Cosmetic Indications Research Articles

Breast implant-associated anaplastic large cell lymphoma: Proposal for optimal management.

8550 Background: Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a newly identified lymphoma arising around breast implants placed for cosmetic or reconstructive indications. ...

Comments on Singh et al.: Laser vaginal rejuvenation: not ready for prime time

Dear Editor, We read with interest the recently published article by Singh et al. entitled BLaser vaginal rejuvenation: not ready for prime time^ [1]. In this editorial, the role of CO2 laser in gynecology was discussed, focusing on its cosmetic indications. The authors correctly pointed out the almost complete lack of scientific literature on these emerging cosmetic treatments, of which little is known in terms of indications, standardization of the technique, complication rates, functional outcomes, and long-term safety. Despite this, the so-called Blaser vaginal rejuvenation,^ is very popular among women, and is largely marketed, and, in our opinion, improperly offered on the basis of the current evidence. For this reason, we deem this editorial extremely timely, sensible, and appropriate for stimulating good-quality research in this field and to guide clinical practice to an evidence-based and not a business-oriented path. On the other hand, we would like to clarify that CO2 laser is a light energy with recognized therapeutic effects in manymedical fields. Its use in cosmetic gynecology represents just one application, although it is the one most frequently criticized, which should not lead to the misinterpretation that any clinical CO2 laser application is to be blamed. In fact, the CO2 laser is a surgical instrument and, like the cold knife or the electrical scalpel, it can provide different effects, depending on the way we use it and on the energy that we decide to deliver. We have recently reported the regenerative effects of intravaginal fractional CO2 laser on the vaginal epithelium and lamina propria in postmenopausal women with vulvovaginal atrophy (VVA) [2]. A microablative fractional CO2 laser was demonstrated to be feasible, efficacious, and safe in improving VVA-related symptoms in postmenopausal women, at 12-week follow-up [3]. In addition, this technique caused a significant decrease in the severity of the dyspareunia related to vaginal dryness in these patients, and it was consequently associated with a consistent improvement in sexual function and sexual satisfaction of menopausal women with VVA [4, 5]. Therefore, despite the utmost pertinence of the editorial by Singh et al., we decided to write this letter, to avoid the misunderstanding that all gynecological applications of the CO2 laser are lacking scientific evidence and therapeutic effects.

Safety of modified coronal approach with dissection deep to temporalis fascia for facial nerve preservation.

To evaluate the safety of a modified coronal approach to the upper craniofacial skeleton with dissection deep to the temporalis fascia for enhanced preservation of the frontal branch of the facial nerve. Case series with chart review. Tertiary academic medical center. In total, 271 patients undergoing coronal flap approaches to the upper craniofacial skeleton by a single surgeon from January 2008 through December 2013 were included. Primary outcomes are temporary or permanent weakness of the frontal branch of the facial nerve as well as the incidence of temporal hollowing following surgery. Secondary outcomes include the presence of postoperative hematoma, seroma, infection, scarring, and alopecia. There were no cases involving either temporary or permanent facial nerve weakness. The incidence of other postoperative complications was also exceedingly low, including a hematoma rate of less than 1%, widened scarring in 2.6% of patients, and no cases of clinically significant temporal hollowing encountered during a mean follow-up period of 3 years. A modified coronal approach with dissection deep to the temporalis fascia offers a safe and reliable surgical technique for accessing the upper craniofacial skeleton. Observed complications were minimal, and despite this deeper plane of dissection, there were no cases of either temporary or permanent facial nerve weakness in a large retrospective series of patients from over the past 6 years. Consideration should be given for the routine use of this modified coronal approach for both reconstructive as well as cosmetic indications.

