Jawline Sharp Contouring With Hybrid Filler.

BACKGROUND: Having a well-defined jawline is a sign of youth and attractiveness among both men and women. Soft tissue fillers, such as calcium hydroxylapatite (CaHA) and hyaluronic acid (HA) fillers, offer nonsurgical alternatives for rejuvenating the lower face and enhancing the jawline. The aim of this study was to investigate the use of a premixed combination of HA with cohesive polydensified matrix technology (CPM, Belotero Intense, CPM-I) and CaHA to create a sharply defined jawline. METHODS: A total of 126 patients were enrolled in the study and treated with a premixed combination of CPM-I and CaHA using a retrograde fanning injection technique with cannulas. The injection volumes and product ratios were customized according to the patients' needs. RESULTS: The cohort consisted of 75 females and 51 males. The average injected volume of premixed CaHA:CPM-I was 5.83 mL. In the majority of patients, a 1:1 syringe ratio of CaHA:CPM-I was applied (n = 81, 64.2%). No adverse events were reported during the 6-month follow-up period. CONCLUSION: The hybrid filler approach investigated in this study shows promise for achieving well-defined, long-lasting jawline contours. 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 .

Temporary Delayed Hypersensitivity Reaction to Botulinum Toxin-A After COVID-19 Vaccination: A Case Series.

PURPOSE: The occurrence of a hypersensitivity reaction with the injection of botulinum toxin type A (BTX-A) in cosmetic use is a rare complication. We report the largest case series of temporary delayed hypersensitivity reaction (DHR) with BTX-A following COVID-19 vaccination and the first cases to incobotulinum toxin A (incoBTX-A). METHODS: A retrospective multicentric case series of patients who developed a DHR to BTX-A after COVID-19 vaccination. RESULTS: Twelve patients were treated with BTX-A injections for the management of facial rhytids. The age range was between 29 and 45 years. Ten (83.3%) were female. Ten (83.3%) patients received incoBTX-A, and two received onabotulinum toxin A (onaBTX-A). All patients had COVID-19 vaccination (mRNA vaccine) between 1 and 7 months before. Within an average time of 24 h after BTX-A injection, all patients developed progressive facial swelling and erythema that were more prominent at the injection points. Intradermal allergic tests to BTX-A were performed in six (50%) patients, and the results were all negative. Adequate clinical control was achieved with systemic corticosteroids and antihistamines. After 1 year with no further vaccination, a new BTX-A treatment (provocation test) was performed in all patients with no secondary effects. CONCLUSION: Previous COVID-19 vaccination and the absence of new adverse events with further BTX-A injections suggest a temporary DHR. Clinicians should be aware of the importance of immunization history and its potential post-vaccine immunogenic effects with BTX-A. 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 .

Hand Rejuvenation with Customizable Hybrid Fillers: Premixed Calcium Hydroxyapatite and Hyaluronic Acid.

INTRODUCTION: Hand aging is a prevalent concern characterized by the atrophy of local soft tissues and increased visibility of vessels and tendons. Hyaluronic acid (HA) and calcium hydroxyapatite (CaHA) are well-established treatments for addressing this issue. While hybrid filler containing HA and CaHA has been proposed for facial rejuvenation, studies investigating its efficacy for hand rejuvenation are lacking. OBJECTIVE: This study aims to assess the safety and efficacy of a premixed hybrid filler containing calcium hydroxyapatite (CaHA) and hyaluronic acid (HA) for hand rejuvenation. METHODS: A prospective, double-blind, controlled trial was conducted. The control arm (CA) received conventional subdermal treatment with CaHA at a 1:1 dilution. The intervention arm (IA) underwent hybrid treatment, consisting of CaHA at a 1:1 dilution combined with 1 ml of low-density HA. Evaluation was performed subjectively using the Global Aesthetic Improvement Scale (GAIS) and the Manchester Hand Grading System (MHGS), and objectively using cutometry, corneometry, and ultrasound. RESULTS: Both the CA and the IA exhibited high rates of patient satisfaction and satisfaction as assessed by blinded evaluators. Although numerical superiority was observed in the IA, no statistical difference was found between the two groups. Significant improvements in hydration, elasticity, and skin thickness were observed in both arms, with no discernible difference between them. Greater ultrasound echogenicity was noted in the IA, which, as indicated by existing literature, may suggest enhanced biostimulation. No adverse effects were reported in either arm. CONCLUSION: Premixed filler containing HA and CaHA for hand rejuvenation appears to be a safe and effective approach. LEVEL OF EVIDENCE I: 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 .

Role of Hyperbaric Oxygen in Filler-Induced Vascular Occlusion.

