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Surgeons Differ on Ethics of Rhinoplasty

Aesthetic rhinoplasty surgeons appear to have diverging opinions about the ethical issues they may face in practice. A recent survey of the opinions, practices, and attitudes of experienced and novice facial plastic surgeons presented 15 clinical vignettes addressing ethical quandaries in aesthetic rhinoplasty and based on the experience and observations of the senior author over nearly 30 years of practice and teaching. Five of the 15 vignettes demonstrated significant differences between the responses of the fellowship directors and the fellows, and no single vignette had a unanimous consensus in either group. The survey was fielded anonymously to Fellowship directors and facial plastic surgery fellows of the American Academy of Facial Plastic and Reconstructive Surgery.
Arch Facial Plast Surg. 2012

SAFE Storage Times for Botulinum Toxins Longer than Thought

Assuming standard safe injection techniques are followed, a single vial of onabotulinumtoxinA (BT-A) can be safely administered to multiple patients and, after reconstitution, can be stored beyond the recommended time period of four hours, according to a new study. Investigators examined current clinical practices and expert consensus recommendations regarding the reconstitution and storage of botulinum toxins and conducted an Internet-based study to analyze current practices of members of the ASDS administering botulinum toxins.

After product reconstitution, the majority of physicians (68.6 percent) routinely store botulinum toxin for a period of greater than one week and safely use each toxin vial for more than one patient. Not a single case of infection was observed. However, the authors noted that this was a single survey with a 32.2 percent response rate.
J Am Acad Dermatol; 67(3): 373-8

Full-Face Rejuvenation with Fillers Shown Effective

Full-face rejuvenation using a range of hyaluronic fillers can offer safe, effective results, as well as notable patient satisfaction, new findings indicate. In a six-month study, participants could receive five different fillers from the same range (HA(E)) for up to eight indications (periorbital lines, tear troughs, cheeks, cheek folds, nasolabial folds, upper lip lines, lips, and marionette lines). Outcomes included global aesthetic improvement scores, improvement in each indication, adverse events, local tolerability, and satisfaction.

A total of 77 participants with a mean age of 54.5 were enrolled; 48.1 percent had five or more indications treated. Mean total injection volume (baseline and touch-up) per participant was 6.7mL. At six months, 92.1 percent of participants remained at least improved over baseline, 79.7 percent of participants were satisfied or very satisfied with the durability of results, and 63 percent of participants said they felt a lot or much better than before injection. The researchers noted that no specific safety concerns were reported except expected injection site reactions.
Dermatol Surg; 28 (7 Pt 2):1153-61

Autologous Fat, Fillers Effective for HIV Lipoatrophy

Dermal fillers and autologous fat transfer are effective for treatment of HIV associated facial lipoatrophy, with high rates of facial volume restoration and patient satisfaction, a new analysis shows. The analysis included 19 studies involving 724 patients, with 549 patients in the hyaluronic/poly-l-lactic acid cohort, and 175 patients in autologous fat transfer cohort. Although both objective and subjective measures suggested that improvements in facial volume and durability of treatment were similar between dermal fillers and fat transfer, PLLA was reinjected at a rate three-times that of autologous fat. PLLA was also associated with a relatively high rate (22 percent) of subcutaneous papule formation. The authors note that autologous fat transfer offers less of a financial burden as compared to injectable fillers.
Plast Reconstr Surg. 2012, e-pub

Less Pain Associated with abobotulinumtoxinA with Preserved Saline

Reconstitution of abobotulinumtoxinA with preserved saline may result in significantly less pain on injection than with preservativefree saline, according to a new study. In a prospective, randomized, double-blind, side-by-side trial in a private practice dermatology office in Boulder, CO, researchers enlisted 20 volunteer patients to receive injections on one side of their face with abobotulinumtoxinA reconstituted with preservative-free saline and with abobotulinumtoxinA reconstituted with preserved saline on the other side. Patients reported their pain on a 10-point visual analogue pain scale after each side was injected. Patients kept a diary for the first 48 hours after treatment to track any continued pain, onset of action, or adverse events. Researchers then saw the patients at two-week follow-up visits and recorded any adverse events. They found that 90 percent of patients reported less pain on the side injected with preserved saline than on the side injected with preservative-free saline. In addition, reported pain on the preserved saline side was 60 percent less than on the preservative-free side. Neither the patients nor the investigators noted any difference in onset of action between the two sides.
—Dermatol Surg; 28(6): 867-70

