Treatment of Atrophy of the Labia Majora: Calcium Hydroxyapatite or Hyaluronic Acid?

PURPOSE

The study aimed to evaluate and compare the efficacy and safety of treating atrophied labia majora with hyaluronic acid (HA) and calcium hydroxyapatite (CaHA).

METHODS

Ten participants complaining of sagging or loss of volume in the labia majora were evaluated and randomly assigned to two groups-treated with CaHA or AH. Photographic documentation was taken and appreciated by the participants and by blind observers.

RESULTS

The study showed an improvement in labia majora regarding volumization and flaccidity that was more significant after 90 days of treatment in both treatments. Besides flaccidity, volume replacement resulted in better balance and proportion between the labia majora and labia minora. The evaluators, independent and blind, judged that in 80% of the cases of the HA group and in 50% of cases of the CaHA group, there was an excellent improvement.

CONCLUSION

CaHA and HA are both effective and safe for treating the intimate region, and this study cannot prove the superiority of one over the other. An appropriate assessment involving the analysis of sagging and/or volume loss and the creation of a sequential treatment protocol, involving CaHA and HA, seems to be the best solution.

LEVEL OF EVIDENCE I

Evidence obtained from at least one properly designed randomized controlled trial. 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 .

The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis

BACKGROUND

Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection.

METHODS

This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis.

RESULTS

This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively.

CONCLUSIONS

The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection.

LEVEL OF EVIDENCE I

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 .

Comparative Clinical and Histomorphologic Evaluation of the Effectiveness of Combined Use of Calcium Hydroxyapatite and Hyaluronic Acid Fillers for Aesthetic Indications

Hyaluronic acid and calcium hydroxylapatite (CaHA) have been used for in the field of soft tissue augmentation. Both materials have been used in combination to enhance tissue remodeling and provide a more rejuvenated look. Sequential injections of Belotero Volume (CPM-HA V) and CaHA had a relatively greater remodeling effect on one's skin compared with the simultaneous injections of CPM-HA V and CaHA. Simultaneous injection of the studied products is possible from the point of view of safety, but different levels of administration will be more optimal, which will provide a more pronounced remodeling effect on the skin.

Optimizing Facial Aesthetics: Sequential Application of Botulinum Toxin A and Dermal Fillers for Enhanced Results

In recent years, the field of aesthetic medicine has witnessed significant advancements, offering patients a plethora of options to rejuvenate their appearance. Among the most popular techniques are the administration of botulinum toxin A (BoNT-A) and dermal fillers. This article delves into the rationale and benefits of preparing the face with BoNT-A to weaken depressor muscles before proceeding with dermal filler injections. This sequential approach not only enhances patient outcomes but also improves procedural safety and patient satisfaction while reducing the chances of needing filler. This article reviews the anatomy, scientific evidence, and clinical implications supporting this innovative approach while shedding light on the potential for revolutionizing facial aesthetic procedures. With advanced applications of BoNT-A, it is possible to slim round faces, reduce jowling, create hollowing in some patients by obliterating masseters, slim the parotid, extend the chin, and more.

The Needle Versus Cannula Debate in Soft Tissue Augmentation

In recent years, injectables have become increasingly popular in cosmetic procedures. The choice between using a needle or a cannula depends on several factors, including the site of injection, the filler type, the patient's preferences, and the practitioner's skills. Although needles are easy to use, cost-effective, and best for treating superficial rhytids, they may cause tissue injury. Cannulas are safer, particularly when injecting deep to the bone, and can provide more even distribution of filler material when filling large zones. An in-depth understanding of the facial anatomy and ongoing training are crucial for practitioners to develop and improve technical abilities.

Achieving the Attractive Asian Midface Profile with Hyaluronic Acid-Based Fillers

Despite different ethnic origins among Asians, midface enhancement is the most frequent noninvasive procedure for hyaluronic acid injection either as a stand-alone treatment or as part of the pan-facial beautification strategy. Because Asians often have an aesthetically undesirable wide, flat, and short face, improving the projection of midface and midline facial structures is an indispensable aesthetic procedure in creating a smaller facial appearance with better three-dimensionality. Achieving an oval facial shape together with increased facial height is also required in most circumstances for a natural and balanced result.

Revisiting the Ligament Line of the Face: A New Understanding for Filling the Fixed and Mobile Face

Cosmetic surgeons have conventionally used the line of ligaments to guide facial lifting or volumizing procedures. However, this line is only partially reliable in determining the limits of the mobile and fixed face, as the low point of this line was described in front of the movable jowl fat. This article proposes a new understanding of the ligament. To address this concept, the authors entitled this line the functional ligament line. This article links facial anatomy and its changes during movements to the injectable fillers according to their mechanism of action and rheologic properties.

Volumizing Fillers for Skin: Selection Strategies

The normal processes of aging in the face are accompanied by facial volume loss. Aesthetic treatments have been developed to restore lost volume to and below the skin. Understanding the properties and appropriate usages of those volumizing fillers is vital to achieving the best outcomes for patients. Gel firmness, cohesivity, hydrophilicity, tissue integration, and collagen stimulatory properties are attributes to take into consideration when deciding on a volumizing filler. Beyond filler properties, a clinician's understanding of facial harmony and natural aging changes help in understanding how to visualize a holistic response to the use of fillers for youthful restoration.

