High-intensity focused ultrasound for the reduction of subcutaneous adipose tissue using multiple treatment techniques

BACKGROUND

High-intensity focused ultrasound (HIFU) is a noninvasive alternative to traditional invasive body sculpting procedures.

OBJECTIVE

To assess the effectiveness and tolerability of HIFU treatment using high and low fluence settings with 2 treatment techniques, grid repeat (GR) and site repeat (SR).

MATERIALS AND METHODS

Two multicenter studies were conducted. Subjects underwent 1 HIFU treatment with 1 of 5 treatment protocols (total fluence, 150-180 J/cm). Primary end point was change from baseline in waist circumference (CBWC) at 12 weeks. Secondary end points included CBWC at 4 and 8 weeks and investigator- and subject-assessed clinical improvement. Adverse events were monitored throughout the study.

RESULTS

In the intent-to-treat (ITT) population, all subjects had a statistically significant mean circumferential reduction of -2.3 ± 2.9 cm (p < .0001) from baseline at 12 weeks, with no significant differences among the 5 treatment groups (ITT: p = .153). Analysis of secondary end points in the ITT population demonstrated a significant circumferential reduction starting as early as 4 weeks in all subjects (-1.1 ± 1.9 cm, p < .0001). Most subjects in all treatment groups showed improvements at 12 weeks as rated by the investigators and subjects.

CONCLUSION

High-intensity focused ultrasound treatment using either a low or high fluence setting in a GR or SR method is effective for circumferential waist reduction, resulting in statistically significant CBWC in all treatment groups.

Long-term safety of abobotulinumtoxinA for the treatment of glabellar lines: results from a 36-month, multicenter, open-label extension study

BACKGROUND

Because abobotulinumtoxinA treatment for glabellar lines must be repeated regularly to prevent recurrence, understanding the safety and effectiveness of long-term, repeated administration of abobotulinumtoxinA is important.

OBJECTIVE

To report the long-term safety and efficacy of abobotulinumtoxinA in patients with moderate to severe glabellar lines.

METHODS AND MATERIALS

AbobotulinumtoxinA was administered to 1,415 patients in multiple cycles over 24 months as a fixed dose of 50 U or as a dose based on muscle mass and sex (women: 50-70 U; men: 60-80 U). Adverse events were assessed after each visit on days 7, 14, and 30 and monthly thereafter; monitoring continued every 3 months for a total safety monitoring duration of 36 months or less.

RESULTS

Nine hundred ninety-one (70%) patients reported treatment-emergent adverse effects (TEAEs); most events were mild (70%) or moderate (20%) in severity. The rate of TEAEs did not increase over 24 months of repeated treatment (mean 5.6 cycles; range 1-9). Treatment-related eyelid ptosis followed 53 of 7,938 (0.7%) treatments, all of which resolved spontaneously.

CONCLUSIONS

Multiple cycles of abobotulinumtoxinA treatment over 24 months were well tolerated and effective for the correction of glabellar lines, with no evidence of cumulative safety problems.

Treatment of purpura with lasers and light sources

The potential for bruising is a frequent concern for patients undergoing minimally invasive procedures, particularly injection-based soft tissue fillers and botulinum toxin type A. Decreasing the risk of this side effect with good technique and careful patient selection is key, but interventions that quicken the resolution of bruising are also helpful. Many practitioners have employed the theory of selective photothermolysis, using laser and light devices, to target hemoglobin and its breakdown products to speed time to bruise resolution. 585-595 nm pulsed dye, pulsed 532 nm and 1064 nm long-pulsed neodymium-doped yttrium aluminum garnet (Nd:YAG) lasers and intense pulsed light may be utilized with best results achieved when treatment is performed 1-2 days after the appearance of purpura. Specific therapy recommendations, side effects and contraindications will be addressed in this review.

Fractionated ablative carbon dioxide laser for the treatment of rhinophyma

BACKGROUND

Rhinophyma is a progressive and disfiguring proliferative disorder of the nose, which is related to chronic rosacea. Many different treatment modalities have been utilized both alone and in combination including: loop cautery, CO2 laser, argon laser, dermabrasion, cryotherapy, radiotherapy, full-thickness excision, skin graft, flap reconstruction, and cold scalpel. CO2 resurfacing has been considered first line therapy but is often associated with a shiny, scarred appearance, with patulous pores, and with loss of pigmentation. We report a technique using aggressive parameters with the fractionated ablative CO2 laser, resulting in improvement of appearance with very few complications.

