Suzan Obagi, MD

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

It is an exciting time for dermatologists. In the 16 years that I have been in practice our knowledge of disease pathogenesis has increased and has shaped treatments that can now offer life-changing improvement for patients with extensive dermatologic disease. The everyday practice of cosmetic dermatology also has advanced. Sixteen years ago the only cosmetic options we had for our patients were bovine or human collagen injections, traditional CO₂ laser resurfacing, and the older generations of pulsed dye lasers. Neuromodulators were just being introduced. We quickly learned the limitations and complications associated with these modalities. Collagen injections were directed at fine perioral lines and lasted 3 to 4 months. The worst complication would be a bruise or an allergic reaction to the bovine collagen. If we really needed to restore volume beyond the perioral regions, our only option was autologous fat transfer. CO₂ laser resurfacing was used to firm skin, erase deep wrinkles, and improve sun damage, but its use was limited to older, fair-skinned individuals due to the inherent risk for hypopigmentation and depigmentation. Pulsed dye lasers similarly had no means of cooling the skin, thus they were limited to lighter-skinned individuals and had notable risk for blisters, burns, and hypopigmentation. Since then, our understanding of skin healing, laser-tissue interaction, and facial aging has driven the field to new heights of technological advances and safety. Just as I tell my patients and residents, there is no better time to be in this field than at this moment. Dermatologists have driven the advances behind many of the technologies that are now in widespread use among physicians in a variety of specialties.

Our understanding of facial aging has evolved to include the complex interplay of skeletal change, fat atrophy, and skin aging, which must all be considered when improving a patient’s appearance. Fillers have evolved in physical characteristics to give us the ability to choose between lift, spread, neocollagenesis, or water absorption. Thus, we can select the proper filler for the specific anatomic area we are rejuvenating.

Our understanding of photoaging and laser-tissue physics has allowed for the development of a newer generation of lasers ranging from fractionated lasers to noninvasive modalities that can safely be used in a variety of ethnic skin types to address acne scars, wrinkles, and inflammatory processes such as acne and rosacea. Similarly, the desire to tighten redundant skin has continued to drive ultrasound and radiofrequency technology and sparked growth in a newer field of cryolipolysis and chemical lipolysis agents.

Our dialogue with patients also has evolved to include the 4 R’s of antiaging: resurfacing the skin (eg, lasers, peels), refilling the lost volume (eg, fillers, fat), redraping the excess skin (eg, radiofrequency, ultrasound, laser, surgery), and relaxing dynamic lines (eg, neuromodulators). I propose an additional R: renewal! We must focus on the need for constant renewal so that patients maintain the results we have achieved. I apply the analogy of exercising to get into shape. One must go to the gym regularly to get to the desired level of fitness, but you do not stop exercising, otherwise you will quickly relapse to your former lack of fitness. Similarly, patients should receive the appropriate treatments to bring them to the desired level of rejuvenation, but then some form of constant renewal process is needed to maintain them at that level. Without the stimulation of the skin, the aging process continues and the cycle begins all over again.

In my practice, renewal is achieved by driving the skin to maintain the glow and smoothness that enhances the results of the fillers, neuromodulators, lasers, and peels that we have used. The skin is the first thing people notice. Without the glow, the patient will look good but not great. I tell patients that this part of the process is their responsibility. They must adhere to the skin care regimen specifically designed to address their needs. By incorporating the patient in the rejuvenation process, he/she is empowered to take control over the aging process and has grown more confident in you as a physician.

These are exciting times and there is still so much in the pipeline. By continually learning, reading, and attending workshops and meetings, you can make sure our specialty continue to be the leader in the antiaging field.

The platysma muscle has been widely studied in its course through the cervical region in an attempt to develop more effective surgical approaches for rejuvenation. As a person ages, the platysma muscle becomes thinner, less defined, and ptotic, which results in the clinical appearance of a sagging neck that prompts patients to undergo neck-lift procedures. However, little is known about the course of the platysma in the mid and lower face and the implications on facial aging.

Bae et al (Plast Reconstr Surg. 2016;138:365-371) performed a cadaveric dissection of the facial portion of the platysma muscle to delineate the morphology and extension of the muscle in the mid and lower face. Thirty-four adult hemifaces were dissected. The demographics were broken down by age (mean, 71.4 years; range, 41–93 years), gender (29 men; 5 women), and ethnicity (14 Korean; 20 Thai). The extension of the platysma was documented according to a grid the authors created. The grid was divided along 3 horizontal lines (H1–H3) and 3 vertical lines (V1–V3). The intersection of these lines created a grid that was comprised of 3×3 squares and was labeled superior (S1–S3), middle (M1–M3), and inferior (I1–I3). H1 was a line drawn horizontally from the tragus to the lateral orbit, H2 was a line from the earlobe to the nasal ala, and H3 was a line from the angle of the mandible to the corner of the mouth.

The extension pattern of the facial portion of the platysma muscle was classified into patterns: A (n=3; S1–S2, M1–M3, and I1-I3 were covered by the muscle), B-1 (n=20; M1–M3, I1–I3), B-2 (n=9; M1–M2, I1–I3), and C (n=2; I1-I3).

The platysma muscle is divided into anterior and posterior portions. The anterior platysma ascends superiorly and medially in the face to interdigitate with the depressor anguli oris and the depressor labii inferioris muscles. The morphology pattern of the posterior platysma varied and was classified into 1 of 3 patterns: straight (n=13), straight-curved (n=18), and curved (n=3). The straight pattern showed platysma fibers that travel parallel to the mandibular malar line and head toward the zygomaticus major or the orbicularis oculi muscles. The straight-curved type has fibers that travel straight from the neck to the face but then curve, heading toward the risorius, zygomaticus major, or orbicularis oculi muscle depending on the extent of the platysma muscle in the area. The curved type has fibers that run parallel to the zygomaticus arch and interdigitate with the orbicularis oculi muscle and either the risorius or zygomaticus major muscle.

What’s the issue?

For many years, the cervical platysma muscle was studied and surgical approaches were modified to enhance results. The authors of this study have taken the study of the platysma muscle further to delineate its course through the face. Knowledge of the various pathways of the muscle can help us determine the most natural direction to resuspend ptotic facial tissue during surgery and minimally invasive procedures such as thread-lifting. The most salient points include: (1) the lower one-third of the masseter muscle is covered by the platysma, and (2) straight-curved was the most common morphology type, suggesting that the vector for repositioning the platysma muscle is vertical.

Although Bae et al do not discuss the use of botulinum toxin (BTX) in the treatment of the platysma, the results of this study further support the importance of BTX to the lower face. We can look back at more than 14 years of cosmetic use of BTX for the glabella and see the reduced number of brow-lift surgeries nationwide. Although the preventative effects of BTX on brow depression still need to be scientifically proven, it may behoove us to think preventatively on the use of BTX in the platysma to minimize ptosis of the lower face and neck. The results of this anatomic study support the importance of tailoring the approach to the dynamic lines caused by the platysma muscle in each patient to address jowls and neck bands. Have you been offering lower face BTX treatments to patients in an effort to reduce lower face aging?

We want to know your views! Tell us what you think.

The platysma muscle has been widely studied in its course through the cervical region in an attempt to develop more effective surgical approaches for rejuvenation. As a person ages, the platysma muscle becomes thinner, less defined, and ptotic, which results in the clinical appearance of a sagging neck that prompts patients to undergo neck-lift procedures. However, little is known about the course of the platysma in the mid and lower face and the implications on facial aging.

