Differentiate between different types of Radiation Therapy used to treat NMSC

Recognize the side effectives of different types or Radiation Therapy

Identify the types of complications that can occur with fillers for soft-tissue augmentation

Incorporate treatment regimens for dermal filler complications

2023 Virtual Grand Rounds Session 4: March 22, 2023 - SRT to Treat NMSC, Treating Filler Complications

Aesthetics

TUESDAY, Nov. 12, 2024 (HealthDay News) -- Topical human platelet extract (HPE) performs as well as topical vitamin C for skin rejuvenation of dorsal hands, according to a study published in the November issue of Plastic and Reconstructive Surgery.Saranya Wyles, M.D., Ph.D., from THE Mayo Clinic in Rochester, Minnesota, and colleagues conducted a prospective, longitudinal study to compare the effectiveness of topical HPE (plated) intense serum (Rion Aesthetics) with vitamin C (C E Ferulic with 15 percent L-ascorbic acid) for skin rejuvenation of dorsal hands after 12 to 26 weeks of twice-daily use. Common skin concerns related to aging were assessed with evaluations at baseline and six, 12, and 26 weeks.The researchers found that at 12 weeks after twice-daily use, topical HPE was noninferior to topical vitamin C for improvement in brown spot fractional areas, wrinkle fractional area, and improvement in luminosity."HPE performed as well as vitamin C to rejuvenate the skin on the dorsal hands. Both topical serums could serve as an adjuvant or preprocedure primer to invasive procedures, such as intense pulsed light, in reducing brown spots," the authors write. "Additional randomized controlled studies should be conducted to determine whether a synergistic relationship exists between topical vitamin C and HPE, if used in combination."Several authors disclosed ties to Rion Aesthetics, which funded the study.<a target="_blank" rel="noopener noreferrer" href="https://journals.lww.com/plasreconsurg/fulltext/2024/11000/a_comparative_study_of_two_topical_treatments_for.11.aspx">Abstract/Full Text</a>

HPE performs as well as topical vitamin C for improvement in brown spot fractional area, wrinkle fractional area, luminosity

Topical Human Platelet Extract Noninferior for Photoaging of Hands

WEDNESDAY, Aug. 21, 2024 (HealthDay News) -- A beverage containing collagen peptides (CP), including tripeptides and elastin peptides (EP), is beneficial for the skin health of young and middle-aged women, according to a study published in the June issue of the Journal of Dermatologic Science and Cosmetic Technology.Shan Lu, from the Shenzhen Porshealth Bioengineering Co. in China, and colleagues examined the effects of an orally administered collagen drink combining CP and EP on the skin health of young and middle-aged women in a single-center randomized trial. Participants consumed the WONDERLAB® fish collagen tripeptide beverage over an eight-week period.The researchers found that the collagen drink group showed significant improvement in skin hydration (39.19 percent increase) and reduced transepidermal water loss (33.45 percent decrease) compared to the placebo group; there were also increases in skin elasticity, dermal collagen content, and skin smoothness (25.37, 21.64, and 2.85 percent increases, respectively), and decreases in pore size, wrinkle length, and skin roughness (7.94, 18.09, and 15.32 percent decreases, respectively). There was a 60 percent decrease in pore volume; visual assessments indicated 15.20 and 22.55 percent decreases in skin luminosity and smoothness index, respectively. A significant increase in collage efficacy components, including blood pH and glycine-proline-hydroxyproline levels, was seen in mass spectrometry.The beverage product "effectively improved skin hydration, elasticity and firmness, enhanced radiance and smoothness, reduced transepidermal water loss and wrinkles, minimized pores and roughness, and increased collagen content in the dermal layer and collagen efficacy components in the body," the authors write.Several authors were employed by Shenzhen Porshealth Bioengineering Co.; one author was employed by Sprim (China) Consulting Co.<a target="_blank" rel="noopener noreferrer" href="https://www.sciencedirect.com/science/article/pii/S2950306X24000177?via%3Dihub">Abstract/Full Text</a>

Significant improvements seen in skin hydration, visual radiance and smoothness, and reduction in transepidermal water loss

Collagen Peptide Beverage Beneficial for Skin Health in Young Women

THURSDAY, Aug. 1, 2024 (HealthDay News) -- The U.S. Food and Drug Administration is warning that chemical peels should not be used without the supervision of a dermatologist or other trained professional."FDA is warning consumers not to purchase or use certain chemical peel skin products without appropriate professional supervision due to risk of serious skin injuries," the agency said in a news release issued this week.A dermatologist or licensed and trained practitioner should always be on hand when a peel is being applied. The FDA reminded consumers that it has never approved a chemical peel, and some contain levels of acid so high that they can cause chemical burns.Nevertheless, many of these products "are sold in beauty product stores and online and marketed for purposes such as acne, discoloration, wrinkles, and collagen production," the agency noted. "They contain ingredients such as trichloroacetic acid (TCA), glycolic acid, salicylic acid, and lactic acid in varying concentrations that are too high to be used safely at home without supervision."Just how dangerous an unsupervised chemical peel might be depends on how concentrated an acid is used and the number of applications and length of time each is applied."These products remove layers of skin to varying depths and may cause severe chemical burns, pain, swelling, infection, skin color changes, and disfiguring scars," the FDA warned. "These injuries may even require emergency care or specialty care from a dermatologist or surgeon."The FDA has highlighted six different products and has issued warning letters to their respective makers about selling the peels.<a target="_blank" rel="noopener noreferrer" href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-warns-against-purchasing-or-using-chemical-peel-skin-products-without-professional-supervision">More Information</a>

People who are buying and using at-home chemical peels are ending up burned and scarred

FDA Warns Against Using Chemical Peels Without Professional Supervision

FRIDAY, July 12, 2024 (HealthDay News) -- Seven patients with illness identified after presumed cosmetic botulinum neurotoxin (BoNT) product injection are described in a case report published in the July 11 issue of the U.S. Centers for Disease Control and Prevention Morbidity and Mortality Weekly Report.Christine M. Thomas, D.O., from the CDC in Atlanta, and colleagues characterized illnesses identified after presumed cosmetic BoNT injections and examined implicated BoNT products.The New York City Department of Health and Mental Hygiene identified three patients and the Tennessee Department of Health identified four patients (one a Kentucky resident) with illnesses after presumed cosmetic BoNT injections. The researchers found that all patients were women, aged 26 to 55 years. Ptosis, dry mouth, dysphagia, shortness of breath, and weakness were reported signs and symptoms. Health care was sought by all patients; four were hospitalized and two underwent intensive care unit monitoring. Intubation was not required by any of the patients. Botulinum antitoxin was not required for any of the patients. All patients reported receipt of BoNT injections in nonmedical settings a median of three days prior to onset of symptoms. The three Tennessee residents and Kentucky resident received injections in a nonmedical residential setting; the BoNT product was counterfeit, and the person who administered the injections was not licensed. The three New York City residents received injections in separate nonmedical settings; administration was confirmed to be by an unlicensed person for one resident and suspected for two."Health care providers should ask patients with symptoms of botulism about recent BoNT injections and, if botulism is suspected, immediately contact their local or state health departments," the authors write.<a target="_blank" rel="noopener noreferrer" href="https://www.cdc.gov/mmwr/volumes/73/wr/mm7327a3.htm?s_cid=mm7327a3_w">Abstract/Full Text</a>

