Improved brachial skin hydration and appearance with hyperdiluted calcium hydroxylapatite.

INTRODUCTION: The search for minimally invasive treatments for areas not covered by clothing, such as the arms, has increased, particularly to combat flaccidity resulting from factors such as aging and weight loss. This study evaluated the efficacy of calcium hydroxyapatite (CaHA), an injectable biostimulator, in improving flaccidity and hydration of the skin of the arms. MATERIALS AND METHODS: Six women between 40 and 50 years old with visible signs of brachial flaccidity were selected. Calcium hydroxyapatite was injected into the arms in a 1:4 dilution (1.5 mL per side), with subjective evaluation based on the GAIS score and objective hydration analysis using corneometry. RESULTS: After a single application of CaHA, there was a significant increase in skin hydration (12.2%), objectively assessed by corneometry. Patient and physician satisfaction was high, evidenced by visible improvements in photographs and by the GAIS score. No significant adverse events were reported, demonstrating the safety of the procedure. DISCUSSION: Our clinical observations confirm the ability of CaHA to visibly improve arm flaccidity. In addition, hydration measures support previous histological studies demonstrating increases in dermal proteoglycans. Compared to other studies, the increase in skin hydration with CaHA was similar to those obtained with hyaluronic acid, suggesting comparable results with a more comfortable and less invasive technique. CONCLUSION: This study demonstrates the efficacy of CaHA in improving hydration of brachial skin after a single treatment. Despite the limitations of the sample size, the research contributes to the medical literature, highlighting the utility of the 3 mL CaHA presentation for brachial treatment with objective results in skin hydration.

Hand Rejuvenation with Customizable Hybrid Fillers: Premixed Calcium Hydroxyapatite and Hyaluronic Acid.

INTRODUCTION: Hand aging is a prevalent concern characterized by the atrophy of local soft tissues and increased visibility of vessels and tendons. Hyaluronic acid (HA) and calcium hydroxyapatite (CaHA) are well-established treatments for addressing this issue. While hybrid filler containing HA and CaHA has been proposed for facial rejuvenation, studies investigating its efficacy for hand rejuvenation are lacking. OBJECTIVE: This study aims to assess the safety and efficacy of a premixed hybrid filler containing calcium hydroxyapatite (CaHA) and hyaluronic acid (HA) for hand rejuvenation. METHODS: A prospective, double-blind, controlled trial was conducted. The control arm (CA) received conventional subdermal treatment with CaHA at a 1:1 dilution. The intervention arm (IA) underwent hybrid treatment, consisting of CaHA at a 1:1 dilution combined with 1 ml of low-density HA. Evaluation was performed subjectively using the Global Aesthetic Improvement Scale (GAIS) and the Manchester Hand Grading System (MHGS), and objectively using cutometry, corneometry, and ultrasound. RESULTS: Both the CA and the IA exhibited high rates of patient satisfaction and satisfaction as assessed by blinded evaluators. Although numerical superiority was observed in the IA, no statistical difference was found between the two groups. Significant improvements in hydration, elasticity, and skin thickness were observed in both arms, with no discernible difference between them. Greater ultrasound echogenicity was noted in the IA, which, as indicated by existing literature, may suggest enhanced biostimulation. No adverse effects were reported in either arm. CONCLUSION: Premixed filler containing HA and CaHA for hand rejuvenation appears to be a safe and effective approach. LEVEL OF EVIDENCE I: 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 .

Treatment of Atrophy of the Labia Majora: Calcium Hydroxyapatite or Hyaluronic Acid?

PURPOSE: The study aimed to evaluate and compare the efficacy and safety of treating atrophied labia majora with hyaluronic acid (HA) and calcium hydroxyapatite (CaHA). METHODS: Ten participants complaining of sagging or loss of volume in the labia majora were evaluated and randomly assigned to two groups-treated with CaHA or AH. Photographic documentation was taken and appreciated by the participants and by blind observers. RESULTS: The study showed an improvement in labia majora regarding volumization and flaccidity that was more significant after 90 days of treatment in both treatments. Besides flaccidity, volume replacement resulted in better balance and proportion between the labia majora and labia minora. The evaluators, independent and blind, judged that in 80% of the cases of the HA group and in 50% of cases of the CaHA group, there was an excellent improvement. CONCLUSION: CaHA and HA are both effective and safe for treating the intimate region, and this study cannot prove the superiority of one over the other. An appropriate assessment involving the analysis of sagging and/or volume loss and the creation of a sequential treatment protocol, involving CaHA and HA, seems to be the best solution. LEVEL OF EVIDENCE I: Evidence obtained from at least one properly designed randomized controlled trial. 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 .

RELAX and FIRMNESS: The Combination of Muscle Relaxation with Botulinum Toxin and Collagen Biostimulation with Calcium Hydroxyapatite for the Treatment of the Cervical Region.

