BACKGROUND:Glabellar lines (GLs) are facial furrows that can become aesthetically displeasing because of aging and repetitive muscle contractions. OBJECTIVES:This dose-escalation study evaluated the safety and efficacy of trenibotulinumtoxinE for improving moderate-to-severe GL. METHODS:Adult participants were randomized 3:1 in each of 5 dosage cohorts to receive trenibotulinumtoxinE or placebo as 5 intramuscular injections into the glabellar complex on Day 1, with in-clinic visits through Day 42. The primary endpoint was improvement response (≥2-grade investigator-rated improvement in Facial Wrinkle Scale at maximum frown) assessed cumulatively through Day 7. Treatment satisfaction was assessed by responses of very satisfied or mostly satisfied on Facial Line Satisfaction Questionnaire Items 4 and 5 at Hour 24 and Day 7. RESULTS:The primary objectives were met: all dosage cohorts showed greater efficacy for trenibotulinumtoxinE than placebo, as measured cumulatively through Day 7 (all P < .01, unadjusted). Improvements were seen among Cohort 5 (highest dosage) as early as 8 h postintervention (16.1%, noncumulative responder rate); by Hour 24, the responder rate was 41.9%, with peak efficacy (93.3%) at Day 7 and a decline to 33.3% by Day 14 through Day 42. Responder rates increased with dose (Cohort 1, 40.6%; Cohort 5, 96.8%). At Day 7, more Cohort 5 participants than placebo participants were satisfied with natural look and effect of treatment. No serious adverse events were reported. No events were consistent with local diffusion or distant spread of toxin. CONCLUSIONS:TrenibotulinumtoxinE was efficacious and well tolerated across a range of doses in treating moderate-to-severe GL. LEVEL OF EVIDENCE: 1 (THERAPEUTIC):For image description, please refer to the figure legend and surrounding text.

Lipedema is a painful, chronic and progressive disorder of subcutaneous adipose tissue characterized by disproportionate, symmetrical fat accumulation in the extremities—typically the legs and less often the arms—while sparing hands and feet. It is clinically distinct from obesity and lymphoedema, affects almost exclusively women, and often exacerbates during hormonal transition phases. This paper proposes a unifying pathophysiological concept in which lipedema reflects a regenerative imbalance of adipose tissue. A genetically and estrogen-modulated increase in endothelial permeability (“leaky vessels”) is suggested to activate perivascular/mural adipose-derived stem cells (ADSCs), thereby initiating coupled angiogenesis and adipogenesis. The stromal vascular fraction (SVF) is described as a central mediator, with SVF-derived extracellular vesicles and characteristic microRNAs promoting adipocyte hyperplasia and hypertrophy and leading to large, metabolically less active adipocytes. The organism attempts to counterbalance this surplus through inflammatory activation of mast cells and macrophages; however, inefficient clearance of excess adipocytes (including “crown-like” structures) sustains inflammation and pain. Progressive adipose expansion may compress lymphatic capillaries and precollectors, resulting in dermal and subdermal lymphatic congestion and contributing to oedema and symptom progression. Increased aromatase activity and local estrogen availability are discussed as additional amplifiers of adipogenesis and inflammatory remodeling. Finally, lymphatic-sparing liposuction is outlined as a mechanistically plausible intervention that can reduce tissue pressure, improve lymphatic drainage, and alleviate key symptoms.

BACKGROUND:Lipedema is a chronic disorder characterized by disproportionate accumulation of subcutaneous fat, most commonly affecting the extremities, and is associated with pain, inflammation, and fibrosis. Effective medical therapies are lacking, and liposuction remains the primary treatment. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrate metabolic and anti-inflammatory effects, but their role in lipedema remains unclear. OBJECTIVE:To evaluate the potential role of GLP-1-based therapies in the management of lipedema. METHODS:A literature search of peer-reviewed articles published through March 2026 was conducted using PubMed. Search terms included "lipedema and GLP-1" and related combinations of GLP-1 RAs, tirzepatide, inflammation, and insulin resistance. Relevant studies in lipedema, obesity, and fibroinflammatory conditions were included. RESULTS:Thirteen publications were identified. Two specifically evaluated GLP-1 RAs in lipedema, with only 1 providing direct patient evidence. A small uncontrolled case series of 5 patients treated with exenatide reported improvements in pain and limb volume. Translational evidence suggests that GLP-1 RAs, particularly tirzepatide, may influence inflammatory and fibrotic pathways relevant to lipedema. CONCLUSION:To date, GLP-1 RAs have not been proven to have direct effects on lipedema progression. However, given their known role in weight reduction and metabolic improvement, they may provide benefit as adjunctive therapies.