Four of the cases, identified in Tennessee, received counterfeit botulinum neurotoxin, administered by unlicensed individual

CDC Reports Seven Cases of Illness After Possible Counterfeit Botox Injections

TUESDAY, April 16, 2024 (HealthDay News) -- Counterfeit or mishandled Botox shots have triggered harmful reactions in 19 people in nine states, U.S. health officials warned Monday.In its <a target="_blank" rel="noopener noreferrer" href="https://www.cdc.gov/botulism/outbreaks/harmful-reactions-botox-injections.html">alert</a>, the U.S. Centers for Disease Control and Prevention said nine people had been hospitalized and four were treated with an antitoxin because of concerns that the botulinum toxin had spread beyond the injection site.The reactions occurred in Colorado, Florida, Illinois, Kentucky, Nebraska, New Jersey, New York, Tennessee and Washington.All 19 patients were female and ranged in age from 25 to 59, the CDC said. All but one received the injection for cosmetic purposes.How can women protect themselves when seeking Botox shots?The CDC advises asking clinics or spas if they are licensed and trained to give the injections. It also suggests asking if the product is FDA-approved and obtained from a reliable source. If in doubt, don't get the shots.<a target="_blank" rel="noopener noreferrer" href="https://www.drugs.com/history/botox.html">Botox</a>, which is often used to treat facial wrinkles but has been approved for a myriad of medical uses, uses a purified form of a neurotoxin called botulinum toxin that paralyzes muscles. When the same toxin is found in food, it can lead to widespread paralysis and even death, the CDC noted.Botulism is a rare but serious illness caused by toxins released by bacteria that attack the nervous system. Symptoms can include blurry or double vision, droopy eyelids, difficulty breathing, fatigue, slurred speech or hoarse voice. Muscle paralysis may progress if left untreated and can be fatal, the CDC says.The Clostridium botulinum bacteria is an ingredient in Botox and similar cosmetic substances. The purified form is approved by the U.S. Food and Drug Administration for use as a cosmetic treatment.More informationThe Illinois Department of Health has more on <a target="_blank" rel="noopener noreferrer" href="https://dph.illinois.gov/topics-services/emergency-preparedness-response/public-health-care-system-preparedness/botulism.html">botulism</a>.SOURCE: U.S. Centers for Disease Control and Prevention, news release, April 16, 2024

CDC Warns of 19 Cases of Botched Botox Shots in 9 States

FRIDAY, March 29, 2024 (HealthDay News) -- Some pain-relieving skin products contain potentially harmful doses of the numbing agent lidocaine and should be avoided, the U.S. Food and Drug Administration warns.These creams, gels, sprays and soaps are marketed for topical use to relieve the pain of cosmetic procedures like microdermabrasion, laser hair removal, tattooing and piercing, the FDA said.The agency has issued warning letters to six companies that are marketing products containing concentrations of lidocaine heavy enough to harm people, particularly after cosmetic procedures that could cause the cream to be absorbed more readily through the skin.Products containing lidocaine over 4% can contribute to health problems like an irregular heartbeat, seizures and breathing difficulties, the FDA explained. They also can interact with other medications or supplements a person is taking.“These products pose unacceptable risks to consumers and should not be on the market,” <a target="_blank" rel="noopener noreferrer" href="https://www.fda.gov/about-fda/center-drug-evaluation-and-research-cder/jill-furman">Jill Furman</a>, director of the Office of Compliance in the FDA’s Center for Drug Evaluation and Research, said in an agency news release. “We are committed to using all available tools to stop the sale of these illegal high-risk products.”The companies and products covered by the warning letters include:<ul><li>TKTX Company: TKTX Numb Maximum Strength Pain Reliever, Mithra+ 10% Lidocaine, TKTX During Procedure Numbing Gel 40% and J-CAIN cream [LIDOCAINE] 29.9%</li><li>SeeNext Venture, Ltd.: NumbSkin 5% Lidocaine Numbing Cream (15 grams), NumbSkin 5% Lidocaine Numbing Cream (30 grams) and NumbSkin 10.56% Lidocaine Numbing Cream</li><li>Tattoo Numbing Cream Co.: Signature Tattoo Numbing Cream and Miracle Numb Spray</li><li>Sky Bank Media, LLC, doing business as Painless Tattoo Co.: Painless Tattoo Numbing Cream and Painless Tattoo Numbing Spray</li><li>Dermal Source, Inc.: New &amp; Improved Blue Gel, Superior Super Juice, Premium Pro Plus, Five-Star Vasocaine and Maximum Zone 1</li><li>Indelicare, doing business as INKEEZE: Ink Eeze Original B Numb Numbing Gel, Ink Eeze B Numb Numbing Spray Black Label and Ink Eeze B Numb Numbing Foam Soap</li></ul>The FDA is particularly concerned if these products are applied over large areas of skin for prolonged periods of time, especially if the skin is irritated or broken.Consumers also should not wrap skin treated with any over-the-counter pain relief products with plastic wrap or other dressings, which can increase the risk of side effects, the FDA said.More informationThe Mayo Clinic has more on <a target="_blank" rel="noopener noreferrer" href="https://www.mayoclinic.org/drugs-supplements/lidocaine-topical-application-route/side-effects/drg-20072776">topical lidocaine</a>.SOURCE: U.S. Food and Drug Administration, news release, March 26, 2024

High-Strength Lidocaine Skin Creams Can Cause Seizures, Heart Trouble, FDA Warns

WEDNESDAY, May 17, 2023 -- Art Filler Volume (AFV), a hyaluronic acid-based filler formulated with a unique combination of three sizes of hyaluronic acid chains, produces midface volume restoration, which persists in some individuals for 540 days, according to a study published online May 2 in the Journal of Cosmetic Dermatology.Philippe Kestemont, M.D., from the MEDITI Center in Juan-les-pins, France, and colleagues conducted an open-label study to examine AFV efficacy and safety over 18 months when used to restore midface volume. A maximum of 1.8 mL AFV was injected into each cheek area on day 0. Individuals were assessed on day 21, when a retouch could be performed if necessary. Participants were followed up at seven visits through day 540.The researchers found that 25 of the 79 Caucasians enrolled required a second injection. There was a significant improvement observed in mean overall Medicis Midface Volume Scale (MMVS) scores from day 0 to day 21 and day 42 (3.2 ± 0.4 to 1.8 ± 0.6 and 1.7 ± 0.6) in the intention-to-treat population. For each cheek, there was also significant improvement in MMVS scores, regardless of retouch on day 21; persistent benefit on day 540 was seen for 22 percent of injections without retouch. Pain on palpitation, erythema, and edema were the most common adverse events (19, 15, and 13 percent, respectively); most events were mild or moderate and resolved within two weeks."AFV shows a sustained objective and subjective benefit that persists in some subjects for at least 18 months, often without retouching," the authors write. "The sustained improvement was consistent in both cheeks, and across multiple assessment methods, suggesting the findings are robust and clinically meaningful."Two authors are employees of Laboratories FILLMED, which supported the study.