Introduction: There are several therapeutic modalities for neck rejuvenation, especially calcium hydroxylapatite. Botulinum toxin, by relaxing the mm. platysma, also provides improvement in facial contour. Combination treatments for this region are usually recommended as they offer better results. Objective: This study evaluated the efficacy and safety of the joint dilution of both products (Relax and Firmness - RF), applied in the same device, based on the treatment in the topography of the platysma muscle, ie, starting from the lower third of the face and extending to the neck. Methods: Prospective, blinded, controlled study with 10 participants randomly assigned to RF and 5 in the control group (treated with CaHA only). Results were recorded through the Vectra platform and subjectively evaluated through the GAIS scale by participants and blinded evaluators. Objective analysis was performed using corneometry. Times evaluated: pre-treatment, 30 and 90 days. Considered statistically significant when p<0.1. Results: 100% of the RF group reported "excellent improvement" at D30 and 30% at D90. In the control group, 100% reported "very improved" at D30 and 20% rated "excellent improvement" at D90. A higher and earlier satisfaction rate was observed in the RF group. No difference in corneometry was found between the groups at D30. At D90, the control group had a mean increase of 0.24 versus 5.17 in the RF group (p-value=0.089*). When we analyzed the percentage variation from baseline, the control group was stable, while the RF showed a mean increase of 8.89% (p-value=0.062*). Discussion: We demonstrated the safety and effectiveness of the association of both products, diluted and applied together through microcannulas. Minimization of punctures, patient comfort, and technique based on the anatomy of the platysma muscle underlie the technique. High rates of early satisfaction due to botulinum toxin (Relaxation) and late satisfaction due to CaHA (Firmness).

Facial anatomy applied to live models / Anatomia facial aplicada em modelos vivos

Introduction: Anatomy is one of the foundations in medicine, and choosing a practical and dynamic teaching method is essential for better retention of your learning. The objective is to use facial anatomy applied to live models as an innovative teaching strategy and to evaluate the experience of the learning experience of students assigned to the method. Method: The work analyzes the experience with body painting of 51 students from Instituto Boggio assigned this method (or instructed to use this method) during their classes. Different planes and anatomical structures were represented on live models' faces to simulate and teach the main injectable cosmetic procedures; syringes, needles, cannulas, and ultrasound gel stained with food inks were used. Overlapping latex layers were used for the anatomical study of the temple, middle third of the face, and nose, allowing the reproduction of fillers and biostimulators in these regions. The main muscle groups were represented for the discussion of high-precision botulinum toxin. After the entire demonstration, the students answered a questionnaire via "Google Forms" evaluating the methodology used. Results: According to the answers to the questionnaires, most students considered body painting an innovative methodology that contributed to learning anatomical content and satisfactorily illustrating the demonstrated cosmetic procedures. Conclusion: Practical learning through live models makes this new teaching method something innovative and unique that, in an enjoyable way, enables the study of anatomy and appropriately trains clinical skills.

Introdução: A anatomia é um dos principais alicerces no exercício da medicina e a escolha de um método de ensino prático e dinâmico é fundamental para melhor retenção do seu aprendizado. O objetivo é utilizar a anatomia facial aplicada em modelos vivos como estratégia inovadora de ensino e avaliar a experiência do processo de aprendizagem dos alunos submetidos ao método. Método: O trabalho analisa a experiência vivida com a pintura corporal por 51 alunos do Instituto Boggio submetidos ao método durante as aulas ministradas. Diferentes planos e estruturas anatômicas foram representados nas faces de modelos vivos. Para simulação e ensino dos principais procedimentos cosmiátricos injetáveis, seringas, agulhas, cânulas e gel de ultrassom corado com tintas alimentícias foram utilizados. Camadas de látex sobrepostas foram utilizadas para estudo anatômico da têmpora, terço médio da face e nariz, possibilitando a reprodução do uso de preenchedores e bioestimuladores nestas regiões. Os principais grupamentos musculares foram representados para discussão sobre toxina botulínica de alta precisão. Após toda a demonstração, os alunos responderam a um questionário via "Formulários Google" avaliando a metodologia utilizada. Resultados: De acordo com as respostas dos questionários, a maioria dos alunos considerou a pintura corporal como uma metodologia inovadora e que contribui no aprendizado do conteúdo anatômico, bem como ilustra satisfatoriamente os procedimentos cosmiátricos demonstrados. Conclusão: A aprendizagem prática por meio dos modelos vivos faz deste novo método de ensino algo inovador e único que, de maneira lúdica, possibilita o estudo da anatomia e o treinamento de habilidades clínicas adequadamente.

Safety of the inferolateral orbital access for filling the temporal region with the fanning technique.

