YOUNG ADULTS WANTING BOTULINUM TOXIN COSMETIC TREATMENTS 

Injectable neurotoxins continue to be a staple of aesthetic practices worldwide, but little is known about the use of this therapy in younger patients.

A recent review investigation¹ appearing in the Journal of Cosmetic Dermatology sheds light on this issue and calls for more research to fill the gap. ‘’When I started practicing 15 years ago, some younger patients wanted wrinkle reduction, but the patient was commonly aged 50 and older,” explained author Alain Michon, MD, medical director of The Ottawa Skin Clinic/Project Skin MD in Ottawa, Ontario, Canada. “There has been a recent shift in the patient demographic with younger patients seeking injectable neurotoxin, but also in the treatment paradigm with prevention in mind, rather than correction.”

Despite this shift, there remains a lack of high-quality research on use of injectable neurotoxins in this patient demographic. In fact, Dr. Michon could only find four papers that fit his basic criteria of age range (under 41 years) and therapy choice (neurotoxin injections for facial cosmetic correction only, no combination therapies). “Only two studies were post hoc analysis of randomized controlled trials, the other two were observational studies,” he explained.

In addition to reviewing the existing research, Dr. Michon also conducted a cross-sectional online survey of aesthetic practitioners to get a sense of current practices. “There is always pressure from manufacturers to adhere strictly to recommended dosages, but we all know that, in practice, this does not happen. As a community, we rely on the science, but we also rely on our clinical experience to determine safe and effective dosages, partly aligned with patient desires for correction.”

According to Dr. Michon, the findings suggest that injectable neurotoxin is effective, as expected, but there is much to be learned from the dosing patterns and motivational factors among the younger population. “Our work showed that this population tends to receive smaller doses for the common injection targets and are looking for prevention, rather than correction,” he said. “Furthermore, they want to avoid an unnatural or ‘frozen’ look.”

“We are also seeing a movement toward more neurotoxin microinjection for management of skin quality, called ‘microtox,’ which understandably appeals to the younger population because of their stated goals,” he added. “As practitioners, we need to have a total consultation in an effort to understand the patient’s aims. More study of this would be revealing.”

Dr. Michon also noted that patient goals are not always considered in research. “We see studies that determine efficacy of dosages –the issue of dose-response – but not how this may correlate with what the patient was hoping to achieve. There is a psychosocial aspect in this field of medicine that is very important to account for, especially as we trend toward more holistic approaches in the industry.”

This may help practitioners improve their treatment planning as they attempt to better individualize therapy, but certainly more research is needed. “There are weaknesses inherent to injectable neurotoxin research due to the methodologies and dosage unit differences, but in this case, we are further held back because there is so little research on the specific subject which, given current trends, we should rectify,” Dr. Michon explained.

Reference:
1. Michon A. Botulinum toxin for cosmetic treatments in young adults: An evidence-based review and survey on current practice among aesthetic practitioners. J Cosmet Dermatol2022; epub ahead of print.

Editor’s Note: The original article Botulinum Toxin for Cosmetic Treatments in Young Adults: An Evidence-Based Review and Survey on Current Practice Among Aesthetic Practitioners, is open access and available online at: https://onlinelibrary.wiley.com/doi/full/10.1111/jocd.15513

ELEVATING THE DORSUM FOR ETHNIC RHINOPLASTIES 

Augmentation rhinoplasty, while less common, is more prevalent in ethnic populations where the bridge of the nose is lower, and the tip either does not project adequately and/or tends to be wide.
“For these populations, surgical augmentation makes the nose narrower and more defined-looking in the frontal view and contribute to what the patient perceives as an overall improved facial appearance,” explained plastic surgeon Dean Toriumi, MD, of Toriumi Facial Plastics (Chicago, Ill.).

“The problem is that many current techniques rely on artificial materials; these may become infected, or cause deformity or thinning of the skin over time,” said Dr. Toriumi. “Using autologous material may be intimidating to some physicians but is more desirable, and easily within the scope of what most plastic surgeons can learn to do comfortably, which I believe is worth the effort.” To help patients –and their surgeons – achieve optimal results, Dr. Toriumi published his technique¹ in Facial Plastic Surgery & Aesthetic Medicine.

The cornerstone of Dr. Toriumi’s technique is that unlike many dorsal onlay grafts where new material is placed on top of the nasal dorsum, the bridge of the nose is surgically separated from the underlying septum, and harvested cartilage is placed underneath to elevate it – a key advantage. “This lifts the entire bridge of the nose, which simultaneously preserves and works with the patient’s natural facial contours,” he said. “Each individual’s dorsal aesthetic lines, as they are called, have a unique person-al contour which is very difficult to recreate, so why not try to preserve them?

