Aem - 2-2022
Aem - 2-2022
aestheticmedicinejournal.org
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EPub 15/07/2022
II
Aesthetic Medicine / Volume 8 / Nº 2 / April/June 2022
Contents
Original Article
Forehead contouring with fillers: early experience with 18 consecutive cases
Verega Grigore, Giovanni Francesco Nicoletti, Nicola Zerbinati, Samuel Staglianò, Pierfrancesco Bove,
Romolo Fragola, Raffaele Rauso pag 11
Original Article
The art of aesthetic neuromodulation and facial perception
Meghann M. Reller, Nancy Bredenkamp, Cathy Carrico pag 24
Original Article
Facial aging in patients with schizophrenia
Tal Friedman, Avshalom Shalom, Alex Aviv, Yoram Barak, Yonit Wohl pag 32
Case report
Clinical and histochemical response to an automated microneedling therapy in the
treatment of traumatic scars
Inas Shaker, Hisham Ali Shokeir, Nevien Ahmed Sami, Sara Bahaa Mahmoud, Rana Fathy Hilal, Safinaz Salah EL Din Sayed,
Samia Esmat pag 37
Case report
Evaluation of the beneficial impact of atopic dermatitis treatment with high- and low-
molecular-weight hyaluronic acid hybrid stable cooperative complexes: a case report
Gabriel Siquier-Dameto pag 45
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training needs and priorities of male and female surgeons and
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Journal article – in print - more than 6 authors Fukushima H, Cureoglu S, Schachern P, et al. Cochlear changes
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IX
INTERNATIONAL SOCIETIES
and NATIONAL SOCIETIES OF AESTHETIC MEDICINE
INTERNATIONAL SOCIETY OF AESTHETIC MEDICINE (UIME) Irakli Abashidze str. 77, Tbilisi 0162 - Georgia
Via Monte Zebio, 28 - 00195 Rome, Italy [email protected]
President: E. UGREKHELIDZE
Honorary President: J. J. LEGRAND (France)
INDIAN SOCIETY OF AESTHETIC MEDICINE
President: B. MILLER KOBISHER (Mexico) E-52/Basement/ Greater Kailash-Il, New Delhi-110048
Vicepresident: H. SUBASI (Turkey) [email protected] - https://aestheticindia.in/
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X
Original Article
1Head of Plastic and Reconstructive Microsurgery. Nicolae Testemitanu State University of Medicine and
Pharmacy, Chisinau, Moldova
2Rector of University of Campania “Luigi Vanvitelli”, Naples, Italy
3Head of Dermatology. Insubria University, Varese, Italy
4Resident in Maxillo-Facial Surgery. Maxillo-Facial Surgery Complex Unit. “Luigi Vanvitelli” University
Hospital. Naples, Italy
5Aesthetic Surgeon in private practice. Milan, Italy
6Professor in Maxillo-Facial Surgery. Maxillo-Facial Surgery Complex Unit. “Luigi Vanvitelli” University
Hospital, Naples, Italy
Abstract
Introduction: forehead contouring is a surgical procedure usually performed to reduce frontal bossing in males. Non-
surgical procedures, such as filler injections, in selected cases, could be an alternative to surgical forehead recontouring,
improving the aesthetic of the forehead and achieving a more convex appearance of the upper third. Moreover, by
reducing the perception of supraorbital bossing, it can also be performed as a procedure to camouflage and deal with
the process of forehead aging. Authors describe their early experience in frontal contouring with fillers.
Material and methods: this is a retrospective study that takes into account all the forehead contouring procedures
performed from January 2014 to January 2019. Eighteen patients, ages ranging from 26 to 56 years old, were treated
with hyaluronic acid or calcium hydroxyapatite-based filler injections.
Results: a VAS and a Pain scale were submitted to all the patients in order to evaluate the result achieved, and the pain
felt in performing the procedure. At the end of every procedure for each case, patients experienced redness and surface
irregularities which resolved themselves within 48 hours. No Ecchymosis was ecorded. During the follow-up period, in
one case, a nodule secondary to the CaHa injections was recognized and surgically excised.
Conclusion: although there are several limitations regarding this study, outcomes of the present case series suggest that
a non-surgical contouring of the forehead with the use of fillers could be another possible indication for these medical
devices, although a filler specifically developed for forehead contouring, has yet to exist. Larger, blinded, and controlled
studies are required to support the effectiveness of this technique.
Keywords
Forehead, filler, hyaluronic acid, calcium hydroxyapatite, non-surgical, contouring
Received for publication November 23, 2021; accepted June 14, 2022 - © Salus Internazionale ECM srl - Provider ECM no 763
Corresponding Author
Figure 1 - A schematic view of the injective protocol performed with the Figure 2 - A schematic view of the injective protocol performed with the
cannula; the procedure was performed using 3 entry points, all located needle; the injections were performed perpendicular to the skin, touching
at the hairline: one in the midline and two lateral ones at the level of the the bone and releasing a small bolus of filler (ranging between 0.1 and 0.2
temporal crest. The filler was released retrogradely over the periosteum in mL), after molding with the thumb was performed.
a “spaghetti-like” fashion.
A B
Figure 3 a-b - Lateral view of pre (a) and post (b) treatment (1 month apart) of a 27-year-old woman who requested forehead recontouring; the procedure was
performed injecting CaHa with needles.
A B
C D
E F
Figure 4 a-f - Lateral and frontal views of pre (a; d), post at 1 (b; e) and 8 months (c; f) from the treatment of a 44-year-old woman who requested forehead
recontouring; the procedure was performed by injecting HA with needles.
A B
Figure 5 a-c: Frontal view of pre (a), post 1 (b) and 3 months from the treatment of a 57-year-old woman who requested forehead recontouring; the procedure
was performed by injecting CaHa with needles.
A B
Figure 6 a - c: Three quarter view of pre (a), post 1 (b) and 3 months from the treatment of a 27-year-old man who requested forehead recontouring; the
procedure was performed by injecting CaHa with the cannula.
A B
C D
E F
Figure 7 a - f: Bottom, three quarter right and left views of pre (a; c; e) and post (b; d; f) treatment (1 month apart) of a 42-year-old woman who requested
forehead recontouring; the procedure was performed by injecting HA with the cannula.
3 HA Needle
11 HA Needle
1 Needle 7 1 100
2 Needle 7 2 80
3 Needle 8 3 90
4 Cannula 10 4 90
5 Cannula 10 5 80
6 Needle 7 6 80
7 Cannula 9 7 75
8 Cannula 8 8 80
9 Needle 7 9 80
10 Cannula 8 10 100
11 Needle 8 11 85
12 Needle 7 12 85
13 Needle 9 13 80
14 Cannula 7 14 90
15 Needle 8 15 80
16 Needle 8 16 80
17 Cannula 9 17 80
18 Cannula 10 18 80
Table 2 - Results of the pain scale questionnaire filled out by the patients at Table 3 - Fifteen days following the procedure, patients were asked to
the end of the procedure: 0 was considered no pain, 1 to 3 mild pain, 4 to 6 evaluate the results with a VAS (Visual Analog Scale) where 100 represented
moderate pain, 7 to 10 severe pain. the best possible aesthetic outcome and 0 the worst.
