Impact of Comprehensive, Minimally Invasive, Multimodal Aesthetic Treatment on Satisfaction With Facial Appearance: The HARMONY Study

Higher Responder Rates Observed With Live Participant Assessment Versus Photographic Assessment After VYC-20L Hyaluronic Acid Treatment for Chin Augmentation

BACKGROUND

In an evaluator-blinded, randomized controlled trial, the hyaluronic acid soft-tissue filler VYC-20L injectable gel was safe and effective for correcting volume deficits and retrusion in the chin.

OBJECTIVES

The objective of this subanalysis was to compare responder rates obtained with photographic vs live assessments.

METHODS

Participants were randomized 3:1 to VYC-20L treatment or a 6-month, no-treatment control period followed by optional treatment. Responder rates (≥1-point improvement from baseline on the validated Allergan Chin Retrusion Scale [ACRS]) obtained with photographic assessments and live assessments at Month 6 were compared. Prespecified subgroup analyses compared responder rates by baseline ACRS severity, filler volume, cannula usage, and investigation site.

RESULTS

VYC-20L was effective for chin augmentation as evaluated with both live and photographic assessments. The ACRS responder rates at Month 6 were 91.8% with live assessments and 56.3% with photographic assessments. Consistently higher response rates were observed by live vs photographic assessment regardless of baseline ACRS severity, filler volume, cannula usage, and investigation site.

CONCLUSIONS

Live assessment of ACRS response after VYC-20L treatment resulted in higher responder rates than photographic assessment, supporting the use of live assessment for this indication to approximate real-world clinical practice.

LEVEL OF EVIDENCE: 1

From Nasolabial Folds to Pan-facial Rejuvenation-The Evolution of Fillers in my Career

This is a comprehensive review of facial fillers including landmark studies and expert commentary spanning the years from 2003 (when the first hyaluronic acid [HA] dermal filler underwent Food and Drug Administration approval in United States) to present.

Global facial rejuvenation with one treatment of incobotulinumtoxinA, hyaluronic acid, and calcium hydroxyapatite results in long-term patient-reported satisfaction

Background

Global facial rejuvenation using injectables (neuromodulators and fillers) has reported patient satisfaction after 2 treatments: an initial and touch-up treatment at 2-4 weeks afterward. In practice, patients typically receive only 1 treatment and do not return for a touch-up treatment within a month.

Objective

The purpose of this study was to assess patient-reported satisfaction after only 1 treatment, thus mimicking real-world scenarios.

Methods

Patients with facial photoaging (Glogau facial aging scale ≥2) were treated with calcium hydroxyapatite, hyaluronic acid 22.5 mg/mL, and incobotulinumtoxinA injections for full facial rejuvenation, with no touch-up treatments. Patients completed the FACE-Q Satisfaction with Facial Appearance survey at baseline and 1- and 3-month post-treatment. The treating physician completed the Global Aesthetic Improvement Scale at 1- and 3-month post-treatment.

Results

Twenty-two patients were enrolled in the study, with 1 patient lost to follow-up. There was a significant improvement in mean FACE-Q scores at 1-month (80.1, P = .01) and 3-month (77.9, P = .02) compared to baseline (71.4). Mean Global Aesthetic Improvement Scale scores at 1-month (2.1) and 3-month (2.2) were not statistically significant, indicating sustained improvement at 3 months. The product amount used per patient varied and was not correlated with either score. Limitations included a lack of a control group and follow-up ending at 3 months. Strengths included assessment of patient satisfaction after only 1 treatment, compared to other studies allowing 2 treatments.

Limitations

Limitations include a small sample size and lack of a control group.

Conclusion

Global full facial rejuvenation using 1 treatment of calcium hydroxyapatite, hyaluronic acid 22.5 mg/mL, and incobotulinumtoxinA provides sustained patient-reported satisfaction at 3 months.

Applying the MD Codes™ to Treat Emotional and Social Attributes with HA Fillers: A Retrospective Serial Case Study

Background

Aesthetic treatment directed at improving facial emotional messages and social attributes may maximize patient satisfaction with treatment results. The MD Codes™ is an approach to facial aesthetic treatment that accounts for emotional messages and social attributes while minimizing variability in patient assessment, injection technique, injection sites, and treatment outcomes.

Objective

To assess the impact of the MD Codes systematic treatment approach on emotional and social attributes and natural appearance after facial aesthetic treatment with hyaluronic acid (HA) fillers.

Methods

A retrospective analysis was performed in patients treated with 12 mL of HA fillers (Juvéderm® Vycross™ products) per patient using the MD Codes. Study injectors, experienced clinician observers, clinical staff, laypeople, and patients evaluated impact of treatment on emotional and social attributes and natural appearance based on pre- and post-treatment photographs of patients.

Results

Twelve patients and 49 external observers, from 12 countries, evaluated the images. More than 90% of patients named "eye bags" as the facial area most in need of aesthetic treatment; >55% of external observers identified "cheeks." The top 3 facial emotional attributes noted by all evaluators after treatment were, in order, "less tired", "less saggy", and "younger." All patients reported a visible and positive change in emotional attributes except for "less sad." After 9 months, most patients reported looking "less tired" (n=11/12), "less saggy" (n=8/12), and "less sad" (n=6/12). At months 6 and 9, all patients rated their appearance as natural looking. At least 90% of external observers considered the frontal view results natural for all but 1 patient. Patients reported improved positive social attributes (eg, "looking friendlier") and improvements in well-being after treatment. No serious side effects were reported.

Conclusion

Implementing the MD Codes for facial aesthetic treatment may improve facial emotional attributes as well as enhance social attributes and well-being, with natural-looking results.

