Botulinum Toxin A Adjunctive Use in Manual Chemabrasion: Controlled Long-Term Study for Treatment of Upper Perioral Vertical Wrinkles

BACKGROUND: The treatment of perioral vertical wrinkles is a very common request from female patients as of their 40th decade of life. Actinic damage, cigarette smoking, loss of deep structures volume, sleep positions, orthodontic deformities, and dynamic components have been thought to cause this aesthetic problem. OBJECTIVE: The objective was to investigate the combination of botulinum toxin type A (BoNTA) pretreatment of the orbicularis oris muscle with manual chemabrasion to increase its clinical efficacy in the therapy of upper perioral vertical rhytides. METHODS: Twelve women presenting moderate to severe upper lip vertical rhytides were randomized to receive two unilateral BoNTA injections at the vermilion border, 1 week before chemabrasion (35% trichloroacetic acid followed by dermasanding) of the upper perioral cosmetic unit. Wrinkle severity was assessed by two blinded observers at baseline, 30 days, 90 days, 180 days, and 3 years by using a four-point Facial Wrinkle Severity Scale (FWSS). RESULTS: From Day 90 to Year 3, the BoNTA-injected sides showed smaller grades in the FWSS than control sides (p<.05). CONCLUSION: Previous injections of BoNTA improve short- and long-term results of chemabrasion in the upper lip region.     

Injection of All-Trans Retinoic Acid for Treatment of Thin Wrinkles

The authors propose a treatment to improve skin texture and to decrease thin wrinkles and creases. The treatment is based on the use of 0.1% all-trans retinoic acid intradermic injections (with biopresence of 0.02%) combined with topic cream, immediately followed by 340 Nm blue light skin exposure. These procedures determine the retinoic binding protein stabilization that provides the acid intracellular penetration with its subsequent effects. An average of 10 sessions, once a week was required.     

Immediate and Long-term Clinical Benefits of a Topical Treatment for Facial Lines and Wrinkles

Objective: To evaluate the efficacy and tolerance of a novel line treatment for periocular and perioral wrinkles. The line treatment was formulated with multiple growth factors, antioxidants, and a collagen-building peptide—ingredients that have been shown to increase collagen levels and provide long-term aesthetic benefits. To help provide immediate smoothing effects, hyaluronic acid filling spheres and a muscle contraction-inhibiting peptide were also included in the formulation. Design: Three-month, single-center, open-label, clinical study with clinical assessments at Baseline, Minutes (within 15 minutes of initial application), Month 1, and Month 3. Treatment: Subjects treated periocular and perioral wrinkles twice daily for three months with the line treatment. Participants: Thirty-seven females, 33 to 45 years of age, with mild-to-moderate, fine and coarse periocular and perioral wrinkles, were enrolled in the study. Measurements: Investigator assessments of fine and coarse periocular and perioral wrinkles, digital photography, and tolerance assessments were conducted at all visits. Subject self-assessment questionnaires were conducted within 15 minutes of initial application and at Month 3. Results: Investigator assessments of both periocular and perioral wrinkles showed statistically significant improvements over Baseline within minutes of initial application; these positive findings continued to improve through Months 1 and 3 (all P≤0.0003). No treatment-related adverse events were reported. Conclusions: The results from this study demonstrate that this uniquely formulated line treatment was well tolerated and provided both immediate and long-term improvements in the appearance of fine and coarse wrinkles.One of the most prominent signs of skin aging is the development of fine lines and wrinkles caused by both intrinsic and environmentally induced aging processes.¹ Intrinsic aging is a naturally occurring process relating to chronological age; whereas, environmentally induced aging results from external factors, the most notable of which is ultraviolet (UV) exposure. The main structural changes resulting from both types of aging are characterized by a reduction in collagen and elastin and a loss in hydration; all of which contribute to the appearance of lines and wrinkles. Reactive oxygen species (ROS), a byproduct of both environmentally induced and intrinsic aging, cause a cascade of biochemical reactions within the skin, which results in the production of matrix metalloproteinases (MMPs) and proinflammatory cytokines. MMPs, secreted by fibroblasts and keratinocytes, decrease collagen formation and enhance collagen degradation, contributing to the breakdown of the dermal matrix.^2–4 Proinflammatory cytokines lead to the degradation of elastin and also cause the production of additional ROS.In addition to these structural changes in collagen and elastin, facial areas associated with expression movement, such as the periocular and perioral areas, are especially vulnerable to wrinkle formation. As a result, it can be challenging for physicians and patients to find a topical treatment that produces visible improvement in these areas.To address the challenge of treating expressive facial areas, a topical line treatment containing a combination of ingredients was formulated to provide immediate improvements in the visible signs of aging as well as long-term anti-aging benefits. Multiple growth factors, peptides, and antioxidants were incorporated into the formulation for their ability to increase collagen levels by targeting various biochemical processes involved in collagen production and degradation. In addition, to affect immediate physical improvements in wrinkle appearance, a muscle contraction-inhibiting peptide and dehydrated hyaluronic acid (HA) filling spheres were included in the formulation. The hygroscopic properties of HA and its ability to create and fill space have been well documented.^5,6 The filling spheres, which penetrate into superficial folds of the skin, take advantage of HA’s properties and swell when hydrated, exerting pressure in the direction of the skin surface resulting in a smoothing effect on the skin. To soften the appearance of fine lines, light-diffusing ingredients, such as specialized polymeric microspheres, were also included in the line treatment.In recent years, growth factors have emerged as novel anti-aging agents due to their active role in dermal wound repair.⁷ The significance of the wound-healing process relates to the similarities between the biochemical pathways involved in the aging process and wound formation.⁸ Both processes stimulate the release of growth factors, which affect a variety of biochemical pathways critical to repair of the dermal matrix. In addition, topical growth factors have been shown in clinical studies to decrease the appearance of wrinkles and to stimulate collagen synthesis.^8–11Peptides are another group of novel ingredients included in the line treatment that play an important role in collagen synthesis and degradation. These protein building blocks are used in the body to signal between cells and influence the up- and down-regulation of various cellular functions. One of the peptides included in the treatment, palmitoyl tripeptide-5, is a synthetic peptide that mimics the sequence found in the protein thrombospondin 1 (TSP-1). TSP-1 has been shown to activate latent tissue growth factor β (TGF-β), a growth factor involved in the stimulation of collagen production.^12,13 To aid in the prevention of collagen degradation, the peptide dipalmitoyl hydroxyproline was incorporated for its ability to promote the production of tissue inhibitors of metalloproteinases (TIMPs), thereby suppressing the synthesis of MMPs.¹⁴Another peptide, unrelated to collagen synthesis and degradation, was formulated into the line treatment to target neuromuscular activity. Dipeptide diaminobutyroyl benzylamide diacetate was developed to mimic Waglerin-1, a compound found in temple viper snake venom. Waglerin-1 has been shown to block the nicotinic acetylcholine receptors at the neuromuscular junction, thus inhibiting muscular movement.¹⁵ The function of the Wagerlin-1-mimicking peptide is important for the treatment of lines since facial areas associated with repeated muscle movement are especially susceptible to wrinkle formation.Lastly, the potent antioxidants, ubiquinone and vitamins C and E were incorporated to prevent and reduce oxidative damage, thereby minimizing the effects caused by UV exposure and intrinsic aging.^16–18The purpose of this three-month, open-label, single-center study was to evaluate the efficacy and tolerance of this line treatment for periocular and perioral wrinkles.     

