Validated Composite Assessment Scales for the Global Face

Focused Ultrasound for Dermal Applications

Focused ultrasound (FUS) is emerging as one of the most promising, non-invasive treatment techniques. The advancement of transducer technology has paved the way for dermatological applications. A comprehensive review is presented for healthcare practitioners and researchers, summarizing the effect of various operational parameters on the injury zone produced by ultrasound beams for various dermatological applications, which include skin tightening, fat reduction, hyperpigmentation and cancer treatment. In this article, we aim to highlight the efficient operational parameters of FUS to enhance pain relief during surgery and its affordability for skin treatment. Finally, a prospective future technique for efficient FUS is discussed.

Efficacy, safety, and potential industry bias in using deoxycholic acid for submental fat reduction ‒ A systematic review and meta-analysis of randomized clinical trials

Lipolytic substance injections to reduce localized fat have been extensively used because it is a low-invasive method. This review aimed to evaluate the efficacy and safety of deoxycholic acid in submental fat reduction compared to a placebo and investigate the potential industry sponsorship bias in the results of randomized clinical trials on this topic. Ten electronic databases were extensively searched for randomized clinical trials without restriction on language and year of publication. Two reviewers extracted the data and assessed the individual risk of bias in the studies with the RoB 2.0 tool. The industry sponsorship bias was evaluated according to citations in the articles regarding industry funding/sponsorship throughout the texts. Fixed and random effects meta-analyses were performed, and the results were reported in Risk Ratio (RR) at a 95% Confidence Interval (95% CI). The initial search provided 5756 results, of which only five were included. Only two studies had a low risk of bias. All studies showed a potential industry bias. The meta-analysis showed that patients treated with deoxycholic acid had significant positive results for all efficacy outcomes and a higher risk of fibrosis, pain, erythema, numbness, swelling, edema, pruritus, nodules, headache, and paresthesia. The low to moderate certainty of evidence found allows concluding that deoxycholic acid is effective in submental fat reduction, causing well-tolerated adverse effects. However, all eligible studies showed a potential industry bias.

IncobotulinumtoxinA for Glabellar Frown Lines in Chinese Subjects: A Randomized, Double-blind, Active-Controlled Phase-3 Study

This study evaluated the efficacy and safety of IncobotulinumtoxinA 20 U for treatment of glabellar frown lines in Chinese subjects.

Methods

This was a prospective, randomized, double-blind, active-controlled, phase-3 study conducted in China. Subjects with moderate to severe glabellar frown lines at maximum frown were randomized to receive IncobotulinumtoxinA (N = 336) or OnabotulinumtoxinA (N = 167).

Results

For the primary efficacy endpoint at day 30, response rates at maximum frown (score "none" or "mild") on the Merz Aesthetic Scales Glabella Lines - Dynamic were comparable between IncobotulinumtoxinA (92.5%) and OnabotulinumtoxinA (95.1%) per investigator's live rating. Noninferiority of IncobotulinumtoxinA versus OnabotulinumtoxinA was successfully demonstrated, as the two-sided 95% confidence interval of -0.97% to 0.43% for the difference in Merz Aesthetic Scales-based response rates (-0.27%) lay completely above the predefined noninferiority margin of -15%. For the secondary efficacy endpoints assessed at day 30, Merz Aesthetic Scales-based response rates (score "none" or "mild") at maximum frown were similarly comparable between both groups per subject (>85%) and independent review panel (>96%) rating. Per Global Impression of Change Scales, greater than 80% of subjects and greater than 90% of investigators in both groups rated treatment results as at least "much improved" at day 30 compared with baseline. Safety profiles were consistent between groups; IncobotulinumtoxinA was well tolerated, and no new safety concerns were identified in Chinese subjects.

Conclusion

IncobotulinumtoxinA 20 U is safe and effective for treatment of moderate to severe glabellar frown lines at maximum frown in Chinese subjects and is noninferior to OnabotulinumtoxinA 20 U.

The Study of a Validated Assessment Scale for a Localized Submental Fat Volume

BACKGROUND

This aim of this study was to develop an objective tool for rating submental fat applied to Koreans.

METHODS

The study was conducted between April 2019 and October 2019. A total of 92 subjects were enrolled in the study. Clinical photos of the subjects were categorized using validated CR-SMFRS by three plastic surgeons and one dermatologist. The categorized photos were then shown to six different plastic surgeons for evaluation.

RESULTS

The Cohen's kappa value for the six raters were 0.830, 0.742, 0.703, 0.907, 0.862, and 0.793 with statistical significance (p < 0.001). ICC value was between 0.860 and 0.966 (p < 0.001). Since the Cohen's value and ICC were above 0.6 for all raters, the ratings performed by all six raters were used in the analysis. The ICC values between raters were between 0.899 and 0.902.

CONCLUSIONS

We came up with a set of reference photos that can be used for submental fat rating scale applicable to Korean subjects.

LEVEL OF EVIDENCE

II.

A systematic review of skin ageing genes: gene pleiotropy and genes on the chromosomal band 16q24.3 may drive skin ageing

Skin ageing is the result of intrinsic genetic and extrinsic lifestyle factors. However, there is no consensus on skin ageing phenotypes and ways to quantify them. In this systematic review, we first carefully identified 56 skin ageing phenotypes from multiple literature sources and sought the best photo-numeric grading scales to evaluate them. Next, we conducted a systematic review on all 44 Genome-wide Association Studies (GWAS) on skin ageing published to date and identified genetic risk factors (2349 SNPs and 366 genes) associated with skin ageing. We identified 19 promising SNPs found to be significantly (p-Value < 1E-05) associated with skin ageing phenotypes in two or more independent studies. Here we show, using enrichment analyses strategies and gene expression data, that (1) pleiotropy is a recurring theme among skin ageing genes, (2) SNPs associated with skin ageing phenotypes are mostly located in a small handful of 44 pleiotropic and hub genes (mostly on the chromosome band 16q24.3) and 32 skin colour genes. Since numerous genes on the chromosome band 16q24.3 and skin colour genes show pleiotropy, we propose that (1) genes traditionally identified to contribute to skin colour have more than just skin pigmentation roles, and (2) further progress towards understand the development of skin pigmentation requires understanding the contributions of genes on the chromosomal band 16q24.3. We anticipate our systematic review to serve as a hub to locate primary literature sources pertaining to the genetics of skin ageing and to be a starting point for more sophisticated work examining pleiotropic genes, hub genes, and skin ageing phenotypes.

