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Azzalure (Galderma) is a newly approved European botulinum neurotoxin type A (BoNT-A) specifically designed for aesthetic usages. It is sourced from Dysport (Ipsen Ltd.), which has a 20-year product consistency and has been used widely for various therapeutic and aesthetic applications. Azzalure and Dysport are collectively referred to as BoNT-A (Speywood Unit; s.U) (or abobotulinumtoxinA in the U.S.) after their biological activity unit, which is unique and not interchangeable with units of other commercial BoNT-A preparations. Azzalure is approved for the treatment of moderate-to-severe glabellar lines, with a total dose of 50 s.U distributed evenly among 5 injection points. To ensure optimal treatment outcomes with BoNT-A (s.U), it is crucial for injectors to adopt proper methods of reconstitution and injection, which can be acquired through training. We review here the method of reconstitution for BoNT-A (s.U), as well as the injection dose, points and techniques for glabellar line treatment. We also review the efficacy and safety results of BoNT-A (s.U) demonstrated in 11 clinical studies, most of which were randomized, double-blind and placebo-controlled. The studies included assessments after single injections as well as after up to 6 repeated treatment sessions. We summarize the clinical efficacy results, which include the responder rate 1 month post-injection, onset of response and duration of action, as well as safety results, which include incidence of treatment-emergent adverse events and specifically eyelid ptosis. The efficacy and safety profiles reported here are unique to BoNT-A (s.U) and cannot be generalized to other BoNT-A products. [ABSTRACT FROM AUTHOR]

Background: A range of monophasic dermal fillers made of high-molecular-weight hyaluronic acid (HA) chains with reduced cross-linking was developed for aesthetic procedures., Objective: The efficacy, durability, and safety of 2 of these resilient HA (RHA) fillers, and their noninferiority to an effective HA comparator available in the United States, were tested in the treatment of dynamic facial wrinkles., Methods: A 15-month, prospective, multicenter, active-controlled, randomized, double-blinded, split-face clinical trial was carried out on 174 subjects presenting moderate-to-severe bilateral nasolabial folds (NLFs). Assessed parameters included improvement on a proprietary Wrinkle Severity Rating Scale (WSRS) and Global Aesthetic Improvement Scale, according to Blind Live Evaluators, subjects, and treating investigators. Self-perception was evaluated with FACE-Q and satisfaction scales., Results: The per-protocol populations included 67 and 62 subjects of all Fitzpatrick skin-phototypes, in the 2 comparison groups. Significant improvement of mean WSRS scores and associated responder rates established the noninferiority of RHA fillers to their comparator, over 15 months. Aesthetic improvement and subject satisfaction were durably high, with no meaningful differences between the fillers. Treatments were safe and well tolerated., Conclusion: The 2 RHA fillers are at least equivalent to a well-established comparator for the correction of NLF in subjects of diverse skin-phototypes.

Background: Juvéderm Vollure XC (VYC-17.5L; Allergan plc, Dublin, Ireland) belongs to a family of hyaluronic acid gels based on the Vycross technology platform., Objectives: The authors sought to evaluate the safety and effectiveness of Vollure for correction of moderate to severe nasolabial folds (NLFs) over 18 months and after repeat treatment., Methods: In this prospective, randomized study, patients (N = 123) received initial/touch-up treatment with Vollure in 1 NLF and control filler in the contralateral NLF. Patients received optional repeat treatment with Vollure after month 12, 15, or 18. Assessments included investigator-rated NLF Severity Scale responder rates (≥1-point improvement vs baseline), patient-assessed Appraisal of Nasolabial Folds scale of the FACE-Q questionnaire, and patient satisfaction (11-point scale)., Results: Median volume of Vollure injected was 1.7 mL for initial/touch-up treatment combined and 0.6 mL for repeat treatment. The NLF Severity Scale responder rates were 93%, 85%, and 59% at months 6, 9, and 18 after initial/touch-up treatment and increased to 94% at 1 month after repeat treatment. Mean patient-reported FACE-Q scores significantly improved from baseline at all timepoints. Most patients were very satisfied with treatment at all timepoints from day 3 (75%) through month 18 (68%) and at 1 month after repeat treatment (94%). Common injection site responses after initial/touch-up and repeat treatment were firmness, swelling, and tenderness to touch; most were mild/moderate., Conclusions: Vollure was safe and effective for correction of moderate to severe NLFs, with results lasting 18 months in 59% of NLFs. Repeat treatment required one-third of the injection volume to achieve similar improvement in NLF severity as initial/touch-up treatment., (© 2019 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Skin cancers of the periorbital area present unique challenges to Mohs surgeons., Objective: The need for precise and high-quality Mohs micrographic surgery (MMS) is paramount because of the complex anatomy, vital structures, and potential threat to vision., Methods: A thorough comprehension of anatomy is essential to help predict tumor behavior and ensure successful outcomes for patients., Results: Tumors occurring at the medial and lateral canthi are of greatest concern for deeper orbital penetration., Conclusion: In this study, we present our experience with MMS of periorbital tumors, including clinical pearls and techniques to aid the Mohs surgeon.

