Search

ABSTRACT Background and Objective Methods and Results Conclusions CEFFE (Cell‐free fat extract) treatment for periocular fine lines requires thorough clinical evaluation to determine its efficacy and safety in enhancing skin quality. The research enrolled 10 healthy female participants aged 31–58, focusing on skin texture, elasticity, and barrier function.CEFFE treatment demonstrated significant benefits, with notable improvements observed as early as 3 months posttreatment, which continued throughout the 12‐month follow‐up period. Objective assessments revealed reductions in SEr% and SEw%, indicative of reduced skin roughness and wrinkles, particularly pronounced after the third month of treatment. Enhanced skin elasticity, as indicated by improvements in R2%, R5%, and R7%, was observed, with the most significant enhancements noted at the 6‐month follow‐up. Furthermore, TEWL decreased consistently, highlighting CEFFE's potential in maintaining the skin's barrier function and moisture retention. High patient satisfaction levels, with 70% expressing satisfaction ranging from satisfied to very satisfied, underscored CEFFE's clinical significance.CEFFE demonstrates potential as an effective and safe intervention for addressing periocular fine lines, providing a solution for fine lines while ensuring skin health (ChiCTR1900024329). [ABSTRACT FROM AUTHOR]

ABSTRACT Introduction Methods Conclusion Glucagon‐like peptide‐1 (GLP‐1) receptor agonists, such as semaglutide, have revolutionized the treatment of diabetes and obesity by promoting significant weight loss through incretin effects. However, rapid weight reduction induced by these medications often leads to esthetic challenges, including facial volume loss, skin laxity, and body contour irregularities. This commentary reviews the esthetic consequences of GLP‐1‐induced weight loss and explores solutions for managing these concerns in clinical practice.This review synthesizes available literature and clinical observations to identify key esthetic concerns associated with GLP‐1‐induced weight loss. It examines various treatment modalities, including dermal fillers, biostimulatory agents, energy‐based devices, and surgical procedures. The discussion highlights gaps in empirical data, optimal timing for interventions, and the need for personalized, multimodal treatment strategies. Imaging tools and psychological support are also considered as complementary approaches.As GLP‐1 agonists become a cornerstone in obesity management, their esthetic implications necessitate a proactive response from esthetic practitioners. Effective management of facial volume loss, skin laxity, and body contour challenges requires a combination of injectable treatments, energy‐based devices, and, in some cases, surgical interventions. Future research should focus on understanding the molecular mechanisms of skin and fat changes and developing standardized guidelines for treating this unique patient population. Additionally, a holistic approach that addresses both physical and psychological outcomes is critical to ensuring patient satisfaction and long‐term well‐being. [ABSTRACT FROM AUTHOR]

Introduction: This prospective study evaluates the efficacy and safety of minimally invasive radiofrequency microneedling (RFMN) for the correction of periorbital wrinkles. This study aimed to address the challenges posed by the periorbital region's unique anatomy and the limitations of existing non‐surgical treatments. Methods: Twenty‐four subjects, ranging from 34 to 54 years old with Fitzpatrick skin types II–V, underwent a series of treatments using the Voluderm RF microneedling device. Participants were divided into two groups based on the severity of their wrinkles and treated with customized protocols over four sessions, with a 3‐month follow‐up to assess outcomes. Efficacy was determined through comparisons of pre‐treatment and post‐treatment wrinkle severity, using the Lemperle Classification of Facial Wrinkles (LFW) and the Global Aesthetic Improvement Scale, evaluated by both the investigators and the patients. Safety and tolerability were assessed through adverse event reporting and a Visual Analog Scale for treatment discomfort. Results: The results demonstrated a statistically significant reduction in periorbital wrinkle severity, with an average 49% decrease of LFW score and improvements noted across all skin types in both groups. The aggregated facial LFW score decreased from baseline mean 13.00 ± 4.75 to 6.09 ± 3.90 (p < 0.05). The treatment was well tolerated without anesthetics, with minimal downtime and few adverse events, which were transient and resolved without intervention. Conclusion: The efficacy of Voluderm RF microneedling in improving periorbital wrinkles of variable severity was demonstrated in patients with diverse skin types. The unique RF‐assisted mechanism of the skin penetration granted a high tolerability of the treatments, negligible downtime, and minimum number of adverse events with self‐resolution. [ABSTRACT FROM AUTHOR]