Tightening and Reduction of Unwanted Submental Fat Using Triple-Layer High-Intensity Focused Ultrasound: Clinical and 3-Dimensional Imaging Analysis

BACKGROUND

Unwanted submental fat (SMF) is aesthetically unappealing, but methods of reduction are either invasive or lack evidence of their use.

OBJECTIVE

The authors sought to evaluate the safety and efficacy of a novel triple-layer high-intensity focused ultrasound (HIFU) regimen for SMF reduction.

METHODS

Forty Korean subjects with moderate/severe SMF were evaluated after receiving a session of triple-layer HIFU treatments (using 3.0-, 4.5-, and 6.0-mm focusing transducers). The objective evaluation based on the 5-point Clinician-Reported Submental Fat Rating Scale (CR-SMFRS) and patients' satisfaction based on the 7-point Subject Self-Rating Scale (SSRS) were determined 8 weeks after treatment. Three-dimensional image analysis was also performed.

RESULTS

At the follow-up visit, the proportion of treatment responders defined as subjects with ≥1-point improvement in CR-SMFRS was 62.5%, and the proportion of patients satisfied with appearance of their face and chin (score ≥4 on the SSRS) was 67.5% of the total patients. The results of 3-dimensional analysis were consistent with clinical observations. Only mild and transient side effects were observed for some patients with no serious adverse effects.

CONCLUSION

The triple-layer HIFU regimen including the novel 6.0-mm transducer has benefits for tightening and rejuvenation of the area with unwanted SMF, showing reasonable safety profiles.

Validation of a Chin Retrusion Scale for Chinese Subjects

ABSTRACT

Chin augmentation procedures are gaining in popularity. The purpose of this study was to validate the China (Allergan) Chin Retrusion Scale (CACRS) and to evaluate the reliability of the scale. A team of 10 physicians based in Beijing, China, consisting of 1 principal investigator and 9 independent raters, assessed a pool of subject images. Using standardized equipment to capture 2-dimensional images, 100 subjects were photographed from a left, lateral, 90° view. Two measures were used to assess the validity of the scale: rater evaluations of clinically significant differences in 52 pairs of images and rater assessment of chin retrusion using the CACRS to grade the 100 images. The CACRS demonstrated almost perfect inter-rater agreement during 2 validation sessions, with intraclass correlation coefficients of 0.89 and 0.90 at sessions 1 and 2, respectively. Overall inter-rater agreement for all 9 raters was almost perfect, with a weighted kappa of 0.82. Based on inter- and intra-rater agreement, the CACRS was validated for physician ratings of chin retrusion in Chinese subjects. Results from clinical significance evaluations indicated that a 1-grade difference between image pairs was considered clinically meaningful for the CACRS. The CACRS is a validated and reliable photonumeric scale for the assessment of chin retrusion in Chinese men and women. The scale is a clinically significant reference tool for evaluating the effect of chin augmentation.

Botulinum toxin type A for facial wrinkles

BACKGROUND

Botulinum toxin type A (BontA) is the most frequent treatment for facial wrinkles, but its effectiveness and safety have not previously been assessed in a Cochrane Review.

OBJECTIVES

To assess the effects of all commercially available botulinum toxin type A products for the treatment of any type of facial wrinkles.

SEARCH METHODS

We searched the following databases up to May 2020: the Cochrane Skin Specialised Register, CENTRAL, MEDLINE, Embase, and LILACS. We also searched five trials registers, and checked the reference lists of included studies for further references to relevant randomised controlled trials (RCTs).

SELECTION CRITERIA

We included RCTs with over 50 participants, comparing BontA versus placebo, other types of BontA, or fillers (hyaluronic acid), for treating facial wrinkles in adults.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. Primary outcomes were participant assessment of success and major adverse events (AEs) (eyelid ptosis, eyelid sensory disorder, strabismus). Secondary outcomes included physician assessment of success; proportion of participants with at least one AE and duration of treatment effect. We used GRADE to assess the certainty of the evidence for each outcome.

