Biostimulating fillers and induction of inflammatory pathways: A preclinical investigation of macrophage response to calcium hydroxylapatite and poly-L lactic acid.

INTRODUCTION: Initial macrophage response to biostimulatory substances is key in determining the subsequent behavior of fibroblasts and the organization of newly synthesized collagen. Though histological studies suggest that calcium hydroxylapatite (CaHA) filler initiates a regenerative healing response with collagen and elastin deposition similar to natural, healthy tissue rather than an inflammatory response with fibrosis, the relative activity of macrophages stimulated by CaHA, as well as how this activity compares to that induced by other biostimulatory fillers, has not been explored. The aim of the study is to characterize the in vitro macrophage response to two biostimulory fillers, CaHA and PLLA (poly-L lactic acid), and to evaluate their inflammatory potential. METHODS: Primary human macrophages were incubated with two dilutions (1:50 and 1:100) of commercially available CaHA or PLLA. After 24 h incubation, an inflammation array was used to screen for the expression of 40 cytokines, released by macrophages. ELISA was used to confirm array results. RESULTS: Four cytokines were significantly upregulated in M1 macrophages incubated with PLLA compared to both unstimulated controls and CaHA: CCL1 (p < 0.001), TNFRII (p < 0.01), MIP-1α (p < 0.05), and IL-8 (p < 0.001). In M2 macrophages, MIP-1α (p < 0.01) and MIP-1ß (p < 0.01) were significantly upregulated by PLLA compared to CaHA and unstimulated controls. CONCLUSION: Together, these findings indicate that the CaHA mode of action is a non-inflammatory response while PLLA initiates expression of several cytokines known to play a role in inflammation. Our study supports the concept that these two "biostimulatory" fillers follow distinct pathways and should be considered individually with regard to mechanism of action.

Surgical or Nonsurgical Facial Rejuvenation: The Patients' Choice.

Background: Patients seeking a pan-facial rejuvenation may not receive appropriate medical advice on surgical versus nonsurgical treatments, resulting in those who are best-suited for surgery receiving nonsurgical options, and vice versa. Patients who requested total-face, nonsurgical revitalization were surveyed to understand the factors influencing this decision-making. Methods: Patients consulting for total facial rejuvenation were surveyed on their reasons for seeking nonsurgical versus surgical interventions by an investigator with 30 years of plastic surgery experience, practicing in a nonsurgical clinic alongside a dermatologist and aesthetic physician. Results: Of the 92 patients surveyed, 78% completed the survey, 47% of whom had considered facelift surgery, and 14% of whom proceeded to inquiries or consultations with a plastic surgeon about facelift surgery. All respondents were women, and age was not an exclusion factor. Forty-four percent would still consider facelifts in later life. Among the most common reasons for choosing nonsurgical approaches were a desire for natural and subtle results, cost, having flexibility in treatment choice, concerns about surgical and anesthesia risks, downtime, the ability to distribute treatments over time, and scarring. Conclusions: Many patients book nonsurgical treatments without prior professional advice, and consider these as a temporary solution, but may desire surgery later in life. Before conducting nonsurgical treatments, doctors should identify this group and avoid interventions that may interfere with optimal surgical outcomes later. Also, some patients desire surgical outcomes when surgery is not a feasible option, and thus seek nonsurgical alternatives. For this group, realistic goals must be set before treatment to avoid disappointment.

Hi5 Protocol for the Use of Microfocused Ultrasound with Visualization.

