A Multimodal Approach to Rejuvenation of the Lower Face

Injectable fillers: current status, physicochemical properties, function mechanism, and perspectives

With the increasing understanding of the aging process and growing desire for minimally invasive treatments, injectable fillers have great potential for correcting and rejuvenating facial wrinkles/folds and contouring the face. However, considering the increasing availability of multiple soft tissue fillers, it is important to understand their inherent biophysical features and specific mechanism. Thus, in this review, we aim to provide an update on the current injectable filler products and analyze and compare their critical physicochemical properties and function mechanisms for volume-filling. Additionally, future trends and development processes for injectable fillers are also proposed.

Efficacy of a home-used high-intensity focused ultrasound device on wrinkle reduction

BACKGROUND

High-intensity focused ultrasound (HIFU) has been developed for the treatment of skin wrinkles on the face, neck, and body.

OBJECTIVES

This study aimed to evaluate the effects of a home-used HIFU device on wrinkles in mice based on the expression of fibrosis-related genes and proteins.

METHODS

The backs of 20-week-old mice were treated with a home-used HIFU using the following probes: 4 MHz, 1.5 mm focal depth. The treated mice were compared with young mice by histological examination, real-time polymerase chain reaction (PCR), and immunohistochemistry. Histological examination was performed by trichrome staining. Real-time PCR and immunohistochemistry were conducted to determine the expression of collagen types I and III, matrix metalloproteinase (MMP)-1, and tissue inhibitor of metalloproteinase (TIMP)-1.

RESULTS

Dermal thickness was increased after treatment with the home-used HIFU device at 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks on trichrome. Gene and protein expression of collagen types I and III and elastin were increased after treatment with HIFU at all options of 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks. Gene and protein expressions of MMP-1 and TIMP-1 were decreased after treatment with HIFU device at 30 and 60 s per day for 1 week or 30 and 60 s per day for 2 weeks.

CONCLUSION

The home-used HIFU device can be an effective therapeutic modality for skin tightening.

Contouring Plus: A Comprehensive Approach of the Lower Third of the Face with Calcium Hydroxylapatite and Hyaluronic Acid

A well-defined jawline is aesthetically pleasing, so that rejuvenation of the jawline is becoming part of routine aesthetic practice. Restoring balance to the lower face without surgical intervention requires a multiple treatment approach, among which the minimally invasive injectables play a central role. Nevertheless, amidst the plethora of different injectable products available, choosing the option that best suits the patient's need can be a challenge. A panel of experts sought to describe herein 4 clinical cases, illustrating the Contouring Plus technique, which provides a practical guidance for lower third assessment, choice of products, and treatment execution, especially among hyaluronic acid and calcium hydroxylapatite, aiming for immediate, as well as mid-to-long-term results.

Efficacy and Safety of Monopolar Radiofrequency for Treatment of Lower Facial Laxity in Asians

INTRODUCTION

Monopolar radiofrequency (MRF) is a valuable modality for tightening and contouring mild-to-moderate facial skin laxity. Few studies have evaluated new-generation MRF devices for lower facial laxity in Asians. This study aims to evaluate the efficacy and safety of MRF for treating lower facial laxity in Asians.

METHODS

This prospective cohort study enrolled 30 volunteers with Fitzpatrick Skin Types III-V and mild-to-moderate skin laxity. Subjects received a single MRF treatment. Self-assessments and adverse events were recorded. Two blinded dermatologists graded improvements (6-point scale) after treatment and 1, 3, and 6 months later.

RESULTS

All subjects completed the study. Treatment energy levels ranged from 2 to 4. The average number of shots was 412 ± 49, delivered in 3-4 passes with 15-30% overlap. All patients reported improvement in lower facial laxity immediately after treatment. Most patients had mild-to-moderate improvement over the 6-month follow-up. Continuous improvement was observed at the 1-, 3-, and 6-month follow-ups (P < 0.01). Significant improvement was seen at the 6-month follow-up compared with the 1-month follow-up (P < 0.01). Subjects tolerated the procedure well: the average pain score was 3.13 out of 10, and no serious adverse events were observed.

CONCLUSIONS

The new-generation MRF device we tested was effective and safe for mild-to-moderate lower facial laxity in Asian skin. The latest MRF technology offers improved safety to prevent complications. Appropriate patient selection, setting, and protocols are mandatory to achieve optimal clinical outcomes.

