Novel, Validated 5-Point Photonumeric Scales for Assessment of the Neck and Décolleté.

BACKGROUND: There is a scarcity of scales that assess platysmal bands, wrinkles in the décolleté, and horizontal neck lines in the digital and live setting. OBJECTIVES: The objective of this investigation was to create and validate 5-point photonumeric scales that assess horizontal neck lines, platysmal bands, and wrinkles in the décolleté. METHODS: A medical team created 3 different novel 5-point photonumeric scales for the assessment of horizontal neck lines, platysmal bands, and décolleté wrinkling. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation. RESULTS: The Croma (Leobendorf, Austria) Horizontal Neck Lines Assessment Scale showed substantial interrater agreement and almost perfect intrarater agreement in the digital and live validations, respectively. The Croma Platysmal Bands Assessment Scale showed substantial intrarater agreement in both digital and live validations. For the décolleté, a static scale and a dynamic scale were created and validated. The Croma Static Décolleté Wrinkles Assessment Scale showed substantial and almost perfect interrater agreement in the digital and live validations, respectively, and the intrarater agreement in both was almost perfect. The Croma Dynamic Décolleté Wrinkles Assessment Scale showed almost perfect agreement in both validation settings for both interrater and intrarater measures. CONCLUSIONS: The Croma Horizontal Neck Lines Assessment Scale and the Croma Static and Dynamic Décolleté Wrinkles Assessment Scales have sufficient interrater and intrarater agreement for justifiable use in clinical and research settings.

Novel, Validated, 5-Point Photonumeric Scales for Assessment of the Perioral Region.

BACKGROUND: The use of validated scales is still considered the gold standard for evaluating the severity of an aesthetic facial condition. OBJECTIVES: The aim of this investigation was to create and validate 5-point photonumeric scales for the assessment of perioral lines and marionette lines. METHODS: A medical team created 2 different novel 5-point photonumeric scales for the assessment of perioral lines and marionette lines. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation. RESULTS: For the Croma Static Perioral Lines-Assessment Scale, the digital interrater intraclass correlation coefficients (ICCs) were 0.88 (95% CI, 0.85-0.91) in the first rating and 0.87 (95% CI, 0.83-0.90) in the second rating. The digital intrarater ICCs were 0.90 (95% CI, 0.87-0.92). In the live rating, the interrater ICCs were 0.89 (95% CI, 0.85-0.93) in the first rating and 0.91 (95% CI, 0.87-0.93) in the second rating with an intrarater ICC of 0.91 (95% CI, 0.88-0.95). For the Croma Marionette Lines-Assessment Scale, the digital rating interrater ICCs were 0.85 (95% CI, 0.81-0.89) in the first rating and 0.87 (95% CI, 0.84-0.90) in the second rating with an intrarater ICC of 0.89 (95% CI, 0.88-0.91). In the live rating, the interrater ICCs were 0.73 (95% CI, 0.54-0.83) in the first rating and 0.79 (95% CI, 0.65-0.87) in the second rating with an intrarater ICC of 0.88 (95% CI, 0.83-0.94). CONCLUSIONS: The Croma Static Perioral Lines-Assessment Scale and the Croma Marionette Lines-Assessment Scale have exceptional inter- and intrarater agreements that justify their use in clinical and study settings for all ethnic groups.

Calcium Hydroxyapatite Filler With Integral Lidocaine CaHA (+) for Soft Tissue Augmentation: Results from an Open-Label Multicenter Clinical Study.

