A Comprehensive Approach to Multimodal Facial Aesthetic Treatment: Injection Techniques and Treatment Characteristics From the HARMONY Study

Global facial rejuvenation with one treatment of incobotulinumtoxinA, hyaluronic acid, and calcium hydroxyapatite results in long-term patient-reported satisfaction

Background

Global facial rejuvenation using injectables (neuromodulators and fillers) has reported patient satisfaction after 2 treatments: an initial and touch-up treatment at 2-4 weeks afterward. In practice, patients typically receive only 1 treatment and do not return for a touch-up treatment within a month.

Objective

The purpose of this study was to assess patient-reported satisfaction after only 1 treatment, thus mimicking real-world scenarios.

Methods

Patients with facial photoaging (Glogau facial aging scale ≥2) were treated with calcium hydroxyapatite, hyaluronic acid 22.5 mg/mL, and incobotulinumtoxinA injections for full facial rejuvenation, with no touch-up treatments. Patients completed the FACE-Q Satisfaction with Facial Appearance survey at baseline and 1- and 3-month post-treatment. The treating physician completed the Global Aesthetic Improvement Scale at 1- and 3-month post-treatment.

Results

Twenty-two patients were enrolled in the study, with 1 patient lost to follow-up. There was a significant improvement in mean FACE-Q scores at 1-month (80.1, P = .01) and 3-month (77.9, P = .02) compared to baseline (71.4). Mean Global Aesthetic Improvement Scale scores at 1-month (2.1) and 3-month (2.2) were not statistically significant, indicating sustained improvement at 3 months. The product amount used per patient varied and was not correlated with either score. Limitations included a lack of a control group and follow-up ending at 3 months. Strengths included assessment of patient satisfaction after only 1 treatment, compared to other studies allowing 2 treatments.

Limitations

Limitations include a small sample size and lack of a control group.

Conclusion

Global full facial rejuvenation using 1 treatment of calcium hydroxyapatite, hyaluronic acid 22.5 mg/mL, and incobotulinumtoxinA provides sustained patient-reported satisfaction at 3 months.

Cosmetic Injectable Treatments Improve Quality of Life in Patients With Multiple Serious Medical Comorbidities

Full facial rejuvenation with multi-modal cosmetic treatments can improve quality of life, leading to improvement in confidence and psychological function. These combination treatments are frequently administered at the same or sequential sessions and include neuromodulators and fillers. In patients with significant recent weight loss and other medical comorbidities, these treatments can help restore self-confidence and provide the encouragement they need to continue treatment for their comorbidities. We present a case report of a 71-year-old woman who experienced significant weight loss of 40 lbs (33% body weight) during the course of treatment of multiple medical comorbidities, including surgical intervention for compression fractures. Due to her facial appearance caused by this excessive weight loss, she experienced poor self-esteem as measured by the FACE-Q scales. She was treated cosmetically with 21cc of hyperdilute calcium hydroxyapatite (diluted in a 1:3 ratio; 7cc of calcium hydroxyapatite total) and neuromodulators to replace lost facial volume over three visits. At three months after her last treatment, her FACE-Q scores improved two-and-a-half-fold and fivefold on the psychological function and aging appraisal, respectively. Cosmetic treatments can dramatically improve the quality of life in patients with multiple medical co-morbidities. This population of patients is often excluded from clinical trials or other studies, representing a population for which we have little data on the efficacy of cosmetic treatments.

Cosmetic business mechanics in London: A cross-sectional analysis and audit of ASA compliance

INTRODUCTION

The proliferation of providers and practitioners of cosmetic botulinum toxin and dermal filler has profound public health implications. The Advertising Standards Authority (ASA) regulates the use of advertising materials in the United Kingdom and prohibits the promotion of prescription-only medicines.

AIMS

We aim to perform a cross-sectional analysis of the practitioners in London, UK to evaluate the distribution of clinics within Greater London, prices advertised for interventions, and compliance with the ASA code. We also aim to identify whether there are any differences in cost of botulinum toxin or dermal filler between the boroughs.