Prevalence of Body Dysmorphic Disorder and Impact on Subjective Outcome amongst Singaporean Rhinoplasty Patients

Importance: To improve understanding of body dysmorphic disorder in Asian rhinoplasty patients Objective: To determine the prevalence of body dysmorphic disorder (BDD) in Asian patients who received cosmetic rhinoplasty and determine its impact on subjective outcomes after surgery. Design: A survey study of patients who received cosmetic rhinoplasty between January 2009 and December 2012 was undertaken. Telephone interview using validated instruments (Body Dysmorphic Disorder Questionnaire and Rhinoplasty Outcome Evaluation) were performed to determine the prevalence of BDD and the subjects? pre-/ post-operative subjective scoring of their noses. Setting: Tertiary care hospital Participants: All adult patients who received rhinoplasty for mainly cosmetic indications were included into our study population. Main Outcome Measures: Those who screened positive on the Body Dysmorphic Disorder Questionnaire were considered to have BDD. The Rhinoplasty Outcome Evaluation quantified the individual?s perception of his/her nose before and after the operation. Results: Fifty-two patients who received cosmetic rhinoplasty were approached and forty-seven (90%) agreed to and completed the interview. The mean age of participants was 31.1 years. Twenty-seven (57%) of the participants were male and 20 were female. Of the 47 patients who participated in the study, seven (15%) were identified to have possible BDD. Six out of 7 of them were male. The BDD-group (mean age=26.0) was significantly younger (p=0.003) than the non-BDD group (mean age=32.0). Although the revision rate was clinically higher for the BDD group (29%) than the non-BDD group (12.5%), this was not statistically significant (p=0.276). Both groups reported overall improvement in ROE scores but patients with BDD had significantly lower pre- and post-operative ROE scores compared to non-BDD patients (p<0.05). Conclusion and Relevance: Our results show that BDD is quite prevalent amongst patients who have received cosmetic rhinoplasty. BDD patients are likely to have poorer subjective outcomes after surgery although they may experience some improvement in satisfaction when compared to before surgery. Level of Evidence: 3

Giant corymbiform nevus: A rare entity

Nevus refers to a maternal impression or birthmark. Various categories of nevi have been described in literature, with newer presentations being continuously reported. At times, gigantic presentations of melanocytic nevi may alarm patients to seek medical attention. Most often, though, these nevi are totally benign, the excision of which is indicated solely for cosmetic indications. We hereby report a case of corymbiform nevi, a morphologic rare subtype of lobulated intradermal nevi, which presented as a huge plaque, and is being reported because of its rarity, and the first of its kind from the Indian subcontinent.

구강 악안면 영역에서 보툴리눔 독소 주사 후 사망 부작용의 예방

보툴리눔 독소는 여러 영역에서 치료적 목적으로 사용되어 왔으며, 그 사용량과 적용범위가 점차 커지는 추세이다. 보툴리눔 독소가 강력한 독성 물질임에도 불구하고, 그 효과가 6개월이면 사라지는 가역적 치료방법이라는 인식이 강해서, 부작용이나 사용시 주의사항을 중요하게 생각하지 않는 경향이 있었다. 하지만 미국에서 부작용으로 사망하는 사례가 발생하여, 사용시 사망에 대한 주의사항이 추가되었다. 이에 본 종설은 보툴리눔 독소가 인체 내에서 대사되는 과정과, 발생 가능한 부작용, 사용시 유의사항, 사망 부작용 사례 등에 대해 지금까지 보고된 문헌들을 토대로 자세히 검토하고자 한다. Botulinum toxin (BoNT) has been used for a wide spectrum of therapeutic and cosmetic indications, and the range of indications is continually increased. Though BoNT is a powerful poison, the fact that not only the effect but also the adverse effect of it fader about 6 months after injection makes clinicians to neglect its dangerous property in clinical application. But Many reports about the adverse effects including death of BoNT injection have been reported, the FDA edited in additional warnings about hospitalizations and deaths. In this study, we intended to look through the metabolic process in human body, possible adverse effect, matters to be attended in application, and cases reports about deaths of BoNT by reviewing the previous studies.

