Development and Validation of a Photonumeric Scale for Evaluation of Facial Skin Texture

Advances in Topical Botulinum Therapy

BACKGROUND

A successfully developed topical botulinum toxin product would overcome the disadvantages of injectable administration commonly seen with all available botulinum products, including the potential pain, bleeding, and bruising associated with injection.

OBJECTIVE

Identify the disadvantages of injectable administration of botulinum products and advantages of topical administration. Identify previous attempts to develop topical products and review the only topical product candidate (ET-01, abbreviated EMX) under clinical development.

MATERIALS AND METHODS

A literature review regarding injectable botulinum products and topical botulinum product candidates and an analysis of data regarding EMX development were performed.

RESULTS

Multiple disadvantages of injectable administration and advantages of topical administration of botulinum toxin were identified. If available, topical botulinum products are expected to expand the clinical use of botulinum toxin. Several previous attempts to develop topical products were identified. EMX has been studied for lateral canthal line treatment in multiple controlled phase 2 clinical trials including over 700 subjects. EMX has demonstrated statistically significant positive results.

CONCLUSION

The development of a topical botulinum toxin is appealing because it overcomes multiple disadvantages observed with injectable administration and would likely result in increased clinical use of botulinum toxin. The development of EMX shows promise and merits further study.

Comparative Analysis of Efficacy of Lactic Acid 30% with Ferulic Peel 12% (Combination Peel) Versus TCA 10% with Ferulic Peel 12% (Combination Peel) for Photoageing Skin

OBJECTIVES

Chemical peels are used to treat photoageing, pigmentation, improve complexion and dull skin, fine lines and scars. The objective of this study is to do comparative analysis of Lactic Acid 30% with Ferulic peel 12% (combination peel) versus TCA 10% with Ferulic peel 12% (combination peel) for Photoageing Skin.

MATERIALS AND METHODS

This is a retrospective study from September 2021 to 2022 with total 50 female patients aged between 25 and 40 years were treated. Randomisation of patients was done (simple randomisation using lottery method) for both groups with 25 patients enrolled in each group. The first group (Group A-25 patients) were treated with lactic acid 30% with Ferulic peel 12% (combination peel). The second group (Group B-25 patients) were treated with TCA 10% with Ferulic peel 12% (combination peel). Inclusion and exclusion criteria have been defined for the study. Two scales have been used for assessing the results: Allergan Skin Roughness Scale (ASRS) and Allergan Fine Line Scale (AFLS). ASRS and AFLS scores were assessed at pre-treatment (pre) and post treatment (post-1 month after last peel session). Data were summarised in Mean ± SD (standard deviation). Pre and post groups were compared by paired t test. The pre to post change in outcome measures between two independent groups were compared by independent Student's t test. Discrete (categorical) groups were compared by Chi-square (χ2) test. A two-tailed (α=2) P < 0.05 was considered statistically significant. Analyses were performed on SPSS software (Windows version 22.0). Patients were followed up for 6 months post treatment.

RESULTS

In Group A, comparing the pre and post ASRS score, paired t test showed significant (P < 0.001) decrease or improvement of 56.1%. In Group B, comparing the pre and post ASRS score, paired t test showed significant (P < 0.001) decrease or improvement of 52.8%. Comparing the pre to post mean decrease or improvement in ASRS score of two groups, Student's t test showed similar (P > 0.05) improvement between the two groups though it was 2.5% higher in Group B as compared to Group A. In Group A, comparing the pre and post AFLS score, paired t test showed significant (P < 0.001) decrease or improvement of 63.2% at post as compared to pre. In Group B, comparing the pre and post AFLS score, paired t test showed significant (P < 0.001) decrease or improvement of 58.8% at post as compared to pre. Further, comparing the pre to post mean decrease or improvement in AFLS score of two groups, Student's t test showed similar (P > 0.05) improvement between the two groups though it was 16.7% higher in Group A as compared to Group B.

CONCLUSION

Study found both the treatments equally effective in the management of ageing skin after 6 months of treatment. However, study needs further validation on larger sample size, varied age groups and male gender.

LEVEL OF EVIDENCE V

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Development and Validation of a Composite Skin Quality Scale

Background

The increasing demand for skin quality interventions in aesthetic medicine underscores the necessity for objective, evidence-based assessment tools that may be used to evaluate novel interventions or devices.

Objectives

To develop and validate a 5-point photonumeric rating scale for assessing overall skin quality, including radiance, color evenness, and smoothness.

Methods

The IBSA (Institut Biochimique SA) Composite Skin Quality Scale was developed and underwent live validation with 88 real-world patients, chosen to encompass a broad spectrum of skin qualities and Fitzpatrick skin types. Scale validation was performed by board-certified plastic surgeons and dermatologists over 2 rounds, 2 weeks apart. Reliability was assessed through intrarater and interrater agreements, utilizing weighted kappa statistics and intraclass correlation coefficient (ICC). The scale's ability to discern a clinically relevant 1-grade difference was evaluated with 72 photo pairs.

Results

Combined intrarater reliability results showed weighted kappa values of 0.812 (right side) and 0.815 (left side) and an ICC of 0.903 for both sides, indicating an almost perfect agreement. Interrater reliability ranged from substantial to almost perfect, with kappa coefficients between 0.654 and 0.853 and ICCs between 0.657 and 0.855 across all rater pairs in both rounds. The ability to detect a clinically relevant 1-point difference using the scale was established.

