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Background: Nonsurgical cosmetic procedures, particularly the use of hyaluronic acid (HA)-based soft tissue fillers, are becoming increasingly popular. This trend has catalyzed the development of a plethora of HA-based products differing in product characteristics, thereby catering to an ever-widening spectrum of aesthetic applications. However, complications rise concomitant with the increasing number of procedures. Among the strategies to manage such adverse events is the enzymatic breakdown with hyaluronidase., Objective: To analyze the response of different HA-based soft tissue filler materials to hyaluronidase injections., Methods: A total of 11 different HA-based soft tissue fillers were evaluated using noninvasive ultrasound imaging to assess their behavior in response to hyaluronidase injections. The HA-based soft tissue fillers were categorized according to their product characteristics into a structuring, volumizing, and lip volumizing group. Standardized injections of 0.2 cc were performed in chicken breast to simulate human tissue. Ultrasound measurements of width, height, and calculated volume were performed immediately after filler injection, 1 h and 24 h following hyaluronidase injection., Results: Regardless of the soft tissue filler analyzed, the most significant volume reduction occurred within the first h after applying hyaluronidase, with a 64.1% decrease from the initial volume. After 24 h, the total volume reduction reached 81.7%. No statistically significant differences were found when comparing the three groups at each follow-up time period, except for the height measurement after 1 h. While width was statistically significant in all groups between the investigated follow-up groups, the volume reduction was only statistically significant in the groups with the highest and second highest G' values (i.e., Group 1-structuring, Group 2-volumizing)., Conclusion: The effectiveness of hyaluronidase in dissolving HA-based fillers is initially independent of product characteristics of HA-based fillers such as G-prime, with increased efficacy in fillers with higher G-prime values, as evidenced by significant volume reductions in such groups., (© 2024 The Author(s). Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Given the significant increase in the quantity of cosmetic procedures utilizing hyaluronic acid fillers, including in the nasal region, the initial evaluation of patients using high frequency ultrasound becomes a crucial instrument in evaluating and handling nonsurgical rhinoplasty., Aims: The aim of this article is to introduce an assessment methodology for nasal filling guided by high frequency ultrasound., Patients/methods: A prospective and single-center study was conducted with 12 Latin American patients. The patients underwent nasal filling with hyaluronic acid following high power ultrasound mapping., Results and Conclusions: In the evaluation of the GAIS scale, all patients reported improvement with the treatment. No infections, nodules, ischemia, or other relevant adverse effects were noted. Real-time ultrasound-guided filler techniques have been developed to reduce the risk of vascular compromise, confirming the distribution pattern of blood vessels. It's also crucial to visualize the cannula at the same moment as the vessels, even if the previous vascular mapping was performed. Therefore, the utilization of high frequency ultrasound can act as a pivotal tool in augmenting procedure safety., (© 2024 The Author(s). Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

According to the Federal Council of Medicine's demographic data from 2020, the medical specialty with the highest number of women is dermatology; with 77.9% within the total of 9,078 specialists. The male/female ratio is 0.28, that is, for each man, there are more than 3 women Dermatologists. Analyze the participation of women in Brazilian dermatology and their representation in leadership positions through data review. A literature review of the National Library of Medicine PubMed database was performed in May 2022 and data review of the SBD database. According to the Brazilian Society of Dermatology (SBD), about 80% of its associated Doctors are women. Despite this correlation, since its foundation in 1912, the SBD has already had 62 directorates, of which 53 were known to be presided over by men and 4 of them are unknown. Among the directorates that are known, only five (8.62%) were chaired by women.

