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Niamh Corduff,1 Lanny Juniarti,2 Ting Song Lim,3 Frank Lin,4 Kavita Mariwalla,5 Tatjana Pavicic,6 Arnelle Quiambao,7 Tuck Wah Siew,8 Atchima Suwanchinda,9,10 Fang Wen Tseng,11 Vasanop Vachiramon,10 Choon Shik Youn,12 Wilson WS Ho13 1Cosmetic Refinement Clinic Geelong, Victoria, Australia; 2Miracle Aesthetic Clinic, Surabaya, Indonesia; 3Clique Clinic, Kuala Lumpur, Malaysia; 4Eastern Plastic Surgery, Victoria, Australia; 5Mariwalla Dermatology, New York, NY, USA; 6Private Practice for Dermatology & Aesthetics of Dr. Tatjana Pavicic, Munich, Germany; 7YouPlus Intelligent Aesthetics Clinic, BGC Taguig City, Philippines; 8Radium Medical Aesthetics, Singapore; 9Department of Medicine, Chulabhorn Hospital, Chulabhorn Royal Academy, Bangkok, Thailand; 10Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 11Milano Aesthetic Clinic, Taoyuan City, Taiwan; 12Yemiwon Dermatologic Clinic, Seoul, Korea; 13The Specialists: Lasers, Aesthetic & Plastic Surgery, Central, Hong KongCorrespondence: Niamh Corduff, Cosmetic Refinement Clinic Geelong, T9 400 Pakington St, Newtown VIC, Victoria, 3220, Australia, Tel +61 407122578, Email niamh.crc@outlook.comAbstract: Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.Keywords: hyaluronic acid dermal filler, consensus, practical approaches, safe, natural-looking outcomes, current practices

Jani van Loghem,1 Sonja Sattler,2 Gabriela Casabona,3 Sebastian Cotofana,4 Sabrina Guillen Fabi,5 Kate Goldie,6 Uliana Gout,7 Martina Kerscher,8 Ting Song Lim,9 Carla de Sanctis Pecora,10 Gerhard Sattler,2 Ada Trindade de Almeida,11 Rungsima Wanitphakdeedecha,12 Philip Werschler,13 Tatjana Pavicic14 1Falck Clinic, Aesthetic Medicine Centre, Amsterdam, the Netherlands; 2Rosenpark Clinic, Darmstadt, Germany; 3Ocean Clinic, Marbella, Spain; 4Albany Medical College, Albany, NY, USA; 5Cosmetic Laser Dermatology and University of California, San Diego, CA, USA; 6European Medical Aesthetics Ltd, London, UK; 7Aesthetic Medicine Clinic, London, UK; 8University of Hamburg, Hamburg, Germany; 9Clique Clinic, Kuala Lumpur, Malaysia; 10Dermatologie-Clínica, Cirurgia, Cosmiatria e Laser, São Paulo, Brazil; 11Clínica de Dermatologia do Hospital do Servidor Público Municipal de São Paulo, São Paulo, Brazil; 12iSKY Innovative Skin & Laser Surgery Center, Bangkok, Thailand; 13Premier Clinical Research, Spokane, WA, USA; 14Private Practice for Dermatology and Aesthetics, Munich, GermanyCorrespondence: Jani van LoghemFalck Clinic, Aesthetic Medicine Centre, Falckstraat 51, Amsterdam, 1017 VV, the NetherlandsEmail jani@falckclinic.comBackground: As the treatment indications for the Cohesive Polydensified Matrix® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio.Methods: An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers.Results: Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization.Conclusion: The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.Keywords: anatomy, Belotero, cohesive polydensified matrix, consensus, hyaluronic acid, injection technique

