Factors Influencing Trust and Trustworthiness: Cosmetic Injectable Patient Experience Exploratory Study (CIPEES)-Part 3.

Background: Despite the widely recognized importance of trust in professional relationships, it remains elusive, complex, multidimensional, and difficult to quantify due to the lack of validated tools. Objectives: The authors sought to explore both the important factors for building trust with cosmetic injectable patients and strategies for improving levels of trustworthiness in aesthetic practitioners. Methods: In order to explore factors in building trust with cosmetic injectable practitioners, a global study was conducted via an online survey. The Cosmetic Injectable Patient Experience Exploratory Study (CIPEES) survey assessed the relative importance of qualifications and training; reviewing of previous work (before and after photos); reputation; connection; time spent; online presence; and personal appearance of the practitioner in developing trust in a cosmetic practitioner. Results: The CIPEES survey collected 1488 responses across 75 countries, with 66% of participants completing all 15 questions. The respondents were 95.6% female and 4.4% male, with ages ranging from 18 to >65 years old (median 33 years old). The number 1 ranked reason for being able to trust a cosmetic injector was qualifications and training, followed by the reputation of the practitioner, and time spent by the practitioner with the survey respondent. Practitioner online presence was considered the least important factor in helping develop trust. Conclusions: The CIPEES survey results support patient trust being built through credibility, reliability, and intimacy, with low levels of practitioner self-orientation. The trustworthiness equation provides a framework for identifying practitioner weaknesses in patient relationships and actionable methods of improving trustworthiness.

The Importance of Functional Quality in Patient Satisfaction: Cosmetic Injectable Patient Experience Exploratory Study-Part 2.

Background: Quality assessment comprises 2 distinct forms: technical quality (TQ) and functional quality (FQ). On the one hand, TQ describes accuracy and excellence, the degree to which procedures are done "correctly." On the other hand, FQ is the way services are delivered and represents how the customer perceives and experiences the treatment or service. Objectives: To determine the relative importance of functional quality factors in the care of cosmetic injectable patients and return patronage. Methods: The Cosmetic Injectable Patient Experience Exploratory Study (CIPEES) survey assessed reasons for return patronage to a specific cosmetic injector and the correlation between satisfaction with cosmetic results (patient assessment of TQ) and respondents' trust level in their practitioner, a marker for FQ. Results: The CIPEES survey collected 1488 responses across 75 countries, with 66% of participants completing all 15 questions. The respondents were 95.6% female and 4.4% male, with ages ranging from 18 years to >65 years old (median 33 years old). The number one ranked reason for returning to a previous cosmetic injector (return patronage) was "Trust in my practitioner's action and ability," closely followed by "Cosmetic result/outcome from the previous treatment/s." Respondents' level of satisfaction with their cosmetic results also correlated highly with trust in their practitioners. Conclusions: In order to maximize patient satisfaction and return patronage, healthcare practitioners should focus on improving FQ care and value it at least as high as TQ in the delivery of cosmetic injectable treatments.

The Importance of Patient Mindset: Cosmetic Injectable Patient Experience Exploratory Study-Part 1.

Background: To meet the needs of each individual cosmetic injectable patient, focus is moving toward a detailed, patient-centered, holistic consultation with pretreatment exploration of the patient's mindset. The Cosmetic Injectables Patient Experience Exploratory Study (CIPEES) was developed to explore patient motivation, mindset, engagement, and factors impacting the patient-practitioner relationship. Objectives: In order to best meet the needs of individual aesthetic patients, the authors examine the variability and importance of mindset factors in patients seeking cosmetic injectables. Methods: A study was conducted through an online survey. Participants were asked to respond to a series of statements concerning their thoughts and feelings around appearance, treatment goals, and motivating factors. Participants were asked to select one of the following: "describes me well," "somewhat describes me," or "does not describe me." Results: In total, 1269 participants completed the relevant survey question. Respondents were 95.6% female and 4.4% male, with ages ranging from 18 to > 65 years old (median 33 years old). Responses were also analyzed according to age group. Data analysis revealed a majority of respondents seeking natural results, with a 15%-20% minority considering a "done" look to be acceptable or even ideal. High numbers of respondents reported being critical of their own appearance and concerned about a specific feature to be "fixed." Conclusions: Exploring the nuances of patient mindset will assist practitioners in meeting the unique needs of each patient and may also help them to avoid treating patients whose requirements or expectations are outside their circle of competence.

