Fellows are required to give a series of lectures relating to all aspects of dermatologic surgery. It is expected that fellows will be involved in a research project and present their data at one of the national meetings. In This Section More Info. Rollup Image.
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Request Username Can't sign in? Forgot your username? It is important not to inject at the level of the mental crease, as this will also weaken the lower lip depressors and orbicularis oris, and cause serious adverse effects which can persist for six months or more, depending on the dose.
Again, as in the perioral area, weakening rather than paralysis is the aim of treatment. Performing injections as described above will soften many irregularities in this area; especially those created by trauma or surgery, such as chin implant irregularities.
This was previously treated by soft-tissue augmentation and laser resurfacing. Now, a combination of soft-tissue augmentation and BTX-A injection of the mentalis, or BTX-A injections alone in those who do not require augmentation will soften this appearance of the chin. We have discussed the injection of the DAO and mentalis separately above, because we initially approached those muscles as separate and distinct areas.
However, it is important to look at all muscles functionally, as well as anatomically, both here and elsewhere. The action of BTX on a single muscle is usually associated with a secondary effect on adjacent muscles, which may produce positive or negative effects. We have found that attempts to weaken the DAO or mentalis alone, while appropriate in some individuals, is ineffective or associated with unacceptable side effects in others.
However, if a lower dose of BTX is injected into both muscles at the same time—our optimal treatment for this area at present—the weakening effect is synergistic, and is achieved with fewer side effects. This produces a subtle effect which is not as dramatic as the effect in the glabella, where paralysis is the aim in most individuals. We recommend that this technique be used only in individuals who have experienced the effects of BTX in other areas. Patients should be counseled thoroughly, using a hand mirror to demonstrate the aim of treatment, and Advanced Cosmetic Use of Botulinum Toxin Type A 31 clinicians should take active and passive photographs, and follow-up two weeks after injection to assess and document the response to treatment, including any side effects.
Lower Facial Asymmetry In patients who have experienced surgical or traumatic injury to the orbicularis oris or risorius muscle, the unopposed action of the partner muscles in the normally innervated side may lead to decentration of the mouth. BTX-A injected in the overdynamic risorius, immediately lateral to the lateral corner of the mouth, and in the mid-pupillary line will recenter the mouth when the face is in repose. Some patients have congenital or acquired weakness of the DAO, resulting in inability to depress the corner of one side of the mouth; chemodenervation of the partner muscle will restore functional and aesthetic balance.
Masseteric Hypertrophy BTX-A for contouring in the lower face may be a simple alternative method of shaping the mandible—a relatively common aesthetic procedure among Asians—with a short recovery period, although mostly small studies have published results. To et al. Four patients considered the result satisfactory after a single injection. More recently, Park et al. Clinical effects lasted six to seven months following injection before the muscle thickness retreated to its initial size; at 10 months, 36 patients expressed satisfaction with the results.
Chemodenervation of the Neck Chemodenervation with BTX-A can be useful in the aging neck, reducing the appearance of necklace lines and platysmal bands. Necklace Lines Horizontal necklace lines of skin indentation occur in slightly chubbier necks because of subcutaneous muscular apaneurotic system attachments 32 Carruthers and Carruthers in the neck. Injection is deep dermal, rather than subcutaneous, because there are deeper venous perforators that can bleed, especially lateral in the neck, and the underlying muscles of deglutition are cholinergic and could potentially be affected.
Massaging the neck gently after injection can usually prevent bruising. No more than 10 to 20 U is injected per treatment session. Platysmal Bands Over time, the cervical skin loses its elasticity, more submental fat becomes visible, and the platysma separates anteriorly, becoming two diverging platysmal bands, the anterior borders of which often tighten and become visible when patients animate their neck as when speaking, exercising, or playing a musical instrument.
Kane 32 describes good results of BTX-A for platysmal bands in 44 patients, but cautions that the gold standard for most aging necks remains traditional rhytidectomy surgery. In addition, BTX-A may make platysmal bands appear worse in patients with accompanying jowl formation and bone resorption; it is therefore essential to carefully select patients with obvious platysmal bands, good cervical skin elasticity, and minimal fat descent.