METHODS

Between December 2021 and January 2022, we performed a systematic search using the internet search engine Google. Five searches were performed (1) [london] botox, (2) [london] botulinum toxin, (3) [london] anti wrinkle injection, (4) [london] filler, (5) [london] dermal filler. One hundred websites per search string were systematically reviewed and those which met the inclusion/exclusion criteria of each search string were included and analyzed. Each clinic's product/service range compliance with the ASA/CAP code was assessed. Any reference to Botulinum Toxin or anti-wrinkle injections was noted and analyzed. Further analysis would look to calculate price per milliliter (mL) of botulinum toxin and dermal filler per borough and to calculate whether there were any statistical differences between the 32 different London boroughs.

RESULTS

A total of 500 websites were visited and evaluated. After removal of duplicates, a total of 233 independent clinics was identified. A total of 206 out of the 233 clinics sampled (88%) were in direct infringement of the enforcement notice through advertising a prescription medicine. The overall average cost per mL of dermal filler was £330.89 and there was a statistically significant variance across London boroughs (p < 0.05). The overall average cost per mL of Botulinum Toxin was £284.45 and the variance across London boroughs was close to significant (p = 0.058).

CONCLUSION

This paper demonstrates poor compliance with the ASA/CAP guidelines and further provides an insight into the industry mechanics associated with aesthetic injectables in a major UK city, identifying regional variance in price and clinic density. The advertising of prescription-only medication may pose a potential risk to patients and will be an important consideration in proposed legislation to introduce licensing to the industry.

Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck

Background

Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited.

Objective

Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment.

Methods

Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference.

Results

Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach.

Conclusion

The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Functional ligands for improving anticancer drug therapy: current status and applications to drug delivery systems

Conventional chemotherapy lacking target selectivity often leads to severe side effects, limiting the effectiveness of chemotherapy. Therefore, drug delivery systems ensuring both selective drug release and efficient intracellular uptake at the target sites are highly demanded in chemotherapy to improve the quality of life of patients with low toxicity. One of the effective approaches for tumor-selective drug delivery is the adoption of functional ligands that can interact with specific receptors overexpressed in malignant cancer cells. Various functional ligands including folic acid, hyaluronic acid, transferrin, peptides, and antibodies, have been extensively explored to develop tumor-selective drug delivery systems. Furthermore, cell-penetrating peptides or ligands for tight junction opening are also actively pursued to improve the intracellular trafficking of anticancer drugs. Sometimes, multiple ligands with different roles are used in combination to enhance the cellular uptake as well as target selectivity of anticancer drugs. In this review, the current status of various functional ligands applicable to improve the effectiveness of cancer chemotherapy is overviewed with a focus on their roles, characteristics, and preclinical/clinical applications.

Multimodal Facial Aesthetic Treatment on the Appearance of Aging, Social Confidence, and Psychological Well-being: HARMONY Study

Background

A global approach to facial rejuvenation involves multiple treatment modalities.

Objectives

The aim of this study was to evaluate the impact of multimodal facial aesthetic treatment on self-reported psychological and social outcomes.

Methods

HARMONY, a prospective, multicenter, 4-month study, enrolled patients aged 35 to 65 years to receive on-label treatment with a combination of hyaluronic fillers (VYC-20L, HYC-24L, and/or HYC-24L+), onabotulinumtoxinA, and bimatoprost. Fillers were injected on Day 1, with touch-ups performed on Day 14. OnabotulinumtoxinA was injected at Month 3 into glabellar lines and/or crow’s feet lines. Patients applied bimatoprost to eyelashes once daily for 17 weeks. Mean change from baseline on FACE-Q Psychological Well-being and Social Confidence Scales, FACE-Q Aging Appearance Appraisal Scale, and FACE-Q Age Appraisal Visual Analog Scale were assessed.