Conclusions

Integrating various key aspects of skin quality, the IBSA Composite Skin Quality Scale is a clinically relevant and highly reliable tool, suitable for skin assessment in clinical studies of new aesthetic technologies and products.

Level of Evidence 3

Improved Patient Satisfaction With Skin After Treatment of Cheek Skin Roughness and Fine Lines With VYC-12L: Participant-Reported Outcomes From a Prospective, Randomized Study

BACKGROUND

VYC-12L is a hyaluronic acid filler to improve skin quality. A prospective study showed safety and effectiveness of VYC-12L for improving cheek skin smoothness and fine lines.

OBJECTIVES

To report participant-reported outcomes, subgroup analyses, and physician experience from the prospective study.

METHODS

Adults with moderate to severe Allergan Cheek Skin Smoothness (ACSS) scale scores were randomized 2:1 to VYC-12L or control (no treatment with optional treatment). Participant assessments included FACE-Q Satisfaction With Skin, FACE-Q Appraisal of Lines, natural look and feel, the Global Aesthetic Improvement Scale (GAIS), and safety. Subgroup analyses examined ACSS responder rate (≥1-grade improvement from baseline to 1 month).

RESULTS

FACE-Q Satisfaction With Skin overall mean scores improved from baseline to 1 month posttreatment by 32.0 and 1.4 in the VYC-12L and control groups, respectively. FACE-Q Appraisal of Lines overall mean scores improved from baseline to 1 month posttreatment by 23.3 and 0.4 in VYC-12L and control, respectively. Treated participants had high median scores (≥9.0) of natural look and feel of their cheek skin. GAIS responder rate was high at Month 1 (85.5%; 95% CI, 79.3%-91.7%) and through Month 6 (83.1%; 95% CI, 76.5%-89.7%). Mean participant-rated pain scores were low (<3). The most common injection site reactions were redness, swelling, and lumps/bumps; most resolved within 3 days. Subgroup analyses showed significant differences in ACSS responder rate between VYC-12L and control groups 1 month posttreatment. Physician injectors reported that VYC-12L was easily injected at the superficial skin and integrated quickly.

CONCLUSIONS

VYC-12L treatment produced significant improvements in satisfaction with skin and cheek skin smoothness, as measured by participant-reported outcome measures.

LEVEL OF EVIDENCE: 2

Combining Diamond-Tip Dermabrasion Treatments and Topical Skincare in Participants with Dry, Hyperpigmented, Photodamaged or Acne-Prone/Oily Facial Skin: A Clinical Usage Study

Purpose

An in-office diamond tip microdermabrasion device (DG) was designed to simultaneously exfoliate, extract, and infuse topical cosmetic serums into the skin to improve its appearance. Combining in-office procedures with take-home skincare may enhance treatment outcomes. This study aimed to assess the efficacy of a novel combination of DG treatments with a take-home cosmetic skincare regimen (DGR) to address facial dryness, hyperpigmentation, photodamage, or acne-prone/oily skin.

Patients and Methods

In this 12-week, open-label, single-center study, participants were assigned to 1 of 4 groups according to skin presentation: dry, hyperpigmented, photodamaged, or acne-prone/oily. All participants received 6 bi-weekly DG treatments with tailored DGR topical products. During the DG treatment, the dry, hyperpigmented, photodamaged, and acne-prone/oily groups received hydrating, brightening, antioxidant, and pore-clarifying serums, respectively. Study endpoints included investigator grading, standardized photography, and participant questionnaires.

Results

Sixteen participants aged 22 to 70 years with Fitzpatrick Skin Types I-V completed the study. Immediately after the first DG treatment, significant improvements in dryness, radiance, texture, photodamage, and fine lines were achieved (P<0.01). At 72 hours, significant improvements were maintained in all these parameters except fine lines (P<0.05). The DG and DGR combination provided significant long-term improvements at week 12 compared to baseline for dryness, radiance, texture, hyperpigmentation, photodamage, skin tone unevenness, and periocular/perioral fine lines (P<0.05).

Conclusion

The combination of DG and DGR showed significant immediate and long-term improvements in skin appearance. These results show that the DG and DGR combination is a well-tolerated and effective intervention to enhance different aspects of facial skin quality.

A Randomized, Multicenter, Evaluator-blind Study to Evaluate the Safety and Effectiveness of VYC-12L Treatment for Skin Quality Improvements

BACKGROUND

Skin quality may be assessed by degrees of skin smoothness, fine lines, and hydration. VYC-12L is a recently developed hyaluronic acid filler to improve skin quality.

OBJECTIVE

This was a randomized, evaluator-blind study assessing safety and effectiveness of intradermal VYC-12L treatment for improving cheek skin smoothness, fine lines, and hydration.

METHODS

Participants (≥22 years) with moderate-to-severe investigator-assessed Allergan Cheek Smoothness Scale (ACSS) scores were randomized in 2:1 ratio to receive VYC-12L or control (no treatment with optional treatment). Effectiveness was assessed 1 month after last injection (initial or touch-up) by a responder rate (≥1-grade improvement from baseline on both cheeks) using investigator-rated ACSS and Allergan Fine Lines Scale (AFLS), and tissue dielectric constant probe-measured skin hydration. Safety was evaluated throughout.