Advanced Botulinum Toxin Injections for Dynamic Rhytides: Treating the Upper Face, Lower Face, and Beyond

Botulinum toxin (BT) is a neurotoxin produced by Clostridium botulinum, a Gram-positive anaerobic bacterium with different serotypes. It blocks acetylcholine release after binding to the presynaptic cholinergic receptors, thus preventing muscular contraction of the affected muscles. The muscular effects of BT usually last approximately from 3 to 6 months. Only botulinum neurotoxin A (BoNT-A) and botulinum neurotoxin B (BoNT-B) are commercially available and are approved for cosmetic and therapeutic uses. The BoNT-A is the most used serotype and the onabotulinumtoxin A (ONA), and abobotulinumtoxin A (ABO) are the prototypical products. The main cosmetic indications of BT are facial dynamic wrinkles, including the three thirds of the face, facial asymmetry, and masseteric hypertrophy as well as platysmal bands and selected chest wrinkles. BoNT-A injections can be safely combined with different cosmetic procedures. BT injections are considered a safe and efficient procedure, when performed by an experienced professional. Side effects are temporary and usually injection-related.

Current Fat Grafting Practices for Cosmetic and Reconstructive Breast Surgery

INTRODUCTION: Fat grafting is a popular procedure for breast surgeons yet variable techniques and results are reported.1 We surveyed members of the American Society of Plastic Surgery to elucidate current practice patterns and opinions to identify priorities for future investigation. METHODS: Six thousand letters were mailed (February 2012) followed several weeks later by an email reminder to the 5,942 members with valid addresses. Polling was closed on May 30, 2012 with 590 responses and 527 fully completed surveys. RESULTS: A large majority of responders perform this procedure (n=380, 69.3%). Safety concerns were cited as the most common reason for not performing fat grafting (43.4%). The majority of surgeons performed fat grafting for reconstructive (96.3%) indications with most avoiding the contralateral breast (72.7%). Reconstruction included deformities due to lumpectomy (64.1%) or mastectomy (66.6%), contour irregularities following both implant (93.4%) and tissue (88,4%) reconstruction. Cosmetic indications included augmentation with implant (45.5%) and without implant (48.5%), contour deformities post-augmentation (82.2%), and tuberous breast deformity (25.7%). The preferred donor site was the abdomen (79.9%), then thighs, flanks/back, and gluteal region. The top three fat harvesting techniques were manual aspiration (49.6%), wet liposuction (27.9%), and Lipivage (8.4%). Most employ tumescent solution (78.3%) or local anesthetic (11.4%). Liposuction cannulas are preferred over the syringe/needle for harvest (92.7 vs. 7.3%). Various cannulas are used: Coleman microcannula (21.5%), 1 mm (5.9%), 2 mm (29.4%), 3 mm (47.1%), 4 mm (22.6%), 5 mm (2.4%), and other (1.2%). Fat processing was predominantly centrifugation (28.5%) and filtration (42.4%) using either telfa/gauze or a strainer. Both fat freezing for delayed use (2.2%) and stem-cell enrichment techniques (3.3%) were uncommon. Most surgeons (56.4%) believed fat survival is 50-75% and only 7.9% believe survival is 75-100%. Overcorrection is routinely performed by 78.2% of surgeons and they report adding up to 25% volume (69.7%), 25-50% (27.9%), and greater than 50% (2.4%). Repeat sessions were performed mostly at 3-6 months (45.8%). CONCLUSION: Fat grafting is a promising surgical technique for breast surgeons but lacks standardization in clinical practice. ASPS members remain concerned about safety of this technique and possible oncologic concerns likely limit its use during reconstruction on a contralateral native breast. Further studies are needed to define optimal techniques in fat harvesting, donor-site selection, fat processing, injection technique/volume, and timing to improve safety and obtain reliable results.

Abo‐, Inco‐, Ona‐, and Rima‐Botulinum Toxins in Clinical Therapy: A Primer

Botulinum neurotoxin (BoNT) is an acetylcholine release inhibitor and a neuromuscular-blocking agent used for the treatment of a variety of medical and cosmetic indications. Currently, in the United States, there are four BoNT formulations licensed for use: abobotulinumtoxinA, incobotulinumtoxinA, onabotulinumtoxinA, and rimabotulinumtoxinB. These revised name designations were established to reinforce the understanding that each BoNT product has an individual potency and is not interchangeable with any other BoNT product. The therapeutic use of BoNTs is expanding and new formulations are on the horizon. This article is a primer that describes distinctions among currently available, licensed BoNT formulations. Toxin pharmacology, product characteristics, storage, handling, preparation, and dosages will be reviewed. In addition, issues related to dose equivalency ratios, immunogenicity, potency, and toxin spread will be discussed. Therapeutic indications and safety are discussed briefly. Knowledge of the available and licensed BoNT formulations and the ability to make distinctions in toxin pharmacology, product characteristics, and indications are vital for product selection, preparation, drug information, avoidance of drug errors, quality assurance, and patient safety.