INTRODUCTION: The rising incidence of filler-induced vascular complications in the context of aesthetic procedures necessitates a thorough assessment of therapeutic options. Hyperbaric oxygen therapy (HBOT) has emerged as a potential intervention for filler-induced vascular occlusion (FIVO), although optimal dosing and timing remain undefined. METHODS: This review explores the pathophysiology of FIVO and elucidates HBOT's multifaceted role in salvaging ischemic tissue. The physical and biochemical mechanisms of HBOT, including its vasodilatory, anti-spasmodic, and anti-inflammatory effects, are examined. RESULTS: HBOT serves as an adjunctive therapy in FIVO management, emphasizing timely intervention, adherence to specific pressures (two atmosphere absolute), and session durations (60 minutes) to optimize efficacy and minimize complications. While existing HBOT protocols for compromised grafts provide insights, standardized guidelines for FIVO are lacking. CONCLUSION: HBOT enhances tissue oxygenation, modulates reactive oxygen species, and influences angiogenesis and hypoxia response. However, it does not replace key treatment protocols for filler vascular complications. Further research and standardized protocols are warranted to define HBOT's definitive role in mitigating filler-induced vascular complications. 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 .

The Fish Bone Technique: An Innovative Approach for the Bony Nasal Pyramid.

Among many contributions to the world of art and science, Renaissance artist Leonardo da Vinci created the technique known as sfumato. In this technique, da Vinci considered that the regions to be highlighted should be lit up, while the regions to be hidden should be darkened. Drawing parallel with the face, we can work on the anatomical structures underlying the skin and create a favorable surface anatomy for the entire face, including the nose. However, to achieve the ideal hourglass shape of the nose, the bones must be shaped, and a variety of osteotomies are described and used to achieve this. The new and innovative Fish Bone technique, described in this article, allows for the bony nasal pyramid to be shaped and adapted to the hourglass shape, resulting in a harmonious contour, with smooth transitions and preservation airway.

Preferred Nasolabial Angle in Rhinoplasty: A Cross-Sectional Analysis.

BACKGROUND: The perception of an ideal nose is influenced by a variety of factors, with demographic characteristics playing a significant role in what is considered an ideal nose. The nasolabial angle (NLA) is considered one of the defining features shaping the nose. OBJECTIVES: In this study we set out to capture the perception of the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations. METHODS: An online questionnaire-based cross-sectional study was conducted to investigate the ideal nasolabial angle among Canadian, Saudi, Kuwaiti, and Lebanese populations (n = 197). Participants were patients attending outpatient clinics, plastic surgery residents, and medical students. The questionnaire included demographics and the perception of respondents of the ideal NLA for each gender: male (85°, 90°, 95°, 100°, 110°) and females (95°, 100°, 110°, 115°). RESULTS: The majority of respondents were female (81.2%), ages between 20 and 39 (84.3%). The mean and standard deviation of ideal NLA choices in both male and female models were 97.1 ± 6.39 and 109.5 ± 5.32, respectively. The ideal male NLA choices were found to correlate significantly with age (P = .044) and work status (P = .019). In choosing the ideal female NLA, age was a significant factor (P = .012). CONCLUSIONS: Identifying the ideal NLA is essential to establishing aesthetic goals for patient and surgeon alike. It is important to understand the effects of demographics on the choice of the ideal NLA, which ultimately influences the planning and outcome of the rhinoplasty procedure.

Updated Filler Emergency Kit: Next-Generation Emergency Solution.

INTRODUCTION: The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK). METHODS: The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed. RESULTS: The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions. CONCLUSION: The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. 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 .

Cross-cultural perspectives on patient expectations in cosmetic dermatology: A comparative analysis across countries and ethnicities.

Patient expectations in cosmetic dermatology exhibit significant variations across countries, cultures, and ethnicities, thereby reflecting individual desires, concerns, and goals. While some individuals seek aesthetic enhancements, others prioritize addressing specific skin conditions within the context of beauty norms in their respective countries. The provision of personalized and culturally sensitive care plays a crucial role in meeting these diverse expectations. Skin characteristics and concerns differ among ethnicities, influencing treatment preferences. For instance, individuals with darker skin tones may prioritize the treatment of pigmentation disorders, whereas those with lighter skin tones may focus on achieving a fair complexion. Furthermore, differences in facial anatomy among various ethnicities necessitate tailored treatment approaches. This commentary aims to contribute to the effective understanding and management of patient expectations, ultimately leading to satisfactory outcomes. Additional research and regional studies are required to further deepen our understanding of patient expectations in cosmetic dermatology and enable the delivery of improved and culturally appropriate care on a global scale.

Consensus Statement on the Use of Botulinum Neurotoxin in the Middle East.

Background: Aesthetic minimally invasive procedures have become very popular and culturally acceptable among Middle Eastern populations. Botulinum neurotoxin type A (BoNTA) is a valuable treatment modality for many cosmetic as well as therapeutic indications. The presence of BoNTA in our toolkit has revolutionized the field of aesthetic medicine to the point where it is now one of the most commonly performed cosmetic procedures worldwide. This consensus considers popular on- and off-label BoNTA indications in the Middle East. Methods: A multinational group of ten key opinion leaders, experts in facial plastic surgery and dermatology, convened the Middle East Aesthetics Consensus Group and reviewed the aesthetic applications of BoNTA. Recommendations and position statements were drafted based on the integration of the panel's clinical experience with published data, targeted to the practices implemented in the Middle Eastern and the global population. Results: Guidance statements are presented covering Middle Eastern facial characteristics and beauty ideals, BoNTA characteristics, pre-operative counselling, treatment indications and anatomical considerations, off-label and special uses including high-dose recommendations, and post-treatment advice. Throughout, an evidence-based approach to selection of products and injection techniques is provided, supplemented by the experts' advice on injections dosages and placement. Conclusion: This consensus reflects the knowledge and expertise of physicians practicing in the Middle East. The panel acknowledged the use of on-label indications and variability in the toxin formulations and immunogenicity and agreed upon a wide use of "off-label" indications.