Mechanisms Proposed for Facial Blanching from Neurotoxins

While facial blanching with neurotoxins therapy has been described in the literature, a new study suggests that skin sites injected with botulinum toxins may not experience the expected decrease in cutaneous vessel tone associated with higher body temperature. After reviewing normal physiologic responses to heat stress and the role of cholinergic neurotransmission in modulating cutaneous vascular tone, investigators reported a case of a 32-year-old woman who complained of white patches on her forehead at sites of abobotulinumtoxinA injections administered two weeks before presentation. They found that acetylcholine is a primary mediator of cutaneous vasodilatation; certain co-transmitters modulate its effect. Chemical denervation by botulinum toxin appears to interfere with these normal signaling pathways and can provide symptomatic relief to patients with undesirable facial flushing. Conversely, they noted, it may create an unwanted cosmetic effect in patients who desire isolated muscle paresis.
Dermatol Surg. 2012, Dec 17

OnabotulinumtoxinA Associated with Sustained Effects

Treatment of the glabellar lines with onabotulinumtoxinA provides long-lasting results of up to four months, according to a recent study. Researchers analyzed data from four trials with 621 onabotulinumtoxinA-treated (20 U), 84.2 percent were identified as day-30 responders on the Facial Wrinkle scale (FWS) at maximum contraction. Pooled median duration of effect for day-30 responders was 120 days for FWS at maximum contraction and 131 days for FWS at repose. Higher day 30 SGA scores were correlated with a greater duration of effect on dynamic, but not static lines. Results indicate that more than 50 percent of respondents demonstrated a sustained clinical effect for four months. The researchers also found that patient satisfaction increased with duration of effect.
Dermatol Surg.; 38(11): 1794-803

Comparing 1:1.5 Dose-conversion Ratio for IncobotulinumtoxinA and OnabotulinumtoxinA

Increasing the dose of either incobotulinumtoxinA or onabotulinumtoxinA above the 20 U recommended for glabellar frown lines may not yield the desired effect, according to findings from a new study. To investigate the impact of using 50 percent higher dose of onabotulinumtoxinA, researchers enrolled patients with symmetrical moderate to severe glabellar frown lines and treated them with two injects in the corrugator muscles of either 4 u incobotulinumtoxinA or 6 U onabotulinumtoxinA (equivalent to 20 and 30 U, respectively, if corrugator muscles on both sides and the procerus are treated). They then assessed glabellar frown line severity was from standardized photographs every four weeks for four months and, in a subset of subjects, for up to six months post-treatment. The primary efficacy endpoint was the percentage of subjects with an improvement of greater than one point on the five-point scale at week four. Response rates showed no added benefit of a 50 percent higher dose of onabotulinumtoxinA at all phases of post-treatment.
J Cosmet Dermatol.; 11(4): 267-71

Incobotulinumtoxin A Found Effective for Axillary and Palmar Hyperhidrosis

IncobotulinumtoxinA has been found to have positive effects on axillary hyperhidrosis in a recent study, while also conferring benefits when used in combination in combination with a type B botulinum toxin for palmar hyperhidrosis. A total of 84 patients, 58 with axillary and 26 with palmar hyperhidrosis, were included in this open study. Researchers injected axillae with 107 ± 22 U of incobotulinumtoxinA and palms with 213 ± 19 U. They also injected palms with 264 ± 60 U botulinum toxin B over the thenar eminences to avoid muscle weakness. At three-week follow-up posttreatment, all patients treated for axillary hyperhidrosis reported satisfaction in self-ranking, evaporation decreased by greater than 40 percent, and Dermatology Life Quality Index (DLQI) score improved from 12.0 to 1.7. In the palmar group, 95 percent of patients were satisfied, with more than 50 percent reporting decreased, DLQI score improvement from 10.3 to 1.2. Only one patient in the palmar group experienced muscle weakness, according to investigators.
Acta Derm Venereol. 2012, Oct 11

AbobotulinumtoxinA Effective in Skin of Color

Tolerability and effectiveness of abobotulinumtoxinA for glabellar lines is similar in patients with skin of color and white patients, according to new findings. Investigators used pooled safety data from six clinical trials from which were derived a safety population (1,869 white patients and 472 patients with skin of color), an efficacy population for a comparison of fixed-dose abobotulinumtoxinA 50 U in white patients and patients with skin of color, and an efficacy population for a comparison of abobotulinumtoxin A adjusted to muscle mass in white and patients with skin of color. Adverse event rates were similar between the two groups, as was onset of effect, however the response rate 30 days after treatment was greater in patients with skin of color than in white patients.
Dermatol Surg. 2012 Nov; 38(11): 1804-11