Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations

Safety and Performance of Etermis 3 and 4 in Wrinkles/Folds Treatment and Facial Volume Enhancement: A Prospective, Evaluator-Blinded, Open-Label Study

Background

Facial aging is characterized by increased prominence of nasolabial folds (NLFs), marionette lines, and thinning of the lips. Cross-linked hyaluronic acid injection is a very effective method for the temporary correction of these areas.

Objective

To confirm the clinical performance and the safety of Etermis 3 (ET3) and/or Etermis 4 (ET4) in the treatment of moderate and severe wrinkles/folds, as well as lip volume enhancement.

Methods

Subjects were treated in at least two facial areas (NLFs, marionette lines, lips). ET3 was used in facial moderate wrinkles while ET4 was used in severe facial skin volume loss. An optional touch-up 1 month after treatment was possible. A blinded investigator assessed improvement on Merz Aesthetic Scales (MAS). Subjects were followed-up for 12 months after the last treatment.

Results

In total, 154 healthy subjects were enrolled. The proportion of subjects achieving ≥1 score improvement in MAS after treatment was above 60% for ET4 (Month 6/7: NLFs 94.9% and marionette lines 81.4%, p≤0.0004; Month 3/4: lips 63.0%, p=0.39) and ET3 (Month 6/7: marionette lines 79.4%, p=0.0005; Month 3/4: lips 65.5%, p=0.31). Facial improvement was still visible at Month 12/13 for ET4 (NLFs ≥76.6%, marionette lines ≥61%, lips ≥36%) and ET3 (marionette lines ≥50% and lips ≥21.9%). No treatment-related serious AEs occurred. The most frequent AEs were injection-site reactions.

Conclusion

Etermis 3 and Etermis 4 demonstrated good clinical performance and safety for NLFs and marionette lines volume enhancement for up to 12 months. Both products can also be used safely to treat lips for volume augmentation.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

Effects of different doses of abobotulinumtoxinA for the treatment of anterior gingival smile

Botulinum toxin type A (BoNT-A) is an easy and fast treatment for gingival smile (GS). The objective of the study was to compare the reduction of gingival exposure using three different doses of abobotulinumtoxinA (ABO) in patients with different severities of anterior GS, and to assess treatment safety and patients' satisfaction. A prospective, single-center, randomized, double-blind study was conducted. Mild GS (2 to < 3 mm) was treated with 2.5 U of abobotulinumtoxinA (ABO) per side, moderate GS (3 to < 4 mm) with 5 U of ABO per side, and severe GS (4 mm or more) with either 2.5 U, or 5 U or 7.5 U of ABO per side. All the 41 enrolled patients completed the study. The mean gingival exposure reduced significantly 4 and 12 weeks after treatment. The average reduction of gingival exposure with 5 U was significantly larger than that obtained with 2.5 U, (3.46 ± 1.39 vs. 2.05 ± 1.29 mm; p = 0.004). All groups of GS severity presented statistically significant reduction in the gingival exposure 4 and 12 weeks after ABO injections. Twelve weeks after treatment, more than 80% of the patients were satisfied or very satisfied. There were no treatment-related adverse events reported by the patients or noticed by the investigators. Gingival smile can be safely and effectively managed with BoNT-A injections and specifically with ABO injections to target the LLSAN muscle. Further and larger studies may determine the exact influence of each factor on BoNT-A treatments of GS.

Evaluation of the Rheologic and Physicochemical Properties of a Novel Hyaluronic Acid Filler Range with eXcellent Three-Dimensional Reticulation (XTR™) Technology

Soft-tissue fillers made of hyaluronic acid and combined with lidocaine have recently become a popular tool in aesthetic medicine. Several manufacturers have developed their own proprietary formulae with varying manufacturing tools, concentrations, crosslinked three-dimensional network structures, pore size distributions of the fibrous networks, as well as cohesivity levels and rheological properties, lending fillers and filler ranges their unique properties and degradability profiles. One such range of hyaluronic acid fillers manufactured using the novel eXcellent three-dimensional reticulation (XTR™) technology was evaluated in comparison with other HA fillers and filler ranges by an independent research laboratory. Fillers manufactured with the XTR™ technology were shown to have characteristic rheological, crosslinking and biophysical factors that support the suitability of this filler range for certain patient profiles.

