Treating the double chin with hyaluronic acid injection.

INTRODUCTION: Submental fullness (SMF), or the double chin, is a condition regarded as undesirable. Many treatment modalities are available for SMF reduction, such as energy-based devices, injection lipolysis, or surgery. However, of minimal invasive modalities, hyaluronic acid (HA) injection has not been explored for possible SMF treatment. CASE REPORT: A 52-year-old East Asian female patient with prominent SMF underwent HA filler injection. Aside from marked reduction of SMF prominence, an improvement of sagging over her cheeks and jawline, and a general improvement to facial aging signs was noted. CONCLUSION: HA filler injections for SMF offer an instant, zero downtime, and safe alternative, and can be considered in patients who wish to simultaneously achieve improvement in other facial areas.

Cheek wrinkles revisited: Etiological classifications and nonsurgical treatment options.

BACKGROUND: Wrinkles are one of the key signs of an aging face. Cheek wrinkles have a prominent negative impact on facial aesthetic. Recognizing the pathology and types of different cheek wrinkles, and the possible minimal invasive interventions to treat them, are crucial for optimal aesthetic outcome. OBJECTIVE: The classification of cheek wrinkles based on etiology, past literature, and wrinkle pattern, and the outlining of possible treatment options. RESULT: Five different types of cheek wrinkles are described: Type 1-Atrophic cheek wrinkles, Type 2-dynamic expressional cheek wrinkles, Type 3-static expressional cheek wrinkles, Type 4-laxity cheek wrinkles, and Type 5-sleep cheek wrinkles. Treatment options and techniques for different types of cheek wrinkles are recommended accordingly.

A population-based study to estimate survival and standardized mortality of tuberous sclerosis complex (TSC) in Taiwan.

BACKGROUND: Tuberous sclerosis complex (TSC) is an autosomal dominant disease with systemic manifestations, which can cause significant mortality and morbidity. Population-based epidemiological studies on TSC mortality and survival remain scarce, though several recent studies provide evidence that TSC survival rates are high and disease prognosis is fair for most patients. This study aims to estimate the life expectancy and mortality statistics in Taiwanese TSC patients, investigate prognosis and associations of TSC mortality based on demographic variables, and compare these results to past literature, especially for Asian patients. METHODS: Taiwanese National Health Insurance (NHI) insurees can obtain Catastrophic Illness Certificates (CIC) for certain eligible diseases to waive copayments after diagnosis by two independent physicians. CIC holders for TSC during 1997-2010 were identified from the NHI Research Database. Queries on enrollment (CIC acquisition) age, endpoint (end of query period or death) age, sex, and comorbidities were obtained. Patients were separated into cohorts (endpoint age, sex, and age of diagnosis), and analyzed accordingly. RESULTS: 471 patients (232 male, 239 female) were identified, of which 14 died. Compared to literature, patients showed similar demographics (age range, diagnosis age, sex distribution); similar manifestations and prevalence (epilepsy, intellectual disability, renal disease); lower disease prevalence (1 in 63,290); lower mortality (0.21% per year); and near-identical standardized mortality ratio (4.99). A cumulative mortality of 4.08% was found over 14 years, though mortality plateaued at 7 years post-enrollment, suggesting a good overall survival rate; comparable with previous studies in Asian patients. Enrollment age was a significant prognostic factor, with late-enrollment (age > 18) patients at higher risk for all-cause mortality (Hazard ratio = 6.54). Average remaining lifetime was significantly lower than the general population, and decreased with age. CONCLUSIONS: This study reports a population-based disease database, highlights the importance of diagnosis age in prognosis prediction, and suggests the role of renal manifestations in mortality. Furthermore, it corroborates recent TSC studies in the Asian population in terms of survival. Overall, physician vigilance, early diagnosis, and careful monitoring are beneficial for disease outcome and patient survival.

HA Filler Injection and Skin Quality-Literature Minireview and Injection Techniques.

Aging of the face produces many changes in the structure and integrity of the skin and other anatomical aspects, the three major signs of which are volume loss, sagginess, and skin quality change. Through surgical or nonsurgical procedures, it is possible to slow or even reverse these mechanisms through artificial means, including thread lifting, radiofrequency, or filler injection. Filler injections are particularly popular in recent years, owing to their convenience, efficacy, and long-lasting results. In this minireview, the author outlines the basic mechanisms behind facial aging, discusses current literature on each aspect of facial aging, and offers injection protocol recommendations based on past literature and clinical experience.

Classifications and injection strategy for lip reshaping in Asians.

Filler injections have become very popular in recent decades. Of the various injection procedures, lip injection is an important aspect of filler injection, especially for Caucasian patients. Asians tend to have fuller lips than Caucasians, necessitating a different approach to lip injection. Classification systems for the lip for aesthetic treatment purposes can help a physician assess a patient accordingly, and a simple classification of Asian lips into four types for injection approaches is proposed in this paper. Each patient type is discussed in terms of trait and categorization, injection area, injection techniques, injection goals, and sample patients with treatment results.