Decades of beauty: Achieving aesthetic goals throughout the lifespan

BACKGROUND

Several elements, including age, influence judgments of beauty and attractiveness. Aging is affected by intrinsic factors (e.g., genetics, race/ethnicity, anatomical variations) and extrinsic factors (e.g., lifestyle, environment).

AIMS

To provide a general overview of minimally invasive injectable procedures for facial beautification and rejuvenation to meet the aesthetic goals of patients across their lifespan, organized by decade.

METHODS

This case study review describes aesthetic considerations of females in their third to sixth decade of life (i.e., 20-60 years of age or beyond). Each case study reports the treatments, specifically botulinum toxin type A and soft tissue fillers, used to address aesthetic concerns.

RESULTS

Signs of aging, as well as aesthetic goals and motivations, vary by age groups, cultures, and races/ethnicities. However, there are overarching themes that are associated with each decade of life, such as changes in overall facial shape and specific facial regions, which can be used as a starting point for aesthetic treatment planning. Appropriate patient selection, thorough aesthetic evaluation, product knowledge, and injection technique, as well as good physician-patient communication, are essential for optimal treatment outcomes.

CONCLUSIONS

Nonsurgical facial injectable treatments can successfully enhance and rejuvenate facial features across different age ranges. A comprehensive understanding of facial aging and the aesthetic considerations of patients by the decade contributes to optimal treatment planning and maintenance.

Cosmetic Injectable Treatments Improve Quality of Life in Patients With Multiple Serious Medical Comorbidities

Full facial rejuvenation with multi-modal cosmetic treatments can improve quality of life, leading to improvement in confidence and psychological function. These combination treatments are frequently administered at the same or sequential sessions and include neuromodulators and fillers. In patients with significant recent weight loss and other medical comorbidities, these treatments can help restore self-confidence and provide the encouragement they need to continue treatment for their comorbidities. We present a case report of a 71-year-old woman who experienced significant weight loss of 40 lbs (33% body weight) during the course of treatment of multiple medical comorbidities, including surgical intervention for compression fractures. Due to her facial appearance caused by this excessive weight loss, she experienced poor self-esteem as measured by the FACE-Q scales. She was treated cosmetically with 21cc of hyperdilute calcium hydroxyapatite (diluted in a 1:3 ratio; 7cc of calcium hydroxyapatite total) and neuromodulators to replace lost facial volume over three visits. At three months after her last treatment, her FACE-Q scores improved two-and-a-half-fold and fivefold on the psychological function and aging appraisal, respectively. Cosmetic treatments can dramatically improve the quality of life in patients with multiple medical co-morbidities. This population of patients is often excluded from clinical trials or other studies, representing a population for which we have little data on the efficacy of cosmetic treatments.

Surgical or Nonsurgical Facial Rejuvenation: The Patients' Choice

Background

Patients seeking a pan-facial rejuvenation may not receive appropriate medical advice on surgical versus nonsurgical treatments, resulting in those who are best-suited for surgery receiving nonsurgical options, and vice versa. Patients who requested total-face, nonsurgical revitalization were surveyed to understand the factors influencing this decision-making.

Methods

Patients consulting for total facial rejuvenation were surveyed on their reasons for seeking nonsurgical versus surgical interventions by an investigator with 30 years of plastic surgery experience, practicing in a nonsurgical clinic alongside a dermatologist and aesthetic physician.

Results

Of the 92 patients surveyed, 78% completed the survey, 47% of whom had considered facelift surgery, and 14% of whom proceeded to inquiries or consultations with a plastic surgeon about facelift surgery. All respondents were women, and age was not an exclusion factor. Forty-four percent would still consider facelifts in later life. Among the most common reasons for choosing nonsurgical approaches were a desire for natural and subtle results, cost, having flexibility in treatment choice, concerns about surgical and anesthesia risks, downtime, the ability to distribute treatments over time, and scarring.

Conclusions

Many patients book nonsurgical treatments without prior professional advice, and consider these as a temporary solution, but may desire surgery later in life. Before conducting nonsurgical treatments, doctors should identify this group and avoid interventions that may interfere with optimal surgical outcomes later. Also, some patients desire surgical outcomes when surgery is not a feasible option, and thus seek nonsurgical alternatives. For this group, realistic goals must be set before treatment to avoid disappointment.

Best Practices for FACE-Q Aesthetics Research: A Systematic Review of Study Methodology

BACKGROUND

The FACE-Q Aesthetics module is a validated patient-reported outcome measure (PROM) that evaluates perspectives on facial aesthetic treatments. Improper administration and poor study methodology can compromise the validity and interpretation of this PROM.

OBJECTIVES

This systematic review sought to evaluate the administration and scoring of the FACE-Q Aesthetics scales within the literature.

METHODS

A search of Ovid Medline, Embase, Cochrane, and Web of Science was performed on December 20, 2022, with the assistance of a health-research librarian (CRD42022383676). Studies that examined facial aesthetic interventions using the FACE-Q Aesthetics module as a primary or secondary outcome measure were included for analysis.

RESULTS

There were 114 studies included. The Face Overall (n = 52, 45.6%), Psychological (n = 45, 39.4%), and Social (n = 43, 37.7%) scales were most frequently reported. Errors in FACE-Q administration were identified in 30 (26.3%) studies. The most common error was the presentation of raw ordinal scores rather than the converted Q score (n = 23). Most studies reported a time horizon for their primary analysis (n = 76, 66.7%); however, only 4 studies provided a rationale for this selection. Sample size calculations for the primary outcome were rarely performed (n = 9, 7.9%).

