Treatment of periocular and temporal reticular veins with 1064-nm Nd:YAG Laser.

BACKGROUND: The periocular and temporal regions are important aspects of beauty. The presence of reticular veins in these areas is undesirable and can also interfere with injection of neurotoxins to treat squint lines. 1064-nm Nd:YAG laser shows promise as an effective treatment modality with long-lasting effects. AIM: The aim of the study is to show that the long-pulsed, contact-cooled, variable spot-sized 1064-nm Nd:YAG laser is effective and safe, with good patient satisfaction and tolerability, and is able to achieve long-term results. METHODS: A retrospective study of 35 consecutive patients seen over a 3-year period in a private cosmetic clinic affiliated to the University of Toronto for periocular and temporal reticular veins was conducted. They were all treated with 1064-nm Nd:YAG laser. RESULTS: A total of 35 patients with an average age of 45.8 years old received treatment. 13 had lower eyelids treated, 9 had temples treated, 12 had both lower eyelids and temples treated, and 1 had both upper and lower eyelids treated. The first case of upper eyelid vein being treated with the 1064-nm Nd:YAG laser with great success after only 1 treatment is reported. 80% of the patients required only 1-2 treatment sessions. The average satisfaction score was 7.9 out of 10. The average pain score was 5.0 out of 10. 91% perceived the treatment outcome as excellent or good with the longest result lasting 33 months. There were 4 complications: 1 scabbing, 1 small burn, 1 skin darkening, and 1 teary eye. CONCLUSION: The study showed that the use of the long-pulsed, contact-cooled, variable spot-sized 1064-nm Nd:YAG laser is effective and safe, with good patient satisfaction and tolerability, and is able to achieve long-term results.

Rosacea: pathophysiology and management principles.

This article presents an overview of the pathophysiology, epidemiology, and clinical presentations of rosacea. It also presents the therapeutic spectrum for effective management of this challenging and often confusing clinical entity.

Periorbital rejuvenation: reticular vein treatment.

The safety profile of certain techniques, such as sclerotherapy, is questionable in a region as precarious as the periorbital region, where complications related to vision would be catastrophic. Other safe techniques such as phlebectomy can be performed with successful outcomes but are operator dependent, require a reasonable degree of technical ability, and can result in scarring and other complications. The aim of this article is to explore newer, laser-based treatment of these periorbital veins, discuss the physiology and the therapeutic efficacy, and better delineate the safety profile and evolution of the technique that has led to the present treatment paradigm.

Permanent soft tissue fillers.

As our youth-oriented society ages, interest in nonsurgical aesthetic techniques has generated a dramatic rise in the use of filling agents for facial rejuvenation. Backed by multiple published studies documenting safety and efficacy, soft tissue fillers are often viewed as treatments with minimal recovery time and limited risk of complications when compared with traditional surgical interventions. This has led to a genuine demand for fillers with similar safety profiles but ever increasing longevity in their aesthetic corrections. This review addresses many of the permanent soft tissue fillers that are commercially available worldwide as well as important concerns regarding their complications.

Large needle suction aspiration of permanent fillers.

Temporary injectable fillers have become so widely accepted within the cosmetic medical industry that permanent fillers with longer lasting effects are fast gaining popularity. Both patients and physicians alike have eagerly sought a product to minimize the inconvenience and cost of repeated injections. However, the fear is that the use of permanent fillers may lead to permanent problems. We describe here an in-office technique to remove permanent injectable fillers that achieves consistent, natural results with minimal risk of scarring.

Aging skin: histology, physiology, and pathology.

Skin is a complex organ covering the entire surface of the body. Aged skin is characterized by appearance of wrinkles, laxity, and pigmentary irregularities. These changes occur under the influence of intrinsic and extrinsic factors, with sun exposure being the most deleterious to the skin. Skin changes associated with aging are the focus of many surgical and nonsurgical procedures aimed to improve the appearance of skin. Knowledge of skin histology and physiology will deepen the understanding of cutaneous changes associated with aging and will promote optimal cosmetic and functional patient outcomes.

Standardized photography for skin surface.

Photographic documentation is an essential part of facial plastic surgery practice. Standardization of photographic technique is critical to achieve accurate and consistent images to be used for medicolegal, surgical planning, outcome review, research, and teaching purposes. Standardized, high-quality images can be achieved by using proper equipment, lighting, and patient positioning. Standardized photography is especially important for facial resurfacing procedures when fine details, such as pore size, skin texture, pigmentation, and rhytids, need to be captured and accurately assessed. The purpose of this review is to discuss how to obtain standardized, high-quality images of skin surface.

