Severe Skin Laxity Research Articles

Combined Calcium Hydroxylapatite Plus Microfocused Ultrasound for Treating Skin Laxity of the Chest and Buttocks.

Microfocused ultrasound with visualization (MFU-V) and a calcium hydroxylapatite dermal filler (CaHA) were both developed to meet the patient demand for a noninvasive but effective means for lifting and tightening of lax skin. Recently, there has been growing interest in the use of dilute (1:1) and hyperdilute (1:≥2) CaHA to achieve skin tightening and stimulating neocollagenesis, and the combined use of difference techniques to obtain optimum aesthetic outcomes. Here, two patients with Grade 3 chest laxity on the Décolleté Wrinkling Assessment scale improved by 2 grade points after two treatment sessions because increasing the tissue layers treated with MFU-V and adding an additional syringe of CaHA per 100 cm2. Similarly, two addition patients with Grade 3 scores on the Gluteus Laxity Scale improved by 2 grade points after two or three treatment sessions. Customizing the number and depth of MFU-V treatment lines and the amount of CaHA should be considered when making a treatment plan for patients with severe skin laxity. Similarly, it is important to consider body mass index (BMI) when treating body areas such as the gluteus and the potential need for volume correction. J Drugs Dermatol. 2022;21(1):27-30. doi:10.36849/JDD.6368.

Combined Calcium Hydroxylapatite Plus Microfocused Ultrasound for Treating Skin Laxity of the Chest and Buttocks

Microfocused ultrasound with visualization (MFU-V) and a calcium hydroxylapatite dermal filler (CaHA) were both developed to meet the patient demand for a noninvasive but effective means for lifting and tightening of lax skin. Recently, there has been growing interest in the use of dilute (1:1) and hyperdilute (1:≥2) CaHA to achieve skin tightening and stimulating neocollagenesis, and the combined use of difference techniques to obtain optimum aesthetic outcomes. Here, two patients with Grade 3 chest laxity on the Décolleté Wrinkling Assessment scale improved by 2 grade points after two treatment sessions because increasing the tissue layers treated with MFU-V and adding an additional syringe of CaHA per 100 cm2. Similarly, two addition patients with Grade 3 scores on the Gluteus Laxity Scale improved by 2 grade points after two or three treatment sessions. Customizing the number and depth of MFU-V treatment lines and the amount of CaHA should be considered when making a treatment plan for patients with severe skin laxity. Similarly, it is important to consider body mass index (BMI) when treating body areas such as the gluteus and the potential need for volume correction. J Drugs Dermatol. 2022;21(1):27-30. doi:10.36849/JDD.6368

Evaluation of surgical versus VASER assisted liposuction in management of submental adiposity in moderate to severe skin laxity and significant lipodystrophy

Background Submental adiposity is one of visible signs of the aging process which affects the aesthetic look of the face and neck , and its management usually is difficult without surgery, nowadays we can achieve a good results in double chin without surgical lifting of neck by new technology (VASER liposuction) in many cases. Aim of the work: To Evaluation of surgical versus VASER assisted liposuction in management of submental adiposity in moderate to severe skin laxity and significant lipodystrophy. Patient and Methods: This study is prospective study was conducted on 30 male and female patients starting from September 2018 till march 2021, in Al-Azhar university hospitals presented with moderate or severe submental adiposity (double chin), were categorized in random fashion into two groups, Group (A) management by ultrasound assisted liposuction VASER (15 patient), Group (B) surgical management (neck lifting) (15 patient). Results: Regarding patient acceptance, among the VASER group, 6 patients (40%) reported good score, 5 patients (33.3%) reported very good score, 4 patients (26.7%) reported fair score. While 10 patients (66.7%) reported very good score, 3 patients (20%) reported excellent score and 2 patients (13.3%) reported good score. Conclusion: Surgical neck lifting is the best result , especially in old age however , VASER liposuction have a good results in young and middle age , especially in mild , moderate and some cases of sever lipodystrophy , the vaser liposuction is a good option for the patient whose a fried from the scar of surgery.

A Validated Photonumeric Scale for the Evaluation of Neck Skin Laxity.

