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Background Eyebrow rejuvenation is a common cosmetic concern among patients presenting to dermatologists. Due to increased patient demand for non-invasive procedures, multiple non-surgical, and minimally invasive eyebrow rejuvenation techniques have been developed. Objective This review aims to highlight the various non-surgical eyebrow rejuvenation therapeutic techniques described in the medical literature. Methods a Materials: A review of published articles on non-surgical and minimally invasive eyebrow rejuvenation using neurotoxins, fillers, lasers, threads, bimatoprost solution, and tattooing was conducted using the PubMed database. Results Currently available non-surgical options for eyebrow rejuvenation include neuromodulators, fillers, laser resurfacing, radiofrequency, and minimally invasive procedures such as tattooing and brow lift using threading. Conclusion The eyebrow is a complex and dynamic region. A thorough understanding of the anatomy of the supraorbital region and familiarity with available, minimally invasive treatment options is essential to tailor an individualized approach consisting of one or more treatments to achieve optimal rejuvenation outcomes. J Drugs Dermatol. 2021;20(9):970-978. doi:10.36849/JDD.6188.

The COVID-19 pandemic has led to the global adoption of mask wearing to contain he rampant spread of the virus. Certain occupational groups, particularly health care providers, must wear masks for prolonged periods. Alongside this pandemic emerged the use of the all-encompassing term “Maskne”, used to describe mask-related dermatologic pathologies. Although there is an increase in acne and acneiform lesions associated with prolonged facial mask use, “Maskne” may be a misnomer, causing non-dermatologic providers to misdiagnose patients with acne when they, in fact, have perioral dermatitis.

The pathophysiology of melanoma involves malignant transformation of melanocytes. These can arise de novo or result from malignant transformation of a pre-existing nevus. This case report presents a patient with a new pigmented lesion, arising from a pre-existing neurofibroma, on her left scapula and no personal or family history of systemic neurofibromatosis. Biopsy confirmed the lesion to be malignant melanoma and, after excision, postoperative pathology showed a pre-existing neurofibroma. A review of the literature suggests there may be a link between the pathogenesis of neurofibroma and malignant melanoma, because NF1 mutations are observed in both neurofibromatosis and malignant melanoma. We hypothesize that the pre-existing neurofibroma created a proliferative environment that gave rise to the adjacent neoplasm. Further research is required to understand the shared pathway, because this may lead to novel forms of surveillance and treatment.

Background Botulinum-derived neurotoxins have become a substantial tool in dermatologists' armamentarium for facial/neck rejuvenation. Current literature discusses anatomical "danger zones" to avoid during neurotoxin injection to prevent brow ptosis, blepharoptosis, and lower facial ptosis. Objective The aim of this study was to determine whether lidocaine 1% local anesthetic can be used to predict botulinum toxin treatment outcomes and prevent adverse effects of unwanted paralysis. Materials and methods One percent lidocaine was drawn up using BD ultra-fine 31 G (5/16″), 0.5-mL insulin syringes in the same quantity that would be drawn up for neurotoxin placement. The patient's face was cleansed and mapped; 0.1 mL of 1% lidocaine was injected × 5 sites in the glabella; and 3 sites were injected with 0.05 mL in the frontalis. The patient was assessed after 10 minutes. Results Improvement in frontalis and glabellar rhytides was appreciated, with noted "spocking" of the lateral brows. This technique allowed the authors to visualize the need for placement of toxin more laterally with eventual successful predictive placement for neurotoxin. Conclusion This technique of using local 1% lidocaine allows the practitioner to devise a neurotoxin distribution map tailored for each patient to limit unwanted paralysis from improper neurotoxin placement.

Tear trough and infraorbital region changes are one of the first signs recognizable aging. This is a common consultation for cosmetic dermatologists and there are many treatment options available.This article provides a review of the anatomy and changes that occur in the infraorbital region as we age. We also suggest the use of the osseous, color, underlying anatomy, laxity, adipose, rhytides (OCULAR) mnemonic to evaluate these changes and review the literature for treatments options.A literature search was performed through PubMed, using search terms "Tear trough," "Infra-orbital," "Dark-circles," "Lower-Eyelid," and "Midface."Fillers, lasers, radiofrequency devices, chemical peels, various topicals, and botulinum toxin are available non-surgical treatment options discussed in the literature found to significantly improve and rejuvenate the infraorbital region.A complete understanding of the anatomy and changes that occur with aging are of most importance when assessing the infraorbital region. Organizing these changes into the OCULAR mnemonic is one way to assess the infraorbital region and achieve optimal rejuvenation.