“When you use the more traditional graft above the bridge, the graft may shift or change shape after a while, or the skin may thin, any of which can create an unnatural appearance,” he added.

According to Dr. Toriumi, his technique is a logical extension of a technique known as dorsal preservation. “Essentially, dorsal preservation means cutting bone below the bridge to push the ‘bump’ of the nose down rather than chopping the top of that hump away in patients with a narrow, tall nose. The goal is to preserve the patient’s natural facial contours, letting what is already there provide what would otherwise need to be reconstructed by the surgeon.”

While this technique is beginning to gain traction in the U.S., it is very popular in Europe, South America and Mexico. “I have been using this technique for three years and I find it very effective, so I thought that if we are completely freeing up the bridge, why not elevate it from below for augmentation cases? After all, if your house is shifting you often need to raise and shore up the foundation, not build on top of it or replace the roof with a new one.”

The procedure, and paradigm, of dorsal preservation is less commonly understood in the U.S. “This can be intimidating to some, but if you embrace the dorsal preservation procedure, the bone cuts become familiar quickly, as do the ways in which the cartilaginous vault can be manipulated effectively,” noted Dr. Toriumi.

The patient’s own rib cartilage is an ideal graft. “The rib cartilage is best, not septal or ear cartilage which would not be strong enough to support the bone from below,” he explained. “The graft must sufficiently support the bridge in its new position for the lifetime of the patient.”

A one-inch incision, typically on the right side of the chest, will provide access to the ribcage where a 6 cm to 7 cm segment of costal cartilage can be obtained. “If the patient’s cartilage is softer, a costochondral rib bone segment is best but usually I prefer, denser, more calcified costal cartilage from the seventh rib. A bony portion should be left to provide an ossifying interface to fix the graft properly.” The strength of the graft can be assessed before harvest using a 1.5 inch, 22-gauge needle.

While cadaver rib is a possibility, Dr. Toriumi always prefers an autologous graft. “Going to a secondary site is more complicated and lengthens the procedure, but to me it is worth it to obtain a superior autologous graft.”

Computer imaging can help the physician and patient visualize possible outcomes and make specific choices such as positioning of the middle vault, ideal tip projection, dorsal width and radix elevation, according to Dr. Toriumi.“We often use chin projection as a guide to how much tip projection will be acceptable.”

He added that other procedures such as chin or glabellar augmentation may be called for in some cases.

Also, the utility of the technique is not limited to specific ethnic groups. “This can be used in patients that have a low dorsum or what we call a saddle nose deformity. In fact, close to half of the cases I have treated were caucasian patients with either some natural or post-traumatic deformity, but I believe this will catch on more with the ethnic patients seeking this kind of correction.”

Reference:
1. Toriumi, DM. Subdorsal cantilever graft for elevating the dorsum in ethnic rhinoplasty. Facial Plastic Surgery &Aesthetic Medicine.2022;24(3):143 – 159.

Editor’s Note: The original article Subdorsal Cantilever Graft for Elevating the Dorsum in Ethnic Rhinoplasty, is open access and available online at: https://pubmed.ncbi.nlm.nih.gov/35724256/

ELEVAI LABS, INC., a medical aesthetic biotechnology company specializing in physician-dispensed skincare, proudly announces the addition of Crystal Muilenburg as an independent member of the company’s Board of Directors.

Crystal brings more than two decades of experience in marketing, corporate communications, and public relations for global Fortune 500 companies and public-company start-ups. She will play a key role in supporting the ELEVAI management team as it commercializes ELEVAI’s flagship exosome product line while driving the market adoption for physician-dispensed topical exosomes.
 
“I’m thrilled to join ELEVAI as they establish a new segment of physician-dispensed skincare products harnessing topical exosomes,” shares Muilenburg. “With a science-first approach, an industry-leading management team, and the market’s interest in the novel approach to skin leveraging the power of exosomes, ELEVAI’s future is bright.”
 
Most recently, Crystal served as Chief Marketing Officer for Evolus where she led the re-launch of Jeuveau®[1], a disruptor brand to BOTOX® Cosmetic[2]. Under Crystal’s leadership, Jeuveau became one of the fastest-growing neurotoxins in the United States and one of the top product launches in aesthetics history.
 
Prior to Evolus, Crystal was Head of Global Strategic Marketing for Sienna Biopharmaceuticals, a publicly traded, clinical-stage medical dermatology company. Crystal also spent more than a decade at Allergan in various leadership roles in US and International marketing and communications where she gained significant FDA approval and commercial launch experience with the company’s flagship BOTOX franchise and leading aesthetics brands.
                       