THE TRIAL REGISTRATION NUMBER

TCTR20210326002.

Botulinum toxin A in dentistry and orofacial surgery: an evidence-based review - part 2: cosmetic applications

Objective An evidence-based review on the role of botulinum toxin type A (BoNTA) on diverse cosmetic applications of interest to dental practitioners and allied specialities. In this context, to identify the cosmetic treatments that have an evidence-based rationale against areas requiring further research, with a view to assess the safety and efficacy of BoNTA.Data source and selection A comprehensive search was conducted using Cochrane Library of Systematic Reviews, Cochrane Central Register of Controlled Trials, and PubMed (Medline) electronic databases. Thirty-nine studies of variable quality were included. The Best Evidence Topics (BETs) Critical Appraisal Tool was used to facilitate the quality assessment of relevant studies.Data extraction Based on current level II evidence, BoNTA was safe and effective to improve facial contour, reduce volume and thickness of bilateral hypertrophic masseter. Conservative doses using a combined approach of BoNTA and hyaluronic acid was recommended as a safe and effective treatment for perioral enhancement supported by level II evidence. There was limited evidence, not higher than level III, to support BoNTA effectiveness for gummy smile associated to perioral musculature hyperactivity, while jawline sculpting targeting the platysma muscle had lower level IV evidence up to this date.Conclusion BoNTA has been widely used off-label for the investigated cosmetic orofacial conditions, with reports of 'good patient and practitioner satisfaction'. However, there is limited high-quality evidence to support the long-term safety and effectiveness of repetitive BoNTA injections. Additionally, no studies were found that provided a cost-effectiveness evaluation of BoNTA formulations against other current cosmetic interventions. Well-designed clinical trials, including long-term follow-up, would help to provide robust evidence-based recommendations for clinical practice, supporting BoNTA popularity, independently or in a combined approach.

Skin Quality - A Holistic 360° View: Consensus Results

Introduction

Skin quality is an important component of human attractiveness. To date, there are no standardized criteria for good skin quality. To establish a consensus for good skin quality parameters and measurement and treatment options, a virtual skin quality advisory board consisting of a global panel of highly experienced aesthetic dermatologists/aesthetic physicians was convened.

Methods

A total of 10 dermatologists/aesthetic physicians served on the advisory board. A modified version of the Delphi method was used to arrive at consensus. Members accessed an online platform to review statements on skin quality criteria from their peers, including treatment and measurement options, and voted to indicate whether they agreed or disagreed. Statements that did not have agreement were modified and the members voted again. Consensus was defined as: strong consensus = greater than 95% agreement; consensus = 75% to 95% agreement; majority consent = 50% to 75% agreement; no consensus = less than 50% agreement.

Results

There was strong consensus that good skin quality is defined as healthy, youthful in appearance (appearing younger than a person's chronological age), undamaged skin and that skin quality can be described across all ethnicities by four emergent perceptual categories (EPCs): skin tone evenness, skin surface evenness, skin firmness, and skin glow. The EPCs can be affected by multiple tissue layers (ie, skin surface quality can stem from and be impacted by deep structures or tissues). This means that topical approaches may not be sufficient. Instead, improving skin quality EPCs can require a multilayer treatment strategy.

Conclusion

This global advisory board established strong consensus that skin quality can be described by four EPCs, which can help clinicians determine the appropriate treatment option(s) and the tissue or skin layer(s) to address. Skin quality is important to human health and wellbeing and patients' perception for the need for aesthetic treatment.

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.

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.

Lower Face Rejuvenation with Injections: Botox, Juvederm, and Kybella for Marionette Lines and Jowls

A 55-year-old woman requesting noninvasive rejuvenation of the lower face received multimodal injections in a single office visit to rejuvenate the jowls. The patient experienced no adverse events other than self-limiting bruising at the hyaluronic acid injection site and minimal edema. The outcomes were evaluated as follows: (1) by the patient using the self-rated Face-Q assessment and (2) by 5 plastic surgeons (none of whom were the author of this study) based on the WAS scale and before and after photographs to evaluate the corners of the mouth and the marionette lines. This case study report suggests that the combined use of neuromodulator, hyaluronic acid dermal filler, and synthetic deoxycholic acid can rejuvenate the lower face as a minimally invasive alternative to surgery to the satisfaction of the patient and 6 plastic surgeons (including the author).