Bae et al (Plast Reconstr Surg. 2016;138:365-371) performed a cadaveric dissection of the facial portion of the platysma muscle to delineate the morphology and extension of the muscle in the mid and lower face. Thirty-four adult hemifaces were dissected. The demographics were broken down by age (mean, 71.4 years; range, 41–93 years), gender (29 men; 5 women), and ethnicity (14 Korean; 20 Thai). The extension of the platysma was documented according to a grid the authors created. The grid was divided along 3 horizontal lines (H1–H3) and 3 vertical lines (V1–V3). The intersection of these lines created a grid that was comprised of 3×3 squares and was labeled superior (S1–S3), middle (M1–M3), and inferior (I1–I3). H1 was a line drawn horizontally from the tragus to the lateral orbit, H2 was a line from the earlobe to the nasal ala, and H3 was a line from the angle of the mandible to the corner of the mouth.

The extension pattern of the facial portion of the platysma muscle was classified into patterns: A (n=3; S1–S2, M1–M3, and I1-I3 were covered by the muscle), B-1 (n=20; M1–M3, I1–I3), B-2 (n=9; M1–M2, I1–I3), and C (n=2; I1-I3).

The platysma muscle is divided into anterior and posterior portions. The anterior platysma ascends superiorly and medially in the face to interdigitate with the depressor anguli oris and the depressor labii inferioris muscles. The morphology pattern of the posterior platysma varied and was classified into 1 of 3 patterns: straight (n=13), straight-curved (n=18), and curved (n=3). The straight pattern showed platysma fibers that travel parallel to the mandibular malar line and head toward the zygomaticus major or the orbicularis oculi muscles. The straight-curved type has fibers that travel straight from the neck to the face but then curve, heading toward the risorius, zygomaticus major, or orbicularis oculi muscle depending on the extent of the platysma muscle in the area. The curved type has fibers that run parallel to the zygomaticus arch and interdigitate with the orbicularis oculi muscle and either the risorius or zygomaticus major muscle.

What’s the issue?

For many years, the cervical platysma muscle was studied and surgical approaches were modified to enhance results. The authors of this study have taken the study of the platysma muscle further to delineate its course through the face. Knowledge of the various pathways of the muscle can help us determine the most natural direction to resuspend ptotic facial tissue during surgery and minimally invasive procedures such as thread-lifting. The most salient points include: (1) the lower one-third of the masseter muscle is covered by the platysma, and (2) straight-curved was the most common morphology type, suggesting that the vector for repositioning the platysma muscle is vertical.

Although Bae et al do not discuss the use of botulinum toxin (BTX) in the treatment of the platysma, the results of this study further support the importance of BTX to the lower face. We can look back at more than 14 years of cosmetic use of BTX for the glabella and see the reduced number of brow-lift surgeries nationwide. Although the preventative effects of BTX on brow depression still need to be scientifically proven, it may behoove us to think preventatively on the use of BTX in the platysma to minimize ptosis of the lower face and neck. The results of this anatomic study support the importance of tailoring the approach to the dynamic lines caused by the platysma muscle in each patient to address jowls and neck bands. Have you been offering lower face BTX treatments to patients in an effort to reduce lower face aging?

We want to know your views! Tell us what you think.

The platysma muscle has been widely studied in its course through the cervical region in an attempt to develop more effective surgical approaches for rejuvenation. As a person ages, the platysma muscle becomes thinner, less defined, and ptotic, which results in the clinical appearance of a sagging neck that prompts patients to undergo neck-lift procedures. However, little is known about the course of the platysma in the mid and lower face and the implications on facial aging.

Bae et al (Plast Reconstr Surg. 2016;138:365-371) performed a cadaveric dissection of the facial portion of the platysma muscle to delineate the morphology and extension of the muscle in the mid and lower face. Thirty-four adult hemifaces were dissected. The demographics were broken down by age (mean, 71.4 years; range, 41–93 years), gender (29 men; 5 women), and ethnicity (14 Korean; 20 Thai). The extension of the platysma was documented according to a grid the authors created. The grid was divided along 3 horizontal lines (H1–H3) and 3 vertical lines (V1–V3). The intersection of these lines created a grid that was comprised of 3×3 squares and was labeled superior (S1–S3), middle (M1–M3), and inferior (I1–I3). H1 was a line drawn horizontally from the tragus to the lateral orbit, H2 was a line from the earlobe to the nasal ala, and H3 was a line from the angle of the mandible to the corner of the mouth.

The extension pattern of the facial portion of the platysma muscle was classified into patterns: A (n=3; S1–S2, M1–M3, and I1-I3 were covered by the muscle), B-1 (n=20; M1–M3, I1–I3), B-2 (n=9; M1–M2, I1–I3), and C (n=2; I1-I3).

The platysma muscle is divided into anterior and posterior portions. The anterior platysma ascends superiorly and medially in the face to interdigitate with the depressor anguli oris and the depressor labii inferioris muscles. The morphology pattern of the posterior platysma varied and was classified into 1 of 3 patterns: straight (n=13), straight-curved (n=18), and curved (n=3). The straight pattern showed platysma fibers that travel parallel to the mandibular malar line and head toward the zygomaticus major or the orbicularis oculi muscles. The straight-curved type has fibers that travel straight from the neck to the face but then curve, heading toward the risorius, zygomaticus major, or orbicularis oculi muscle depending on the extent of the platysma muscle in the area. The curved type has fibers that run parallel to the zygomaticus arch and interdigitate with the orbicularis oculi muscle and either the risorius or zygomaticus major muscle.

What’s the issue?

For many years, the cervical platysma muscle was studied and surgical approaches were modified to enhance results. The authors of this study have taken the study of the platysma muscle further to delineate its course through the face. Knowledge of the various pathways of the muscle can help us determine the most natural direction to resuspend ptotic facial tissue during surgery and minimally invasive procedures such as thread-lifting. The most salient points include: (1) the lower one-third of the masseter muscle is covered by the platysma, and (2) straight-curved was the most common morphology type, suggesting that the vector for repositioning the platysma muscle is vertical.

Although Bae et al do not discuss the use of botulinum toxin (BTX) in the treatment of the platysma, the results of this study further support the importance of BTX to the lower face. We can look back at more than 14 years of cosmetic use of BTX for the glabella and see the reduced number of brow-lift surgeries nationwide. Although the preventative effects of BTX on brow depression still need to be scientifically proven, it may behoove us to think preventatively on the use of BTX in the platysma to minimize ptosis of the lower face and neck. The results of this anatomic study support the importance of tailoring the approach to the dynamic lines caused by the platysma muscle in each patient to address jowls and neck bands. Have you been offering lower face BTX treatments to patients in an effort to reduce lower face aging?

We want to know your views! Tell us what you think.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

What does your patient need to know at the first visit?

In my practice, we try our best to start the education process before the patient even comes in for the first visit. If a patient is going to have a filler injection, we mail out an information packet that contains information on what to expect, how to minimize bruising, what side effects (eg, bruising, swelling) may occur, and what to avoid posttreatment. By providing them with this information prior to their visit, they can better plan their treatment around social and work obligations.

We ask patients to avoid or minimize blood-thinning agents such as aspirin, ibuprofen, fish oil, or vitamin E starting 2 weeks prior to and 1 week after the procedure. We recommend that patients take a pineapple extract such as bromelain 500 mg twice daily on an empty stomach starting 1 week prior to the treatment and for up to 1 week posttreatment. We ask that patients avoid exercise for 24 hours to reduce late-onset bruising and to avoid dental work for 2 weeks posttreatment to reduce the risk for the filler becoming infected.

What are your go-to treatments?