Treatment of Human Immunodeficiency Virus-Associated Facial Lipoatrophy With Hyaluronic Acid Filler Mixed With Micronized Cross-Linked Acellular Dermal Matrix

BACKGROUND

Human immunodeficiency virus (HIV)-associated facial lipoatrophy (FLA) is a stigmatizing side effect associated with the use of highly active antiretroviral therapy. We sought to evaluate the safety and efficacy of the hyaluronic acid filler mixed with micronized cross-linked acellular dermal matrix (HA/MADM) in HIV-associated FLA.

METHODS

We conducted an open-label safety and efficacy study in patients with HIV-associated FLA. Fourteen patients received single injection of the HA/MADM, and 13 patients completed the 24-week follow-up evaluation. Treatment efficacy, safety, and patient and physician satisfaction were evaluated. Repeated measure analysis of variance with post-hoc analysis with the Wilcoxon signed rank test was performed to compare and incorporate parameters at each time point.

RESULTS

All 13 patients maintained a significant improvement of the Carruthers Lipoatrophy Severity Scale grade throughout the study period, along with improvement of the depressed volume due to lipoatrophy measured using a three-dimensional camera system. More than 80% of patients and physicians were satisfied with the treatment, and no treatment-related adverse events were reported, except for one case of transient subcutaneous nodule formation.

CONCLUSION

Our study findings suggest that injectable HA/MADM is a potentially effective and safe treatment option for treating HIV-positive patients with FLA.

The Potential Use of Novel Plant-Derived Recombinant Human Collagen in Aesthetic Medicine

SUMMARY

Recombinant human type I collagen, identical in structure and functionality to human type I collagen, was successfully expressed and extracted from genetically modified tobacco plants. Contrarily to tissue extracted protein, rhCollagen is not immunogenic and not allergenic and has an intact triple helix structure showing superior biological functionality. A photocurable rhCollagen was developed by chemically modifying the protein to allow cross-linking under illumination at various wavelengths, maintaining the protein structural and biological functions. The use of the photocurable rhCollagen in aesthetic medicine, especially as a dermal filler and as a bioink for 3D-printed breast implant is discussed in this article.

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.

Open-Label, Post-Marketing Study to Evaluate the Performance and Safety of Calcium Hydroxylapatite With Integral Lidocaine to Correct Facial Volume Loss

Background: Calcium hydroxylapatite (CaHA, Radiesse®) with integral 0.3% lidocaine (CaHA(+)) has recently been approved for use in aesthetic medicine. This study assessed the performance of CaHA(+) in subjects undergoing treatment for facial volume loss and evaluated subject and physician satisfaction. Methods: In a prospective, open-label, post-marketing study, 25 women seeking treatment for age-related facial volume loss received CaHA(+) injections in 1–3 facial areas including the cheeks, marionette lines, prejowl sulcus, and jawline. Subjects returned for follow-up at 14 and 120 days, with the option of touch-up injections at day 14 if required to achieve optimal correction. Filler performance was assessed using the Merz Aesthetics Scales (MAS) and subject satisfaction using the Global Impression of Change Scale (GICS). Physician satisfaction was assessed in terms of CaHA(+)-related properties (eg, ease of injection, distribution, positioning) and aesthetic outcomes. Adverse events were recorded. Results: Mean MAS scores at baseline were ~2 corresponding to moderate facial volume loss/sagging in the treated area. At day 14, the mean score had improved to ≤1.4 for all treated areas, indicating mild volume loss. At day 120, mean scores had further improved to ≤1.1. At both follow-up visits, mean GICS scores were ≥2 indicating facial appearance was ‘much improved’ compared with baseline. All subjects reported willingness to repeat treatment and recommend it to family/friends. Physician ratings were high for ease of CaHA(+) injection, distribution, positioning, sculpturing outcome, and effect on skin tension. Compared to CaHA without lidocaine, the physician rated CaHA(+) as better or similar in performance. Adverse events were mostly mild and expected with CaHA and filler injections in general. Conclusion: The well-established efficacy and safety profile of CaHA appears unchanged by the addition of integral lidocaine. CaHA(+) was effective for volume enhancement in a number of facial areas and associated with high subject and physician satisfaction. J Drugs Dermatol. 2019;18(1):86-91.

Open Label Study Evaluating Efficacy, Safety, and Effects on Perception of Age After Injectable 20 mg/mL Hyaluronic Acid Gel for Volumization of Facial Temples

Objective: To study the safety, efficacy, optimal volume, and longevity of an injectable hyaluronic acid (HA) gel dermal filler to treat facial temporal fossa fat loss. Methods and materials: This open-label, single-site, 12-month study used 20 mg/mL HA gel to correct volume loss in both temples in 30 subjects. Touch-ups were allowed at week 2. At each visit, the investigator completed a Frontal Temporal Fossa Scale and a 7-point satisfaction scale. Subjects completed a 7-point satisfaction scale, Subject Global Aesthetic Improvement Scale (GAIS), and self-perception of age assessment. Photos were taken at each visit. Results: Subjects who returned for the one-month visit (29) achieved a ≥ 1-point improvement on the Temporal Fossa Scale in both temples. At month 12, 98% of the temples maintained a ≥ 1-grade, 18% showed a 3-grade, 34% showed a 2-grade, and 46% showed a 1-grade improvement. All subjects received an average of 1.1 mL per temple. Mild to moderate jaw pain after injections was noted by 40% of patients. The pain was reported to occur during mastication. There was no correlation between the amount of the study device injected and the incidence of jaw pain, which did not occur at the touch-up injections and was self-limited. Injections were well tolerated, and no patients developed vascular compromise, vascular events, or visual disturbances. Conclusion: HA gel (20 mg/mL) is safe and efficacious when used in the facial temporal fossa. The results lasted at least 12 months in 98% of subjects. Most subjects perceived themselves as looking younger than at baseline. J Drugs Dermatol. 2019;18(1):67-74.