MATERIALS AND METHODS

Five patients who presented with rhinophyma of varying degrees were treated with a series of fractional ablative CO2 laser treatments (Fraxel re:Pair, Solta Medical, Hayward, CA). These patients were treated with settings of up to 70 mJ, 70% density and 16-18 passes. All patients received HSV prophylaxis using either acyclovir 400 mg TID or valacyclovir 500 mg BID. Patients were rendered anesthetic by 1% lidocaine and epinephrine regional perinasal nerve block.

RESULTS

All of the patients tolerated the procedure well with reepithelialization at days 4-7 and self-limited edema and erythema. Patients with relatively early to moderate signs of rhinophyma proved optimal candidates for this treatment. There were no adverse events. Patients and physicians noted significant improvement and reduction in the rhinophyma without the typical scarring noted with most other treatments.

CONCLUSION

Rhinophyma treated with fractionated ablative CO2 laser using relatively aggressive parameters achieved good cosmetic outcomes in this group of early to moderate cases of rhinophyma, while still retaining the benefits of a fractionated treatment such as faster healing times and fewer adverse events.

American Society for Dermatologic Surgery dermatologic surgery drug and device nomenclature recommendations

BACKGROUND

There is a lack of consensus regarding appropriate nomenclature for drugs and devices used in surgical and cosmetic dermatology.

OBJECTIVE

To develop a rules-based system for naming drugs and devices commonly used in dermatologic surgery that generates identifiers and modifiers that are clear, complete, and brief.

METHODS

Using an iterative modified consensus process, five subject-area work groups of the ASDS Lexicon Task Force were charged with developing standard terminology for the drugs and devices subsumed under their topic. A subcommittee comprising the chairs of the workgroups initially developed the general rules that guided the consensus process; subsequently, this subcommittee merged the 5 resulting documents into a single work product. Two external reviewers with expertise in dermatologic drugs and devices reviewed the final document for errors and omissions.

RESULTS

General characteristics sought in systematic names included: brevity, clarity, non-overlapping (mutually exclusive) nature, within-class similarity, preservation of current usage when possible, and potential for inclusion of future refinements.

CONCLUSION

Naming of drugs and devices in dermatologic surgery can be improved to increase comprehensibility and utility in both clinical and research contexts. Particularly for devices, the use of systematic names can reduce repeated mention of proprietary names in scientific discourse. Any naming system should be amenable to modification, correction, and the continual incorporation of novel agents.

A phase IV, open-label study evaluating the use of triple-combination therapy with minocycline HCl extended-release tablets, a topical antibiotic/retinoid preparation and benzoyl peroxide in patients with moderate to severe acne vulgaris

BACKGROUND

Moderate to severe acne vulgaris is often treated with a combination of an oral antibiotic, topical antibiotic/retinoid, and benzoyl peroxide (BP), but data are limited on the efficacy of this and other combination regimens that incorporate both oral and topical therapies.<BR>

METHODS

Patients were required to be aged 12-30 years with moderate to severe acne (grades 3-4 acne on the Investigator's Global Assessment [IGA]) and deemed potential candidates for treatment with isotretinoin. Enrolled patients were given triple-combination therapy, defined in this study as oral minocycline HCl extended release 1 mg/kg QD, 6% BP foaming cloths used QD, and clindamycin phosphate 1.2%/tretinoin 0.025% gel applied QD, and were evaluated at baseline and weeks 2, 4, 8, and 12.<BR>

RESULTS

A total of 97 patients were enrolled in the study. At week 12, 89% of patients had at least a one-grade improvement from baseline IGA and 96% had at least a one-grade improvement from baseline Global Aesthetic Improvement Scale score. Mean ± SD in- flammatory, non-inflammatory, and total lesion counts decreased from baseline by 61.8% ± 38.3%, 48.8% ± 34.5%, and 56.5% ± 29.9%, respectively. The percentage of patients evaluated as candidates for isotretinoin by independent photographic review was 77% (69/90) at baseline and only 16% (14/90) at week 12. Treatment-related adverse events (AEs) occurred in eight of 97 (8%) patients. Triplecombination therapy was not associated with any serious AEs or AEs leading to discontinuation.<BR>

CONCLUSION

Triple-combination therapy was well tolerated and substantially reduced facial acne lesion counts, with 84% of patients judged to no longer be candidates for isotretinoin therapy by study end. These data support the clinical observation that a triple-combination regimen incorporating oral minocycline (dosed by patient weight), BP foaming cloths 6% QD, and clindamycin phosphate 1.2%/ tretinoin 0.025% gel QD can substantially improve moderate to severe acne vulgaris.

