Sandra Fyfe

Botulinum toxin A (BTA) is effective in upper lip enhancement and in shortening the philtrum, according to study findings published in the 

Fillers are a common treatment to improve lip fullness. To see how BTA stands up in enhancing lip fullness, investigators examined 3 patients (2 women and 1 man) who had not previously received BTA. The mean age of patients was 28.7 years, and they were each given 4 U of BTA injections, 1 unit per site, in the upper lip at the vermillion border.1 Patients had 3-dimensional photographs taken prior to and 2 weeks after treatment to evaluate for lip fullness. Investigators measured the upper lip surface and 8 linear distances. These measurements were compared before and after BTA treatment.

Following the treatments, measurements showed taller upper lip vermillion height (

=.038) and shorter cutaneous upper lip height (

=.024).1Investigators noted that although it seemed upper lip surface area was larger, it was not statistically significant. All 3 patients experienced slight perioral muscular palsy and incompetence of the mouth that lasted 3 months, but they improved gradually after 1 month.

Because BTA interferes with lip function, the procedure should be avoided in patients such as singers who require high mouth competency, the investigators wrote. They also noted that patients should be informed beforehand that the procedure reduces the height of the cupid’s bow, resulting in a slightly flattened lip.

Joel Cohen, MD, FAAD, FACMS, ASDS, director of AboutSkin Dermatology and DermSurgery in Greenwood Village and Lone Tree, Colorado; fellowship codirector for the American Society of Dermatologic Surgery’sDermatologic Surgery Colorado Fellowship; and associate clinical professor at the University of California, Irvine, shared some clinical insights with 

He says he uses BTA for a prominent orbicularis oris muscle that has no imprinted lines.

“These are often younger patients,” Cohen explains. “[I see] the patients I address with botulinum toxin about every 3 or 4 months. I use very low doses, 10 to 14 units of Dysport [abobotulinumtoxinA] or 4 to 6 units of Botox [onabotulinumtoxinA], Xeomin [incobotulinumtoxinA], or Jeuveau [prabotulinumtoxinA].”

For some imprinted lines, Cohen says uses a 30- to 31-gauge needle for filler. “I go right into the edge line with filler,” he says. “And I often repeat this about every 6 months. This seems to stimulate some collagen, so over time people do this less frequently.”

Cohen also says that for patients with many imprinted, severely etched lines too numerous for filler or too small for filler, he prefers ablative resurfacing. “If they want to see major improvement with usually just 1 treatment, then I will do full-field erbium such as Sciton JouleX 2940, which takes 10 to 14 days for skin to re-epithelialize, but then [patients] often experience red to pink [skin] for 6 to 8 weeks.”

If patients want less downtime, he will do fractional ablative carbon dioxide or erbium laser, with time to re-epithelialize at approximately 5 to 6 days, and then the skin will be pink for a few weeks.

Cohen adds that “it’s important to point out that these treatments are not mutually exclusive. To prevent a lot of muscle contraction that could recapitulate edge lines, I do botulinum toxin very frequently a week or 2 before this type of resurfacing around the mouth.”

In many cases, he still uses fillers for volume support in the marionette area, nasolabial folds or cheeks, and sometimes in imprinted lines like the horizontal line of the depressor septi area.

“And then starting 3 or 4 months after the resurfacing, I will still use botulinum toxin to help try to prevent the muscle from contracting and reestablishing,” he says.

Li Y, Chong Y, Yu N, Dong R, Long X. The use of botulinum toxin A in upper lip augmentation

. 2021;20(1):71-74. doi:10.1111/jocd.13731

Articles

A recent study finds BTA an effective alternative to fillers, but it should be used with caution.

Botulinum Toxin A Effective in Upper Lip Enhancement 

Microwave and microablative CO2 laser treatment is effective for postpartum abdominal laxity, according to findings of a 2020 study published in the

Laxity can occur post pregnancy due to loss of muscle tone and abdominal elasticity, wrote study coauthors Paolo Bonan, MD, and Alice Verdelli, MD, of the Laser Cutaneous Cosmetic & Plastic Surgery Unit at Villa Donatello Clinic in Florence, Italy.