“We are excited to welcome Crystal to ELEVAI’s Board,” details ELEVAI Founder, Jordan R. Plews, Ph.D. “We believe her track record, accomplishments, and science-first approach will help propel ELEVAI in becoming the preferred topical exosome company as this segment continues to grow in interest and demand.”

ABOUT ELEVAI

ELEVAI LABS, INC. is a biotechnology company developing cutting-edge physician-dispensed skincare applications. The company solves unmet needs in the regenerative aesthetics space through a combination of cutting-edge science and next-generation consumer applications. ELEVAI Labs develops state-of-the-art topical aesthetic and medical-grade skin care with a focus on leveraging a proprietary stem cell exosome technology.

Source:

ELEVAI

Candela, the leading provider of energy-based solutions worldwide, and the pioneer of the first and only long-pulse radiofrequency (RF) microneedling device, announces the launch of the all-new Profound Matrix™ system.

Designed to correct, maintain, and restore skin at various stages of the aging journey, this multi-application system features the Sublime™, Sublative™ RF, and all-new Matrix Pro™ applicators. The renowned Sublime and Sublative RF applicators deliver bipolar RF treatments that improve the appearance of fine lines and wrinkles, while the all-new Matrix Pro applicator is designed to regenerate and build new collagen^1,2 with the added benefit of delivering a marked improvement in overall skin appearance and texture.^3,4

The Matrix Pro applicator uses an array of the thinnest microneedles on the market* that deliver short-pulse RF energy to the skin, designed to improve patient comfort, minimize downtime, and maximize results. ** With its one-of-a-kind Depth Intelligence™ technology complete with real-time impedance monitoring, the Matrix Pro applicator can deliver up to 3 distinct user-controlled depth and energy settings in a single insertion, allowing for customized and consistent treatment outcomes. 

"The Matrix Pro applicator is a major breakthrough in energy-based devices," states Macrene Alexiades, MD, Ph.D., FAAD. "Its Depth Intelligence technology and real-time impedance monitoring allow for precise energy delivery at up to 3 adjustable and penetrable depths with a single insertion, while also providing vital feedback to the user during treatment. The Profound Matrix system presents a huge technological leap in RF microneedling technology."  

Powered by Dimensional RF™, the first-in-class Profound Matrix system creates an entirely new category of medical aesthetic treatments that deliver multi-dimensional treatment outcomes. Achieved by leveraging multiple modalities working at up to 3 depths of the skin, this approach allows practitioners to customize and deliver precise treatments based on patient needs while creating volume³ and strengthening skin structure.5

"The Profound Matrix system and its Matrix Pro applicator take radiofrequency to a whole new level," states Gilly Munavalli, MD, MHS, FACMS. "The versatility of the Profound Matrix system, with its user-controlled depth and energy settings, allows the user to easily tailor treatment depths and the number of passes to accommodate each patient's anatomy and comfort level. Using only topical numbing, my patients have been extremely happy with their results and report low pain scores with minimal downtime". **

Scott Gerrish, DO, has also seen success with the Profound Matrix system by offering complementary treatments with the Sublative RF and Matrix Pro applicators. "We've seen improvement in the patient's skin luminosity, texture, and overall skin appearance as soon as one-week post-treatment. The Sublative RF applicator effectively resurfaces the skin, while the Matrix Pro applicator stimulates new collagen growth with a completely customized treatment. Patient satisfaction has gone through the roof after receiving these complementary treatments."

"With its advanced outcome-focused technical innovations that deliver consistent results, we expect the Profound Matrix system to be the #1 choice for providers looking to add radiofrequency-based skin treatments to their offerings," states Geoffrey Crouse, Chief Executive Officer of Candela. "With the launch of the Profound Matrix system, Candela is now the first and only company in the aesthetics space to deliver a full range of microneedling products that span the spectrum from mechanical microneedling pens (Exceed™) to short-pulse RF microneedling devices (Matrix Pro applicator) to long-pulse RF microneedling devices (Profound®)," he concludes.  

To learn more about the Profound Matrix system please visit candelamedical.com or reach out to a Candela Sales representative today.

Continue reading here.

