PRIME Journal Nov/Dec 2022

ITH THE END OF THE YEAR FAST APPROACHING, WE ALREADY find ourselves turning our attention to the much-anticipated marquee events in aesthetic medicine. On 30th March 2023, the internationally renowned Aesthetic & Anti-Aging Medicine World Congress (AMWC) will return to Monaco for its 21st edition — welcoming over 12,000 participants, 250 esteemed speakers, and 250 of the industry’s most trusted companies to engage in a world-class scientific programme and bustling exhibition.

Under the scientific supervision of the Aesthetic Multispecialty Society (AMS), AMWC’s 2023 programme is designed to deliver the latest updates in aesthetics and anti-aging medicine research, techniques, and innovations. The programme will cover a wide range of topics, including aesthetic and functional dermatology, minimally invasive aesthetics, lasers and EBD’s, anti-aging medicine and more.

Making its return in 2023 will be the AMWC Aesthetic Medicine Awards. Now in its 9th edition, the AMWC Aesthetic Medicine Awards, in partnership with the AMS, is a prestigious annual competition that gives recognition to physicians and companies aspiring for innovation, excellence, and the advancement of aesthetics and anti-aging medicine. The call for entries is still open, so visit the AMWC website (www.amwc-conference.com) for more details on how to enter. Looking to the current issue of PRIME Journal and we have a timely feature from Patrick Treacy delving into the interaction of COVID-19 vaccines and cosmetic fillers. With the onset of the COVID-19 pandemic, there were reports some patients who had undergone cosmetic fillers had experienced side-effects after receiving the vaccines. The cause of these side-effects — nodules at the site of filler injection — was thought to be due to type IV hypersensitivity causing foreign body granulomas. A cohort of patients remained unresponsive to any established treatment protocols, such as antihistamines, 5-fluorouracil, hyaluronidase, and intralesional steroids. Patrick Treacy delivers an excellent feature evaluating the efficacy of using the immunosuppressant methotrexate to treat COVID-19 vaccine-related delayed onset nodules in twenty-three patients who were unresponsive to the established treatment protocols. You can read the full article on page 26.

If you would like to contribute to PRIME in 2023 or would like to make suggestions about the content we cover for the year ahead, please get in touch.

Finally, from the team at PRIME, we wish you all happy holidays and a great end to the year.

Balraj Juttla Editor, PRIME balraj.juttla@informa.com

International Journal of Aesthetic and Anti-Ageing Medicine Informa, Floor 4, 24 York St, Sydney, NSW 2000, Australia

ISSN 2159-8908 (print) ISSN 2159-8916 (online)

FOR THOUSANDS OF PHYSICIANS AROUND THE WORLD, THERE IS NO BETTER place than the Aesthetic & Anti-Aging Medicine World Congress (AMWC) to learn from and connect with likeminded professionals — whether at the flagship event in Monaco, or the Latin America (LATAM) edition.

‘In my experience, there are no other conferences that draw so many big-hearted people who are willing to share,’ said Francisco Llano, MD (Mexico City, Mexico). ‘These professionals are willing to teach others — I love it.’

This is why Dr. Llano is thrilled that the world-class scientific powerhouse is coming to North America (Miami, Fl.) for the first time ever on February 23–25, 2023.

Jesper Thulesen, MD, an oculoplastic and aesthetic surgeon in Copenhagen, Denmark, agreed. ‘AMWC Monaco has evolved over recent decades to become one of the largest and most honorable events for professionals in the field,’ explained Dr. Thulesen. ‘AMWC is unique due to the very high standard of its international speakers. The overwhelming success of the European version of the AMWC will now be offered in North America, targeting a wide audience with delegates participating from around the world. In the medical aesthetic field, physical national borders do not exist.’

The AMWC North America (AMWC NA) program explores many subsectors of aesthetic and anti-aging medicine, incorporating a unique, international perspective on leading-edge nonsurgical treatments, minimally invasive surgical techniques and emerging areas such as cellular aging, regenerative medicine and integrative aesthetics.

The event includes four concurrent tracks with science-backed, globally-vetted and endorsed programming over three days. The program offers up to 17 CME/ACCME AMA PRA Category 1 Credits™ for physicians and 17 contact hours for nurses. Every session in the program is thoroughly vetted and carefully curated by a global Scientific Advisory Board (SAB).

Another unique feature to expect when attending AMWC NA, is an intense focus on the latest evidence-based research and cutting-edge innovations in the industry.

The event will feature a Treatment Center where attendees can try innovative new products, services and techniques in one-hour sessions to personally gauge the results for themselves.

AMWC NA is an event that attracts medical professionals from across the globe and from a variety of specialties. Dr. Llano believes this multispecialty audience is a real benefit to AMWC NA.

‘I have been so fortunate to make friends from around the world by attending AMWC events,’ he highlighted. ‘I have made connections with people from Europe, South America, North America and lots of other places. And this is so important because it is not about the individual — it is about the community. To give an example, in a song it is not about an individual instrument, like the drums or the horns; it is about the entire orchestra. That is what matters. And I want to be a part of that.’

BOARD MEMBER SPECIALISM COUNTRY

Dr Gustavo Leibaschoff Cosmetic Surgery USA

Dr Sohail Mansoor Dermatology UK

Prof Leonardo Marini Dermatology Italy

Dr Sly Nedic Aesthetic & anti-ageing medicine South Africa

Prof Daniel Pella Cardiology Slovakia

Dr Chariya Petchngaovilai Dermatology Thailand

Prof Ascanio Polimeni Neuro-endocrinology Italy

Dr Herve Raspaldo Facial plastic surgery France

Dr Christopher Rowland-Payne Dermatology UK

Dr Neil Sadick Dermatology USA

Dr Hema Sundaram Dermatology USA

Dr Pakpilai Thavisin Dermatology & Anti-ageing medicine Thailand

Dr Patrick Treacy Aesthetic surgery Ireland

Germany

Prof Ilaria Ghersetich Dermatology Italy

Dr Michael H. Gold Dermatology USA

Dr Kate Goldie Aesthetic Physician UK

Prof Eckart Haneke Dermatology Germany

Dr Steven Hopping Plastic surgery USA

Prof Andreas Katsambas Dermatology Greece

Dr Mario Krause Anti-ageing medicine Germany

Dr Marina Landau Dermatology Israel

Dr Mario Trelles Plastic surgery Spain

Dr Ines Verner Dermatology Israel

Dr Octavio Viera Anti-ageing medicine Spain

Dr Jean-Luc Vigneron Aesthetic dermatology France

Prof Bernard Weber Genetics Luxembourg

Dr Sabine Zenker Dermatology Germany

Catherine Decuyper Industry expert & consultant France

Wendy Lewis Industry expert USA

Christophe Luino Industry expert & consultant France

Lisa Richter Contributing Editor, The Aesthetic Guide

NEWS

The aesthetic society’s aesthetic one® app registers over 22,000 breast implants 12 Aveeno® releases inaugural State of Skin Sensitivity report

10

AESTHETIC FEATURES

Hyaluronic acid fillers from the cohesive polydensified matrix range for the Asian patient

The Aesthetics China Expert (ACE) Steering Committee outline their insights and recommendations 20 Temporal-zygomatic lifting of the mandibular edge with high G’ fillers

Prof. Redaelli Alessio discusses his experience treating moderate ptosis of the mandibular edge with high G’ fillers and the results he witnessed in a single-centre study 26 Treating COVID-19 vaccine-related nodules with methotrexate

Patrick Treacy unveils the results of a study investigating the use of the immunosuppressant methotrexate to treat twenty-three patients unresponsive to any established treatment protocols

Improved monopolar radiofrequency treatments Weng Yu-Ching examines whether monopolar radiofrequency treatments using low energy and multiple passes can be effective

A round-up of news stories in the aesthetic and anti-ageing medicine industry

he Aesthetic Society, a 2,600-member organisation of board-certified plastic surgeons devoted to aesthetic plastic surgery, announced that Aesthetic One, a free app developed through support From Allergan Aesthetics® and built by The Aesthetic Society’s technology partner ANZU®, to inform and empower patients and plastic surgeons, has registered over 22,000 breast implants since launching in December 2021. The Aesthetic One app is the only implant registration platform that empowers patients with lifetime, on-demand access to their breast implant info and operative summary. The revolutionary HIPAA-compliant platform also features a paired app for patients allowing surgeons to share breast implant ID cards, operative summaries, photos, and more.

