The Chronicle of Cosmetic Medicine + Surgery - Autumn 2023

The Chronicle of

Cosmetic

Medicine + Surgery

On the leading edge of research, discoveries and new clinical findings in aesthetic medicine

Facial rejuvenation: Interest in combination treatments rising

Using AI to gauge public perception of plastic surgery on social media

A new take on facial lifting uses soft tissue filler injections Cosmetic pearls: Retinol may be too powerful and irritating for some, especially those with sensitized skin.

Cosmetic update: Transgender patients and aesthetic medicine

From the publishers of The Chronicle of Skin & Allergy and www.derm.city Volume 11 Number 1 Canada Post No. 40016917

Autumn 2023

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The Chronicle of Editors Sheetal Sapra, Oakville, Ont. Nowell Solish, Toronto

Guest Editor

Cosmetic

Medicine + Surgery

Martie Gidon, Toronto

National Editorial Board Sheldon V. Pollack, Toronto (Chairman) Scott Barr, Sudbury, Ont. Arie Benchetrit, Montreal Vince Bertucci, Woodbridge, Ont. Yves Hébert, Montreal Frances Jang, Vancouver Julie Khanna, Oakville, Ont.

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From the editors Dr. Martie Gidon, Toronto-based dermatologist, discusses the rise in aesthetic procedures after a decline during the Covid pandemic ........................................................4 Cosmetic news Hair care practices can influence outcomes in alopecia—according to researchers patients with no history of thyroid disease, taking metformin for diabetes, and wearing natural hairstyles had higher odds of improvement after treatment ........................................................6

Cosmetic update On the leading edge of research, discoveries and new clinical findings in aesthetic medicine. Dr. Anil Sharma discusses transgender patients and aesthetic medicine ............8 Plastic surgery Using AI to gauge public perception of plastic surgery on social media AI has the potential to predict consumer motivation according to a study led by Dr. Heather Levites.................10 Facial cosmetic surgery Real-world data shows no new safety signals when hyaluronic acid-based product is used with neuromodulators, fillers or lasers................................................14

Assistant Editors Jeremy Visser Cristela Tello Ruiz Client Experience Associate Joyce Pitter-Hinds Associate Conference Planner Sydney John-Baptiste Manager, Operations Cathy Dusome Comptroller Rose Arciero www.chronicle.ca health@chronicle.org

Mohs surgery Researchers have determined that patients who undergo Mohs micrographic surgery (MMS) for facial skin cancer have unrealistic expectations for scar outcomes. Dr. Christian Murray comments on the findings ..........................................................................................20

Pearls Injectable tools are used to highlight, define, and refine, according to Dr. Monica Li at the ninth annual Skin Spectrum Summit ..........................................................................................28

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Organizers of: Skin Spectrum Summit, and National Pharmaceutical Congress.

www.derm.city

From the editors of

Cosmetic

Medicine

+ Surgery

Moving onward and upw n Dr. Martie Gidon, DERMATOLOGIST, TORONTO

Commentary and opinion on current topics of interest in aesthetic medicine

Welcome to the autumn edition of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. With the warm, sunny weather over the summer, as well as a decline in Covid cases across the country, we are spending more time outdoors, socializing, travelling, enjoying concerts and attending sports events. There has been an enthusiastically renewed interest in aesthetic procedures. Patients are comfortable to come back into our offices for treatments and are interested in looking healthy and being their best possible selves. Most cosmetic practices have been thriving again and hopefully this trend will continue. Enjoy this issue and have a fantastic fall.

A study published in Plastic and Reconstructive Surgery used AI to gauge public perception of plastic surgery on social media (see page 10). The authors evaluated Twitter posts and the emotional responses to plastic surgery-related keywords on social media and suggest that AI has the potential to predict consumer motivation and future behaviour. Lead author Dr. Heather Levites explained that better understanding of patients’ feelings about procedures and what drives their behaviour will help surgeons improve their skillsets and provide better ser-

vice to patients. Interestingly, the keywords “plastic surgery” resulted in a negative motivation, but when written as a single word, “plasticsurgery”, it resulted in a positive motivation.

Still images may not be enough to fully evaluate natural-looking aesthetic treatment outcomes. With aging and volume loss, there is more movement in the overlying skin causing more strain. In a study published in Plastic and Reconstructive Surgery and reported on page 24, Dr. Vince Bertucci used 3D videos to analyze dynamic strain at the marionette lines and nasolabial folds as patients progressed from a neutral position through a series of facial expressions. He compared patients aged 41 to 65 years of age treated with hyaluronic acid filler to untreated individuals aged 25 to 35 years. There was a statistically significant difference between the two groups at baseline in the level of stretch, with the older cohort having the higher stretch profile. Treatment with HA filler reduced peak stretch compared to baseline and even resembled the profile in the younger group. He found that filler treatments in older individuals can revert the strain pattern to mimic their younger self.

A paper published in Dermatologic Surgery found that skin rejuvenation with the hyaluronic acid (HA) gel product VYC-12 (Juvederm Volite) can be safely used in com-

Your feedback, please: The editors of The Chronicle of Cosmetic Medicine + Surgery invite your comments concerning the articles in this publication, on issues of current interest in the practice of aesthetic medicine, and on matters at large. Write us at: cosmetic@chronicle.ca. We also welcome you to connect with us through The Chronicle’s continually updated online portal, www.derm.city, “Where Dermatology Lives.”

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The Chronicle of Cosmetic Medicine + Surgery

ard: The next wave is ours to create bination with other aesthetic facial treatments (turn to page 14). The Vancouver-based authors, led by Dr. Misha Zarbafian, mention that this cross-linked HA-based gel improves skin smoothness and hydration and is not a volumizing filler. This retrospective study observed that combining other treatment modalities such as neuromodulators, volumizing technologies and laser procedures used on the same day or within nine months following VYC-12 injections did not cause any unique adverse events. Combination treatments were performed on all skin types with extremely high patient satisfaction.

A study from the University of Pennsylvania published online in JAMA Network Open determined that patients who undergo Mohs Micrographic Surgery (MMS) for facial skin cancer have unrealistic expectations for scar outcomes (see page 20).

Scars were a median of 2.2 times larger than patient estimates and only 1.1 times larger than surgeon estimates. Study participants filled out a survey to gather information regarding history of MMS, pre-operative consultation and the use of resources prior to their scar estimation. Findings suggested that education through these consultations or resources did not significantly improve the patients’ post-operative scar length estimates. Dr. Christian Murray, a Mohs surgeon in Toronto, feels that while the cosmetic outcome is important, the excision of the cancer is more important and discussions with patients should include realistic scar expectations.

There are specific aesthetic considerations when providing care for gender transitioning individuals. Dr. Anil Sharma, who Volume 11 Number 1

practices in Edmonton, has an interest in facial aesthetics, scalp surgery with hairline lowering which is a specific concern for transitioning from male to female, and eyebrow transplantation (see page 8). When providing aesthetic procedures, it is important to consider the whole gender spectrum and how individuals want to express and present themselves. Racial and geographic differences should also be considered since ideals of attractiveness vary.

When planning aesthetic treatments, it is important to take into account the status of hormone therapy and work together as a team with other health care providers involved with the patient’s care.

A small study suggests that soft tissue subdermal filler augmentation in the posterior superior temple region can reduce volume in the middle face and accentuate the contours of the jawline. Dr. Sebastian Cotofana’s article in the Journal of Cosmetic Dermatology pointed out that the face exists in a connected, layered system. If you treat one area, it will have an impact on the other layers.

In the study reported on page 26, a single bolus of 1 cc of hyaluronic acid or 0.75 cc of calcium hydroxylapatite filler was injected with a cannula with no massage or manipulation. Although the treating physicians and patients were happy with the improvement, 3D skin vector analysis demonstrated minimal lifting. Patient selection is important since patients with skin laxity or heavy faces may not significantly benefit from this technique. A subsequent cadaveric study by Dr. Cotofana in Plastic and Reconstructive Surgery found that combining deep supraperiosteal injection with subder-

mal injection in the temple, lateral midface and mandibular angle can induce lifting effects of the total lateral face.

--I thank you for making time to read this edition of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY, and I welcome your comments at health@chronicle.org.

Dr. Martie Gidon is a board-certified dermatologist in both Canada and the United States.

She has extensive experience in Cosmetic and Laser Dermatology. She has an active cosmetic dermatology office in Downtown Toronto. In addition to being a lecturer at the University of Toronto, Dr. Gidon is past President of the Canadian Society for Dermatologic Surgery, the Canadian Laser and Aesthetic Specialists Society, and the Toronto Dermatological Society. Dr. Gidon has been involved in many research studies and has published articles in peer-reviewed medical journals. She has presented at conferences and participated in live patient demonstrations.

n Cosmetic Update

Exosome therapy more popular n According to an article in Marie Claire (July 4, 2023), exosome therapy, a trend in aesthetics that uses small vesicles from stem cells to boost collagen, hair growth, and skin renewal, has become increasingly popular. Dr. Julie Russak, a New York-based dermatologist, says exosome therapy is comparable to platelet-rich plasma treatments without the variability associated with using a patient's platelets.

She notes exosomes are derived from processes involving donor tissues placenissues such as placen ta or bone marrow. This therapy can be administered topically or through procedures such as laser treatments, microneedling, or chemical peels.

—Read more at https://tinyurl.com/4vcj3ntd

Are people getting Botox too early? n According to an article in the HuffPost (July 27, 2023), the consensus among specialists is that people should not get Botox before their late 30s or early 40s when facial lines are visible at rest.

However, there is a surge in younger people seeking Botox, which raises concerns about premature use and consequent unnatural facial results. The experts consulted said that on also als lso play pl vital vit ital al genetic factors and sun protection roles when considering Botox. They add that prioritizing skin care practices such as micro-needling is recommended to delay wrinkling and reduce early dependence on Botox.

—Read more at https://tinyurl.com/bdzkkd4f

Hair care practices can influence outcomes in alopecia n According to study findings published in the

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Archives of Dermatological Research (May 15, 2023), central centrifugal cicatricial alopecia (CCCA) is the most common form of primary scarring alopecia in Black women and negatively impacts their quality of life. The researchers analyzed the clinical data of 100 patients diagnosed reatment ffor at le leastt one with CCCA who received treatment year to identify medical features, comorbidities, hair care practices, and treatment outcomes. The results showed that patients with no history of thyroid disease, taking metformin for diabetes, and wearing natural hairstyles had higher odds of improvement after treatment.

