BACKGROUNDClinical and ultrasound experience has revealed that after soft tissue injections of the lateral cheek, the filler may displace from the zygoma to the caudal temporal area.OBJECTIVETo obtain more data to provide insight into product distribution when soft tissue fillers are injected in the zygomatic region.METHODSTwo hundred patients were examined with facial ultrasound imaging of the zygomatic and temporal region. Inclusion criteria were simply a positive response on the screening questionnaire as to whether or not they had filler injections placed in their lateral cheek. Control injections were also performed to the zygomatic regions of a body donor and in 10 patients ultrasound-guided.RESULTSA correlation was found between the layers in which filler was detected on the zygoma and where it was ultimately found in the temples. Four different redistribution patterns were observed: (1) migration of filler within the superficial muscular aponeurotic system (SMAS) on the zygoma into the superficial temporal fascia. Migration of filler from the lateral suborbicularis oculi fat to (2) the deep interfacial plane of the temple or (3) to the superficial temporal fat pad; (4) migration from the supraperiosteal layer of the zygoma to the superficial temporal fat pad. Body donor and patients: filler deposits injected on the zygoma were witnessed to shift during injection into the caudal part of the temple.CONCLUSIONSoft tissue filler aliquots may be redistributed into the temples after injections of the lateral side of the zygomatic arch. The displacement follows a distinct pattern depending on the initial layer of injection.

Exceptional patient care requires well-educated, excellently trained physicians and access to the most up-to-date therapies. Dermatologists deliver this type of care daily; however it does not occur in a vacuum as it requires the support of many. With a heavy heart and profound sadness, I note that Dermatology lost one of our great Dermatology supporters with the passing of Charles (Charlie) Stiefel (Fig 1). An icon of industry and a great philanthropic supporter of Dermatology, Charlie and his wonderful wife Daneen showed tremendous generosity that affected many and embodied the meaning of giving back. Charlie’s vision to improve health through innovation and technology; and his support of education and research leaves a legacy. Charlie grew up in Oak Hill, New York, built a home in Catskill, New York, thrived in Miami, Florida, and retired to Raleigh, North Carolina. An Eagle Scout, a graduate of Yale University (1972), and valedictorian of his class at Albany Law School (1975), Charlie served as president and eventually Chairman and CEO (2001) of Stiefel Laboratories, Inc. The origin of Stiefel Laboratories dates back to 1847 in Germany, and Charlie was the sixth generation Stiefel to lead the company. Charlie led the company until it’s sale to GlaxoSmithKline (2009). Under Charlie’s leadership, Stiefel Laboratories developed, patented, and distributed dermatology products in more than 100 countries and was considered the largest independent manufacturer of dermatological products. Charlie's published book, Skin Saga, recounts Stiefel Laboratories and Stiefel family stories. Charlie helped many causes and was deeply passionate about curing cancer and skin disease. He earned the Ernst & Young Florida Entrepreneur of the Year Award (2006) and was honored as the South Florida Business Journal’s Ultimate CEO Awardee (2009). He received the South Florida Dermatology Foundation Lifetime Achievement Award (2003), the American Academy of Dermatology’s Distinguished Service Award (2007), the American Skin Association Distinguished Service to Humanity Award (2015) and several other lifetime achievement awards. He was the only nonphysician to be inducted into the inaugural class of the Dermatology Hall of Fame. In 2008, Charlie and Daneen endowed the Stiefel Family Chair in Dermatology in our Department at the University of Miami. As the first Chairholder, I (R.S.K.) felt a special connection to Charlie, Daneen, their sons Brent and Todd, and their families. Their support helped advance research, helped train over one hundred dermatology residents, helped educate thousands of medical students, and helped advance the care of countless patients. Charlie also supported the endowed William Eaglstein, MD, Chair in Wound Healing, and the ongoing efforts toward endowing the Lawrence Schachner, MD, Chair in Pediatric Dermatology. Charlie’s philanthropic largess extended well beyond University of Miami to many institutions, to Dermatology organizations, and to cancer research. Charlie was a modern-day Renaissance man. An accomplished movie producer, Charlie also loved and played music, and was a crazed sports fan. Most of all he was a wonderful family man and great friend. He shared his love, his passion, his personality and his time with his children, grandchildren (Cole, Amber, Sienna, and Tyler), family, and friends. All who knew him called him a friend. Dermatology owes Charlie a debt of gratitude. He will be dearly missed but never forgotten. None disclosed.