Ofir Artzi,1,2 Joel L Cohen,3 Jeffrey S Dover,4– 6 Atchima Suwanchinda,7,8 Tatjana Pavicic,9 Marina Landau,10 Greg J Goodman,11 Sahar Ghannam,12 Firas Al Niaimi,13 Jani AJ van Loghem,14 Kate Goldie,15 Sonja Sattler,16 Daniel Cassuto,17 Ting Song Lim,18 Rungsima Wanitphakdeedecha,19 Ines Verner,20,21 Tanja C Fischer,22,23 Vivian Bucay,24 Eli Sprecher,1,2,25 Dana Shalmon1,2 1Department of Dermatology, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel; 2Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel; 3AboutSkin Dermatology and AboutSkin Research, , Greenwood Village and Lone Tree, CO, USA; 4SkinCare Physicians, Chestnut Hill, MA, USA; 5Dermatology, Yale University School of Medicine, New Haven, CT, USA; 6Dermatology, Brown Medical School, Rhode Island, USA; 7Department of Dermatology, School of Anti-Aging and Regenerative Medicine, Mae Fah Luang University, Bangkok, Thailand; 8Division of Dermatology, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand; 9Private Practice for Dermatology and Aesthetics Dr. Tatjana Pavicic, Munich 80539, Germany; 10Dermatology, Private Practice, Herzliya, Israel; 11Monash University, Clayton, Victoria, Australia; 12Associate Prof. of Dermatology, Alexandria University, Alexandria, Egypt; 13 152, Harley street, London, UK; 14UMA Institute, Amsterdam 1017, TX, Netherlands; 15Medical Director European Medical Aesthetics Ltd, London W1G 8QN, UK; 16Rosenpark Klinik, Darmstadt, Germany; 17Private Practice, Milan, Italy; 18Clique Clinic, Kuala Lumpur, Malaysia; 19Department of Dermatology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand; 20Verner Clinic, Tel Aviv, Israel; 21Department of Dermatology, University of Rome, Guglielmo Marconi, Italy; 22Skin and Laser Center, Potsdam, Germany; 23School of Medicine, University of Frankfurt, Germany; 24Bucay Center for Dermatology and Aesthetics, UTHSC, San Antonio, TX, USA; 25Department of Human Molecular Genetics & Biochemistry, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, IsraelCorrespondence: Ofir ArtziTel Aviv Sourasky Medical Center, Weizman 6, Tel Aviv, IsraelTel +972-54-5968961Fax +972-77-2001801Email ofira@tlvmc.gov.ilBackground and Objectives: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose.Materials and Methods: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists.Results: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3– 6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement.Conclusion: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.Keywords: cosmetic techniques, dermal fillers/adverse effects, hyaluronic acid/adverse effects

Sabrina Fabi,1 Tatjana Pavicic,2 André Braz,3 Jeremy B Green,4,5 Kyle Seo,6 Jani AJ van Loghem7 1Cosmetic Laser Dermatology, San Diego, CA, USA; 2Private Practice for Dermatology and Aesthetics, Munich, Germany; 3Division of the Policlínica Geral do Rio de Janeiro (PGRJ), Rio de Janeiro, Brazil; 4Skin Associates of South Florida, Miami, 5University of Miami Department of Dermatology, Miami, FL, USA; 6Seoul National University, Seoul, South Korea; 7Doctors Inc., Amsterdam, The Netherlands Abstract: The Merz Institute of Advanced Aesthetics Expert Summit was held in Prague, Czech Republic, from 19–20 November 2016. The meeting had a distinct advisory board character and invited aesthetic practitioners from all over the world to hear an international faculty present a range of keynote lectures and conduct live injection sessions with an emphasis on recent developments in combination aesthetic interventions for face and body rejuvenation and beautification. Aging is associated with changes in bones, muscles, ligaments, adipose tissue, and skin and, moreover, involves interactions among these tissue types. To achieve the most natural and harmonious rejuvenation of the face, all changes that result from the aging process should be corrected, which generally involves treatment with more than a single agent or technology. Presentations described innovative treatment algorithms for the face and body and focused on patients’ desires for natural-looking rejuvenation and how this requires a three-dimensional approach combining products that relax the musculature, volumize, and re-drape the skin. Besides treating the aging face, these procedures are increasingly used to enhance facial features as well as to delay facial aging in younger patients. The presentations covered patients from different ethnicities as well as the treatment of non-facial areas, with a particular focus on the use of Ultherapy® for skin lifting and tightening, and new aesthetic procedures such as Cellfina® and diluted Radiesse®. The current report provides a summary of key presentations from the meeting. Keywords: calcium hydroxylapatite, Cellfina, hyaluronic acid, incobotulinumtoxinA, Ultherapy