BACKGROUND: Soft tissue augmentation with calcium hydroxylapatite (CaHA) is a versatile technique for line filling, skin tightening, lifting, contouring, and volumizing. The present study was designed to confirm safety and effectiveness of the product with lidocaine (CaHA (+)) in a holistic treatment of nasolabial folds (NLFs), marionette lines, and/or cheeks. METHODS: A total of 207 subjects with moderate to severe facial volume deficit were treated with CaHA(+) in this open-label study. Effectiveness assessments included Merz Aesthetics Scales® (MAS), investigator- and subject-assessed Global Aesthetic Improvement Scales (iGAIS/sGAIS), and FACE-QTM questionnaires. Responder rates were defined as at least one-point improvement on MAS according to blinded rating. Safety was assessed through adverse event reporting. RESULTS: Primary endpoint was evaluated 12 weeks after last injection. Responder rates were 93.6%, 88.7%, and 81.9% in the NLFs, marionette lines, and cheeks, respectively, and were statistically significant above the pre-defined 60% threshold (P< 0.0001). Investigator- and subject-assessed GAIS were consistent and showed high rates of improvement throughout the study, with peak values of 98.0% at week 4 on iGAIS and 93.5% at 12 weeks after last injection on sGAIS. After 18 months, the majority of subjects (52.5%) still perceived improvement via sGAIS. Moreover, total FACE-Q scores demonstrated high subject satisfaction with treatment. All related treatment emergent adverse events were transient and expected injection-site reactions mostly of mild to moderate intensity. CONCLUSION: CaHA (+) has demonstrated safety and effectiveness in the treatment of NLFs, marionette lines, and cheek volume loss in real-life conditions up to 18 months. J Drugs Dermatol. 2022;21(5):481-487. doi:10.36849/JDD.6737.

Safety of Cohesive Polydensified Matrix Cross-Linked Hyaluronic Acid Volumizing Gel in Temporal Hollows and Cheeks: A Prospective, Open-Label, Postmarket Study.

BACKGROUND: Facial aging is characterized by volume loss and progressive hollowing of temples and cheeks. Biodegradable filler materials are preferred over nonabsorbable materials; of these, hyaluronic acid (HA) fillers are the most often used because of their favorable effectiveness and safety profile. OBJECTIVE: To confirm the safety and effectiveness of Cohesive Polydensified Matrix (CPM)-HA26 gel in the treatment of volume deficiency. METHODS: Subjects received up to 2 treatments in the temples and/or cheeks. A blinded investigator assessed improvement according to the Merz Temple Volume Scale (MTVS) and Merz Cheek Fullness Assessment Scale (MCFAS). Subjects were followed for 48 weeks after the last treatment. RESULTS: In total, 87 healthy subjects were enrolled. The proportion of subjects achieving at least a 1-grade improvement on MTVS and/or MCFAS was above 70% for each (MTVS: Weeks 4, 24, and 48 = 95.4%, 94.2%, and 77.0%; MCFAS: Weeks 4, 24, and 48 = 92.3%, 83.1%, and 71.8%). Based on MTVS and MCFAS scores at Visit 5, improvement remained visible at up to 48 weeks. No treatment-related serious AEs occurred. CONCLUSION: CPM-HA26 demonstrated both a favorable safety and effectiveness profile, with improvement in facial volume evident for up to 48 weeks. It was well tolerated and had a positive, long-lasting effect.

Intraarterial Degradation of Calcium Hydroxylapatite Using Sodium Thiosulfate - An In Vitro and Cadaveric Study.

BACKGROUND: The most severe complications following soft tissue filler injections result from the intraarterial administration of the filler product. Although hyaluronic acid-based filler can be trans-arterially dissolved with hyaluronidase, no information is available on calcium hydroxylapatite (CaHA)-based fillers. OBJECTIVE: The authors sought to test whether CaHA-based fillers can be trans-arterially dissolved by sodium thiosulfate (STS) when evaluated in cadaveric and in vitro models. METHODS: Human cadaveric facial arterial segments were each filled with 0.2 cc of commercially available CaHA product and submerged for 24 hours in 4 different STS-containing solutions: 10 cc STS (300 mg/cc) (pure, 1:1 dilution, 1:2 dilution), 0.9% saline and 10 cc STS (300 mg/cc), and 300 IU (bovine) hyaluronidase in a 1:1 ratio. RESULTS: Intraarterial CaHA was detected in human facial artery segments after 24 hours independent of the STS concentration employed. Submerging the arterial segments in STS (300 mg/cc) and 300 IU (bovine) hyaluronidase (1:1 ratio) also did not dissolve the intraarterial CaHA product. Gray scale analyses did show, however, that increasing concentrations of STS resulted in increased disintegration of CaHA in an in vitro experimental setting. CONCLUSIONS: The results of this study indicate that STS is limited in its potential to dissolve intraarterial CaHA of cadaveric human facial arteries, despite the fact that it appears effective when in direct contact with the CaHA. Adverse events caused by intraarterial administration of CaHA-based fillers still lack a suitable antidote.