Lipedema is a chronic adipose tissue disorder characterized by disproportionate and often painful enlargement of the extremities, occurring predominantly in women. Despite increasing clinical recognition, the underlying pathophysiology remains incompletely understood and is likely multifactorial. Existing evidence suggests contributions from vascular alterations, adipose tissue remodeling, inflammatory activation, hormonal influences, and lymphatic dysfunction. This review proposes a hypothesis-generating integrative framework in which lipedema may reflect a regenerative imbalance of subcutaneous adipose tissue. Within this model, genetically and hormonally modulated endothelial permeability could promote activation of perivascular adipose-derived stromal/stem-cell niches and stromal vascular fraction signaling pathways, thereby facilitating coupled angiogenesis and adipogenesis. Progressive adipocyte hyperplasia and hypertrophy may subsequently contribute to inflammatory remodeling, pain generation, and secondary impairment of dermal and subdermal lymphatic drainage. The proposed framework attempts to integrate clinical, histological, imaging, molecular, and endocrine observations into a biologically coherent conceptual model. At the same time, the review emphasizes the current limitations of the available evidence, the heterogeneity of lipedema phenotypes, and the ongoing controversies regarding disease progression, obesity overlap, and the relative role of lymphatic dysfunction. Finally, the potential mechanistic rationale of lymphatic-sparing liposuction is discussed in the context of tissue decompression, restoration of lymphatic transport, and interruption of persistent adipose remodeling. The model presented here should be interpreted as a hypothesis-generating conceptual scaffold requiring prospective validation. Importantly, the present framework should be interpreted as a biologically plausible and hypothesis-generating conceptual model rather than a definitive mechanistic doctrine. Several proposed interactions remain associative and require prospective biological validation.

BACKGROUND:Post-Mohs surgical wounds may be painful, slow to heal, and prone to scarring. Comparative data for advanced wound care biomaterials in this setting are limited. OBJECTIVE:The aim of this study was to evaluate the safety of a flowable, synthetic, microporous annealed particle (MAP) wound matrix versus hydrocolloid dressing and explore effects on pain, wound healing, and scarring. MATERIALS AND METHODS:In this multicenter randomized study, a flowable synthetic MAP wound matrix was applied immediately after surgery and compared with a hydrocolloid dressing (control). The primary endpoint was safety. Exploratory endpoints included pain, Wound Bed Score, time to granulation, time to closure, and scarring at 6 months. RESULTS:Forty patients were randomized to receive the wound matrix (n = 26) or control (n = 14). The primary safety endpoint was met. Pain was low in both groups and numerically lower in the matrix group. The matrix group achieved a Wound Bed Scoreof 12 or greater 14 days earlier than control. Granulation and closure times were similar. Scarring scores were significantly better in the matrix group (p = .0027). CONCLUSION:The MAP wound matrix was safe, did not delay healing, improved early wound bed quality, and reduced scarring versus standard of care.

