Front Matter| Volume 6, ISSUE 1, Pix-xvi, May 2023

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        Editorial Board,  iii

        Contributors,  v

        Introduction,  xvii

        By Gregory H. Branham, Jeffrey S. Dover, Shilpi Khetarpal, Smita R. Ramanadham, and Allan E. Wulc

        Preface: Hot Topics in Aesthetic Medicine,  xix

        By Shilpi Khetarpal

        Nonsurgical Rhinoplasty,  1

        By Usha Rajagopal, Jacqueline Watchmaker, and Jeffrey S. Dover
        Video content accompanies this article at
        This article describes brief history of nonsurgical rhinoplasty along with a description of nasal anatomy. Also included are product selection for optimum results, injection techniques to improve safety, and best patient selection for treatment. Detailed videos demonstrating each injection techniques of all nasal subunits.
         Introduction,  1
         Anatomy,  1
         Patient selection,  1
         Preparation and patient positioning,  2
         Injection techniques,  3
         BD syringe danger,  3
         Complications,  3
         Clinics care points,  4
         Disclosure,  4

        Facial Volume Rejuvenation Using Alloplastic Facial Implants,  5

        By Ryan M. Diepenbrock
        Facial volume loss related to the aging process and congenital volume deficiencies can easily and predictably be treated with the use of facial implants. When properly utilized, facial implants augment bony deficiencies with biologically compatible implants that are permanent with little chance of complication. Facial implants come in a variety of pre-formed (stock) shapes and sizes which are easily modified for individual customization. Additionally, with the use of virtual surgical planning, facial implants can be customized to encompass large volume augmentation or to address asymmetries. Whether utilized as a solo procedure, or as an adjunct to more invasive procedures, facial implants add volume to the facial skeleton to improve patients’ final aesthetic results.
         Introduction,  5
        Preoperative Planning,  5
        Implant Selection,  6
        Chin Evaluation and Management,  8
        Preparation and Patient Positioning,  9
        Chin Implant Procedure,  10
        Cheek Evaluation and Management,  12
        Cheek Implant Procedure,  14
        Facial Implant Postoperative Care and Recovery,  15
        Postoperative Complications,  16
        Rehabilitation and Recovery,  17
         Summary,  17
         Clinics care points,  18
         Disclosure,  18

        Laser-Assisted Drug Delivery,  19

        By Jessica G. Labadie, Omer Ibrahim, and Jeffrey S. Dover
        Video content accompanies this article at
        Laser-assisted drug delivery (LADD) is an emerging and rapidly evolving approach to the treatment of a variety of conditions including benign and malignant neoplasms, photoaging, pigmentary disorders, scar revision, and topical anesthesia. In LADD, a laser-induced zone of thermal damage (or microscopic ablation zone) renders the skin more vulnerable to topically applied medications, enhancing their absorption and optimizing their results. This article discusses the clinical evidence behind LADD, as well as proper patient selection, preparation, and appropriate surgical technique to safely and effectively perform LADD.
         Introduction: a paradigm shift in dermatology,  19
         A step-by-step approach to laser-assisted drug delivery,  20
        Preoperative Planning,  20
        Preparation and Patient Positioning,  21
        Laser Parameters,  21
        Immediate Post-Procedural Care,  22
         Laser-assisted drug delivery applications from the literature,  22
        Dysplasia,  22
        Nonmelanoma Skin Cancers,  23
        Scars,  23
        Anesthesia,  23
        Hyperhidrosis,  24
        Esthetics,  24
        Melasma,  24
        Alopecia,  24
        Onychomycosis,  24
        Macular Amyloid,  24
        Vitiligo,  25
        Condyloma,  25
        Plaque Psoriasis,  25
         Potential risks and complications,  25
        Laser-Assisted Drug Delivery Safety: Laser Characteristics,  25
        Laser-Assisted Drug Delivery Safety: Drug Characteristics,  25
        Laser-Assisted Drug Delivery Safety: Patient Characteristics,  26
        Laser-Assisted Drug Delivery Safety: Local Cutaneous Reactions,  26
        Laser-Assisted Drug Delivery Safety: Systemic Reactions and Toxicity,  26
         Summary,  27
         Clinics care points,  27
         Disclosure,  28

