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Daniel Cassuto,1 Giovanni Pellacani,2 Antonello Tateo,1 Ofir Artzi,3 Fabio Massimo Ingallina,4 Giovanni Salti,5 Elena Rossi,2 Arturo Lanzarotti,6 Malika Laouedj,7 Nicolas Dapis,7 Gilberto Bellia8 1Private Practice, Milan, Italy; 2Department of Dermatology, University of Modena and Reggio Emilia, Modena, Italy; 3Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 4Private Practice, Catania, Italy; 5Private Practice, Florence, Italy; 6IBSA Institut Biochimique SA, Lugano, Switzerland; 7Quantificare SA, Valbonne, France; 8IBSA Farmaceutici Italia, Lodi, ItalyCorrespondence: Gilberto BelliaIBSA Farmaceutici Italia, Lodi, ItalyEmail gilberto.bellia@ibsa.itObjective: To describe the development and validation of the 5-grade photographic IBSA inner upper arm scale.Methods: From 2 real-life pictures, a scale made up of 5 morphed images showing increasing severity of inner upper arm laxity was created. For validation, a set of 50 images (half of which real and the other morphed) was developed and sent to 5 trained physicians in two rounds 30 days apart. Raters’ task was to make a selection of each image according to the given scale. Inter-rater and intra-rater reliability were evaluated in both rounds.Results: As to intra-rater reliability, single-rater kappa scores between 0.74 and 1.00 and a global kappa score of 0.846 were observed, while inter-rater agreement was calculated with intra-class correlation coefficient reporting scores higher than 0.91, which indicate excellent reliability.Conclusion: IBSA inner upper arm laxity scale proved to be a validated and reliable tool.Keywords: photographic scale, upper inner arm, laxity, aesthetic medicine, scale validation, scale development

Antonello Tateo,1 Gabriel Siquier-Dameto,2– 4 Ofir Artzi,5 Dalvi Humzah,6 Beatriz Molina,7 Ravi Jain,6 Arturo Lanzarotti,8 Malika Laouedj,9 Nicolas Dapis,10 Gilberto Bellia11 1Private Practice, Milan, Italy; 2Private Practice, Amsterdam, the Netherlands; 3Private Practice, Mallorca, Spain; 4Research Group of Clinical Anatomy, Embryology and Neuroscience (NEOMA), Department of Medical Sciences, Universitat de Girona (UdG), Girona, Spain; 5Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 6Private Practice, London, UK; 7Private Practice, Bristol, UK; 8Research & Development, IBSA Institut Biochimique SA, Lugano, Switzerland; 9Clinical Operations, Quantificare SA, Valbonne, France; 10Business Development, Quantificare SA, Valbonne, France; 11Medical Affair, IBSA Farmaceutici Italia, Lodi, ItalyCorrespondence: Gilberto BelliaIBSA Farmaceutici Italia, Lodi, LO, ItalyEmail gilberto.bellia@ibsa.itObjective: To describe the development and validation of the 5-grade photographic IBSA Neck Laxity Scale.Methods: The scale was developed from 2 real images, which led to the creation of 5 morphed images, representing different degrees of severity of laxity of the neck. For validation, a set of 50 images (25 real and 25 morphed) was created and sent for evaluation to 6 trained raters (physicians) in 2 rounds, 1 month apart. Raters had to assess each image according to the 5-image scale. Inter-rater and intra-rater reliability in both rounds was evaluated.Results: As to intra-rater reliability, single rater kappa scores between 0.69 and 0.87, and a global kappa score of 0.78 were observed. Inter-rater agreement was measured by means of the intra-class correlation coefficient and scores higher than 0.85 were reported, indicating excellent reliability.Conclusion: IBSA Neck Laxity Scale is a validated and reliable scale.Keywords: photographic scale, neck, laxity, aesthetic medicine, scale validation, scale development

Dana Shalmon,1 Joel L Cohen,2 Marina Landau,3 Ines Verner,4 Eli Sprecher,1,5 Ofir Artzi1 1Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 2AboutSkin Dermatology and AboutSkin Research, Greenwood and Lone Tree, CO, USA; 3Private Practice, Herzliya, Israel; 4Verner Clinic Tel Aviv, University of Rome “Guglielmo Marconi”, Israel, Italy; 5Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Ofir Artzi Email ofira@tlvmc.gov.ilBackground: Over the past few decades, soft tissue augmentation is ever-increasing, specifically hyaluronic acid (HA)-based filler injections. As the number of these procedures have risen, so have the adverse reactions. Delayed-type inflammatory reactions (DIRs) secondary to tissue fillers are typically classified according to the time of appearance post-procedure and have various presentations including nodules, abscesses, edema, and discoloration. Currently, the treatment of these complications varies among physicians.Objective: The aim of this study was to assess the knowledge and experience of practitioners in Israel who inject HA-based tissue fillers with respect to the management of late-onset procedural complications.Materials and Methods: A survey regarding management and treatment of late-onset inflammatory reactions was sent to 1120 physicians and dentists in Israel who practice tissue filler injections.Results: Three hundred thirty-four out of the 1120 practitioners replied to the questionnaire. The majority of respondents were dentists (group A) comprising 31% of all respondents. Group B accounted for 31% of injectors and consisted of dermatologists (19%) and plastic surgeons (12%), and group C (38%) accounted for all other practitioners; 48.2% of all injectors indicated that they have not previously encountered a DIR, whereas 11.4% responded that they have encountered more than 5 DIRs. In order to assess treatment management, we presented the injectors with a simulatory case of a woman with a late-onset complication. Most injectors referred the patient to the emergency department. When asked to establish a treatment plan, the majority of practitioners prescribed short-term oral steroids, ie, prednisone (35.3%). A limited number of patients were treated with intra-lesional hyaluronidase (31.4%) injection as only 34% of injectors kept hyaluronidase at their clinic.Conclusion: The varied approach regarding the management of delayed type reactions to HA-based filler injections, reflected in our study, illustrates the existing ambivalence in the current literature regarding the management and therapy of late-onset complications.Keywords: cosmetic techniques, dermal fillers/adverse effects, hyaluronic acid/adverse effects, delayed reaction, nodules, filler, hypersensitivity