—Read more at https://tinyurl.com/2hu68pzw

Erasing reminders of stigmatizing and traumatic past n A Harvard Gazette interview (Oct. 23, 2023) with Massachusetts General Hospital dermatologist Dr. Shadi Kourosh sheds light on her work with a laser tattoo removal program. This program aims to erase tattoos that often serve as covert branding for gang members or sex-trafficking victims, allowing

survivors to escape past trauma and create a new life. Dr. Kourosh discusses the clinic’s mission, the common symbols found in these tattoos, and the significant impact of tattoo removal on the victims’ safety and healing process.

—Read more at https://tinyurl.com/ypsywm8b

Minimally invasive procedures for mothers of brides n A recent study in the Journal of Cosmetic Dermatology (Nov. 6, 2023) emphasizes the role of brides’ mothers in wedding celebrations, underscoring the behavioural patterns they have when seeking aesthetic treatments. The article suggests personalized strategies for better communication and decision-making based on individual personalities. It also presents a specific timeline for the implementation of cosmetic interventions, such as neuromodulators, collagen stimulators, and fillers. It also notes that financial considerations, s, often oft ften prioritizing pri riorit itiz izin ing wedding costs, influence decision-making.

Periorbital skin rejuvenation using fractional microneedle radiofrequency n Research published in Annals of Dermatology (Sept. 20, 2023) evaluated the effect and safety of a fractional microneedle radiofrequency (RF) device on periorbital wrinkles. The study included 11 healthy Korean patients between 30 and 75 years old with periorbital wrinkles. Results showed that all patients exhibited wrinkle improvement in the lateral periorbital area, and two patients also showed efficacy in the lower eyelid area. The authors also found a statistically significant decrease in the wrinkle assessment scale and a significant improvement in the melanin index.

—Read more at https://tinyurl.com/4zbp5dh4 The Chronicle of Cosmetic Medicine + Surgery

Lip flip vs. filler⏤which one is best? n An article in New Beauty (Oct. 20, 2023) explores the rising popularity of lip flips, a cosmetic procedure that turns the upper lip outward to create a fuller appearance. It advises patients to choose between lip flips and lip fillers based on their aesthetic goals and lip anatomy. Lip fillers are recommended when seeking greater volume, while a lip flip can be suitable for those wanting more lip surface area. Combining both procedures may be ideal for individuals with thin lips.

—Read more at https://tinyurl.com/4dytvxka

Additionally, it suggests that the motivation to look good for their daughters’ big day makes them frequent patients in dermatologists’ offices.

—Read more at https://tinyurl.com/4d4r2d46

Dermatologists share crow's feet remedies n A Yahoo! Life article (Oct. 30, 2023) delves into the persistence of crow’s feet and their causes. The author consulted with some dermatologists who noted that some at-home remedies, including eye creams with hyaluronic acid, ceramides, peptides, and retinol, help reduce the appearance of crow’s feet. Additionally, inoffice treatments like chemical peels, Botox, dermal fillers, and lasers provide more permanent solutions, but they can be pricey.

—Read more at https://tinyurl.com/bdpwpkh8 Volume 11 Number 1

HFUS in anti-aging skin therapy monitoring n In a study published in Scientific Reports (Oct. 17, 2023), high-frequency ultrasound (HFUS) demonstrated promise in assessing anti-aging skin therapy. The study used an automated algorithm for image selection and echo layer segmentation. The key findings emphasize HFUS’s utility in providing crucial information for evaluating the efficacy of anti-aging products and procedures, particularly trichloroacetic acid (TCA) therapy. The researchers found the fully automated HFUS image processing method allows for reliable analysis of high-quality images. These findings highlight HFUS as a valuable tool for assessing the effectiveness of therapeutic interventions, especially in the context of anti-aging treatments.

—Read more at https://tinyurl.com/222vphjr

Cosmetic

Update

Transgender patients and aesthetic A whole gender spectrum n Anil Sharma, MD, MB ChB, MRCS,

On the leading edge of research, discoveries and new clinical findings in aesthetic medicine

DRCOG, Medical Director of Sharma Skin and Hair Surgery in Edmonton, was educated in the U.K. and worked at a private cosmetic surgery practice in London. Dr. Sharma continues to offer hair transplantation and a variety of other aesthetic services.

He began seeing patients who are gender transitioning, changing their outward gender identity to reflect their internal gender identity, when he started practicing in England. Correspondent Louise Gagnon of THE CHRONICLE OF COSMETIC MEDICINE + SURGERY spoke with Dr. Sharma about his LGBTQ+ friendly practice, to talk about providing aesthetic care to individuals who are undergoing gender transition.

How did you come to start offering aesthetic services for transgender patients?

My primary area of expertise is scalp surgery and facial aesthetics. In my practice we did a lot of hairline lowering and hair surgery, which is how I came into contact with the transgender community. Many of my patients were transitioning from male to female. They were often experiencing a lot of dysphoria around how their face looks in terms of how high their hairline is from several angles. We know that [cisgender] women will naturally have a lower hairline than [cisgender] men do. I was very ignorant about the transgender community. I had to admit that and had to educate myself.

Do you take a specific approach in delivering aesthetic medicine to transgender patients?

When you are in the aesthetic field, you are accustomed to differences in the male face and the female

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face. Traditionally, if I am treating a cisgender male, and sculpting the jawline, a man wants a wide jawline, very acute angles, and have the volume in the lower face whereas in cisgender females, they want volume in the mid-face and a very tapered chin.

In aesthetic medicine, there is a whole gender spectrum, and it is about where people want to express themselves on the spectrum. Some patients may want to be gender diverse. We always have to take into consideration racial differences and where they grew up. I come from an immigrant family but I grew up in London. My ideals of beauty are very aligned with the Western European viewpoint. When I was practicing in London, I was dealing with transgender patients who were transitioning to female and had come from the Middle East. Their ideals of feminine beauty were completely different from Western feminine ideals of beauty.

How do you manage the expectations of your transgender patients?

I think one of the problems we have in the field in today’s world is that everyone wants to be like an Instagram superstar. Young adults, in particular, aspire to be like this. In my industry, we know that people use filters, and these Instagram stars don’t really look like that in real life. We want to work with what people have, be proud of it, and augment that, rather than making them try to look like somebody else. I like the notion that our patients are diamonds, and we are just polishing the diamonds. I think patients will be happier psychologically with that approach.

Are you performing both non-invasive and invasive procedures in transgender patients?

We perform surgical procedures like hairline lowering using various techniques. The hairline is pivotal for a masculine face. We may be lowering them [for transgender women] or raising them [for transgender men]. Another big procedure in this population of The Chronicle of Cosmetic Medicine + Surgery

medicine: patients is eyebrow transplantation. This is because a lot of men have a very low-sitting brow. When they transition, they seek different characteristics of how the brow sits. The transgender woman would generally not want a heavy brow that is thick. We may try to destroy the roots of the brow and create a very nice arc and tail because that opens up the eyes. With transgender men, you want to create a heavier brow, which is a sign of masculinity. We know that testosterone gives you a more pronounced supraorbital ridge, and that is the way the hormone works. We are trying to emulate that for transgender men.

What facial characteristics are key to address in individuals who are transitioning?

Many people are focused on the lips and the cheeks, but there are some overlooked areas in facial aesthetics. Eyes are the first thing we see, and if you don’t balance the ratios of the forehead, the contours, and the temples, then you won’t do your patient justice. Start with the big areas like the forehead and the jawline. Frame the face first, and work your way in, rather than addressing the lips and the cheeks first. Start with the foundation like you would with a house and then fill in the rest. Transgender female patients want laterally peaked eyebrows, and they want the peak to be slightly above the supraorbital ridge.

Transgender females also tend to want a slightly more concave nose, more like a slight ski slope, whereas men want a very defined, straight nose. Transgender females want slightly more superior cheeks that are pronounced.

The most important thing in female-to-male transition, is that you want to bring the apex, which is the highest point, down. Depending on their cultural background, they may want the highest point on the cheek to be more medial or lateral. With transgender men, we want cheeks that are not rounded and not very prominent either.

If patients are taking hormones, how does that affect your use of products like fillers?

It is important to ask patients whether they have started hormone therapy. Some of the patients have not. I often find that hormone therapy will help with some aspects of the changes they are desiring. It will give them a head start. We do know that high estrogen will give them higher cheekbones, and it is also going to thin the skin if they have thicker skin. Conversely, if they are getting testosterone therapy, they will develop bulkier bone mass, which will help with the jawline and give them more square, masculine features. It is important to know where they are in their transition, and also to work with their other physicians like endocrinologists and know what medications they are taking. Whenever I do surgery on the scalp, and am adjusting the hairline, I will write my colleague a note saying what I intend to do, and if there is anything I should take into consideration with their hormonal treatments.

Volume 11 Number 1

“In aesthetic medicine, there is a whole gender spectrum, and it is about where people want to express themselves on the spectrum. Some patients may want to be gender diverse. We always have to take into consideration racial differences and where they grew up.”

Do doses of neurotoxins and fillers have to be stronger for men transitioning to women?

I do find that I have to use higher doses of fillers and neurotoxins when the transition is male to female. A cisgender male will have facial skin that is thicker and muscle mass that is larger. It is important to let them know they will require more frequent maintenance of neurotoxins and fillers and that’s not an indication of treatment failure or an indication that the treatment is not working for them. They were born with more facial mass, which makes fillers degrade faster.

How do you tailor your care for young patients?

For younger patients, I want to liaise with their other healthcare providers like their psychologist or endocrinologist because I think that I am only a small slice of the pie. My colleagues may say that these individuals are not yet ready for changes in facial aesthetics or their hairline. You don’t want to do major treatments like lowering or raising the hairline if they are not ready. The nice thing about minimally invasive treatments like fillers is that it gives them a window into what they may look like to the outside world and how that makes them feel. That way, they then experience how it feels and may come back feeling stronger or not about making the transition. Also, all patients have to understand that these procedures carry very real risks.

What role do aesthetic treatments play in patients with gender dysphoria?

Aesthetic treatments can allow patients to bring their appearance more in line with how they feel about themselves and how they wish to present themselves to the world. I wouldn't consider myself an expert on gender dysphoria.

However, I do feel that what we can do is assist in validating a person’s change in gender identity, and that would reduce the frequency of gender dysphoria.

