Embracing Spectrum: Celebrating LGBTQIA+ Journeys in Aesthetic Medicine: A Kaleidoscope of Identity.

PURPOSE: This synaptic systemised review critically examines the provision of aesthetic medical care to LGBTQIA+ (lesbian, gay, bisexual, transgender, queer or questioning, intersex, asexual, and more) individuals, assessing both the clinical practices and the educational frameworks that guide interactions with LGBTQIA+ patients in aesthetic settings. METHODS: Following PRISMA-S guidelines, a comprehensive review was conducted, initially identifying 159 potentially relevant articles. Upon stringent full-text review, 33 studies met the inclusion criteria and were subject to an in-depth thematic analysis. The scope encompassed qualitative studies, quantitative analyses, and a cross section of interdisciplinary research, predominantly from Western settings. RESULTS: The analysis distilled four principal themes: the imperative of identity affirmation in aesthetic interventions, substantial barriers to inclusive and empathetic care, the critical need for patient empowerment, and the existing deficiencies within medical education regarding LGBTQIA+ care. These themes highlight a complex interplay between the clinical aspirations of LGBTQIA+ individuals and the current capacity of aesthetic medicine to cater to this diversity. CONCLUSIONS: There is a pressing need for a paradigmatic shift towards more inclusive, competent, and sensitive aesthetic medical care for LGBTQIA+ patients. It underscores the necessity of reform in medical education and advocates for policy changes that promote a more equitable healthcare environment. This research serves as a call to action, emphasizing the ethical imperative to integrate comprehensive LGBTQIA+ care competencies into aesthetic medicine curricula and practice. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

A Systematic Review on the Reinforcement Loop in Aesthetic Medicine and Surgery: The Interplay of Social Media, Self-Perception, and Repeat Procedures.

INTRODUCTION: This systematic review delves into the impact of social media on self-perception and the escalating interest in clinical aesthetic procedures, proposing that social media significantly influences beauty standards and increases demand for aesthetic enhancements. METHOD: Following PRISMA guidelines, a mixed-method analysis of 34 articles was conducted, sourced from various databases, focusing on social media's psychological effects on clinical aesthetics decisions. The studies encompassed a broad spectrum, including qualitative, quantitative, and mixed methodologies, reflecting diverse geographical and cultural perspectives. RESULTS: The quantitative analysis demonstrated a strong positive correlation between social media usage and the consideration of aesthetic procedures (r=0.45, p<0.001), indicating a significant impact. Specific findings included a large effect size (Cohen's d=0.8) for the relationship between time spent on social media and the desire for aesthetic enhancements. Individuals spending more than 3 hours per day on social media platforms were twice as likely to consider aesthetic procedures compared to those with less usage, with a 95% confidence interval indicating robustness in these findings. CONCLUSION: Confirming the reinforcing effect of social media on aesthetic decision-making, this study highlights the complex interplay between digital media exposure, altered self-perception, and the increased inclination towards aesthetic procedures. It suggests a critical need for practitioners to carefully navigate the digital influence on patient's desires, reinforcing the significance of understanding psychological motivations and societal pressures in clinical aesthetics. This comprehensive analysis offers pivotal insights for clinical practice and ongoing research into social media's role in contemporary beauty standards. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

"Filler-Associated Acute Stroke Syndrome": Classification, Predictive Modelling of Hyaluronidase Efficacy, and Updated Case Review on Neurological and Visual Complications.

INTRODUCTION: The rising use of soft tissue fillers for aesthetic procedures has seen an increase in complications, including vascular occlusions and neurological symptoms that resemble stroke. This study synthesizes information on central nervous system (CNS) complications post-filler injections and evaluates the effectiveness of hyaluronidase (HYAL) treatment. METHODS: A thorough search of multiple databases, including PubMed, EMBASE, Scopus, Web of Science, Google Scholar, and Cochrane, focused on publications from January 2014 to January 2024. Criteria for inclusion covered reviews and case reports that documented CNS complications related to soft tissue fillers. Advanced statistical and computational techniques, including logistic regression, machine learning, and Bayesian analysis, were utilized to dissect the factors influencing therapeutic outcomes. RESULTS: The analysis integrated findings from 20 reviews and systematic analyses, with 379 cases reported since 2018. Hyaluronic acid (HA) was the most commonly used filler, particularly in nasal region injections. The average age of patients was 38, with a notable increase in case reports in 2020. Initial presentation data revealed that 60.9% of patients experienced no light perception, while ptosis and ophthalmoplegia were present in 54.3 and 42.7% of cases, respectively. The statistical and machine learning analyses did not establish a significant linkage between the HYAL dosage and patient recovery; however, the injection site emerged as a critical determinant. CONCLUSION: The study concludes that HYAL treatment, while vital for managing complications, varies in effectiveness based on the injection site and the timing of administration. The non-Newtonian characteristics of HA fillers may also affect the incidence of complications. The findings advocate for tailored treatment strategies incorporating individual patient variables, emphasizing prompt and precise intervention to mitigate the adverse effects of soft tissue fillers. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Generational Exploration on Aesthetic Medicine Products: Influence of Social Media, Reviews, and Brand Identity-GEMS Bond Survey.