Refinements in Tear Trough Deformity Correction: Intraoral Release of Tear Trough Ligaments: Anatomical Consideration and Clinical Approach

BACKGROUND

Correction of tear trough (TT) deformity is a crucial aspect of facial rejuvenation. Because the anatomical origins of TT deformity lie in the TT ligaments, which firmly attach the dermis to the periosteum, the release of TT ligaments should be considered when performing an etiological correction. The aim of this paper is to propose an alternative method for TT deformity correction, comprising use of filler together with the release of TT ligaments. This technique was compared to the procedure of only percutaneous filler.

METHODS

From January 2014 to December 2015, 10 patients were enrolled in the study for recurrence of TT deformity. All the patients underwent TT ligament release and filler injections; all had been previously treated with percutaneous hyaluronic acid injection without ligament release. Under local anesthesia, the TT ligaments were detached using a blunt cannula introduced directly in the supra periosteal plane through an intraoral access. Once the ligament was released, the TT depression was evenly recontoured with a very small amount of filler. The clinical data, digital images, evaluations of outcomes, including patient satisfaction rates were collected and compared.

RESULTS

Adding the procedure of TT ligament release to filler injections showed satisfactory results, avoiding an unnatural puffy appearance. The comparison between the two different methods showed improved outcomes and increased patient satisfaction with minor patient discomfort among those who underwent TT ligament release.

CONCLUSION

Because TT ligaments are among the etiologic factors of TT deformity, they have a strong impact on procedures that are designed to improve TT deformity; therefore, TT ligament release should always be considered to obtain satisfactory, natural results.

LEVEL OF EVIDENCE IV

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 .

A Single Site, Open Label Clinical Trial, Evaluating the Duration, Efficacy, and Safety of a Novel Lip Plumper

INTRODUCTION

Lip plumpers are topical agents that offer immediate, but temporary, volumization of the lips. While these products are becoming increasingly popular and are available at multiple retailers, there is a lack of clinical studies to evaluate the efficacy, longevity, and safety of the lip plumping products.

METHODS

This is a prospective, single center, clinical trial to evaluate the duration, efficacy, and safety of a lip plumping agent in two clinical visits. Lip volume and adverse event were assessed by two clinicians at various time points: 15 minutes, 1 hour, 2 hours, 3 hours, and 4 hours.

RESULTS

Twenty-two subjects were enrolled in the study, and eighteen completed the study. Investigator assessments of global improvement 15 minutes after application of the lip plumping product demonstrated improvement in lip fullness in 100% of the subjects (18/18), and 1 hour post-application 67% (12/18) showed an improvement in lip fullness that was statistically significant compared to the 2-hour assessment (P less than 0.05). Subject evaluations noted improvement in lip fullness 15 minutes post-application in 94.4% (17/18) of subjects, and 1 hour post-application, 89% (16/18) of the subjects who completed the trial noted some improvement in the volume of their lips that was statistically significant compared to the 2-hour post-application time point (P less than 0.0001). Subjects noted that they did experience a tingling and heat sensation, but a majority noted that that this sensation lasted less than 15 minutes.

DISCUSSION

Our study demonstrated that the lip plumping product increased lip volume in almost all patients 15 minutes post-application and showed a continued improvement in lip fullness per investigator assessments 1 hour after application. Adverse events of a tingling or heat sensation were expected and observed as the topical product contained capsaicin, cinnamon, and menthol, all of which can induce this sensation by the release of substance P. J Drugs Dermatol. 2018;17(9):999-1004.

A Novel and More Aesthetic Injection Pattern for Malar Cheek Volume Restoration

The loss of superior midface contour and projection can be corrected with the use of injectable hyaluronic acid (HA) dermal fillers, however, the most frequently used injection pattern employs a technique which was originally designed for malar implant surgery. Here we describe a novel injection pattern for restoring facial contours with a HA dermal filler inspired by traditional make-up artistry, which includes greater superolateral positioning of injection sites. Importantly, this technique helps injectors avoid creating an excess of volume in the anterior portion of the malar complex. Contributing authors/injectors, who now use this technique exclusively, have found that it has so far provided optimal aesthetic results for hundreds of patients with no observables complications. The malar cheek contributes much to the aesthetic curvature of the face and deserves a thoughtful update for injectable HA, as the traditional technique has never actually been aligned with its medium. In the experience of the contributing authors, this technique helps achieve a greater aesthetic outcome in the correction of midface contour deficiencies and has consistently resulted in high patient satisfaction. Level of Evidence IV 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 .

