Treating Glabellar Lines With Botulinum Toxin: Does Your Patient Need to Frown Steadily?

BACKGROUND: The variable relationship between the orbicularis supercilii and frontalis muscles may cause side effects with botulin toxin; steadily frowning is the usual recommendation. Eliminating the need to frown until all injections are over might enhance efficacy and lessen the neurotoxicity risks related to muscle exhaustion. OBJECTIVES: The goal of this study was to investigate whether the digital caliper-assessed distances between the medial and lateral corrugator injection sites and the midline differed significantly in patients persistently frowning from patients resting. METHODS: Seventy-six individuals with glabellar wrinkles treated with botulinum toxin in the authors' private practices for glabellar lines voluntarily contributed their retrospective data about the positions of injection sites. The investigators had freely chosen to inject the medial and lateral sections of the corrugator supercilii during persistent maximum frown or at rest. RESULTS: The mean differences in distances between the medial and lateral injection points and the estimated midline were clinically trivial (1.0 ± 1.28 and 1.5 ± 2.53 mm, respectively), although the distances between the relaxed and contracted medial and lateral injection sites exceeded 1.8 and 2.5 mm in 33.9% and 46.4% of patients, respectively. Distance differences, not significant before 40 years old, were statistically significant only for the lateral injections in older patients (on average, 1.9 ± 3.01 mm). CONCLUSIONS: The average distances from the medial and lateral injection points and the midline appear minimally different in patients who frown until all injections are over and, conversely, patients who rest. Persistently frowning might be advisable only in patients older than 40. Facial asymmetries may be a confounding factor.

Eyebrow lifting with barbed threads: A simple, safe, and effective ambulatory procedure.

INTRODUCTION: Changes in brow positioning are one of the first facial aging signs. A more beautiful and younger look can be achieved by repositioning the tissues involved in brow descent and sagging eyelids. METHODS: We report the outcome of eyebrow thread lifting in a series of patients who came to our clinic to improve their gaze. Response to treatment was assessed at 6- and 12-months using FACE-Q™ upperlids and eyebrow/forehead scales. RESULTS: A total of 38 patients with mild-to-moderate brow ptosis or without ptosis underwent eyebrow thread lifting (mean age 35.5, all female). No serious complications were observed during or after treatment. All patients were satisfied with the outcome of the intervention. Mean FACE-Q™ scores improved at six months compared with baseline. A statistically significant increase in mean FACE-Q™ scores was still seen at 12 months and was more evident in younger women. Patients were able to go back to their daily lives the day after the procedure. CONCLUSION: Eyebrow thread lifting is a minimally invasive procedure able to overcome mild-to-moderate ptosis with excellent aesthetic results. In the absence of ptosis, thread lifting is a good choice to reposition the brow and improve the gaze. The technique is simple to perform and safe.

The Rheology and Physicochemical Characteristics of Hyaluronic Acid Fillers: Their Clinical Implications.

Hyaluronic acid (HA) fillers have become the most popular material for facial volume augmentation and wrinkle correction. Several filler brands are currently on the market all around the world and their features are extremely variable; for this reason, most users are unaware of their differences. The study of filler rheology has become a wellspring of knowledge, differentiating HA fillers, although these properties are not described thoroughly by the manufacturers. The authors of this review describe the more useful rheological properties that can help clinicians understand filler characteristics and the likely correlation of these features with clinical outcomes.

OnabotulinumtoxinA from lines to facial reshaping: A new Italian consensus report.

BACKGROUND: Botulinum neurotoxin type A is the most widely used nonsurgical treatment for esthetic improvement of the face and neck. In 2015, an Italian consensus panel met to discuss the optimal methods for using onabotulinumtoxinA. However, clinical practice continues to evolve and the original report is now considered obsolete. AIMS: To provide updated guidance on the esthetic uses of onabotulinumtoxinA in the face and neck. METHODS: A panel of 10 Italian specialists (including plastic and maxillofacial surgeons, dermatologists, and esthetic doctors) individually completed a questionnaire on their own clinical practice, and then met to discuss their responses and agree on a revised treatment consensus. RESULTS: Recommendations are provided on patient assessment, reconstitution of onabotulinumtoxinA, and preferred procedures (injection sites, doses, anatomical targets, safety precautions, etc.) across a variety of treatment areas, including glabellar, crow's feet, and forehead lines; brow lifting and shaping; lower eyelid hypertrophy; bunny lines; sagging nasal tip; gummy smile; masseter hypertrophy; perioral lines; marionette lines and "sad mouth;" mentalis hypertonia; and platysma bands. Some of the recommended doses are substantially increased from the previous consensus (particularly in the upper third and masseter) for the purpose of achieving longer lasting results without affecting safety. Furthermore, two increasingly popular techniques-the Nefertiti lift and Microbotox-are included in the consensus for the first time. CONCLUSIONS: Optimal practice with onabotulinumtoxinA requires a systematic approach to maximize safety and effectiveness across the range of potential uses. The present consensus was developed to support these aims.