Background: The objective was to provide international recommendations on anti-aging dermocosmetics for clinical practice starting with essential ingredients for protection and repair before working up to advanced products for specific concerns.  Methods: Seven international experts reviewed 8 hypothetical case scenarios covering different ages, skin issues (eg, sensitivity, acne, melasma), and exposure to exposome factors for both sexes and all Fitzpatrick skin types (FST). The RAND/UCLA appropriateness method was used to obtain consensus. Seventeen key ingredients were rated on a scale from 1 (totally inappropriate) to 9 (totally appropriate). Statistical analysis, 2 meetings, and email discussions refined the recommendations., Results: High-factor broad-spectrum sunscreen (ie, protects against ultraviolet [UV] A and B rays), niacinamide, and other topical antioxidants were recommended for all scenarios. Further discussions were required for other ingredients. Tinted sunscreen/iron oxide were recommended for all FST, although compliance may be sub-optimal for darker skin phototypes (IV-VI), if not cosmetically acceptable. Combining a facial foundation with broad-spectrum sunscreen was recommended for darker phototypes to obtain visible light protection closely matching diverse color tones. Retinols were not recommended as a first-line treatment for sensitive skin, especially FST V and VI, due to the risk of irritation. After ablative laser treatment, alpha hydroxy acids should be avoided or used with caution in FST IV to VI due to the risk of post-inflammatory hyperpigmentation., Conclusion: We describe a simple, practical tool for use in daily dermatology consultations for providing recommendations on anti-aging dermocosmetics to cover diverse and inclusive populations of patients, addressing all skin types and international needs.  J Drugs Dermatol. 2024;23(1):1337-1343.     doi:10.36849/JDD.7798.

Background: Oral isotretinoin (ISO) is the drug of choice for the treatment of severe acne. For photoaging treatment, ISO has been proved to be effective in some controlled and noncontrolled trials and is an alternative to topical retinoic acid (RA) therapy, which causes an expected skin irritation., Objective: To evaluate and compare the skin remodeling in patients taking ISO 20 mg 3 times a week for 12 weeks and 12 weeks after the end of the treatment to quantify collagen I and collagen III augmentation., Material and Methods: Immunohistochemical studies were performed to evaluate the expression of collagen I and collagen III, metalloproteinases (MMPs) -1, -3, -7, -9, -12, and the tissue inhibitor of MMP type-1 (TIMP-1) of the skin of 20 45 to 50-year-old women through morphometry in a semiquantitative method. The inclusion criteria were facial aging 2 and 3 of Glogau's classification, with phototypes between II and V who had not entered menopause. Biopsies of the skin of the left preauricular region were performed at three different times: pre-treatment (T0), end of 12-week treatment (T1), and 12 weeks posttreatment (T2)., Results: Collagen fibers I and III increased with statistical significance in T1 (50.7%; P = 0.012) but not in T2 (49.7%), which in turn was higher than in T0 (47.2%) for collagen I and T1 (33.3%; P = 0.002) but not in T2 (32.7%), and also was higher than T0 (32.0%) for collagen III. MMP-9 presented a decreased activity with statistical significance in T1 (P = 0.047) and T2 (P = 0.058). MMP-1 showed a reduction in T2 only (P = 0.015). MMPs -3, -7, -12, and TIMP-1 did not present significant modification in their expressions during or after the treatment., Conclusions: Low-dose ISO is effective in remodeling the extracellular matrix (ECM). This study found that the increase of collagen occurs through the augmentation of both collagen I and collagen III fibers. With originality, it was possible to verify the durability of these fibers for at least 12 weeks. This may be related to the decrease in MMP-9 expression verified at the end of the treatment and 12 weeks posttreatment., (© 2023 the International Society of Dermatology.)

Hyaluronic acid filler injections are regarded as the gold standard procedure for facial rejuvenation. Standing as the second most injected cosmetic filler, calcium hydroxyapatite-based fillers are also widely used worldwide. However, to our knowledge, prospective studies assessing patient satisfaction and sonographic changes in dermal thickness after a single session of a hybrid filler combining hyaluronic acid and calcium hydroxyapatite have not been previously published., Methods: This was a single-center, prospective, quasi-experimental study comprising 15 participants between 32 and 63 years of age. Each participant received a single-session treatment based on facial subcutaneous injections of HArmonyCa, a hybrid combination filler comprising hyaluronic acid and calcium hydroxyapatite. This study involved an intrapatient control design and a 120-day follow-up with clinical and sonographic assessment. For this purpose, standardized photographic images, high-frequency ultrasound evaluations, and physician- and patient-oriented overall aesthetic improvement scores were recorded at 0, 30, 90, and 120 following the procedure., Results: According to our findings, 20% of the subjects had an exceptional improvement; 20%, "very improved"; and 60%, "improved." Intrapatient sonographic comparison showed a significant increase in dermal thickness, at 90 and 120 days, only on the side treated ( P < 0.001)., Conclusion: In our clinical study, a single-session treatment with a hybrid product combining hyaluronic acid and calcium hydroxyapatite resulted in positive cosmetic satisfaction and increased dermal thickness., Competing Interests: Dr. Bruna S.F. Bravo is a medical consultant of Merz, Allergan, and Lóreal. All the other authors have no financial interests to declare in relation to the content of this article. Disclosure statements are at the end of this article, following the correspondence information., (Copyright © 2023 The Authors. Published by Wolters Kluwer Health, Inc. on behalf of The American Society of Plastic Surgeons.)