Benefit persists for 540 days in some individuals, even without retouch

Hyaluronic Acid-Based Filler Produces Midface Volume Restoration

For mild-to-moderate thigh cellulite, collagenase clostridium histolyticum-aaes (CCH-aaes) is effective and generally well tolerated, according to a study published in the January issue of the
 
 Journal of Cosmetic Dermatology
 
 .




 John H. Joseph, M.D., a plastic surgeon in private practice in Encino, California, and colleagues analyzed data from a phase 3, open-label study involving women with mild-to-moderate cellulite on both thighs. Participants received ≤0.84 mg CCH-aaes subcutaneously in up to 12 dimples per posterolateral thigh in up to three treatment sessions on days 1, 22, and 43. The interim analysis included follow-up on day 90 for 22 women (44 thighs).




 The researchers found that the percentage of responders (score of "improved" or better on the Investigator Global Aesthetic Improvement Scale) at day 90 was 86.4 percent for either thigh and 72.7 percent for both thighs. At day 90, there was a reduction noted in patient-reported bother due to cellulite (mean change, 15.3 points [85.5 percent reduction] in the BODY-Q Appraisal of Cellulite Scale total score). In some of the treated thigh areas, there was improvement from baseline in skin roughness seen on day 90 three-dimensional image scans. Injection-site bruising and pain were the most commonly reported adverse events.




 "These data support that CCH-aaes treatment is effective, markedly reduces cellulite-related bother, and is generally well tolerated for the treatment of mild-to-moderate thigh cellulite," the authors write.




 Several authors disclosed financial ties to Endo Pharmaceuticals, which manufactures CCH-aaes and funded the study.




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CCH-aaes found to be effective and well tolerated for thigh cellulite, with reduction seen in patient-reported bother due to cellulite

Is Collagenase Clostridium Histolyticum-aaes Effective for Thigh Cellulite?

Duplex ultrasonography (DUS) can be used to detect hyaluronic acid (HA) filler-causing intra-arterial obstruction, according to a study published in the January issue of the
 
 Journal of the American Academy of Dermatology
 
 .




 Noting that complications, including serious vascular events, occur with use of HA filler treatments, Leonie W. Schelke, M.D., from the Erasmus Medical Center in Rotterdam, Netherlands, and colleagues aimed to improve treatment outcomes after a vascular adverse event. Twenty-one patients, aged 18 years or older, were enrolled from July 2018 through May 2019. All patients underwent physical and DUS examination of the affected area on arrival at an outpatient clinic. The treating physician attempted to inject 35 to 50 units of hyaluronidase into the obstructing intravascular bolus of filler under ultrasonographic guidance.




 The researchers found that all 21 patients with a vascular adverse event due to HA fillers were treated with hyaluronidase injections that were guided ultrasonographically. After injection of hyaluronidase into the deposits responsible for the occlusion, blood flow was immediately restored. After restoration of blood flow, clinical improvement of the livedo reticularis aspect of the skin was noted. A second treatment session was performed within 24 hours of the initial treatment in seven patients.




 "The use of DUS for facial arterial mapping, safe deployment of HA, and directed low-dose hyaluronidase reversal of impending intravascular adverse events is a welcome technological advancement," the authors write.




 <a class="rm-stats-tracked" href="https://www.jaad.org/article/S0190-9622(19)32392-8/fulltext" target="_blank">
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Blood flow can be immediately restored following ultrasonographically guided hyaluronidase injections into deposits responsible for the occlusion

Can Duplex US Help to Reverse HA Filler-Causing Intra-Arterial Obstruction?

A single well-healed facial scar does not negatively affect first impressions of attractiveness, confidence, or friendliness, but specific scar location and orientation may result in lower perceived attractiveness, according to a study published in the December issue of
 
 Plastic and Reconstructive Surgery
 
 .




 Zachary D. Zapatero, M.D., from the Children's Hospital of Philadelphia, and colleagues recruited adult volunteers to complete a face rating scale to examine how facial scars are perceived. For each face, scars were added digitally in different locations and orientations for a total of 14 unique scars. Fifty different faces were rated on confidence, friendliness, and attractiveness by each participant.




 A total of 88,850 ratings (93.4 percent scarred) were analyzed for attractiveness, friendliness, and confidence. The researchers found that the presence of a facial scar did not significantly impact attractiveness in a univariate linear mixed effects model. Interactions between location, subunit placement, and orientation to facial tension lines were examined in a second set of linear mixed effects models. Scars that were located on the lower lid mid subunit perpendicular to facial tension lines were rated as less attractive.




 "Contrary to our predictions, we found that a single well-healed scar generally does not affect individuals' first impressions of perceived attractiveness or confidence negatively and may even increase perceived friendliness," a coauthor said in a statement.




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However, scar located on lower lid mid subunit perpendicular to facial tension lines was rated as less attractive

Facial Scars Do Not Affect Perceived Attractiveness, Confidence

Hyaluronic acid lip filler products differ in terms of outcomes, but no product is superior in all outcome categories, according to a research letter published online Nov. 9 in the
 
 Journal of the American Academy of Dermatology
 
 .




 Serge A. Steenen, M.D., from the University of Amsterdam, and colleagues conducted a multicenter randomized clinical trial involving 143 women who requested lip augmentation. Participants were randomly assigned to receive Juvéderm Ultra 3, Belotero Intense, Restylane Kysse, or Stylage M brands in a 1:1:1:1 ratio. Outcomes were assessed at baseline, day 14, and follow-up (week 13).




 The researchers found that from baseline to follow-up, there was an overall increase in lip height ( 18.9 percent), with more of an increase for Stylage than Juvéderm ( 26.3 versus 10.9 percent). From baseline to follow-up, appearance appraisal increased overall ( 40.7 percent), with more of an increase for Juvéderm than Belotero ( 50.7 versus 29.8 percent). There were no serious adverse events reported. From baseline to follow-up, increases were seen in social function ( 9.8 percent) and psychological well-being ( 8.7 percent) scores. A greater increase in social function was seen with Stylage than Belotero ( 11.0 versus 6.3 percent). Lip height increased from baseline to day 14 checkup ( 34.4 percent), with more of an increase for Belotero than Juvéderm and Stylage ( 41.3 percent versus 27.7 and 31.1 percent, respectively). Higher side effect scores were seen for Juvéderm than Stylage.




 "Statistically significant but clinically arguably relevant superiority was found with regard to duration, patient satisfaction, and quality of life," the authors write. "No product was superior in all categories."




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 Abstract/Full Text (subscription or payment may be required)
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No one product is superior for all categories; more of an increase seen in lip heig

How Do Lip Filler Products Differ in Terms of Outcomes?

Hyaluronic acid fillers with mepivacaine or lidocaine are equally effective for pain reduction during treatment, according to a study published in the October issue of
 
 Dermatologic Surgery
 
 .