Background: Juvéderm Vollure XC (VYC-17.5L) belongs to a family of nonanimal hyaluronic acid (HA) gels based on the Vycross technology platform., Objective: To evaluate the safety and effectiveness of VYC-17.5L for correction of moderate to severe nasolabial folds (NLFs) compared with a control HA dermal filler., Methods: In this double-blind study, 123 adults with 2 moderate or severe NLFs as measured on the 5-point photonumeric NLF severity scale (NLFSS) were randomized to VYC-17.5L in 1 NLF and control in the contralateral NLF. The coprimary effectiveness end points at Month 6 were difference in improvement in mean NLFSS score for VYC-17.5L versus control and NLFSS responder rate (≥1-point improvement) for VYC-17.5L., Results: The coprimary effectiveness end points were met. NLFSS scores improved by 1.4 with VYC-17.5L and by 1.3 with control; NLFSS responder rate with VYC-17.5L was 93.2%. More than three-quarters of subjects (82%) treated with VYC-17.5L were very satisfied at Month 6. Investigators reported that VYC-17.5L was smoother and more natural looking and easier to inject and mold than control. VYC-17.5L resulted in significantly fewer severe injection site responses than control., Conclusion: VYC-17.5L was safe and effective for correcting moderate to severe NLFs, with results lasting through 6 months in 93% of subjects.

Background: Hyaluronic acid (HA) dermal fillers are frequently used to correct or smooth facial wrinkles and folds such as nasolabial folds., Objective: To compare the efficacy and safety of 2 HA gels, formulated by 2 different manufacturing processes: XpresHAn Technology (HARRL [with lidocaine]) and Hylacross technology (HAJU-a comparator product without lidocaine)., Patients and Methods: One hundred seventy subjects with bilateral nasolabial folds rated as moderate or severe, according to the Wrinkle Severity Rating Scale (WSRS), received injections of HARRL in the nasolabial folds on one side of the face and HAJU on the other side. Investigator- and subject-assessed wrinkle severity was measured up to 48 weeks after final injection., Results: HARRL exhibited a similar safety and efficacy profile compared with HAJU. Noninferiority of HARRL was demonstrated at 24 weeks (WSRS mean change from baseline mean difference -0.1 [95% confidence interval: -0.15, 0.01], p = .090). Incidence of adverse events was 40% for both treatments., Conclusion: HARRL exhibited a similar safety and efficacy profile compared with HAJU.