INTRODUCTION: The anatomical complexity of the temporal region makes it so treatments with fill-ins are challenging due to high vascular risk. Techniques which provide safer procedures must be encouraged. GOAL: Suggest access to the temple through the inferolateral orbital region as a means for safer temporal fill-ins. METHODS: The fanning technique was plotted out not only via the conventional access (pretragal) but via the proposed one as well. The superficial temporal artery (STA) was mapped with ultrasound. The angles for each of the five retroinjection vectors were calculated in relation to STA and their mean was extracted. The longitudinality of the vector in regard to the vessel was considered the least safe factor. RESULTS: The mean injection angle towards the artery was a 35-degree angle for the conventional access technique and a 73-degree angle for the inferior-lateral orbital access technique (p < 0.05). The more a degree is tangential to the vessel, the higher the chances for inadvertent puncture due to small technical issues. The safety of the procedure through the inferolateral orbital access is corroborated with blind ultrasound imaging done in real-time by radiologists. CONCLUSION: The suggested access is shown to be comparably safer from a vascular perspective than the conventional pretragal access.

High Precision Use of Botulinum Toxin Type A (BONT-A) in Aesthetics Based on Muscle Atrophy, Is Muscular Architecture Reprogramming a Possibility? A Systematic Review of Literature on Muscle Atrophy after BoNT-A Injections.

Improvements in Botulinum toxin type-A (BoNT-A) aesthetic treatments have been jeopardized by the simplistic statement: "BoNT-A treats wrinkles". BoNT-A monotherapy relating to wrinkles is, at least, questionable. The BoNT-A mechanism of action is presynaptic cholinergic nerve terminals blockage, causing paralysis and subsequent muscle atrophy. Understanding the real BoNT-A mechanism of action clarifies misconceptions that impact the way scientific productions on the subject are designed, the way aesthetics treatments are proposed, and how limited the results are when the focus is only on wrinkle softening. We designed a systematic review on BoNT-A and muscle atrophy that could enlighten new approaches for aesthetics purposes. A systematic review, targeting articles investigating BoNT-A injection and its correlation to muscle atrophy in animals or humans, filtered 30 publications released before 15 May 2020 in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Histologic analysis and histochemistry showed muscle atrophy with fibrosis, necrosis, and an increase in the number of perimysial fat cells in animal and human models; this was also confirmed by imaging studies. A significant muscle balance reduction of 18% to 60% after single or seriated BoNT-A injections were observed in 9 out of 10 animal studies. Genetic alterations related to muscle atrophy were analyzed by five studies and showed how much impact a single BoNT-A injection can cause on a molecular basis. Seriated or single BoNT-A muscle injections can cause real muscle atrophy on a short or long-term basis, in animal models and in humans. Theoretically, muscular architecture reprogramming is a possible new approach in aesthetics.

Perda de definição do contorno do submento: correto diagnóstico e algoritmo de tratamento / Loss of definition of the submental contouring: correct diagnosis and treatment algorithm

A busca por procedimentos estéticos voltados para a perda de definição do submento é crescente. Um correto diagnóstico é imperativo para o sucesso do tratamento e redução das complicações. Adiposidade localizada, flacidez cutânea e perda da estrutura óssea são os principais achados. Um algoritmo de tratamento foi discutido nesta revisão, lembrando-se, claro, da possibilidade de tratamentos combinados e sequenciais para melhores resultados

The search for aesthetic procedures aimed at the loss of submental definition is increasing. A correct diagnosis is imperative for successful treatment and the reduction of complications. Localized adiposity, skin flaccidity, and loss of bone structure are the main findings. A treatment algorithm was discussed in this review, remembering, of course, the possibility of combined and sequential treatments for better results.

Mamoplastia: passos para uma cirurgia segura. Evidências da literatura / Mammoplasty: steps for safe surgery. Evidence from literature

RESUMO Introdução: A mamoplastia é uma das cirurgias mais realizadas pelos cirurgiões plásticos. Como todo procedimento, não é isenta de riscos ou complicações. Objetivos: Discutir questões controversas e intercorrências em cirurgia mamária e principais tratamentos. Métodos: Participaram da discussão quatro membros titulares da SBCP com ampla experiência em cirurgia plástica mamária, além do regente do capítulo de mamoplastias. Foram avaliados fatores que apresentavam maior controvérsia em mamoplastias: utilização de antibióticos; infiltração pré-operatória; associação da mamoplastia com implantes mamários; grandes ptoses mamárias; mamoplastia masculinizadora; retalhos para ascensão do complexo areolopapilar (CAP); utilização de drenos; curativos em mamoplastias e enxerto de gordura. Resultados: A literatura e discussão entre especialistas gerou as observações: há evidencias robustas da efetividade no uso de antibióticos perioperatório de mamoplastias redutoras, mas não há evidências de benefícios em se manter o uso por mais de 24 horas; a infiltração pré- operatória com soluções vasoconstritoras não reduz a incidência de hematoma; em mamoplastia associada a implantes não houve consenso sobre a melhor técnica, plano ou textura do implante; não houve consenso sobre a melhor técnica na ascensão do CAP em grandes ptoses, se enxertos ou retalhos; a mamoplastia masculinizadora não apresenta complicações diversas das encontradas na literatura; não existe protocolo específico para conduta quando há sofrimento do CAP; curativos podem ser removidos no primeiro dia de pós-operatório ou mantidos por mais tempo, e deve haver parcimônia no enxerto de gordura. Conclusão: O presente estudo concluiu que a mamoplastia é uma cirurgia segura, porém são necessários estudos continuados que possibilitem minimizar complicações.

