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This course focuses on the injection of Botulinum toxin type A in the entire face with an effective technique. The injection points based on the literature and on global faculty consensus will be demonstrated with consideration of the facial anatomy.

This course covers the anatomical changes in the face that occur with age. After completion of the course you will be able to: Describe the intrinsic and extrinsic factors of ageing; recognise the signs of ageing in the face, including changes in the facial skeleton, muscles, fascia, ligaments, adipose tissue and skin; possible improvements by rejuvenation techniques.

Get to know not only the musculature and fat compartments of the upper, mid and lower face, but also the key differences based on ethnicity.

Understand the regular course of the nerves and vessels and become aware of the most important anatomical variations. Avoid complications by familiarising yourself with all the risks of anastomosis of the facial arteries, which are visualised specifically in a new technique.

Book this course and you will benefit from a practical guide for healthcare professionals performing aesthetic medicine. The course comprises everything you need to know to optimise outcomes such as pre-treatment considerations, facial mapping, scales, photo documentation as well as ethical considerations such as informed consents, mental health aspects and legal issues.

BOCOUTURE® 4 units/0.1 ml powder for solution for injection Active substance: Botulinum toxin type A (150 kD), purified from Clostridium Botulinum cultures (Hall strain), free from complexing proteins. Prescription-only medicine! Qualitative and quantitative composition: One vial contains: 50 units of Botulinum toxin type A (150 kD), free from complexing proteins, human albumin, sucrose. Due to the differences in the potency assays, unit doses are specific to BOCOUTURE®. Therefore the recommended dose units for BOCOUTURE® are not interchangeable with those for other Botulinum toxin preparations. Therapeutic indications: For temporary improvement in the appearance of upper facial lines in adults below 65 years when the severity of these lines has an important psychological impact for the patient:
  • moderate to severe vertical lines between the eyebrows seen at maximum frown (glabellar frown lines) and/or
  • moderate to severe lateral periorbital lines seen at maximum smile (crow's feet lines) and/or
  • moderate to severe horizontal forehead lines seen at maximum contraction.

Contraindications: Hypersensitivity to the active substance or to any of the excipients, generalised disorders of muscle activity (e.g. myasthenia gravis, Lambert-Eaton syndrome), infection or inflammation at the proposed injection site. Do not use during pregnancy unless clearly necessary. Do not use during breast-feeding. Undesirable effects: Undesirable effects usually occur within the first week following injection and are temporary in nature. They may be related to the active substance, the injection procedure, or both. Application-related: Localised pain, inflammation, paraesthesia, hypoaesthesia, tenderness, swelling, oedema, erythema, itching, localised infection, haematoma, bleeding and/or bruising. Caused by the injection procedure: Pain and/or anxiety may lead to vasovagal responses such as transient symptomatic hypotension, nausea, tinnitus, and syncope. Undesirable effects of the substance class Botulinum toxin type A: Localised muscle weakness, blepharoptosis (possibly caused by the injection technique) are an expression of the pharmacological effect. Toxin spread: When treating other indications with Botulinum toxins, undesirable effects related to spread of the toxin distant from the site of administration have been reported very rarely (exaggerated muscle weakness, dysphagia, and aspiration pneumonia with a fatal outcome in some cases). These cannot be completely ruled out with the use of BOCOUTURE®. Hypersensitivity reactions: Rare reports of severe and/or immediate hypersensitivity reactions such as anaphylaxis, serum sickness, urticaria, soft tissue oedema, and dyspnoea, sometimes either following the administration of conventional Botulinum toxin type A complex preparations alone or in combination with other active substances known to cause similar reactions. The following undesirable effects were reported from clinical experience with BOCOUTURE®: Vertical lines between the eyebrows seen at maximum frown (glabellar frown lines) Common (≥1/100 to <1/10): headache, muscle disorders (elevation of eyebrow); Uncommon (≥1/1,000 to <1/100): Bronchitis, nasopharyngitis, influenza-like illness, depression, insomnia, facial paresis (brow ptosis), eyelid oedema, eyelid ptosis, blurred vision, pruritus, skin nodule, muscle twitching, muscle spasm, sensation of heaviness, injection site: haematoma, pain, tenderness, fatigue. Lateral periorbital lines seen at maximum smile (crow's feet lines) Common (≥1/100 to <1/10): Eyelid oedema, dry eye, injection site: haematoma. Upper facial lines: Very common (≥1/10):headache; Common (≥1/100 to <1/10):hypoaesthesia , eyelid ptosis, dry eye, facial asymmetry, sensation of heaviness, nausea, injection site: haematoma, pain. Post-marketing experience: Flu-like symptoms and hypersensitivity reactions such as swelling, oedema (also apart from the injection site), erythema, pruritus, rash (local and generalized), and breathlessness have been reported. Merz Pharmaceuticals GmbH, 60048 Frankfurt/Main, Germany.
Date of revision of the text: March 2016 Further information is provided in the Summary of Product Characteristics and the Package Leaflet.