Background: Several formulations of Botulinum toxin serotype A (BoNT-A) for aesthetic indications are available, with numbers likely to increase. Preparations are not interchangeable, based on dose unit comparisons., Objective: Numerous myths and misconceptions regarding the use of BoNT-A for aesthetic indications have arisen, which this review aims to lay to rest., Materials and Methods: This review assesses evidence for and against each of the most common myths regarding BoNT use in aesthetics., Results: BoNT-A neurotoxin/protein complexes are irrelevant to the toxin's therapeutic/aesthetic indications. BoNT-A neurotoxin/protein complexes do not influence movement from injection site or immunogenicity. Any relationship between neutralizing antibody formation and clinical response is complex and clinicians should consider other factors that may induce an apparent loss of clinical response. Diffusion appears predominately, perhaps exclusively, dose dependent. Careful placement and correct dosing optimizes likelihood of good outcomes. Manufacturers recommend reconstitution of products with sterile nonpreserved saline. However, compelling evidence suggests that reconstitution using preserved saline dramatically improves patient comfort without compromising efficacy. Several post-treatment instructions/restrictions are widely used despite the lack of evidence, but muscle activity after injection may be beneficial. Cooling the treatment area might hinder BoNT-A translocation and should probably be abandoned., Conclusion: The existing evidence suggests that experienced users should achieve equivalent results regardless of BoNT-A formulation, but additional, well-designed, adequately powered, controlled randomized studies should be performed.

Background: Effacement of horizontal forehead lines (FHL) with onabotulinumtoxinA has not been investigated in prospective Phase 3 studies., Objective: To evaluate safety and efficacy of onabotulinumtoxinA treatment of FHL together with glabellar lines (GL)., Materials and Methods: A 12-month, Phase 3 study randomized subjects with moderate-to-severe FHL and GL to onabotulinumtoxinA 40 U or placebo, distributed between the frontalis (20 U) and glabellar complex (20 U). After Day 180, subjects could receive up to 2 additional open-label onabotulinumtoxinA treatments. Efficacy was assessed using the Facial Wrinkle Scale (FWS) and Facial Line Outcomes questionnaire., Results: The intent-to-treat (ITT) population included 391 subjects, and the modified ITT (mITT) population (subjects with psychological impact) included 254 subjects. After 30 days, onabotulinumtoxinA significantly improved the investigator- and subject-assessed appearance of FHL severity by at least 2 FWS grades in 61.4% of ITT subjects versus 0% of placebo subjects (p < .0001). In the mITT population, 94.8% of onabotulinumtoxinA subjects and 1.7% of placebo subjects achieved investigator- and subject-assessed FWS ratings of none/mild (p = .0003). Patient-reported outcomes were consistent with FWS ratings. OnabotulinumtoxinA was well tolerated., Conclusion: OnabotulinumtoxinA 40 U distributed between the frontalis and glabellar complex was safe and effective for treatment of moderate-to-severe FHL.

This third article of a three-part series addresses techniques and recommendations for aesthetic treatment of the lower face. The lower face is considered an advanced area for facial aesthetic treatment. In this region, soft-tissue fillers play a more important role than neuromodulators and should be used first to provide structure and support before neuromodulators are considered for treatment of dynamic lines. Treatment of the lip, perioral region, and chin, in addition to maintaining balance of the lower face with the face overall, is challenging. Procedures on the lip should avoid overcorrection while respecting the projection of the lips on the profile view and the ratio of lip size to chin. The chin is often neglected, but reshaping the jawline can provide dramatic improvement in facial aesthetics. Both profile and anterior views are critical in assessment and treatment of the lower face. Finally, rejuvenation of the neck region requires fillers for structural support of the chin and jawline and neuromodulators for treatment of the masseter and platysma.

Botulinum toxin (BoNT) has been approved for aesthetic use since 2002. Since then, clinical studies and expert use have informed our understanding of how BoNT exerts its clinical effect and the practical use of this product across a number of aesthetic applications. This review discusses the clinical properties and characteristics of abobotulinumtoxinA, which patients are suitable for its use, and how it can be utilized to treat facial rhytides., (© 2017 The American Society for Aesthetic Plastic Surgery, Inc.)