CONCLUSIONS

There continues to be limitations in PROM administration and the quality of articles that report FACE-Q Aesthetic scale data. The authors suggest that future investigators using the FACE-Q refer to the User's Guide regarding administration and scoring of this scale, report a rationale for the study time horizon, and provide an a priori sample size calculation for the primary outcome of interest.

Treatment of crow's feet lines and forehead lines with Botox (onabotulinumtoxinA): Development, insights, and impact

Extrinsic and age-related intrinsic factors contribute to the development of facial lines, including lateral canthal lines (called crow's feet lines [CFL]) and horizontal forehead lines (FHL). OnabotulinumtoxinA is a highly effective treatment for facial lines that inhibits acetylcholine release at the neuromuscular junction. This temporary chemical denervation leads to localized muscle relaxation and subsequent wrinkle reduction. Early studies of onabotulinumtoxinA treatment for facial neuronal disorders such as dystonia documented improvements in FHL and CFL. After the neurotoxin was approved for treating frown lines (glabellar lines [GL]), individuals requested treatment for other rhytids, and physicians continued assessing use in new areas. Once onabotulinumtoxinA was in clinical trial development, its efficacy and safety for CFL and FHL were successively evaluated as required by the US Food and Drug Administration and by key global health authorities, including those in the European Union, Japan, and China. Allergan, collaborating with leading physicians, established clinical programs that included novel safety and efficacy measures to meet regulatory requirements. Global, phase 3, randomized, controlled studies of CFL and FHL met rigorous primary endpoints. Some countries mandated clinical trial data beyond US and European regulations, and Allergan conducted 11 studies in total, fulfilling diverse regulatory and study population data requirements. Adverse events associated with local spread, including brow and eyelid ptosis, diplopia, headache, and eyelid sensory disorder, were infrequent and well tolerated. Consequently, onabotulinumtoxinA treatment of upper facial lines is now established globally as a highly effective, minimally invasive treatment for patients to achieve a natural appearance and look younger.

Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck

Background

Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited.

Objective

Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment.

Methods

Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference.

Results

Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach.

Conclusion

The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Evidence-Based Medicine for Lower Facial Rejuvenation

Lower facial rejuvenation is an expanding area in facial plastic surgery with both surgical and nonsurgical treatment options. Evidence-based medicine is essential to providing high-quality care and creating long-lasting results. A systematic approach and understanding of the layers of the aging lower face is important to develop an individualized treatment plan. This review will focus on surgical and nonsurgical treatments for the aging lower face with an emphasis on evidence-based medicine.

Evidence-Based Medicine for Nonsurgical Facial Rejuvenation

Options for nonsurgical facial rejuvenation treatment have increased significantly in both availability and popularity over the past two decades. However, there remains a paucity of clinical practice guidelines and evidence-based recommendations for these procedures. The purpose of this article is to assess the presence of current high-level research for various methods of nonsurgical facial rejuvenation using the Oxford Centre for Evidence-Based Medicine. Botulinum toxin injections remain the best-studied method, with several randomized controlled trials guiding recommendations for safety and efficacy. Several studies on injectable fillers document complications and recommendations to avoid these, but sample sizes are small and many are noncomparative. Deoxycholic acid has been well examined and Food and Drug Administration approved to address submental fat but has not been studied in other areas of the face. Although chemical peels, laser skin resurfacing, energy-based facial rejuvenation, microneedling, and platelet-rich plasma have a variety of facial rejuvenation applications with minimal side effect profiles, there is significant variability with treatment protocols, outcomes measures, and randomized controlled trials with extended follow-up to develop clinical practice guidelines.

Satisfaction outcomes for patients and physicians following use of a new hyaluronic acid fillers

BACKGROUND

The aesthetic appearance of the skin, with the emergence of wrinkles, blemishes, and infraorbital hollowing, can be a cause of social distress and is a process exacerbated by aging. The presence of skin imperfections and aging is partly due to a loss of hyaluronic acid (HA), which normally contributes to a maintain a healthy and voluminous skin. Attempts to restore volume and revert the signs of aging have therefore focused on the use of dermatologic fillers based on HA.

AIM

Here, we tested the safety and efficacy of MelHA®-Monophasic Elastic Hyaluronic Acid (Concilium FEEL® filler products) containing HA at different concentrations and injected at different sites according to recommendations.

METHODS

Five different physicians assessed 42 patients across five different medical facilities in Italy, where they performed the treatment and assessed the patients after a follow-up visit. Safety and efficacy of the treatment and change in quality of life after treatment were evaluated with two surveys, one directed to medical personnel, and one directed to patients.

RESULTS

Our results show that, across all products and personalized treatments, patients', physicians' and "independent photography reviewer" satisfaction was very high and that the treatment show a favorable safety profile.

CONCLUSION

These results are promising and suggest the use of Concilium Feel® filler products can contribute to an increased self-esteem and quality of life in aging patients.

Intraorbital Fixation Midface Lift

BACKGROUND

Subperiosteal midface lift provides a comprehensive solution to the soft tissue component of midfacial aging. However, midfacial aging also has a skeletal component that is rarely addressed with conventional mid-facelift techniques. Moreover, many of the adverse outcomes after a mid-facelift are closely related to failures and limitations of mid-face fixation. The author's technique was designed to overcome these limitations.

OBJECTIVES

The author aimed to describe the rationale, technical details, and outcomes of the author's mid-facelift technique with intraorbital fixation.

METHODS

This study was a retrospective review of 82 nonconsecutive cases where the intraorbital fixation mid-facelift was performed by the author between September 2016 and December 2021. Patient data were obtained from patient records and standardized photography. Preoperative differences in mid-face volume were assessed utilizing the Allergan midface volume deficit scale on standardized photography.

