One of the main consequences of skin aging is the progressive reduction of the subcutaneous tissue with loss of firmness and tone of the tissues. By the association of high-intensity focused ultrasound and biostimulation threads, a lifting-like effect can be achieved without the post-operative and the risks of surgical lifting. The TBS Lift is indicated in all those cases in which there are signs of body aging related above all to skin laxity. High intensity focused ultrasound used in this study causes tissue warming and contraction to a depth of 4.5 mm. They also stimulate the collagen genesis in the superficial and deep dermis at 1.5 mm and 3.0 mm. In my experience it is useful, in order to amplify the results of high intensity focused ultrasound, the association with the polydoxanone biostimulation threads, a medical device already widely used in general surgery and cardiovascular surgery. By inserting the threads into the skin tissue immediately after performing the high-intensity focused ultrasound , an improvement of the final effect is obtained and an increase in the duration of the obtained improvement. This is because in turn polidioxanone stimulates the production of collagen and cell metabolism, while increasing the microcirculation and therefore the flow of blood in the treated areas. The whole procedure is outpatient, takes just around an hour, does not require anesthesia or at most a local anesthesia for the insertion of the threads in particularly sensitive patients.  The results on the firming and compacting of the skin are appreciated gradually until obtaining the maximum result in about 3 months. Results stable one year from treatment, The TBS Lift is aimed at patients who have a slight breakdown of body tissues or who want a preventive intervention. The treatment is indicated to counteract the skin failure of arms, thighs and knees. The association of the two methods in the same session also allows a clear economic advantage.

Objectives: 1) Know different factors contributing to the nasal ptosis. 2) Acknowledge different methods for correction of drooping nose with the advantages of augmentation. 3) Learn and apply efficient augmentation techniques for prevention of nasal ptosis during rhinoplasty.

Abstract: Maintaining long term results in rhinoplasty is the state of art in nasal plastic surgery. Numerous parameters in nasal wound healing and nasal support mechanisms have made rhinoplasty as the most difficult plastic surgery. In the recent years the role of augmentation for nasal support has been emphasized by many authors to prevent unwanted long term changes. Unpleasant appearance on animation, inducing aging face and impairing nasal valve function are considerable effects of ptotic noses. The profile view of the nose is the standard view for assessing tip rotation by measuring the nasolabial angle. The nasolabial angle is measured by a line from the subnasale to the superior vermilion and by a tangent of the columella from the subnasale. The ideal nasolabial angle is 90-100° in men and 100-110° in women. The most common indication for correction of the nasal tip ptosis is primary rhinoplasty. It is also a common feature of nasal aging in the aging face. Most rhinoplasty operations include techniques to attain and preserve acceptable tip rotation. Nasal ptosis is a common complant in secondary rhinoplasty due to damage of nasal tip support and subsequent nasal ptosis. Aesthetic nasolabial angle and tip location are affected by different factors. These factors include the cartilaginous framework of the lower third of the nose and the motor unity of this portion consists of levator labii superioris alaeque nasi and depressor septi nasi. The cartilaginous framework and these muscles stand for the static and dynamic factors respectively. This presentation will demonstrate advanced features of the most effective augmentation techniques to make stable aesthetic results and prevent nasal ptosis.

In the field of plastic surgery liposuction succeeded in becoming the most frequently performed cosmetic surgery procedure during the last decade in both man and women. First liposuction was described with curettage technique and then dry, wet and superwet techniques performed as suction assisted liposuction (SAL). The first aim with liposuction is removing excess fat and making body smaller. On the other hand in last year’s everything was changed and liposuction techniques are become different due to understanding fat anatomy under the skin. In order to get better results all innovative plastic surgeons need more superficial liposuction with less complications, so more dynamic liposuction or liposculpture techniques was essential. When we want to get shaping on the body we have to do more superficial liposuction. In this point plastic surgeons needs to get experience about dynamic zones, transition zones, positive and negative spaces. These zones provide us as a key what will be going and what will be left. Advanced body liposculpture provides more attractive and more successfull results. As we are aware the ideal male body form is V shape therefore this technique focused to succeed this body form. In order to achieve the ideal body form, deltoids, pectorals, latissimus, abdominal rectus muscle and external oblique muscles are the most important dynamic parts. Between this muscle groups have transition and negative zones. Also we have positive zones that fat stays above the muscles. Some surgeons keep the fat on positive zones and thinks they can achive more definition, this however is not the case. In order to achive permanent, attractive and naturel results most important part of surgery is patient selection. Even if you use the best technique you cannot achive best results if your patient is not eligible. Patient selection depends on the BMI, degree of skin excess, skin elasticity, patient's sportive history. Between December 2010- August 2018, More than 1300 Patient have undergone liposculpture. 40% cases were male and 60%Cases were female. In these cases advanced liposculpture procedure was performed to 70% male patient. All patients satisfied with aesthetic results of their liposculpture within the time of follow-up. Seroma rates were %7, unsatisfied definition rates were %1 due to patient selection, hematoma rates were %1, and skin necrosis did not occurred.