Extended deep plane techniques have become the benchmark of facelift surgery. Yet these techniques assume release of the medial most of zygomatic retaining ligaments, which makes them rather complex and highly dependent on training and experience. In this article, we will review and describe the adapted extended high-superficial musculoaponeurotic system (SMAS) approach of the author and discuss the obstacles that can be encountered mastering this technique. [ABSTRACT FROM AUTHOR]

Objective: Platelet rich plasma (PRP) is an autologous substance widely used to stimulate dermal collagen synthesis. This study aimed to investigate the efficacy of a single PRP treatment for facial rejuvenation. Materials and Methods: This study was conducted at the Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand from August 2020 to March 2021. Enrolled patients underwent a single intradermal injection treatment of 0.1 mL PRP at 30 locations on the face. Outcomes were assessed at 1, 2, and 4 weeks post-intervention using the patient-perceived age visual analog scale (VAS), FACE-Q assessment, and elasticity index (EI) with a Cutometer. Results: Forty Thai patients with an average age of 36.4 years, Fitzpatrick skin type 3-4 were enrolled. The mean Patient-perceived Age VAS significantly decreased one month after treatment (-2.71±2.42, p<0.001). FACE-Q satisfaction with facial skin was 74.29±14.49, and satisfaction with the outcome was 73.41±16.26 (scale 0-100). The PRP significantly affected skin EI, with the peak improvement observed at 1-2 weeks post-injection, predominantly at the cheek, crow’s feet, and perioral area (all p<0.05). All patients had an overall improvement in satisfaction scores throughout the study. Conclusion: A single treatment of PRP injection resulted in overall satisfaction in facial skin rejuvenation as measured by patient-perceived age VAS and FACE-Q assessment. The PRP showed positive outcomes in EI with peak performance at 1-2 weeks post-treatment. [ABSTRACT FROM AUTHOR]

ABSTRACT Background Methods Results Conclusion An in‐depth and detailed facial assessment is critical in treating and achieving desirable dermal filler and neurotoxin results.An acronym called A.S.S.E.S.S. simplifies an often complex and overwhelming amount of data needed to assimilate when performing facial filler and neurotoxin injections. Applying this method to patients in six simple steps provides a starting point and offers a guideline to capture key details for a more comprehensive facial assessment. The A.S.S.E.S.S. acronym stands for animate, shape, side, external, symmetry, and shadows and is helpful in following a methodical approach in analyzing facial shape, profile, and natural facial curves in both static and dynamic states.Following a regimented A.S.S.E.S.S. approach prior to treating filler and neurotoxin patients allows providers a straightforward guide to achieve a desirable facial shape and profile.This stepwise facial assessment establishes a logical and detailed approach to ensure the important aspects of facial details are appreciated in creating reliable and pleasing filler and neurotoxin results. [ABSTRACT FROM AUTHOR]

Facelift surgery, also known as rhytidectomy, is a popular cosmetic procedure aimed at reversing the signs of facial aging. While facelift surgery is more commonly performed in women, an increasing number of men are seeking this procedure to maintain a youthful appearance. The long recovery period conflicts the overall primary outcome anticipated by men undergoing rhytidectomy, i.e., appear younger, youthful, and ready to reaffirm their value in the working environment. Anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling are three techniques that have been shown to be effective in improving facial rejuvenation outcomes in elderly male patients. However, there is little to no evidence of the safety and efficacy of these techniques when used in combination. By combining these techniques, we hypothesized that we could achieve outcomes comparable to traditional facelift surgery, but with a lower risk of complications and a shorter recovery time. We conducted a retrospective case series study of 18 male patients who underwent facial rejuvenation surgery using the combination of anterior direct neck lift, blepharoplasty (upper and lower eyelid blepharoplasty), and lipofilling at our institution between 2018 and 2021. All 18 patients completed the study, with an average follow-up of 12 months. No major complications were observed, and all patients reported a high level of satisfaction with their outcomes. Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266. [ABSTRACT FROM AUTHOR]