Discussion
Regarding the soft tissue evaluation in frontal eminence, than a procedure before achieving an optimal result36.
it has been demonstrated that in males, the subcutaneous The role of forehead contouring has also been
tissue is thicker (425 µm) than in females (350 µm)29. highlighted in some papers focusing on the “lateral
Thus, the characteristics of females’ forehead are in aspect” of the forehead itself, considering forehead
severe contrast to those of males, in whom the forehead contouring as an adjunct to nose and chin remodeling.
protrudes. In fact, women with excessive supraorbital Oguzhan Demirel released a paper with his early
ridge protrusion usually complain about this unpleasant experience treating 15 patients combining forehead fat
characteristic that exerts a negative impact on their grafting and rhinoplasty, recording important benefits
social life. For this reason, they frequently refer to such as higher patient satisfaction and improvement of
plastic surgeons for its resolution31. Moreover, during facial appearance and personal traits; concluding that
the aging process, a female facial appearance becomes forehead contouring with fat graft was an efficient and
more masculine. Regarding the relationship between applicable procedure to be added to rhinoplasty37.
age and attractiveness, Zimm and Kwart respectively Also, Bertossi et al, in 2018, presented their experience
described an improvement in attractiveness score after proposing a medical algorithm in the management of
the frontal rejuvenation associated with a decrease in the profile which focused on the forehead, nose, lips,
their perceived age32,33. Facial manifestations of aging and chin; the authors concluded that the correction
in the forehead area reflect the complex dynamic, of the aforementioned anatomical areas with filler
synergic, and combined effects of gravity, loss of injections could be a viable non-surgical solution in
facial volume, skin textural changes such as decreased order to ameliorate facial aesthetics, avoiding scars and
elasticity, redistribution of subcutaneous fullness, as the cost of general anesthesia, providing the maximal
well as progressive bone resorption with a gradual loss patient satisfaction23.
of underlying support responsible for the descent of the In the present case series, 18 patients consecutively
soft tissue34. The process of forehead aging is related treated for forehead contouring with fillers were
to a progressive loss of subcutaneous fullness and a considered. The main indications were:
consequent accentuation of underlying structures such - to get a more rounded forehead to improve attractiveness
as the supraorbital rims, bony surface and muscles35. In in female patients.
youth, the subcutaneous fullness conceals the muscles - to reduce the perception of supraorbital bossing (male
of facial expression in the forehead region. During the or female patient).
aging process, this fullness between the muscles and - to deal with forehead aging.
the skin disappears and the tone of the corrugator, A VAS evaluation demonstrated a high degree of patient
procerus and frontalis muscles, presents wrinkles or satisfaction with a mean score of 84.1. Based on the pain
folds. A skeletonized supraorbital rim with the relative scale questionnaire filled out by each patient, we can
excess of upper eyelid skin, glabellar frown lines and state that the procedure is to be considered painful as
transverse forehead furrows are considered the main every score given corresponds to severe pain. Moreover,
features of upper facial third aging34,35. a difference in patient discomfort (pain) during the
An emerging interest in forehead contouring has been procedure was recorded based on the type of delivery
raised in the last few years23-27. system employed: needle injections were rated 7.6,
In 2020, Hong et al. evaluated the tomography of forehead while cannula injections were rated 8.8 on the pain
arteries in order to perform safe filler injections in this scale. Stable results were recorded during the follow-up.
area. Sixty-six cadaver heads were dissected, and all This outcome has been largely described in literature:
the superficial temporal arteries were identified and when an HA filler is injected under or just above the
followed; a total of 319 arteries identified in 48 cadavers periosteum, a semi-permanent filling effect lasting
passed through the midline; 292 superficial arteries up to 3 years can be achieved38. This issue has been
and 27 deep ones were found13. hypothesized for the first time by Mashiko et al.; sub-
Outcomes of this study confirmed that deep injections periosteal hyaluronic acid injections seem to be related
over the bones are safe to avoid vascular impairment. to periosteal stem cell activation and long-lasting
Also, Kim, in 2018, stated that deep filler injections results: published clinical experience confirmed it38.
are safe for forehead contouring in Asian patients. The In one case, a complication that required further
author, in a 10 year experience, treated 218 patients with treatment was recorded. The patient was injected,
CaHa injections with a personal technique characterized through a needle, with CaHa based filler; three weeks
by tumescent solution injections, done in order to cause later, a hard and mobile nodule was recognized.
supraperiosteal hydrodissection, thus avoiding all the Despite one month of weekly washings with saline and
vascular structures, followed by subperiosteal filler lidocaine, there was no resolution was appreciated. For
injections with a cannula. Kim recorded 100% patient this reason, surgical removal of the CaHa nodule via
satisfaction with no complications24. tab incision was performed under local anesthesia. The
Some recent papers introduced the role of fat grafting patient complained about the minimal postoperative
in forehead remodeling. Li and their colleagues scar (5 mm) that was visible on the forehead.
evaluated 24 consecutive patients undergoing forehead Paradoxically, 15 days following the procedure, the
fat grafting in an overall period of 6 years; stable and patient rated 80, and the result was achieved.
satisfactory results were recorded, with an average The first case treated in this case series was performed
forehead projection increase of 0.24 U (ratio of in 2014. Forehead contouring with fillers at that time
horizontal distance from mid-forehead plane to corneal was a procedure unknown to most people. Moreover, a
plane/corneal diameter) after one round of fat grafting specific filler for that area, so far, does not exist. The
(p = 0.01); although seven patients (29.2%) required more choice to perform forehead treatments with a CaHa
based filler was due to the large experience collected by as the use of needles instead of cannulas or the use
the senior author (RR) during previous years. Using this of different fillers; nevertheless, due to the paucity of
filler did not cause any adverse events39; moreover, the papers concerning this topic, we think that sharing
idea to inject CaHa over the bone was considered safe due this early experience with physicians involved in
to the presence of CaHa itself in the bones. The adverse facial contouring with injectables could be useful.
event recorded in the sixth patient treated induced the Larger, blinded, and controlled studies are required to
senior author to approach other cases with HA in order standardize this medical procedure.
to treat with hyaluronidase injections, avoiding surgery,
and any potential arising complications.
The use of CaHa filler in a diluted or hyper-diluted
formulation with lidocaine and saline has been Disclosures
proposed during the last years, for both facial and body
treatments, in order to get tightening and no volume The authors declared no potential conflicts of interest
enhancement40,41, although in an off-label fashion. The with respect to the research, authorship, and publication
use of diluted or hyper-diluted CaHa fillers seems to of this article.
be related to a low incidence of nodules42,43; further
studies should be performed to evaluate the safety and
stability of forehead contouring with diluted or hyper-
diluted CaHa fillers. Funding
Kim, among 218 patients treated for forehead contouring,
never recorded such complications when injecting with The authors received no financial support for the
CaHa; this could be probably related to the tumescent research, authorship, and publication of this article.
solution injected before the filler which could work
as a diluent for the CaHa microspheres24. In order to
reduce the incidence of nodules following the CaHa
filler, a potential hypothesis could be, as suggested for
permeant fillers44, to perform small droplet injections
spaced in different sessions.