 Noting that hyaluronic acid fillers incorporating lidocaine are usually used to maximize patient comfort during hyaluronic acid gel injection, Joely Kaufman-Janette, M.D., from the Skin Research Institute LLC in Coral Gables, Florida, and colleagues conducted two randomized, split-face trials to demonstrate the noninferiority of specific hyaluronic acid fillers incorporating mepivacaine (RHA-M) versus their lidocaine controls for pain relief. In each trial, 30 patients received injections of RHA
 
 R
 
 -M versus RHA
 
 R
 
 and RHA4-M versus RHA4 in the perioral rhytids (PR) and nasolabial folds (NLF).




 The researchers found that for reducing pain, RHA-M fillers were as effective as their lidocaine counterparts. In both the PR and NLF trials, bilateral wrinkle improvement was measured at one month; responder rates were virtually identical (≥96.7 percent). Between treated sides, the common treatment responses and adverse events were similar; none was clinically significant.




 "Regardless of the anesthetic agent, RHA
 
 R
 
 and RHA4 showed an excellent effectiveness and safety profile for the treatment of dynamic wrinkles and folds as per their respective indications while ensuring patient comfort and minimal injection pain," the authors write.




 Several authors disclosed financial ties to TEOXANE, which provided materials and funding for the study.




 <a class="rm-stats-tracked" href="https://journals.lww.com/dermatologicsurgery/pages/articleviewer.aspx?year=2022&amp;issue=10000&amp;article=00010&amp;type=Fulltext" target="_blank">
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Mepivacaine found to be noninferior versus lidocaine for pain relief and bilateral wrinkle improvement

Are Hyaluronic Acid Fillers With Mepivacaine, Lidocaine Equally Effective?

People wanting to keep wrinkles at bay will soon have a new option now that the U.S. Food and Drug Administration has
 <a class="rm-stats-tracked" href="https://www.fda.gov/drugs/new-drugs-fda-cders-new-molecular-entities-and-new-therapeutic-biological-products/novel-drug-approvals-2022" target="_blank">
 approved
 </a>
 the first competitor for Botox in decades.




 Daxxify, made by Revance Therapeutics Inc. in Nashville, Tennessee, is injected into the face along worry lines. It lasts longer than Botox, with about 80 percent of users seeing no or mild facial lines at four months after injection. For half of users, the treatment lasted six months, the company said in a
 <a class="rm-stats-tracked" href="https://investors.revance.com/news-releases/news-release-details/revance-announces-fda-approval-daxxifytm-daxibotulinumtoxina" target="_blank">
 statement
 </a>
 .




 "Users do not have to go once every three months," Balaji Prasad, M.D., who covers specialty pharmaceuticals as an analyst for Barclays Investment Bank, told
 
 The New York Times
 
 . "In a world where time is of the essence, having a product with a long duration factor is extremely useful."




 The new drug now enters the $3 billion field of facial injection drugs. It is also a neuromuscular blocking agent and a botulinum toxin, like AbbVie's Botox. "It also opens up the door for what we can do with therapeutics," Revance CEO Mark Foley, told
 
 The Times
 
 . "If you think of migraines, cervical dystonia, overactive bladder, there's a huge medical opportunity as well."




 The company has begun testing the drug on these other medical issues, Foley said. While the company had been trying to create a product that needed no needle, it instead discovered a way to use peptide technology to keep the product stable. Typically, animal protein or human serum is used.




 Users of Daxxify in the Revance studies included some who experienced side effects. About 2 percent of people developed a drooping eyelid, while about 6 percent experienced headache, the company said. Toxin-based treatment can carry the potential for other side effects, such as general muscle weakness or breathing difficulties, the FDA cautioned. Daxxify study participants showed none of those symptoms.




 <a class="rm-stats-tracked" href="https://www.nytimes.com/2022/09/08/health/wrinkle-drug-botox-daxxify-fda.html" target="_blank">
 
 The New York Times
 
 Article
 </a>








 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
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Daxxify lasts longer than Botox, with about 80 percent of users seeing no or mild facial lines at four months after injection

FDA Approves Botox Competitor That Lasts Longer

Early Postoperative Microneedling May Improve Surgical Scars

Topical tretinoin precursors (TTP) do not appear to differ from tretinoin (RA) for treating moderate-to-severe facial photodamage, according to a study published online June 8 in
 
 JAMA Dermatology.
 




 Anna L. Chien, M.D., from the Johns Hopkins School of Medicine in Baltimore, and colleagues conducted a randomized, double-blind study involving 24 patients with moderate-to-severe facial photodamage. Participants were randomly assigned to receive daily topical application of RA or TTP formulation, containing retinol, retinyl acetate, and retinyl palmitate, for 24 weeks. The analysis included 20 White women (nine randomly assigned to TTP and 11 randomly assigned to RA).




 The researchers observed no significant difference in Griffiths photoaging scores at week 24 among those receiving TTP versus RA (median, 4 versus 5). TTP treatment was associated with erythema less frequently than RA (11 versus 64 percent). In a target gene analysis, significant
 
 CRABP2
 
 mRNA induction was seen, confirming retinoic acid receptor signaling, but there were no significant changes seen in procollagen I or
 
 MMP1/3/9
 
 mRNA in samples treated with TTP. However, TTP-treated samples had a significant reduction in
 
 MMP2
 
 mRNA, and there was a strong association for changes in
 
 MMP2
 
 with changes in fine wrinkles. Greater improvements were seen in patients with severe baseline wrinkles.




 "These results highlight the potential role that
 
 MMP2
 
 may play in mediating retinoid efficacy in photoaging," the authors write. "Larger studies with more diverse patients should be pursued to validate these findings in a broader population."




 Several authors disclosed financial ties to the biopharmaceutical industry, including SkinMedica, which funded the study.




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology/fullarticle/2792866" target="_blank">
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MMP2 mRNA was significantly reduced in TTP-treated samples; changes in MMP2 were associated with changes in fine wrinkles

Tretinoin Precursors, Tretinoin Work Similarly for Facial Photodamage

Twelve companies have been issued warning letters about selling over-the-counter skin lightening products containing hydroquinone, the U.S. Food and Drug Administration announced Tuesday.




 The products are unapproved drugs that are not recognized as safe and effective, according to the FDA, which has received reports of serious side effects, including rashes, facial swelling, and skin discoloration that may be permanent. The FDA said consumers should not use these products due to the potential risks. Instead, they should talk to their health care provider about treatment options for certain skin conditions, including dark or age spots.




 There are no FDA-approved or otherwise legally marketed over-the-counter skin lightening products. Some manufacturers and distributors have already removed such products from the U.S. marketplace, and the FDA said it plans to take action against businesses that continue to market what it called "potentially harmful and illegal" products. The companies that received warning letters were told to immediately correct their violations. They were given 15 days to tell the FDA what actions they have taken to address violations and prevent them from happening again.




 Currently, a prescription product called Tri-Luma is the only FDA-approved therapy containing hydroquinone. Tri-Luma is approved for short-term treatment of dark spots associated with moderate-to-severe melasma (patchy brown discoloration) of the face. The FDA said Tri-Luma should only be used under the supervision of a licensed health care professional.




