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.

Combination of Calcium Hydroxylapatite Diluted With Normal Saline and Microfocused Ultrasound With Visualization for Skin Tightening.

Background/Objectives: Treatment options for the correction of age-related changes in skin include the use of energy-based devices and dermal fillers. In this study, we evaluate the clinical efficacy and tolerability of microfocused ultrasound with visualization (MFU-V) and injectable calcium hydroxylapatite (CaHA) filler diluted with normal saline, for the correction of age-related changes and to assess patients' satisfaction with this combination therapy. Methods: This was a randomized, split-face, comparative clinical study and immunohistochemical analysis in 20 subjects with indications for lower face, neck and décolleté lifting. Over five visits, CaHA diluted with normal saline (1:2) was injected subdermally in the lower third of the face, neck and décolleté, and lower abdominal quadrant. MFU-V was performed on the lower third of the face, neck, and décolleté, and the right lower abdominal quadrant. Results: Upon baseline examination, the age-related changes were quantified as follows: marionette lines score 2.47 ± 0.8, jawline contour score 2.2 ± 0.7 and neck score 2.1 ± 0.7 points; and after 15 months, they changed to 1.8 ± 0.7 (P≤0.00003), 1.89 ± 0.56 (P≤0.005), and 1.7 ± 0.6 (P≤0.005) points, respectively. The procedures were well tolerated, and subject satisfaction was high. Conclusions: The injections of CaHA in combination with MFU-V treatment stimulated neoangiogenesis, led to the increased synthetic activity of cells, a marked increase in collagen and elastin fibers, and remodeling of both the superficial and deep layers of the dermis. An improvement in the severity of age-related changes was observed in all areas studied. J Drugs Dermatol. 2020;19(4):405-411. doi:10.36849/JDD.2020.4625.

Managing intravascular complications following treatment with calcium hydroxylapatite: An expert consensus.

BACKGROUND: Inadvertent intra-arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra-arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence-based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. METHODS: An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra-arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. RESULTS: For prevention of intra-arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow-up treatment. A separate section details the treatment options for open and closed wounds. CONCLUSIONS: All physicians should be prepared for the eventuality of intra-arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up-to-date office-based protocol for the prevention and treatment of complications arising from intra-arterial CaHA injection.

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.

Global Consensus Guidelines for the Injection of Diluted and Hyperdiluted Calcium Hydroxylapatite for Skin Tightening.

BACKGROUND: Calcium hydroxylapatite (CaHA) is approved to correct moderate-to-severe wrinkles and folds and soft-tissue volume loss in the face and hands. More recently, subdermal injection using diluted CaHA has been used to improve skin laxity. OBJECTIVE: To review evidence for the safe and effective use of diluted CaHA in the face and body and provide best practice recommendations. METHODS: A global panel of expert aesthetic physicians convened to develop consensus-based guidelines for treating laxity and superficial wrinkles using diluted (ratio of 1:1) and hyperdiluted (≥1:2) CaHA. RESULTS: Diluted and hyperdiluted CaHA stimulates targeted neocollagenesis in the injection area to improve laxity and skin quality in the mid- and lower face, neck, décolletage, upper arms, abdomen, upper legs, and buttocks. Treatment can be used as an adjunct to volume augmentation or combined with additional modalities for optimal results. Adverse events are related to the injection and include bruising, swelling, mild pain, and induration. In thinner and darker skin, too-superficial injections of less diluted CaHA can lead to more adverse events. CONCLUSION: This report provides preliminary guidelines for the novel off-label use of CaHA for biostimulation in the face and body. Further trials will provide additional clarity regarding treatment paradigms for optimal outcomes.

Improved Neocollagenesis and Skin Mechanical Properties After Injection of Diluted Calcium Hydroxylapatite in the Neck and Décolletage:A Pilot Study.

BACKGROUND: Calcium hydroxylapatite (CaHA; Radiesse (R)) provides safe and effective correction of moderate-to-deep lines, volume replacement, lift and contour, and induction of neocollagenesis and neoelastogenesis for improved skin quality. CaHA hyperdilution takes advantage of its skin-tightening properties without a volumizing effect. OBJECTIVE: To evaluate the collagen- and elastin-stimulating effects of diluted CaHA in subjects with skin laxity in the neck and décolletage. METHODS: Twenty subjects with skin laxity in the neck and décolletage received multiple, linear, subdermal injections of CaHA diluted with preserved saline at baseline and 4 months: 1:2 dilution (normal skin), 1:4 dilution (thin skin), and 1:6 dilution (atrophic skin). Subjects also received deep subdermal injection of CaHA (~0.1 ml) of the same dilution in the peri-auricular area for skin biopsy. Biopsy tissue was obtained at baseline, 4 months, and 7 months for immunohistochemical evaluation of neocollagenesis. Changes to skin mechanical properties were measured by ultrasound scanning and cutometry. Subject and investigator satisfaction was evaluated using the Global Aesthetic Improvement Scale. RESULTS: Immunohistochemical analysis of biopsy tissue demonstrated signi cant increases in collagen I expression at 4 months (P less than 0.05) and 7 months (P less than 0.00001) compared with baseline. Increases in collagen III levels were also significant at 4 months (P less than 0.00001); they declined by 7 months but remained above baseline. Staining for elastin and angiogenesis signi cantly increased at 4 months (P less than 0.05 and P less than 0.01, respectively) and 7 months (P less than 0.00001 for both) compared with baseline. Immunohistochemical data correlated with improvements in skin elasticity and pliability evaluated by cutometry, and with ultrasound-assessed increases in dermal thickness. Subject and investigator satisfaction was high, and the procedure was well tolerated. CONCLUSIONS: Injection of diluted CaHA is very effective for skin tightening of the neck and décolletage. J Drugs Dermatol. 2017;16(1):68-74..