—Louise Gagnon, Correspondent

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n Plastic surgery Using AI to gauge public perception of plastic surgery on social media n by John Evans OF THE CHRONICLE

Findings from a project using artificial intelligence (AI) to evaluate emotional responses to plastic surgery-related keywords on social media suggest that AI has the potential to predict consumer motivations. AI may even predict future behaviour related to plastic surgery procedures, according to researchers.

The paper was published in Plastic and Reconstructive Surgery (144(2):499-504).

“Plastic surgeons increasingly feel the need to better understand how patients feel and what is driving their behaviour,” said the paper’s lead author, Dr. Heather Levites, in an email interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “This understanding has many implications to providing better service and improving our practice and skillsets.”

Surveys are the most common method of evaluating how the public perceives plastic surgeons and the services they provide, said Dr. Levites, an integrated plastic and reconstructive surgery resident at the Duke University School of Medicine in Durham, N.C. The AI tool tested by Dr. Levites and her team could represent another way to gather such information.

For a period of four months spanning January to Dr. Levites April of 2018, the AI tool was used to search and analyze Twitter posts for commonly hashtagged words.

Search terms included the most common aesthetic surgery procedures, and colloquial terms for the same procedures.

“The emotional AI programming requires a certain amount of input data to generate a meaningful interpretation, so a lot of the reconstructive surgery terms were not able to be analyzed using social media,” said Dr. Levites, explaining why some search terms were excluded.

Dr. Nikolis Algorithm can identify sarcasm, irony Keyword searches were evaluated by the system in three categories: awareness— the amount of social media ‘buzz’ on a topic, devoid of emotion; engagement— the relative amount of social media posts that had any sort of emotion behind them; and motivation—a measure of a consumer’s desire to act, quantified as avoidance or attraction to a product or brand. Dr. Levites noted that the machinelearning algorithm used for emotion extraction is sensitive enough to identify sarcasm and irony when generating its analysis.

“As a general statement, I think that artificial intelligence will impact pretty much every aspect of medicine going forward,” said Dr. Andreas Nikolis,

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senior medical director of Victoria Park Medispa in Westmount, Que. While not a part of this research, he is involved in several projects evaluating AI in plastic surgery, including the development of self-propagated technologies that can assess skin characteristics.

“We know [AI] works. We know that it is a question of time, and we know that there is an exponential increase in how data is analyzed every single day,” said Dr. Nikolis.

However, he said that while the findings from this research team are interesting, as is often the case with novel ideas and new concepts in medicine, the paper raises more questions than it answers.

During the study period, the keyword ‘nose job’ had the highest awareness, while ‘liposuction’ was fifth in awareness but highest in emotional engagement.

The strongest positive motivations were seen to the keywords ‘plastic surgery’ and ‘cosmetic surgery,’ while ‘tummy tucks’ had the lowest motivation.

However, ‘nose job’ and ‘rhinoplasty’ both were strongly associated with negative motivation.

Identifying this data is really a first step, said Dr. Nikolis. “The problem is what do you do with that data?”

“If somebody is fearing plastic surgery as one of their outcomes, does that mean that patient will not come in? Or does that mean that patient will come to see somebody who is a little bit older and perhaps has a more gentle approach to certain things because of reputation?” he said.

“I do not doubt that they can acquire this information quite readily. I do not doubt that they can actually expand it to multiple platforms. The real question is what is the next step? Just because you can stimulate an emotional response— favourable or unfavourable—can you translate that into a patient walking into your office?”

Even if a strong emotional response leads to a patient entering a physician’s office, it might also be associated with a patient who has unreasonable expectations about plastic surgery treatments, he said.

Presentation of keywords changes results Most surprisingly among the findings, according to both the authors and Dr. Nikolis, is that the almost identical keywords ‘plasticsurgery’ and ‘plastic surgery’ resulted in opposite motivations. Written as two words, it resulted in a negative motivation, while written as a single word without a space it resulted in a positive motivation. They did note that the form without a space was more often used by physicians, while the form with a space was more used by consumers.

“That, to me, is concerning,” said Dr. Nikolis. “I would understand somebody not liking the word breast reconstruction with flaps, or tummy tuck versus abdominoplasty. The problem I have here is how could one space impact opposite reactions—plasticsurgery as one word vs. plastic surgery. What does that mean? And is it a red herring or is it real?”

Dr. Levites agreed that this study revealed that more work is needed in eduThe Chronicle of Cosmetic Medicine + Surgery

“The emotional AI programming requires a certain amount of input data to generate a meaningful interpretation. So a lot of the reconstructive surgery terms were not able to be analyzed using social media” ⏤Dr. Heather Levites

cating the public about what aesthetic surgery is. “While only a pilot, the findings from this study show that we have much more work to do,” she said.

However, she sees the potential for emotional AI to be of benefit to surgeons. “Having the ability to measure and quantify patients’ emotional attitude and response toward plastic surgery can significantly improve the conversation about various procedures,” she said. “By connecting with the patient on an emotional level, plastic surgeons can reduce the patient’s apprehensions and concerns, while at the same time creating new and enhanced business opportunities.”

A few questions that Dr. Nikolis identified as remaining to be answered include; cross-language validity—his own practice being in Quebec; validity across different demographics; how much direct overlap between social media users and consumers of plastic surgery services; and how will these results hold up when looking at more than one social media platform?

More types of social media under study At the time of this study, the AI system was only capable of evaluating Twitter posts. Currently the developers are extending that to other short-form social media, Dr. Levites said.

Other planned follow-up includes using the system to look at certain larger plastic surgery groups and more prominent individual plastic surgeons, said Dr. Levites. “From this, we hope to garner new insights as to which practices and surgeons are having the greatest impact on the general public, which will in turn inform the community at large how to improve its social media presence.”

“Additionally, Dr. Jeffrey Marcus, division of plastic surgery chief at Duke University Hospital and former president of the rhinoplasty society, and I plan to look deeper into the public’s emotional response to rhinoplasty, given the overwhelmingly negative impact seen in this initial pilot study.”

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New treatment for in Study shows Restylane Eyelight™ has long-lasting results to 12 months

“It’s a precise product, and it gives you targeted definition.” ⏤Dr. Lisa Kellett

Suggested reading 1. Expert recommendations on the use of hyaluronic acid filler for tear troughrejuvenation.

J Drugs Dermatol 2022 Apr 1; 21(4):387-392 2. A randomized, crossover-controlled evaluatorblinded trial evaluating cannula- vs needle-assisted hyaluronic acid injections for infraorbital deformities.

Aesthetic Surg J 2022 Feb 15; 42(3):285-297.

3. Infraorbital dark circles: A review of the pathogenesis, evaluation and treatment. J Cutan Aesthet Surg 2016 Apr-Jun; 9(2):6572.

4. Tear trough deformity: Review of anatomy and treatment options. Aesthet Surg J 2012 May; 32(4):426-440.

Canadian patients will now have the option of a new treatment for infraorbital hollowing, commonly known as dark shadows.

Restylane’s® Eyelight™, a hyaluronic acid (HA) filler, is designed to decrease the under-eye grooves that develop because of a lack of volume and volume loss in the area under the eye, improving periorbital aesthetics.

Dermatologists who are early adopters of this HA dermal filler are impressed by its treatment effects, its robust safety, and Dr. Jacob point out that subjects in studies and patients in real-world clinical practice have provided highly positive feedback about outcomes with the filler.

How it works The HA dermal filler uses non-animal stabilized hyaluronic acid (NASHA) that offers increased firmness and the ability to remain in the injected site. “The gel technology is a little bit firmer [than other hyaluronic acid fillers],” said Dr. Carolyn Jacob, a dermatologist and Medical Director at Chicago Cosmetic Surgery and Dermatology in Chicago. “It stays in place and does what it’s going to do without flattening or spreading, which some of the other types of hyaluronic acid technology tend to do a little bit more.”

Patients sometimes express concerns about the migration of fillers, particularly when they see social media posts about the topic, but filler migration does not occur with Eyelight™, noted Dr. Jacob.

“Patients have said to us in office that ‘I heard that fillers migrate’,” Dr. Jacob told THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “This is not a filler that is going to migrate. There is a lot out there in social media about filler feeling

like it’s in some other different place [than the injected site]. There were no reports of migration because this product doesn’t migrate.”

Another characteristic of the product is that it does not readily absorb water, which curtails the potential for swelling, noted Dr. Jacob. “It doesn’t over-absorb water, so you shouldn’t get an abundant amount of swelling from it,” she said.

Dr. Lisa Kellett, a dermatologist at Dr. Kellett DLK on Avenue in Toronto, agreed that the composition of Eyelight™ minimizes the risk of puffiness. “You do not want a product that is going to draw a lot of water in that area,” said Dr. Kellett. “That is the beauty of the product, it’s low hydrophilic nature. It also has high G-prime.”

Other advantages of the product are that it is very exact and delivers an accurate outcome, an important trait considering the site of injection, said Dr. Kellett. “It’s a precise product, and it gives you targeted definition,” she added. “In this area the skin is very thin, so you have to be very careful. Because it can be quite an unforgiving area.”

Comparing the impact of needle vs. cannula Published research has demonstrated the effects of the filler using a needle versus using a cannula show no difference in the efficacy of the filler, regardless of the injection tool used. Studies have been designed comparing the effects of Eyelight™ using cannula vs. filler, to address preferences that some injectors have for needles and that others have for cannulas (Aesthetic Surg J 2022 Feb 15; 42(3):285-297).

This study, published in Feb. 2022, was a prospective, randomized-controlled, evaluator-blinded investigation of 42 patients with a mean age of 44 years and compared the impact of needle vs. cannula injection at baseline and then results at four weeks post-treatment. Patients underwent two treatment sessions, spaced two weeks apart, and then attended a follow-up visit at Week 4.

Scales such as the GAIS (Global Aesthetic Improvement Scale), a seven-point scale that measures the improvement or worsening of a patient’s appearance relative to baseline, and the GIHS (Galderma Infraorbital Hollows Scale), a four-point photo-numeric scale designed to assess the severity of infraorbital hollowing from 0=none; 1=mild; 2=moderate; and 3=severe, were used in this study.

In this study, GIHS improvement was defined by at least a one-point decrease from baseline on either side of the face.

GAIS improvement was designated by any score above zero (denoting no change) at all follow-up visits.

Adverse events reported in this study included ecchymosis, edema, erythema, and pain, and were linked to the injection technique rather than Eyelight™ itself. All adverse events in that study resolved in two weeks. Of note, there were no cases of the Tyndall Effect (bluish discolouration) observed in any case in the study.