The current practice in the case of CaHa nodules
consists of washing procedures performed with
lidocaine and saline; surgery is indicated in refractory
cases45. Thanks to the possibility of inducing filler
resorption with hyaluronidase injections, this kind of
complication could be avoided with the use of HA-based
fillers46,47. Some studies are trying to understand if
sodium thiosulfate may act as a reversal agent for CaHa
fillers; however, up to now, the only filler that can be
easily and safely reversed is the HA-one48-51.
Redness and irregularities, which solved themselves
within 48 hours, were always recorded after the
procedure, but they could be easily explained by the
thickness of the soft tissue of the forehead. In 10 out
of 18 cases, frontal vein congestion, which also solved
itslef within 48 hours, was recorded at the end of the
procedure; this can be explained by the thickness of the
frontal flap and by the vascular compression secondary
to filler injections.
Conclusions
4. Garcia-Rodriguez L, Thain LM, Spiegel JH. Scalp advancement 25. Bae B, Lee G, Oh S, Hong K. Safety and Long-Term Efficacy of
for transgender women: Closing the gap. Laryngoscope. 2020; Forehead Contouring With a Polycaprolactone-Based Dermal Filler.
130(6):1431-1435. Dermatol Surg. 2016; 42(11):1256-1260.
5. Lee SH, Oh YH, Youn S, Lee JS. Forehead Reduction Surgery via an 26. de Maio M, Swift A, Signorini M, Fagien S; Aesthetic Leaders in
Anterior Hairline Pretrichial Incision in Asians: A Review of 641 Facial Aesthetics Consensus Committee. Facial Assessment and
Cases. Aesthetic Plast Surg. 2021; 45(4):1551-1560. Injection Guide for Botulinum Toxin and Injectable Hyaluronic
Acid Fillers: Focus on the Upper Face. Plast Reconstr Surg. 2017;
6. Spiegel JH. Facial determinants of female gender and feminizing 140(2):265e-276e.
forehead cranioplasty. Laryngoscope. 2011; 121(2):250–61.
27. Aguilera SB, Hall M, Carvajal DCS, Gaviria A. Frontoplasty Technique
7. Farkas LG, Kolar JC. Anthropometrics and art in the aesthetics of for the Mestizo Patient. J Clin Aesthet Dermatol. 2021; 14(3):14-16.
women’s faces. Clin Plast Surg. 1987; 14(4):599-616.
28. Ricketts RM. Divine proportion in facial esthetics. Clin Plast Surg.
8. Salti G, Rauso R. Facial Rejuvenation with Fillers: The Dual Plane 1982; 9(4):401–22.
Technique. J Cutan Aesthet Surg. 2015; 8(3):127-33.
29. Hage JJ, Becking AG, de Graaf FH, Tuinzing DB. Gender-confirming
9. Rauso R, Tartaro G, Chirico F, Zerbinati N, Albani G, Rugge L. facial surgery: considerations on the masculinity and femininity of
Rhinofilling with hyaluronic acid thought as a cartilage graft. J faces. Plast Reconstr Surg. 1997; 99(7):1799-807.
Craniomaxillofac Surg. 2020; 48(3):223-228.
30. Bartlett SP, Wornom I 3rd, Whitaker LA. Evaluation of facial skeletal
10. Rauso R, Federico F, Zerbinati N, De Cicco D, Nicoletti GF, Tartaro aesthetics and surgical planning. Clin Plast Surg. 1991; 18(1):1-9.
G. Hyaluronic Acid Injections to Correct Lips Deformity Following
Surgical Removal of Permanent Implant. J Craniofac Surg. 2020; 31. Forte AJ, Andrew TW, Colasante C, Persing JA. Perception of Age,
31(6):e604-e606. Attractiveness, and Tiredness After Isolated and Combined Facial
Subunit Aging. Aesthetic Plast Surg. 2015; 39(6):856-69.
11. Zerbinati N, Haddad RG, Bader A, et al. A new hyaluronic acid
polymer in the augmentation and restoration of labia majora. J Biol 32. Zimm AJ, Modabber M, Fernandes V, Karimi K, Adamson PA.
Regul Homeost Agents. 2017; 31(2 Suppl. 2):153-161. Objective assessment of perceived age reversal and improvement
in attractiveness after aging face surgery. JAMA Facial Plast Surg.
12. Melfa F, Siragusa D, Caruso DG, et al. An Italian experience of a 2013; 15(6):405-10.
new personalized injective protocol (Botutouch) for botulinum
toxin application in aesthetic medicine. Dermatol Ther. 2020; 33. Kwart DG, Foulsham T, Kingstone A. Age and beauty are in the eye
33(6):e14395. of the beholder. Perception. 2012; 41(8):925-38.
13. Hong WJ, Liao ZF, Zeng L, Luo CE, Luo SK. Tomography of the 34. Zimbler MS, Kokoska MS, Thomas JR. Anatomy and pathophysiology
Forehead Arteries and Tailored Filler Injection for Forehead of facial aging. Facial Plast Surg North Am. 2001; 9(2):179-187.
Volumizing and Contouring. Dermatol Surg. 2020; 46(12):1615-
1620. 35. Gosain AK, Klein MH, Sudhakar PV, Prost RW. A volumetric
analysisof soft-tissue changes in the aging midface using high-
14. https://www.surgery.org/sites/default/files/ASAPS-Stats2018_0. resolution MRI: implications for facial rejuvenation. Plast Reconstr
pdf Surg. 2005; 115(4):1143-1152.
15. Monticelli D, Martina V, Mocchi R, et al. Chemical Characterization 36. Li X, Kubiak CA, Yang X, Kemp SWP, Cederna PS, Ma J. Forehead Fat
of Hydrogels Crosslinked with Polyethylene Glycol for Soft Tissue Grafting: Asian Facial Contouring and Augmentation. Plast Reconstr
Augmentation. Open Access Maced J Med Sci. 2019; 7(7):1077-1081. Surg. 2019; 144(5):1057-1065.
16. Rauso R. Deoxycholate (ATX-101) Mixed with Lidocaine to Minimize 37. Demirel O. Forehead Contouring as an Adjunct to Rhinoplasty:
Pain/Discomfort in Nonsurgical Treatment of Submental Fullness Evaluation of the Effect on Facial Appearance, Personal Traits and
Appearance. J Cutan Aesthet Surg. 2018; 11(4):229-233. Patient Satisfaction. Aesthetic Plast Surg. 2021; 45(5):2257-2266.
17. Cong LY, Duan J, Luo CE, Luo SK. Injectable Filler Technique for Face 38. Mashiko T, Mori H, Kato H, et al. Semipermanent volumization by
Lifting Based on Dissection of True Facial Ligaments. Aesthet Surg J. an absorbable filler: onlay injection technique to the bone. Plast
2021; 41(11):NP1571-NP1583. Reconstr Surg Glob Open. 2013; 1(1):e4-e14.