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Fabi et al., Retrospective evaluation of micro-focused ultrasound for lifting and tightening the face and neck – Dermatol Surg 2014;40:569-575

BACKGROUND: Microfocused ultrasound (MFU) is an effective means for tightening and lifting lax facial and neck skin.

OBJECTIVE: To evaluate the safety and efficacy of MFU with visualization (MFU-V) for noninvasive treatment of facial and neck skin laxity 180 days after treatment and determine what lifestyle factors affect treatment outcomes.

PATIENTS AND METHODS: Healthy women (N = 48) previously treated with MFU-V on the face and upper neck were enrolled. Depending on when MFU-V treatment occurred, subjects completed 90- or 180-day follow up visits or both. Digital images of each subject were obtained before treatment and at follow-up visits.

RESULTS: Data were obtained at 90 (N = 16) and 180 days (N = 45), and physician Global Aesthetic Improvement Scale (GAIS) scores demonstrated that 81.3% and 77.7% patients achieved improvement, respectively. At 90 and 180 days, subject GAIS scores showed 75% and 77.8% of subjects perceived improvement, respectively. At 180 days, blinded reviewer assessments indicated that 67% of subjects showed improvement in appearance. There was no association between improvement and age, Fitzpatrick skin type, alcohol intake, or major illness. One minor adverse event was reported.

DISCUSSION: Although the data obtained at 90 days must be interpreted cautiously because of the smaller number of patients, subjects achieved significant lifting and tightening of facial and neck skin up to 180 days after one MFU treatment.

Fabi et al., A prospective multicenter pilot study of the safety and efficacy of microfocused ultrasound with visualization for improving lines and wrinkles of the décolleté – Dermatol Surg 2015;41:327–335

BACKGROUND: A previous pilot study demonstrated microfocused ultrasound with visualization (MFU-V) to lift and tighten the décolleté produced significant and durable aesthetic improvements.

OBJECTIVE: To further evaluate the safety and effectiveness of MFU-V for improving lines and wrinkles of the décolleté in a larger patient population.

MATERIALS AND METHODS: Healthy women with moderate-to-severe décolleté skin lines and wrinkles were enrolled. After obtaining digital images, MFU-V was administered using 3 transducers emitting ultrasound at frequencies of 4 MHz and a focal depth of 4.5 mm, 7 MHz/3.0 mm, and 10 MHz/1.5 mm. During the procedure, 280 lines of discrete thermal coagulative points 25 mm long and 2 to 3 mm apart were applied to the treatment area. Additional imaging for masked assessments and live assessments were completed at 90 and 180 days.

RESULTS: Among the evaluable subjects, 77 (66.4%) demonstrated aesthetic improvement at 180 days based on blinded assessments. Approximately, 75% and 65% of treated subjects demonstrated some degree of improvement at 90 and 180 days, respectively, and most were satisfied with treatment outcomes. Adverse events were generally mild.

CONCLUSION: A single MFU-V treatment provided significant aesthetic improvement for moderate-to-severe décolleté lines and wrinkles for at least the 180-day duration of the study.

Kaminer et al., Multicenter pivotal study of vacuum-assisted precise tissue release for the treatment of cellulite – Dermatol Surg 2015;41:336–347

BACKGROUND: Cellulite refers to the dimpled appearance of skin occurring where the dermis is tethered by subcutaneous fibrous septa arranged perpendicularly to the skin surface.