In a subsequent study including 333 patients that also compared the impact of cannula vs. needle with the injection of Eyelight™, most subjects (283) completed the entire study and 87.4% of patients achieved correction of the infraorbital hollows at the pivotal three months.

“A study with cannula versus needle basically showed that the responder rates were similar via a cannula or via a needle,” said Dr. Kellett. “The adverse events were very similar too.”

n fraorbital hollowing settles in, then you will really know what you are going to see [as a result of treatment].”

The number of injections required in a single treatment with Eyelight™, either with a needle or cannula, is tied to a patient’s anatomy, explained Dr. Kellett. “It is difficult to say [how many injections will be needed],” she said. “It is totally dependent on the patient.”

and that might seem daunting. It is done in a very careful, practiced way that does not require a lot of needle pokes,” said Dr. Jacob.

Because of the possibility of swelling and bruising, Dr. Jacob recommends that patients time their treatment between social occasions or professional commitments.

“We will tell people to schedule this [treatment] around your big events because we don’t want to have you either dealing with a possibility of a bruise or possibility of swelling,” said Dr. Jacob.

“We have ways to mitigate the bruising by using a cream called Alastin INhance, which also helps to decrease swelling. It is a nice additional thing that we can do here in the office. Patients can take it home with them too. If they have something important at work on a Monday, then doing the treatment on a Friday is a really good idea.”

Dr. Jacob noted that delivery of the product under the eye using either a cannula or needle results in histamine release that produces transient edema.

“Because there's a poke of a needle or cannula, there is going to be a tiny bit of swelling just from that histamine release,” said Dr. Jacob. “But after that

In terms of stopping any medications prior to treatment, Dr. Kellett does not advise patients to halt taking medical therapies that are preventive against any acute events.

“For my patients who say they are on blood thinners to prevent blood clots or for other reasons, I don’t ask them to stop taking these medications,” said Dr. Kellett. “I just tell them that they may have more puffiness and bruising [after treatment].”

Photo courtesy of Dr. Lisa Kellett

In real-world practice, Dr. Jacob noted her patients report they experience very mild pain with injection. Using a scale of one to 10, with one being no pain, people typically rate injection with Eyelight™ at two in real-world practice, she said.

“Patients might feel a little pressure, a little movement, but it is not really [painful], even though we're coming really close to the eye area,

Treating darker skin types Clinical studies with Eyelight™ included a diversity of patients of different races to assess the impact of treatment in patients of all skin types.

According to Dr. Jacob, there are considerations in using Eyelight™ in patients of colour. There can be much peri-orbital hyperpigmentation, owing to either sun exposure or genetics, in patients of colour, particularly with aging, she explained. “We tend to see that [peri-orbital hyperpigmentation] as patients get older.”

If there is existing dyspigmentation under the eye in a patient with skin of colour, that dyspigmentation should first be addressed before injection of Eyelight™, added Dr. Jacob.

“We can take the hollows out, but we also have to lighten the discolouration,” she said.

Patient selection and patient satisfaction with treatment Patient selection is critical to success with Eyelight™ treatment, Dr. Kellett stressed.

“You want to make sure that patients would be those where the filler would add some volume, address dark circles, address some medial or lateral cheek volume loss and address a tired look,” said Dr. Kellett. “Those are patients who are good candidates.

“Candidates who are not as good would be those who have chronic edema around their eyes, those who would have moderate-to-severe skin laxity, those who have herniation of the fat pads, those who have poor skin quality, and those who have dyspigmentation of the skin,” she added. Patients treated with Eyelight™ have expressed a high degree of satisfaction in research studies, noted Dr. Kellett.

“Patient satisfaction rates at month 12 were very high,” said Dr. Kellett. “They found that patients felt better about themselves, felt happier, more attractive, and more confident. They had a higher overall improved satisfaction with their appearance.

They also had reduced hollows under their eyes.”

Evaluations that were held 12 months after the first treatment indicated that 84% of patients remained pleased with results, 89% thought the results looked natural, and 79% expressed that they thought they looked less tired. When asked if they would recommend Eyelight™ to a friend, 94% of respondents who were treated with Eyelight™ said they would recommend it to a friend and would repeat treatment.

Dr. Jacob echoed Dr. Kellett’s view of the longevity of the treatment effect of Eyelight™.

“We have the confidence to let people know that this is a product that’s going to be great for usage because we’ve now shown follow-up to 18 months in a study, and found that after optimal treatment, these patients are still experiencing improvements from it,” said Dr. Jacob.

Supplement to THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the participants and do not necessarily reflect those of the publisher or sponsor. Support for distribution of this report was provided by Galderma Canada, Inc. through an unrestricted educational grant without conditions.

Information provided in this report is not intended to serve as the sole basis for individual care.

Printed in Canada for Chronicle Information Resources Ltd., 1460 The Queensway, Suite 212, Etobicoke, Ont. M8Z 1S4 Canada. Telephone 416.916.2476; facsimile 416.352.6199; e-mail: health@chronicle.org.

Copyright 2023 by Chronicle Information Resources Ltd., except where noted. All rights reserved. Reproduction in any form is expressly prohibited without written permission of the publisher.

n Cosmetic procedures

Facial rejuvenation

Real-world data shows no new safety signals when hyalu acid-based product is used with neuromodulators, fillers n by John Evans OF THE CHRONICLE

Skin rejuvenation with the hyaluronic acid (HA) gel product VYC-12 (Juvederm Volite) can be safely used in combination with other aesthetic facial treatments.

These findings come from a paper published both online and in print in Dermatologic Surgery (March 2022).

Study authors Drs. Misha Zarbafian, Katie Beleznay, Jean Carruthers and Shannon Humphrey note that VYC-12, a cross-linked HA-based gel, has demonstrated efficacy in improving skin smoothness and hydration in prospective studies. However, they write that there is limited published data on the use of VYC-12 in combination with other modalities.

While it is a HA-based product, the authors

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note that VYC-12 should be considered distinct from fillers that are used as targeted volumizing treatments. VYC-12 treatment is performed using multiple superficial (intradermal) microdroplet injections—0.01 to 0.05 mL per injection—in an evenly-spaced grid, 0.5 to 1.0 cm apart across the treatment area, to enhance overall skin smoothness and hydration.

Interest in combination treatments rising “Combination aesthetic interventions are increasingly being used to achieve skin rejuvenation in the most natural-looking way possible,” said the study’s lead author Dr. Misha Zarbafian in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “This will often involve more than one type of treatment, since we might use different modalities to relax muscles, increase volume, or achieve other goals.”

Dr. Zarbafian is a cosmetic dermatology fellow at Cosmetic Laser Dermatology in San Diego.

He said that these holistic plans may include a range of treatments delivered on the same clinic visit or sequentially. Those could include neuromodulators, volumizing technologies, laser treatment, or a variety of other therapeutic tools. “[VYC-12] is distinct from HA-based fillers that we have seen previously. And so it is always important for us Dr. Zarbafian to make sure that the treatment that we are administering can be safely and effectively used in combination with other modalities.”

The Chronicle of Cosmetic Medicine + Surgery

of VYC-12 in the clinical trials. They also collected data on the volumes of VYC12 used, the time interval between treatments, patient age, gender, and adverse events.

The average age of the patients was 53.7 years, and their skin phototypes ranged from I to V on the Fitzpatrick scale. A majority—1,444 of 1,577—of the VYC-12 treatments were performed with same-day combination treatments.

Neuromodulators and fillers were most frequently combined with VYC-12. On average, repeat VYC-12 treatments were spaced 212.4 days apart.

uronic or lasers Outcomes of more than 1,500 treatments studied “To assess the safety of VYC-12 Dr. Zarbafian and his colleagues conducted a systematic chart review of all patients treated with the HA product at a single cosmetic dermatology clinic in Vancouver. This totalled 1,577 treatments involving 736 patients.

“Clinical trials provide excellent data that we certainly need, but they do not always reflect how the treatment is used in clinical practice,” Dr. Zarbafian said.

“One of the good things about the retrospective nature of this study is that nothing was planned or altered for the purposes of this study,” said Dr. Zarbafian.

“These patients were simply on the treatment regimens that were felt to best suit their skincare needs. So, we were able to study how the treatment fared in the context of how the dermatologists felt it was best incorporated.”

“Although we focused on combination treatments in this study, another valuable aspect of our paper is to publish real-world data from our clinical experiences with a relatively new product.”

In this study, the investigators recorded other treatment modalities used on the same day or within the nine months following each VYC-12 treatment. Nine months was used as the cut-off because this was the reported duration of effect Volume 11 Number1

No unique safety signals seen The most common adverse events included mild and self-limited injection-site reactions. There were no unique adverse events observed due to combination treatments.

One case of monomorphous, skin-coloured dermal papules on the cheeks was seen, which appeared after three months in the same distribution as the VYC-12 injections. The papules resolved after a few weeks without treatment.

In addition to the good safety findings, patients appeared to be pleased with the experience, Dr. Zarbafian said.

“Some of this was not commented on in the paper, but we observed that patient satisfaction was extremely high. The one indicator of this that was published was that the average number of treatments was more than two per patient,” he said. “It is not a perfect statistic, of course, but it is a good indicator that patients were happy enough with the treatment to chose to come back.”

“The fact that patients remember to come back [after roughly seven months] and are interested to come back tells you that they are happy with the results. That stood out to me personally.”

Tx suitable for all skin types Most patients in this study had Fitzpatrick skin types I to III, though there were patients from skin types IV and V as well, Dr. Zarbafian said. He noted the researchers saw similar results in patients with all skin types. However, the results may be subtler in some patients.

“We comment that patients with thicker skin, for example some male patients or some patients with darker skin phototypes, might have more subtle benefit,” he said. “But in general, everyone is a candidate [for VYC-12 treatment].”

Dr. Zarbafian also provided a few tips for improving the patient experience when using VYC-12.

• Have many needles prepared in advance. Due to the large number of injections, needles can dull quickly and could increase patient discomfort.

• The lateral, outside portion of the cheek is an area that is less visible and injecting there may be less painful for patients. Starting the injection grid pattern there may allow a practitioner to calibrate the depth of their injections. They can then move centrally as they get more comfortable.

• Injection should be done at a 45° angle, and superficial placement should be avoided. If superficial placement occurs, the product should be massaged into the area immediately.

