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Correction was attempted using a 24 mg/mL crosslinked HA injectable gel premixed with anesthetic. First, a small aliquot of lidocaine with epinephrine was injected as a superficial bleb at the superior portion of the facial defect. Next, using a 23-G 1$ needle, an entry point was created, allowing easy access for the 25-G 2$ blunt-tipped microcannula (Figure 1). Linear threading in the preperiosteal plane was performed until optimal correction was achieved (Figures 2 and 3). To limit complications such as necrosis from vascular compromise, the total product injected was less than 1 mL in attempt to prevent external arterial compression. Aspiration before injection is not possible with microcannula injection and was avoided. Ice packs were applied immediately after procedure following light massage. The patient was satisfied with the immediate results and denied any recommended future treatments. Improvement was maintained for more than 9 months of follow-up. Soft tissue fillers can be used as less invasive treatment options for aesthetically displeasing defects, and the use of blunt-tipped microcannulas are an excellent alternative to traditional sharp needle injection by being less traumatic during injection, thus minimizing the risk for procedural complications such as pain, bruising, swelling, and risk of tissue necrosis from intravascular compromise. Only one other report of using an HA filler alone for the treatment of ECDS has been reported with successful improvements using sharp-needle injection.5 Other reports have used multiple fillers with success in cases of hemifacial atrophy seen in patients with Parry–Romberg syndrome. Although it seems attractive to offer a more permanent reversal with

long-lasting agents such as autologous fat, bone grafting, synthetic implants, and/or liquid silicone, the results may be unpredictable and complications, if they were to occur, may be devastating and potentially irreversible. Although excellent and immediate clinical results were demonstrated with little risk, more studies are needed to determine optimal guidelines for injection technique and proper use of blunt-tipped microcannulas for soft tissue filler injection.

References 1. Katz K. Frontal linear scleroderma (en coup de sabre). Dermatol Online J 2003;9:10. 2. Brownell I, Soter N, Franks A. Familial linear scleroderma (en coup de sabre) responsive to antimalarials and narrowband ultraviolet b therapy. Dermatol Online J 2007;13:11. 3. Consorti G, Tieghi R, Clauser L. Frontal linear scleroderma: long-term result in volumetric restoration of the fronto-orbital area by structural fat grafting. J Craniofac Surg 2012;23:e263–5. 4. Karaaltin M, Akpinar A, Baghaki S, Akpinar F. Treatment of “en coup de sabre” deformity with adipose-derived regenerative cell–enriched fat graft. J Craniofac Surg 2012;23:e103–5. 5. Thareja SK, Sadhwani D, Alan Fenske N. En coup de sabre morphea treated with hyaluronic acid filler. Report of a case and review of the literature. Int J Dermatol. [published online ahead of print October 29, 2013] doi: 10.1111/ijd.12108.

Rachel Sivek, BA Jason Emer, MD* *Both the authors are affiliated with Spalding Drive Plastic Surgery and Dermatology, Beverly Hills, California. Address correspondence and reprint requests to: Jason Emer, MD, Spalding Drive Plastic Surgery and Dermatology, 120 S. Spalding Drive, Suite 315, Beverly Hills, CA, 90212, or e-mail: [email protected]

Photodynamic Therapy for the Prevention of Skin Cancer In the article by Anthony J. Dixon, Howard K. Steinman, Jason D. Mazzurco, and Stuart J. Anderson, on preventing skin cancer using photodynamic therapy,1 there are a number of statements and claims made that may not be supported by evidence.