Nanotechnology and nanomaterial based products are finding their way from electronics to medicine and now sets a multi-trillion industry. This transformation is also finding its applications in the field of cosmetics by taking the name of nanocosmetics. A variety of products including moisturizers, hair care products, makeup and sunscreens has used nanotechnology. Currently, research focuses on delivery of functional cosmetics using delivery systems such as liposomes, niosomes, solid lipid nanoparticles, nano structured lipid carriers, nanocrystals, Nanoemulsions and many more. A brief review of latest findings on delivery systems will be presented in this lecture. More precisely, discussing on potential next generation cosmetic delivery agents that can provide enhanced skin hydration, bioavailability, stability of the agent and controlled occlusion. Specific information on potential risks caused by the nanomaterials both to human life and also to the environment and regulations are part of discussion. Depending upon the availability of time, some other concerns may come under discussion like the type of nanomaterials used, as well as stability, potential for skin absorption, route of exposure, and how they are formulated in cosmetic products.

Introduction: Acne   scarring   is   often   an   unfortunate   and permanent complication of acne vulgaris. It has high prevalence, significant impact on quality of life and therapeutic challenge. As  a  standard  protocol,  right  side  of  the  face  was microneedling with PRP (Group A) and left side of microneedling alone (Group B). The patients were 1wk for any side effects. A total of four similar sittin at intervals of 4 weeks each .

Results: Mean age of patients was 25 years ,13 (43%) group A had excellent response as compared to 6 (2 in    Group    B    according    to    physician    assessm satisfaction  was  more  in  Group  A    compared  to 11(36%) patients had more than 75% improvement in compared to 1 (3%) patient in Group B.

Discussion:  Acne   scars   management   is   challen patients as well as for the treating physician. In our results  was  better  with  microneedling  with  PRP. multiple  sessions  with  results  improving  with  ever does  not  ensure  100%  results  .  In  group  A  skin  ap firmer   and   smoother.   Hence   PRP   with   microneed economical and more promising in acne scars with acceptance.

Plasma electro-surgical devices have long been used for coagulation, cutting tissue, drying, and burning. Notwithstanding all the advantages, these technologies cause tissue warming, and their effects are mostly thermal. Recently, significant progress made in atmospheric pressure plasma science and engineering (CAP), by which the temperature of the CAP is controlled and works at temperatures below 40 ° C. In the past decade, an innovative new field has emerged from the combination of plasma physics, life science, and clinical medicine, which is known as plasma medicine (Heinlin J Isbary G Stolz W Morfill G Landthaler M et. al., 2011; Isbary et al., 2011). Thanks to these modern systems and plasma-medicine, the use of plasma in the human body is made possible. The purpose of this field is to employ the effects of cold plasma by managing the interaction between plasma elements with particular structural elements and features of living cells. Recent advances in comprehending the phenomena of the physical plasma, along with the development of new plasma sources, have opened a new way to cold atmospheric plasma healing, particularly in skin infections. The active components of the plasma such as molecules, atoms, ions, electrons and photons, reactive species, UV, and heat enable, control and catalyzes the reactions and complicated biochemical methods. Thermal and non-thermal (cold) plasma is now extensively used in medicine. It has very high potential in dermatology, for example, in wound healing, disinfection, sterilization, the treatment of various skin infections, or tissue recovery, and ultimately skin rejuvenation. This review is a general overview of the potential of plasma therapy in medicine, including recent research on skin diseases and interactions of plasma and living tissue (Choi et al., 2017) . Thanks to both better understanding of plasma phenomena and the development of new plasma sources in the past few years, plasma medicine has become an innovative research field with a high potential for healing. While thermal plasma is used in various medical fields (for example, to burn and sterilize medical devices), current research focuses mainly on the use of non-thermal plasmas. Experiments show that Cold-Air Plasma (CAPs) allows efficient, non-contact and painless disinfection, even in microscopic openings, without damaging healthy tissues. CAP can affect the biochemical processes. In the skin, new horizons open for wound healing, tissue regeneration, treatment for skin infections, and possibly other illnesses. The first clinical trial demonstrates the efficacy and tolerability of plasma in the treatment of chronically infected wounds (Gentile, 2018; Heinlin et al., n.d.). An important task is the introduction of plasma into clinical medicine and simultaneously examining the mechanisms of plasma action at the cellular level.