Acne rosacea: effectiveness of 532 nm laser on the cosmetic appearance of the skin.

OBJECTIVE: The aim of the study was to perform a prospective blinded trial to compare the improvement of midface acne rosacea using 532 nm laser therapy with and without a retinaldehyde-based topical application. SETTING: A private clinic and surgicentre specializing in facial plastic surgery. DESIGN: A prospective randomized blinded clinical trial. METHODS: Fourteen patients with type 1 erythematotelangiectatic acne rosacea were enrolled in the study. The side of the face to be treated was chosen randomly. The opposite side of the face served as the control. Patients underwent six treatments with the 532 nm laser, with four sets of photodocumentation over a period of 3 months. Following each treatment, patients were asked to rate their degree of improvement based on a 5-point improvement scale. A final assessment was performed by five separate blinded evaluators. MAIN OUTCOME MEASURES: Final photographic evaluation to assess (1) reduction in overall redness, (2) reduction in visible telangiectasia, (3) difference between left and right sides of the face, and (4) degree of overall skin texture improvement. RESULTS: Three men and eight women completed the study. Six right hemifaces and five left hemifaces were treated. One hundred percent of patients noted a mild to moderate improvement in all signs of type 1 acne rosacea, including overall redness of the face, telangiectasia, and skin texture. The blinded evaluators were able to note a difference between the treated and untreated sides 47% of the time. CONCLUSION: The 532 nm laser combined with the topical retinaldehyde improved overall redness, telangiectasia, and skin texture in acne rosacea patients. The degree of improvement was greater when compared to using the laser alone as the sole treatment modality.

Nasal tip refinement: analysis of surgical technique, efficacy, and secondary effect of skin thickness.

BACKGROUND: Effective control and refinement of the nasal tip is an integral component of the rhinoplasty operation. A multitude of techniques exist to complement the rhinoplasty surgeon's approach, but attaining consistent and long-lasting results is still challenging due to the complex interplay between nasal anatomy and surgical technique. OBJECTIVES: The authors sought to determine whether the degree of tip narrowing with rhinoplasty is associated with the narrowing technique selected by the surgeon and whether there is an association between skin thickness and tip narrowing. METHODS: A retrospective chart review was conducted of all patients undergoing rhinoplasty in a single-surgeon practice between April 2004 and November 2006. Demographic information and specific operative techniques were recorded. Standard basal views of pre- and postoperative photographs were examined by two blinded observers, who measured nasal tip width relative to interpupillary distance with imaging software. Skin thickness was assessed and categorized by a surgical expert according to Fitzpatrick classification. RESULTS: Forty patients were identified with adequate follow-up and complete data sets. A statistically significant reduction in tip width pre- and postoperatively was seen (P = .041). No significant difference in tip narrowing between various techniques was found (P = .309), and no significant association between tip narrowing and skin thickness was identified (P = .186). CONCLUSIONS: Although tip-narrowing techniques are effective in rhinoplasty, the specific technique employed may not be clinically relevant. Furthermore, skin thickness may not be as significant a factor in tip narrowing as is commonly believed.

Informed consent in rhinoplasty: prospective randomized study of risk recall in patients who are given written disclosure of risks versus traditional oral discussion groups.

OBJECTIVE: To determine the effectiveness of providing written information in enhancing patient understanding and retention. DESIGN: A multicentre prospective randomized study was conducted in university-affiliated ambulatory surgical centres. One hundred consecutive patients seen for rhinoplasty consultation were included. Patients were randomly assigned to (1) those receiving traditional oral dialogue of the surgical risks or (2) those receiving an oral discussion and a written pamphlet outlining the risks of the procedure. Fourteen to 18 days after the consultation, each patient was contacted for an assessment of risk recall. RESULTS: Overall risk recall was higher in the group that received written information (2.3 vs 1.3 of 5 risks; p < .008). As well, in the group that received a pamphlet, patients with university and postgraduate levels of education had a better rate of recall (p < .05). Female patients in both groups reported higher risk recall (p < .01). CONCLUSION: Patient risk recall of rhinoplasty is improved with the addition of written information during the informed consent process. As the process of informed consent plays a very decisive role in facial plastic surgery, enhanced postoperative satisfaction may result from the use of supplemental educational materials.

The Canadian experience with fillers.