In 2015, over 2.4 million patients had treatments with soft tissue fillers, with the largest population between 40 and 54 years of age and ranging in age from teenagers to nonagenarians (ASPS, Plastic Surgery Statistics Report 2015, 2015) (4). This data is also representative of the patient population seeking treatment with temporary fillers of the trunk and extremities where the average age is around 60 years, with females significantly outweighing males. All skin types are represented in this demographic, but skin types II–IV are far more common than V–VI.

Background The American Council of Graduate Medical Education, which oversees much of postgraduate medical education in the United States, has championed the concept of "milestones," standard levels of achievement keyed to particular time points, to assess trainee performance during residency. Objective To develop a milestones document for the American Society for Dermatologic Surgery (ASDS) Cosmetic Dermatologic Surgery (CDS) fellowship program. Methods An ad hoc milestone drafting committee was convened that included members of the ASDS Accreditation Work Group and program directors of ASDS-approved Cosmetic Dermatologic Surgery (CDC) fellowship training programs. Draft milestones were circulated through email in multiple rounds until consensus was achieved. Results Thirteen milestones were developed in the 6 Accreditation Council for Graduate Medical Education (ACGME) competency areas, with 8 of these being patient-care milestones. Additional instructions for milestone administration more specific to the CDS fellowship than general ACGME instructions were also approved. Implementation of semiannual milestones was scheduled for the fellowship class entering in July 2018. Conclusion Milestones are now available for CDS fellowship directors to implement in combination with other tools for fellow evaluation.

BACKGROUND Cutaneous biopsy sites are often difficult to discern or are frequently misidentified when patients present for the treatment of skin cancers. This frustrating situation can lead to delays in treatment and wrong site surgeries. Current methods aiming to prevent this situation are not perfect. OBJECTIVE This study seeks to determine the efficacy of ultraviolet-fluorescent tattoos in facilitating the correct identification of suspected nonmelanoma skin cancer biopsy sites. METHODS In this prospective cohort, 51 shave biopsy sites were tattooed with ultraviolet-fluorescent ink in a series of 31 patients suspected of having a cutaneous malignancy. At the time of follow-up, the ability of the patient and the physician to identify the correct site with and without ultraviolet illumination of the tattoo was recorded. Visibility of the tattoo was graded before and after treatment. RESULTS Patients could not positively identify their biopsy site in 35% of cases. In 7% of cases, physicians could not confidently identify the site without the aid of ultraviolet illumination. In conjunction with tattoo illumination, physicians confidently identified the site in 100% of the cases. No adverse events occurred. CONCLUSION Ultraviolet-fluorescent tattoos offer a safe and reliable means of accurately marking cutaneous biopsy sites.

Importance Minor bleeding is the most common complication of dermatologic surgery. Topical brimonidine, 0.33%, gel has been reported for the use of hemostasis in dermatologic surgery. The safety profile and risk of systemic toxic effects when brimonidine is used topically for hemostasis is unknown. Objective To determine the risk of systemic toxic effects of topical brimonidine, 0.33%, gel when used for hemostasis. Design, Setting, and Participants In this case series from a private practice (Hollywood Dermatology), 2 patients presented for dermatologic procedures, complicated by persistent bleeding. Interventions Patients were treated with 10 g of brimonidine, 0.33%, gel applied under occlusion for hemostasis. Main Outcomes and Measures Mental status, cardiopulmonary function. Results Both patients experienced deterioration of mental status, respiratory depression, and somnolence. Results from cardiac testing, laboratory workup, and imaging were negative for cardiac or neurologic etiology. Both patients improved in less than 24 hours. Conclusions and Relevance Topical brimonidine, 0.33%, gel can result in systemic central nervous system toxic effects when used as a hemostatic agent. At present, it is not possible to define a quantity with which brimonidine can be used safely, nor can a safe wound size be defined. We, therefore, urge against the use of topical brimonidine as a hemostatic agent until its safety is further investigated.

