Treating the double chin with hyaluronic acid injection.

INTRODUCTION: Submental fullness (SMF), or the double chin, is a condition regarded as undesirable. Many treatment modalities are available for SMF reduction, such as energy-based devices, injection lipolysis, or surgery. However, of minimal invasive modalities, hyaluronic acid (HA) injection has not been explored for possible SMF treatment. CASE REPORT: A 52-year-old East Asian female patient with prominent SMF underwent HA filler injection. Aside from marked reduction of SMF prominence, an improvement of sagging over her cheeks and jawline, and a general improvement to facial aging signs was noted. CONCLUSION: HA filler injections for SMF offer an instant, zero downtime, and safe alternative, and can be considered in patients who wish to simultaneously achieve improvement in other facial areas.

Cheek wrinkles revisited: Etiological classifications and nonsurgical treatment options.

BACKGROUND: Wrinkles are one of the key signs of an aging face. Cheek wrinkles have a prominent negative impact on facial aesthetic. Recognizing the pathology and types of different cheek wrinkles, and the possible minimal invasive interventions to treat them, are crucial for optimal aesthetic outcome. OBJECTIVE: The classification of cheek wrinkles based on etiology, past literature, and wrinkle pattern, and the outlining of possible treatment options. RESULT: Five different types of cheek wrinkles are described: Type 1-Atrophic cheek wrinkles, Type 2-dynamic expressional cheek wrinkles, Type 3-static expressional cheek wrinkles, Type 4-laxity cheek wrinkles, and Type 5-sleep cheek wrinkles. Treatment options and techniques for different types of cheek wrinkles are recommended accordingly.

Classifications and injection strategy for lip reshaping in Asians.

Filler injections have become very popular in recent decades. Of the various injection procedures, lip injection is an important aspect of filler injection, especially for Caucasian patients. Asians tend to have fuller lips than Caucasians, necessitating a different approach to lip injection. Classification systems for the lip for aesthetic treatment purposes can help a physician assess a patient accordingly, and a simple classification of Asian lips into four types for injection approaches is proposed in this paper. Each patient type is discussed in terms of trait and categorization, injection area, injection techniques, injection goals, and sample patients with treatment results.

Treating the tear trough-eye bag complex: Treatment targets, treatment selection, and injection algorithms with case studies.

BACKGROUND: The tear trough is a commonly requested area for aesthetic correction, but is difficult to treat well, especially when concurrent with other deformities such as eye bags. There are multiple possible treatment methods for the tear trough and eye bag, such as surgery and hyaluronic acid (HA) filler injection, with the latter gaining popularity in recent years. AIMS: To explore tear trough and eye bags etiology, describe the process for treatment selection, outline possible contraindications for filler injection, and expand upon the previously published atrophy-bulging-laxity (ABL) system of tear trough classification and treatment algorithm, with special focus on tear troughs complicated with eye bags. METHODS: Six major etiologies of the eye bag were described, and three main contraindications for HA injection were outlined. Three useful tests (snap test, push test, lift test) to aid in treatment selection were described. A comprehensive treatment algorithm was developed to counteract each etiology: "Lifting" injections at the zygoma and anteromedial cheek help counteract senescent or congenital bone deficiency; "Supporting" injections into the anteromedial cheek fat pads help counteract fat atrophy or prolapse; and "Volumization" injections directly at the deformity help smooth out structural grooves or troughs. RESULTS: Patients with pronounced eye bags and tear troughs were treated according to this algorithm and obtained good, long-lasting outcomes. CONCLUSIONS: Tear troughs complicated with eye bags can be successfully classified and treated with the ABL system and the additional procedures described by this report.

755 nm picosecond laser for facial atrophic scar-Case reports of long-term clinical efficacy following up.

