Update on Blindness From Filler: Review of Prognostic Factors, Management Approaches, and a Century of Published Cases

BACKGROUND

Vision loss secondary to aesthetic filler treatment is a rare but disastrous complication.

OBJECTIVES

The aim was to update the published cases of blindness after filler injection that have occurred since our group published reviews of 98 cases in 2015 and an additional 48 cases in 2019.

METHODS

A literature review was performed to identify all cases of visual complications caused by filler injection published between September 2018 and March 2023. The cases were analyzed independently and in combination with previously reviewed cases. Analyses are based on the number of cases with data available.

RESULTS

365 new cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nose (40.6%), forehead (27.7%), and glabella (19.0%). The filler injected was hyaluronic acid in 79.6% of cases. The most common associated signs were ptosis (56.2%), ophthalmoplegia (44.1%), pain (31.2%), and skin changes (73.2%). Stroke-like features were seen in 19.2% of cases. Of the cases reporting visual outcomes (318), 6.0% experienced complete vision recovery, 25.8% had partial improvement in visual acuity, and 68.2% had no vision recovery. Partially preserved visual acuity at onset was a significant predictor of visual improvement (p < .001). The three most common treatments were subcutaneous hyaluronidase at or near the filler site (70.1%), systemic steroids (57.3%), and intra-arterial thrombolytic therapy (56.0%). No treatments were significantly associated with visual improvement (p > .05).

CONCLUSIONS

Although blindness and stroke from fillers is a rare complication, practitioners who inject filler should have a thorough knowledge of prevention and management strategies.

Effectiveness and Safety of a New Hyaluronic Acid Injectable for Augmentation and Correction of Chin Retrusion

BACKGROUND

A hyaluronic acid (HA) filler intended for non-surgical improvement of chin appearance should ideally be of high strength/firmness (high G') to allow for deep injections on the bone. HASHA (Restylane Shaype) is a new hyaluronic acid (HA) injectable with high G' and high HA concentration (25 mg/mL), engineered by the new NASHA-HD (High Definition) technology. HASHA is suitable to be placed periosteally, aiming to mimic the natural shape of the bony chin. This pivotal clinical investigation evaluated effectiveness and safety of HASHA for augmentation and correction of chin retrusion.  Methods: Subjects 18 years or older with mild or moderate chin retrusion by the Galderma Chin Retrusion Scale (GCRS), were randomized 3:1 to HASHA (n=103) or no treatment (n=37). Assessments included GCRS (blinded evaluator), aesthetic improvement (Global Aesthetic Improvement Scale [GAIS]), subject satisfaction, and safety.  Results: GCRS responder rate (1-grade or greater improvement from baseline) was significantly higher for HASHA (83.3%) versus controls (10.8%) at month 3 (P<0.001) and maintained through month 12 (P<0.001). Aesthetic improvement was high throughout the study in the HASHA group, according to investigators (97% or greater) and subjects (89% or greater). Overall, subject satisfaction was high at month 3 and maintained at month 12. Product- or injection-related adverse events were mostly mild or moderate and transient. No product- or injection-related serious adverse events were reported.

CONCLUSIONS

HASHA, a new NASHA-HD injectable with extra strength/firmness, was safe and effective for chin augmentation and correction of chin retrusion, with high aesthetic improvement and subject satisfaction throughout 12 months. J Drugs Dermatol. 2024;23(4):255-261.     doi:10.36849/JDD.8145.

Immunogenicity of DaxibotulinumtoxinA for Injection in Glabellar Lines

DaxibotulinumtoxinA-lanm for injection (DAXI), a novel botulinum toxin type A formulation, contains a purified 150-kD core neurotoxin (daxibotulinumtoxinA) and proprietary stabilizing peptide (RTP004), and is approved for glabellar line treatment. As with any biologic product, DAXI may potentially be immunogenic and elicit unwanted antibody formation, possibly resulting in partial or complete treatment failure. The immunogenicity of DAXI was assessed in 2 double-blind, placebo-controlled, single-dose studies and an open-label safety study of up to 3 repeat treatments. Of the 2737 evaluable patients, none developed neutralizing antibodies to daxibotulinumtoxinA and 0.8% developed treatment-related nonneutralizing anti-daxibotulinumtoxinA-binding antibodies. Of evaluable patients exposed to RTP004 with either DAXI or placebo, 1.3% developed treatment-related anti-RTP004-binding antibodies, which were mostly transient. No patient developed binding antibodies to both daxibotulinumtoxinA and RTP004. All patients with treatment-related binding antibodies to daxibotulinumtoxinA or RTP004 achieved a clinical response (none or mild glabellar line severity) at Week 4 following each DAXI treatment cycle. The duration of clinical response was not different between treatment cycles when antibodies were detected vs when they were absent. Although the analysis population was small compared to the number of patients likely to receive repeated treatment in clinical practice, these results suggest that DAXI administration at the approved glabellar lines dose has low immunogenic potential and that nonneutralizing antibodies to daxibotulinumtoxinA or RTP004 occur infrequently and often transiently, and have no impact on clinical efficacy, safety, or duration of action. Real-world data encompassing larger numbers of patients is needed to substantiate these results.