INTRODUCTION: The study investigates the impact of social media reviews and brand identity on consumer preferences in the non-surgical aesthetics products across different generations. It highlights the evolving landscape of aesthetic medicine and surgery, driven by technological advancements and a cultural shift towards individual well-being. The research aims to explore the interplay between generational preferences, the influence of social media, and the role of brand identity in shaping consumer decisions. METHODS: A cross-sectional study design was employed, with a sample size of > 5000 participants stratified across various generational cohorts. The study utilized an online questionnaire to capture both quantitative and qualitative insights into consumer behaviour, with statistical analysis performed to identify patterns and relationships. RESULTS: Analysis of 5850 responses revealed distinct generational preferences and behaviours. Social media engagement varied significantly across generations, with younger cohorts placing a higher emphasis on online reviews. The study also found that brand identity's influence is diminishing in decision-making processes, with consumers increasingly relying on peer reviews and social media content. CONCLUSION: The findings highlight a pivotal shift in the non-surgical aesthetics consumer market, emphasizing the growing importance of social media and peer reviews over traditional brand identities. Importantly, the study underscores the critical need for integrating patient safety and evidence-based practice within marketing strategies. As consumer preferences evolve towards valuing transparency and authenticity, non-surgical aesthetics providers must prioritize these elements, ensuring that their services are not only appealing but also grounded in safety and scientific validity. LEVEL OF EVIDENCE IV: "This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 ."

A novel description of the supporting system of the orbicularis oculi muscle in the infraorbital area: Tear trough muscle fiber.

BACKGROUND: The aim of this study was to elucidate the anatomical structures of supporting system of the infraorbital area. MATERIALS AND METHODS: Forty-four hemifaces from eleven Korean and eleven Thai cadavers were used to dissect the infraorbital area. Based on the dissection and previous histologic results, they were analyzed. RESULTS: The orbicularis oculi muscle (OOc) had two portions (palpebral and orbital portion) and four subparts (pretarsal, preseptal, prezygomatic, and premaxillary part). The elliptical muscle fiber of OOc was supported by circumferential connective tissue including skin ligament, orbicularis retaining ligament, zygomatic ligament, and zygomatic cutaneous ligament. The vertical muscle fiber, the tear trough muscle fiber, and medial muscular band directly attached to the skin. CONCLUSION: Full of subcutaneous tissue in the tear trough groove, strong attachment to the bone by tear trough ligament and to the skin by tear trough muscle fiber would multiply result in the tear trough on the face.

The design and validation of a low-cost trans perineal (TP) prostate biopsy simulator for training: improving trainees' confidence and cognitive targeting skills.

PURPOSE: The aim of this research was to create a novel and low-cost TP prostate biopsy simulator that has face, content and construct validity with high educational value. METHODS: This research developed a trans perineal prostate (TP) biopsy simulator using 3D-printed moulds and tissue-mimicking materials. Important regions (anterior, mid, and posterior zones) were coded with different colours. Ultrasound visible abnormal lesions were embedded in the prostate phantom. Expert and novice participants in TP biopsies were recruited. Essential skills were identified through the consensus of six experts. These skills were assessed through tasks performed by participants. This included the accuracy and timing of systematic and target biopsies. Immediate feedback was determined by the colour of the biopsy cores taken. A survey was distributed to evaluate its realism and educational value. RESULTS: The material cost of one simulator was £7.50. This simulator was proven to have face, content, and construct validity. There was a significant difference (p = 0.02) in the accuracy of systematic biopsies between both experts and novices. Significant difference was also observed (p = 0.01), in accurately identifying target lesion on ultrasound between both groups. Participants rated the overall realism of the simulator 4.57/5 (range 3-5). 100% of the experts agreed that introducing this simulator to training will be beneficial. 85.7% of the participants strongly agree that the simulator improved their confidence in TP biopsies. CONCLUSION: There is value in integrating this proof-of-concept TP prostate biopsy simulator into training. It has highly rated educational value and has face, content, and construct validity.

