NewFill for Skin Augmentation: A New Filler or Failure?

Background New injectable materials for skin augmentation that promise to be the ideal filling material are introduced every year. Recently, we treated three patients with adverse reactions to a new substance for skin augmentation: polylactic acid (NewFill, Ashford Aesthetics Inc, Belgium).
Objective To present three cases in which serious adverse reactions had occurred after skin augmentation with a new filling substance, polylactic acid (NewFill). Because an identical substance (Sculptra, Aventis Pharmaceuticals, Bridgewater, NJ, USA) was recently introduced in the United States, we want to alert future users of these substances to possible adverse events.
Materials and Methods We report three cases with serious adverse events more than 12 months after skin augmentation with polylactic acid (NewFill). They were treated with intralesional steroid therapy and topical imiquimod application.
Results Both intralesional steroid therapy and topical imiquimod application lead to moderate results. If feasible, surgical excision is the best available option.
Conclusions Great care should be taken when polylactic acid is used for intradermal injection because giant cell granulomatous reactions may be the result. Other than surgical excision, effective treatment options are lacking.     

Incorporating skin care into a facial plastic surgery practice

Starting a skin care practice takes patience and dedication, but it provides your patients with a necessary service for a comprehensive facial plastic and reconstructive surgery practice. This article discusses the differences between physician-directed skin care and spa-directed skin care and emphasizes procedures that may be performed by an aesthetician in a physician's office. Skin care practice can be classified into skin care regimens: chemical peels, microdermabrasion, and makeup. Optimal skin care regimens incorporate pharmaceutical-grade ingredients, including tretinoin, topical vitamin C, and hydroquinone. Microdermabrasion and superficial chemical peels, such as glycolic, salicylic, and trichloroacetic acid peels, are discussed. Noninvasive procedures by the physician, such as Botox and laser treatments, complement the procedures performed by the aesthetician. However, the physician is ultimately responsible for the philosophy of the skin care practice. Patient education, customer service, and skin health are key ingredients for success.     

Double-Blinded, Placebo-Controlled Trial of Green Tea Extracts in the Clinical and Histologic Appearance of Photoaging Skin

Background. Green tea extracts have gained popularity as ingredients in topical skin care preparations to treat aging skin. Green tea polyphenolic compounds have significant antioxidant and anti-inflammatory activities, and studies suggest that these extracts help mediate ultraviolet radiation damage.
Objective. To evaluate the effects of a combination regimen of topical and oral green tea supplementation on the clinical and histologic characteristics of photoaging.
Methods. Forty women with moderate photoaging were randomized to either a combination regimen of 10% green tea cream and 300 mg twice-daily green tea oral supplementation or a placebo regimen for 8 weeks.
Results. No significant differences in clinical grading were found between the green tea–treated and placebo groups, other than higher subjective scores of irritation in the green tea–treated group. Histologic grading of skin biopsies did show significant improvement in the elastic tissue content of treated specimens (p<.05).
Conclusion. Participants treated with a combination regimen of topical and oral green tea showed histologic improvement in elastic tissue content. Green tea polyphenols have been postulated to protect human skin from the cutaneous signs of photoaging, but clinically significant changes could not be detected. Longer supplementation may be required for clinically observable improvements.
THIS STUDY WAS SUPPORTED BY NU SKIN INTERNATIONAL, INC. DR. KIMBALL HAS SERVED AS A CONSULTANT TO NU SKIN AND HAS RECEIVED HONORARIA FOR SPEAKING.     

Effect of Pretreatment on the Incidence of Hyperpigmentation Following Cutaneous CO2 Laser Resurfacing

Background. Transient hyperpigmentation is the most common complication seen following cutaneous carbon dioxide (CO₂) laser resurfacing.
Objective. The purpose of this study was to determine whether the use of a topical skin lightening regimen prior to cutaneous laser resurfacing reduces the incidence of post-laser resurfacing hyperpigmentation.
Methods. One hundred consecutive CO₂ laser resurfacing patients (skin types I–III) were randomized to receive preoperative treatment with 10% glycolic acid cream twice daily (n = 25), hydroquinone 4% cream qHS and tretinoin 0.025% cream twice daily (n = 25) or no pretreatment (n = 50, control) for at least 2 weeks. Clinical and photographic assessments were performed prior to laser resurfacing and at 4 and 12 weeks following treatment.
Results. There was no significant difference in the incidence of post-CO₂ laser resurfacing hyperpigmentation between subjects who received pretreatment with either topical glycolic acid cream or combination tretinoin/hydroquinone creams and those who received no pretreatment regimen.
Conclusion. It is postulated that reepithelialization after cutaneous laser resurfacing includes follicular melanocytes that have not been affected by topical pretreatment. When instituted as a component of the skin care regimen postoperatively, topical hydroquinone, tretinoin and/or glycolic acid preparations may be helpful in reducing post-laser resurfacing hyperpigmentation.     