Results

Of 100 patients treated, 93 were evaluated at 4 months posttreatment. Significant improvement vs baseline was observed on the FACE-Q Scales for Psychological Well-being (mean change, −19.9; P < 0.00001), Social Confidence (mean change, −18.2; P < 0.00001), and Aging Appearance (mean change, −28.5; P < 0.0001). On average, patients’ self-assessed age was 0.1 years older than actual age at baseline and 4.5 years younger at Month 4 (P < 0.001 vs baseline). Forty-two patients experienced adverse events, all mild to moderate.

Conclusions

Multimodal, full facial aesthetic treatment improves patients’ self-reported psychological well-being, social confidence, aging appearance, and perceptions of chronologic age.

Level of Evidence: 4

Whole-Face Approach with Hyaluronic Acid Fillers

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

Maximizing Panfacial Aesthetic Outcomes: Findings and Recommendations From the HARMONY Study

BACKGROUND

Aesthetic medicine has evolved from targeting individual treatment areas to a global approach of panfacial rejuvenation. HARMONY was the first clinical study to systematically demonstrate positive physical and psychosocial impacts of panfacial treatment.

OBJECTIVE

Provide evidence-based guidance on treatment strategies to help maximize outcomes in patients seeking panfacial rejuvenation.

MATERIALS AND METHODS

Study sites with the lowest (n = 2) and highest (n = 2) improvements based on FACE-Q Satisfaction with Face Overall scores were analyzed to understand differences in treatment strategy that may contribute to incrementally greater patient satisfaction.

RESULTS

The highest scoring sites exhibited greater improvement in all patient-reported outcomes and investigator-assessed measures related to dermal filler treatment compared with the lowest scoring sites. The highest sites favored lateral malar augmentation and used less volume medially versus the lowest sites. In the lower face, the highest sites used greater volumes and more HYC-24L than HYC-24L+. Initial treatment volumes were more conservative at highest than lowest sites; greater volumes were used by highest sites in touch-up treatments.

CONCLUSION

Product usage trends common to the highest scoring sites (including injection volume, injection sites, and product selection) may provide guidance on best practices for a panfacial approach to aesthetic treatment to maximize patient satisfaction.

Repeated Full-Face Aesthetic Combination Treatment With AbobotulinumtoxinA, Hyaluronic Acid Filler, and Skin-Boosting Hyaluronic Acid After Monotherapy With AbobotulinumtoxinA or Hyaluronic Acid Filler

BACKGROUND

Full-face aesthetic treatment involving several treatment modalities may improve facial aesthetic outcome.

OBJECTIVE

To evaluate clinical outcomes and patient perceptions of monotherapy with either abobotulinumtoxinA (ABO) or hyaluronic acid (HA) filler followed by full-face combination treatments of ABO, HA filler, and skin-boosting HA (RSB).

MATERIALS AND METHODS

Subjects aged 35 to 50 years were randomized to monotherapy with 50 s.U ABO in the glabella or ≤1 mL HA filler in the nasolabial folds (NLFs)/cheeks. At Month 6 and Month 12, all subjects received combination treatment with ≤50 s.U ABO in the glabella, ≤2 mL HA filler in the NLFs/cheeks (and other facial areas as applicable), and ≤1 mL RSB (additional RSB treatment at Month 7). Assessments included global facial aesthetic appearance and improvement, first impression, perceived age, wrinkle severity, satisfaction questionnaires, and adverse events.

RESULTS

Repeated full-face combination treatment with ABO, HA filler, and RSB was associated with considerably higher levels of aesthetic improvement and subject satisfaction than monotherapy with ABO or HA filler. Improvement rate of glabellar lines was increasing with each treatment.

CONCLUSION

Repeated combination treatment achieved greater change in global facial aesthetic appearance than monotherapy. Aesthetic improvement and subject satisfaction was high and increased with each treatment. All treatments were well tolerated.