We previously reported one patient treated with 60 U in the neck who developed profound dysphagia, necessitating a nasogastric tube until she could swallow again As additional injections can always be given in subsequent treatments, no more than 30 to 40 U is injected per cervical treatment and caution is exercised. Sometimes there is no replacement for surgery, skin resurfacing, soft-tissue augmentation, or proper skin care; however, neuromodulation has been reported to enhance and increase the duration of other cosmetic procedure results Surgical Procedures Since the constant action of facial muscles can interfere with or reverse the results of cosmetic surgery, weakening the muscles with BTX-A before surgery may make it easier to manipulate tissues, allowing for greater surgical correction or better concealment of the surgical incisions.
In addition, some experts report that BTX-A during or after the procedure prevented or slowed the return of the wrinkles by reducing the action of the responsible muscles Concurrent treatment, BTX-A with periorbital rhytidectomy, has been reported to improve and increase the longevity of the surgical results.
Soft-Tissue Augmentation As previously discussed, BTX-A is used routinely as adjunctive therapy in soft-tissue augmentation to achieve more effective, longer-lasting results, especially in the mid- and lower face. Fagien and Brandt 25 found that BTX-A in patients undergoing soft-tissue augmentation in certain facial areas, i. Laser Resurfacing The adjunctive use of BTX-A with laser resurfacing leads to superior and longer-lasting outcomes and aids the healing of newly resurfaced skin long enough to effect more permanent eradication of wrinkles 13,25 , and regular postoperative injections, given every 6 to 12 months, prolong the effects of resurfacing West and Alster 36 found an enhanced and longer-lasting improvement of forehead, glabellar, and canthal rhytides when BTX-A injections were given postoperatively in conjunction with CO2 laser resurfacing, compared to patients who received laser resurfacing alone.
Lowe et al. Most complications are relatively uncommon and are related to poor injection techniques. Upper Face Complications Generally, proper injection techniques and patient selection can avoid the most worrisome complications in the upper face—namely brow and lid ptosis and asymmetrical changes to the appearance of the eyebrows.
Brow Ptosis Brow ptosis, which occurs when the injected toxin affects the frontalis during glabellar or brow treatment, is one of the most undesirable adverse events and is related to poor injection technique. In general, a higher concentration allows for more accurate placement, greater duration of effect, and fewer side effects, since lower concentrations encourage the spread of toxin; there is an area of denervation associated with each point of injection due to toxin spread of about 1 to 1.
Patients must be advised strictly to avoid rubbing or massaging the injected area for two hours following the treatment. Brow ptosis can be annoying, lasting for up to three months creating a very negative appearance, and is avoided by proper selection of patients BTX-A works best in younger patients, aged 20—45 years and preinjection of the brow depressors if necessary i. It is important to remember that the brow shape can be changed, and lack of expressivity may be caused by injection of the frontalis lateral to the mid-pupillary line.
BTX-A is injected above the lowest fold produced when the patient elevates his or her frontalis and limit the treatment of forehead lines is limited to the portion 3 cm or more above the brow. Injecting the glabella and the whole forehead in one session is more likely to produce brow ptosis Upper Eyelid Ptosis Upper eyelid ptosis, most commonly seen after the treatment of the glabellar complex, occurs when the toxin diffuses through the orbital septum, affecting the upper eyelid levator muscle.
Ptosis can appear in as early as 48 hours or as late as 14 days after injection, and can persist from 2 to 12 weeks Again, eyelid ptosis has been linked to poor injection technique; injection of large volumes is avoided, accurately place injections are accurately placed no closer than 1 cm above the central bony orbital rim, and patients are advised to remain upright and not to manipulate the injected area for several hours after injection.
BTX-A is not injected at or under the mid-brow Eyelid ptosis can be treated by using apraclonidine, which elevates the lid by 1 to 2 mm and compensates the loss of levator palpebrae superioris Fig. One or two drops three times a day can be continued until the ptosis resolves. However, it is important to note that allergic contact dermatitis can occur with the use of apraclonidine.
Periorbital Complications Bruising, diplopia, ectropion, or a drooping lateral lower eyelid and an asymmetrical smile caused by the spread of toxin to the zygomaticus major are all reported complications of BTX-A in the periorbital area. It is to be injected laterally at least 1 cm outside the bony orbit or 1. B shows an image taken 20 minutes later, after two drops of 0. Questioning patients about dry eye symptoms such as whether they experience dry eyes during air travel may identify individuals who will experience an exacerbation of these symptoms with weakening of the infraorbital orbicularis oculi.