Noninvasive Lower Eyelid Blepharoplasty: A New Technique Using Nonablative Radiofrequency on Periorbital Skin

Background. Laxity and rhytids of the lower eyelids are common cosmetic concerns. Historically, correction has either been surgical through either transcutaneous or transconjunctival blepharoplasty or ablative through laser resurfacing or chemical peeling. Therapeutic options usually require significant postoperative healing and have the potential risk of scarring ectropion or pigmentary loss.
Objective. To report the use of a new technique that uses nonablative radiofrequency (NARF) to tighten noninvasively and nonsurgically the flaccid skin of the lower eyelids by treating the periorbital area to produce cosmetic improvement.
Methods. Nine patients with skin flaccidity of the lower eyelids had a single treatment session with NARF in a small area of skin in the periorbital region, specifically the zygomatic and/or temporal areas. All patients were treated with topical anesthesia only. The treatment lasted approximately 10 minutes. No postoperative care was required.
Results. All of the nine patients in the study achieved cosmetic improvement of the eyelids ostensibly through skin contraction. All patients were able to return to their normal routines immediately. Although the results were gradual, patient satisfaction was remarkable. No complications were seen in this study.
Conclusion. This new procedure using NARF was successful in providing a safe, noninvasive, cosmetic improvement in these patients with excessive skin laxity of the lower eyelids. Postoperative morbidity, including down time and complications, was not seen.     

Cosmeceutical Peptides

Background. Cosmeceuticals are skin care products that lie in a gray area between cosmetics and drugs. The desire for the improvement of aging skin has resulted in a plethora of products designed to improve the appearance beyond the simple camouflage of cosmetics. Many ingredients have been added to these products based on theoretical benefits discovered from in vitro studies on wound healing and other metabolic processes.
Objective. To help the practicing dermatologist who is often the source of information for patients regarding the benefits of available cosmeceuticals.
Methods and Materials. This article is a compilation of published studies on the effects and the practical applications of peptides as topical agents for skin improvement.
Results. There does seem to be science that shows that these peptide cosmeceuticals have the potential to improve the appearance of aging skin. It is important to remember, however, that for benefit to be realized, the final product must be stable in formula, absorbed into the skin, and biologically active at the target for clinical benefit.
Conclusion. This article will provide dermatologists with more background to answer pressing questions from patients on this subject.
MARY P. LUPO, MD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Niacinamide: A B Vitamin that Improves Aging Facial Skin Appearance

Background. In multiple chronic clinical studies, topical niacinamide (vitamin B3) has been observed to be well tolerated by skin and to provide a broad array of improvements in the appearance of aging facial skin (eg, reduction in the appearance of hyperpigmentated spots and red blotchiness).
Objective. To clinically determine the effect of topical niacinamide on additional skin appearance and property end points (wrinkles, yellowing, and elasticity).
Methods. Female white subjects (  N = 50  ) with clinical signs of facial photoaging (fine lines and wrinkles, poor texture, and hyperpigmented spots) applied 5% niacinamide to half of the face and its vehicle control to the other half twice daily for 12 weeks (double blind, left-right randomized). Facial images and instrumental measures were obtained at baseline and at 4-week intervals.
Results. Analyses of the data revealed a variety of significant skin appearance improvement effects for topical niacinamide: reductions in fine lines and wrinkles, hyperpigmented spots, red blotchiness, and skin sallowness (yellowing). In addition, elasticity (as measured via cutometry) was improved. Corresponding mechanistic information is presented.
Conclusion. In addition to previously observed benefits for topical niacinamide, additional effects were identified (improved appearance of skin wrinkles and yellowing and improved elasticity).
ALL OF THE AUTHORS ARE EMPLOYED BY THE PROCTER & GAMBLE COMPANY, WHICH FUNDED THIS STUDY.     