 Consumers or health care providers are asked to
 <a class="rm-stats-tracked" href="https://www.fda.gov/safety/medwatch-fda-safety-information-and-adverse-event-reporting-program" target="_blank">
 report
 </a>
 problems associated with over-the-counter skin lightening products to the FDA.




 <a class="rm-stats-tracked" href="https://www.fda.gov/drugs/drug-safety-and-availability/fda-works-protect-consumers-potentially-harmful-otc-skin-lightening-products" target="_blank">
 More Information
 </a>




 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
 </a>




 <a class="rm-stats-tracked" href="https://jamanetwork.com/journals/jamadermatology/article-abstract/2791589" target="_blank">
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There are no FDA-approved or otherwise legally marketed over-the-counter skin lightening products

FDA Warns 12 Companies About Skin Lightening Products

Botulinum toxin type A (BTXA) is effective for preventing and treating postoperative cleft lip and/or palate (CL/P) scar hypertrophy, according to a review published online March 29 in the
 
 Journal of Cosmetic Dermatology
 
 .




 Qiang Ji, M.D., from West China Hospital at Sichuan University in Chengdu, and colleagues conducted a systematic review and meta-analysis to examine the efficacy of BTXA for preventing and treating postoperative CL/P scars. Data were included from four randomized controlled trials, with 161 cases: 83 scars were treated with BTXA and 78 were treated with placebo.




 The researchers found that BTXA showed significant differences in preventing and treating postoperative CL/P scars in terms of scar width and the Visual Analog Scale (mean difference, –0.20 and 1.30, respectively); there were no significant between-group differences noted on the Vancouver Scar Scale.




 "The meta-analysis supports the use of BTXA for aesthetically pleasing scars following CL/P repair, as evidenced by our findings from four clinical trials," the authors write. "To provide more firm data, more high-quality randomized controlled trials for the treatment of CL/P scars with BTXA should be compared thoroughly."




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Review of four studies shows significant difference in terms of scar width and Visual Analog Scale for BTXA group

Is Botulinum Toxin Type A Effective for Postop Cleft Lip/Palate Scars?

The quality of YouTube videos related to aesthetic injectables is lower than that of websites, according to a study published in the March issue of
 
 Plastic and Reconstructive Surgery
 
 .




 Anooj A. Patel, from the Northwestern University Feinberg School of Medicine in Chicago, and colleagues assessed and compared the information quality of videos related to the two most performed aesthetic procedures -- botulinum toxin type A (Botox) and soft-tissue filler injections -- with that of websites. The most popular health information videos were identified by performing a YouTube search for "Botox" and "fillers" in July 2020. The quality was assessed, and quality scores were compared for different groups of video contributors and against websites.




 A total of 720 measurements of quality were performed across 95 YouTube videos and 85 websites. The researchers found mean quality scores of 1.74/4 for the
 
 Journal of the American Medical Association
 
 ; 6.66/16 for Health on the Net; 40.0/80 for DISCERN criteria; and 39.1/100 for content. Compared with patient-based videos, physician, nonphysician health professionals, and other (news, magazine channels, and influencers) videos were all of higher quality. The mean DISCERN percentage score was 50.04 for videos, which was significantly less than the 55.46 percent for websites. A similar result was seen for the mean content scores (39.06 versus 60.76).




 "Physicians should focus their online presence to video-based platforms, where the viewership may be larger, and seek to increase the quality of their content by using the criteria set forth by various health information quality instruments," the authors write.




 <a class="rm-stats-tracked" href="https://journals.lww.com/plasreconsurg/Fulltext/2022/03000/Websites_or_Videos__Which_Offer_Better_Information.11.aspx" target="_blank">
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 <a href="https://consumer.healthday.com/u/physiciansbriefingstaff">
 <img alt="HealthDay" src="https://assets.rbl.ms/23636171/origin.png" style="max-width: 150px;"/>
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Physician, nonphysician health professionals, and other videos were all of higher quality than patient videos

YouTube Video Quality for Aesthetic Injectables Lower Than Quality of Websites

In Episode 23 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Patricia Farris, MD who is in practice in Old Metairie, Louisiana. Dr. Farris talks about building a successful aesthetic dermatology practice, selling skincare products, and offers tips on office dynamics.

In Episode 23 of Derms and Conditions, our host James Q. Del Rosso, DO talks with Patricia Farris, MD who is in practice in Old Metairie, Louisiana. Dr. Farris begins the episode discussing tips on how to build a successful aesthetic dermatology practice. She also offers helpful tips on office dynamics. Dr. Del Rosso asks Dr. Farris to give some advice on how to sell skin care products in a clinical practice setting. The episode ends with Dr. Farris discussing important considerations when selling a dermatology practice to a private equity group.&nbsp; FINANCIAL DISCLOSURES:&nbsp; JAMES DEL ROSSO, DO: CONSULTANT/ADVISOR Abbvie, Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), BioFrontera, BioPharmX, Bristol-Myers-Squibb, Cassiopea, Dermata, Dermavant, Encore, EPI Health, Evommune, Ferndale, Galderma, Incyte, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), MC2, Novan, Pfizer, Regeneron, Sanofi-Genzyme, SolGel, Sonoma (IntraDerm), Sun Pharma, Trevi, UCB, Verrica, Vyne (Foamix; Menlo) SPEAKER BUREAU Aclaris, Almirall, Amgen, Arcutis, Bausch Health (Ortho Dermatology), EPI Health, Ferndale, Galderma, Genentech, JEM Health, Leo Pharma, La Roche Posay, Lilly (Dermira), Pfizer, Regeneron, Sanofi-Genzyme, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo) RESEARCH INVESTIGATOR Aclaris, Almirall, Amgen, Anaptys Bio, Arcutis, Athenex, Bausch Health (Ortho Dermatology), BioPharmX, Biorasi, Botanix, Brickell, Cara Therapeutics, Cassiopea, Dermavant, EPI Health, Ferndale, Galderma, Incyte, Leo Pharma, Lilly (Dermira), Novan, Pfizer, Ralexar, Regeneron, SolGel, Sun Pharma, UCB, Verrica, Vyne (Foamix; Menlo).&nbsp; PATRICIA FARRIS, MD: Co-founder of RegimenMD and serves as a consultant and/or advisory board member for Neutrogena, Neostrata, Skinceuticals, Fig-1 Skincare, Nutraceutical Wellness, and U.SK Under Skin.

Derms and Conditions Podcast

What Type Of Practice Is Right For You?

