A Practical Algorithm Integrating Skin Care With Nonenergy and Injectable Dermatologic Procedures to Improve Patient Outcomes and Satisfaction.

BACKGROUND: The most rapidly increasing medical aesthetic procedures for facial antiaging comprise nonenergy and injectable treatments. Currently, standards for skin care before, during, and after nonenergy and injectable treatments are lacking. The algorithm on supportive skin care for facial antiaging nonenergy and injectable treatments aims to stimulate healing, reduce downtime, and improve comfort and treatment outcomes.  Methods: A panel of 7 global physicians employed a modified Delphi method and reached a consensus on an algorithm for supportive skin care for nonenergy and injectable antiaging treatments based on the best available evidence and the panel members’ clinical experiences and opinions. RESULTS: The algorithm has a pretreatment (starts 2 – 4 weeks before the procedure) and treatment or ongoing (day of treatment) section, followed by care after the procedure (0 – 7 days) and follow-up care (1 – 4 weeks after the procedure). Applying a broad-spectrum sunscreen with an SPF 30 or higher, combined with protective measures, such as wearing a wide-brimmed hat and sunglasses, is recommended to protect the face from sun exposure. Dyschromia is a significant concern for those with richly pigmented skin. Clinicians may recommend skin care using a gentle cleanser and moisturizer containing vitamins C and E, retinoid, or other ingredients, such as niacinamide, kojic acid, licorice root extract, azelaic acid, and tranexamic acid, depending on the patient's facial skin condition. CONCLUSION: Nonenergy and injectable procedures combined with skin care or topical treatments may improve outcomes and patient satisfaction. Topical antioxidants and free radical quenchers can combat photodamage and may offer a safe alternative to topical hydroquinone.    J Drugs Dermatol. 2024;23(4):     doi:10.36849/JDD.7918.

Treatment of acne in the aesthetic patient: A round table update.

BACKGROUND: The popularity of social media appears to be increasing the acceptance of cosmetic treatments, prompting more consumers to seek cosmetic treatments. As the estimated prevalence of acne vulgaris among adult women may be as high as 54%, acne is commonly observed among patients presenting for cosmetic treatments. Concomitant treatment of acne in the aesthetic patient population will improve overall clinical outcomes. AIMS: The goal of this work was to deliver a high-quality ethical and evidence-based educational program to physicians and adjunctive health care providers to advance patient care. METHODS: This paper is based on a webcam presentation with roundtable discussion by several notable experts in their field. RESULTS: A range of topical medications, injectable products, chemical peels, and energy-based devices are available for treating acne vulgaris. In most instances, these are compatible with rejuvenation procedures in the aesthetic patient. CONCLUSION: The growth of social media is raising awareness of aesthetic procedures and appears to be increasing the number of patients seeking aesthetic treatment. Educating patients about the importance of treating acne vulgaris can improve overall treatment outcomes. In most instances, the presence of acne is not a barrier to aesthetic care.

Update: Cellulite Therapies and Optimizing Treatment Combinations.

Cellulite in the proximal lower extremities is a reported concern among many adult females. The unsightly appearance of cellulite leads many affected individuals to seek treatment by trained specialists. The objective of this review is to provide the reader with an update on new and innovative therapies for cellulite including various treatment combinations to maximize therapeutic outcomes, and strategies for minimizing adverse events. The availability of new technologies and the results from recent clinical trials provide additional tools and data to consider when creating treatment plans for cellulite patients. This update to previous treatment recommendations is based on the most recent developments in cellulite management including the personal experiences of the authors with an emphasis on injectable enzymes, acoustic subcision, targeted verifiable subcision, and biostimulators. Formal clinical studies are warranted to compare various treatment modalities and further investigate combination regimens.

Aesthetic considerations for treating the Asian patient: Thriving in diversity international roundtable series.

