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Background: From early dynamic lines in smiling and squinting young people, crow's feet lines in the lateral canthal region evolve through prolonged tissue remodeling into mature, stable rhytids after the mid‐to‐late thirties, and requests for rejuvenating treatment. Because of the heterogeneous fanning behavior of crow's feet lines, individualizing neuromodulation with botulinum toxin injections might be a sound strategy to maximize aesthetic outcomes. Aims: To investigate the prevalence of variable crow's feet line patterns at maximum contracture and while smiling and comment on the relative distribution of such patterns and the influence of aging. These considerations will be the basis and rationale for future studies that will individualize the total 24‐unit dose according to the distribution of crow's feet lines. Methods: Identifying CFL orientation at maximum frown and while smiling; assessment tool: the four‐class 2015‐version of Kane's classification further modified by converting the former "central fan pattern" into a new, more precisely defined "extended full‐fan pattern" class. Results: The 323 cohort subjects had a mean age of 51.5 ± 9.28 years. Although with some differences, outcomes in a central‐southern real‐world European Caucasian population appear similar to the distribution first studied in 2003 in a highly selected population in New England involved in double‐blind clinical trials. The full‐fan pattern predominated both at maximum contraction and when smiling, followed in prevalence by the upper‐fan pattern at maximum contraction and the extended full‐fan pattern while smiling. Age significantly influenced the crow's feet line pattern—lower‐fan patterns were more frequent than other patterns in the real‐world younger middle‐age group (40–49 years old); full‐fan and extended full‐fan patterns progressively more prevalent with aging. Conclusions: The study confirms but somewhat modifies the previous evidence about the non‐homogeneous distribution of crow's feet line fanning patterns in different age groups and reinforces the case to individualize the topography of botulinum toxin injections. [ABSTRACT FROM AUTHOR]

Background: Wasting of soft tissues leads to flattening and deflation of the aging midface skin. Polynucleotides Highly Purified Technology (PN‐HPT®) demonstrated dermal hydration and elasticity as well as fibroblasts vitality and activity. Aims: To probe the value of PN‐HPT® in middle third rejuvenation in an open‐design, exploratory prospective cohort study in 40 real‐life ambulatorily treated women. Methods: Three treatment sessions—at baseline (2‐ml prefilled syringe containing 10 mg/ml PN‐HPT®, 10 mg/ml hyaluronic acid, 200 mM mannitol) as intradermic gel, and after 3 weeks (2‐ml prefilled syringe containing 20 mg/ml PN‐HPT® intradermic gel) and 6 weeks (same treatment as baseline). The protocol allowed supplemental treatment with specifically formulated PN‐HPT® (7.5 mg/ml) when needed in periocular and eyelid areas. Assessments: sequential photographs of the facial middle third at baseline, third treatment session and 6–8 weeks after the third treatment session; scoring of overall skin quality and texture, skin quality determinants (wrinkles and skin roughness, skin elasticity, skin brightness), scar appearance, and subjective satisfaction with impromptu 10‐cm Visual Analogue Scales. Results: Significant improvement of overall skin quality and texture (from 7.0 ± 1.06 at baseline session to 7.8 ± 0.99 at follow‐up), associated with highly significant improvements of wrinkles and skin roughness, elasticity, and brightness (–17.1%, +39.6%, and +51.1%, respectively). The severity scores of post‐acne scars decreased from 7.6 ± 1.32 to 4.2 ± 2.13. Individual satisfaction score at the end of treatment: 0.8 ± 0.28. Conclusions: PN‐HPT® candidate as a valuable option for facial middle third rejuvenation. Further trials will hopefully confirm these early results. [ABSTRACT FROM AUTHOR]

This article discusses the degradation of hyaluronic acid (HA) fillers after the injection of hyaluronidase, an enzyme used to reverse the effects of HA fillers. The study compares the degradation of different HA fillers, including VYC-25L, using a rat model. The results show that all HA fillers tested were susceptible to degradation by hyaluronidase, with no significant differences in degradation rates among the fillers. The study suggests that the properties of HA fillers do not significantly impact their sensitivity to enzymatic degradation. However, the study acknowledges that further research is needed to understand the factors that affect the sensitivity of HA fillers to hyaluronidase in a clinical setting. [Extracted from the article]

Background: Injective procedures using polynucleotides‐based products to promote dermal rejuvenation and revitalization are steadily evolving, yet no structured protocols are available that discuss and provide guidance in aesthetic treatments with highly purified polynucleotides. The goal of this document was to provide consensus‐based recommendations for the safe and effective use of Polynucleotides Highly Purified Technology™ (PN‐HPT™) devices for skin rejuvenation. Patients/Methods: A team of eight experts with extensive experience in treatments for skin rejuvenation and revitalization integrated the best available evidence and clinical judgment and devised a series of practical guidance to support dermatologists, plastic surgeons, and aesthetic physician in the use of PN‐HPT™ products, alone and in combination, in aesthetic medicine. Results: For most items, the expert group achieved a majority consensus. "Recommendations" (consensus >80%) were reached for the face, periocular area, décolleté and neck, hands, scalp, and stretch marks. Recommendations include details of techniques, information on dosage, volumes to be injected, and the ideal number of required treatment sessions, as well as time intervals between them for different areas of face and body. A lower agreement level of 60% was reached on but one item related to the initial treatment cycle for the face, leading to a "Consensus statement" for that area instead of a full "Recommendation." Conclusion: The expert consensus illustrates the value of natural‐origin, highly purified polynucleotides (PN‐HPT™) as biostimulatory booster strategy for skin priming and revitalization of face and body and provides a detailed guide for the use. [ABSTRACT FROM AUTHOR]

