Simplifying the injector's armamentarium: An international consensus regarding the use of gel science to differentiate hyaluronic acid fillers and guide treatment recommendations.

BACKGROUND: The Restylane portfolio of soft tissue fillers spans a wide range of indications, due in part to their complementary manufacturing technologies [non-animal stabilized hyaluronic acid (NASHA) and Optimal Balance Technology (OBT/XpresHAn)]. Using an array of products, injectors can achieve a holistic, natural looking effect for their patients. However, with a wide range of products it may be difficult to choose an optimal combination. AIM: Simplify and align global use recommendations for NASHA versus OBT products. METHODS: Two pre-meeting surveys were completed by 11 key opinion leaders with international representation, with the goal of collecting information regarding their current injection practices for various anatomical regions of the face (i.e., temporal region, forehead, tear trough, lateral zygoma, anteromedial cheek, nose, pyriform aperture, nasolabial fold, perioral area, lips, labiomental crease, marionette lines, chin, and jawline). The data collected from these surveys was subsequently discussed in a consensus group meeting involving 11 voting members and 3 nonvoting members. RESULTS: Top product recommendations were identified for each anatomical area, along with secondary and tertiary recommendations that can also be used under defined circumstances. Recommendations were provided based on a consideration of elements such as patient features (e.g., skin thickness, bone structure), the desired aesthetic outcome, experience of the injector, and the preferred injection technique. CONCLUSION: A majority consensus regarding the top NASHA versus OBT product choice for each anatomical region of the face was reached. These recommendations represent international agreement regarding the use of Restylane products.

An absence of imperfections: A proposed framework for defining, assessing, and achieving skin glow.

BACKGROUND: Skin glow is a subcomponent of skin quality. It has become entrenched in the cosmeceuticals and aesthetics lexicons as a synonym for health and youth, but is not well-defined as a scientific metric. AIMS: To examine the concept of skin glow and determine if it is an objective concept that can be defined and quantified. METHODS: Literature review was used to develop a survey on current concepts relating to skin quality. The survey results were analyzed descriptively and presented to a focus group comprising five dermatologists and four aesthetic physicians. This group then discussed the concept of skin glow, how to define it and what metrics could be used to assess it. RESULTS: Surveyed practitioners (n = 38) ranked skin quality as the fourth most important factor related to a person's overall aesthetic first impression. Almost all (95%) respondents reported routinely assessing skin quality, citing serial photography (83%), and visual inspection (67%) as the main means of achieving this. The focus group defined skin glow as even reflectance from an unaffected papillary and reticular dermal collagen layer, which is created only when skin does not exhibit any characteristics that detract from this even reflectance. Due to its complexity, the focus group proposed a hierarchal framework for assessment, encompassing patient self-rating, practitioner severity rating, and supplemental use of validated measurement devices. CONCLUSIONS: Skin glow can be defined and quantified. More work is warranted to develop a practical skin glow assessment tool suitable for use in the clinic setting.

Consensus recommendations on the use of injectable poly-l-lactic acid in Asian patients.

BACKGROUND: Injectable poly-L-lactic acid (PLLA) has been proven safe and effective with numerous medical applications for more than 25 years. The product has been approved in over 40 countries and is being used for soft tissue augmentation in the face and certain body parts. With the increased demand for subtle and natural-looking aesthetic treatments in the Asia-Pacific region, there is also a heightened need for consistent preparation and effective treatment methodologies to optimize outcomes for Asian patients. METHODS: The body of evidence in medical literature, clinical data of presented case reports, and the collective experience of the authors are reflected in these consensus recommendations, which also take under consideration the availability of biostimulators in the Asia-Pacific region. RESULTS: The resulting consensus recommendations include patient selection and assessment, management of treatment expectations, appropriate preparation and storage, proper injection techniques and treatment plans, management of adverse effects, PLLA combination with other facial rejuvenation procedures, and other constructive considerations. CONCLUSIONS: In the above consensus recommendations, the authors shared their best practices in accordance with the updated preparation and treatment protocols of PLLA. These recommendations represent the clinical and real-world techniques utilized by authors in providing PLLA treatments for Asian patients.

Facial Soft Tissue Repositioning With Neuromodulators: Lessons Learned From Facial Biomechanics.