MAIN RESULTS

We included 65 RCTs, involving 14,919 randomised participants. Most participants were female, aged 18 to 65 years. All participants were outpatients (private office or day clinic). Study duration was between one week and one year. No studies were assessed as low risk of bias in all domains; the overall risk of bias was unclear for most studies. The most common comparator was placebo (36 studies). An active control was used in 19 studies. There were eight dose-ranging studies of onabotulinumtoxinA, and a small number of studies compared against fillers. Treatment was given in one cycle (54 studies), two cycles (three studies), or three or more cycles (eight studies). The treated regions were glabella (43 studies), crow's feet (seven studies), forehead (two studies), perioral (two studies), full face (one study), or more than two regions (nine studies). Most studies analysed moderate to severe wrinkles; mean duration of treatment was 20 weeks. The following results summarise the main comparisons, based on studies of one treatment cycle for the glabella. AEs were collected over the duration of these studies (over four to 24 weeks). Compared to placebo, onabotulinumtoxinA-20 U probably has a higher success rate when assessed by participants (risk ratio (RR) 19.45, 95% confidence interval (CI) 8.60 to 43.99; 575 participants; 4 studies; moderate-certainty evidence) or physicians (RR 17.10, 95% CI 10.07 to 29.05; 1339 participants; 7 studies; moderate-certainty evidence) at week four. Major AEs are probably higher with onabotulinumtoxinA-20 U (Peto OR 3.62, 95% CI 1.50 to 8.74; 1390 participants; 8 studies; moderate-certainty evidence), but there may be no difference in any AEs (RR 1.14, 95% CI 0.89 to 1.45; 1388 participants; 8 studies; low-certainty evidence). Compared to placebo, abobotulinumtoxinA-50 U has a higher participant-assessed success rate at week four (RR 21.22, 95% CI 7.40 to 60.56; 915 participants; 6 studies; high-certainty evidence); and probably has a higher physician-assessed success rate (RR 14.93, 95% CI 8.09 to 27.55; 1059 participants; 7 studies; moderate-certainty evidence). There are probably more major AEs with abobotulinumtoxinA-50 U (Peto OR 3.36, 95% CI 0.88 to 12.87; 1294 participants; 7 studies; moderate-certainty evidence). Any AE may be more common with abobotulinumtoxinA-50 U (RR 1.25, 95% CI 1.05 to 1.49; 1471 participants; 8 studies; low-certainty evidence). Compared to placebo, incobotulinumtoxinA-20 U probably has a higher participant-assessed success rate at week four (RR 66.57, 95% CI 13.50 to 328.28; 547 participants; 2 studies; moderate-certainty evidence), and physician-assessed success rate (RR 134.62, 95% CI 19.05 to 951.45; 547 participants; 2 studies; moderate-certainty evidence). Major AEs were not observed (547 participants; 2 studies; moderate-certainty evidence). There may be no difference between groups in any AEs (RR 1.17, 95% CI 0.90 to 1.53; 547 participants; 2 studies; low-certainty evidence). AbobotulinumtoxinA-50 U is no different to onabotulinumtoxinA-20 U in participant-assessed success rate (RR 1.00, 95% CI 0.92 to 1.08, 388 participants, 1 study, high-certainty evidence) and physician-assessed success rate (RR 1.01, 95% CI 0.95 to 1.06; 388 participants; 1 study; high-certainty evidence) at week four. Major AEs are probably more likely in the abobotulinumtoxinA-50 U group than the onabotulinumtoxinA-20 U group (Peto OR 2.65, 95% CI 0.77 to 9.09; 433 participants; 1 study; moderate-certainty evidence). There is probably no difference in any AE (RR 1.02, 95% CI 0.67 to 1.54; 492 participants; 2 studies; moderate-certainty evidence). IncobotulinumtoxinA-24 U may be no different to onabotulinumtoxinA-24 U in physician-assessed success rate at week four (RR 1.01, 95% CI 0.96 to 1.05; 381 participants; 1 study; low-certainty evidence) (participant assessment was not measured). One participant reported ptosis with onabotulinumtoxinA, but we are uncertain of the risk of AEs (Peto OR 0.02, 95% CI 0.00 to 1.77; 381 participants; 1 study; very low-certainty evidence). Compared to placebo, daxibotulinumtoxinA-40 U probably has a higher participant-assessed success rate (RR 21.10, 95% CI 11.31 to 39.34; 683 participants; 2 studies; moderate-certainty evidence) and physician-assessed success rate (RR 23.40, 95% CI 12.56 to 43.61; 683 participants; 2 studies; moderate-certainty evidence) at week four. Major AEs were not observed (716 participants; 2 studies; moderate-certainty evidence). There may be an increase in any AE with daxibotulinumtoxinA compared to placebo (RR 2.23, 95% CI 1.46 to 3.40; 716 participants; 2 studies; moderate-certainty evidence). Major AEs reported were mainly ptosis; BontA is also known to carry a risk of strabismus or eyelid sensory disorders.

AUTHORS' CONCLUSIONS

BontA treatment reduces wrinkles within four weeks of treatment, but probably increases risk of ptosis. We found several heterogeneous studies (different types or doses of BontA, number of cycles, and different facial regions) hindering meta-analyses. The certainty of the evidence for effectiveness outcomes was high, low or moderate; for AEs, very low to moderate. Future RCTs should compare the most common BontA (onabotulinumtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, daxibotulinumtoxinA, prabotulinumtoxinA) and evaluate long-term outcomes. There is a lack of evidence about the effects of multiple cycles of BontA, frequency of major AEs, duration of effect, efficacy of recently-approved BontA and comparisons with other treatments.

Multi-Dimensional Aesthetic Scan Assessment (MD ASA™): Initial experience with a novel consultation, facial assessment, and treatment planning tool

BACKGROUND

Comprehensive patient assessment and planning are central to esthetic treatment with injectables. MD ASA™ (Multi-Dimensional Aesthetic Scan Assessment) is a novel tool developed for this purpose.

AIMS

To describe the MD ASA technique and present its preliminary application.

METHODS

MD ASA breaks down the face into five hierarchies (H1-H5). H1 shifts patients' focus from "distractions" (individual lines and folds) toward the overall messages their face portrays, based on eight Emotional Attributes: four negative (tired, sad, angry, and saggy); four positive (youthful, attractive, contoured, and feminine/masculine). Three priority Emotional Attributes are selected for each patient. This is followed by a process of narrowing down through facial thirds (H2), periorbital and perioral dynamics (H3), facial units (H4), and subunits (H5), to arrive at a final assessment. Based on the key facial signs identified, this can be translated into MD Codes equations and thus a treatment formula. A retrospective analysis was performed based on 12 female patients injected by expert clinicians at an educational event. All patients were selected for, and treated using, a single MD Codes formula derived from a common MD ASA work-up.

RESULTS

There were substantial differences between patients and clinicians in their views of which anatomical areas needed treatment-but good alignment on priority Emotional Attributes. Patients were treated only for three negative Emotional Attributes, but improvements were observed across all eight attributes.

CONCLUSIONS

MD ASA provides a practical method for translating facial messages into actionable injectable treatment plans and facilitates greater patient-clinician alignment. Prospective studies are warranted.