‘I use Aesthetic One because of how easy implant registration is. I’m proud to be among the 570-plus physicians who invest in their patients by using Aesthetic One to provide their vital breast implant data,’ says Dr. Nolan Karp, plastic surgeon, and Aesthetic Society member and Chair of the Aesthetic One Committee.

‘Aesthetic One users have registered over 22,000

breast implants a milestone that keeps patients informed and empowered.”

Aesthetic One was created as a direct result of the March 2019 meeting of the FDA General and Plastic Surgery Devices Panel discussing the safety and risks of breast implants. The Panel heard from members of The Aesthetic Society, patient advocates and manufacturers. There was a clear need for improved patient monitoring and collection of critical data, crucial steps to keep patients informed so they better understand risks associated with breast implants.

Aesthetic One addresses the concerns around device tracking and long-term implant safety. The

2019 FDA hearings highlighted the need for better long-term implant safety data as physicians, regulators, patients, and the media examined the incidence and impact of BII and BIA-ALCL. The Aesthetic One development team worked directly with high-volume implant physicians to develop an app that not only addresses concerns about device tracking and patient safety but also simplifies the registration process for physicians and staff. During focus groups and development meetings, physicians expressed that existing registries are timeconsuming, hard to access, and fail to empower patients with details of their implants and surgical procedure. The team also sought to create a platform that would save the office time and improve data storage and access for the practice. Aesthetic One is a quick and easy digital implant registration option that replaces antiquated triplicate forms and faxes with a digital solution available on any device.

All implants registered with the Aesthetic One app are stored in a digital library permanently accessible to the physician and patient, empowering both with on-demand access to critical data.

Crown Aesthetics, a division of Crown Laboratories, announced the news that their product, SkinPen Precision, was named ‘Best in Industry Nonsurgical Innovation’ at the 2022 Aesthetic Awards. Presented by The Aesthetic Guide, the Aesthetic Awards shine a spotlight on product manufacturers and practice management companies that are shaping the future of aesthetic medicine.

SkinPen is the first FDA-cleared

microneedling device on the market, with over two million treatments performed worldwide. It is the device of choice for aesthetic practices, as it stimulates the body’s natural wound healing process, which triggers the immune system to remodel the scar tissue. In SkinPen’s clinical trials, 90% of patients reported an improvement in the appearance of their acne scars at the end of six months and would recommend this procedure

to friends and family.

‘We’re thrilled to receive this honour from the esteemed group of professionals at The Aesthetic Guide,’ says Michael McKenna, General Manager & Executive Vice President of Crown Aesthetics. ‘We strive to offer best-in-class medical technologies like SkinPen Precision, the first FDA-cleared microneedling device on the market, and to have those efforts recognised by our peers and colleagues is a testament

to Crown Aesthetics’ dedication to efficacy and safety.’

SkinPen is backed by 90+ validation studies to ensure quality, safety, and performance. The U.S.A. engineered and manufactured device has set the standard in the microneedling industry with an unyielding pursuit to deliver therapeutic excellence and enhanced patient outcomes. For more information, visit skinpen.com/.

AVEENO® RELEASES INAUGURAL STATE OF SKIN SENSITIVITY REPORT

REPORT REVEALS THAT 71% OF ADULTS HAVE SENSITIVE SKIN

The Aveeno® brand launched its first-ever State of Skin Sensitivity Report, which examines the causes of sensitive skin, and explores the connection between body, mind, and skin. While body positivity has spread to mainstream culture in recent years, self-love can be challenging for those of us with sensitive skin. The groundbreaking Aveeno® report shows that 71% of adults identify as having sensitive skin, an astounding increase of 55% in just two decades. The impact of this sensitivity is more than skin deep, as common skin conditions can carry significant psychological impact, influencing quality of life and emotional well-being.

Research from the State of Skin Sensitivity report validates the relationship between emotions and perceptions of sensitive skin.

Skin is both a receiver and a reactor to sensory stimuli, meaning that everything from the environment to skin products can show up in our pores and negatively influence emotions. For example, one-third of patients with skin diseases like acne, atopic dermatitis, psoriasis, and rosacea are estimated to struggle with emotional disorders, including anxiety and depression. Additionally, 50 percent of adults with moderate to severe atopic dermatitis reported that it puts a damper on their social functions, sleep, work productivity, leisure activities, and family relationships.

Aveeno® recognises the broad issue of sensitivity as a skin state, rather than a clinical diagnosis and seeks to shine a light on its prevalence, as well as possible areas of prevention.

‘Treating patients goes well beyond simply analysing their skin. It’s about how their skin impacts their overall emotional well-being, which

is something I consistently see with my patients,’ said Dr. Mara Weinstein Velez, Board Certified Dermatologist and paid Aveeno® consultant. ‘The mind-skin connection is a powerful one, and the Aveeno® brand’s ability to assemble this in-depth report examining the impact of skin sensitivity provides much needed visibility for the dermatology community.’

‘Our brand heritage is built on leadership and expertise in the sensitive skin state, and this report illustrates the meaningful impact sensitive skin has on people’s lives,’ said KC Hagin, Commercial Leader for Aveeno® at Johnson & Johnson Consumer Inc.

‘We have an obligation not only to provide product solutions but to help de-stigmatise the word ‘sensitive’ and to turn a common struggle into a strength. Aveeno® wants to be front and centre of the conversation and is encouraging everyone to be proud of their sensitive skin.’

To further encourage conversation around what it really means to have sensitive skin, Aveeno® is calling on consumers to share their #ProudlySensitiveSkin stories on social media. The campaign aims to highlight various consumer experiences with skin conditions and showcase how people have learned to love their sensitive skin. By changing the narrative, Aveeno® is facilitating connection with likeminded individuals in a deeper way and celebrating sensitive skin, and all that comes with it.

Aveeno® knows that sensitive skin is real and can have a tremendous impact on quality of life which is strongly illustrated in this report. The brand is committed to igniting and fueling the positive narrative around sensitive skin, while also being dedicated to delivering products that bring nourishing solutions to sensitive skin.

BIOLEXA SCORES POSITIVE TRIAL RESULTS

Hoth Therapeutics, Inc., a patient-focused biopharmaceutical company, announced positive data for BioLexa, its investigational therapeutic in a Phase 1b clinical trial in adult patients with mild-to-moderate atopic dermatitis.

Using the SCORAD (SCORing Atopic Dermatitis) as a clinical tool for assessing the severity of atopic dermatitis and EASI score, which is a tool used to measure the extent and severity of atopic eczema all patients showed improvement during the study compared to the day one score. Using the EASI scale, 100% of patients showed clinically-relevant improvement >50% compared to Day 1 during the entire 28 day study treatment period. Using SCORAD 60% of patients showed overall clinically relevant improvement by SCORAD (>35% improvement) during the study compared to the Day 1 score. 42% of patients maintained improvement from day 14 to day 28 (which includes 2 weeks without active treatment). This supports the long-term effect of BioLexa based on the mechanism of action to treat the underlying staphylococcal infection.

A clinically relevant reduction in the total body surface area affected by atopic dermatitis was observed in 71% patients treated with BioLexa; within these patients, the total reduction ranged from 37.5%–71.4%.

BioLexa was well tolerated with no serious adverse events and no drugrelated treatment-emergent adverse events observed, according to the safety results. In addition, >50% of patients reported an improvement in the effect of atopic dermatitis on their quality of life.

Robb Knie, Chief Executive Officer of Hoth Therapeutics, stated, ‘Today’s positive results give us even more confidence that BioLexa can help provide relief from atopic dermatitis in patients, without the harmful long-term effects of corticosteroids and other side effects that many patients suffer with today’s choice of approved therapeutics.’

Skin is both a receiver and a reactor to sensory stimuli, meaning that everything from the environment to skin products can show up in our pores and negatively influence emotions.

Recently, an injectable HA gel based on Cohesive Polydensified Matrix (CPM) technology received approval in China for injection into the mid-dermis for filling of moderate nasolabial folds.