Treating the tear trough-eye bag complex: Treatment targets, treatment selection, and injection algorithms with case studies.

BACKGROUND: The tear trough is a commonly requested area for aesthetic correction, but is difficult to treat well, especially when concurrent with other deformities such as eye bags. There are multiple possible treatment methods for the tear trough and eye bag, such as surgery and hyaluronic acid (HA) filler injection, with the latter gaining popularity in recent years. AIMS: To explore tear trough and eye bags etiology, describe the process for treatment selection, outline possible contraindications for filler injection, and expand upon the previously published atrophy-bulging-laxity (ABL) system of tear trough classification and treatment algorithm, with special focus on tear troughs complicated with eye bags. METHODS: Six major etiologies of the eye bag were described, and three main contraindications for HA injection were outlined. Three useful tests (snap test, push test, lift test) to aid in treatment selection were described. A comprehensive treatment algorithm was developed to counteract each etiology: "Lifting" injections at the zygoma and anteromedial cheek help counteract senescent or congenital bone deficiency; "Supporting" injections into the anteromedial cheek fat pads help counteract fat atrophy or prolapse; and "Volumization" injections directly at the deformity help smooth out structural grooves or troughs. RESULTS: Patients with pronounced eye bags and tear troughs were treated according to this algorithm and obtained good, long-lasting outcomes. CONCLUSIONS: Tear troughs complicated with eye bags can be successfully classified and treated with the ABL system and the additional procedures described by this report.

Histology of ex vivo skin after treatment with fractionated picosecond Nd:YAG laser in high and low-energy settings.

Background: The fractionated picosecond laser produces microscopic lesions in the epidermis and dermis, which are known as laser-induced optical breakdown (LIOB) and intra-dermal laser-induced cavitation (LIC). There have been multiple histological reports on these phenomena, although some have been challenged on the grounds of similarity to artifacts. Asian skins, with a higher melanin content, may react differently to this treatment, and present literature is also lacking in this area.Purpose: To observe and report the histological effect of different energy levels and parameters of the fractional 532 nm/1064 nm picosecond laser on Asian skin ex vivo.Methods: Six skin samples were taken from clinically normal-looking perilesional areas and treated with different energy levels and parameters of the fractional 532 nm/1064 nm picosecond laser. The specimens were then sent to the lab for H&E staining, and the slides were reviewed by a dermatopathologist.Results: Superficial, intra-epidermal LIOBs were seen in skin treating at higher laser energies; deep, intra-dermal LICs were seen in skin treated at lower energies. Lesion sizes and depths were consistent with previously reported values on Caucasian skins, and lesions were spaced in 600-µm intervals or its multiple.Conclusions: The histological findings are consistent with results from other ethnicities, and the spacing of lesions is a strong indication of their validity as LIOBs or LICs.

755 nm picosecond laser for facial atrophic scar-Case reports of long-term clinical efficacy following up.

INTRODUCTION: Acne vulgaris is one of the most common dermatological problems in Asia. While the disease itself is self-limited and temporary, the dystrophic texture changes after the inflammatory process are often a serious aesthetic concern. Many energy-based devices have seen good results in treating atrophic acne scars, and the picosecond laser with specific lens is one of the newer options, and lack reports on its long-term efficacy. MATERIALS AND METHODS: We report three Taiwanese cases who, to our knowledge, consist of the longest clinical follow-up times for atrophic scar treatment with the 755 nm diffractive lens picosecond laser. Photographs were compared on a by-session basis by two blinded dermatologists independent of the primary treating physician and given an improvement range of <25%, 25%-50%, 50%-75%, and >75%. RESULTS: While there are minor (<25%) improvements in all cases after the first four treatment sessions, all three cases saw the greatest improvement in skin texture (>75% in two cases, 50%-75% in one) when they were followed up 6, 13.5, and 28 months post-last treatment. CONCLUSION: Our results demonstrate excellent, long-onset, and long-term efficacy of the picosecond laser with diffractive lens in the treatment of acne atrophic scars. It also demonstrates the safe use of the device on Asian skins without symptoms of postinflammatory hyperpigmentation.

Noninvasive Atrophic Acne Scar Treatment in Asians With a 755-nm Picosecond Laser Using A Diffractive Optic Lens-A Retrospective Photographic Review.