Background: Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility., Objectives: The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula., Methods: This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection., Results: A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area., Conclusions: Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region., Objective: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments., Methods: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m 2 were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues., Results: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle., Conclusion: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region., (© 2022 Wiley Periodicals LLC.)

Background: Melasma is a common hypermelanosis characterized by symmetrical brownish macules, especially on the face. Histologic analysis demonstrates increased epidermal and dermal melanin. Dermoscopy is useful to estimate the depth of the melanin and may help in the diagnosis and classification of melasma, with therapeutic importance., Objectives: To evaluate the diagnostic concordance of dermoscopic classification of epidermal or mixed subtypes of melasma and the correlation between dermoscopic and histopathological findings., Methods: Twenty-eight women with facial melasma, phototypes III to V, ages between 30 and 61 years were selected. Based on the evaluation of clinical and dermoscopic images, two independent observers classified melasma into epidermal or mixed subtypes. The intra and interobserver concordances were calculated. Histopathological analysis of epidermal melanin extension and maximum number of melanophages per high-power field (400×; HPF) have been assessed. Association between the melanophages count and the dermoscopic classification was evaluated., Results: Intraobserver agreement was 82.1%, and between observers, from 78.6% to 89.3%, according to the Kappa index. Histopathology revealed increased intraepidermal melanin and the presence of dermal melanophages in all the samples. Ten or more melanophages/HPF was significantly associated with mixed melasma., Conclusions: Moderate to substantial concordance in the dermoscopic classification of melasma was found, and the correlation between this classification and the dermal melanophages count have been suggested. Intradermal component of every case of melasma should be considered for therapeutic and prognostic purposes., (© 2022 Wiley Periodicals LLC.)

Introduction: The aging process occurs in all anatomical layers of the face; therefore, rejuvenation should not be limited to the dermic signs of aging (Aesthet Surg J. 2018;38:73) The treatment with fillers in strategic points can reconstruct young anatomy, providing natural results (Aesthet Surg J. 2018;38:73). There are two instruments used for facial application of hyaluronic acid: cannula and needle. Both of them have advantages and disadvantages., Objective: In this study, we aim to compare the limitations of application with cannula by cutaneous ultrasound when compared to the needle by ultrasound, since some injectors suggest that one of the disadvantages would be the inability to reach certain application plans (periosteum)., Materials and Methods: A 52-year-old female patient was treated with 22 mg/ml hyaluronic acid (Juvéderm® Voluma), guided by high-frequency ultrasound (LogicE device, Logic brand (GE Healthcare), with high-frequency linear probe (L8-L18i-RS). The left hemiface was treated with a 27G needle and the right hemiface with a 5 cm 22G cannula (SoftFil®)., Conclusion: This study proved that, in the malar/zygomatic and the chin region, it is possible the cannula and needle reached the supraperiosteal region. In the temporal region, the cannula did not reach the supraperiosteal plane., (© 2021 Wiley Periodicals LLC.)

Background: The aesthetic treatment based on fillers with hyaluronic acid presents an increasing demand in the present day because it is considered a safe and minimally invasive procedure. In the management of adverse effects or more severe complications of hyaluronic acid-based fillers, hyaluronidase is the treatment of choice., Aims: To demonstrate efficacy in reversibility and safety in the treatment of HA complications., Patients/methods: It is a retrospective study article that reports the use of hyaluronidase in the main undesirable effects of fillers in 114 patients in a private dermatological clinic from 2015 to 2018., Results: The target of the application was 51 cases of overcorrection (45%), 50 cases of Tyndall effect (44%), and 13 late nodules (11%). When we evaluated the areas where HYAL was injected, we found that the area with the most indication of the application of the product was the eyelid region (58 injections)., Conclusion: This study concluded that HYAL is a safe and effective drug in the management of mild adverse events of HA applications with no severe side effects in our protocol of use., (© 2021 Wiley Periodicals LLC.)