Ofir Artzi,1,2 Joel L Cohen,3 Jeffrey S Dover,4– 6 Atchima Suwanchinda,7,8 Tatjana Pavicic,9 Marina Landau,10 Greg J Goodman,11 Sahar Ghannam,12 Firas Al Niaimi,13 Jani AJ van Loghem,14 Kate Goldie,15 Sonja Sattler,16 Daniel Cassuto,17 Ting Song Lim,18 Rungsima Wanitphakdeedecha,19 Ines Verner,20,21 Tanja C Fischer,22,23 Vivian Bucay,24 Eli Sprecher,1,2,25 Dana Shalmon1,2 1Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3AboutSkin Dermatology and AboutSkin Research, , Greenwood Village and Lone Tree, CO, USA; 4SkinCare Physicians, Chestnut Hill, MA, USA; 5Dermatology, Yale University School of Medicine, New Haven, CT, USA; 6Dermatology, Brown Medical School, Rhode Island, USA; 7Department of Dermatology, School of Anti-Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand; 8Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 9Private Practice for Dermatology and Aesthetics Dr. Tatjana Pavicic, Munich 80539, Germany; 10Dermatology, Private Practice, Herzliya, Israel; 11Monash University, Clayton, Victoria, Australia; 12Associate Prof. of Dermatology, Alexandria University, Alexandria, Egypt; 13 152, Harley street, London, UK; 14UMA Institute, Amsterdam 1017, TX, Netherlands; 15Medical Director European Medical Aesthetics Ltd, London W1G 8QN, UK; 16Rosenpark Klinik, Darmstadt, Germany; 17Private Practice, Milan, Italy; 18Clique Clinic, Kuala Lumpur, Malaysia; 19Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 20Verner Clinic, Tel Aviv, Israel; 21Department of Dermatology, University of Rome, Guglielmo Marconi, Italy; 22Skin and Laser Center, Potsdam, Germany; 23School of Medicine, University of Frankfurt, Germany; 24Bucay Center for Dermatology and Aesthetics, UTHSC, San Antonio, TX, USA; 25Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Ofir ArtziTel Aviv Sourasky Medical Center, Weizman 6, Tel Aviv, IsraelTel +972-54-5968961Fax +972-77-2001801Email ofira@tlvmc.gov.ilBackground and Objectives: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose.Materials and Methods: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists.Results: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3– 6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement.Conclusion: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.Keywords: cosmetic techniques, dermal fillers/adverse effects, hyaluronic acid/adverse effects

Summary: Background: Severely debilitating plantar keratoderma pain is the most distressing clinical feature of pachyonychia congenita (PC). Several earlier publications have reported therapeutic success with plantar injections of botulinum toxin (Btx). Objectives: To describe our 4‐year experience during which we administered a total of 30 plantar Btx injections to five patients with PC following an optimized protocol. Methods: Five patients with PC (age 21–54 years) who were treated at our medical centre from April 2015 to June 2018 were included in the study. After an ultrasound‐guided nerve block performed by an anaesthesiologist, the patients received plantar intradermal injections of Btx A. To ascertain the effect of the treatment, we used a dedicated quality‐of‐life questionnaire for patients with PC (PCQoL) and asked the patients to evaluate the intensity of eight parameters pertaining to their symptoms at baseline and before every treatment session. At study closure, patients were asked to evaluate the maximal improvement in the same eight parameters throughout the study period. Results: All patients demonstrated a decrease in PCQoL scores during the follow‐up period. All patients showed a significant improvement in PCQoL after the first treatment session and at the last evaluation (P = 0·043). The scores with the best improvement concerned morning feet burning and long‐distance walking (> 500 m). The scores were significantly lower if the intervals between Btx injections were <100 days. Conclusions: Btx treatment of PC‐associated keratoderma following an optimized protocol leads to a major change in patients' quality of life. What's already known about this topic? Plantar pain is considered by patients to be the most severe and debilitating manifestation of pachyonychia congenita (PC).Over the past few years, a number of reports have shown that plantar injections of botulinum toxin (Btx) reduce or even eliminate pain, blistering and callosities in patients with PC.However, the injection technique, doses of Btx and methods of anaesthesia varied between reports and patients. What does this study add? Here we report our 4‐year experience in providing 30 treatments to five patients following an optimized protocol.Btx was found to provide a quantifiable improvement in all patients treated. What is the translational message? Btx treatment of PC‐associated keratoderma using a structured approach, which includes the use of a sufficient dose of Btx (200–400 U of onabotulinumtoxinA or 500–1000 U of abobotulinumtoxinA), and regular intervals between treatment sessions (of < 100 days), leads to a major change in patients' quality of life. Linked Editorial:Steele and O'Toole. Br J Dermatol 2020; 182:521–522. Linked Comment:Thomas and Sahota. Br J Dermatol 2020; 182:531–532. Plain language summary available online [ABSTRACT FROM AUTHOR]

Summary: Background: Tranilast [N‐(3,4‐dimethoxycinnamoyl) anthranilic acid] has never been investigated for the prevention and treatment of acne scars. Aim: To evaluate the efficacy and safety of tranilast 8% gel in improving the final appearance of patients with acne scarring concomitantly treated by isotretinoin. Methods: This was a prospective, double‐blind, split‐face study, which enrolled 40 otherwise healthy participants (aged 18–49 years) with facial acne scars. For each patient, one half of the face were treated with tranilast 8% liposomal gel and the other half with a water‐based placebo. Using the Global Aesthetic Improvement Scale (GAIS), acne scars were evaluated by two dermatologists and by the patients, and the patients also rated their satisfaction with the treatment and reported adverse effects. Results: In total, 32 participants completed the trial. The mean GAIS scores at 5 months post‐treatment were significantly lower (better outcome) for the tranilast‐treated side than the placebo‐treated areas in patients concomitantly treated with isotretinoin (P < 0.001). All the isotretinoin‐treated patients reported greater satisfaction and better general improvement in the skin's appearance and texture, and also greater improvement of pigment and redness on the tranilast 8% gel‐treated side compared with the control side. Conclusion: Combined topical application of tranilast 8% gel twice daily with oral isotretinoin treatment in the active phase of acne vulgaris may result in fewer scars, finer skin texture and enhanced appearance. [ABSTRACT FROM AUTHOR]