ABSTRACT Introduction: Mammoplasty is one of the most performed surgeries by plastic surgeons. Like every procedure, it is not free of risks or complications. Objectives: Discuss controversial issues and complications in breast surgery and main treatments. Methods: Four full members of the SBCP with extensive experience in breast plastic surgery participated in the discussion, in addition to the regent of the mammoplasty chapter. Factors that presented the greatest controversy in mammoplasties were evaluated: use of antibiotics; preoperative infiltration; association of mammoplasty with breast implants; large mammary ptoses; masculinizing mammoplasty; flaps for the elevation of the nipple-areola complex (NAC); use of drains; dressings in mammoplasties and fat grafting. Results: The literature and discussion among specialists generated the observations: there is robust evidence of the effectiveness in the use of perioperative antibiotics of reducing mammoplasties, but there is no evidence of benefits in maintaining use for more than 24 hours; preoperative infiltration with vasoconstrictor solutions does not reduce the incidence of hematoma; in mammoplasty associated with implants there was no consensus on the best technique, plane or texture of the implant; there was no consensus on the best technique in the elevation of NAC in large ptoses, whether grafts or flaps; masculinizing mammoplasty does not present complications different from those found in the literature; there is no specific protocol for conduct when there is suffering from the NAC; dressings can be removed on the first postoperative day or kept longer, and there should be parsimony in the fat graft. Conclusion: The present study concluded that mammoplasty is safe surgery, but continued studies are needed to minimize complications.

Embelezamento facial com injetáveis e principais diferenças entre os gêneros / Facial beautification with fillers and main differences between genders

A percepção da beleza é ainda algo pouco compreendida, apesar de francamente notável. Pessoas consideradas belas notadamente tem melhor autoestima e um melhor desempenho em suas relações interpessoais. A procura por tratamentos cosmiátricos está em franca ascensão e o crescimento entre os homens é ainda maior. A perfeita compreensão das diferenças entre os atributos masculinizantes e feminilizantes em uma face deve ser encorajado, a fim de obter melhores resultados estéticos e a prevenção de estigmas de tratamento. Nesta revisão, será abordada cada região facial, pormenorizando os padrões de beleza de cada gênero, norteando os detalhes do tratamento.

The beauty perception is still poorly understood, though downright remarkable. People considered beautiful notably have better self-esteem and perform better in their interpersonal relationships. Demand for cosmetic treatments is on the rise and growth among men is even higher. Perfect understanding of the differences between masculinizing and feminizing attributes on a face should be encouraged in order to achieve better aesthetic results and the prevention of treatment stigmas. This review will cover each facial region, detailing the beauty standards of each gender, guiding the details of treatment.

Assimetria mamária: revisão da literatura e nova proposta de classificação clínica / Breast asymmetry: literature review and a new proposal for clinical classification

A assimetria mamária é um diagnóstico prevalente com diversas modalidades cirúrgicas para seu tratamento. O correto diagnóstico, levando-se em conta os sistemas de classificação existentes é imperativo para que os melhores resultados sejam alcançados. Através de revisão da literatura foram levantadas as principais e mais aceitas propostas de classificação e tratamento das assimetrias mamárias. Estas classificações disponíveis datam da década de 60 e 70 e carecem de atualização para o contexto clínico atual. Após ampla revisão da literatura foi proposta uma classificação mais simplificada e reprodutível, levando-se em conta as assimetrias mais frequentes nos consultórios de cirurgia plástica estética, com seus respectivos guias de tratamento. Cinco grupos foram criados: 1 - mamas hipotróficas com assimetria de volume; 2 - hipotrofia com assimetria de volume e contorno; 3 - mamas normotróficas, ptóticas e sem desejo de aumento do volume; 4 - mamas normotróficas, ptóticas e com desejo de aumento do volume final; 5 - mamas assimétricas e hipertróficas. Baseado nos achados clínicos, foi criado um algoritmo de tratamento para cada subtipo de assimetria, incluindo neste arsenal, próteses mamárias de volumes diferentes, mastopexias, mamoplastia redutoras, além da lipoenxertia. Importante ressaltar que a assimetria mamária é a regra e não a exceção, entretanto, é motivo de insatisfação das pacientes e um desafio para o cirurgião plástico.