Development and validation of a global photonumeric scale for evaluating skin quality of aged female facial skin

BACKGROUND

Skin quality plays an important role in overall attractiveness. However, so far, no visual grading scales have been published while their development seems to be an essential key step to provide validated grading scales for the evaluation of efficacy of minimally invasive procedures and cosmeceuticals aims on the improvement of skin quality, esthetic research, and clinical application.

OBJECTIVES

To develop and validate a visual five-point assessment scale for the evaluation of skin quality of female facial skin.

METHODS

The five-point photonumeric Scientific Assessment Scale of Skin Quality is based on six parameters. Fifty standardized photos were rated by 13 experts. This examination was carried out in two cycles with an interval of 4 weeks. The intraclass correlation coefficient contributes to the identification of the inter-rater and intrarater reliability.

RESULTS

Statistical analysis investigated six specific and two general parameters: The results of inter- and intrarater reliability for skin elasticity (ICC 0.816; ICC 0.883), wrinkles (ICC 0.840; 0.885), and age (ICC 0.885; 0.925) were almost perfect. The reliabilities for pigmentation (ICC 0.637; ICC 0.797), erythema (ICC 0.688; ICC 0.797), and overall skin quality (ICC 0.652; ICC 0.756) were substantial and for pore size moderate (ICC 0.405; ICC 0.584). Skin surface roughness (ICC 0.480; ICC 0.645) indicated a substantial intrarater reliability and a moderate interrater reliability. These data revealed good and excellent results.

CONCLUSIONS

The Scientific Assessment Scale of Skin Quality represents an innovative universal and reliable measurement instrument for a valid and reproducible evaluation of six parameters of aged female facial skin quality.

Deep Layer Radiofrequency Thermo-coagulative Technology for Cervicofacial Contouring: Sonographic and Clinical Results

Radiofrequency energy thermally induces collagen contraction and remodeling. The resultant dermal tightening is well established. However, facial aging encompasses also deeper layers of collagen-containing tissues. We present a deep layer radiofrequency-based thermo-coagulative technique for cervicofacial contouring and evaluate its efficacy.

METHODS

This prospective single center study was conducted from June 2017 to June 2018 and included 10 women. Echogenicity and thickness of layers 1-5 of the lower face, lateral neck, and submental regions were sonographically measured at baseline and at 6 weeks postoperatively. Echogenicity analysis was based on the number of high echogenic pixels counted and processed using Matlab-based image application (The Mathworks, Natick, Mass.). Clinical outcome at 12 months postoperatively was evaluated by 2 independent evaluators using a validated 5-point lower face improvement scale and the Merz jawline scale (0-4). Patient satisfaction and adverse effects were recorded.

RESULTS

Mean age was 60.2 years (range, 52-76). A statistically significant increase in echogenicity (P ≤ 0.02) and a decrease in thickness (P = 0.01) was noted. Echogenicity increased at 149%, 78%, and 60%, for the lateral neck, lower face, and submental region, respectively. The corresponding decrease in thickness per site was 16%, 6%, and 19%. The average physicians' improvement in lower face contour was 3.8, and the Merz jawline scale was improved from 2.85 at baseline to 1.05 at 12 months postoperatively. Patient satisfaction was high. Side effects were minimal.

CONCLUSIONS

Deep layer radiofrequency-based technology thermally induces profound soft tissue tightening and neocollagenesis. It is a safe and effective technique for cervicofacial contouring in selected patients.

Physician survey on pre-/postprocedure measures for injectable treatments

INTRODUCTION

Every year in the United States, over 1 billion dollars are spent on aesthetic injectables, such as soft tissue fillers and neurotoxins. In 2018, the total amount of injectable treatments performed surpassed 2 671 130 procedures. While often mild and transient, adverse events (AEs) can occur following these procedures. AEs may include common side effects such as bruising, or rare, but serious AEs such as infections. While previous investigators have evaluated methods of reducing risks of AEs due to the treatment procedure itself, few investigations have evaluated measures employed before and/or after treatment (ie, peri-procedure).

METHODS

An electronic survey was sent to aesthetic clinicians with experience performing injectable treatments. The survey collected information regarding general information (eg, demographics and specialty), type of injectable devices used, current peri-procedures, and an exploration of future options for peri-procedural measures.

RESULTS

Most aesthetic clinicians did not use prophylactic topical or systemic antimicrobials, nor prophylactic topical antiviral therapy. However, approximately 65% of clinicians reported using prophylactic systemic antivirals for patients with a history of herpes simplex virus. A variety of products were used to prepare the skin prior to injectable procedures. Postprocedure, multiple over-the-counter wound repair products were recommended by >70% of injectors. However, there was a large variety of products recommended with no majority consensus.

CONCLUSIONS

Currently, there are no peri-procedural standards of practice when performing aesthetic injectable treatments. Efforts are underway for the development of best-practice algorithms.

A new method for skin aging evaluation of Chinese women

BACKGROUND

With the development of cosmetic industry in China, an aging evaluation method of Chinese women is in great need.

AIMS

The aim of this study is to establish a skin aging assessment method using convenient portable machine Antera 3D.

METHODS

The quantitative approach was developed by capturing 11 areas of the face, and overall, 48 parameters were extracted for aging evaluation. Later, 297 subjects were recruited to take facial image and life style questionnaire. Evaluation of age was accomplished by establishing prediction method with detected skin traits.

RESULTS

The age prediction model was built by using the evaluated facial traits, and a R square of 0.6 is achieved by comparing to the chronological age. The crow's feet, cheek skin pigmentation, forehead skin tone, and wrinkles around the month are critical factors in evaluating Chinese women skin aging. In addition, we also explored life styles associated with important skin aging traits.

CONCLUSION

The method developed in this research provides reliable alternative in aging study of Chinese women.

Histological Analysis of the Effect of ATX-101 (Deoxycholic Acid Injection) on Subcutaneous Fat: Results From a Phase 1 Open-Label Study

BACKGROUND

ATX-101 is approved for submental fat reduction.

OBJECTIVE

To characterize the histological effect of ATX-101 injection into subcutaneous fat.