I use a variety of fillers depending on the area I am treating (thin vs thick skin) or the amount of lift I need (ie, G')(Restylane [Galderma Laboratories, LP] has a high G', thus it gives a lot of lift) versus the amount of water absorption I am seeking to further plump an area after the filler integrates (Juvéderm [Allergan] can absorb up to 300% its weight in water) versus the filler’s cohesiveness (Belotero [Merz Aesthetics] is highly cohesive). If I am treating a thin-faced individual, I may start with a global volumizer such as poly-L-lactic acid to get a good foundation set in the temples, cheeks, and jawline, and then after a few months, I will add a hyaluronic acid filler to focal areas that still need to be lifted (eg, nasolabial folds, tear troughs).

What are the side effects?

Side effects are divided into common and rare. Common would be bruising and swelling, which are temporary and will go away in all patients. Rare but serious side effects are infection and embolization. Both can cause notable tissue loss and risk to the patient. Every practitioner needs to know how to recognize and treat these complications should they arise.

How do you keep patients compliant?

Patients who get good results will always return, which means being up front about how much filler a patient needs and how frequently he/she will need it, and also doing everything we can to reduce bruising and swelling.


Suggested Readings

• Dayan SH, Arkins JP, Brindise R. Soft tissue fillers and biofilms. Facial Plast Surg. 2011;27:23-28.
• Orsini RA; Plastic Surgery Educational Technology Assessment Committee. Bromelain. Plast Reconstr Surg. 2006;118:1640-1644.

Hyaluronic acid (HA) fillers are among the most commonly injected soft-tissue fillers worldwide. However, even with proper technique, there may be instances in which the filler becomes visible (Tyndall effect) or edematous, prompting the need to dissolve it. Not all HA fillers are identical; many differ in their degree of cross-linking or classification as monophasic or biphasic, which may affect the success in dissolving them with hyaluronidase. Rao et al (J Drugs Dermatol. 2014;13:1053-1056) published a study that looked at 2 commonly used hyaluronidase agents and how well they dissolved 4 commonly used HA fillers in the United States.

Rao et al performed an in vitro study using Vitrase (ovine testicular hyaluronidase)(Bausch & Lomb Incorporated) and Hylenex (recombinant human hyaluronidase)(Halozyme Therapeutics). The HA fillers tested were Restylane (Galderma Laboratories, LP), Juvéderm and Juvéderm Voluma (Allergan), and Belotero (Merz Aesthetics).

Phase 1 of the study looked at the volume of hyaluronidase on 3 of 4 fillers. The researchers utilized 0.1 mL of Vitrase or Hylenex to treat 0.2 mL of Restylane, Belotero, and Juvéderm. A control slide was kept for each filler. For Vitrase, 0.1 mL is 20 U of hyaluronidase. For Hylenex, 0.1 mL is 15 U of hyaluronidase. The filler and hyaluronidase were mixed together for 10 seconds using a 27-gauge needle. Photograph assessment of the slides was taken at 1 and 5 minutes.

Phase 2 of the study looked at the number of units of hyaluronidase on all 4 fillers. For this phase, 15 U and 30 U of Hylenex were mixed with 0.2 mL aliquots of each filler. Photographs and qualitative observations were taken at 1 and 5 minutes. The aliquots were observed for a total of 15 minutes.

For phase 1, the 2 hyaluronidase agents worked similarly on all 3 HA fillers. The greatest effect on dissolving or changing the shape of a filler was on Restylane, followed by Juvéderm and Belotero (a monophasic filler). The greatest effect was in the first minute and continued through the fifth minute. Even at 5 minutes, Belotero maintained most of its shape.

Phase 2 showed similar results with Restylane reacting the most to the hyaluronidase, followed by Juvéderm Voluma, Juvéderm, and Belotero. The higher dose (30 U) of hyaluronidase had a more dramatic effect on all fillers compared to the lower dose (15 U). Results were time dependent with the greatest changes seen at 5 minutes as opposed to 1 minute. The results of the 15-minute observation did not show any further changes. Belotero also maintained most of its shape during this phase.

What’s the issue?

With the increased number of HA fillers coming onto the market, it will become more important to understand the interaction between HA fillers and hyaluronidase. Hyaluronic acid fillers will vary in their degree of cross-linking, water absorption, and classification as monophasic (cohesive) or biphasic. Oftentimes, it is not until we use fillers in off-label manners that we realize some unintended consequences. We realized all too quickly that fillers, such as Restylane, placed superficially under eyelid skin gave an unsightly Tyndall effect. We then relied on hyaluronidase injections to resolve this issue. Furthermore, we learned that Juvéderm Ultra Plus XC could hold approximately 300% of its weight in water, causing unsightly eyelid edema in some patients. Luckily, the use of hyaluronidase can be a saving grace for physicians. However, the success of hyaluronidase injections varies. From the results of this study, it may be true that certain fillers need higher volumes or a higher number of units than other fillers to dissolve them. I would like to see this study expanded as newer HA fillers are brought onto the market.

Have you found that you have had to use varying amounts of hyaluronidase to address different filler complications?

We want to know your views! Tell us what you think.

Hyaluronic acid (HA) fillers are among the most commonly injected soft-tissue fillers worldwide. However, even with proper technique, there may be instances in which the filler becomes visible (Tyndall effect) or edematous, prompting the need to dissolve it. Not all HA fillers are identical; many differ in their degree of cross-linking or classification as monophasic or biphasic, which may affect the success in dissolving them with hyaluronidase. Rao et al (J Drugs Dermatol. 2014;13:1053-1056) published a study that looked at 2 commonly used hyaluronidase agents and how well they dissolved 4 commonly used HA fillers in the United States.

Rao et al performed an in vitro study using Vitrase (ovine testicular hyaluronidase)(Bausch & Lomb Incorporated) and Hylenex (recombinant human hyaluronidase)(Halozyme Therapeutics). The HA fillers tested were Restylane (Galderma Laboratories, LP), Juvéderm and Juvéderm Voluma (Allergan), and Belotero (Merz Aesthetics).

Phase 1 of the study looked at the volume of hyaluronidase on 3 of 4 fillers. The researchers utilized 0.1 mL of Vitrase or Hylenex to treat 0.2 mL of Restylane, Belotero, and Juvéderm. A control slide was kept for each filler. For Vitrase, 0.1 mL is 20 U of hyaluronidase. For Hylenex, 0.1 mL is 15 U of hyaluronidase. The filler and hyaluronidase were mixed together for 10 seconds using a 27-gauge needle. Photograph assessment of the slides was taken at 1 and 5 minutes.

Phase 2 of the study looked at the number of units of hyaluronidase on all 4 fillers. For this phase, 15 U and 30 U of Hylenex were mixed with 0.2 mL aliquots of each filler. Photographs and qualitative observations were taken at 1 and 5 minutes. The aliquots were observed for a total of 15 minutes.

For phase 1, the 2 hyaluronidase agents worked similarly on all 3 HA fillers. The greatest effect on dissolving or changing the shape of a filler was on Restylane, followed by Juvéderm and Belotero (a monophasic filler). The greatest effect was in the first minute and continued through the fifth minute. Even at 5 minutes, Belotero maintained most of its shape.

Phase 2 showed similar results with Restylane reacting the most to the hyaluronidase, followed by Juvéderm Voluma, Juvéderm, and Belotero. The higher dose (30 U) of hyaluronidase had a more dramatic effect on all fillers compared to the lower dose (15 U). Results were time dependent with the greatest changes seen at 5 minutes as opposed to 1 minute. The results of the 15-minute observation did not show any further changes. Belotero also maintained most of its shape during this phase.

What’s the issue?