BACKGROUND: The unique anatomy of the Asian face, along with the influence of cultural forces and regional preferences, has led to the development of specialized approaches to rejuvenation and beautification that are applicable to the aesthetic practice within Asia as well as those who serve these patients internationally. AIMS: To discuss similarities and differences in anatomy and treatment preferences of Asian patients and explore how these differences may influence aesthetic practices. PATIENTS/METHODS: In support of clinicians who wish to serve a diverse patient population, a six-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021 to May 16, 2022. RESULTS: The results of the sixth and final roundtable in the series, the Asian Patient, are described here. Anatomical differences and their influence on treatment preferences are discussed, and specific procedural information provided for management of facial shape and projection, including advanced injection techniques for the eyelid-forehead complex. CONCLUSIONS: The continued exchange of ideas and treatment techniques support not only optimal aesthetic outcomes for a diverse range of patients within a given practice, but also the evolution of aesthetic medicine. The expert approaches detailed here may be used to inform treatment plans tailored to the Asian population.

Microtoxin for Improving Pore Size, Skin Laxity, Sebum Control, and Scars: A Roundtable on Integrating Intradermal Botulinum Toxin Type A Microdoses Into Clinical Practice.

BACKGROUND: In aesthetic clinical practice, botulinum toxin type A (BoNT-A) is best known for its use as a neuromodulator for the treatment of dynamic facial lines; however, when injected intradermally as microdroplets, BoNT-A can improve skin quality and overall skin appearance. OBJECTIVES: To discuss key aspects of microtoxin use in clinical practice and provide expert guidance on utilization. METHODS: As part of a continuing medical education lecture series and roundtable, the authors discussed key aspects of microtoxin patient selection, injection technique, and safety. RESULTS: The experiences of expert faculty are shared here. Clinical experience is consistent with reported data. Microtoxin can be used to reduce pore size, sebum production, rosacea, acne, and fine lines, and to improve jawline and neck definition. Intradermal injection can also be employed for the improvement of transverse neck lines as well as for the safe prevention and management of scars and keloids. CONCLUSIONS: Expanding the use of BoNT-A, a predictable, minimally invasive, and affordable treatment to address commonly encountered complaints is appealing. The authors have found that making patients aware of microtoxin as a treatment option results in an increased interest in and utilization of BoNT-A, and high satisfaction among appropriately selected patients.

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

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

Aesthetic considerations when treating the Latin American patient: Thriving in diversity international roundtable series.

BACKGROUND: The Hispanic/Latin American population is the fastest growing non-Caucasian group in the United States. Within this group, demand for aesthetic procedures is on the rise. High ethnic variability among these patients influences treatment approaches and patient priorities. Understanding these ethnic differences is central to providing optimal care. AIMS: To discuss similarities and differences in anatomy and treatment preferences of Hispanic/Latin American patients both within the United States and internationally and explore how these differences may influence or inform aesthetic practices. PATIENTS/METHODS: In support of clinicians who wish to serve a diverse patient population, a 6-part, international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021 to May 16, 2022. In this roundtable, held in Medellin, Columbia, expert clinicians from across Latin America and the United States were invited to contribute and share best practices. RESULTS: The results of the second roundtable in the series, the Latin American Patient, are described here. A special emphasis is placed on procedures that address the most commonly encountered concerns in these patients. CONCLUSIONS: Hispanic and Latino patients represent a broad demographic with unique anatomical features, aesthetic preferences, and treatment priorities. Clinicians should consider these differences when treating this patient population.

Aesthetic considerations for treating the North American multi-ethnic patient: Thriving in diversity international roundtable series.