Throughout history, people have struggled to find out the secret of youth. The aim of the manuscript is to review the main achievements regarding the exploration of the aging face phenomenon. It should be very important to know the evolution in this field due to the increase in life expectancy among the population. Our purpose is for the current study to serve as a starting point towards exploring novel research avenues in molecular biology and the confocal immunofluorescence of cervicofacial soft tissues, employing cutting-edge techniques. All changes in the shape of the facial skeleton, soft tissue, retaining ligaments, fat compartments, and the skin envelope contribute to facial aging to varying degrees. [ABSTRACT FROM AUTHOR]

Background: With the increasing age of the westernized population, there is also increasing economic and aesthetic interest in reducing the signs of skin aging. Additionally, the physical aspect of aging can be displeasing and have detrimental effects psychologically in individuals. Probiotics have shown potential as anti‐aging agents, albeit proper studies are needed to confirm their potential. Aims: Proving that Lactiplantibacillus plantarum LB244R® could alleviate aging signs relative to its placebo vehicle. Patients/Methods: In total, 46 subjects were randomly assigned either the ointment with live bacteria, L. plantarum LB244R® or its vehicle ointment, and had to use the assigned ointment twice daily for 56 days. On Day 0, Day 28, and Day 56 subepidermal low echogenic band (SLEB) thickness, dermal density, skin firmness and elasticity, skin hydration, transepidermal water loss (TEWL), skin pH, collagen fiber visualization using confocal microscopy, Crow's feet, spot score, skin smoothness, and complexion radiance were assessed by dermatologists. Results: All parameters except TEWL improved relative to their baseline (D0) for the active group. L. plantarum LB244R® improved SLEB thickness, dermal density, skin elasticity, skin hydration, and Crow's feet wrinkle score relative to the placebo vehicle ointment. Conclusion: The study demonstrates an anti‐aging effect of L. plantarum LB244R® for topical skin use in the first double‐blinded, vehicle‐ointment placebo‐controlled clinical study. [ABSTRACT FROM AUTHOR]

Background: The implantation of artificial hair is a successful standardized procedure to restore bald areas or scarred alopecic surfaces of the scalp in both sexes. Materials and Methods: Sebometric measurements were taken, pre, 1, 3, and 6 months postimplant in two symmetric frontotemporal areas of the scalp of seven volunteers to be implanted with 50 units of artificial hair. The artificial hair used in this study are Biofibre 4.0 produced by Medicap srl, Italy. Results: The dermaroller assisted procedure was performed only on one side, and the plain random implant contralaterally for comparison. A marked downregulation of the sebum concentration was observed in the dermaroller treated area 1, 3, and 6 months later in respect to the control side. Conclusion: The dermaroller assisted procedure is safe and effective in reducing the foreign body reaction by the sebaceous glands and the vascular axis injured by the implanting needle; a longer standing success of the implanted hair can thus be achieved reducing the burden of inflammatory reaction. [ABSTRACT FROM AUTHOR]

Background: Thread lifting is a minimally invasive aesthetic procedure that lifts and realigns sagging tissue. Definisse double‐needle threads are the latest fourth generation absorbable, monofilament, suspension barbed threads of synthetic origin with convergent bidirectional barbs. Definisse thread produces dual action; mechanical action gives a lifting effect and over a period, it promotes histological revitalizing action. Objectives: To evaluate the real‐world efficacy and safety of Definisse double‐needle threads for lower facial lifting for jaw line reshaping in Indian patients. Methods: This is an observational, retrospective study involving patients who underwent treatment for lower‐face reshaping using Definisse double‐needle 12 cm threads. Results: Fifty patients with a mean age of 47.44 years were included in the study with an average follow‐up of 5.14 months. All the patients have undergone Jawline Reshaping (JR) procedure, while 70% of patients also underwent Malar Reshaping (MR) technique simultaneously. Mean of Physician and Subject Global Aesthetic Improvement Scale (PGAIS and SGAIS) showed improvement immediately after the procedure (mean scores 2.82 and 2.7, respectively) and showed further improvement at the follow‐up (3.72 and 3.58, respectively). Moreover, most of the patients immediately after the procedure rated the improvement in PGAIS and SGAIS as "much improved" compared to pre‐procedure appearance (78% and 66%, respectively), while, at follow‐up, 76% and 66% of the patients, respectively, rated "improved very much" compared to pre‐procedure appearance. Conclusion: Current study has demonstrated the effectiveness of the latest Definisse threads in Indian patients in performing tissue repositioning to provide a noticeable lifting effect. Procedure was also well tolerated and none of the patients developed serious complications. [ABSTRACT FROM AUTHOR]

