Eyebrow lifting with barbed threads: A simple,safe, and effective ambulatory procedure

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.     

Is it possible to obtain long-lasting results with thread lift in the brow region? Introduction of a new suspension technique and evaluation of 50 patients

Background

Eyebrow region is a dynamic region, and it has a thinner skin prone to wrinkles and sagging. Descended brows could be repositioned immediately with fewer complications by the use of the threads. Despite all its advantages, the main drawback of absorbable thread lift is its short duration of lifting effect.

Aims

This report aims to describe our thread lift technique we have implemented to counteract the descent of the brows and evaluate our results in 50 patients.

Patients/Methods

A retrospective chart review was carried out over a period of 1 year from September 2019 to 2020 for the patients who underwent thread lifting for eyebrows in a private clinic in Ankara. Complications after the procedure, durability of the results, global esthetic improvement scale (GAIS) score, and patient satisfaction survey scores were recorded.

Results

The study group was composed of 50 female patients with a median age of 34 years. The median duration of the procedure is 15 months. Nine (18%) patients experienced complications related to the procedure including ecchymosis, edema, erythema, skin dimpling, and pain. Three weeks after the procedure, the position of the eyebrows of eight (16%) patients were improved, 18 (36%) patients were much improved, and 24 (48%) patients were very much improved according to GAIS.

Conclusions

So far, the most disappointing feature of the threads was the poor long-term sustainability of the outcomes. Our thread lift technique for brows offers a significant improvement in the position of the eyebrows in a short time with decreased downtime. More importantly, it can be possible to improve the longevity of the results with this approach.     

Locking the line of convergence by botulinum toxin type A for the treatment of dynamic forehead wrinkles

Background

Treatment of horizontal forehead lines with botulium toxin type A is a common procedure that helps achieve a youthful and rejuvenated look. Adequate knowledge of the anatomy and an individualized treatment approach is the key to successful treatment outcome.

Aim

To evaluate the cosmetic outcome following treatment of dynamic forehead wrinkles by locking the line of convergence using botulinum toxin type A.

Patients and Methods

Fifty female patients with dynamic forehead wrinkles were included. The line of convergence was identified, and injection points were determined. Patients received injections of botulinum toxin type A in the upper part of the frontalis along the line of convergence. Patients were evaluated before injection and the response was evaluated after 2 weeks and after 3 months of injection.

Results

Post-treatment significant decrease in dynamic wrinkle scale was detected. The distance between the medial and lateral canthi and their corresponding lower brow margins on maximum brow elevation was also significantly decreased after treatment. Meanwhile, the validated brow positioning score revealed no significant change in the resting brow position when pre-and post-treatment scores were compared.

Conclusions

Treating forehead wrinkles by injecting botulinum toxin along the line of convergence is an effective technique that requires less overall amount of toxin, improves the appearance of the wrinkles and minimizes the risk of development of side effects.     

Comparison of different thread products for facial rejuvenation: Materials and barb designs

Background

In recent years, the thread-lifting technique has become widely used in clinical settings. Several thread products are used in clinical practice, and there are many differences between products in terms of many aspects.

Methods

Six commercial thread products were collected and evaluated. The general structure, microstructure, elastic modulus, and strength were evaluated using microscopies and tensile testing in vitro. Seventy-two female rats were divided into six groups. Tissue samples were harvested and histologically evaluated at 1st, 4th, 8th, and 12th week using hematoxylin and eosin and Masson's trichrome staining.

Results

There were differences between products in terms of barb shape, microstructure, elasticity, and strength, and that could be attributed to the materials and barb structures. All threads showed good biological safety, and the density of collagen area in the dermis was increased compared to that in the control group.

Conclusions

This study provided an objective evaluation of barbed thread products, which indicated that all products can be used safely with certain effects in different indications.     

Two years’ outcome of thread lifting with absorbable barbed PDO threads: Innovative score for objective and subjective assessment

Background: Thread-lifting rejuvenation procedures have evolved again, with the development of absorbable threads. Although they have gained popularity among plastic surgeons and dermatologists, very few articles have been written in literature about absorbable threads. This study aims to evaluate two years’ outcome of thread lifting using absorbable barbed threads for facial rejuvenation. Methods: Prospective comparative stud both objectively and subjectively and follow-up assessment for 24 months. Results: Thread lifting for face rejuvenation has significant long-lasting effects that include skin lifting from 3–10 mm and high degree of patients’ satisfaction with less incidence rate of complications, about 4.8%. Augmented results are obtained when thread lifting is combined with other lifting and rejuvenation modalities. Conclusion: Significant facial rejuvenation is achieved by thread lifting and highly augmented results are observed when they are combined with Botox, fillers, and/or platelet rich plasma (PRP) rejuvenations.     