RESULTS

Participants (VYC-12L, n = 131; control, n = 71) were 86.1% female with a median age of 58.0 years. At month 1, ACSS and AFLS responder rates were statistically significantly higher in the VYC-12L group (57.9%, 58.3%, respectively) than in the untreated controls (4.5%, 5.4%, respectively; p < .001). VYC-12L ACSS and AFLS responder rates remained consistent throughout the 6-month follow-up. Six participants reported treatment-related adverse events; none led to study discontinuation.

CONCLUSION

VYC-12L is an effective, well-tolerated treatment for lasting improvement of cheek skin smoothness, fine lines, and hydration.

The Use of Validated Visual Scales in Plastic Surgery: Where Are We Now?

BACKGROUND

The assessment of the human body, whether for aesthetic or reconstructive purposes, is an inherently visual endeavor. Ideally, reproducible, prompt, and cost-effective systems of visual evaluation would exist that can provide validated assessments of the aesthetic endpoints of treatment. One method to accomplish a standardization of the appreciation of visual endpoints is the use of visual scales. The goal of this systematic review is to summarize and evaluate the use of validated visual scales within aesthetic medicine, dermatology, and plastic and reconstructive surgery.

METHODS

A literature search was performed with a defined search strategy and extensive manual screening process. The Medical Outcomes Trust guidelines for visual scales in medicine were used, with special attention paid to each study's validation metrics. The review process identified 44 publications with validation data of sufficient quality from an initial survey of 27,745 articles. All rating scales based on imaging other than standardized clinical photographs were excluded.

RESULTS

The review demonstrates that validated visual assessment in plastic surgery is incomplete. Within specific subfields of aesthetic medicine and dermatology, many of the ( n = 20) facial aging scales were well-validated and demonstrated high reliability. Publications ( n = 8) focused on the evaluation of facial clefts demonstrated heterogeneity in the methods of validation and in overall reliability. Within the areas of breast surgery ( n = 9), body contouring ( n = 2), and scarring ( n = 5), the scales were variable in the methods used and the validation procedures were diverse. Scales using a visual guide tended to have better interrater (kappa = 0.75) and intrarater reliability (kappa = 0.78), regardless of the specific area of interest.

CONCLUSIONS

The fields of aesthetic medicine, and aesthetic and reconstructive plastic surgery require assessment of visual states over time and between many observers. For these reasons, the development of validated and reliable methods of visual assessment are critical. Until recently, the use of these tools has been limited by their time-consuming nature and cost.

PN-HPT® (Polynucleotides Highly Purified Technology) in facial middle third rejuvenation. Exploring the potential

Background

Wasting of soft tissues leads to flattening and deflation of the aging midface skin. Polynucleotides Highly Purified Technology (PN‐HPT^®) demonstrated dermal hydration and elasticity as well as fibroblasts vitality and activity.

Aims

To probe the value of PN‐HPT^® in middle third rejuvenation in an open‐design, exploratory prospective cohort study in 40 real‐life ambulatorily treated women.

Methods

Three treatment sessions—at baseline (2‐ml prefilled syringe containing 10 mg/ml PN‐HPT^®, 10 mg/ml hyaluronic acid, 200 mM mannitol) as intradermic gel, and after 3 weeks (2‐ml prefilled syringe containing 20 mg/ml PN‐HPT^® intradermic gel) and 6 weeks (same treatment as baseline). The protocol allowed supplemental treatment with specifically formulated PN‐HPT^® (7.5 mg/ml) when needed in periocular and eyelid areas. Assessments: sequential photographs of the facial middle third at baseline, third treatment session and 6–8 weeks after the third treatment session; scoring of overall skin quality and texture, skin quality determinants (wrinkles and skin roughness, skin elasticity, skin brightness), scar appearance, and subjective satisfaction with impromptu 10‐cm Visual Analogue Scales.

Results

Significant improvement of overall skin quality and texture (from 7.0 ± 1.06 at baseline session to 7.8 ± 0.99 at follow‐up), associated with highly significant improvements of wrinkles and skin roughness, elasticity, and brightness (–17.1%, +39.6%, and +51.1%, respectively). The severity scores of post‐acne scars decreased from 7.6 ± 1.32 to 4.2 ± 2.13. Individual satisfaction score at the end of treatment: 0.8 ± 0.28.

Conclusions

PN‐HPT^® candidate as a valuable option for facial middle third rejuvenation. Further trials will hopefully confirm these early results.

Platelet-Rich Plasma in Aesthetics

Platelet-rich plasma (PRP) is being used as a treatment modality for skin rejuvenation since the last decade. There has been a lot of ambiguity regarding the ideal protocol to be followed and the specific indications where its use should be promoted. The use of PRP as monotherapy for skin rejuvenation, acne scars, periorbital rejuvenation, lipofilling and in combination with fractional CO₂ and other resurfacing modalities is increasing rapidly. In this article, we have reviewed the current scientific evidence available and the IADVL national task force for PRP has come up with standard recommendations for use of PRP in esthetics along with the grade of evidence and strength of recommendation for each indication. The aim of this review is to provide a standard protocol for use of PRP in esthetics, for clinicians and academicians, leading to excellent results with this promising treatment modality.