LEVEL OF EVIDENCE: 3

Clinical Immunogenicity of DaxibotulinumtoxinA for Injection in Glabellar Lines: Pooled Data from the SAKURA Phase 3 Trials

DaxibotulinumtoxinA for Injection (DAXI) is a novel botulinum toxin type A product containing daxibotulinumtoxinA with a stabilizing excipient peptide (RTP004). DAXI immunogenicity was assessed in three phase 3 glabellar line studies (two placebo-controlled, single-dose studies and an open-label repeat-dose safety study). Binding antibodies to daxibotulinumtoxinA and RTP004 were detected by validated ELISAs. Samples positive for daxibotulinumtoxinA-binding antibodies were evaluated further for titer and neutralizing antibodies by mouse protection assay. Overall, 2786 subjects received DAXI and 2823 subjects were exposed to RTP004 as DAXI (n = 2786) or placebo (n = 37). Treatment-related anti-daxibotulinumtoxinA binding antibodies were detected in 21 of 2737 evaluable subjects (0.8%). No subject developed neutralizing antibodies. Treatment-related anti-RTP004 binding antibodies were detected in 35 (1.3%) of 2772 evaluable subjects. Binding antibodies were generally transient, of low titer (<1:200), and no subject had binding antibodies to both daxibotulinumtoxinA and RTP004. All subjects with treatment-induced binding antibodies to daxibotulinumtoxinA or RTP004 achieved none or mild glabellar line severity at Week 4 following each DAXI cycle, indicating no impact on DAXI efficacy. No subjects with binding antibodies to daxibotulinumtoxinA or RTP004 reported immune-related adverse events. This evaluation of anti-drug antibody formation with DAXI shows low rates of antibody formation to both daxibotulinumtoxinA and RTP004.

B cell phenotypes and maturation states in cows naturally infected with Mycobacterium avium subsp. Paratuberculosis

Little is known about the role that B cells play in immune responses to infection with the intracellular pathogen, Mycobacterium avium subsp. paratuberculosis (MAP). Traditionally, the role of B cells has been constrained to their function as antibody-producing cells, however, antibodies are not thought to play a protective role in mycobacterial infections. The present study was designed to characterize B cell subpopulations as well as activation/maturation states in cattle with paratuberculosis. Peripheral blood mononuclear cells (PBMCs) were isolated from noninfected control cows (n = 8); as well cattle naturally infected with MAP in the subclinical (n = 8) and clinical (n = 7) stage of infection and stimulated with MAP antigen for 6 days. MAP infection resulted in greater numbers of total B cells for clinical cows compared to control noninfected cows. The major subpopulation in freshly isolated PBMCs in clinical cows was B-1a B cells, but this shifted to a composite of both B-1a and B-2 B cells upon stimulation of PBMCs with either MAP antigen or pokeweed mitogen, with higher numbers of B-2 B cells. Early B cells were observed to predominate the population of B cells in PBMCs, with lesser populations of germinal B cells, memory B cells and plasma cells. These subpopulations were elevated in clinical cows upon stimulation of PBMCs with MAP antigen, except for plasma cells which were lower compared to control noninfected cows. Increased numbers of B cells in clinical cows aligned with higher expression of B cell markers such as MAPK1/3, BTG1, Bcl2, CD79A and SWAP70, depending upon in vitro stimulation with either mitogen or antigen. This would indicate that the B cells were capable of activation but were anti-apoptotic in nature. The shift to B-2 B cells in the periphery of clinical cows seems to be indicative of an expansion of memory B cells, rather than plasma cells. This may be a last attempt by the host to control the rampant inflammatory state associated with advanced clinical disease.