        Exosomes and Hair Restoration,  31

        By Aditya K. Gupta, Deanna C. Hall, Jeffrey A. Rapaport, and Christopher R. Paradise
        Extracellular messenger vesicles known as exosomes are being investigated widely as a new therapy for hair loss. A wide body of preclinical research has demonstrated the potential of exosomes for hair regeneration. Exosomes can affect hair growth by targeting transport of molecular signals to hair follicle components and interacting with hair growth cycle regulation molecules. Preliminary human clinical data seem favorable. The molecular effects of exosomes on hair regeneration are not completely understood and may vary widely based on exosome source. Problems with unregulated human use have emphasized the need for greater standardization and control of exosome use.
         Introduction,  31
         Exosomes,  32
         Exosomes for hair restoration,  32
        Dermal Papilla-Derived Exosomes,  32
        Adipose-Derived Stem Cell-Exosomes,  33
        Mesenchymal Stem Cell-Derived Exosomes,  33
        Platelet-Derived Exosomes,  33
        Other Source-Derived Exosomes,  37
        Exosome Enhancement and Exosome-Like Alternatives,  37
        In Vivo Human Studies,  38
         Regulation of exosome products in the United States,  38
         Experience from the authors,  39
         Summary,  39

        Use of Tranexamic Acid for Melasma,  43

        By Taylor A. Bullock and Shilpi Khetarpal
        Melasma is an acquired disorder of hyperpigmentation that can severely impact appearance, self-esteem, and quality of life. No standard melasma treatment works for all patients and many patients have treatment-resistant melasma. Tranexamic acid is an effective off-label treatment that can be used orally and/or topically with minimal side effects. Tranexamic acid acts by reducing melanogenesis, blood vessel count, and erythema. Oral administration may be more effective than other routes of administration, at the expense of possible systemic side effects. Topical administration has been shown to be as effective as standard melasma treatments, with fewer side effects.
         Introduction: melasma is a complex disease with severe psychosocial impacts,  43
         Scales and indices for assessing melasma,  43
         Tranexamic acid: a drug for more than just hemostasis,  44
        Adverse Effects and Safety Profile,  45
         Tranexamic acid as an off-label treatment of melasma,  45
        Mechanism of Action for Melasma,  45
        The Evidence for Oral Tranexamic Acid,  46
         The evidence for topical administration of tranexamic acid,  48
        Administration: Intradermal Injection,  50
        The Evidence for Intradermal Administration of Tranexamic Acid,  50
         Summary,  50
        Suggested Readings,  50
         Clinics care points,  51
         Disclosure,  51

        Nonsurgical Facial Rejuvenation in Males,  53

        By Jameson Loyal
        Video content accompanies this article at
        There are many treatment options for men seeking facial rejuvenation. It is important to get a clear sense of the apprehensions, desires, and expectations of the patient before formulating a treatment plan. A stepwise approach that will highlight a patient’s natural beauty rather than drastically change their appearance is optimal. Combining neuromodulators, dermal fillers, and improving photodamaged skin with the goal of enhancing masculine facial features should be the overall aesthetic goal.
         Introduction,  53
         Facial anatomy and aging,  54
        General considerations,  54
        Upper Face,  54
        Midface,  54
        Lower Face,  54
        Aging,  54
         Optimizing the cosmetic consultation,  54
         Use of neuromodulators for male facial optimization,  55
        Special Considerations for the Male Patient,  55
        Upper Face,  55
        Glabellar Complex,  55
        Frontalis,  55
        Orbicularis Oculi,  56
         Lower face,  57
        Nasalis and Depressor Septi Nasi,  57
        Levator Labii Superioris Alaeque Nasi,  57
        Mentalis,  57
        Masseters,  58
         Dermal fillers and biostimulators,  58
        Medial Cheeks,  58
        Jawline,  58
        Chin,  60
         Improving skin quality,  60
        Acne and Rosacea,  60
        Photodamage,  60
        Clinical Pearls and Potential Adverse Events,  61
         Summary,  61
         Disclosure,  61

        Expanded Use of Biostimulators,  63

        By Nina Hartman
        Biostimulators comprise a distinct type of dermal filler that act through the induction of dermal regeneration via the production and proliferation of type I collagen, elastin, and dermal fibroblasts. These qualities allow for both volume replacement and skin quality enhancement. Given their unique functions, the use of biostimulatory fillers has been expanded to numerous off-face indications. The neck, decolletage, upper arms, above the knees, and thighs can be successfully treated with both calcium hydroxylapatite (CaHA) and poly-l-lactic acid (PLLA) to improve skin quality and laxity. The literature supports the use of PLLA as a safe and effective treatment of gluteal augmentation and CaHA for dorsal hand rejuvenation. When injecting biostimulatory fillers, it is absolutely imperative to understand the anatomy and ensure the correct plane of injection to avoid complications such as nodules and vascular occlusion.
         Introduction,  63
        Biostimulatory agents,  63
         Biostimulators for neck and decolletage rejuvenation,  65
         Biostimulators for body rejuvenation,  66
        Upper extremities,  66
        Cellulite and lower extremities,  66
        Gluteal augmentation,  67
         Biostimulators for hands,  68
         Potential complications,  68
         Disclosure,  68