Safety Alert: Essential Guidance for Dermatologists on Counterfeit Botox 

In this installment of Topical Conversations, Cheri Frey, MD, an assistant professor of dermatology at Howard University, comments on the concerning issue of counterfeit Botox recently highlighted by an FDA notice.&nbsp;A critical safety notice&nbsp;The FDA has issued a safety notice to health care practitioners and the public regarding the presence of a counterfeit version of Botox found in the United States, which may have been sold to doctors’ offices and medical clinics nationwide. This counterfeit product, distributed by an unlicensed supplier unauthorized to distribute drug products in the US, poses a significant risk to public health.&nbsp;Recognizing the symptoms&nbsp;Dr Frey details some of the severe health complications seen in patients who received counterfeit Botox products, including difficulty swallowing, difficulty breathing, and blurry vision; in some cases, patients required hospitalization and treatment with an antitoxin.&nbsp;Importance of counseling patients&nbsp;She emphasizes the critical need for dermatologists to disseminate this information not only among their peers but also to patients and their networks. She stresses the importance of counseling individuals seeking botulinum injections to visit licensed providers, whose qualifications vary by state.&nbsp;Ensuring patient safety&nbsp;Dr Frey underscores the significance of dermatologists being vigilant about recognizing the signs and symptoms of counterfeit botulinum toxin complications. Additionally, she stresses the importance of counseling patients who may be affected to seek immediate emergency care at the first indication of trouble.

The Science of Botulinum Toxin

Mark Nestor, MD, PhD, took us through a rigorous review of key clinical postulates of botulinum toxin type A to optimize results for our patients and assess properties to discern differences between commercially available products. His first postulate states that all the type A toxins have the same mechanism of action: the heavy chain of the 150kDa active molecule irreversibly binds SV2 receptors on presynaptic cholinergic neurons, leading to cellular uptake, disulfphide bond breakage, and cleavage of the SNAP 25 protein by the light chain to prevent acetylcholine vesicles from fusing with the cell membrane. The rate-limiting step of this cascade of events is the first, SV2 receptor binding. Potency, therefore, is defined by the amount, activity, and affinity of toxin to bind to this SV2 receptor. This is not directly proportional to manufacture units, as lyophilized toxins may vary by 20% within each vial, and daxibotulinumtoxin peptide may prevent aggregation thereby increasing affinity. It follows that increasing the potency may be possible by increasing the number of SV2 receptors, and there is technology looking at additive enhancer toxins for this purpose. The light chain remains active in the cytoplasm for up to 10 months, but the recovery of response leaves many investigators with questions. While muscle mass and age may play a role in differences seen among patients, acetylcholine receptor gene upregulation, proliferation of neuronal axon sprouts, and myogenesis are the least understood parts of toxin response and lifecycle. &nbsp; These myriad factors that influence clinical efficacy are addressed by Postulate II and III, while also bringing in more clinical variables like the distribution of toxin. The efficacy and duration of the effect of botulinum toxin is proportional to the degree of molecular saturation of molecules bound at neuromuscular junctions as well as the time to recovery, but this is difficult to ascertain objectively for commercial products. While each manufacturer uses its own methodology to tout potency results, Dr Nestor recommended comparing independent trial data or results in an individual split-face study. For example, noninferiority trials looking at glabellar lines and the frontalis muscle compare different toxins on contralateral sides of the face. Abobotulinum toxin demonstrated a faster result than onabotulinum toxin for the frontalis, while there was a slight but insignificant preference for prabotulinum toxin compared to onabotulinum toxin for glabellar lines.&nbsp; Postulate V states that increased molecular potency will decrease the time to onset and increase the duration of effect, up until a certain point that is. Diffusion, a passive process that is the same for all toxins, and spread, based on anatomy, technique, and reconstitution, should also be considered when administering toxin. The later postulates consider the impact of diffusion and spread on clinical effect, and while increasing injection sites may allow for optimal spread, the technique comes with more risk of bruising and consumes more time. Looking into 2024, Dr Nestor also mentioned 2 new toxins in the process of garnering FDA approval, letibotulinumtoxin A and relabotulinumtoxin A, the latter of which is derived from clostridium botulinum. Overall, this was a thorough evaluation of one of the most commonly administered injections in the aesthetic domain.&nbsp;

30 Innovations in 30 Minutes: Aesthetics and Regenerative

Rounding out our first day in Miami was a favorite multispeaker session on the newest technologies in aesthetics and regenerative dermatology. Mark Nestor, MD, PhD, started this session with an overview of how he runs a successful dermatology practice by bridging clinical patients into aesthetic referrals and retaining patients.&nbsp; Dr Glaser also encouraged us to use complications from outside providers as opportunities to retain new patients and demonstrate a collaborative clinical manner. She later covered a trending area for cosmetic products and procedures, the neck, which can have a higher risk of complications with energy-based devices. She recommended hyaluronic acid diluted with 0.4 cc of 1% lidocaine for horizontal lines, though bruising can occur, and high-intensity focused ultrasound, which has no downtime. Dr Weinkle demonstrated an injection technique using a cannula for this area as well as the central face.&nbsp; Dr Goldenberg encouraged us to use devices to their fullest potential in our clinical practice, including for diverse indications like acne. Dr Katz also emphasized the importance of reviewing data on devices before incorporating them into clinical practice. His go-to devices are fractional CO2 and erbium lasers, pulsed dye lasers, radiofrequency microneedling, and picosecond lasers. Dr Goldenberg underscored the importance of anxiolytics and cooling devices or NSAIDs in a device-heavy practice to help retain patients. New aesthetic treatments reviewed included a new injectable polypeptide nanoparticle that delivers siRNA to target TGF-B1 and COX-2, leading to apoptosis of adipocytes in novel fat remodeling technology which is now in Phase 1 trials. Dr Katz also showed the mechanism of the new microcoring energy-based device for skin laxity. Another novel device is a bilayer patch with alkali metals to reduce sweat and inhibitor bacteria in the axilla by generating heat when in contact with sweat, thereby inactivating the sweat gland. Dr Glaser showed us how this novel process of alkali thermolysis works with application of under 3 minutes and a peak temperature equivalent to that of a hot tub.&nbsp; Diosmin, a medical food, is a flavonoid covered by Dr Nestor that may be able to improve progressive pigmentary dermatosis, or Schamberg disease, senile purpura, and rosacea by impacting capillaries and vascular wall permeability. Curcumin, a derivative of turmeric that requires specific complexes and processing to become bioavailable, may also help with pigmentation, premature aging, and dark circles by suppressing melanogenesis and tyrosinase activity. Another medical food covered was genistein, which works at the estrogen-beta receptor and is cancer protective, unlike its alpha-type counterpart. It may play a role in improving skin hydration, increasing collagen synthesis, and decreasing bruising and has a small (n=26) RCT that indicated significant improvement in fine wrinkles and elasticity.&nbsp; Lastly, Dr Weinkle covered some practical injection tips like dropping injections of the procerus to be in line with the medial canthus and similarly lowering corrugator injections to avoid frontalis fibers. She cautioned us to avoid zygomaticus major, levator labii alaeque nasi, and the depressor labii inferioris when injecting the masseter, platysma, or orbicularis oris to avoid impacting facial expression.&nbsp;