 The study’s goal was to assess the efficacy of combined microwave and fractional microablative CO

 laser treatment to improve these postpartum effects.

The investigators examined 15 women who were 18 years or older (median age, 38) and who were at least 12 months postdelivery. The patients received microwave treatments (ONDA Coolwaves; Deka)

 to the abdomen once a month for 3 months followed by fractional microablative CO

 1 month later, for a total of 4 months of treatment.

Coolwaves, a patented microwave technology, reduces localized adiposities in the abdomen and other areas, according to Deka. It dissolves fat, tightens and contours the skin, and firms tissue. The technology is to be used in place of radiofrequency for tightening and skin toning, according to the company.

 fractional microablative system to cause a rapid tightening of the skin; it reduces blemishes and softens irregularities and scarring. The laser stimulates collagen production, making the skin look younger and plumper. This collagen production in turn helps prolong the treatment effects and gives more even results.

Patients were instructed to maintain the same eating and exercise habits prior to the treatments throughout the study. The investigators also did a follow-up of patients’ eating habits and weight. They used a patient satisfaction index, abdominal laxity score and measurements, and digital and 3D photography to assess the treatment’s effectiveness.

The investigators reported the overall mean circumference as 3.6 cm plus/minus 1.2 cm. Both physicians and patients reported great improvement in tightening and skin laxity, and striae distensae were also reduced. The investigators noted umbilicus repositioning following the treatment and reported that the procedure was well tolerated, with no adverse effects.

“This initial study confirms that the combined ONDA Coolwaves and SmartXide2 (microablative CO

 laser) treatment are safe and effective for the treatment of postpartum skin laxity and striae distensae,” the study authors wrote. “Thus, combined treatment could be a promising option for those patients who refuse surgical procedures in the rapidly growing demand for noninvasive aesthetic treatment.”

Jessica A. Shepherd, MD, MBA, an aesthetic gynecologist and CEO and founder of Sanctum Med + Wellness, spoke with

 as an independent commentator on the study. She says postpartum abdominal skin laxity is caused by a combination of genetics, hormonal changes, and weight gain. She adds that an increase in relaxin decreases adhesiveness between collagen fibers, and that formation of ground substance creates striae in areas causing stretch marks and loose skin. Shepherd notes that even with weight loss through diet and exercise, factors such as genetics and number of pregnancies also affect abdominal skin laxity.

“Alternative therapies for skin tightening that do not require significant downtime or surgical intervention are important options to present to women,” Shepherd says.

Regarding the study, she notes that using this particular type of laser treatment not only tightened the skin but also improved the appearance of its texture. “The upgraded technology of the Coolwaves brings up the energy to 3 times the efficiency and selectively targets subdermal fat,” she explains.

Shepherd emphasizes that although the study had a small population, the findings highlight the sustainable changes in the reduction of circumference and appearance of skin, which is appealing for women seeking marked changes in this area.

“Convenient and time-saving options for women in the postpartum phase are important, and with the variety of complex physiological changes in the skin during pregnancy, [we need] to have solutions,” she says. “This combined technology…seems promising and may create another innovative option that is safe and decreases the need for surgical intervention.”

1. Bonan P, Verdelli A. Combined microwaves and fractional microablative CO2 laser treatment for postpartum abdominal laxity. J Cosmet Dermatol. 2021;20(1):124-131. doi:10.1111/jocd.13510 

2. SmartXide2 laser. Deka. Accessed June 9, 2021. https://www.dekalaser.com/en-GB/product.aspx?item=samrt1 

3. ONDA Coolwaves. Deka. Accessed June 9, 2021. https://www.thecoolwaves.com

4. Smartxide CO2 Laser. Ciao Bella Medical Spa & Vein Clinic. Accessed June 9, 2021. https://www.ciaobellaplasticsurgery.com/smartxide-co-2-laser/

Combining microwave and microablative CO2 laser treatment is both safe and effective for treating postpartum abdominal laxity.