        Energy-Based Devices for Vulvovaginal Rejuvenation,  71

        By George Kroumpouzos, Sejal Ajmera Desai, and Tassahil Messas
        Energy-based devices (EBDs) for vulvovaginal rejuvenation include laser sources such as fractional carbon dioxide and erbium:YAG, radiofrequency, and photobiomodulation. Clinical studies have shown significant improvements in vulvovaginal laxity, symptoms of genitourinary syndrome of menopause, and sexual function, associated with improvements in quantifiable, reproducible measures of vulvovaginal health. Our review shows that these modalities have a favorable short-term safety profile. However, the lack of reliable, objective methods to quantify vaginal introital laxity and factors contributing to sexual dysfunction complicates the evaluation of EBDs. More powerful randomized, controlled trials with longer follow-ups and true sham are needed.
         Introduction,  71
         Fractional CO2 laser,  72
        Mechanism of Rejuvenation,  72
        Review of Fractional Carbon Dioxide Laser Studies,  72
        Systematic Reviews and Meta-analyses,  77
         Mechanism of rejuvenation,  77
        Mechanism of rejuvenation,  77
        Clinical studies,  77
         Radiofrequency,  77
        Mechanism of Rejuvenation,  78
        Clinical Studies,  78
         Photobiomodulation,  82
         Summary,  83
         Clinics care points,  83
         Conflict of interest disclosure,  84
         Funding sources,  84

        Facial Gender-Confirming Surgery,  89

        By Katherine Nicole Vandenberg and Jeffrey Howard Spiegel
        Facial Feminization Surgery (FFS) is the blanket term for a group of procedures employed to alter the perceived gender of an individual's face. A majority of people seeking FFS are transgender woman who wish to soften their masculine features, but the techniques are valuable for cis women as well. Specifically, these surgical techniques include forehead and orbital cranioplasty, brow lift, hairline feminization, and mandible contouring. Reductive rhinoplasty, cheek augmentation, and anti-aging procedures including blepharoplasty, and facelift also have a role.
         Introduction,  89
         Patient evaluation,  89
         Preoperative counseling,  90
         Feminizing the upper third of the face,  91
        Patient Position and Markings,  91
        Procedural Approach,  91
         Energy-based skin tightening,  92
         Mandibuloplasty,  92
        Procedural Approach,  93
         Postoperative care,  94
         Rehabilitation and recovery,  95
         Clinical results,  95
         Potential complications,  96
         Summary,  96
         Clinics care points,  96
         Disclosure,  96

        Lower Face Botulinum Toxin,  99

        By Lisa Akintilo, Jeremy B. Green, and Joely Kaufman
        The use of botulinum toxin in the lower face has gained in frequency and popularity as both providers and patients are recognizing the substantial impact this treatment can have on overall facial esthetics. Rejuvenation of the lower face requires expert knowledge of facial anatomy and precise placement of toxin to prevent any untoward effects. Treatments must be customized to each individual patient to achieve optimal treatment goals. Providers must be knowledgeable of the anatomy of the lower face and the importance of careful toxin dilution and placement to achieve optimal results and minimize risk of complications.
         Introduction: nature of the problem,  99
         Surgical technique,  99
        Preoperative Planning,  99
        Prep and Patient Positioning,  100
        Procedural Approach,  100
        Immediate Postprocedural Care,  100
        Rehabilitation and Recovery,  100
        Clinical Results in the Literature,  100
         Injection of depressor anguli oris,  100
         Injection of orbicularis oris,  100
         Injection of mentalis,  102
         Injection of platysma,  102
         Injection of masseters,  102
         Injection of levator labii superioris alaeque nasi (gummy smile),  102
         Microbotox,  103
         Potential complications/risks/benefits/limits,  103
         Management,  104
         Summary,  104
         Clinics care points,  104
         Declaration of Interests,  104

