Neurotoxins: Current Concepts in Cosmetic Use on the Face and Neck--Jawline Contouring/Platysma Bands/Necklace Lines.

The platysma muscle acts as a major depressor in the lower face with subsequent inaesthetic implications. Botulinum toxin-A can be very useful to reverse some of these and this chapter describes how to (1) sharpen the jawline with the Nefertiti Lift, (2) treat anterior neck bands, and (3) soften necklace lines.

Longevity of effects of hyaluronic acid plus lidocaine facial filler.

BACKGROUND: A new hyaluronic acid filler containing pre-incorporated 0.3% lidocaine reduces pain and enhances patient comfort. In vitro studies confirm functional equivalence with non-lidocaine-containing products, but only limited data are available on the long-term effects of lidocaine on filler performance in the clinical setting. AIMS: To investigate whether inclusion of lidocaine impacts the longevity of hyaluronic acid fillers. PATIENTS/METHODS: 60 patients with moderate-severe bilateral nasolabial folds received 24 mg/mL hyaluronic acid with pre-incorporated lidocaine or an equivalent product without lidocaine and were followed-up for up to 76 weeks. RESULTS: Significantly better results were found in favor of HA gel with pre-incorporated lidocaine for physician assessment of injection pain and patient pain assessment after injection (both P < 0.001). Long-term follow-up of patients after almost a year showed that 91% (52/57) of patients had no evidence of facial asymmetry, and investigators confirmed lidocaine had no effect on filler longevity. High levels of patient satisfaction and prolonged benefits due to persistence of the product were noted, with those patients needing additional treatment requiring 'top-up' rather than full re-treatment. CONCLUSIONS: The addition of 0.3% lidocaine does not affect product longevity and the small volume required for 'touch-up' also suggests that longevity is maintained.

A split-face comparison of a new hyaluronic acid facial filler containing pre-incorporated lidocaine versus a standard hyaluronic acid facial filler in the treatment of naso-labial folds.

This split-face, single-blind study compared the comfort and ease of injection of a new hyaluronic acid facial filler containing pre-incorporated lidocaine (Juvederm ULTRA 3) versus the established hyaluronic acid facial filler Restylane-Perlane. A total of 126 individuals were treated with both products, randomly assigned to the right or left naso-labial fold. Injector assessment-indicated mean injection pain, pain of massaging the injected area and post-injection discomfort (based on a scale of 0=no pain to 10=extreme pain) were 2.1, 0.9 and 0.4 for Juvederm ULTRA 3, and 4.1, 3.3 and 1.7 for Restylane-Perlane, respectively (p<0.0001). Patient assessment of the same parameters were 2.8, 1.3 and 0.4 for Juvederm ULTRA 3, and 4.9, 3.6 and 1.8 for Restylane-Perlane (p<0.0001). Injectors indicated that 92% of Juvederm ULTRA 3 injections were 'very easy', compared with 21% for Restylane-Perlane. Post-treatment smoothness was comparable, but 95% of individuals preferred Juvederm ULTRA 3 for overall injection comfort. A total of 95% of individuals indicated that Juvederm ULTRA 3 was a more comfortable and gentle experience.

Comparison of injection comfort of a new category of cohesive hyaluronic acid filler with preincorporated lidocaine and a hyaluronic acid filler alone.

BACKGROUND: A smooth, cohesive, 24-mg/mL hyaluronic acid (HA) gel with uniform consistency, even flow characteristics, and extended duration was designed for injection into the mid to deep dermis. OBJECTIVE: To compare injection pain of a HA gel with preincorporated lidocaine with that with a non-lidocaine formulation. METHODS & MATERIALS: This double-blind study at three centers enrolled 60 subjects, injected with both products, randomly assigned to left or right nasolabial fold. The injecting physician assessed severity of pain and ease of injection. Subjects used a visual analog scale (0-10) for pain assessment. Adverse events were recorded. RESULTS Physician assessment of injection pain was none or mild in 81% of HA gel injections with preincorporated lidocaine and 36% of HA-alone injections (p<.001). Mean pain assessment by subjects was 3.6 for HA+lidocaine and 5.8 for HA alone (p<.001). Ninety-five percent of the injections were considered easy or very easy; a greater percentage of HA+lidocaine injections were rated very easy. Mild to moderate adverse events were reported for both products. CONCLUSION: The smooth, cohesive HA gel with preincorporated lidocaine increased subject comfort during treatment and improved the injection experience.

Hyaluronidase offers an efficacious treatment for inaesthetic hyaluronic acid overcorrection.

BACKGROUND: Hyaluronic acid is generally accepted today as the "gold standard" filler agent, and its use has subsequently grown enormously. In addition, newer facial volume augmentation indications are constantly evolving. Rare adverse events, such as granulomas, have been described. However, complications are more commonly due to product misplacement or overcorrection leading to unsightly lumps and masses. Hyaluronidase treatment of these latter adverse effects can be both effective and rapid. OBJECTIVE: This paper aims to confirm the efficacy of hyaluronidase injections in dissolving unsightly hyaluronic acid overcorrection. METHODS: A case of hyaluronic acid overcorrection is described with evaluation of the effects of hyaluronidase. RESULTS: The use of hyaluronidase, injected intracutaneously permits the elimination of patient discomfort and inaesthetic lumps within a few hours. CONCLUSIONS: Hyaluronidase is highly effective in eliminating HA volume overcorrection.

The 'Nefertiti lift': a new technique for specific re-contouring of the jawline.

Botulinum toxin type A (BoNTA) is now used extensively for rejuvenation of the forehead, glabellar and periocular regions and there is increasing focus on treatment of the lower face. Although there is well-documented evidence for the efficacy of botulinum toxin in the correction of platysmal bands, little work has been done to explore its potential role in rejuvenation of the jawline. To date, effects in this area have been reported as a consequence of platysmal banding treatment and are inconsistent. Hesitancy to explore treatment may be due to evidence of a greater, more durable response to the toxin in the lower facial muscles as well as reports of increased potential migration and subsequent side effects. This paper describes a new technique using BoNTA (Vistabel); Allergan, Irvine, CA, USA) to drape the skin of the jawline contour and provide the visual effect of a 'mini lift'. Experience with 130 patients with doses of BoNTA up to 20 U is described. Patient satisfaction is extremely high and the specificity of dosing and technique has led to a low incidence of adverse effects. The 'Nefertiti lift' is a minimally invasive, effective and acceptable alternative for those patients seeking an effective way to push back surgery.