Late-Onset Inflammatory Adverse Reactions Related to Soft Tissue Filler Injections

An ever-increasing number of persons seek medical solutions to improve the appearance of their aging skin or for aesthetic and cosmetic indications in diverse pathological conditions, such as malformations, trauma, cancer, and orthopedic, urological, or ophthalmological conditions. Currently, physicians have many different types of dermal and subdermal fillers, such as non-permanent, permanent, reversible, or non-reversible materials. Despite the claims of manufacturers and different authors that fillers are non-toxic and non-immunogenic or that complications are very uncommon, unwanted side effects do occur with all compounds used. Implanted, injected, and blood-contact biomaterials trigger a wide variety of adverse reactions, including inflammation, thrombosis, and excessive fibrosis. Usually, these adverse reactions are associated with the accumulation of large numbers of mononuclear cells. The adverse reactions related to fillers comprise a broad range of manifestations, which may appear early or late and range from local to systemic. Clinicians should be aware of them since the patient often denies the antecedent of injection or is unaware of the material employed. Most of these adverse effects seem to have an immunological basis, the fillers acting more as adjuvants than as direct T-cell activators, on a background of genetic predisposition. Their treatment has not been the subject of well-designed studies; management of both acute and systemic reactions is often difficult, and requires anti-inflammatory and occasionally immunosuppressive therapy. The clinical, pathological, and therapeutic aspects of inflammatory and immune-mediated late-onset adverse reactions related to soft tissue filler injections are thoroughly reviewed herein.

Cutaneous Serratia marcescens Infection in an Immunocompetent Patient after Filler Injection

®, a permanent filler containing polymethylmethacrylate (PMMA), into the glabellar area, administered by an unlicensed practitioner. Approximately 3 months prior to presentation she visited the same practitioner again and underwent an unknown procedure (explained as removal of collagen materials) along with injections of Juvederm ® , a hyaluronic acid (HA) filler, into the glabella and forehead. Thereafter, her face gradually became swollen, and an inflamed nodular lesion developed on the glabellar area. The lesions had been treated with topical antibiotics (fusidic acid and mupirocin), systemic antibiotics (amoxicillin-clavulanate and ceftezole) and several attempts at incisional drainage, but continued to wax and wane. No accompanying other skin lesions, enlarged lymph nodes, or signs of systemic involvement were detected. Laboratory data revealed normal biochemical and haematological study results. The results of skin tests with tuberculin, radiographic chest studies and atypical mycobacterial cultures were all normal. Histopathological findings showed a non-specific inflammatory reaction. Tissue and pus cultures were positive for S. marcescens and were sensitive to parenteral aminoglyco sides, oral trimethoprim-sulphamethoxazole (TMP-SMX) and ciprofloxacin. Treatment with oral TMP-SMX (160–800 mg twice daily for 3 weeks) and 2 attempts at incisional drainage of abscess were performed, which resulted in resolution of the lesion and negative culture findings (Fig. 1B). No recurrence was observed one year after the completion of therapy. DISCUSSION The use of dermal filler for cosmetic dermatological indications is increasing rapidly. Infection or contamination can occur with the use of soft-tissue augmentation agents, even after the injection of licensed products by experienced aesthetic physicians (1). In our case, the unlicensed practitioner injected HA filler into the patient’s skin in an area that was previously filled with PMMA filler. PMMA filler is a permanent synthetic filler, and such permanent fillers can induce long-lived, low-grade bacterial infections surrounding the implants (2, 3). S. marcescens usually causes infections of the lower respiratory tract, urinary tract, and surgical wounds and otitis, endocarditis, and septicaemia (4, 5). S. marcescens infections are predominantly observed in immunocompromised patients (6). In the reported case, we suppose that the patient’s skin was prone to infection due to the presence of PMMA filler, and that the additional HA filler injection allowed the entry of S. marcescens. Although we cannot specify the exact cause of contamination, it is likely that a lack of proper procedural hygiene played a crucial role in this infec tion. S. marcescens was possibly carried by humans in this case. To our knowledge, this is the first reported case of S. marcescens facial infection after filler injection in an im munocompetent patient. The possibility of pathogenicity of S. marcescens should be considered when treating infections caused by filler injection. To help minimize the risk of infection, clean preparation of the skin is recommended in the area of treatment prior to filler placement, and physicians should consider that skin previously treated with permanent filler may be vulnerable to infection even by minor additional procedures. This