IncobotulinumtoxinA in aesthetics: Russian multidisciplinary expert consensus recommendations.

BACKGROUND: Although there are various international consensus recommendations on the use of botulinum neurotoxin type A (BoNT/A) in facial aesthetics, there are no global or Russian guidelines on the optimal dose of incobotulinumtoxinA, free from complexing proteins, within specific aesthetic indications. This article reports the outcomes of two expert consensus meetings, conducted to review and analyze efficacy and tolerability data for incobotulinumtoxinA in various facial aesthetic indications and to give expert consensus recommendations to ensure best clinical practice among Russian clinicians. METHODS: Thirteen dermatology and/or plastic surgery experts attended meetings held in Paris, France (November 2013), and Moscow, Russia (March 2014). The expert group reviewed and analyzed the existing evidence, consensus recommendations, and Russian experts' extensive practical experience of incobotulinumtoxinA in aesthetics to reach consensus on optimal doses, potential dose adjustments, and injection sites of incobotulinumtoxinA for facial aesthetics. RESULTS: All experts developed guidance on the optimal doses for incobotulinumtoxinA treatment of different regions of the upper and lower face. The expert panel agreed that there are no differences in the efficacy and duration of the effect between the four BoNT/As that are commercially available for facial aesthetic indications in Russia and that, when administered correctly, all BoNT/As can achieve optimal results. Experts also agreed that nonresponse to BoNT/A can be caused by neutralizing antibodies. CONCLUSION: On the basis of the scientific and clinical evidence available for incobotulinumtoxinA, coupled with the extensive clinical experience of the consensus group, experts recommended the optimal doses of incobotulinumtoxinA effective for treatment of wrinkles of the upper and lower face to achieve the expected aesthetic outcome. These first Russian guidelines on the optimal use of incobotulinumtoxinA for augmentation of glabellar lines, periorbital wrinkles, forehead lines, bunny lines, perioral wrinkles, depressor anguli oris, mentalis, masseters and platysmal bands, and performing the Nefertiti lift, are presented here.

Calcium hydroxylapatite: over a decade of clinical experience.

BACKGROUND: Calcium hydroxylapatite is one of the most well-studied dermal fillers worldwide and has been extensively used for the correction of moderate-to-severe facial lines and folds and to replenish lost volume. OBJECTIVES: To mark the milestone of 10 years of use in the aesthetic field, this review will consider the evolution of calcium hydroxylapatite in aesthetic medicine, provide a detailed injection protocol for a global facial approach, and examine how the unique properties of calcium hydroxylapatite provide it with an important place in today's market. METHODS: This article is an up-to-date review of calcium hydroxylapatite in aesthetic medicine along with procedures for its use, including a detailed injection protocol for a global facial approach by three expert injectors. CONCLUSION: Calcium hydroxylapatite is a very effective agent for many areas of facial soft tissue augmentation and is associated with a high and well-established safety profile. Calcium hydroxylapatite combines high elasticity and viscosity with an ability to induce long-term collagen formation making it an ideal agent for a global facial approach.

A randomized, split-face, histomorphologic study comparing a volumetric calcium hydroxylapatite and a hyaluronic acid-based dermal filler.

BACKGROUND: Soft-tissue augmentation with fillers is an aesthetic procedure for restoring age-related volume loss. OBJECTIVE: To compare neocollagenesis and elastin production stimulated by Radiesse® (calcium hydroxylapatite; CaHA, Merz Pharmaceuticals GmbH) and a hyaluronic acid-based filler (HA; Juvéderm® VOLUMA®). METHODS: Twenty-four women, aged 35-45, participated in this split-face, comparative study. Punch biopsies were taken 4 and 9 months after supraperiostal injection of each filler into the ipsilateral or contralateral postauricular area. Samples were analyzed for collagens type I and III, elastin, Ki-67, and inflammatory and angiogenic markers. RESULTS: At month 4, collagen type III was greater with CaHA vs HA (P=0.0052). By month 9, type I staining was higher with CaHA vs HA (P=0.0135), whereas type III was lower with CaHA than HA (P=0.0019). Staining for elastin, Ki-67 and angiogenesis was greatest with CaHA at both timepoints. Inflammatory markers increased most with HA treatment. CONCLUSIONS: CaHA resulted in more active, physiologic remodeling of the extracellular matrix than HA by stimulating a two-step process whereby collagen type I gradually replaced type III. Increased elastin stimulated by CaHA also indicates active remodeling. The results of this study suggest that, in the first 9 months after treatment, by reconstituting tissue homeostasis without inducing inflammation suggests CaHA has more desirable characteristics for a dermal filler than HA.

IncobotulinumtoxinA in esthetics.

IncobotulinumtoxinA (Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™) is a botulinum toxin type A that differs from other commercially available botulinum toxin type A preparations in that it is free from complexing proteins ([150 kDa]/NT 201). The proven efficacy of incobotulinumtoxinA in various therapeutic indications preceded its use in the field of esthetic medicine, where it is widely approved for the treatment of glabellar frown lines on the basis of positive efficacy and safety findings from a number of clinical trials. Here, we discuss the characteristics of incobotulinumtoxinA and review the clinical data supporting its use in esthetics.