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

Although the modifications of the aging face have been widely described, to our knowledge, there are no studies that quantitatively analyze the degree of soft tissues facial ptosis. Using a specific iPhone application, the faces of a heterogeneous group of volunteers were scanned and studied with the aim to virtually measure the entity of facial ptosis.Two facial scans, upright and supine, were performed by using the Bellus3D Face app for iPhone in a sample of 60 volunteers. We virtually superimposed the two scans, and then, we calculated the discrepancy between them through the Geomagic Design X 3D software. A multivariate regression statistical model was used to analyze the correlation between the mean discrepancy values compared to three main variables: age, BMI and gender. Mean ptosis increases with age (coeff. = 0.02; 95% CI = 0.01–0.02, p < 0.001), BMI (coeff. = 0.03; 95% CI = 0.01–0.05; p < 0.001) and has been found higher in females (female versus male: coeff. = 0.22; 95% CI = 0.13–0.31; p < 0.001). The method we used allowed us to measure the degree of ptosis, and to make a complete morphological study of the effect of gravity on the facial surface in a very accurate, low cost and easily reproducible way. [ABSTRACT FROM AUTHOR]

Background: This aim of this study was to develop an objective tool for rating submental fat applied to Koreans. Methods: The study was conducted between April 2019 and October 2019. A total of 92 subjects were enrolled in the study. Clinical photos of the subjects were categorized using validated CR-SMFRS by three plastic surgeons and one dermatologist. The categorized photos were then shown to six different plastic surgeons for evaluation. Results: The Cohen's kappa value for the six raters were 0.830, 0.742, 0.703, 0.907, 0.862, and 0.793 with statistical significance (p < 0.001). ICC value was between 0.860 and 0.966 (p < 0.001). Since the Cohen's value and ICC were above 0.6 for all raters, the ratings performed by all six raters were used in the analysis. The ICC values between raters were between 0.899 and 0.902. Conclusions: We came up with a set of reference photos that can be used for submental fat rating scale applicable to Korean subjects. Level of Evidence: II. [ABSTRACT FROM AUTHOR]

Introduction: Facial aging is a multifactorial process in which considerable changes occur in different face structures. Thread lifting is one of the most common minimally invasive treatments related to facial rejuvenation. This study aimed to evaluate the efficacy and safety of jawline, jaw angle, and marionette lines correction in combination with APTOS threads and ELLANSE M types through an innovative technique. Materials and Methods: In this prospective chart review study, 50 patients with ptosis candidates for lower face correction were included between October 2019 and February 2020. To perform correction of the jawline, jaw angle, and marionette lines, APTOS thread (LLN2GS) and ELLANSE M type were used through an innovative technique. The efficacy (6 and 12 months after the surgery) and safety (1, 6, and 8 weeks after the surgery) were assessed by two surgeons independently. Data were analyzed by SPSS ver. 22 for windows (IBM Inc.). Results: In this study, 50 patients (4 male and 46 female) with Mean ± SD age of 53.84 ± 10.79 years old (Range: 42 years) were included. Regarding the results, patients' level of satisfaction (improved to excellent levels) increased from 74% at 6 months after the surgery to 86% at 12 months after the surgery. Moreover, the level of satisfaction obtained from surgeons (improved to excellent levels) decreased from 96% to 86% at 6 and 12 months after the surgery, respectively. Based on the results, there were substantial and perfect agreements between the surgeon and the independent surgeon to evaluate the surgery efficacy of facial rejuvenation 6 and 12 months after the surgery. No side effects were reported 6 and 8 weeks after surgery. Conclusion: Regarding the results, due to rare complications, deep satisfaction, and short downtime, the correction of the lower face in combination with APTOS thread (LLN2G) and ELLANSE M type through our innovative technique be considered an efficient and safe treatment. [ABSTRACT FROM AUTHOR]