IMPORTANCE: Despite the growing popularity of cosmetic procedures, the sociocultural and quality-of-life factors that motivate patients to undergo such procedures are not well understood. OBJECTIVE: To estimate the relative importance of factors that motivate patients to seek minimally invasive cosmetic procedures. DESIGN, SETTING, AND PARTICIPANTS: This prospective, multicenter observational study was performed at 2 academic and 11 private dermatology practice sites that represented all US geographic regions. Adult patients presenting for cosmetic consultation or treatment from December 4, 2016, through August 9, 2017, were eligible for participation. EXPOSURES: Participants completed a survey instrument based on a recently developed subjective framework of motivations and a demographic questionnaire. MAIN OUTCOMES AND MEASURES: Primary outcomes were the self-reported most common motivations in each quality-of-life category. Secondary outcomes were other frequently reported motivations and those associated with specific procedures. RESULTS: Of 529 eligible patients, 511 agreed to participate, were enrolled, and completed the survey. Typical respondents were female (440 [86.1%]), 45 years or older (286 [56.0%]), white (386 [75.5%]), and college educated (469 [91.8%]) and had previously received at least 2 cosmetic procedures (270 [52.8%]). Apart from motivations pertaining to aesthetic appearance, including the desire for beautiful skin and a youthful, attractive appearance, motives related to physical health, such as preventing worsening of condition or symptoms (253 of 475 [53.3%]), and psychosocial well-being, such as the desire to feel happier and more confident or improve total quality of life (314 of 467 [67.2%]), treat oneself or celebrate (284 of 463 [61.3%]), and look good professionally (261 of 476 [54.8%]) were commonly reported. Motivations related to cost and convenience were rated as less important (68 of 483 [14.1%]). Most motivations were internally generated, designed to please the patients and not others, with patients making the decision to undergo cosmetic procedures themselves and spouses seldom being influential. Patients younger than 45 years were more likely to undertake procedures to prevent aging (54 of 212 [25.5%] vs 42 of 286 [14.7%] among patients ≥45 years; P

Introduction: Calcium hydroxyapatite (CaHa; also spelled “hydroxylapatite”) is the main mineral component of bone, calcified cartilage, and teeth. It has been used since the 1970s in many specialties, including orthopedics, urology, otolaryngology, maxillofacial surgery, and radiology, as a bioactive implant that promotes chemical attachment of the soft tissue to its surface. In 2001, Radiance FN (now Radiesse) was introduced as a CaHa-based product and approved by the US Food and Drug Administration (FDA) as a radiographic tissue marker, for soft tissue vocal fold augmentation, and for implants in maxillofacial defects. Currently, it is also used outside the United States and off-label in the United States for facial soft tissue augmentation. Microspheres of CaHa are suspended in a mixture of water, glycerin, and carboxymethylcellulose gel that provides a scaffold for tissue infiltration. Once injected, the gel is degraded and the CaHa infiltrates the surrounding cells. CaHa is nonirritating, and the carrier gel components are classified as safe by the FDA. Although a great variety of fillers are currently on the market, CaHa (Radiesse) has demonstrated the longest duration in tissue without any reports of antigenicity, migration, or granuloma formation. In this study, we report our experience with CaHa (Radiesse) for aesthetic soft tissue augmentation. Materials and Methods: A total of 139 patients were treated over an 18-month period at 2 private offices in Argentina and the United States. Exclusion criteria included previous use of permanent tissue fillers in the treatment area. Patients with previous use of hyaluronic acid fillers in the treatment area (up to 1 year prior to the study) were allowed to participate in the study. Radiesse was injected from 1-mL prefilled syringes with 27½-gauge needles in different areas such as nasolabial folds, lips, marionettes lines, cheeks, and cellulite dimples. Patient satisfaction and adverse effects were assessed by both physicians and patients during the procedure and during follow-up visits up to 1 year later. Results: Minimal pain, erythema, edema, and bruising were noted during and immediately after the procedure. All of the patients treated were satisfied with their results after one visit. There were no long-term adverse effects during the study period or on follow-up visits. Evaluation of 75% of the patients 1 year after treatment revealed persistence of filling effects. Discussion: CaHa used for aesthetic soft tissue augmentation yields immediate clinical results with high patient satisfaction.