A Review on the Combined Use of Soft Tissue Filler, Suspension Threads, and Botulinum Toxin for Facial Rejuvenation.

The aim of combining different minimally invasive techniques is to achieve the most harmonious and most natural-looking facial rejuvenation as effectively and as safely as possible. Due to their safety and versatility, botulinum toxin and soft tissue fillers have become the most sought-after modalities for correcting the signs of facial aging. Recently, bioabsorbable threads used for repositioning ptotic facial tissue have been added into the picture. More practitioners are also combining threads with fillers and botulinum toxin to achieve longer-lasting and natural-looking results. Our aim is to provide guidance on basic anatomical landmarks and areas where botulinum toxin injections, subcutaneous filler injections, and bioabsorbable suspension threads are placed on the face. We would also like to share our best practices on the best combination, spacing the appropriate time intervals in between each procedure to allow for the shortest possible recovery time, as well as periprocedural advice for an integrated treatment approach.

Absorbable Barbed Threads for Lower Facial Soft-Tissue Repositioning in Asians.

INTRODUCTION: Asian patients often seek to address lower facial aging through clinical interventions that increase anterior projection and jawline contouring. The Definisse™ (also known as Happy Lift™) thread lift treatment uses barbed absorbable threads to suspend tissues and induce biostimulation. We evaluated the efficacy and safety of absorbable barbed threads for lower facial reshaping in Thai patients. METHODS: This prospective, evaluator-blinded study enrolled 27 Thai patients diagnosed with mild to moderate facial laxity. Patients underwent thread implantation along the mandibular angle with one of two double needle thread lengths (12 and 23 cm) to create a "J stitch". Primary outcome was the clinical improvement in facial laxity as graded by two blinded dermatologists at baseline, immediately after treatment, and at 1 week and 1, 2, 3, 6, and 12 months follow-up. Objective measurements included volume in the jawline, nasolabial folds, and submental area. Patients' self-assessment scores and adverse reactions were recorded. RESULTS: Of the 27 patients recruited to the study, 25 (92.6%) attended all follow-up visits. Clinical improvement of facial laxity was observed immediately after thread implantation. There was significant volume improvement in the jawline, nasolabial folds and submental area at almost all follow-up visits (p < 0.007), with most patients (51.9%) reporting excellent lifting effect as early as the 1 week follow-up visit. All adverse reactions were mild and resolved spontaneously without any medical intervention. CONCLUSION: Implantation of absorbable barbed threads is a safe and effective treatment for facial rejuvenation in Thai patients. Long threads (23 cm) showed a slight superiority to short threads (12 cm) in terms of face-lifting efficacy, which suggests the benefit of additional barbs in tissue suspension and biostimulation. The disadvantage of absorbable threads is that their visible lifting effects are not as long-lasting as those of non-absorbable ones, since they are reabsorbed from 6 months onwards. TRIAL REGISTRATION: ClinicalTrials.gov identifier: TCTR20210415001. This clinical trial was retrospectively registered 12 April 2021.

Expert Consensus on Soft-tissue Repositioning Using Absorbable Barbed Suspension Double-needle Threads in Asian and Caucasian Patients.