A Multicenter, Double-Blinded, Randomized, Split-Face Study of the Safety and Efficacy of a Novel Hyaluronic Acid Gel for the Correction of Nasolabial Folds

BACKGROUND

Injectable hyaluronic acid is frequently used to correct volume loss in nasolabial folds.

OBJECTIVE

To compare the safety and efficacy of a novel hyaluronic acid gel to a non-animal stabilized hyaluronic acid (Comparator) gel for the correction of nasolabial folds (NLF).

METHODS

Qualified subjects had NLF with a Wrinkle Severity Rating Scale (WSRS) score of 3 or 4 (moderate or severe). NLFs were treated with Test Product on one side of the face and Comparator on the other side of the face (facial side randomly assigned). Improvement from baseline was evaluated at weeks 1, 2, 4, 12, and 24 weeks. The primary study endpoint was the mean change in WSRS score from baseline to week 24.

RESULTS

The mean changes in WSRS score from baseline were 1.02 ±0.689 for Test Product and 0.91±0.762 for Comparator. The mean difference in change from baseline in WSRS scoring (Comparator minus Test Product) at week 24 was -0.11 (-0.225-0.001, 95% confidence interval [CI]). The upper boundary (0.001) of the 95% CI was less than the prespecified non-inferiority limit of 0.50, indicating that the Test Product was non-inferior to the Comparator. No subject discontinued the study due to adverse events.

CONCLUSION

The Test Product is safe and non-inferior to the Comparator for the correction of nasolabial folds. The Test Product was associated with less swelling, pain, and overall severity of treatment-emergent adverse events than the Comparator. <p><em>J Drugs Dermatol. 2018;17(1):66-73.</em></p>.

A Randomized Study to Assess the Efficacy of Skin Rejuvenation Therapy in Combination With Neurotoxin and Full Facial Filler Treatments

<p>BACKGROUND: Although non-surgical treatment options for facial rejuvenation are well-established, the literature remains limited regarding the combined effect of topical skin treatment with filler and neurotoxin on patient appearance and satisfaction. The objectives of this study were to assess the impact of a skin rejuvenation therapy in combination with neurotoxin or hyaluronic acid filler injection on skin quality and general aesthetic improvement as well as on short-term self-esteem.</p> <p>METHODS: From 2015 to 2017, 20 female patients were enrolled in our study and were randomized into two groups. Patients in Group A used a basic skin care regimen following hyaluronic acid filler and neurotoxin treatment, while those in Group B utilized the Nu-Derm® skin care system (Obagi Medical Products, Inc) afterwards. Each subject and the principal investigator filled out various assessments pre- and post-treatment to evaluate for change in skin quality (Fitzpatrick Wrinkle Assessment Scale [FWAS] and Skin Quality Assessments [SQA]), aesthetic appearance (Global Aesthetic Improvement Scale [GAIS]), patient satisfaction (Subject Satisfaction Assessment [SSA]), and self-esteem (State Self-Esteem Scale [SSES]).</p> <p>RESULTS: Subjects in both treatment groups demonstrated significant improvement in skin quality, as illustrated in the change in FWAS and SQA scores, at 12 weeks after initiating full facial rejuvenation treatment. However, there were no significant differences in FWAS and SQA ratings between the treatment groups. Regarding aesthetic appearance, a statistically significant difference in GAIS scores between Groups A and B was observed at 6 weeks after treatment only. In evaluating for patient satisfaction and self-esteem, there were no significant differences in SSA and SSES ratings over time within each treatment group or between the treatment groups.</p> <p>CONCLUSIONS: Our study confirms that facial rejuvenation therapy involving hyaluronic acid filler and neurotoxin injections combined with a topical skin treatment regimen leads to improvement in skin quality and aesthetic appearance as well as to patient satisfaction. Additional larger studies are needed to better delineate the most ideal combination facial rejuvenation therapy for optimizing patient appearance and satisfaction.</p> <p><em>J Drugs Dermatol. 2018;17(1):48-54.</em></p>.

Attention to Infection Prevention in Medical Aesthetic Clinics

The risk of infection is a concern for all medical aesthetic industry and all providers. Steps to reduce the risk and improve patient outcomes begin with vigilance to proper aseptic technique and being less concerned about the "beauty image" to attract new patients. This article is based on the guidelines outlined in Infection Prevention and Control for Clinical Office Practice by Public Health Ontario.

Hyaluronic Acid in Dermatology

Hyaluronic acid (HA) is a major component of the extracellular matrix of the skin and plays an important role in the metabolism of the dermis. It has a key position in wound healing and tissue repair processes owing to its ability to maintain a humid environment favorable to healing and the stimulation of growth factors, cellular constituents, and the migration of various cells essential for healing. This review aims to describe briefly the physical, chemical, and biologic properties of HA, together with some details of the dermatologic indications of this unique molecule.