Facial Aesthetic Priorities and Concerns: A Physician and Patient Perception Global Survey.

BACKGROUND: Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed. OBJECTIVES: The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries. METHODS: This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care. RESULTS: A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow's feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes. CONCLUSIONS: This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments.

Dermal filler treatments require constant reassessment for improving and safeguarding the rapidly evolving aesthetic field. Suboptimal injection technique, patient selection and product knowledge have touted a concerning increase in filler complications, with new challenges such as the COVID-19 pandemic leading to new paradigms in the understanding, prevention, diagnosis and treatment of complications. The updated 10-point plan has been developed to curtail complications through consideration of causative factors, categorized as patient, product, and procedure-related. Patient-related factors include a preprocedural consultation with careful elucidation of skin conditions (acne, rosacea, dermatitis), systemic disease (allergies, autoimmune disease, underlying bacterial and viral disease (herpes simplex virus, COVID-19 infection), medications (antineoplastic drugs, recreational drugs) and previous cosmetic procedures (including fillers and energy-based devices). Patient assessment should include standardized photography and also evaluate the role of social media, ethnicity, gender, generational, and LGBTQ+ needs. Specified informed consent for both adverse events and their treatment is essential due to the increase in vascular complications, including the risk of blindness. Product-related factors include the powerful advantage of reversibility when using hyaluronic acid (HA) products. Product characteristics such as molecular weight and filler degradation should be understood. Product layering over late or minimally degradable fillers is still inadvisable due to the initial filler being teased into reactivity. Procedural factors such as consistent photographic documentation, procedural planning, aseptic non-touch technique (ANTT), knowledge of topographical anatomy and angiosomes, and technical dexterity including pinch anatomy and needle skills are of pivotal importance. The final section is dedicated to algorithms and checklists for managing and treating complications such as allergic hypersensitivity reactions, vascular events, infection, edema and late-onset adverse events (LOAEs). The updated 10-point plan is a methodical strategy aimed at further minimising the risk of dermal filler complications.

Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals.

There is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodeling and transformation. These procedures may increase transgender individuals' satisfaction with their appearance and allow them to more effectively harmonize their physical appearance with their perception of self. There is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. In this report, the authors provide experience-based treatment considerations and recommendations for use of minimally invasive facial aesthetic procedures in transgender patients, including case studies illustrating the use of these procedures for both male-to-female and female-to-male transitioning patients. This report highlights the success of minimally invasive methods for assisting transgender patients in achieving their facial remodeling goals. Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process. When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients' self-perception and overall quality of life.

Enhanced patient retention after combination vs single modality treatment using hyaluronic acid filler and neuromodulator: A multicenter, retrospective review by The Flame Group.

BACKGROUND: It is believed that combination treatment with both neuromodulators (NM) and hyaluronic acid soft-tissue fillers (HA) results in superior aesthetic results and increased patient satisfaction compared to either treatment alone. AIMS: To determine whether combined treatment with NM and HA leads to greater patient retention than treatment with NM or HA alone. PATIENTS/METHODS: This is a large, multi-center, retrospective review of patient retention rates from 7 aesthetic practices across 5 continents, incorporating over 2600 patients. Patient retention is interpreted as a surrogate marker for overall patient satisfaction. Retention rates were compared at 1, 3, and 5 years for patients who received NM only, HA only, or combination treatment with both NM and HA. RESULTS: Combination therapy significantly increased the probability of retention for each time point (1, 3, and 5 years) compared with NM alone (P < .0001) and HA alone (P < .0001). CONCLUSION: This large multicenter, global retrospective review demonstrates that patients who received combined HA and NM were more likely to be retained in the same practice over many years than those who received either treatment alone.

The Treatment of Facial Asymmetry with Botulinum Toxin: Current Concepts, Guidelines, and Future Trends.

