BACKGROUND: Botulinum neurotoxin (BoNT) is approved as single-use vials containing doses higher than necessary for most patients, which contributes to waste and lost revenue. It is common practice to administer a single-...BACKGROUND: Botulinum neurotoxin (BoNT) is approved as single-use vials containing doses higher than necessary for most patients, which contributes to waste and lost revenue. It is common practice to administer a single-use BoNT vial to multiple patients, but data are lacking to support the safety of this practice. OBJECTIVE: To determine the safety and efficacy of a multiuse vial protocol for BoNT at an academic medical center. MATERIALS AND METHODS: A retrospective review of the electronic medical record identified patients receiving cosmetic BoNT at Oregon Health & Science University between 2020 and 2025. Adverse events that occurred within 30 days of the procedure were recorded. RESULTS: A total of 2,666 patients receiving cosmetic BoNT were included. Overall, 354 (13.28%) follow-ups occurred within 30 days, and 39 (1.46%) adverse events occurred. The majority of these were related to inadequate paralysis (16) or asymmetrical paralysis (12). No serious complications or infections were identified. CONCLUSION: Complications when using a multiuse vial policy for BoNT are infrequent and not related to infection. Adoption of similar policies nationwide will lead to a reduction in medical waste and increased revenue.
BACKGROUND: No adequately powered, randomized studies have compared different absorbable suture types used for epidermal closure on facial scar cosmesis. OBJECTIVE: To assess postsurgical facial scar appearance using rap...BACKGROUND: No adequately powered, randomized studies have compared different absorbable suture types used for epidermal closure on facial scar cosmesis. OBJECTIVE: To assess postsurgical facial scar appearance using rapidly absorbable polyglactin 910 or fast absorbing gut for epidermal closure. MATERIALS AND METHODS: Randomized, blinded, split-scar clinical trial of 5-0 rapidly absorbable polyglactin 910 (Vicryl Rapide) and 5-0 fast absorbing gut. Patients with facial wounds resulting from Mohs micrographic surgery (n = 105) were assigned for epidermal closure. One dermatologist and 1 plastic surgeon, blinded to original suture location, evaluated photographs of each healed scar at 6 months after surgery and graded each half of the scar using the visual analog scale (VAS), Stony Brook Scar Evaluation Scale (SBSES), and wound evaluation scale (WES). RESULTS: At 6 months, mean (SD) scores from the dermatologist all statistically favored rapidly absorbable polyglactin 910: VAS 76.5(14.5) versus 73.2(15.2), p = .05; SBSES 4.4(0.9) versus 4.0(1.1), p = .006; WES 5.4(1.0) versus 5.1(1.1), p = .05. Scores from the plastic surgeon also favored rapidly absorbable polyglactin 910 but were not statistically significant. CONCLUSION: Rapidly absorbable polyglactin 910, placed through the epidermis, was the favored absorbable suture material for facial epidermal closure.
INTRODUCTION: The morphologic and physiologic changes with use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to the dermatologic surgery community. More specifically, many patients note changes in per...INTRODUCTION: The morphologic and physiologic changes with use of glucagon-like peptide-1 receptor agonists (GLP-1RAs) are known to the dermatologic surgery community. More specifically, many patients note changes in periorificial appearance relating to inadvertent cosmetic and oral health concerns that span not only dermatology but also dentistry. This article explores the overlap between the dentistry and dermatology fields in managing effects of this class of medications. METHODS: The available peer-reviewed literature evaluating perioral changes and impacts of the GLP1RAs was evaluated in the PubMed database. RESULTS: The findings from the review of the peer-reviewed literature were limited. These findings were combined with clinical experience and reports from related topics to identify culprits for the clinical findings including but not limited to skin changes, volume loss, xerostomia, and periodontal changes. In addition, opportunities for collaborative efforts for patient care were explored. DISCUSSION/CONCLUSION: The benefit of a collaborative effort of dermatologic surgeons and dentists is demonstrated. This multidisciplinary collaboration can yield comprehensive solutions to some of the less desirable adverse effects of GLP1RAs.