RESULTS

The average mid-face volume deficit score significantly improved after surgery. Failure of fixation, flat midface deformity, and relapse of mid-face ptosis were not seen in any of the primary patients. Infraorbital hollow did not recur in any of the patients operated on with this technique. None of the primary patients (0/58) in this series developed ectropion or permanent lower eyelid malposition.

CONCLUSIONS

Intraorbital fixation mid-face lift is an effective and durable surgical option for the treatment of midfacial aging. The technique is applicable in problem cases such as negative vector patients, negative canthal tilt patients, male patients with large bags, and secondary lower blepharoplasties where conventional techniques tend to fail.

The Use of the FACE-Q Aesthetic: A Narrative Review

INTRODUCTION

In the past decade there has been an increasing interest in the field of patient-reported outcome measures (PROMs) which are now commonly used alongside traditional outcome measures, such as morbidity and mortality. Since the FACE-Q Aesthetic development in 2010, it has been widely used in clinical practice and research, measuring the quality of life and patient satisfaction. It quantifies the impact and change across different aspects of cosmetic facial surgery and minimally invasive treatments. We review how researchers have utilized the FACE-Q Aesthetic module to date, and aim to understand better whether and how it has enhanced our understanding and practice of aesthetic facial procedures.

METHODS

We performed a systematic search of the literature. Publications that used the FACE-Q Aesthetic module to evaluate patient outcomes were included. Publications about the development of PROMs or modifications of the FACE-Q Aesthetic, translation or validation studies of the FACE-Q Aesthetic scales, papers not published in English, reviews, comments/discussions, or letters to the editor were excluded.

RESULTS

Our search produced 1189 different articles; 70 remained after applying in- and exclusion criteria. Significant findings and associations were further explored. The need for evidence-based patient-reported outcome caused a growing uptake of the FACE-Q Aesthetic in cosmetic surgery and dermatology an increasing amount of evidence concerning facelift surgery, botulinum toxin, rhinoplasty, soft tissue fillers, scar treatments, and experimental areas.

DISCUSSION

The FACE-Q Aesthetic has been used to contribute substantial evidence about the outcome from the patient perspective in cosmetic facial surgery and minimally invasive treatments. The FACE-Q Aesthetic holds great potential to improve quality of care and may fundamentally change the way we measure success in plastic surgery and dermatology.

LEVEL OF EVIDENCE III

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Evaluating the impact of calibration of patient-reported outcomes measures on results from randomized clinical trials: a simulation study based on Rasch measurement theory

Background

Meaningfully interpreting patient-reported outcomes (PRO) results from randomized clinical trials requires that the PRO scores obtained in the trial have the same meaning across patients and previous applications of the PRO instrument. Calibration of PRO instruments warrants this property. In the Rasch measurement theory (RMT) framework, calibration is performed by fixing the item parameter estimates when measuring the targeted concept for each individual of the trial. The item parameter estimates used for this purpose are typically obtained from a previous “calibration” study. But imposing this constraint on item parameters, instead of freely estimating them directly in the specific sample of the trial, may hamper the ability to detect a treatment effect. The objective of this simulation study was to explore the potential negative impact of calibration of PRO instruments that were developed using RMT on the comparison of results between treatment groups, using different analysis methods.

Methods

PRO results were simulated following a polytomous Rasch model, for a calibration and a trial sample. Scenarios included varying sample sizes, with instrument of varying number of items and modalities, and varying item parameters distributions. Different treatment effect sizes and distributions of the two patient samples were also explored. Cross-sectional comparison of treatment groups was performed using different methods based on a random effect Rasch model. Calibrated and non-calibrated approaches were compared based on type-I error, power, bias, and variance of the estimates for the difference between groups.

Results

There was no impact of the calibration approach on type-I error, power, bias, and dispersion of the estimates. Among other findings, mistargeting between the PRO instrument and patients from the trial sample (regarding the level of measured concept) resulted in a lower power and higher position bias than appropriate targeting.

Conclusions

Calibration does not compromise the ability to accurately assess a treatment effect using a PRO instrument developed within the RMT paradigm in randomized clinical trials. Thus, given its essential role in producing interpretable results, calibration should always be performed when using a PRO instrument developed using RMT as an endpoint in a randomized clinical trial.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12874-022-01680-z.

Subject Satisfaction and Psychological Well-being with Escalating AbobotulinumtoxinA Injection Dose for the Treatment of Moderate to Severe Glabellar Lines

Background

Previous studies indicate that the efficacy and durability of a single AbobotulinumtoxinA (ABO) treatment for moderate to severe glabellar lines may be enhanced with increasing dose, while safety outcomes remain consistent with those of the licensed dose (50 U).

Aims

Evaluation of subject‐reported indicators of treatment efficacy, satisfaction, and psychological well‐being with ABO dose escalation.

Methods

A Phase 2, 36‐week, multicenter, randomized, dose‐ranging, double‐blind, placebo‐controlled study was conducted in adults with moderate to severe glabellar lines. Subjects received a single ABO treatment, dosed at 50, 75, 100, or 125 U, or placebo. Efficacy endpoints comprised subject‐assessed improvement in line severity of ≥1‐grade from baseline at maximum frown, global aesthetic improvement scale (GAIS) grade, FACE‐Q™ appraisal of lines, psychological well‐being and age, and subject satisfaction.