Neck aging is usually evaluated together with the lower face. To date, a skin laxity scale for the neck as an independent anatomical district is lacking. To create and validate a proposed photonumeric neck skin laxity (NSL) scale. Frontal neck photographic images of 110 subjects were collected. Each standardized neck image was evaluated twice by 3 independent doctors, 1 week apart. A 4-point photonumeric NSL scale was developed (0 = absence of skin laxity and 4 = severe skin laxity) and validated in terms of intraobserver and interobserver correlation and internal consistency. The intraobserver reliability analysis of the 2 assessments performed by each observer revealed excellent correlation and consistency of the severity grading, independently of the time of evaluation (from 0.96 to 0.99, p < .01). Furthermore, the interobserver reliability analysis revealed an excellent agreement between the evaluators and an internal consistency independent of the evaluator (0.97, p < .01). The newly developed NSL scale is a reliable and reproducible scoring system for the aesthetic evaluation of skin laxity of the neck.

Noninvasive skin tightening: focus on new ultrasound techniques.

Microfocused ultrasound (MFU) has been recently developed to meet the ever-growing public demand for achieving significant, noninvasive skin lifting and tightening. MFU can be focused on subcutaneous tissue where the temperature briefly reaches greater than 60°C, producing small (<1 mm3) thermal coagulation points to a depth of up to 5 mm within the mid-to-deep reticular layer of the dermis and subdermis. The intervening papillary dermal and epidermal layers of skin remain unaffected. The application of heat at these discrete thermal coagulation points causes collagen fibers in the facial planes such as the superficial musculoaponeurotic system and platysma, as well as the deep reticular dermis, to become denatured, contracting and stimulating de novo collagen. A commercially available device combines MFU with high-resolution ultrasound imaging (MFU-V), which enables visualization of tissue planes to a depth of 8 mm and allows the user to see where the MFU energy will be applied (Ultherapy®; Ulthera Inc., Mesa, AZ, USA). Using different transducers, MFU-V treatment can be customized to meet the unique physical characteristics of each patient by adjusting energy and focal depth of the emitted ultrasound. By targeting the facial superficial musculoaponeurotic system, noninvasive tightening and lifting of sagging facial and neck skin and improvements in the appearance of wrinkles can be achieved. MFU-V can also improve lines and wrinkles of the décolleté. Treatment protocols for the use of MFU-V continue to be refined, and its use in combination with other rejuvenation techniques has been demonstrated. Brief discomfort that often occurs during treatment can be minimized with oral nonsteroidal anti-inflammatory drugs. Other treatment-related adverse events include transient erythema, edema, and occasional bruising. MFU-V is best suited for patients with mild-to-moderate skin and soft tissue laxity. For older patients with severe skin laxity and marked platysmal banding, surgical treatment should be considered.

Modified Lateral SMASectomy

Sir: Recently, advances on facial anatomy have been significantly achieved by Rohrich and Pessa1 and Mendelson et al.2 For this reason, various face-lift techniques have evolved and been introduced into clinical practice.3,4 Although limited-incision face lifts are popular, conventional face lifts have their own indications for treatment of aging face with severe skin laxity. Recently, face lifts with lateral superficial musculoaponeurotic system (SMAS)-ectomy technique have gained prominence among plastic surgeons. The theoretical benefits of lateral SMASectomy for facial rejuvenation are a short recovery time, relatively simple operation, low incidence of complications such as tearing of the SMAS and potential facial nerve injury, vertical elevation and strong fixation of the SMAS, comparable outcome with extended SMAS technique, and a short scar because of limited incision. Because of these advantages, we think the original technique is a good option with regard to overall improvement of skin tightness and effacement of fine wrinkles. However, we are somewhat suspicious of the effect on midface ptosis. Thus, following the original lateral SMASectomy described by Daniel Baker in 1992, various modified techniques have been introduced.5 We also adopted our own modified lateral SMASectomy design. The procedure was performed under local anesthesia with intravenous sedation. After access skin incision, dissection extends across the zygoma to release the zygomatic ligaments and masseteric cutaneous ligaments. We do not dissect further anteriorly. Then, we designed a trapezoid SMAS flap. The superior border of the incision was approximately at the level of the zygomatic arch and the inferior border was approximately 4 to 5 cm below the jaw line. A representative design is shown in Figure 1.Fig. 1: Intraoperative design of the modified lateral flap.Over a 2-year period, the patients underwent modified lateral SMASectomy. The treatment outcomes were evaluated both subjectively and objectively. All but four patients [33 of 37 (89.1 percent)] were satisfied with the outcomes after the surgical procedure. Consensus ratings by the two independent plastic surgeons found that objective outcomes were divided among excellent, good, and fair. None of the outcomes was rated as no change or worse. The postoperative course was uneventful, with the exception of five patients (13.5 percent) who presented with skin slough, hypertrophic scar, and hematoma. We think that our modified technique can be considered as another option that yields a better effect on midface ptosis, jowl, and jaw line and more powerful effacement of nasolabial folds. DISCLOSURE The authors have no financial interest to declare in relation to the content of this communication. Tae Hwan Park, M.D. Jin Hyuk Park, M.D. Kwi Whan Whang, M.D., Ph.D. Research Department Miz Aesthetic Surgery Clinic Seoul, Republic of Korea