Introduction: The shape and contour of the chin and neck play an important role in facial esthetics. As such, excess fat within the submental area (double chin) can negatively affect facial esthetics and body image. Common treatments for submental contouring include invasive procedures such as surgical rejuvenation and targeted liposuction. Energy devices (lasers, radiofrequency, and ultrasound) may be used to improve submental skin laxity while cryolipolysis was recently cleared in the United States for use in the submental area. However, ATX-101 (deoxycholic acid injection) is the only injectable drug approved in the United States and Canada for reduction of submental fat., Areas Covered: The efficacy and safety of ATX-101 have been extensively evaluated in a global clinical development program including multiple Phase I/II studies and four large Phase III trials. Available data from ATX-101 trials are reviewed. Expert commentary: Injectables have been well established for facial rejuvenation. Extending injectable treatment into the chin and neck is a major advance for nonsurgical cosmetic correction. Overall, the evidence supports ATX-101 as a safe and effective, minimally invasive treatment alternative for reduction of submental fat that will provide a major tool for the esthetic physician.

Background: Although the safety profile of hyaluronic acid fillers is favorable, adverse reactions can occur. Clinicians and patients can benefit from ongoing guidance on adverse reactions to hyaluronic acid fillers and their management., Methods: A multinational, multidisciplinary group of experts in cosmetic medicine convened the Global Aesthetics Consensus Group to review the properties and clinical uses of Hylacross and Vycross hyaluronic acid products and develop updated consensus recommendations for early and late complications associated with hyaluronic acid fillers., Results: The consensus panel provided specific recommendations focusing on early and late complications of hyaluronic acid fillers and their management. The impact of patient-, product-, and technique-related factors on such reactions was described. Most of these were noted to be mild and transient. Serious adverse events are rare. Early adverse reactions to hyaluronic acid fillers include vascular infarction and compromise; inflammatory reactions; injection-related events; and inappropriate placement of filler material. Among late reactions are nodules, granulomas, and skin discoloration. Most adverse events can be avoided with proper planning and technique. Detailed understanding of facial anatomy, proper patient and product selection, and appropriate technique can further reduce the risks. Should adverse reactions occur, the clinician must be prepared and have tools available for effective treatment., Conclusions: Adverse reactions with hyaluronic acid fillers are uncommon. Clinicians should take steps to further reduce the risk and be prepared to treat any complications that arise.

Background: Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades., Methods: A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes., Results: Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders., Conclusions: The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each., Clinical Question/level of Evidence: Therapeutic, V.

Background: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction., Methods: A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications., Results: Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action., Conclusions: The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age., Clinical Question/level of Evidence: Therapeutic, V.

Background: A polymethylmethacrylate-collagen filler is generally believed to give long-term benefits, but the risk of granuloma formation over time remains unclear., Objective: To determine the incidence of granuloma formation and response to treatment and assess the degree of patient satisfaction over 5 years., Materials and Methods: Adults seeking correction of nasolabial folds underwent up to 3 injection sessions over 2 months. Subjects were then queried regularly for the development of signs and symptoms of a granuloma. Any positive responses were evaluated, and lesions suspicious for granulomas were confirmed by biopsy. Granulomas were treated at the discretion of the investigator. Subjects also completed regular satisfaction questionnaires., Results: A total of 1,008 subjects were enrolled and 871 completed the full 5 years of the study. A biopsy-confirmed granuloma developed in 1.7% of subjects. Almost all granulomas responded to treatment. At study exit, 0.9% of subjects had an unresolved granuloma. Patient satisfaction remained high throughout the duration of the study., Conclusion: The incidence of granuloma formation with a polymethylmethacrylate-collagen dermal filler is low, and almost all lesions are manageable with simple therapeutic measures. Patient satisfaction remains durable over 5 years. Polymethylmethacrylate-collagen offers a well-characterized and very favorable risk/benefit profile.

There are 3 Food and Drug Administration-approved botulinum toxin formulations now being successfully used for treatment in the upper face. The most common areas for botulinum toxin treatment are the upper face, including the glabella, forehead, brows, and lateral canthal lines or crow's feet. The frozen look is no more desired in patients. Thus, physicians are more commonly individualizing dosage based on the patient's variation in anatomy, muscle mass, asymmetry, and, most importantly, desired outcome.