The Efficacy and Duration of Onabotulinum Toxin A in Improving Upper Facial Expression Lines With 64-Unit Dose Optimization: A Systematic Review and Meta-Analysis With Trial Sequential Analysis of the Randomized Controlled Trials.

BACKGROUND: Onabotulinumtoxin A (Onabot A) was the first treatment to be approved for aesthetic indications, namely glabellar lines (GLs), crow's feet lines (CFLs), and forehead lines (FHLs), with a cumulative dose of 64 U. OBJECTIVES: The aim of this study was to conduct a meta-analysis to combine the available data for approved doses for GLs, CFLs, and FHLs to explore the effect and duration of simultaneous treatment with Onabot A. METHODS: PubMed/MEDLINE, Embase, and other national clinical trial registries were searched for randomized controlled trials from January 2010 to July 2022. The meta-analysis, trial sequential analysis, and investigator-assessed time to return to nonresponder status in GLs, CFLs, and FHLs following Onabot A were plotted to elicit a cumulative dose-adjusted response curve based on Kaplan-Meier analysis with a log-rank test. RESULTS: Fourteen randomized controlled trials were eligible for quantitative analysis. A total of 8369 subjects were recruited across the trials. The meta-analysis results show that Onabot A is very effective in reducing moderate to severe GLs, CFLs, and FHLs. The cumulative Z-curve for GLs, CFLs, and FHLs also exceeds the required information size (RIS). Kaplan-Meier analysis with a log-rank test demonstrated that simultaneous treatment of GLs, CFLs, and FHLs requires 182 days (95% CI = 179, 215 days) (P < 0.00002) to return to nonresponder status. CONCLUSIONS: Treatment of the upper facial expression lines with Onabot A is effective, and the approved cumulative dose of 64 U gives longer-lasting effects.

Botulinum Toxins for Esthetic Facial Injections: A Scientific Review to Support Evidence-Based Best Practice.

Botulinum toxins (BoNT) are complex biological products. Each licensed BoNT type A (BoNTA) has its own individual characteristics resulting into different attributes, some of them being of clinical relevance. Besides profound anatomical knowledge and understanding of esthetic principles, the responsible injecting physician should be aware of those pharmaceutical and clinical properties. Especially against the background of new BoNTA formulations receiving approval by the authorities, a critical and dedicated discussion on the individual characteristics should take place, and the potential relevance on the treatment outcome should be taken into consideration.

A Systematic Review on the Current Trend in Nonsurgical Aesthetic Training for Knowledge, Skill, and Professional Identity Formation.

BACKGROUND: Non-surgical aesthetics is a rapidly growing healthcare domain and lacks pedagogically sound education and training programs. The trainee physicians often participate in short courses which are outside of the scope of an existing postgraduate training program to acquire the necessary knowledge and procedural skills. However, such training programs lack values and interests that shape critical thinking and holistic decision-making, often referred to as professional identity. OBJECTIVES: This systematic review aims to analyze current trends in non-surgical aesthetic clinical education to form knowledge, skills, and professional identity. METHODS: A detailed literature search was conducted in electronic databases-PubMed, Cochrane, Centre for Reviews and Dissemination, and Google Scholar-for relevant studies published between January 2010 and December 2020, with an update in September 2021. RESULTS: Fifty-five articles were identified through electronic searches, among which 40 were selected following a review of the abstracts. Sixteen articles were identified as the best evidence for the detailed and iterative review based on their relevance and fit to the inclusion criteria. Unfortunately, none of the included studies designed their questionnaire based on the Kirkpatrick Model, which is best known for analyzing and evaluating the results of training and educational programs. CONCLUSIONS: This systematic review provides valuable insight into graduate professional identity formation and graduates' readiness for independent clinical practice. Therefore, particular consideration should be given to incorporating these triggers when developing evidence-based postgraduate curricula for non-surgical aesthetics.

Immunogenicity to Botulinum Toxin Type A: A Systematic Review With Meta-Analysis Across Therapeutic Indications.