Background: Cosmetic procedures with lasers, nonenergy devices, and injectables are increasing in popularity among patients with skin of color. Published algorithms address measures to reduce side effects related to aesthetic procedures; however, none focus on reducing adverse events in skin of color. Methods: An expert panel of dermatologists and plastic surgeons conducted face-to-face and online meetings to develop an algorithm for measures before, during, and after using aesthetic devices (energy and nonenergy-based) and injectable treatments based on the best available evidence for skin of color. Published algorithms and literature searches for aesthetic procedures provided guidance for the current algorithm. A modified Delphi method was used to reach a consensus to apply outcomes of literature searches, along with expert opinion, resulting in the current algorithm. Results: The four sections of the algorithm outline an approach to optimize outcomes with specific before, during, and after procedure considerations. Pre-procedural consultation includes the development of a specific treatment plan based on individual patient goals and risk profile (including history and signs that may predict a higher risk for pigmentary or scarring complications). Before the procedure, sun avoidance and sunscreen use are emphasized; herpes simplex virus 1 prophylaxis and bleaching agents are administered if indicated. During the procedure, skin cleansing products are addressed, along with judicious techniques to minimize unintended cutaneous injury or inflammation. Post-procedural sunscreen and gentle skincare that may include skin-lightening agents or formulations designed to prevent infection and promote optimum healing are advised. Conclusions: The algorithm strives to optimize treatment outcomes for patients with skin of color by providing their physicians with guidance on measures before, during, and after office-based medical aesthetic procedures.

BACKGROUND:Nonenergy and injectable treatments are frequently used for facial rejuvenation. Many publications have addressed methods to reduce adverse events related to the procedure; however, no algorithm exists on temporol before, during, and after measures for nonenergy and injectable treatments.METHODS:A panel of dermatologists and plastic surgeons convened a virtual meeting to develop an algorithm for measures before, during, and after nonenergy and injectable treatments based on the best available evidence and the panelists' experience and opinion. For the project, a Delphi method was applied, which was adapted from face-to-face meetings to a virtual meeting to discuss the outcome of literature searches to reach a consensus on the algorithm.RESULTS:The four sections of the algorithm address measures for optimizing outcome before, during, and after the procedure. Prevention includes avoiding excessive sun exposure and the use of a broad-spectrum sunscreen with an SPF 30 or higher. Before nonenergy-based and injectable treatments, the avoidance of alcohol, retinol peels, and agents such as acetylsalicylic acid and non-steroidal anti-inflammatory drugs, amongst other agents, is advised. Isopropyl alcohol, chlorhexidine, or hypochlorous acid (HOCl) prepare the skin before nonenergy and injectable treatments. The advisors recognize HOCL as particularly useful as it is active against bacterial, viral, fungal microorganisms and biofilm. The literature is inconsistent about the use of topical agents and skincare before and after the procedure.CONCLUSIONS:The algorithm aims to support an optimal treatment outcome for their patients, providing physicians with guidance on measures before, during, and after nonenergy and injectable treatments. J Drugs Dermatol. 2021;20:11(Suppl):s3-10.