Hyaluronic Acid-Mediated Drug Delivery System Targeting for Inflammatory Skin Diseases: A Mini Review

Hyaluronic acid (HA), a major component of extracellular matrix has been widely applied in pharmaceutical and cosmetic industries due to its reported pharmacological properties. Various types of HA drug delivery system including nanoparticles, cryogel-based formulations, microneedle patches, and nano-emulsions were developed. There are studies reporting that several HA-based transdermal delivery systems exhibit excellent biocompatibility, enhanced permeability and efficient localized release of anti-psoriasis drugs and have shown to inhibit psoriasis-associated skin inflammation. Similarly HA is found in abundant at epidermis of atopic dermatitis (AD) suggesting its role in atopic AD pathology. Anti-allergenic effect of atopic eczema can be achieved through the inhibition of CD44 and protein kinase C alpha (PKCα) interaction by HA. Herein, we aim to evaluate the current innovation on HA drug delivery system and the other potential applications of HA in inflammatory skin diseases, focusing on atopic dermatitis and psoriasis. HA is typically integrated into different delivery systems including nanoparticles, liposomes, ethosomes and microneedle patches in supporting drug penetration through the stratum corneum layer of the skin. For instance, ethosomes and microneedle delivery system such as curcumin-loaded HA-modified ethosomes were developed to enhance skin retention and delivery of curcumin to CD44-expressing psoriatic cells whereas methotrexate-loaded HA-based microneedle was shown to enhance skin penetration of methotrexate to alleviate psoriasis-like skin inflammation. HA-based nanoparticles and pluronic F-127 based dual responsive (pH/temperature) hydrogels had been described to enhance drug permeation through and into the intact skin for AD treatment.

Non surgical facial reshaping using MD Codes

BACKGROUND

Both age-related and congenital volume deficiencies may be addressed through the injection of hyaluronic acid (HA) fillers. Deep injection provides structural support, more superficial fat-tissue injection mediates contouring, and superficial intradermal use of HA filler and/or onabotulinumtoxinA may be used for refinement.

AIMS

To evaluate the clinical efficacy, patient satisfaction, and safety of the MD Codes approach as a proposed standardized methodology for full-face rejuvenation.

METHODS

This was a retrospective, single-center study of 250 consecutive adult patients undergoing full-face rejuvenation with HA fillers (Vycross) and onabotulinumtoxinA based on the MD Codes approach.

RESULTS

The mean age was 39.4 ± 11.6 years, and 80.4% were female. All patients were treated with HA filler in the midface; 89.6% were also treated in the upper face, and 63.2% in the lower face. The mean number of syringes used was 14 ± 4 (range 4-25), with more syringes typically required in older versus younger patients. All patients received onabotulinumtoxinA treatment. Mean FACE-Q Appearance-Related Psychosocial Distress score decreased from 54.3 ± 9.3 pretreatment to 36.1 ± 8.9 at 3 months post-treatment (P < .05). The most common complications were bruising (35.2%), transient soft-tissue edema (14.0%), and prolonged periorbital edema (3.6%).

CONCLUSIONS

Full-face rejuvenation based on the MD Codes approach provides significant esthetic improvements, with no major safety issues observed.

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.

Aesthetic Treatment Positively Impacts Social Perception: Analysis of Subjects From the HARMONY Study

BACKGROUND

The impact of facial aesthetic treatments not only enhances physical appearance but also psychological well-being. Accordingly, patient-reported outcomes are increasingly utilized as an important measure of treatment success. Observer-reported outcomes are a relevant yet often overlooked measure of treatment benefit.

OBJECTIVES

The authors aimed to evaluate the impact of panfacial aesthetic treatment on the perception of an individual in a variety of social contexts.

METHODS

A total 2000 men and women (aged 18-65 years) participated in an online study designed to capture the blinded observer's social perception of pretreatment and posttreatment patients who received panfacial aesthetic treatment in the HARMONY study. Perceptions relevant to character traits, age, attractiveness, and social status were evaluated. Observers were divided into 2 groups. Single image respondents (n = 1500) viewed 6 single, randomized patient images (3 pretreatment, 3 posttreatment), and paired image respondents (n = 500) viewed 6 pretreatment and posttreatment image pairs.