Source:

Candela / PR Newswire

Anti-aging hormone therapies allow patients to reclaim hope of counteracting age-related hormonal changes. With nearly 48% of menopausal American women taking hormone therapies, this industry is already a multi-billion-dollar business expected to reach around $53 billion by 2030. Francisco Llano, MD, a specialist in nutrition and anti-aging in Mexico City, Mexico, compares the endocrine system to an orchestra. “One out-of-tune hormone can result in significant changes to some of the body’s standard processes,” he said. In addition to skin aging, waning hormone levels manifest as weight gain, energy loss, decreased sex drive, sleepless nights, memory loss, mood swings, hot flashes, decreased muscle mass and more.
 
As the sex hormones estrogen (estradiol), progesterone, and testosterone lessen, shifts in bone health, protein synthesis, and muscle mass transpire in both sexes.

“There is this idea that only sex hormones age, but all hormones age,” Dr. Llano reported. Take, for example, declining cortisol, which hampers the body’s ability to react to stressors. Or changes to DHEA (considered an anti-aging hormone) levels. The adrenal gland shrivels, making low levels of DHEA, which compromises hormone function and can trigger dementia, osteoporosis, and cardiovascular disease.

Changes in sleep affect hormones as well. When melatonin is not secreted correctly, tiredness, increased weight and lack of energy result. Production of human growth hormone (HGH), which is critical for tissue and muscle growth, metabolism, cell division, strength, protein synthesis, and standard body structure, peaks during sleep. Growth hormone is paramount because of its involvement in the secretion of all other hormones, and a lack of it affects the body’s ability to carry out essential functions.

Other hormones, like cortisol, insulin, thyroid, follicle-stimulating, luteinizing, and parathyroid hormones, are equally susceptible to changes. However, not all hormones age proportionally or identically. For example, leptin (responsible for decreasing appetite and controlling weight) and the hunger hormone ghrelin do not decrease much. On the contrary, insulin – the only hormone that increases with age – causes insulin sensitivities, including glucose intolerance and diabetes.

Midlife Hormone Shifts

Menopause occurs in female patients around midlife and marks the end of the menstrual cycles. During this time estrogen dips suddenly, resulting in moodiness, hot flashes, sleeplessness, vaginal dryness and atrophy, as well as painful intercourse. Bone and skin health change as well.

According to Felice Gersh, MD (Irvine, Calif.), who is board certified in the practice of obstetrics and gynecology, as well as integrative medicine and an expert in menopause and hormones, “Estrogen-supported components of skin like fat, elastin and collagen levels change.” This can cause skin thinning, as well as an increase in wrinkles and dry skin. Chronic inflammation during menopause can also be attributed to low estrogen because estrogen regulates the immune system. “High levels of inflammation up-regulates 5-alpha reductase, which converts testosterone into dihydrotestosterone (DHT), increasing hair growth on the face and hair loss on the head,” added Dr. Gersh.

Men also experience hormone changes as they age, called late-onset hypogonadism. Unlike menopause, this shift results in a gradual decrease in testosterone. In addition to declining testosterone, male patients may also experience changes to androgen levels and the secretion of DHEA and DHEA-S. Symptoms from these changes can include muscle tone and mass changes, low libido and erectile dysfunction, low energy levels, depression, skin health decline and musculoskeletal deficiencies.

Is Hormone Replacement Therapy the Fountain of Youth?

Hormone replacement therapy (HRT) places power back in the hands of physicians and patients, and acts as a valuable tool to counteract the effects of aging.

Bioidentical hormone replacement therapy (BHRT) uses hormones that are most similar to those produced by the body to slow the negative effects of aging. However, BHRT is not a one-size-fits-all solution.

Jennifer Pearlman, MD, a medical doctor focusing on women’s health and wellness in Toronto, Canada, stressed the importance of customization so that each patient receives hormones to improve their specific symptoms. “Mammograms and vaginal ultrasounds, which provide accurate biomarkers of estrogen status, are necessary to determine any underlying malignancies in the breasts or uterine lining since both are hormone receptor-positive,” she explained. “Other hidden dangers and diseases, like hypothyroidism, may also be present and should be identified.”

Many doctors have hormones they prefer to administer to relieve a patient’s symptoms. “I give precedence to DHEA, growth hormone and testosterone for male patients, and estrogen for female patients,” said Jose Vazquez Tanus, MD, a board-certified integrative physician specializing in anti-aging and regenerative medicine in Ponce, Puerto Rico.

“In male patients, growth hormone must measure the insulin micro factor of insulin-like growth factor-1 (IGF1) and insulin-like growth factor binding protein-3 (IGFBP3); however, replacing growth hormone is controversial,” Dr. Tanus explained. “Integrating lifestyle changes can also help patients delay the decline of growth hormone and IGF1 secretion.

