JAN-FEB 2019

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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Injectors who want to help patients reduce their forehead lines without signifi cantly lowering brow height may benefi t from a study published in the No- vember 2018 issue of Plastic and Reconstructive Surgery. Authors Samer Jabbour, MD, et al, evaluated three different injection patterns to determine the effect on forehead lines and brow positioning. Forty-fi ve patients were separated into three equal groups. The re- searchers injected the frontalis using either a V-pattern (group 1), a middle horizontal pattern (group 2) or a high horizontal pattern (group 3). They used standardized preinjection and postinjection photographs to measure eyebrow positioning and validated photonumeric scales to assess the forehead lines. Two weeks postinjection, the three techniques had improved the forehead lines at rest and with contraction, but the forehead lines with contraction were more improved in group 1 (V-pattern) compared with both groups 2 and 3. The brow was lower at all measured positions except the lateral brow edge in all three groups, but the middle horizontal pattern lowered the eyebrow more than the high horizontal injection pattern. BEST PR ACTICES © GETTY IMAGES 12 JANUARY/FEBRUARY 2019 | Med Esthetics There is strong evidence to support the use of diluted (1:1) and hyperdiluted (1:2 or greater) calcium hydrox- ylapatite (CaHA, Radiesse) for skin laxity, according to a global panel of 14 aesthetic physicians, with the most promising outcomes occurring in the décolletage. The panel reviewed the literature and their own experiences using diluted and hyperdiluted CaHA to stimulate neocol- lagenesis and neoelastogenesis on the face and body in an effort to provide guidelines and develop best practice recommendations. Their preparation guidelines recommend at least 20 passes between syringes to ensure product homogeneity and immediate injection as the product separates quickly. Due to the fast separation, the consensus panel recom- mends that the injector perform the dilution rather than a nurse practitioner or assistant. The guidelines, published in Dermatologic Surgery (No- vember 2018), cover treatments in areas ranging from the mid- to lower face to the upper arms, buttocks and upper legs. For the most common treatment areas, their treat- ment guidelines include: Face. Diluted ratio of 1:1 injected in the immediate subdermal plane and fanned across the cheeks and jawline to improve laxity in the mid- and lower face. They offer no recommendations for use in the temple or forehead. Neck and Décolletage. Hyperdiluted CaHA (1:2 to 1:4) effectively tightens skin in the neck for individuals with mild laxity. In the décolletage, they recommend hyper- diluted CaHA (1:2 to 1:3) for the correction of mild laxity and photodamage. Cellulite. Subdermal injection of diluted CaHA (1:1) using a vector-fanning approach stimulates neocollagen- esis. Injecting the CaHA immediately after treatment with MFU-V (Ultherapy) offers signifi cant improvement in the appearance of cellulite. DILUTED CAHA FOR SKIN TIGHTENING Industry-reported pain levels during energy-based device treatments are often signifi cantly lower than what patients report. Understanding this discrepancy can help clinicians set more realistic expectations and improve patient satisfac- tion, according to a study published in Lasers in Surgery and Medicine (October 30, 2018). Researchers Lauren M. Bonati, MD, et al, of Skincare Physicians in Chestnut Hill, Massachusetts, collected average and mode pain scores from the records of a previously conducted clinical trial investigating a radiofrequency micronee- dling device at three different settings. Subject-reported pain scores and verbal pain descriptors from the device manual and trial protocol were translated onto validated pain scales—the Numerical Rating Scale (NRS) and the Verbal Rating Scale (VRS)—for comparison. After reviewing patient-reported pain scores from 30 subject charts, the authors found that the average procedural pain scores for three different device settings were 5.3, 6.7 and 4.6 out of 10. The mode pain score was 6 out of 10. This corresponded to a 5–6 and 7–8 on the NRS, respectively, and classifi cation as "painful but bearable" and "considerable pain" on the VRS. Industry-sourced pain levels—gathered from device manuals—translated to a 2–4 on the NRS and classifi cation as "little pain" on the VRS. The researchers concluded, "Physicians should be wary of manufacturer materials or anecdotal evidence that might mislead patients and cause undue physiological or emo- tional stress." Setting Pain Expectations for Energy-Based Devices FOREHEAD INJECTIONS AND EYEBROW POSITIONING

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