Minimally Invasive Aesthetic Treatment of the Face and Neck Using Combinations of a PCL-Based Collagen Stimulator, PLLA/PLGA Suspension Sutures, and Cross-Linked Hyaluronic Acid

Background

Combinations of minimally invasive procedures (MIPs) are often used in aesthetic treatments and are increasingly considered as the new standard of care. Three agents with specific properties are available in this perspective: a polycaprolactone (PCL)-based collagen stimulator, a poly-L-lactic acid (PLLA)- and a poly-glycolic acid (PLGA)-based resorbable suspension suture with a 3D-cone technology, and a cross-linked hyaluronic acid (HA).

Objective

To develop the first practice guidelines on rejuvenation treatment of the face and the neck using combinations of these agents, whether associated or not with other widely used MIPs such as botulinum neurotoxins or energy-based devices.

Methods

A multi-disciplinary, multi-national board of plastic surgeons and dermatologists convened to develop guidelines using a predefined consensus method. The consensus was defined as ≥83% agreement rate between participants.

Results

Practice guidelines and algorithms, describing optimal procedure sequence and spacing, are proposed for the treatment of upper-, mid-, lower-face and neck, combining the PCL collagen stimulator, the PLLA/PLGA suspension sutures, and the cross-linked HA, whether associated or not with other MIPs.

Conclusion

These new guidelines provide general support to optimal management strategies. Individual treatment plans should be adapted according to the physician’s individual competence and the patient’s preferences.

New Frontiers in Skin Rejuvenation, Including Stem Cells and Autologous Therapies

One of the greatest challenges in the progression of aesthetic medicine lies in providing treatments with long-term results that are also minimally invasive and safe. Keeping up with this demand are developments in autologous therapies such as adipose-derived stem cells, stromal vascular fraction, microfat, nanofat, and platelet therapies, which are being shown to deliver satisfactory results. Innovations in more traditional cosmetic therapies, such as botulinum toxin, fillers, and thread lifts, are even more at the forefront of the advancement in aesthetics. Combining autologous therapies with traditional noninvasive methods can ultimately provide patients with more effective rejuvenation options.

Relationship between forehead motion and the shape of forehead lines-A 3D skin displacement vector analysis

OBJECTIVE

Neuromodulator injections of the forehead are often performed using standardized protocols. This study was designed to identify the individual skin motion pattern of the forehead and to relate this pattern to the underlying frontalis muscle morphology to offer guidance for neuromodulator placement.

MATERIAL AND METHODS

Thirty-seven healthy volunteers (29 Caucasians, six African Americans, two Asians) with a mean age of 39.84 ± 14.4 years [range: 22-73] were enrolled. 3D images of the forehead were analyzed using a Vectra H1 camera system computing skin displacement vectors between the noncontracted and the maximally contracted forehead of the volunteers. Relationships between the shape of the horizontal forehead lines (straight vs wavy) and the forehead motion pattern were calculated.

RESULTS

Independent of age or gender, a greater forehead motion angle was associated with the presence of wavy forehead lines 21.34°± 5.9 with P < 0.001, whereas straight forehead lines were associated with a smaller forehead motion angle 6.68°± 2.9 P < 0.001. Females had more frequently straight horizontal forehead lines versus males: 68.4% vs 44.4% (P = 0.037). Young volunteers (<39.8 years) did not differ in their mean forehead motion angle when compared to older volunteers (>39.8 years): 13.70°± 9.0 vs 12.39°± 8.0 with P = 0.530.

CONCLUSION

Injections of neuromodulators in the forehead can be individualized by respecting the shape of the horizontal forehead lines. Wavy lines require injection points that are located more laterally, whereas straight lines require more centrally located injection points.

Face Treatment Using Nonsurgical Mini-Invasive Techniques as Postsurgical Procedure for Traumatic Injury

BACKGROUND

Facial trauma can cause major psychological damage and compromise a patient's quality of life. Unfortunately, surgery cannot always solve this problem or provide an acceptable result.

OBJECTIVES

Treatment with injectables may provide a solution that is minimally invasive and better accepted by patients as a means to improve poor outcomes after facial trauma.

METHODS

This retrospective study involved 50 patients (29 men, 21 women) who underwent primary surgery to treat facial trauma between January 2015 and January 2017. Based on the facial area affected by poor outcomes (upper face, midface, and lower face), patients underwent ≥1 aesthetic medicine treatments with hyaluronic acid dermal fillers and botulinum toxin injections. To evaluate patient satisfaction and the effect of the treatment on quality of life, patients were asked to complete 2 questionnaires, POSAS and FACE-Q, prior to treatment and 90 days after the last treatment session.

