Global, 3-dimensional approach to natural rejuvenation: part 1 - recommendations for volume restoration and the periocular area

Cross-linked Sodium Hyaluronate Gel with PLLA-b-PEG Microsphere for Facial Contouring in Chinese: A Retrospective Study

BACKGROUND

In Asia, the demand for cosmetic facial treatments has surged due to technological advancements, increased social acceptability, and affordability. Poly-L-lactic acid (PLLA) fillers, known for their biocompatibility and biodegradability, have emerged as a popular choice for facial contouring, yet studies specifically addressing their use in Asian populations are scarce.

METHODS

This retrospective study examined 30 Chinese patients who underwent facial contouring with PLLA fillers, focusing on product composition, injection techniques, and safety measures. A comprehensive clinical evaluation was performed, including the Global Aesthetic Improvement Scale (GAIS) and Global Impression of Change Scale (GICS) for effectiveness and patient satisfaction, respectively.

RESULTS

No significant difference in GAIS scores was observed between injectors and blinded evaluators over a 12-month period, indicating consistent effectiveness. Patient satisfaction remained high, with GICS scores reflecting positive outcomes. The safety profile was favorable, with no serious adverse events reported. The study highlighted the importance of anatomical knowledge to avoid complications, particularly in areas prone to blindness.

CONCLUSIONS

PLLA fillers offer a safe, effective option for facial contour correction in the Asian population, achieving high patient satisfaction and maintaining results over time. The study underscores the need for tailored approaches in cosmetic procedures for Asians, considering their unique facial structures and aesthetic goals. Further research with larger, multicenter cohorts is recommended to validate these findings and explore long-term effects.

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 .

Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques

Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.

Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures

BACKGROUND

An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region.

OBJECTIVE

To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments.

METHODS

A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m² were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues.

RESULTS

The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle.

CONCLUSION

On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.

Hyaluronic Acid Filler Injections for Nasolabial Folds in Asian Patients: A Treatment Plan Based on a Practical Nasolabial Assessment Method

BACKGROUND

There are multiple techniques used to inject hyaluronic acid to minimize the appearance of nasolabial folds. These techniques vary in accordance with the etiology of the nasolabial folds. Based on our understanding of nasolabial anatomy and our experience with the injection of hyaluronic acid fillers, we herein summarize a systemic treatment plan based on a practical nasolabial fold assessment method.

METHODS

From November 2015 to December 2017, 180 patients received hyaluronic acid injections in our clinic to improve the appearance of nasolabial folds. All patients were followed up for at least 1 month. All patients underwent our nasolabial fold assessment and were then treated with an appropriate plan. The therapeutic effect was assessed via the photonumeric wrinkle assessment scale. Patients with complications were monitored for up to 1 year. A follow-up survey was performed 1 month postoperatively, with the outcome rated as excellent, satisfactory, moderate, or unsatisfactory.

RESULTS

Patients demonstrated a significant improvement in the appearance of the nasolabial folds. No infection or vascular complications occurred. The 1-month follow-up survey revealed that the patient satisfaction rate was 96.7% (excellent or satisfactory outcome).

CONCLUSION

This systemic treatment method for nasolabial folds is effective, safe, and practical.

Recommendations for the treatment of tear trough deformity with cross-linked hyaluronic acid filler

Background

Recent years have seen a growing interest in the appearance of the eyes among the concerns expressed by patients in cosmetic clinics. This has led to an increase in the frequency of diagnosis of tear trough deformity, and, as a result, the number of treatments performed by specialized professionals has also risen. Hyaluronic acid filler injection is a rapid, nonsurgical technique that gives good long‐lasting, but not permanent, results. However, to achieve optimal results, the attending physician must have good anatomical knowledge of the area and involvement of the structures in the tear trough, carry out proper clinical assessment of the patient, and use an appropriate injection technique with the right product.

Aims

To support good practice among the professionals who carry out these procedures, this interdisciplinary consensus document describes the relevant issues and recommendations, in order to improve safety standards and to help successfully resolve this aesthetic problem.

Consensus on Current Injectable Treatment Strategies in the Asian Face

BACKGROUND

The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce.

METHODS

The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience.

RESULTS

The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to[55 years are presented.

CONCLUSIONS

In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages.

LEVEL OF EVIDENCE V

This journal requires that the 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 .

Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty

BACKGROUND

Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers.

METHODS

The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations.

RESULTS

Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty.

CONCLUSIONS

Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. Level of Evidence V 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).

Practical Approach and Safety of Hyaluronic Acid Fillers

Supplemental Digital Content is available in the text.