The chin is a frequently overlooked feature in facial appearance and rejuvenation. The lower one-third of the face, of which the lips and chin are the most prominent components, should be equal in height to each of the upper and midface areas. When the chin is anatomically small (congenital), or has receded because of bone reabsorption (age), the balance and proportion of overall appearance suffers. This study by Beer and colleagues in the January issue evaluates the safety and efficacy of VYC 20L, a high G prime, mixedmolecular weight hyaluronic acid (HA) injectable filler previously evaluated for midface correction. The 144 active participants in the study received a median total injection volume of 2.8 mL (combined volume of initial injection and touch up at 1 month). The primary endpoint was a 1-point correction of a 5-point assessment scale at 6 months. That outcome was achieved by 56.3% of the participants, which the authors stated was lower than expected. They attributed it to the modest volumes injected and the fact that only two-thirds of the active patients received a touch up. The volume used was certainly larger thanmight be used inmost clinical settings, especially in lieu of the risk of mental artery injection which has been reported. Perhaps a higher G prime filler such as calcium hydroxyl apatite might retain its correction longer given the high motion of the area associated with eating and speech. Only a moderate number of adverse events (AE’s) were encountered, mostly injection related, and resolved quickly. Less AE’s were experienced when cannulas were used in place of needles. Only 2 serious AE’s occurred and resolved with treatment by the study’s end. No late onset nodules were encountered during the 2 years of the study, a problem known to occur with this type of the HA filler in the past. In summary, this study established the safety and efficacy of VYC 20L in addressing the chin as an important aspect of facial aesthetics.

Department of Dermatology, Miller School of Medicine University of Miami, Miami, Florida The author has indicated no significant interest with commercial supporters.

Department of Dermatology and Cutaneous Surgery Miller School of Medicine University of Miami, Miami, Florida The author has indicated no significant interest with commercial supporters.

This is a disturbing, well-researched article that was provoked by a presumptive case of intracranial penetration while restoring temporal volume with injectable hyaluronic acid. The injector reportedly used a blunt cannula guided to the floor of the fossa and unintentionally penetrated the cranial cavity. Fortunately, no immediate or delayed catastrophic consequences occurred. The evidence is compelling but not absolute and given the remainder of the data provided by measuring the force of penetration required in fresh cadavers and the reproducibility of being able to penetrate the bony skull, one would have to give the authors the benefit of the doubt. There are questions that go unanswered, however, that relate to the angle of approach, the exact point of penetration, the variation of instruments such as smaller gauge versus large-gauge needle or cannula, and perhaps the most poignant, the skill, and experience of the injector. The authors state that “The indentation device used in our study as well as the selected cannulae for measuring the mechanical properties was both blunt and thick in diameter (1.25 mm). It can be suspected that using sharp devices or devices with a smaller diameter, the applied forces can surpass the bony stability of the temporal fossa easier, and the risk for intracranial penetration is higher than that in our tested scenarios. From the clinical perspective, this study tries to create awareness for the potential risk of accidental intracranial penetration.” It is this type of question that challenges the relationship of the experiments performed to clinical settings. It also does not account for the thickness and resistance of the periosteum in a living individual. In the author’s experience, most injectors who are experienced have a “light touch” and have a familiarity with the anatomy enough to be appropriately cautious especially in the high-risk areas. Nonetheless, the authors do suggest a previously unexpected adverse event of which all practitioners should be cognizant. In recent articles, physicians were cautioned about blindness and stroke as a consequence of filler injections in the periocular area. Furthermore, there have been recent publications identifying the ideal location for safe temporal injection. This article adds additional information to the database which will further guide the method of injection.

A complete approach to facial rejuvenation includes restoration of the skin's surface, relaxation of muscles that contribute to hyperkinetic movement, revolumization, and repositioning/recontouring of descended tissues and fat pads. After receiving 510(k) clearance from the US Food and Drug Administration (FDA) in 2015, the Silhouette InstaLift™ absorbable suspension suture became the only available non-surgical technique for repositioning of facial tissue. In January 2017, a consensus paper presented a review of the literature on the efficacy and safety of absorbable suspension sutures and provided information on treatment procedures. Since that time, the clinical experience of the authors has further shaped their treatment practices, highlighting the need for additional guidelines to support an optimal treatment approach. This update will expand upon the 2017 consensus paper on the safety and efficacy of absorbable suspension sutures and provide guidance for obtaining consistently high patient satisfaction with the procedure. Recommendations are based on the extensive clinical experience of expert physicians with absorbable suspension sutures over the past 2.5 years. Here, the authors provide guidance on full face assessment and treatment to support maximum benefit and provide patient selection and procedural recommendations. In addition, the authors stress the benefits of the dual mechanisms of action within the absorbable suspension suture: the immediate lift and volumizing over time that together lead to the outcome of recontouring. J Drugs Dermatol. 2018;17(6):647-655.