Breast asymmetry is a prevalent diagnosis that has several surgical modalities for its treatment. The correct diagnosis, taking into account the existing classification systems, is imperative for achieving the best results. The leading and most accepted proposals for the classification and treatment of breast asymmetries were raised through the literature review. These available classifications date from the 60s and 70s and need to be updated to the current clinical context. A more simplified and reproducible classification was proposed after a comprehensive literature review, considering the most frequent asymmetries in aesthetic plastic surgery offices, with their respective treatment guides. Five groups were created: 1 - hypotrophic breasts with volume asymmetry; 2 - hypotrophy with volume and contour asymmetry; 3 - normotrophic, ptotic breasts and with no desire to increase the volume; 4 - normotrophic, ptotic breasts and with a desire to increase the final volume; 5 - asymmetric and hypertrophic breasts. Based on the clinical findings, a treatment algorithm was created for each subtype of asymmetry, including in this arsenal, breast implants of different volumes, mastopexies, reduction mammoplasty, and fat grafting. It is important to emphasize that breast asymmetry is the rule and not the exception, therefore, it is a reason for patient dissatisfaction and a challenge for the plastic surgeon.

Padronização da aplicação corporal de hidroxiapatita de cálcio com a técnica de figuras vetorizadas / Standardization of the body vectoring technique with calcium hydroxyapatite

Introdução: a hidroxiapatita de cálcio em gel carreador de carboximetilcelulose apresenta resultados inequívocos para a melhora cutânea facial, estimulando a produção de colágeno e elastina. Seu uso para tratamento corporal tornou-se on- label apenas recentemente, após comprovações científicas de seu benefício em maior diluição. O objetivo deste trabalho foi demonstrar uma padronização técnica para racionalização da aplicação corporal. Neste estudo foram idealizadas figuras vetorizadas para aplicação da hidroxiapatita de cálcio com diluição intermediária. Com a técnica proposta, é possível calcular, com exatidão, o volume de produto necessário para cada paciente em função do tamanho da unidade anatômica a ser tratada e das características topográficas da região. A racionalidade desta técnica permite ainda distribuição homogênea, minimização das complicações por acúmulo de produto, boa tolerabilidade pela paciente e otimização dos resultados. Conclusões: a simplicidade técnica das figuras vetorizadas facilita a aplicação da hidroxiapatita de cálcio, e as customizações devem ser feitas com a maior experiência do injetor.

Introduction: Calcium hydroxyapatite in a carboxymethylcellulose carrier gel presents unequivocal results for facial skin improvement, stimulating the collagen and elastin production. Regulatory agencies recently approved its use after scientific proof of its benefit in greater dilution. Objective: This study aimed to demonstrate a technical standardization to rationalize body application. Methods: This study idealized vectorized figures to apply calcium hydroxyapatite with intermediate dilution (1:4). Results and discussion: The proposed technique makes it possible to accurately calculate the required for each patient, depending on the anatomical unit's size to be treated and the region's topographic characteristics. This technique's rationale also allows homogeneous distribution, minimization of complications due to product accumulation, good tolerability by the patient and optimization of results. Conclusions: The vectorized figures' technical simplicity facilitates calcium hydroxyapatite application, and customizations must be made with the injector's greatest experience

Six years of experience using an advanced algorithm for botulinum toxin application.

BACKGROUND: Botulinum toxin (BTX) products continue to be widely used for facial rejuvenation. Variables to consider prior to BTX treatment include the anatomical area to be treated, gender, muscle mass, ethnicity, skin thickness, and the effects of aging. OBJECTIVE: To describe a treatment algorithm which has been developed for facial rejuvenation to help physicians to easily and systematically customize BTX treatment, and to describe its use in a large number of patients. METHODS AND MATERIALS: Prior to treatment, digital images of patients were obtained while relaxed and while forming different facial expressions. This information was used to plan the depth, dose, and location of BTX injections (onabotulinumtoxinA; Botox® ; Allergan, Inc). Dilution was 100 U of BTX to 1 mL 0.9% preserved saline. Injections were performed with 30 U insulin syringes and 30 gauge needles. RESULTS: The treatment algorithm described here has been used by the author for facial rejuvenation for more than 5 years. It was originally based on published guidelines; however, by carefully noting treatment outcomes, the number and location of injection points and the dose of BTX used have been modified to create the current treatment system. CONCLUSION: Published guidelines for the use of BTX are an excellent starting point for clinicians with little experience; however, each practitioner is likely to develop their own algorithm for achieving good facial rejuvenation outcomes.