OBJECTIVE: To demonstrate the safety and efficacy of a new system for vacuum-assisted precise tissue release for the treatment of cellulite.

MATERIALS AND METHODS: Adult women with moderate to severe cellulite (N = 55) underwent a single treatment. Post-treatment assessments were performed after 3 and 14 days; 1, 3, and 6 months; and at 1 year. Outcome measures included blinded assessments of subject photographs, a validated Cellulite Severity Scale (CSS), and the Global Aesthetic Improvement Scale. Subject satisfaction and pain ratings were also recorded.

RESULTS: The mean baseline CSS score of 3.4 decreased to 1.3 at 3 months (p < .0001) and 1.4 at 1 year (p < .0001), with 47 subjects (93%) having ≥1-point improvements. Subject satisfaction was 85% at 3 months and 94% at 1 year. Transient treatment-related adverse events were mild in severity.

CONCLUSION: This study demonstrates the safety, efficacy, and subject satisfaction with vacuum-assisted precise tissue release in the treatment of cellulite. There was no reduction in treatment benefits for up to 1 year. These results supported the Food and Drug Administration clearance of the device for the long-term reduction in the appearance of cellulite.

Pavicic et al., IncobotulinumtoxinA use in aesthetic indications in daily practice: a European multicentre, noninternventional, retrospective study – Clin Cos and Invest Derm, 2015;8:135-142

PURPOSE: To characterise 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.

Werschler et al., Long-term efficacy of micro-focused ultrasound with visualization for lifting and tightening lax facial and neck skin using a customized vectoring method – J Clin Aesthet Dermatol, 2016:9(2):27-33

BACKGROUND and OBJECTIVE: Micro-focused ultrasound with visualization has been cleared by the United States Food and Drug Administration to noninvasively lift the eyebrow, lift submental and neck tissue, and improve lines and wrinkles of the décolleté. The objective of this prospective, open-label pilot study was to evaluate the efficacy and safety of patient-specific, customized micro-focused ultrasound with visualization treatment with vertical vectoring to lift and tighten facial and neck tissue.

METHODS: Subjects 25 to 60 years of age (N=20) with areas of skin laxity on the face and neck were enrolled and treated. A duel depth treatment was administered using a vectored pattern. Subjects were evaluated after 90 days, 180 days, and one year.

RESULTS: Overall improvements in Subject Global Aesthetic Improvement Scale and Physician Global Aesthetic Improvement Scale scores were reported by 90 and 100 percent of subjects at 90 and 190 days, respectively, and 95 percent for both measures at one year. Six of 14 evaluable subjects were rated as improved by blinded assessment at one year. Self-reported improvements maintained for up to one year included less sagging (79%), fewer lines and wrinkles (58%), and smoother skin texture (47%).

CONCLUSION: Based on these results, treatment with micro-focused ultrasound with visualization with vertical vectoring demonstrated appreciable lifting and tightening of facial and neck tissue resulting in improved Global Aesthetic Improvement Scale scores and a high degree of patient satisfaction for up to one year.

Alam et al., Evaluation of micro-focused ultrasound for lifting and tightening neck laxity – J Drugs Dermatol, 2016:15(5):607-614

BACKGROUND and OBJECTIVE: A novel device using micro-focused ultrasound with high-resolution ultrasound visualization (MFU-V) produces non-invasive lifting and tightening of lax skin on the face and neck when treatment is delivered at a single focal depth (Ulthera System; Ulthera Inc., Mesa, AZ). The following study was performed to test the hypothesis that customized application of MFU-V at two focal depths will produce clinical results that are superior to treatment at a single focal depth.

METHODS: Adult subjects (N=71) with skin laxity in the lower face and neck were enrolled; 64 met all entrance criteria and received treatment. On the basis of physical and anatomical characteristics, patients were assigned in nonrandomized fashion to one of three treatment groups to undergo treatment on the submental, submandibular, lower neck, and platysmal areas with MFU-V at single or dual depths.

RESULTS: Among evaluable subjects (N=64), investigator-assessment and subject-self-assessment demonstrated improved aesthetic changes at 60, 90, and 180 days after treatment. Overall, subjects that received MFU-V at two focal depths to the entire treatment area achieved slightly greater aesthetic improvement than subjects receiving MFU-V at single focal depths. There were no unexpected adverse events.