Non-proprietary and brand name of therapy: VYC-12, a cross-linked HAbased gel (Volite, Allergan/AbbVie).

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before

after 1 month

after

LetibotulinumtoxinA now available in LetibotulinumtoxinA (Letybo, Hugel Aesthetics Canada) is an effective neuromodulator for the treatment of moderate-to-severe glabellar lines with a quick onset of action, good durability, and high safety in clinical trials, according to interviews with dermatologists familiar with the product.

LetibotulinumtoxinA was recently approved in Canada for temporary improvement in the appearance of moderate to severe glabellar lines associated with corrugator or procerus muscle activity in adult patients under 65 years of age.

THE CHRONICLE OF COSMETIC MEDICINE + SURGERY spoke with three physicians regarding the science behind this neuromodulator and their experience treating patients with it.

LetibotulinumtoxinA has been extensively studied, with more than 1,200 participants in the clinical trials that led to the Canadian approval, said Dr. Michael Kane, a board-certified plastic surgeon with a private practice limited to aesthetic plastic surgery in New York, N.Y. He is the author of The Botox Book.

Three identical Phase III clinical trials (BLESS I, BLESS II, and BLESS III) enrolled healthy adults, ranging in age from 19 to 75 years, with moderate to severe glabellar frown lines at maximum frown, determined by both the investigator and the subject independently.

Each trial involved an initial parallel-group, randomized, double-blind, placebo-controlled study and an open-label, uncontrolled extension of up to three treatment cycles. In each treatment cycle, eligible subjects had one treatment session, and the cycles lasted from 12 to 48 weeks.

In these trials, a composite response was defined as having a two or more-step improvement in Facial Wrinkle Score (FWS) as assessed independently by the investigator and the subject.

This definition of response is relatively new and is based on a change in U.S. FDA guidelines roughly 10 years ago, said Dr. Kane. “In the old days, patients had to be moderate or severe, and to be a responder they had to essentially cross the midline and [achieve] either a Dr. Kane none or mild [rating].”

of them thought they jumped two grades. When you overlap them, it ended up being 65 per cent of the people were what we call composite two-point responses. That is a robust number.”

LetibotulinumtoxinA has shown similar efficacy in clinical practice.

“My experience with Letybo has been excellent,” said Dr. Syed Haq. “What I’ve found is consistency, good efficacy, and longevity without any adverse outcome. To date, I’ve used Letybo now for about one-

Good efficacy Dr. Kane said that even with this higher standard of response, in BLESS III the investigators rated 79% of the participants as improving by two full grades, “which is a strong number. The patients, of course, were less sure of their improvement, and 69 per cent

and-a-half years.” This amounts to several thousand individual treatments, he said.

Dr. Haq is a consulting physician who specializes in treating the aging brain, skin, and immune system. He is the co-founder of the AM Aesthetics clinics in London, Belfast, and Derry, U.K. He is also the

Dr. Haq

Dr. Sinno

4 monthV

n Canada founder of BioImmunitas Ltd., which is focused on developing pharmaceutical therapeutics for targeting systemic inflammatory disorders and Covid-19.

While patients up to 65 years is the age limit approved for letibotulinumtoxinA use in Canada, in the U.K. it is approved for patients up to age 75, said Dr. Haq. “I have quite a few older patients. One of the problems that they can experience [with other neuromodulators] is a lack of natural effect or brow drop. And I wasn't seeing that much [with letibotulinumtoxinA].”

Rapid onset of results In addition to good efficacy, letibotulinumtoxinA produces improvement quickly.

This rapid onset is appreciated by patients in the clinic. Dr. Hani

Sinno said his patients are saying they feel they are getting an extra week or two of benefit.

Montreal-based Dr. Sinno is an aesthetic and reconstructive plastic surgeon, and President of Follicl MD, a hair transplant clinic in Montreal. At the time of the interview, he had treated 115 patients with letibotulinumtoxinA Dr. Haq said he saw even faster results. “In about 20 per cent of patients, I saw a measurable clinical effect within 24 hours. The majority, I would say, were within two to three days; very few required any greater length of time to see a significant difference.”

Duration and safety The data on duration of letibotulinumtoxinA is also good, said Dr. Kane.

“In the studies, the duration was 16 weeks, and sometimes even a little further out than that,” he said. “The time to retreatment was a couple of weeks longer, up to 18 weeks or four and a half months. A good number, I would say.”

LetibotulinumtoxinA also showed excellent safety, Dr. Kane said, with zero severe adverse events recorded in both the initial treatment arm and the subsequent retreatment arms. There were also no cases of eyelid droop in the initial treatment arm.

“That’s an outlier. I circled it and said that’s really something,” he said. Through the retreatment arms, there was a rate of droopy eyelids of less than 1%, “which I would say is a good number,” he added.

“The other adverse event that sometimes happens is people can get a little headache,” Dr. Kane said. “Personally, I think that does not have much to do with the drug. I think that’s to do with the pain of injection and stabbing the needle into bone under the muscle. And some patients hold their breath when you inject them, and that gives them a bit of a headache.”

“In terms of adverse events profiles, we really didn't see anything [in my clinic],” said Dr. Haq. “I didn’t even see the headache that was reported in the BLESS III trial of about one per cent of cases. We didn’t see any issues with lid ptosis or brow ptosis.”

In the BLESS studies, researchers collected blood samples and tested for an immune response, Dr. Kane said. “In this study, they drew blood and they did different tests on [patients’] serum. [The investigators found] that no one had neutralizing antibodies, which is good.”

Dr. Sinno said that in his practice there was one patient who had developed resistance to abobotulinumtoxinA, botulinumtoxinA, and incobotulinumtoxinA, but who then achieved some improvement in their glabellar lines when injected with letibotulinumtoxinA. LetibotulinumtoxinA “didn’t paralyze [the muscle] completely, but it weakened it,” he said, so there may be some difference in immune recognition between the different neuromodulators.

Psychological, social functioning benefits The BLESS studies also investigated the impact of treatment with letibotulinumtoxinA on non-medical parameters, said Dr. Haq. “I think one of the things that is becoming a bigger trend, particularly since Covid-19, is the positive psychological impact that this type of treatment can provide patients,” he said. “BLESS III included an extensive analysis of different parameters of psychological and emotional impact. That, to me, is something that I do convey to my patients. They appreciate it and it makes them want to try [neuromodulators] more readily.”

Dr. Kane noted the studies included evaluations on the Skindex 16 quality of life scale, measuring patient-experience changes in emotional and social functioning factors. Patients reported 40% improvements in emotional factors and 30% improvement in social functioning, he said.

Ease of use “It is kind of astounding how much better people feel,” Dr. Kane said.

Dr. Sinno said he found it very easy to adopt letibotulinumtoxinA into his practice as it has the same dilution and injection pattern as botulinumtoxinA. “There’s nothing new to learn from it, you do exactly what you do with the other products,” he said. “So it’s very easy for the injectors, there’s no fear regarding having to change dilution or changing the volume injected.”

The ideal patient for glabellar line treatment with this agent is one where the area between their brows has aged out of proportion to the rest of their face, said Dr. Kane.

“They don’t really have heavy crow’s feet, they don't really have large jowls, everything's going okay, they just have the habit of frowning hard all the time, even though they’re not angry people. Those people look much older than they are.

They look much angrier than they are, and they look unhappy.” Treating those patients with letibotulinumtoxinA can dramatically improve their appearance and make them incredibly happy, he said.

Injector confidence “I think it’s extraordinary that we have one more product to provide our patients, especially because there are advantages [to the new product],” said Dr. Sinno. Even if this new neuromodulator had identical performance to other products, having more players in the market reduces the risk of supply disruption, he said.

Dr. Haq agreed, noting that the manufacturer of letibodulinumtoxinA, Hugel Inc., is the second largest toxin provider in the world. “That gives physicians a lot of reassurance about standards, safety, efficacy, and the integrity of a clinical trial.”

Supplement to The ChroniCle of CosmetiC mediCine + surgery. Printed in Canada for Chronicle Information Resources Ltd., 1460 The Queensway, Suite 212, etobicoke, Ont. M8Z 1S4 Canada. Telephone 416.916.2476; facsimile 416.352.6199; e-mail: health@chronicle.org. Copyright 2023 by Chronicle Information Resources Ltd., except where noted. All rights reserved. Reproduction in any form is expressly prohibited without written permission of the publisher.

n Regenerative aesthetics Treatments to reduce signs of aging may also stimulate growth of new cells or structural proteins n by John Evans, OF THE CHRONICLE

Regenerative aesthetics—encouraging the body’s natural processes to restore skin health and reduce signs of aging—is an emerging field of dermatology that could lead to improved patient satisfaction and a better understanding of skin function.

These ideas are explored in a recent paper in Dermatologic Surgery (Jan. 1, 2022; 48(1):101-108).

The paper’s authors write that tissue regeneration appears to be a property present in most animals that is lost as the organism ages. They note that human children and postnatal mice, rats, and rhesus monkeys are all able to regenerate amputated fingertips. However, the conditions necessary for this type of regeneration are not present in human adults.

In their review of the existing literature on regenerative approaches to aesthetic dermatology, the authors discuss the evidence and emerging therapies relevant to three key pillars of regenerative aesthetics: stem cells, biochemical cues, and scaffolds.

“Regenerative aesthetics is a unique field, and it is still relatively in its infancy,” said Dr. Misha Zarbafian, the paper’s lead author, in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “It is a field that we believe can have enormous potential within the realm of aesthetic medicine.”

Dr. Zarbafian, who is a cosmetic dermatology fellow at Cosmetic Laser Dermatology in San Diego, said that being able to achieve the goals of aesthetic medicine—aging gracefully, recapturing some degree of youthful appearance and function— by making use of the body’s regenerative processes, will be very appealing to both medical providers and patients.

“We often hear patients wanting to achieve goals naturally. [Regenerative aesthetics] would likely be very appealing to these patients if we are Dr. Zarbafian able to develop some of these techniques within this field.”

Many of the treatments explored in the article reduce the signs of aging directly—often through the restoration of volume or structure to the face.

However, evidence suggests they may play a further role, Dr. Zarbafian said.

“The emerging understanding is that the true power of a lot of the therapies that we use in regenerative medicine may not just be related to the treatments being administered themselves, but rather their ability to modify the local environment within the body,” he said. “Having looked at the literature, it seems to suggest that the true power of regenerative therapies may lie in releasing different chemical messengers, such as cytokines or growth factors, to modify traits such as cell growth, extracellular matrix remodelling or angiogenesis.”