Safety, Tolerability, and Efficacy of Repeat-Dose Injections of IncobotulinumtoxinA in the Treatment of Upper Facial Lines: Results from a Prospective, Open-Label, Phase III Study.

In aesthetic practice, wrinkles in the upper face are commonly treated with repeat-dose injections. The objective of this study was to investigate the safety, tolerability, and efficacy of repeat-dose injections of incobotulinumtoxinA in the combined treatment of moder-ate to severe upper facial lines (UFL) [glabellar frown lines (GFL), horizontal forehead lines (HFL), and lateral periorbital lines (LPL)]. Healthy subjects (≥18 years) with moderate to severe GFL, HFL, and LPL on the Merz Aesthetics Scales (MAS) at maximum contrac-tion were administered 54 to 64 U of incobotulinumtoxinA (GFL, 20 U; HFL, 10 to 20 U; LPL, 24 U) in up to four, 120-day treatment cycles. Adverse events (AE) were recorded for each cycle until 120 ± 7 days after treatment. Investigator-assessed MAS scores were evaluated for each treated area at maximum contraction on day 30 [responder = score of “none” (0) or “mild” (1)]. Subject-assessed scores for overall appearance of the upper face of “much improved” or “very much improved” were noted at day 30 of each treatment cycle on the Global Impression of Change Scale (GICS). Overall, 140 subjects were treated, and 125 subjects completed the study. Mean injected units per injection cycle ranged from 56.3 U to 57.7 U. During the four-cycle study period 17.1% of total treated subjects experienced a treatment emergent adverse event (TEAE). TEAEs of special interest were documented for 9 subjects (6.4%), in 6 of these subjects (4.3%) the TEAEs were related to treatment. No clinically significant mean changes in laboratory and vital-sign values were observed from screening to final-treatment visit. Over the study interval, a response rate of > 80% on the investigator-assessed MAS was reported for all treated areas except HFL. Greater than 80% of subjects in cycles 1, 3, and 4 and 78.5% of subjects in cycle 2 reported ratings of “much improved” or “very much improved” on the GICS for the overall appearance of the upper face. Incobotu-linumtoxinA for the repeat-dose treatment of UFL is safe and well tolerated with a stable safety profile, without new formation of neutralizing antibodies and has excellent efficacy during prolonged administration. J Drugs Dermatol. 2020;19(5):461-469. doi:10.36849/JDD.2020.5013.

A Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management.

BACKGROUND: Hyaluronic acid fillers have a satisfactory safety profile. However, adverse reactions do occur, and rarely intravascular injection may lead to blindness. Currently there is no internationally recognized consensus on the prevention or management of blindness from hyaluronic acid filler. OBJECTIVES: The authors sought to give guidance on how to minimize the risk and optimize the management of this rare but catastrophic adverse reaction. METHODS: A multinational group of experts in cosmetic injectables from multiple disciplines convened to review current best practice and develop updated consensus recommendations for prevention and bedside intervention if visual loss occurs after cosmetic injection of hyaluronic acid filler. RESULTS: The consensus group provided specific recommendations focusing on the consenting process, prevention, and early management of visual impairment related to intravascular hyaluronic acid filler injection. CONCLUSIONS: Although visual loss due to filler injections is rare, it is important that both patient and physician be aware of this risk. In this paper the authors describe methods and techniques available to reduce the risk and also document suggested initial management should a clinician find themselves in this situation.

Validated Assessment Scales for the Female Asian Calf.

BACKGROUND: Clinical photonumeric scales have been developed and validated to objectively measure the effectiveness of aesthetic treatments in specific anatomical areas; however, these are based on the typical features of Caucasian patients. No clinical scale for Asian calf appearance currently exists. OBJECTIVE: To develop and validate a calf assessment scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed calf images of female Asian subjects (N = 35) viewed from behind with feet flat on the floor (at rest) and on tiptoes (dynamic). Images were rated from 0 (very slim, linear profile) to 4 (very severe convex profile). RESULTS: Inter-rater and intra-rater reliability were "substantial" (≥0.6, intraclass correlation coefficient [ICC] and weighted kappa) for the calf-at rest, calf-dynamic, and calf summary score. Reliability was "substantial" for calf-at rest and calf-dynamic (≥0.6, ICC and weighted kappa) and "almost perfect" (0.85) for the calf summary score. BMI and calf circumference were highly correlated with scale ratings, and calf circumference was a significant predictor. CONCLUSION: This new photonumeric assessment scale has value for assessing the female Asian calf, providing a standardized measure of calf appearance in clinical practice and clinical research settings.