Microwave and Fractional Microablative CO2 Laser for Postpartum Abdominal Laxity

While scalp hair transplants are common in aesthetics, using hair transplant technology to improve facial hair outcomes is gaining increased popularity for patients who wish to improve beard and eyebrow fullness. In an interview with 

, Gary Linkov, MD, board-certified facial plastic and hair surgeon and founder and medical director of 

 in New York, New York, gives an overview of beard and eyebrow grafting to improve patient facial hair appearance.


First, when patients are preparing for grafting, he says, they are directed to stop all oral supplements along with over-the-counter medications that can cause blood thinning.


“Vitamin C and Vitamin K a week before the facial hair transplant procedure can help improve healing and minimize bleeding,” he says.


Patients shower the night before or the morning of the procedure to prevent infection and are also prescribed an antibiotic, an anti-inflammatory pill, a sedative, and ananxiolytic the morning of the procedure, he explains. Following patient consent, the beard area or eyebrow area is marked carefully to incorporate the patient’s wishes.


Patients then undergo follicular unit extraction (FUE), which takes hair strands with the follicles attached from one body site and then transplants them to the desired area. Another method of transplanting hair is follicular unit transplantation (FUT), which excises a strip of skin with hair follicles to be used.


“Once the grafts are removed, recipient site creation and then placement of the grafts occurs,” Linkov says. “The overall process may take a few hours for smaller cases, up to a full day for larger cases, and occasionally may require an extra day. A lunch break is provided for longer cases.”


Explaining the procedure downtime, he says bleeding, swelling, and bruising are all possible after a facial hair transplant. “The most important precaution in the recovery phase of a beard transplant is to not get the transplanted hairs wet for the first 5 days. This allows them to set in the proper orientation and to eventually grow,” he emphasizes.


Post-procedure, patients are also given both an oral and topical antibiotic for the donor area, he says.


For beard transplants, patients are able to shave after 10 days, he says. Linkov explains that after about 3 weeks the shafts of the transplanted hairs will usually fall out. Hair regrowth then starts at 4-6 months, with patients having final results assessed at 1 year.


There are some associated risks with the procedure; one of which is poor angulation. 

“Despite every best effort to use an acute angle to the skin surface when making recipient sites and placing grafts, occasionally, grafts may still grow at a more perpendicular angle and may need to be removed,” he notes.


There is also the chance of bump formation. “The main area at risk of small bump formation is the goatee area under the lower lip,” Linkov says. “These can be difficult to correct.”


The risk of poor regrowth, while possible, is rare, according to Linkov. “The face has very good blood supply and typically results in excellent hair regrowth,” he says. “A touch-up procedure is sometimes needed after 10 months if certain areas show poor growth.”


Finally, inclusion cysts can occur but are very rare in the transplanted beard area and may need to be incised and drained or removed, he says.


Linkov explains that scar formation is another consideration. Small circular scars are left after using the FUE method, “but they are barely noticeable even with a shaved head,” he said. The FUT method, however, leaves a linear scar across the back of the head, which makes it more difficult to wear shorter hairstyles.


“The recipient area where the new beard hairs grow should not display any scars,” he explains.


Medical conditions not compatible with local anesthesia containing epinephrine would be contraindications to FUE and FUT facial hair transplantation.


“Contraindications to facial hair transplants is scarring alopecia’s or autoimmune alopecia areata, in which the body will continue to try and destroy the hair follicles,” he says, adding that having minimal hair supply for transplantation to the facial area is also a contraindication.


1.	NYC Beard Transplant/New York Beard Restoration/UES. City Facial Plastics. 2021. Accessed May 25, 2021. https://cityfacialplastics.com/beard-transplant/


2.	NYC Eyebrow Restoration/New York Eyebrow Hair Transplant/UES. City Facial Plastics. 2021. Accessed May 25, 2021. https://cityfacialplastics.com/eyebrow-transplant/

Facial hair grafting is becoming an increasingly popular procedure with methods such as follicular unit extraction (FUE) and follicular unit transplantation (FUT) to improve the hair appearance of beards and eyebrows. 