BACKGROUND: Anxiety toward pain has been shown in several studies to increase postoperative pain after surgical procedures. This anxiety can be measured by several validated questionnaires, the Pain Catastrophizing Scale (PCS) and the Pain Anxiety Symptoms Scale (PASS). Higher scores on these scales correlate with increased pain after surgery, but this has not yet been demonstrated in dermatologic surgery. OBJECTIVE: To assess whether pain anxiety will predict postoperative pain after Mohs micrographic surgery (MMS). MATERIALS AND METHODS: Patients at 2 private Mohs practices were recruited to fill out 2 pain questionnaires, the PCS and the PASS. Their postoperative pain was assessed after MMS. RESULTS: Three hundred fifty-six patients completed the study. Overall, most patients experienced little postoperative pain after Mohs surgery. However, for people with high anxiety toward pain, they also experienced statistically significant greater postoperative pain. Other factors that contributed to greater postoperative pain included female gender and lower extremity location. Second intention healing had lower pain than other repair types. CONCLUSION: This study shows that postoperative pain is affected by pain anxiety, even in dermatologic surgery. However, most patients still had very little discomfort after surgery, further supporting MMS as an effective and safe procedure with relatively few postoperative problems.

Intense pulsed light (IPL) is a high-intensity, polychromatic, noncoherent light source used to treat a variety of skin conditions. It is frequently used to treat vascular lesions using the principles of selective photothermolysis, and it is often the technique of choice due to its range of effective wavelengths. When used properly, it can be more effective than vascular lasers with fewer side effects such as purpura and scarring, and may reach deeper targets within the skin with its longer wavelengths. The various cutoff filters and energy settings make IPL a versatile and indispensible tool in dermatology.

A simplified approach to treat venous lakes of the vermillion lip is presented. Our method involves the use of a 30 gauge hypodermic needle to deliver a low-powered, high-frequency electrical current from a hyfrecator power source into the venous lake lesion.

The nail unit can be a challenging anatomic location for surgical removal of neoplasms. Although uncommon, malignancies do affect this specialized epithelial structure. In particular, Bowen's disease and more invasive squamous cell carcinoma (SCC) are the most common neoplasm's to affect the nail unit and surrounding structures. Other neoplasm's such as basal cell carcinoma and malignant melanoma can also affect the nail unit, but less frequently, and will not be discussed in the scope of this review. Mohs micrographic surgery continues to be the treatment of choice because of the procedure's tissue-sparing qualities. A clear understanding of the anatomy and the histology of the nail unit, a review of the technique of Moh's surgery of the nail anatomy, as well as a review of the literature are presented.

A 50-year-old previously healthy white woman developed a tender erythematous draining subcutaneous nodule on her left cheek, 9 months after receiving multiple injections of bovine embryonic cells in different areas of the face, neck, and chest as a skin rejuvenation treatment. Over the subsequent 4 months, multiple similar nodules developed on the injected areas. The lesions, which were initially painful, became asymptomatic as they developed purulent drainage and ruptured onto the skin surface. There were no associated fevers, chills, or sweats. The nodules failed to respond to a 2-month course of oral prednisone and intralesional triamcinolone acetonide. Physical examination showed red, firm, subcutaneous nodules some of which were draining a serosanguinous exudate ( Fig. 1). While a presumptive diagnosis of foreign body granuloma was made, the possibility of an atypical mycobacterial infection remained, and therefore tissue was submitted for culture. While awaiting culture results, the patient was started on minocycline, 50 mg twice daily. Figure 1. Neck with disseminated subcutaneous erythematous nodules due to M. chelonae that developed following injections of “bovine embryonic cells” Download figure to PowerPoint The biopsy showed a collection of chronic and granulomatous inflammatory cells, intermixed with a few areas of polymorphonuclear abscesses within the dermis ( Fig. 2). Doubly refractile foreign material was not detected. Although acid-fast bacilli were not observed with Ziehl–Neelsen stain, tissue culture grew mycobacterial colonies after 1 week of incubation. The isolate was subsequently identified as Mycobacterium chelonae, and clarithromycin, 500 mg twice daily, was added to the antimicrobial regimen on the basis of the susceptibility profile. There was significant improvement and the lesions resolved clinically over the following 6 weeks. Figure 2. Skin biopsy specimen from facial nodule shows granulomatous inflammation within the papillary dermis (hematoxylin and eosin, ×40) Download figure to PowerPoint