Background: Intralesional corticosteroid administration (ICA) is a first-line keloid treatment. However, it faces significant variability in current clinical and scientific practice, which hinders comparability of treatment results., Objectives: The aim of the study was to reach consensus on different aspects of ICA using hypodermic needles in keloids among an international group of dermatologists and plastic surgeons specialized in keloid treatment to provide consensus-based clinical treatment recommendations for all physicians treating keloids., Methods: The keloid expert panel of 12 dermatologists and 11 plastic surgeons rated 30 statements. Two online e-Delphi rounds were held, both with a response rate of 100%. Fifteen (65%) keloid experts participated in the final consensus meetings. Consensus was defined as ≥ 75% of the participants choosing agree or strongly agree on a 7-point Likert scale., Results: Consensus was reached on treatment goals, indication for ICA, triamcinolone acetonide (TAC) 40 mg/mL as the preferred corticosteroid administered at a maximum of 80 mg per month and at intervals of 4 weeks, minimizing pain during ICA, the use of 1 mL syringes and 25 or 27 Gauge needles, blanching as endpoint of successful infiltration, caution of not injecting subcutaneously, and the option of making multiple passes in very firm keloids prior to infiltration. Consensus could not be reached on TAC dosing, methods of prior local anesthesia, and location of injection., Conclusions: This e-Delphi study provides important clinical treatment recommendations on essential aspects of ICA in keloids. By implementing these recommendations, uniformity of ICA in keloid treatment will increase and better treatment results may be achieved., (© 2024. The Author(s).)

Background: For three decades, fractional ablative CO 2 lasers have been used for skin rejuvenation. With breakthroughs in laser technology and expanding popularity, new recommendations and suggestions arise on a regular basis., Objective: To develop up-to-date clinical recommendations on safety measures, therapeutic framework, and techniques to improve treatment outcomes., Methods: Using Google Forms, a questionnaire with 188 questions was given to a varied sample of 21 dermatologists and plastic surgeons from various countries and practice contexts. A second questionnaire with 11 items was created to resolve any gaps or discrepancies., Results: Active face infections are considered a treatment contraindication by 95% of panelists. Burns, recent sun exposure, and pregnancy or breastfeeding were also considered contraindications (according to 67% of panelists). Over 90% employ bacterial and viral prophylaxis, however the majority (67%) do not prescribe antifungal prophylaxis. The most often stated anesthetic treatments by panelists are topical anesthetic cream, nerve blocks, and oral analgesics (according to 95%, 81%, and 62% of panelists respectively). Over 90% of panel members suggested treatment setting alterations for individuals with Fitzpatrick skin types III-IV. Following reepithelization, which happens between 8 and 42 days after the treatment, the majority (76%) of panelists advocate continuing standard skin care routines including active ingredients. Eighty-one percent of panelists recommend using supplementary treatment to maximize results. Supplementary treatment recommendations included use of neuromodulators (76% of panelists), Intense Pulsed Light Therapy treatments pre and postprocedure (61% of panelists), and injection-based therapies such as (Hyaluronic Acid fillers, and biostimulatory fillers) (recommended by 48% of panelists). 60% of panelists perform FACL to improve skin laxity treatment in nonfacial areas and adjust their settings accordingly., Limitations: Our results reflect only a modest panel size; with a focus on a specific device. Although experienced, the small number of panelists, recommendations, and personal adverse reactions encounters for resurfacing indication, might be biased., Conclusion: Fractional CO 2 laser is a popular and effective skin rejuvenation treatment with minimal downtime and side effects. This study presents new therapy recommendations to resolve treatment uncertainty and provide complete care suggestions for best results., (© 2024 The Author(s). Lasers in Surgery and Medicine published by Wiley Periodicals LLC.)

Background: Therapeutic dogma has been to treat acne scars no less than 6 months after isotretinoin (ITN) cessation., Objective: To evaluate the safety and efficacy of fractional radiofrequency (FRF) in patients treated concurrently with ITN., Methods: We conducted a prospective randomized control 3-arm comparative trial to evaluate the treatment of acne scars. Patients received one of three treatment options: (A) ITN and FRF concurrent treatment, (B) ITN monotherapy, and (C) FRF 6 months post-ITN treatment. Patients in the FRF cohorts received three monthly sessions. Patients were followed for adverse effects up to 6-9 months post-FRF treatment. Final cosmesis was scored by three independent dermatologists using two scales: the Echelle d'Evaluation Clinique des Cicatrices d'Acne (ECCA) and an internal 5-point investigator's scale, indicating the percentage of improvement. Subjective analyses by patients were also assessed., Results: Objective and subjective analyses revealed improvement in the ITN-FRF cohort, which was superior to the delayed FRF cohort and the ITN monotherapy cohort. Specifically, the concurrently treated cohort (ITN-FRF) had a significant reduction in acne scar volume from baseline mean (151.1 ± 44.7 to 97.0 ± 31.2, p < 0.005), outperforming both the delayed FRF and monotherapy ITN treatment cohorts, respectively (155.4 ± 37.8 to 122.0 ± 46.2, 144.6 ± 82.8 to 132.4 ± 62.7). Additionally, the concurrently treated cohort demonstrated improved ECCA scores (36.8 ± 15.5), significantly better than the ITN monotherapy cohort (101.5 ± 20.1, p < 0.01)., Limitations: Limited patient sample size: 38 patients completed the study; mostly Fitzpatrick Type II-III skin; photographic assessments utilized., Conclusion: Per our prospective trial, concurrent treatment of ITN-FRF is superior to delayed FRF treatment 6 months post-ITN cessation., (© 2024 The Author(s). Lasers in Surgery and Medicine published by Wiley Periodicals LLC.)