Efficacy of 1% 4-Ethoxybenzaldehyde in Reducing Facial Erythema

Background. Facial erythema is a common postsurgical and dermatologic problem. It is commonly the result of dermal inflammation arising from either a facial surgical procedure, such as laser resurfacing, dermabrasion, or a face peel, or from an underlying dermatologic condition, such as rosacea. Facial erythema is difficult for the dermatologist to treat in both settings because topical corticosteroids cannot be used long term on the thin facial skin and anti-inflammatory oral or topical antibiotics have associated side effects.
Objective. The goal of this pilot study was to evaluate the anti-inflammatory effect of 1% 4-ethoxybenzaldehyde in a rosacea model of facial erythema.
Methods. Thirty subjects with mild to moderate stable rosacea were enrolled in this 4-week, double-blind, vehicle-controlled study. Photographs, investigator assessment, and subject assessment were the efficacy criteria.
Results. There was a statistically significant reduction in facial erythema (p<.01) in those subjects who used the active for 4 weeks, as well as a statistically significant improvement in uneven skin tone (p<.01) and the overall severity of the disease (p<.01). There was no statistically significant difference in any of these three indices in the vehicle-treated group.
Conclusion. The results suggest that benzaldehyde-derived anti-inflammatory agents may be useful in reducing facial erythema in a rosacea model.
THIS STUDY WAS FUNDED BY AN EDUCATIONAL GRANT FROM CUTANIX CORPORATION. ZOE DRAELOS, MD, HAS INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS. BRYAN FULLER, PHD, IS THE INVENTOR OF THE ACTIVE, WHICH WAS LICENSED THROUGH THE OKLAHOMA HEALTH SCIENCES CENTER TO CUTANIX.     

Endogenous Growth Factors as Cosmeceuticals

Background. Research into the pathophysiology of photodamaged skin has revealed correlations with certain aspects of acute and chronic wound healing. In wound healing, growth factors accumulate at the wound site and interact synergistically to initiate and coordinate wound healing.
Objectives. To review the effects of topical growth factors in wound healing and their potential use in treating photodamaged skin.
Methods. A mixture of multiple growth factors derived from human fibroblasts was applied topically to 14 patients twice daily for 60 days to stimulate the remodeling phase of wound healing.
Results. A total of 78.6% of patients with photodamaged skin showed clinical improvement at 60 days. New collagen formation increased by 37%, and epidermal thickening increased by 27%.
Conclusions. These data, as well as other studies of growth factors in wound healing, demonstrate positive cosmetic and clinical outcomes of topical application of growth factors for the treatment of photodamaged skin.
DR. FITZPATRICK IS THE FOUNDER OF SKIN MEDICA AND OWNS STOCK AS WELL AS STOCK OPTIONS.     

Congenital tylosis and the role of the plastic and reconstructive surgeon

Congenital tylosis or hereditary palmoplantar keratoderma is a group of heterogeneous diseases characterised by thickening of the skin on the palms and soles of feet. A case history of a patient with congenital tylosis is presented to highlight the involvement of plastic and reconstructive surgery in the management of this issue. The management of this condition is discussed and poses a difficult challenge requiring the corroborative efforts of many health care professionals. It appears that there is no single answer to the treatment of this condition, although topical and systemic treatments, in conjunction with surgical management of extensive disease and physiotherapy for contracture formation seem to be the appropriate management plan.     

Vitamin E: Critical Review of Its Current Use in Cosmetic and Clinical Dermatology

Background and Objective. The lipophilic antioxidant vitamin E has been used for more than 50 years in clinical and experimental dermatology. However, although a large number of case reports were published, there is still a lack of controlled clinical studies providing a rationale for clinical indications and dosage. In contrast, advances in basic research on the physiology, mechanism of action, penetration, bioconversion, and photoprotection of vitamin E in human skin have led to the development of numerous new formulations for use in cosmetics and skin care products.
Results. This article reviews the basic mechanisms and possible cosmetical and clinical implications of the recent advances in cutaneous vitamin E research. Experimental evidence suggests that topical and oral vitamin E has anticarcinogenic, photoprotective, and skin barrier–stabilizing properties.
Conclusion. Although its current use is largely limited to cosmetics, controlled clinical studies for indications such as atopic dermatitis or prevention of photocarcinogenesis are needed to evaluate the clinical benefit of vitamin E.
JENS J. THIELE, MD, SHERRY N. HSIEH, PHD, AND SWARNA EKANAYAKE-MUDIYANSELAGE, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Excellent Clinical Results with a New Preparation for Chemical Peeling in Acne: 30% Salicylic Acid in Polyethylene Glycol Vehicle