Nd:YAG laser hair removal in Fitzpatrick skin types IV to VI

Safe and effective laser treatments are crucial, especially in darker-skinned individuals. Herein, we report our experience treating Fitzpatrick skin types IV to VI with a long-pulsed, 1,064-nm neodymium-doped yttrium aluminum garnet laser. With the right treatment settings, darkly pigmented individuals can undergo laser hair removal effectively.

Abbreviations for device names: a proposed methodology with specific examples

BACKGROUND

Many devices used in dermatology lack generic names. If investigators use commercial device names, they risk the appearance of bias. Alternatively, reliance on ad-hoc names and abbreviations may confuse readers who do not recognize these.

OBJECTIVE

To develop a system for assigning abbreviations to denote devices commonly used in dermatology. Secondarily, to use this system to create abbreviations for FDA-approved neurotoxins and prepackaged injectable soft-tissue augmentation materials.

METHODS

The American Society for Dermatologic Surgery convened a Lexicon Task Force in March 2012. One charge of this Task Force was to develop criteria for assigning abbreviations to medical devices. A modified consensus process was used.

RESULTS

Abbreviations to denote devices were to be: based on a standardized approach; transparent to the casual reader; markedly brief; and in all cases, different than the commercial names. Three-letter all caps abbreviations, some with subscripts, were assigned to denote each of the approved neurotoxins and fillers.

CONCLUSION

A common system of abbreviations for medical devices in dermatology may avoid the appearance of bias while ensuring effective communication. The proposed system may be expanded to name other devices, and the ensuing abbreviations may be suitable for journal articles, continuing medical education lectures, or other academic or clinical purposes.

The evolution of quality-switched lasers

Quality-switched (QS) lasers and their applications have evolved greatly since the ruby laser's effect on tattoo ink was first reported in the 1960s. The 1983 description of selective photothermolysis explained the efficacy of QS lasers for the treatment of cutaneous pigmented lesions and tattoos and cemented their status as the gold standard for these targets. Within the past decade, the uses for QS lasers have expanded dramatically, including nonablative rejuvenation and the treatment of onychomycosis. Additional applications and refined techniques and technologies promise to maintain the stature of QS lasers as an integral part of the laser surgeon's arsenal.

Fractional laser skin resurfacing

Laser skin resurfacing (LSR) has evolved over the past 2 decades from traditional ablative to fractional nonablative and fractional ablative resurfacing. Traditional ablative LSR was highly effective in reducing rhytides, photoaging, and acne scarring but was associated with significant side effects and complications. In contrast, nonablative LSR was very safe but failed to deliver consistent clinical improvement. Fractional LSR has achieved the middle ground; it combined the efficacy of traditional LSR with the safety of nonablative modalities. The first fractional laser was a nonablative erbium-doped yttrium aluminum garnet (Er:YAG) laser that produced microscopic columns of thermal injury in the epidermis and upper dermis. Heralding an entirely new concept of laser energy delivery, it delivered the laser beam in microarrays. It resulted in microscopic columns of treated tissue and intervening areas of untreated skin, which yielded rapid reepithelialization. Fractional delivery was quickly applied to ablative wavelengths such as carbon dioxide, Er:YAG, and yttrium scandium gallium garnet (2,790 nm), providing more significant clinical outcomes. Adjustable laser parameters, including power, pitch, dwell time, and spot density, allowed for precise determination of percent surface area, affected penetration depth, and clinical recovery time and efficacy. Fractional LSR has been a significant advance to the laser field, striking the balance between safety and efficacy.

Safety and tolerability of high-intensity focused ultrasonography for noninvasive body sculpting: 24-week data from a randomized, sham-controlled study

BACKGROUND

High-intensity focused ultrasonography (HIFU) is a nonsurgical, noninvasive method for body sculpting in nonobese patients. The technique ablates subcutaneous adipose tissue by causing molecular vibrations that increase tissue temperature and induce rapid cell necrosis.