BACKGROUND: Botulinum toxin A (BTX-A) is commonly employed as a neuromodulator in several neurological diseases and aesthetic indications. Formation of neutralizing antibodies (NAbs) after BTX-A injections may be responsible for treatment failure. OBJECTIVES: The authors sought to quantify the prevalence of NAbs following treatment with Abobotulinumtoxin A, Incobotulinumtoxin A, and Onabotulinumtoxin A for therapeutic indications. METHODS: An electronic systematic search (2000-2020) of PubMed, Scopus, Web of Science, and Embase was conducted. Original studies reporting prevalence of NAbs were included. Data analysis was carried out through open meta-analysis softwares. RESULTS: Forty-three studies involving 8833 patients were included in this meta-analysis. The incidence of NAbs was 1.8% (summary estimate = 0.018, 95% CI [0.012, 0.023]); a meta-regression analysis revealed that BTX-A duration was significantly associated with increased incidence of NAbs (P = 0.007). Patients with dystonia had the highest incidence (7.4%) of NAbs against BTX-A (summary estimate = 0.074, 95% CI = [0.045, 0.103], I2 = 93.%, P < 0.00) followed by patients with spasticity (6.7%) and urological indications (6.2%). Abobotulinumtoxin A was associated with the highest incidence of NAbs (7.4%) (summary estimate = 0.074, 95% CI = [0.053, 0.096], I2 = 97.24%, P < 0.00) by the Incobotulinumtoxin A and Onabotulinumtoxin A 0.3% (summary estimate <0.003%, 95% CI = [-0.001, 0.007], P < 0.003). CONCLUSIONS: Although the overall incidence of NAbs following BTX-A injections is relatively low, patients with secondary nonresponse to BTX-A with no apparent causes should be investigated for NAbs. A consensus needs to be developed for the optimal management of such patients.

Complications of Cosmetic Botulinum Toxin A Injections to the Upper Face: A Systematic Review and Meta-Analysis.

BACKGROUND: Botulinum toxin A (BoNT-A) injections are a popular non-surgical procedure for facial rejuvenation. Its increase in popularity and utilization is met with limited regulations, potentially posing a significant risk to patient safety and public health. OBJECTIVES: The authors sought to assess the safety profile of cosmetic glabellar and forehead BoNT-A injections and evaluate BoNT-A type on complication rate. METHODS: A systematic search of MEDLINE and EMBASE was performed for studies reporting complications after cosmetic BoNT-A in the glabellar or in the forehead region in the glabellar or in the forehead region. A random effects meta-analysis was carried out to assess complication rate. Where there were sufficient randomized-controlled trials, a network meta-analysis was performed. RESULTS: Of 556 identified articles, 24 were included in the final quantitative analysis, with 4268 BoNT-A injection sessions and 1234 placebos. Frequently observed treatment-related complications in the BoNT-A intervention group included headache, local skin reactions, and facial neuromuscular symptoms. The overall BoNT-A complication rate was 16%. The odds ratio of developing complications from abobotulinum toxin injections compared with placebo was 1.62 (1.15, 2.27; P > 0.05) and that from onabotulinum toxin injections compared with placebo was 1.34 (0.52, 3.48; P > 0.05). In 30% of the studies, the injectors were doctors, whereas the training status of the practitioner was not reported in the remaining 70%. CONCLUSIONS: Cosmetic BoNT-A injections in the glabellar and forehead region appear to be safe, and most complications are mild and transient. Nevertheless, the literature demonstrates heterogeneous reporting of complications and a lack of consistency of the definition of treatment-related complications.

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.

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.

A Novel Three-Dimensional Interactive Virtual Face to Facilitate Facial Anatomy Teaching Using Microsoft HoloLens.

BACKGROUND: In-depth understanding of facial anatomy is the foundation of clinical education and practices. Lately, anatomy education has undergone many changes due to the adoption of integrated medical curriculums. The time allocated to anatomy teaching on occasion been shortened to allow more time for clinical education. Innovation in visual technology such as virtual reality (VR), augmented reality (AR) and mixed reality (MR) has added a new dimension to anatomy education. The authors present a mixed reality virtual face model to facilitate complex anatomy teaching using Microsoft HoloLens in various educational settings. MATERIALS AND METHODS: Close-range photogrammetry technique was utilised to construct a virtual face using a dissected fresh-frozen cephalus. Scanning was undertaken using DSLR cameras, capable of capturing ten frames per second, in ten different angles on the dissected side and four for the undissected side. The images of the entire cephalous were also separately captured in twenty different angles. These images were processed using software to reconstruct the three-dimensional virtual face. RESULT: The virtual face using a mixed reality platform was able to demonstrate individual layers of the face and relevant clinically significant structures clearly with interactive labelling. Face and the content validity by 12 experts (plastic surgeons and dermatologists) demonstrated strong inter-rater reliability expressed as interclass correlation coefficient. CONCLUSION: An immersive experience by using Microsoft HoloLens provides an accurate 3D perception of the face to enhance anatomy learning. This can be utilised in undergraduate, postgraduate and continued medical education as an additional teaching tool in the constraints of cadaveric dissection. LEVEL OF EVIDENCE V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Review of Complications Due to the Use of Botulinum Toxin A for Cosmetic Indications.