Results

The study included 399 subjects (88.2% were female). Respective responder rates (≥1‐grade improvement) with ABO 50–125 U doses ranged between 96.3%–100% at Week 4, 65.0%–67.9% at Week 24, and 33.8%–44.4% at Week 36. GAIS responder rate and FACE‐Q appraisal of lines showed a similar pattern of change. Satisfaction was high and psychological well‐being was improved from Week 4 through Week 36, with natural, youthful, and refreshed appearance reported for all ABO doses.

Conclusions

A single ABO treatment (dosed at 50–125 U) provided significant and sustained improvements in glabellar line severity over durations up to 36 weeks, versus placebo. Treatment satisfaction was high with all doses. Participants reported natural and youthful appearance, alongside improvements in psychological well‐being.

Nanocarriers as Active Ingredients Enhancers in the Cosmetic Industry-The European and North America Regulation Challenges

“Flawless skin is the most universally desired human feature” is an iconic statement by Desmond Morris. Skin indicates one´s health and is so important that it affects a person’s emotional and psychological behavior, these facts having propelled the development of the cosmetics industry. It is estimated that in 2023, this industry will achieve more than 800 billion dollars. This boost is due to the development of new cosmetic formulations based on nanotechnology. Nanocarriers have been able to solve problems related to active ingredients regarding their solubility, poor stability, and release. Even though nanocarriers have evident benefits, they also present some problems related to the high cost, low shelf life, and toxicity. Regulation and legislation are two controversial topics regarding the use of nanotechnology in the field of cosmetics. In this area, the U.S. FDA has taken the lead and recommended several biosafety studies and post-market safety evaluations. The lack of a global definition that identifies nanomaterials as a cosmetic ingredient is a hindrance to the development of global legislation. In the EU, the legislation regarding the biosafety of nanomaterials in cosmetics is stricter. “The cost is not the only important issue, safety and the application of alternative testing methods for toxicity are of crucial importance as well”.

Multimodal Facial Aesthetic Treatment on the Appearance of Aging, Social Confidence, and Psychological Well-being: HARMONY Study

Background

A global approach to facial rejuvenation involves multiple treatment modalities.

Objectives

The aim of this study was to evaluate the impact of multimodal facial aesthetic treatment on self-reported psychological and social outcomes.

Methods

HARMONY, a prospective, multicenter, 4-month study, enrolled patients aged 35 to 65 years to receive on-label treatment with a combination of hyaluronic fillers (VYC-20L, HYC-24L, and/or HYC-24L+), onabotulinumtoxinA, and bimatoprost. Fillers were injected on Day 1, with touch-ups performed on Day 14. OnabotulinumtoxinA was injected at Month 3 into glabellar lines and/or crow’s feet lines. Patients applied bimatoprost to eyelashes once daily for 17 weeks. Mean change from baseline on FACE-Q Psychological Well-being and Social Confidence Scales, FACE-Q Aging Appearance Appraisal Scale, and FACE-Q Age Appraisal Visual Analog Scale were assessed.

Results

Of 100 patients treated, 93 were evaluated at 4 months posttreatment. Significant improvement vs baseline was observed on the FACE-Q Scales for Psychological Well-being (mean change, −19.9; P < 0.00001), Social Confidence (mean change, −18.2; P < 0.00001), and Aging Appearance (mean change, −28.5; P < 0.0001). On average, patients’ self-assessed age was 0.1 years older than actual age at baseline and 4.5 years younger at Month 4 (P < 0.001 vs baseline). Forty-two patients experienced adverse events, all mild to moderate.

Conclusions

Multimodal, full facial aesthetic treatment improves patients’ self-reported psychological well-being, social confidence, aging appearance, and perceptions of chronologic age.

Level of Evidence: 4

Puzzle Facelift: A non-surgical, whole treatment for facial modelling and rejuvenation

The assessment of correct anatomy of face and the evaluation of the dynamic interplay between anatomy and function, in order to get an overall improvement, is a leading topic in aesthetic surgery and has increased its impact in the recent years. A non-surgical impact technique reduces both post-treatment discomfort and the overall cost. Obtaining the simultaneous correction in forehead, nose, lips and chin means obtaining an overall improvement in face view. Likewise, the high predictability of the procedure and the absence of alloplastic implant, bone re-absorption and scars have to be considered in non-surgical aesthetic medicine. In conclusion, a single-session of profile correction using HA filler should be proposed to patient, every time the aesthetic practitioner sees a coexistence of forehead, nose lips and chin defects.

Botulinum Toxins for Aesthetic Facial Injections - A scientific review to support evidence-based best practice

Botulinum Toxins (BoNT) are complex biological products. Each licensed BoNTA has its own individual characteristics resulting into different attributes, some of them being of clinical relevance. Besides profound anatomical knowledge and understanding of aesthetic principles, the responsible injecting physician should be aware of those pharmaceutical and clinical properties. Especially against the background of new BoNTA formulations receiving approval by the authorities a critical and dedicated discussion on the individual characteristics should take place and the potential relevance on the treatment outcome should be taken into consideration.

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.

Outcome Measurement of Beauty and Attractiveness of Facial Aesthetic Rejuvenation Surgery

ABSTRACT

Aesthetic plastic surgery is a most unusual and unique subspecialty. Unlike other medical and surgical specialties driven primarily by objective medical diagnosis and outcome, aesthetic surgery is patient driven; it represents a special exercise in professional competence by adapting objective medical standards to a mostly subjective field. Given the subjectivity of facial beauty and of the projected aesthetic intervention outcome, in addition to be able to determine beauty of the final result as precisely and objectively as possible, it is also essential to be able to assess patient's satisfaction. However, lack of standardized facial measurements and clear definition of aesthetic outcome and beauty are still major obstacles preventing real change in the consultation dynamics to help better serve patients' expectations. Because of the tremendous increase in demand for all types of facial aesthetic procedures, an objective understanding of aesthetics and beauty is becoming of utmost importance. Recognition of the importance of science and evidence-based medicine is long overdue in our specialty. This study aims at identifying the most recently available evidence-based measures to quantitatively assess beauty and measure outcome of rhytidoplasty that can be useful in everyday aesthetic practice.