        Otoplasty,  105

        By Nneoma S. Wamkpah, Catie Newsom-Stewart, Abby Kimball, Laura Baratta, and John J. Chi
        Otoplasty has existed for over a hundred years, with more than 200 modifications and refinements described in that time. Although there is no one standard technique, there is a standard goal: achieve normalized appearance and projection of the external ear. This review includes indications for surgery, pertinent anatomy, key physical examination findings, and stepwise surgical instructions. Then, basic concepts relevant to cartilage-sparing and cartilage-cutting techniques, complications and management of surgery, and a brief review of recently published otoplasty literature are outlined. Lastly, newer developments, such as nonsurgical otoplasty, are also described.
         Introduction,  105
        Anatomy,  106
         Surgical technique,  108
        Preoperative Planning,  109
        Preparation and Patient Positioning,  110
        Procedural Approach,  111
         Immediate postprocedural care,  120
        Rehabilitation and Recovery,  120
        Clinical Results in the Literature,  120
         Potential complications/risks/benefits/limits,  120
         Management,  121
         Summary,  121
         Clinics care points,  122

        Understanding Breast Implant Illness,  125

        By Brian R. Buinewicz, Danielle Valoras, and Robyn Towt
        The goal of this article is to provide you with a better understanding of breast implants and their impact on health. Studies have shown that the removal of implants leads to improved health in most patients. Breast implants have been associated with autoimmunity and other systemic symptoms for over 60 years. The terms for the symptoms have been labeled many things and only recently have they been referred to as breast implant illness (BII). BII remains a poorly defined and controversial complication.
         Understanding breast implant illness,  125
         Clinics care points,  132

        Which Is Better?: An Academic Reputation or 100,000 Followers? Social Media’s Impact on Reputation,  137

        By Gary Linkov and Marko Vuckovic
        The combination of increased esthetic surgery popularity with growing social media usage has had a synergistic impact on how people make decisions about which doctor to choose. The physician’s image and character projected online needs to be congruent with how the practice functions and feels in real life. Our reputation as cosmetic surgeons is intricately tied to our social media presence.
         Introduction,  137
         Success versus reputation,  137
         How does the general public use social media?,  138
         Social media as a health community,  138
         How are surgeons using social media platforms?,  138
         Is the impact of 100,000 followers the same on all platforms?,  139
         What are the pitfalls of social media?,  140
         What is the future of social media?,  140
        Which Is Better: an Academic Reputation or 100,000 Followers?,  140
         Funding,  141
         Financial disclosures,  141
         Conflicts of interest,  141

        Special Considerations in the Treatment of Skin of Color,  143

        By Chelsea Handfield, Shilpi Khetarpal, and Mara Weinstein Velez
        The changing demographics of the US population has led to a surge in interest, knowledge and need for cosmetic procedures in ethnic skin patients (Fitzpatrick skin types IV–VI). In Dermatology, there is increased interest in lasers and energy-based therapies for use in ethnic skin to treat dyspigmentation, fine lines, scars and unwanted hair. A challenge arises in ethnic skin related to the presence of varying quantities of melanin increasing the risks of procedure-related dyspigmentation. This article explores various energy-based devices and filler injections and how treatments can be modified for safe and effective use in ethnic skin patients.
         Introduction,  143
         Photoaging in skin of color,  143
         Evaluating the ethnic skin patient,  144
         Soft tissue augmentation,  145
         Laser,  145
        Resurfacing,  145
        Hyperpigmentation,  146
        Acne and Scarring,  146
        Vascular Lasers,  146
        Hair Removal,  146
        Tattoo Removal,  147
         Intense pulsed light,  147
         Microneedling,  147
         Microplasma radiofrequency,  148
         Skin-tightening devices,  148
         Summary,  148
         Clinics care points,  148
         Disclosure,  149

        Acne Treatment Strategies 2023,  151

        By Jordan Borash and Emmy Graber
        Acne is an exceptionally prevalent disorder. There are several available treatment options consisting of topical, oral and procedural therapies. Frequently a combination of therapies is needed to combat acne. As many treatments take months to be effective, patients should be encouraged to be compliant and persistent to see optimal results. Each patient’s treatment regimen should be tailored depending on a multitude of factors including, but not limited to: severity of disease, acne morphology, distribution of acne (ie, facial or truncal), patient preferences, age, cost, and psychological burden. In this article, several mainstay treatment methods are discussed.
        Acne treatment strategies 2023,  151
         Treatments,  151
         Topicals,  152
        Systemic Therapies,  156
        Hormonal Therapies,  159
        Acne Surgery,  160
        Intralesional Glucocorticoids,  160
         Summary,  162
         Clinics care points,  162
         Disclosures,  163