Background: Because abobotulinumtoxinA treatment for glabellar lines must be repeated regularly to prevent recurrence, understanding the safety and effectiveness of long-term, repeated administration of abobotulinumtoxinA is important., Objective: To report the long-term safety and efficacy of abobotulinumtoxinA in patients with moderate to severe glabellar lines., Methods and Materials: AbobotulinumtoxinA was administered to 1,415 patients in multiple cycles over 24 months as a fixed dose of 50 U or as a dose based on muscle mass and sex (women: 50-70 U; men: 60-80 U). Adverse events were assessed after each visit on days 7, 14, and 30 and monthly thereafter; monitoring continued every 3 months for a total safety monitoring duration of 36 months or less., Results: Nine hundred ninety-one (70%) patients reported treatment-emergent adverse effects (TEAEs); most events were mild (70%) or moderate (20%) in severity. The rate of TEAEs did not increase over 24 months of repeated treatment (mean 5.6 cycles; range 1-9). Treatment-related eyelid ptosis followed 53 of 7,938 (0.7%) treatments, all of which resolved spontaneously., Conclusions: Multiple cycles of abobotulinumtoxinA treatment over 24 months were well tolerated and effective for the correction of glabellar lines, with no evidence of cumulative safety problems., (© 2013 by the American Society for Dermatologic Surgery, Inc. Published by Wiley Periodicals, Inc.)

The introduction of botulinum neurotoxin type A (BoNTA) for the treatment of glabellar lines marked a revolution in aesthetic medicine, allowing for noninvasive facial rejuvenation and sculpting. Treatment of the glabellar area requires a thorough understanding of facial anatomy and the interaction of adjacent muscle groups with respect to facial expression. Because the muscles underlying the glabella are among the larger muscles commonly treated with BoNTA, they may require higher doses than other facial sites. In addition, men typically have a greater glabellar muscle mass than women and require larger BoNTA doses. For optimal outcomes, it is necessary to account for individual variation in muscle mass, anatomy, and function to determine the proper dose, number, and location of injections. The validated Medicis Glabellar Muscle Mass Scale was developed to facilitate research on dose adjustment for muscle mass in the glabella and can be applied as a clinical tool. This review will discuss techniques for optimizing BoNTA treatment of the glabella, with emphasis on the need to assess muscle mass in individual patients and adjust BoNTA dosing and technique accordingly.

In this roundtable discussion, the physicochemical properties and potential clinical applications of two new ranges of hyaluronic acid fillers are reviewed. These fillers display enhanced tissue integration after implantation due to novel manufacturing processes, and one of the ranges is customized for specific clinical applications by variation of filler gel calibration and cross-linking.

Background: A new botulinum neurotoxin type A formulation, abobotulinumtoxinA (BoNTA-ABO; Medicis Aesthetics Inc., Scottsdale, AZ), was approved in 2009 in the United States for treatment of moderate to severe glabellar lines in adults younger than 65. OBJECTIVE To determine onset of response based on participant assessments recorded from days 1 through 7., Materials & Methods: Time to onset was assessed as a secondary endpoint in four multicenter, double-blind, placebo-controlled, randomized phase 3 trials evaluating BoNTA-ABO efficacy. Participants received 50 to 80 U of BoNTA-ABO (n=1,160) or placebo (n=580) at five injection sites in the glabellar region. Participants self-evaluated and recorded first effects., Results: Response on day 1 was 13.4% to 32.5% in participants receiving BoNTA-ABO and 3% to 7% in those receiving placebo. Integrated analysis of three studies showed that 19.7% of participants responded by day 1; median onset was 3 days for BoNTA-ABO and 15 days for placebo. Men responded less frequently in fixed-treatment studies than in the study in which doses were adjusted for muscle mass., Conclusions: Treatment with BoNTA-ABO demonstrates significantly greater reduction in glabellar lines than placebo. Improvement was seen as early as 24 hours, with median time to onset of 2 to 4 days., (© 2011 by the American Society for Dermatologic Surgery, Inc.)