With the increased number of HA fillers coming onto the market, it will become more important to understand the interaction between HA fillers and hyaluronidase. Hyaluronic acid fillers will vary in their degree of cross-linking, water absorption, and classification as monophasic (cohesive) or biphasic. Oftentimes, it is not until we use fillers in off-label manners that we realize some unintended consequences. We realized all too quickly that fillers, such as Restylane, placed superficially under eyelid skin gave an unsightly Tyndall effect. We then relied on hyaluronidase injections to resolve this issue. Furthermore, we learned that Juvéderm Ultra Plus XC could hold approximately 300% of its weight in water, causing unsightly eyelid edema in some patients. Luckily, the use of hyaluronidase can be a saving grace for physicians. However, the success of hyaluronidase injections varies. From the results of this study, it may be true that certain fillers need higher volumes or a higher number of units than other fillers to dissolve them. I would like to see this study expanded as newer HA fillers are brought onto the market.

Have you found that you have had to use varying amounts of hyaluronidase to address different filler complications?

We want to know your views! Tell us what you think.

Hyaluronic acid (HA) fillers are among the most commonly injected soft-tissue fillers worldwide. However, even with proper technique, there may be instances in which the filler becomes visible (Tyndall effect) or edematous, prompting the need to dissolve it. Not all HA fillers are identical; many differ in their degree of cross-linking or classification as monophasic or biphasic, which may affect the success in dissolving them with hyaluronidase. Rao et al (J Drugs Dermatol. 2014;13:1053-1056) published a study that looked at 2 commonly used hyaluronidase agents and how well they dissolved 4 commonly used HA fillers in the United States.

Rao et al performed an in vitro study using Vitrase (ovine testicular hyaluronidase)(Bausch & Lomb Incorporated) and Hylenex (recombinant human hyaluronidase)(Halozyme Therapeutics). The HA fillers tested were Restylane (Galderma Laboratories, LP), Juvéderm and Juvéderm Voluma (Allergan), and Belotero (Merz Aesthetics).

Phase 1 of the study looked at the volume of hyaluronidase on 3 of 4 fillers. The researchers utilized 0.1 mL of Vitrase or Hylenex to treat 0.2 mL of Restylane, Belotero, and Juvéderm. A control slide was kept for each filler. For Vitrase, 0.1 mL is 20 U of hyaluronidase. For Hylenex, 0.1 mL is 15 U of hyaluronidase. The filler and hyaluronidase were mixed together for 10 seconds using a 27-gauge needle. Photograph assessment of the slides was taken at 1 and 5 minutes.

Phase 2 of the study looked at the number of units of hyaluronidase on all 4 fillers. For this phase, 15 U and 30 U of Hylenex were mixed with 0.2 mL aliquots of each filler. Photographs and qualitative observations were taken at 1 and 5 minutes. The aliquots were observed for a total of 15 minutes.

For phase 1, the 2 hyaluronidase agents worked similarly on all 3 HA fillers. The greatest effect on dissolving or changing the shape of a filler was on Restylane, followed by Juvéderm and Belotero (a monophasic filler). The greatest effect was in the first minute and continued through the fifth minute. Even at 5 minutes, Belotero maintained most of its shape.

Phase 2 showed similar results with Restylane reacting the most to the hyaluronidase, followed by Juvéderm Voluma, Juvéderm, and Belotero. The higher dose (30 U) of hyaluronidase had a more dramatic effect on all fillers compared to the lower dose (15 U). Results were time dependent with the greatest changes seen at 5 minutes as opposed to 1 minute. The results of the 15-minute observation did not show any further changes. Belotero also maintained most of its shape during this phase.

What’s the issue?

With the increased number of HA fillers coming onto the market, it will become more important to understand the interaction between HA fillers and hyaluronidase. Hyaluronic acid fillers will vary in their degree of cross-linking, water absorption, and classification as monophasic (cohesive) or biphasic. Oftentimes, it is not until we use fillers in off-label manners that we realize some unintended consequences. We realized all too quickly that fillers, such as Restylane, placed superficially under eyelid skin gave an unsightly Tyndall effect. We then relied on hyaluronidase injections to resolve this issue. Furthermore, we learned that Juvéderm Ultra Plus XC could hold approximately 300% of its weight in water, causing unsightly eyelid edema in some patients. Luckily, the use of hyaluronidase can be a saving grace for physicians. However, the success of hyaluronidase injections varies. From the results of this study, it may be true that certain fillers need higher volumes or a higher number of units than other fillers to dissolve them. I would like to see this study expanded as newer HA fillers are brought onto the market.

Have you found that you have had to use varying amounts of hyaluronidase to address different filler complications?

We want to know your views! Tell us what you think.

One of the determinants of a successful surgical outcome is the perception, on the part of the patient, of the cosmesis of a scar. The use of Z-plasty is an accepted means by which to break a scar up into smaller geometric segments. In some instances, a Z-plasty is used for scar revision to elongate a scar that may be pulling. However, a study published online in JAMA Facial Plastic Surgery on April 7 mentions the lack of studies measuring the perception of these scars among the normal population after surgery.

Ratnarathorn et al designed a prospective Internet-based survey with a goal of 580 responses to give a power of 90%. The survey was distributed to a diverse sample of the US population. Using editing software, Ratnarathorn et al superimposed a mature linear scar and a mature zigzag scar onto the faces of standardized headshots from 4 individuals (2 males, 2 females). Each individual had 1 image of the linear scar and 1 image of the zigzag scars superimposed onto each of 3 anatomical areas—forehead (flat surface), cheek (convex surface), and temple (concave surface)—yielding 24 images for the respondents to assess.

A 24.5% (n=876) response rate was achieved with 3575 surveys distributed. Of the 876 respondents, 810 (92.5%) completed the survey (46.1% male, 53.9% female). Respondents were asked to rate the scars on a scale of 1 to 10 (1=normal skin; 10=worst scar imaginable).

Results were statistically significantly lower (better) for the linear scars compared to the zigzag scars in all 3 anatomic areas and across both male and female groups with a mean score of 2.9 versus 4.5 (P<.001). A multivariable regression model of respondent age, sex, educational level, and income showed no statistically significant effect on the rating of the scars.

What’s the issue?

This study highlights some interesting points. Coming from an academic practice, we oftentimes find ourselves teaching residents a variety of skin closure techniques to deal with defects from skin cancer excisions. It is both challenging and fun to design complex closures; however, we must keep in mind what is in the best interest of the patient. One of the points I try to emphasize is that we must understand that there are no true straight lines on the face. In fact, when scars from procedures appear as geometric shapes on the face, our eyes tend to be drawn to them. For this reason, it often is best to use curvilinear lines wherever possible. Ratnarathorn et al highlights that point exactly. More studies of this nature are needed to assess what is perceived as a successful outcome, by both physicians and patients.

As you follow your patients for the long-term, have you noticed that you perform more or fewer zigzag scars?

We want to know your views! Tell us what you think.

One of the determinants of a successful surgical outcome is the perception, on the part of the patient, of the cosmesis of a scar. The use of Z-plasty is an accepted means by which to break a scar up into smaller geometric segments. In some instances, a Z-plasty is used for scar revision to elongate a scar that may be pulling. However, a study published online in JAMA Facial Plastic Surgery on April 7 mentions the lack of studies measuring the perception of these scars among the normal population after surgery.