Aesthetic considerations for treating the Middle Eastern patient: Thriving in Diversity international roundtable series.

BACKGROUND: The Middle East has a significant influence on the global aesthetic market. Within the United States and globally, patients with Middle Eastern heritage have a wide range of ethnic and cultural backgrounds that affect their perceptions of beauty and motivations to seek cosmetic treatment. AIMS: The aim of this roundtable was to discuss similarities and differences in anatomy and treatment preferences of Middle Eastern patients and explore how these differences may influence aesthetic practices. PATIENTS/METHODS: In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022. RESULTS: The results of the fourth roundtable in the series, the Middle Eastern Patient, are described here. A discussion of treatment preferences is included, and specific procedural information is provided for  commonly treated areas in this population (forehead, infraorbital area, and jawline). CONCLUSIONS: Middle Eastern patients have a variety of aesthetic preferences, which are influenced by a wide range of cultural backgrounds, making it difficult to develop general statements about this demographic. There is an unmet need for research into this diverse group of patients to help physicians understand and incorporate their unique needs and desires into clinical practice.

Combining Calcium Hydroxylapatite and Hyaluronic Acid Fillers for Aesthetic Indications: Efficacy of an Innovative Hybrid Filler.

BACKGROUND: Limited data are available describing effectiveness of combining the use of calcium hydroxylapatite (CaHA) and hyaluronic acid (HA). METHODS: The authors performed a retrospective chart review of patients injected with a premixed combination of CaHA and a cohesive polydensified matrix (CPM®) HA (CaHA:CPM-HA ) in the authors' aesthetic practices. The midface and lower face were injected. Patients' records were evaluated, and treatment results were scored using the Merz Aesthetics Scale for the jawline® (clinician rated, CR-MASJ). Adverse events were recorded. RESULTS: A total of 41 patients were included, all females with a mean age of 47.5 years (range 21-63 years). The mean CR-MASJ score improved from 2.12 at baseline to 0.68 at t = 3 months (SD = 0.69, 95% CI 1.28-1.60) and 1.27 at t = 12 months (SD = 0.74, 95% CI 0.43-0.74). 100% of the subjects had experienced a ≥1-point improvement in CR-MASJ score at t = 3 months, versus 85% at t = 12 months. No adverse events were reported. CONCLUSION: The results of this study support the volumizing and lifting potential of the hybrid mix CaHA:CPM-HA for treatment of cheeks and jawline. 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 .

Repair of complete bilateral cleft lip with severely protruding premaxilla performing a premaxillary setback and vomerine ostectomy in one stage surgery.

BACKGROUND: The authors present a technique for selected cases of CBCL. The primary repair of the CBCL with a severely protruding premaxilla in one stage surgery is very difficult, essentially because a good muscular apposition is difficult, forcing synchronously to do a premaxillary setback to facilitate subsequent bilateral lip repair and, thus, achieving satisfactory results. We achieve this by a reductive ostectomy on the vomero-premaxillary suture. MATERIAL AND METHODS: 4 patients with CBCL and severely protruding premaxilla underwent premaxillary setback by vomerine ostectomy at the same time of lip repair in the past 24 months. The extent of premaxillary setback varied between 9 and 16 mm. The required amount of bone was removed anterior to the vomero-premaxillary suture. The authors did an additional simultaneous gingivoperiosteoplasty in all patients, achieving an enough stability of the premaxilla in its new position, to be able to close the alveolar gap bilaterally. The authors have examined the position of premaxilla and dental arch between 6 and 24 months. We did not do the primary nose correction, because this increased the risk of impairment of the already compromised vascularity of the philtrum and premaxilla. RESULTS: The follow-up period ranged between 6 and 24 months. None of the patients had any major complication. During follow-up, the premaxilla was minimally mobile. We achieved a good lip repair in all cases: adequate muscle repair, symmetry of the lip, prolabium and Cupid's bow, as well as good scars. Conclusions: To our knowledge, there are few reports of one stage surgery with vomerine ostectomy to repair CBCL with severely protruding premaxilla. Doing this vomerine ostectomy, we don't know how it will affect the subsequent growth of the premaxila and restrict the natural maxillary growth. Applying this alternative treatment for children with CBCL and protruded premaxilla without any preoperative orthopedic, we can successfully perform, in a single-stage surgery, a good primary lip repair at our center. Further confirmations of this surgery with follow up and anthropometric studies of these patients during childhood and adolescence are required.