18. Cohen S, Artzi O, Mehrabi JN, Heller L. Vectorial facial sculpting: 39. Rauso R, Curinga G, Rusciani A, Colella G, Amore R, Tartaro G. Safety
A novel sub-SMAS filler injection technique to reverse the impact and efficacy of one-step rehabilitation of human immunodeficiency
of the attenuated retaining ligaments. J Cosmet Dermatol. 2020; virus-related facial lipoatrophy using an injectable calcium
19(8):1948-1954. hydroxylapatite dermal filler. Dermatol Surg. 2013; 39(12):1887-94.
19. Casabona G, Bernardini FP, Skippen B, et al. How to best utilize the 40. Yutskovskaya YA, Kogan EA. Improved neocollagenesis and
line of ligaments and the surface volume coefficient in facial soft skin mechanical properties after injection of diluted calcium
tissue filler injections. J Cosmet Dermatol. 2020; 19(2):303-311. hydroxylapatite in the neck and d´ecolletage: a pilot study. J Drugs
Dermatol. 2017; 16(1):68–74.
20. Scheuer JF 3rd, Sieber DA, Pezeshk RA, Gassman AA, Campbell CF,
Rohrich RJ. Facial Danger Zones: Techniques to Maximize Safety 41. Goldie K, Peeters W, Alghoul M, et al. Global consensus guidelines for
during Soft-Tissue Filler Injections. Plast Reconstr Surg. 2017; the injection of diluted and hyperdiluted calcium hydroxylapatite
139(5):1103-1108. for skin tightening. Dermatol Surg. 2018; 44 Suppl 1:S32–S41.
21. Costa CR, Kordestani R, Small KH, Rohrich RJ. Advances and 42. Lapatina NG, Pavlenko T. Diluted calcium hydroxylapatite for skin
Refinement in Hyaluronic Acid Facial Fillers. Plast Reconstr Surg. tightening of the upper arms and abdomen. J Drugs Dermatol.
2016; 138(2):233e-236e. 2017; 16(9):900–906.
1APRN, FNP-C
2MD, PhD, APRN, FNP-C
3MD, DNP, APRN-NP
Abstract
Background: living in a fast-track world, timely identification of the patient’s goals, expectations, and current state of
self-confidence is imperative, applicable knowledge for the aesthetic injector. The absence of a timely evaluation tool
for neuromodulation in the aesthetic industry may instigate an environment of melancholy related to patient outcomes,
overall satisfaction, and waste management.
Aim: the purpose of this QI project is the development of the Functional Facial Assessment Tool (FAST), a quick tool
that aims to educate providers on the aesthetic patient’s potential product utilization, goals, and current state of self-
confidence.
Method: a two-phase patient focused quality improvement (QI) project was implemented to quickly extract vital
information on history, product utilization, goals, and confidence level on the pre-survey and gauge goal achievement,
confidence progress, and overall patient outcomes on the post-survey.
Results: the FAST provided vital information about the clientele. One of the most encouraging discoveries within this
project was the improvement seen in self-confidence, rising 44% post-injection.
Conclusion: findings of this QI project’s success has led to significant advances in the evaluation of patient satisfaction,
patient outcomes, and cost efficiency through the utilization of the FAST surveys.
Keywords
Aesthetic, neuromodulation, botox, quick tool, survey, evaluation
Received for publication November 9, 2021; accepted June 14, 2022 - © Salus Internazionale ECM srl - Provider ECM no 763
Corresponding Author
Demographics and Costs The promotion of beauty as it exists in the world today
Americans spend upwards of 15 billion dollars annually in conjunction with mental health considerations such
on aesthetic procedures both surgical and non-surgical as confidence, reduction of depression, and overall well-
to improve their perceived appearance3. According being is a pertinent relationship2. Aesthetic providers of
to the American Society for Aesthetic Plastic Surgery, neuromodulation treatments have opportune access and
(ASAPS) (2016) neuromodulation with botulinum toxin ability to screen patients both pre and post neuromodulation
products has held the number one and number two gaining an invaluable comprehension of vital information
spots for the largest amount of non-surgical aesthetic as it relates to the patient’s satisfaction, costs, and overall
procedures completed in the nation for the last eight outcomes. The purpose of this quality improvement
(QI) project was to develop and implement the FAST Measurement Methods/Data Collection Procedures
survey into an aesthetic practice bi-modally improving
the overall neuromodulation experience and enhancing The FAST surveys development stemmed from the
the patient-provider relationship. By incorporating the PRO tools already in existence and examined in
FAST survey into practice, the QI project provided a the available knowledge. The survey was created
comprehensive, patient-centered approach to quickly taking different concept attributes from PRO tools
delineate the patient’s product needs, specific goals and combining them for the common purpose of
for the procedure, current confidence status, and post- improving patient satisfaction and cost effectiveness
evaluation patient outcomes facilitating the shared of the business. The FAST survey, as illustrated in
decision-making process between the patient and Appendices A and B, quickly extracts vital information
provider. on history, product utilization, goals, and confidence
level on the pre-survey and gauge’s goal achievement,
confidence progress, and overall patient outcomes on
the post-survey. Once received, the FAST pre-survey was
Design assessed examining what area the patient would like to
have injected allowing the project lead to estimate the
The QI project was implemented in an upper class amount of product that would be utilized during that
privately-owned metropolitan spa. Analysis of the FAST appointment. This was done with each patient, allowing
survey data occurred in two phases pre-neuromodulation for ordering of the proper product amount, eliminating
survey and post-neuromodulation survey. This privately- waste and optimizing cost effectiveness.
owned clinic manages approximately 50 patients per The subject’s names were associated with their phone
month. number and kept identifiable, so the FAST surveys
were able to be compared, and the outcomes analyzed
properly. The dates were also tracked by phone number
to verify that the two-week time constraints were
Population Sample followed. The practice offered participation in the
project to any clients that met the inclusion criteria
The sample population included female patients during the two-month window of implementation.
ages 25-65 years old that were seen by the privately-
owned practice for new and routine neuromodulation
appointments. Both new and existing patients receiving
neuromodulation were included as well as novice and Data Analysis
those with prior injection history. All patients received
neuromodulation with either Botox or Dysport. Patients Data from both survey phases was collected and
were included in the project despite which area(s) of the analyzed using descriptive statistics. Continuous
face were injected. During a two-month time period, variables are expressed as ranges while discrete
patients were asked to fill out the FAST surveys prior to variables are quantified in percentages. The pre-
their appointment. The pre-neuromodulation surveys injection screen and post-injection surveys were
were sent to the patients via text message one week analyzed and compared for validity, patient satisfaction
prior to their injection appointment. The post surveys data, and waste management purposes.
were sent via text message two weeks post injection.
A $25 coupon incentive to be used by the patient for
their next injection appointment for taking the time to
complete and return the post neuromodulation survey Results
and participating in the study was included.
FAST Pre-injection Screen
Each client was screened for inclusion and given the
opportunity to participate. Thirty-three clients met the
Ethical Considerations inclusion criteria for participation during the 30-day
implementation phase. The FAST pre-injection screen
The QI project was reviewed by Creighton University had a total of 33 responses with a 100% completion rate.