Hyaluronidase for Treating Complications Related to HA Fillers: A National Plastic Surgeon Survey

Background: Hyaluronic acid (HA) fillers have become a popular modality to address changes in the ageing face. There are many described indications of hyaluronidases in aesthetic medicine which include their use in the management of HA-associated complications. To better understand the current practice patterns, we surveyed Canadian plastic surgeons on their use of hyaluronidases. Methods: With the approval of the Canadian Society of Plastic Surgeons, an electronic survey was emailed to members. A total of 350 surveys were distributed and 98 surveys were completed for a response rate of 28%. Results: Approximately half (48%) of the survey respondents used HA fillers in their practice. Skin testing for hypersensitivity reactions was performed by less than 10% of hyaluronidase users. Nearly all respondents used hyaluronidase for filler over-correction (95.5%) and asymmetry (86.4%). Over half of the respondents have used hyaluronidase for inflammatory or infectious nodules and the Tyndall effect. Other reported applications included restoration of vascular compromise, and one respondent reported using hyaluronidase for assisting with haematoma resolution. When compared with the most recent guidelines, there was a wide range of doses used for common side effects and complications. Twenty-four percent of the respondents reported that their hyaluronidase formulation was prepared by a compounding pharmacy, and 20% of respondents who inject HA fillers did not stock hyaluronidase. Conclusion: There are many indications for hyaluronidase in aesthetic plastic surgery. Plastic surgeons should stock hyaluronidase and develop a specific plan in anticipation of adverse events. Although hyaluronidase is commonly used by plastic surgeons for over-correction and asymmetry, the dosages used in aesthetic practice is rather diverse and heterogeneous. When possible, plastic surgeons should perform allergy testing before hyaluronidase use.

Submental Area Treatment with ATX-101: Relationship of Mechanism of Action, Tissue Response, and Efficacy

ATX-101 is an injectable, synthetically derived formulation of deoxycholic acid used for submental fat reduction.

Methods

A narrative review of references relevant to the mechanism of action of ATX-101 and its relationship to efficacy and inflammatory adverse events was conducted.

Results

When injected into subcutaneous fat, deoxycholic acid physically disrupts adipocyte cell membranes, leading to local adipocytolysis, cell death, and a mild, local inflammatory reaction consisting of macrophage infiltration and fibroblast recruitment. At Day 28 postinjection, inflammation largely resolves, and key histologic features include fibrotic septal thickening, neovascularization, and atrophy of fat lobules. Based on the mechanism of action of ATX-101 and the demonstrated inflammatory response, localized inflammation and swelling are expected following treatment. Indeed, postinjection swelling and other local injection-site events, including pain, erythema, and bruising, are common during and after treatment. Because of inflammatory sequelae following injection, reduction in submental fat is gradual and may require months before the full response is apparent. Patients may also require multiple treatment sessions to achieve their treatment goals. Repeated treatments may result in less pain and swelling over time owing to a combination of factors, including less target tissue allowing for lower doses/injection volumes, persistent numbness, and greater tissue integrity from thickened fibrous septa.

Conclusions

Physicians can manage expectations by counseling patients that, based on the mechanism of action of ATX-101 and data from pivotal clinical trials, ATX-101 treatment results in localized inflammation/swelling and gradual submental fat reduction. Patient education about common local adverse events is critical.

Improvements in Submental Contour up to 3 Years After ATX-101: Efficacy and Safety Follow-Up of the Phase 3 REFINE Trials

BACKGROUND

ATX-101 (deoxycholic acid) significantly reduced submental fat (SMF) severity in two 24-week Phase 3 studies (REFINE-1 and REFINE-2).

OBJECTIVES

The aim of this study was to evaluate the durability of effect and long-term safety of ATX-101.

METHODS

REFINE study patients who maintained ≥1-grade improvement on the Clinician-Reported SMF Rating Scale (CR-1 responders) 12 weeks after their last REFINE treatment were eligible for enrollment in this multicenter, double-blind, nontreatment, long-term, follow-up study (NCT02163902). The primary endpoint was CR-1 response at Years 1, 2, and 3. Patient-reported satisfaction, psychological impact, and adverse events were monitored.