Objectives: To examine the effects of percutaneous tetracycline delivery to the malar area using a thermomechanical device (Tixel) in patients suffering from festoons., Methods: This retrospective study included patients who underwent combination treatment with a thermomechanical device (Tixel) followed by application of topical tetracycline 1% at two private clinics between 2019 and 2023. Demographic and medical data, treatment parameters along with before and after treatment photographs were retrieved retrospectively. All patients were asked to answer a questionnaire, assessing self-reported pre and posttreatment disturbance, patient global impression of change (PGIC) score, overall satisfaction with treatment, and the onset and duration of treatment effect. Finally, three masked reviewers evaluated and graded the severity of before and after treatment photographs., Results: Twenty healthy patients received the combination treatment. The mean age was 59.4 ± 8.2 years (range: 45-72 years), and 90.0% (n = 18) were female. The number of treatment sessions per patient ranged from 2 to 8, mean of 5.0 ± 1.9, performed at 5.4 ± 1.2-week intervals. The masked reviewers' grading scores demonstrated a significant improvement (2.81 ± 1.3 before vs. 1.6 ± 1.1 after, p < 0.001). The self-reported disturbance caused by the festoons improved significantly as well (4.7 ± 0.98 vs. 1.7 ± 1.1, p < 0.001). On the PGIC score, 85% (17/20) reported moderate (grade 5) to significant (grade 7) improvement of symptoms and life quality after treatment. Improvement onset was reported to occur 11.2 ± 6.6 days after the first treatment (range 2-30 days), and 90% (18/20) of the patients reported improvement lasting at least 4 months after completion of the second treatment., Conclusions: Topical tetracycline application following Tixel treatment induced significant improvement in patient with festoons., (© 2024 Wiley Periodicals LLC.)

Background: Poly- l -lactic acid (PLLA) is a biostimulator that enhances collagen production and leads to volume restoration. It became popular because of its improvement of facial wrinkles and long-lasting effect, although the specific visible changes it causes in the facial area are not fully described., Objective: To identify and characterize the visible changes resulting from injecting PLLA into the facial area., Methods: A list of 678 patients who underwent 2 to 3 treatments with PLLA injections in this center between 2021 and 2022 were retrieved. After 2 rounds of evaluations, 31 independent international evaluators described the 3 main changes they observed in the before-and-after images (taken approximately 7 months after the last injection session) of the 12 patients with the most significant improvement., Results: A total of 1,015 descriptions were received. They were divided into categories based upon similarity. The main detected changes were better contouring and enhancement of the lateral face, a lifting effect and secondary impact on the nasolabial fold, and improvement of skin texture and skin firmness., Conclusion: Poly- l -lactic acid injections were judged to be effective for contouring, lifting, and improving skin texture in the facial area. Further research is needed to validate these results and create an assessment scale for PLLA injections., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Human papillomavirus (HPV) is ubiquitously distributed in the population worldwide and its most frequent clinical presentation is cutaneous warts. Despite various treatment options currently available, many patients experience persistent and refractory disease. We sought to evaluate the clinical effectiveness and safety profile of intralesional HPV 9-valent vaccine for the treatment of recalcitrant warts. A retrospective study was performed for all cases of cutaneous warts treated with intralesional 9-valent HPV vaccine between January 2017 and March 2021. Epidemiologic, clinical, and treatment data, including safety and effectiveness scores, were reviewed. Our cohort was composed of 20 patients: 13 adults and seven children. Twelve patients (60%) displayed a complete response whereas 8 patients (40%) showed a partial response. Older age was associated with a better response to treatment, while a history of laser therapy was associated with a worse prognosis. Adverse events were local, transient, and negligible. No systemic adverse effects were reported. Intralesional 9-valent HPV vaccine may be considered for the treatment of recalcitrant cutaneous warts. Controlled studies are required to confirm these results., (© 2023 The Authors. The Journal of Dermatology published by John Wiley & Sons Australia, Ltd on behalf of Japanese Dermatological Association.)

Background: Hyaluronic acid (HA)-based fillers are effective at mitigating acne scars due to their filling effect. Complexes of high and low molecular weight HA demonstrated a delayed biostimulatory effect., Objective: The authors sought to compare the results of acne scar treatment using a filler composed of complexes of high and low molecular weight HA versus a traditional cross-linking HA filler., Methods: Thirty patients with moderate-to-severe atrophic acne scarring were included in this prospective, split-face, double-blinded, randomized controlled study. Each underwent 3 monthly injections of a novel formula of combined high and low molecular weight HA (P) to the base of acne scars on 1 side of the face and traditional cross-linking HA (JV) filler on the other. Patients were evaluated 6 months after their last treatment for objective and subjective improvements., Results: For JV, statistically significant reductions were observed in the acne scar volume but nearly no change in elasticity and stretch during early treatments. For P, no significant differences were observed in early treatments; however, statistically significant improvements were observed in later visits., Conclusion: Although the traditional JV filler demonstrated an earlier impact than P, the latter produced delayed positive changes that were more pronounced than the traditional filler., Competing Interests: The authors have no conflict of interest to declare., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Many modalities are used for periorbital rejuvenation, with a wide range of efficacy and safety. To achieve favorable outcomes with minimal downtime and adverse effects, professionals developed a hybrid laser, which allows simultaneous treatment with 2 wavelengths: fractional ablative and fractional nonablative lasers., Objective: To evaluate the safety and efficacy of a new hybrid laser for periorbital rejuvenation., Materials and Methods: This retrospective single-center study includes 24 patients who underwent a single-pass treatment with a CO 2 and 1570-nm hybrid laser for periorbital rejuvenation between 2020 and 2022. Patients' standardized clinical photographs before and after the treatment were assessed by 4 independent physicians for objective improvement. Treatment data, safety, and patients' satisfaction were also reviewed., Results: Statistically significant objective improvements were found in all investigated scales with an improvement of 1 to 2 points on each scale. Patients' satisfaction was 3.1/4. Average downtime was 5.9 ± 1.7 days. Most adverse effects were mild to moderate in severity (89.7%), including erythema, crusting, pruritis, edema, and hyperpigmentation., Conclusion: After a single-pass treatment, the laser generates 26% to 50% improvement in the periorbital area, with a strong safety profile and a relatively simple recovery. Further research is needed to validate the efficacy of this technology compared with more aggressive modalities., (Copyright © 2023 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Middle East has a significant influence on the global aesthetic market. Within the United States and globally, patients with Middle Eastern heritage have a wide range of ethnic and cultural backgrounds that affect their perceptions of beauty and motivations to seek cosmetic treatment., Aims: The aim of this roundtable was to discuss similarities and differences in anatomy and treatment preferences of Middle Eastern patients and explore how these differences may influence aesthetic practices., Patients/methods: In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022., Results: The results of the fourth roundtable in the series, the Middle Eastern Patient, are described here. A discussion of treatment preferences is included, and specific procedural information is provided for  commonly treated areas in this population (forehead, infraorbital area, and jawline)., Conclusions: Middle Eastern patients have a variety of aesthetic preferences, which are influenced by a wide range of cultural backgrounds, making it difficult to develop general statements about this demographic. There is an unmet need for research into this diverse group of patients to help physicians understand and incorporate their unique needs and desires into clinical practice., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Delayed inflammatory reactions (DIRs) to hyaluronic acid-based dermal fillers following COVID-19 vaccination has been reported in a few anecdotal reports and small series of cases., Aim: To evaluate the clinical characteristics, incidence, and management options relevant to BNT162b2 vaccination-associated DIR-A nationwide survey was conducted., Methods: An online self-administered survey was sent to physicians who actively practice tissue filler injections. The data acquired included demographic and clinical characteristics of relevant DIR cases., Results: Out of 262 responders, 20 cases with DIR following the vaccination were reported. 35% and 65% occurred shortly after the first and second vaccination dose, respectively. Overall, 65% of the DIRs appeared ≤5 days after vaccine administration and most DIRs resolved within 21 days. The filler's volume (p = 0.016) was associated with higher DIR severity, and the same tendency was noted among some filler types and locations of injection. Medical intervention was provided in 12 (60%) cases., Conclusion: DIR associated with BNT162b2 vaccination is rare and tends to resolve spontaneously or with short-term medical intervention., (© 2022 Wiley Periodicals LLC.)