Institutional Review Board and deemed to be a Quality Typically, it took each client 45 seconds to complete the
Improvement Project. Once permission to proceed survey.
was granted the Health Insurance Portability and The first question in the FAST pre-injection screen was,
Accountability Act (HIPAA) Privacy Rule was strictly “Have you ever had neurotoxin injections before?” 87%
followed. Participation in this project was voluntary percent responded, “yes” to this question while 12.5%
for all selected patients. Collected data was stored in a responded “no”. One person “skipped” or did not
private and secure location protected from unauthorized complete this question. The second question asked,
personnel. Any patient participating in the project could “What areas of the face would you like to have injected?”
request education regarding the project’s purpose, The top answer was forehead at 54.55% followed by
intents, and results. crow’s feet at 21.21%. Injection of glabellar lines came in
at 18.18% followed by a lip flip at 6.06%. Spa lift, gummy
smile, and “other” areas did not generate a need with
this client group with zero response reflected. The third
question on the pre-injection screen was “What are your FAST Post-Injection Evaluation
goals for the procedure?” The response options included The FAST pre-injection screen had 33 respondents
smoothness, with greater than a 50% margin totaling complete the survey. The FAST post injection evaluation
22 respondents at 66.67%. Lift/refreshed appearance is the second half of this study’s assessment and had
followed at 30.30% with 10 respondents. One client 32 respondents to complete the survey, achieving a 99%
responded “other”, and no one chose symmetry as a completion rate. The first question in the post injection
primary goal. This question had a 100% completion rate evaluation was, “Were you happy with the injection
with no skips. process?” The feedback was positive with 100% of
The fourth and fifth questions in the FAST pre-injection the respondents replying “yes.” The second question
screen encompass the concepts of eyebrow movement asked if the respondent’s goals they depicted in the
with neurotoxin injections and overall self-confidence. pre-injection screen were met. Thirty-one out of 32
Question four states, “What is more important to you, respondents (96.88%) answered “yes” to this question,
elimination of all wrinkles or eyebrow movement?” The one respondent answered “no” (3.13%). Question three
dominant answer was exactly parallel with “wrinkles of the post-injection evaluation asked, “How would
be gone” with 16 respondents at 48.48% and “both you rate your current self-confidence as it relates to
if possible” also with 16 respondents at 48.48%. One your outward appearance?” “Excellent” and “good” ran
respondent chose the third answer option “I need my parallel as the highest rated answers, both at 43.75%.
eyebrows to move” making up 3% of the population. “Average” followed at 12.5% with the answer option
There was a 100% completion rate on this question. “poor” with zero respondents. All 32 respondents
The final question of the pre-injection screen asked, completed this question.
“How would you rate your current self-confidence?” The Question four of the post injection evaluation asked the
response options were displayed as “excellent, good, respondents to give a “star rating” for their service. Five
average, and poor”. “Good” was the most prevalent stars being the highest rating one could give and one
answer at 63.64%, with 21 respondents choosing star being the lowest potential rating. All 32 respondents
this option. Seven respondents (21.21%) reported an completed this question with approximately 88% of the
“average” confidence level while five (15.15%) of the respondents awarding a five-star review. Three people
respondents reported an “excellent” confidence level. (9.38%) gave a four-star review, and one respondent
None of the respondents reported a poor confidence (3.13%) gave one star. None of the respondents gave a
level. There was 100% compliance with zero skips on two or three-star review.
question five. Figure 1 reflects the star rating scale results.
88 %
1% 0 0 9%
33 Respondents
Question five asked the respondents to leave a comment skipped this question. The comments left emulated
or suggestion to illustrate any feedback they may have. positivity and satisfaction. See table 1 for a list of
Twenty-two respondents left comments while ten comments.
“I didn’t mean to rate that last one for worst!!! It was the best!!!”
“I am loving how awake my eyes are after getting my injections. My eyebrows have more definition and Ive
received a few compliments on how nice my eyebrows look.”
Table 1 - The table illustrates illustrates various patient comments articulated in Question 5 of the FAST post injection evaluation.
Discussion and Conclusion most minimal side effects. This gains the provider
knowledge on how much product they could anticipate
The absence of a timely evaluation tool surrounding ordering and addresses the aims of waste management
aesthetic neuromodulation patients was identified in and cost efficiency. The second question on the pre-
a metropolitan aesthetic med spa. Therefore, a two- injection screen asks what areas of the face the patient
phase patient focused quality-improvement project would like injected. Each area of the face that can be
was implemented to develop a timely evaluation tool injected with neurotoxin has an approximate maximum
that would distinguish patient’s goals, expectations, and minimum amount that can be injected. Providing
and current state of self-confidence as it relates to this information to the aesthetic injector allows them
neuromodulation injections. The primary purpose of to know the ratio of product that should be ordered
this QI project was to utilize the knowledge gained based on which areas of the face are being considered.
to foster a basis for patient-provider communication, Question two aligns with the first question’s aims of
improve overall patient satisfaction/outcomes, and waste management and cost efficacy.
optimize waste management. The two-phase survey Questions three and four on the pre-injection screen
served this purpose based on the illustrated results. discussing procedural goals, correlate with question
The first question on the FAST pre-injection screen asked two on the post-injection evaluation determining if
patients if they had ever been injected with neurotoxin those pre-procedural goals were met. The most sought-
before. This question informs the injector whether the after goals by the clients surveyed was smoothness
patient is neurotoxin naïve. In which case the provider (question 3) (67%), lift (question 3) (30%), and elimination
could potentially anticipate a conservative amount of of wrinkles (49%) with the option to still be able to move
product to be injected due to the unknown metabolism their eyebrows (49%) (question 4). In the post-injection
of the product in the new patient. Not unlike many evaluation, an astonishing 97% of respondents reported
medication regimens, when administering neurotoxins, their goals were met. The common aims of patient
the smallest dose is often utilized first as best practice satisfaction and improved patient outcomes resonates
for a maximal response of the medication with the with this evaluation.
The FAST pre-screen evaluated the respondent’s self Questions one, four, and five on the FAST post-injection
confidence in question five. Self-confidence was then evaluation aim to evaluate patient satisfaction and
re-evaluated in question three on the post evaluation. patient outcomes. The results also revealed a hidden
Perhaps one of the most encouraging discoveries within goal and satisfaction piece from the clientele regarding
this project is the improvement seen in self-confidence time management and efficiency. In question one 100%
illustrated from the pre-injection screen to the post- of the respondents reported “yes” they were happy with
injection evaluation. “Excellent” rated self-confidence the injection process. Question four asked respondents
started at 15% in the pre-screen phase and elevated to to give a “star rating” regarding their entire experience
44% in the post injection survey with an approximate 30% with 88% giving a five-star rating and 9% giving a four-
self-confidence improvement rate! With the “excellent” star rating.
rating rising the “good” and “average” ratings fell, One respondent gave a one-star rating in question four
“good” fell by 20%, the “average” rating declined by 8%. but made a comment in question five stating, “I didn’t
The “poor” self-confidence rating had zero responses in mean to rate that last one for worst!!! It was the best!!!”.
both the pre and post evaluations. The aim of improved Question five illustrated any comments or suggestions
patient outcomes is defined in this assessment. These the respondents shared this feedback is listed in table
results are illustrated below in figures 2 and 3. 1. Two of the respondents wrote in the comments they
were pleased with the efficiency of the process. This
brings about a new goal for Faces by Meghann to ensure
a quality yet timely injection process.