BACKGROUND: Botulinum toxin A (botulinum toxin A) was found to provide a wide variety of therapeutic and aesthetic benefits as one of the most potent toxins in the world. Injectable remedies, including soft tissue fillers and botulinum toxin, have become very common in wrinkling and face rejuvenation management. While these methods of treatment are relatively safe, serious side effects can occur. In this review, the complications of BoNTA are highlighted. METHODS: A literature research considered published journal articles (clinical trials or scientific reviews). Electronic databases (PubMed, Scopus, Science Direct) were searched using key terms, and for identification of additional relevant studies, reference lists have also been examined. Only articles published in English were included in this review with a time restriction from 2000 to 2020. RESULTS: There are various injection-related adverse effects associated (AE) with botulinum toxins such as erythema, oedema, pain, ptosis of eyelid or brow and ecchymosis. The overall majority of adverse events identified are mild and temporary. CONCLUSION: As the use of toxins becomes increasingly more common, adverse events can be expected to increase as well. The practitioners need to be aware of such AEs, and the patients should be informed of these before undertaking such procedures. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Global Needs-Assessment for a Postgraduate Program on Nonsurgical Facial Aesthetics.

BACKGROUND: Standardizing training and education in nonsurgical facial aesthetic procedures during residency training has long been challenging because majority of the procedures are performed outside the usual teaching hospital settings. Several areas of refinement have been suggested and an increased need for more hands-on training identified in the available literature. Despite the growing demand for nonsurgical facial aesthetics (NSFA), it is yet to be fully integrated into standard postgraduate medical or surgical curriculum. OBJECTIVES: The objective of this study was to explore the current state and the need for medical education and training of aesthetic clinicians across specialties in a formal postgraduate curriculum. METHODS: A mixed-method, cross-sectional, online research was conducted among physicians involved in training and practicing NSFA between July 2018 and December 2018. Focus group discussion was conducted to ensure the face and content validity of the survey items. RESULTS: The total responses collected in the trainer's group was 179 and 496 in the trainee's group. The majority of trainers (95%) and trainees (93.8%) across specialties expressed their opinion for the need of a standard postgraduate course in NSFA. Moreover, more than 55% of them felt that 12 months, with a work-based, blended learning approach, would be most suitable for training and education. CONCLUSIONS: The survey results have underlined the need for specialized training in NSFA to enable clinicians to pursue independent practice with confidence. The authors recommend the inclusion of evidence-based postgraduate programs on NSFA in higher academic institutions as per their educational curriculum.

Onabotulinumtoxin Type A Dosage for Upper Face Expression Lines in Males: A Systematic Review of Current Recommendations.

BACKGROUND: Botulinum toxin injection is the most commonly performed minimally invasive aesthetic procedure in men. Despite various recommendations by experts on the use of onabotulinumtoxin type A in the literature, distinct guidelines for its use in males and females do not exist. OBJECTIVES: The aim of this study was to delineate safe and effective doses for the use of onabotulinumtoxin type A in males for correction of upper facial expression lines. METHODS: PubMed (MEDLINE), Embase, the Cochrane database, and Google Scholar were searched from 2002 to 2019 inclusive. Three researchers independently assessed trials for inclusion, extracted data, checked for accuracy, and assessed the evidence with AGREE II. RESULTS: Average dosing recommended for the treatment of upper face expression lines was specific to glabellar frown lines, crow's feet, and horizontal forehead lines. Changing trends and gender variation was noted in each of the studies. Six of the 11 recommendations suggest the need to alter dosing in male patients, although do not give separate recommendations. CONCLUSIONS: There is an urgent need for up-to-date recommendations for the use of onabotulinumtoxin type A in upper face expression lines of male patients.