Background: Current approaches for assessment of acne scars are subjective, including counting scar subtypes, subjective self-assessment, or scoring global acne scar severity., Aims: We aimed to validate accuracy and present initial data of a new, simple, non-contact, high-resolution 3D stereoscopic optical imaging system in the setting of acne scarring., Patients/methods: Ten patients treated for acne scars in the dermo-esthetic outpatient clinics in our institution from July to December 2019 were recruited from medical files and completed by telephone interview. Each patient was assessed by the 3D imaging system, the Qualitative Scarring Grading Score (QSGS), and the patient's questionnaire for Self-assessment of Clinical Acne-Related Scars (SCARS) before and 4 weeks after a single intervention., Results: Scar depth measured by the imaging system correlated significantly with the actual depth of printed surface depressions and the 3D optical imaging assessments. The changes in SCARS and 3D optical imaging assessments correlated significantly, but there were no correlations between changes in QSGS and 3D optical assessment measures, or between the QSGS and SCARS results., Conclusion: The new stereoscopic optical system is a reliable and practical objective method for assessing the cumulative depth of atrophic acne scars and monitoring treatment response. It is more sensitive, accurate, and informative than subjective scales., (© 2021 Wiley Periodicals LLC.)

Background: Atopic dermatitis (AD) is a remitting relapsing chronic eczematous pruritic disease. Several studies suggest that gut microbiota may influence AD by immune system regulation., Methods: We performed the first in-human efficacy and safety assessment of fecal microbiota transplantation (FMT) for AD adult patients. All patients received 2 placebo transplantations followed by 4 FMTs each 2 weeks apart. AD severity and fecal microbiome profile were evaluated by the Scoring Atopic Dermatitis Score (SCORAD), the weekly frequency of topical corticosteroids usage, and gut microbiota metagenomic analysis, at the study beginning, before every FMT, and 1-8 months after the last FMT., Results: Nine patients completed the study protocol. There was no significant change in the SCORAD score following the two placebo transplants. The average SCORAD score significantly decreased from baseline at Weeks 4-12 (before and 2 weeks after 4 times of FMT) (59.2 ± 34.9%, Wilcoxon p = .011), 50% and 75% decrease was achieved by 7 (77%) and 4 (44%) patients, respectively. At Week 18 (8 weeks after the last FMT) the average SCORAD score decreased from baseline at Week 4 (85.5 ± 8.4%, Wilcoxon p = .018), 50% and 75% decrease was achieved by 7 (77%) and 6 (66.7%) patients respectively. Weekly topical corticosteroids usage was diminished during the study and follow-up period as well. Two patients had a quick relapse and were switched to a different treatment. Two patients developed exacerbations alleviated after an additional fifth FMT. Metagenomic analysis of the fecal microbiota of patients and donors showed bacterial strains transmission from donors to patients. No adverse events were recorded during the study and follow-up period., Conclusions: FMT may be a safe and effective therapeutic intervention for AD patients, associated with transfer of specific microbial species from the donors to the patients. Further studies are required to reconfirm these results., (© 2021 The Authors. Immunity, Inflammation and Disease published by John Wiley & Sons Ltd.)

Background: Melasma is an acquired disorder of hyperpigmentation, affecting a million individuals worldwide. Energy-based devices (EBDs) employed to treat melasma include various types of lasers, intense pulsed light (IPL), and radiofrequency (RF). Recent studies have attempted to address recalcitrant and recurring melasma by combining energy-based devices with topical or oral medications., Objective: This article reviews EBDs-based augmented treatment for melasma and suggests practical pathogenesis-oriented treatment regimens. Treatment algorithms are proposed to address various components of melasma., Methods: A systematic PubMed search was conducted acquiring information from various studies on combination treatments of melasma involving EBDs., Results: The 286 retrieved articles were filtered by title to contain at least one type of energy-based modality such as laser, IPL, or RF along with at least one other treatment method. Based on their subject matter, combinations were further categorized into the subheadings: laser plus medication, laser plus laser, and IPL- and RF-containing treatment methods., Conclusion: There are many energy-based combination treatments that have been explored for mitigation of melasma including laser therapy with medication, multi-laser therapies, IPL, RF, and microneedling devices. Melasma is an exceedingly difficult condition to treat, however, choosing the appropriate tailor-made treatment combination can improve the final outcome., (© 2021 Wiley Periodicals LLC.)