        Nonsurgical Chin Augmentation,  167

        By Maria C. Bell, Perry B. Hooper, Ariel Eber, Jessica Labadie, and Jeffrey Dover
        Chin augmentation has grown in popularity due to the chin’s prominent role in the overall appearance of the face. Fillers provide a safe, versatile alternative to more invasive surgical options. Corrections can be made gradually, and treatments may be adjusted with age-related changes of the lower face. A variety of proposed metrics help physicians analyze the chin in the context of a patient’s other features to guide treatment. Filler use may be complemented by supplemental procedures, such as neuromodulators, deoxycholic acid, ultrasound/radiofrequency-based therapy, and fractionated laser, depending on a patient’s specific needs.
         History,  167
        Chin and Lower Face Anatomy,  168
         Preoperative anatomical analysis,  168
        Anterior Analysis,  168
        Vertical Analysis,  169
        Horizontal Analysis,  169
         Preoperative evaluation,  169
        Filler Selection,  170
        Injection Technique,  172
        Potential Complications,  174
         Summary,  175
         Clinics care points,  175
         Disclosure,  176

        Cellulite Management Update,  177

        By Ariel E. Eber, Perry B. Hooper, Jessica G. Labadie, Prasanthi Kandula, Jeffrey Dover, and Michael S. Kaminer
        Video content accompanies this article at
        Cellulite is a common esthetic concern for a large majority of post-pubertal women usually regardless of body habitus and body mass index. Previous therapies have been largely ineffective or lack durable responses. Cadaveric studies have elucidated anatomic differences in the fibrous septae within the subcutaneous tissue between men and women. The orientation of the septae in women may explain the appearance of cellulite. Treatments targeting the fibrous septae have proven to be most successful and long-lasting. The aim of this article is to describe the latest updates in cellulite treatment, specifically vacuum-assisted tissue-stabilized guided subcision, targeted verifiable subcision, rapid acoustic pulse, and enzymatic treatment with collagenase clostridium histolyticum-aaes.
         Introduction,  177
         Preprocedural considerations,  179
        Preprocedural Evaluation,  179
        Preprocedural Approach,  179
         Treatment update,  181
        Surgical Subcision,  181
        Procedural Approach,  181
        Complications,  182
        Clinical Results,  182
        Procedural Approach,  183
        Complications,  184
        Clinic Results,  184
        Acoustic Subcision,  185
        Procedural Approach,  187
        Complications,  187
        Clinical Results,  187
        Chemical Subcision,  188
        Procedural Approach,  189
        Complications,  189
         Clinical results,  190
         Summary,  190
         Clinics care points,  190

        Update on Melasma Management,  193

        By Heidi Oi-Yee Li, Elena Pastukhova, and Jeffrey Dover
        Melasma is a complex hyperpigmentary disorder with a multifactorial etiology. There are multiple treatment options that aim at achieving pigment homeostasis, by either decreasing melanin production or accelerating its elimination. The mainstay of melasma management remains diligent photoprotection and topical therapy, such as hydroquinone and triple therapy (hydroquinone, retinoid, and steroid) creams. Additional novel topical treatments can be considered, such as tranexamic acid, cysteamine, azelaic acid, methimazole, metformin, and botanic agents like Rumex occidentalis. Microneedling as an adjuvant to topical therapies is an appropriate step-up second-line option.
         Introduction,  193
        Pathogenesis and Therapeutic Targets,  194
        Topical Therapies for Melasma,  195
        Clinics care points,  195
        Topical Therapies,  195
        Cysteamine,  196
        Azelaic Acid,  196
        Methimazole,  196
        Metformin,  197
        Botanicals,  197
        Anti-Vascular Therapies,  197
         Clinics care points,  198
        Adjunctive Therapies to Increase Drug Delivery,  198
         Clinics care points,  201
        Lasers,  202
        Ablative Lasers,  202
        Non-ablative Q-Switched Lasers,  202
        Picosecond Lasers,  202
        Non-ablative Fractionated Lasers,  202
        Lasers Targeting Hypervascularization,  203
        Laser-Assisted Drug Delivery,  203
        Clinical Considerations,  203
         Clinics care points,  205
        Putting It All Together: Designing a Therapeutic Strategy,  205
        Medical History,  205
        First-Line Therapy,  205
        Second- and Third-Line Therapies,  206
        Clinical Considerations,  206
         Disclosure,  206