TREATING GLABELLAR LINES IN PATIENTS AGED 65+
While injectable neurotoxin is not new, its huge impact on the field of aesthetic medicine continues to this day. Despite the presence of a few strong, tried-and-true offerings dominating the market, new ones continue to appear. PrabotulinumtoxinA is a relatively new iteration and, in the interests of establishing firmer ground for established off-label uses, a recent study in the Journal of Cosmetic Dermatology provides concrete evidence of how neurotoxin can be used in elderly patients successfully.1
Sue Ellen Cox, MD is a dermatologist and medical director of aesthetic solutions at her clinical and research practice in Chapel Hill, N.C. She is also adjunct associate professor at the UNC School of Medicine, as well as consulting associate professor at Duke University Medical Center (Durham, N.C.). “The widely held belief is that you cannot use toxins in people who are over 65 years old and expect good results,” she began. “This mythology stems from phase III clinical trial data early in the study of toxins because companies eliminated patients older than 65 in their registration trials, which are the bedrock the community relies on for basic guidance. But the fact is that while many physicians shy away from treating the older population without that rubber stamp approval, many regularly inject neurotoxin for patients 65 years and older, and there is a reason – because it works for many. More importantly, it has been shown to be safe.
“In this study,” Dr. Cox continued, “we performed a post hoc analysis as part of our placebo-controlled Phase III clinical trials for prabotulinumtoxinA precisely because we did not limit the age range to under 65. We simply extracted additional data from the studies and evaluated it.”
Analyses were performed for all patients who were treated for glabellar lines with one 20 U dose of prabotulinumtoxinA within the three 150-day trials, together. Patients were grouped by age, ≥65 years (n=70) versus
What was the verdict of this post hoc analysis? “In terms of statistical significance, the older patient population did as well as the younger patients with the prabotulinumtoxinA used in our study,” Dr. Cox stated. In fact, responder rates among patient groups, proportionally, showed an absolute mean difference of only 2.7% overall. Differences between groups were not statistically significant at any point in the evaluation timeline.
“We found that the most prevalent treatmentrelated adverse event was headache in 5.7% of subjects from the ≥65 years age group, and 9.7% among those in the younger group. This is important because part of the mythology surrounding use of neurotoxins in the 65+ age group is that the adverse events profile is less favorable,” Dr. Cox shared. “As a result, physicians want to inject lower doses to prevent ptosis, for example. What that tends to do is reduce the longevity of outcomes. This study showed no increase in adverse events; no additional ptosis, so no need to lower your dose. Also, the older patient population is likely to have more severe lines, so they are at a worse starting point, yet that patient population still had a ≥ one point improvement by the standard scale regularly used by the community.”
In short, according to Dr. Cox, the study dispels the myth that toxins are not really good for patients over 65 years old. “Moreover, they can see some of the same types of correction, and over time it is not hopeless for them to see more correction with continued, regular treatment, in my personal experience. You just have to keep in mind who you are dealing with and that the expectations must be managed, which is par for the course in aesthetic medicine of any kind.”
1. Cox, SE, Ascher, B, Avelar, RL, et al. PrabotulinumtoxinA for the treatment of glabellar lines in adults, 65 years of age and older: The fourth in a series of post hoc analyses of the phase III clinical study data. J Cosmet Dermatol. 2023; 22: 1745- 1756. doi:10.1111/jocd.15783
The original article: PrabotulinumtoxinA for the treatment of glabellar lines in adults, 65 years of age and older: The fourth in a series of post hoc analyses of the phase III clinical study data, is open access and available online at: https://onlinelibrary.wiley. com/doi/full/10.1111/jocd.15783#pane-pcw-references
LASER-ASSISTED TREATMENT OF HYPERTROPHIC BURN SCARS
When rehabilitating burn patients, the goal is to restore as much function and wellbeing as possible. Very often one must focus on maximizing health and function of healing burn scar tissue, which may be characterized by tightness, pain and/or itching and lack of elasticity among many other issues, according to acute and reconstructive burn care specialist Taryn Travis, MD of the burn center at MedStar Washington Hospital Center (Washington, D.C.). “These are what we care most about when treating burn scars because they are functionally significant. However, improving – if not restoring – the appearance of the healed area is a major contributor to quality of life,” she shared.
Lasers have long been a mainstay in the armamentarium of physicians laboring to restore the youthful, healthy look of skin, making them a first line tool in the treatment of many skin conditions, including scar revision. An investigation put forth in the journal Lasers in Surgery and Medicine examines changes in scar melanin index after CO2 fractional ablative laser scar revision (FLSR) via non-invasive probe measurement among patients of diverse Fitzpatrick skin types.1
Dr. Travis, a co-author of the study, is an assistant professor of surgery at Georgetown University School of Medicine (Washington, D.C.). “Improvement of the appearance of scars is a small but important part of what we do,” she explained. “The whole thing is very complex because pigmentation may be darker or lighter than surrounding healthy skin, and these are two physiologically different issues that can sometimes be present in the same patient or the same scar. To the patient there is a significant psychological impact, so any visible improvement is cause for celebration.”