Histologic Evaluation of a Q-Switched Nd:YAG Laser in the Nonablative Treatment of Wrinkles

BACKGROUND: A variety of nonablative dermal remodeling techniques are currently available. The Q-switched Nd:YAG laser, in addition to its role in tattoo removal, hair removal, and vascular and pigmented lesion treatment, may also play a role in dermal remodeling for the treatment of wrinkles. The histologic changes seen in human skin after Q-switched Nd:YAG laser exposure have yet to be evaluated. OBJECTIVE: To study histologic changes after the use of a Q-switched Nd:YAG laser in the nonablative treatment of photoaged skin. METHODS: Sun-damaged infrauricular skin from six female subjects was exposed to a Q-switched Nd:YAG laser at fluences of 7 J/cm2 with two laser passes. Histologic examinations were performed before laser treatment and 3 months later. RESULTS: Biopsy specimens showed slight fibrosis in the superficial papillary dermis with unremarkable epidermal changes. CONCLUSION: The Q-switched Nd:YAG laser produced morphologic changes similar to, but lesser in degree, than those seen with both CO2 and Er:YAG laser resurfacing.     

尿激酶股动脉注射治疗急性下肢深静脉血栓形成

目的：观察尿激酶股动脉注射急性下肢深静脉血栓形成的疗效。方法：尿激酶股动脉注射联合常规疗法治疗急性下肢深静脉血栓形成45例，非手术常规疗法治疗53例，手术取栓（发病2d以内）12例，应用平均住院天数和临床治愈率指标回溯性比较疗效。结果：股动脉注射联合常规疗法组平均住院天数明显短于常规疗法组和手术取栓组，P＜0．05，前者临床治率率明显高于规疗法组（P＜0．05），但与手术取栓组无明显差别（P＞0．05）。结论：尿激酶动脉注射联合常规疗法较单用非手术常规疗法及手术取栓疗程短，较非手术常规疗法临床治愈率高。     

Treatment of Upper Lip Wrinkles: A Comparison of 950 μsec Dwell Time Carbon Dioxide Laser with Unoccluded Baker's Phenol Chemical Peel

BACKGROUND: The high energy, pulsed, or computer-scanned continuous wave carbon dioxide laser (CO2 laser) has gained popularity as a wrinkle treatment because of its minimal thermal injury and precise control of tissue vaporization depth. Chemical peels such as phenol have also been effective in treating facial wrinkles. This is, to our knowledge, the first study comparing the use of CO2 laser to phenol for treatment of wrinkles on the upper lip. OBJECTIVE: To compare the effectiveness and side effect profile of the 950 microsec dwell time CO2 laser to that of unoccluded Baker's phenol chemical peel in the treatment of upper lip wrinkles. METHODS: Twenty female subjects with moderate to severe upper lip wrinkles were randomly treated with Baker's phenol on one side of the upper lip and the 950 microsec dwell time CO2 laser on the other side. RESULTS: The average upper lip laser-treated wrinkle score (0 = none to 5 = severe) decreased from 4.30+/-0.20 before treatment to 1.11+/-0.28 at 6 months after treatment. The average upper lip phenol-treated wrinkle score decreased from 4.20+/-0.20 to 0.47+/-0.12. The degree in which the wrinkle score improved after phenol treatment compared with that after laser treatment was statistically significant (p<0.03). CONCLUSION: Treatment of upper lip wrinkles with Baker's phenol resulted in greater improvement than treatment with the 950 microsec dwell time CO2 laser.     