Handheld microfocused ultrasound device for facial lifting: A preliminary study of ULTIGHT

Objective

Although focused ultrasound modalities have achieved positive clinical results in noninvasive skin rejuvenation, they presented various side effects and particularly severe pain during treatment. This study introduces a microfocused ultrasound (MFU) device, ULTIGHT, to overcome the severe pain issue, providing quasi-facial lifting.

Materials and Methods

Transducer surface was imaged with a scanning electron microscope. The energies of four treatment cartridges were measured using an ultrasound power meter. In vitro experiments were performed to quantitatively evaluate the MFU thermal zones (MFUTZs) and treatment line (TL) of 10 MFUTZs. Ex vivo experiments were performed to evaluate the MFUTZs and temperature rise in tissue. Clinical trials using eight volunteers were performed to qualitatively evaluate facial lifting.

Results

The MFU transducer clearly showed a smooth and no air gap surface. ULTIGHT produced 10 discrete MFUTZs in a TL of length 10 mm. In ex vivo tissue, discrete linear MFUTZs were clearly observed at lower number of TLs; however, they started to aggregate at higher number of TLs. The temperature rise was linearly increased as a function of the number of treatments. A single MFUTZ resulted in a temperature rise of 3°C–10°C that could cause hyperthermia for body temperature. In the clinical trials, the volunteers showed quasi-facial lifting right after treatment on the lower facial region.

Conclusions

ULTIGHT provides relatively low energy, which may be advantageous or disadvantageous depending on clinical applications. Additionally, it has the advantage of being pain-free even without anesthetic during treatment, providing quasi-facial lifting right after treatment.     

Peptide-pro complex serum: Investigating effects on aged skin

Background

Effective anti-aging treatments are an unmet consumer need.

Aim

Ex vivoand clinical tests have evaluated the efficacy of a topical facial serum containing a proprietary blend of neuropeptides, proteins, amino acids, and marine extracts on aged skin.

Methods

In the ex vivo study the facial serum was compared to a commercially marketed face serum and to an untreated control on skin explants using microrelief, smoothness, and epidermal thickness endpoints. The 12 weeks monadic clinical study was designed for the test product to be used on the whole face. Subjects functioned as their own control; evaluating change from baseline. Skin was evaluated clinically by a Dermatologist for tolerability and for efficacy. Also part of the product assessment was skin hydration measurements, imaging, and a subject questionnaire.

Results

The facial serum improved skin condition by significant reductions in skin surface area occupied by microfolds and in skin roughness. Additionally, it increased epidermal thickness as compared to the untreated control as well as the commercially marketed face serum. The facial serum provided a statistically increased skin moisturization compared to pretreatment values. Dermatological evaluation of the skin concluded that there were statistically and clinically significant improvements in skin smoothness, wrinkles severity, fine lines visibility and lifting, and tightening effects at crow's feet area, forehead, and upper lip.

Conclusion

A facial serum, containing a proprietary blend of neuropeptides, proteins, amino acids, and marine extracts, has been shown to improve the overall quality of aged skin in a series of ex vivo and clinical tests.     

Eyelid skin tightening: a novel ‘Niche’ for fractional CO2 rejuvenation

Background The periorbital area is a barometer of chronologic and environmental age for which patients usually seek rejuvenation; fractional CO₂ laser plays a key role among the variety of available dermatologic treatments. Objectives The purpose of this study is to evaluate the efficacy and safety of Fractional CO₂ laser in eyelid tightening and periorbital wrinkles. Methods Forty‐five patients received a range of 2–3 treatments in the upper, lower eyelids and periorbital area with a fractional laser device. Photographs were taken before and after each treatment and 2 weeks, 4 weeks, 3 months, 6 months and 12 months after the final treatment. The results were judged by three dermatologists who had not taken part in the treatments. Results One year after the last laser session, all patients showed global improvements in eyelid skin tightening: five patients (11.1%) achieved excellent improvement, 11 patients (24.5%) marked improvement, 15 patients (33.3%) moderate improvement and 14 subjects (31.1%) slight improvement. At the 1‐year follow‐up, the percentage of subjects with a lift in their eyebrows and consequently a widened palpebral fissure was 82.2 (37 patients), whereas 17.8% (eight patients) showed no eyebrow elevation. Conclusions Fractional CO₂ laser treatments allow dermatologists to achieve notable improvements in eyelid skin tightening, and eyebrow elevation safely and without significant side‐effects.     