BACKGROUND: Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral periorbital region, underscoring the versatility of neuromodulator treatments. OBJECTIVES: The aim of this study was to analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. METHODS: Seventy-five study participants (8 males, 67 females) with a mean [standard deviation] age of 37.5 [8.5] years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement measured by 3-dimensional imaging at baseline, Day 14, and Day 30. RESULTS: Three-dimensional volume analysis revealed an increase in midfacial volume by 0.46 mL, and a decrease of the lower facial volume by 0.30 mL compared with baseline. Additionally, an improvement of midfacial fullness (by 0.13) and jawline contour (by 0.44) was reported on clinical rating scales at Day 30 compared with baseline. CONCLUSIONS: Facial soft tissues can be repositioned during the 30-day follow-up period following a neuromodulator treatment; this was reflected through an increase in midfacial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.

A Prospective, Multicenter Trial on the Efficacy and Safety of Poly-L-Lactic Acid for the Treatment of Contour Deformities of the Buttock Regions.

BACKGROUND: There is a significant emphasis on minimally invasive whole-body rejuvenation throughout the world. Recently, gluteal aesthetics have become an increasingly common patient concern. Although the application of poly-L-lactic acid (PLLA) to the face is already well known, there are relatively fewer publications on its use in other corporeal regions. This study aims to extend previous findings by evaluating the efficacy and safety of PLLA in the treatment of contour (including lifting) deformities of the buttock region. METHODS: This was a prospective, multicenter (3 sites), single cohort, open-label clinical trial. Thirty female subjects were treated with PLLA in the bilateral buttocks, with three treatment sessions, each spaced one month apart and followed for six months after completion of the treatment regimen. At each visit, various safety and clinical efficacy parameters were collected, these included: Global Assessment of Improvement Scale (GAIS), subject satisfaction, skin hydration, elasticity, scaliness, roughness, and 3-dimensional imagery. RESULTS: Six months following the last treatment, 84.00% of patients were rated as having “improved” or more on the physician assessed GAIS, accompanied by a 96.00% patient satisfaction rate. Approximately three vials of PLLA, per buttock and treatment were used. There were no serious adverse events throughout the duration of the trial, nor adverse events related to the investigational device. The most common subject-reported adverse events included pain during treatment (Mean: 70.97%) and bruising (Mean: 28.80%). Objective improvements were persistent after treatment in measurements of skin elasticity (improved 63.5% - 82.5% from weeks 16-32), hydration (increased ~11 Corneometer® units by week 16), roughness (decreased 36.95% at week 32), and scaliness (desquamation; decreased 60.41% at week 32). CONCLUSIONS: PLLA is safe and effective for the indication of buttock contouring and improving parameters of skin health. PLLA can provide long-lasting effects with a high level of patient and physician satisfaction. J Drugs Dermatol. 2022;21(3):304-308. doi:10.36849/JDD.5924.

Expert Recommendations on the Use of Injectable Poly-L-lactic Acid for Contour Deficiencies of the Buttocks.

Poly-L-lactic acid (PLLA) is an injectable biodegradable biostimulator that promotes collagen production and is approved for use in aesthetic facial augmentation. PLLA is well tolerated with minimal downtime and has demonstrated an excellent safety profile, as well as a longevity benefit of at least 2 years following injection. The robust safety and efficacy profile associated with PLLA for facial rejuvenation has resulted in a growing interest in the use of PLLA for other body areas such as the buttocks, which are an increasingly popular target of aesthetic enhancement. Patient goals for gluteal enhancement include improving contour and texture, reduction in visible cellulite and increased volume and lift. In order to achieve optimal outcomes and patient satisfaction, it is essential to ensure correct usage of PLLA; however, there is currently a lack of guidelines and expert recommendations in this area. This report reflects consensus recommendations for the use of PLLA in non-invasive buttock contouring, including patient selection, PLLA preparation, dosing, injection and, efficacy and safety assessments. Recommendations were provided by the collective author group, comprising international leaders in the field of aesthetics, dermatology, and plastic surgery. J Drugs Dermatol. 2022;21(1):21-26. doi:10.36849/JDD.6180.

Evaluation of Cannula Safety in Injection of Poly-L-Lactic Acid.