Autonomic nervous system (ANS) plays a role in the intrinsic skin ageing and it could be minimal compared to external factors induced, especially sun exposure. Most of the cutaneous vascular functions controlled by ANS such as the local blood flow and the loss of fluid through sweat. A recent hypothesis about a possible relationship between wrinkles and ANS activity and reversible wrinkling of the skin in response to water immersion is a marker of the limb sympathetic function. Factors that increase sympathetic activity such as stress, smoking and amphetamine may induce skin wrinkling. Heart rate variability (HRV) is the indirect measures of global ANS activity like high frequency [HF], low frequency [LF], LF/HF ratio. Facial xerosis was related to a decreased HF component that means impairment of parasympathetic autonomic activity. It might be associated with a decrease sweat production and stimulate vasodilatation which in turn leads to skin xerosis. Application of local and systemic administration of drugs and medical devices which electrically modulate autonomic nervous system activity and prognosis of skin ageing.

Skin is the outermost part of our body which is continuously exposed external assaults especially UV radiations. Prolonged exposure of unprotected skin to ultraviolet radiation (UVR) includes inflammation, premature photoageing, DNA damage, photocarcinogenesis, and immunosuppression. Five most significant signs of aging skin are; wrinkles, dark spots and uneven skin tone, sagging, dry skin and open visible pores. Sunscreen will continue to be an important component of Photoprotection. The active ingredients in topically applied sunscreens generally fall into two categories: organic or inorganic. Among inorganic actives, nanosized TiO 2 and ZnO are being used since 1980. These first generation nano sunscreens shown various disadvantages which will be discussed in this talk. The current sunscreens on the market are more aesthetically acceptable and superior to older generation sunscreens due to more advanced nanoparticle technology. Emphasis of discussion will be on encapsulation efficiency, stability and degradation in blood circulation, endocytosis by target cells, endosomal escape, delivery efficiency, and toxicity of nanoparticles. To overcome these obstacles, many types of nanocarriers are proposed; broadly into three categories; (i) lipid-based nanoparticles, (ii) polymer-based nanoparticles, and (iii) inorganic nanoparticles.

Objectives: (1) Know different nose and chin parameters contributing to the facial profile harmony. (2) Detect the specific facial imbalance of the nose and chin in any patient who is seeking correction of facial profile. (3) Apply different surgical techniques for chin advancement with the least complications and best results.

The chin like the nose is in a prominent position on the face and plays very important role in facial profile. The important relationship between the nose and chin may be ignored by many patients who are seeking rhinoplasty and may be underestimated by facial plastic surgeons who perform rhinoplasty This is the task of a facial plastic surgeon to mention this relationship and emphasize its importance for the patient. It is estimated that approximately one fifth of patients requesting rhinoplasty have an underdeveloped mandibular symphysis with normal occlusion (Angle, class I) can benefit from chin augmentation. The relationships between the nose and face were formulated by many authors considering the nasofrontal angle, nasolabial angle, nasofacial angle, and nasomental angle as important aesthetic parameters. Each facial component affects the perception of the balance of the other facial components. An underdeveloped chin with deficient projection will stimulate the image of an over projected nose. For this reason, we evaluated nose-chin proportions and nasal projection before and after genioplasty in rhinoplasty patients. In this presentation different nose and chin parameters contributing to the facial profile harmony will be described. Chin analysis will be discussed according to the most consistent methods. Surgical techniques for osteoplastic chin advancement will be demonstrated. All procedures were performed under general anesthesia with intraoral incision. After exposing the mentum, mental nerves were explored. After markings 5mm below the mental nerves, horizontal osteotomy was performed for chin advancement at the extent which was estimated on preoperative evaluation. The advanced segment was fixed in place with titanium plates or screws. Genioplasty could be performed in patients with chin problems during, before or after rhinoplasty to make a beautiful profile. Our experience with osteoplasty showed satisfactory results with no significant complication.