Objective:Dermatologists regularly encounter patients having expanded fields with numerous actinic keratosis (AK) lesions on the face and scalp. Field-directed red light photodynamic therapy (PDT) is a well-established treatment, yet published data on the safety of PDT on large areas is scarce. We aimed to evaluate the safety and tolerability of red light PDT in treating expanded AK fields on the face and scalp. Methods:This was a non-randomized, open-label, multicenter study. After lesion preparation, 6g of 10% aminolevulinic acid (ALA) gel were applied to the treatment field (60 cm2) and incubated for three hours under a light-blocking, occlusive dressing before 10-minute illumination with a red light lamp (~635nm, 37 J/cm2). Safety and tolerability were assessed throughout the study. Results:All participants (n=100) had adverse reactions. No previously unknown effects, serious adverse events, or deaths were reported. The most frequent application site reactions were pain/burning (96.0%), exfoliation (87.0%), and erythema (86.0%). Most treatment-emergent adverse events were of mild to moderate severity and lasted slightly longer compared to those experienced after treatment of smaller areas. The mean maximum pain during PDT was 7.4±2.1 on an 11-point numeric rating scale. A transient increase in blood pressure on the day that PDT was performed was not clinically significant. Limitations:Although the allowed use of pain-reducing measures might have influenced evaluation of pain, it reflects how the procedure is managed in current practice. Concklusion:PDT with 10% ALA gel and red light illumination on an expanded treatment field was generally well tolerated.

Background: Nasal defects after skin cancer excision can often be healed by second intention in certain circumstances. Objective: We aim to demonstrate the utility of bovine collagen xenografts in supplementing second-intention healing of a variety of nose surgical defects. Results: Thirty-nine patients underwent Mohs micrographic surgery of the nasal tip (33%), ala (23%), dorsum (31 %), sidewall (10%), and root (3%) with the application of bovine collagen xenograft. The average defect size was 1.89 cm' (0.36 - 75 cm2). The average time to re-epithelialization was 33 days (range, 11 - 60 days) at a rate of 19.4 days to healing per cm' of defect size, which represented an improved time to reepithelialization of over 40% compared to historical controls of second intention healing. Cosmetic outcomes were outstanding or acceptable in 77% of the cases. Conclusion: Bovine collagen xenografting is a safe and effective method to enhance the second intention of healing Mohs excision defects of the nose, with overall excellent cosmetic results.

BACKGROUND:OnabotulinumtoxinA (onabotA) treatment of prominent platysma muscles demonstrates a safety profile consistent with other onabotA aesthetic indications and effectively improves the appearance of vertical neck bands and jawline definition. The authors evaluated the safety and efficacy of repeat onabotA treatment for improving the appearance of moderate to severe platysma prominence. METHODS:Participants received up to 4 onabotA treatments administered a minimum of 3 months apart, including treatment with onabotA or placebo in the double-blind lead-in study. RESULTS:All treatment-emergent adverse events related to study treatment were mild in severity with no observed trends across treatment cycles. Four participants reported 6 adverse events of special interest, including dysphagia (4 events) and facial paresis (2 events). All were mild in severity with no evidence of distant spread of toxin; almost all resolved by study end and none resulted in discontinuation. The percentages of participants achieving a one-grade or better improvement at maximum contraction on day 14 for each treatment cycle were 83.6%, 92.0%, 90.0%, and 98.0% as assessed by clinicians, and 82.5%, 90.4%, 87.0%, and 94.0% as assessed by participants. CONCLUSION:Repeated onabotA treatment is well tolerated and improves platysma prominence over the course of multiple treatment cycles.

BACKGROUND:Surgical wounds confined to the vermilion lip and superficial orbicularis musculature can be allowed to heal by second intention with good aesthetic and functional results. Historically, defects extending onto the cutaneous lip or into the deeper orbicularis musculature have generally required more extensive repairs with local flaps to avoid cosmetic distortion or functional issues. We aim to demonstrate the utility of bovine collagen xenografts to augment second intention healing of surgical defects on the lip, including those defects extending into the cutaneous lip and musculature. TYPE OF STUDY:Retrospective observational study with historical control. RESULTS:Twenty-nine patients with 31 tumors underwent Mohs surgery on the lip, with most wounds extending into the orbicularis oris musculature (65%) and onto the cutaneous lip (65%). The average defect size was 2.8 cm2 (range, 0.7-6.3 cm2). The average time to re-epithelialization was 29.7 days, with a rate of 10.2 days per cm2 of defect size, which was faster than historical controls of second-intention healing. Cosmetic outcomes were rated as acceptable to outstanding in 92% of cases. CONCLUSION:For wounds on the vermilion lip, including those extending onto the cutaneous lip and into the orbicularis musculature, bovine collagen xenografts are an effective adjunct to second-intention healing with good cosmetic and functional outcomes. J Drugs Dermatol. 2025;24(3):270-274. doi:10.36849/JDD.8570.