Prevention of Fat Embolism in Fat Injection for Gluteal Augmentation,Anatomic Study in Fresh Cadavers

Introduction: Liposuction is a popular surgical procedure. As in any surgery, there are risks and complications, especially when combined with fat injection. Case reports of fat embolism have described a possible explanation as the puncture and tear of gluteal vessels during the procedure, especially when a deep injection is planned. Methods: A total of 10 dissections were performed in five fresh cadavers. Each buttocks was divided into four quadrants. We focused on the location where the gluteal vessels enter the muscle and the diameter of the vessels. Colorant at two different angles was injected (30° and 45°). We evaluated the relation of the colorant with the main vessels. Results: We found two perforators per quadrant. The thickness of the gluteal muscle was 2.84 ± 1.54 cm. The area under the muscle where the superior gluteal vessels traverse the muscle was located 6.4 ± 1.54 cm from the intergluteal crease and 5.8 ± 1.13 cm from the superior border of the muscle. The inferior gluteal vessels were located 8.3 ± 1.39 cm from the intergluteal crease and 10 ± 2.24 cm from the superior border of the muscle. When we compared the fat injected at a 30° angle, the colorant stayed in the muscle. Using a 45° angle, the colorant was in contact with the superior gluteal artery and the sciatic nerve. No puncture or tear was observed in the vessels or the nerve. Conclusions: The location where the vessels come in contact with the muscle, which can be considered for fat injection, were located in quadrants 1 and 3. A 30° angle allows for an injection into the muscle without passing into deeper structures, unlike a 45° injection angle.     

Cutaneous Electrosurgery in a Patient with a Deep Brain Stimulator

BACKGROUND: Deep brain stimulators are implantable devices with electrical activity used to treat certain movement disorders such as essential tremor and Parkinson's disease. Similar to implantable cardiac devices, use of electrosurgery on patients with these devices may produce adverse effects. CASE REPORT: We describe the effects of electrosurgery on a patient with essential tremor and an implantable deep brain stimulator who required Mohs micrographic surgery to excise a basal cell carcinoma. The patient experienced immediate lancinating "electrical shock" using electrosurgery in the monopolar mode. The patient experienced no discomfort when a bipolar electrosurgical device was used or when his deep brain stimulator was "turned off." Appropriate positioning of the dispersive plate also reduced adverse effects. CONCLUSION: Dermatologic surgeons should be aware of patients with devices implanted in the CNS with electrical activity and proceed with caution when using electrosurgery. Different approaches can be utilized to help reduce adverse effects.     

Renal Autotransplantation in Lynch Syndrome: A Viable Option in a Patient With Contralateral Metachronous Ureteral Cancer

The success of human kidney allotransplantation was realized over six decades ago. First described 50 years ago, renal autotransplantation has been utilized sparingly as a salvage procedure for patients at risk of losing renal function, either from a benign or malignant condition. While classically associated with colorectal malignancies, Lynch syndrome also carries a small yet significant risk for the development of ureteral carcinoma. For these patients who develop chronic kidney disease, allotransplantation may not be an option due to the lifelong risk of several malignancies. We report the first known case of renal autotransplantation in a patient with metachronous ureteral cancer due to Lynch syndrome.     

1例假性动脉瘤患者瘤腔内注射凝血酶的护理

对1例妊娠合并阵发性睡眠性血红蛋白尿患者进行治疗及护理，结果患者病情稳定，足月剖宫产1活男婴，病情好转出院。提出针对性地做好病情观察与身心护理是取得满意疗效的关键。     

1例假性动脉瘤患者瘤腔内注射凝血酶的护理

对1例假性动脉瘤患者在超声引导下局部注射凝血酶,注射后彩色多普勒血流显像示假性动脉瘤内血液凝固,血流信号消失.提示瘤腔内注射凝血酶治疗假性动脉瘤创伤小、效果好、安全易行.而完善术前准备,术中密切配合,术后加强并发症的观察是保证治疗成功的关键.     

1例假性动脉瘤患者瘤腔内注射凝血酶的护理

对1例假性动脉瘤患者在超声引导下局部注射凝血酶，注射后彩色多普勒血流显像示假性动脉瘤内血液凝固,血流信号消失。提示瘤腔内注射凝血酶治疗假性动脉瘤创伤小、效果好、安全易行。而完善术前准备，术中密切配合，术后加强并发症的观察是保证治疗成功的关键。