The Canadian Society for Aesthetic Plastic Surgery 40th Annual Meeting

BACKGROUND: Breast implant-associated anaplastic large cell lymphoma (BI-ALCL) is a newly identified lymphoma arising around breast implants placed for cosmetic or reconstructive indications. Patterns of disease progression and optimal treatment strategies have not been described.

Impact of passing mesenchymal stem cells through smaller bore size needles for subsequent use in patients for clinical or cosmetic indications

BackgroundNumerous preclinical and clinical studies have investigated the regenerative potential and the trophic support of mesenchymal stem cells (MSCs) following their injection into a target organ. Clinicians favor the use of smallest bore needles possible for delivering MSCs into vascular organs like heart, liver and spleen. There has been a concern that small needle bore sizes may be detrimental to the health of these cells and reduce the survival and plasticity of MSCs.MethodsIn this report, we aimed to investigate the smallest possible bore size needle which would support the safe delivery of MSCs into various tissues for different clinical or cosmetic applications. To accomplish this we injected cells via needle sizes 24, 25 and 26 G attached to 1 ml syringe in the laboratory and collected the cells aseptically. Control cells were ejected via 1 ml syringe without any needle. Thereafter, the needle ejected cells were cultured and characterized for their morphology, attachment, viability, phenotypic expression, differentiation potential, cryopreservation and in vivo migration abilities. In the second phase of the study, cells were injected via 26 G needle attached to 1 ml syringe for 10 times.ResultsSimilar phenotypic and functional characteristics were observed between ejected and control group of cells. MSCs maintained their cellular and functional properties after single and multiple injections.ConclusionsThis study proves that 26 G bore size needles can be safely used to inject MSCs for clinical/therapeutics purposes.