A Validated Assessment Scale for Asian Chin Projection.

BACKGROUND: As the number of different aesthetic treatments increase, numerous photonumeric assessment scales have been developed and validated to measure the effectiveness of these new treatments and techniques. Photonumeric rating scales have been developed to objectively assess improvements in anatomical areas; however, these have been based on the features of Caucasian patients. OBJECTIVE: To develop and validate a Chin Projection Scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial views of 50 Asian subjects and also estimated their age and the aesthetic treatment effort required for each subject. Chin projection was rated on a scale from 0 (optimal) to 4 (very severely receding). RESULTS: Inter-rater reliability was 0.80 (substantial) for Validation Session 1 and 0.83 (almost perfect) for Validation Session 2. The results for Estimated Age and Estimated Treatment Effort were essentially the same. CONCLUSION: This study demonstrated the validity of the first photonumeric assessment scale for assessing the appearance of the female Asian chin. This new scale will provide a standardized measure of chin projection for Asian patients in clinical practice and clinical research settings.

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.

Clinical Validation of the Surface Volume Coefficient for Minimally Invasive Treatment of the Temple

Objective: The aim of the present study is to compare the temporal surface volume coefficient obtained in the cadaveric model from subdermal and supraperiosteal injections to the clinical setting when treating temporal hollowing. Material and Methods: A total of 36 subjects were included in this investigation, 17 patients (16 females, 1 male; 46.3 ± 8.9 years; 25.5 ± 2.8 kg/m2) and 19 cadaveric specimens (11 females, 8 males; 76.4 ± 11.5 years; 24.0 ± 5.1 kg/m2). Subdermal and supraperiosteal injections were performed and live subjects were evaluated and followed for 12 months. The surface volume coefficients were calculated using 3D surface volume scanning and compared for validity. Results: No statistically significant difference was detected between the clinical outcome scores of the subdermal vs supraperiosteal injection technique. The supraperiosteal injection technique utilized significantly more product 1.20 ± 0.5 cc [range: 0.50 ­ 2.6 cc] compared to the subdermal 0.71 ± 0.2 cc [range: 0.30 ­ 1.20 cc] vs with P< 0.001. This difference was consistent with the different values of the cadaveric surface volume coefficient (subdermal vs supraperiosteal): 1.00 ± 0.2 vs 0.70 ± 0.2. At 12-month follow-up, the product loss was 19% for the subdermal injection and 21% for patients treated with supraperiosteal injections. Conclusion: The results of the study support the clinical validity of the surface volume coefficient. They demonstrate that the different injection volumes necessary to deliver aesthetically appealing results when utilizing the subdermal vs the supraperiosteal technique can be explained by the region-specific surface volume coefficient. J Drugs Dermatol. 2019;18(6):533-540.

Age and Gender Differences of the Frontal Bone: A Computed Tomographic (CT)-Based Study.

BACKGROUND: Age-related changes of the frontal bone in both males and females have received limited attention, although understanding these changes is crucial to developing the best surgical and nonsurgical treatment plans for this area. OBJECTIVES: To investigate age-related and gender-related changes of the forehead. METHODS: Cranial computed tomographic images from 157 Caucasian individuals were investigated (10 males and 10 females from each of the following decades: 20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, 80-89 years, and of 8 males and 9 females aged 90-98 years). Frontal bone thickness and forehead distance measurements were carried out to analyze age and gender differences. RESULTS: With increasing age, the size of a male forehead reduces until no significant differences to a female forehead is present at old age (P = 0.307). The thickness of the frontal bone of the lower forehead (≤4 cm cranial to the nasal root) increased slightly in both genders with increasing age. In the upper forehead (≥4 cm cranial to the nasal root), frontal bone thickness decreased significantly (P = 0.002) in males but showed no statistically significant change in thickness in females (P = 0.165). CONCLUSIONS: The shape of the frontal bone varies in young individuals of different genders and undergoes complex changes with age because of bone remodeling. Understanding these bony changes, in addition to those in the soft tissues, helps physicians choose the best surgical and nonsurgical treatment options for the forehead.