Correction of Rhytides, Peau d'Orange, and Thin Dermis of the Face by Neocollagenesis Using Novel Collagen Stimulating Slurry Protocol

We reviewed 200 patient records from 2009 to 2015 of individuals who presented at the authors offices for facial wrinkle reduction and who on physical examination had rhytides, peau d'orange, or thin dermis and underwent novel adipose slurry injections. The patients were evaluated at week 2, 1, 3 and 6 months revealing an 80, 60 and 40% improvement in rhytides and dermis density, respectively. We present the protocol and description of a reasonable alternative or adjunct to manufactured fillers that is comprised of autologous adipose, stem cells, and growth factor slurry. The slurry is easily produced and injected at the bedside in the office setting, and has remarkable and reproducible positive outcomes in skin tone, color, texture, and rhytides as judged by both patient and physician.

LEVEL OF EVIDENCE IV

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 .

Techniques for Optimizing Surgical Scars, Part 1: Wound Healing and Depressed/Atrophic Scars

Surgical management of benign or malignant cutaneous tumors may result in noticeable scars that are of great concern to patients, regardless of sex, age, or ethnicity. Techniques to optimize surgical scars are discussed in this three-part review. In part 1, an overview of the importance of preoperative planning, intraoperative technique, and pathophysiology of wound healing is followed by a discussion of scar revision options for depressed/atrophic scars. Scar revision options for these scars include dermabrasion, needling and subcision, punch excision and grafts, fillers, nonablative fractional lasers, ablative and fractional ablative lasers, and platelet-rich plasma (PRP). This review examines the scar revision outcomes for each technique, discusses potential adverse effects, and highlights the importance of further studies to optimize postsurgical scar revision.

RESULTS OF MINIMAL INVASIVE TREATMENT IN LOCALIZED ACQUIRED CUTIS LAXA TYPE 1 AND TYPE 2 - CASE REPORT AND DISCUSSION

Cutis laxa is a disease of premature ageing. While the congenital type is characterized by mutations of genes involved in extracellular matrix turnover, acquired cutis laxa is a rare disease that can be induced by a variety of exogenous factors. We present a case of acquired type 2 cutis laxa of the neck due to excessive exposure to natural sunlight and a type 1 facial acquired cutis laxa, both significantly improved by minor invasive procedures. The etiology, prevention and treatment options are discussed.

New Uses of AbobotulinumtoxinA in Aesthetics

BotulinumtoxinA (BoNT-A) is now widely established for the main approved indication of reducing glabellar lines, and is also widely used off-label to improve the appearance of wrinkles and lines in other parts of the face. The number of aesthetic procedures continues to increase as the patient population becomes more diverse, in particular with increasing numbers of people of color and men. Further developments in treatment may continue to expand the audience for BoNT-A by making procedures more comfortable and by delivering a more natural, less static appearance. These may be achieved through use of combinations of BoNT-A with other aesthetic procedures, tailoring the dose of toxin to the patient's muscle mass or by using novel injection and application techniques. Beyond amelioration of facial lines, encouraging results have been seen with the use of BoNT-A to improve the appearance of hypertrophic and keloid scars and even to prevent them. Studies have been conducted with scars in various parts of the body and further research is ongoing. Dermatological and other medical uses for BoNT-A are also active areas of research. Injections of BoNT-A have been shown to reduce signs and symptoms of acne, rosacea, and psoriasis, to reduce neuromuscular pain, and to bring about significant improvements in a number of rare diseases that are caused or exacerbated by hyperhidrosis. This paper reviews these new uses for BoNT-A, looking at the rationale for their use and discussing the results of published case studies and clinical trials. These areas have shown great promise to date, but more and larger clinical studies will be required before these treatments become a clinical reality. To this end details are also provided of clinical trials currently listed in the main clinical trials database to highlight research areas of particular interest.

Biologic Behavior of Hydroxyapatite Used in Facial Augmentation

INTRODUCTION

The recent finding that shrinkage of key areas of the facial skeleton contributes to the aging appearance of the face has prompted a search for the most appropriate bone-like implant material. Evidence that hydroxyapatite, in granular form, maintains volume in the long term supports its use in the correction of aging, in addition to its use in the correction of inherently deficient areas of the facial skeleton. The biologic response of hydroxyapatite needs to be fully understood for its use to be confidently recommended.

MATERIALS AND METHODS

Samples of 'living' hydroxyapatite from the anterior maxilla, zygoma, and mandible of 17 patients were analyzed. These were obtained during revision procedures performed between 6 months and 15 years following original placement on the facial skeleton.

RESULTS

Histology showed that in every case, the individual granules were embedded within a mass of collagen that made up about half of the total implant volume. The collagen mass also contained fine elastin, fibroblasts, lymphocytes, occasional granulomas, and vessels. By 2 years, a new compact bone containing osteoblasts and osteocytes was present in all specimens in the deep (osseous) aspect. Bone progressively replaced the original collagen between the granules with a sharply defined transition at the interface.

CONCLUSIONS

This study confirmed a two-stage biologic change following onlay placement of hydroxyapatite granules on the facial skeleton, i.e., initial collagen formation with subsequent conversion to bone. This integrates the implant with the host bone which stabilizes the implant position and shape initially and in long term.

NO LEVEL ASSIGNED

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 .

Current concepts in lip augmentation

Facial rejuvenation, particularly lip augmentation, has gained widespread popularity. An appreciation of perioral anatomy as well as the structural characteristics that define the aging face is critical to achieve optimal patient outcomes. Although techniques and technology evolve continuously, hyaluronic acid (HA) dermal fillers continue to dominate aesthetic practice. A combination approach including neurotoxin and volume restoration demonstrates superior results in select settings.