Tatjana Pavicic,1 Welf Prager,2 Markus Klöppel,3 Simon Ravichandran,4 Olivier Galatoire5 1Private Practice, Munich, Germany; 2Dr. Prager & Partner, Derma-Hamburg, Hamburg, Germany; 3Private Practice Clinic of Esthetic Surgery, MediCenter Munich-Solln, Munich, Germany; 4Clinetix Rejuvenation, Glasgow, Scotland, UK; 5Department of Ophthalmology, Adolphe Rothschild Ophthalmological Foundation, Paris, France Purpose: To characterize utilization patterns and treatment satisfaction with incobotulinumtoxinA for aesthetic indications and assess adherence to the Summary of Product Characteristics. Patients and methods: Data were collected retrospectively from physicians in Germany, France, and the UK regarding patients (n=638) treated with incobotulinumtoxinA for aesthetic indications. Data on indication, treatment interval, dose injected, physician and patient satisfaction, and adverse drug reactions were recorded according to routine daily practice. Results: Most patients (76.0%) received incobotulinumtoxinA for glabellar frown lines (GFL) and were given doses of ≤20 U. The majority of treatment intervals were 5 months or longer. Overall, 64.1% of patients were treated for off-label indications, sometimes in combination with treatment for GFL. The most frequently treated off-label indications were horizontal forehead lines (38.6%) and/or crow's feet (CF; 31.7%); for CF, >95% of injected doses were ≤24 U. In Germany, a smaller proportion of patients were given incobotulinumtoxinA treatment for CF (27.6%), compared with France (40.4%) and the UK (33.2%), although country-specific differences were less prominent when treatment cycle data for CF were examined. Treatment satisfaction among physicians and patients (overall, and for GFL specifically) was very high, with excellent tolerability and only one mild adverse drug reaction reported. Conclusion: In daily practice, incobotulinumtoxinA is mainly used for GFL; however, its use for CF and horizontal forehead lines (often in combination with GFL) is relatively common. Treatment satisfaction across aesthetic indications is high, and incobotulinumtoxinA is well tolerated, with time intervals of 5 months or longer between injections in the majority of cases. When considering factors such as dose and treatment interval, adherence to the Summary of Product Characteristics when treating GFL in daily practice is good. These results support previous reports that incobotulinumtoxinA is an effective treatment for GFL, with an excellent safety profile. Furthermore, incobotulinumtoxinA may display efficacy and tolerability in other indications. Keywords: incobotulinumtoxinA, Xeomin®/Xeomeen®/Bocouture®/XEOMIN Cosmetic™, NT 201; free from complexing proteins, retrospective, daily practice, glabellar frown lines, crow's feet

Tatjana Pavicic Private Practice, Munich, Germany Background: Radiesse® (Calcium hydroxylapatite [CaHA]) is a biocompatible, injectable gel for facial soft tissue augmentation. It is a completely biodegradable filler and this is well documented, but objective imaging methods to confirm this property are scarce.Methods: We present a case report in which CaHA was injected into the midface of a 50-year-old woman for volume restoration and shaping of the cheek region. On the right side of the face, 1.6 mL CaHA was injected as several (5-7) small depots (0.1-0.2 mL) using a 28G 3/4 inch needle and the vertical supraperiosteal depot technique. On the contralateral side of the face, the subject received 1.6 mL CaHA over three entry points using a 27G 1 1/2 inch blunt cannula and the fanning technique. CaHA location and degradation were assessed using magnetic resonance imaging (MRI).Results: CaHA appears as low-to-intermediate signal intensity on MRI images taken immediately after injection for malar enhancement with a symmetrical distribution. On MRI images taken 2.5 years after injection, no CaHA was visible but tissue volume remained increased, indicating a collagen-stimulating effect. The treatment was well tolerated.Conclusion: In addition to producing long-lasting aesthetic and collagen-stimulating effects, MRI images confirm that CaHA is completely biodegradable with no product remaining 2.5 years after injection. Keywords: aesthetic, biodegradable, calcium hydroxylapatite, MRI, Radiesse

