin and nude mouse skin as the barriers. Hyperproliferative and ultraviolet (UV)-irradiated skins were also used as barrier models to mimic the clinical therapeutic conditions. Confocal laser scanning microscopy (CLSM) was used to examine the in vivo nude mouse skin uptake of peptide, FITC, and FD. Both in vitro and in vivo results indicated an improvement in permeant skin delivery by the laser. The laser fluence and number of passes were found to play important roles in controlling drug transport. Increases of 46- and 127-fold in imiquimod flux were detected using the respective fluences of 2 and 3 J/cm(2) with 4 pulses. An imiquimod concentration of 0.4% from aqueous vehicle with laser treatment was sufficient to approximate the flux from the commercial cream with an imiquimod dose of 5% without laser treatment, indicating a reduction of the drug dose by 125-fold. The enhancement of peptide permeation was size and sequence dependent, with the smaller molecular weight (MW) and more-hydrophilic entities showing greater enhancing effect. Skin permeation of FD with an MW of at least 150 kDa could be achieved with fractional laser irradiation. CLSM images revealed intense green fluorescence from the permeants after exposure of the skin to the laser. The follicular pathway was significant in laser-assisted permeation.

Fractional laser as a tool to enhance the skin permeation of 5-aminolevulinic acid with minimal skin disruption: a comparison with conventional erbium:YAG laser.

The aim of this study was to examine the in vitro skin delivery and in vivo protoporphyrin IX (PpIX) accumulation of topically applied 5-aminolevulinic acid (ALA) enhanced by a fractional laser pretreatment. This was achieved by applying an array of microscopic treatment zones (MTZ) to the skin by ablation of superficial stratum corneum in a determined area. Re-epithelialization determined by transepidermal water loss was completed within 1 day after fractional laser irradiation. The conventional laser used in comparison showed more severe skin disruption and a greater recovery duration of 2 days. The in vitro ALA permeation was measured using a Franz cell apparatus, with nude mouse skin and porcine skin as the permeation barriers. The efficacy of the enhancement was determined as a function of various laser fluences (2 and 3 J/cm(2)) and number of passes (1-6 passes). The flux of ALA via laser-treated nude mouse skin was 27-124-fold higher than that across intact skin. A 3-260-fold increase in ALA flux was detected by using the porcine skin as the permeation barrier. The skin permeation was also investigated in a model of hyperproliferative skin obtained by repeated tape stripping. The results showed that the hyperproliferative skin was more permeable to ALA in comparison to the normal skin. The in vivo localization of PpIX in nude mouse skin was imaged using confocal laser scanning microscopy. As expected, an intense red fluorescence was observed in the lower epidermis and upper dermis after fractional laser irradiation. The penetration depth was also increased by the laser. The safety and efficacy of enhancing ALA permeation were demonstrated by using the fractional laser at low fluences.

Acyclovir-induced neuropsychosis successfully recovered after immediate hemodialysis in an end-stage renal disease patient.

A 70-year-old man developed herpes zoster over the right L5-S2 region for 3 days and was admitted for acyclovir therapy. He had a medical history of rectal cancer status post-colostomy and end-stage renal disease undergoing thrice weekly hemodialysis. Without a prior loading dose, acyclovir 500 mg (7.7 mg/kg) daily was given intravenously in two divided doses. On the third dosage, the patient became confused and agitated and developed insomnia. Within the following 24 h, delirium, visual and auditory hallucinations, disorientation to place and time, as well as impaired recent memory occurred. At the same time, a transient low grade fever (38 degrees C) was noted but resolved spontaneously after ice pillow (Fig. 1). The etiology was vigorously explored. He had no history of any neurological or psychiatric disorders. Drug history was reviewed, but no other medications besides acyclovir were currently being used. Physical examination revealed neither meningeal signs nor focal neurological deficits. Serum blood urea nitrogen, glucose, and electrolytes were within normal limits except for an elevated creatinine level at 6.2 and 5.7 mg/dl (before and after neuropsychotic symptoms, respectively). Complete blood count with differentiation was also unremarkable. Cerebrospinal fluid examination was not possible as the patient's family refused the lumbar puncture. Moreover, an electroencephalograph study and head computed tomography scan disclosed no abnormalities. Acyclovir-induced neurotoxicity was suspected. Therefore, acyclovir was discontinued. Subsequently, serum acyclovir and CMMG were checked by enzyme-linked immunosorbent assay. Serum acyclovir level was 1.6 mg/l (normal therapeutic level, 0.12-10.8 mg/l) and CMMG level was 5 mg/l. Emergent hemodialysis (4-h/session) was given; the neuropsychotic symptoms, including agitation, delirium, and visual and auditory hallucinations, greatly abated after the second session. The patient fully recovered after three consecutive days of hemodialysis; the serum was rechecked and revealed that the acyclovir level was below 0.5 mg/l and the CMMG level was undetectable. At the same time, his herpetic skin lesions resolved well.