Lower Face and Cervical Complications Studies of the lower face report complications such as effects on muscle function and facial expression, usually due to overenthusiastic use of BTX-A in large doses Injections are avoided in singers, musicians, or other patients who use their perioral muscles with intensity. Treatment of the upper face with BTX-A is no longer considered novel, and once a thorough understanding of the resting and dynamic musculature of the face has been achieved, clinicians are able to branch out into the aesthetic artistry of facial contouring and sculpting.
Moreover, the adjunctive use of BTX-A has taken its place in many cosmetic protocols, enhancing or prolonging the effects of other procedures and achieving more aesthetically pleasing results. Product monograph. Markham, Ontario: Allergan Inc. Botulinum toxin type B Myobloc in the management of hyperkinetic facial lines. Otolaryngol Head Neck Surg ; — Sadick NS.
Botulinum toxin type B Myobloc for glabellar wrinkles: a prospective openlabel response study. Dermatol Surg ; 29 5 — Prospective open-label study of botulinum toxin type B Myobloc at doses of and units for the treatment of glabellar wrinkles. Dermatol Surg. In press Botulinum toxin type B for dynamic glabellar rhytides refractory to botulinum toxin type A.
New Orleans, LA, Feb 22—27, Matarasso SL. Comparison of botulinum toxin types A and B: a bilateral and doubleblind randomized evaluation in the treatment of canthal rhytides. Klein AW. Dilution and storage of botulinum toxin. Pharmacology of botulinum toxin. Pain associated with injection of botulinum A exotoxin reconstituted using isotonic sodium chloride with and without preservative: a doubleblind, randomized controlled trial.
Carruthers A, Carruthers J. Botulinum toxin type A: history and current cosmetic use in the upper face. Semin Cutan Med Surg ; — Dose dilution and duration of effect of botulinum toxin type A BTX-A for the treatment of glabellar rhytids. Package insert. Dose-ranging study of botulinum toxin type A in the treatment of glabellar lines.
Presented at the 20th World Congress of Dermatology. Paris, France, July 1—5, Botulinum toxin type A BTX-A in the treatment of glabellar rhytids: an objective analysis of treatment response. Botulinum toxin type A for treating glabellar lines in men: a dose-ranging study. Raising eyebrows with botulinum toxin. Temporal brow lift using botulinum toxin A. Plast Reconstruct Surg ; — Brow lift with botulinum toxin.
Glabella BTX-A injection and eyebrow height: a further photographic analysis. San Francisco, CA, March 21—26, Fagien S, Brandt FS. Primary and adjunctive use of botulinum toxin type A Botox in facial aesthetic surgery: beyond the glabella. Clin Plast Surg ; — Carruthers J, Carruthers A. BOTOX use in the mid and lower face and neck. Botulinum-A toxin treatment of the lower eyelid improves infraorbital rhytides and widens the eye. Goldman MP. Festoon formation after infraorbital botulinum A toxin: A case report.
A prospective study of the effect of botulinum toxin A on masseteric muscle hypertrophy with ultrasonographic and electromyographic measurement. Br J Plast Surg ; — Type A botulinum toxin for the treatment of hypertrophy of the masseter and temporal muscle: an alternative treatment. Botulinum toxin type A treatment for contouring of the lower face. Kane MA. Nonsurgical treatment of platysmal bands with injection of botulinum toxin A.
Guerrissi JO. The power of combined therapies: Botox and ablative facial laser resurfacing. Am J Cos Surg ; — Effect of botulinum toxin type A on movement-associated rhytides following CO2 laser resurfacing. Complications and adverse reactions with the use of botulinum toxin. It has been estimated that there has been a greater than threefold increase in total cosmetic procedures from to 1.
Baby boomers ages 40—58 account for the largest generational group globally, estimated at 80 million in 2. In the past, a youthful appearance was sought through invasive surgical face-lifting techniques.
However, there has been a shift in the perception of what constitutes a youthful appearance. The new movement has been toward more conservative approaches that deal with the underlying loss of soft tissue to achieve a plumper, less wrinkled, more three-dimensional appearance. There is also loss of dermal thickness and subcutaneous fat, and skeletal and muscular atrophy. The aged face has prominent rhytides in the glabella, forehead, nasolabial folds, and perioral areas.