Soft-tissue filler use has grown considerably related to the increasing popularity of minimally invasive cosmetic procedures. Hyaluronic acid products are currently the most utilized soft-tissue fillers. Proper working knowledge of individual products, limitations to use, and anatomic principles can improve outcomes. Prevention is key to minimize complications; however, when present, complications must be managed methodically. Complications are categorized based on the timing of presentation and include early, late, and delayed. Vascular compromise and tissue necrosis are among the most devastating complications seen with filler use. Nodules can be related to an inflammatory or infectious etiology but should be distinguished as treatment varies. Hyaluronidase is mandatory to have available as a reversal agent for hyaluronic acid products and can be used in treatment for many complications and untoward sequela.

Tear Trough Deformity: Study of Filling Procedures for Its Correction

The aim of this work is to discuss the anatomy of the tear trough region with relative danger areas, and to describe 2 different options to correct this deformity.The tear trough is a concave deformity of the orbital fat that is noticeable as a result of inherited anatomic differences and aging. However, the periorbital region is a complex area with its own septa and ligaments, fat compartments, muscles, vascularization, and lymphatic drainage and presents anatomic characteristics that must be taken into account in order to achieve good results and avoid complications.The use of hyaluronic acid gel or autologous fat for soft tissue correction is a good option.A total of 96 patients with periorbital hollowing were divided into 2 groups; each group received a different treatment, from December of 2013 to December of 2015, with hyaluronic- or lipo-filling.

Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Midface

This second article of a three-part series addresses techniques and recommendations for aesthetic treatment of the midface. Injectable fillers are important for rejuvenation of the midface by replacing lost volume and providing structural support; neuromodulators play a smaller role in this facial region. Fillers are used for volumization and contouring of the midface regions, including the upper cheek and lid-cheek junction and the submalar and preauricular areas. Also, treatment of the frontonasal angle, the dorsum, the nasolabial angle, and the columella may be used to shape and contour the nose. Neuromodulators may be used to treat bunny lines and for elevation of the nasal tip. The midface is considered an advanced area for treatment, and injectors are advised to obtain specific training, particularly when injecting fillers near the nose, because of the risk of serious complications, including blindness and necrosis. Injections made in the midcheek must be performed with caution to avoid the infraorbital artery.

Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study

Background

Enhancement of the midface can be achieved with volumizing hyaluronic acid (HA) fillers.

Objective

The objective of this study was to compare the safety and effectiveness of Cohesive Polydensified Matrix^® 26 mg/mL HA gel (CPM-26) and Vycross^® 20 mg/ml HA gel (VYC-20) in a controlled, randomized, evaluator-blind, split-face clinical study.

Patients and methods

Subjects with moderate-to-severe malar volume loss on the Merz Aesthetics Scale (MAS) received CPM-26 on one side and VYC-20 on the contralateral side of the face. Effectiveness assessments were performed by blinded evaluators including photographic and live MAS ratings and live Global Aesthetic Improvement Scale (GAIS) ratings. Calculations of anatomical volume variations at month 3 (M3), month 6 (M6), month 12 (M12) and month 18 (M18) were also performed.

Results

Non-inferiority of CPM-26 versus VYC-20 was demonstrated at M3 (primary end point) based on MAS. GAIS rating showed that significantly more subjects had better improvement with CPM-26 than with VYC-20 at month 1, M3, M12 and M18 (p=0.0032, p=0.0074, p=0.0384 and p=0.0110, respectively). Standardized evaluation of volume variations from baseline to M3, M12 and M18 showed that CPM-26 created more volume augmentation at all time points, and the difference was significant at M3.

Conclusion

CPM-26 was non-inferior to VYC-20 based on MAS ratings at M3 and demonstrated a favorable safety and effectiveness profile for midfacial volume enhancement with results lasting up to M18.

Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty

BACKGROUND

Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers.

METHODS

The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations.

RESULTS

Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty.

CONCLUSIONS

Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized.

LEVEL OF EVIDENCE V

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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Consensus on Current Injectable Treatment Strategies in the Asian Face

BACKGROUND

The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce.

METHOD

The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience.

RESULTS

The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to >55 years are presented.

CONCLUSIONS

In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages.

LEVEL OF EVIDENCE V

This journal requires that the 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.

Facial dynamics and emotional expressions in facial aging treatments

Facial expressions convey emotions that form the foundation of interpersonal relationships, and many of these emotions promote and regulate our social linkages. Hence, the facial aging symptomatological analysis and the treatment plan must of necessity include knowledge of the facial dynamics and the emotional expressions of the face. This approach aims to more closely meet patients' expectations of natural-looking results, by correcting age-related negative expressions while observing the emotional language of the face. This article will successively describe patients' expectations, the role of facial expressions in relational dynamics, the relationship between facial structures and facial expressions, and the way facial aging mimics negative expressions. Eventually, therapeutic implications for facial aging treatment will be addressed.