What's New and Hot in Cosmeceuticals

Keeping up with cosmeceuticals can feel like a full time job as the field has grown to include everything from botanicals to exosomes. To make things more challenging, our patients increasingly desire clarification on postulates consumed on social media regarding myriad products and techniques. Emmy Graber, MD walked us through the data to ensure we have all the information to answer our patients’ questions and contextualize the newest skincare trends. The current on-trend ingredient list she covered includes niacinamide, snail mucin, alternative retinoids, which differ from their prescribed counterparts as they do not bind directly to nuclear retinoid receptors, and mushrooms.&nbsp; Niacinamide has shown substantial growth in the past few years for its seemingly innumerable benefits by inhibiting sebum production and inflammatory cytokines, increasing production of collagen and skin barrier lipids thereby reducing transepidermal water loss, and decreasing melanosome transfer to keratinocytes. One placebo-controlled split-face trial (n=50) showed decreased fine lines, hyperpigmentation spots, and redness with the use of niacinamide 5% in middle-aged women in 12 weeks. Another split-face trial (n=50) in patients with rosacea also demonstrated improvement in a variety of features including inflammatory lesions and erythema by week 4.&nbsp; Snail mucin, another hot topic in the cosmeceutical industry, contains secretions from cryptomphalus aspersa which, in a 14 week split-face RCT, demonstrated significant improvement in periocular rhytides that persisted 2 weeks after discontinuation of this anti-photoaging product. Alternative retinols, or “bio-retinols”, such as bakuchiol have been touted to be less irritating, and this was supported by a RCT in which patients applied either bakuchiol 0.5% cream twice daily or retinol 0.5% cream daily. Bakuchiol users did report less skin scaling and stinging without significant impact to grading of rhytides. The last popular ingredient Dr. Graber discussed was mushrooms, which may be referred to as “adaptogens”. One study on veratric acid, which can be derived from medicinal mushrooms, reported significant impact on rhytides by modulating matrix metalloproteinases and epidermal layer integrity. More studies are required to ascertain efficacy against alternative options. She concluded by addressing an emerging concern of visible light in photoaging by inducing reactive oxygen species. An adequate method to mitigate this is opting for a sunscreen product with antioxidants.&nbsp;

What You Need To Know NOW About Cosmeceuticals

Hello, everyone. I'm Cherie Fry, a board certified dermatologist who practices at Howard University in Washington, DC. I am so excited that I got the chance to speak at fall clinical. My talk was on cosmeceuticals. What you need to know now, I spoke on advances in retinoids and retinol, some really exciting and ingredients like sodium elascorbate. You haven't heard of that, have you? But if you are interested in hearing more about cosmeceuticals, I invite you all to attend fall clinical winter clinical, where we dive into the science of these products and you can understand the mechanism behind them so you can make sure that you're delivering the best care to your patients. Thank you so much for having me, and look forward to seeing you at another conference soon.

In this session, Cheri Frey, MD, provided an in-depth look at popular cosmeceutical ingredients on the market that all dermatologists should be aware of. Beginning with retinoids, Dr Frey reviewed a new ester of all trans retinoic acid, hydroxypinacolone retinoate, which demonstrates less skin irritation than retinol. Newer combination products containing double-conjugated retinoids and alpha hydroxy acids can improve skin clarity and pore appearance while also having high tolerability. Moving on to antioxidants, Dr Frey discussed flavonoids such as silymarin before diving into the various formulations of vitamin C. L-ascorbic acid is the most biologically active form of vitamin C but is highly unstable as it is oxidized by air and degraded by light and heat. Other more stable forms include magnesium ascorbyl phosphate and tetrahexyldecyl ascorbate. Common additives for vitamin C products include ferulic acid, an antioxidant free-radical scavenger, and vitamin E, a lipophilic antioxidant that works synergistically with vitamin C to provide photoprotection from UV radiation.Dr Frey briefly reviewed alpha and beta hydroxy acids before finishing off with a discussion of lightening agents. Hydroquinone 2% is no longer available as a cosmeceutical but remains available in pharmaceutical strengths (4% and up). L-cysteamine is a biological antioxidant produced by metabolization of cysteine that inhibits tyrosinase and removes dopaquinone from the melanin synthesis pathway. It is available in a short-contact, wash-off product. Tranexamic acid (TXA) is another lightening agent available in oral or topical form. TXA is a synthetic derivative of lysine that decreases melanogenesis via inhibition of the plasmin/plasminogen pathway and blocks the interaction between melanocytes and keratinocytes. Other lightening agents include ascorbic acid, kojic acid, arbutin, licorice extract, linoleic acid, and aloesin.&nbsp;

Why should you consider treating the chin with fillers when considering lip augmentation?

You. We live in an area where big lips are all the rage, and I found that more often than not, sometimes they tend to look unbalanced. I'm a big fan of the natural look, and having that third, the lower third of the face being proportional to the rest of your face and to your lips is really important. The chin is a very comfortable area to treat. There's very little swelling, very little bruising. And sometimes by extending that lower third of the face, you expose a little bit more of that lower vermilion border, and you might not even need filler in that area. And if you do pursue with filler, you just give the face a little bit more of a balanced, natural look and.

Botox for the neck: where do you start and how many units do you recommend?

You. The neck is a great area to be treated with Botox. It's one of my favorite areas to treat. The Nefertiti necklift is one of my favorite procedures, and I typically start with ten units on each side that addresses the jowls really well, and more often than not, patients don't need to have their melabial folds addressed once having that procedure. Necklines or the tech neck these days is also a great area to be treated with Botox. I typically start with 18 to 20 units. Never go higher than 30, at least in the first injection. Patients tolerate it really well when you just do very little droplets around the necklines and patients get great results.

How do you stagger Poly-L-lactic acid treatments with hyaluronic acid and botox?

You. Polylactic acid and botox and hyaluronic acid fillers are amazing products that we have the luxury to have in our toolbox. They do different things. However. Most patients need a combination of both the polylactic acid and filler. But as you know, the polylactic acid is more of a long term investment in the collagen of your skin. So you really don't get that immediate reward that we do get with replacing the volume from the filler. I typically like to start with the polylactic acid, first, erate a couple of months, and then address what is left and what other areas still need volume replacement. But I do remind patients that this is not an immediate thing, really. It's a long term investment that will help their skin build their own collagen and give them ultimately the most youthful result. All.

How do you combine thread lifts with hyaluronic acid fillers?

You. Thread lifts are in all the rage these days and a lot of patients that need thread lifts often have some volume loss as well and need the filler. Just the fillers alone won't get that lift that we're hoping for. So typically I do the thread lifts first, let the swelling go down, let the things settle and patient get more adjusted and more comfortable. And then I follow with replacing the volume if it is the patient where think just replacing volume alone would get the result that they're looking for. I then start with the hyaluronic acid first. All.

Do you recommend treating cheeks and tear trough with hyaluronic acid filler?

You when addressing tear trough concerns. A lot of patients have some volume loss in that area, but also have volume loss in the mallor, cheek and zygoma. So I tend to address the cheeks and zygoma first, really let that filler settle, incorporate, let the swelling go down, and more often than not, you find that you get really good improvement in the nasal juggle folds and no longer need to address that area with filler.

With how much NS do you reconstitute your Dysport?