HYALURONIC ACID FILLERS FROM THE COHESIVE POLYDENSIFIED MATRIX RANGE FOR THE ASIAN PATIENT

The Aesthetics China Expert (ACE) Steering Committee outline their insights and recommendations

ABSTRACT

In conjunction with the launch of Belotero* Balance Lidocaine (Merz Aesthetics, Geneva, Switzerland) in China, the ACE (Aesthetics China Experts) Steering Committee held their inaugural meeting on 9 June 2022, during which global experts shared their clinical experience and the panel discussed current practices and recommendations on the clinical use of the Belotero range, with particular emphasis on applications in Asian

populations and for currently approved indications in China.

Treatment aims in Asians and current practice regarding the use of Belotero HA fillers were presented. In addition, injection techniques and indications for Belotero Balance Lidocaine and other Belotero products that have been developed in other territories with additional approved indications were introduced.

The Belotero range of HA fillers offers efficacious and safe

HYALURONIC ACID (HA) DERMAL fillers are a popular cosmetic treatment to correct various aesthetic issues such as lines, wrinkles, and facial volume loss, as they are minimally invasive, have a favourable safety profile, and create immediate results in a reproducible manner1,2. Recently, an injectable HA gel based on Cohesive Polydensified Matrix (CPM) technology (Belotero* Balance Lidocaine, Merz Aesthetics, Geneva, Switzerland) received approval in China for injection into the mid-dermis for filling of moderate nasolabial folds3

To that end, the ACE (Aesthetics China Experts) Steering Committee, a 13-member expert panel comprising plastic surgeons, dermatologists and experienced injectors practising in China, including an international expert from Germany and Hong Kong, China, gathered for the first time to disseminate knowledge gained from clinical experience and discuss current practices and recommendations on the clinical

results due to excellent dermal integration that minimises tissue disruption. Belotero Balance Lidocaine possesses unique rheological characteristics that allow it to fulfil the unmet therapeutic needs of injecting superficially to address fine lines with immediate and durable results and thus is poised to be a welcome addition to the aesthetic doctor’s armamentarium in China.

*Belotero is a registered trademark of Merz Pharma GmbH & Co. KGaA.

use of the Belotero range, with particular emphasis on applications in East Asian patients.

CPM technology affords Belotero HA fillers with unique rheological properties

All HA fillers undergo crosslinking modification to provide higher resistance to endogenous hyaluronidase action, thereby increasing efficacy and duration of results. The proprietary crosslinking technique, known as cohesive polydensified matrix (CPM) technology (Figure 1)2,4, utilised confers the resultant HA gel with a unique set of rheologic properties that informs its suitability for different treatment indications, injection techniques, and injection depths. A range of HA fillers based on the same technology is formulated by varying the crosslinking ratio and HA concentration.

The relevant rheological properties typically referred to when discussing a HA gel’s therapeutic indications are cohesivity, viscosity, elasticity, and plasticity5–7. Cohesivity is defined as the capacity of a material not to dissociate

WENZHI LI, PHD

Beijing Anzhen Hospital, Capital Medical University, China; SHENGKANG LUO, PHD

Guangdong Second Provincial General Hospital, China; HANG WANG, PHD

West China School/Hospital of Stomatology Sichuan University, China;

SUFAN WU, PHD

Zhejiang Provincial People’s Hospital; HONGYI ZHAO, PHD

Beijing Hospital, National Geriatrics Centre; HAIYAN CUI, PHD

Tongji Hospital of Tongji University, Shanghai, China; BI LI, PHD

Peking University Third Hospital, China

KEYWORDS

Hyaluronic acid, Dermal fillers, Belotero balance, China, CPM technology

because of its constituent molecules for each other even under mechanical stress, e.g., muscular action5 Viscosity is the ability of a gel to resist shearing forces and can be characterized according to how it ‘flows’6. Viscosity is therefore used to define the thickness of a gel - the higher a gel’s viscosity, the more resistant it is to spreading7. Elasticity, measured as elastic modulus (G’), is defined as the ability of a gel to revert to its initial shape after mechanical stress6. Plasticity refers to the ability of a gel to be shaped. It is desirable for a gel to be malleable so as to follow the dynamic motions of the face. Together, these four parameters control the suitability of a filler to treat various treatment goals (e.g., a HA gel indicated for volumisation and tissue support as compared to one intended for superficial filling of fine lines).

The Belotero range of injectable dermal fillers is produced using cohesive polydensified matrix (CPM) technology. As with most other HA fillers, CPM uses

CROSS-LINKING TECHNOLOGY

CPM technology produces gels with non-uniform crosslinking and molecular weight, allowing for better dermal integration.

1,4-butanediol diglycidyl ether (BDDE) as the crosslinking agent, but then undergoes a specific additional step to first stretch the initial crosslinked matrix and continue the crosslinking process dynamically through the supplementation of additional HA. CPM-based gels are cohesive with zones that have varying degrees of density8. The Belotero range is characterised by higher cohesivity, scoring 5 (fully cohesive) on the 5-point Gavard-Sundaram Cohesivity Scale5 in comparison with other HA filler ranges. This translates clinically to excellent dermal integration with similar distribution to endogenous HA in tissue, as histology and ultrasound imaging studies have shown9,10. Moreover, compared to monodensified HA gels, Belotero distributes diffusely and evenly with minimal disruption to the dermal plane structure2. This atraumatic placement, together with its non-particulate nature, is postulated to be the reason why treatment is very well-tolerated, with almost no inflammatory reactions compared to other technologybased HA gels11. No persisting nodules, granulomas, and tissue necrosis due to intravascular injection have been reported in long-term safety reports for any Belotero dermal filler12

Of the HA fillers in the Belotero range, Belotero Balance Lidocaine is the earliest product introduced to the market and thus is well-studied. Formulated with a HA concentration of 22.5 mg/mL, this product exhibits low elasticity, and low viscosity, which allows it to be injected easily13, and — like other products in this range — high cohesivity, allowing for seamless and optimal tissue integration properties13,14. In China, Belotero Balance Lidocaine comes with lidocaine (0.3%) to address the common side effect of injection-related discomfort3

Clinical applications of HA in Asian patients: treatment aims and considerations

The typical desired feminine face shape is oval, narrow, elongated and projected, especially in the mid-face, nose, and chin15. HA fillers are typically used in the young Asian female face to correct perceived inaesthetic features such as ‘flatness’ of the infraorbital and medial malar regions, a lack of projection of the midline facial features that result in a broad face, as well as an angular jawline16 To correct age-related aesthetic defects, HA fillers are mainly used to replace age-related volume loss and subsequent tissue sagging as well as structural deficiencies that become more pronounced as a result16

Advancements in technology have allowed the formulation of HA fillers that satisfy most of the criteria of an ‘ideal’ injectable filler, including optimal rheology to achieve seamless tissue integration, resiliency towards repeated movements, and delivery of predictable, reproducible, and natural results17. In particular, it is sometimes important to have a dermal filler with similar characteristics to the bone structure. Additionally, the filler should play a secondary role as a stable platform onto which changes in bone structure leading to ageing or aesthetic deficiency can be compensated — this creates better support and avoids product migration and

PROF HAIYAN CUI Tongji Hospital of Tongji University, Shanghai

PANEL OF EXPERTS THE ACE (Aesthetics China Experts) Steering Committee

Belotero Balance is created with a dual cross-linking process

PROF XUEFENG HAN Plastic Surgery Hospital, CAMS, PUMC

PROF DAN JIAN Xiangya Hospital, Central South University

PROF BI LI Peking University Third Hospital

PROF WENZHI LI Beijing Anzhen Hospital, Capital Medical University

PROF SHENGKANG LUO Guangdong Second Provicial General Hospital

PROF XIONGZHENG MU Huashan Hospital, Fudan University, Shanghai

PROF DANRU WANG Shanghai Ninth People’s Hospital, Shanghai Jiao Tong University School of Medicine

PROF HANG WANG West China School/Hospital of Stomatology Sichuan University

PROF SUFAN WU Zhejiang Province People’s Hospital

PROF LEIHONG XIANG Huashan Hospital, Fudan University, Shanghai

PROF HONGYI ZHAO Beijing Hospital

PROF LEI WANG Zhongda Hospital Southeast University

ensures the normal function of surrounding soft tissue. HA fillers that have high elasticity, plasticity, and viscosity, such as Belotero Volume, can compensate for the appearance of bone loss due to ageing-related bone resorption, acting as the aforementioned stable platform.