“ Female patients notice increased libido, plus other benefits when starting testosterone and estrogen,” Dr. Tanus continued. “Most patients see a difference in the body and brain. It helps those with dementia since testosterone improves focus, sharpness, brain health and memory.” BHRT can be administered via pellets, injections, topical creams, patches, vaginal suppositories and oral capsules. Dr. Tanus is a proponent of pellets, but not all physicians agree with this approach.

“In human physiology we never have a bolster of hormones that last a month,” Dr. Pearlman asserted. “Hormones work the opposite way; they have a rhythm and release profile,” she continued. So, her approach is to administer hormones via creams and patches instead of loading them up.

Dr. Gersh also favors transdermal methods like patches, gels and creams to deliver a steady dose of estrogen, progestin and testosterone for female patients, and testosterone for male patients. She uses other methods for non-sex hormones. “I usually prescribe a pill or another oral solution for thyroid hormone replacement. The goal is to create an environment akin to a patient at their healthiest via human identical hormones,” she noted.

BHRT injections are another modality. These weekly injections are a quick and cost-effective way to reestablish hormone levels but often result in dips by the end of the week

Alternative Approaches

Some physicians, like Dr. Llano, use more natural approaches like supplements, diet and exercise to balance hormones. For example, clinical-grade supplements of melatonin and DHEA can protect against dementia, obesity, lipid metabolism, diabetes, atherosclerosis, and osteoporosis, and can elevate testosterone production in older male patients. “DHEA is one of the most important hormones to integrate into a treatment plan,” Dr. Tanus indicated. “I prefer supplements that increase the DNA chain’s length by reducing the loss of telomeres.”

Something that Dr. Pearlman often introduces is DHT supplements to treat low androgen and testosterone levels in female patients, as it helps to reverse the effects of hormone-related hair loss and thinning.

A well-devised nutrition plan can also help counteract age-related hormonal changes. Anti-inflammatory diets that incorporate antioxidant-rich fruits and vegetables may help improve metabolic function and insulin secretion. High-calorie restrictive diets may reduce obesity and improve longevity.

“Exercise is also critical,” Dr. Llano stated. “Patients who do not workout lose the ability to maintain hormone health. Routine exercise is essential for maintaining bone and brain health, and resistance exercise stimulates muscle protein synthesis. ”Newer technologies like PRP injections can also help declining hormone levels, according to Dr. Tanus. Extracting platelets from a patient’s blood allows the growth factors in the platelets to stimulate healing. “Platelets are regulated by estrogen, which accelerates vascular system healing. That is why older skin does not heal as well as younger skin,” Dr. Gersh commented.

Incorporating Hormone Therapies in Your Practice

Patients and consumers continue to invest in therapies that will improve their health span, making anti-aging treatments and therapies here to stay. While HRT can be a valuable addition to any practice, experience is paramount. “Patients should only receive bioidentical hormones from doctors well versed in the therapy,” stressed Dr. Pearlman. “When hormones are out of balance or taken in the wrong form, they can contribute to serious problems like estrogen-dependent breast cancer in female patients. Even though hormone replacement can be part of a successful anti-aging plan, there is liability associated with this type of therapy and it requires a skillful, experienced physician.” Dr. Llano suggests incorporating basic hormone practices with plant-based options for physicians interested in integrating hormone therapy into their practice. “Some schools teach how herbal supplements work and how to dose and administer them,” he shared. He also recommends physicians explore additional courses to learn about normal and optimal hormone levels.

Some doctors also partner with hormone experts and endocrinologists to offer services within their practice so that therapies can be provided under the watchful eye of an expert.

References:
1. https://www.merckmanuals.com/home/hormonal-and-metabolic-disorders/biology-of-the-endocrine-system/effects-of-aging-on-the-endocrine-system
2. https://my.clevelandclinic.org/health/articles/15660-bioidentical-hormones
3. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC8020896/
4. http://www.surgicalcosmetic.org.br/details/229/en-US/hormones-in-rejuvenation--a-review-of-their-true-effective-ness
5. https://www.verywellhealth.com/why-we-age-theories-and-effects-of-aging-2223922
6. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3636678/
7. https://academic.oup.com/biomedgerontology/article/75/2/394/5623032
8. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6780820/
9. https://www.menopause.org/for-women/sexual-health-menopause-online/changes-at-midlife/changes-in-hormone-levels
10. https://journals.physiology.org/doi/full/10.1152/ajpendo.00366.2002
11.  https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3746247/
12. https://www.karger.com/Article/Fulltext/367692
13. https://eje.bioscientifica.com/view/journals/eje/176/6/R283.xml