Background and Objectives: Acne scars are one of the most distressing and long-term consequences of acne vulgaris, with damaging effect on a person's physical, mental, and social well-being. Numerous treatment options are available including surgical and nonsurgical techniques, depending on the clinical presentation. Although considerable advances in the development of new treatment technologies and applications have been made in the last decade, international treatment guidelines and reimbursement schemes have not yet caught up with current knowledge and practice in many centers. The authors intend to highlight the potential utility of energy-based devices (EBDs) for acne scarring, offer recommendations for safe and efficacious treatment, and provide consensus-based EBD treatment options based on varying presentations demonstrated in a series of real-life clinical photographs., Study Design/materials and Methods: An international panel of 24 dermatologists and plastic surgeons from 12 different countries and a variety of practice backgrounds was self-assembled to develop updated consensus recommendations for the treatment of acne scars. A two-step modified Delphi method took place between March 2020 and February 2021 consisting of two rounds of emailed questionnaires. The panel members approved the final manuscript via email correspondence., Results: The manuscript includes a comprehensive discussion and panel recommendations regarding the following topics: 1. the role of EBD in mitigating and treating acne scars in a patient with active acne, 2. the use of various EBDs for the treatment of different acne scar types with special focus on commonly used laser platform such as vascular lasers, ablative fractional lasers (AFLs) and non-AFLs (NAFLs), 3. treatment combinations, and 4. acne scar treatments in skin of color. The last part comprised of 10 photos of real-life clinical cases with the panel recommendation treatment plan to achieve best aesthetic outcome., Conclusion: Panel members were unanimous in their view that EBDs have a role in the management of acne scars, with AFLs, NAFLs, vascular lasers, and RF devices preferentially selected by most of the panel experts. EBDs are considered a first-line treatment for a variety of acne scar types and patients without access to these treatments may not be receiving the best available care for optimal cosmetic results. Future high-quality research and updated international treatment guidelines and reimbursement schemes should reflect this status., (© 2021 Wiley Periodicals LLC.)

Background: Injecting dermal fillers in patients with autoimmune inflammatory rheumatic diseases (AIIRDs) is controversial., Objective: To evaluate the attitudes of patients with AIIRDs regarding the use of dermal fillers and the side effects of those who underwent them., Methods: Patients with AIIRDs who attended a rheumatology outpatient clinic between 2016 and 2018 filled in a questionnaire about their attitudes toward dermal filler injections. The questionnaire evaluated information received from professionals and the factors that influenced their decision of whether or not to undergo the procedures., Results: Overall, 194 patients with AIIRDs (mean age 56.5 ± 14.0, 99% women) responded. Forty-two of them had previously undergone the injections and intended to repeat them (Group A), 37 had not received filler injections but intended to do so (Group B), and 114 who had never undergone them did not intend to undergo them. The major motivation for undergoing filler injections was social. Patients treated with dermal fillers refrained from informing their rheumatologist about their injections. They were, however, highly satisfied with the procedure and reported negligible side effects., Conclusion: The use of dermal fillers was apparently safe and well received by patients with AIIRDs. Physicians' recommendations to refrain from injecting them with dermal fillers should be reconsidered and evaluated in clinical studies., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: The Chemical Reconstruction of Skin Scars (CROSS) technique was first described in 2002 and has since demonstrated safety and efficacy in multiple studies. We describe the treatment of six patients with a modified version of the CROSS method-the Painting CROSS trichloroacetic acid (TCA) technique. This technique has the advantage of offering even higher tissue selectivity and better control of the scar edges, enhancing both safety and efficacy., Methods: We retrospectively evaluated 31 scars of six patients who underwent a single treatment by the Painting CROSS TCA method. A 0.3 ml insulin syringe with a 30-gauge needle was filled with 0.05 ml of 85% TCA solution and then applied to the scar base with slight pressure until frosting was achieved. Patients were evaluated before and 3 months after treatment for scar volume deficit by a high-resolution three-dimensional imaging system., Results: The average volume of the 31 scars assessed in our study was 2.71 mm 3 before treatment and 1.96 mm 3 after treatment. There was a 26.3% average decrease in the volume of the scars after one treatment. Transient mild hyperpigmentation was noted in two patients after the treatment., Conclusion: Painting CROSS TCA technique has demonstrated efficacy in the treatment of acne scars after a single treatment., (© 2021 Wiley Periodicals LLC.)

Background: Glycolic acid (GA) is a commonly used superficial peel with higher concentrations and lower pH levels leading to a stronger effect despite a higher risk of adverse effects (AE), which include burning, pain, itching, erythema, and edema., Objective: This study aimed to evaluate the potential of a novel protective complex (NPC) to reduce facial AEs following a GA chemical peel treatment., Methods and Materials: Twenty volunteers were selected for the study. A pair of numbered kits were supplied by and randomly assigned to be applied to each side of a patient&rsquo;s face with either a 50% GA peel plus NPC or a control formulation with only a 50% GA peel. AEs, patient photographs, and standard and red filtered VISIA scans were evaluated by three independent dermatologists., Results: The average post-treatment pain and itching were significantly higher in the control half as compared to the study half. Recovery time appeared to be significantly shorter in the treated side compared to the control side., Conclusion: The addition of the NPC to GA 50% peel is a highly effective, safe modality in the reduction of erythema, pain, and itching after peel application, and it provides an advantage in the post-treatment healing period. J Drugs Dermatol. 2021;20(12):1336-1339. doi:10.36849/JDD.5939.

Background: Photodynamic therapy (PDT) is considered an effective treatment for acne vulgaris. A significant drawback is pain during illumination. Daylight PDT (DL-PDT) is more tolerable., Objective: To assess and compare the efficacy and tolerability of DL-PDT and C-PDT for acne vulgaris through a prospective split-face trial., Methods and Materials: Fifteen patients underwent 4 treatment sessions at 3-week intervals. First, 5-aminolevulinic acid (ALA) was applied to the entire face, after which the face was divided into 2 symmetrical areas: The right side was exposed to sunlight, and the left half was illuminated with red light. Photographs were obtained and evaluated by two dermatologists blinded to the study protocol. The patients reported side effects and downtime., Results: There was a statistically significant decrease in the number and percent change of inflammatory and non-inflammatory lesions on both sides. Adverse effects were markedly decreased on the DL-PDT side compared to the C-PDT side (p < .01). The average downtime duration was longer for the C-PDT side (p < .001)., Conclusion: DL-PDT was at least as effective as C-PDT with fewer adverse effects and a shorter downtime duration., (© 2021 Wiley Periodicals LLC.)