BACKGROUND AND OBJECTIVE: Poly-L-lactic acid (PLLA) has been used in various medical applications for decades, including aesthetic ones. The use of a cannula technique in injecting PLLA has been proposed in order to lower the incidence rate of adverse events (AEs) following treatment. Such AEs include nodule formation, which may occur less frequently by fanning the product with a cannula, thus creating a more uniform product placement compared to that resulting from the use of a needle. Currently, however, there is a lack of comparative research regarding the safety of cannulas versus needles for PLLA injections, as the selection of either remains highly subjective. Therefore, the objective of our study was to investigate the safety of cannula use in the administration of PLLA, in order to report safety outcomes. MATERIALS AND METHODS: A single-center, retrospective chart review was conducted to examine the data of patients who had previously undergone treatment with PLLA in the form of Sculptra® Aesthetic™ in the face and/or neck regions. Twenty-seven subject charts met eligibility. Descriptive data regarding treatment and follow-up visits were collected and analyzed. RESULTS: A total of seven AEs resulted from eighty-two treatment sessions (8.54%), with 6/27 patients having experienced at least one AE (22.22%). Mild bruising was the most commonly reported AE (57.14%). The majority of the AEs were mild and transient in nature, with one moderate AE being a nodule that was possibly related to a concomitant treatment. All AEs were resolved with follow-up care. CONCLUSION: Mild AEs such as bruising, swelling and pain should be expected following the use of a cannula for PLLA injections. However, the incidence rates of AEs following treatment can remain low if proper product preparation and treatment techniques are utilized.

Understanding Facial Muscle Aging: A Surface Electromyography Study.

BACKGROUND: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood. OBJECTIVES: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers. METHODS: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles. RESULTS: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity). CONCLUSIONS: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.

Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique.

BACKGROUND: Current injection algorithms for treating the glabella rely on a five- or seven-point injection technique with possible medial eyebrow ptosis and lateral eyebrow elevation as undesirable outcomes. OBJECTIVE: The objective of this study was to investigate the efficacy and safety profile of a refined 3-point injection technique targeting horizontal and vertical glabellar lines. METHODS: A total of n=105 patients (27 males and 78 females) with a mean age of 40.90 ± 9.2 years were investigated. The injection technique relied on targeting the muscular origin of the procerus and the corrugator supercilii muscles exclusively. The time of effect onset and the injection-related outcome 120 days after the treatment was evaluated using the 5-point glabellar line severity scale. RESULTS: The onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There was no statistically significant difference in the amplitude of movement before or 14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for the lateral head of the eyebrow, respectively. CONCLUSION: Incorporating anatomic concepts into clinical practice for glabellar frown line neuromodulator treatments with the investigated 3-point injection technique resulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, medial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated efficacy throughout the 4-month study period.

Calculating the Thickness of the Superficial Fatty Layer of the Body Using Age, Gender, and Body Mass Index

BACKGROUND: Injections of biostimulator agents are increasing in popularity as an alternative to surgical or energy-based skin tightening procedures. The present study was designed to develop a formula that helps to guide health care providers injecting biostimulators into the correct plane to enhance effectiveness and longevity by targeting precisely the superficial fascial system. METHODS: 150 Caucasian individuals (75 males and 75 females) were investigated with a balanced distribution of age (n=30 per decade: 20­29, 30­39, 40­49, 50­59, and 60­69 years) and body mass index (n=50 per group: BMI≤24.9kg/m2, BMI between 25.0 and 29.9kg/m2 BMI≥30kg/m2). The distance between skin surface and the superficial fascia was measured via ultrasound in the buccal region, premasseteric region, the lateral neck, posterior arm, abdomen, buttocks, anterior thigh, medial thigh, and posterior thigh. RESULTS: Mean thickness of the superficial fatty layer is variable between the different locations investigated with smallest values for the lateral neck of 3.71mm ± 0.55 [range, 2.00­5.00mm] and greatest values for the gluteal region with 20.52mm±10.07 [range, 6.10­38.40mm]. A formula was developed to estimate the thickness of the superficial fatty layer based on the targeted region, age, gender, and body mass index of the patient: Thickness of superficial fatty layer (mm): Region constant + (XX* BMI) - (YY*Age). CONCLUSIONS: Injections of biostimulators deeper than the calculated values might result in reduced efficacy as the superficial fascial system is not targeted and the effected collagen neogenesis does not affect the skin surface. J Drugs Dermatol. 2020;19(1):36-44. doi:10.36849/JDD.2020.4619

Recommendations on the Use of Injectable Poly-L-Lactic Acid for Skin Laxity in Off-Face Areas

Injectable poly-L-lactic acid (PLLA) is a biodegradable synthetic polymer that stimulates collagen production, leading to gradual volume restoration. The treatment of sagging skin in body areas is still a big challenge, as there are few aesthetic procedures aiming to improve it. This article provides recommendations on the use of PLLA in the treatment of skin laxity in off-face areas, as the neck, décolletage, arms, abdomen, buttocks, and thighs, including the patient selection, product preparation, and injection techniques. The use of PLLA is a promising method for the treatment of skin laxity in corporal areas, improving body contour and appearance. Further investigation is needed to better understand the efficacy and durability of PLLA in non-facial indications and to provide the best evidence for optimal patient outcomes. J Drugs Dermatol. 2019;18(9):929-935.