BACKGROUND: The United States is becoming increasingly diverse, and between 2016 and 2019, an increase of 945 832 aesthetic procedures was recorded for Hispanic, African American, and Asian American patients combined. In aesthetics, where outcomes are technique dependent and tied to the clinician's ability to tailor treatment to the needs of individual patients, a knowledge of ethnic differences in anatomy and how aesthetic issues can be safely and effectively addressed in different groups is paramount. AIMS: To discuss similarities and difference in anatomy and treatment preferences of patients from a variety of ethnic and racial backgrounds and how these differences may influence the products or techniques utilized to achieve natural-looking results and minimize side effects. PATIENTS/METHODS: In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022. RESULTS: The results of the first roundtable in the series, the North American Multiethnic Patient, are described here. CONCLUSIONS: A diverse range of patients can benefit from the tailored use of fillers, fat transfer, neuromodulators, lasers, and energy-based devices, as long as differences in structural support, skin, and aging patterns, are appreciated.

High-Dose Neuromodulators: A Roundtable on Making Sense of the Data in Real-World Clinical Practice.

BACKGROUND: For aesthetic treatment with botulinum neurotoxin type A (BoNTA), interest in maximizing treatment duration and efficacy has prompted study of doses higher than those used in registration studies. As data emerge, it is important that physicians understand how to apply study findings to their own practice so that patient demand is satisfied. OBJECTIVES: To bring together leading experts in neuromodulators for a roundtable discussion on the implications of high-dose BoNTA studies for patient care. METHODS: The authors reviewed and discussed recent data from high-dose BoNTA studies for abobotulinum toxin A, incobotulinum toxin A, and Oonobotulinumtoxin A. RESULTS: Discussion focused on the challenges of data interpretation and extrapolation of study findings for real-world patient care. The authors participated in a candid discussion of whether the observed improvements in treatment duration and patient satisfaction warrant treatment with high-dose regimens delivered as high-concentration injections. Safety was also discussed, as well as economic considerations for both practices and patients. Of note, for BoNTA products, the registration dose, when administered in a smaller total volume, appears to give rise to more durable results than those observed in pivotal trials, implicating product concentration as an important consideration. Importantly, at higher doses, extended duration of effect does not appear to be at the expense of natural-looking results. CONCLUSIONS: While the authors provide considerations for the development of individual clinical practice, there is no one-size-fits-all recommendation. It may be that "high-dose" BoNTA is in reality the optimal dose; however, important economic considerations may prevent rapid uptake for all patients.

Consensus on the Use of Hyaluronic Acid Fillers from the Cohesive Polydensified Matrix Range: Best Practice in Specific Facial Indications.

BACKGROUND: As the treatment indications for the Cohesive Polydensified Matrix® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio. METHODS: An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers. RESULTS: Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization. CONCLUSION: The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.

Aesthetic Delusions: An Investigation into the Role of Rapid Visual Adaptation in Aesthetic Practice.

BACKGROUND: To date, the process of adaptation in the setting of aesthetic medicine has not been investigated. The combination of complex advanced feedback in the current intense social media milieu, in conjunction with easily accessible and effective aesthetic treatments, has produced pockets of overtreated patients and over-zealous practitioners. We examine whether aesthetic assessments of attractiveness and what appears natural can be distorted by the cognitive process of adaptation. METHODS: Forty-eight female participants were exposed to photographs of female faces in whom lip fullness had been strongly under- or over-exaggerated, while remaining within the bounds of natural appearing lips. Before and after evaluation of the exaggerated images, participants were asked to rate an alternative set of faces in terms of attractiveness (reflecting direct assessment of effective beauty impression) and naturalness (reflecting indirect assessment of beauty norms). The evaluation set consisted of six base faces that had been digitally altered to create a systematically varying 11 step set of lip sizes from extremely thin, to the original version, to very full. RESULTS: Second-order polynomial fits indicated clear shifts of the subjects' facial aesthetic assessments towards the specific lip fullness of the adaptors. In contrast, such adaptions were not found for ratings of face naturalness. In contrast to research demonstrating mathematical foundations and unchanging rules governing perceptions of beauty, we show that simple viewing of exaggerated feature morphologies can rapidly result in recalibration of a person's assessment of attractiveness. CONCLUSION: This paper provides evidence that facial attractiveness is fluid, and that there are psychological mechanisms that cause an aesthetic bias. Over-exposure to exaggerated features can lead to significant changes to a person's ideas of attractiveness.