Objective: To demonstrate the safety and effectiveness of MelaFind, a noninvasive and objective computer-vision system designed to aid in detection of early pigmented cutaneous melanoma., Design: A prospective, multicenter, blinded study. The diagnostic performance of MelaFind and of study clinicians was evaluated using the histologic reference standard. Standard images and patient information for a subset of 50 randomly selected lesions (25 melanomas) were used in a reader study of 39 independent dermatologists to estimate clinicians' biopsy sensitivity to melanoma., Setting: Three academic and 4 community practices in the United States with expertise in management of pigmented skin lesions., Patients: A total of 1383 patients with 1831 lesions enrolled from January 2007 to July 2008; 1632 lesions (including 127 melanomas-45% in situ-with median Breslow thickness of invasive lesions, 0.36 mm) were eligible and evaluable for the study end points., Main Outcome Measures: Sensitivity of MelaFind; specificities and biopsy ratios for MelaFind and the study investigators; and biopsy sensitivities of independent dermatologists in the reader study., Results: The measured sensitivity of MelaFind was 98.4% (125 of 127 melanomas) with a 95% lower confidence bound at 95.6% and a biopsy ratio of 10.8:1; the average biopsy sensitivity of dermatologists was 78% in the reader study. Including borderline lesions (high-grade dysplastic nevi, atypical melanocytic proliferations, or hyperplasias), MelaFind's sensitivity was 98.3% (172 of 175), with a biopsy ratio of 7.6:1. On lesions biopsied mostly to rule out melanoma, MelaFind's average specificity (9.9%) was superior to that of clinicians (3.7%) (P=.02)., Conclusion: MelaFind is a safe and effective tool to assist in the evaluation of pigmented skin lesions., Trial Registration: clinicaltrials.gov Identifier: NCT00434057., (©2011 American Medical Association. All rights reserved.)

Background: Repeat treatments of nonpermanent dermal fillers are used in the long-term treatment of wrinkles and folds and to volumize. OBJECTIVE To determine the safety and effectiveness of a nonanimal-sourced hyaluronic acid (HA) (which uses a cohesive polydensified matrix (CPM) technology [CPMHA]) for the treatment of nasolabial folds (NLFs) during an 18-month open-label extension trial., Methods and Materials: Ninety-five of 118 subjects continued with this optional open-label extension of a split-face, double-blind trial. All subjects received CPMHA in both NLFs at 24 weeks after treatment in this study and were assessed at weeks 32, 48, 72, and 96. Touch-ups were allowed for optimal correction. Safety was assessed according to reported adverse events (AEs) and serum antibody measurement., Results: At all four post-week 24 time points, the severity of the NLFs showed a decrease from baseline on the Wrinkle Severity Rating Scale. The effects persisted in the majority (∼80%) of subjects without repeat treatment for at least one interval of 48 weeks. The study filler was well tolerated, with only one related AE (injection site bruising) reported. Little potential for immunogenic reactions was identified., Conclusion: This CPMHA is a well-tolerated and effective treatment for at least 48 weeks in the majority of subjects for the correction of moderate to severe NLFs with repeat injections given over an 18-month period., (© 2010 by the American Society for Dermatologic Surgery, Inc.)

Objective: To evaluate the safety and efficacy of a 2.5% polyacrylamide hydrogel in the aesthetic enhancement of nasolabial folds., Methods and Materials: The safety and efficacy of a polyacrylamide hydrogel were compared with those of nonanimal stabilized hyaluronic acid (NASHA) in 315 subjects in a double-blind, randomized, multicenter, noninferiority trial with a 12-month follow-up. The primary efficacy end point was mean change in Wrinkle Assessment Scale (WAS) scores at 6 months. The primary safety end point was rate of serious adverse events (AEs) through 12 months after treatment., Results: Polyacrylamide hydrogel was as effective as NASHA, and effectiveness persisted throughout the 12-month follow-up. Treatment-related AEs occurred with equal incidence; most were mild to moderate, transient, and related to injection procedure. One serious AE (infection) was thought to be related to treatment with polyacrylamide hydrogel; it resolved within 5 days after appropriate treatment., Conclusion: This 2.5% polyacrylamide hydrogel offers promise as a long-lasting soft tissue filler. It is well tolerated, as effective as NASHA in correction of nasolabial folds, and persistent. Longer evaluation is required to evaluate longer-term safety and demonstrate duration of effect beyond 12 months. This, (© 2010 by the American Society for Dermatologic Surgery, Inc.)