CONCLUSION: Applying treatment with MFU-V at two focal depths may provide improved aesthetic results in some subjects.

Kaminer et al., A multicenter pivotal study to evaluate tissue stabilized-guided Subcision using the Cellfina device for the treatment of cellulite with 3-year follow up – Dermatol Surg 2017;0:1–9

BACKGROUND: Cellulite is a common female cosmetic concern for which no single treatment option had been proven effective over the long term. A novel tissue stabilized-guided subcision system (TS-GS system) has demonstrated significant reduction in the appearance of cellulite after treatment.

OBJECTIVE: The objective of this extended follow-up period was to assess the effectiveness of TS-GS out to 3 years after initial treatment.

PATIENTS AND METHODS: After completing an open-label, multicenter, pivotal study, 45 subjects were followed for an extended period of up to 3 years after receiving a single treatment using the TS-GS system. Treatment areas were photographed prior to the procedure and at multiple time points post-treatment throughout the 3 years. In this open-label study, subjects served as their own controls. Effectiveness was assessed based on blinded independent physician panel assessments of improvement from baseline using a cellulite severity scale. Subject aesthetic improvement and patient-reported satisfaction were also collected.

RESULTS: The results of this trial supported Food and Drug Administration clearance of the device for the long-term reduction in the appearance of cellulite following TS-GS.

CONCLUSION: These data further demonstrate the safety and efficacy of this treatment with no reduction in treatment benefits out to 3 years.

Baspeyras et al., Restoring jawline contour with calcium hydroxylapatite: a prospective, observational study – J Cosmet Dermatol. 2017;1–6

BACKGROUND and AIM: Jawline reshaping by replacing volume has become an indispensable component of modern facial rejuvenation. The aim of this study was to evaluate calcium hydroxylapatite (CaHA) for the treatment of an aging jawline in a routine setting.

METHODS: Five investigators enrolled 35 subjects requesting jawline rejuvenation with CaHA. Injections were performed according to investigators usual practice. Baseline and post-treatment scores were evaluated using Merz Aesthetics Scales®. Follow-up visits took place at Day 30 (Day 60 for those with touch-up at Day 30), 180, and 360. Physician and patient satisfaction, aesthetic impact of treatment, and adverse events were recorded.

RESULTS: Improvements in jawline contour compared with baseline were statistically significant at each visit, with scores of 2.42 (moderate to severe sagging) at baseline, 1.02 (mild) at Day 30/60 (P≤.0001), 1.11 at Day 180 (P≤.0001), and 1.45 at Day 360 (P=.0015). Statistically significant improvements in marionette line scores were also observed. Investigators rated results as “improved” to “very much improved” in all subjects up to Day 180, and in 81% of subjects at Day 360. Satisfaction with treatment was very high. Adverse events were mostly mild and related to either the procedure or injection technique.

CONCLUSION: CaHA is a very effective agent for restoring jawline contour in routine practice and is associated with high levels of physician and patient satisfaction.

Prager et al., IncobotulinumtoxinA for aesthetic indications: a systematic review of prospective comparative trials – Dermatol Surg, 2017:959-966

BACKGROUND: IncobotulinumtoxinA is a botulinum toxin type A (BoNTA) indicated for temporary improvement in the appearance of upper facial lines with well-established efficacy and safety profiles. Whether incobotulinumtoxinA and other BoNTAs are equipotent is subject of debate.

OBJECTIVE: To compare the efficacy of incobotulinumtoxinA and other BoNTAs for aesthetic applications.

MATERIALS AND METHODS: PubMed and Embase were systematically searched for prospective clinical trials comparing incobotulinumtoxinA with onabotulinumtoxinA, abobotulinumtoxinA, or placebo for aesthetic applications.