BACKGROUND Chemical peeling by salicylic acid in ethanol or another vehicle may be accompanied by stinging and burning followed by postinflammatory hyperpigmentation in the treated area, or salicylism. We have developed a new formulation: 30% salicylic acid in polyethylene glycol (SA-PEG). A topical application of SA-PEG remodels photodamaged skin in mice and humans, without systemic absorption.
OBJECTIVE The objective was to evaluate the safety and efficacy of SA-PEG for clinical use in the treatment of acne.
MATERIALS AND METHODS We evaluated the effects of the preparation histologically in mice and its safety and efficacy in 44 volunteers with normally aged skin and in 436 patients with acne.
RESULTS Histologic studies in animals showed no inflammatory changes in the skin following topical application of SA-PEG. Volunteers noted an improved skin texture. In the acne patients, the comedones and papules disappeared, resulting in an excellent outcome. There was a notable absence of stinging and burning, edema, bleeding, or crusting in the treated area.
CONCLUSION The SA-PEG preparation appeared to be safe and effective, with minimal associated inflammation or adverse effects, even in Asian patients who tend to develop hyperpigmentation or keloids. This preparation is thus ideal for chemical peeling.     

Decreased Efficacy of Topical Anesthetic Creams in Presence of Benzoyl Peroxide

Background. Topical anesthetics are widely used to diminish the sensation of pain from various medical cutaneous procedures. Any topical agent that reduces the desired effect has clinical ramifications.
Materials and Methods. Topical 6% benzocaine cream was applied to both inner forearms of five persons and covered with a bandage. One of the arms was additionally treated simultaneously with 5% benzoyl peroxide. The areas were tested with a pinprick examination every 10 minutes for the ensuing hour.
Results. There was an estimated 75% increased perception of pain on the forearm to which benzoyl peroxide was applied in consort with the topical anesthetic at all examination times.
Conclusions. Benzoyl peroxide chemically reacts with topical anesthetics such as tetracaine, procaine, pramoxine, prilocaine, and lidocaine, causing a significant reduction in their numbing effect. Clinically, make sure that the skin area to be topically anesthetized is devoid of any previous treatment with benzoyl peroxide or insist that the skin is thoroughly washed prior to application of the anesthetic.
CRAIG G. BURKHART, MPH, MD, AND CRAIG N. BURKHART, MSBS, MD, HAVE INDICATED NO SIGNIFICANT INTEREST WITH COMMERCIAL SUPPORTERS.     

Combined 5-Fluorouracil and Er:YAG Laser Treatment in a Case of Recurrent Giant Keratoacanthoma of the Lower Leg

Background. Keratoacanthomas are fast-growing squamous tumors, which usually show spontaneous regression. The development of giant variants with an aggressive behavior has been described. Although surgical excision remains the treatment of choice for very large keratoacanthomas, other therapeutic options including laser surgery and topical chemotherapy may be superior in special situations.
Objective. The objective was to evaluate the efficacy of Er:YAG laser surgery combined with topical 5-fluorouracil treatment in a case of recurrent giant keratoacanthoma.
Methods. A 64-year-old woman presented for evaluation and treatment of recurrent tumors in her face and extremities. Despite repeated invasive surgical removal of these lesions, recurrence of fast-growing giant keratoacanthomas developed in the pretibial region of her left lower leg. Owing to recurrence after conventional surgery and the tumor size, a novel treatment method using ablative Er:YAG laser combined with topical 5-fluorouracil was performed.
Results. After four treatments with excellent patient compliance, histologic analysis of punch biopsies revealed tumor-free ulcerations. Complete epithelization was obtained after 9 weeks. Six months after the treatment, no recurrence was observed.
Conclusion. The combined use of ablative Er:YAG laser and topical 5-fluorouracil chemotherapy may be considered as an effective treatment option in cases of giant keratoacanthoma when conventional surgery is not indicated.     