Injection of botulinum toxin type A (BoNTA) is the most common nonsurgical aesthetic procedure undertaken in the United States (U.S.). A new formulation of BoNTA (abobotulinumtoxinA, Dysport™) has recently been approved in the U.S. for the treatment of glabellar lines. This product has been used for facial aesthetics in other parts of the world for more than 15 years, whereas in the U.S. a different formulation (onabotulinumtoxinA, Botox® Cosmetic) has been used for many years. The various formulations of neurotoxins are unique and are not interchangeable nor are doses convertible from one product to another, so it is important that recommendations be developed to assist U.S. clinicians in understanding the differences between the two available formulations of BoNTA, which should ensure successful outcomes with these products. A group of worldwide experts on the aesthetic use of BoNTA convened in February 2009 in New York, NY, to review the use of BoNTA and to develop consensus recommendations for the use of the new formulation, since such guidelines previously had only been published in German. This publication summarizes key discussions from the meeting as well as recommendations and suggestions regarding the use of abobotulinumtoxinA in the areas of the face most commonly treated with BoNTA.

Objective: To evaluate the long-term safety of repeated administrations of a new botulinum toxin type A (Reloxin; Medicis Pharmaceutical Corp, Scottsdale, Arizona) in the treatment of moderate to severe glabellar lines., Methods: Open-label assessment of 1200 patients receiving as many as 5 treatments of Reloxin over a 13-month period. The product was diluted in 2.5-mL sterile physiologic saline solution, 0.9%, without preservative to a concentration of 50 U of Reloxin per 0.25 mL of solution. Investigators injected 0.05 mL of the solution (10 U each) into each of 5 injection sites in the glabellar area on day 0 of each treatment cycle. There was a minimum 85-day gap between treatments. Postinjection clinical evaluation was performed on days 14 and 30 and monthly thereafter until retreatment, study completion, or early termination. The patients were telephoned on day 7 to check for adverse events (AEs) and concomitant medications, and patient diaries were used to document the onset of treatment effect., Results: The majority (72%) of treatment-emergent AEs were considered unlikely or not related to study treatment. Probably or possibly related treatment-emergent AEs occurred in 36% of patients. The most frequently occurring related AEs were injection site disorders (18%), nervous system disorders (14% and 12% headache), and eye disorders (9%). Related AEs around the injection site or eyes were usually reported by day 7 and then resolved. Reported ptosis does not differentiate between brow ptosis and eyelid ptosis. A total of 45 patients had a total of 55 instances of ptosis across all cycles, with most episodes lasting less than 3 weeks. The rates of ptosis decreased during successive cycles from 2.4% in cycle 1 to 0.6% in cycle 5. The proportion of patients reporting an onset of response by day 7 ranged from 93% to 95%. By investigator assessment, the response rate (patients reporting none or mild glabellar line severity scale scores on day 30) ranged from 80% to 91% during cycles 1 to 5., Conclusions: There was no evidence of cumulative AEs or tachyphylaxis with multiple Reloxin treatments over a period of 13 months. The treatments were well tolerated. The rates of ptosis decreased over successive cycles, and the proportion of responders by day 7 ranged from 93% to 95%.

Background: Botulinum toxin is used to treat glabellar lines, but the optimal dose of Reloxin (Dysport, Ipsen Biopharm Ltd.) for this indication remains to be established., Objective: The objective was to evaluate three doses of Reloxin to determine its efficacy and safety in treating glabellar lines., Methods and Materials: Participants were given 20, 50, or 75 U of Reloxin, or placebo, injected across the glabella. Follow-up was on Days 7, 30, 60, 90, and 120. Adverse events were also elicited by telephone on Day 3., Results: From investigators' and participants' assessments at Day 30, there were significantly more responders in each Reloxin-treated group than placebo (p< or = 0.001). The 50-U dose was as effective as the 75-U dose, with a similar duration. The most common adverse events were mild headache and nasopharyngitis, occurring similarly in all groups., Conclusions: Reloxin (Dysport/botulinum toxin type A) treatment resulted in a significant improvement in glabellar lines, and the 50-U dose was identified as optimal. All doses were well tolerated.