Copyright of Journal für Ästhetische Chirurgie is the property of Springer Nature and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use. This abstract may be abridged. No warranty is given about the accuracy of the copy. Users should refer to the original published version of the material for the full abstract. (Copyright applies to all Abstracts.)

In the field of facial rejuvenation, among the recurrent topics, one of the most discussed is the return to less invasive techniques. Lower face rejuvenation is best achieved acting on the platysma muscle. Many techniques are used and usually include platysma section, redundancy reduction, and redraping. Platysma plication is also used especially in secondary cases because of the increased risk of nerve injury due to possible anatomical damage caused by previous operations. A technique that preserves the deep planes based on a new plication method is proposed (conservative neck rejuvenation). In this technique, the dissection plane is only subcutaneous to reduce the risk of nerve injuries. An effective neck contouring is possible using a simpler technique with very good results and a lower rate of morbidity. [ABSTRACT FROM AUTHOR]

Upper eyelid surgery is a common procedure performed by a variety of subspecialists including facial plastic surgeons, oculoplastic surgeons, general otolaryngologists, and plastic surgeons. Traditionally, a skin incision is marked in the preoperative setting to allow for an excision that eliminates upper eyelid hooding while preventing lagophthalmos. Many different methodologies have been proposed to maximize results and minimize complications. In this article, the authors propose a unique way to safely and effectively address dermatochalasis. The pinch technique allows for an accurate assessment of excess skin and provides a method that requires less operative time than traditional techniques. The use of both local anesthetic with epinephrine and hyaluronidase helps achieve the appropriate plane and attain better hemostasis. Importantly, the presented technique allows for reassessment and revision of the amount of skin excision before incision creation. It is a useful methodology for any surgeon performing upper lid blepharoplasty. [ABSTRACT FROM AUTHOR]

Objective: Patients are increasingly seeking nonsurgical treatment for the aging face. The purpose of this study was to evaluate the clinical efficacy and outcomes of a thermistor‐controlled subdermal skin tightening device (ThermiTight) as a treatment modality for the aging face. Methods: A retrospective analysis of 12 patients was completed on patients having undergone ThermiTight for midface and neck skin tightening. Only five patients had a greater than 1 year follow‐up and were included in the study. Two blinded reviewers assessed photographs taken pre‐procedure and 1 year post‐procedure using a standardized skin laxity scale. Patient charts were reviewed to assess for complications up to 12 months post‐treatment. Results: The mean age of included patients was 57 years, and all five patients were female. One (20%) patient treated with ThermiTight was also treated with injectables (Botox, Juvéderm) simultaneously. One (20%) patient developed a wound complication. One (20%) patient complained of incisional site pain at her first postoperative visit that subsequently self‐resolved. On a five‐point scale to assess facial skin laxity, there was an average improved score of 0.85 per patient (P <.001) at one year post‐procedure. Two blinded reviewers correctly categorized photographs as either being "baseline" or "post‐procedure" 100% of the time. There was no significant difference between the skin laxity scores by the blinded reviewers (P =.05). Conclusion: ThermiTight is a new technology used for nonsurgical treatment of the aging face. Long‐term outcomes demonstrate the safety and efficacy of the procedure. Complications are rare, but possible, in the use of ThermiTight. Level of Evidence: 3 [ABSTRACT FROM AUTHOR]