BACKGROUND: Lipedema is a chronic disorder characterized by disproportionate accumulation of subcutaneous fat, most commonly affecting the extremities, and is associated with pain, inflammation, and fibrosis. Effective m...BACKGROUND: Lipedema is a chronic disorder characterized by disproportionate accumulation of subcutaneous fat, most commonly affecting the extremities, and is associated with pain, inflammation, and fibrosis. Effective medical therapies are lacking, and liposuction remains the primary treatment. Glucagon-like peptide-1 receptor agonists (GLP-1 RAs) demonstrate metabolic and anti-inflammatory effects, but their role in lipedema remains unclear. OBJECTIVE: To evaluate the potential role of GLP-1-based therapies in the management of lipedema. METHODS: A literature search of peer-reviewed articles published through March 2026 was conducted using PubMed. Search terms included "lipedema and GLP-1" and related combinations of GLP-1 RAs, tirzepatide, inflammation, and insulin resistance. Relevant studies in lipedema, obesity, and fibroinflammatory conditions were included. RESULTS: Thirteen publications were identified. Two specifically evaluated GLP-1 RAs in lipedema, with only 1 providing direct patient evidence. A small uncontrolled case series of 5 patients treated with exenatide reported improvements in pain and limb volume. Translational evidence suggests that GLP-1 RAs, particularly tirzepatide, may influence inflammatory and fibrotic pathways relevant to lipedema. CONCLUSION: To date, GLP-1 RAs have not been proven to have direct effects on lipedema progression. However, given their known role in weight reduction and metabolic improvement, they may provide benefit as adjunctive therapies.
BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are an increasingly prescribed class of antidiabetic medications with expanded use in chronic weight management. Emerging literature has raised concerns re...BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) are an increasingly prescribed class of antidiabetic medications with expanded use in chronic weight management. Emerging literature has raised concerns regarding dermatologic adverse effects of GLP-1RAs, including various forms of alopecia. OBJECTIVE: To evaluate the prevalence of GLP-1RA-associated alopecia, differences among agents, and proposed underlying mechanisms. MATERIALS AND METHODS: A scoping review of GLP-1RAs and alopecia was conducted using PubMed, including articles published up to April 2026. RESULTS: Current literature presents conflicting evidence regarding the effects of GLP-1RAs on hair loss. Available data suggest an association between GLP-1RAs and telogen effluvium and androgenic alopecia, with risk potentially increasing with longer duration of use, greater weight loss, and higher doses, particularly with tirzepatide and semaglutide. Proposed mechanisms include weight loss-related changes, alterations in dermal white adipose tissue, and hormonal influences, although their relative contributions remain unclear. Conversely, a smaller body of literature suggests improvement in inflammatory alopecia with GLP-1RA use, particularly among patients with metabolic dysfunction. CONCLUSION: Given the increasing use of GLP-1RAs, dermatology practitioners should be aware of their association with alopecia and consider patient counseling, monitoring, and proactive treatment in patients receiving GLP-1RA therapy.
BACKGROUND AND OBJECTIVES: The demand for male aesthetic treatments continues to rise, and with increased utilization of the glucagon-like peptide-1 receptor agonists (GLP-1RAs), we anticipate a growing need to address t...BACKGROUND AND OBJECTIVES: The demand for male aesthetic treatments continues to rise, and with increased utilization of the glucagon-like peptide-1 receptor agonists (GLP-1RAs), we anticipate a growing need to address these concerns. This narrative review examined the intersection of skin-related effects of GLP-1RAs and male aesthetics, focusing on the role of the dermatologic surgeon in their management. METHODS: A search of the available peer-reviewed literature through March 2026 in the PubMed database was conducted. Search terms included combinations of terms related to GLP-1RAs, male aesthetics, and dermatologic treatments. Studies were included if they were peer-reviewed, published in English, and relevant to the topic. RESULTS: Many concerns that drive men to seek aesthetic treatments overlap with secondary cutaneous manifestations of GLP-1RA treatments including hair loss, changes in facial and body volume, and skin quality and laxity. Management options include, but are not limited to, dermal fillers for volume restoration and biostimulatory agents for skin laxity, along with medical and procedural interventions for hair loss. CONCLUSION: Dermatologic surgeons are well-positioned to address GLP-1 receptor agonist-related aesthetic concerns in male patients. Practitioners should be prepared to offer evidence-based, customized treatment strategies as this population grows.
BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have transformed medical weight-loss therapy and have been associated with characteristic facial changes, including hollowing, skin laxity, and contour altera...BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have transformed medical weight-loss therapy and have been associated with characteristic facial changes, including hollowing, skin laxity, and contour alterations that may accentuate pre-existing signs of aging. OBJECTIVE: To review the anatomical basis of facial changes after GLP-1-associated weight loss and provide an evidence-based rationale for injectable aesthetic treatment using collagen-stimulating agents and hyaluronic acid (HA) fillers. METHODS: A narrative review was conducted focusing on region-specific facial aging anatomy, fat-compartment behavior, skeletal remodeling, soft-tissue mechanics, and skin changes associated with rapid weight loss. These findings were integrated with current international consensus recommendations for patients undergoing medication-derived weight loss. RESULTS: Facial changes after medical weight loss involve multiple structural layers, including deflation of superficial fat compartments, loss of deep support, skeletal resorption, and increased skin laxity. Midfacial volume loss seems to occur mainly in superficial fat compartments, contributing to contour flattening and more pronounced transition lines. These changes support a treatment strategy combining early collagen stimulation with targeted HA filler placement to address tissue quality, support, and volume loss. CONCLUSION: Effective management of the medical weight-loss face requires an anatomically informed, multimodal approach using early biostimulation and selective HA-based structural restoration.
BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have expanded from metabolic therapeutics to agents with broad effects on inflammation, tissue repair, cutaneous and adipose biology, and aging-related pat...BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) have expanded from metabolic therapeutics to agents with broad effects on inflammation, tissue repair, cutaneous and adipose biology, and aging-related pathways. Clinicians increasingly encounter cutaneous manifestations and aesthetic sequelae with important implications for dermatologic counseling and multidisciplinary care. OBJECTIVE: To review current evidence regarding GLP-1RA effects on skin biology, inflammatory dermatoses, wound healing, cutaneous adverse events, and aesthetic aging. MATERIALS AND METHODS: A narrative review of clinical, translational, and mechanistic literature was performed, emphasizing psoriasis, hidradenitis suppurativa, wound repair, skin hypersensitivity reactions, autoimmune blistering disease, and facial volume loss associated with pharmacologic weight reduction. RESULTS: GLP-1RAs are hypothesized to improve inflammatory skin conditions and wound repair through anti-inflammatory, immunometabolic, and proreparative pathways. Yet, their use may also be associated with injection-site reactions, hypersensitivity eruptions, rare autoimmune blistering disorders, and clinically significant facial deflation and skin laxity. Current evidence is strongest for mechanistic plausibility and observational clinical signals, whereas dermatology-specific randomized trials remain limited. CONCLUSION: GLP-1RAs exert bidirectional effects on cutaneous biology. Recognition of both therapeutic opportunities and potential aesthetic or adverse sequelae is important, with patient counseling ideally occurring within a multidisciplinary framework that integrates metabolic benefits with skin health and appearance.
BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have been associated with cutaneous changes including accelerated skin aging and volume loss. The biological mechanisms underlying these effects remain poorly...BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists have been associated with cutaneous changes including accelerated skin aging and volume loss. The biological mechanisms underlying these effects remain poorly understood, with limited in vivo human data. OBJECTIVE: The aim of this study was to evaluate adipogenesis-associated cellular markers in subcutaneous adipose tissue of patients receiving GLP-1 receptor agonist therapy. METHODS: Abdominal adipose tissue biopsies from patients receiving GLP-1 receptor agonists and untreated controls were analyzed using multiplex immunofluorescence to quantify FSP1, CD90, CD105, CD73, and ERG and to characterize adipose-derived stem cells (ADSCs) and fibroblast populations. RESULTS: Baseline analysis of 10 adipose tissue samples demonstrated a statistically significant reduction in adipose-derived stem-cell counts in the GLP-1 group compared with controls (11.0 vs 44.8 cells/mm2, p = .039), representing an approximately four-fold decrease. CD90+ cell counts were also significantly lower in the GLP-1 group (p = .047). Fibroblast populations were not significantly different between groups, suggesting selective depletion of the stem-cell compartment. CONCLUSION: This is the first in vivo human study demonstrating a significant reduction in the ADSC population in patients on GLP-1 receptor agonist therapy. Selective depletion of ADSCs offers a potential mechanism for the accelerated skin aging changes in this population beyond weight loss alone.
