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.

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.

A Prospective, Open-Label Study of Hyaluronic Acid-Based Filler With Lidocaine (VYC-15L) Treatment for the Correction of Infraorbital Skin Depressions.

BACKGROUND: Infraorbital skin depressions are one of the most troublesome facial areas for aesthetically aware patients. OBJECTIVE: Evaluate effectiveness and safety of Juvéderm Volbella with Lidocaine (VYC-15L; Allergan plc, Dublin, Ireland) for correction of bilateral infraorbital depressions. METHODS: In this 12-month, prospective, uncontrolled, open-label study, subjects aged ≥18 years with infraorbital depressions rated ≥1 on the Allergan Infra-oRbital Scale (AIRS) received injections of VYC-15L with optional touch-up treatment on Day 14. The primary efficacy measure was ≥1 AIRS grade improvement from baseline at month 1. RESULTS: Of 80 subjects initially treated with VYC-15L, 75 (94%) completed the study. All injections were intentionally deep, most using multiple microbolus technique. At 1 month, 99.3% of eyes achieved ≥1 AIRS grade improvement. The responder rate (subjects with ≥1 AIRS grade improvement in both eyes) was 99% at month 1, 92% at month 6, and 54% at month 12. Most injection site reactions (e.g., bruising, redness, irregularities/bumps) were mild and resolved by day 14. Late-onset mild to moderate edema was observed in 11% of eyes at month 6% and 4% of eyes at month 12. CONCLUSION: VYC-15L is effective and safe for the treatment of infraorbital depressions, with effectiveness lasting up to 12 months.

Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers: Focus on the Upper Face.

Techniques for the administration of injectable fillers and neuromodulators for facial aesthetic rejuvenation and enhancement continue to evolve. As the number of physicians with limited experience in providing aesthetic treatments expands, the need for guidance and training from more experienced injectors has become apparent. The use of a slow, careful, and methodical injection technique is imperative in all treatment settings and for all facial areas. Constant attention to local anatomy, particularly arteries, veins, and nerve bundles, is critical for minimizing complications. This first article of a three-part series addresses techniques and recommendations for aesthetic treatment of the upper face. Traditionally, the upper face has been considered a basic area for treatment with neuromodulators but an advanced area for treatment with fillers. Injectable fillers may be used for temple volumization, eyebrow shaping, and forehead contouring. Neuromodulators are well suited for diminishing the appearance of dynamic facial lines such as forehead, glabellar, and crow's feet lines, and eyebrow lifting and eye-aperture widening. These techniques may be used independently or together, sequentially or concurrently, to address rejuvenation of individual or multiple facial regions. Overall, this series provides a practical framework of techniques for physicians who desire to perform safe and effective aesthetic treatments using a multimodal approach.

Creation and Validation of a Photonumeric Scale to Assess Volume Deficiency in the Infraorbital Region.

BACKGROUND: The eyes are particularly important aesthetic features of the face and revitalization of the infraorbital region has become a focus of aesthetic treatments. Published infraorbital scales to date have limitations in that they have been descriptive, subjective, or have used computer-generated images. Thus, there is an unmet need for a validated scale based on actual images. OBJECTIVE: To develop a practical photonumeric scale that respects the complex anatomy and age-related changes occurring in the orbital area. METHODS AND MATERIALS: The Allergan Infra-oRbital Scale (AIRS) was developed through a multistep process in collaboration with 16 physicians (plastic surgeons, dermatologists, and aesthetic physicians). Scale development involved both online photographs and live assessments of subjects. Interrater and intrarater reliability was assessed using intraclass correlation coefficients (ICCs). RESULTS: The final AIRS showed intrarater and interrater ICCs of 0.78 to 0.86 and 0.91 to 0.98 for live validation and 0.76 to 0.82 and 0.86 to 0.91 for online validation, respectively, demonstrating robust validity. CONCLUSION: The AIRS can be considered a photonumeric scale that accurately describes volume loss in the infraorbital region. It has been validated and is appropriate for use in research or for everyday clinical use for both live and photographic assessment.

