Signs of Facial Aging in Men in a Diverse, Multinational Study: Timing and Preventive Behaviors

PrabotulinumtoxinA vs OnabotulinumtoxinA for the Treatment of Adult Males With Moderate to Severe Glabellar Lines: Post-hoc Analyses of the Phase III Clinical Study Data

BACKGROUND

Despite a growing interest among men in cosmetic procedures such as botulinum toxin, comparator clinical trial data in this population are limited.

OBJECTIVES

The authors sought to compare the efficacy and safety of prabotulinumtoxinA and onabotulinumtoxinA for the treatment of males with moderate to severe glabellar lines.

METHODS

Post-hoc analyses were performed on the subpopulation of male patients treated with either a single dose of 20 U prabotulinumtoxinA (n = 25) or 20 U onabotulinumtoxinA (n = 31) in the EVB-003 Phase III glabellar line clinical study. One key efficacy endpoint was the proportion of responders with a ≥1-point improvement from baseline at maximum frown on the 4-point Glabellar Line Scale.

RESULTS

Compared with onabotulinumtoxinA-treated males, the percentages of responders who had a ≥1-point improvement on the Glabellar Line Scale at maximum frown were higher at all postbaseline time points for prabotulinumtoxinA-treated males (P > 0.05 at all visits) by an absolute overall mean difference of 10.1% across all visits. Similar trends were observed for efficacy endpoints based on global aesthetic improvement and subject satisfaction. PrabotulinumtoxinA-treated males had a higher incidence of treatment-related headache and eyelid ptosis.

CONCLUSIONS

The percentages of patients who met the definition of a responder were higher at almost all time points examined for prabotulinumtoxinA-treated males. Despite the high level of consistency across all measures, differences between the 2 treatment groups did not reach statistical significance. Further study is warranted to establish if these post-hoc analyses observations are reproducible in a larger male patient population.

LEVEL OF EVIDENCE: 1

Juvéderm Volift (VYC-17.5L), a Hyaluronic Acid Filler with Lidocaine, is Safe and Effective for Correcting Nasolabial Folds in Chinese Subjects

PURPOSE

Hyaluronic acid injectable gels are commonly used to treat nasolabial folds (NLFs). We evaluated the safety and effectiveness of VYC-17.5L for correcting NLFs in Chinese subjects.

PATIENTS AND METHODS

This prospective, multicenter, double-blind, within-subject‒controlled study randomized adults with moderate-to-severe NLFs to VYC-17.5L treatment (initial and touch-up) in 1 NLF and control (without lidocaine) in the contralateral NLF. Effectiveness endpoints at 6 months included noninferiority of VYC-17.5L to control in NLF Severity Scale response rate (primary endpoint), subject-reported procedural pain (11-point scale), and investigator and subject assessments using the Global Aesthetic Improvement Scale (GAIS).

RESULTS

A total of 175 subjects were included. The primary endpoint was met, with response rates of 84.2% for VYC-17.5L and 82.5% for control. Mean pain scores after initial and touch-up treatments were 2.4 for VYC-17.5L versus 5.2 for control (P < 0.001) and 2.0 versus 3.3 (P < 0.001), respectively. Investigator-rated GAIS scores were 86.5% for VYC-17.5L versus 86.0% for control. There were no between-group differences in subject-rated GAIS scores. Safety profiles were comparable for VYC-17.5L and control.

CONCLUSION

VYC-17.5L was noninferior to control without lidocaine for correcting moderate-to-severe NLFs in Chinese subjects and was superior to control in reducing procedural pain.

The Facial Aging Process From the "Inside Out"

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. With this evidence-based paper, the authors aim to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the “inside out,” that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy is presented, including facial skeleton remodeling, fat pad atrophy or repositioning, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

Management patterns for skin aging among Saudi dermatologists: A questionnaire-based study

Background:

Skin aging is a complicated process affected by intrinsic, chronological, and extrinsic, environmental, determinants, and it is affected, to a large extent, by exposure to ultraviolet radiation (UVR). The present study aims to assess the antiaging treatment strategies in a real-world setting in Saudi Arabia.