METHODS

This Phase 1 open-label study enrolled 14 adults to receive injections of ATX-101 into abdominal fat at varying concentrations (0.5%, 1.0%, 2.0%, or 4.0%), volumes (0.2 or 0.4 mL), spacing (0.7, 1.0, or 1.5 cm), and time points before scheduled abdominoplasty (1, 3, 7, or 28 days). During abdominoplasty, tissue was excised and preserved for histology.

RESULTS

All injection paradigms resulted in histological changes confined to the subcutaneous layer, which were more prominent at higher concentrations and independent of volume and spacing. Key features at Day 1 after injection were adipocytolysis, blood vessel injury, neutrophilic inflammation, and lysis of locally present neutrophils. At Day 3, inflammation was reduced versus Day 1, and hemorrhage and lipid lake formation (at higher concentrations) were observed. Day 7 samples exhibited prominent adipocytolysis, mild inflammation, lipid-laden macrophages in the septae, and repair of vascular injury. At Day 28, inflammation was largely resolved and prominent features were septal thickening, neovascularization, and atrophy of fat lobules.

CONCLUSION

Subcutaneous injection of ATX-101 induces adipocytolysis and local inflammation with septal thickening and resolution of inflammation by 28 days after injection.

A 3-Dimensional Quantitative Analysis of Volume Loss Following Submental Cryolipolysis

BACKGROUND

Cryolipolysis is a proven and effective means of fat reduction; however, there are no standardized means of measuring volume reduction.

OBJECTIVES

We aim to assess the volume loss using a 3-dimensional (3D) analysis following submental cryolipolysis.

METHODS

A retrospective cohort study between April 2016 and August 2018 was performed. Thirty-five patients underwent a single 45-minute cycle of cryolipolysis to the submental region using the CoolSculpting System. A 3-fold analysis was performed employing an independent observer assessment of 2-dimensional photographs and 3D volumetric analysis utilizing the Vectra XT system, and patient satisfaction was measured with the FACE-Q questionnaire.

RESULTS

Our results suggested the mean (standard deviation) pretreatment volume (n = 35) was 104.12 cm3 (28.78). The 6-week mean posttreatment volume (n = 26) was 81.55 cm3 (21.29). The mean volume reduction found at 6 weeks posttreatment showed a reduction of 22.46 cm3 (19.10) (95% CI 14.74 to 30.17, P < 0.0001). The 12-week mean posttreatment volume (n = 24) was 82.24 cm3 (23.97). The 12-week posttreatment demonstrated a reduction of 22.30 cm3 (14.04) (95% CI 16.37 to 28.23, P < 0.0001). The mean percentage correct for each reviewer correctly identifying the pretreatment and posttreatment photograph was 76.33% (7.14). Patient satisfaction showed a mean FACE-Q score of 54.10 (20.41).

CONCLUSIONS

The study further affirms that submental cryolipolysis is an efficacious and safe, noninvasive method for reducing submental adiposity resulting in notable patient satisfaction rates. Furthermore, results suggest that patients can have a volume loss of about 20% on average, allowing them to be more confident and comfortable with their appearance.

LEVEL OF EVIDENCE: 4

Development of a Global Subjective Skin Aging Assessment score from the perspective of dermatologists

Objective

Several skin aging assessment scales exist but no standard scale is widely used. Dermatologists may be the most appropriate persons for skin assessment but their perceptions regarding the signs of skin aging are unexplored. To develop a simple global skin aging assessment score from the perspective of dermatologists, an online questionnaire, the Thai Dermatologist Survey of Skin Aging Assessment, was conducted from October to December, 2016. Twenty-nine signs with published evidence of their relevancy to skin aging were included. Certified dermatologists were asked to score each sign using a 5-point Likert scale. Descriptive statistics and exploratory factor analysis (EFA) were used for data analysis.

Results

Of 213 randomly selected dermatologists, 145 responded to the survey. EFA revealed 3 important factors related to skin aging: Factor 1 comprised 8 signs related to atrophy (deep/superficial wrinkles, eye bags, lax appearance, etc.); Factor 2 comprised 7 signs related to discoloration (freckles, lentigines, melasma, etc.); and Factor 3 comprised 3 malignant skin lesions. The Global Subjective Skin Aging Assessment (GS2A2) score is a simple numerical score that can be used to evaluate the anti-aging effects of a cosmetic product or dermatologic intervention. This score should be tested further for validity and reliability.

Electronic supplementary material

The online version of this article (10.1186/s13104-019-4404-z) contains supplementary material, which is available to authorized users.

Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead

BACKGROUND

As the number of aesthetic treatments has grown, so have the number of photonumeric assessment scales used to compare the effectiveness of these aesthetic treatments in specific anatomical areas; however, these are primarily based on Caucasian features.

OBJECTIVE

To assess the validity of the first aesthetic scale for assessing the slope of the Asian forehead. A secondary objective was to correlate this scale with subject demographics and baseline characteristics.

METHODS

During 2 validation sessions, 13 raters assessed full frontal and lateral facial images of female (n = 28; 56.0%) and male (n = 22; 44%) subjects. For each subject, the severity of forehead sloping was graded from 0 (convex forehead, optimal forehead volume) to 4 (concave forehead, very severe sloping). Raters also assessed the age of each subject and the estimated aesthetic treatment effort required to treat each subject.

RESULTS

Inter-rater reliability was "substantial" with scores of 0.67 and 0.68 for the first and second validation sessions, indicating high reliability. BMI showed the highest correlation with the scale and was a significant predictor in the final regression model.

CONCLUSION

This photonumeric assessment scale will be useful for assessing the slope of the Asian forehead in both clinical and research settings.

Validated Assessment Scales for the Female Asian Calf

BACKGROUND

Clinical photonumeric scales have been developed and validated to objectively measure the effectiveness of aesthetic treatments in specific anatomical areas; however, these are based on the typical features of Caucasian patients. No clinical scale for Asian calf appearance currently exists.