In addition to being age-appropriate, durable, and natural, another important consideration is how the results look at rest and in motion. The filler must therefore produce good static and dynamic results. HA also behaves as a mild moderator of muscle function and can affect the interactions between different muscles, thereby impacting muscle movement. Theories as to the pathogenesis of this mechanism include that the HA filler behaves as support and that it changes the way the muscle elongates and contracts. In this manner, filler treatment can be used to address aesthetic concerns caused by lack of bone support or distortions on animation by correcting facial structural deficiencies, either by supporting muscles to facilitate their action or mechanically obstructing muscle overaction, leading to favourable aesthetic outcomes18

Best practices: clinical application in aesthetic treatments

Nasolabial folds and mid-face volume loss are common aesthetic issues, even in young patients. In such patients, combination treatments of deep injections of Belotero Volume and superficial injections of Belotero Balance Lidocaine can be used to enhance the overall shape of the face. The advantages given by the unique characteristics of this gel provide immediate, natural results without the risk of overfilling19

With high cohesivity and low viscosity, Belotero Balance Lidocaine is suitable for superficial injection even into the superficial reticular dermis. The gel’s structure and high degree of dermal integration led to the development of the ‘blanching’ injection technique20 , which makes it possible to inject into the reticular dermis for the treatment of fine lines, such as perioral and neck lines.

As full integration into the dermis is achieved, common side effects associated with superficial injection of HA, such as the Tyndall effect, can be mitigated20. When using the ‘blanching’ technique, it is important to control the volume of product injected. Another advantage to using Belotero Balance Lidocaine — a crosslinked, highconcentration HA product — for superficial injection is the duration of effect, which has been reported to last up to 2 years in neck lines and perioral lines20. This is because other HA products with similar indications are typically non-crosslinked or lower crosslinked HA or have low HA concentration, which typically confer

results with a shorter duration of effect. Similarly, there is no need to inject as much product to achieve the same results as other HA products. According to our experience, the duration of effect may also be longer in Asian patients because they have thicker skin than Caucasian patients and are thus able to accommodate slightly more product volume injected intra-dermally. The performance of Belotero Balance Lidocaine for the improvement of moderate to severe nasolabial folds has been evaluated in several clinical trials12,13,21. A review of clinical data concerning the performance, tolerability and safety of Belotero Balance Lidocaine compared to collagen and to other HA fillers in the treatment of nasolabial folds found that Belotero Balance Lidocaine was superior to collagen and resulted in a greater reduction of wrinkle depth than a comparator HA filler 4 weeks after injection12. These findings also translated to greater patient and practitioner satisfaction, the latter particularly due to the ease of use12. The favourable performance of Belotero Balance demonstrated in Caucasian patients in the treatment of NLFs, was validated in patients with Fitzpatrick skin types IV, V, and

While Belotero Balance Lidocaine is approved in China for injection into the mid-dermis for filling of moderate nasolabial folds, it has been authorised for additional indications in other territories. For this reason, global physicians have amassed significant user experience and clinical data on the application, performance and safety of this product for other treatment areas. Other areas suited to Belotero Balance Lidocaine treatment include sensitive areas such as the infraorbital region and lip contour, where low inflammation and hydrophilicity are essential to reduce the occurrence of oedema, erythema, and other immune reactions. Treating the infraorbital hollows with Belotero Balance Lidocaine requires deep-layer injections using a stiff blunt tip cannula (of at least 25 gauge) due to special consideration of the anatomy. It has been observed that treatment of infraorbital hollows with Belotero Balance Lidocaine is not associated with the appearance of thick horizontal lines that sometimes appear 3–8 weeks after treatment, indicative of product displacement due to gel dispersal. This is an occurrence typically seen with gels of low cohesivity. Another notable observation is the absence of oedema, indicating that treatment is welltolerated. For lip contour, Belotero Balance Lidocaine is injected into the subdermal plane.

With high cohesivity and low viscosity, Belotero Balance Lidocaine is suitable for superficial injection even into the superficial reticular dermis.

Key points

Belotero Balance

Lidocaine, approved in China for injection into the mid-dermis for filling of moderate nasolabial folds

The Belotero range of injectable dermal fillers is produced using cohesive polydensified matrix (CPM) technology

HA fillers are typically used in the young Asian female face to correct perceived inaesthetic features such as ‘flatness’ of the infraorbital and medial malar regions

Combination treatments of deep injections of Belotero Volume and superficial injections of Belotero Balance Lidocaine can be used to enhance the overall shape of the face

With high cohesivity and low viscosity, Belotero Balance Lidocaine is suitable for superficial injection even into the superficial reticular dermis

Volumetric restoration of the midface is the first essential step in global rejuvenation as it has the most significant impact on the malar contour and the surrounding areas22. To treat facial volume loss, the HA filler should have both projecting capacity as well as modelling capacity to allow for adequate shaping. Belotero Volume has moderate cohesivity, and high viscosity and elasticity, making it an excellent volumiser while being extremely malleable. In terms of efficacy, a split-face study evaluating the effectiveness of Belotero Volume against another HA dermal filler showed that Belotero Volume created more volume augmentation at all time points studied22

Final thoughts and considerations

From the presented clinical evidence and user experience, there is strong agreement among the committee that Belotero Balance Lidocaine possesses unique rheological characteristics that allow it to meet the currently unmet need for superficial injection without any Tyndall effect. This product produces long-lasting effects that are expected to be even longer lasting in Asian patients13. With over 50 HA product lines currently available in the Chinese market, Belotero Balance Lidocaine’s distinct rheological features, established track record of safety, efficacy and long-term tolerability will help it stand out in a dense HA dermal filler market13

Conclusions

Optimal tissue integration is key for performance and predictable results, thereby ensuring greater patient satisfaction. With high cohesivity and relatively lower viscosity, Belotero Balance Lidocaine, approved in China for injection into the mid-dermis for filling of moderate nasolabial folds, has excellent tissue integration and can

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6. Stocks D, Sundaram H, Michaels J, Durrani MJ, Wortzman MS, Nelson DB. Rheological evaluation of the physical properties of hyaluronic acid dermal fillers. J Drugs Dermatol 2011; 10: 974–980.

7. Sundaram H. Going with the Flow: An Overview of Soft Tissue Filler Rheology and Its Potential Clinical Applications (2 of 3). Practical Dermatology 2011; 23–28.

8. Bezzola A, Micheels P. Esthélis®, acide hyaluronique de conception suisse. Première étude complète des caractéristiques physico-chimiques et essais cliniques. J Med Esthet Chir Dermatol 2005; 32: 11–20.

9. Flynn TC, Sarazin D, Bezzola A, Terrani C, Micheels P. Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers. Dermatol Surg 2011; 37: 637–643.

10. Micheels P, Besse S, Sarazin D. Two Crosslinking Technologies for Superficial Reticular Dermis Injection: A Comparative Ultrasound and Histologic Study. J Clin Aesthet Dermatol 2017; 10: 29–36.

11. Lee JM, Kim YJ. Foreign Body Granulomas after the Use of Dermal Fillers: Pathophysiology, Clinical Appearance, Histologic Features, and Treatment. Arch Plast Surg 2015; 42: 232–239.

12. Prasetyo AD, Prager W, Rubin MG, Moretti EA, Nikolis A. Hyaluronic acid fillers with cohesive polydensified matrix for soft-tissue augmentation and rejuvenation: a literature review. CCID 2016; 9: 257–280.

13. Lorenc ZP, Fagien S, Flynn TC, Waldorf HA. Review of key Belotero Balance safety and efficacy trials. Plast Reconstr Surg 2013; 132: 33S-40S.

14. van Loghem J, Sattler S, Casabona G, Cotofana S, Fabi SG, Goldie K et al. Consensus on the Use of Hyaluronic Acid Fillers from the Cohesive Polydensified Matrix Range: Best Practice in Specific Facial Indications. Clin Cosmet Investig Dermatol 2021; 14: 1175–1199.

15. Chao YYY, Chhabra C, Corduff N, Fabi SG, Kerscher M, Lam SCK et al. PAN-ASIAN CONSENSUS—Key Recommendations for

be injected superficially, placing it in a unique position to fulfil the current unmet needs of the HA dermal filler market, and thus is poised to be a welcome addition to the aesthetic doctor’s armamentarium in China.