Materials and Methods:

We conducted an online cross-sectional survey that was conducted from May 2020 to October 2020, involving all eligible dermatologists working at different academic, governmental, and private sectors in Saudi Arabia.

Results:

A total of 200 dermatologists were included in this study, of them, 33% were aged between 24–35 years. 28.5%, 25.5%, 24.5%, and 21.5% of the participants had 7–10, 4–6, >10, and 0–3 years of practice, respectively. Generally, 80 (40%) of the dermatologists reported that 10–20% of their patients consulting for antiaging, while 50 (25%) reported that 41–60% of their patients consulted for antiaging treatment. Cream products were preferred by 105 (52.5%) of the users. In general, 158 (79%) prescribe growth factors Post-procedures, while 29 (14.5), 24 (12%), and 22 (11%) prescribe them for under-eye dark circles, acne scars, and aging skin, respectively. 124 (62%) prefer to use it in combination with retinoids.

Conclusion:

The results of this survey indicate the fact that female patients and the age group 31-40 years old are more likely to seek skincare and antiaging therapy. Most dermatologists prescribed growth factors together with retinoids and only a small proportion of them used growth factors are antiaging modalities.

Depiction of ethnic facial aging by forensic artists and preliminary assessment of the applicability of facial averages

Many characteristics of facial aging are common to all. The age of their onset and which characteristics tend to predominate varies among individuals depending on many factors including their genetic makeup, life experiences, environment in which they live, and the regional, ethnic, or socially perceived group to which they belong. Forensic artists are often asked to provide sketches, 2D or 3D digital renderings, or sculptures representative of how an individual may appear at an older age based on a provided photograph, victim or witness description, and/or cranial remains. The challenge escalates when the subject is a member of a regional, ethnic, or other socially perceived group to which the artist has had little or no exposure. We describe aspects of adult facial aging that are of particular relevance to the forensic artist, applicable software tools, and pertinent facial databases, especially those emphasizing non-white populations. We demonstrate that facial averaging offers two key advantages to the artistic portrayal of facial aging: first, the technique requires relatively small reference databases from groups that may present logistical challenges to collect and second, that a facial average provides a useful representation of the gestalt of the age and ethnicity cohort to which a subject belongs. The artist may use an average along with other available information such as photo reference books, eyewitness descriptions, photos of immediate family members, and cranial structure to guide production of a facial composite drawing, digital age progression, or sculpture of the subject in question.

OnabotulinumtoxinA Treatment for Moderate to Severe Forehead Lines: A Review

Background:

With onabotulinumtoxinA approved for the treatment of glabellar and crow’s feet lines and, most recently, for forehead lines (FHL), it is possible to simultaneously treat multiple areas of the upper face that are of high concern and treatment priority for aesthetically oriented individuals. This review aims to present key insights on the use of onabotulinumtoxinA for the treatment of moderate to severe FHL.

Methods:

Double-blind, placebo-controlled registration trials of onabotulinumtoxinA for the treatment of FHL were included. Using findings from 3 such published studies, we discuss key concepts and clinical experience for the treatment of moderate to severe FHL with onabotulinumtoxinA (20 U in the frontalis and 20 U in the glabellar complex, with/without 24 U in crow’s feet lines), including injection pattern, dose selection, efficacy and safety data, and considerations for patient selection.

Results:

Across the 2 pivotal phase 3 studies, responder rates on investigator- and subject-assessed measures of appearance of FHL severity were significantly higher with onabotulinumtoxinA versus placebo for the treatment of FHL at day 30 (P < 0.0001), and results were maintained through 3 cycles of onabotulinumtoxinA.

Conclusions:

OnabotulinumtoxinA treatment also resulted in high patient satisfaction rates. The incidence of eyebrow and of eyelid ptosis was low, and no new safety signals were detected. OnabotulinumtoxinA is safe and effective and an appropriate option for patients with moderate to severe FHL encountered in clinical practice.