• It is stated that the trial was suspended “because of problems with trial governance and the reporting of severe adverse events.” No adverse events had been reported to Bond University Human Research Ethics Committee (BUHREC) at the time the trial

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was suspended. The trial was stopped purely because of governance issues. BUHREC embargoed any use of the data from the suspended trial. The claim that “some intervention patients experienced prolonged adverse events” was not experienced by any other sites in the trial. Dr. Dixon refers to Allmedic Pty Ltd. as the trial sponsor. Although Allmedic was entered in the trial documentation as the sponsor, no sponsorship agreement was ever entered into or agreed to by Allmedic. In the “Results” section, it states “the sponsor formally stopped it in June 2009.” The trial was stopped initially and unilaterally by Dr. Dixon in March 2009, and then finally by BUHREC in July 2009. Allmedic Pty Ltd. did not decide to stop the trial. In the discussion area, Dr. Dixon states “we are unable to identify any other regulatory approval of this novel ALA product.” 5-ALA is approved for use in Australia as a compounded product supplied on prescription. It can be found on the ComLaw Web site (http://www.comlaw.gov.au/Details/ F2012L01200/Download) in the Poisons Standard 2012 (page 68). The Poisons Standard is a Therapeutic Goods Administration document. Dr. Dixon claims that the “novel ALA” used in the trial resulted in greater adverse events than Levulan. The only person to experience any unexpected prolonged adverse events in the trial with the ALA is Dr. Dixon. No other trial participants had a similar experience. Dr. Dixon incorrectly states “Intervention patients were to be offered the option of undergoing PDT free of charge once the trial was completed.” This presumably should read control patients (not intervention patients). However, despite this grammatical error, it is important to know that Dr. Dixon, through his practice staff, did request more 5-ALA in July 2009 to treat the controls, several months after his patients had experienced the severe side effects he claims. Dr. Dixon suggests in his conclusions that the use of PDT as a chemopreventative treatment in field cancerization does not have literature support. There are numerous studies describing the preventative benefit of PDT (with both 5-ALA and

mALA), especially in patients with organ transplantation.2–6 Dr. Dixon’s experience seems to be unique. Dr. Dixon has made similar claims in other articles, and Allmedic has responded to them in similar terms. The article submitted to JPRAS7 for publication in March 2013 has been temporarily removed by the Journal Editor.

References 1. Dixon AJ, Anderson SJ, Mazzurco JD, Steinman HK. Novel photodynamic therapy does not prevent new skin cancers—randomized controlled trial. Dermatol Surg 2014;40:412–9. 2. Perrett CM, McGregor JM, Warwick J, Karran P, et al. Treatment of post-transplant premalignant skin disease: a randomized intrapatient comparative study of 5-fluorouracil cream and topical photodynamic therapy. BR J Dermatol 2007;156:320–8. 3. Apalla Z, Sotiriou E, Chovarda E, Lefaki I, et al. Skin cancer: preventative photodynamic therapy in patients with face and scalp cancerization: a randomized placebo-controlled study. BR J Dermatol 2010;162:171–5. 4. Wennberg AM, Stenquist B, Stockfleth E, Keohane S, et al. Photodynamic therapy with methyl aminolevulinate for prevention of new skin lesions in transplant recipients: a randomized study. Transplantation 2008;86: 423–9. 5. Willey A, Mehta S, Lee PK. Reduction of incidence of squamous cell carcinoma in solid organ transplant recipients treated with cyclic photodynamic therapy. Dermatol Surg 2010;36:652–8. 6. Goldberg LH, Landau JM, Moody MN, Marquez D, et al. Evaluation of the chemopreventative effects of ALA PDT in patients with multiple actinic keratosis and a history of skin cancer. J Drugs Dermatol 2012;11:593–7. 7. Dixon AJ, Anderson SJ, Dixon MP, Dixon JB, et al. Post-procedural pain with photodynamic therapy is more severe than skin surgery: prospective data. J Plast Reconstr Aesthet Surg 2013. Temporarily removed from publication.

Douglas Grose, MBBS, BSc (Med), DObsRCOG, FFMACCS Skin Alert Paradise Point, Australia William Anseline, BMedSci (Hons), BMed Department of Clinical Medicine Griffith University School of Medicine Ashmore, Australia Peter Smith, MBBS, BMedSci, PhD, FRACP Department of Clinical Medicine Griffith University Ashmore, Australia

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Photodynamic therapy for the prevention of skin cancer.

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