Employment of Needles

Sir:FigureAutologous fat grafting has become a well-established and frequently applied method for soft-tissue regeneration and augmentation with both cosmetic and reconstructive indications. Nowadays, capabilities of this surgical procedure to improve the tissue quality are well known.1–5 In the past 20 years, although many different techniques have been developed, a standard procedure has not been chosen. Variables include harvesting technique, centrifugation, and injection technique. In our opinion, injection technique is a possible factor that has biological effects on adipose tissue. In our experience, blunt cannulas are not the perfect instruments needed to reach our target, which is the ability to perform a quick, safe, and painless procedure. Our choice for the reinjection of transplanted fat is an 18-gauge angiographic sharp needle (Cordis Corp., Bridgewater, N.J.) and the Seldinger technique. This choice has matured as a result of our first experiences in the use of autologous fat grafting; indeed, we started to treat burn scars, whose damaged tissues were characterized by a high level of fibrosis that conditioned a significant resistance to the sliding of the devices used for fat injection. From 2005 until now, we have performed more than 1000 procedures to treat not only burn scars, but also surgical scars, hard-to-heal wounds, and radiodystrophic tissues, all cases with a common feature: the presence of overflowing fibrous tissue. During our experience, we noted that the sharp angiographic cannulas, compared with the blunt ones, allow us to achieve better results. We are able to perform a highly precise technique; angiographic cannulas allow us to easily overcome tissue resistance related to the presence of fibrous tissue, thus making it possible to lay a constant amount of fat at the dermal-hypodermal junction. The lysis of scar tissue is obtained by moving the needle through two different methods by which fat is released: the first one consists of pushing the plunger of the syringe and leveraging the strength of exiting fat to overcome the fibrous tissue resistance or, otherwise, we can use a retrograde technique that is performed entering the needle for its entire length at the dermal-epidermal junction and then, while extracting the needle, releasing fat. Moreover, we suppose that a sharp cannula stimulates new collagen deposition and remodeling of fibrous tissues, similar to a “needling” procedure used in aesthetic medicine. Using sharp cannulas, we do not need to perform skin incisions with a scalpel for cannula access, and this minimizes patient discomfort related to the surgical procedure and avoids causing new scars. Another worthy consideration is that 18-gauge angiographic sharp needles for the Seldinger technique are disposable, low-cost devices, adding an additional favorable point in comparison with classic blunt cannulas. The main risks are related to the risk of intravascular fat injection, which can be easily avoided by choosing the retrograde injection method (as described above). Furthermore, in our clinical experience using angiographic needles, we found that edema and bleeding of treated areas have been comparable to those of the standard technique, which are virtually nil. We think that sharp cannulas are the best option for autologous fat grafting, considering the versatility and the excellent results obtained. Fabio Caviggioli, M.D. Università degli Studi di Milano, MultiMedica Holding S.p.A., U.O.C. Chirurgia Plastica, Sesto San Giovanni, Milan, Italy Davide Forcellini, M.D. Università degli Studi di Milano, IRCCS Istituto Clinico Humanitas, U.O. Chirurgia Plastica 2, Rozzano, Milan, Italy Valeriano Vinci, M.D. Università degli Studi di Milano, MultiMedica Holding S.p.A., U.O.C. Chirurgia Plastica, Sesto San Giovanni, Milan, Italy Guido Cornegliani, M.D. Università degli Studi di Milano, IRCCS Istituto Clinico Humanitas, U.O. Chirurgia Plastica 2, Rozzano, Milan, Italy Francesco Klinger, M.D. Università degli Studi di Milano, MultiMedica Holding S.p.A., U.O.C. Chirurgia Plastica, Sesto San Giovanni, Milan, Italy Marco Klinger, M.D. Università degli Studi di Milano, IRCCS Istituto Clinico Humanitas, U.O. Chirurgia Plastica 2, Rozzano, Milan, Italy DISCLOSURE The authors have no financial interest to declare in relation to the content of this article. No outside funding was received.

Patient satisfaction following Bio-Alcamid injection for facial contour defects

Bio-Alcamid, a polyalkylimide gel, can be injected into subcutaneous tissue as an endoprosthesis for correcting contour deformities and soft tissue defects. We have reviewed its facial uses and longer-term outcomes over a 7-year period, including a patient satisfaction survey. 69 patients were included in the study, 89.9% undergoing treatment secondary to HIV-associated facial lipoatrophy. 55.0% of patients responded to questionnaires: 52.5% experienced severe pain associated with injections, and 50.0% experienced at least one complication (migration, hardening, irregularity). 94.4% stated an improvement in their cheek volume, 77.8% would undergo the procedure again, and 86.1% would recommend the treatment to a friend. Despite the relatively high patient satisfaction, we no longer recommend this treatment to our patients for cosmetic indications, due to significant long-term complication rates.