Safety and Effectiveness of VYC-17.5L for Long-Term Correction of Nasolabial Folds

BACKGROUND

Juvéderm Vollure XC (VYC-17.5L; Allergan plc, Dublin, Ireland) belongs to a family of hyaluronic acid gels based on the Vycross technology platform.

OBJECTIVES

The authors sought to evaluate the safety and effectiveness of Vollure for correction of moderate to severe nasolabial folds (NLFs) over 18 months and after repeat treatment.

METHODS

In this prospective, randomized study, patients (N = 123) received initial/touch-up treatment with Vollure in 1 NLF and control filler in the contralateral NLF. Patients received optional repeat treatment with Vollure after month 12, 15, or 18. Assessments included investigator-rated NLF Severity Scale responder rates (≥1-point improvement vs baseline), patient-assessed Appraisal of Nasolabial Folds scale of the FACE-Q questionnaire, and patient satisfaction (11-point scale).

RESULTS

Median volume of Vollure injected was 1.7 mL for initial/touch-up treatment combined and 0.6 mL for repeat treatment. The NLF Severity Scale responder rates were 93%, 85%, and 59% at months 6, 9, and 18 after initial/touch-up treatment and increased to 94% at 1 month after repeat treatment. Mean patient-reported FACE-Q scores significantly improved from baseline at all timepoints. Most patients were very satisfied with treatment at all timepoints from day 3 (75%) through month 18 (68%) and at 1 month after repeat treatment (94%). Common injection site responses after initial/touch-up and repeat treatment were firmness, swelling, and tenderness to touch; most were mild/moderate.

CONCLUSIONS

Vollure was safe and effective for correction of moderate to severe NLFs, with results lasting 18 months in 59% of NLFs. Repeat treatment required one-third of the injection volume to achieve similar improvement in NLF severity as initial/touch-up treatment.

LEVEL OF EVIDENCE: 2

Management of aging skin: A questionnaire-based study among Indian dermatologists

INTRODUCTION

With increased life expectancy, the desire to look younger has increased. Hence, many patients approach dermatologists for antiaging treatment. However, data regarding management of skin aging in India are scarce.

AIMS

To understand management patterns for skin aging among dermatologists in India.

METHODS

Overall, 147 Indian dermatologists were administered a questionnaire-based survey about patient characteristics, signs of skin aging, treatment options, and cost.

RESULTS

Among all the patients coming for dermatologists' consultation, 10%-40% were for antiaging treatment. About 70% dermatologists opined that majority of patients aged 30-40 years consulted for antiaging treatment, and the male to female ratio was 3:7. Approximately 46% of dermatologists felt that antiaging treatment should be initiated by the age of 30. Common signs of aging were wrinkles, pigmentation, dull skin or complexion, and dry skin. Based on patient's age and sex, dermatologists prescribed a combination of 2-4 products, which included antioxidants, retinoids, growth factors, and moisturizers. Improvement was assessed by photographic and clinical evaluation, and by patients' satisfaction (55%). Effect of the antiaging products was evident within 4-6 months. Earliest improvement was noted in dry skin and dull complexion. Average extent of improvement noted by 6 months was approximately 20%-30%. The average monthly expenditure on antiaging treatments was 2000-4000 INR.

CONCLUSION

Both men and women seek clinical treatment for skin aging in India. Dermatologists prescribe a combination of 2-4 products, including antioxidants, retinoids, growth factors, and moisturizers. Available antiaging therapies show an average improvement of up to 30% by 6 months.

The Psychological Impacts of Upper Facial Lines: A Qualitative, Patient-Centered Study

Background

The 11-item Facial Line Outcomes (FLO-11) questionnaire is content validated for measuring the negative psychological impacts of crow’s feet lines (CFL).

Objectives

The aims of this study were to determine psychological impacts of forehead lines (FHL) alone and upper facial lines (UFL: FHL + CFL + glabellar lines [GL]) and to assess adequacy of FLO-11 to measure these impacts.

Methods

Participants aged at least 18 years participated in concept elicitation and cognitive interviews to identify and define psychological impacts of UFL. They completed the FLO-11 questionnaire to assess its ability to measure psychological impacts of facial lines and its comprehensiveness in doing so.