Background: Microfocused ultrasound with visualization (MFU-V) is used for lifting and tightening of facial tissues. Standard protocols are completed in a single session. Despite excellent outcomes, we identified several barriers of entry for a significant number of patients. Therefore, we devised an individualized pan-facial protocol that is delivered as a series of short, intense treatments to address these issues. Methods: We enrolled 12 participants with mild-to-moderate skin and fibromuscular laxity to receive one superficial and one deep pass per visit (average 280 lines). Qualitative improvements were rated by both patients and physicians at 6 or 10 months due to COVID-19 delays. Changes in the submentum and eyebrow heights were quantified. Results: Ten patients (age range: 31-61 years) underwent an average of four MFU-V treatments. Two patients were excluded after massive weight gain. Skin and fibromuscular ptosis and overall soft tissue laxity improved in all patients. Mean brow height increased by 1.7 mm, whereas the mean submental lift was 78.7 mm2. All patients and treating physicians rated an improvement in appearance, whereas independent physicians rated improvements in 87% of cases. Four patients self-rated as "markedly improved." Pain was rated at up to 6.2 (out of 10). Although mask-wearing was mandatory, loss of elasticity, wrinkles, and skin roughness all improved. Superficial welts (n = 5), erythema (n = 3), tenderness (n = 3), and mild bruising (n = 2) occurred, but all resolved within a few days and no severe or permanent adverse events occurred. Conclusion: The Hi5 protocol was noninferior to standard single-session protocols and improved brow heights and submental lifting.

Addressing the Real-World Challenges of Immunoresistance to Botulinum Neurotoxin A in Aesthetic Practice: Insights and Recommendations from a Panel Discussion in Hong Kong.

With increasing off-label aesthetic indications using higher botulinum neurotoxin A (BoNT-A) doses and individuals starting treatment at a younger age, particularly in Asia, there is a greater risk of developing immunoresistance to BoNT-A. This warrants more in-depth discussions by aesthetic practitioners to inform patients and guide shared decision-making. A panel comprising international experts and experienced aesthetic practitioners in Hong Kong discussed the implications and impact of immunoresistance to BoNT-A in contemporary aesthetic practice, along with practical strategies for risk management. Following discussions on a clinical case example and the results of an Asia-Pacific consumer study, the panel concurred that it is a priority to raise awareness of the possibility and long-term implications of secondary non-response due to immunoresistance to BoNT-A. Where efficacy and safety are comparable, a formulation with the lowest immunogenicity is preferred. The panel also strongly favored a thorough initial consultation to establish the patient's treatment history, explain treatment side effects, including the causes and consequences of immunoresistance, and discuss treatment goals. Patients look to aesthetic practitioners for guidance, placing an important responsibility on practitioners to adopt risk-mitigating strategies and adequately communicate important risks to patients to support informed and prudent BoNT-A treatment decisions.

Introducing aesthetic regenerative scaffolds: An immunological perspective.

BACKGROUND: Skin aging arises from immunological responses to tissue deterioration and damage. Tissue repair processes encompass the regeneration of original tissue and 'scarless' wound healing seen in foetuses, and the extreme fibrotic responses and scarring seen in adults. Anti-aging aesthetic medicine uses interventions like biomaterial-based fillers to influence these immunological responses and renew aged tissue structure and function. At filler injection sites, an inflammatory response occurs that causes a spectrum of outcomes, ranging from tissue regeneration to fibrosis and filler encapsulation. Importantly, the resulting inflammatory pathway can be predetermined by the biomaterial injected. AIMS: By understanding this immunological process, we can develop Aesthetic Regenerative Scaffolds (ARS) - aesthetic injectable biomaterials - to direct inflammatory wound healing away from chronic, fibrotic responses, and towards physiological tissue regeneration. MATERIALS AND METHODS: We identified and reviewed literature on the immunological and cellular responses to injected dermal fillers, whereby the wound healing response to the injection was moderated under the influence of an injected biomaterial. RESULTS: We described the mechanisms of dermal wound healing and the use of ARS to direct healing towards tissue regeneration instead of scarring. We also summarised studies on extracellular matrix remodeling by calcium hydroxylapatite. We found that Calcium hydroxylapatite fillers produce collagen as they gradually degrade and their spherical structures serve as a scaffold for tissue regeneration. Furthermore, CaHA improved fibroblast contractility, collagen type III and elastin production, proliferation and angiogenesis with less inflammation than hyaluronic acid fillers. DISCUSSION: Regneration pathways can be influenced at specific points between a facial filler biomaterial and the wound healingmechanisms at its site of implantaion. CONCLUSION: Physicians can select scaffolds that direct the immune response away from a fibrotic chronic inflammatory pathway and towards regeneration to enable true repair of the aging skin.

Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections.

BACKGROUND: The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain. OBJECTIVES: To formulate a rational theory for DTN development and their avoidance and treatment. METHODS: A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought. Consensus was set at 75% agreement. RESULTS: Consensus was reached in 16 of 20 questions regarding the pathogenesis of DTNs, forming the basis for a classification and treatment guide. CONCLUSIONS: The group believes that filler, pathogens, and inflammation are all involved in DTNs and that DTNs most likely are infection initiated with a variable immune response. Injected filler may incorporate surface bacteria, either a commensal or a true pathogen, if the skin barrier is altered. The initially high molecular weight HA filler is degraded to low molecular weight HA (LMWHA) at the edge of the filler. Commensals positioned within the filler bolus may be well tolerated until the filler is degraded and the commensal becomes visible to the immune system. LMWHA is particularly inflammatory in the presence of any local bacteria. Commensals may still be tolerated unless the immune system is generally heightened by viremia or vaccination. Systemic pathogenic bacteremia may also interact with the filler peripheral LMWHA, activating Toll-like receptors that induce DTN formation. Given this scenario, attention to practitioner and patient hygiene and early systemic infection treatment deserve attention. Classification and treatment systems were devised by considering each of the 3 factors-filler, inflammation, and infection-separately.

Sensory Symptoms Associated with Aesthetic Botulinum Toxin A Treatments.

A retrospective review of patients who switched from onabotulinumtoxinA (onaA) and/or abobotulinumtoxinA (aboA) to incobotulinumtoxinA (incoA) found anecdotal reports of differences in "feel," including a "lighter" feel or treatment-associated tightness. We surveyed the frequency of these sensations as an initial proof of concept of toxin proprioception among our patients who switched toxins. Methods: Seventy-nine patients who had past facial aesthetic treatments with more than one botulinum toxin A (BoNT/A) formulation completed a questionnaire on their experience of treatment-associated sensations, including stiffness or a frozen feeling. Results: Treatment-associated sensations of tightness (47.3%), headache (41.8%), heaviness (38.2%), feeling frozen (29.1%), stiffness (20.0%), and weakness (20.0%) were reported by 55 of 79 patients. Furthermore, 78.2% of 55 patients noted an interformulation sensory difference. Of 79 patients surveyed, 68.4% of onaA-treated patients associated sensations with onaA, 39.1% of aboA-treated patients associated sensations with aboA, and 12.2% of incoA-treated patients associated sensations with incoA. Conclusions: Some patients reported a different feel between toxins, and the difference in frequency of treatment-associated sensation varies between the different formulations used. Given the fine coordination of facial expressive muscles, we suspect that associated proprioceptive afferents are involved. Our findings confirm that post-toxin treatment-associated sensations can be detected by some patients, and this is likely due to the variations between the formulations. Failing to advise patients of this before switching formulations may cause a misperception that the treatment is not working well or that its effect has worn off prematurely, and some patients may consider switching formulations to reduce these conscious proprioceptive sensations.

Creating Lift in the Lower Face With Botulinum Toxin A Treatment: An Anatomical Overview With Videos and Case Studies Illustrating Patient Evaluation and Treatment.