BACKGROUND: Glucagon-like peptide-1 (GLP) receptor agonists have demonstrated anti-inflammatory and wound-healing properties, but their impact on outcomes after dermatologic surgery has not been evaluated. OBJECTIVE: Thi...BACKGROUND: Glucagon-like peptide-1 (GLP) receptor agonists have demonstrated anti-inflammatory and wound-healing properties, but their impact on outcomes after dermatologic surgery has not been evaluated. OBJECTIVE: This study assessed the one-month risk of postoperative inflammatory complications (IC) in patients taking GLPs. METHODS: Patients undergoing Mohs Micrographic Surgery and wide local excisions for melanoma or nonmelanoma skin cancer while taking a GLP were identified using the TriNetx Research Network. GLPs included semaglutide, tirzepatide, liraglutide, dulaglutide, exenatide, albiglutide, and lixisenatide. IC included wound disruption, hematoma, infection of the skin and subcutaneous tissue, infections after a procedure, and other complications of procedures. After accounting for demographics and proinflammatory comorbid conditions, hazard ratios and 95% confidence intervals were used to identify the one-month risk of postoperative complications. RESULTS: Compared with patients without GLP use, the GLP cohort was associated with a significantly reduced risk of infection after a procedure, wound disruption, skin and subcutaneous tissue infection, hematoma, and other complications. Among individual drug comparisons, semaglutide and tirzepatide demonstrated the greatest reductions in postoperative complications. CONCLUSION: GLP receptor agonists were associated with a significantly reduced risk of postoperative inflammatory complications after dermatologic surgery, supporting their perioperative safety and potential beneficial role in wound healing.
BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) exert systemic metabolic and anti-inflammatory effects that may be relevant to cellular senescence, a key driver of skin aging. However, human cutaneous da...BACKGROUND: Glucagon-like peptide-1 receptor agonists (GLP-1RAs) exert systemic metabolic and anti-inflammatory effects that may be relevant to cellular senescence, a key driver of skin aging. However, human cutaneous data are lacking. OBJECTIVE: To explore whether systemic GLP-1RA therapy translates to a detectable reduction in cutaneous senescence, quantified by epidermal p21 expression and supported by AI-driven facial imaging. MATERIALS AND METHODS: In this controlled observational pilot study, 3 male adults (GLP-1RA n = 2; GLP-1RA-naïve control n = 1) underwent 3-mm punch biopsies from a standardized, sun-protected gluteal site to isolate intrinsic aging. Senescence was quantified through blinded whole-epidermis digital annotation of p21-positive nuclei. Clinical phenotypes were assessed using noninvasive cheek measurements and AI-based facial age estimation. RESULTS: The cohort demonstrated divergence in senescence-associated biomarkers correlating with GLP-1RA exposure. The GLP-1RA-naïve control exhibited 8.0% (n = 2,062 nuclei) epidermal senescence. By contrast, participants with 163 and 62 days of GLP-1RA exposure showed reduced senescence burdens of 2.4% (n = 2,045) and 0.6% (n = 1,636), respectively. Automated facial age estimation remained concordant with chronological age across subjects. CONCLUSION: Systemic GLP-1RA exposure is associated with a substantial reduction in epidermal p21 expression in some subjects, suggesting a senomorphic effect and supporting further mechanistic studies at the interface of metabolic regulation and skin aging.