Results

Forty interviews were completed by 29 participants. Twenty participants each provided interviews for FHL and for UFL. The most commonly reported psychological impacts for FHL and UFL, respectively, were feeling unattractive (85%, 80%), looking less attractive than desired (85%, 70%), feeling bothered (80%, 70%), feeling good/bad about appearance (80%, 70%), looking older than actual age (75%, 65%), and feeling stressed (70%, 70%). For FHL, 70% of participants also reported looking older than desired as a psychological impact. More than 50% of participants agreed that all 11 FLO-11 items measured a psychological impact for FHL. More than 50% reported that 9 of 11 items measured a psychological impact for UFL. The majority of participants (FHL, 65%; UFL, 60%) reported that the FLO-11 questionnaire is comprehensive in measuring psychological impacts of facial lines.

Conclusions

FHL and UFL have psychological impacts on patients, and FLO-11 is a content valid, comprehensive instrument for measuring them.

Horizontal Forehead Lines: A Reflection of Eyelid Ptosis or Blepharodermachalasia

BACKGROUND

In his facial aesthetics practice, the senior author (B.G.) observed that many patients presenting with horizontal forehead lines also demonstrated upper eyelid ptosis or enough blepharodermachalasia to require compensation. This study was conducted to investigate this observation.

METHODS

Photographs of patients presenting for facial rejuvenation were retrospectively reviewed for the presence of forehead lines, ptosis, brow ptosis, and blepharodermatochalasia. Patient age, gender, and race were reported. Only patients over age 50 were included. Patients who had previous eyelid or forehead surgery, congenital abnormalities, or post-traumatic deformities were excluded. Ptosis was defined as more than 1.5-mm overlap between the upper eyelid and the iris. Patients were divided into two groups based on presence of forehead lines for comparative analysis.

RESULTS

One hundred sixty patients, including 100 patients with and 60 patients without horizontal forehead lines, were included. Patients with forehead lines were likely to be older (age 61.56 ± 8.93 vs. 58.58 ± 7.59; P = 0.0337), male (36 vs. 11.67%; P = 0.0008), have ptosis (90 vs. 76.67%; P = 0.0377), and have blepharodermatochalasis (20 vs. 5%; P = 0.0097). All 28 patients with unilateral forehead lines (17 left, 11 right) had ipsilateral ptosis.

CONCLUSIONS

Ptosis and blepharodermatochalasis may result in the development of horizontal forehead lines through compensatory frontalis activation. Whenever horizontal forehead rhytids are noted, it is imperative to search for ptosis or blepharodermachalasia in repose. Otherwise, forehead rejuvenation may fail to eliminate these compensatory forehead lines, and chemodenervation may have significant adverse effects on the visual field by forcibly blocking frontalis compensation.

LEVEL OF EVIDENCE III

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 .

Instrumental Assessment of the Face Skin Aging in Women

The aim of this study is to conduct several non-invasive methods for assessing the level of circulatory disturbance, elasticity and aging of skin in patients of different age groups in order to expand the diagnostic capabilities and evaluate the effectiveness of current research in aesthetic medicine. Clinical and instrumental exploration of 160 women aged 17 to 75 years with varying degrees of involutional skin changes was carried out. To objectify the assessment of skin condition, in all group of patients modern instrumental methods were used, such as: elastometry, ultrasound examination of the skin, laser Doppler flowmetry, transcutaneous oxygen tension. Concurrent implementation of several non-invasive methods for assessing the level of circulatory disturbance, elasticity and aging of the skin, allowed us to find new possibilities for studying the functional state of the skin. These methods extend the possibilities of ultrasonic research methods used today in aesthetic cosmetology. The obtained comparative data of elastometry, ultrasonography, laser Doppler flowmetry and transcutaneous oximetry in patients of different age groups showed the presence of elasticity and structure defect, skin thickness and subcutaneous fat, as well as microcirculation changes since 25 years and marked changes after 40 years.