Background: Relaxation of depressor muscles in the lower face with botulinum toxin A (BoNT-A) can create a lifting effect and dramatically improve jawline contour and resting facial expression. Even with the recent increase in interest in lower face rejuvenation, BoNT-A is a relatively under-recognized tool for treatment of this area. When treating the lower face, an understanding of anatomy and the relationship between the facial muscles is especially important, as injection patterns must be customized for consistently positive outcomes. Objectives: This study was aimed to provide basic knowledge of the activities of the muscles in the lower face and neck and to describe the basis for injecting BoNT-A to create lift in this area. Expert guidance for injection is also provided. Methods: As part of a continuing medical education course on differentiating botulinum toxin products, a panel of 4 expert physician injectors participated in a live webinar to discuss the implications of increasing toxin use. Results: The practical guidance in this manuscript is based on the most frequently requested information by audience members and the information considered critical for success by the authors. The authors outline the functional anatomy of the lower face most relevant for BoNT-A treatment and case studies as well as methods for patient evaluation and injection technique are also provided. Videos showing treatment planning and injection technique for the lower face and neck are included. Conclusions: BoNT-A is an important nonsurgical tool for creating lift in the lower face.

Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results.

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

Emerging Trends in Botulinum Neurotoxin A Resistance: An International Multidisciplinary Review and Consensus.

Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand. Methods: An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations. Consensus statements relating to awareness, assessment, and management of the risk of NAb-related secondary nonresponse in aesthetic practice were developed. Results: There was a consensus that, as doses used in aesthetic practice become like those in therapeutics, rates of NAb formation may be expected to increase. However, the true extent of NAb formation in aesthetics is likely underestimated due to limitations of published evidence and variability in treatment patterns of aesthetic patients. Since BoNT-A therapy is often lifelong, practitioners need to recognize immunogenicity as a potential complication that might affect future therapeutic use and strive to minimize modifiable risk factors. The selection and use of a BoNT-A product with the least immunogenic potential from the beginning may thus be advantageous, especially when treatment with high doses is planned. Conclusions: In view of current trends in BoNT-A aesthetic use, it is essential for practitioners to conduct thorough clinical assessments, inform patients of treatment risks, and develop BoNT-A treatment plans to minimize immunogenicity. This can help preserve the option of continued or future BoNT-A treatment with satisfactory outcomes.

Immunogenicity Associated with Aesthetic Botulinumtoxin A: A Survey of Asia-Pacific Physicians' Experiences and Recommendations.

Background: Most botulinum toxin A (BoNT/A) products contain unnecessary bacterial components that increase the risk of developing neutralizing antibodies (nAbs). Reports of secondary nonresponse and treatment failures (STF) due to nAbs have accompanied a surge in new BoNT/A products. Methods: To formulate recommendations on managing toxin resistance, we reviewed the evidence on BoNT/A-associated immunogenicity and evaluated Asian physicians' current BoNT/A practices, knowledge, and real-world experiences, as provided by survey outcomes conducted with 128 Asian experts (regular botulinum toxin injectors). Results: Most doctors believe STF occurs, some patients exhibit partial symptoms, and impurities (eg, complexing proteins) in BoNT/A preparations risk STF. Bioassays that distinguish non-nAbs from nAbs that hinder toxin function remain unavailable to most doctors, though most would perform testing if given the option. Doctors in the Asia-Pacific region have differing strategies for managing STF, depending on the availability of alternatives or tests. They recommended switching to a highly-purified formulation free of complexing proteins and other impurities to lower the risk of immunogenicity, or offering treatment holidays of 2 -2.5 years. They suggested restarting treatment with the same highly purified formulation, especially for repeated treatments, large-dose injections, and younger patients who will accumulate higher lifetime doses, so as to minimize immunogenic risks and preserve long-term treatment outcomes. Importantly, doctors should always initiate patients on pure formulations rather than switching to these only after resistance develops. Conclusion: Choosing highly purified BoNT/A products at treatment initiation enhances long-term efficacy and patient satisfaction while minimizing the risk of immune activation and nAb formation.

Movement of the Syringe During Filler Aspiration: An Ultrasound Study.