Acknowledgements

The Authors wish to thank the other members of the ACE Steering Committee (listed in alphabetical order by last name):

Prof. Xuefeng Han, Plastic Surgery Hospital, CAMS. PUMC

■ Prof. Dan Jian, Xiangya Hospital, Central SU, Changsha

■ Prof. Xiongzheng Mu, Huashan Hospital, Fudan University, Shanghai

■ Prof. Danru Wang, Shanghai Ninth People’s Hospital, Shanghai Jiaotong University School of Medicine

■ Prof. Lei Wang, Zhongda Hospital, Affil. to Southeast University

■ Prof. Leihong Xiang, Huashan Hospital, Fudan University, Shanghai

And the international expert presenters:

■ Dr Wilson Ho, The Specialists: Lasers, Aesthetics and Plastic Surgery, Central, Hong Kong, China

■ Dr Tatjana Pavicic, Private Practice for Dermatology and Aesthetics Dr. Tatjana Pavicic, Munich 80539, Germany

Figure 1 © ACE Steering Committee

* Belotero is a registered trademark of Merz Pharma GmbH & Co. KGaA.

Adapting the World Congress of Dermatology Consensus on Combination Treatment with Injectable Fillers, Toxins, and Ultrasound Devices in Asian Patients. J Clin Aesthet Dermatol 2017; 10: 16–27.

16. Wu WTL, Liew S, Chan HH, Ho WWS, Supapannachart N, Lee H-K et al. Consensus on Current Injectable Treatment Strategies in the Asian Face. Aesthetic Plast Surg 2020; 44: 1195–1207.

17. Corduff N, Juniarti L, Lim TS, Lin F, Mariwalla K, Pavicic T et al. Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results. Clin Cosmet Investig Dermatol 2022; 15: 1213–1223.

18. de Maio M. Myomodulation with Injectable Fillers: An Innovative Approach to Addressing Facial Muscle Movement. Aesthetic Plast Surg 2018; 42: 798–814.

19. Lim T, Frank K, Hadjab B. Target-Specific Sandwich Technique: Facial rejuvenation leveraging CPM technology. J Cosmet Dermatol 2022; 21: 207–219.

20. Micheels P, Sarazin D, Besse S, Sundaram H, Flynn TC. A blanching technique for intradermal injection of the hyaluronic acid Belotero. Plast Reconstr Surg 2013; 132: 59S-68S.

21. Narins RS, Coleman W, Donofrio L, Jones DH, Maas C, Monheit G, Kaur M et al. Nonanimal Sourced Hyaluronic Acid–Based Dermal Filler Using a Cohesive Polydensified Matrix Technology is Superior to Bovine Collagen in the Correction of Moderate to Severe Nasolabial Folds: Results from a 6-Month, Randomized, Blinded, Controlled, Multicenter Study. Dermatol Surg 2010;36:730–740

22. Kerscher M, Agsten K, Kravtsov M, Prager W. Effectiveness evaluation of two volumizing hyaluronic acid dermal fillers in a controlled, randomized, double-blind, split-face clinical study. Clin Cosmet Investig Dermatol 2017; 10: 239–247.

TEMPORAL-ZYGOMATIC LIFTING OF THE MANDIBULAR EDGE WITH HIGH G’ FILLERS

Prof. Redaelli Alessio discusses his experience treating moderate ptosis of the mandibular edge with high G’ fillers and the results he witnessed in a single-centre study

ABSTRACT

The orbital-zygomatic-mandibular ligament line divides the face in the medial and lateral midface.

Settings and Design: a single centre study on case histories of temporo-zygomatic injections and their effects on the jawline.

Materials and Methods: Fifteen patients

were treated from March to May 2022 with upper lateral injections to the mandible on one side while on the other side, injections were placed at the jawline to the upper lateral face.

Discussion: If we inject the upper and lateral face, the quantity of filler needed to correct the jaw line is smaller, and finally, the

THE CONCEPT THAT MODERN aesthetic medicine can correct specific defects caused by the ptosis of the face’s lateral tissues and that it is possible to obtain a lifting of the medialised tissues by injecting the face’s lateral and high tissues is rather new and, in my opinion, must be further confirmed through daily clinical practice. Many techniques have been suggested to obtain this result, such as suspension threads, fillers, and botulinum toxin–A. So-called temporo-zygomatic lifting to improve the mandibular edge has been amply confirmed in the scientific literature over the past 3–4 years. The fact this technique has, in recent years, become increasingly popular can be due to many factors, such as the simplicity, the near-total absence of complications, extremely short — I would even say non existent — recovery time, and the notable duration of the results when using volumising high G’ hyaluronic acid.

mandible is thinner and lighter. If we start from the mandible, the quantity of filler that we need to fill the mandibular edge is much higher, and result in a heavier and thicker mandible.

Conclusions: injection of the upper and lateral face reduces the quantity of filler needed to improve the jawline.

comes to obtaining results that are very much appreciated by patients, which was the exclusive prerogative of the surgical approach until recently.

Behind this technique, is the anatomical concept that the orbital-zygomatic-mandibular ligament line divides the face at the medial and lateral midface1,2 (Figure 1).

Based on this anatomical concept, placing a temporal and zygomatic volumetric bolus makes it possible in certain selected cases to obtain excellent results on the mandibular edge3. The technique is very simple and the results are immediate. I have not encountered complications. The choice of the patient and the indication are still the fundamental parameters to obtain aesthetically valid results and avoid the complications described in the literature. I have personally treated 47 patients to date, all with good results, without encountering any significant complications.

KEYWORDS

hyaluronic acid, temporal lift, mandibular lift, cannula, filler, face medical lift

For the reasons highlighted above, the demand for minimally invasive procedures continues to increase, to the detriment of surgical and invasive procedures. In some cases, aesthetic medicine can even be the Gold Standard in the field of tissue lifting when it

The fact this technique has, in recent years, become increasingly popular can be due to many factors, such as the simplicity, the near total absence of complications,

This study analyses a series of 15 consecutive female patients with good indications for lifting the mandibular edge following standardised temporo-zygomatic filling. The purpose of this article is to describe the personal technique and the main practical steps so that the reader may execute it immediately.

extremely short recovery time, and the notable duration of the results when using volumising high G’ hyaluronic acid.

REDAELLI ALESSIO, PHD Chairman and Scientific Director of IPAM International Congress, Private practice, Milan,

Italy

The temporo-zygomatic lifting technique uses a single type of volumetric high G’ hyaluronic acid (Art Filler Volume by LABORATOIRES FILLMED, Paris, France), a blunt cannula, usually 22G for 50 mm and 25G for 55 mm, and 27G needles supplied directly in the filler packaging.

Figure 1 Illustration of the anatomical concept that the orbital-zygomaticmandibular ligament line divides the face at the medial and lateral midface

Materials and methods

The temporo-zygomatic lifting technique uses a single type of volumetric high G’ hyaluronic acid (Art Filler Volume by LABORATOIRES FILLMED, Paris, France4), a blunt cannula, usually 22G for 50 mm and 25G for 55 mm, and 27G needles supplied directly in the filler packaging.

Fifteen (15) consecutive patients were treated from March to May 2022; all were women, and their average age was 46 (37–58 years of age). The patients were all of normal weight and presented a modest relaxation of the mandibular rim with an initial temporo-zygomatic skeletonisation with moderate visibility of the nasojugal groove.

Four patients were treated on the left-hand side in the first session and on the right-hand side 7 days later. This was to make it possible to determine the exact quantity of filler required on each side for the mandibular line in the absence of oedema that appears immediately after the injections. When using Art Filler Volume, postinjection oedema was found to be very low, which is why all remaining patients were treated in the same session on both right- and left-hand sides, complying with the injection order described below.

Figure 2 Injection points: 1. lateral temples, 2. medial temples, 3. lateral zygomatic, 4. medial zygomatic, 5. mandibular edge.

Technique

No type of anaesthesia was used. The patients were treated while seated.

Injection points were standardised: lateral temples, medial temples, lateral zygomatic, medial zygomatic, and mandibular edge (Figure 2).