Dynamic Model of Applied Facial Anatomy with Emphasis on Teaching of Botulinum Toxin A.

BACKGROUND: The use of botulinum toxin type A is considered one of the most revolutionary and promising face rejuvenation methods. Although rare, most of the complications secondary to the use of botulinum toxin A are technician dependent. Among the major shortcomings identified in the toxin administration education is unfamiliarity with applied anatomy. This article proposes the use of body painting as an innovative method of teaching the application of botulinum toxin A. METHODS: Using the body painting technique, facial anatomy was represented on the face of a model showing the major muscle groups of botulinum toxin A targets. Photographic records and films were made for documentation of represented muscles at rest and contraction. RESULTS: Using the body painting technique, each of the muscles involved in facial expression and generation of hyperkinetic wrinkles can be faithfully reproduced on the model's face. The documentation of the exact position of the points of application, the distribution of the feature points in the muscular area, the proper angulation and syringe grip, as well as the correlation of the points of application with the presence of hyperkinetic wrinkles, could be properly registered, providing professional training with information of great practical importance, development of highly effective treatments, and low complication rates. CONCLUSION: By making it possible to interrelate anatomy of a function, body painting is proposed in the present study as an innovative method, which in a demonstrative and highly didactic manner presents great potential as a teaching tool in the application of botulinum toxin A.

Diagnóstico e tratamento dos eventos adversos do ácido hialurônico: recomendações de consenso do painel de especialistas da América Latina / Diagnosis and treatment of hyaluronic acid adverse events: Latin American expert panel consensus recommendations

Introdução: Na última década, o uso do preenchimento com ácido hialurônico para aprimoramento facial aumentou na América Latina. O preenchimento com ácido hialurônico é considerado seguro com baixa incidência de eventos adversos. Como eventos adversos são pouco observados na prática clínica ou têm sido possivelmente sub-relatados são necessárias mais orientações para diagnosticar e tratar eventos adversos relacionados ao ácido hialurônico. Objetivo: Compreender melhor os eventos adversos relacionados ao ácido hialurônico e propor recomendações para o diagnóstico e tratamento. Métodos: Reunião em painel de 25 especialistas médicos multidisciplinares da América Latina foi realizada em São Paulo, Brasil, para discutir o que se conhece sobre eventos adversos relacionados ao ácido hialurônico e fornecer conhecimentos baseados na experiência clínica. Por meio de consenso, foram desenvolvidos recomendações e algoritmos. Resultados: O painel categorizou eventos adversos relacionados ao ácido hialurônico baseado em três momentos de início (imediato, precoce e tardio) e propôs um novo termo para eventos adversos que apresentam edema tardio intermitente persistente ("Etip"). Foram criados algoritmos para diagnóstico e tratamento em cada momento. Conclusões: Novos algoritmos consensuais para diagnósticos e tratamentos associados ao momento de início dos eventos adversos relacionados ao ácido hialurônico orientarão melhores práticas no uso clínico do preenchimento com ácido hialurônico.

Introduction: In the last decade, the use of hyaluronic acid fillers for facial enhancement has increased in Latin America. Hyaluronic acid fillers are considered relatively safe with a low incidence of adverse events. Because adverse events are not seen frequently in clinical practice or have been potentially underreported, there is a need for more guidance on the diagnosis and treatment of Hyaluronic acid-related adverse events. Objecti ve: To provide an enhanced understanding of hyaluronic acid-related adverse events and to propose recommendations for their diagnosis and treatment. Methods: A 25-member multi-disciplinary expert panel meeting of Latin-American physicians was convened in Sao Paulo, Brazil to discuss what is known about hyaluronic acid-related adverse events and to provide insights based on clinical experience. Recommendations and algorithms were developed through a consensus process. Results: The panel categorized hyaluronic acid-related adverse events based on 3 time frames of onset (immediate, early and Late) and proposed a new term for adverse events that display persistent, intermittent, delayed Swelling (PIDS). Algorithms were created for diagnosis and treatment for each time frame. Conc lusions: The new consensus algorithms for time-related diagnosis and treatment of hyaluronic acid-related adverse events will provide guidance for best practices in the clinical use of hyaluronic acid fillers.