Skin Quality - A Holistic 360° View: Consensus Results.

INTRODUCTION: Skin quality is an important component of human attractiveness. To date, there are no standardized criteria for good skin quality. To establish a consensus for good skin quality parameters and measurement and treatment options, a virtual skin quality advisory board consisting of a global panel of highly experienced aesthetic dermatologists/aesthetic physicians was convened. METHODS: A total of 10 dermatologists/aesthetic physicians served on the advisory board. A modified version of the Delphi method was used to arrive at consensus. Members accessed an online platform to review statements on skin quality criteria from their peers, including treatment and measurement options, and voted to indicate whether they agreed or disagreed. Statements that did not have agreement were modified and the members voted again. Consensus was defined as: strong consensus = greater than 95% agreement; consensus = 75% to 95% agreement; majority consent = 50% to 75% agreement; no consensus = less than 50% agreement. RESULTS: There was strong consensus that good skin quality is defined as healthy, youthful in appearance (appearing younger than a person's chronological age), undamaged skin and that skin quality can be described across all ethnicities by four emergent perceptual categories (EPCs): skin tone evenness, skin surface evenness, skin firmness, and skin glow. The EPCs can be affected by multiple tissue layers (ie, skin surface quality can stem from and be impacted by deep structures or tissues). This means that topical approaches may not be sufficient. Instead, improving skin quality EPCs can require a multilayer treatment strategy. CONCLUSION: This global advisory board established strong consensus that skin quality can be described by four EPCs, which can help clinicians determine the appropriate treatment option(s) and the tissue or skin layer(s) to address. Skin quality is important to human health and wellbeing and patients' perception for the need for aesthetic treatment.

Efficacy and safety of ATX-101 as a treatment for submental fullness: A retrospective analysis of two aesthetic practices.

BACKGROUND: Submental fullness (SMF) is a common cosmetic concern that can have negative impact on one's self-esteem. ATX-101 has shown promise as a minimally invasive treatment for SMF correction in clinical trials. AIMS: To assess the safety and efficacy of ATX-101 for SMF correction. PATIENTS/METHODS: This was a retrospective review of 90 patients from two aesthetic practices who received ATX-101 injections for SMF (January 2016-August 2017). There were no exclusion criteria. Initial SMF severity was assigned using standardized photographs and a validated 5-point scale. Eighty one patients subsequently answered questionnaires regarding improvement, satisfaction, and adverse effects. Degree of SMF correction was also evaluated by the investigator and a blinded reviewer. RESULTS: Eighty one patients (mean initial submental fullness severity 1.6) received a mean of 1.84 ATX-101 treatment sessions using a median of 2.0 vials per treatment (mean 3.02, range 1-9). Mean Physician Global Aesthetic Improvement Scale scores were 2.73 and 2.25, after the first and second treatments, respectively (P = .04). Mean Subject Goal Aesthetic Improvement Scale scores were 2.7 and 2.25 after the first and second treatments, respectively (P = .01). Sixty-seven percentage of patients were "somewhat" or "very" satisfied. Adverse events were transient and limited to the treatment area. CONCLUSION: Patients achieved progressive improvement in SMF after the 1st and 2nd treatments, as judged by patients themselves, investigators, and blinded evaluators. These results of SMF correction suggest that significant benefit can be obtained with proper dosing at the initial visit. These data support the efficacy and safety profile of ATX-101 use for SMF correction.

Youth versus femininity: What are we truly trying to achieve?