Retrospective real-world study of Definisse threads for jaw line reshaping in Indian patients (REDEFINE JAW study)

Background

Thread lifting is a minimally invasive aesthetic procedure that lifts and realigns sagging tissue. Definisse double-needle threads are the latest fourth generation absorbable, monofilament, suspension barbed threads of synthetic origin with convergent bidirectional barbs. Definisse thread produces dual action; mechanical action gives a lifting effect and over a period, it promotes histological revitalizing action.

Objectives

To evaluate the real-world efficacy and safety of Definisse double-needle threads for lower facial lifting for jaw line reshaping in Indian patients.

Methods

This is an observational, retrospective study involving patients who underwent treatment for lower-face reshaping using Definisse double-needle 12 cm threads.

Results

Fifty patients with a mean age of 47.44 years were included in the study with an average follow-up of 5.14 months. All the patients have undergone Jawline Reshaping (JR) procedure, while 70% of patients also underwent Malar Reshaping (MR) technique simultaneously. Mean of Physician and Subject Global Aesthetic Improvement Scale (PGAIS and SGAIS) showed improvement immediately after the procedure (mean scores 2.82 and 2.7, respectively) and showed further improvement at the follow-up (3.72 and 3.58, respectively). Moreover, most of the patients immediately after the procedure rated the improvement in PGAIS and SGAIS as “much improved” compared to pre-procedure appearance (78% and 66%, respectively), while, at follow-up, 76% and 66% of the patients, respectively, rated “improved very much” compared to pre-procedure appearance.

Conclusion

Current study has demonstrated the effectiveness of the latest Definisse threads in Indian patients in performing tissue repositioning to provide a noticeable lifting effect. Procedure was also well tolerated and none of the patients developed serious complications.     

Category of upper eyelid morphology and the preferred double eyelid shape in Asians according to questionnaire survey

Background

The morphological classification of the upper eyelid in Asian people is complex and diverse and usually not consistent with what we know well.

Aims

To improve the classification of upper eyelid morphology and investigate the preferred double eyelid shape by Asian people.

Methods

An investigation of 640 patients' preferences for double eyelid shape was conducted, and the pre- and post-operative effects were assessed. The shapes of the natural eyelids of 247 people (485 eyes) who provided real photographs of the eyelids were counted. The chi-square test was used to analyze the differences.

Results

There were 10 eyelid shapes: single eyelid, parallel-shaped double eyelid, fan-shaped double eyelid, parallel fan-shaped double eyelid, opened fan-shaped double eyelid, crescent-shaped double eyelid, hidden-shaped double eyelid, horizontal-shaped double eyelid, triangle-shaped double eyelid, and multiple-fold eyelid. The difference in the shape of the natural eyelid between males and females was statistically significant (p < 0.05). The most popular eyelid shapes were single eyelid (24.9%), open fan-shaped double eyelid (21.0%), fan-shaped double eyelid (16.3%), and hidden-shaped double eyelid (12.6%). Men and women preferred a parallel fan-shaped double eyelid (18.0%), a parallel-shaped double eyelids (17.0%), and an open fan-shaped double eyelids (18.1%).

Conclusions

The most popular upper eyelid shapes were single eyelid, open fan-shaped double eyelid, and fan-shaped double eyelid. The parallel fan-shaped, parallel-shaped, and open fan-shaped double eyelid were favored by men and women.     

Effect of pdo facelift threads on facial skin tissues: An ultrasonographic analysis

Background

Recent studies demonstrate that PDO threads, after being introduced into the facial skin, provide benefits due to collagen formation around the thread and improved vascularization.