Summary: 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. [ABSTRACT FROM AUTHOR]

Objective: Facial aging is a complex process that involves genetic, biological, and environmental factors. This paper aimed to present the first aesthetic and safety outcomes of a hybrid filler that combines hyaluronic acid (HA) (20 mg/mL) and calcium hydroxyapatite (HA/CaHa). Methods: Prospective and non‐randomized interventional study conducted on consecutive healthy patients who attended the clinic for an aesthetic facial rejuvenation procedure. HA/CaHa was injected with 23G cannula (retrograde threads, 1.25 mL per side) in the preauricular region. Ultrasound examinations, elastography images, and 2D and 3D photographs were performed before and after treatment. The primary endpoint were the volumetric changes at Day 180. Results: Fifteen patients were included in the study. At Day 180 after treatment, median (interquartile‐range) volume increased by 2.1 (1.9–2.3) cc and 2.1 (1.8–2.2) cc in the right‐ and left‐side, respectively, p < 0.0001 each. As compared to pretreatment values, facial‐tension vectors significantly increased by 2.2 (1.6–2.2) mm and 2.0 (1.7–2.2) mm in the right and left side, respectively, p < 0.0001 each. Elastography images demonstrated an increase in collagen fibers at post‐treatment Day 60, which was confirmed on Day 90, and reached the peak effect between Days 90 and 180. Regarding safety, there were no either unexpected or serious treatment‐related adverse events. Most patients experienced a mild redness and inflammation that resolved within the first 48 h without treatment. Conclusions: The HA/CaHa hybrid filler (HArmonyCa™), besides its volumizing and lifting properties, was associated with an increase in the viscoelasticity, both at the level of the reticular dermis and the subcutaneous cellular tissue, which might be indicative of the formation of new collagen fibers. [ABSTRACT FROM AUTHOR]

Background: OnabotulinumtoxinA (onabotA) is indicated for upper facial lines (UFL). Fear of unnatural‐looking outcomes is a frequently reported treatment barrier. Aims: Examine patient‐reported outcomes (PROs) after onabotA treatment for UFL. Methods: A post hoc analysis was conducted on two 12‐month pivotal studies of onabotA for forehead and glabellar lines (20 U each), with/without treatment of crow's feet lines (±24 U). This analysis used PROs from the Facial Line Satisfaction Questionnaire: Items 4 (natural look), 5 (treatment effect), 11 (met expectations), and Impact Domain (appearance and psychological impact). The analysis included 458 neurotoxin‐naive adults achieving a ≥2‐grade improvement in forehead line (FHL) severity on the Facial Wrinkle Scale at Day 30 (primary endpoint). [Corrections made on 28 December 2023, after first online publication: 'UFL' in the previous sentence has been corrected to 'forehead line (FHL)' in this version.] Data were further stratified into millennials and men. Results: At Day 30, 90.5% of all participants, 94.6% of millennials, and 85.7% of men were satisfied with receiving a natural look. Millennials had higher odds of being satisfied with natural outcomes at Day 30. This measure remained > 80% for all groups throughout the 12 months. Additionally, ≥80% were satisfied with the treatment effect, and >90% reported results met expectations. At Day 30, ≥50% reported positive impacts on self‐perceived appearance and psychological well‐being, but millennials had higher, and men had lower odds of reporting these improvements. Conclusions: Participants achieving a ≥2‐grade improvement in FHL severity after onabotA reported high satisfaction with natural outcomes and the treatment effect, with improved self‐perceived appearance and psychological well‐being. [Corrections made on 28 December 2023, after first online publication: 'UFL' in the previous sentence has been corrected to 'FHL' in this version.] These results may help aesthetic providers and patients address fears regarding unnatural results with onabotA. [ABSTRACT FROM AUTHOR]

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

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. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive procedures, such as thread suspension techniques, are a growing trend for facial rejuvenation. However, not enough data are available on the efficacy, outcomes, and morbidity of suture suspension techniques in mid‐face reshaping. Aims: Our goal was to assess treatment outcomes and patient satisfaction following mid‐face reshaping using threads with bidirectional convergent barbs (DefinisseTM free floating threads). Patients/Methods: We performed a retrospective analysis of 60 patients who underwent treatment for mid‐face reshaping using DefinisseTM free floating threads. Response to treatment was assessed at 6 months using the mid‐face‐specific Mid‐Face Volume Deficit scale (Allergan®), Global Aesthetic Improvement and FACE‐QTM scales. Results: Sixty patients underwent mid‐face treatment with the suspension thread technique (mean age 51.3, 90% female). No concomitant procedures were done. A reduction by one point or more in the Mid‐Face Volume Deficit Scale (MDFVS) score treatment was seen in all patients after 6 months. Mean overall MFVDS and FACE‐QTM scores were significantly improved. On the GAIS, most patients were rated as improved or better both by the evaluating investigators and during self‐assessment. No major complications were observed, and none of the patients requested the removal of the threads (mean follow‐up 9.8 months, range 6–14 months). Conclusion: Our results suggest that mid‐face reshaping with DefinisseTM free floating threads is a safe and reliable procedure characterized by low complication rates and good esthetic results. This minimally invasive procedure is a good alternative for normal or combination skin patients who refuse or want to delay the need for traditional rhytidectomy. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]