Bioabsorbable barbed suspension double-needle threads have recently been thrust into the limelight as a minimally invasive alternative for skin repositioning. When compared to surgical face lifting, use of these threads requires reduced procedural and recovery time, no general anesthesia, confers immediate patient satisfaction, with no cutaneous incisions and no apparent scars, and is more tolerable. There is currently limited literature providing clinical guidance on the use of these suspension threads; hence, this consensus document was developed as the first publication to discuss the technical aspects of facial rejuvenation using the double-needle barbed bioabsorbable and hydrolyzable thread composed of copolymer poly (ε-caprolactone-co-L-lactic acid) or PCxLyA, that is, Definisse threads. The Board of Aesthetic Leaders and Investigators (BALI) is a panel of dermatologic surgery and plastic surgery experts who convened last July 2018 in Indonesia to discuss the aforementioned challenges. A thorough literature search was done where a review of specific technical recommendations based on prevailing practice and available guidelines pertaining to suspension threads were described and are summarized in this paper. A detailed list of pretreatment recommendations in the assessment of both Asian and Caucasian facial types, aging facial types, guidance on insertion techniques, and aftercare instructions for clinicians to review has been included here.

Evaluation of the Rheologic and Physicochemical Properties of a Novel Hyaluronic Acid Filler Range with eXcellent Three-Dimensional Reticulation (XTR™) Technology.

Soft-tissue fillers made of hyaluronic acid and combined with lidocaine have recently become a popular tool in aesthetic medicine. Several manufacturers have developed their own proprietary formulae with varying manufacturing tools, concentrations, crosslinked three-dimensional network structures, pore size distributions of the fibrous networks, as well as cohesivity levels and rheological properties, lending fillers and filler ranges their unique properties and degradability profiles. One such range of hyaluronic acid fillers manufactured using the novel eXcellent three-dimensional reticulation (XTR™) technology was evaluated in comparison with other HA fillers and filler ranges by an independent research laboratory. Fillers manufactured with the XTR™ technology were shown to have characteristic rheological, crosslinking and biophysical factors that support the suitability of this filler range for certain patient profiles.

Italian consensus report on the aesthetic use of onabotulinum toxin A.

BACKGROUND: The aesthetic treatment of facial and neck wrinkles with botulinum toxin is constantly increasing, thus making it necessary to collect procedures guidelines for the use of botulinum toxin in the treatment of wrinkles and/or cosmetic defects. METHODS: A group of nine Italian doctors, plastic and maxillo-facial surgeons, dermatologists and aesthetic physicians, experts in face and neck aesthetic treatments with onabotulinum toxin A, discussed on procedures used in their clinical practice. From the data collected and discussed by the board, some recommendations on aesthetic treatment with onabotulinum toxin A were developed. RESULTS: Recommendations have been made on pretreatment, reconstitution of onabotulinum toxin A, as well as on treatment procedures, in terms of injection sites and total dose of onabotulinum toxin A for the following indications: glabellar lines, crown's feet lines, forehead lines, eyebrow shaping, lower orbicularis oculi hypertrophy, bunny lines, sagging nasal tip, gummy smile, masseter hypertrophy, perioral lines, marionette lines, hypertonic mentalis, and platysma bands. CONCLUSIONS: The use of onabotulinum toxin A in the aesthetic field requires careful initial assessment of the patient in its complexity and individuality. Moreover, this treatment needs the use of standardized procedures to achieve the effectiveness and safety of onabotulinum toxin A in clinical practice.

Safety of botulinum toxin A in aesthetic treatments: a systematic review of clinical studies.

BACKGROUND: The use of botulinum toxin A (BoNT-A) for aesthetic treatments is growing steadily, and new safety data have been reported in recently published studies. OBJECTIVE: To investigate the safety data on the use of the three BoNT-A formulations approved for facial aesthetics from recent studies and to confirm their safety profiles. METHODS: The literature search was conducted using three online databases restricted to the timeframe from January 2000 to June 2012. Only clinical trials, randomized or open label, with safety as the primary or secondary endpoint, were included. RESULTS: Thirty-five papers were selected, with a total of subjects 8,787 studied. OnabotulinumtoxinA was used in 60.0% of the studies, abobotulinumtoxinA in 37.1%, and incobotulinumtoxinA in 2.8%. The glabella was the most investigated area (51.4%), followed by the upper face (25.7%), crow's feet (11.4%), and lower face (11.4%). Treatment-related adverse events were blepharoptosis (2.5%), brow ptosis (3.1%), and eye sensory disorders (3%) in the upper face and lip asymmetries and imbalances in the lower face (6.9%). All of these events resolved spontaneously. CONCLUSION: The short-term safety profile of BoNT-A in cosmetic nonsurgical procedures was confirmed for all the three commercial formulations.