OBJECTIVES

The authors evaluate the long-term safety of a HIFU device for sculpting the abdomen and flanks.

METHODS

Adults with subcutaneous abdominal fat ≥2.5 cm in thickness who met screening criteria were randomized to receive HIFU treatment of the anterior abdomen and flanks at 1 of 3 energy levels (3 passes per patient): 47 J/cm(2) (141 J/cm(2) total), 59 J/cm(2) (177 J/cm(2) total), or 0 J/cm(2) (no energy applied; sham control). Safety was assessed for 24 weeks and included laboratory testing, physical examinations, and documentation of adverse events.

RESULTS

Adverse events (AE) included mild to moderate discomfort, ecchymosis, and edema, all of which were transient. There were no reports of scarring or burns and no clinically meaningful changes in lipid panel findings, inflammatory markers, or renal or hepatic function. Physical examination results were unremarkable.

CONCLUSIONS

This HIFU device exhibited an AE profile similar to that of sham treatment. There were no significant changes from baseline in laboratory values, including lipid levels.

A randomized, controlled trial of four ablative fractionated lasers for photoaging: a quadrant study

BACKGROUND

Fractionated technology has revolutionized laser therapy. With the success of initial devices, several fractionated lasers have appeared on the market. Claims of superiority have made device choice difficult for physicians and patients.

MATERIALS AND METHODS

Twelve subjects were treated with fractionated ablative lasers (10,600-nm carbon dioxide and 2790-nm yttrium scandium gallium garnet) in this institutional review board-approved trial. Each face was divided into four quadrants, and each quadrant was randomly treated using one of four lasers. Clinical experience was used to optimize settings. Two patients submitted biopsies from each quadrant immediately after treatment. Patients and blinded investigators assessed pain during treatment and post-treatment improvement in photoaging (measured by rhytides, lentigines, texture, and pore size) using a five-point scale.

RESULTS

All devices resulted in statistical improvement in photoaging in all patients, but no device was statistically significantly superior. No statistically significant difference was found in pain scores. All patients reported satisfaction 1 month after treatment. Three patients experienced adverse reactions. Histologically, there were no statistically significant differences between devices.

CONCLUSIONS

Fractionated ablative lasers reliably result in improvement in photoaging. Despite marketing claims, no statistically significant differences were found in outcomes, pain during treatment, or histologic findings. Even with experienced users, significant adverse reactions are possible.

Two cases of herpes zoster appearing after botulinum toxin type a injections

Two patients under the authors' care developed facial herpes zoster that erupted soon after cosmetic treatment with botulinum toxin type A (BTA). Both patients received typical doses of BTA in the glabella, forehead, and lateral periorbital areas. Within one week after treatment, each patient began experiencing symptoms of herpes zoster in one of the dermatomes supplied by the trigeminal nerve. Since the resolution of the herpes zoster, both patients have gone on to receive further treatments of BTA with prophylactic oral antivirals without sequelae.

Predicting migraine responsiveness to botulinum toxin type A injections

BACKGROUND

Botulinum toxin type A (BTX) is used prophylactically to reduce the frequency of migraine headaches, with inconsistent responses reported in the literature. The purpose of our study was to determine whether BTX injections at doses used for upper-face cosmetic purposes, which differ from doses typically used by headache specialists, could prevent imploding and ocular but not exploding migraines.

OBSERVATIONS

Study participants were recruited among patients who had received or were planning to receive BTX injections for upper-face cosmetic purposes but also reported having migraines. Among the 18 patients who completed the study, most with imploding and ocular migraines experienced a significant reduction in their headache frequency, whereas those with exploding migraines generally did not.

CONCLUSIONS

Our study supports the hypothesis that patients with imploding and ocular migraines are more responsive to BTX than those with exploding migraines. Injections of BTX at doses appropriate for cosmetic purposes may be sufficient to prevent migraine attacks.

The filler revolution: a six-year retrospective

There are currently more than 20 FDA-approved fillers in the United States (U.S.), noteworthy considering that it was only six years ago that the first hyaluronic acid filler was approved. The pace of development of filler substances in the last few years has been extremely rapid. The authors review the development, advantages, and disadvantages of fillers currently available in the U.S.