Faculty Bibliography

The forehead skin closely resembles the texture and color of the midface region. As such, the use of a paramedian forehead flap to repair a midface defect provides optimal cosmesis; however, the donor forehead site may be left with an undesirable scar in a highly visible region of the face. Cutaneous surgeons possess a variety of traditional techniques intended to minimize scarring. We have found that the addition of 50 units of botulinum toxin at the time of wound closure has improved scar outcomes for patients undergoing reconstruction with paramedian interpolated flaps. Possible mechanisms for the efficacy of botulinum toxin lie in its ability to chemically paralyze the frontalis muscle and glabella complex. This immobilization leads to a reduction in unwanted wound tension during the most vulnerable first few days of healing.

BACKGROUND:There is increased emphasis on the importance of the gluteal region in the perception of beauty. Biodegradable fillers provide a nonsurgical method of augmenting and rejuvenating this area. OBJECTIVE:To review pertinent aspects of anatomy, patient evaluation, injection technique, and complications for gluteal augmentation using injectable biodegradable fillers. METHODS:The authors review the literature for poly-L-lactic acid-based gluteal augmentation. RESULTS:Like many aesthetic procedures, there is a paucity of literature on this emerging treatment modality (Level 4, Centre for Evidence-Based Medicine, Oxford). However, the collective clinical experience is that poly-L-lactic acid fillers are an effective treatment for patients seeking noninvasive gluteal enhancement with minimal downtime. Physicians must understand gluteal anatomy and avoid injecting deeply in the danger triangle to prevent intravascular injection into the gluteal vessels or injury to the sciatic nerve. Other safety elements include the use of blunt cannulas, reduced pressures, smaller volumes, and retrograde delivery. CONCLUSION:Gluteal augmentation with fillers can safely and effectively improve gluteal firmness, shape, proportion, and projection. Practitioners injecting fillers in the gluteal region must be aware of appropriate patient selection, regional anatomy, and safe injection techniques. Given the increasing demand for this procedure, further high-quality studies are needed.

The fusion of technology and medicine has led to the advent of advanced wound healing techniques that may be adapted to the management of surgical defects. Shortened duration of healing and ease-of-use are two potential benefits under investigation. Here we describe a 65-year-old male with a nasal alar wound that was allowed to heal with secondary intention, assisted by a novel methacrylate polymer powder dressing.

Non-invasive procedures targeting the submental fat or “double chin” have undergone a surge in popularity. Injections of deoxycholic acid, a secondary bile acid, have recently received FDA-approval for fat reduction in this area. With appropriate patient selection, this preparation of 10 mg/mL of sodium deoxycholate (Kybella®, Kythera Biopharmaceuticals, Westlake Village, CA) leads to aesthetic improvement of moderate-to-severe convexity or fullness associated with submental fat in adults.

BACKGROUND:Presurgical curettage before nonmelanoma skin cancer surgery may help delineate tumor subclinical extensions. OBJECTIVE:To determine histologically whether presurgical curettage appropriately or inappropriately changes excision specimen size. MATERIALS AND METHODS/METHODS:One hundred fifty consecutive nonmelanoma skin cancers treated with Mohs micrographic surgery. The clinical margin (CM) was marked. Presurgical curettage was then performed and the resultant presurgical curettage margin (PCM) marked. Frozen section analysis of the CM and PCM revealed whether the curettage-induced margin change was appropriate or unnecessary. RESULTS:Presurgical curettage appropriately increased the surgical margin in 9.3% of cases, reducing the number of Mohs stages from 2 to 1. It appropriately decreased the surgical margin in 17.3% thereby conserving normal skin. In 19.4% of cases the curettage increased the margin in situations where the CM had underestimated the size of the tumor; however, in these cases, the curettage did not increase the margin sufficiently to clear the tumor. In 44.0% of cases the PCM did not change the size of the stage I specimen compared to the CM and confirmed the CM. In 10.0% of cases, preoperative curettage reduced margin accuracy by removing healthy tissue (8.0%) or underestimating tumor (2.0%). These errors were associated with eyelid location, severe background photodamage, and morpheiform/infiltrating/sclerosing basal cell carcinomas. CONCLUSION/CONCLUSIONS:Presurgical curettage can improve tumor excision accuracy and efficiency. Careful tumor selection is important to optimize curette utility.

BACKGROUND:Local anesthetic injections can be painful and distressing. OBJECTIVE:The aim of this study was to determine whether nitrous oxide, ice, vibration, or topical anesthetic improves analgesia for local anesthetic injections. METHOD/METHODS:= 50). Pain was rated using the Visual Analogue Scale (VAS) and Wong-Baker FACES Pain Rating Scale. RESULTS:= .02). CONCLUSION/CONCLUSIONS:Nitrous oxide, ice, and vibration reduce injection pain. These interventions are especially useful for younger males undergoing surgery on the nose, lip, ear, or eyelid.

Non-invasive body contouring is a rapidly growing field in cosmetic dermatology. Non-invasive contouring devices improve the body's appearance through the removal of excess adipose tissue, particularly in areas in which fat persists despite optimal diet and exercise routine. The technology can also be used for skin tightening. This article reviews the five FDA-approved non-invasive body contouring modalities: cryolipolysis, laser, high-intensity focused electromagnetic field, radiofrequency and high-intensity focused ultrasound. These devices have emerged as a popular alternative to surgical body contouring due to their efficacy, favourable safety profile, minimal recovery time and reduced cost. Although they do not achieve the same results as liposuction, they are an attractive alternative for patients who do not want the risks or costs associated with surgery. When used appropriately and correctly, these devices have demonstrated excellent clinical efficacy and safety.

BACKGROUND: Poly-L-lactic acid (PLLA) is increasingly used for a range of indications, from HIV lipodystrophy to gluteal augmentation; however, there is no clear consensus on appropriate product preparation and use.

BACKGROUND:Hyaluronic acid (HA) fillers have increased in popularity. Although complications are rare, knowledge regarding their prevention and management are crucial. The utility of preinjection aspiration has become controversial. OBJECTIVE:Our study investigated the utility of preinjection aspiration as a safety checkpoint for HA fillers through comparison of physiochemical and rheological properties in an in vitro model. MATERIALS AND METHODS:Whole blood was drawn from vacutainers using syringes containing 10 commonly used HA fillers. Each HA filler was examined with the plunger pulled back at volumes of 0.2 and 0.5 cc. The time required to visualize a flash was recorded. Data were compared using physiochemical and rheological properties, pullback volumes, and needle gauges. RESULTS:Using a multivariable regression model, HA concentration, elastic modulus (G'), viscous modulus (G″), and complex modulus (G*) had significant relationships with time to flash, whereas needle gauge and pullback volume did not. However, when comparing pullback volume using an appropriate paired analysis, 0.5 cc pullback volume had a significantly decreased mean time to flash than 0.2 cc. CONCLUSION:Preinjection aspiration may have utility as a safety checkpoint for HA fillers. Practitioners may have to adjust pullback volume and waiting time to visualize the flash based on physiochemical and rheological properties.