INTRODUCTION: Acne vulgaris is one of the most common dermatological problems in Asia. While the disease itself is self-limited and temporary, the dystrophic texture changes after the inflammatory process are often a serious aesthetic concern. Many energy-based devices have seen good results in treating atrophic acne scars, and the picosecond laser with specific lens is one of the newer options, and lack reports on its long-term efficacy. MATERIALS AND METHODS: We report three Taiwanese cases who, to our knowledge, consist of the longest clinical follow-up times for atrophic scar treatment with the 755 nm diffractive lens picosecond laser. Photographs were compared on a by-session basis by two blinded dermatologists independent of the primary treating physician and given an improvement range of <25%, 25%-50%, 50%-75%, and >75%. RESULTS: While there are minor (<25%) improvements in all cases after the first four treatment sessions, all three cases saw the greatest improvement in skin texture (>75% in two cases, 50%-75% in one) when they were followed up 6, 13.5, and 28 months post-last treatment. CONCLUSION: Our results demonstrate excellent, long-onset, and long-term efficacy of the picosecond laser with diffractive lens in the treatment of acne atrophic scars. It also demonstrates the safe use of the device on Asian skins without symptoms of postinflammatory hyperpigmentation.

Literature review of the adverse events associated with botulinum toxin injection for the masseter muscle hypertrophy.

BACKGROUND: Masseteric hypertrophy is a benign condition characterized by the enlargement of the masseter muscles. A square-shaped jawline due to masseter muscle prominence or hypertrophy is one of the general characteristics of the Asian face, making it a frequent target for esthetic treatment requests. While the application of botulinum toxin on the masseter muscle is an off-label use, it is very popular in Asian countries. However, comprehensive reviews of the complications associated with this procedure remain limited in scope. OBJECTIVES: The goal of this study is to help physicians achieve a comprehensive understanding of the complications associated with neuromodulator injection over the masseter muscle via a thorough literature review. METHODS: A literature search was performed on the PubMed/MEDLINE, Google Scholar, and Science Direct databases using the search terms botulinum toxin, masseter hypertrophy, masseteric hypertrophy, and/or masseter hyperplasia. Literature from January 1994 to February 2018 was deemed to be allegeable for inclusion and analysis. All available prospective and retrospective studies, case series, case reports, and expert reviews were included, with an emphasis on types of complications, incidence rate, onset time, recovery time, and product used. Articles that do not mention side effects, complications, or adverse events were excluded. RESULTS: Thirty-six articles were found, covering type, incidence rate, and clinical course of the complications. These studies were summarized into tabular form for easy reference and comparison. CONCLUSION: Botulinum toxin masseter injections are commonly performed procedures with good results and safety profiles. The majority of complications appeared within 2-4 weeks of injection and disappeared within 12 weeks. Despite the temporary nature of these complications, they often decrease patient satisfaction and confidence, so physicians should familiarize themselves with the regional anatomy and injection safety zones.

Complications of botulinum toxin injection for masseter hypertrophy: Incidence rate from 2036 treatments and summary of causes and preventions.

BACKGROUND: Masseter hypertrophy is a common, prominent feature in many Asian patients, and correction procedures are often requested for esthetic reasons. Toxin masseter injections have a high efficacy and safety profile, but the risks of a variety of side effects or complications remain. OBJECTIVES: The categorization of various complications was based on etiology, with a presentation of the author's own incidence rates for consideration and comparison. METHODS: Six hundred and eighty patients received a total of 2036 sessions of toxin injection for masseter hypertrophy from 2011 to 2016, and complications or complaints were recorded through follow-up on a by-treatment basis. Complications were grouped together based on etiology and discussed. RESULTS: Of 2036 sessions, temporary mastication force decrease was reported after 611 (30%), bruising after 51 (2.5%), headaches after 12 (0.58%), smile limitation after 3 (0.15%), paradoxical bulging after 10 (0.49%), sunken cheeks (subzygomatic volume loss) after 9 (0.44%), and sagging after 4 (0.20%). CONCLUSIONS: Masseter injections remain very safe. To further decrease the incidence rate, injections should only be inside the recommended safety zone, a quadrilateral within the muscle that avoids most important local structures. Keeping injections inside the safe zone, and ideally in 3-4 different locations at least 1 cm from any border, is crucial for the prevention of complications.

Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers.

BACKGROUND: Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications. METHODS: Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers. RESULTS: The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply. CONCLUSION: The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations. CLINCIAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.