RESULTS

Questionnaire scores indicated improvements in aesthetic and psychological metrics, perceived both by the patient and the observer.

CONCLUSIONS

Minimally invasive aesthetic treatments represent a valuable adjunct to surgical procedures for improving facial aesthetics after injury and consequently the quality of life of patients affected by facial trauma.

LEVEL OF EVIDENCE: 4

Non-Surgical Correction of Nasal Dorsum and Tip in Primary Cases

Nowadays, minimally invasive and non-invasive approaches in aesthetic medicine are increasingly popular and non-surgical rhinoplasty is one of the procedures with rising demand worldwide. In Bulgaria, this procedure seems to be uncommonly performed, since there are no reports in the local scientific literature. The aim of this preliminary study was to briefly explore the possibilities of hyaluronic acid (HA) fillers for correcting three of the most common nasal deformities – dorsal hump, under-projected and under-rotated nasal tip in primary cases. In order to accomplish this objective, a retrospective clinical study was conducted encompassing 11 cases of the authors’ practices with the above mentioned nasal irregularities and no previous surgical/non-surgical treatment. The analysis of patient-reported outcomes suggested a high satisfaction rate, with no major complication in the series. The HA filler has shown to be safe, relatively easily applicable and highly effective for camouflaging nasal deformities. A special emphasis was put on the patient safety and ten golden rules for staying out of trouble were given.

Consensus Opinions on Facial Beauty and Implications for Aesthetic Treatment in Middle Eastern Women

Background:

Middle Eastern women worldwide increasingly seek aesthetic treatment to enhance their beauty and improve self-esteem, but literature describing standards of beauty across the Middle East are scarce. Knowledge of facial anthropometry and Middle Eastern subregional beauty preferences and aesthetic weaknesses are key to develop an effective facial enhancement strategy that does not jeopardize ethnic identity or facial harmony.

Methods:

Dermatologists and plastic surgeons from 8 Middle Eastern countries who had 7.5–25 (mean 13.5) years of experience in aesthetic medicine examined female Middle Eastern beauty in 4 geographic subregions: the Gulf (comprising Bahrain, Kuwait, Saudi Arabia, and the United Arab Emirates), Iran, Lebanon, and Egypt. They developed consensus opinions regarding facial beauty, aesthetic deficiencies, and injectable treatment solutions.

Results:

Facial anthropometry differs between Middle Eastern and Western women, and also within the region. Although subregional differences are seen, beauty is generally recognized by an oval or round face; temple fullness; pronounced, elevated, arched eyebrows; large almond-shaped eyes; well-defined, laterally full cheeks; a small, straight nose; full lips; a well-defined jawline; and a prominent, pointed chin. The relative prominence of the nose necessitates attention to the lips and the shape and projection of the chin. Aging is often accompanied by midface sagging that leads to increased heaviness in the lower facial third.

Conclusions:

Middle Eastern beauty is characterized by striking eyes, defined cheeks, and full lips. These consensus opinions inform aesthetic practitioners who treat Middle Eastern women worldwide about their aesthetic ideals and the implications for treatment.

Nonsurgical Rhinoplasty: Nasal Grid Analysis and Nasal Injecting Protocol

BACKGROUND

Nonsurgical rhinoplasty using injectable fillers improved skin quality and texture, cost-effectiveness, and quick recovery. The aim of this study was to provide a valid and customized protocol for injecting the nose with the aid of a nasal grid.

METHODS

From January of 2016 to October of 2017, 150 consecutive patients entered the trial. The mean patient age was 36 years (range, 16 to 60 years). The patients were divided into two arms: primary nasal defects (no previous surgery, n = 109) and secondary nasal defects (previous surgery, n = 41). The primary defect group included 43 male patients and 66 female patients, and the secondary nasal defect group included 14 male patients and 27 female patients. Within each arm, patients were stratified into three age group tiers: younger than 30 years, 30 to 45 years, and older than 45 years.

RESULTS

The grid became the reference for quantity and sequence of injection records. The overall complication rate was 1.82 percent, and a visual analogue scale ranging from 1 to 10 was implemented (with 10 being the most accurate correction). Of the patients evaluated, 98.350 percent scored 8 to 10, 0.825 percent scored 6 to 8, and 0.825 percent scored below 6.