David Funt,1 Tatjana Pavicic21Mount Sinai Hospital, Department of Plastic Surgery, New York, NY, USA; 2Department of Dermatology and Allergy, Ludwig-Maximilian University of Munich, Munich, GermanyBackground: The ever-expanding range of dermal filler products for aesthetic soft tissue augmentation is of benefit for patients and physicians, but as indications and the number of procedures performed increase, the number of complications will likely also increase.Objective: To describe potential adverse events associated with dermal fillers and to provide structured and clear guidance on their treatment and avoidance.Methods: Reports of dermal filler complications in the medical literature were reviewed and, based on the publications retrieved and the authors' extensive experience, recommendations for avoiding and managing complications are provided.Results: Different dermal fillers have widely varying properties, associated risks, and injection requirements. All dermal fillers have the potential to cause complications. Most are related to volume and technique, though some are associated with the material itself. The majority of adverse reactions are mild and transient, such as bruising and trauma-related edema. Serious adverse events are rare, and most are avoidable with proper planning and technique.Conclusion: For optimum outcomes, aesthetic physicians should have a detailed understanding of facial anatomy; the individual characteristics of available fillers; their indications, contraindications, benefits, and drawbacks; and ways to prevent and avoid potential complications.Keywords: aesthetic medicine, complications

Welf Prager,1 Jürgen Huber-Vorländer,2 A Ziah Taufig,3 Matthias Imhof,4 Ulrich Kühne,4 Ruth Weissberg,5 Lars-Peter Kuhr,6 Volker Rippmann,3 Wolfgang G Philipp-Dormston,7 Thomas M Proebstle,8 Claudia Roth,9 Martina Kerscher,10 Claudius Ulmann,11 Tatjana Pavicic121Dermatologikum, Hamburg, 2Fort Malakoff Klinik, Mainz, 3Praxisklinik für Plastische und Ästhetische Chirurgie, Cologne, 4Ästhetische Dermatologie im Medico Palais, Bad Soden, 5Taimerhofstrasse 28, Munich, 6Aqua Medical Spa, Munich; 7Hautzentrum Köln, Cologne, 8Privatklinik Proebstle GmbH, Mannheim, 9Kö-Klinik, Düsseldorf, 10MIN Fakultät/Department Chemie/Kosmetikwissenschaft, Hamburg, 11Kosmas Klinik, Bad Neuenahr-Ahrweiler, 12Klinik und Poliklinik für Dermatologie und Allergologie, Munich, GermanyBackground: Botulinum toxin type A treatment has been used for over 20 years to enhance the appearance of the face. There are several commercially available botulinum toxin type A products used in aesthetic clinical practice. The aim of this retrospective analysis was to compare the clinical efficacy of the most commonly used botulinum toxin type A preparations in daily practice.Methods: Physicians from 21 centers in Germany completed questionnaires based on an inspection of subject files for subjects 18 years of age or over who had received at least two, but not more than three, consecutive treatments with incobotulinumtoxinA, onabotulinumtoxinA, or abobotulinumtoxinA within a 12-month period in the previous 2 years. Data on subject and physician satisfaction, treatment intervals, dosages, and safety were collected from 1256 subjects.Results: There were no statistically significant differences between incobotulinumtoxinA and onabotulinumtoxinA with respect to physician and subject satisfaction, dosages, and adverse effects experienced. Both botulinum toxin type A preparations were well tolerated and effective in the treatment of upper facial lines. Due to low treatment numbers, abobotulinumtoxinA was not included in the statistical analysis.Conclusion: The results of this retrospective analysis confirm the results of prospective clinical trials by demonstrating that, in daily practice, incobotulinumtoxinA and onabotulinumtoxinA are used at a 1:1 dose ratio and display comparable efficacy and safety.Keywords: NT 201, incobotulinumtoxinA, onabotulinumtoxinA, abobotulinumtoxinA, upper face, retrospective analysis