Background and Objectives: Thermo-mechanical fractional injury (TMFI) therapy (Tixel®; Novoxel®, Netanya, Israel) is an innovative technology. Along with its drug delivery enhancement features, it is widely used for facial skin rejuvenation. Our study explores the beneficial effect of the Tixel® on the different features of facial skin rejuvenation along with patients' satisfaction rate, aiming to suggest practical recommendations for an optimal aesthetic result., Study Design/materials and Methods: A retrospective chart review of 24 patients (20 women, 4 men, average age 56 years old) with skin types II-V who received 2 or 3 Tixel® treatments, 3-5 weeks apart in two medical centers (12 from Israel, 12 from the United Kingdom). Four experienced dermatologists compared standardized clinical photographs taken before each treatment and 3 months after the final treatment based on seven parameters that were set by 10 physicians and rated the difference on a scale of -1 to 4. Furthermore, epidemiology, treatment data, satisfaction, and safety were reviewed., Results: Out of the seven parameters that were compared (blood vessels and erythema, skin complexion, periorbital wrinkles, pigmentation and toning, pore size, vitality, wrinkles, and laxity), all features demonstrated an overall improvement, with the greatest improvement demonstrated in skin complexion (2.1 ± 0.49) and periorbital wrinkling (2.09 ± 0.65) followed by vitality (1.7 ± 0.49). Side effects were transient, including erythema and hyperpigmentation, and the average downtime was 1.7 days., Conclusion: TMFI is a safe and effective method for improving facial skin quality. Addressing patient's expectations while maximizing the benefits of this novel technology will provide superior aesthetical results., (© 2021 Wiley Periodicals LLC.)

Background: Melasma is a complex and poorly understood disorder, with high rates of treatment failure and recurrences., Objectives: We aimed to review the current knowledge of the pathogenesis of melasma and apply this knowledge to clinical implications on relevant therapeutic interventions., Methods: A systematic PubMed search was performed using the search term "((melasma[Text Word]) OR facial melanosis[Text Word]) AND (pathogenesis OR causality[MeSH Terms])" for articles published between 1990 and 2020. Included articles were then evaluated by two authors and assessed for relevant pathomechanistic pathways, after which they were divided into groups with minimal overlap. We then reviewed current treatment modalities for melasma and divided them according to the involved pathomechanistic pathway., Results: A total of 309 search results were retrieved among which 76 relevant articles were identified and reviewed. Five main pathomechanisms observed in melasma were identified: (1) melanocyte inappropriate activation; (2) aggregation of melanin and melanosomes in dermis and epidermis; (3a) increased mast cell count and (3b) solar elastosis; (4) altered basement membrane; and (5) increased vascularization. Treatment modalities were then divided based on these five pathways and detailed in 6 relevant tables., Conclusion: The pathophysiology of melasma is multifactorial, resulting in treatment resistance and high recurrence rates. This wide variety of pathomechanisms should ideally be addressed separately in the treatment regimen in order to maximize results., (© 2021 Wiley Periodicals LLC.)

Background: Acne vulgaris is common dermatologic condition with an estimated prevalence of 80%. Acne has been shown to have a significant impact on patient quality of life and mental health, especially as inflammatory lesions typically occur on cosmetically sensitive areas with the potential for permanent scarring. There have been numerous advances in the treatment of inflammatory acne with light-based and laser devices. This technology permits effective treatment of active acne and scarring, with a short recovery and a decreased side effect profile as compared to medicinal standard-of-care and photodynamic therapies., Objective: The case series study was aimed at evaluating the safety and efficacy of a 1064 nm Nd: YAG Quasi-longed pulse laser treatment for acne vulgaris., Methods: This was a prospective study of 19 subjects with moderate to severe. All subjects received 1064 nm Nd: YAG Quasi-longed pulse laser treatments, at 8 J/cm 2 fluence and accumulated 1000-4000 kJ according to treatment area at two weeks intervals. Primary end point was reaching a minimal AGSS score of between 1 and 2. Acne severity was assessed by two independent dermatologists according to AGSS scale before each treatment session and at the follow-up visit (8 weeks following last treatment). Subjects' self-assessment of Patient Global Impression of Change (PGIC) and overall satisfaction were also recorded. Safety was assessed by recording pain, adverse events, and downtime throughout the trial., Results: Investigator's US FDA AGSS scoring of acne appearance improvement shows an average of 6.6 treatments were required to reach the minimal AGSS score endpoint. Significant reduction in AGSS scores was recorded after 2 treatments (4.21 ± 0.65 vs 3.05 ± 0.83 p = 1.63E -05 ), and maintained a statistically significant reduction rate throughout the trial. Minimal AGSS scores were still detected after 8 weeks following final treatment. Subjects scored high satisfaction rates and PGIC scores (2.9 and 5.3, respectively). Some patients reported transient erythema as only adverse events recorded in the study., Conclusion: The 1064 nm Nd: YAG Quasi-longed pulse laser was found to be safe and highly effective for the treatment of facial acne. The treatments were well tolerated, and the subjects experienced no pain and no downtime. Light-based treatments do and will probably continue to play an important and enlarging role in acne management., (© 2021 Wiley Periodicals LLC.)

Background: Botulinum neurotoxin is one of the most versatile and widely used medical products in the world., Aims: The review's focus is the plastic and dermatologic uses of botulinum neurotoxin currently supported by published data., Methods: Relevant clinical articles regarding botulinum neurotoxin use in plastic surgery, dermatology, and general esthetic literature were searched and reviewed., Results: The search yielded 258 studies. Two hundred articles were excluded following title and abstract review. Twenty-one studies were excluded following full-text screening. A total of 37 studies remained and were discussed in this review., Conclusions: Botulinum neurotoxin is widely used for numerous off-label indications from head to toe. Some uses are well documented, and their safety has been demonstrated in controlled trials, yet most remain poorly researched., (© 2021 Wiley Periodicals LLC.)