Arm Dynamic Definition by Liposculpture and Fat Grafting

The contour of the arm is determined by muscular shape and volume. Liposuction in this area is challenging due to the difficulties of achieving symmetry and the high risk of contour irregularities due to fat structures in the region. The authors describe a new technique to achieve muscular definition in the arm. From January 2005 to December 2011, a total of 651 arm-sculpting procedures were performed in consecutive patients. Patients with body mass index (BMI) >30 kg/m(2) and/or severe skin laxity were excluded. Fat grafting was performed in the deltoid area in selected cases. The areas of fat extraction and grafting were specific to gender: in men, an athletic, muscular look was preferred, whereas in women, a slimmer and less-defined shape was desired. Of the 651 patients, 158 were men (24.3%) and 493 were women (75.7%). Most patients (98.3%) were satisfied with the results in arm dynamic definition. All patients underwent other body contouring procedures at the time of arm enhancement. Complications (n = 21) included 1 soft tissue abscess in the posterior arm, 2 unilateral hematomas, and 3 unilateral seromas that required puncture, along with 15 cases of minor asymmetry. Transitory hardening of the skin of the posterior arm was frequent (n = 104) due to superficial fat extraction, but all cases resolved within 6 months. The authors were able to achieve natural results with this new procedure in arm contouring. The technique is safe and effective with reproducible results when performed through multilayer fragmentation and liposuction with an anatomical extraction. Fat grafting can be performed for contouring with no additional complications.

Costello syndrome with severe cutis laxa and mosaic HRAS G12S mutation

Costello syndrome is a rare developmental disorder characterized by coarse face, postnatal growth retardation, skin and musculoskeletal anomalies, cardiovascular abnormalities, mental retardation, and tumor predisposition. Dermatological manifestations usually include redundant, soft and thickened skin. Loose skin is especially present over the neck, hands, and feet. Heterozygous missense mutations in HRAS are causative for Costello syndrome, with the c.34G > A (p.G12S) mutation as the most commonly found alteration. In the majority of affected individuals pathogenic sequence changes appeared de novo, however, two individuals with somatic mosaicism for the HRAS mutation have been reported. Here, we describe a boy with somatic mosaicism for the c.34G > A mutation in HRAS. Allelic quantitation revealed the mutation in approximately 58% of his lymphocytes; however, in DNA derived from buccal cells we could not detect the sequence change. The patient presented with the typical clinical findings of Costello syndrome such as increased birth weight, severe failure to thrive, characteristic facial appearance, and skin abnormalities. The dermatological anomalies were remarkable as he showed severe skin laxity with wrinkling of skin on all parts of the body due to loss of subcutaneous fat that decreased significantly by age 13 months. This case further adds to the phenotypic variability seen in patients with somatic mosaicism for an HRAS mutation and highlights the awareness of mosaic mutations in Costello syndrome when molecular testing is performed.

Pseudoxanthoma Elasticum-Like Phenotype with Cutis Laxa and Multiple Coagulation Factor Deficiency Represents a Separate Genetic Entity

Data on six patients with a Pseudoxanthoma Elasticum (PXE)-like phenotype, characterized by excessive skin folding (resembling cutis laxa) and a deficiency of the vitamin K-dependent clotting factors (II, VII, IX, and X) are presented. A comparison is made between the clinical, ultrastructural, and molecular findings in these patients and those seen in classic PXE and cutis laxa, respectively. Clinical overlap with PXE is obvious from the skin manifestations of yellowish papules or leathery plaques with dot-like depressions at presentation, angioid streaks and/or ocular peau d'orange, and fragmentation and calcification of elastic fibers in the dermis. Important phenotypic differences with PXE include much more severe skin laxity with spreading toward the trunk and limbs with thick, leathery skin folds rather than confinement to flexural areas, and no decrease in visual acuity. Moreover, detailed electron microscopic analyses revealed that alterations of elastic fibers as well as their mineralization were slightly different from those in classic PXE. Molecular analysis revealed neither causal mutations in the ABCC6 gene (ATP-binding cassette subfamily C member 6), which is responsible for PXE, nor in VKORC1 (vitamin K 2,3 epoxide reductase), known to be involved in vitamin K-dependent factor deficiency. However, the GGCX gene (gamma-glutamyl carboxylase), encoding an enzyme important for gamma-carboxylation of gla-proteins, harbored mutations in six out of seven patients analyzed. These findings all support the hypothesis that the disorder indeed represents a separate clinical and genetic entity, the molecular background of which remains to be unraveled.