Liquid Formulation of AbobotulinumtoxinA Exhibits a Favorable Efficacy and Safety Profile in Moderate to Severe Glabellar Lines: A Randomized, Double-Blind, Placebo- and Active Comparator-Controlled Trial.

BACKGROUND: In most countries, approved botulinum toxin type A formulations require reconstitution before injection. OBJECTIVES: To evaluate the efficacy and safety of a ready-to-use liquid formulation of abobotulinumtoxinA (abobotulinumtoxinA solution for injection, ASI) in subjects with moderate to severe glabellar lines (GL). METHODS: In this Phase II, double-blind, placebo-controlled, randomized study, 176 female subjects (aged 30 to 60 years) were randomized into five treatment groups: ASI 20, 50, or 75 U, reconstituted abobotulinumtoxinA (aboBoNT-A) 50 U, and placebo. GL severity was assessed at maximum frown using a 4-point grading scale. Responders were subjects with severity grade of moderate [2] or severe [3] at baseline improving to none [0] or mild [1], evaluated at each time-point by Investigator's Live Assessment (ILA) or Subject's Self-Assessment (SSA). Safety profiles were also determined. RESULTS: Baseline characteristics were similar across groups. Responder rates on Day 29 by ILA were significantly greater for ASI 20, 50, and 75 U versus placebo (88.9%, 91.4%, and 87.9% vs. 0%, respectively; P < 0.0001). Similar results were observed by SSA. A greater proportion of responders was observed in ASI groups vs placebo from Day 8 to 113 for ILA and SSA (P < 0.001). AboBoNT-A responder rate on Day 29 for ILA was 77.1% (P < 0.1006 vs ASI 50 U); with comparable results by SSA. The ASI safety profile was comparable to that of aboBoNT-A. CONCLUSIONS: Ready-to-use liquid formulation of abobotulinumtoxinA was shown to be efficacious, with comparable results to reconstituted abobotulinumtoxinA, and to have a favorable safety profile in subjects with severe to moderate GL.

Precision in Dermal Filling: A Comparison Between Needle and Cannula When Using Soft Tissue Fillers.

BACKGROUND: Precise implantation of soft tissue fillers to treat the signs of aging is crucial for patient safety and the best aesthetic outcome. Injections are performed commonly with either needles or cannulas, but quantitative comparative data on precise implantation are still elusive. METHODS: Ten fresh-frozen cephalic foreheads (9 male, 1 female) were injected with radiopaque material using both needles and cannulas. Needle injection relied on a perpendicular transcutaneous approach, whereas cannulas were moved in the supra-periosteal plane until reaching the same location as the needle. Two-dimensional distribution of the material in the horizontal and in the vertical axes was quantified using fluoroscopic imaging. Additional CT and MR imaging was performed to confirm results. RESULTS: The two-dimensional extent of injected material in the horizontal plane was 25.6 mm±10.5 mm vs 13.5 mm ± 6.5 mm (cannula vs needle; P=0.006) and 3.0 mm ± 0.90 mm vs 3.99 mm ± 0.97 mm (cannula vs needle; P=0.028) in the vertical plane. In 60% of injections using a needle, the implanted material changed its plane; this was not observed when using the cannula (0%; P=0.003). Retrograde backflow, however, was greater with a cannula (90.2%) compared to a needle (33.3%). CONCLUSIONS: If precision in filler injection is defined as the filler material remaining in the plane of intended implantation, then using cannulas resulted in a more precise injection of material as compared to needles. Applications with needles resulted in the distribution of material into more superficial layers, which was not noted for cannulas.

J Drugs Dermatol. 2017;16(9):866-872.

First Consensus on Primary Prevention and Early Intervention in Aesthetic Medicine.