Pontos de adesão na cirurgia do contorno corporal / Adhesion suture in plastic of body countering

INTRODUÇÃO: Seromas, hematomas e alterações cicatriciais são complicações potenciais no pós-operatório das abdominoplastias. Drenagem aspirativa e pontos de adesão são estratégias utilizadas na prevenção destas complicações. A proposta deste estudo é avaliar a eficácia dos pontos de adesão na prevenção ou redução da formação de seroma, hematoma e de complicações cicatriciais em pacientes submetidos a cirurgia plástica do contorno corporal. MÉTODO: Cento e quinze pacientes (grupo 2: janeiro de 2006 - junho de 2010) submetidos a cirurgia plástica do contorno corporal com o uso dos pontos de adesão foram comparados, retrospectivamente, com um grupo de 39 pacientes (grupo 1: janeiro de 2004 - dezembro de 2005) submetidos a mesma cirurgia com o uso de drenagem aspirativa. Avaliação clínica dos pacientes foi realizada com 7 dias, 2 semanas, um, dois, três e seis meses de pós-operatório. RESULTADOS: No grupo 1, houve 9 (23 por cento) casos de seroma, 1 (2,5 por cento) de hematoma e 20 (55 por cento) de complicações cicatriciais, enquanto que, no grupo 2, nenhum caso de seroma ou hematoma foi reportado. A avaliação clínica revelou diferenças estatísticas entre o uso dos pontos de adesão e a drenagem aspirativa, no que se refere à incidência de seroma e de complicações cicatriciais. CONCLUSÃO: O uso dos pontos de adesão é um método eficiente na prevenção de seromas, hematomas e complicações cicatriciais nas cirurgias do contorno corporal.

INTRODUCTION: Seroma, hematoma and wound alterations are potential complications following abdominoplasty. Aspiratory drainage and adhesion suture are widely employed strategies for prevention of these complications. The purpose of this study is to evaluate the efficacy of adhesion suture in preventing or reducing seroma, hematoma formation and local wound complications in patients undergoing plastic of body countering. METHODS: 115 patients (group 2: January 2006 - June 2010) who underwent plastic of body countering with the use of adhesion suture were retrospectively compared with a group of 39 patients (group 1: January 2004 - December 2005) who underwent with the use aspiratory drainage. Clinical evaluation of the patients was performed seven days, two weeks, one, two, three and six months postoperatively. RESULTS: In group 1, there was 9 (23 percent) cases of seroma, 1 (2.5 percent) case of hematoma and 20 (55 percent) cases of wound complications, whereas in group 2 no seroma or hematoma was reported. In this group, there were 14 (12 percent) cases of wound complications. Clinical evaluation revealed statistical difference between the use of adhesion suture and the aspiratory drainage in the incidence of seroma and wound complications. CONCLUSION: The use of adhesion suture is an effective measure to prevent seroma, hematoma and wound complications in patients undergoing plastic of body countering.

Effect of a calcium-channel blocker (verapamil) on the morphology, cytoskeleton and collagenase activity of human skin fibroblasts.

The effects of verapamil modulating collagen biosynthesis have prompted us to study the role of this drug in cultured fibroblasts. In this article, we describe the effects of verapamil on fibroblast behaviour, with special emphasis to phenotypic modifications, reorganisation of actin filaments and secretion of MMP1. Human dermal fibroblasts treated with 50-µM verapamil changed their normal spindle-shaped morphology to stellate. Treated cells showed discrete reorganisation of actin filaments, as revealed by fluorescein isothiocyanate (FITC)-phalloidin staining and confocal microscopy. We hypothesised that these effects would be associated to lower levels of cytosolic Ca(2+). Indeed, short time loading with calcium green confirmed that verapamil-treated fibroblasts exhibited lower intracellular calcium levels compared to controls. We also observed that verapamil increases the secretion of MMP1 in cultured fibroblasts, as demonstrated by zymography, specific substrate assays and immunoblot. The morphological alterations induced by verapamil are neither cytotoxic nor associated with other dramatic cytoskeleton alterations. Thus we may conclude that this drug enhances collagenase secretion and does not disrupt the major tracks necessary to deliver these enzymes in the extracellular space. The present results suggested that verapamil could be used at physiological levels to enhance collagen I breakdown, and may be considered a potential candidate for intralesional therapy of wound healing and fibrocontractive diseases.

Prevenção e tratamento da contratura capsular após implantação de prótese mamária / Prevention and treatment of capsular contracture after mammary prosthesis implantation