Background: The methods described to achieve intraoperative tissue expansion have drawbacks., Objective: To report an intraoperative tissue expansion technique using standard suture material and hemostats to create a "modified" winch stitch., Methods: A continuous running suture is placed with both ends left free. A "fixed" hemostat is placed above the skin at one end. After pulling at the other end with a second hemostat, a third hemostat is placed proximal to this hemostat just above the skin, which is left in place to produce stretching. The second and third hemostats are then used in an alternating pulling and holding fashion., Results: This method produces significant tissue expansion. If the desired degree of approximation is achieved, the ends of the suture can be tied together, as in the previously described winch stitch., Conclusion: The modified winch stitch is a simple and inexpensive means to facilitate closure of wounds under a significant amount of tension.

Chemical peeling remains a valuable tool for the cosmetic surgeon to treat photoaging skin. Choices available include superficial, medium, and deep chemical peeling agents along with preparatory cosmoceutical agents to prep the skin and maintain rejuvenation. This article will prepare the cosmetic surgeon to include the latest agents in his practice and correctly choose which treatment is best for patients with individual problems of photoaging of the face and body, acne scars, and pigmentary problems. These modalities will be compared with other treatment modalities, such as laser and dermabrasion.

The combination medium-depth chemical peel (Jessner's solution +35% TCA) has been accepted as a safe, reliable, and effective method for the treatment of moderate photoaging skin. This article discusses the procedure in detail, including postoperative considerations.

For many decades, chemical peeling has played an important role in facial rejuvenation. These procedures are safe and effective in the management of photoaging, scarring, pigmentary dyschromias, and in the destruction of superficial skin lesions. Chemical peels are classified into superficial, medium, and deep according to their level of injury to the skin. It is the responsibility of the surgeon to assist the patient in choosing the resurfacing procedure that will most effectively satisfy his or her goals while maintaining a high margin of safety. With the current availability of various microdermabrasion and laser systems for facial rejuvenation, chemical peeling continues to be an integral part of a facial rejuvenation program because of its popularity with patients and minimal costs to the physician.

Background: As the number and methods of skin resurfacing procedures are increasing, there is a small number of patients that develop a prolonged inflammation during the postoperative period., Objective: We attempted to correlate risk factors for the development of prolonged postpeel erythema (PPPE) and inflammation. A treatment regimen will be described to eliminate permanent skin changes., Methods: A retrospective chart review is presented to define and correlate risk factors for the development of PPPE and a treatment protocol is described. The setting is a large multisurgeon aesthetic center. Two-hundred and thirty-six consecutive chemical phenol peels on 196 patients over a 2-year period were reviewed., Results: Eleven percent of patients developed PPPE. Allergy to tape was the only factor significantly correlated with PPPE. All patients had complete resolution of skin changes with appropriate treatment., Conclusion: A small population of patients undergoing skin resurfacing procedures will develop prolonged erythema. No major risk factor could be correlated with its development. A treatment plan was devised and was successful in all cases.

The Jessner's + TCA peel is an enhanced medium-depth peel that is a combination of two acidic compounds. It has been found to be effective as a peeling procedure for moderately photoaging skin, actinic keratoses, and superficial acne scars.

The Jessner's-trichloroacetic acid (TCA) peel is a procedure developed by Monheit to produce a safe, effective medium-depth chemical peel for the treatment of photoaged skin, actinic keratoses, and superficial acne scars. The technique of pretreatment degreasing and combination chemicals allow a deeper penetration for the 35% TCA, increasing its efficacy while preserving its safety. Technique and methods are reviewed.

An approach to head and neck skin lesions is presented as an alternative to excisional surgery. Dermaplaning, curettage, electrodesiccation, cryosurgery, and chemosurgery are presented as alternative approaches to the eradication of selective skin lesions.