BACKGROUND: Facial aging is a complex interplay of extrinsic and intrinsic factors leading to progressive changes in the skin, subcutaneous tissue, and bone. Clinical experience suggests that early aesthetic intervention may slow the signs of aging, but treatment in the absence of symptoms or with minimal signs of aging has not yet been properly addressed. OBJECTIVES: To provide treatment recommendations for primary prevention and early intervention in individuals with no or minimal signs of aging. METHODS: Fourteen specialists in aesthetic medicine convened over a full-day meeting under the guidance of a certified moderator. RESULTS: Tailored treatment recommendations have been provided for prevention and early intervention of fine wrinkles, static lines and folds, irregular pigmentation, laxity, and subcutaneous volume loss by protecting the epidermis, stimulating neocollagenesis, reducing hyperkinetic musculature, and reinforcing supporting structures. CONCLUSION: Preventive measures and early therapeutic interventions that may alter the course of facial aging were defined. Further studies are needed to support these recommendations with the best possible evidence.

J Drugs Dermatol. 2017;16(9):846-854.

Communication Concepts for Prevention and Early Intervention in Aesthetic Medicine: Consensus and Literature Review.

BACKGROUND: Communication concepts relating to prevention and early intervention (P&E) within aesthetic medicine are poorly understood and highly underexplored. However, effective communication is a key criterion for successful outcomes. OBJECTIVES: To introduce the framework for P&E communication strategies within a younger population and explore the barriers that may be encountered. METHODS: A literature review on P&E communication strategies in aesthetic medicine and related topics of interest was conducted and used to construct a working framework that may be applied in clinical practice. RESULTS: Examination of existing literature revealed a need for a more structured communication framework for P&E encompassing up-to-date evidence-based learning and educational marketing that is tailored to individual needs and target populations. Message framing-the way in which a message is presented-is an important consideration in the dissemination of information to promote changes in health behaviour. A structured consultation is key to optimising patient engagement and ensures a tailored approach to understanding and catering to the specific needs of each patient. CONCLUSION: This is the first paper to discuss the communication concepts behind P&E within aesthetic medicine and paves the way for further research and focus in this significant field.

J Drugs Dermatol. 2017;16(9):859-864.

Tempering Patient Expectations and Working With Budgetary Constraints When It Comes to a Single Versus a Multimodal Approach.

BACKGROUND: This article is a review of the literature and the authors' experience in managing patients seeking facial and nonfacial rejuvenation procedures with budgetary constraints. OBJECTIVE: To provide readers with an approach to the cosmetic patient with financial limitations. METHODS AND MATERIALS: This article is written from a review of the literature and the authors' experience. RESULTS: The readers should learn how to better manage a patient with financial limitations seeking cosmetic procedures. CONCLUSION: Because patients seeking cosmetic procedures are often faced with budgetary constraints, it is important for the cosmetic physician to educate patients about available treatment options and their costs. Giving patients realistic expectations and tailoring treatment plans to the patient's primary goals and financial limitations can help maximize overall patient satisfaction.

Consensus Recommendations for Combined Aesthetic Interventions Using Botulinum Toxin, Fillers, and Microfocused Ultrasound in the Neck, Décolletage, Hands, and Other Areas of the Body.

BACKGROUND: The popularity of aesthetic procedures in the face has led to greater disparity between treated areas and those that still show evidence of true age. Although many areas of the body often require multiple treatment procedures for optimal rejuvenation, combination therapy for specific areas is not yet well defined. OBJECTIVE: To develop recommendations for the optimal combination and ideal sequence of botulinum toxin (BoNT), hyaluronic acid, calcium hydroxylapatite (CaHA), and microfocused ultrasound with visualization in nonfacial areas across all skin phototypes. METHODS: Fifteen specialists convened under the guidance of a certified moderator. Consensus was defined as approval from 75% to 94% of all participants, whereas agreement of ≥95% denoted a strong consensus. RESULTS: Recommendations have been provided for the neck, décolletage, and hands and include the timing and sequence of specific procedures when used concurrently or over several treatment sessions. Position statements are offered in lieu of consensus for the upper arms, abdomen, buttocks, and knees. CONCLUSION: Nonfacial rejuvenation often requires multiple procedures for optimal results in individuals with significant age-related changes. Further clinical studies are recommended to raise awareness of non-facial indications and provide clinicians with the best evidence for best treatment practices.