RESULTS

Single image respondents reported significantly (P < 0.05) higher levels of agreement that posttreatment subjects appeared to possess more positive character traits (eg, healthy and approachable), were more socially adept, younger, more attractive, more successful at attracting others, and possessed a higher social status. Paired image respondents also reported a higher level of agreement for posttreatment images being aligned with positive character traits, representative of a younger and more attractive individual, and one with a higher social status.

CONCLUSIONS

The results suggest that the positive impact of minimally invasive panfacial treatment extends beyond enhancing physical appearance and highlights the importance of social perception and observer-reported outcomes in aesthetic medicine.

Improvement of Radial Cheek Lines With Hyaluronic Acid-Based Dermal Filler VYC-17.5L: Results of the BEAM Study

BACKGROUND

Radial cheek lines (RCL) may convey an older, potentially less attractive appearance.

OBJECTIVE

To evaluate the effectiveness of hyaluronic acid-based dermal filler VYC-17.5L for correcting RCL.

MATERIALS AND METHODS

Fifty-three women (40-65 years) received injections of VYC-17.5L in both cheeks on Day 1 (optional Day 14 touch-up). Effectiveness was evaluated on Day 45 by subject-rated dynamic RCL improvement (Global Aesthetic Improvement Scale [GAIS]; primary end point) and independent, noninjecting investigator-rated GAIS; subject Self-Perception of Age (SPA); subject-assessed satisfaction with and natural look of treatment; and instrument-assessed changes in static and dynamic RCL roughness, amplitude, and texture (secondary end points). Safety assessments included injection site responses (ISRs).

RESULTS

On Day 45, 98% of subjects rated RCL as improved or much improved (investigator rated: 95%). Subjects with same or older SPA before treatment (n = 38) perceived themselves as 2.0 and 5.5 average years younger after treatment, respectively. Day 45 mean satisfaction with and natural look of treated areas was 7.9/10 and 7.2/10, respectively. Treatment significantly improved RCL roughness, amplitude, and texture (all p < .001). Most common ISRs were hematoma (35.9%), bruising (30.2%), and irregularities/bumps (22.6%); most ISRs were mild.

CONCLUSION

VYC-17.5L effectively corrected dynamic RCL, improved instrument-assessed indicators of skin quality, and resulted in younger age perception.

Topical skin therapies in subjects undergoing full facial rejuvenation

BACKGROUND

Cosmeceutical therapies including face washes, moisturizers, chemical peels and antioxidant formulations are intended to improve the esthetic appearance of skin. The use of these products as adjuncts to full facial rejuvenation with hyaluronic acid filler and abobotulinumtoxinA may improve cosmetic and socio-esthetic outcomes.

OBJECTIVE

To characterize the effect of skin care products in subjects undergoing full facial rejuvenation with abobotulinumtoxinA and hyaluronic acid in improving facial skin appearance, patient satisfaction, and projected first impressions.

METHODS

Twenty subjects were recruited and divided into two treatment groups. Subjects in Group A followed a standard skin care regimen, whereas subjects in Group B received a more robust skin care regimen including chemical peels and antioxidant formulations. All subjects underwent facial rejuvenation treatments with hyaluronic acid at Visit 2 and with abobotulinumtoxinA at Visit 7. Patient esthetic improvement, satisfaction, self-esteem, and first impression were evaluated via the Fitzpatrick Wrinkle Assessment Scale, Global Aesthetic Improvement Scale, Skin Quality Assessment, Heatherton & Polivy State Self-Esteem Scale, Subject Satisfaction Scale, and the First Impressions Questionnaire.

RESULTS

Both treatment groups experienced significant improvements in the Skin Quality Assessment, Fitzpatrick Wrinkle Assessment Scale, Heatherton and Polivy State Self-Esteem Scale, and First Impressions Questionnaire.

CONCLUSION

The cosmeceutical therapies used in this study in combination with abobotulinumtoxinA and hyaluronic acid filler improved subjects' skin quality, self-esteem, and projected first impressions. Larger studies are needed to determine the most efficacious combination of topical skin therapies with facial rejuvenation therapy.