Brachioplasty After Massive Weight Loss: A Simple Algorithm for Surgical Plane

After massive weight loss, patients experience a severe skin laxity of the arms with or without associated fat deposits. More than 20 years elapsed after the first aesthetic brachioplasty in 1954 before this problem was addressed with significant technical innovation. The current brachioplasty techniques are somewhat unpredictable and commonly associated with significant untoward results and complications including misplaced, widened, or hypertrophic scars as well as contour deformities resulting from overcorrection centrally and underresection. The authors define preoperative marking that permits reduction of overcorrection problems and makes the surgical technique easy for young surgeons. They have performed this procedure for 6 years with satisfactory results.

A Classification System for Facial Fat Atrophy

Introduction: With aging, senescent fat atrophy occurs, with progressive degenerative changes in elastin and collagen in conjunction with marked bony resorption. The resultant effect is a noticeable deflation of the volume and contour of the face over time. We present here a study of facial fat atrophy in an attempt to develop a useful and transferable classification system for each type of identifiable area of noted volume loss. Materials and Methods: Three groups of patients (group I, 9 patients aged 10–30 years; group II, 8 patients aged 31–45 years; and group III, 9 patients aged 46–70 years) were evaluated by computed tomography head scans using standard radiologic cuts measuring 4 distinct areas of localized facial fat deposition: (1) periorbital, (2) buccal, (3) preauricular, and (4) temporal. The areas were measured on the right (R) and left (L) sides of the face, and an average value determined for each age group. Results: Buccal fat measurements for group I were (R) 23.84 mm, (L) 20.76 mm; for group II, (R) 27.56 mm, (L) 29.63 mm; and for group III, (R) 15.51 mm, (L) 14.34 mm. Group I exhibited a midrange of buccal fat in comparison to groups II and III, whereas group II showed the largest amount and group III the least. Preauricular fat measurements for group I were (R) 10.84 mm, (L) 10.00 mm; for group II, (R) 14.00 mm, (L) 13.82 mm; and for group III, (R) 6.86 mm, (L) 6.83 mm. Again, group I exhibited a midrange of preauricular fat in comparison to groups II and III, whereas group II showed the largest amount and group III the least. Temporal fat measurements for group I were (R) 12.04 mm, (L) 11.76 mm; for group II, (R) 18.86 mm, (L) 19.68 mm; and for group III, (R) 15.67 mm, (L) 16.63 mm. In this area, group I had the smallest amount of temporal fat, whereas group II had the largest amount, and group III showed a decline from the amount noted in group II. Periorbital fat measurements for group I were (R) 6.22 mm, (L) 5.72 mm; for group II, (R) 6.31 mm, (L) 7.21 mm; and for group III, (R) 7.33 mm, (L) 7.61 mm. In this instance, group I had the least amount of fat noted infraorbitally, with group II midrange, and group III had the most because of pseudoherniation of orbital fat. Discussion: The data collected in this paper display for each area of localized facial fat—except the periorbital area, which reflects the pseudoherniation of orbital fat contents—a progressive increase in localized facial fat deposits from group I to group II, with a subsequent decrease in group III in each area, consistent with senescent facial fat atrophy. Four types of facial fat atrophy classifications are thus described: type I, with fat atrophy limited to 1 area, minimal skin laxity, and minimal bony resorption; type II, with fat atrophy limited to 2 areas, mild skin laxity, and mild bony resorption; type III, with fat atrophy limited to 3 areas, moderate skin laxity, and moderate bony resorption; and type IV, with fat atrophy in all 4 areas, severe skin laxity, and severe bony resorption. Conclusion: Facial fat atrophy occurs progressively with aging in conjunction with loss of skin elasticity, collagen degradation of the skin, and bony resorption of the facial skeleton. This results in a progressive deflation of the face with obvious volume loss and subsequent skin redundancy. This classification system attempts to organize and categorize this occurrence.