RESULTS

In total, 224 patients (ATX-101, n = 113; placebo, n = 111) were enrolled. Maintenance of CR-1 response was significantly better in the ATX-101 group than in the placebo group at Year 1 (86.4% vs 56.8%; P < 0.001), Year 2 (90.6% vs 73.8%; P = 0.014), and Year 3 (82.4% vs 65.0%; P = 0.03). Most (74%) ATX-101‒treated patients satisfied at 12 weeks remained satisfied at Year 3. Significant reductions from baseline in psychological impact scores were sustained through Year 3 (P < 0.001). No new treatment-related adverse events were reported.

CONCLUSIONS

Improvements in submental contour achieved with ATX-101 are maintained for 3 years in most patients. No new safety signals emerged.

LEVEL OF EVIDENCE: 2

The impact of COVD-19 on North American dermatology practices

COVID‐19 continues to affect the delivery of healthcare services, as practices across North America gradually re‐open with new safety measures and practice guidelines. Specifically in dermatology, clinical care is delivered in close physician‐patient proximity through physical examination and the use of additional diagnostic and therapeutic procedures. We designed a 10‐question survey to better understand how COVID‐19 has impacted the delivery of care in North American dermatology practices. Survey questions explored themes including changes in patient volumes, the use of virtual visits/teledermatology, the frequency of aesthetic and surgical procedures, and other related topics. We invited 102 board‐certified dermatologists working in a variety of medical, aesthetic, surgical, and mixed practices, to participate in our survey hosted through Qualtrics XM. These dermatologists were selected based on their geographic location and our ability to access their contact information. Each dermatologist received an individualized e‐mail and survey link; however, all survey responses were anonymized. In 2.5 weeks after survey invitations were sent, the survey was viewed and completed by 71 and 54 dermatologists, respectively. The second wave of e‐mails was sent to the remaining 48 dermatologists who had not yet completed the survey, after which 15 participants both viewed and completed the survey. In total, 69 responses were recorded with an overall response rate of 67.6%. We report decreased patient volume capacity, fewer aesthetic and surgical procedures, and an increase in the use of virtual medicine among board‐certified North American dermatologists. However, this represents a reflection on perspectives at a single time point in a rapidly evolving situation. Understanding the full scope of the impact that COVID‐19 continues to have on dermatologic care is paramount to effectively serve our patients.

Clinical Relevance of Elastin in the Structure and Function of Skin

Elastin is the main component of elastic fibers, which provide stretch, recoil, and elasticity to the skin. Normal levels of elastic fiber production, organization, and integration with other cutaneous extracellular matrix proteins, proteoglycans, and glycosaminoglycans are integral to maintaining healthy skin structure, function, and youthful appearance. Although elastin has very low turnover, its production decreases after individuals reach maturity and it is susceptible to damage from many factors. With advancing age and exposure to environmental insults, elastic fibers degrade. This degradation contributes to the loss of the skin's structural integrity; combined with subcutaneous fat loss, this results in looser, sagging skin, causing undesirable changes in appearance. The most dramatic changes occur in chronically sun-exposed skin, which displays sharply altered amounts and arrangements of cutaneous elastic fibers, decreased fine elastic fibers in the superficial dermis connecting to the epidermis, and replacement of the normal collagen-rich superficial dermis with abnormal clumps of solar elastosis material. Disruption of elastic fiber networks also leads to undesirable characteristics in wound healing, and the worsening structure and appearance of scars and stretch marks. Identifying ways to replenish elastin and elastic fibers should improve the skin's appearance, texture, resiliency, and wound-healing capabilities. However, few therapies are capable of repairing elastic fibers or substantially reorganizing the elastin/microfibril network. This review describes the clinical relevance of elastin in the context of the structure and function of healthy and aging skin, wound healing, and scars and introduces new approaches being developed to target elastin production and elastic fiber formation.

Defining Skin Quality: Clinical Relevance, Terminology, and Assessment

BACKGROUND

Flawless skin is one of the most universally desired features, and demand for improvements in skin quality is growing rapidly. Skin quality has been shown to substantially impact emotional health, quality of life, self-perception, and interactions with others. Although skin quality improvements are a common end point in studies of cosmeceuticals, they are rarely assessed in clinical studies of other aesthetic treatments and products. Descriptive terminology for skin quality parameters also varies considerably within the aesthetic field, relying on a range of redundant and occasionally contradictory descriptors. In short, skin quality has not been clearly defined.

OBJECTIVE

The goal of this review is to highlight the importance of skin quality to patients and physicians, explore known and unknown factors comprising skin quality, and provide clarity regarding terminology, descriptors, and evaluation tools for assessing skin quality.