Use of a Hyaluronic Acid Soft-tissue Filler to Correct Congenital and Post-traumatic Lip Asymmetry.

BACKGROUND: The use of hyaluronic acid soft-tissue fillers for enhancement of lip features is a popular and minimally invasive office-based procedure used worldwide due to its relative simplicity and favorable safety profile. MATERIALS AND METHODS: Hyaluronic acid was used in illustrative cases to attempt correction of congenital and acquired lip asymmetries. RESULTS: In the cases presented, accurate and cosmetically acceptable results were attained and maintained for the duration of the product life. CONCLUSIONS: Hyaluronic acid may be used successfully when lip asymmetry is evident and is a relatively simple nonsurgical alternative.

Global Aesthetics Consensus: Avoidance and Management of Complications from Hyaluronic Acid Fillers-Evidence- and Opinion-Based Review and Consensus Recommendations.

BACKGROUND: Although the safety profile of hyaluronic acid fillers is favorable, adverse reactions can occur. Clinicians and patients can benefit from ongoing guidance on adverse reactions to hyaluronic acid fillers and their management. METHODS: A multinational, multidisciplinary group of experts in cosmetic medicine convened the Global Aesthetics Consensus Group to review the properties and clinical uses of Hylacross and Vycross hyaluronic acid products and develop updated consensus recommendations for early and late complications associated with hyaluronic acid fillers. RESULTS: The consensus panel provided specific recommendations focusing on early and late complications of hyaluronic acid fillers and their management. The impact of patient-, product-, and technique-related factors on such reactions was described. Most of these were noted to be mild and transient. Serious adverse events are rare. Early adverse reactions to hyaluronic acid fillers include vascular infarction and compromise; inflammatory reactions; injection-related events; and inappropriate placement of filler material. Among late reactions are nodules, granulomas, and skin discoloration. Most adverse events can be avoided with proper planning and technique. Detailed understanding of facial anatomy, proper patient and product selection, and appropriate technique can further reduce the risks. Should adverse reactions occur, the clinician must be prepared and have tools available for effective treatment. CONCLUSIONS: Adverse reactions with hyaluronic acid fillers are uncommon. Clinicians should take steps to further reduce the risk and be prepared to treat any complications that arise.

Global Aesthetics Consensus: Hyaluronic Acid Fillers and Botulinum Toxin Type A-Recommendations for Combined Treatment and Optimizing Outcomes in Diverse Patient Populations.

BACKGROUND: Combination of fillers and botulinum toxin for aesthetic applications is increasingly popular. Patient demographics continue to diversify, and include an expanding population receiving maintenance treatments over decades. METHODS: A multinational panel of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated guidelines with a worldwide perspective for hyaluronic acid fillers and botulinum toxin. This publication considers strategies for combined treatments, and how patient diversity influences treatment planning and outcomes. RESULTS: Global Aesthetics Consensus Group recommendations reflect increased use of combined treatments in the lower and upper face, and some midface regions. A fully patient-tailored approach considers physiologic and chronologic age, ethnically associated facial morphotypes, and aesthetic ideals based on sex and culture. Lower toxin dosing, to modulate rather than paralyze muscles, is indicated where volume deficits influence muscular activity. Combination of toxin with fillers is appropriate for several indications addressed previously with toxin alone. New scientific data regarding hyaluronic acid fillers foster an evidence-based approach to selection of products and injection techniques. Focus on aesthetic units, rather than isolated rhytides, optimizes results from toxin and fillers. It also informs longitudinal treatment planning, and analysis of toxin nonresponders. CONCLUSIONS: The emerging objective of injectable treatment is facial harmonization rather than rejuvenation. Combined treatment is now a standard of care. Its use will increase further as we refine the concept that aspects of aging are intimately related, and that successful treatment entails identifying and addressing the primary causes of each. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Global Aesthetics Consensus: Botulinum Toxin Type A--Evidence-Based Review, Emerging Concepts, and Consensus Recommendations for Aesthetic Use, Including Updates on Complications.