Periocular fillers and related anatomy

Aging of the periocular area involves changes of the skin, muscle, fat, and bones. Facial fillers can be helpful in minimizing these changes by restoring youthful fullness to periocular areas that have undergone volume loss or loss of support. Physicians should understand the complicated anatomy surrounding the eyes, both to understand the aging process and to minimize treatment complications.

Efficacy and safety of new dermal fillers

Many dermal fillers are available for various cosmetic rejuvenation purposes including but not limited to treatment of facial rhytides, nasolabial folds (NLFs), facial volume deficits, and lipoatrophy; facial contouring; and lip and/or cheek augmentation. To update clinicians on best practices, we review the efficacy and safety data on the most recently approved dermal fillers.

Dermatologic care of the transgender patient

Literature is limited regarding the medical and cosmetic dermatologic issues pertinent to transgender patients and the reasons why 19 transgender individuals seek care from dermatologists. Clinical management of this population has historically been limited to 20 mental health providers, endocrinologists, and select surgeons with expertise in sex reassignment surgery. The impact of hormonal 21 therapy on transgender skin has been well documented in endocrinology journals, but is underrepresented in dermatology 22 literature. Hormonal therapy leads to drastic skin alterations, impacting sebum production, hair growth, and acne, all of which may 23 become a dermatologic concern for the transgender patient. Dermatologists may also be consulted regarding issues such as 24 permanent hair removal, androgenic alopecia, or scar revision following breast reduction surgery or genital reassignment surgery. 25 The purpose of this review is to provide relevant information for use by all dermatology providers who care for transgender 26 patients or patients undergoing transition.

Interventions for acne scars

BACKGROUND

Acne scarring is a frequent complication of acne and resulting scars may negatively impact on an affected person's psychosocial and physical well-being. Although a wide range of interventions have been proposed, there is a lack of high-quality evidence on treatments for acne scars to better inform patients and their healthcare providers about the most effective and safe methods of managing this condition. This review aimed to examine treatments for atrophic and hypertrophic acne scars, but we have concentrated on facial atrophic scarring.

OBJECTIVES

To assess the effects of interventions for treating acne scars.

SEARCH METHODS

We searched the following databases up to November 2015: the Cochrane Skin Group Specialised Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in the Cochrane Library (2015, Issue 10), MEDLINE (from 1946), EMBASE (from 1974), and LILACS (from 1982). We also searched five trials registers, and checked the reference lists of included studies and relevant reviews for further references to randomised controlled trials.

SELECTION CRITERIA

We include randomised controlled trials (RCTs) which allocated participants (whether split-face or parallel arms) to any active intervention (or a combination) for treating acne scars. We excluded studies dealing only or mostly with keloid scars.

DATA COLLECTION AND ANALYSIS

Three review authors independently extracted data from each of the studies included in this review and evaluated the risks of bias. We resolved disagreements by discussion and arbitration supported by a method expert as required. Our primary outcomes were participant-reported scar improvement and any adverse effects serious enough to cause participants to withdraw from the study.

MAIN RESULTS

We included 24 trials with 789 adult participants aged 18 years or older. Twenty trials enrolled men and women, three trials enrolled only women and one trial enrolled only men. We judged eight studies to be at low risk of bias for both sequence generation and allocation concealment. With regard to blinding we judged 17 studies to be at high risk of performance bias, because the participants and dermatologists were not blinded to the treatments administered or received; however, we judged all 24 trials to be at a low risk of detection bias for outcome assessment. We evaluated 14 comparisons of seven interventions and four combinations of interventions. Nine studies provided no usable data on our outcomes and did not contribute further to this review's results.For our outcome 'Participant-reported scar improvement' in one study fractional laser was more effective in producing scar improvement than non-fractional non-ablative laser at week 24 (risk ratio (RR) 4.00, 95% confidence interval (CI) 1.25 to 12.84; n = 64; very low-quality evidence); fractional laser showed comparable scar improvement to fractional radiofrequency in one study at week eight (RR 0.78, 95% CI 0.36 to 1.68; n = 40; very low-quality evidence) and was comparable to combined chemical peeling with skin needling in a different study at week 48 (RR 1.00, 95% CI 0.60 to 1.67; n = 26; very low-quality evidence). In a further study chemical peeling showed comparable scar improvement to combined chemical peeling with skin needling at week 32 (RR 1.24, 95% CI 0.87 to 1.75; n = 20; very low-quality evidence). Chemical peeling in one study showed comparable scar improvement to skin needling at week four (RR 1.13, 95% CI 0.69 to 1.83; n = 27; very low-quality evidence). In another study, injectable fillers provided better scar improvement compared to placebo at week 24 (RR 1.84, 95% CI 1.31 to 2.59; n = 147 moderate-quality evidence).For our outcome 'Serious adverse effects' in one study chemical peeling was not tolerable in 7/43 (16%) participants (RR 5.45, 95% CI 0.33 to 90.14; n = 58; very low-quality evidence).For our secondary outcome 'Participant-reported short-term adverse events', all participants reported pain in the following studies: in one study comparing fractional laser to non-fractional non-ablative laser (RR 1.00, 95% CI 0.94 to 1.06; n = 64; very low-quality evidence); in another study comparing fractional laser to combined peeling plus needling (RR 1.00, 95% CI 0.86 to 1.16; n = 25; very low-quality evidence); in a study comparing chemical peeling plus needling to chemical peeling (RR 1.00, 95% CI 0.83 to 1.20; n = 20; very low-quality evidence); in a study comparing chemical peeling to skin needling (RR 1.00, 95% CI 0.87 to 1.15; n = 27; very low-quality evidence); and also in a study comparing injectable filler and placebo (RR 1.03, 95% CI 0.10 to 11.10; n = 147; low-quality evidence).For our outcome 'Investigator-assessed short-term adverse events', fractional laser (6/32) was associated with a reduced risk of hyperpigmentation than non-fractional non-ablative laser (10/32) in one study (RR 0.60, 95% CI 0.25 to 1.45; n = 64; very low-quality evidence); chemical peeling was associated with increased risk of hyperpigmentation (6/12) compared to skin needling (0/15) in one study (RR 16.00, 95% CI 0.99 to 258.36; n = 27; low-quality evidence). There was no difference in the reported adverse events with injectable filler (17/97) compared to placebo (13/50) (RR 0.67, 95% CI 0.36 to 1.27; n = 147; low-quality evidence).