Volume 11 Number 1

He noted that the U.S. Food and Drug Administration has begun implementing legislation on the development and use of many treatments and products within the realm of regenerative medicine.

“So, we also intended for this review to serve as a potential prompt or trigger for any colleagues to consider performing larger systemic studies in regenerative aesthetics.”

Stem cells In the article, Dr. Zarbafian and his colleagues look at several aspects of stem cells. These include adipose-derived stem cells and stromal vascular fraction, which have been researched along with platelet-rich plasma (PRP) for skin rejuvenation and for correcting hair loss.

Human umbilical cord blood-derived stem cells have also been explored as a tool for skin regeneration, according to the paper. Dr. Zarbafian and his colleagues note some research has shown that topical application of such cells supports the growth and extracellular matrix production of human dermal fibroblasts as well as collagen synthesis, possibly through a paracrine mechanism. However, they note the potential for ethical concerns surrounding the method of harvest, and that the number of these cells that can be harvested from an umbilical cord are often insufficient for treatment, even after expansion.

Biochemical cues Dr. Zarbafian and his colleagues reference studies that found a significant reduction in visible pores, superficial wrinkles, and other signs of facial aging after applications of growth factor (GF) and cytokine-containing topical agents.

The use of GFs and cytokines as injectable treatments have also been explored. This has been done not only through PRP but also through cell-free autologous conditioned serum and extracellular vesicles. Conditioned serum is prepared by incubating whole venous blood in the presence of treated glass beads that concentrate GFs, cytokines and other biochemical cues. Extracellular vesicles are cell-derived membranous structures composed of proteins, lipids, and nucleic acids, that play a role in intercellular communication.

Some studies have shown improvements in skin smoothness or elasticity using autologous conditioned serum, and Dr. Zarbafian and colleagues also cite studies showing treatment with extracellular vesicles promoting hair growth.

Scaffolds Another type of material being investigated for regenerative aesthetics are scaffolds—materials that both stimulate the body’s regenerative processes but also provide structure around which tissues can take hold. Dr. Zarbafian’s paper discusses the current science on several of these, including calcium hydroxyapatite dermal filler, non-permanent resorbable soft tissue threads—including ones made of polylactic acid, platelet-rich fibrin matrix and allograft adipose matrix.

He and his colleagues also —continued on page 21

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Photo courtesy of Adobe Stock

Mohs surgery Patient satisfaction linked to surgical outcomes n by Jeremy Visser OF THE CHRONICLE

Researchers have determined that patients who undergo Mohs micrographic surgery (MMS) for facial skin cancer have unrealistic expectations for scar outcomes. The cross-sectional study, which was published online in JAMA Network Open, was performed at the University of Pennsylvania in Philadelphia.

In total, 101 adult participants’ MMS scar estimates were compared to the estimates made by 86 surgeons, with investigators finding that scars were a median of 2.2 times larger than patient estimates and only 1.1 times larger than surgeon estimates.

Dr. Christian Murray commented on these findings in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “I think this study is an example of something we all knew and believed but this was a way to put this in data. It’s nice to have some evidence that explains to patients who may be confused about what surgery really results in.”

Dr. Murray Dr. Murray is a surgeon at Women’s College

20

Hospital Mohs Centre in Toronto and director of the American College of Mohs Surgery accredited fellowship at the University of Toronto.

Applicable to a Canadian population While the study used an American population, the findings are still applicable to Canadian patients, according to Dr. Murray. “The generalizability of the study would really be determined by what these patients knew coming in,” he said.

Study participants filled out a survey to collect information regarding history of MMS, pre-operative consultation and use of resources prior to their scar estimation. The findings suggested that education through these consultations or resources did not significantly improve the patients postoperative scar length estimates.

In the U.S., Mohs practices typically retain patients and see patients on a regular basis, allowing them to immediately screen high risk patients into surgery. In Canada, where there is limited access to MMS, patients are typically seen and referred by many providers before seeing a Mohs surgeon. In this way, they have had the benefit of several consultations and are able to be informed on the process by multiple physicians.

“It would also be significant [to know] what the referring doctor has conveyed to the patient regarding the surgery,” said Dr. Murray.

The authors describe the importance of the finding that “patients are satisfied when surgical outcomes meet their expectations.” They suggest that patient The Chronicle of Cosmetic Medicine + Surgery

dissatisfaction with surgical scars is one of the most common reasons patients in the U.S. pursue litigation against MMS surgeons. However, these findings are less relevant to Canadian physicians as litigation for MMS surgical outcomes is less common, according to Dr. Murray.

“I would say that in Canada, it is a very low risk,” he said. “[Litigation] is very rare and when it does happen, it typically does not have to do with the cosmetic result as much as it has to do with the ability to remove the cancer.”

While cosmetic outcome is important, it is not nearly as important as excision of the cancer. With so few Mohs surgeons in Canada, virtually all have completed accredited fellowships and there are strict criteria on which patients are eligible for MMS. “There haven’t been many cases of litigation related to cosmetic outcomes for MSS,” said Dr. Murray. “In fact, I’m not aware of any.”

Being realistic regarding both the likelihood of cancer removal and cosmetic outcome are important, Dr. Murray said. “We all want the same thing. We all want the cancer removed and the best results. Not only that, but we want to have the same understanding of those two things.”

Setting realistic expectations for surgical outcomes It is important to be realistic with the patient and explain the range of possible outcomes, according to Dr. Murray. He describes this as the primary role of a Mohs surgeon before surgery takes place. “The most predictive thing that determines patient satisfaction is how well they’re informed of the process and the possible outcome before you begin [surgery],” said Dr. Murray.

As a patient is referred to a Mohs surgeon, they will receive the best estimation for outcomes and alternatives from each physician. However, only a Mohs surgeon can be expected to predict something as specialized as scar length outcome.

While it is important to set realistic expectations before surgery and discuss outcomes after the procedure, Mohs surgery is unique in that patients are awake during surgery. This allows ongoing discussion and consent during the procedure. “I consider [the patient] an equal partner in the decision-making,” said Dr. Murray. “If you don’t partner with them, then I think you set yourself up for patient dissatisfaction, even if the results are good.”

The authors noted one of the limitations of the paper was that not enough information about wound repair techniques was collected, and the effect of these techniques on patient satisfaction.

“I think the simplest repair method is usually the most effective,” said Dr. Murray.

He described the simplest method as the one most likely to have the least negative effects or complications and easiest to manage if problems arise in the future. Each surgery requires unique approaches, and different reconstruction techniques must be tailored to each individual’s preference to ensure patient satisfaction.

“There is a tendency for all of us, especially in academia, to want to try new techniques that have very artistic repair options,” said Dr. Murray. “I typically will try to do the easiest and most natural reconstruction method possible.”

While Dr. Murray will show textbook examples of potential scar outcomes to patients, surgeries don’t always go to plan and not every surgery can be predicted. An ongoing dialogue and partnering with the patient should include all of these decisions, risks and backup plans so that patients are aware of all potential facial scar outcomes.

“It’s a difficult topic for people to understand and predict in many cases,” said Dr. Murray. “Explaining to them in simple terms so they can understand what to expect is going to result in better patient outcomes in the end.”

Volume 11 Number 1

Regenerative aesthetics an emerging field —continued from page 19 note that some research also suggests that hyaluronic acid dermal fillers may also hold scaffold-like properties, having modulatory and regenerative effects on stem cells.

Research is limited While the existing literature on regenerative aesthetic dermatology is promising, Dr. Zarbafian notes that all of the existing studies are in quite small samples or have other limitations.

“Often with new emerging therapies, data is initially published as single case reports or case series with small sample sizes,” Dr. Zarbafian said.

“There are so many potential therapies, as we discussed in the paper, that fall under the umbrella of aesthetic medicine that it will take some time to collect the evidence for each one.”

Long-term outcomes unknown The small body of literature also means that the long-term results of these treatments are not known, said Dr. Zarbafian.

“Regenerative aesthetics is a unique field, and it is still relatively in its infancy, it is a field that we believe can have enormous potential within the realm of aesthetic medicine.”

“If we are modifying these signalling messengers and these immune characteristics, how long can these effects last? Can we expect them to be permanent? Or will they have to be repeated? If they have to be repeated, at what time will this have to take place?”

Many existing studies follow patients for 24 weeks after treatment and have found evidence that improvement persists, he said. However, longer-term stability is still unclear.

“Sometimes it takes waiting until these treatments are being performed on a greater volume of patients before we can properly assess these real-world factors,” said Dr. Zarbafian.

Another challenge to understanding and comparing outcomes between regenerative aesthetic treatments that will need to be overcome is a lack of standardization, he said, using PRP as an example.

“We talk in the paper about the variability in terms of different types of stem cells, and we talk about differences in terms of preparation for PRP,” he said. “There are so many different sources of stem cells that each has its pros and cons. There are almost endless ways that PRP can be produced. So I would expect that as we continue to advance in this field [of regenerative aesthetics], we will have some degree of standardization in terms of preparation and standards for final treatment products that hit the market.”

21

Special Report

Coming soon: New cream for Slow-release double-conjugated retinoid/AHA formulation has good efficacy and is well tolerated, making retinoid treatments an option for more patients A non5prescription, double5conjugated retinoid/AHA cream can provide effective manage5 ment of the signs of photoaging with minimal irrita5 tion and improved skin hydration. This product, marketed under the name AlphaRet Overnight Cream by skinbetter science, a brand recently acquired by L’Oreal Dermatological Beauty, has been available in the U.S. for 6 years, and is expect5 ed to become available in Canada in January 2024.

“We’ve known that both alpha hydroxy acids and retinoids have been significant ingredients in the management of photodamage,” said Dr. Sam

Dr. Hanna

Dr. Abdulla

Hanna, in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “For a long time, what has been challenging is having medications that are potent enough to make a difference without also being saddled by irritation. Certainly, that’s been the big issue with retinoids. We all as derma5 tologists use retinoids by prescription or over5the5 counter and in various formulations.”

Toronto5based dermatologist Dr. Hanna is the Medical Director at Dermatology On Bloor and has served as a principal investigator for numerous cosmetic and medical clinical trials with Probity Medical Research of Waterloo, Ont. Dermatologists are always “striking a bargain” with retinoids to try and provide patients with enough potency to have an effect while also keep5 ing irritation low, he said.