Defining Skin Quality: Clinical Relevance, Terminology, and Assessment

BACKGROUND

Flawless skin is one of the most universally desired features, and demand for improvements in skin quality is growing rapidly. Skin quality has been shown to substantially impact emotional health, quality of life, self-perception, and interactions with others. Although skin quality improvements are a common end point in studies of cosmeceuticals, they are rarely assessed in clinical studies of other aesthetic treatments and products. Descriptive terminology for skin quality parameters also varies considerably within the aesthetic field, relying on a range of redundant and occasionally contradictory descriptors. In short, skin quality has not been clearly defined.

OBJECTIVE

The goal of this review is to highlight the importance of skin quality to patients and physicians, explore known and unknown factors comprising skin quality, and provide clarity regarding terminology, descriptors, and evaluation tools for assessing skin quality.

MATERIALS AND METHODS

A review of the literature on skin quality was performed without limitation on publication date. Relevant articles are presented.

RESULTS AND CONCLUSION

We propose a framework of attributes contributing to skin quality rooted in 3 fundamental categories-visible, mechanical, and topographical-with the aim to provide information to help guide clinicians and inform future clinical studies.

A Multicenter Study to Evaluate Subject Satisfaction With Two Treatments of AbobotulinumtoxinA a Year in the Glabellar Lines

BACKGROUND

Real-world re-treatment intervals for botulinum toxins vary, but most subjects receive treatment less frequently than the manufacturer-recommended minimum intervals. In subjects receiving treatment with AbobotulinumtoxinA (ABO) less frequently, high levels of satisfaction and psychosocial improvements in well-being, self-confidence, and quality of life are observed.

OBJECTIVE

To evaluate subject satisfaction with a twice yearly re-treatment schedule.

METHODS AND MATERIALS

This open-label, multicenter, interventional study evaluated subject satisfaction following injections of ABO 50 U in the glabellar lines at baseline and 6 months. The primary end point was subject satisfaction at 12 months. Secondary endpoints included subject satisfaction, FACE-Q scales, and glabellar line severity scale (GLSS).

RESULTS

Ninety-five percent of the 120 subjects were "highly satisfied" or "satisfied" with their treatment outcomes at 12 months. FACE-Q total scores suggested that subjects were less bothered by glabellar lines and felt better about their facial appearance with each treatment versus baseline. Approximately half of subjects had ≥1-grade improvement from baseline in GLSS at 12 months. Median onset of effect was 2 days.

CONCLUSION

The majority of subjects (95%) were satisfied with ABO treatment every 6 months; results were supported by high subject satisfaction, long duration, rapid onset, natural-looking results, and overall psychological wellness and safety.

Whole-Face Approach with Hyaluronic Acid Fillers

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

The Impact of Dermal Fillers on Perceived Personality Traits and Attractiveness

BACKGROUND

Dermal fillers are increasingly popular for facial rejuvenation and enhancement, including effacement of nasolabial folds (NLFs) and marionette lines and lip augmentation. This study aimed to evaluate casual observer perception of physical and interpersonal traits of subjects who receive filler treatment.

METHODS

An anonymous survey of 8 before/after treatment photographical sets was administered in Likert scale format (1-7) using online crowdsourcing. Three sets of photographs were before/after NLF/ marionette line treatment, three of lip augmentation, and two internal controls. Respondents were surveyed on personal demographics, as well as perceptions of subject photographs across nine domains (facial symmetry, confidence, likeability, youthfulness, trustworthiness, attractiveness, intelligence, approachability, happiness).

RESULTS

In total, 260 respondents completed the survey. The majority were male (63.1%), Caucasian (58.1%), 18-34 years old (58.1%), and college graduates (66.2%). Respondents rated photographs with line filler treatment and lip filler treatment as significantly improved compared to the pre-treatment photographs across all nine trait domains [p < 0.001, for all]. No differences were found between the control photosets [p > 0.05, for all]. Middle-aged respondents (35-55 years) were more likely to perceive treated filler photographs as more youthful than younger respondents (18-34 years) [p < 0.006] Additionally, respondents with lower educational attainment (high-school graduate or less) were more likely to perceive treated patients as less intelligent compared to higher-educated respondents (college/postgraduates) [p < 0.05, for both].

CONCLUSION

The use of dermal fillers for treatment of NLF/marionette lines and lip augmentation have significant associations with the perception of improved attractiveness and several personality traits. Additionally, casual observer demographic subgroups may influence perceptions.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

[Correction of age-related changes in facial tissues and restoration of the body's functional reserves using dynamic electroneurostimulation and spectral phototherapy]

Theoretical background of a rational combination of dynamic electric neurostimulation (DENS) and spectral phototherapy (SPT) for complex elimination of age-related changes of facial tissues (ARCFT) and restoration of the body's functional reserves (BFR) is provided. Comparative results of separate and combined application of DENS and SPT (DENS&SPT) are provided. The results obtained upon examination of 90 patients have shown that DENS&SPT is more effective compared to separate application of the above procedures for both eliminating ARCFT and increasing BFR. After a course of DENS&SPT procedures, 87.5% of women evaluated the obtained aesthetic result as «significant improvement» and «improvement». When exposed to DENS&SPT, 5 of 8 measured parameters of facial skin condition improved significantly. At the same time, there was a restoration of BFR stress levels to moderate and optimal levels. DENS&SPT provides a mutually potentiating effect both in the aspect of correction of ARCFT and restoration of BFR decreasing with age.