Background: The starch iodine test (SIT) is the gold-standard diagnostic tool for primary palmar hyperhidrosis (PPH)., Objective: This study aimed to evaluate the clinical effectiveness and safety profile of a novel approach for the detection of PPH by moisture response films (MRF) in comparison to the SIT., Methods: This prospective comparative study of the 2 tests was conducted on 17 patients with PPH. Disease severity was evaluated by the SIT and the MRF methods during 4 sessions (twice before and twice after botulinum toxin [BTX] injections) on different days and by different investigators. The physician's global assessment (PGA) scoring of the comparable visual results was evaluated by 2 blinded independent dermatologists. The Hyperhidrosis Disease Severity Scale (HDSS) scores of the patients at baseline and after the BTX injections were correlated with the SIT and MRF results., Results: The objective PGA scoring of the SIT results demonstrated poor correlation, whereas the objective PGA scoring of the MRF results correlated highly with the patients' HDSS scores both at baseline and after the BTX injections., Conclusion: Analysis of palmar hyperhidrosis by means of MRF was superior to SIT and was demonstrated to be more efficient, convenient, and accurate., (Copyright © 2021 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Nail psoriasis is a common and potentially debilitating condition for which no effective and safe nonsystemic therapy is currently available. Recently, laser-assisted drug delivery (LADD) is being increasingly used to facilitate transcutaneous penetration of topical treatments., Objectives: We set to assess the efficacy and safety of combined pulse-dye laser and fractional CO2 laser-assisted betamethasonecalcipotriol gel delivery for the treatment of nail psoriasis., Material and Methods: We conducted a prospective, intrapatient comparative study in a series of 22 patients with bilateral fingernail psoriasis. Nails on the randomized hand were treated with 3 monthly sessions of pulse-dye laser to the proximal and lateral nail folds followed by fractional ablative CO2 laser to the nail plate. Between treatments and one month following the last treatment, the participants applied betamethasone propionate-calcipotriol gel once daily to the nail plate. Clinical outcome was ascertained using nails photography, the Nail Psoriasis Severity Index (NAPSI) and patient satisfaction., Results: Seventeen completed the study. Three participants withdrew from the study because of treatment-associated pain. Treatment was associated with a statistically significant improvement of the NAPSI scale (p < .002). Patient satisfaction was high., Conclusion: Combined PDL and fractional ablative CO2-LADD of betamethasone-calcipotriol gel should be considered for the treatment of nail psoriasis., (Copyright © 2020 by the American Society for Dermatologic Surgery, Inc. Published by Wolters Kluwer Health, Inc. All rights reserved.)

Background: Effective nonsurgical treatments for the aging face are widely accepted and utilized. Although changes in the aging neck, often patients to seek esthetic rejuvenation protocols are neither well defined nor well designed. Increasingly, patients desire less invasive cosmetic treatments with less morbidity and downtime. A significant challenge exists in managing expectations and educating patients about the pros and cons of a surgical approach compared to the plethora of nonsurgical options. When equipped with state of the art information and technique, using a multi-modality nonsurgical approach, surprisingly outstanding results may be obtained., Aims: In this paper, we aim to revisit the neck's anatomy and then demonstrate current nonsurgical techniques in managing actual cases., Methods: To achieve that, we have utilized an intuitive four-point grading scale to guide both physician and patient regarding appropriate treatment combinations., Results: The proposed four-point scale was applied to six patients and their treatment plan was described in detail., Conclusions: Skin laxity is not the only factor that comes into play when assessing the neck. careful analysis of the neck and face hold the key for treatment choice and execution., (© 2020 Wiley Periodicals LLC.)

Background: Many modalities have been described for the treatment of periorbital wrinkling., Aims: The purpose of this study is to quantify the improvement of periorbital wrinkling achieved by current nonablative modalities, using a fractional 1565 nm Er:glass fiber laser., Methods: Our study is a retrospective two-center case series including 16 patients treated with nonablative laser for periorbital wrinkling at the Tel-Aviv Sourasky Medical Center in Israel and Laserplast Aesthetic Medicine Center in Italy between 2017 and 2019. Patients were assessed for objective and subjective improvement, patient satisfaction, side effect profile, and downtime., Results: Improvement in average Fitzpatrick Wrinkle Scale scores (from 4.3 to 2.7 by ranking physician 1 and 3.8 to 2.4 by ranking physician 2, P < .001) was observed after 8 weeks. Global Assessment Improvement Scale scores were 2.6 (physician 1) and 2.2 (physician 2) on average. This correlated to mild-moderate subjective sense of improvement by patients. Side effects and downtime were minimal., Conclusion: Our study suggests that current nonablative laser skin resurfacing technology offers a mild-moderate improvement in periorbital wrinkling., (© 2020 Wiley Periodicals LLC.)

Radiofrequency energy thermally induces collagen contraction and remodeling. The resultant dermal tightening is well established. However, facial aging encompasses also deeper layers of collagen-containing tissues. We present a deep layer radiofrequency-based thermo-coagulative technique for cervicofacial contouring and evaluate its efficacy., Methods: This prospective single center study was conducted from June 2017 to June 2018 and included 10 women. Echogenicity and thickness of layers 1-5 of the lower face, lateral neck, and submental regions were sonographically measured at baseline and at 6 weeks postoperatively. Echogenicity analysis was based on the number of high echogenic pixels counted and processed using Matlab-based image application (The Mathworks, Natick, Mass.). Clinical outcome at 12 months postoperatively was evaluated by 2 independent evaluators using a validated 5-point lower face improvement scale and the Merz jawline scale (0-4). Patient satisfaction and adverse effects were recorded., Results: Mean age was 60.2 years (range, 52-76). A statistically significant increase in echogenicity ( P ≤ 0.02) and a decrease in thickness ( P = 0.01) was noted. Echogenicity increased at 149%, 78%, and 60%, for the lateral neck, lower face, and submental region, respectively. The corresponding decrease in thickness per site was 16%, 6%, and 19%. The average physicians' improvement in lower face contour was 3.8, and the Merz jawline scale was improved from 2.85 at baseline to 1.05 at 12 months postoperatively. Patient satisfaction was high. Side effects were minimal., Conclusions: Deep layer radiofrequency-based technology thermally induces profound soft tissue tightening and neocollagenesis. It is a safe and effective technique for cervicofacial contouring in selected patients., Competing Interests: Disclosure: The authors have no conflicts of interest to declare. No funding was procured for this work., (Copyright © 2020 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)