Injection point 1

The technique begins by making an entry point 1 cm in

front of the tragus with a vertical upwards direction. For this initial opening, a 21G needle is used, which is only inserted up to the chamfer. We only insert through the epidermis and the dermis to reach the area’s subcutis. Next, a 22G cannula for 50 mm is inserted through this entry opening, strictly in the subcutaneous tissue. The direction is parallel to the ear to reach the subcutaneous tissue medial to the ear in the area of the temporal scalp (Figure 3). It is very important to be in the subcutaneous tissue to obtain a good projection of the surface tissue, which, trigonometrically, will result in lifting and elevation of the inferomedial tissue, especially of the mandibular edge.

The bolus injection is initiated once the 50 mm cannula has been inserted up to the temporal area, ensuring that we have remained in the subcutis and thus with total visibility of the subcutaneous cannula. It is typical to inject 0.6 ml in the subcutis. The injection is performed slowly to prevent the hyaluronic acid from spreading to the adjacent tissues instead of remaining localised. A finger of the non-injecting hand is placed 1 cm below the end of the cannula to avoid retrograde propagation, and the bolus is kept localised using lateral finger pressure. Too superficial an intradermal injection should be avoided since, in the author’s opinion, it could lead in particular cases to alopecia, due to the high pressure created on local hair bulbs; mid-subcutaneous tissue is the ideal target.

Injection point 2

The second area usually treated is the temples under the temporal crest to the zygomatic bone edge, laterally to the orbital bone margin.

The same cannula that was used for the posterior temple or a 25G cannula for 55 mm (Bio Nutri Lift Cannulas by FILLMED, Paris, France) can be used to inject this area. Personally, I still prefer the 22 G cannula, which is less traumatic and a lot safer, given the local presence of a very large number of subcutaneous veins and the superficial temporal artery and its branches in the superficial temporal fascia. Another entry opening is made at the edge of the scalp, immediately above the upper margin of the zygomatic bone. This entry opening is used to make a fanning injection to the entire temporal area up to the orbital edge. The channels must be very close together to prevent visible irregularities from the injections that can last for some time, despite being destined to disappear in any case.

The usual practice for this area is to inject 0.6 ml of volumetric high G’ hyaluronic acid, the same as that used for the posterior temporal area. Lately, in most cases, I use a bolus of 0.6 ml for the posterior temporal area and a fanning injection of 0.6 ml for the subcrestal temporal area, using the entire first hyaluronic acid vial (1.2 ml). The malar zygomatic area is then injected during the same session.

Figure 3 An entry point is made 1 cm in front of the tragus with a vertical upwards direction. For this initial opening, a 21G needle is used. A 22G cannula is inserted for 50 mm through this entry opening, strictly in the subcutaneous tissue. The direction is parallel to the ear to reach the subcutaneous tissue medial to the ear in the area of the temporal scalp

Figure 4 A 25G x 55 mm cannula, 0.6 ml of high G’ hyaluronic acid is injected medially at the ligament line to even out the malar area and make it project

Figure 5 We refine the mandibular line with a blunt 22G x 70 mm cannula. The entry opening is performed with a 21G needle at the third medial of the mandibular edge. The cannula is inserted in the subcutaneous tissue above the facial artery and vein

Injection point 3

The protocol envisages the injection with a deep bolus in the lateral zygomatic bone area at the ligament line with 0.4-0.6 ml of high G’ hyaluronic acid.

The injection is performed on the periosteum with two or three deep boluses following aspiration test.

Injection point 4

Having determined the malar eminence accurately with Powell’s method, an entry opening is made, and using a 25G x 55 mm cannula, 0.6 ml of high G’ hyaluronic acid is injected medially at the ligament line to even out the malar area and make it project. We normally use a second vial of volumetric filler for the malar-zygomatic area (Figure 4).

Injection point 5

At this point, we refine the mandibular line with a blunt 22G x 70 mm cannula. The entry opening is performed with a 21G needle at the third medial of the mandibular edge. The cannula is inserted in the subcutaneous tissue above the facial artery and vein (Figure 5). The material used after the temporo-zygomatic injection was consistently smaller in all patients compared to the contralateral side, where the mandibular line was injected first. The lateral part is filled first, followed by the medial. Not all patients required the medial injection.

Injection point 6

The contralateral side was injected in the opposite direction, from the mandibular edge to the temples. The quantity injected at the mandibular edge has always been significantly larger compared to the area previously treated with injections at the lateral temples to obtain symmetry of the bilateral mandibular edge. In 75% of cases, the patients were treated in the same session. The entry point is exactly the same as the previous side — at the third medial of the mandibular line, alongside the edge of the bone. A 22G x 70 mm cannula is introduced first laterally and then in the third medial to even out the mandibular edge. The injection must be made in the subcutaneous tissue, avoiding injecting under the SMAS.

Injection points 7–10

The injections at the zygomatic and temporal level are performed exactly as on the contralateral side, starting from the medial zygomatic area, then the lateral, to finally injecting the medial and lateral temple. The technique and filler quantity are exactly the same as those used for the previous side.

Discussion

The concept that the face can be divided into medial and lateral areas by the ligament line and that medial injections are volumising, whereas lateral injections displace tissue laterally and upwards, is fairly new; therefore, I have only recently fully accepted it in my clinical practice. It is certainly necessary to perform some treatments and see the practical results to truly espouse them and recommend them to patients

Patient #

Figure 1 Millilitres used on jawline

In the cases I have presented in this article, I have confirmed that the quantity of filler required to improve the mandibular edge, if the face’s lateral and upper tissues are treated first, is a lot smaller than the contralateral side treated in the opposite way (see Table 1).

No significant collateral effects were encountered in any patient. The possibility of alopecia in the temporal area as described in the literature following the injection, was not witnessed in the author’s experience and was most likely caused by very superficial injections that can cause hyper compression of hair bulbs and, therefore, ischemia in local tissues. Additionally, intra-arterial injection to the superficial temporal artery is very unusual using a 22 G cannula even if theoretically possible.

The immediate effect is achieved primarily due to a trigonometric effect demonstrated in the literature5 , whereby the increase in lateral tissue thickness causes the superficial medial tissues to be lifted laterally and upwards by a few millimetres but sufficient enough to determine the lifting effect.

Furthermore, a neocollagenesis effect, which has been demonstrated with specific types of hyaluronic acid4 , surely plays a significant role in consolidating the results for some time following the injections. In my case, the patients injected at the start of my experience have certainly improved a few months down the line, and this must be proven in the future with additional practical clinical studies.

Moreover, we should not underestimate the fact that the smaller quantity of filler injected into the mandible makes it possible to finally obtain a thinner and lighter mandibular edge than the side on which the mandible is initially treated. On that side, the larger quantity of filler used makes the mandible a little bit heavier and thicker, even if this detail did not cause any problems for the patients.

The final effect was very much appreciated by all patients who saw results immediately; this treatment, therefore, is suggested as the Gold Standard treatment in middle-aged female patients with moderate ptosis of the mandibular edge, with a thin or frankly skeletal face (Figure 6).

Key points

The face can be divided into upper, mid, and lower sections but also medial and lateral according to the line of ligaments

The concept that injection in one area of the face produces results in another area has now been confirmed (Domino effect).

Lateral and upper injection at the temples can lift medial tissues

Before injecting the mandibular edge and naso-labial folds it is better to inject the lateral and upper tissues (zygomas and temples)

Medical lifting of the face must be done with high G’ fillers to get an immediate but also long lasting result

The use of thick cannulas (at least 25 G) is safer then thin cannulas or needles

Conclusions

Patient selection is the first essential element to obtain credible results. Ptosis that is too pronounced is not the right indication.

It is necessary to use a filler with specific rheological and volumetric characteristics to obtain visible and longlasting results.

The quantity of filler required for injection at the mandibular edge has been proven to be markedly smaller if the temples and cheekbones are filled first. However, the quantity of filler required for a full face result remains generally quite large, and the procedure is rather arduous for the patients.

The results are encouraging, but further studies are required to prove the difference in the quantity of filler injected and its effective duration over time.

Lastly, tolerability was excellent, and no significant side-effects were reported.

Declaration of interest Prof. Alessio is a KOL for Ipsen and Fillmed company.