The Growing Rate of Facial Hair Transplants

The safety and efficacy of the nutraceutical supplement, Nutrafol Women’s Balance Capsules (Nutraceutical Wellness Inc), was analyzed in a randomized, double-blind, placebo-controlled study and found to be effective, according to results published in the 

Nutrafol is a proprietary supplement containing bio-optimized phytoactive extracts, as well as vitamins, minerals, and a variety of botanicals. Specifically for Women’s Balance, the supplement has three additional ingredients from the original formula: maca, astaxanthin, and extra saw palmetto. It also includes hydrolyzed marine collagen and organic kelp.

Glynis Ablon, MD, FAAD, associate professor of clinical dermatology at the University of California at Los Angeles and director of the Ablon Skin Institute and Research Center, and Sophia Kogan, MD, cofounder and chief medical advisor of Nutraceutical Wellness Inc, conducted the research.

Seventy women aged 40 to 65 with self-perceived hair thinning were put randomly into an active treatment group (n = 40) and a placebo group (n = 30).

Prior to administering Nutrafol Women’s Balance Capsules or placebo, the study subjects had a baseline clinic visit that included a physical exam and scalp assessment. They were interviewed about lifestyle habits such as diet, exercise, stress, alcohol use, and smoking.

Study investigators examined along the frontalis bone, where the frontal and lateral hairlines come together. This location was recorded for future assessments. A square centimeter was marked for monitoring. They used macrophotography to take phototrichograms of the target area to count terminal, vellus, and total hairs.

Participants in the active group took Nutrafol Women’s Balance Capsules, while the placebo group was given an inert material that looked similar to the supplement taken by the active group. All subjects took 4 capsules with or immediately after a meal around the same time of day. Subjects then completed 90- and a 180-day follow-up visits.

Hair shedding was measured by subjects washing their hair in a cheesecloth covered sink. Fallen hairs were then counted and recorded. Investigators also took 2-dimensional global photographs to help grade hair growth and quality. A blinded investigator scored global hair growth and global hair quality on a 7-point scale (–3 to 3) at 90- and 180-day visits.

Study investigators reported a statistically significant increase in the number of terminal and vellus hairs from the phototrichogram analysis and noted the active supplement group had a progressive and significant increase in terminal and total hair counts on both 90- and 180-day visits, as well as a significant increase in vellus hair counts.

The active group saw a 32.41% decrease in hair shedding by day 180. In addition, the investigators reported that the supplement was well tolerated.

®, Ablon says the most important takeaway of the interim study for providers is that it is the first study showing these effective results.

She says providers should educate their patients about diet and nutrition to help them understand how and why Nutrafol Women’s Balance Capsules work.

“They are a natural extension of diet and nutrition,” she says. “They have been rigorously tested, standardized, and rated for efficacy.”

She also says that while the 6-month published study had interim results, the follow-up 12-month study data is in process to be published.

 Results of that follow up study, Ablon says, continues to support that Nutrafol Women’s Balance Capsules reduce shedding and promote hair growth for perimenopausal, menopausal, and postmenopausal women.

Ablon G, Kogan S. A randomized, double-blind, placebo-controlled study of a nutraceutical supplement for promoting hair growth in perimenopausal, menopausal, and postmenopausal women with thinning hair. 

. 2021;20(1):55-61. doi:10.36849/JDD.2021.5701

Nutrafol Women’s Balance. Nutrafol. Accessed March 5, 2021. 

Efficacy and safety of a nutraceutical supplement with standardized botanicals in peri-menopausal and menopausal women with thinning hair. ClinicalTrials.gov. Published August 7, 2019. Updated August 9, 2019. Accessed March 5, 2021. https://clinicaltrials.gov/ct2/show/NCT04048031

A novel nutraceutical effectively and safely improves hair growth and reduces shedding for perimenopausal, menopausal, and postmenopausal women, according to a new study.

Nutraceutical Efficacy in Perimenopausal, Menopausal, and Postmenopausal Women

Results of a 2020 prospective study published in 

show that a novel helium plasma device has potential for treating facial rhytidosis safely and effectively, significantly improving facial appearance with rapid recovery and delivering high subject satisfaction with relatively few unanticipated adverse events.