Managing the Aesthetic Patient

wide variety of therapeutic options, some challenges have arisen: designing an adequate treatment plan, electing the most suitable procedures for the patient, taking into consideration the rheological characteristics of the products, considering the amount needed to achieve a natural look, but also defining the safest way to deliver the treatment. Aging of the facial structural tissue layers occurs at a different pace and the requirements for the aesthetic approach of a 30-year-old patient are different from a 60-year-old patient. A group of twelve experts in minimally invasive injectable procedures sought to identify common changes observed in different age groups in order to help in establishing a plan of treatment for patients of different ages. The individualized aesthetic plan should consider the main pillars of the aesthetic treatment -- aging process, facial assessment, and facial anatomy, to identify and systematize common changes observed in different age groups, as well as the safest and most reproducible techniques, especially for new injectors. J Drugs Dermatol. 2019;18(1):92-102.

Dynamic Changes of Facial Supporting Cornerstones (Pillars): Considerations in Aesthetic Approach.

The bony structures of the face provide the framework upon which the soft-tissue envelope rests, such that facial symmetry and proportionality usually depend upon the morphological patterns and anthropometrical measurements of a symmetrical skull. Facial bony pillars are dynamic and variable according to the demands placed upon them, as well as gender and aging differences. Thus, a more profound knowledge of facial supporting pillars and their dynamic behavior by physicians who practice minimally cosmetic procedures would allow for a more natural approach to facial beautification. It would help them to rebalance age-related and asymmetric congenital imperfections, and minimize any harmful stigma associated with bad cosmetic practice.

J Drugs Dermatol. 2018;17(4):466-470.

Aging and Sexual Differences of the Human Skull.

BACKGROUND: The aging process of the face comprises all layers: skin, subcutaneous fat, muscles, and skeleton, and the signs of aging depend mainly on which layer is mostly affected. OBJECTIVE: To evaluate the aging facial skeleton, as well as establish the sexual differences, areas with a strong predisposition to resorption, and aesthetic repercussion for better treatment approach. METHODS: Skulls from the Forensic Anthropology Department of the Institute of Forensic Medicine of Belo Horizonte, Brazil, were classified according to gender and age group (i.e., <20 years, 20-50 years, >50 years). Structural changes were classified according to gender and age group. RESULTS: Of the 241 skulls included, 192 were male skulls and 49 female. Sexual dimorphism and age-related peculiarities are described herein. CONCLUSIONS: The knowledge of the anatomy of the aging face, taking into consideration all the layers (skin, fat pads, muscles, and bones), as a whole, for the treatment of folds and shadows is vital for a better and more natural final aesthetic outcome.

Análise anatômica da abdominoplastia / Anatomical analysis of abdominoplasty

A abdominoplastia está entre os procedimentos cirúrgicos mais realizados na cirurgia plástica, de forma que muitas variações técnicas têm sido criadas com o objetivo de se reduzirem as complicações e para se obter melhores resultados no contorno abdominal. Nesse contexto, a anatomia da parede abdominal ganha papel de destaque, uma vez que as justificavas em defesa de técnicas, como a abdominoplastia clássica e lipoabdominoplastia, estão atreladas a princípios anatômicos. Isso evidencia a necessidade do domínio da anatomia da região pelo cirurgião plástico, pois, além de entender os motivos de se adotar determinados procedimentos cirúrgicos, o torna mais capacitado de adaptá-los às características anatômicas de cada paciente, além de compreender as alterações morfofuncionais provocadas pela cirurgia. Diante disso, esse trabalho teve o objetivo de buscar na literatura estudos que enfocassem a descrição anatômica da abdominoplastia, tanto clássica quanto de outras variantes, como a lipoabdominoplastia, bem como as explicações anatomofisiopatológicas das principais complicações operatórias inerentes.

Abdominoplasty is a common surgical procedure in plastic surgery. Consequently, several technical variations have been created with the aim of reducing complications and obtaining better results in the abdominal contour. The anatomy of the abdominal region plays an important role in this procedure, since arguments in favor of techniques, such as classic abdominoplasty and lipoabdominoplasty are linked to anatomical principles. This highlights the plastic surgeon's need to have a good knowledge of the anatomy of this region. Not only will this knowledge enable plastic surgeons to understand the reasons for adopting certain surgical procedures, but it will also enable them adapt these procedures to the anatomical characteristics of each patient. In addition, this knowledge will help determine the morphological changes caused by surgery. Therefore, this study aimed to identify studies in the literature focusing on the anatomical description of both classical abdominoplasty and other variants, such as lipoabdominoplasty. It also aimed to discover the anatomical and physiopathological explanations for the major inherent surgical complications.