MATERIALS AND METHODS

A review of the literature on skin quality was performed without limitation on publication date. Relevant articles are presented.

RESULTS AND CONCLUSION

We propose a framework of attributes contributing to skin quality rooted in 3 fundamental categories-visible, mechanical, and topographical-with the aim to provide information to help guide clinicians and inform future clinical studies.

Photoprotection With Mineral-Based Sunscreens

BACKGROUND

Although chemical sunscreens have traditionally been at the forefront of sun protection, safety concerns and increasing awareness of the environmental impact of personal-care products have led to greater interest in the use of mineral blockers as photoprotective agents.

OBJECTIVE

To examine the safety and efficacy of mineral-based sunscreens to allow patients to make informed choices about ultraviolet (UV) protection.

MATERIALS AND METHODS

A review of the literature was performed using the PubMed database.

RESULTS

This article provides an overview of physical blockers and focuses on the efficacy of mineral sunscreens in offering broad-spectrum UV protection and safety concerns, including the controversy surrounding the use of nanoparticles. Practical tips for application are also reviewed.

CONCLUSION

Mineral sunscreens are an attractive, efficacious option for consumers who prefer alternative choices in sun protection.

Enhanced patient retention after combination vs single modality treatment using hyaluronic acid filler and neuromodulator: A multicenter, retrospective review by The Flame Group

BACKGROUND

It is believed that combination treatment with both neuromodulators (NM) and hyaluronic acid soft-tissue fillers (HA) results in superior aesthetic results and increased patient satisfaction compared to either treatment alone.

AIMS

To determine whether combined treatment with NM and HA leads to greater patient retention than treatment with NM or HA alone.

PATIENTS/METHODS

This is a large, multi-center, retrospective review of patient retention rates from 7 aesthetic practices across 5 continents, incorporating over 2600 patients. Patient retention is interpreted as a surrogate marker for overall patient satisfaction. Retention rates were compared at 1, 3, and 5 years for patients who received NM only, HA only, or combination treatment with both NM and HA.

RESULTS

Combination therapy significantly increased the probability of retention for each time point (1, 3, and 5 years) compared with NM alone (P < .0001) and HA alone (P < .0001).

CONCLUSION

This large multicenter, global retrospective review demonstrates that patients who received combined HA and NM were more likely to be retained in the same practice over many years than those who received either treatment alone.

Photographic assessment of postsurgical facial scars epidermally sutured with rapidly absorbable polyglactin 910 or nylon: A randomized clinical trial

BACKGROUND

Surgeons use absorbable and nonabsorbable sutures for epidermal wound closure. No large, randomized studies have compared the effect of these suture types on facial scar appearance.

OBJECTIVE

To assess postsurgical facial scar appearance using either rapidly absorbable polyglactin 910 or nylon for epidermal closure.

METHODS

Randomized, blinded, split-scar clinical trial. A total of 105 patients with facial wounds resulting from Mohs micrographic surgery excisions were randomly assigned for epidermal closure with rapidly absorbable 5-0 polyglactin 910 (Vicryl Rapide) on one half of the repair and 5-0 nylon (Ethilon) on the other half. Two physicians (1 dermatologist and 1 plastic surgeon), unaware of the original suture location, examined photographs of each healed wound at 6 months after surgery and graded the appearance of each half of the scar using the visual analog scale, wound evaluation scale, and Stony Brook Scar Evaluation Scale.

RESULTS

At 6 months, there was no significant difference in the combined mean (standard deviation) visual analog scale scores (83.1 [14.2] and 83.0 [13.7]), Stony Brook Scar Evaluation Scale scores (4.3 [0.9] and 4.4 [0.9]), or wound evaluation scale scores (5.3 [1.1] and 5.2 [1.1]) for rapidly absorbable polyglactin 910 versus nylon (P = .72, .57, and .21, respectively).

LIMITATIONS

Single institution.

CONCLUSIONS

Both rapidly absorbable polyglactin 910 and nylon sutures placed through the epidermis resulted in an equivalent photographic appearance of facial scars at 6 months after surgery.