Poly-L-lactic acid is presented as freeze-dried preparation of 150 mg per vial and, according to consensus, the recommendation on your preparation is hydrate in sterile water for injection (SWFI) or bacteriostatic water at room temperature for ≥24 hours. (J Drugs Dermatol; 2014;13:s44) However, in these long periods of hydration, it is time-consuming and costly for the physicians. To demonstrate the safeness of immediate reconstitution of facial biostimulation treatment with PLLA. A clinical prospective study with 26 Latin American female patients, aged between 27 and 80 years, complaining of facial laxity of treated with immediate PLLA reconstitution. One PLLA vial was injected per session in 12 mL total dilution. All patients had their pictures taken before and after the treatment in Photo Analysis Program Vectra 3D (Canfield ® ). A follow-up 90 days was performed. The total of 58 facial applications of PLLA was reported in female patients with a mean age 52.62 (±13.46) years. Pain was reported in 17 injections (29.31%) and ecchymosis in 6 (10.34%). Also, 2 patients (3.44%) developed a nodule. None of the patients presented significant bruising, edema, or papules formation. Despite the literature declare that a longer hydration times (up to 48 hours) have been shown to reduce the risk of nodule formation (Aesthet Surg J; 2011;31:95), our study demonstrated the safeness of injection with immediate reconstitution and a very low adverse events rate. Immediate PLLA reconstitution is a great asset for physicians, injections in account of being less laborious, less time-consuming, and reducing product loss for the injector., (© 2020 Wiley Periodicals LLC.)

The possibilities for facial and body treatments are wide, but when it comes to treatment for the cervical region, the options are more restricted and among them, the use of poly-l-lactic acid (PLLA) stands out. PLLA is used for collagen biostimulation and improvement of skin turgor with good results; however this procedure is not free of complications, and for the treatment of these, a correct diagnosis is essential. As it is esthetic medicine, the guarantee of results requires that complications are not tolerated, and thus, any resource that enriches the diagnostic and therapeutic arsenal is of great value. The objective of this study is to report the diagnosis of a PLLA nodule with the help of high-frequency ultrasound, establishing a clinical, radiological, and histopathological correlation, in a patient submitted to PLLA injection for esthetic improvement of the cervical region. We present a case in a female patient presenting a nodule in the cervical region after the application of PLLA, where we performed the excision guided by high-frequency ultrasound. Mastering the diagnostic technique with high-frequency ultrasound can play a valuable role in indicating early surgical exeresis, also contributing to complete patient care. It allows the application of the product, monitoring, diagnosis of the complication, and treatment to be carried out dynamically and precisely by the injector., (© 2020 Wiley Periodicals, LLC.)

Background: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide with a high rate of efficacy and patient satisfaction., Objective: This study aims to demonstrate the importance of individualization of botulinum toxin doses to treat the upper face according to the age of the patients, considering the muscles particularities and the specificities of each face area., Materials and Methods: A retrospective study with 389 female patients treated with botulinum toxin type A in the upper third of the face (forehead, glabellar, and periorbital lines). Statistical analysis of the data was performed., Results: The mean age was 47.49 years old and the median total dose of botulinum toxin type A was 53.76 units, whereas the median dose in the glabella was 26.28 U, the mean forehead dose was 12.23 U, and in the periorbital area was 14.79 U, adding both sides. It is possible to observe that the doses are negatively correlated with age, except in the periorbital area, where an increase in the dose was observed., Conclusion: It is important to highlight that although there is consensus on pre-established dose suggestions, the treatment should be individualized, respecting the individual characteristics of each patient., Competing Interests: There are no conflicts of interest., (Copyright: © 2021 Journal of Cutaneous and Aesthetic Surgery.)