Double-conjugated molecule AlphaRet combines a retinoid with an alpha

hydroxy acid (AHA), specifically lactic acid, Dr. Hanna explained. This double5conjugation results in a slow release of both agents.

“Previously, with many of our retinols and retinoids the greatest challenge has been tolerabil5 ity,” said Dr. Sonya Abdulla. “So [AlphaRet] is a double conjugate molecule that combines a patented retinoid with lactic acid that will give patients the clinical benefit, but in an option that is well tolerated.”

Dr. Abdulla is a double board5certified derma5 tologist in Canada and the U.S. She has an active medical and cosmetic dermatology practice where she is involved in clinical research and teaching.

Her clinical interests include acne, rosacea, and psoriasis as well as minimally invasive aesthetic procedures including injectables, energy5based devices, and laser surgery. Dr. Abdulla is a strong proponent of evidence5based skin care.

She said the lactic acid in the double conju5 gate molecule acts as a humectant, improving both skin penetration and hydration.

These features make retinoid treatment more accessible to patients who have sensitive or rosacea5prone skin and may not have been able to use skincare products from this family of medica5 tions, Dr. Abdulla said.

“We have known for a long time that lactic acid helps both the epidermal and skin surface level, but also will help with some dermal remod5 elling as well,” said Dr. Hanna. “There’s an instant improvement in moisture which we’ve seen and then the retinoid benefits skin cell turnover.”

Double-blind, split-face study Dr. Hanna cited a split5face study published in the Journal of Cosmetic Dermatology (Dec. 2017; 16(4):5425548) that compared AlphaRet to either tretinoin 0.025% cream or 1.0% retinol cream. The 125week randomized trial was conducted in 48 female subjects, aged 30 to 65 years with mild to severe photodamage.

“This was a robust study,” he said. The dou5 ble5blinded study compared the efficacy of the dif5

ferent agents across multiple domains.

Investigators “looked at efficacy in terms of red5 ness, dyschromia, wrinkle scores, skin tone degra5

Figure 1: Efficacy and tolerability of a double5con5 jugated retinoid cream vs. 1.0% retinol cream or 0.025% tretinoin cream in subjects with mild to severe photoaging. dation, and pore size.”

“Across all of those factors there was signifi5 cant benefit for the AlphaRet side from the begin5 ning, even from week four, on almost all the met5

photoaging management rics,” Dr. Hanna said. “And for all the metrics by week 12, they were seeing a statistically significant reduction in those markers of sun damage.”

The study also showed that tolerability was sig5 nificantly better with AlphaRet than with the tretinoin and comparable to the retinol, he said.

Dermatologists frequently talk about intermit5 tent use with retinoids, reducing treatment fre5 quency during the winter, and having patients pause use if they develop irritation, Dr. Hanna said.

“We may have to do that with some folks with [AlphaRet] but given what we’ve seen both in trials and in the real5life experience that we’ve had so far, I think that is going to happen a lot less.” “[AlphaRet] is pretty comparable, if not better, to the tretinoin effect that we've seen for other non5prescription agents.”

He noted that the trial also looked at hydration measures. “The combination product did very well right from the beginning. By week four, they had significant improvement. The retinol group had this

interesting thing where they had significance, but it dropped off as they went on. They lost that hydra5 tion. And of course, as predicted, the tretinoin group had worse hydration just because of the potential irritancy with classic retinoids.”

Accessibility to patients While this agent is not yet available in Canada, Dr. Abdulla noted dermatologists have significant real5 world experience in the U.S. “We’re fortunate to have the experience of our

colleagues in the U.S., who have had the opportunity to integrate the entire AlphaRet product line into their offerings,” she said. “The feedback from those patients and colleagues south of the border has been very positive, both in terms of clinical efficacy, includ5 ing improvement in things such as fine lines, wrinkles, dyschromia, redness, and pore size. And also in terms of the tolerability, opening treatment up to patients of any skin type, and also any phototype.”

Dr. Abdulla said that skincare is the backbone of all aesthetic dermatology and corrective treat5 ments such as retinols and retinoids are an impor5

tant part of treatment. She said AlphaRet can help introduce patients to a positive aging plan,“and also to protect the investments that they’re making if they are considering other non5invasive aesthetic procedures.”

As a non5prescription product, AlphaRet is not a prescription agent so it wouldn’t be covered by private or public health insurance, Dr.Hanna said, “so budget considerations are going to come into play for some people as they often do. Prescription products are also often not covered for aesthetic indications, so this may not be as significant differ5 ence in cost,” he said However, he noted that even if the out5of5 pocket costs for older “prescription strength” prod5 ucts are lower than this new option, it is important to consider the difference between value and cost.

It may be worthwhile to a patient to pay more out of pocket for a product that is more tolerable and consequently will achieve better results.

Stronger research for non-prescription products The scientific rigour behind this product and a gener5 al trend to stronger scientific backing of over5the5 counter skin products is encouraging, said Dr. Hanna.

“It’s heartening to see better and better invest5 ments in good science,” he said, noting that histori5 cally many products were supported by studies of simple clinical outcomes, such as before5and5after photos. “Whereas here, the researchers are meas5 uring very specific things. We have scales, blinded assessments, for both patients and providers, and also some more objective measures, such as the Novameter that measures hydration.”

“Even though this isn’t a prescription agent, patients deserve their skincare not to be driven by marketing, but to be driven by measurable effects and science.”

Supplement to THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. Chronicle is an independent medical news service that provides educational updates regarding medical developments around the world. Views expressed are those of the participants and do not necessarily reflect those of the pub lisher or sponsor. Support for distribution of this report was provided by skinbetter science by L’Oreal Dermatological Beauty, through an unre stricted educational grant without conditions. Information provided in this report is not intended to serve as the sole basis for individual care.

Printed in Canada for Chronicle Information Resources Ltd., 1460 The Queensway, Suite 212, Etobicoke, Ont. M8Z 1S4 Canada. Telephone 416.916.2476; facsimile 416.352.6199; e mail: health@chronicle.org.

Copyright 2023 by Chronicle Information Resources Ltd., except where noted. All rights reserved. Reproduction in any form is expressly prohibited without written permission of the publisher.

n Hyaluronic acid filler Still photographs do not adequately portray effects of filler treatment n by John Evans, OF THE CHRONICLE

Researchers using 3D video to measure stretch and strain in the skin of animated faces have shown objective evidence that hyaluronic acid (HA) filler treatments in patients aged 41 to 65 years result in stretch characteristics resembling a younger phenotype in areas prone to the effects of facial aging.

Published in Plastic and Reconstructive Surgery (145(2):295e-305e), the findings come from a study of 30 women with moderate to severe bilateral nasolabial folds and marionette lines, who had been treated with HA filler products. This cohort were compared to an untreated group of 20 individuals aged 25 to 35 years.

For each participant in the treatment and comparison groups, 3D videos were collected using a Dr. Bertucci Canfield Vectra 3D system at baseline and at day 42.

Dynamic strain was analyzed at the marionette lines and nasolabial folds as subjects progressed from a neutral position through a series of facial expressions.

Limitations of static assessments The idea for the study arose in part from a growing understanding that still images may not be enough to fully evaluate how natural-looking aesthetic treatment outcomes really are, said study author Dr. Vince Bertucci in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “I think we have come to recognize that while appearance at rest matters, appearance with expression, movement, and animation is also very important in discerning naturalness of results,” he said. “Simple photos in repose where we look at frontal, profile, and 45 degree views are not adequate. Our patients are living beings and we need to do better at capturing that in our assessments.”

Dr. Bertucci is co-director of the Dermatologic Laser Surgery & Aesthetic Dermatology Fellowship at the University of Toronto, and founder and medical director of Bertucci Dermatology in Woodbridge, Ont. He said that he and his colleagues were interested to know if, using 3D videos to assess the stress and strain on faces that were animating, it was possible to identify patterns of strain in the younger population that were changed in the older group. “ And if that is the case, do our treatments actually help our patients to revert back to their younger selves, in terms of animation and strain?”

The perioral region, which is highly animated, was chosen as the part of the face to evaluate in this study, Dr. Bertucci said. “As we speak, we chew, we smile, we make expressions, that is the area that moves a lot. And so, we thought that if we were going to see a change, the perioral area would be ideal to study changes that may occur over time.”

24

Age-related strain changes The research team found statistically significant (pS0.05) differences between the two groups at baseline in the level of stretch in the nasolabial folds and marionette lines. The older cohort had higher stretch profiles.

Treatment with HA filler reduced peak stretch in both areas in the older cohorts compared to baseline, across all the facial expressions tested.

Interestingly, the post-treatment stretch profile of the older treated individuals resembled the profile in the youthful control group.

The research team's hypothesis for the difference in strain patterns, and the improvements from HA filler treatment, is that age-related volume loss allows for more movement in the overlying skin, and consequently more strain, said Dr. Bertucci. “By carefully filling the areas that are affected, we are reducing the compression or strain that occurs.

There are two main take-aways from this study, said Dr. Bertucci. “One, yes, there are differences between younger and older individuals in the strain pattern. And two, with filler treatments we can help older individuals revert the strain pattern to more closely mimic their younger self.

He and his colleagues have recently completed a similar study looking at changes after HA treatment in dynamic strain in the lips—a region in which he said unnatural results are most visible and obvious.

“The data is being analyzed right now. So that will be an interesting one to look at as well.”

Next steps Looking forward, Dr. Bertucci said it would be interesting to see the impact of different injection techniques and products, other even other aesthetic procedures, on dynamic facial strain.

“I think those would be very interesting concepts to explore,” he said.

“Looking at deeper versus more superficial injections, cannula versus needle, product A versus product B, more volume versus less volume—and so on. These are all unanswered questions that would be very interesting to look into.”

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n Soft tissue filler A new take on facial lifting: Study looks at overall facial effects of soft-tissue filler injections in the temple region n by John Evans, OF THE CHRONICLE

A small study has shown evidence that suggests soft tissue filler augmentation in the posterior superior temple region can reduce volume in the middle face and accentuate the contours of the jawline.

Published in Journal of Cosmetic Dermatology (doi: 10.1111/jocd.13491), the research was aimed at clinically validating a previously-described technique of exclusively targeting the subdermal plane of the posterior and superior temple with soft tissue filler treatment to improve the appearance of the whole face, includ- Dr. Cotofana ing reducing mid-facial volume.