Background The practice of soft-tissue implantation has a long, well-described history since its employment over a century ago. Today, it is a crucial tool in the armamentarium of facial rejuvenation. There are approximately 40 agents currently being used worldwide. These agents consist of many different biologic and alloplastic materials that can be injected with ease into the dermis and subcutis, and with minimal side effects.
The most popular of the agents used in the United States are bovine collagen, humanized collagen, and hyaluronic acid HA derivatives. Moreover, it is important for injectors to be aware of the various agents available, including their indications and shortcomings, to offer the best available treatment to their patients. Table 4 Text continues p. Non-animal derived; from streptococcal bacteria fermentation Non-animal derived; from streptococcal bacteria fermentation Non-animal derived; from streptococcal bacteria fermentation Extracted from rooster combs Abbreviation: FDA, Food and Drug Administration.
This chapter focuses on the more common biologic and alloplastic agents developed for soft-tissue augmentation. The nature of these agents, their indications and contraindications for usage, as well as their adverse effects are presented in the following sections in groups, according to their duration of effect. In a subsequent clinical trial, over patients were treated with injectable bovine collagen which established excellent clinical correction of rhytides, acne scars, and lip defects.
It should be noted that not all scars are correctable with collagen. The bovine stock is harvested from a closed American herd, and therefore contamination with bovine spongiform encephalopathy virus or prions is not a concern and has never been noted in over 25 years of use. Both are suspended in phosphate-buffered solution with 0.
Contraindications to injection with bovine collagen include a history of bovine collagen hypersensitivity positive test-dose reaction , autoimmune disease, lidocaine hypersensitivity, and anaphylactoid reactions. Adverse events are characterized as hypersensitive and non-hypersensitive.
The former include erythema and edema of the injection site and, rarely, mild systemic responses. The formation of cysts and small abscesses has rarely been reported at injection sites. Patients who develop this type of complication have a high presence of antibovine antibodies Non-hypersensitive adverse reactions include edema, purpura, local tissue necrosis, and infection, as well as herpes simplex exacerbation Necrosis in the area of injection rarely occurs with treatment of the glabellar region Symptoms include early blanching of the treatment site and pain.
If these occur, injection should be discontinued immediately and topical nitroglycerin paste should be applied. There are also isolated case reports of bovine collagen injection causing loss of vision, likely secondary to a vascular occlusion event involving the retinal artery There is no evidence that bovine collagen has a causative role in the induction of autoimmune diseases in humans Transformation to a solid gel is optimal when it occurs once the product has reached the body temperature.
Skin testing is necessary prior to treatment with bovine collagen; it accurately determines potential allergenicity. The test-dose syringes are preloaded with 0. Evaluation of the site should be undertaken at 48 to 72 hours post-injection and then again at four weeks. It is recommended that a single repeat test be done on patients who have been successfully treated for more than two years, prior to administration at another treatment center Many experienced injectors feel that ZC-1 is the most versatile form of bovine collagen as it is the most forgiving and has less association with beading and overcorrection Implants usually last three to six months depending on the area injected; however, most experienced users report that touch-ups are generally required at two to three months.
An effort is made to reduce antigenicity by using formaldehyde for processing the collagen, and neither hormones nor antibiotics are part of the cattle diet. It is available in 3. Skin testing is required. The company claims less than a 0. Lidocaine is not added to the preloaded syringes, and thus, concurrent use of topical anesthetic or nerve blocks is recommended.
Tokyo, Japan. There is widespread use in Asia of this particular compound. Essentially, it is an acellular dermal matrix. It is thought to be less immunogenic than bovine collagen; and no hypersensitivity reactions have been reported in a recent case series It requires extensive harvesting and processing from excisional procedures such as abdonmenoplasty or rhytidectomy Two square inches of skin are excised and are sent to the manufacturer.
No skin test is necessary, and there is no lidocaine present in the suspension. However, a concurrent topical anesthetic or nerve block is recommended. They are prepared in a phosphate-buffered physiological saline containing 0. Because these products are human based, skin testing is not required prior to use. Soft-Tissue Augmentation: Skin Fillers 49 Figure 1 The use of injectable filler for tissue augmentation of the dorsal hands. It is a micronized form of Alloderm. Alloderm is an acellular human dermal allograft prepared in sheets and harvested from tissue banks under sterile conditions.