Introdução: A contratura capsular é definida como uma cicatrização esférica com contração da cápsula que envolve a prótese mamária. A proposta desse trabalho foi elaborar um protocolo para prevenção e tratamento da contratura capsular. Método: Foram avaliadas 9 pacientes que desenvolveram contratura capsular, 3 foram classificadas como Baker II, 5 como Baker III e 1 como Baker IV. As pacientes com contratura capsular Baker II foram tratadas clinicamente, associando-se microcorrente (MENS), ultrassom (US) e drenagem linfática manual (DLM). Nos casos de contratura grau III e IV de Baker, substituiu-se a prótese mamária, reposicionando-a em plano submuscular, associando-se tratamento clínico (MENS/US/DLM) e zafirlucaste 20mg, via oral, de 12/12 horas, por 90 dias. Resultados: Oito (89%) pacientes tiveram resolução completa da contratura, retornando a Baker I e uma (11%) apresentou redução da contratura de Baker III para Baker II, mesmo após substituição da prótese mamária. Clinicamente, nenhuma paciente apresentou efeitos colaterais. Conclusão: A associação MENS/US/DLM mostrou-se como uma importante ferramenta no tratamento das contraturas Baker II. Nos casos de contratura Baker III e IV, a associação MENS/US/DLM, reposicionamento da prótese no plano submuscular e utilização do zafirlucaste demonstrou bons resultados na resolução das contraturas. Os resultados obtidos encorajaram-nos a utilizar a associação MENS/US/DLM de maneira preventiva em todas pacientes submetidas ao implante de prótese de silicone.

Introduction: Capsular contracture is defined as a spherical scar with contraction of the capsule involving the prosthesis. The proposal suggested by this study is to elaborate a protocol to treat and prevent capsular contracture. Methods: Nine patients were evaluated, who developed capsular contracture. Three patients were graded as Baker II, five as Baker III and one as Baker IV. The Baker II patients were clinically treated associating micro electro neuro stimulation (MENS), ultrasound (US) and manual lymphatic drainage (MLD). The Baker III and IV patients had the breast implant replaced, repositioning the implant in submuscular plane, associating the clinical treatment (MENS/US/MLD) and zafirlukaste 20mg oral intake twice daily for a period of 90 days. Results: There was complete resolution of the contracture, returning to Baker grade I in8 patients (89%). There was reduction on Baker grade from III to II in one patient, even after breast implant replacement. Clinically, none patient presented side effects. Conclusion: The association of MENS/US/MLD demonstrated an important tool for the management of grade II contractures. The association of breast implant replacement and repositioning in submuscular plane, associated to the clinical treatment (MENS/US/MLD) and zafirlukaste demonstrated good results in capsular contracture resolution. These results encouraged us to use the MENS/US/MLD to prevent capsular contracture in all breast implant patients.

Estudo in vitro dos efeitos do bloqueador do canal decálcio (verapamil) sobre a biossíntese e contração damatriz extracelular / In vitro study of effects of calcium channel blocker (verapamil) on biosyntheses

Introdução: A adequada formação do tecido de granulação depende do equilíbrio entre abiossíntese e a degradação da matriz extracelular (MEC). A síntese excessiva de colágeno e adeficiente remodelação da MEC podem induzir o aparecimento de lesões dérmicas tipo quelóidese cicatrizes hipertróficas. Método: No presente estudo, utilizamos fibroblastos dérmicoshumanos povoados em gel de colágeno I, tratados ou não pelo bloqueador de canal de cálcio(verapamil). Uma vez no gel de colágeno, a morfologia tridimensional dos fibroblastos foianalisada por microscopia confocal e em cortes corados por hematoxilina & eosina. A atividadeda colagenase (MMP-I) foi determinada por “immunoblot” do meio condicionado. Resultados:Observamos neste estudo maior contração do gel de colágeno povoado por fibroblastoscontrole, quando comparado ao gel povoado por fibroblastos tratados com verapamil. A maiorcontração demonstrada pelos fibroblastos controle foi relacionada à reorientação das fibrascolágenas, à organização dos filamentos de actina e aos níveis de cálcio citosólico. Observamos,também, que o verapamil aumenta a secreção de colagenase. Conclusão: Concluímos que overapamil, ao alterar o metabolismo celular do cálcio, exerce influência sobre a contração daMEC e produção de proteases, com consequente efeito sobre o desenvolvimento de afecçõescicatriciais, como quelóides e cicatrizes hipertróficas.

Background: The appropriate formation of the granulation tissue depends on the balancebetween the biosyntheses and the degradation of the extracellular matrix (EM). The excessivesynthesis of collagen and the deficient degradation of the EM might cause dermal lesions suchas keloids and hypertrophic scars. Methods: In this study we used an experimental modelwhere collagen gels populated by dermal human fibroblast underwent progressive contraction.Fluorescence preparations were studied by confocal microscopy. Collagenase activity (MMPI)was determined in conditioned medium from fibroblasts using immunoblot. Results: Thisstudy showed a greater contraction of the gels populated with control fibroblasts per the timestudied in relation to the gels populated with fibroblasts treated with verapamil. Perhaps thishigher contracting ability is involved with actin organization and levels of cytosolic calcium.We also observed that verapamil increase the secretion of MMP-I. Conclusion: We concludethat cellular calcium metabolism appears to regulate EM production and contraction and thosehypertrophic disorders of wound healing (keloids and hypertrophic scars) may respond totherapy with calcium antagonist drugs (verapamil).