CONCLUSIONS

Fillers can be either alternatives or complementary to plastic surgery. Nonsurgical rhinoplasty, with its avoidance of general anesthesia, splints, swelling, and bruising, represents a distinct advantage, allowing the patient to return to work as quickly as the same or the next day.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, IV.

Randomized Double-Blind Controlled Study on the Safety and Efficacy of a Novel Injectable Cross-linked Hyaluronic Gel for the Correction of Moderate-to-Severe Nasolabial Wrinkles

INTRODUCTION

The current study compares two hyaluronic acid fillers, Ial System Duo and Belotero Basic/Balance, for the treatment of wrinkles.

MATERIALS AND METHODS

This is a single-center, double-blind randomized controlled study. Inclusion criteria consisted of subjects with bilateral nasolabial wrinkles. Each subject was treated with both products: One was applied on the right side and the other on the left side of the face. The quantity of product injected and any problems or local reactions (erythema, edema, pain or itching) were recorded and reassessed at 3 and 6 months and then monthly until complete absorption of the product. The Wrinkle Severity Rating Scale (WSRS) and the Global Aesthetic Improvement Scale (GAIS) were used for the assessment, as well as an ultrasound measurement of the skin thickness.

RESULTS

Complete data were available for 59 subjects. At 3 and 6 months, both products showed improvement in the WSRS and GAIS score in the areas treated compared to pre-treatment assessments, although no significant differences were observed between them. No resulting significant differences were observed on skin thickness among the two products, which were completely reabsorbed in 285 ± 34 days (Ial System Duo) and 277 ± 34 days (Belotero Basic/Balance; Student's t test: p = 0.2181). No significant differences were observed with regard to the subject's satisfaction and adverse events.

CONCLUSIONS

The Ial System Duo achieves long-term permanence (more than 9 months confirmed by ultrasound) in correction of moderate and severe wrinkles, similar to Belotero Basic/Balance. Both products showed a high safety profile and a high degree of subject and physician satisfaction.

LEVEL OF EVIDENCE II

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Phase 3 Study of OnabotulinumtoxinA Distributed Between Frontalis, Glabellar Complex, and Lateral Canthal Areas for Treatment of Upper Facial Lines

BACKGROUND

Although commonly practiced, simultaneous onabotulinumtoxinA injections to multiple facial areas have not been investigated in prospective studies.

OBJECTIVE

Evaluate safety and efficacy of onabotulinumtoxinA for treatment of forehead lines (FHL) distributed between the frontalis (20 U) and glabellar complex (20 U), with or without simultaneous lateral canthal areas (crow's feet lines [CFL], 24 U) treatment.

METHODS

Subjects with moderate to severe FHL were randomized (2:2:1) to onabotulinumtoxinA 40 U, onabotulinumtoxinA 64 U, or placebo. After 180 days, subjects could receive up to 2 additional open-label onabotulinumtoxinA 64 U treatments.

RESULTS

The intent-to-treat (ITT) population comprised 787 subjects, and the modified ITT (mITT) population (subjects with psychological impact) comprised 568. After 30 days, onabotulinumtoxinA 40 U and 64 U significantly improved investigator- and subject-assessed FHL severity by at least 2 Facial Wrinkle Scale (FWS) grades in 45.6% and 53.0% of ITT subjects, respectively, versus 0.6% receiving placebo (both, p < .0001). Significantly more mITT subjects receiving onabotulinumtoxinA achieved investigator- and subject-assessed FWS ratings of none/mild versus placebo (p < .0001). OnabotulinumtoxinA was well tolerated.

CONCLUSION

OnabotulinumtoxinA distributed between the frontalis and glabellar complex, with or without additional CFL injections, was safe and effective for treatment of moderate to severe FHL.

A Single-visit Approach Using Fillers and Incobotulinumtoxin A: Full Face Enhancement in Asian Patients

A 3-dimensional, multi-layered approach combining modalities targeting different manifestations is recommended for achieving optimal esthetic outcomes. To date, studies reporting same-day treatment with dermal fillers and botulinum toxin have not been published. This article documents the practical use of a single-visit, pan-facial multimodal approach in addressing the varying esthetic needs of 8 Asian adults. The case series included male or female patients of varying age and degrees of facial fat, who received combination treatment with calcium hydroxylapatite filler, polydensified hyaluronic acid filler, and incobotulinumtoxin A in a single visit in August 2016 at a treatment center in Taiwan. Treatments were individualized based on the needs of each patient, according to guideline recommendations. The agents, with distinctive rheological properties indicated for different purposes, were applied sequentially across different facial tissue planes within a single visit. Patients were monitored for development of side effects after treatment. Photographs taken before treatment and 2 weeks after treatment were evaluated by the treating physicians. For all patients, treatment produced substantial improvements in all treated facial areas. Inherent morphological deficiencies in younger patients were addressed, age-related changes in older patients were corrected, and facial sexual dimorphism was enhanced in male and female patients. No major side effects occurred after treatment. This case series showcases the real-life implementation of a flexible, single-visit, multimodal approach that can be adapted for a variety of indications.