Aims

This work aims to report the ultrasound and photographic follow-up after the execution of the facelift thread technique, thus evaluating the anti-aging treatment that PDO threads will provide for human facial skin.

Methods

The facelift will be performed using PDO thread 18G cannulated Sculpt i- Thread FML 100 × 185 mm, and 29G PDO thread Needled Flat i-Thread 38 × 50 mm. A total of 10 patients were selected for the study; all of them had medium-grade facial ptosis and aged 40–50 years old. In order to control tissue changes after thread, insertion ultrasound measurements will be made with Philips ultrasound 12 MHz linear probe at maximum resolution, initial evaluations and control of 30, 60, 90, and 120 days, measuring the skin layers: epidermis\dermis and hypodermis. Photographic control was performed before and after 120 days of intrusion of the PDO threads.

Results

The formation of collagen around the PDO thread was evidenced through ultrasound images in all patients in this study, as well as improvement in the appearance of the skin and sagging, evaluated by photographic control.

Conclusions

We can define that the PDO threads used for the facelift are effective in the formation of collagen around the thread (observed through the increase in the dermal layer), and improvement of the condition of the anti-aging factor through sagging skin, vascularization and thinning of the superficial fat layer (observed through the reduction of the subcutaneous or hypodermis layer).     

A home-based eyebrows lifting effect using a novel device that emits electrostatic pulses containing RF energy,resulting in high frequency,low level transdermal microcurrent pulsations: Double blind,randomized clinical study of efficacy and safety

Background: As the appearance of the face is a primary concern of many people, ways in which to tighten the skin are increasingly in demand. In recent years, radiofrequency (RF) has become a promising nonablative, non-invasive, technique for facial rejuvenation. Objective: To assess the safety and the efficacy of a unipolar RF-based device for home use in increasing skin tightness (lifting effect) in the eyebrows area. Methods: Subjects (N = 50) aged between 30 and 70 years old showing skin wrinkledness all over the face and skin laxity in the eyebrows area were enrolled. The primary endpoint was the assessment of the eyebrow to hairline distance by means of a morphometric digital image analysis technique. Results: The eyebrows to hairline distance was statistically significant (both vs. basal condition and placebo) decreased by 1.338 ± 0.170 cm in the treated eyebrow. Conclusion: The obtained results confirm the safety and the efficacy of the tested device in decreasing skin laxity in the eyebrows area. The treatment is not time-consuming (about 6 minutes) and can be done at home. The device seems to be then a useful tool to delay skin laxity or to prolong the time to the first surgical facial lift.     

Evaluation of the effects of 10% and 30% gluconolactone chemical peel on sebum,pH, and TEWL

Background

Gluconolactone (GLA) exhibits antioxidant and moisturizing effects. It also presents soothing effects, protects elastin fibers from UV-induced degradation, and improves the function of the skin barrier.

Aims

Evaluation of skin parameters such as pH, transepidermal water loss (TEWL), sebum levels before, during, and after a series of applications of 10% and 30% GLA chemical peel in a split-face model.

Materials and Methods

The study involved 16 female subjects. Three split-face procedures were performed using two concentrations of GLA solution applied on two sides of the face. The skin parameters were measured before treatments and 7 days after the last procedure at four measurement sites on either side of the face, that is, on the forehead, around the eye, on the cheek, and on the nose wing.

Results

Measurement of sebum demonstrated some statistically significant changes between sebum levels in the cheeks after a series of treatments. The pH measurement showed that the pH value was reduced after each treatment at all measurement points. The level of TEWL after treatments was significantly lower around the eyes, on the left forehead, and on the right cheek. There were no significant differences between the use of different concentrations of the GLA solution.

Conclusions

The results of the study show that GLA has a significant influence on lowering skin pH and TEWL. GLA also has seboregulatory properties.     

TREATMENT OF PERIOCULAR HYPERPIGMENTATION DUE TO LEAD OF KOHL (SURMA) BY PENICILLAMINE: A SINGLE GROUP NON-RANDOMIZED CLINICAL TRIAL

Background:

Periocular hyperpigmentation is a condition in which skin of eyelids become darker in color than the normal surrounding skin. Lead and other heavy metals produce increased pigmentation because of deposition of metal particles in the dermis and increased epidermal melanin production.

Aims:

This study was conducted to evaluate the dual effect of chelation therapy in treating periocular hyperpigmentation and lead toxicity.