This article will describe facial asymmetry secondary to facial nerve paralysis (FNP), and review current concepts, guidelines, and future trends. Despite the increasing use of botulinum toxin (BoNTA) in treating FNP, ideal dosage, timing, and additional therapies are not unequivocally established. Facial asymmetry significantly impacts quality of life (QOL) by strongly affecting self-perception and social interactions; injectables may mediate great clinical improvement. This article provides practical guidelines for the use of BoNTA and provides schemes for accurate assessment and documentation. A systematic, stepwise approach is recommended with methodical assessment, meticulous placement, conservative dosage, and careful follow-up. Future trends include the potential use of newly developed toxins, muscle modification with fillers, improved imaging techniques, and targeted QOL studies. Hopefully, a growing number of aesthetic injectors may become technically proficient and join multidisciplinary teams for managing FNP.

Re Facial aesthetic injections in clinical practice: Pretreatment and post-treatment consensus recommendations to minimise adverse outcome Region-specific changes in line with the Covid-19 pandemic.

Despite the recent publication in March 2020 of guidelines for facial injectable treatments, the speed of the COVID-19 pandemic and its safety implications necessitate changes to these guidelines The authors described what would constitute safest practice in the provision of facial injectable treatments and summarised these in table form. Adherence to a high standard of asepsis and infectious disease precautions remain a key patient safety requirement when performing facial aesthetic injections. A revision and update of these guideline summary tables follows. Changes made should enhance both patient and staff safety regarding COVID-19/SARS-CoV-2, a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions and contaminated fomites. Some of the additions are COVID-19 specific and are likely to evolve and change, particularly should serological tests determining acquired immunity become available. Other additions represent further tightening of our infection control precautions.

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.

A Systematic Literature Review of the Middle Temporal Vein Anatomy: 'Venous Danger Zone' in Temporal Fossa for Filler Injections.

BACKGROUND: Treatment of a sunken appearance of the temporal region using injectable fillers is a popular procedure. The temporal fossa has very complex anatomy due to multiple vessels running in the different tissue layers. A severe complication in the form of non-thrombotic pulmonary embolism (NTPE) can occur as a result of an inadvertent injection in the middle temporal vein (MTV) while performing temporal fossa filler procedures. Therefore, in-depth knowledge and understanding of the MTV anatomy are essential for successful and safer injectable procedures of the temporal fossa. OBJECTIVES: While there have been many studies to describe the arteries in this region, there is limited information about the location and course of the middle temporal vein. This literature review is aimed at providing detailed information about the course, depth, and size of the MTV to help aesthetic practitioners in performing safer temporal fossa filler injections. This information is imperative to delineate the 'venous danger zone' in the temple region. METHODS: The preferred reporting items for systematic reviews and meta-analyses guidelines were used for this review. A literature search was performed to find the articles providing details about the MTV anatomy and the measurements related to its course and size. RESULTS: A review of the literature showed that the MTV displays a consistent course and depth in the temporal region, with high variability in its diameter. The middle temporal vein width varied between 0.5 and 9.1 mm in various studies. The middle temporal vein receives many subfascial tributaries from the surface of the temporalis muscle, and for most of its course runs in the fat pad enclosed between superficial and deep layers of the deep temporal fascia. A 'venous danger zone,' in the interfascial planes of the temporal fossa, which contain the main part of the MTV and its tributaries, has been proposed in this paper. CONCLUSIONS: The temporal fossa filler procedures need great caution, and knowledge of the depth and course of the MTV is essential for avoiding NTPE. 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 .

Global Approaches to the Prevention and Management of Delayed-onset Adverse Reactions with Hyaluronic Acid-based Fillers.