Ratnarathorn et al designed a prospective Internet-based survey with a goal of 580 responses to give a power of 90%. The survey was distributed to a diverse sample of the US population. Using editing software, Ratnarathorn et al superimposed a mature linear scar and a mature zigzag scar onto the faces of standardized headshots from 4 individuals (2 males, 2 females). Each individual had 1 image of the linear scar and 1 image of the zigzag scars superimposed onto each of 3 anatomical areas—forehead (flat surface), cheek (convex surface), and temple (concave surface)—yielding 24 images for the respondents to assess.

A 24.5% (n=876) response rate was achieved with 3575 surveys distributed. Of the 876 respondents, 810 (92.5%) completed the survey (46.1% male, 53.9% female). Respondents were asked to rate the scars on a scale of 1 to 10 (1=normal skin; 10=worst scar imaginable).

Results were statistically significantly lower (better) for the linear scars compared to the zigzag scars in all 3 anatomic areas and across both male and female groups with a mean score of 2.9 versus 4.5 (P<.001). A multivariable regression model of respondent age, sex, educational level, and income showed no statistically significant effect on the rating of the scars.

What’s the issue?

This study highlights some interesting points. Coming from an academic practice, we oftentimes find ourselves teaching residents a variety of skin closure techniques to deal with defects from skin cancer excisions. It is both challenging and fun to design complex closures; however, we must keep in mind what is in the best interest of the patient. One of the points I try to emphasize is that we must understand that there are no true straight lines on the face. In fact, when scars from procedures appear as geometric shapes on the face, our eyes tend to be drawn to them. For this reason, it often is best to use curvilinear lines wherever possible. Ratnarathorn et al highlights that point exactly. More studies of this nature are needed to assess what is perceived as a successful outcome, by both physicians and patients.

As you follow your patients for the long-term, have you noticed that you perform more or fewer zigzag scars?

We want to know your views! Tell us what you think.

One of the determinants of a successful surgical outcome is the perception, on the part of the patient, of the cosmesis of a scar. The use of Z-plasty is an accepted means by which to break a scar up into smaller geometric segments. In some instances, a Z-plasty is used for scar revision to elongate a scar that may be pulling. However, a study published online in JAMA Facial Plastic Surgery on April 7 mentions the lack of studies measuring the perception of these scars among the normal population after surgery.

Ratnarathorn et al designed a prospective Internet-based survey with a goal of 580 responses to give a power of 90%. The survey was distributed to a diverse sample of the US population. Using editing software, Ratnarathorn et al superimposed a mature linear scar and a mature zigzag scar onto the faces of standardized headshots from 4 individuals (2 males, 2 females). Each individual had 1 image of the linear scar and 1 image of the zigzag scars superimposed onto each of 3 anatomical areas—forehead (flat surface), cheek (convex surface), and temple (concave surface)—yielding 24 images for the respondents to assess.

A 24.5% (n=876) response rate was achieved with 3575 surveys distributed. Of the 876 respondents, 810 (92.5%) completed the survey (46.1% male, 53.9% female). Respondents were asked to rate the scars on a scale of 1 to 10 (1=normal skin; 10=worst scar imaginable).

Results were statistically significantly lower (better) for the linear scars compared to the zigzag scars in all 3 anatomic areas and across both male and female groups with a mean score of 2.9 versus 4.5 (P<.001). A multivariable regression model of respondent age, sex, educational level, and income showed no statistically significant effect on the rating of the scars.

What’s the issue?

This study highlights some interesting points. Coming from an academic practice, we oftentimes find ourselves teaching residents a variety of skin closure techniques to deal with defects from skin cancer excisions. It is both challenging and fun to design complex closures; however, we must keep in mind what is in the best interest of the patient. One of the points I try to emphasize is that we must understand that there are no true straight lines on the face. In fact, when scars from procedures appear as geometric shapes on the face, our eyes tend to be drawn to them. For this reason, it often is best to use curvilinear lines wherever possible. Ratnarathorn et al highlights that point exactly. More studies of this nature are needed to assess what is perceived as a successful outcome, by both physicians and patients.

As you follow your patients for the long-term, have you noticed that you perform more or fewer zigzag scars?

We want to know your views! Tell us what you think.

Many male and female patients seek therapy for androgenetic alopecia (AGA) at some point. Results are rarely achieved with single-modality therapy. In fact, the treatment of AGA often requires a combination approach of systemic medications and supplements; topical therapy; and if indicated, some type of minimally invasive procedure or surgical option.

The use of platelet-rich plasma (PRP) to pretreat follicular unit hair grafts may increase hair growth and density. Although the method by which PRP helps promote hair growth remains a source of speculation, it is known that platelets contain many growth factors in the platelet α granules. When these granules become activated, they release many types of growth factors ranging from vascular endothelial growth factor, transforming growth factor ß, epidermal growth factor, platelet-derived growth factor, and insulinlike growth factor.

Injection or topical application of PRP has become a popular treatment for skin rejuvenation, alopecia, and autologous fat grafting; however, many of these treatments are being done without the studies to support them.

Alves and Grimalt (Dermatol Surg. 2016;42:491-497) conducted a prospective, split-scalp, placebo-controlled study evaluating the use of PRP injections in the treatment of AGA in 25 patients (12 men, 13 women) with a mean age of 39 years (age range, 21–62 years). Photographs were taken and 4 areas per split scalp were marked with red tattoo dots. The patients were randomized to receive PRP on 1 side and saline injections on the other side. Patients were blinded, but the physician performing the treatment was not blinded. Treatments were performed monthly for 3 sessions. Follow-up photographs and hair density counts were performed at 3 and 6 months after treatment.

Results showed that after 6 months there was a statistically significant (P<.05) increase in the total hair density and terminal hair counts on the PRP-treated side compared to baseline and to the placebo-treated side. When broken down by demographics, patients who did best were men 40 years or younger with AGA beginning at 25 years or older, a positive family history of AGA, and AGA duration of greater than 10 years.

What’s the issue?

The results of this study suggest that PRP has a mild to modest effect (approximately 10% increase) on increasing hair density in a specific patient population. This split-scalp, placebo-controlled study is one of the few of its kind in the field of PRP research and the authors should be applauded for the design of this study. However, it would be beneficial to have a 1-year follow-up to see if the results are maintained and to better help determine if maintenance injections would be needed to sustain the results.

The field of hair restoration and regeneration will continue to grow as newer technologies in hair stem cell injections come to the forefront as well. Rigorous studies will be needed to better help physicians and patients make the right treatment decisions.

Have patients been asking you about PRP for skin rejuvenation and hair restoration?

We want to know your views! Tell us what you think.

Many male and female patients seek therapy for androgenetic alopecia (AGA) at some point. Results are rarely achieved with single-modality therapy. In fact, the treatment of AGA often requires a combination approach of systemic medications and supplements; topical therapy; and if indicated, some type of minimally invasive procedure or surgical option.

The use of platelet-rich plasma (PRP) to pretreat follicular unit hair grafts may increase hair growth and density. Although the method by which PRP helps promote hair growth remains a source of speculation, it is known that platelets contain many growth factors in the platelet α granules. When these granules become activated, they release many types of growth factors ranging from vascular endothelial growth factor, transforming growth factor ß, epidermal growth factor, platelet-derived growth factor, and insulinlike growth factor.

Injection or topical application of PRP has become a popular treatment for skin rejuvenation, alopecia, and autologous fat grafting; however, many of these treatments are being done without the studies to support them.

Alves and Grimalt (Dermatol Surg. 2016;42:491-497) conducted a prospective, split-scalp, placebo-controlled study evaluating the use of PRP injections in the treatment of AGA in 25 patients (12 men, 13 women) with a mean age of 39 years (age range, 21–62 years). Photographs were taken and 4 areas per split scalp were marked with red tattoo dots. The patients were randomized to receive PRP on 1 side and saline injections on the other side. Patients were blinded, but the physician performing the treatment was not blinded. Treatments were performed monthly for 3 sessions. Follow-up photographs and hair density counts were performed at 3 and 6 months after treatment.