Conducted by J. David Holcomb, MD, president and medical director of Holcomb – Kreithen Plastic Surgery and Medspa, Sarasota and Tampa, Florida, and founder and executive medical director of the Institute for Integrated Aesthetics, and colleagues, the study included 55 healthy men and women 30 years or younger were selected from 3 study sites who wanted to improve the appearance of facial rhytids and wrinkles.

For the study, patients were required to have a Fitzpatrick Wrinkle and Elastosis Scale (FWS) score of 2 or less and a Fitzpatrick Skin Scale score of III or more. In addition, patients agreed to not have any other facial cosmetic procedures through a 6-month follow-up visit, investigators report.

Patients had any facial wrinkles and rhytids assessed and documented prior to the procedure with digital imaging. This was also used for assessment at follow-up visits.

Given prophylactic treatment of bacterial and viral infections at the investigator’s discretion, patients also completed a visual analog scale pain assessment before and immediately after the procedure, according to investigators.

The face was divided into 5 zones: zone 1, perioral; zone 2, periorbital; zone 3, forehead; zone 4, nose; and zone 5, cheek. After pain mitigating procedures, tissue was ablated with steady movement and a single, non-overlapping pass of the helium plasma beam on all 5 zones.

Zone 1 and 2 used a maximum of 20% power and 4 L/minute helium flow and the vast majority of subjects were treated at 20% power across all treatment zones (1 through 5). The procedure was performed in continuous, nonpulsing mode and treated tissue was left undisturbed, the authors say.

“Power levels were limited to 20% at peri-oral and peri-orbital areas-a level that correlates to an energy density 40% lower than the highest setting on the predicate device,” investigators write.

Patients were given posttreatment protocol consisting of keeping the skin moist for 10 days after the procedure, covering the skin with petroleum jelly, cool water vinegar soaks every 1 to 2 hours on days 0 to 2 and every 2 to 4 hours on days 3 to 10. After 10 days, patients were instructed to use moisturizer and sunscreen, along with discontinuing the other topical treatments.

Patients were assessed by investigators directly post procedure and at 10 days, 1 month, 3 months, and 6 months. No serious adverse effects were reported. Baseline FWS scores and 3-month assessment scores were compared by blinded independent photographic reviewers (IPRs) and study investigators.

Blinded IPRs reported 63.64% of patients had a 1‐point FWS improvement or greater, while study investigators reported 98.18% had1‐point FWS improvement or greater. Nearly 91% said they believed their appearance had improved using the modified Global Aesthetic Improvement Scale.

“Subgroup analysis showed 1‐point (±0.05) FWS improvement by IPRs and study investigators for Fitzpatrick skin types II and III, age 62 [years or older], 2 of 3 study sites, and posttreatment oral steroid use,” investigators write.

The greatest FWS improvement was seen in patients aged 62 years and older when the cohort was divided into 2 groups using the age as a mediator.

“A finding of greater improvement with slightly thinner and therefore more compliant skin in the older subgroup is an expected finding that is consistent with observed skin response with other dermal resurfacing technologies,” according to investigators.

After 6 months, they reported clinically significant improvement, with “a mean (SD) change in baseline FWS of −3.0 (0.92) points.”

®, Holcomb says the key takeaway from the study was that “even at modest treatment parameters of 20% power and a single pass, we observed very significant improvements in skin tone and texture including in some cases rather dramatic wrinkle reduction.”

He added that the findings most helpful to aesthetic physicians who already perform the procedure or are thinking about offering it, are to restrict treatment to Fitzpatrick Skin types I, II, and III while also only doing a single pass with helium plasma until the provider is comfortable with the technology.

“A more vigorous treatment study with higher power and double pass treatment is currently underway,” Holcomb says.

Holcomb JD, Kelly M, Hamilton TK, DeLozier JB 3rd. A prospective study evaluating the use of helium plasma for dermal resurfacing. 

 2020;52(10):940-951. doi:10.1002/lsm.23257.

Renuvion Dermal System for dermal resurfacing. ClinicalTrial.gov. Published December 4, 2019. Updated November 12, 2020. Accessed March 3, 2021. 

https://clinicaltrials.gov/ct2/show/NCT04185909

A single pass with a low-energy helium plasma device appears safe and effective in treating facial rhytidosis, especially in patients aged 62 years and older.