BACKGROUND: Delayed-onset adverse reactions to hyaluronic acid (HA) fillers are uncommon but have received increased attention, particularly with regard to late-onset nodules. Globally, there is a need for comprehensive prevention and management strategies. METHODS: Experts with clinical practices in diverse regions of the world and extensive experience in managing complications related to HA fillers convened to propose and evaluate approaches to prevent delayed-onset adverse reactions after HA filler administration and manage late-onset nodules. RESULTS: The expert panel agreed to define delayed-onset adverse reactions as those presenting more than 4 weeks posttreatment, with swelling, induration, and nodulation being the most common clinical signs. The panel recommended 5 general key approaches for the prevention of delayed-onset reactions (patient selection, anatomic location of injection/product selection, aseptic technique, injection procedure/filler, and posttreatment care). Strategies recommended for managing late-onset nodules included oral antibiotics, oral steroids, nonsteroidal anti-inflammatory drugs if needed, hyaluronidase for noninflammatory nodules (recognizing the limitations and regional availability of this treatment), intralesional antibiotics, intralesional immunosuppressive drugs such as steroids and fluorouracil, and surgical excision as a last resort. The panel noted that late-onset nodules may vary in both clinical presentation and etiology, making them challenging to address or prevent, and stressed individualized treatment based on clinical presentation. Regional differences in aseptic protocols, antibiotic selection, and steroid formulations were described. CONCLUSION: Insights from global experts on approaches to prevent and manage delayed-onset adverse reactions following HA filler administration, including late-onset nodules, support clinicians worldwide in optimizing patient outcomes and safety.

Expert Consensus on Injection Technique and Area-Specific Recommendations for the Hyaluronic Acid Dermal Filler VYC-12L to Treat Fine Cutaneous Lines.

BACKGROUND: VYC-12L is a hyaluronic acid (HA) injectable gel designed to treat fine cutaneous lines and improve skin quality attributes such as hydration and elasticity. OBJECTIVE: Expert consensus was sought on VYC-12L injection technique and primary treatment target areas. METHODS: A multinational group of aesthetic medicine clinicians (n = 128) attended product training and each identified ~10 patients for VYC-12L. After treating their first and last patients, the clinicians completed a survey on preferred injection methodology/technique, including injection angle, volume, and spacing. An expert panel (n = 12) discussed survey results and their clinical experiences to obtain consensus on VYC-12L technique and appropriate treatment areas. RESULTS: Recommendations included micro-depot injections of VYC-12L into the deep dermis with a 32G ½ inch needle inserted at <45º to the skin, spaced 0.5‒1.0 cm apart, with 0.01‒0.05 mL volume per injection (full-face total volume: ~2 mL). Recommended primary treatment areas were the malar, perioral, neck, and décolletage regions. Injection techniques for different treatment areas/demographic characteristics were similar, with some variability in treatment approach. Patient selection criteria, pre- and post-treatment guidelines, and managing patient expectations are important components of treatment. CONCLUSION: These consensus recommendations may assist clinicians in optimizing the treatment of fine lines with VYC-12L.

Vision Loss Associated with Hyaluronic Acid Fillers: A Systematic Review of Literature.

BACKGROUND: With the global increase in the use of injectable fillers, more cases with serious adverse events such as skin ischemia and vision loss are being reported. This article aims to review the role of HA fillers, as a subgroup separate from fat graft and non-HA fillers, in causing vision loss and to elucidate various features and outcomes of post-HA filler vision loss. METHODS: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to report this review. A total of 29 articles presenting 60 unique cases of post-HA filler vision loss were identified in the literature. Based on various inclusion and exclusion criteria, 26 articles with details of 44 cases were included in this study. RESULTS: The majority of cases were seen in women and in the 20-40 years age group. The maximum number of cases was reported from Korea, followed by China. Nearly half of the cases reported after HA filler-related visual complications had partial loss of sight, hence 'partial vision loss' and 'complete vision loss' were used as differentiating descriptive terms to the degree of 'blindness.' Nearly all the cases were unilateral, with immediate onset of visual signs and symptoms. The nose, glabella, and forehead were the most commonly implicated areas, while no cases of post-HA filler vision loss were reported from lower face anatomical areas, including the chin, jawline, and lips. Partial vision loss after HA filler has a better prognosis than complete vision loss. HA filler volumes as low as 0.2 ml can cause permanent, complete vision loss, which is suggestive of the embolic nature of HA filler blockage. Ophthalmic artery occlusion (OAO) and central retinal artery occlusion (CRAO) were the two most commonly involved arterial obstruction patterns followed by branch retinal artery occlusion (BRAO). BRAO is the most favorable involved arterial pattern for a chance of recovery after HA filler-related vision loss while CRAO and OAO patterns carry a very poor prognosis. CONCLUSION: Post-HA filler vision loss is nearly always of immediate onset. Partial vision loss after HA filler injection with the involvement of smaller branches of the retina, other than central retinal artery or ophthalmic artery, has more favorable visual outcomes. 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.

A Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management.

BACKGROUND: Hyaluronic acid fillers have a satisfactory safety profile. However, adverse reactions do occur, and rarely intravascular injection may lead to blindness. Currently there is no internationally recognized consensus on the prevention or management of blindness from hyaluronic acid filler. OBJECTIVES: The authors sought to give guidance on how to minimize the risk and optimize the management of this rare but catastrophic adverse reaction. METHODS: A multinational group of experts in cosmetic injectables from multiple disciplines convened to review current best practice and develop updated consensus recommendations for prevention and bedside intervention if visual loss occurs after cosmetic injection of hyaluronic acid filler. RESULTS: The consensus group provided specific recommendations focusing on the consenting process, prevention, and early management of visual impairment related to intravascular hyaluronic acid filler injection. CONCLUSIONS: Although visual loss due to filler injections is rare, it is important that both patient and physician be aware of this risk. In this paper the authors describe methods and techniques available to reduce the risk and also document suggested initial management should a clinician find themselves in this situation.

A 10-point plan for avoiding hyaluronic acid dermal filler-related complications during facial aesthetic procedures and algorithms for management.

The recent rapid growth in dermal filler use, in conjunction with inadequate product and injector control, has heralded a concerning increase in filler complications. The 10-point plan has been developed to minimize complications through careful preconsideration of causative factors, categorized as patient, product, and procedure related. Patient-related factors include history, which involves a preprocedural consultation with careful elucidation of skin conditions, systemic disease, medications, and previous cosmetic procedures. Other exclusion criteria include autoimmune diseases and multiple allergies. The temporal proximity of dental or routine medical procedures is discouraged. Insightful patient assessment, with the consideration of ethnicity, gender, and generational needs, is of paramount importance. Specified informed consent is vital due to the concerning increase in vascular complications, which carry the risk for skin compromise and loss of vision. Informed consent should be signed for both adverse events and their treatment. Product-related factors include reversibility, which is a powerful advantage when using hyaluronic acid (HA) products. Complications from nonreversible or minimally degradable products, especially when layered over vital structures, are more difficult to control. Product characteristics such as HA concentration and proprietary cross-linking should be understood in the context of ideal depth, placement, and expected duration. Product layering over late or minimally degradable fillers is discouraged, while layering of HA of over the same brand, or even across brands, seems to be feasible. Procedural factors such as photographic documentation, procedural planning, aseptic technique, and anatomical and technical knowledge are of pivotal importance. A final section is dedicated to algorithms and protocols for the management and treatment of complications such as hypersensitivity, vascular events, infection, and late-onset nodules. The 10-point plan is a systematic, effective strategy aimed at reducing the risk of dermal filler complications.

Patient factors influencing dermal filler complications: prevention, assessment, and treatment.

While rare, complications do occur with the esthetic use of dermal fillers. Careful attention to patient factors and technique can do much to avoid these complications, and a well-informed practitioner can mitigate problems when they do occur. Since cosmetic surgery is usually an elective process, requested by the patient, clinical trials are complex to organize and run. For this reason, an international group of practicing physicians in the field of esthetics came together to share knowledge and to try and produce some informed guidance for their colleagues, considering the literature and also pooling their own extensive clinical experience. This manuscript aims to summarize the crucial aspects of patient selection, including absolute contraindications as well as situations that warrant caution, and also covers important considerations for the pre- and posttreatment periods as well as during the procedure itself. Guidance is given on both immediate and long-term management of adverse reactions. The majority of complications are related to accepting patients inappropriate for treatment or issues of sterility, placement, volume, and injection technique. It is clear that esthetic practitioners need an in-depth knowledge of all aspects of treatment with dermal fillers to achieve optimal outcomes for their patients.