Figures 3–6 © Redaelli Alessio, Table 1 © Redaelli Alessio

References

1. Hernandez C. et Al.: Clinical validation of the temporal lifting technique using soft tissue fillers. J Cosmet Dermatol 2020 Oct;19(10):25292535. doi: 10.1111/jocd.13621. Epub 2020 Jul 27.

2. Freytag L., Redaelli A. et Al.: Aging through Facial Biomechanics. A Clinically Applicable Guide for Improved Outcomes. Facial Plast Surg Clin N Am(2022), https://doi.org/10.1016/j. fsc.2022.01.001

3. Casabona G. et Al: lifting vs volumizing. The difference in facial

minimally invasive procedures when respecting the line of ligaments. JCD, 2019, Aug 12. doi: 10.1111/jocd. 13089.

4. Trevidick P. et Al: Prospective, Split-Face, Randomized, Long-Term Blinded Objective Comparison of the Performance and Tolerability of Two New Hyaluronic Acid Fillers. Dermatol Surg 2017 Dec;43(12):1448-1457. doi: 10.1097/DSS.0000000000001193

5. Suwanchinda A. et Al: The posterior temporal supraSMAS minimally invasive lifting technique using soft-tissue fillers. J Cosm Derm. 2018, Aug, 17(4): 617-24

The use of thick cannulas (at least 25 G) is safer then thin cannulas or needles.

TREATING COVID-19 VACCINE-RELATED NODULES WITH METHOTREXATE

Patrick Treacy unveils the results of a study investigating the use of the immunosuppressant methotrexate to treat twenty-three patients unresponsive to any established treatment protocols

ABSTRACT

During the COVID-19 pandemic, it was reported that patients who had cosmetic fillers experienced side effects after receiving the vaccines. The exact mechanism was thought to be due to

Type IV hypersensitivity causing foreign body granulomas. These problems were initially treated with antihistamines, 5-fluorouracil, hyaluronidase and intralesional steroids. However, a cohort of patients remained unresponsive to any

DURING THE COVID-19 PANDEMIC, dermal fillers made world headlines as it was reported that patients who had cosmetic fillers experienced side effects after receiving vaccines that utilised both viral vector and mRNA technology. Initially, the Moderna mRNA-1273 vaccine trial reported an incidence rate of facial swelling of 0.02% after receiving the vaccine, and later similar effects were noted from both the AstraZeneca and the Pfizer/BioNTech COVID-19 vaccine1,2. The exact mechanism was thought to be due to Type IV

established treatment protocols.

The objective was to evaluate the efficacy of using the immunosuppressant methotrexate to treat Covid vaccinerelated delayed onset nodules in twenty-three patients with moderate

facial disfigurement unresponsive to established treatment protocols.

All patients successfully responded to 10mgs of methotrexate for a three-month period and all their nodules dissipated

hypersensitivity causing foreign body granulomas. These problems appeared globally and were initially treated with antihistamines, 5-fluorouracil, hyaluronidase and intralesional steroids. However, the medical world also experienced a cohort of patients unresponsive to any established treatment protocols and we proceeded to solve the problem.

Objective

KEYWORDS

Covid-19, vaccines, Injectables, nodules

The objective of this study was to evaluate the efficacy of using the immunosuppressant methotrexate to treat COVID-19 vaccine-related delayed onset nodules in

twenty-three patients with moderate facial disfigurement unresponsive to established treatment protocols, including intralesional steroids and hyaluronidase.

Implementation, tactics and strategy

We identified a cohort of 23 international patients injected with dermal filler or collagen stimulators who presented with delayed onset nodules after receiving the COVID-19 vaccine. Eighteen of these patients were from Ireland, three from the United Kingdom, and one each from France, the United States, and Dubai. All of the patients were unresponsive to established treatment protocols, including antihistamines, 5-fluorouracil (5-FU), 5-FU and lidocaine, and intralesional steroids. Some presented with as many as thirty to forty nodules in the case of poly-L-lactic acid (PLLA; Sculptra®, Galderma, Zug, Switzerland), and excision of implanted material was considered only as a last resort.

Eighteen of these complications related to both cross-linked and non-cross-linked hyaluronic acid fillers; fourteen to monophasic HA products (Juvederm®, Allergan, Irvine, CA, USA), (Teosyal®, TEOXANE Laboratories, Genève, Switzerland) (Stylage M, Vivacy, Paris, France); two to the biphasic filler, Restylane®, (Q-MED, Uppsala, Sweden), and two were an unknown product. Five were related to poly-L-lactic acid (PLLA; Sculptra®) and two of these patients had been injected nearly two years

previously. All of the hyaluronic acid patients were injected intradermally or supraperiosteally. Two patients received Teosyal® HA filler (0.2 ml on each side) to their tear trough areas with microcannula, and both had received previous hyaluronidase with little effect. None of the patients developed swelling, erythema, or nodules directly after dermal filler injection but presented with hard nodules about two weeks after vaccination. The patients received various vaccines, including the AstraZeneca COVID-19 vaccine, Pfizer/ BioNTech COVID-19 vaccine, and the Moderna vaccine. The Moderna and Pfizer/BioNTech vaccines are forms of mRNA vaccine. These vaccines work by teaching immune cells to make a harmless piece of ‘spike protein’. Unlike the Pfizer/BioNTech and Moderna coronavirus vaccines, the Oxford/AstraZeneca vaccine is not an mRNA vaccine. Instead, the AstraZeneca vaccine is a viral vector vaccine made from a weakened form of a common cold virus from chimpanzees.

Methods and material

Methotrexate is a chemotherapy agent and immunesystem suppressant. It is used to treat cancer, autoimmune diseases, and ectopic pregnancies. It is particularly used to reduce the activity of the immune system when it mistakenly attacks parts of the body, such as skin and joints, causing illness. Methotrexate is used to treat rheumatoid arthritis, psoriatic arthritis, vasculitis, systemic sclerosis, and severe psoriasis. It initially

email: ptreacy@gmail.com

We identified a cohort of 23 international patients injected with dermal filler or collagen stimulators who presented with delayed onset nodules after receiving the

PATRICK TREACY, MD, PHD, Medical Director, Ailesbury Clinics Ltd and Ailesbury Hair Clinics Ltd, Dublin, Cork, London, and Middle East

Table 1

Methotrexate monitoring recommendations

needs to be closely monitored, requiring blood tests every two weeks until stable and then every three months.

LABORATORY FREQUENCY

WHAT TO DO IF MONITORING OUTSIDE LIMITS

Dosing

Full blood count Baseline

Discuss with specialist team (FBC)

Every two to four weeks immediately. initially, then every month to three months if results have been normal on a stable dose.

When methotrexate is used for Covid-19 vaccine nodules, it may be taken once a week (or in certain circumstances as three divided doses over 36 hours once a week). Folic acid is normally prescribed to be taken on a different day to methotrexate. Treatment of psoriasis with methotrexate is also prescribed intermittently over a week.

Liver function Baseline

Withhold until discussed tests (LFTs)

Every two to four weeks with specialist team. initially, then every month to Other factors to consider: three months if results have been normal on a stable • Check alcohol intake. dose.

• Review medicines which may cause liver dysfunction (eg, NSAIDs).

These are unusual dose regimens that may confuse some patients. It is important to clearly explain the dosing schedule to each patient and make sure they have understood the information. Specify on every prescription and on the dispensed medicine label the day of the week (written in full) the dose is to be taken.

Serum creatinine Baseline

Reduce dose. Often performed at same time as LFTs and FBC monitoring during dosing changes.

Every three months for patients on stable treatment.

Chest X-ray Baseline

Repeat if respiratory symptoms occur (see below).

Table 2 Management of methotrexate toxicity

SYMPTOMS WHAT TO DO

Rash or oral ulceration

Withhold methotrexate until discussed with specialist team. Folic acid mouth wash may help with mucositis.

Nausea and vomiting, Dividing the dose over the day or giving methotrexate diarrhoea by subcutaneous injection is often a good way of avoiding nausea.

Healthcare professionals should also check that the patient is taking methotrexate correctly. Serious and sometimes life-threatening or fatal adverse effects can be caused by incorrect methotrexate dosing.