OBJECTIVE

To develop and validate a calf assessment scale for use in the female Asian patient population.

METHODS AND MATERIALS

During 2 validation sessions, 13 raters assessed calf images of female Asian subjects (N = 35) viewed from behind with feet flat on the floor (at rest) and on tiptoes (dynamic). Images were rated from 0 (very slim, linear profile) to 4 (very severe convex profile).

RESULTS

Inter-rater and intra-rater reliability were "substantial" (≥0.6, intraclass correlation coefficient [ICC] and weighted kappa) for the calf-at rest, calf-dynamic, and calf summary score. Reliability was "substantial" for calf-at rest and calf-dynamic (≥0.6, ICC and weighted kappa) and "almost perfect" (0.85) for the calf summary score. BMI and calf circumference were highly correlated with scale ratings, and calf circumference was a significant predictor.

CONCLUSION

This new photonumeric assessment scale has value for assessing the female Asian calf, providing a standardized measure of calf appearance in clinical practice and clinical research settings.

Aesthetic dermatology: What's new, what's true?

Aesthetic dermatology (AD) is a rapidly growing subspecialty of dermatology. The acceptance of AD in scientific community and the society is associated with its competence, efficiency, and seriousness. This review highlights some recent developments toward new tools, techniques, and understanding in the field of AD. Analyzing the specific needs of patients and assessing the effect by objective measurements is important for further progress. For long time ignored, white adipose tissue has gained increasing interest in biology and rejuvenation. Characterization of dermal and subcutaneous white adipose tissue has made progress. The interaction of hyaluronic acid and calcium hydroxyl apatite (CaHA) fillers with adipocytes could be responsible for clinical efficacy. New developments of oral collagen treatment and highly diluted CaHA to contour the body outside the face will be discussed. Submental contouring using purified desoxycholic acid is another new development.

Cryolipolysis for the treatment of submental fat: Review of the literature

BACKGROUND

Submental fat accumulation is a common cosmetic concern. Cryolipolysis utilizes noninvasive cooling to lyse adipocytes. A cryolipolysis device was recently approved for treatment of submental fat.

OBJECTIVE

This manuscript provides a review of the preclinical work and clinical trials related to cryolipolysis for the treatment of submental fat. Settings, efficacy, and side effects are also discussed.

MATERIALS AND METHODS

A literature search was performed through Pubmed, EMBASE, Web of Science, and CINAHL, using the search terms "cryolipolysis," "submental," and "paradoxical adipose hyperplasia". Additional sources from the original source bibliographies were used to further supplement this review.

RESULTS

There are 4 clinical trials and one case series (total 101 patients) that evaluated the use of cryolipolysis for treatment of submental fat. In these studies, there was a statistically significant reduction in submental fat and patients expressed high satisfaction with the treatment. Adverse effects were mild and transient.

CONCLUSIONS

Cryolipolysis is a noninvasive cooling technique that is safe and effective for treatment of submental fat. To date, there are no reports of marginal mandibular nerve injury or paradoxical adipose hyperplasia following treatment with this device.

Deoxycholate (ATX-101) Mixed with Lidocaine to Minimize Pain/Discomfort in Nonsurgical Treatment of Submental Fullness Appearance

In the present study pain/discomfort reduction in submental fullness treatment with the injections of a DC based drug (ATX-101, Allergan, Dublin, Ireland) premixed with lidocaine 2% on a sample of 12 patients retrospectively evaluated has been performed All patients indicated improvement in skin tightening from the 2nd month postinjection. Three patients had minor ecchymoses at the injection sites, which resolved spontaneously within 10 days posttreatment. One patient experienced dysesthesia of the treated area, which lasted approximately 40 days and resolved spontaneously. No other complications—such as nerve paresis or alopecia—were recorded. No patient required analgesic drugs postinjection.

Noninvasive submental fat reduction using colder cryolipolysis

BACKGROUND

Cryolipolysis has shown to significantly reduce localized subcutaneous fat, including submental fat. Temperatures below -11°C have not been used to treat the submental region.

OBJECTIVE

The purpose of this study was to evaluate safety and efficacy of Cryolipolysis for noninvasive reduction of submental fat using lower temperatures and reduced treatment time.

METHODS

A small volume applicator was used to treat 15 subjects, using a noninvasive tissue cooling device (CoolSculpting System, ZELTIQ Aesthetics, Pleasanton, CA, USA) during 45 and 30 minutes at -12 and -15°C, respectively, to induce reduction of submental fat. Two treatments with an interval of 10 weeks were performed. Adverse events were monitored to assess safety. Treated area was evaluated using digital photography, and caliper measurements prior treatment, 10 weeks after first treatment and 12 weeks after second treatment. All patients were also evaluated before and after 12-week postlast treatment by Magnetic Resonance Imaging (MRI).

RESULTS

The mean (SD) reduction measured by skin fold caliper was 33% (3.2 mm [1.7 mm]), (95% CI, 0.2297-0.4236; P=.05), and by MRI, mean (SD) reduction was 1.78 mm (1.157 mm). Independent blinded panel was able to correctly identify 60% of before and after photographs; 12 of 15 subjects (80%) were satisfied or very satisfied with the treatment. Side effects were mild and resolved completely within 10 weeks, except for one hyperpigmentation, which resolved spontaneously within 6 months after last treatment.

CONCLUSION

Cryolipolysis with colder temperature and reduced treatment time continues to be effective and is safe for noninvasive reduction of the submental fat.

Early Experience in 100 Consecutive Patients With Injection Adipocytolysis for Neck Contouring With ATX-101 (Deoxycholic Acid)

BACKGROUND

Deoxycholic acid (DCA) is approved for improvement in the appearance of moderate to severe convexity or fullness associated with submental fat.

OBJECTIVE

To assess early treatment experience with DCA injection in a clinical practice setting.