RESULTS: Fifteen articles met the selection criteria. Two studies found that incobotulinumtoxinA was noninferior or equivalent to onabotulinumtoxinA for the treatment of glabellar frown lines (GFLs). Eight studies found no difference in efficacy between incobotulinumtoxinA and other BoNTAs. One study suggested differences in response rates at certain time points between incobotulinumtoxinA and onabotulinumtoxinA for GFLs, and one suggested differences for dynamic horizontal forehead lines but not for GFLs or lateral periorbital lines, but both had study design issues limiting the ability to draw conclusions. Finally, 3 placebo-controlled studies demonstrated the efficacy of incobotulinumtoxinA for treating GFLs and upper facial lines.

CONCLUSION: The weight of the evidence from comparative clinical trials indicates that incobotulinumtoxinA, onabotulinumtoxinA, and abobotulinumtoxinA have similar efficacy for aesthetic applications.

Prager et al., Mid-face volumization with hyaluronic acid: injection technique and safety aspects from a controlled, randomized, double-blind clinical study – J Drugs Dermatol, 2017;16(4):351-357

BACKGROUND: Injection of hyaluronic acid (HA) volumizing fillers in the malar area is intended for rejuvenation of the mid-face. The choice of products, depth, and technique of injection depends on the desired level of volume enhancement and practitioners’ preferences.

OBJECTIVE: To describe a volumizing injection technique in the scope of a controlled, randomized, double-blind, single-center, split-face clinical study.

MATERIALS & METHODS: A total of 45 subjects with bilateral symmetrical moderate to severe volume loss in the malar area received a single 2 mL injection of CPM®-26 (Cohesive Polydensified Matrix®) on one side and VYC-20 (VYCROSS) on the contralateral side of the face. The same injection technique was applied for both sides of the face. Use of anesthetics, overcorrection, and touch-ups were not permitted. The investigator completed a product satisfaction questionnaire. Adverse events (AE) and injection-site reactions (ISRs) were reported during the study.

RESULTS: The products were placed at the epiperiosteal depth in 88.9% (n=40), at the subdermal depth in 8.9% (n=4) and at both levels in 2.2% (n=1) of subjects. Fanning technique using cannulae was applied in most cases (97.8%, n=44). Results of the investigator satisfaction questionnaire allowed to characterize CPM-26 in comparison to other volumizing gels. Both study products were generally well tolerated. Local reactions were transient and of mild to moderate intensity, with the most frequent ones being redness, pain, and swelling.

CONCLUSION: Adequate injection technique in volumizing treatments is essential to create a natural aesthetic rejuvenation while respecting the safety aspect of the procedures. A 22G blunt cannula used with CPM-26 was preferred due to an easier and a more homogenous distribution of the product. The investigator also appreciated CPM-26 for its ease of injection, positioning, lifting, and volumizing capacity.

Kerscher et al., Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study – Clin Cos and Invest Derm, 2017;10:239-247

BACKGROUND: Enhancement of the midface can be achieved with volumizing hyaluronic acid (HA) fillers.

OBJECTIVE: The objective of this study was to compare the safety and effectiveness of Cohesive Polydensified Matrix® 26 mg/mL HA gel (CPM-26) and Vycross® 20 mg/ml HA gel (VYC-20) in a controlled, randomized, evaluator-blind, split-face clinical study.

PATIENTS AND METHODS: Subjects with moderate-to-severe malar volume loss on the Merz Aesthetics Scale (MAS) received CPM-26 on one side and VYC-20 on the contralateral side of the face. Effectiveness assessments were performed by blinded evaluators including photographic and live MAS ratings and live Global Aesthetic Improvement Scale (GAIS) ratings. Calculations of anatomical volume variations at month 3 (M3), month 6 (M6), month 12 (M12) and month 18 (M18) were also performed.

RESULTS: Non-inferiority of CPM-26 versus VYC-20 was demonstrated at M3 (primary endpoint) based on MAS. GAIS rating showed that significantly more subjects had better improvement with CPM-26 than with VYC-20 at month 1, M3, M12 and M18 (p=0.0032, p=0.0074, p=0.0384 and p=0.0110, respectively). Standardized evaluation of volume variations from baseline to M3, M12 and M18 showed that CPM-26 created more volume augmentation at all time points, and the difference was significant at M3.

CONCLUSION: CPM-26 was non-inferior to VYC-20 based on MAS ratings at M3 and demonstrated a favorable safety and effectiveness profile for midfacial volume enhancement with results lasting up to M18.