Results showed that after 6 months there was a statistically significant (P<.05) increase in the total hair density and terminal hair counts on the PRP-treated side compared to baseline and to the placebo-treated side. When broken down by demographics, patients who did best were men 40 years or younger with AGA beginning at 25 years or older, a positive family history of AGA, and AGA duration of greater than 10 years.

What’s the issue?

The results of this study suggest that PRP has a mild to modest effect (approximately 10% increase) on increasing hair density in a specific patient population. This split-scalp, placebo-controlled study is one of the few of its kind in the field of PRP research and the authors should be applauded for the design of this study. However, it would be beneficial to have a 1-year follow-up to see if the results are maintained and to better help determine if maintenance injections would be needed to sustain the results.

The field of hair restoration and regeneration will continue to grow as newer technologies in hair stem cell injections come to the forefront as well. Rigorous studies will be needed to better help physicians and patients make the right treatment decisions.

Have patients been asking you about PRP for skin rejuvenation and hair restoration?

We want to know your views! Tell us what you think.

Many male and female patients seek therapy for androgenetic alopecia (AGA) at some point. Results are rarely achieved with single-modality therapy. In fact, the treatment of AGA often requires a combination approach of systemic medications and supplements; topical therapy; and if indicated, some type of minimally invasive procedure or surgical option.

The use of platelet-rich plasma (PRP) to pretreat follicular unit hair grafts may increase hair growth and density. Although the method by which PRP helps promote hair growth remains a source of speculation, it is known that platelets contain many growth factors in the platelet α granules. When these granules become activated, they release many types of growth factors ranging from vascular endothelial growth factor, transforming growth factor ß, epidermal growth factor, platelet-derived growth factor, and insulinlike growth factor.

Injection or topical application of PRP has become a popular treatment for skin rejuvenation, alopecia, and autologous fat grafting; however, many of these treatments are being done without the studies to support them.

Alves and Grimalt (Dermatol Surg. 2016;42:491-497) conducted a prospective, split-scalp, placebo-controlled study evaluating the use of PRP injections in the treatment of AGA in 25 patients (12 men, 13 women) with a mean age of 39 years (age range, 21–62 years). Photographs were taken and 4 areas per split scalp were marked with red tattoo dots. The patients were randomized to receive PRP on 1 side and saline injections on the other side. Patients were blinded, but the physician performing the treatment was not blinded. Treatments were performed monthly for 3 sessions. Follow-up photographs and hair density counts were performed at 3 and 6 months after treatment.

Results showed that after 6 months there was a statistically significant (P<.05) increase in the total hair density and terminal hair counts on the PRP-treated side compared to baseline and to the placebo-treated side. When broken down by demographics, patients who did best were men 40 years or younger with AGA beginning at 25 years or older, a positive family history of AGA, and AGA duration of greater than 10 years.

What’s the issue?

The results of this study suggest that PRP has a mild to modest effect (approximately 10% increase) on increasing hair density in a specific patient population. This split-scalp, placebo-controlled study is one of the few of its kind in the field of PRP research and the authors should be applauded for the design of this study. However, it would be beneficial to have a 1-year follow-up to see if the results are maintained and to better help determine if maintenance injections would be needed to sustain the results.

The field of hair restoration and regeneration will continue to grow as newer technologies in hair stem cell injections come to the forefront as well. Rigorous studies will be needed to better help physicians and patients make the right treatment decisions.

Have patients been asking you about PRP for skin rejuvenation and hair restoration?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Injectable soft-tissue fillers continue to be popular in the cosmetic arena. In the United States there are many fillers currently on the market and many more coming through the pipeline. A multitude of products are available outside the United States. As with any procedure, the more fillers we inject, the more complications we are bound to see.

Conrad et al (Modern Plastic Surgery. 2015;5:14-18) performed a retrospective analysis of patients treated over a 10-year period with soft-tissue injections (1559 patients) looking for cases complicated by abscess formation. Four patients were identified (0.3% of total patients). The authors discussed the 4 cases, the patients’ medical history and experience with other injectable agents, and the management of each complication.

Case 1 was a 52-year-old woman with systemic lupus erythematosus on a low-dose steroid who presented with an inflammatory response in the lower lip 7 days following injection with a hyaluronic acid (HA)–based gel filler in 2011. Her history was notable for prior HA filler in 2008 and polyacrylamide filler in 2009 and 2010. She was treated with 4 sessions of incision and drainage (I&D) and systemic clindamycin. Most of the cultures were negative, but one showed streptococci.

Case 2 was a 56-year-old woman treated in the nasolabial fold with HA in 2009. She developed inflammation shortly after and an abscess at the site a month later. She was treated with clindamycin both times, though cultures were negative. Furthermore, the abscess was treated with I&D and an intralesional steroid. She was a smoker and had been treated with a polymethyl methacrylate filler in 2002 and subsequently in 2013 with no issues.

Case 3 was a 39-year-old woman injected with an HA filler in the upper and lower lips in 2011. One month later she developed abscesses in both areas that were treated twice with I&D. Cultures were negative. She had a history of polyacrylamide injections of the nasolabial fold in 2009. The patient’s medical history was notable for scleroderma.

Case 4 was a 58-year-old woman injected with an HA filler in 2009 in the prejowl sulcus and nasolabial fold. She developed recurrent sterile abscesses in the areas 8 months after treatment that were managed by drainage of the areas and intralesional steroid injections over the ensuing 6 months. The scars were then excised, lasered 6 weeks later, and then filled in with expanded polytetrafluoroethylene implants, followed by 1 more session of laser resurfacing. She had a history of polymethyl methacrylate filler in 2002.

All patients eventually recovered. The authors stressed 3 important factors in managing dermal filler complications: (1) identifying the causative pathogen, (2) choosing the appropriate treatment of delayed-onset abscess formation, and (3) identifying the risk factors for patients at risk for abscess formation.

The issue of biofilms complicates the ability to identify the bacterial agent, yet biofilms are becoming recognized as the causative factors in what were previously thought of as sterile abscesses. The authors suggested using a peptide nucleic acid fluorescent in situ hybridization test to identify the biofilm bacteria. Conrad et el also discussed the development of slippery liquid-infused porous surfaces technology to coat the inside of syringes to help prevent biofilm formation.

The management of these patients is tricky because it is difficult to differentiate between a biofilm abscess and a hypersensitivity reaction. For this reason, the authors advocated using hyaluronidase versus intralesional steroids in the initial management to make the area more susceptible to antibiotics and to avoid promoting the growth of bacteria with the use of steroids. For patient risk factors, the authors focused on the fact that 2 of 4 patients had concomitant autoimmune disorders—scleroderma and systemic lupus erythematosus—that may have predisposed them to infection. Lastly, 2 patients had prior polyacrylamide injections and the authors also speculated if the positive charge of this filler attracted bacteria.

What’s the issue?