BACKGROUND: Aspiration prior to hyaluronic acid filler injection is often taught as a safety maneuver to minimize the risk of intravascular injection; however, the validity of this technique in aesthetic practice is being increasingly challenged. One key assumption underpinning the validity of the aspiration test is that the needle tip does not move during the aspiration and subsequent injection of filler. OBJECTIVES: The aim of this study was to visualize and measure needle tip movement in real time during aspiration and injection of filler. Secondary objectives were to assess the impact of injector experience and double-handed versus single-handed aspiration technique in maintaining stability of the syringe. METHODS: Under real-time ultrasound visualization, 3 injectors with different levels of experience injected hyaluronic acid filler into pork belly tissue utilizing both double-handed and single-handed aspiration techniques. Needle tip movements were recorded and measured by means of ultrasound and video. RESULTS: The aspiration maneuver is in all cases associated with retrograde movement of the needle tip, ranging from 1.1 to 5.3 mm (mean, 2.9 mm), whereas injection leads to anterograde movement ranging from 0.6 to 4.1 mm (mean, 1.9 mm). Double-handed aspiration is associated with less needle tip movement than single-handed aspiration (P = 0.037). Greater experience is also associated less movement of the needle tip (P < 0.0001). CONCLUSIONS: In all cases, the aspiration and injecting maneuver is associated with micromovements of the needle tip, of a magnitude consistently significant relative to the typical size of facial vessels. Although needle tip movement is only a single factor limiting the usefulness of the aspiration test, the results of this study suggest that it is not advisable to rely only on aspiration as a method to prevent intravascular injection.

Microfocused ultrasound with visualization: Consensus on safety and review of energy-based devices.

BACKGROUND: Microfocused ultrasound with visualization (MFU-V; Ultherapy® , Merz North America) is US Food and Drug Administration-cleared as a non-invasive procedure that lifts the soft tissue of the neck, submentum and brow, and improves lines and wrinkles on the upper chest. Several other energy-based devices are in use in countries outside the USA where they are marketed for indications similar to those of MFU-V, although published studies supporting these indications are limited and none of the other devices provides visualization or verification they reach the superficial musculoaponeurotic system. METHODS: Due to the evolving landscape of ultrasound technology as more devices enter the market, seven global thought leaders who are qualified experts on the use of various high-intensity focused ultrasound (HIFU)/MFU-V technologies convened to review data from an independent evaluation of the software, thermal characteristics, transducer acoustics and ultrasound therapy of MFU-V and three other ultrasound-based devices. RESULTS: The independent testing demonstrated the devices have key differences in several parameters that play a role in safety and effectiveness. Specifically, MFU-V has visualization capability but the other devices lack that feature. Other differences include the retention of patient history, consistent size and uniformity of thermal coagulation points (TCPs), precise localization of energy concentration at the focal point, and reliable thermal regulation during use. The expert panel established a consensus on the types of preventable complications associated with ultrasound-based energy devices and techniques for preventing and treating complications. CONCLUSIONS: The independent test results of MFU-V/HIFU devices and the consensus panel conclusions provide strong support that real-time visualization and the capability to detect coupling, features found only in MFU-V, help prevent complications and enhance the safety and effectiveness of energy-based devices. The independent evaluation also revealed that MFU-V has several additional features that play key roles in safety and clinical effectiveness, including uniformity of TCPs, tight thermal regulation, large focal gain, and short beam length, that were not found collectively in any of the HIFU devices.

Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice.

BACKGROUND: Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration. OBJECTIVES: The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient. METHODS: Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined. RESULTS: The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection. CONCLUSIONS: To prevent intravascular injection, understanding "injection anatomy" and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on.

Evaluating the Effect of Incobotulinumtoxin A for Glabellar, Forehead, and Crow's Feet Lines Using A High Dilution.