AUTHORS' CONCLUSIONS

There is a lack of high-quality evidence about the effects of different interventions for treating acne scars because of poor methodology, underpowered studies, lack of standardised improvement assessments, and different baseline variables.There is moderate-quality evidence that injectable filler might be effective for treating atrophic acne scars; however, no studies have assessed long-term effects, the longest follow-up being 48 weeks in one study only. Other studies included active comparators, but in the absence of studies that establish efficacy compared to placebo or sham interventions, it is possible that finding no evidence of difference between two active treatments could mean that neither approach works. The results of this review do not provide support for the first-line use of any intervention in the treatment of acne scars.Although our aim was to identify important gaps for further primary research, it might be that placebo and or sham trials are needed to establish whether any of the active treatments produce meaningful patient benefits over the long term.

Clinical comparison between two hyaluronic acid-derived fillers in the treatment of nasolabial folds in Chinese subjects: BioHyalux versus Restylane

Hyaluronic acid fillers are used to improve the appearance of nasolabial folds (NLF). This study aimed to compare the efficacy, safety, and durability of a new hyaluronic acid gel (BioHyalux) versus Restylane for the correction of NLF. This was a multicenter, double-blinded, randomized, controlled, non-inferiority clinical trial involving 88 subjects with moderate to severe NLF. Subjects were randomized to BioHyalux and Restylane on either sides of the NLF. NLF was assessed before and right after injection, and at 1 week, 1, 3, and 6 months. Patients were followed up for 13-15 months to evaluate the durability and long-term safety. A clinically meaningful response was predefined as at least one-point improvement on the Wrinkle Severity Rating Scale, which is a five-point scale. At 6 months, the response rate of BioHyalux was not inferior to that of Restylane (P < 0.05). At the 13-15 months follow-up, the response rate by investigators was 58.0 % on the BioHyalux side versus 63.8 % on the Restylane side. The response rate by subjects showed similar results, which was 56.5 % on the BioHyalux side versus 60.9 % on the Restylane side at 13-15 months. The subjects' Global Aesthetic Improvement Scale (GAIS) showed that most subjects felt improvements on both sides of NLF (P > 0.05) at all time points. At 6 months, 100 % reported improvements on both side; at 13-15 months, 60 % of subjects reported improvements with BioHyalux versus 64 % with Restylane. Adverse events were transient and predominantly mild or moderate in severity including injection site swelling, pain, itching, bruising, and tenderness. BioHyalux had reliable safety and tolerance, and could be an effective injectable filler for correcting NLF.

Common Dermatologic Procedures

Dermatologists perform a wide variety of procedures on a daily basis. The skin biopsy is a fundamental technique that can be performed by all physicians who manage cutaneous conditions. Specimens should always be sent for pathologic evaluation, regardless of whether the sampled lesion appears benign. Postoperative care and education are critical for minimizing complications.

Motivations for seeking minimally invasive cosmetic procedures in an academic outpatient setting

BACKGROUND

The demand for minimally invasive cosmetic procedures has continued to rise, yet few studies have examined this patient population.

OBJECTIVES

This study sought to define the demographics, social characteristics, and motivations of patients seeking minimally invasive facial cosmetic procedures.

METHODS

A prospective, single-institution cohort study of 72 patients was conducted from 2011 through 2014 at an urban academic medical center. Patients were aged 25 through 70 years; presented for botulinum toxin or soft tissue filler injections; and completed demographic, informational, and psychometric questionnaires before treatment. Descriptive statistics were conducted using Stata statistical software.

RESULTS

The average patient was 47.8 years old, was married, had children, was employed, possessed a college or advanced degree, and reported an above-average income. Most patients felt that the first signs of aging occurred around their eyes (74.6%), and a similar percentage expressed this area was the site most desired for rejuvenation. Almost one-third of patients experienced a "major life event" within the preceding year, nearly half had sought prior counseling from a mental health specialist, and 23.6% were being actively prescribed psychiatric medication at the time of treatment.