BACKGROUND: Weight loss associated with glucagon-like peptide-1 (GLP-1) agonists is frequently accompanied by reduced facial fat, sagging skin, and stubborn pockets of body fat. OBJECTIVE: To identify aesthetic concerns...BACKGROUND: Weight loss associated with glucagon-like peptide-1 (GLP-1) agonists is frequently accompanied by reduced facial fat, sagging skin, and stubborn pockets of body fat. OBJECTIVE: To identify aesthetic concerns related to GLP-1 agonist-associated weight loss and current nonsurgical treatment trends. MATERIALS AND METHODS: An electronic survey was sent to health care professionals (HCPs) who were part of 3 large, opt-in databases. HCPs must have had experience treating patients with aesthetic concerns after GLP-1 agonists. RESULTS: The 406 HCPs who completed the survey (n = 100 dermatologists, n = 100 plastic surgeons, n = 105 physicians in other specialties, n = 101 nurses/physician assistants) reported treating a mean of 1,249 cosmetic patients per year. HCPs reported a mean increase of 137% in the number of patients receiving GLP-1 agonists from 2023 to 2024. HCPs perceive midface volume loss, face/neck skin laxity, and loose or sagging body skin to be the aesthetic changes most impacted by GLP-1 agonists, with patients also reportedly concerned about stubborn pockets of fat. Hyaluronic acid was considered the best treatment for facial concerns for an average of 47% of patients. CONCLUSION: This large survey of HCPs representing various specialties provides insights into patient face- and body-related aesthetic concerns associated with GLP-1-mediated weight loss.
BACKGROUND: Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have demonstrated substantial therapeutic benefits for patients with Type 2 diabetes mellitus and/or obesity. Their use has recently expanded rapidly acro...BACKGROUND: Glucagon-like peptide 1 receptor agonists (GLP-1 RAs) have demonstrated substantial therapeutic benefits for patients with Type 2 diabetes mellitus and/or obesity. Their use has recently expanded rapidly across diverse patient populations. However, GLP-1 RA-associated changes in body composition and skin quality, including premature skin aging and alterations in body contour, may create functional and aesthetic concerns for patients. Effective strategies to address these visible and unwanted effects are needed. OBJECTIVE: To summarize preclinical and clinical evidence supporting the potential role of AP31, a novel multifunctional micropeptide, in mitigating skin-laxity effects relevant to patients treated with GLP-1 RAs. MATERIALS AND METHODS: Preclinical studies have evaluated the biological activity of AP31 across multiple aging-related end points, including inflammatory pathways, extracellular matrix integrity, and age-associated gene expression. In addition, clinical studies have assessed AP31-containing regimens in middle-aged women, with outcomes focused on visible markers of skin aging such as firmness, elasticity, fine lines, wrinkles, facial contour, and structural support. RESULTS: Preclinical investigations demonstrated that AP31 reduced proinflammatory markers, increased key extracellular matrix components, and favorably modulated genes associated with intrinsic skin aging. In clinical studies, AP31-containing regimens produced rapid and visible improvements in multiple parameters of skin aging, including enhanced firmness and elasticity, reduction in fine lines and wrinkles, improvement in jawline definition, global facial lift, and reduced prominence of nasolabial folds. CONCLUSION: AP31 shows promising biological and clinical activity in improving visible signs of skin aging. While current findings are encouraging in the context of normal aging, randomized controlled trials are warranted to further establish the efficacy of AP31 for patients experiencing skin-related changes associated with GLP-1 RA use.
BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) used for weight management have introduced unintended facial changes only partially addressed by conventional volumizing fillers. OBJECTIVE: Evaluate th...BACKGROUND: Glucagon-like peptide-1 (GLP-1) receptor agonists (RAs) used for weight management have introduced unintended facial changes only partially addressed by conventional volumizing fillers. OBJECTIVE: Evaluate the mechanistic rationale and clinical evidence supporting poly-l-lactic acid Sculptra (PLLA-SCA) as a biostimulatory and regenerative treatment for GLP-1 RA-associated facial changes. METHODS: This narrative review synthesizes mechanistic and clinical data alongside expert opinion regarding PLLA-SCA for GLP-1 RA-driven weight loss, focusing on its biostimulatory and regenerative effects across skin layers. RESULTS: Poly-l-lactic acid Sculptra induces fibroblast recruitment and stimulates regeneration of collagen and elastin, and effects vasculature and adipose tissue, resulting in durable improvements in skin quality, elasticity, facial contour, and perceived age that persist for 2 years or longer. Clinical studies and real-world experiences demonstrate clinically meaningful corrections of midface and perioral volume loss, jawline contour, and radiance, including in patients with GLP-1 RA-related facial changes. CONCLUSION: Poly-l-lactic acid Sculptra may help address GLP-1 RA-associated facial atrophy by supporting long-term regeneration and restoration of facial definition, contour, and skin quality. The effects potentially extend across all 3 skin layers affected by the GLP-1 RA phenotype, including atrophy and gauntness. Poly-L-lactic acid Sculptra offers clinicians an option to deliver durable regenerative treatment that helps restore facial aesthetics in this patient population.