Maximizing Panfacial Aesthetic Outcomes: Findings and Recommendations From the HARMONY Study

BACKGROUND

Aesthetic medicine has evolved from targeting individual treatment areas to a global approach of panfacial rejuvenation. HARMONY was the first clinical study to systematically demonstrate positive physical and psychosocial impacts of panfacial treatment.

OBJECTIVE

Provide evidence-based guidance on treatment strategies to help maximize outcomes in patients seeking panfacial rejuvenation.

MATERIALS AND METHODS

Study sites with the lowest (n = 2) and highest (n = 2) improvements based on FACE-Q Satisfaction with Face Overall scores were analyzed to understand differences in treatment strategy that may contribute to incrementally greater patient satisfaction.

RESULTS

The highest scoring sites exhibited greater improvement in all patient-reported outcomes and investigator-assessed measures related to dermal filler treatment compared with the lowest scoring sites. The highest sites favored lateral malar augmentation and used less volume medially versus the lowest sites. In the lower face, the highest sites used greater volumes and more HYC-24L than HYC-24L+. Initial treatment volumes were more conservative at highest than lowest sites; greater volumes were used by highest sites in touch-up treatments.

CONCLUSION

Product usage trends common to the highest scoring sites (including injection volume, injection sites, and product selection) may provide guidance on best practices for a panfacial approach to aesthetic treatment to maximize patient satisfaction.

Enhanced patient retention after combination vs single modality treatment using hyaluronic acid filler and neuromodulator: A multicenter, retrospective review by The Flame Group

BACKGROUND

It is believed that combination treatment with both neuromodulators (NM) and hyaluronic acid soft-tissue fillers (HA) results in superior aesthetic results and increased patient satisfaction compared to either treatment alone.

AIMS

To determine whether combined treatment with NM and HA leads to greater patient retention than treatment with NM or HA alone.

PATIENTS/METHODS

This is a large, multi-center, retrospective review of patient retention rates from 7 aesthetic practices across 5 continents, incorporating over 2600 patients. Patient retention is interpreted as a surrogate marker for overall patient satisfaction. Retention rates were compared at 1, 3, and 5 years for patients who received NM only, HA only, or combination treatment with both NM and HA.

RESULTS

Combination therapy significantly increased the probability of retention for each time point (1, 3, and 5 years) compared with NM alone (P < .0001) and HA alone (P < .0001).

CONCLUSION

This large multicenter, global retrospective review demonstrates that patients who received combined HA and NM were more likely to be retained in the same practice over many years than those who received either treatment alone.

Aesthetic Treatment Positively Impacts Social Perception: Analysis of Subjects From the HARMONY Study

BACKGROUND

The impact of facial aesthetic treatments not only enhances physical appearance but also psychological well-being. Accordingly, patient-reported outcomes are increasingly utilized as an important measure of treatment success. Observer-reported outcomes are a relevant yet often overlooked measure of treatment benefit.

OBJECTIVES

The authors aimed to evaluate the impact of panfacial aesthetic treatment on the perception of an individual in a variety of social contexts.

METHODS

A total 2000 men and women (aged 18-65 years) participated in an online study designed to capture the blinded observer's social perception of pretreatment and posttreatment patients who received panfacial aesthetic treatment in the HARMONY study. Perceptions relevant to character traits, age, attractiveness, and social status were evaluated. Observers were divided into 2 groups. Single image respondents (n = 1500) viewed 6 single, randomized patient images (3 pretreatment, 3 posttreatment), and paired image respondents (n = 500) viewed 6 pretreatment and posttreatment image pairs.

RESULTS

Single image respondents reported significantly (P < 0.05) higher levels of agreement that posttreatment subjects appeared to possess more positive character traits (eg, healthy and approachable), were more socially adept, younger, more attractive, more successful at attracting others, and possessed a higher social status. Paired image respondents also reported a higher level of agreement for posttreatment images being aligned with positive character traits, representative of a younger and more attractive individual, and one with a higher social status.

CONCLUSIONS

The results suggest that the positive impact of minimally invasive panfacial treatment extends beyond enhancing physical appearance and highlights the importance of social perception and observer-reported outcomes in aesthetic medicine.

Improvements in satisfaction with skin after treatment of facial fine lines with VYC-12 injectable gel: Patient-reported outcomes from a prospective study

BACKGROUND

VYC-12, a hyaluronic acid injectable gel, is designed to treat fine lines and provides improvements in other skin quality attributes. A prospective study demonstrated the safety and effectiveness of VYC-12 for the improvement of fine lines as measured by changes in skin texture.

AIMS

To evaluate patient-reported outcomes in subjects treated intradermally with VYC-12 in the cheeks, forehead, and neck (optional) in the prospective study.

METHODS

Subjects received an initial treatment of VYC-12 (N = 131), with a touch-up treatment, if deemed necessary, offered 30 days later, and optional repeat treatment 9 months after initial or touch-up treatment. Subjects completed the FACE-Q Satisfaction With Skin scale and assessed willingness to recommend treatment to a friend at baseline, months 1, 4, 6, and 9, and month 1 after repeat treatment. Subjects also evaluated their return to normal daily social activities.