The ???Anterior-Only??? Approach to Neck Rejuvenation: An Alternative to Face Lift Surgery

The ideal procedure for those patients with aging of the lower face and neck is a cervicofacial rhytidectomy. However, within this group is a subset of patients whose goals can be met with a lesser procedure. These patients must be interested in profile change only, with no desired change in the midface. Patients undergoing neck rejuvenation by means of a submental approach fall into three groups: (1) patients with obtuse cervicomental angles and good skin elasticity (who may be treated with liposuction alone); (2) patients with subplatysmal fat or mild to moderate skin and muscle laxity (these patients are best treated by anterior lipectomy and platysmaplasty); and (3) patients with marked skin excess or severe skin laxity (best treated by procedures with excised skin, i.e., traditional face lift or direct excision of neck skin and Z-plasty). Thirty-three consecutive patients with mild (grade II, 16 patients), moderate (grade III, 11 patients), and severe (grade IV, six patients) cervicomental angle deformities were treated with anterior platysmaplasty and submental lipectomy. Twenty of 33 patients improved by one grade (61 percent), whereas 12 of 33 improved by two grades (36 percent). Young patients with minimal subplatysmal fat can be treated by liposuction alone. Patients with subplatysmal fat and mild or moderate skin or muscle laxity will obtain consistent results with platysmaplasty and submental lipectomy. Skin excisional procedures are reserved for those patients with severe skin excess or laxity.

Serial notching of the platysma bands

Background: Traditional procedures for the reduction of platysma bands can result in scarring and hardening of tissue in the submental region. Objective: A technique for serial notching of the platysma bands is described that is more effective and causes fewer complications than the traditional submental and midline approaches. Methods: The platysma bands are marked for incision; optimal results require multiple incisions with a distance of 3 to 4 cm between each incision. The muscle band is dissected and undermined, and notching is performed with an electrocautery. Suturing is necessary only if severe skin laxity is present; otherwise, Steri-strips for 3 to 4 days are sufficient. In most cases, submental lipoplasty is also necessary. Results: A series of 51 procedures performed over 14 months produced satisfactory results with no major complications. Conclusions: Serial notching is a good adjuvant to a neck lift or lower-face procedures, particularly in older patients. (Aesthetic Surg J 2001;21:412-417.)

Dispersal of radioisotope labelled solution following deep dermal injection in Ehlers-Danlos syndrome

Ehlers-Danlos syndrome (EDS) is the commonest inherited disorder of connective tissue, affecting around 10 000 patients in the UK. Patients with EDS have reported that local anaesthetic is often ineffective. Patients with less severe skin laxity often have the most problems. We have postulated that this resistance to local anaesthetics is not due to the lax connective tissues as is often assumed. This study used radioactively labelled solution ((99m)Tc-pertechnetate) administered as a deep dermal injection in the forearm. The rate of dispersal of isotope was measured over 60 min and found to be identical between six patients with EDS and three controls. The effects of local anaesthetics are complex and depend on the individual chemical properties of the agent and a number of tissue factors. This study would suggest that the lack of effectiveness of local anaesthetic solutions is not due to rapid dispersal of solution. It is unlikely therefore that its lack of effect can be compensated for by simply increasing the amount used. The diagnosis of EDS should be considered in any patient who complains unexpectedly of pain during their procedure, particularly when the surgeon knows that an adequate volume of local anaesthetic has been used.

Brachioplasty with superficial fascial system suspension.

Although significant innovations in brachioplasty occurred in the 1970s, it remains an unpopular procedure. Current brachioplasty techniques are somewhat unpredictable and are commonly associated with significant untoward results. Recent anatomic studies demonstrate that in youth the posteromedial arm soft tissues are firmly suspended to a tough yet dynamic fascial system sling that ultimately gains its strength from the clavicular periosteum by means of the clavipectoral and axillary fasciae. Loosening of the connections of the arm superficial fascial system to the axillary fascia, as well as relaxation of the axillary fascia itself, with age, weight fluctuations, and gravitational pull yields a "loose hammock" effect, resulting in significant ptosis of the posteromedial arm. On the basis of this anatomic concept, the brachioplasty procedure was modified to provide secure anchoring of the arm flap to the axillary fascia along with strong superficial fascial system repair of incisions, reducing the risk of widening or migration of scars and unnatural contours. Five patients having brachioplasty with or without liposuction were followed for 6 to 12 months. The primary indication for surgery is moderate to severe skin laxity of the arms with or without associated arm fat deposits. Results were consistent, and complications were limited.