objective. To emphasize the wisdom of small test areas when treating cosmetic tattoos and the need for multiple laser systems. methods. A 48-year-old woman requested removal of permanent makeup (cosmetic tattoos) of her eyebrows and around her lips. Physical examination revealed a brown tattoo of both eyebrows and dark red lip liner around both lips. A test area was performed on the red tattoo of the lips. A frequency-doubled Nd:YAG laser (532 nm, 2.0 J/cm2, 2 mm spot size) was used for the lip area, while the same laser at 1064 nm, 3.9 J cm2, 2 mm spot size was utilized for the eyebrows. The lip area immediately turned black. The patient returned for follow-up 1 month later; the black ink on the lip was treated with the same laser at 1064 nm, 3 mm spot size, 4.2 J/cm2, with satisfactory resolution in two monthly treatments. Both brown eyebrow turned bright orange and were treated with 532 nm, 3 mm, 3.0 J/cm2. One month later the eyebrows were a mixture of yellow ink and dark green. The yellow area was treated with 532 nm, 3 mm, 2.3 J/cm2, while the dark green was treated with the 1064 nm, 3 mm spot size, 4.2 J/cm2. One month later little improvement was noted, so Q-switched ruby laser at 694 nm, 6 mm spot size, 16 J/cm2 was utilized. An additional four monthly treatments were given utilizing a combination of both ruby and 532 nm ND:YAG lasers for green and yellow pigment, respectively. results. Significant but incomplete resolution of the tattoo ink was achieved. conclusion. Multiple laser systems are needed to remove cosmetic tattoos. Test areas must be done before treatment.

BACKGROUND The degree of skin induration (lipodermatosclerosis) around venous ulcers has prognostic significance; however, objective measurements are needed to assess the induration. The durometer, an engineering instrument used to measure the hardness of metals and plastic, has recently been adapted to assess skin induration. OBJECTIVE The purpose of this study was to measure skin induration and its relationship to skin ulceration by the use of a durometer, and to determine the influence of edema, if any, on durometer measurements. METHODS The degree of skin induration on the medial leg was determined in six sequential, nonselected patients with lipodermatosclerosis and leg ulcers, and in five normal volunteers by using a blinded observer's clinical score (0 = normal to 3 = maximal induration) and a hand-held Type 0 durometer. In addition, durometer readings in 14 patients with edema and eight control subjects were taken on the tibia, the dorsum of the foot, and behind the ankle. RESULTS Durometer readings in patients with leg ulcers and lipodermatosclerosis diminished as one measured from the superior edge of the ulcer to the knee (r = 0.925). The higher the clinical skin score the higher were the durometer readings (P = 0.0062). The presence of edema did not influence durometer measurements. CONCLUSION The durometer is an effective and reliable instrument for measuring the degree of skin induration in venous ulceration and its readings are not affected by edema. Ulcers occur in skin most affected by lipodermatosclerosis.

A man of Portuguese nationality presented with increased volume of the forehead and multiple pustules, which subsequently ulcerated. The pustules appeared progressively on the rest of the face and in the right scapular region during a period of 2 years. Physical examination revealed multiple rounded ulcers of different sizes with erythematous and infiltrated borders covered by serosanguineous scabs on the face and right scapular region (Figs. 1 and 2). The otorhinolaryngologic examination showed an infiltrate of granulomatous aspect in the anterior third of the septum. Posterior rhinoscopy was normal. When the patient was first seen, complete hematology and hepatic and renal tests were normal. Additional tests included: HIV, nonreactive; venereal disease reference laboratory test, nonreactive; chest x-ray, normal; Montenegro skin test, 14 mm; purified protein derivative, 0 mm. The skin biopsy revealed a granulomatous infiltrate with a dense infiltrate composed principally of plasmocytes, with few lymphocytes (Fig. 3). A skin smear stained with Giemsa and culture of biopsy material in blood agar were positive for the presence of Leishmania. Antibodies against Leishmania measured in an ELISA test were strongly positive, titer 1:6400. Typing of the isolate using absorbed polyclonal antisera revealed Leishmania braziiiensis. During hospitalization, the patient received systemic immunotherapy with a combined vaccine containing heat-killed Leishmania mexicana promastigotes and bcg,1,2 as well as chemotherapy with meglumine antimoniate in a dose of 50 mg/kg/day IM, two cycles of 20 days with an in-terval of 7 days of rest. The patient presented clinical healing of his lesions without relapse during a 2 year follow up after completion of therapy.

Observation chez un Haitien de 31 ans hospitalise au Venezuela pour fievre continue, diarrhee, perte de poids et malaises depuis 2 mois. 7 jours apres l'admission le malade presente une insuffisance respiratoire et une coagulopathie de consommation. Il meurt 10 jours apres l'admission. L'autopsie revele une bronchopneumonie hemorragique bilaterale, un petit abces de la rate, et des ganglions lymphatiques mediastinaux. Des etudes en microscopie optique et electronique montrent la presence de Histoplasma capsulatum dans la moelle osseuse, les reins, la peau, le cœur, l'intestin, la rate et les poumons