The Evolving Field of Regenerative Aesthetics: A Review and Case Series.

Dermal fillers such as calcium hydroxyapatite-carboxymethylcellulose (CaHA-CMC), polycaprolactone (PCL), and poly-l-lactic acid (PLLA) are increasingly used as 'biostimulators' to stimulate native collagen production for longer-lasting aesthetic improvement. Volume replacement should, ideally, renew local tissue architectures and functions, but the replaced volume may not align structurally or functionally with the original tissue. The ability to achieve this regenerative, biostimulatory aesthetic rejuvenation requires a thorough understanding of the principles and mechanisms of tissue regeneration and its proper application.

The Immunologic Spectrum of Biostimulators and Its Clinical Importance.

Background: Biostimulators have become important tools in aesthetic medicine to address age-related volume loss and tissue changes. They stimulate the body's natural processes to produce collagen and other components that contribute to a youthful appearance. Understanding the immunologic mechanisms underlying these processes is crucial for achieving optimal clinical outcomes.

Botulinum Toxin: Surely, We Can Do Better? Optimizing Results Beyond On-Label Techniques and Teaching.

Facial expressions and their emotional attributes are essential as an adjunct to verbal communication and for nonverbal communication. Botulinum toxin (BoNTA) used to limit wrinkles induced by aging changes on expressive faces. However, suboptimal injection techniques can lead to undesirable outcomes, such as brow ptosis, unnatural eyebrow elevation, flattening of the cheeks, and unnatural smiles.

Multimodal Treatment Combinations and Layering to Restructure the Aging Face: Recommendations From an Expert Panel.

Background: Facial aging is a complex process that varies by facial layer and patient characteristics. Correction of the signs of facial aging can be achieved with various aesthetic treatments, including Cohesive Polydensified Matrix hyaluronic acid (CPM-HA), calcium hydroxylapatite in carboxymethylcellulose (CaHA-CMC), microfocused ultrasound with visualization (MFU-V), and incobotulinumtoxinA (incoBoNT-A). This article describes how these treatments can be used in an individualized, layered approach for whole-face rejuvenation that optimizes outcomes and patient satisfaction.

Consensus Agreements on Regenerative Aesthetics: A Focus on Regenerative Biostimulation With Calcium Hydroxylapatite.

Background: A growing population of patients is seeking treatments that not only affect their overlying features but also restore a more biologically youthful structure and function to the underlying tissue. These strategies are part of what is known as regenerative aesthetics (RA). As an emergent field, clarity regarding the precise definitions and aims of RA and methods to measure the regenerative capacity of RA treatments are lacking.

Real-world Implications of Botulinum Neurotoxin A Immunoresistance for Consumers and Aesthetic Practitioners: Insights from ASCEND Multidisciplinary Panel.

Background: As long-term, regular aesthetic botulinum neurotoxin A (BoNT-A) use becomes more commonplace, it is vital to understand real-world risk factors and impact of BoNT-A immunoresistance. The first Aesthetic Council on Ethical Use of Neurotoxin Delivery panel discussed issues relating to BoNT-A immunoresistance from the health care professionals' (HCPs') perspective. Understanding the implications of BoNT-A immunoresistance from the aesthetic patient's viewpoint allows HCPs to better support patients throughout their aesthetic treatment journey.

The Use of Hyaluronidase in Aesthetic Practice: A Comparative Study of Practitioner Usage in Elective and Emergency Situations.

Background: Hyaluronic acids (HAs) continue to be the fillers of choice worldwide and their popularity is growing. Adverse events (AEs) are able to be resolved through the use of hyaluronidase (HYAL). However, routine HYAL use has been at issue due to perceived safety issues.

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.

Biostimulating fillers and induction of inflammatory pathways: A preclinical investigation of macrophage response to calcium hydroxylapatite and poly-L lactic acid.

Introduction: Initial macrophage response to biostimulatory substances is key in determining the subsequent behavior of fibroblasts and the organization of newly synthesized collagen. Though histological studies suggest that calcium hydroxylapatite (CaHA) filler initiates a regenerative healing response with collagen and elastin deposition similar to natural, healthy tissue rather than an inflammatory response with fibrosis, the relative activity of macrophages stimulated by CaHA, as well as how this activity compares to that induced by other biostimulatory fillers, has not been explored. The aim of the study is to characterize the in vitro macrophage response to two biostimulory fillers, CaHA and PLLA (poly-L lactic acid), and to evaluate their inflammatory potential.