MATERIALS AND METHODS

In this single-center, prospective, single-arm, observational study, 100 consecutive patients seeking to decrease submental fullness received subcutaneous DCA (2 mg/cm) injections in the submental area (maximum of 6 sessions at ≥1 month intervals). Treatment response was assessed 1 and 5 to 7 weeks posttreatment using the clinician-reported submental fat rating scale (CR-SMFRS) and retrospective independent photograph review by 2 physicians.

RESULTS

Overall, 100 patients had 152 treatment sessions (58, 33, 8, and 1 patients had 1, 2, 3, and 4 sessions, respectively). CR-SMFRS score improved by ≥1 point from baseline in 88 (88%) patients; of these, 46, 33, 8, and 1 patients had 1, 2, 3, and 4 sessions, respectively. Local edema, numbness, and tenderness were reported for a mean (SD) of 7.7 (5.3), 28.5 (11.4), and 3.5 (3.5) days, respectively. Two patients experienced marginal mandibular nerve paresis.

CONCLUSION

Deoxycholic acid injection, a minimally invasive procedure for neck contouring, was effective and generally well tolerated in the private practice setting.

Creation and Validation of a Photonumeric Scale to Assess Volume Deficiency in the Infraorbital Region

BACKGROUND

The eyes are particularly important aesthetic features of the face and revitalization of the infraorbital region has become a focus of aesthetic treatments. Published infraorbital scales to date have limitations in that they have been descriptive, subjective, or have used computer-generated images. Thus, there is an unmet need for a validated scale based on actual images.

OBJECTIVE

To develop a practical photonumeric scale that respects the complex anatomy and age-related changes occurring in the orbital area.

METHODS AND MATERIALS

The Allergan Infra-oRbital Scale (AIRS) was developed through a multistep process in collaboration with 16 physicians (plastic surgeons, dermatologists, and aesthetic physicians). Scale development involved both online photographs and live assessments of subjects. Interrater and intrarater reliability was assessed using intraclass correlation coefficients (ICCs).

RESULTS

The final AIRS showed intrarater and interrater ICCs of 0.78 to 0.86 and 0.91 to 0.98 for live validation and 0.76 to 0.82 and 0.86 to 0.91 for online validation, respectively, demonstrating robust validity.

CONCLUSION

The AIRS can be considered a photonumeric scale that accurately describes volume loss in the infraorbital region. It has been validated and is appropriate for use in research or for everyday clinical use for both live and photographic assessment.

A Randomized, Blinded Study to Validate the Merz Hand Grading Scale for Use in Live Assessments

BACKGROUND

The Merz Hand Grading Scale (MHGS) is a 5-point scale used to grade appearance of the dorsum of the hand. The MHGS has been previously validated for assessment of photographed hands but not for live assessment.

OBJECTIVE

The purpose of this randomized, blinded study was to validate the MHGS for live assessment of the hands in the clinical setting.

METHODS

Three physician raters completed a scale qualification program that included MHGS training, ratings of standardized hand photographs, and statistical analysis for reliability. Eighty-four subjects (28 males, 30% Fitzpatrick skin Types IV-VI, mean age of 42 years), randomized to 2 live assessment sessions for independent and blinded observation of dorsa of their right hands, completed the study.

RESULTS

Overall MHGS intrarater weighted Kappa value was 0.74 (0.68-0.79 [CI 95%]). First- and second-time hand-rating agreement scores ranged from 64% to 75%. Interrater weighed Kappa values ranged from 0.59 to 0.71, representing between-rater paired results of each combination of raters.

CONCLUSION

High-weighted Kappa values and agreements demonstrate that consistency at different time points can be achieved individually and by different raters for live assessments. The MHGS is a suitable instrument for live assessment in the clinical setting.

Facial Filler Grid (FAFI GRID): A New Method of Facial Analysis

Despite the expert execution of the most sophisticated techniques, a precise descriptive guide of the treated areas to produce clinical records is lacking. The aim of our study was to develop a method of facial analysis to get a classification of areas that have to be treated for precise records. Our aim was to find an easy and original method for positioning and recording facial filler quantities and results.

METHODS

We studied this method of analysis on 300 nonsmoker patients aged between 25 and 55 years. It involves the use of vertical and horizontal lines to divide the middle lower third into areas. It is this grid-like framework of perpendicular lines that gives rise to the name selected for the method.

RESULTS

Postsurgical analysis with FAFI GRID (Facial Filler Grid) indicated a satisfactory outcome, and it proved useful for precise records.

DISCUSSION

FAFI GRID allows us to treat precise facial points that are treated in steps: (1) malar, (2) nose, (3) lower third. The method thus provides an easy way to position and orient facial fillers in the entire face.

Evaluation of skin ageing: a systematic review of clinical scales

Clinical scales are widely used in anti-ageing research and practice. More than 100 skin ageing scales exist, which makes it difficult to choose outcome measures and to compare study results. The objectives were to assess and evaluate the quality of measurement properties of available clinical skin ageing scales. A systematic review was conducted. Electronic databases including Medline (1970 to June 2013) and EMBASE (1974 to June 2013) were searched via Ovid SP. To enhance the sensitivity forward searches were conducted in Scopus and Web of Science. We identified 111 scales in 52 included publications. Thirty studies had good methodology for at least one measurement property. Forty-two scales were evaluated for their test-retest or interrater reliability. Nineteen showed high reliability coefficients. A further 15 instruments were partly supported by content and/or structural and/or criterion validity and/or hypotheses-testing evidence. The majority of existing clinical skin ageing scales were developed for evaluating facial characteristics. Many scales quantify similar constructs. In contrast to the high number of available scales there is limited evidence supporting their measurement properties. Recommendations for the use of specific skin ageing scales for clinical studies must be made with caution because of the high number of studies with poor methodology. Development of new instruments should be justified, and existing ones investigated for scale behaviour using appropriate methods. Future research should aim to select and/or adapt existing scales to identify the 'best' to improve clinical research and practice.