CONCLUSIONS

Patients undergoing injectable aesthetic treatments in an urban outpatient academic center were mostly employed, highly educated, affluent women who believed that their procedure would positively impact their appearance. A significant minority experienced a major life event within the past year, which an astute clinician should address during the initial patient consultation. This study helps to better understand the psychosocial factors characterizing this patient population.

LEVEL OF EVIDENCE

4 Therapeutic.

Voluma: A Systematic Review of Clinical Experience

BACKGROUND

Dermal fillers are important for facial aesthetic enhancement as patients are favoring non-surgical procedures with minimal recovery time. Voluma is a volumizing hyaluronic acid filler, 20 mg/ml HA dermal filler, which was FDA-approved in 2013 as the first dermal filler for treatment of age-related volume loss in the midface.

OBJECTIVE

We sought to systematically review clinical studies and expert opinions of this 20 mg/ml HA dermal filler and to provide evidence-based recommendations and expert opinions.

METHODS AND MATERIALS

A search of the computerized bibliographic databases Medline, Embase, Embal, Biosis, SciSearch, Pascal, HCAPlus, IPA, and Dissertation Abstracts was performed on August 18th 2014.

RESULTS

Thirteen articles met inclusion and were included in our review: clinical trials with this 20 mg/ml HA dermal filler (10) and expert opinions and questionnaire survey studies of experts (3). This 20 mg/ml HA dermal filler has shown consistent, favorable results for treatment of age-related facial volume loss, aesthetic enhancement, and HIV facial lipoatrophy.

CONCLUSION

HA fillers are safe and effective with minimal recovery time and complications. Future studies with longer follow-up period and use of this 20 mg/ml HA dermal filler on areas other than midface may provide additional efficacy and safety outcomes.

Injectable Cosmetic Procedures for the Male Patient

More than ever, male patients are seeking cosmetic procedures for a variety of reasons including but not limited to: a less aged appearance, social, or work related issues. Injectable neurotoxins and fillers are appealing to the male patient for their safety, rapid results, and minimal downtime. However, methods applied to the female patient do not always translate to the male patient. In this article, we review the anatomical, biological, and behavioral differences in men. We also provide an in-depth discussion of the techniques and dosages that are used in men, emphasizing the distinctions between the sexes. While once overlooked, this gender is becoming an important demographic in cosmetic dermatology.

Male Aesthetics: A Review of Facial Anatomy and Pertinent Clinical Implications

Aesthetics continues to be a rapidly growing field within dermatology. In 2014, Americans spent 5 billion dollars on an estimated 9 million minimally invasive cosmetic procedures. Between 1997 and 2014, the number of aesthetic procedures performed on men increased by 273%. The approach to male aesthetics differs from that of females. Men have a squarer face, a more angled and larger jaw, and equally balanced upper and lower facial proportions. Facial muscle mass, subcutaneous tissue, and blood vessel density are also increased in men relative to women. While many of the same cosmetic procedures are performed in males and females, the approach, assessment, and treatment parameters are often different. Improper technique in a male patient can result in feminizing facial features and patient dissatisfaction. With an increasing number of men seeking aesthetic procedures, it behooves dermatologists to familiarize themselves with male facial anatomy and the practice of cosmetic dermatology in this population.

Efficacy of a New Flowable Wound Matrix in Tunneled and Cavity Ulcers: A Preliminary Report

INTRODUCTION

In chronic wounds the healing is stagnant, and regenerative surgery is often needed. Many engineered tissues with a conventional bidimensional sheet are ineffective for tunneling wounds, because adherence to the wound bed is not complete. An advanced wound matrix for treating wounds with irregular geometries has been developed (Integra Flowable Wound Matrix, Integra LifeScience Corp, Plainsboro, NJ).

METHODS AND MATERIALS

Between March 2013 and December 2013 the authors treated 18 patients (11 female) with tunneled or cavity ulcers with the advanced wound matrix at the Unit of General and Geriatric Surgery of the Second University of Naples, Naples, Italy. Two patients (11.1%) had postsurgical wounds, two (11.1%) had post-traumatic wounds, and 14 (77.8%) had neuropathic ulcers. After debridement and antibiotic therapy, the lesions were filled with the wound matrix product. Surgical wound edges were either approximated with stitches or left to heal by secondary intention and covered with wet gauze. During the first week, follow-up visits were carried out every 3 days, then once a week until complete healing was achieved. All patients underwent preoperative and postoperative ultrasonography scans and plain radiograph controls.

RESULTS

Twenty-one applications were performed. Engraftment was complete in all but 1 patient who had diabetes and graft failure. Three patients needed repeated applications to complete the filling of the lesions. Median (range) pain Visual Analog Scores-on a scale of 0 to 10, where 0 = no pain, and 10 = intolerable pain-were 6.3 (range 3-8) preoperatively and 0.5 (range 0-2) at first follow-up (P ≤ 0.001). All but 2 patients showed a progressive remodeling of the tissue gap at scheduled radiographic controls.

CONCLUSIONS

To the author's knowledge, the advanced wound matrix used in this study is the only available biomaterial for the treatment of tunneled lesions. It stimulates tissue regeneration by filling surfaces which cannot be repaired spontaneously or by using conventional biomaterials in the form of sheets. Its application is atraumatic, painless, and safe.