Backgroud: Aging is the result of the interplay of changes occurring in the facial skeleton, ligaments, muscles, adipose tissue, and skin (1), and these changes befall each mentioned structure at a different pace, start in each individual at a different age, and differ between ethnic background. (4) It changes directly the measurements of the face angles, making the face more concave and flattened aspect, while the young face presents a more convex and rounded aspect. Female skulls had an increase in all transverse facial widths and depth of the middle face with increasing age. Therefore, aging is consequence of progressive changes through intrinsic and extrinsic factors (5) and different methods can be used to assess and diagnose these changes., Aims: The aim of the study is to evaluate facial angles and their aging changes., Methods: A retrospective study was performed with a total of 1213 Caucasian female patients in the author's private clinic. The angles evaluate age-related changes were analyzed: facial, naso-mental, and columella-labial angle. Photograph analysis program Vectra 3D (Canfield) was used to perform the anthropometric assessment of the angles, and after data collection, the analysis was performed statistics., Results and Conclusion: We could conclude angles analyzed change with age, while two angles increase (naso-mental and facial angle), the other decreases (columella-labial angle). The study reinforces the principle of an objective clinical anthropometric assessment of facial angles as a relevant guide for a more appropriate treatment plan for the doctor to perform aesthetic procedures in order to restore a youthful face., (© 2020 Wiley Periodicals, Inc.)

Background: Currently, there are no scales that address lower-face muscular contraction patterns, and there is only one that addresses platysmal bands., Objective: The goal of this article is to create scales to classify the strength and contraction patterns of the lower face and neck based on (1) the muscular anatomy and contraction patterns of the platysma and (2) the strength of the depressor anguli oris (DAO)., Methods: Three hundred sixty patients participated in the study. Standardized photogarphs were taken in an effort to characterize muscle contraction patterns., Results: A novel classification measuring the strength of the DAO is presented. For the DAO, 4 different contraction patterns were observed: Type 1 (38%), Type 0 (26.3%), Type 2 (25.2%), and Type 3 (8.6%). The remainder (1.9%) used asymmetric contraction. For platysmal bands, 3 different contraction patterns were observed: complete contraction (64.53%), lateral contraction (19.83%), and central contraction pattern (11.73%). A small percentage of patients (3.91%) had an asymmetric contraction pattern., Conclusion: Categorization of contraction of the DAO and platysmal bands into these proposed classifications provides objective measurements that can be helpful for designing treatment protocols and assessing response to treatment.

Generally, the shape of women's eyes are distinctly different in intercatal height from that in men. Ideally, in a woman, the lateral intercostal point is positioned above the medial intercostal point, which gives the eyes a cat-like appearance that culturally suggests youth and health. Because of aging and/or physiological changes, this area can be altered with the inversion of the lateral intercantal line lower than the medial intercantal line, producing a tired and/or sad looking appearance. Hyaluronic acid is a quick and safe method of elevating the lateral intercantal area of the eye. This article describes a technique for using hyaluronic acid for the treatment of scleral show., Competing Interests: FUNDING:No funding was provided. DISCLOSURES:Dr. B. Bravo is a consultant for Allergan. The other authors have no conflicts of interest relevant to the content of this article.

The nose is an essential feature when considering the aesthetic appeal of the face. As aesthetic preferences vary from person to person, the concept of the "ideal" nose must be applied on a case-by-case basis, with respect to the classical patterns of anthropometry, sex, ethnic group, and psychosocial factors. Interest in less invasive procedures for nasal correction has increased considerably, among which is the emerging use of hyaluronic acid for nonsurgical rhinoplasty. In this article, the authors present an objective review of the anatomy of the nasal region, the evaluation and indications of nasal filling with hyaluronic acid, a description of the technique, and brief discussion of associated complications., Competing Interests: FUNDING:No funding was provided for this article. DISCLOSURES:Dr. BSF Bravo reports that he is a speaker for Allergan. The other authors have no conflicts of interest relevant to the content of this article.

Vascular lesions such as hemangiomas can be found in the oral cavity. Some therapeutic modalities can be used in the treatment of these lesions and Nd:YAG 1064 nm long pulse laser shows good results with easy application, fewer complications and satisfactory results. This study describes the technique and outcome of a case of hemangioma located on the tongue treated with Nd:YAG laser.