The aim of this portion focuses on patient satisfaction.
The target survey participation rate of 80% during the 30
days of implementation was surpassed demonstrating
support for future endeavors.
As implicated in the evidence summary a culmination
of the literature supports the ideation that is also
demonstrated in the results of this QI project that
injection therapy with BoNT-A produces favorable
aesthetic outcomes emulating positivity and patient
retention.
The literature also reinforces the clinical practice
recommendation highlighting the importance of a
regular evaluation with PRO based tools as a best practice
method in aesthetics to emphasize quality of care13.
The research surrounding mental health supports
the notion of findings in this QI project illustrating
improvement in self-confidence post neuromodulation
which relates to an overall improvement in mental
health capacity.
This concept is also perpetrated in the literature
Figure 2 - Self Confidence Rating Results from the FAST Pre-Injection Screen. review with various studies showing improvement
in depression scores, mood, confidence, and overall
psychological state. Further research is required to fully
delineate clinical practice guidelines and fulfill further
knowledge deficits based in mental health. Findings of
this QI projects success has led to significant advances
in evaluation of patient satisfaction, patient outcomes,
and cost efficiency through utilization of the FAST two
phase pre and post neuromodulation evaluation tool for
this independent practice.
Policy change requiring bi-annual evaluations will be
implemented using the FAST.
Initial application of the FAST bi-annually instead of
creating a daily policy utilization requirement will
likely increase the sustainability of the tool eliminating
overwhelming “busy-work” for staff and “survey-
fatigue” for clients thus preserving the authenticity
of the responses rendered. Allowing for intermittent
application when obstacles arise will potentiate problem-
solving strategies and reinforce the cornerstone of
any flourishing medical practice, the patient provider
relationship.
Acknowledgements
Funding
Conflict of Interest
REFERENCES
1. Aesthetic-Society Stats2019Book FINAL. Scribd.
https://www.scribd.com/document/496403472/Aesthetic-Society-
Stats2019Book-FINAL. Accessed November 3, 2020.
2. Alam M, Barrett KC, Hodapp RM, Arndt KA. Botulinum toxin and
the facial feedback hypothesis: can looking better make you feel
happier? J Am Acad Dermatol. 2008; 58(6):1061-1072.
5. Center for Disease Control and Policy. Apr 18 2002. FDA approves
cosmetic use of botulinum toxin. CIDRAP. https://www.cidrap.
umn.edu/news-perspective/2002/04/fda-approves-cosmetic-use-
botulinum-toxin. Published April 18, 2002. Accessed September 1,
2021.
6. Chang BL, Wilson AJ, Taglienti AJ, Chang CS, Folsom N, Percec I.
Patient Perceived Benefit in Facial Aesthetic Procedures: FACE-Q as
a Tool to Study Botulinum Toxin Injection Outcomes. Aesthet Surg
J. 2016; 36(7):810-20.
12. Reavey PL, Klassen AF, Cano SJ, et al. Measuring Quality of Life and
Patient Satisfaction After Body Contouring: A Systematic Review
of Patient-Reported Outcome Measures. Aesthet Surg J. 2011;
31(7):807-813.
14. Yaworsky A, Daniels S, Tully S, et al. The impact of upper facial lines
and psychological impact of crow’s feet lines: Content validation
of the Facial Line Outcomes (FLO-11) Questionnaire. J Cosmet
Dermatol. 2014; 13(4):297-306.
1Department of Plastic Surgery, Assaf Harofeh Medical Center, Zerifin, Israel, affiliated with the Sackler
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
2Department of Plastic Surgery, Meir Medical Center, Kfar Saba, Israel, affiliated with the Sackler Faculty
of Medicine, Tel Aviv University, Tel Aviv, Israel
3Abarbanel Mental Health Center, Bat Yam, Israel, affiliated with the Sackler Faculty of Medicine, Tel Aviv
University, Tel Aviv, Israel
4Macabbi Health Services, Tel Aviv, Israel, affiliated with the Faculty of Health Sciences Ben Gurion of the
Negev University, Beer Sheva, Israel
Abstract
Background: schizophrenia has long been associated with accelerated physical aging, along with increased and premature
medical comorbidities and mortality. Several anatomical and functional abnormalities have a higher prevalence among
people with schizophrenia.
Aim: to assess facial aging of patients with schizophrenia compared to an age-matched control group, without
schizophrenia.
Methods: wrinkle depth using Lemperle’s classification and a subjective age estimation were independently evaluated by
two investigators and the two groups were compared. Data regarding BMI, sun exposure habits, the use of sunscreens,
and current medications were recorded.
Results: seventy-four participants were enrolled, including 37 patients in each group. Age, sex, BMI and smoking status
did not differ significantly between the groups. Patients with schizophrenia took significantly more medications, had
more sun exposure and used less sunscreen than the controls did. They had significantly deeper periorbital, nasolabial,
chin, and cheek wrinkles and their ages were estimated to be older than the controls’.
Conclusions: patients with schizophrenia had increased facial aging, evidenced by deeper facial wrinkles and were
estimated to be significantly older than the controls. Probable causes include an unhealthy lifestyle, an increased facial
muscle tone due to the chronic use of antipsychotic drugs and a genetic diathesis related to the aging process.
Keywords
Wrinkle assessment, schizophrenia, aging, sunlight
Received for publication March 8, 2022; accepted June 13, 2022 - © Salus Internazionale ECM srl - Provider ECM no 763
Corresponding Author
Avshalom Shalom
Address: Department of Plastic Surgery, Meir Medical Center , 59 Tchernichovsky St. Kfar Saba 4428164 Israel
Email: [email protected]
Phone: +972-9-7471823
Fax: +972-9-7471319
Table 2 - Wrinkle assessment scores of schizophrenic patients (0) and controls (1).
of a deep dermal creasing caused by repeated facial patients. The deepening of these facial creases and
movements and expressions. They are perpendicular to furrows might be a consequence of higher facial
the direction of the underlying facial muscles. In the mimetic muscle tonus over a long period.
nasolabial fold, the dermis is attached to the muscles Cigarette smoking is another potentially exacerbating
along the nasolabial crease, with the bulge of the factor in skin aging, with a direct correlation between the
fold created mostly by fat15. The nasolabial folds are number of packs smoked a year and aged appearance.
exaggerated by smiling, which is a repeated contraction Also not investigated in our study, previous studies
of the upper lip elevators, mainly the zygomaticus have shown that schizophrenic patients have a higher
muscles. Radial lip and marionette lines are caused rate of smoking than the general population and more
by the concomitant movement of mimetic muscles difficulty with smoking cessation22,23.
during chewing and lip tightening. It is well-known that
mimetic wrinkles respond to the decreased muscle tone
induced by therapeutic measures, such as the injection
of botulinum toxin to the muscle or a direct muscle Conclusion
resection. In contrast, patients with long-standing
unilateral facial nerve paralysis will develop a descent In summary, we found deeper facial wrinkles and
of the hemifacial cheek soft tissues and flattening of the increased facial aging in patients with schizophrenia
nasolabial crease, as compared with the contralateral compared to controls, as evidenced by the subjectively
healthy cheek. older facial appearance.