RESULTS

Satisfaction with skin improved from baseline in 90.8% of subjects at month 1, 88.4% at month 4, 83.6% at month 6, 76.4% at month 9, and 91.9% at month 1 after repeat treatment (P < .001, all time points). At least 94% of subjects returned to normal daily social activities one day after treatment (initial, touch-up, or repeat). More than 80% of subjects said they would recommend treatment to a friend at all time points through month 9 (97% at month 1 after repeat treatment).

CONCLUSION

Treatment with VYC-12 significantly improved satisfaction with skin in the majority of subjects, with most subjects returning to normal activities 1 day after treatment.

European survey on criteria of aesthetics for periodontal evaluation: The ESCAPE study

OBJECTIVE

The ESCAPE multicentre survey was designed to (a) compare the agreement of three relevant aesthetic scoring systems among different centres, and (b) evaluate the reproducibility of each question of the questionnaires.

MATERIALS AND METHODS

EFP centres (n = 14) were involved in an e-survey. Forty-two participants (28 teachers, 14 postgraduate students) were asked to score the one-year aesthetic outcomes of photographs using the Before-After Scoring System (BASS), the Pink Esthetic Score (PES) and the Root coverage Esthetic Score (RES). Mean values of kappa statistics performed on each question were provided to resume global agreement of each method.

RESULTS

Between teachers, a difference of kappa ≥ 0.41 (p = .01) was found for BASS (75%) and PES (57%). Similarly, RES (84%) and PES (57%) were different (p < .001). No difference was found between BASS (75%) and RES (84%). No difference was found between students, whatever the scoring system. Questions of each scoring system showed differences in their reproducibility.

CONCLUSIONS

The outcomes of this study indicate that BASS and RES scoring systems are reproducible tools to evaluate aesthetic after root coverage therapies between different centres. Among the various variables, lack of scar, degree of root coverage, colour match and gingival margin that follows the CEJ show the best reliability.

The signature featureTM : A new concept in beauty

Signature Feature^TM (SF) is a universal, yet highly personalized treatment approach to aesthetic facial enhancement that applies to all patients, independent of age, gender, or ethnicity. Its philosophical basis maintains that a patient's beauty is anchored by their most distinctive invariant features (invariant features like eyes, nose, cheekbones, or jawline), and preservation of such signature features should be an essential consideration in any aesthetic treatment plan. The principles central to the SF concept include: (a) identifying the patient's most distinctive signature feature, (b) matching the patient's persona to their signature feature while preserving alignment with their cultural/ethnic aesthetic, and (c) highlighting the patient's signature feature by increasing the "signal-to-noise" ratio between the strength of the signature feature and those factors that may be interfering with it (lines, wrinkles, and sun damage). Every patient represents a new combination of treatment challenges which are not only related to the patient's physical baseline characteristics but also by their subjective self-perceptions. This subjective gray area is where the SF treatment approach has the greatest contribution to the patient's positive self-perception and self-esteem, as the practitioner can help the patient realize their own personal brand through enhancement of their signature feature using an array of aesthetic options.

Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures

INTRODUCTION

Hormone treatment induces feminization of the body in transwomen and masculinization in transmen. However, the effect of hormone treatment on facial characteristics is still unknown.

AIM

We aimed to study whether hormone treatment induces facial feminization and masculinization and how this potential change affects satisfaction and self-esteem.

METHODS

In this single-center cohort study, we included 27 transwomen and 15 transmen who received standardized hormone treatment in the Center of Expertise on Gender Dysphoria, VU University Medical Center Amsterdam. Facial 3-dimensional images were obtained at baseline and at 3 and 12 months. At each image, 22 facial landmarks were placed. Furthermore, the FACE-Q Satisfaction with Facial Appearance Overall and the Rosenberg self-esteem scale were obtained at the same measurement points.

MAIN OUTCOME MEASURES

The main outcome measures included the relative local shift of skin in millimeters in the 22 landmarks in the transverse (x-axis), coronal (y-axis), and sagittal (z-axis) anatomic axes, the color maps, and the outcomes of the questionnaires.

RESULTS

After 12 months, cheek tissue in transwomen increased, with 0.50 mm (95% CI 0.04-0.96) in the x-axis and 1.08 mm (95% CI 0.31-1.85) in the z-axis. Tissue in the jaws decreased with -0.60 mm (95% CI -1.28-0.08) in the x-axis and -0.18 mm (95% CI -0.03-0.33) in the y-axis. Cheek tissue in transmen decreased with -0.45 mm (95% CI -1.00-0.11) in the x-axis and -0.84 mm (95% CI -1.92-0.25) in the z-axis. These changes already started after 3 months. An increase in satisfaction with the facial appearance was found in both transwomen and transmen. There were no changes in reported self-esteem.

CLINICAL IMPLICATION

These results could lead to more realistic expectations of facial changes. Furthermore, our results suggest that the face continues to change for at least a year, which could suggest that performing facial feminization surgery after 1 year of hormone treatment might be too early.

STRENGTH & LIMITATIONS

This study is the first that provides insight into the facial changes in transgender individuals receiving hormone treatment, and it introduces an objective method to examine (small) facial changes. Our study is limited by the poor reliability of the landmarks, the difficulty of facial fixation, and the lack of gender-specific questions in the questionnaires.

CONCLUSIONS

Hormone treatment in transwomen induces an increase in cheek tissue and a decrease in jaw tissue. In transmen a tendency of decrease in cheek tissue and an increase in jaw tissue was found. These changes are in the direction of the desired gender. Tebbens M, Nota NM, Liberton NPTJ, et al. Gender-Affirming Hormone Treatment Induces Facial Feminization in Transwomen and Masculinization in Transmen: Quantification by 3D Scanning and Patient-Reported Outcome Measures. J Sex Med 2019;16:746-754.