Tumor necrosis factor (TNF)-α inhibitors, including adalimumab (Humira; AbbVie, IL) have been shown to be effective in controlling chronic inflammatory diseases.

Injection site reactions (ISRs) are the most common adverse events associated with TNF-α inhibitors such as adalimumab, but systemic effects are rarely described.³We report the case of a woman who developed marked ISR and systemic leukocytoclastic vasculitis (LCV) after initiating adalimumab for rheumatoid arthritis (RA).

Case

The patient is a 75-year-old woman with seropositive RA with polyarthropathy, who had recently started adalimumab presented with a diffuse skin eruption. She had been previously treated with tocilizumab (4mg/kg monthly), methotrexate (10 mg weekly), and prednisone (5 mg weekly), with declining therapeutic effect. She was to undergo treatment with adalimumab (40 mg / 2 weeks). The patient reported that she administered a first adalimumab injection in the right lower abdominal quadrant two weeks prior to dermatologic evaluation. One day prior to dermatologic evaluation, she noted a round rash at the injection site and then overnight developed multiple skin lesions. She reported pruritus but otherwise felt well. Of note, she had taken 2 g of amoxicillin four days prior for a dental procedure. She had no additional medications. Physical examination revealed an 8 cm round erythematous patch with central, dusky hyperpigmentation over the right abdomen. There were numerous 3-8 mm urticarial macules and papules scattered over the legs, trunk, and arms, some with dusky centers. Urticarial patches were present on the palms. Oral mucosa and conjunctivae were unremarkable.

A punch biopsy of the abdominal injection site showed perivascular lymphocytes and eosinophils, indicative of a drug eruption. Punch biopsy of an urticarial papule on the left thigh showed LCV, characterized by fibrinoid degeneration of small blood vessels and a mixed infiltrate, with abundant neutrophils and prominent nuclear dust.

Discussion

Various adverse events have been reported in clinical trials of subcutaneous TNF-α inhibitors, most commonly ISRs. ISR, by definition, includes any of: erythema, pruritus, hemorrhage, pain, or swelling at the site of injection.

LCV is a small vessel vasculitis involving dermal postcapillary venules. Drugs cause roughly 10% of LCV, which generally manifest between 7 and 21 days following treatment.⁶Numerous studies have associated anti-TNF-α therapy with vasculitis,^7-10most commonly cutaneous vasculitis (most prevalent in patients with RA).⁸During RA clinical trials using adalimumab, the incidence of LCV was 0.01 events per 100 person-years of exposure.⁴The pathogenesis of anti-TNF-α associated vasculitis remains unclear. One hypothesis is that anti-drug host antibodies initiate an immune-complex mediated hypersensitivity reaction. Another theory suggests that TNF-α antagonists induce a switch from the predominant T helper 1 (Th1) profile of RA to a Th2 response.^11,12

In our patient, the skin lesions began at the injection site and subsequently spread. Given the injection site localization and the time course, adalimumab was presumed to be causative. It is possible that amoxicillin could also have caused the diffuse eruption. Our patient was successfully treated with discontinuation of adalimumab and initiation of corticosteroid therapy, with antihistamines as needed.

Management of dermatoses in older populations has emerged as an important area of consideration today and many skin diseases have been demonstrated to result in significant stress and impairment in the quality of life. The present study included 250 patients, the age range was from 60-85 years old with a mean age of 64.9±4.0. Eczema was the leading disease group (24.4%) followed by psoriasis (12.4%) and fungal infections (12.0%). Regarding the quality of life, patients were assessed using the Dermatology Life Quality Index (DLQI) questionnaire. More than half of the study sample (55.6%) showed very large effect of the skin disease on their quality of life and 34.4% were moderately affected. The DLQI had a mean of 11.2±4.1, median of 11.0 and range of (0-26). Large impact on the quality of life of the study sample was higher among males represented by 59.2% versus 53.1% for females. Also, large impact on the quality of life of the study sample was found to be the highest among those suffering from psoriasis and eczema represented by 83.8% and 75.4% respectively. It was also reported that patients suffering from xerosis, psoriasis, fungal infections and eczema reported increase in the flare of the disease in winter. Also, large impact on the quality of life of the study sample was observed in more than half of those taking four or more medications.