Dermatologic Training and Practice in Canada: An In-Depth Review [Formula: see text]

As part of an in-depth review of the specialty for the Royal College of Physicians and Surgeons of Canada (RCPSC), the Dermatology Working Group (DWG) was tasked with leading a comprehensive and objective analysis of the current state of Dermatology practice and training patterns in Canada. Preliminary research for the report was conducted in 3 areas: a jurisdictional analysis, a literature review, and a landscape overview. The results of this research were published in the spring 2019 edition of the Journal of Cutaneous Medicine and Surgery. Various factors impacting the discipline were explored, including trends in the workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. The DWG, supported by the RCPSC's Office of Specialty Education, used information gained from the reviews, a national survey, and stakeholder perspectives to develop recommendations that address the current challenges and build upon opportunities for advancement in the specialty.

Update on Avoiding and Treating Blindness From Fillers: A Recent Review of the World Literature

BACKGROUND

Sudden loss of vision secondary to filler treatments is a rare but catastrophic complication.

OBJECTIVES

The aim of this study was to update the published cases of blindness after filler injection that have occurred since we published our review of 98 cases in 2015, and to discuss prevention and management strategies.

METHODS

A literature review was performed to identify all cases of visual complications caused by filler injection identified between January 2015 and September 2018.

RESULTS

Forty-eight new published cases of partial or complete vision loss after filler injection were identified. The sites that were highest risk were the nasal region (56.3%), glabella (27.1%), forehead (18.8%), and nasolabial fold (14.6%). Hyaluronic acid filler was the cause of this complication in 81.3% of cases. Vision loss, pain, ophthalmoplegia, and ptosis were the most common reported symptoms. Skin changes were seen in 43.8% of cases and central nervous system complications were seen in 18.8% of cases. Ten cases (20.8%) experienced complete recovery of vision, whereas 8 cases (16.7%) reported only partial recovery. Management strategies varied greatly and there were no treatments that were shown to be consistently successful.

CONCLUSIONS

Although the risk of blindness from fillers is rare, practitioners who inject filler should have a thorough knowledge of this complication including prevention and management strategies.

LEVEL OF EVIDENCE: 5

Dermatologic Training and Practice in Canada: A Historical Overview

The specialty of dermatology is constantly changing to meet the medical needs of our society. The discipline is in flux because of a variety of factors such as growing population needs, technological advancements, fiscal restraint, and demographic changes. As part of an in-depth review of the specialty, the Dermatology Working Group (DWG) for the Royal College of Physicians and Surgeons of Canada sought to determine whether the current training configuration is suitably preparing graduates to meet the societal health needs of dermatology patients. In this first of a 2-part series, the authors conducted comprehensive literature and historical reviews and a jurisdictional analysis to understand the current state of dermatology practice in Canada. Herein, they explore trends in the dermatology workforce, population needs, accessibility, and wait times, as well as issues in undergraduate and postgraduate medical education. In a subsequent publication, the DWG will utilize information gained from this historical analysis and jurisdictional review, stakeholder perspectives, and a national survey to shape the future of dermatology training in Canada.

Efficacy and Safety of ATX-101 by Treatment Session: Pooled Analysis of Data From the Phase 3 REFINE Trials

Background

ATX-101 (deoxycholic acid injection) is the only injectable drug approved for submental fat (SMF) reduction. In the phase 3 REFINE trials, adults with moderate or severe SMF who were dissatisfied with the appearance of their face/chin were eligible to receive up to 6 treatment sessions with ATX-101 (2 mg/cm²) or placebo. Primary and secondary endpoints, evaluated at 12 weeks after last treatment, significantly favored ATX-101 supporting its efficacy for reducing SMF and the psychological impact of SMF, and increasing satisfaction with the appearance of the face/chin.

Objectives

To evaluate the efficacy and safety of ATX-101 by treatment session.

Methods

This post hoc analysis used pooled data from the REFINE trials to evaluate efficacy endpoints and adverse events following each treatment session to further characterize the ATX-101 treatment response and safety profile.

Results

In both treatment groups, mean injection volume declined over subsequent treatment sessions, though more markedly in the ATX-101 group. The majority of ATX-101–treated patients achieved a ≥1-grade improvement in SMF within 2 to 4 treatment sessions based on either clinician or patient assessment. Furthermore, 19.1% of ATX-101–treated patients (vs 3.9% of placebo-treated patients) received fewer than 6 treatment sessions owing to patient satisfaction with treatment or lack of sufficient SMF for further treatment. In both treatment groups, the incidence/severity of common injection-site adverse events declined over subsequent treatment sessions.