BACKGROUND: The diffractive lens of the picosecond laser is relatively new, and there are few reports on its efficacy in treating atrophic acne scars, especially in Asian populations. OBJECTIVE: Evaluating the efficacy of diffractive lens 755-nm picosecond laser for atrophic acne scar treatment in Asians. PATIENTS AND METHODS: Forty-two patients who were treated for facial atrophic acne scars at a private dermatological clinic were enrolled in this retrospective analysis. Mean session count was 4.28. Before and after photographs were assessed by 2 blinded dermatologists, who rated the amount of overall skin quality improvement on a 5-point scale. RESULTS: All patients experienced improvements in scar texture and overall skin quality after 2 to 6 sessions, with scores of +1.4, 1.45, 1.7, 1.33, 2.3, and 1.66 points after 2, 3, 4, 5, 6, and >6 treatments, respectively. There were no obvious adverse effects after treatment. The postinflammatory hyperpigmentation (PIH) risk was 4.7% (2 of 42, both spontaneously resolved). CONCLUSION: The 755-nm diffractive lens picosecond laser showed good efficacy and low PIH rates when treating atrophic acne scars in darker skin-type patients. In addition to treatment results, additional improvements in overall skin quality and pigmentation make the picosecond laser an effective and desirable treatment option for Asians.

Literature review of the adverse events associated with botulinum toxin injection for the masseter muscle hypertrophy.

BACKGROUND: Masseteric hypertrophy is a benign condition characterized by the enlargement of the masseter muscles. A square-shaped jawline due to masseter muscle prominence or hypertrophy is one of the general characteristics of the Asian face, making it a frequent target for esthetic treatment requests. While the application of botulinum toxin on the masseter muscle is an off-label use, it is very popular in Asian countries. However, comprehensive reviews of the complications associated with this procedure remain limited in scope. OBJECTIVES: The goal of this study is to help physicians achieve a comprehensive understanding of the complications associated with neuromodulator injection over the masseter muscle via a thorough literature review. METHODS: A literature search was performed on the PubMed/MEDLINE, Google Scholar, and Science Direct databases using the search terms botulinum toxin, masseter hypertrophy, masseteric hypertrophy, and/or masseter hyperplasia. Literature from January 1994 to February 2018 was deemed to be allegeable for inclusion and analysis. All available prospective and retrospective studies, case series, case reports, and expert reviews were included, with an emphasis on types of complications, incidence rate, onset time, recovery time, and product used. Articles that do not mention side effects, complications, or adverse events were excluded. RESULTS: Thirty-six articles were found, covering type, incidence rate, and clinical course of the complications. These studies were summarized into tabular form for easy reference and comparison. CONCLUSION: Botulinum toxin masseter injections are commonly performed procedures with good results and safety profiles. The majority of complications appeared within 2-4 weeks of injection and disappeared within 12 weeks. Despite the temporary nature of these complications, they often decrease patient satisfaction and confidence, so physicians should familiarize themselves with the regional anatomy and injection safety zones.

Treating the tear trough: A new classification system, a 6-step evaluation procedure, hyaluronic acid injection algorithm, and treatment sequences.

INTRODUCTION: The tear trough deformity is commonly requested for correction, most often by filler injections. However, the tear trough remains difficult to treat due to its complex anatomy, a variety of other concurrent deformities, and the high risk of complications. OBJECTIVES: To create a standardized categorization, evaluation, and treatment protocol for the management of tear troughs with fillers. METHODS: (1) Patient deformity profiles are determined using three categories of traits: A (Atrophy), B (Bulging), L (Laxity). (2) A 6-step evaluation process (Tilt, Snap, Smile, Squint, Pull, Push) aids in ABL determination. (3) Treatment is simplified into a comprehensive protocol for each category (with 6 major injection points and a variety of injection depths and volumes). RESULTS: The author has achieved satisfactory results using the presented protocols, with photographic examples. CONCLUSION: The author proposes a comprehensive categorization system that takes into account both the tear trough and other concurrent deformities. The author also presents 6 tests to aid in categorization, and simple protocols with injection sequences, amounts, and depth.

Complications of botulinum toxin injection for masseter hypertrophy: Incidence rate from 2036 treatments and summary of causes and preventions.

BACKGROUND: Masseter hypertrophy is a common, prominent feature in many Asian patients, and correction procedures are often requested for esthetic reasons. Toxin masseter injections have a high efficacy and safety profile, but the risks of a variety of side effects or complications remain. OBJECTIVES: The categorization of various complications was based on etiology, with a presentation of the author's own incidence rates for consideration and comparison. METHODS: Six hundred and eighty patients received a total of 2036 sessions of toxin injection for masseter hypertrophy from 2011 to 2016, and complications or complaints were recorded through follow-up on a by-treatment basis. Complications were grouped together based on etiology and discussed. RESULTS: Of 2036 sessions, temporary mastication force decrease was reported after 611 (30%), bruising after 51 (2.5%), headaches after 12 (0.58%), smile limitation after 3 (0.15%), paradoxical bulging after 10 (0.49%), sunken cheeks (subzygomatic volume loss) after 9 (0.44%), and sagging after 4 (0.20%). CONCLUSIONS: Masseter injections remain very safe. To further decrease the incidence rate, injections should only be inside the recommended safety zone, a quadrilateral within the muscle that avoids most important local structures. Keeping injections inside the safe zone, and ideally in 3-4 different locations at least 1 cm from any border, is crucial for the prevention of complications.