Effectiveness of botulinum toxin (type-A) administered by the fixed-site dosing approach versus the muscle area identification

INTRODUCTION

Botulinum toxin is widely used in glabellar musculature. The authors express the need to individualize the approach by means of muscular identification to improve effectiveness. Despite these guidelines, the fixed-point technique is still used.

OBJECTIVE

Comparison of effectiveness of botulinum toxin administration in the glabellar zone by using fixed-site application versus objective-muscle-identification.

MATERIALS AND METHODS

Prolective dynamic cohort study. Patients (after previous informed consent) were assessed on their facial expressions, level of satisfaction, re-interventions, adverse effects, dosage, dilution, and number of injections. All patients who experienced either of both techniques of botulinum toxin administration (fixed-site or objective-muscle-identification) were subjected to followup by the following parameters: statistical analysis: student's t Test (inter-group mean comparisons), paired student's t test (intra-group mean comparisons), χ (2) with Fisher exact text.

RESULTS

Sixty-two patients were evaluated (31 fixed-site approach, 31 objective-muscle-identification). No patient abandoned the trial during followup. Fixed-site injections required larger doses (16 vs 12 U, p = 0.001), greater volume (0.48 vs. 0.37 ml, p = 0.001), and more application sites (4 vs 2, p = 0.001), compared to the objective-muscle-identification approach. Under the objective-muscle-identification technique, facial expressions were better attenuated (52 vs 65%, p = 0.001), with a higher initial satisfaction level (6 vs 9, p = 0.001) and final satisfaction level (9 vs 9.9, p = 0.001).

CONCLUSIONS

Botulinum toxin application is more effective when administered through the objective-muscle-identification approach (less frowning, lower doses, less fixed sites injected, and patients more satisfied at the end).

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

Reduction of unwanted submental fat with ATX-101 (deoxycholic acid), an adipocytolytic injectable treatment: results from a phase III, randomized, placebo-controlled study

Summary

What's already known about this topic?

What does this study add?

Efficacy, patient-reported outcomes and safety profile of ATX-101 (deoxycholic acid), an injectable drug for the reduction of unwanted submental fat: results from a phase III, randomized, placebo-controlled study

Background

Unwanted submental fat (SMF) may result in an unattractive chin profile and dissatisfaction with appearance. An approved and rigorously tested non-surgical method for SMF reduction is lacking.

Objective

To evaluate the efficacy and safety of ATX-101 for the pharmacological reduction of unwanted SMF in a phase III randomized, double-blind, placebo-controlled study.

Methods

Patients (n = 360) with moderate or severe SMF were randomized to receive ATX-101 1 or 2 mg/cm² or placebo injected into their SMF for up to four treatments ∼28 days apart, with a 12-week follow-up. Coprimary efficacy endpoints were the proportions of treatment responders, defined as a ≥1-point reduction in SMF on the Clinician-Reported Submental Fat Rating Scale (CR-SMFRS), and those satisfied with their appearance in association with their face and chin after treatment on the Subject Self-Rating Scale (SSRS score ≥4). Secondary efficacy endpoints included a ≥1-point improvement in SMF on the Patient-Reported Submental Fat Rating Scale (PR-SMFRS) and changes in the Patient-Reported Submental Fat Impact Scale (PR-SMFIS). Additional patient-reported outcomes and changes in the Skin Laxity Rating Scale were recorded. Adverse events (AEs) and laboratory test results were monitored.

Results

Compared with placebo, a greater proportion of patients treated with ATX-101 1 and 2 mg/cm² showed a ≥1-point improvement in CR-SMFRS (58.3% and 62.3%, respectively, vs. 34.5% with placebo; P < 0.001) and patient satisfaction (SSRS score ≥4) with the appearance of their face and chin (68.3% and 64.8%, respectively, vs. 29.3%; P < 0.001). Patient-reported secondary efficacy endpoints showed significant improvements in SMF severity (PR-SMFRS; P = 0.009 for ATX-101 1 mg/cm², P < 0.001 for ATX-101 2 mg/cm² vs. placebo) and emotions and perceived self-image (PR-SMFIS; P < 0.001). No overall worsening of skin laxity was observed. AEs were mostly transient, mild to moderate in intensity and localized to the treatment area.

Conclusion

ATX-101 was effective and well tolerated, and may be an alternative to surgery for patients desiring improvement of their submental profile.

Validated assessment scale for platysmal bands

BACKGROUND

Marked platysmal bands in the neck are an unwelcome sign of aging. Botulinum neurotoxin type A has been used successfully to treat this indication, but there is a need for a validated tool for accurate assessment of dynamic platysmal bands to evaluate treatment efficacy objectively.

OBJECTIVE

To develop a scale for objective assessment of dynamic platysmal bands and to validate its use in the clinical setting.

METHODS

A new 5-point photonumeric assessment scale for platysmal bands was developed. Ten experts experienced in aesthetic dermatology used the scale to rate frontal and lateral neck photographs of 50 subjects in two separate validation cycles. Inter- and intrarater reliability of the scale was assessed.

RESULTS

The scale comprises five ratings of platysmal band severity ranging from 0 (no relevant prominence of platysmal bands) to 4 (very severe prominence of platysmal bands). Interrater reliability was "almost perfect," with intraclass correlation coefficients of 0.81 for the first validation cycle and 0.82 for the second. Mean intrarater reliability was also high (0.89), with Pearson correlation coefficients ranging between 0.87 and 0.91.

CONCLUSION

The new 5-point dynamic platysmal band photonumeric assessment scale is a valuable tool for use in the aesthetic clinical setting.

Update on techniques for the quantitation of facial skin characteristics

The purpose of this article is to review the strategies and methods for quantifying treatment outcomes, perhaps defined by the consumer/patient as a "decrease in perceived age." The demand for the rejuvenation of facial skin is expected to increase as the population ages and seeks optimal outcomes from the array of available treatment modalities. This information will be of value to the plastic surgeon in collaborating with patients on evaluation and treatment strategies.