Based on the subjective clinical observation of the The accelerated aging presumed to be associated with
“older appearance” of the schizophrenic patients, the schizophrenia may have a multifactorial pathogenesis.
present study was designed to assess facial aging. Factors such as antipsychotic drugs, which increase
We evaluated wrinkle depth using a dependable and facial muscle tonus and photosensitizing drugs, which
reproducible technique, but found it unreliable for increase damage from sun exposure, as well as lifestyle
precisely evaluating other facial anatomical changes factors such as increased cigarette smoking and sun
that occur with aging, such as progressive fat atrophy exposure are contributing factors.
and folds. Therefore, we added subjective general age Further studies that assess additional features
estimations by a plastic surgeon and a dermatologist. associated with accelerated aging might contribute to
Our results showed an overall significant deepening a better understanding of the mechanisms involved in
of facial wrinkles in the schizophrenia group in both aging and schizophrenia. Patients with schizophrenia
sexes, as compared to the control group. The correlation should be made aware of the negative consequences of
ratio between the estimated and true ages was lower for sun exposure and smoking to help minimize the effects
the patients with schizophrenia than for the healthy of accelerated aging associated with their condition.
individuals, with the patient group considered older
than they were.
Deeper facial wrinkles can be explained by accelerated
photo-aging. Ultraviolet radiation from sun exposure is Acknowledgments
another factor that can influence aging. We previously
reported that hospitalized schizophrenic patients have Conflict of interest
higher ultraviolet radiation exposure and use less sun
protection16. This increased sun exposure contributes None to declare.
to changes involving all skin layers, including actinic
keratosis (damage to the epidermis), solar elastosis
(damage to the dermal connective tissue, wrinkles
(damage to the dermis), telangiectasia (damage to Funding
the blood vessels), solar comedones (damage to the
sebaceous glands), as well as lentigines and other This study was not funded.
pigmentary changes, which contribute to the older
appearance of these patients.
In addition, periorbital wrinkles are believed to stem
partially from the repeated mimetic contraction of
the orbital muscles, primarily the orbicularis oculi, as
a defense from solar radiation, when the eyes are not
protected by sunglasses.
Schizophrenic patients used more psychotropic
drugs than the healthy controls did. Because of
an increased physical co-morbidity, patients with
schizophrenia are treated with a myriad of systemic
drugs. Many of these agents from different classes,
such as anti-hypertensives and anti-hyperlipidemics,
are potentially photosensitizing17-21. It is also well-
recognized that higher facial muscle tonus is a side-
effect of antipsychotic drugs. This might be a possible
pathogenesis of the deeper nasolabial crease in these
REFERENCES
1. Haslam J. Illustrations of Madness. London, United Kingdom: Printed
by G. Hayden; 1810.
11. Fitzpatrick TB. The validity and practicality of sun reactive skin type
I through VI. Arch Dermatol. 1988; 124(6):869–871.
13. Jeste DV, Twamley EW, Eyler Zorrilla LT, Golshan S, Patterson TL,
Palmer BW. Aging and outcome in schizophrenia. Acta Psychiatr
Scand. 2003; 107(5):336–343.
14. Weinberg SM, Jenkins EA, Marazita ML, Maher BS. Minor physical
anomalies in schizophrenia: a meta-analysis, Schizophr Res. 2007;
89(1-3):72-85.
22. Weinberger AH, Sacco KA, Creeden CL, Vessicchio JC, Jatlow
PI, George TP. Effects of acute abstinence, reinstatement, and
mecamylamine on biochemical and behavioral measures of cigarette
smoking in schizophrenia. Schizophr Res. 2007; 91(1-3):217–225.
Abstract
Background: post traumatic skin injuries tend to pose as a challenge. Patients may have erythematous, hypertrophic,
or atrophic scars. Microneedling therapy is minimally invasive non-surgical and non-ablative procedure used for skin
rejuvenation that relies on the principle of neocollagenesis.
Aim: our aim was to assess the clinical and histochemical response to an automated microneedling therapy in the
treatment of traumatic scars.
Methods: this prospective study included twenty patients with traumatic scars. All patients received 4 monthly sessions
of said automated microneedling therapy. The outcome assessment included a modified Vancouver Scar Scale, digital
photographic documentation and a representation of the patient’s satisfaction. A Histochemical evaluation was obtained
by a quantitative morphometric assessment for collagen and elastic fibers using an image analyzer performed before
and 3 months after treatment for Masson’s trichrome and Orcein stained sections respectively.
Results: there was a statistically significant improvement in scar vascularity (p= 0.018), scar pigmentation (p= 0.008),
and scar pliability (p= 0.002) and the sum of mVSS (P=0.000002). Histochemically, there was a significant increase in the
the amount of collagen, (p= 0.023), and elastin (p= 0.003) as quantified by an image analyzer. There was no significant
correlation (r: 0.158 and -0.259; p-values: 0.55 and 0.34) between the micro-needling therapy and the scar type (atrophic
versus hypertrophic). The Treatment was associated with a satisfactory outcome and, except for a temporary erythema,
no adverse effects were noted in any patient.
Conclusions: the Microneedling therapy for post traumatic scars showed clinical improvement associated with a
significant increase in the amount of collagen and elastin. Microneedling seems to be a promising form of treatment,
and is a safe, effective and affordable treatment option for the patient.
Key words
Automated Microneedling, histochemical, traumatic scars
Received for publication January 6, 2022; accepted June 14, 2022 - © Salus Internazionale ECM srl - Provider ECM no 763
Corresponding Author
Treatment procedure
All patients received 4 automated microneedling Results
sessions (4 weeks apart), using an electric Derma
stamp pen, Ostar Beauty -OB-DG 01-12 pins-0.25: 2.00 The age of the patients in the study group ranged
mm depth of penetration. It was adjusted at a 1.5 mm between 17 and 43 years old (mean ± SD 27.27± 9.65).
depth and speed level 4. It contains 12 stainless steel Males represented 65% (13 patients) and females
needles, where each needle has a 33-gauge diameter, represented 35% (7 patients). Fourteen patients (70%) had
with a 250 μm diameter at entry point. A 25% Lidocaine Fitzpatrick skin type III and the remaining 6 patients
cream was applied under occlusion 60 minutes before (30%) had Fitzpatrick skin type IV. The duration of their
and wiped off just before the session. Sterile saline was Scars ranged between 1 and 5 years (mean ± SD: 3.13±
used to help the gliding action of the tip of the pen 1.4 years). Thirteen patients (65%) had atrophic scars
over the skin. All patients were recommended a topical and 7 patients (35%) had hypertrophic scars. The length
antibiotic cream and a broad-spectrum sunscreen after of their Scars ranged between 15 and 154 mm (mean ±
each micro needling session. All patients were followed SD: 54.13±42.7 mm) and the scar width ranged between
up for 3 months after last treatment session. 1 and 5 mm (mean ± SD: 2.73±1.1mm).