Muscle Insertion and Strength of the Muscle Contraction as Guidelines to Enhance Duration of the Botulinum Toxin Effect in the Upper Face

BACKGROUND

In this series of patients the cutaneous insertion and strength of voluntary contraction of the muscles in the upper third of the face were used as guidelines for botulinum toxin application named "BTA Codes."

METHOD

Anatomical dissection of fresh cadavers identified the shape and cutaneous insertions of the muscles in the upper third of the face. Patient voluntary contraction of the muscles in the upper third of the face created different patterns of skin lines classified by the 4-grade Facial Wrinkle Scale. For botulinum toxin application injections points followed the muscle cutaneous insertion and dose the 4-grade Facial Wrinkle Scale.

RESULTS

Injection points ranged from 3 to 23 points per patient, average of 9.4 points. Dose per point varied from 2.5 to 7.5 U, ranging from 12.5 to 72.5 U per patient, average of 33.82 U. Skin lines resulting from the voluntary contraction of the muscle prior to toxin application were stated as baseline 1. The absence of skin lines and muscle activity on day fifteen after toxin application defined baseline 2. Skin lines resulting from the recovered voluntary contraction of the muscle after toxin application like those of baseline 1 established baseline 3. The botulinum toxin effect was the time elapsed between baselines 2 and 3, ranging from 171 to 204 days, average of 183.72 days, greater than the 3 or 4 months reported in the literature.

CONCLUSION

"BTA Codes" is a set of rules to apply botulinum toxin supported by muscle anatomy and degree of voluntary contraction to enhance the duration of its effect.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Italian consensus report on the aesthetic use of onabotulinum toxin A

BACKGROUND

The aesthetic treatment of facial and neck wrinkles with botulinum toxin is constantly increasing, thus making it necessary to collect procedures guidelines for the use of botulinum toxin in the treatment of wrinkles and/or cosmetic defects.

METHODS

A group of nine Italian doctors, plastic and maxillo-facial surgeons, dermatologists and aesthetic physicians, experts in face and neck aesthetic treatments with onabotulinum toxin A, discussed on procedures used in their clinical practice. From the data collected and discussed by the board, some recommendations on aesthetic treatment with onabotulinum toxin A were developed.

RESULTS

Recommendations have been made on pretreatment, reconstitution of onabotulinum toxin A, as well as on treatment procedures, in terms of injection sites and total dose of onabotulinum toxin A for the following indications: glabellar lines, crown's feet lines, forehead lines, eyebrow shaping, lower orbicularis oculi hypertrophy, bunny lines, sagging nasal tip, gummy smile, masseter hypertrophy, perioral lines, marionette lines, hypertonic mentalis, and platysma bands.

CONCLUSIONS

The use of onabotulinum toxin A in the aesthetic field requires careful initial assessment of the patient in its complexity and individuality. Moreover, this treatment needs the use of standardized procedures to achieve the effectiveness and safety of onabotulinum toxin A in clinical practice.

Impact of Comprehensive, Minimally Invasive, Multimodal Aesthetic Treatment on Satisfaction With Facial Appearance: The HARMONY Study

BACKGROUND

Individuals seeking aesthetic treatment have concerns regarding multiple facial areas.

OBJECTIVES

Assess the aesthetic impact and satisfaction achieved with a multimodal approach to aesthetic treatment using a combination of minimally invasive treatments.

METHODS

Prospective, multicenter, rater-blinded, 4-month HARMONY study evaluated patient satisfaction and aesthetic impact of a combination of fillers (VYC-20L, HYC-24L, and HYC-24L+), onabotulinumtoxinA, and bimatoprost. Males and females aged 35 to 65 years received on-label, staged treatment with fillers, as needed per investigator assessment, on day 1, with touch ups allowed on day 14. Bimatoprost was self-administered once daily for 17 weeks. OnabotulinumtoxinA was injected into glabellar lines, crow's feet lines, or both at month 3. Primary effectiveness measure was mean change from baseline on the FACE-Q 10-item Satisfaction with Facial Appearance Overall Scale.