1 MAC-incision sevoflurane prevents explicit awareness during surgical skin incision and tracheal intubation

Background: This study tested the hypothesis that 1 MAC-incision anesthesia secures unconsciousness during surgical skin incision and tracheal intubation.
Methods: Twenty patients scheduled for gynecological laparotomy were anesthetized with sevoflurane as the sole agent. At 1 MAC-incision steady-state conditions, the patients were observed for autonomic /movement responses and wakefulness (response to verbal commands) in the 1-min period following surgical skin incision and tracheal intubation.
Results: Blood pressure and heart rate increased significantly secondary to both stimuli, and significantly more after tracheal intubation than skin incision. Ten and 19 patients moved in response to skin incision and tracheal intubation, respectively. None of the patients showed wakefulness.
Conclusion: It is concluded that 1 MAC-incision sevoflurane secures unconsciousness during surgical skin incision and tracheal intubation.     

Possible Hazards of Cryogen Use with Pulsed Dye Laser A Case Report and Summary

Background.  Pulsed dye laser treatment of port-wine stains is safe and effective. However, the pain associated with this treatment is often difficult to tolerate, especially for children. A laser-coupled delivery system known as dynamic epidermal cooling has recently been developed to improve local anesthesia.
Objective.  To report laser ignition of a commercially-available, hand-held cryogen spray used for local anesthesia, and describe possible mechanisms of the fire; to define the chemical characteristics of other skin coolants suitable and unsuitable for skin cooling with laser treatment.
Methods.  Case report and literature review.
Conclusions.  Clinicians must be aware of the thermodynamic properties, potential for skin damage, cost and environmental consequences of commercially available cryogens before considering their use for topical anesthesia with laser surgery.     

Anesthesia for Office-Based Oculoplastic Surgery

Background Many common oculoplastic surgical procedures can be performed in an office-based setting.
Objective To describe a system of local anesthetic use that provides superb anesthesia administered in a nearly painless manner.
Methods Combined conjunctival, topical, and injected local anesthesia is used in outpatient oculoplastic surgical procedures. The use of optional adjuvant oral sedation can decrease pain and anxiety in selected patients.
Results We have successfully employed our described system of local anesthesia for office-based oculoplastic surgery.
Conclusion In suitable patients, the shifting of operative location from the hospital or ambulatory surgery center to the office provides many benefits to both the patient and the surgeon.     

Specialty Clinics for the Dermatologic Care of Solid-Organ Transplant Recipients

Background. Solid-organ transplant recipients constitute a complex patient population that experiences numerous and aggressive skin cancers. Proactive, comprehensive, ongoing, and effective dermatologic care of these patients is a necessity.
Objective. The objective of this study was to emphasize the need for organized dermatologic care for transplant recipients and to collect and present various proactive paradigms established in and designed for different practice settings to manage organ transplant recipients at high risk for skin cancer.
Methods. Information about practice setting, patient demographics, and the care model used was obtained through questionnaires sent to a selection of 12 physicians known to care for transplant recipients in various practice settings.
Results. All 12 physicians completed the questionnaire. The organized dermatologic care of transplant recipients occurs in three basic clinic settings: multidisciplinary transplant clinics, designated dermatology transplant subspecialty clinics, and integration of transplant recipient care within existing dermatology clinics.
Conclusions. Various practice settings offer both advantages and disadvantages in providing preventive and therapeutic care of organ transplant recipients at risk for skin cancer. Regardless of the clinic design used, an organized and firmly established clinic model to allow proactive and ongoing care for these patients is important for education, prevention, and early intervention.     

Methicillin-resistant Staphylococcus aureus screening in total joint arthroplasty: a worthwhile endeavor

Infections with methicillin-resistant Staphylococcus aureus (MRSA) are an ever growing problem in the community, hospitals, and for orthopedic surgeons in particular. A conscious effort must be made to deal with this pathogen prior to total joint arthroplasty procedures. The drastic increase in prevalence of surgical-site infections (SSIs) after total joint replacement surgery has proved to be a major health care burden for both patients and surgeons from both a medical and financial standpoint. The development of screening techniques for detection of MRSA colonization in patients being admitted to hospitals is steadily increasing popularity. Particularly nasal swab rapid polymerase chain reaction detection of MRSA allows surgeons to identify patients at high risk for postoperative SSI. A variety of treatment regimens for eradication of MRSA colonization from the nares of surgical patients have surfaced, such as topical mupirocin prior to undergoing surgery. Decolonization of MRSA in patients undergoing joint arthroplasty procedures has demonstrated encouraging initial results in preventing SSIs and should be a serious focus of the future for orthopedic surgeons.