Conclusions

Although up to 6 treatment sessions were permitted in the REFINE trials, most ATX-101–treated patients achieved an improvement in SMF within 2 to 4 treatment sessions.

Level of Evidence: 3

Injectable DaxibotulinumtoxinA for the Treatment of Glabellar Lines: A Phase 2, Randomized, Dose-Ranging, Double-Blind, Multicenter Comparison With OnabotulinumtoxinA and Placebo

BACKGROUND

Injectable daxibotulinumtoxinA (RT002) is an investigational botulinum toxin Type A in clinical development. It is formulated with a proprietary peptide and offers the potential of a longer acting neurotoxin therapy.

OBJECTIVE

To compare the safety, efficacy, and duration of response of daxibotulinumtoxinA with onabotulinumtoxinA and placebo [www.clinicaltrials.gov NCT02303002].

METHODS

In this Phase 2, randomized, dose-ranging, parallel-group, double-blind, multicenter study, subjects with moderate or severe glabellar lines at maximum frown were randomly assigned to 20U, 40U, or 60U daxibotulinumtoxinA, 20U onabotulinumtoxinA, or placebo. Glabellar line severity was evaluated by investigators and subjects at least every 4 weeks, for at least 24 weeks.

RESULTS

Overall, 268 subjects enrolled. Statistical and clinical superiority were observed for 40U and 60U daxibotulinumtoxinA over 20U onabotulinumtoxinA for a range of efficacy outcomes despite the study not being powered to detect statistically significant differences between these active treatment groups.

CONCLUSION

The 40U dose of daxibotulinumtoxinA was well tolerated (e.g., absence of ptosis) and had the most favorable risk: benefit profile. Compared with 20U onabotulinumtoxinA, it exhibited a significantly greater response rate and a significantly longer duration of response (median of 24 weeks vs 19 weeks; p = .030).

Neurotoxins: Evidence for Prevention

<p>Onabotulinum Toxin A is the gold standard treatment for temporary dynamic rhytid reduction. Clinicians have observed a long-term and preventive benefit for patients beyond muscle relaxation particularly in patients who receive repeated treatments over time. These changes include progressive reduction of rhytides, prevention of dynamic rhytides, and improvements in skin quality. In this brief paper, we review basic science, clinical, and anecdotal evidence that explores a long-term and potential preventive effect of Onabotulinum Toxin A injections.</p> <p><em>J Drugs Dermatol. 2017;16(6 Suppl):s87-90.</em></p>.

The First Detection of Ornithobacterium rhinotracheale in New Zealand

Ornithobacterium rhinotracheale (ORT) has been considered exotic to New Zealand and thus, any samples from poultry suspected of ORT infection are submitted as part of an exotic disease investigation managed by Ministry for Primary Industries (MPI) and subjected to standardized test protocols carried out in the physical containment level 3+ laboratory at MPI's Animal Health Laboratory (AHL). All previous exotic disease investigations concerning ORT produced negative results by bacterial culture and conventional PCR. Following the recent introduction of a real-time PCR for ORT at the AHL, several tracheal wash fluids from backyard chickens ( Gallus gallus domesticus ) were tested positive. This identification constituted the first detection of ORT in New Zealand poultry. As a result, a second premise was investigated with further samples testing positive for ORT by molecular assays. This paper describes the two exotic disease investigations associated with the first detection of ORT in New Zealand poultry and its implications.

Sodium Deoxycholate for Submental Contouring

The chin and jaw line are integral parts of an individual's aesthetic profile, and the presence of submental fat detracts from this and can lead to displeasure with one's facial appearance. While liposuction and cosmetic surgery are regarded as the gold standard in treating submental fat, surgical intervention is not appealing to all patients and has potential surgical complications including longer recovery, and contour irregularities. Despite ample advances in aesthetic medicine to enhance the appearance of the face, very little is available in non-invasive options to reduce submental fat that has been supported by robust evidence. ATX-101, a proprietary formulation of deoxycholic acid that is synthetically derived, has been extensively explored in a vigorous clinical development program that has established the safety and efficacy of the injectable. It has recently received approval by regulatory authorities in Canada (Belkyra™) and the US (Kybella®) for the treatment of submental fat.

ATX-101 for reduction of submental fat: A phase III randomized controlled trial

BACKGROUND

ATX-101, an injectable form of deoxycholic acid, causes adipocytolysis when injected subcutaneously into fat.