Alloderm is used as a temporary graft in patients with burns or other soft-tissue defects. It is implanted via a gauge needle into the subcutis, and the treatment area is gently massaged post-injection. No skin testing is necessary, and the product is FDA approved for the purpose of tissue augmentation.
However, a case report describing hypersensitivity and foreign body reaction has been reported Lidocaine is not present in the compound, creating a need for topical anesthetic or nerve block. It is manufactured in 3. Experienced injectors state that the 3. A skin test was performed, and at 72 hours there was no reaction; however, at one month post-treatment she developed erythema and induration at the site of implantation.
Histologically this was diagnosed to be a foreign body reaction. At two months, the adverse response had resolved without intervention. It has been established via clinical trials that particulate fascia lata, when injected intradermally, stimulates native collagen formation in acne scars Exton, Pennsylvania, U.
These biopsies are sent to the manufacturer, and in six to eight weeks, injections are initiated. HA is a glycosaminoglycan polysaccharide composed of alternating residues of the monosaccharides D-glucuronic acid and N-acetylD-glucosamine forming a linear polysaccharide chain 1. This compound exists as part of the normal constituent of the dermis and provides the elastoviscous matrix within which connective tissue structures are located 1. First, HA derivatives confer less risk of immunogenicity because, unlike collagen, HA is chemically identical across all species, eliminating the need for preliminary allergy testing HA gels also possess a unique isovolemic pattern of degradation.
That is, the HA molecule binds more water as the implant is being degraded within the skin. Hence, its original volume is maintained even with decreasing concentration of the implant. Clinically, this translates into a longerlasting augmentation effect. Hyaluronidase has been used by some to correct problems that arise from excessive administration of HA-based products. Instead, simple needle puncture 22G and expression of excess HA or the use of an infrared 52 Rao et al. The cross-linking agent used is highly soluble in water, which makes it easy to clean the residual chemicals and avian proteins from the gel.
The cross-linked hyaluronan forms a gel-like substance, which is then pushed through a sieve, breaking the gel into smaller particles. The cross-linking agent and any of the few proteins that remain after processing are largely washed out of the soft, minimally cross-linked matrix. This gel is well suited for use in dermal augmentation because of its insolubility and resistance to degradation and migration.
The high water content mimics the natural hydrating functions of the precursor, HA. The U. FDA does not stipulate the requirement for prior skin testing even though this is an avian-derived product. One study in guinea pigs showed that tolerability and longevity of this compound were better than that of bovine collagen It is crosslinked using a butanediol diglycidyl ether BDDE and then heat sterilized. It was recently approved for use in the United States in December It is injected via a gauge needle usually under local anesthetic.
It is generally used for deeper rhytides and lip augmentations Fig. The non-animal origin of HA gel should, in theory, eliminate the potential for antigenic stimulation. Safety trials in several animal species found that a stabilized form of HA does not elicit humoral or cellmediated immune reactions This new formulation has a protein load six times lower than the previous product. Medicis Aesthetics reports that delayed reactions occur at a rate of one in 25, of worldwide injections only two substance-related reactions. Manna et al. Currently, it is not approved for use in the United States.
The 30 to 42 micron spheres of PMMA bone cement were found to be long lasting and well tolerated with very little tissue reaction The spheres themselves are small enough to be injected via a gauge 56 Rao et al. The company also reports histologic evidence that PMMA microspheres promote connective tissue deposition surrounding the injected particles Due to the presence of bovine collage, allergy testing is required prior to administration to predict the risk of hypersensitivity reactions.
Units come prepackaged in 0.
It is indicated for deep rhytides including glabellar furrows, marionette lines, nasolabial folds, scar revision, lip augmentation, and more. It is therefore recommended that practitioners begin using this product on rhytides that are easier to work with, such as glabellar frown lines A slight overcorrection is recommended. Combination treatments such as ablative laser therapy are not contraindicated with this product, as laser peeling of the epidermis and upper dermis does not interfere with the more deeply placed product.
Similarly, dermabrasion and chemical peels are effective before or after product placement. Botox can be used concurrently Care must be taken with people who have larger pore size, highly sebaceous skin, or loose, thin skin as the implant may be palpable and even visible through the skin. Hypersensitivity, telangiectasias at the injection site, hypertrophic scarring, and granuloma formation may occur.