In the study, FLSR was employed in the treatment of scars of various sizes and etiologies. The patient population (n=63) was culled from a pool of 189 patients undergoing laser treatment who completed at least two laser sessions, with melanin index measurements for both sessions, as well as the preoperative visit. In addition to melanin index, patient and observer scar assessment scale (POSAS) pigmentation and color scores, along with vancouver scar scale (VSS) pigmentation scores, were examined over the course of the study. “Bear in mind that our treatment protocols were not altered to maximize the chance of a therapeutically relevant aesthetic result,” Dr. Travis mentioned. “We were simply taking note of the effect of treatments we normally administer to help heal burn scars.”
If melanin index indicated lower levels of hyperpigmentation after FLSR treatment in more than half of their total number of visits, patients were considered a responder; if not, they were a non-responder. Almost two-thirds (41 of 63) of the cohort were responders, among which significantly improved levels of hyperpigmentation in hypertrophic scars were noted after two FLSR sessions (p
One of the major takeaways, according to Dr. Travis, is that insurance companies do not pay to improve the scar aesthetically, and perhaps they should revisit this practice. “Insurance companies call it cosmetic, but to us – and especially, the patients – aesthetic improvement dramatically impacts quality of life. It is a big part of what helps patients re-integrate into their pre-injury lives.
“Also, this is just scratching the surface using our normal treatment protocols,” Dr. Travis continued. “We were not treating the appearance of the scar specifically. There is so much to explore beyond the scope of this paper that I am excited to see where we, and others, can take it.”
1. Kurup, S, Travis, TE, Shafy, RAE, Shupp, JW, Carney, BC. Treatment of burn hypertrophic scar with fractional ablative laser-assisted drug delivery can decrease levels of hyperpigmentation. Lasers Surg Med. 2023; 55: 471– 479. https://doi. org/10.1002/lsm.23662
The original article: Treatment of burn hypertrophic scar with fractional ablative laser-assisted drug delivery can decrease levels of hyperpigmentation, is open access and available online at: https://onlinelibrary.wiley.com/doi/full/10.1002/ lsm.23662
HOW CONSUMERS FIND ANSWERS FOR RHINOPLASTIES
Owing to the rapid advancements, and proliferation of information technology, the modern patient is more informed than ever. This reality begs several questions. Where are they getting their information? Is the information any good? What questions are they asking, and how can the medical community use this information to everyone’s benefit?
For the vast majority, the search for answers starts with Google, which is a logarithmically evolving body of available information. Constantly adapted machine learning algorithms are relied on by billions daily, but when it comes to rhinoplasties what do patients ask, and where are they getting their information?
More importantly, what does it all mean? These are questions addressed in a recent study published in Facial Plastic Surgery & Aesthetic Medicine.1
Co-author Clinton Humphrey, MD practices in Kansas City, Kan. and is currently professor of facial plastic surgery at the University of Kansas Health System, specializing in otolaryngology and facial plastic surgery. “Physicians are motivated to help patients find their practices in an internet search,” he noted, “but there is also intellectual curiosity which compels us to learn about how good the information is that is out there – not just ‘where are they finding it?’ but ‘what are they finding?’”
Google searches cause its algorithms to generate and display frequently associated (‘people also ask,’ or PAA) questions with corresponding answers from websites. Google data was analyzed using Ahrefs, a search engine optimization (SEO) gateway to search pattern data for a particular topic or term. “This allowed us to analyze search volumes, trends and related keywords surrounding the terms ‘rhinoplasty,’ ‘nose surgery’ and ‘nose job,’” Dr. Humphrey explained. Query volume per month was the measure of popularity, and all data collected were specific to the U.S. “We categorized websites by type, using the Journal of the American Medical Association (JAMA) benchmark criteria to assess the quality of the information.”
Overall, the top searches involved preoperative factors (46%), cost of the procedure (35.7%) and recovery timeline (7.3%). Sources for the answers to PAA questions, most often, were single surgeon personal (39.3%) and medical practice (20.6%) websites. The quality of information was not considered to be particularly good, based on study results. “This is difficult to assess because there are limits to the application of JAMA criteria,” Dr. Humphrey reported.
“The conclusion, therefore, is that the answers to the most popular questions should be emphasized on physician websites to drive patient traffic,” explained Dr. Humphrey. “While many may not want to advertise cost, it may help to provide a cost range to satisfy patient curiosity, which is admittedly understandable.”
Two of the most obvious weaknesses to the study, according to Dr. Humphrey, are that there is no way to be sure who exactly is performing searches – actual prospective patients or the curious, for example – and that social media (which was not factored into the study) plays an important role in the patient online research process. “Social media changes so often and there are numerous platforms, so it is difficult to assess that, but it is a clear avenue for further study,” he shared.
Constantly evolving information technology demands that we seek answers to these and other questions. There is always new information and new perspectives. A major goal of the paper that may not be clear is to stimulate further investigation along these lines, claimed Dr. Humphrey. “When you look at all of this and place it in the context of what is happening in the world of computerized information, we are clearly behind in our examination of how patients, doctors and the body of easily available medical information interact. As physicians it is our responsibility to maintain curiosity about these issues to keep us informed and push the conversation forward.”
1. Fassas SN, Krane NA, Zonner JG, et al. Google search analysis: what do people want to know about rhinoplasty and where do they find the answers? Facial Plast Surg Aesthet Med 2022;24(5):363 – 368.
The original article: Google search analysis: what do people want to know about rhinoplasty and where do they find the answers?, is open access and available online at: https:// pubmed.ncbi.nlm.nih.gov/34591713/