BACKGROUND: As aesthetic preferences have evolved and patients wish their muscles to be relaxed, but not frozen, a higher dilution of incobotulinumtoxinA (INCO) has allowed for increased spread using fewer units, yet no studies to date have investigated the efficacy, longevity, and safety of hyperdiluted INCO. OBJECTIVE: We evaluated the effect of incobotulinumtoxinA (INCO) in glabellar, forehead, and lateral periorbital lines using a high dilution. METHODS: Subjects with moderate-to-severe upper facial lines at rest according to the Merz Aesthetics Scales™ (Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany) received 15U of INCO to the glabellar (n=4 injection sites), 10U to the rest of the forehead (n=10 injection sites), and 5U to the lateral periorbital lines (n=3 injection sites/eye). Primary outcomes were physician- and subject-rated improvement at one month using the Global Aesthetic Improvement Scale (GAIS) and changes in line severity using the Merz Aesthetics Scales™. RESULTS: The study included 15 women aged 35 to 65 years. At one month, physician GAIS scores indicated 91.2% of subjects were very much improved and 8.8% were much improved; 91.5%, 78.0%, and 57.6% of participants remained at least improved at four, five, and six months, respectively. Subject GAIS scores at one month were in agreement with physician scores. At one month, an improvement of at least one point in Merz Aesthetics Scales™ scores in glabellar, forehead, and lateral periorbital lines was reported in 88.9%, 98.3%, and 94.8% of participants, respectively. Subject satisfaction was high throughout the study. No treatment-related adverse events were observed. CONCLUSION: Hyperdilute INCO was effective at improving overall appearance and reducing line severity in individuals with moderate-to-severe upper facial lines. Patient satisfaction was maintained up to six months and treatment was well tolerated.

Pan-Asian Consensus on Calcium Hydroxyapatite for Skin Biostimulation, Contouring, and Combination Treatments.

BACKGROUND: Several usage guidelines for calcium hydroxylapatite (CaHA), a dermal filler material, exist for non-Asian patients, making it necessary to determine whether their findings and consensuses are applicable to Asian patients who have distinct anatomies, cultural preferences, and aesthetic requests. OBJECTIVE: We sought to develop a Pan-Asian consensus on CaHA use in skin biostimulation, contouring, and combination treatments for face and body indications. METHODS: A survey on CaHA usage for contouring and biostimulation indications in Asian patients was conducted, followed by discussions to establish consensus statements and topics for examination. RESULTS: Several aspects of facial shaping and contouring or skin biostimulation with CaHA were agreed on, including that dilution is not a key consideration, that microfocused ultrasound with visualisation precedes CaHA in same day or session treatments, and that cannulas should be used. Among the many agreements on interventions in specific facial and body areas, there were also disagreements due to the diverse Asian patient presentations, requests, and access to tools or products; for example, CaHA should be placed in the interfascial layer for temple contouring, CaHA should not be injected directly into the infraorbital area for safety, and diluted CaHA should be injected subdermally for nonfacial or whole-face biostimulation and contouring. CONCLUSION: Our disagreements highlight the diversity of Asian facial morphotypes and desired aesthetic outcomes and underscore the need for customized aesthetic strategies to accommodate the heterogeneity of Asian anatomies, cultural preferences, and aesthetic ideals. Establishing consensus statements on critical aspects of Asian patient considerations, efficacy and safety, is crucial. This document provides strategic guidance on the use of classic, diluted CaHA for biostimulation or undiluted Radiesse®(+) (Merz Pharma GmbH & Co. KGaA, Frankfurt, Germany) for lifting and contouring to ensure consistent CaHA delivery for successful patient outcomes.

Neuromodulating the SMAS for Natural Dynamic Results.

Physicians using neuromodulators need to develop an in-depth and holistic understanding of the facial musculature as a single, large, functional structure that does not work in isolation. In this Special Topic, I review the anatomy of the continuous fibromuscular layer of the face, discuss how certain age-related indications develop as a consequence of imbalances to this unified structure, and propose considerations for neuromodulator-based interventions of the upper, mid, and lower face. I provide evidence-supported recommendations on the most optimal applications of neuromodulators to help rebalance the musculoaponeurotic layer for more natural outcomes. Through outcomes of my patients, I show how the facial mimetic muscles can be modulated with careful placement of botulinum toxin, without causing unnatural facial expressions, to achieve an expressive, well-balanced face that reflects health, vitality and happiness.