The number of commercially available injectable soft tissue fillers has increased dramatically over the past decade. In the United States, a variety of temporary fillers have received Food and Drug Administration (FDA) approval. However, at the present time, there are no permanent soft tissue injectable fillers available. This article will discuss the authors' experience with some of the more popular soft tissue fillers on the market in Canada that are not currently available in the United States.

Treatment alternatives for the lip-cheek groove.

This article discusses a new clinical classification system of the lip-cheek groove to better manage this clinical problem. Treatment options ranging from injectable fillers to allogenic implants and surgical techniques, including thread-lifts and malar fat pad elevation, are discussed.

Therapeutic options for lip augmentation.

Aesthetic ideals vary with emerging fashion trends and within different cultures. However, over the past few decades, fuller lips have been considered a desirable trait. Many younger patients are presenting for lip augmentation to achieve the sought-after look commonly seen in many fashion magazines. In addition, as individuals age, they lose lip volume, with a thinning of the red lip, some effacement of the vermillion border, and elongation and flattening of the white portion of the lip. Rejuvenation of the lips plays a key role in restoring a more youthful appearance. As a result, lip augmentation appeals to a wide spectrum of patients who present with various different aesthetic goals and expectations. Numerous therapeutic options exist for aesthetic lip augmentation, ranging from temporary and permanent injectable fillers to implants and other surgical techniques.

Review of non-FDA-approved fillers.

The number of commercially available injectable soft tissue fillers has increased dramatically worldwide over the past decade. In the United States, a variety of temporary non-collagen-based fillers have been approved. However, no permanent soft tissue injectable fillers are currently approved by the US Food and Drug Administration. This article discusses some of the more popular soft tissue fillers, such as Restylane Fine Line, Restylane SQ, Perlane, Artecoll, Dermalive, Dermadeep, Bioalcamid, Bioplastique, Evolution, Outline, Argiform, and Aquamid, which are all available outside of the United States.

The lip-cheek groove: a new analysis with treatment options.

OBJECTIVE: To present a clinical classification of the lip-cheek groove. DESIGN: The clinical classification, which is based on years of analysis, will provide optimal management options for achieving the greatest degree of correction and rejuvenation of the lip-cheek groove. RESULTS: The use of the clinical classification of the lip-cheek groove will guide the surgeon to the management option(s) that will attain the best aesthetic outcome. CONCLUSION: The classification of the lip-cheek groove enables the surgeon to choose the optimal approach for improvement of the groove.

Applications of aminolevulinic Acid-based photodynamic therapy in cosmetic facial plastic practices.

Photodynamic therapy (PDT) using aminolevulinic acid (ALA) is a promising new technique that is being studied extensively and used in a variety of cosmetic facial plastic arenas. These applications include U.S. Food and Drug Administration-approved treatment of premalignant and malignant skin conditions, as well as off-label uses for photorejuvenation, and the treatment of acne vulgaris, sebaceous gland hyperplasia, rosacea, and hirsutism. This article reviews the interplay of factors that contribute to the appearance of actinically damaged or photoaged skin, also known as dermatoheliosis. This is followed by a brief review of the mechanisms of action of ALA-based PDT and some of its cosmetic facial plastic uses.

Informed consent in facial plastic surgery: effectiveness of a simple educational intervention.

OBJECTIVE: To evaluate the effectiveness of oral communication about the risks of facial cosmetic procedures compared with oral and written communication. DESIGN: A prospective randomized study conducted in an ambulatory surgery center. One hundred twenty consecutive patients were included; they presented for consultation for rhinoplasty, rhytidectomy, or laser resurfacing. Patients were randomly assigned to 1 of 2 groups: (1) those receiving oral discussion of the risks of the procedure and (2) those receiving oral and written communication about the risks. Two weeks after the initial consultation, patients were surveyed for recall of the risks. RESULTS: The group that received a pamphlet had a better risk recall than the group that did not (2.5 vs1.5 of 5 risks; P<.001). The recall rate in the following groups that received a pamphlet was also better: (1) university-educated patients (P =.02), (2) patients who underwent rhinoplasty (P<.001), (3) patients who underwent laser resurfacing (P =.02), and (4) female patients (P<.001). CONCLUSIONS: Written disclosure of the risks of cosmetic procedures enables patients to retain and understand more clearly those potential risks. They are, therefore, able to give an informed consent to the proposed procedure. This study also identifies patient groups who may require more intensive presurgical teaching. The medicolegal implications are apparent.