RESULTS

Of 100 patients treated, 93 underwent at least the 4-month posttreatment assessment and were assessed for efficacy. The FACE-Q Satisfaction with Facial Appearance Overall Scale total score increased from baseline (41.2) to month 4 (72.9; P < 0.00001; effect size, 2.7). Improvement following multimodal treatment was observed on FACE-Q individual items. Self-perceived age decreased from 0.2 years older than actual age at baseline to 4.6 years younger at month 4. Nearly all patients (99%) rated themselves as improved or much improved on the Global Aesthetic Improvement Scale. Investigator assessments also demonstrated improvement. Mild to moderate adverse events occurred in 42 patients.

CONCLUSIONS

Minimally invasive, multimodal treatment resulted in improvements in FACE-Q scores and perceived age, indicating a high degree of patient satisfaction and a younger facial appearance.

LEVEL OF EVIDENCE 4

Efficacy and Tolerability of IncobotulinumtoxinA for Treating Glabellar Frown Lines in Korean Adults: A Postmarketing Observational Study

BACKGROUND

IncobotulinumtoxinA is safe and effective in Caucasian adults. Its effects have been less documented in Asian adults.

OBJECTIVE

To describe the efficacy and tolerability of incobotulinumtoxinA for treating glabellar frown lines (GFLs) in South Korean adults.

METHODS

South Korean adults aged 18 to 65 years with moderate-to-severe GFLs received a single dose of 10 to 28 U incobotulinumtoxinA during routine clinical practice. After 30 ± 14 days, investigators assessed the efficacy using the Global Aesthetic Improvement Scale and rated tolerability using a 4-point scale.

RESULTS

Six hundred seventy-three subjects were enrolled, of which 528 completed the study according to protocol. Glabellar frown lines improved in 98.7% (521/528) of subjects, with 30.8% of cases rated as "very much improved" and 47.4% as "much improved." The extent of improvement was unaffected by sex, age, and weight but was greater when the time between GFL identification and treatment was <6 months (p < .001) and when concomitant aesthetic nondrug treatments were used (p < .001). For 94% of subjects, tolerability was good or very good. All reported adverse events were transient and mild or moderate in severity.

CONCLUSION

IncobotulinumtoxinA was well tolerated and effective for treating moderate-to-severe GFLs in Korean adults irrespective of age, sex, or weight.

PAN-ASIAN CONSENSUS-Key Recommendations for Adapting the World Congress of Dermatology Consensus on Combination Treatment with Injectable Fillers, Toxins, and Ultrasound Devices in Asian Patients

BACKGROUND. The demand for minimally invasive aesthetic procedures has driven requests by physicians for guidance on their use in Asian patients, who have unique cultural preferences, social trends, and anatomy. However, few guidelines exist, particularly on combination treatment strategies for different facial shapes or indications such as the modification of face shapes to the "oval ideal."Physicians must, therefore, apply Caucasian patient-optimized guidelines to their Asian patients. METHODS. Eleven specialists developed a consensus on the use of botulinum toxin A (BoNT-A), calcium hydroxylapatite (CaHA) and hyaluronic acid (HA) fillers, and microfocused ultrasound with visualization (MFU-V) devices in Asian patients on upper-, middle-, and lower-face indications, including strategies to modify different facial shapes to the oval shape. Approval from 70 to 90 percent of all participants led to moderate consensus, while 90 percent agreement denoted a strong consensus. RESULTS. For early intervention/enhancement and restoration, most combination strategies are similar between Asian and Caucasian patients. Compared to Caucasian patients, however, beautification is a more common focus in Asian patients. The "ideal" oval facial shape can be created using different interventions depending on the patient's baseline characteristics. CONCLUSIONS. Although treatments and treatment sequences for early intervention/enhancement and restoration for beautification in Asian patients are similar to those in Caucasian patients, different treatment strategies may be required.

Global Updates on the Future Directions of Neurotoxins and Fillers

Neurotoxins and fillers continue to remain in high demand, comprising a large part of the growing business of cosmetic minimally invasive procedures. Multiple Food and Drug Administration-approved safe yet different products exist within each category, and the role of each product continues to expand. The authors review the literature to provide an overview of the use of neurotoxins and fillers and their future directions.

Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications

BACKGROUND

Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction.

METHODS

A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications.

RESULTS

Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action.

CONCLUSIONS

The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.