Methods:

The study population consisted of nine females complaining from dark coloration of their eyelids. The nine females were continuously using kohl as eyeliner. Lead levels in conjunctiva and serum before and after D-penicillamine (D-PCN) oral administration were estimated in relation to vertical, horizontal length, and degree of hyperpigmentation score.

Results:

Highly significant P values (0.000) were obtained as regard to the conjunctival lead levels, serum lead levels, horizontal length, and degree of darkness score before and after D-PCN therapy. A less significant P value (0.040) was recorded as regard to the vertical length.

Conclusion:

Regardless other causes, this study spots the light on a new concept for periocular hyperpigmentation from lead toxicity in adult females using kohl and suggests D-PCN in a low divided dose (750 mg/day) for its treatment.     

Degreasing method for the seborrheic areas with respect to regaining sebum excretion rate to casual level

Background/aims: Sebum excreted from the seborrheic glands keeps the skin surface subtle and moist. Before determining the activity of seborrheic glands, the skin surface must be degreased to remove contamination but without provoking sebum excretion. The purpose of this study was to set up a standardised degreasing procedure for various seborrheic areas in different skin types. The method will take day‐to‐day variations into account with respect to the kinetics of refatting. Methods: The Sebumeter^® from Courage+Khazaka is used to quantify the sebum excretion. Day‐to‐day variations were measured on the forehead in groups of 12 volunteers on 2 consecutive days. The degreasing procedure was investigated by individual cleaning with alcohol compared to washing with a mild detergent followed by wipes with alcohol on the forehead. The degree of refatting was monitored until 3 h after defatting on seborrheic areas: the forehead, cheek, nose, chin and upper back. Results: There was no statistical significant difference in the variation from day to day (P<0.05), although a change in the individual skin types was observed. An individual difference in the number of alcoholic wipes needed to degrease the forehead was seen. Washing followed by several repetitions of alcoholic wipes was not sufficient for the forehead, chin and nose (P>0.05). For the cheek and upper back, it was sufficient to wash with soap (P<0.05). The time from degreasing the skin until the sebum output reached the casual level was 2 h (P>0.05). The area under the curve (AUC) indicates that individual skin types return to casual level after defatting. Conclusion: There was no statistically significant day‐to‐day variation using the Sebumeter^®. We ended up with different degreasing procedures in different seborrheic areas. Washing gently with a detergent solution and then performing three wipes with alcohol was optimal for degreasing the forehead, nose and chin. For the cheek and upper back, it was sufficient to use a mild soap. Casual level was reached after 2 h in all seborrheic areas, irrespective of level of oiliness.     

Second Intention Healing after Shave Excision of Benign Tumors on the Lid Margin

Background

Defects caused by excision of benign lid margin tumors are conventionally repaired by reconstructive surgery. However, second intention healing is another option for managing wounds on the lid margin.

Objective

To evaluate the effectiveness of second intention healing after a shave excision of benign tumors on the lid margin.

Methods

Lid defects following a shave excision of the lid margin tumor were allowed to heal by second intention in 25 patients (26 lesions). The epithelialzation period was calculated, and cosmetic and functional results and complications were evaluated by photographs and ophthalmological examination.

Results

The locations of the defects were as follows: upper lid (n=13), lower lid (n=11), and both upper and lower lids (n=1). The mean tumor size was 3.8×3.6 mm, and the mean epithelialization period by second intention was 6.1±1.2 weeks. Pathological examinations revealed intradermal nevus (12 cases), compound nevus (five cases), squamous papilloma (five cases), and epidermal cyst (three cases). No patients had a corneal erosion, trichiasis, or hypertrophic scar, except loss of cilia in two cases. The functional and cosmetic results were satisfactory in all patients.

Conclusion

Healing by second intention is a safe and effective alternative to surgical reconstruction after a shave excision of benign lid margin tumors.     