Scale Pre Post P value Pre Post P value Pre Post P value
0 6 14 0.018 7 14 0.008 0 7 0.002
1 11 5 3 2 0 12
2 3 1 10 4 7 1
3 0 0 0 0 9 0
4 0 0 0 0 4 0
Table 1 - Modified VSS (before) and (3 months) after the microneedling therapy.
Figure 1 - Collagen content before and after 4 monthly microneedling therapy, Masson stain, x 400.
Photographic Assessment
There was an improvement in the clinical appearance of
scars as shown in table 2, figures 5 and 6. 0
Figure 3 - Elastin content before and after 4 monthly microneedling therapy, Orcein stain, x 400.
12
7
o
10
Figure 4 - Collagen content (Masson stain area) before and after 4 monthly
microneedling therapy.
Photographic outcome
Total
SB Fair Good Excellent
Patient satisfaction
Figure 5 - Atrophic scar, before and 3 months after treatment with microneedling.
Figure 6 - Atrophic scar, before and 3 months after treatment with microneedling.
Conflict of interest
Author’s contributions
REFERENCES
1. Tripathi BP, Nelson JS and Wong BJ. Posttraumatic Laser Treatment
of Soft Tissue Injury. Facial Plast Surg Clin North Am. 2017;
25(4):617-628.
5. Mahfouz SM, El-Sharkawy SL, Sharaf WM, Hussein HE, El-Nemr RS.
Image cytometry of fine needle aspiration of thyroid epithelial
lesions. image cytometry of fine needle aspiration of thyroid
epithelial lesions. Appl Immunohistochem Mol Morphol. 2012;
20(1):25–30.
7. Seo KY, Kim DH, Lee SE, Yoon MS, Lee HJ. Skin rejuvenation by
microneedle fractional radiofrequency and a human stem cell
conditioned medium in Asian skin: a randomized controlled
investigator blinded split-face study. J Cosmet Laser Ther. 2013;
15(1):25-33.
9. Bandral MR, Padgavankar PH, Japatti SR, Gir PJ, Siddegowda CY, Gir
RJ. Clinical Evaluation of Microneedling Therapy in the Management
of Facial Scar: A Prospective Randomized Study. J Maxillofac Oral
Surg. 2019; 18(4):572–578.
11. Juhasz MLW, Cohen JL. Microneedling for the Treatment of Scars:
An Update for Clinicians. Clin Cosmet Investig Dermatol. 2020;
13:997-1003.
13. Zayed AA, Mashaly HM, Abdel Raheem HM, et al. Microneedling
versus fractional CO2 laser in the treatment of atrophic postburn
scars. J Egypt Womens Dermatol Soc. 2019; 16(1):37-42.
14. Aust MC, Reimers K, Vogt PM. Medical needling: improving the
appearance of hypertrophic burn-scars. GMS Verbrennungsmedizin.
2009; 3.
Abstract
Background: in the general population up to 10% of adults and 20% of children are affected by atopic dermatitis (AD).
This is presented as an inflammatory skin alteration that can chronify with a pattern of skin lesions with pruritus. The
primary pathogenic mechanism of AD is thought to be an immune malfunction. The mainstream therapy is composed of
steroids applied topically and an oral immunosuppressant: both treatments may generate side effects in the long-term.
High and low molecular weight hyaluronic acid hybrid stable cooperative complexes (HCC) are considered different
ways to cure, prevent and manage AD.
Purpose: to report a two year follow up assessment of a therapy where an injection of HCC in a female person with AD
was performed.
Materials and methods: product treatment sessions have been done according to the HCC protocol of injection, i.e.
0,2mL per point on 10 points for the full face following the technique described as Bio Aesthetic Points (Figure 1).
The suggested protocol included 2 treatments that were performed one month apart from each other, then there were
programmed follow-up sessions every 2 months. The follow-up sessions, as well as assessing the patient skin status,
were performed as a maintenance treatment.
Results: the injection of HCC created a steady beneficial impact with a visible improvement in two aspects: curing the
inflammatory lesions and keeping the skin barrier in the adult affected by AD. There were not observed adverse events.
Conclusions: even though these results need to be corroborated, there is strong evidence that the HCC treatment may
be used as an additional therapy for the treatment of AD.
Keywords
Atopic dermatitis, hyaluronic acid, stable hybrid cooperative complexes
Received for publication February 10, 2022; accepted June 14, 2022 - © Salus Internazionale ECM srl - Provider ECM no 763
Corresponding Author
Gabriel Siquier-Dameto, MD
Email: [email protected]
Figure 2 - Representative images of AD before HCC injection (A) (baseline), one month after 2nd treatment (B), one year after 1st treatment (C) and two years
after 1st treatment (D), a progressive reduction on eritema and scaling with an improvement of skin texture have been observed (B, C and D).
The BAP technique was used to avoid danger zones and Conclusion
to promote a better diffusion of the product into the
tissue26. Contraindications, such as an active infection This report demonstrates that an injectable treatment
of the skin, pregnancy and anyone younger than 18 with HCC is beneficial to conserve the skin barrier and
years old, were not present. reduce inflammation. This outcome suggests that the
No adverse events occurred, except for a visible bruise wound healing and reduction on inflammation capacity
on the lower malar mound region that healed within 2 of HCC, as recently published evidence support23,24,28,
days. may help to reduce the symptoms of AD. This data
The treatment was able to produce a significant needs to be corroborated, but suggests that HCC has
improvement of both the pruritus and eczema, in a a therapeutic and preventive benefit in the handling
time-dependent manner already observable after 1 of AD. The molecular mechanisms underlying the
month of therapy (Figure 2). In addition, a progressive observed effect need to be investigated further.
reduction on the erythema with an improvement of skin
texture have been observed (B, C and D). Two years after
the first treatment, the patient was very satisfied with
the overall outcome and with no evidence of relapse. Ethics and consent
11. Eichenfield LF, Hanifin JM, Luger TA, Stevens SR, Pride HB.
Consensus conference on pediatric atopic dermatitis. J Am Acad
Dermatol. 2003; 49(6):1088-1095.
16. Sidbury R, Davis DM, Cohen DE, et al. Guidelines of care for the
management of atopic dermatitis: section 3. Management and
treatment with phototherapy and systemic agents. J Am Acad
Dermatol. 2014; 71(2):327-349.
17. Qi HJ, Li LF. New Biologics for the Treatment of Atopic Dermatitis:
Analysis of Efficacy, Safety, and Paradoxical Atopic Dermatitis
Acceleration. Biomed Res Int. 2021; 2021:5528372.
19. Jordan AR, Racine RR, Hennig MJP and Lokeshwar VB. The role of
CD44 in disease pathophysiology and targeted treatment. Front
Immunol. 2015; 6:182.