South Beach Dermatology, Miami Beach, Florida The authors have indicated no significant interest with commercial supporters.

BACKGROUND: Signs of facial aging include wrinkles, loss of subcutaneous volume, decreased tone, texture, and sagging of the skin. The objective of this review is to determine whether facial suspension absorbable sutures are a safe and effective modality for facial rejuvenation. METHOD: A group of US plastic surgeons and dermatologists who practice medical aesthetics convened to review evidence obtained from literature searches and to reach a consensus on clinical practice guidelines for the use of facial absorbable suspension sutures. RESULTS: Currently, there are different types of lifting sutures available. Absorbable, facial suspension sutures allow for superior repositioning of tissue along a vector line together with the added benefit of volumization of the area. These benefits are for patients who have moderate facial aging and require treatment beyond the use of injectable products only. CONCLUSIONS: Treatment with absorbable facial suspension sutures, when performed properly, is associated with minor and infrequent complications and offers a beneficial clinical alternative to traditional facial rejuvenation techniques. J Drugs Dermatol. 2017;16(7):661-666. .

Botulinum toxin type A (BoNTA) is currently approved by the Food and Drug Administration (FDA) in the United States for the treatment of glabellar rhytides, strabismus, primary axillary hyperhidrosis, blepharospasm, hemifacial spasm, cervical dystonia in adults, and, most recently, chronic migraine, overactive bladder, upper/lower limb spasticity, and crow's feet. Small studies and case reports in the literature have demonstrated positive results using BoNTA for the treatment of challenging painful and pruritic conditions, dyshidrotic eczema, inverse psoriasis, Hailey-Hailey and Darier's disease, facial flushing, ischemic digits, parotid duct injury, and more. Patients with painful disorders in areas of medicine outside of dermatology have been treated with BoNTA. Recent studies have shown promise for the treatment of arthritic joint pain. BoNTA is also approved to treat primary axillary hyperhidrosis. Hyperhidrosis has been shown to exacerbate several dermatologic conditions.

BACKGROUNDCross-linked hyaluronic acids (HAs) with varying characteristics and formulations are available. Despite the popularity of HA, limited studies compared the effectiveness of monophasic monodensified hyaluronic acid (MMHA) and biphasic nonanimal stabilized hyaluronic acid (BHA) products in correcting nasolabial folds (NLFs) in the Asian population.OBJECTIVEThis double-blinded, randomized research aimed at evaluating the outcomes of MMHA and BHA products in treating Asian NLFs.MATERIALS AND METHODSSubjects aged between 18 and 65 years with moderate-to-severe NLFs were randomized to receive MMHA or BHA treatment. A touch-up treatment with the same product was performed at the 4-week follow-up, if needed. The effectiveness was evaluated for 24 weeks by masked investigators. All adverse events were recorded for safety evaluation.RESULTSTwenty-five subjects in the MMHA Group and twenty-four subjects in the BHA Group finished 24-week follow-up. Results showed that subjects from both groups obtained satisfactory outcome in NLF correction. A lower amount of MMHA was required to achieve a similar result as that of BHA (p< .01). Both HA products maintained the effectiveness at the end of the 24-week follow-up.CONCLUSIONBoth MMHA and BHA are effective for correcting NLF in Asian patients, producing satisfactory results. Monophasic monodensified hyaluronic acid provides similar satisfaction to BHA while requiring less injection volume.

This chapter contains sections titled: Introduction Physiology and pharmacology Indications and techniques Complications Conclusions References

BACKGROUND:Injection of dermal fillers is one of the most commonly performed cosmetic procedures. Serious complications from fillers are rare but potentially devastating to patients and physicians. Skin necrosis, such as nasal alar necrosis, is one of the most feared serious complications of dermal fillers, but there is a paucity of literature on the incidence of such events, as well as potential treatment options.METHODS:We present a review of the literature and three cases of nasal alar necrosis after dermal filler injection.CONCLUSION:Nasal alar necrosis associated with dermal filler injection is a rare event. Proper technique and recognition of risk factors may reduce the incidence of this complication. Physicians should be aware of early intervention and treatment options should impending necrosis become apparent.