The latter effect has been reported to occur in less than 0. As a very rare complication, blindness and total ophthalmoplegia after injection of PMMA in the glabellar region has been reported It is not currently FDA approved for aesthetic facial use, but can be used in the United States as a soft-tissue marker radiologically and for stress urinary incontinence and vocal cord paralysis. For more than 15 years CaHA has been used in dental, orthopedic, and reconstructive surgery Augmentation of soft tissue has been noted when this compound is placed subcutaneously, intramuscularly, or in close proximity to periosteum The particles range in size from 25 to 45 microns suspended in a gel vehicle which deposits the spherical particles subcutaneously or intramuscularly, via either or gauge needles.
Intradermal injection may give rise to granuloma formation and induration, and thus should be avoided In this study the glabellar region was avoided due to the watershed properties of the area and the theoretical possibility of tissue necrosis. Results were positive in all areas studied, with the nasolabial folds and zygoma responding best. It comprises poly-L-lactic acid, sodium carboxymethyl cellulose, and nonpyrogenic mannitol. There is widespread experience with poly-L-lactic acid compounds because of their use in medical devices such as suture material, meshes, and solid surgical implants and as vehicles for many different sustained-release injectable medications.
Due to its inert nature, skin testing is not necessary Adverse effects have been limited locally to the site of injection, with temporary redness, edema, and smaller, palpable bumps It is injected via a gauge needle into the deep dermis or subcutis every four to eight weeks until the desired effect is reached and tends to last 18 to 24 months, therefore offering a more prolonged augmentation than HA or collagen compounds. It has been used in Europe for more than 10 years in industry and biomedical research. Cosmetically, it has been used for breast and soft-tissue augmentation.
As a polymer, PAAG is considered to be extremely safe and touted as nontoxic, nonteratogenic, and nonbiodegradable The patient developed urticarial plaques near the injection sites within a few days following the initial injections. The plaques returned, and a draining noninfectious nodule formed in an injected site. Soon after, nodules began to form on both cheeks. Intralesional triamcinalone helped to improve these lesions.
However, silicone has been used for over 40 years for soft-tissue augmentation in the United States, Asia, and Europe. Silicone is a polymer of dimethylpolysiloxane available in liquid or solid form and is the most permanent that is, longest lasting injectable available. In soft-tissue augmentation, silicone is injected using microdroplet technique into the subdermal space via a gauge needle.
Numerous injections every four to eight weeks Soft-Tissue Augmentation: Skin Fillers 61 and layering are required with silicone, and undercorrection is recommended. Figure 7 Before A and after B silicone treatment of the lips. Almost all case reports of an adverse reaction do not involve the use of medically pure silicone given in a microdroplet technique. A recent case report describes a Hispanic woman who received silicone for lip augmentation in Columbia Approximately six months after the procedure, she developed fevers, chills, and myalgias, along with painfully swollen lips.
Her lips underwent ulceration and desquamation, and she developed submandibular lymphadenopathy. The microdroplet technique was not used. One dermatologist reports having seen a patient who was experiencing silicone nodule formation biopsy proven 36 years following treatment of acne pits Currently, studies are underway to evaluate the use of liquid silicone for HIV-associated facial lipoatrophy.
One case report of an HIV-positive man with facial lipoatrophy treated with liquid injectable silicone showed promising results Box 1 Administration Guidelines 1. For example, in correction of scars, a stretch test should be performed to evaluate their candidacy. Ensure the patient has realistic expectations of the probable result.
Herpes prophylaxis in the form of oral antiviral medication is recommended in those patients with a history of cold sores if the lips are to be injected. Generally, a gauge, 0. Ensure the needle is not blocked by applying slight pressure to squeeze a little bit of product out of its tip. It is important to note that pain and possible purpura formation may result from this action.
Some advocate the use of external devices, such as a teaspoon, to assist with massage Care must be taken not to overmassage as product effects may be lost. If immediate correction is required, digital pressure can be employed to force the product back out of the dermis through the original entry site. An external instrument, such as a teaspoon, can be used in a hoe-like manner to assist in the extraction of the product A needle and a syringe can also be used to withdraw excess product. Use of ice packs is useful to reduce swelling and pain following the procedure.
Here, corticosteroid creams and possibly intradermal corticosteroid injections may be necessary. Conversely, intralesional corticosteroid injections may be used to diminish a robust response. Should intradermal granulomas form, dermabrasion, imiquimod cream, infrared laser therapy or radiofrequency dermal heating may be used with limited success. These lesions may require excisional surgery. Intralesional corticosteroid injections may be useful to soften dislodged nodules that have migrated. Care must be taken on injecting the glabellar region due to the watershed properties of this anatomic area and the theoretical possibility of tissue necrosis upon occlusion of the tenuous arterial blood supply.