The use of fillers will continue to increase as there are more fillers with novel properties entering the market. As with new technology, only time will tell if we will see any particular type of reaction or risk for infection with them. The issue of biofilm bacterial contamination is real. It is recognized as one of the causes of capsular contraction following breast implant surgery. The etiology may not be from contamination during production but from contamination of the filler after injection due to any transient bacteremia that the patient may experience. A concern is that dental manipulation (eg, dental cleaning, filling of dental caries, periodontal surgery) during the 2- to 4-week postfiller period may “seed” bacteria into the area and cause the bacteria to settle and grow on the foreign substance. For patients who have semipermanent or permanent fillers such as polyacrylamide, polymethyl methacrylate beads, or poly-L-lactic acid, biofilm risk is greater and can occur months to years after the procedure. I have personally seen 2 cases of poly-L-lactic acid filler develop red, tender, sterile abscesses 1 year after placement in the tissue. Both cases responded to prolonged clarithromycin use (2 months). However, these cases highlight the fact that the fillers persist long after we place them, and any bacteremia, even mild, can cause an unsightly reaction.

Have you seen delayed soft-tissue filler reactions in your practice? Given this information, will you change the way you advise patients on dental procedures in the 2- to 4-week postfiller period?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

Cryolipolysis is a popular noninvasive treatment for areas of excess adipose deposition, such as in the abdomen and flanks. During the 60-minute procedure, a uniquely shaped treatment applicator is applied to the area with suction, causing cold exposure–induced crystallization of adipocytes through apoptosis. Overall, cryolipolysis treatment has a good safety profile and is well tolerated by patients without the need for anesthesia. A rare side effect of cryolipolysis is paradoxical adipose hyperplasia, which has been reported to be more common in men. Another rare adverse effect is the development of substantial posttreatment pain. Most patients usually experience minimal posttreatment discomfort and the phenomenon of delayed posttreatment pain rarely has been reported in the literature.

An online article published in Dermatologic Surgery in November evaluated posttreatment pain. Keaney et al performed a retrospective review that looked at the incidence of posttreatment pain after cryolipolysis as well as any correlating factors among patients that experience this pain.

In this retrospective chart review, 125 patients who received 554 consecutive cryolipolysis procedures over 1 year were evaluated for at least 2 of the following symptoms: (1) neuropathic symptoms (ie, stabbing, burning, shooting pain within treatment area), (2) increased pain at night that disturbed sleep, and (3) discomfort not alleviated by analgesic medication (ie, nonsteroidal anti-inflammatory drugs, narcotics). In these patients, 114 treatments were performed on 27 men and 440 treatments on 98 women; 36.6% of treatments were performed on the lower abdomen, 34.7% on the flanks, 11.9% on the upper abdomen, 9.4% on the back, 6.0% on the thighs, and 1.4% on the chest. A small cryolipolysis applicator was used for 95% of the treatments and a large applicator for 5% of the treatments.

Of 125 patients, 19 (15.2%) developed delayed postcryolipolysis pain and all were female patients. These patients received a total of 75 treatments (3.9 treatments per patient). All but 1 patient developed pain on the abdomen. One patient had pain on the flanks only. Three patients had pain at multiple sites (eg, abdomen and flanks, abdomen and thighs). Younger women (average age, 39 years) were more likely to have posttreatment pain. The number of treatments did not correlate with the development of pain. The average onset of pain was 3 days, with an average resolution time of 11 days (range, 2–60 days). Three patients underwent a second cryolipolysis treatment in the same area, which induced delayed pain again. Six patients underwent treatments on other body regions and did not develop pain.

Although postcryolipolysis pain is self-limiting and self-resolving, it can still be debilitating in some cases. Keaney et al managed the posttreatment discomfort with compression garments, lidocaine 5% transdermal patches, low-dose gabapentin, and/or acetaminophen with codeine. Low-dose oral gabapentin appears to have a good effect in pain treatment for these patients, which had a complete response in 14 patients as the sole treatment. Interestingly, 2 other large patient series were reported, with 518 patients in one study (Dermatol Surg. 2013;39:1209-1216) and 528 treatments in another study (Aesthetic Surg J. 2013;33:835-846); there were only 3 reports of mild to moderate pain.

What’s the issue?

Delayed posttreatment pain seems to be a common phenomenon, affecting primarily younger women who have had cryolipolysis of the abdominal region. It is reassuring that this pain is self-limiting and that it is responsive to oral gabapentin treatment. However, it is important to discuss this possible not-so-rare side effect with patients considering this treatment. Do you discuss delayed posttreatment pain with your cryolipolysis patients?

We want to know your views! Tell us what you think.

As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

As more patients undergo facial rejuvenation procedures for a more youthful look, there is a growing demand for rejuvenation of the décolletage (neck and chest) to achieve a more natural and seamless transition from the skin of the face to the chest. The same modalities that are used on the face to treat skin rhytides, texture, and discoloration have been used successfully in the décolletage area.

Vanaman and Fabi (Plast Reconstr Surg. 2015;136[suppl 5]:276S-281S) recently reviewed the chest anatomy and discussed the safe and effective use of cosmetic injectables alone or in combination with other modalities to address rhytides of the décolletage. The relatively low density of skin pilosebaceous units on the chest allows for slower healing and thus makes the area more vulnerable to scarring with the use of more invasive resurfacing modalities (eg, deeper chemical peels, ablative lasers). The use of cosmetic injectables offers a safer treatment option of chest rhytides. Furthermore, proper candidate selection excludes patients with known sensitivity to cosmetic injectables or their components, history of keloid or hypertrophic scar formation, and active inflammation in the treatment area.

Poly-L-lactic acid (PLLA) is a biodegradable, biocompatible, semipermanent, synthetic soft tissue biostimulator that promotes neocollagenesis by fibroblasts over time (3–6 months). The manufacturer’s recommendation for PLLA reconstitution is at least 2 hours prior to injection with sterile water of no less than 5 mL dilution. Vanaman and Fabi reported usually diluting the day prior to injection with 16 mL total volume. This technique showed the greatest improvement in chest rhytides with no adverse events reported in a retrospective analysis. Poly-L-lactic acid should be injected in a retrograde linear fashion in the plane of the subcutaneous fat, with injection boundaries on the suprasternal notch superiorly, the midclavicular line laterally, and the fourth rib inferolaterally for rejuvenation of the décolletage.

Nodule formation is a well-known complication of PLLA injection, although pain, bruising, edema, pruritus, and hematomas are more commonly seen. The risk of nodule formation can be decreased using several techniques, including avoiding overcorrection and excessive use of product in each individual session, avoiding intradermal injection, diluting to more than 5 mL with reconstitution at least overnight, massaging the area posttreatment (in office by the clinician and at home by the patient), and scheduling treatment sessions at least 4 weeks apart. Usually, 3 to 4 treatments are required and the results can last 2 years or longer without touch-ups.

Nonanimal stabilized hyaluronic acid (NASHA) fillers also can be used to correct chest rhytides; however, using NASHA fillers requires more syringes and results typically last only 6 to 8 months, making it more cost effective to use 2 to 3 vials of PLLA. Moreover, in Vanaman and Fabi’s experience, PLLA is associated with fewer nodules, possibly due to the depth of injection of PLLA into the subcutaneous fat versus injection into the deep dermis with NASHA fillers. Vanaman and Fabi currently are investigating the use of calcium hydroxylapatite fillers alone or in combination with an energy-based modality (microfocused ultrasound) with visualization in the treatment of rhytides in the décolletage.

What’s the Issue?

The availability of many modalities to keep facial skin looking fresh and rejuvenated has led to an increased demand for products and procedures to rejuvenate the décolletage. It is important for dermatologists to acknowledge the more delicate nature of the décolletage versus the face. Less invasive modalities such as cosmetic injectables can be employed in a safe and effective manner to correct rhytides of the chest with proper techniques, products, and patient selection. For a more natural transition from the skin of the face to the décolletage, it also may be necessary to adopt a multimodal approach by using botulinum toxin and fillers, as well as going beyond correction of rhytides to address skin texture and discoloration with chemical peels and lasers. Have you seen an increased demand for procedures to rejuvenate the décolletage in your practice?