Comparing the effectiveness of laser vs. conventional endoforehead lifting

The objective of this study was to compare the efficacy and safety of laser versus conventional endoforehead lifting. Over a period of 12 years (January 2000–January 2012), a total of 110 patients with hyperactive muscles over the frontal region have been collected for a retrospective study. The SurgiLase 150XJ CO₂ laser system, in conjunction with the flexible FIBERLASE, was used. The endoscope was 4 mm in diameter with an angle of 30°. The primary efficacy measurement was the assessment of the final outcome for using laser vs. conventional methods. Both groups were observed at three weeks, six weeks and six months after surgery. The most common complication in early convalescence (three weeks) was swelling. This was followed by local paraesthesia, ecchymosis, localized hematomas and scar with alopecia. All these problems disappeared completely after the 6-month study period. Based on a chi-square analysis, there were clinically and statistically significant differences favouring the laser endoforehead surgery in the operative time, early and late complications. All patients achieved significant improvement after both laser and conventional endoforehead surgery in the final outcome. However, the early and late complications indicated a greater difference in the laser group.     

Epidemiologic Study of Malassezia Yeasts in Patients with Malassezia Folliculitis by 26S rDNA PCR-RFLP Analysis

Background

So far, studies on the inter-relationship between Malassezia and Malassezia folliculitis have been rather scarce.

Objective

We sought to analyze the differences in body sites, gender and age groups, and to determine whether there is a relationship between certain types of Malassezia species and Malassezia folliculitis.

Methods

Specimens were taken from the forehead, cheek and chest of 60 patients with Malassezia folliculitis and from the normal skin of 60 age- and gender-matched healthy controls by 26S rDNA PCR-RFLP.

Results

M. restricta was dominant in the patients with Malassezia folliculitis (20.6%), while M. globosa was the most common species (26.7%) in the controls. The rate of identification was the highest in the teens for the patient group, whereas it was the highest in the thirties for the control group. M. globosa was the most predominant species on the chest with 13 cases (21.7%), and M. restricta was the most commonly identified species, with 17 (28.3%) and 12 (20%) cases on the forehead and cheek, respectively, for the patient group.

Conclusion

Statistically significant differences were observed between the patient and control groups for the people in their teens and twenties, and in terms of the body site, on the forehead only.     

Multi-polydioxanone (PDO) scaffold for forehead wrinkle correction: A pilot study

Background: Forehead wrinkles are the result of contracture of the frontalis muscle and the skin aging process. Currently, hyaluronic acid filler and botulinum toxin are the main materials used for correction of these wrinkles. In addition, polydioxanone (PDO) thread has also been applied for this treatment. Objective: In order to evaluate the efficacy and safety of multi-PDO scaffold in animal and human skin, we tested PDO insertion in rat and mini-pig models and human volunteers with forehead wrinkles. Methods: A stent-shaped multi-PDO scaffold was inserted under the panniculus carnosus of rat dorsal skin and the subcutaneous layer of mini-pig dorsal skin and forehead wrinkles in three human volunteers. Results: Histological analysis at 12 weeks revealed evidence of de novo collagen synthesis, which was consistent with clinical results on photo evaluation. Conclusion: Stent-shaped multi-PDO scaffolds may be another effective and safe treatment modality for reduction of forehead wrinkles.     

SAMCEP Society consensus on the treatment of upper facial lines with botulinum neurotoxin type A: A tailored approach

Background

The safety and efficacy of botulinum neurotoxin type A (BoNTA) treatments are well established, but injection techniques, target muscles, and toxin doses continue to evolve, with each refinement producing improvements in treatment outcomes. The recommendations in this consensus move away from standard templates and illustrate how to tailor treatments to individual patterns and strengths of muscle activity, and patient preferences.

Methods

Seventeen experts in the fields of plastic surgery, dermatology, ophthalmology, otorhinolaryngology, and neurology convened in 2022 to develop consensus-based recommendations for the use of botulinum toxin A for the treatment of horizontal forehead lines, glabellar frown lines, and crow's feet lines that reflect current clinical practice. The focus was on how to tailor injections to individual patients to optimize treatment outcomes.

Results

For each upper face indication, consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is presented for commonly observed patterns of dynamic lines. Units of Inco are defined and the precise location of injection points, illustrated with the use of anatomical images.

Conclusion

This consensus provides up-to-date recommendations on the tailored treatment of upper facial lines based on the latest research and collective clinical experience of the expert injectors. Optimal outcomes require thorough patient evaluation, both at rest and during animation, using both visual and tactile cues; detailed understanding of facial muscular anatomy and how opposing muscles interact; and use of a BoNTA with high precision to target identified zones of excess muscle activity.