There is a case report of a woman who developed blindness and total ophthalmoplegia after injection of PMMA microspheres in the glabellar region A similar problem was reported in a patient treated with bovine-based collagen Telangiectasia Formation Patients at highest risk for telangiectasia formation are those with thinner skin, making the elderly susceptible. Most post-treatment telangiectasias disappear within 6 to 12 months of injection. Persistent lesions can be effectively treated with electrocautery, laser treatment, or intense pulsed light therapy. Allergic Reaction With proper testing prior to product placement, the chances of an allergic reaction occurring are less.
If an allergic reaction occurs, such as the delayed type IV hypersensitivity reaction, intralesional triamcinolone injections into the injection site are recommended. Even though anaphylaxis is unlikely, a practitioner should always be mindful of the possibility and be ready to respond accordingly with the administration of 5 cc intramuscular injection of epinephrine Light treatment with either the pulsed dye laser or intense pulsed light may serve to diminish any erythema of scar tissue.
Topical application of imiquimod and occlusive materials such as silicone gel sheetings may diminish the scar thickness. Granuloma Formation It has been reported that granulomas form in 0. Granulomas are Soft-Tissue Augmentation: Skin Fillers 65 collections of histiocytes derived from monocyte-macrophage differentiation that may form within the dermis of the skin in an attempt to envelop and destroy or contain immunogenic foreign material.
These have been reported for therapy that is both collagen based 59 and HA based Intralesional injection of corticosteroid is a good initial therapy for managing granulomas. Chronic recalcitrant cases, however, are most amenable to surgical excision alone. The number of products available can be intimidating, but this chapter has provided a basis for familiarity and background knowledge of the most common items in this expanding group. As the practice of skin rejuvenation itself advances gracefully, it is a combination therapy of various cosmetic modalities that will prevail. It is therefore important to be aware of the new agents and indications as they become available.
This is particularly true for cosmetic patients who take special interest in researching new products and technologies. It is the 66 Rao et al. Informed treatment strengthens the provider—patient relationship and minimizes disappointing results. Ferreira M. What are we doing and where are we going? Aesthetic Plast Surg ; Smart T. Not acting their age. Fagien S. Facial soft tissue augmentation with injectible autologous and allogeneic human tissue collagen matrix autologen and dermalogen.
Gross J, Kirk D.
The heat precipitation of collagen from neutral salt solutions. J Biol Chem ; — Injectible collagen for soft tissue augmentation. Plast Reconstr Surg ; Injectible collagen: a clinical overview. Cutis ; — Soft tissue augmentation with injectible collagen. Facial Plastic and Reconstructive Surgery. Louis: Mosby Year Book, Behavior of solubilized collagen as a bioimplant.
Dermatologic Surgery and Procedures. In order to improve the properties and the longevity of the transplants, tissue engineering methods such as cell removal are used. Unparalleled phototherapy expertise: Very few dermatological centers in the US have the breadth of knowledge and extensive experience in phototherapy treatments that exists at Weill Cornell Medicine. Oasis is another skin substitute good for deeper wounds and chronic, seeding wound of the IIB type. The Comprehensive Vascular Anomaly Center: In addition to the treatments listed above, the dermatologists at Weill Cornell Medicine also use laser therapy to effectively target vascular anomalies, including:. Cellular residue, however, coming from the aftermath of the process of restructuring of allogeneic cells can provoke an unwanted immune response, which can in turn destroy the transplant [ 58 , 59 ]. Skin substitutes The use of skin substitutes is an alternative to auto-and allogeneic transplants in the treatment of wounds of various provenance, including burn wounds and chronic wounds.
J Surg Res ; — Burgess L, Goode R. Injectable collagen. Facial Plast Surg ; — Cooperman LS, Michaeli D. The immunogenicity of injectible collagen. Part 2: A retrospective review of seventy-two tested and treated patients. J Dermatol Surg Oncol ; Abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implant. Collagen implantation: clinical applications and lesion selection. Sudden blindness secondary to injection of common drugs in the head and neck. Part 1: Clinical experiences.
Otolaryngology ; — Elson ML.