Relationship Between Midface Volume Deficits and the Appearance of Tear Troughs and Nasolabial Folds

BACKGROUND

Understanding interrelationships among aging facial features is important in facial aesthetics as a global treatment approach becomes standard.

OBJECTIVE

Examine empirical relationships between midface volume deficit and severity of tear troughs (TTs) and nasolabial folds (NLFs) in women and men of different racial/ethnic groups.

METHODS

A web-based study was administered to health panel members (aged 18-75 years). Participants compared their midface volume, TTs, and NLFs against photonumeric scales depicting degrees of severity. Linear regressions were conducted to assess the relationship of midface volume on severity of TTs and NLFs, controlling for demographic factors.

RESULTS

Of 4,086 participants (80.0% female), 3,553 had complete data. Increasing severity of midface volume deficit was associated with increasing severity of TTs and NLFs in both sexes (all p < .001). Race/ethnicity was associated with differences in severity in all 3 facial areas, although specific differences between races/ethnicities varied for women and men. Progression rates of severity differed between racial/ethnic groups. Correlations between midface volume deficit, TTs, and NLFs were positive and significant (all p < .001).

CONCLUSION

Midface volume deficit was associated with severity of TT deformity and NLFs after controlling for age and other demographic variables.

OnabotulinumtoxinA and Hyaluronic Acid in Facial Wrinkles and Folds: A Prospective, Open-Label Comparison

Background

OnabotulinumtoxinA and hyaluronic acid are effective in improving moderate to severe facial wrinkles and folds, with treatment selection traditionally based upon facial area.

Objectives

This prospective, multicenter, open-label, crossover study evaluated physician-rated efficacy and patient-rated outcomes following moderate to severe facial wrinkles and folds treatment with onabotulinumtoxinA and hyaluronic acid.

Methods

152 subjects (25-65 years) were randomized (1:1) to a treatment-sequence of onabotulinumtoxinA/hyaluronic acid or hyaluronic acid/onabotulinumtoxinA, with initial treatment administered on day 1 and 6 additional visits: week 2 (touch-up); week 4 (crossover); week 6 (touch-up); and weeks 8, 12, and 24 (follow-up).

Results

Between 92% and 100% of subjects in each treatment-sequence group exhibited at least some improvement from baseline at each study visit in the Physician Aesthetic Improvement Scale and the Objective Observer and Patient Global Assessments of Improvement, with no significant between-sequence differences. Subjects reported looking 3 to 6 years younger at each visit, with significant improvements in glabellar, lateral canthal, and horizontal forehead lines, and nasolabial folds. Treatments were well tolerated.

Conclusions

OnabotulinumtoxinA and hyaluronic acid provide clinically meaningful improvements as rated by physicians, objective observers, and subjects, with clinical synergy in aesthetic effects and duration of response regardless of treatment administration order in subjects seeking improvement in moderate to severe facial wrinkles and folds.

Level of Evidence 2

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

BACKGROUND

The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes.

OBJECTIVES

The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction.

METHODS

An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection.

RESULTS

Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days.

CONCLUSIONS

Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area.

LEVEL OF EVIDENCE 4

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

A Novel and More Aesthetic Injection Pattern for Malar Cheek Volume Restoration

The loss of superior midface contour and projection can be corrected with the use of injectable hyaluronic acid (HA) dermal fillers, however, the most frequently used injection pattern employs a technique which was originally designed for malar implant surgery. Here we describe a novel injection pattern for restoring facial contours with a HA dermal filler inspired by traditional make-up artistry, which includes greater superolateral positioning of injection sites. Importantly, this technique helps injectors avoid creating an excess of volume in the anterior portion of the malar complex. Contributing authors/injectors, who now use this technique exclusively, have found that it has so far provided optimal aesthetic results for hundreds of patients with no observables complications. The malar cheek contributes much to the aesthetic curvature of the face and deserves a thoughtful update for injectable HA, as the traditional technique has never actually been aligned with its medium. In the experience of the contributing authors, this technique helps achieve a greater aesthetic outcome in the correction of midface contour deficiencies and has consistently resulted in high patient satisfaction. 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 .