Clinical Relevance of Botulinum Toxin Immunogenicity

Botulinum toxin type A is a 150 kD protein produced by Clostridium botulinum, which exists in a complex with up to six additional proteins. The ability of botulinum toxin to inhibit acetylcholine release at the neuromuscular junction has been exploited for use in medical conditions characterized by muscle hyperactivity. As such, botulinum toxin is widely recommended by international treatment guidelines for movement disorders and it has a plethora of other clinical and cosmetic indications. The chronic nature of these conditions requires repeated injections of botulinum toxin, usually every few months. Multiple injections can lead to secondary treatment failure in some patients that may be associated with the production of neutralizing antibodies directed specifically against the neurotoxin. However, the presence of such antibodies does not always render patients non-responsive. The reported prevalence of immunoresistance varies greatly, depending on factors such as study design and treated indication. This review presents what is currently known about the immunogenicity of botulinum toxin and how this impacts upon patient non-response to treatment. The complexing proteins may act as adjuvants and stimulate the immune response. Their role and that of neutralizing and non-neutralizing antibodies in the response to botulinum toxin is discussed, together with an assessment of current neutralizing antibody measurement techniques. Botulinum toxin preparations with different compositions and excipients have been developed. The major commercially available preparations of botulinum toxin are Botox® (onabotulinumtoxinA; Allergan, Inc., Ireland), Dysport® (abobotulinumtoxinA; Ipsen Ltd, UK), and Xeomin® (incobotulinumtoxinA; botulinum toxin type A [150 kD], free from complexing proteins; NT 201; Merz Pharmaceuticals GmbH, Germany). The new preparations of botulinum toxin aim to minimize the risk of immunoresistance in patients being treated for chronic clinical conditions.

Preoperative Incidence of Olfactory Dysfunction in Nasal Surgery Patients

Learn the incidence of olfactory dysfunction in preoperative patients prior to nasal surgery and compare with a control group of patients who are not going to have such surgery. Assess the usefulness of the coffee/tea differentiation test in assessing preoperative dysosmia. Prospective controlled cohort study. Urban medical center. One hundred fifty-one adult patients (aged 18-65 years) whose olfactory function was tested using the Pocket Smell Test and a coffee/tea differentiation test. A failed test required missing at least 1 item on the card or failure to report a difference between tea and coffee. The statistical analysis using the t test and the Fisher exact test were calculated using MINITAB. The study group (n = 55) had 38% men and 62% women compared with 58% men and 42% women in the control group (n = 96). The incidence of dysosmia was 32% in the study group and 14% in the control group. In the study group, 34.5% of patients failed the Pocket Smell Test and 12.4% failed the coffee/tea differentiation test as compared with 12.4% and 0%, respectively, in the control group. Patients who are scheduled for nasal surgery for medical or cosmetic indications are more likely to suffer from olfactory dysfunction before surgical intervention. This should be taken into consideration when counseling patients regarding possible postoperative complications.

Botulinum Toxin for Glabellar Lines

Facial rhytides represent a widespread aesthetic concern. In particular, glabellar lines are perceived as a sign of aging and may give an erroneous impression of negative emotions. The onset of glabellar lines is closely related to the movements of the underlying muscles. Botulinum toxins inhibit the release of acetylcholine into the synaptic cleft and therefore result in temporary muscle paralysis. The observation that botulinum toxin (BTX) smoothed facial lines when used therapeutically led researchers to study the toxin effect on glabellar lines. Nowadays, the use of BTX to smooth glabellar frown lines represents the leading procedure in aesthetic facial treatments and an increasing number of BTX formulations are becoming available. This article provides a comparative evaluation of currently available BTX options for the treatment of glabellar lines. Toxins have been divided into three groups, based on whether they have obtained approval for cosmetic use (approved treatments) or not (off-label treatments), or whether they are still under investigation (experimental treatments). We examine the basic similarities and differences between available botulinum toxins, and summarize the pharmacokinetics and dosing. All approved treatments consist of BTX type A (BTX-A) and differ in their molecular weight, as some formulations are made of a BTX-A complex of 900 kDa while the latest option on the market is a 150 kDa BTX-A that is free from complexing proteins. As for the dosage, the important aspect that emerges from this comparison is that even within a given serotype, such as BTX-A, formulations are not interchangeable as each possesses distinctive characteristics that are attributed to the unique toxin purification and manufacturing processes. There is a substantial body of published evidence on the use of these approved treatments for facial enhancement, proving efficacy and safety. We investigate the methods of evaluation used for each toxin and review the safety and efficacy data reported in the literature. Minor adverse effects, such as headache, blepharoptosis, and injection-site reactions, are relatively frequent but transient, whilst major adverse effects are rare. Some botulinum toxins, i.e. BTX type B, that are approved for therapeutic applications are used off-label for cosmetic indications, thus without the approval of the health regulatory committees and without sufficient published evidence on safety and efficacy. As for experimental treatments, a number of BTX products are currently in development or have been recently launched for aesthetic applications. These products have been specifically designed to overcome some of the limitations present in the older generation of products. However, some of these toxins may be easily purchased via the Internet, without having any license or approval for cosmetic or therapeutic indications; these products must be considered unsafe and are potentially a severe health risk for patients.