BACKGROUND: Botulinum toxin type A injection remains the leading nonsurgical cosmetic procedure worldwide, with a high rate of efficacy and patient satisfaction. METHODS: A multinational, multidisciplinary group of plastic surgeons and dermatologists convened the Global Aesthetics Consensus Group to develop updated consensus recommendations with a worldwide perspective for botulinum toxin and hyaluronic acid fillers. This publication on botulinum toxin type A considers advances in facial analysis, injection techniques, and avoidance and management of complications. RESULTS: Use of botulinum toxin has evolved from the upper face to also encompass the lower face, neck, and midface. The Global Aesthetics Consensus Group emphasizes an integrative, diagnostic approach. Injection dosage and placement are based on analysis of target muscles in the context of adjacent ones and associated soft and hard tissues. The indication for selection of botulinum toxin as a primary intervention is that excessive muscular contraction is the primary etiology of the facial disharmony to be addressed. Global Aesthetics Consensus Group recommendations demonstrate a paradigm shift toward neuromodulation rather than paralysis, including lower dosing of the upper face, more frequent combination treatment with hyaluronic acid fillers, and intracutaneous injection where indicated to limit depth and degree of action. CONCLUSIONS: The accumulation of clinical evidence and experience with botulinum toxin has led to refinements in treatment planning and implementation. The Global Aesthetics Consensus Group advocates an etiology-driven, patient-tailored approach, to enable achievement of optimal efficacy and safety in patient populations that are rapidly diversifying with respect to ethnicity, gender, and age. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

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.

A manual therapy intervention improves symptoms in patients with carpal tunnel syndrome: a pilot study.

In carpal tunnel syndrome (CTS), manual therapy interventions (MTI) reduce tissue adhesion and increase wrist mobility. We evaluated the efficacy of a MTI in relieving CTS signs and symptoms. Twenty-two CTS patients (pts) (41 hands) were treated with a MTI, consisting in 6 treatments (2/week for 3 weeks) of soft tissues of wrist and hands and of carpal bones. Pts were assessed for hand sensitivity, paresthesia, hand strength, hand and forearm pain, night awakening; Phalen test, thenar eminence hypotrophy and Boston Carpal Tunnel Questionnaire (BCTQ) Symptom Severity Scale (SSS) and Functional Status Scale (FSS). Median nerve was studied by sensory nerve conduction velocity (SNCV) and distal motor latency (DML). CTS was scored as minimal, mild, medium, severe and extreme. We considered as control group the same pts assessed before treatment: at baseline (T0a) and after 12 weeks (T0b). Pts were evaluated at the end of treatment (T1) and after 24-week (T2) follow-up. At T0b, versus T0a, forearm pain and Phalen test positivity were increased and hand strength reduced (p < 0.05). BCTQ-SSS and BCTQ-FSS scores improved at T1 versus T0b (p < 0.05) with the amelioration maintained at T2. At T1, the number of pts with paresthesia, night awakening, hypoesthesia, Phalen test, hand strength reduction and hand sensitivity was reduced with the lacking of symptoms maintained at T2 (p < 0.05). No changes in SNCV, DML and CTS scoring were shown. MTI improved CTS signs and symptoms, with benefits maintained at follow-up. Thus, it may be valid as a conservative therapy.

Combating photoaging with percutaneous collagen induction.

Medical clinicians are used to being consulted by patients who want to restore their youthful appearance. Although structural changes to the face and body may be achieved with surgery, for example, face lifts, the impression of youth also relies heavily on young-looking skin. It is desirable to have thicker and tighter skin to properly fulfill the desire for youth. Percutaneous collagen induction offers an antiaging effect to improve the appearance of old skin. It allows us to improve our patients' skin from the inside outward as well as from the surface. Experience has shown that percutaneous collagen induction works optimally when combined with a scientific skin care program to restore a youthful appearance. In addition, the same technique has proven to be very effective in minimizing acne scars and burn scars by removing scar collagen and replacing it with normal collagen. Consequently, scar contractures and depressed scars are improved. With the introduction of percutaneous collagen induction therapy in 1997, a simple and fast method was developed with regard to safely treating wrinkles and scars and producing lasting smoothness. As opposed to ablative laser treatments, the epidermis remains intact and is not damaged. For this reason, the operation can be safely repeated if needed, and it can be also applicable to regions where laser treatments or deep peelings cannot be done.