Helium Plasma for Facial Rhytids

Laser-assisted drug delivery (LADD) helps the skin absorb exogenous macromolecules and improve treatment for wrinkles.

Research published by Barbara Helena Barcaro Machado, MD, of the Pharmaceutical Research Group at the School of Allied Health, Faculty of Health, Education, Medicine and Social Care at Anglia Ruskin University in Chelmsford, UK and colleagues, in 

examined the efficacy of using LADD to improve vitamin C delivery, concluding that while the use of LADD improved the delivery of vitamin C and vitamin C plus growth factor (GF), vitamin C plus GF showed the best results for wrinkle reduction.

Machado et al say it is established knowledge that lasers can affect drug delivery and bio-distribution, and this study builds on that initial research. However, LADD is not an established therapy. Current evidence mostly relies on laboratory tests, animal experiments, and cadaver skin for published data.

The study authors conducted a randomized, double-blind, prospective clinical trial that enrolled 149 women, aged 43 to 70 years, with periorbital wrinkles. Divided into 2 groups, the control group of 74 women received vitamin C only (R-C), while 75 women in the experimental group received vitamin C with a GF cosmeceutical (R-CGF).

Investigators examined the effects of topical drug application immediately after laser skin resurfacing of wrinkles, with the R-C group receiving vitamin C alone (Vitasantisa) and the R-CGF grouping receiving both Vitasantisa and the patented cosmeceutical TNS Recovery Complex (SkinMedica; Allergan)

 that contained added growth factor. Both groups’ treatment areas were kept under occlusion for 30 minutes, according to study authors.

Researchers used a 3D stereophotogrammetry digital camera system (LifeViz Micro; QuantifiCare)

 that provided software readouts (DermaPix; QantifiCare)

 to provide statistical analysis for effectiveness of treatments. Patients were evaluated before treatment and at a 3-month follow-up. Machado and colleagues examined pre- and post procedure results for significant changes in average wrinkle depth and in the roughness of skin.

Patients were given a single round of treatment. Investigators reported any skin crusting that lasted 5 to 8 days, and all patients were noted to have early moderate periorbital swelling that was gone by the third day. After the seventh day, post laser erythema was reported, and had disappeared by day 20, investigators said.

“There was a significant reduction in both skin roughness and average depth of the wrinkles in the group treated with vitamin C and growth factors (

 < .01) than those treated with LADD followed by topical application of vitamin C alone,” Machado and colleagues reported, in the study, continuing that there were no adverse systemic or cutaneous reactions in patients.

Despite promising results, study authors emphasize that more research is needed to examine the “theoretical risk of systemic toxicity” based on prior studies.

They noted it was difficult to determine how the skin absorbs drugs only using molecular properties due to a variety of factors: dietary intake, endogenous production of substances, blood flow variations, and “the complex, new surface area and geometry created by the laser-induced microchannels.”

This raises concerns about approval and “has limited further objective research and restricted the commercialization of active delivery products,” according to the authors and but continue to say that “to date, no adverse toxicity has ever actually been linked to LADD.”

Machado BHB, Frame J, Zhang J, Najlah M. Comparative study on the outcome of periorbital wrinkles treated with laser-assisted delivery of vitamin C or vitamin C plus growth factors: a randomized, double-blind, clinical trial. 

 2020;10.1007/s00266-020-02035-z. doi:10.1007/s00266-020-02035-z

TNS Recovery Complex. SkinMedica. Accessed February 25, 2021. 

https://www.skinmedica.com/products/correct/tnsrecoverycomplex

LifeViz Micro: a portable 3D system for skin microstructure analysis. Quantificare. Accessed February 25, 2021. 

https://www.quantificare.com/3d-photography-systems/lifeviz-micro/

DermaPix. Quantificare. Accessed February 25, 2021. 

https://www.quantificare.com/mobile-technology/

Laser-assisted drug delivery helps the skin absorb exogenous macromolecules and improve treatment for wrinkles; however, more research is needed to determine patient safety.