BACKGROUND:Surgical procedures remain the gold standard for treating basal cell carcinoma (BCC), although commonly associated with cosmetic defects. The demand for noninvasive alternatives remains high. OBJECTIVE:To determine efficacy and safety of red light photodynamic therapy (PDT) with 10% 5-aminolevulinic acid (ALA) gel vs vehicle for treatment of superficial BCC. METHODS:This randomized, double-blind, vehicle-controlled, pivotal phase III study was conducted at 21 centers in the US. Eligible participants had ≥1 naïve superficial BCC and received 1-2 PDT cycles (2 PDTs each cycle) followed by clinical and histological assessment 12 weeks after start of the last PDT cycle. RESULTS:Of 187 randomized participants, 145 received PDT with 10% ALA gel and 42 with vehicle. Histological clearance was 75.9% with 10% ALA gel vs 19.0% with vehicle (P < .0001). Clinical clearance was 83.4% with 10% ALA gel vs 21.4% with vehicle (P < .0001). A total of 88.1% of participants treated with 10% ALA gel rated the esthetic outcome as very good or good. No previously unknown adverse events occurred. LIMITATIONS:Few participants with lesions on face/scalp; to date, a 60-month follow-up is still ongoing. CONCLUSION:10% ALA gel showed significantly higher clearance rates than vehicle with unproblematic safety and positive esthetic outcome.

The anchor or Peng flap, first described in 1987, has not been comprehensively discussed in the literature since 2008. The anchor flap is worth revisiting as a useful advancement-rotation flap for medium-sized defects of the distal nose. More recent variations to the flap design incorporate medial cheek advancement and allow for versatility in its use for wide defects of the nasal tip, supratip, and dorsum. The anchor flap is a suitable reconstructive option for defects for which the bilobed/trilobed flap, dorsal nasal rotation flap, or interpolated flap would be considered. We review various designs of the anchor flap and discuss how it can be considered in the modern reconstructive paradigm.

The history of botulinum toxin dates back to the late 1700s, when food preparation, storage, and later canning practices led to outbreaks of botulism across Europe and the United States. It is from these initial incidents that the remarkable discovery of botulinum toxin was eventually made, sparking over 200 years of further scientific inquiry and medical innovation. To date, 6 botulinum toxin products have been commercialized in North America with numerous indications across the specialties of ophthalmology, neurology, urology, dermatology, plastic surgery, and otolaryngology. This article traces the key moments and important players in the remarkable journey of this biologic poison and wonder drug.

Background: Amid a movement toward value -based healthcare, increasing emphasis has been placed on outcomes and cost of medical services. To define and demonstrate the quality of services provided by Mohs surgeons, it is important to identify and understand the key aspects of Mohs micrographic surgery (MMS) that contribute to excellence in patient care. Objective: The purpose of this study is to develop and identify a comprehensive list of metrics in an initial effort to define excellence in MMS. Methods: Mohs surgeons participated in a modified Delphi process to reach a consensus on a list of metrics. Patients were administered surveys to gather patient perspectives. Results: Twenty-four of the original 66 metrics met final inclusion criteria. Broad support for the initiative was obtained through physician feedback. Limitations: Limitations of this study include attrition bias across survey rounds and participation at the consensus meeting. Furthermore, the list of metrics is based on expert consensus instead of quality evidence -based outcomes. Conclusion: With the goal of identifying metrics that demonstrate excellence in performance of MMS, this initial effort has shown that Mohs surgeons and patients have unique perspectives and can be engaged in a data -driven approach to help define excellence in the field of MMS. ( J Am Acad Dermatol 2024;90:798805.)