Bilateral Irreversible Severe Vision Loss From Cosmetic Iris Implants

To report a case of bilateral neovascular glaucoma with central retinal vein occlusions secondary to cosmetic iris implantation. Interventional case report. setting: Tertiary care center; ophthalmology clinic. patient: A 25-year-old woman presented with persistent bilateral blurry vision after simultaneous bilateral cosmetic iris implantation. Examination showed best-corrected visual acuity of hand motion in the right and 20/400 in the left eye with intraocular pressures (IOP) of 48 mm Hg in the right and 40 mm Hg in the left eye on maximal medical therapy. She had bilateral neovascularization of the iris and angle with synechial angle closure, surgical aniridia, central retinal vein occlusion, and end-stage glaucomatous optic neuropathy. She was diagnosed with neovascular glaucoma in both eyes, associated with cosmetic iris implants. intervention procedures: Humphrey 24-2 visual field testing, optic nerve coherence tomography, and fundus imaging were performed. After bilateral intravitreal bevacizumab and panretinal photocoagulation, Ahmed glaucoma drainage devices were implanted in both eyes. main outcome measures: IOP, anterior chamber inflammation, neovascularization. Despite aggressive treatment, severe permanent bilateral vision loss ensued. We strongly advise against the use of anterior chamber iris implants for cosmetic indications. Close monitoring of implanted individuals is necessary. Explantation should be considered at the earliest sign of adverse reaction.

Fractional lasers in dermatology - Current status and recommendations

Fractional laser technology is a new emerging technology to improve scars, fine lines, dyspigmentation, striae and wrinkles. The technique is easy, safe to use and has been used effectively for several clinical and cosmetic indications in Indian skin. Different fractional laser machines, with different wavelengths, both ablative and non-ablative, are now available in India. A detailed understanding of the device being used is recommended. Common indications include resurfacing for acne, chickenpox and surgical scars, periorbital and perioral wrinkles, photoageing changes, facial dyschromias. The use of fractional lasers in stretch marks, melasma and other pigmentary conditions, dermatological conditions such as granuloma annulare has been reported. But further data are needed before adopting them for routine use in such conditions. Any qualified dermatologist may administer fractional laser treatment. He/ she should possess a Master's degree or diploma in dermatology and should have had specific hands-on training in lasers, either during postgraduation or later at a facility which routinely performs laser procedures under a competent dermatologist or plastic surgeon with experience and training in using lasers. Since parameters may vary with different systems, specific training tailored towards the concerned device at either the manufacturer's facility or at another center using the machine is recommended. Fractional lasers can be used in the dermatologist's minor procedure room for the above indications. Detailed counseling with respect to the treatment, desired effects and possible postoperative complications should be provided to the patient. The patient should be provided brochures to study and also adequate opportunity to seek information. A detailed consent form needs to be completed by the patient. Consent form should include information on the machine, possible postoperative course expected and postoperative complications. Preoperative photography should be carried out in all cases of resurfacing. A close-up front and 45-degree lateral photographs of both sides must be taken. There are different machines based on different technologies available. Choice parameters depend on the type of machine, location and type of lesion, and skin color. Physician needs to be familiar with these requirements before using the machine. Fractional laser treatment can be carried out under topical anesthesia with eutectic mixture of lidocaine and prilocaine. Some machines can be used without any anesthesia or only with topical cooling or cryospray. But for maximal patient comfort, a topical anesthetic prior to the procedure is recommended. Proper postoperative care is important in avoiding complications. Post-treatment edema and redness settle in a few hours to a few days. A sunscreen is mandatory, and emollients may be prescribed for the dryness and peeling that could occur.