Development and Validation of IBSA Photographic Scale for the Assessment of Inner Upper Arm Laxity

Objective

To describe the development and validation of the 5-grade photographic IBSA inner upper arm scale.

Methods

From 2 real-life pictures, a scale made up of 5 morphed images showing increasing severity of inner upper arm laxity was created. For validation, a set of 50 images (half of which real and the other morphed) was developed and sent to 5 trained physicians in two rounds 30 days apart. Raters’ task was to make a selection of each image according to the given scale. Inter-rater and intra-rater reliability were evaluated in both rounds.

Results

As to intra-rater reliability, single-rater kappa scores between 0.74 and 1.00 and a global kappa score of 0.846 were observed, while inter-rater agreement was calculated with intra-class correlation coefficient reporting scores higher than 0.91, which indicate excellent reliability.

Conclusion

IBSA inner upper arm laxity scale proved to be a validated and reliable tool.

Defining Skin Quality: Clinical Relevance, Terminology, and Assessment

BACKGROUND

Flawless skin is one of the most universally desired features, and demand for improvements in skin quality is growing rapidly. Skin quality has been shown to substantially impact emotional health, quality of life, self-perception, and interactions with others. Although skin quality improvements are a common end point in studies of cosmeceuticals, they are rarely assessed in clinical studies of other aesthetic treatments and products. Descriptive terminology for skin quality parameters also varies considerably within the aesthetic field, relying on a range of redundant and occasionally contradictory descriptors. In short, skin quality has not been clearly defined.

OBJECTIVE

The goal of this review is to highlight the importance of skin quality to patients and physicians, explore known and unknown factors comprising skin quality, and provide clarity regarding terminology, descriptors, and evaluation tools for assessing skin quality.

MATERIALS AND METHODS

A review of the literature on skin quality was performed without limitation on publication date. Relevant articles are presented.

RESULTS AND CONCLUSION

We propose a framework of attributes contributing to skin quality rooted in 3 fundamental categories-visible, mechanical, and topographical-with the aim to provide information to help guide clinicians and inform future clinical studies.

Development and Validation of IBSA Photographic Scale for the Assessment of Neck Laxity

Objective

To describe the development and validation of the 5-grade photographic IBSA Neck Laxity Scale.

Methods

The scale was developed from 2 real images, which led to the creation of 5 morphed images, representing different degrees of severity of laxity of the neck. For validation, a set of 50 images (25 real and 25 morphed) was created and sent for evaluation to 6 trained raters (physicians) in 2 rounds, 1 month apart. Raters had to assess each image according to the 5-image scale. Inter-rater and intra-rater reliability in both rounds was evaluated.

Results

As to intra-rater reliability, single rater kappa scores between 0.69 and 0.87, and a global kappa score of 0.78 were observed. Inter-rater agreement was measured by means of the intra-class correlation coefficient and scores higher than 0.85 were reported, indicating excellent reliability.

Conclusion

IBSA Neck Laxity Scale is a validated and reliable scale.

Microneedling: Percutaneous Collagen Induction (PCI) Therapy for Management of Scars and Photoaged Skin-Scientific Evidence and Review of the Literature

Demand for safe, less aggressive and cost-efficient treatment modality to improve skin quality and appearance following scarring or photoaging is increasing steadily. A treatment modality that preserves the epidermis while promoting regeneration rather than cicatrization would be ideal. Percutaneous collagen induction (PCI) therapy or microneedling is claimed to approach this ideal objective. The current comprehensive literature review is intended to analyze the scientific basis supporting this therapeutic modality and to evaluate the efficacy of PCI microneedling therapy versus no treatment of patients with photoaged skin and scars of various etiologies on aesthetic skin rejuvenation, skin tightening and scar quality in prospective, retrospective and experimental studies. Twenty-five published studies were identified and included in this review. Four publications are experimental animal studies; most clinical reports are case series or small cohort non-randomized studies or trials lacking methodological unity with a heterogenous mix of scars, wrinkles and skin laxity being treated. The majority are studies about management of scars of various etiologies while only 4 specifically investigated the effect of PCI on wrinkles and aging skin. One study compared burn scar erythema in the treated area to the untreated area, and 5 studies included histologic evaluation of biopsies. Despite PCI promising therapeutic benefits and its increasing cosmetic applications, the current literature review unfortunately revealed a limited number of high-quality studies mostly experimental. Data and conclusions of clinical studies must be carefully interpreted before translating the evidence presented into clinical recommendations. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Comparative Analysis of Efficacy of Lactic Acid with Ferulic Peel (Combination Peel) Vs Ferulic Peel Alone as a Monotherapy for Photoaging

OBJECTIVES

Chemical peels are used to treat fine lines, photoaging, skin discoloration and scars. The objective of this study is to do a comparative analysis of lactic acid 30 % with ferulic peel 12 % (combination peel) versus ferulic peel 12% alone as a monotherapy for photoaging.