BACKGROUND: Diminished facial and body skin qualities have emerged as unintended consequences of rapid weight loss associated with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Patients experiencing facial and bo...BACKGROUND: Diminished facial and body skin qualities have emerged as unintended consequences of rapid weight loss associated with glucagon-like peptide-1 receptor agonists (GLP-1RAs). Patients experiencing facial and body skin sagging (laxity) are increasingly seeking corrective treatments to address aesthetic concerns. OBJECTIVE: To present available information on the effectiveness of topical skincare in addressing post-weight loss concerns such as skin quality and sagging/laxity. MATERIALS AND METHODS: A literature review was conducted to assess mechanisms underlying skin effects of GLP-1RA and rapid weight loss, and the role of topical skincare in addressing skin quality and sagging/laxity. RESULTS: GLP-1RA effects on subcutaneous adipose tissues and the dermal extracellular matrix include dehydration and nutrient deficiencies, and may lead to reduced skin quality and fibroblast function, decreased production of collagen, and increased degradation of collagen, elastic fibers, and glycosaminoglycans, causing loss of elasticity and skin sagging/laxity. Recent advances in skincare research have identified growth factors, peptides, and botanical extracts with potential rejuvenating effects on skin. Clinical studies have validated the effectiveness of topical formulations in improving facial and body skin sagging/laxity. CONCLUSION: Topical skincare formulations with demonstrated effectiveness in improving skin quality and sagging/laxity may be important adjuncts to post-weight loss multimodal aesthetic treatments.
BACKGROUND: Autologous fat transfer (AFT) provides a natural alternative to implants for breast augmentation. While most large-volume AFT is performed under general anesthesia, experience with fully tumescent local anest...BACKGROUND: Autologous fat transfer (AFT) provides a natural alternative to implants for breast augmentation. While most large-volume AFT is performed under general anesthesia, experience with fully tumescent local anesthesia is limited. This study evaluates the safety, efficacy, and volumetric outcomes of Breast Autologous Fat Transfer Entirely Under Tumescent Anaesthesia (BAFTEUTA) and examines the role of pre-expansion versus enrichment in graft survival. PATIENTS AND METHODS: In this prospective single-center study, 87 patients (174 breasts) underwent large-volume AFT under local tumescent anesthesia between 2018 and 2024. Preoperative expansion used either rigid dome systems or negative-pressure wound-therapy (NPWT) dressings. Fat was harvested manually or mechanically, processed without centrifugation, and injected in multiple subcutaneous planes. Volumes were measured by 3-D imaging and water displacement. Outcomes included percentage of successfully grafted fat (%SGF), final increase in size at 6 months (%FIS), and complications. RESULTS: No infections, hematomas, or systemic complications occurred. Five patients (6.25%) developed benign fat granulomas, all unilateral ( ≈3% of breasts). Median graft survival was 82%. Dome expansion achieved higher mean %SGF (84.5% vs 79.5%) and %FIS (193% vs 158%) than NPWT, with strong correlation between expansion hours and %FIS (r ≈ 0.9, p < .001). Smaller breasts and nulliparous women showed greater proportional gains. The mean satisfaction scores were 4.7 to 5.0 across domains. CONCLUSION: Large-volume breast fat transfer can be safely and reproducibly performed under tumescent anesthesia. Pre-expansion-particularly with dome systems-is the most critical determinant of graft survival, enabling durable, natural results without stem-cell enrichment, general anesthesia, or implants.