“Since the initial paper [which described this technique] was published in 2018, doctors were trying this technique and everybody was impressed by the results,” said the study’s senior author Dr. Sebastian Cotofana in an email interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “Because I like scientific evidence and ‘evidence-based’ medicine and not ‘eminence-based’ medicine, I wanted to provide proof for the technique. That’s why we designed a study to support the clinical findings that doctors were already observing.” Dr. Cotofana is an associate professor of anatomy in the department of clinical anatomy at Mayo Clinic College of Medicine and Science in Rochester, Minn.

“I think the concept of lifting the face by injecting the temple region is fascinating,” said Dr. Vince Bertucci in an interview with THE CHRONICLE OF COSMETIC MEDICINE + SURGERY. “One that has allure in that it would be nice to show that treating one area positively affects other areas.

As pointed out in the paper, the face exists in a layered system, so you would think that if you treat one area, because the layers are connected, it is going to

26

have an impact on the other layers.”

Dr. Bertucci, who was not involved in the research, is the medical director of Bertucci MedSpa in Woodbridge, Ont., and co-director of the University of Toronto’s Dermatologic Laser Surgery and Cosmetic Dermatology fellowship program.

In the study, some 12 patients—one male and 11 females—were included from a single centre.

Their mean age was 36.75±6.6 years, and their mean body mass index was 23.04±1.3 kg/m2. The treatment involved the injection of a single bolus (1.00 cc of hyaluronic acid -based, or 0.75 cc of calcium hydroxylapatite-based) of soft-tissue filler via Dr. Bertucci blunt-tipped cannula, with no manual massage or manipulation.

The investigators evaluated injection‐related outcome through use of 3D skin vector displacement measurement and surface volume analyses, as well as scoring based on five different evaluators.

Improvement was evaluated by the treating physician and the patient as well.

Three months after treatment, three independent observers recorded improved outcome among the patients on the global aesthetic improvement scale (3.08). The treating physicians evaluated the improvement as very improved (4.33), and the patients evaluated it as exceptional improvement (4.83).

The mean horizontal lifting, three months after the treatment, was 0.13 mm, and the mean vertical lifting was 0.02 mm. A mean increase of 0.26 cubic centimetres (cc) was seen for the total temple, while the mid-face and lower face had a mean decrease of 0.22 cc.

No major adverse events were reported during the three‐month observational period, though in 10 out of 24 treated temples, the patients reported a headache which resolved within one day without

medical intervention. One patient in the calcium hydroxylapatite-treated group presented with nonscarring alopecia at an interim visit at two months, though the hair loss resolved without medical intervention four months after the original treatment.

“I think that the results need to be interpreted with caution,” said Dr. Cotofana. “The technique is great but it does not work in every patient. Patients with skin laxity or with heavy faces will not have such a benefit as young, non-obese and non-skin laxity patients. Patient selection is important for this technique.”

Larger study needed While the findings are interesting, they need to be validated with a larger patient population, said Dr. Bertucci.

“Because the study was performed at a single site, had a small number of participants, and the results were modest, it raises the issue of reproducibility, making it challenging to know what to make out of the study,” he said. “I like the concept and look forward to confirmatory data from a larger study.”

Dr. Cotofana noted that other physicians using this technique are in the process of collecting additional case information. “I am curious about their results and how they objectified the outcome,” he said.

Dr. Bertucci noted that the average posterior and superior displacements, as well as the volume changes seen, were quite small.

The largest aesthetic improvements were reported by the patients and the treating physicians, Dr. Bertucci noted.

“If you look at the patient improvement, most of them said that they were extremely improved. I participate in many studies and find that patients that participate in studies and get free treatments tend to have an optimistic assessment of the results,” he said.

“The treating physician ratings also showed improvement, but not to the same degree as the patients’ self-ratings,” Dr. Bertucci noted. “It could The Chronicle of Cosmetic Medicine + Surgery

Photo courtesy of Adobe Stock

be argued that both the physician who is treating and the patient who is being treated are not objective. So I think we have to interpret the results with a bit of caution.”

Considerations before using technique While the safety signals in this study were good, Dr. Bertucci said it is important to be aware of three considerations.

The first consideration is that 42% of the patients developed a headache, which Dr. Bertucci said is not surprising given the 1 mL bolus injected into the temple, an area that tends to be tight.

“Headaches resolve. But a one millilitre bolus injection can be uncomfortable in this tight area.”

Second, he noted that one of the 12 patients developed alopecia, which as a percentage is a relatively large number, even if it spontaneously resolved after four months. “One wonders if the alopecia might have been avoided if the product had been injected over a larger area so as to reduce local pressure on hair follicles. Having said that, spreading the product over a larger area may or may not impact the lifting capacity,” Dr. Bertucci commented.

“Additionally, the technique involves injecting in the region of the superficial temporal artery.

While the primary author carefully injected subderVolume 11 Number 1

mally so as to avoid the deeper position of the artery, beginners may find it a challenge to discern precise injection depth,” he said. While the technique is well described in this paper and in an earlier paper from the same authors, Dr. Bertucci expressed reservations about less experienced injectors using this approach.

“It raises the question about who should be performing this technique. Non-expert injectors, may put patients at risk if they inadvertently inject slightly more deeply, in the layer where the superficial temporal artery is located. And that would cause a lot of problems.”

“I am intrigued by the technique and its potential to produce indirect benefits. However, more robust data is needed before this technique be can considered standard practice,” Dr. Bertucci said.

Dr. Cotofana said he believes this approach is a good starting point for a facial rejuvenation plan.

“I hope doctors will start working with this technique and understand that this technique can be—in 90 per cent of all filler patients—the starting point for facial lifting and facial rejuvenation,” he said. “Doing this technique first will reposition the facial soft tissues substantially and will pre-condition the face for any following treatment.”

Following up on this research, Dr. Cotofana said he and his research team are investigating com-

bining this technique with use of neuromodulators for inducing facial lifting. “This will be a very interesting study and I am very curious about that outcome.”

Two additional papers have been published on the technique by Dr. Cotofana and his colleagues since the time of the interview.

“Full-face effects of temporal volumizing and temporal lifting techniques” (Journal of Cosmetic Dermatology, doi: 10.1111/jocd.13728) compared the facial changes of supraperiosteal, interfascial, and subdermal injection techniques. That investigation found that the three approaches each influenced other parts of the face differently, so the authors conclude that the best approach for future injection algorithms could be to combine all three techniques into a multi-layer injection approach. “Quantitative analysis of the lifting effect of facial soft-tissue filler injections” (Plastic and Reconstructive Surgery, doi: 10.1097/PRS.0000000000007857). The research team of this cadaveric study used three-dimensional surface scanning procedures to assess the facial lifting results of soft tissue filler injections. The authors conclude that there may be limited lifting from temporal deep supraperiosteal injections alone but combining subdermal injections in the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face.

27

The Chronicle of

Cosmetic

Medicine

+ Surgery

Pearls Injectable tools are used to highlight, define, and refine

l

Male patients experiencing inflammation in the neck

l

Retinol used in a variety of treatments

When we are using aesthetic injectable tools, we are not trying to change that person’s face, but we’re trying to highlight, define, and refine their underlying ethnic features. Ultimately, if we are using combination approaches, we can help our patients age gracefully, and we can treat them as a whole.

—Dr. Monica Li, medical and cosmetic dermatologist,.

Vancouver, speaking at the 9th annual Skin Spectrum Summit in Oct. 2023.

For my male patients with pseudofolliculitis, even if they ask me to treat their whole face, I treat the lower part of the neck. I find that that’s where most of the inflammation is occurring.

—Dr. Jonathan Shapero, a Toronto dermatologist, speaking at the 9th annual Skin Spectrum Summit in Oct. 2023.

l

Retinol is one of the most well-studied and highly-recommended skin care ingredients at our disposal, doing everything from addressing and preventing signs of aging like fine lines, wrinkles, and hyperpigmentation, to treating and preventing acne. [But] retinol may be too powerful and irritating for some, especially those withsensitized skin.

—Dr. Geeta Yadav, Toronto dermatologist, in an interview with The Zoe Report

Sun protection important in anti-aging skin care routines

l

The best anti-aging skin care routine includes strict sun protection during the day and a retinoid at night. I also try to prioritize organic moisturizers and topicals.

—Dr. Julie Jackson, a dermatologist in Austin, Texas, in an interview with Real Simple Magazine.

Have you (or your colleagues) determined a Best Practice in aesthetic medicine that might deserve wider attention among your peers? Or have you picked up a takeaway message from a conference that you’d like to disseminate further? By all means, here’s the opportunity to share your knowledge and expertise.

Forward your pearl to cosmetic@chronicle.ca

28

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Atelier Beauty of the idealized human form, depicted through artistic expression through the ages

JO, LA BELLE IRLANDAISE Gustave Courbet (1819-1877) Courtesy The Metropolitan Museum of Art, New York City

I NTRO D U C I N G

E XIT S HADOWS

ENTER LIGHT TARG E TED TR E ATM ENT FO R TH E TE AR TRO U G H

TARG E TE D. R ECO M M E N DE D BY E XP E RT S .

TR U STE D. 1 - 4 References: 1. Verpaele A, Strand A. Restylane SubQ, a non-animal stabilized hyaluronic acid gel for soft tissue augmentation of the mid- and lower face. Aesthet Surg J 2006;26(1S):S10-7. 2. Galderma. Data on file. MA-53284-US Study. 2022. 3. Nikolis A, et al. A randomized, crossover-controlled evaluator-blinded trial evaluating cannula vs needle-assisted hyaluronic acid injections for infraorbital deformities. Aesthet Surg J 2022;42(3):285-297. 4. Nikolis A, et al. Expert recommendations on the use of hyaluronic acid filler for tear trough rejuvenation. J Drugs Dermatol 2022;21(4):387-392.

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Restylane and Galderma are registered trademarks.

www.galdermaaesthetics.com/ca/ restylane-lift-fill-volumize

PIONEER AND RECOGNIZED FOR ITS ANTI-SPOT SKINCARE

10% niacinamide 90%

concentrate

INGREDIENTS of NATURAL origin

A detoxifying, oxygenating and moisturizing prep formula

WITH PREBIOTIC AND HYALURONIC ACID

REDUCES THE APPAREANCE OF DARK SPOTS, BOOSTS BRIGHTNESS AND REFINES SKIN TEXTURE

0%

paraben, oil, silicone, alcohol, perfume

AVAILABLE AT SHOPPERS DRUG MART

A CANADIAN FAMILY BUSINESS SINCE 1985