Background The neck is not only the first area to show aging but it also represents the persona of the individual. The understanding of the aging process of the neck is essential for neck rejuvenation. The purpose of this study was to evaluate the outcomes and safety of elastic lift in relation to neck region lifting. Methods Forty-seven patients with sagging and laxity of the neck skin treated by elastic lift were enrolled in this study from November 2015 to February 2016. To evaluate the safety of elastic lift, a retrospective chart review was conducted. We used an automatic skin diagnosis system to evaluate the efficacy of elastic lift. Results Forty-five patients were female and 2 patients were male. The mean age of the patients was 45.3 years and their mean follow-up period was 3 months. There were no major complications requiring the removal of the elastic thread during the follow-up period. The median skin laxity grade score was 5 (4-5) preoperatively; the median skin laxity grade score was 3 at 3 months postoperatively. In comparing the skin grade score at these two points in time, there was a statistically significant difference (P < 0.01). Conclusions Neck rejuvenation using elastic lift is a safe and effective procedure in selected patients with moderate sagging and laxity of the neck skin.

Background Thread lift is a minimally invasive procedure for facial rejuvenation, but complications of thread lift have been reported. The purpose of this study was to evaluate outcomes and safety associated with elastic lift in relation to midface and upper mandibular region lifting. Methods Thirty-eight patients with sagging and laxity of the facial skin treated with elastic lift from September 2015 to October 2015 were enrolled in this study. Treatment was performed following the manufacturer's recommended protocol that called for 300 treatment lines. To evaluate elastic lift safety, a retrospective chart review was conducted. We used an automatic skin diagnosis system to evaluate the efficacy of elastic lift. Results Thirty-seven patients were female, and one patient was male. The mean age of the patients was 40.4 years, and their mean follow-up period was 3 months. There were no major complications manifesting in removal of the elastic thread during the follow-up period. The median skin laxity grade score was 5 (3-6) before surgery; the median skin laxity grade score was 3 (2-4) 3 months post-surgery, resulting in a statistically significant difference in skin grade score (P

Background Noninvasive radiofrequency (RF) and lasers have been used for skin tightening and body contouring since the 1990s. The safety, efficacy, and patient satisfaction with the procedure using a novel RF device (BodyTite™; Invasix Ltd, Yokneam Ilit, Israel) were evaluated. Methods We retrospectively included 13 patients who were treated with the BodyTite™ to rejuvenate neck skin from May 2012 to May 2014. The power of the device was set between 10 and 15 W. The target temperature was set at 38degrees C. Three independent evaluators were asked to grade baseline and 6- to 12-month follow-up photographs using a comprehensive quantitative 4-point laxity grading scale. All patients were asked to rate their satisfaction with the aesthetic outcome and quality of life after treatment. Results Grading results of baseline and follow-up photographs of patients were statistically significant with an average grade improvement of 1.01 points on the 4 point scale. Using a patient satisfaction scale, patients were also significantly more satisfied (poor, 0%; fair, 15%; good, 46%; and excellent, 39%). There were transient complications, such as minimal erythema, mild edema, and focal hardness, which resolved spontaneously within 1 week. There were no significant adverse effects or complications. Conclusions The BodyTite™ is a minimally invasive, RF treatment that was demonstrated to improve skin laxity without significant adverse effects or complications. The BodyTite™ provides a nonsurgical option for the safe and effective rejuvenation of neck skin under local anesthesia.

Background Micro-focused ultrasound (MFU) has developed as an effective, noninvasive, skin-tightening method. However, certain factors have limited its replacement of invasive surgical procedures, including a relative lack of efficacy, persistence, and reliability. The purpose of this study was to evaluate the efficacy and safety of MFU for noninvasive skin tightening and to determine how long the skin tightening can be maintained. Methods Between October 2013 and November 2014, 41 patients with sagging and laxity of the facial skin were treated with MFU. The treatment was performed following the manufacturer's recommended protocol that called for 300 treatment lines. We evaluated the patients using an automatic skin diagnosis system at pretreatment, and 2 and 4 months after treatment. Results Of the 41 patients treated using MFU, 3 patients were lost to follow-up for non-study-related reasons. In our study, 38 patients (1 male and 37 female) were evaluated and ranged in age from 37 to 52 years. The median skin grade scores were 5 at pretreatment, 3 at 2 months posttreatment and 3 at 4 months posttreatment. After comparing pretreatment and 2 months posttreatment, pretreatment and 4 months posttreatment, and both 2 and 4 months posttreatment, there were statistically significant differences (P