OBJECTIVE

We sought to evaluate the efficacy and safety of ATX-101.

METHODS

In this phase III trial (REFINE-2), adults dissatisfied with their moderate or severe submental fat (SMF) were randomized to ATX-101 or placebo. Coprimary end points, evaluated at 12 weeks after last treatment, were composite improvements of 1 or more grades and 2 or more grades in SMF observed on both the validated Clinician- and Patient-Reported SMF Rating Scales. Other end points included magnetic resonance imaging-based assessment of submental volume, assessment of psychological impact of SMF, and additional patient-reported outcomes.

RESULTS

Among those treated with ATX-101 or placebo (n = 258/treatment group), 66.5% versus 22.2%, respectively, achieved a composite improvement of 1 or more grades (Mantel-Haenszel risk ratio 2.98; 95% confidence interval 2.31-3.85) and 18.6% versus 3.0% achieved a composite improvement of 2 or more grades in SMF (Mantel-Haenszel risk ratio 6.27; 95% confidence interval 2.91-13.52; P < .001 for both). Those treated with ATX-101 were more likely to achieve submental volume reduction confirmed by magnetic resonance imaging, greater reduction in psychological impact of SMF, and satisfaction with treatment (P < .001 for all). Overall, 85.7% of adverse events in the ATX-101 group and 76.9% in the placebo group were localized to the injection site.

LIMITATIONS

Follow-up was limited to 44 weeks.

CONCLUSION

ATX-101 is an alternative treatment for SMF reduction.

Clinical Recognition of Melanoma in Dermatologists and Nondermatologists

Background:

The incidence of melanoma is increasing annually in Canada.

Objectives:

This retrospective study was designed to assess the ability of physicians of different specialties to accurately recognize melanoma.

Methods:

Pathology reports of biopsies submitted to Vancouver Coastal Health with clinical diagnoses of melanoma were reviewed (January to July 2013). The clinical diagnoses made by dermatologists, general practitioners and family physicians, and all other specialists were correlated with the final histopathologic diagnoses.

Results:

The dermatologists, general practitioners and family physicians, and all other specialists achieved diagnostic accuracies of 24.75%, 3.52%, and 12.75%, respectively.

Conclusions:

Although the diagnostic accuracy of dermatologists was significantly better than that the other practitioners, the majority of patients with suspicious skin lesions present to family physicians or general practitioners first. Thus, there is considerable value in providing more training and education to nondermatologists, because it can have a meaningful impact on patient care.

Canadian Clinical Practice Guidelines for Rosacea

Rosacea is a chronic facial inflammatory dermatosis characterized by background facial erythema and flushing and may be accompanied by inflammatory papules and pustules, cutaneous fibrosis and hyperplasia known as phyma, and ocular involvement. These features can have adverse impact on quality of life, and ocular involvement can lead to visual dysfunction. The past decade has witnessed increased research into pathogenic pathways involved in rosacea and the introduction of novel treatment innovations. The objective of these guidelines is to offer evidence-based recommendations to assist Canadian health care providers in the diagnosis and management of rosacea. These guidelines were developed by an expert panel of Canadian dermatologists taking into consideration the balance of desirable and undesirable outcomes, the quality of supporting evidence, the values and preferences of patients, and the costs of treatment. The 2015 Cochrane review "Interventions in Rosacea" was used as a source of clinical trial evidence on which to base the recommendations.

Introduction to Fillers

BACKGROUND

Over the last few years, injectable soft-tissue fillers have become an integral part of cosmetic therapy, with a wide array of products designed to fill lines and folds and revolumize the face.

METHODS

This review describes cosmetic fillers currently approved by the Food and Drug Administration and discusses new agents under investigation for use in the United States.

RESULTS

Because of product refinements over the last few years-greater ease of use and longevity, the flexibility of multiple formulations within one line of products, and the ability to reverse poor clinical outcomes-practitioners have gravitated toward the use of biodegradable agents that stimulate neocollagenesis for sustained aesthetic improvements lasting up to a year or more with minimal side effects. Permanent implants provide long-lasting results but are associated with greater potential risk of complications and require the skilled hand of the experienced injector.

CONCLUSIONS

A variety of biodegradable and nonbiodegradable filling agents are available or under investigation in the United States. Choice of product depends on injector preference and the area to be filled. Although permanent agents offer significant clinical benefits, modern biodegradable fillers are durable and often reversible in the event of adverse effects.