Documentação fotográfica intra-operatória / Intraoperative photographic documentation

O prontuário médico é um dever ético, sendo a documentação fotográfica uma extensão deste, e muitas vezes de grande importância, principalmente na Cirurgia Plástica. A documentação fotográfica pré-operatória e pós-operatória em Cirurgia Plástica é rotineiramente utilizada, enquanto a fotografia intra-operatória ainda não, apesar de facilitar e auxiliaras divulgações científicas e ser uma forte aliada nos registros médicos. O presente artigo apresenta uma forma simples, de baixo custo, capaz de permitir a documentação fotográfica intra-operatória com ótima qualidade, preservando-se o ângulo de visão do próprio cirurgião, com menores riscos de contaminação, demandando menor tempo de interrupção e independente de auxiliares externos. Tal ferramenta consiste na associação de uma capa à prova de água à câmera fotográfica digital.

The medical records are an ethic obligation and the photographic documentation is part of it; many times with huge importance, mainly in Plastic Surgery. The preoperative and postoperative photographic documentation are commonly used in Plastic Surgery, while the intraoperative photograph is not yet, although it helps and facilitates scientific reports and it is a strong ally in medical records. The present article shows a simple way of taking intraoperative photography documentation, with high quality, low cost, preserving the surgeons angle of vision, with low risk of contamination, demanding less time of interruption and independent of external. This tool consists simply the association of a waterproof case with the digital camera.

Reconstrução mamária nos quadrantes inferiores após quadrantectomias / Breast reconstruction of the lower quadrants after quadrantectomies

Introdução: No tratamento cirúrgico do câncer de mama, as quadrantectomias, quando reparadas por meio da simples aproximação das bordas da área cruenta resultante, podem levar a sequelas de difícil solução. Métodos: Os autores apresentam uma padronização para a reconstrução dos quadrantes inferiores da mama após quadrantectomias, sub dividindo a região em três áreas de localização do defeito gerado pela ressecção e sugerindo condutas específicas para cada uma destas, por meio da utilização de técnicas clássicas, bem comode inovações em tratamento local com retalhos. Apresentam os resultados, seguimento e limitações das técnicas empregadas, fazendo uma análise comparativa crítica com os dados encontrados na literatura disponível.

Introduction: In the surgical treatment for breast cancer, the quadrantectomies, when done by the simple approximation of the wounded borders, can result in difficult solution sequelae. Methods: The authors present a standardization reconstruction of the lower breast quadrants after quadrantectomies dividing the region into three areas of localization for there section wound, suggesting specific solutions for each of them, by classic techniques as well as new local flaps procedures. They present the results, the follow-up and the limitations of the utilized techniques in a critical comparative analysis with available reported data.

Retalhos do músculo oblíquo externo / External oblique muscle flaps

O uso de retalhos do músculo oblíquo externo é um importante complemento às abdominoplastiasestéticas, por proporcionar melhora no contorno corporal, com afinamento da cintura,e servindo ainda como um grande reforço nos casos de reconstruções da parede abdominalântero-lateral. Os autores apresentam um estudo de 42 casos, no qual foi realizado o retalhopara diferentes indicações, sendo 34 operações estéticas e 8 operações reparadoras. Avaliamo objetivo e o resultado obtido em cada indicação, detalham aspectos técnicos, bem comoas complicações apresentadas. O estudo visa divulgar os retalhos músculo-aponeuróticosdo oblíquo externo como sendo de fácil execução, grande avançamento e cobertura, e consequentemente,de importante valor funcional e estético.

The external oblique myofascial flaps are an important complement of the aesthetic abdominoplasty,making possible to achieve better body contouring and to thin the waist. The flapis also useful to give strength to the anterior abdominal wall in reconstructive abdominalsurgeries. The authors present a study of 42 cases where the flap was done for differentindications, 34 for aesthetic purposes and 8 for reconstructive purposes. They analyze theobjectives and results of each operation, describe technical details and the complications.The purpose of this study is to show the external oblique myofascial flaps as one of easyexecution, spread advancement, high abdominal wall protection for reconstructive surgeriesand a complement in wasting for body contour procedures.