MATERIALS AND METHODS

This is a prospective study from Feb 2016 to 2020 in which a total of 60 female patients with ages between 25 and 36 years were treated. Randomization of patients was done for both groups with 30 patients enrolled in each group. The first group of 30 patients was treated with ferulic peel 12 % (hydroalcohol base) with L-ascorbic acid 15% as a sealer alone (i.e., Group A). In the second group, 30 patients were treated with lactic acid 30 % with ferulic peel 12% (hydroalcohol base) with L-ascorbic acid 15% as a sealer (combination peel) (i.e., Group B). Inclusion and exclusion criteria have been defined for the study. Two scales have been used for assessing the results, Allergan Skin Roughness Scale (ASRS) and Allergan Fine Line Scale (AFLS). ASRS and AFLS scores were assessed at pre-treatment (pre) and post-treatment (post 1 month after last peel session) and compared using Student's paired t test and independent t test.

RESULTS

The results showed significant and higher improvement of 27% and 42%, respectively, in ASRS (1.37 ± 0.49 vs. 1.87 ± 0.51, diff = 0.50, 95% CI = 0.24 to 0.76, p < 0.001) and AFLS (1.20 ± 0.41 vs. 2.07 ± 0.58, diff = 0.87, 95% CI = 0.61-1.13, p < 0.001) scores in patients treated with lactic acid and ferulic peel as compared to patients treated with ferulic peel alone. No complications were observed in our study.

CONCLUSION

The study found the combination of lactic acid and ferulic peel significantly more effective than ferulic peel alone in the management of fine lines, photoaging and skin discoloration. The findings of this study may need to be further validated on a larger sample size and multicentric analysis. Initial results of our 4-year study have yielded promising results.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Almond consumption increased UVB resistance in healthy Asian women

BACKGROUND

Almonds are a rich source of phenolic and polyphenolic compounds, which have antioxidant activity. In vitro and in vivo studies have demonstrated that topical application of almond oil and almond skin extract reduces UVB-induced photoaging. Ultraviolet-B (UVB) protection by oral almond consumption has not been previously studied in humans.

OBJECTIVES

To investigate whether oral almond consumption can increase resistance to UVB radiation and reduce skin aging in healthy Asian women.

METHODS

Thirty-nine female participants (18-45 years) with Fitzpatrick skin type II-IV were randomly assigned to consume either 1.5 oz of almonds or 1.8 oz of pretzels daily for 12 weeks. Minimal erythema dose (MED) was determined using a standardized protocol, which determined the minimal radiation needed to induce erythema on the inner arm following UVB exposure. Facial skin texture was evaluated by two dermatologists using the Clinician's Erythema Assessment scale and Allergan Roughness scale. Facial melanin index, hydration, sebum, and erythema were determined using a cutometer.

RESULTS

The MED was increased in the subjects consuming almonds compared to the control group consuming pretzels. There were no differences noted between the groups consuming almonds versus pretzels in Allergan roughness, melanin, hydration, or sebum on facial skin.

CONCLUSIONS

Our findings suggest that daily oral almond consumption may lead to enhanced protection from UV photodamage by increasing the MED.

Microbotulinum: A Quantitative Evaluation of Aesthetic Skin Improvement in 62 Patients

BACKGROUND

Microbotulinum refers to the systematic injection of tiny blebs of diluted botulinum toxin at repeated intervals into the skin. This targets the superficial fibers of the facial muscles, and weakens their insertion into the undersurface of the skin, which is responsible for the fine lines and wrinkles on the face. The authors present a pilot study based on quantitative evaluation, by means of a skin-scanning technology, of the aesthetic improvement of skin texture, microroughness, and enlarged pore size in a patient group treated with microbotulinum injections for cosmetic purposes.

METHODS

The treatment was performed using a 32-gauge needle to deliver injections on a regular 1-cm grid from the forehead to the cheek and down to the jawline.

RESULTS

Sixty of the 62 patients completed the study. All analyzed parameters improved significantly (p < 0.0001) at 90 days with respect to the pretreatment time point (skin texture, -1.93 ± 0.51; microroughness, -2.48 ± 0.79; and pore diameter, 2.1 ± 0.43). Best results have been obtained in patients aged between 42.7 and 46.8 years, and standard deviation calculation allows us to recommend it in patients aged between 36.5 and 53 years.

CONCLUSIONS

The results of this pilot study suggest that intradermal botulinum toxin injection, or so-called microbotulinum, is a safe and effective method to treat skin flaws. Because of the high satisfaction rate among both physicians and patients, further studies are indeed mandatory to determine the optimal number of units needed for a longer and lasting effect with this particular novel dilution.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Expert Consensus on Injection Technique and Area-Specific Recommendations for the Hyaluronic Acid Dermal Filler VYC-12L to Treat Fine Cutaneous Lines

Background

VYC-12L is a hyaluronic acid (HA) injectable gel designed to treat fine cutaneous lines and improve skin quality attributes such as hydration and elasticity.

Objective

Expert consensus was sought on VYC-12L injection technique and primary treatment target areas.

Methods

A multinational group of aesthetic medicine clinicians (n = 128) attended product training and each identified ~10 patients for VYC-12L. After treating their first and last patients, the clinicians completed a survey on preferred injection methodology/technique, including injection angle, volume, and spacing. An expert panel (n = 12) discussed survey results and their clinical experiences to obtain consensus on VYC-12L technique and appropriate treatment areas.