Clinical evaluation of a new self-drying silicone gel in the treatment of scars: a preliminary report.

Topical silicone gel sheeting and intralesional steroids are the only evidence-based recommendable forms of treatment to control the quality of a scar. The advantages and disadvantages of both are well known. This study was undertaken to verify the efficacy of a new topical silicone treatment: a self-drying spreadable gel that needs no means of fixation and cannot be seen because of complete transparency. Fresh surgical scars treated with the tested product showed significantly better outcomes than those untreated in a prospective trial involving a group of 160 patients. Patient compliance was particularly good, especially for scars on exposed areas such as the face, where the traditional gel sheeting is frequently discontinued at an early stage by patients who object to its visibility. The results of the self-drying silicone gel have indeed been satisfactory. Considering the effective results obtained and the good patient compliance, the authors currently rate this concept of treatment as the first choice for preventing hypertrophy of recent scars.

Intense pulsed light treatment of 1,000 consecutive patients with facial vascular marks.

BACKGROUND: Facial teleangectasias or vascular marks often represent a very cosmetically detracting problem for the affected patient, who tries to cover the lesions by camouflage strategies. This study describes the response of these vascular lesions after an intense pulsed light source was used on 1,000 consecutive patients. METHODS: Between October 1998 and April 2005, 1,000 consecutive patients with various skin types (Fitzpatrick I to IV) were treated with Photoderm VL. The average age of the patients was 47.1 years. These patients were subjected to a mean of 2.16 treatments (range, 1-9), then followed up 48 h, 72 h, 1 week, 3 weeks, and 1 month after each treatment. All the patients were followed up 2 months after the last treatment, and the percentage of clearance was assessed by comparison of pre- and posttreatment photographs. The patients also answered a questionnaire in which they expressed personal satisfaction. The final physicians-nurse evaluation also was recorded on the same form. RESULTS: Most of the patients (89.70%) experienced a clearance of 75% to 100%. The results appear to be correlated with operator experience, but not with lesion size, age, or skin type. Minimal adverse side effects occurred for 14.6% of the patients, but only for 6.76% of the treatments. CONCLUSION: The intense pulsed light source Photoderm VL can be considered a fast, safe, and effective treatment for facial teleangectasias or vascular marks.

Facial teleangectasias: our experience in treatment with IPL.

BACKGROUND AND OBJECTIVES: Facial teleangectasias can be a relevant cosmetic problem, which the patient usually hides with a thick layer of makeup. This study will describe the response on these vascular lesions using the intense pulsed light (IPL) source. METHODS: Five hundred eighteen consecutive patients were treated with Photoderm VL (Lumenis Ltd.). The average age of patients of various skin types (Fitzpatrick I to IV) was 48.5 years. They were subjected to a mean of 1.69 treatments (range 1-9) followed up 48 hours, 72 hours, 1 week, 3 weeks, and 1 month after each treatment. All patients were followed up after 2 months from the last treatment and the percentage of clearance was assessed by comparing pre- and post-treatment photographs. The patients also answered a questionnaire in which they expressed personal satisfaction. The physicians evaluation was also recorded on the same form. RESULTS: Patients (87.64%) presented a clearance of 75%-100%. The results appear not correlated with lesions size, age, skin type but with operator experience. Minimal side adverse effects occurred in 20% of the patients. CONCLUSION: The IPL source, Photoderm VL, can be considered an alternative or a supplement to the existing laser devices for facial teleangectasias treatment.