Hi5 Protocol for the Use of Microfocused Ultrasound with Visualization.

Background: Microfocused ultrasound with visualization (MFU-V) is used for lifting and tightening of facial tissues. Standard protocols are completed in a single session. Despite excellent outcomes, we identified several barriers of entry for a significant number of patients.

Addressing the Real-World Challenges of Immunoresistance to Botulinum Neurotoxin A in Aesthetic Practice: Insights and Recommendations from a Panel Discussion in Hong Kong.

With increasing off-label aesthetic indications using higher botulinum neurotoxin A (BoNT-A) doses and individuals starting treatment at a younger age, particularly in Asia, there is a greater risk of developing immunoresistance to BoNT-A. This warrants more in-depth discussions by aesthetic practitioners to inform patients and guide shared decision-making. A panel comprising international experts and experienced aesthetic practitioners in Hong Kong discussed the implications and impact of immunoresistance to BoNT-A in contemporary aesthetic practice, along with practical strategies for risk management.

Introducing aesthetic regenerative scaffolds: An immunological perspective.

Background: Skin aging arises from immunological responses to tissue deterioration and damage. Tissue repair processes encompass the regeneration of original tissue and 'scarless' wound healing seen in foetuses, and the extreme fibrotic responses and scarring seen in adults. Anti-aging aesthetic medicine uses interventions like biomaterial-based fillers to influence these immunological responses and renew aged tissue structure and function.

Making Sense of Late Tissue Nodules Associated With Hyaluronic Acid Injections.

Background: The pathogenesis of delayed-onset tissue nodules (DTNs) due to hyaluronic acid (HA) injections is uncertain.

Objectives: To formulate a rational theory for DTN development and their avoidance and treatment.

Methods: A multidisciplinary and multicountry DTN consensus panel was established, with 20 questions posed and consensus sought.

Sensory Symptoms Associated with Aesthetic Botulinum Toxin A Treatments.

Unlabelled: A retrospective review of patients who switched from onabotulinumtoxinA (onaA) and/or abobotulinumtoxinA (aboA) to incobotulinumtoxinA (incoA) found anecdotal reports of differences in "feel," including a "lighter" feel or treatment-associated tightness. We surveyed the frequency of these sensations as an initial proof of concept of toxin proprioception among our patients who switched toxins.

Methods: Seventy-nine patients who had past facial aesthetic treatments with more than one botulinum toxin A (BoNT/A) formulation completed a questionnaire on their experience of treatment-associated sensations, including stiffness or a frozen feeling.

Creating Lift in the Lower Face With Botulinum Toxin A Treatment: An Anatomical Overview With Videos and Case Studies Illustrating Patient Evaluation and Treatment.

Background: Relaxation of depressor muscles in the lower face with botulinum toxin A (BoNT-A) can create a lifting effect and dramatically improve jawline contour and resting facial expression. Even with the recent increase in interest in lower face rejuvenation, BoNT-A is a relatively under-recognized tool for treatment of this area. When treating the lower face, an understanding of anatomy and the relationship between the facial muscles is especially important, as injection patterns must be customized for consistently positive outcomes.

Emerging Trends in Botulinum Neurotoxin A Resistance: An International Multidisciplinary Review and Consensus.

Unlabelled: Botulinum neurotoxin A (BoNT-A) injection is the most widely performed aesthetic procedure and a first-line therapeutic option for various medical conditions. The potential for BoNT-A immunoresistance and secondary nonresponse related to neutralizing antibody (NAb) formation warrants attention as the range of BoNT-A aesthetic applications continues to expand.

Methods: An international multidisciplinary panel reviewed published evidence on BoNT-A immunoresistance in aesthetic and therapeutic applications and discussed best practices integrating clinical, ethical, and aesthetic considerations.

Immunogenicity Associated with Aesthetic Botulinumtoxin A: A Survey of Asia-Pacific Physicians' Experiences and Recommendations.