Results

Recommendations included micro-depot injections of VYC-12L into the deep dermis with a 32G ½ inch needle inserted at <45º to the skin, spaced 0.5‒1.0 cm apart, with 0.01‒0.05 mL volume per injection (full-face total volume: ~2 mL). Recommended primary treatment areas were the malar, perioral, neck, and décolletage regions. Injection techniques for different treatment areas/demographic characteristics were similar, with some variability in treatment approach. Patient selection criteria, pre- and post-treatment guidelines, and managing patient expectations are important components of treatment.

Conclusion

These consensus recommendations may assist clinicians in optimizing the treatment of fine lines with VYC-12L.

Skin Quality Improvement With VYC-12, a New Injectable Hyaluronic Acid: Objective Results Using Digital Analysis

BACKGROUND

VYC-12 is a novel hyaluronic acid-based dermal filler designed to treat fine lines and improve skin quality. A specialist digital camera and proprietary Digital Analysis of the Cutaneous Surface (DACS) software have previously been used to objectively measure changes in skin features.

OBJECTIVE

To assess the effect of facial treatment with VYC-12 on skin texture using the specialist camera.

MATERIALS AND METHODS

This was a prospective, open-label, 2-center study of 40 women aged 35 to 60 years treated with multiple, microdepot intradermal injections of VYC-12 (2 mL in the face; 1 mL in the neck if required). Eight patients (20.0%) required a touch-up at Day 45. Images were acquired using the specialist camera at baseline and 45 days and 6 months after treatment, and were analyzed by DACS. Clinical improvements were also assessed subjectively using the Global Aesthetic Improvement Scale (GAIS).

RESULTS

VYC-12 improved skin texture from baseline after 45 days (mean improvement: 25.9% ± 9.2%) and 6 months (mean improvement: 30.7% ± 18.2%). Improvements were also evident using the GAIS. There were no major adverse events.

CONCLUSIONS

VYC-12 improves skin quality, as measured using an objective, fast, and reproducible measuring tool. VYC-12 represents a valuable addition to the treatment armamentarium.

Perspective Morphometric Criteria for Facial Beauty and Proportion Assessment

Common sense usually considers the assessment of female human attractiveness to be subjective. Nevertheless, in the past decades, several studies and experiments showed that an objective component in beauty assessment exists and can be strictly related, even if it does not match, with proportions of features. Proportions can be studied through analysis of the face, which relies on landmarks, i.e., specific points on the facial surface, which are shared by everyone, and measurements between them. In this work, several measures have been gathered from studies in the literature considering datasets of beautiful women to build a set of measures that can be defined as suggestive of female attractiveness. The resulting set consists of 29 measures applied to a public dataset, the Bosphorus database, whose faces have been both analyzed by the developed methodology based on the expanded set of measures and judged by human observers. Results show that the set of chosen measures is significant in terms of attractiveness evaluation, confirming the key role of proportions in beauty assessment; furthermore, the sorting of identified measures has been performed to identify the most significant canons involved in the evaluation.

VYC-12 Injectable Gel Is Safe And Effective For Improvement Of Facial Skin Topography: A Prospective Study

Objective

Evaluate safety and effectiveness of VYC-12 (Juvéderm Volite; an injectable crosslinked hyaluronic acid gel designed to improve skin quality attributes such as surface smoothness and hydration) for facial intradermal injection.

Materials and methods

In a prospective, single-arm study, subjects with moderate/severe cheek skin roughness per Allergan Skin Roughness Scale (ASRS) received VYC-12 in the cheeks and forehead, and/or neck, with touch-up treatment to correct asymmetry 30 days later and optional repeat treatment 9 months after last treatment. The primary effectiveness measure was ASRS responder rate (percentage of cheeks with ≥1-point improvement from baseline) at month 1. Skin hydration was instrument-assessed.

Results

Of 131 subjects treated, 31 (23.7%) received touch-up treatment. ASRS responder rate was 96.2% at month 1, 76.3% at month 4, 34.9% at month 6, and 87.1% after repeat treatment. Responder rate in cheeks with severe baseline roughness was 93.8%, 83.1%, and 52.3% at months 1, 4, and 6, respectively. Skin hydration improved significantly (P<0.01) from baseline at all timepoints through month 9. Injection site responses were as expected. All treatment-related adverse events were mild/moderate.

Conclusion

VYC-12 safely and effectively improved skin smoothness up to 6 months and hydration lasting 9 months.

Improvements in satisfaction with skin after treatment of facial fine lines with VYC-12 injectable gel: Patient-reported outcomes from a prospective study

BACKGROUND

VYC-12, a hyaluronic acid injectable gel, is designed to treat fine lines and provides improvements in other skin quality attributes. A prospective study demonstrated the safety and effectiveness of VYC-12 for the improvement of fine lines as measured by changes in skin texture.

AIMS

To evaluate patient-reported outcomes in subjects treated intradermally with VYC-12 in the cheeks, forehead, and neck (optional) in the prospective study.

METHODS

Subjects received an initial treatment of VYC-12 (N = 131), with a touch-up treatment, if deemed necessary, offered 30 days later, and optional repeat treatment 9 months after initial or touch-up treatment. Subjects completed the FACE-Q Satisfaction With Skin scale and assessed willingness to recommend treatment to a friend at baseline, months 1, 4, 6, and 9, and month 1 after repeat treatment. Subjects also evaluated their return to normal daily social activities.