The desire for a more youthful appearance is that for which men and women often present for consideration of aesthetic interventions. For the female patient who is contemplating facial cosmetic enhancement, a true myriad of possible treatments exist. These options include neuromodulators, light-based therapies, and soft tissue fillers, and are often touted as restoring a more "youthful" appearance to an otherwise aged-appearing face. Perhaps it is not only youth that is being restored, but femininity, which in turn is appraised as being more beautiful.

Validated Assessment Scales for Cellulite Dimples on the Buttocks and Thighs in Female Patients.

BACKGROUND: New treatment methods for cellulite require globally accepted scales for aesthetic research and patient evaluation. OBJECTIVE: To develop a set of grading scales for objective assessment of cellulite dimples on female buttocks and thighs and assess their reliability and validity. MATERIALS AND METHODS: Two photonumeric grading scales were created and validated for dimples in the buttocks in female patients: Cellulite Dimples-At Rest, and Cellulite Dimples-Dynamic. Sixteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. RESULTS: Overall inter-rater reliability and intra-rater reliability were both "almost perfect" (≥0.81, intraclass correlation efficient and weighted kappa) for the At Rest scale. For the Dynamic scale, inter-rater reliability and intra-rater reliability were "substantial" (0.61-0.80). There was a high correlation between the cellulite scales and body mass index, age, weight, and skin laxity assessments. CONCLUSION: Consistent outcomes between raters and by individual raters at 2 time points confirm the reliability of the cellulite dimple grading scales for buttocks and thighs in female patients and suggest they will be a valuable tool for use in research and clinical practice.

Validated Assessment Scales for Skin Laxity on the Posterior Thighs, Buttocks, Anterior Thighs, and Knees in Female Patients.

BACKGROUND: The demand for noninvasive skin-tightening body procedures is increasing. OBJECTIVE: To develop a set of grading scales for the objective assessment of skin laxity and assess their reliability and validity. MATERIALS AND METHODS: Two photonumeric grading scales were created and validated for skin laxity in female patients: Skin Laxity-Posterior Thighs/Buttocks, and Anterior Thighs/Knees. Fifteen aesthetic experts rated photographs of 50 women in 2 validation sessions. Responses were analyzed to assess inter-rater and intra-rater reliability. RESULTS: Overall inter-rater reliability according to intraclass correlation efficient (ICC) 2.1 and weighted kappa was at least "substantial" for both scales in both sessions, and "almost perfect" (≥0.81) for the Anterior Thighs and Knees scale in session 2. Intra-rater reliability was "almost perfect" for both scales (ICC 2.1) and "substantial" to "almost perfect" by weighted kappa. A correlation between the skin laxity scales and body mass index, age, weight, sun exposure, and cellulite severity was observed. CONCLUSION: The skin laxity photonumeric grading scales are valid and reliable instruments for assessing laxity on the posterior thighs and buttocks, and anterior thighs and knees. The scales will be of value for standardizing clinical evaluations and quantifying outcome measurements in research and clinical practice.

Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead.

BACKGROUND: As the number of aesthetic treatments has grown, so have the number of photonumeric assessment scales used to compare the effectiveness of these aesthetic treatments in specific anatomical areas; however, these are primarily based on Caucasian features. OBJECTIVE: To assess the validity of the first aesthetic scale for assessing the slope of the Asian forehead. A secondary objective was to correlate this scale with subject demographics and baseline characteristics. METHODS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial images of female (n = 28; 56.0%) and male (n = 22; 44%) subjects. For each subject, the severity of forehead sloping was graded from 0 (convex forehead, optimal forehead volume) to 4 (concave forehead, very severe sloping). Raters also assessed the age of each subject and the estimated aesthetic treatment effort required to treat each subject. RESULTS: Inter-rater reliability was "substantial" with scores of 0.67 and 0.68 for the first and second validation sessions, indicating high reliability. BMI showed the highest correlation with the scale and was a significant predictor in the final regression model. CONCLUSION: This photonumeric assessment scale will be useful for assessing the slope of the Asian forehead in both clinical and research settings.