Background: Most botulinum toxin A (BoNT/A) products contain unnecessary bacterial components that increase the risk of developing neutralizing antibodies (nAbs). Reports of secondary nonresponse and treatment failures (STF) due to nAbs have accompanied a surge in new BoNT/A products.

Methods: To formulate recommendations on managing toxin resistance, we reviewed the evidence on BoNT/A-associated immunogenicity and evaluated Asian physicians' current BoNT/A practices, knowledge, and real-world experiences, as provided by survey outcomes conducted with 128 Asian experts (regular botulinum toxin injectors).

Movement of the Syringe During Filler Aspiration: An Ultrasound Study.

Background: Aspiration prior to hyaluronic acid filler injection is often taught as a safety maneuver to minimize the risk of intravascular injection; however, the validity of this technique in aesthetic practice is being increasingly challenged. One key assumption underpinning the validity of the aspiration test is that the needle tip does not move during the aspiration and subsequent injection of filler.

Objectives: The aim of this study was to visualize and measure needle tip movement in real time during aspiration and injection of filler.

Microfocused ultrasound with visualization: Consensus on safety and review of energy-based devices.

Background: Microfocused ultrasound with visualization (MFU-V; Ultherapy , Merz North America) is US Food and Drug Administration-cleared as a non-invasive procedure that lifts the soft tissue of the neck, submentum and brow, and improves lines and wrinkles on the upper chest. Several other energy-based devices are in use in countries outside the USA where they are marketed for indications similar to those of MFU-V, although published studies supporting these indications are limited and none of the other devices provides visualization or verification they reach the superficial musculoaponeurotic system.

Methods: Due to the evolving landscape of ultrasound technology as more devices enter the market, seven global thought leaders who are qualified experts on the use of various high-intensity focused ultrasound (HIFU)/MFU-V technologies convened to review data from an independent evaluation of the software, thermal characteristics, transducer acoustics and ultrasound therapy of MFU-V and three other ultrasound-based devices.

Pan-Asian Consensus on Calcium Hydroxyapatite for Skin Biostimulation, Contouring, and Combination Treatments.

Background: Several usage guidelines for calcium hydroxylapatite (CaHA), a dermal filler material, exist for non-Asian patients, making it necessary to determine whether their findings and consensuses are applicable to Asian patients who have distinct anatomies, cultural preferences, and aesthetic requests.

Objective: We sought to develop a Pan-Asian consensus on CaHA use in skin biostimulation, contouring, and combination treatments for face and body indications.

Methods: A survey on CaHA usage for contouring and biostimulation indications in Asian patients was conducted, followed by discussions to establish consensus statements and topics for examination.

Evaluating the Effect of Incobotulinumtoxin A for Glabellar, Forehead, and Crow's Feet Lines Using A High Dilution.

Background: As aesthetic preferences have evolved and patients wish their muscles to be relaxed, but not frozen, a higher dilution of incobotulinumtoxinA (INCO) has allowed for increased spread using fewer units, yet no studies to date have investigated the efficacy, longevity, and safety of hyperdiluted INCO.

Objective: We evaluated the effect of incobotulinumtoxinA (INCO) in glabellar, forehead, and lateral periorbital lines using a high dilution.

Methods: Subjects with moderate-to-severe upper facial lines at rest according to the Merz Aesthetics Scales (Merz Pharmaceuticals GmbH, Frankfurt am Main, Germany) received 15U of INCO to the glabellar (n=4 injection sites), 10U to the rest of the forehead (n=10 injection sites), and 5U to the lateral periorbital lines (n=3 injection sites/eye).

Neuromodulating the SMAS for Natural Dynamic Results.

Physicians using neuromodulators need to develop an in-depth and holistic understanding of the facial musculature as a single, large, functional structure that does not work in isolation. In this Special Topic, I review the anatomy of the continuous fibromuscular layer of the face, discuss how certain age-related indications develop as a consequence of imbalances to this unified structure, and propose considerations for neuromodulator-based interventions of the upper, mid, and lower face. I provide evidence-supported recommendations on the most optimal applications of neuromodulators to help rebalance the musculoaponeurotic layer for more natural outcomes.