RESULTS

Satisfaction with skin improved from baseline in 90.8% of subjects at month 1, 88.4% at month 4, 83.6% at month 6, 76.4% at month 9, and 91.9% at month 1 after repeat treatment (P < .001, all time points). At least 94% of subjects returned to normal daily social activities one day after treatment (initial, touch-up, or repeat). More than 80% of subjects said they would recommend treatment to a friend at all time points through month 9 (97% at month 1 after repeat treatment).

CONCLUSION

Treatment with VYC-12 significantly improved satisfaction with skin in the majority of subjects, with most subjects returning to normal activities 1 day after treatment.

Performance of intraclass correlation coefficient (ICC) as a reliability index under various distributions in scale reliability studies

Many published scale validation studies determine inter‐rater reliability using the intra‐class correlation coefficient (ICC). However, the use of this statistic must consider its advantages, limitations, and applicability. This paper evaluates how interaction of subject distribution, sample size, and levels of rater disagreement affects ICC and provides an approach for obtaining relevant ICC estimates under suboptimal conditions. Simulation results suggest that for a fixed number of subjects, ICC from the convex distribution is smaller than ICC for the uniform distribution, which in turn is smaller than ICC for the concave distribution. The variance component estimates also show that the dissimilarity of ICC among distributions is attributed to the study design (ie, distribution of subjects) component of subject variability and not the scale quality component of rater error variability. The dependency of ICC on the distribution of subjects makes it difficult to compare results across reliability studies. Hence, it is proposed that reliability studies should be designed using a uniform distribution of subjects because of the standardization it provides for representing objective disagreement. In the absence of uniform distribution, a sampling method is proposed to reduce the non‐uniformity. In addition, as expected, high levels of disagreement result in low ICC, and when the type of distribution is fixed, any increase in the number of subjects beyond a moderately large specification such as n = 80 does not have a major impact on ICC.

Development and Validation of a Photonumeric Scale for Evaluation of Transverse Neck Lines

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of horizontal neck lines before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Transverse Neck Lines Scale.

METHODS

The Allergan Transverse Neck Lines Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject rating validation study (N = 297) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A difference of ≥1 point on the scale was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 1.22 [1.09–1.35] for clinically different image pairs and 0.57 [0.42–0.72] for not clinically different pairs). Intrarater agreement between the 2 live-subject rating validation sessions was substantial (mean weighted kappa = 0.78). Interrater agreement was substantial during the second rating session (0.73, primary end point).

CONCLUSION

The Allergan Transverse Neck Lines Scale is a validated and reliable scale for rating of severity of neck lines.

Development and Validation of a Photonumeric Scale for Evaluation of Volume Deficit of the Hand

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of hand appearance before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Hand Volume Deficit Scale.

METHODS

The scale was developed to include an assessment guide, verbal descriptors, morphed images, and real-subject images for each grade. The clinical significance of a 1-point score difference was evaluated in a review of image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 296) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A score difference of ≥1 point was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 1.12 [0.99–1.26] for clinically different image pairs and 0.45 [0.33–0.57] for not clinically different pairs). Intrarater agreement between the 2 validation sessions was almost perfect (mean weighted kappa = 0.83). Interrater agreement was almost perfect during the second session (0.82, primary end point).

CONCLUSION

The Allergan Hand Volume Deficit Scale is a validated and reliable scale for physician rating of hand volume deficit.

Development and Validation of a Photonumeric Scale for Evaluation of Static Horizontal Forehead Lines

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of static forehead lines before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Forehead Lines Scale.

METHODS

The Allergan Forehead Lines Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 295) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A difference of ≥1 point on the scale was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 1.06 [0.91–1.21] for clinically different image pairs and 0.38 [0.26–0.51] for not clinically different pairs). Intrarater agreement between the 2 live-subject validation sessions was almost perfect (mean weighted kappa = 0.87). Interrater agreement was almost perfect during the second rating session (0.86, primary end point).

CONCLUSION

The Allergan Forehead Lines Scale is a validated and reliable scale for physician rating of static horizontal forehead lines.

Development and Validation of a Photonumeric Scale for Assessment of Chin Retrusion

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of chin appearance before and after chin augmentation in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Chin Retrusion Scale.

METHODS

The Allergan Chin Retrusion Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 298) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A difference of ≥1 point on the scale was shown to reflect a clinically meaningful difference (mean [95% confidence interval] absolute score difference, 1.07 [0.94–1.20] for clinically different image pairs and 0.51 [0.39–0.63] for not clinically different pairs). Intrarater agreement between the 2 live-subject validation sessions was substantial (mean weighted kappa = 0.79). Interrater agreement was substantial during the second rating session (0.68, primary end point).

CONCLUSION

The Allergan Chin Retrusion Scale is a validated and reliable scale for physician rating of severity of chin retrusion.

Effect of Topical Fluorouracil Cream on Photodamage: Secondary Analysis of a Randomized Clinical Trial

Importance

Photoaging, which is premature skin aging caused by long-term UV exposure, is of aesthetic concern to many patients.

Objective

To investigate the effect of topical fluorouracil, 5%, cream on photoaging using validated photonumeric scales.