We want to know your views! Tell us what you think.

Noninvasive cosmetic surgery procedures continue to increase in number, according to the American Society of Plastic Surgeons. Furthermore, these procedures are being performed in the offices of a growing number of physician specialties. As demand increases and offices become busy, there is increased delegation of these procedures to nurses, physician assistants, aestheticians, and medical assistants.

Austin et al (Dermatol Surg. 2015;41:827-832.) performed an Internet-based survey of physician members of the American Society for Dermatologic Surgery, the American Society for Laser Medicine and Surgery, and the American Society for Aesthetic Plastic Surgery to evaluate the delegation practices among the various specialties. The survey asked for physician training, age, gender, residency, and geographic location, as well as a breakdown of how much of their practice involved cosmetic procedures. Respondents were asked if they delegate procedures, to whom do they delegate (eg, registered nurse, physician assistant, MAs), and which procedures they delegate. A point system was used to give a score based on the perceived level of education and/or training of the person delegated to perform a procedure: do not delegate (1); physician assistant or nurse practitioner (2); registered nurse (3); and MA, aesthetician, or other (4).

Respondents included 823 physicians: 521 dermatologists and 302 nondermatologists. Of the respondents, 291 of dermatologists (55.9%) and 223 of nondermatologist physicians (73.8%) delegated cosmetic procedures. Procedures most often delegated by dermatologists compared to nondermatologists included chemical peels, neuromodulator and filler injections, laser hair removal, pulsed dye laser, tattoo removal, intense pulsed light, nonablative factional laser, and sclerotherapy.

The outcome of this survey shows that delegating certain cosmetic procedures is common, with more than half of all survey respondents delegating at least 1 cosmetic procedure. Dermatologists, as a whole, delegated less frequently than nondermatologist physicians, and when they did, dermatologists delegated to higher-level providers compared to nondermatologists. Medical practices in which the focus is primarily cosmetic and in those in which the physician is older also were more likely to delegate procedures.

What’s the issue?

There is tremendous variability between states about who is competent to perform many of the noninvasive cosmetic procedures. Some state medical boards specify the type of provider and the procedures allowed, while other states have no policy. However, this rule is changing, and there are more regulations being brought before the state medical boards with the goal of ensuring patient safety. As the demand for noninvasive procedures continues to grow, there will be an increase in the number of nonphysician providers performing these procedures. Patient safety should be at the forefront of all legislation, but at the same time there should be training courses and oversight boards to allow for safe delegation. Do you see yourself delegating more of these noninvasive procedures in the future?

We want to know your views! Tell us what you think.

Noninvasive cosmetic surgery procedures continue to increase in number, according to the American Society of Plastic Surgeons. Furthermore, these procedures are being performed in the offices of a growing number of physician specialties. As demand increases and offices become busy, there is increased delegation of these procedures to nurses, physician assistants, aestheticians, and medical assistants.

Austin et al (Dermatol Surg. 2015;41:827-832.) performed an Internet-based survey of physician members of the American Society for Dermatologic Surgery, the American Society for Laser Medicine and Surgery, and the American Society for Aesthetic Plastic Surgery to evaluate the delegation practices among the various specialties. The survey asked for physician training, age, gender, residency, and geographic location, as well as a breakdown of how much of their practice involved cosmetic procedures. Respondents were asked if they delegate procedures, to whom do they delegate (eg, registered nurse, physician assistant, MAs), and which procedures they delegate. A point system was used to give a score based on the perceived level of education and/or training of the person delegated to perform a procedure: do not delegate (1); physician assistant or nurse practitioner (2); registered nurse (3); and MA, aesthetician, or other (4).

Respondents included 823 physicians: 521 dermatologists and 302 nondermatologists. Of the respondents, 291 of dermatologists (55.9%) and 223 of nondermatologist physicians (73.8%) delegated cosmetic procedures. Procedures most often delegated by dermatologists compared to nondermatologists included chemical peels, neuromodulator and filler injections, laser hair removal, pulsed dye laser, tattoo removal, intense pulsed light, nonablative factional laser, and sclerotherapy.

The outcome of this survey shows that delegating certain cosmetic procedures is common, with more than half of all survey respondents delegating at least 1 cosmetic procedure. Dermatologists, as a whole, delegated less frequently than nondermatologist physicians, and when they did, dermatologists delegated to higher-level providers compared to nondermatologists. Medical practices in which the focus is primarily cosmetic and in those in which the physician is older also were more likely to delegate procedures.

What’s the issue?

There is tremendous variability between states about who is competent to perform many of the noninvasive cosmetic procedures. Some state medical boards specify the type of provider and the procedures allowed, while other states have no policy. However, this rule is changing, and there are more regulations being brought before the state medical boards with the goal of ensuring patient safety. As the demand for noninvasive procedures continues to grow, there will be an increase in the number of nonphysician providers performing these procedures. Patient safety should be at the forefront of all legislation, but at the same time there should be training courses and oversight boards to allow for safe delegation. Do you see yourself delegating more of these noninvasive procedures in the future?

We want to know your views! Tell us what you think.

Noninvasive cosmetic surgery procedures continue to increase in number, according to the American Society of Plastic Surgeons. Furthermore, these procedures are being performed in the offices of a growing number of physician specialties. As demand increases and offices become busy, there is increased delegation of these procedures to nurses, physician assistants, aestheticians, and medical assistants.

Austin et al (Dermatol Surg. 2015;41:827-832.) performed an Internet-based survey of physician members of the American Society for Dermatologic Surgery, the American Society for Laser Medicine and Surgery, and the American Society for Aesthetic Plastic Surgery to evaluate the delegation practices among the various specialties. The survey asked for physician training, age, gender, residency, and geographic location, as well as a breakdown of how much of their practice involved cosmetic procedures. Respondents were asked if they delegate procedures, to whom do they delegate (eg, registered nurse, physician assistant, MAs), and which procedures they delegate. A point system was used to give a score based on the perceived level of education and/or training of the person delegated to perform a procedure: do not delegate (1); physician assistant or nurse practitioner (2); registered nurse (3); and MA, aesthetician, or other (4).

Respondents included 823 physicians: 521 dermatologists and 302 nondermatologists. Of the respondents, 291 of dermatologists (55.9%) and 223 of nondermatologist physicians (73.8%) delegated cosmetic procedures. Procedures most often delegated by dermatologists compared to nondermatologists included chemical peels, neuromodulator and filler injections, laser hair removal, pulsed dye laser, tattoo removal, intense pulsed light, nonablative factional laser, and sclerotherapy.

The outcome of this survey shows that delegating certain cosmetic procedures is common, with more than half of all survey respondents delegating at least 1 cosmetic procedure. Dermatologists, as a whole, delegated less frequently than nondermatologist physicians, and when they did, dermatologists delegated to higher-level providers compared to nondermatologists. Medical practices in which the focus is primarily cosmetic and in those in which the physician is older also were more likely to delegate procedures.

What’s the issue?

There is tremendous variability between states about who is competent to perform many of the noninvasive cosmetic procedures. Some state medical boards specify the type of provider and the procedures allowed, while other states have no policy. However, this rule is changing, and there are more regulations being brought before the state medical boards with the goal of ensuring patient safety. As the demand for noninvasive procedures continues to grow, there will be an increase in the number of nonphysician providers performing these procedures. Patient safety should be at the forefront of all legislation, but at the same time there should be training courses and oversight boards to allow for safe delegation. Do you see yourself delegating more of these noninvasive procedures in the future?

We want to know your views! Tell us what you think.