You? Well, I use 2.4 mls, and the reason for that is that for botox, I tend to use two mls and I use this at a two to one ratio for dysport of Botox. And if I use 2.4, I get more. I get about 20% more out of a vial. And I have published extensively showing at 2.5 to one, DySport has more molecular potency. The idea somehow that it somehow travels more, it diffuses more, and all that that's absolute has been shown to be wrong. What is true is because it's more molecularly potent, you get a bigger area of effect, not because it travels more, but because you have more toxin there at 2.5 to one. The reason that I do two versus 2.4 is I inject exactly the same volume from one to the other. So if anything ever gets screwed up and gets mislabeled, it doesn't matter. I'm injecting exactly the same amount of volume. My hand knows exactly what to do and I'm doing it at a 2.5 to one ratio.

How much normal saline do you use to reconstitute Dysport?

Which hypochlorous acid spray do you use?

I tend to use episin and laserson. The data on hypochlorous acid, and now there are a number of companies making this, are on the stabilized hypochloric acid, hyperchlorous acid, which is epic, and lasersin. It's also called levicin, both prescription, non prescription, sold in the office, not sold in the office. All of the data, all the science, all of the inflammatory anti inflammatory data, as well as all of the bacteriological data are all based on the specific aspect of stabilized hypochlorous acid, because it is something that's difficult to make. And the companies that make the stabilized used to sonoma. Now, I believe it's EMC that has the product line, has a very specific, standardized way of manufacturing that spray.

How are noncompete agreements handled in dermatology practices?

It's really a legal state to state issue. And what's interesting is that the Biden administration just put out an executive order essentially looking to limit non compete agreements because they feel it's anti competitive. Most states, the way it's looked at is it's got to be reasonable, meaning you can't say you can't practice dermatology, you can't practice forever. You can't practice normally. It's somewhere around 5 miles, because if the practices patients are not yours, but the practices, they don't want you opening up across the street and saying, hey, patients come to me. What generally happens is it's about 5 miles is considered reasonable all in most states. And there is normally now also a monetary aspect that goes along with it. In other words, you can do non compete and go 5 miles. Or if you break that, there is a specific set monetary aspect as well that you have to pay back the practice.

Is there any basis to the concern about delayed nodules with the Voluma group of products?

Every single filler, hyaluronic acid filler has different manufacturing attributes. And some of the manufacturing attributes of the voluma group have been published and have been shown to perhaps cause more of a reaction. It's not clear whether that's an immune reaction, whether it sets up a little bit of an increased ability to have an indolent infection, a biome infection, but there is definitely published data now. It's still limited, meaning you don't see this very often. And it's very clear that if you use small aloquots of any filler, and that includes voluma, you will dramatically decrease the risk of any delayed nodules for these products.

Can you make a comment on rate of blindness in fat injections?

The rate of blindness from fillers per se, fat as well as ha, et cetera, is very low, but it has gone up over the years. And the key issue is not necessarily the type of filler that you're using, it's where you're injecting. So there are certainly risk areas. The globe, bella, is one of the highest. Lower forehead and nose are probably the key areas that you have to be extremely careful or avoid for blindness because you have the chance, obviously, of the retinal artery being embolized. Now, there is a data that fat is, ah, highest up on the list in a sense, but that has to do with where some of the studies are published, where they're using fat more ha, certainly can cause blindness as well. There are many reported cases of this. So it's really about being careful in terms of where you are injecting, no matter what you're using. From that perspective.

Gwyneth Paltrow is promoting Xeomin as a 'natural' Botox. In my 13 years, we mostly use Xeomin for people that are resistant to Botox or Dysport. Thoughts?

So, number one, all type a toxins, every single one of them, work. It's exactly the same. And the reason that xiaomin is different is that it doesn't have in its native state, the complexing proteins that either Botox or dysport or jubot has. And those are obviously the approved toxins. However, it's been shown very clearly that you get disassociation of those proteins, literally in the syringe, if not immediately after it's injected. So those complex proteins don't seem to have a factor in this. From that perspective. The reason it's called natural, they're saying, is because it's the 150 kilojolton protein and not the complexing proteins. However, there is no evidence, or virtually no evidence that having those complexing proteins, number one, is increasing the immune resistance to toxin, either botox or dysport. And there's also no evidence that those people who are, quote, resistant, and I'll talk about that in a second, get better results from Xemin. It's all about the issue of molecular potency, and I've published on this. You can just look my name up. I published on Journal of Cosmetic Dermatology last year on this for the paper on the science of botulinum toxin, the postulate paper, so you can look that up. It's really about molecular potency. There are people who are genetically more resistant, and there probably is a mechanism where the receptor gets toned down as you inject more. It really does not seem to be an immune response for any of these toxins, per se.

How far laterally will you inject the frontalis?

You. It really has to do with the patient and what their needs are. Generally, if you draw a line up in the lateral aspect of the little upward bulge of the lateral eyebrow and go up, that's probably a good place. You don't want to be too medial because then you can have the quote Bach look, and being too lateral may drop the lateral brow. So as a general rule of thought, I think if you're looking at this general normal curve of the eyebrow and go straight up from there, generally you want to go up at least 2 cm from there to inject the frontalis.

Which cosmeceuticals do you recommend for lightening?

You for lightning. Mostly I recommend things that have athalaic acid and vitamin C. If someone's not on a prescription retinol, I also like to have them use some type of retinol or vitamin A product. Those are my main go to for lightning brown spots and keeping the skin nice and light with eclo.

Can you comment on hot topic of J Lo and her olive oil and non use of BOTOX?

Here's what I will say. Look, ideally, people have integrity and don't misrepresent what types of things you're doing for the face. I would argue that just because JLO is not or anybody else is not necessarily doing Botox doesn't mean there aren't a lot of other things they might actually be doing. So there are ultrasonic wave tightening and all sorts of stuff, chemical peels and serums that you can use to help keep your skin flawless. Also, hey, some people just have good genes, but given that she now actually has her own brand of skincare, I would say she probably is definitely doing more than olive oil, even if she isn't, in fact, using.

Which toxin is best?

One of the most common questions that patients and colleagues alike ask is which neuromodulator and toxin works best, lasts longer, etc. Well, all the data out there, all the head to head studies show that each of the four products that are currently FDA approved is very similar. An onset of action. I do think, from a practical perspective, that some patients may prefer one versus another. So what I usually do is give the patients an option of different toxins that I have available and let them decide, and let them try one or the other each time they come in and pick the one that's their favorite. In my practice, I think most patients do not have favorite, but I do think that each product has some differences, and you as a practitioner may be able to pick the one that's right for each and individual patient.

What resources exist for those new to cosmetic procedures?

If you are new to cosmetic procedures, whether it's neuromodulators or toxins or fillers, lasers, etc. There are many resources that are available for you to become quite good at using these cosmetic treatments. I think that it's a great idea to continue to participate in CME meetings such as fall and winter clinical. I also think that you can approach each individual company for training. Companies would love to train you to use their products. Now, one thing that you have to know is they can only train you to use the products on label, but in CME forms, you are going to be able to learn more advanced techniques. But I think in the very beginning, it's great to go to meetings, discuss with colleagues, et cetera, but also approach each individual company and have them set up training sessions for you so you can become an injector, learn how to use neuromodulators, learn how to use fillers, learn how to use lasers and devices. And I think this way you could be on your way to becoming a master injector and using advanced techniques for cosmetic procedures. Teachers.

Aesthetics Condition Center

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