Design, Setting, and Participants

The Veterans Affairs Keratinocyte Carcinoma Chemoprevention Trial was a randomized clinical trial of 932 US veterans with a recent history of 2 or more keratinocyte carcinomas performed from September 30, 2011, through June 30, 2014, to assess the chemopreventive effects of a standard course of topical fluorouracil. Photographs were taken at baseline and at numerous time points for up to 4 years. In our secondary analysis, 2 independent dermatologists graded these photographs using 4 validated photonumeric scales. A total of 3042 photographs from 281 participants randomized to apply topical fluorouracil or placebo were evaluated at baseline, 6 months, 12 months, and 18 months using 4 photonumeric scales (Griffiths scale, Allergan forehead lines scale, melomental folds scale, and crow's feet scale). Data analysis was performed from November 1, 2016, to January 1, 2017.

Interventions

Participants were randomized to apply topical fluorouracil, 5%, cream or a vehicle control cream to the face and ears twice daily for 2 to 4 weeks for a total of 28 to 56 doses.

Main Outcomes and Measures

Effect of a standard course of fluorouracil on the extent of photodamage as measured using 4 photonumeric scales.

Results

The study population was predominantly male (274 [97.5%]) and white (281 [100%]), with a mean (SD) age of 71.5 (0.57) years. No statistically significant changes were found in photodamage between baseline and 6 months (Griffiths scale: χ2 = 0.01, P = .93; Allergan forehead lines scale: χ2 = 0.18, P = .67; melomental fold scale: χ2 = 0.03, P = .87; crow's feet scale: χ2 = 2.41, P = .12), 12 months (Griffiths scale: χ2 = 1.39, P = .24; Allergan forehead lines scale: χ2 = 0.64, P = .43; melomental fold scale: χ2 = 0.12, P = .73; crow's feet scale: χ2 = 1.07, P = .30), and 18 months (Griffiths scale: χ2 = 3.11, P = .08; Allergan forehead lines scale: χ2 = 0.89, P = .34; melomental fold scale: χ2 = 1.64, P = .20; crow's feet scale: χ2 = 0.46, P = .50).

Conclusions and Relevance

This study did not demonstrate improvement in photoaging with a standard course of topical fluorouracil, 5%, cream, a finding that may be attributable to a true lack of effect in photodamage or limitations of the photonumeric scales in capturing the effect. The development of photonumeric scales that include manifestations of photoaging other than rhytids, such as lentigines, hyperpigmentation, and telangiectasias, should be considered.

Trial Registration

clinicaltrials.gov Identifier: NCT00847912.

Development and Validation of a Photonumeric Scale for Evaluation of Volume Deficit of the Temple

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of temple appearance before and after aesthetic treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Temple Hollowing Scale.

METHODS

The scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each grade. The clinical significance of a 1-point score difference was evaluated in a review of image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 298) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A score difference of ≥1 point was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 1.1 [0.94-1.26] for clinically different image pairs and 0.67 [0.51-0.83] for not clinically different pairs). Intrarater agreement between the 2 validation sessions was almost perfect (mean weighted kappa = 0.86). Interrater agreement was almost perfect during the second session (0.81, primary endpoint).

CONCLUSION

The Allergan Temple Hollowing Scale is a validated and reliable scale for physician rating of temple volume deficit.

Development and Validation of a Photonumeric Scale for Evaluation of Facial Fine Lines

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of facial fine lines before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Fine Lines Scale.

METHODS

The Allergan Fine Lines Scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each scale grade. The clinical significance of a 1-point score difference was evaluated in a review of multiple image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live subject validation study (N = 289) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A score difference of ≥1 point was shown to reflect a clinically significant difference (mean [95% CI] absolute score difference, 1.06 [0.92-1.21] for clinically different image pairs and 0.50 [0.38-0.61] for not clinically different pairs). Intrarater agreement between the 2 live subject validation sessions was almost perfect (weighted kappa = 0.85). Interrater agreement was substantial during the second rating session (0.76, primary end point).

CONCLUSION

The Allergan Fine Lines Scale is a validated and reliable scale for physician rating of severity of superficial fine lines.

Development and Validation of a Photonumeric Scale for Evaluation of Infraorbital Hollows

BACKGROUND

A validated scale is needed for objective and reproducible comparisons of infraorbital hollows (i.e., tear troughs) before and after treatment in practice and clinical studies.

OBJECTIVE

To describe the development and validation of the 5-point photonumeric Allergan Infraorbital Hollows Scale.

METHODS

The scale was developed to include an assessment guide, verbal descriptors, morphed images, and real subject images for each grade. The clinical significance of a 1-point score difference was evaluated in a review of image pairs representing varying differences in severity. Interrater and intrarater reliability was evaluated in a live-subject validation study (N = 297) completed during 2 sessions occurring 3 weeks apart.

RESULTS

A score difference of ≥1 point was shown to reflect a clinically significant difference (mean [95% confidence interval] absolute score difference, 0.90 [0.79-1.02] for clinically different image pairs and 0.33 [0.19-0.46] for not clinically different pairs). Intrarater agreement between the 2 validation sessions was substantial (mean weighted kappa = 0.79). Interrater agreement was substantial during the second rating session (0.70, primary end point).

CONCLUSION

The Allergan Infraorbital Hollows Scale is a validated and reliable scale for physician rating severity of hollowing in the infraorbital area.