Monitoring

It is imperative that monitoring of renal and liver function tests, full blood count and chest radiography occur before and during treatment. The Best Practice Advocacy Centre (BPAC) recommendations for monitoring methotrexate and management of methotrexate toxicity are outlined in Tables 1 and 23. Please note that local guidelines may vary3

Adverse effects

The risk of serious adverse effects is greater with higher doses and with prolonged methotrexate treatment. Hepatotoxicity may occur without previous signs of gastrointestinal or haematological toxicity. Pulmonary toxicity, including pneumonitis and pulmonary fibrosis,

New or increasing

Withhold and discuss URGENTLY with specialist team. dyspnoea or dry cough Arrange chest x-ray and respiratory function tests. (pneumonitis)

Severe sore throat, Request immediate FBC and withhold until results abnormal bruising available. Discuss any unusual results with specialist team.

These problems appeared centred on hyaluronic acid dermal fillers and poly-L-lactic acid collagen stimulators, which usually rarely cause persistent side effects.

Scientific Program Guided by the Aesthetic Multispecialty Society

can also occur at any time during therapy. Methotrexate is usually contraindicated in patients with impaired renal function.

Discussion

These problems appeared centred on hyaluronic acid dermal fillers and poly-L-lactic acid collagen stimulators, which usually rarely cause persistent side effects4. Dermal fillers and collagen stimulators are essentially foreign bodies, and some patients may develop a Type I hypersensitivity reaction after initial or repeated exposure to these injected products when exposed to the immune response to both viral and bacterial infection. This is related to immunoglobulin E (IgE)-mediated immune hypersensitivity. It is known that IgE stimulates mast cells to degranulate, releasing proteases, heparin, histamine, cytokines, prostaglandins, leukotrienes, and platelet-activating factor, which result in oedema, erythema, pain, and

Figure 1 Evidence of nodules at the site of poly-L-lactic acid (PLLA) injection following COVID-19 vaccination

itching characteristic of an allergic response5. Reactions can be severe and can last for several weeks6

Delayed hypersensitivity reactions also occur, mediated by T-lymphocytes rather than antibodies. They typically occur 1 day after injection but may be seen as late as several weeks after injection and may persist for many months. These are characterised by induration, erythema, and oedema7,8

Figure 2 Evidence of nodules at the site of poly-L-lactic acid (PLLA) injection following COVID-19 vaccination

The different HAs have varying degrees of hardness (G’), which will influence their suitability for a particular procedure. In general, the greater the G’ of the product, the deeper it should be injected. It should be noted that while more concentrated products with a greater degree of cross-linking have a longer duration of effect, they also increase reactivity in the body and, thus, the risk of inflammation and granuloma formation. Fillers with biodegradable particles that stimulate the body to produce its own collagen have a longer duration of effect; such products include calcium hydroxylapatite (CaHA; Radiesse®; Merz Pharmaceuticals GmbH, Frankfurt, Germany) and poly-L-lactic acid (PLLA; Sculptra®). CaHA consists of synthetic CaHA microspheres suspended in a carrier gel. Injection provides immediate visual improvement with long-term deposition of new collagen surrounding the microspheres, which contributes to an average duration of effect of around 15 months.

Cases of dermal filler swelling resulting from SARS-CoV-2 vaccination with the Moderna-type vaccine had been successfully treated with lisinopril, an angiotensin-

converting enzyme inhibitor (ACE-1) in the United States. ACE-1 treatment has previously been used in the treatment of hypertrophic scars, keloids, and other inflammatory skin disorders and can assist in downregulating CD44 by inhibiting the pro-inflammatory Angiotensin II. Other cases were successfully treated in the United Kingdom and Germany with 0.5 mL of 50 mg/mL 5-FU, 0.3 mL of 10 mg/mL triamcinolone (or 40 mg/mL triamcinolone, depending on localisation and degree of inflammation), and 0.2 mL 2% lidocaine with adrenalin5

Outcomes

All patients successfully responded to 10 mg of methotrexate for a three-month period and all their nodules dissipated. One patient had to stop the treatment in week ten due to moderately severe anergia. The treatment protocol above was submitted and accepted by peer review at both the AIDA Dermatology Conference in Abu Dhabi (May 2022) and the IMCAS World Conference in Paris (June 2022). It has changed the lives of many patients by reducing the distress caused by this condition.

Key points

We identified a cohort of 23 international patients injected with dermal filler or collagen stimulators who presented with delayed onset nodules after receiving the Covid booster vaccine

Methotrexate is a chemotherapy agent and immune-system suppressant.

Healthcare professionals should also check that the patient is taking methotrexate correctly. Serious and sometimes lifethreatening or fatal adverse effects can be caused by incorrect methotrexate dosing

The risk of serious adverse effects is greater with higher doses and with prolonged methotrexate treatment.

All patients successfully responded to 10mgs of methotrexate for a three-month period and all their nodules dissipated

acid dermal filler following novel coronavirus infection- a case report. J Cosmet Dermatol. 2021; 20:1557-1562.

6. Arron ST, Neuhaus IM. Persistent delayed-type hypersensitivity reaction to injectable non-animal-stabilized hyaluronic acid. J Cosmet Dermatol. 2007;6(3):167–171.

7. Turkmani MG, De Boulle K, Philipp-Dormston WG. Delayed hypersensitivity reaction to hyaluronic acid dermal filler following influenza-like illness. Clin Cosmet Investig Dermatol. 2019; 12:277-283

8. Van Dyke S, Hays GP, Caglia AE, Caglia M. Severe Acute Local Reactions to a Hyaluronic Acid-derived Dermal Filler. J Clin Aesthet Dermatol. 2010;3(5):32–35

Figure 3 Evidence of nodules at the site of poly-L-lactic acid (PLLA) injection following COVID-19 vaccination

Figure 4 Evidence of nodules at the site of hyaluronic acid filler injection following COVID-19 vaccination

Declaration of interest None

Figures 1–4

© Patrick Treacy Tables 1–2 © Patrick Treacy

All patients successfully responded to 10 mg of methotrexate for a three-month period and all their nodules dissipated.

The objective of this study was to determine whether using lower energy and multiple passes for treatment to achieve a clinical endpoint of visible tightening would yield better results than the established methodology of fewer passes at higher energy levels.

IMPROVED MONOPOLAR RADIOFREQUENCY TREATMENTS

Weng Yu-Ching examines whether monopolar radiofrequency treatments using low energy and multiple passes can be effective

ABSTRACT

Objective: To evaluate the effectiveness of lower energy and multiple passes monopolar radiofrequency treatment, compared to the method with fewer passes at higher energy, to visibly tighten skin. Research design and methods: Sixteen female volunteers were treated with the true ligaments heating method or the full-face true ligament heating treatment combined with the neck-circular tightening method. Both methods used lower energy and multiple passes. The neckcircular tightening method was administered to one side of the face

MONOPOLAR RADIOFREQUENCY

(RF) is established as an effective means of nonsurgical facial skin tightening. It uses energy in the radio frequency segment of the electromagnetic spectrum to produce heat internally within the skin1,2

Heating of the dermis to between 50–60°C induces an inflammatory response termed neocollagenesis and neoelastogenesis. Neocollagenesis in the papillary dermis, as well as the upper, mid, and deep reticular dermis, and neoelastogenesis in the papillary dermis, along with the upper and mid reticular dermis, increase fibroblast stimulation and elastin and collagen deposits. These changes improve skin elasticity and create a tightening effect3

As RF energy usually follows the path of least resistance, fibrous septa of the subcutaneous fat lobules are preferentially heated and account for the deeper thermal effects of RF devices. This is thought to be important in the subsequent re-modelling of subcutaneous tissue and tightening of the skin4

The established treatment methodology for true ligaments to achieve a tightening and rejuvenating effect is comparatively aggressive. The established methodology uses high energy settings (of 7-8 watts µW/cm2) and a low number of passes with a handpiece device. This methodology can be uncomfortable for the patient and has a high risk of causing skin blisters. Hence, alternative methods to provide treatment using a monopolar radiofrequency device are needed.

to compare to the untreated side. Photographs were compared using a newly developed facial data analysis software and improvements in facial features were measured based on patient satisfaction. Results: An improved angle of tightening was observed on the treated sides of the patients’ faces. Both treatment methods were better tolerated, and patients were comfortable during the procedure.

Conclusion: Patients were satisfied with their more youthful appearance post-treatment. The improved methods offer a safer facial rejuvenation effect using the Thermage device.

Improving results

With support from Bausch & Lomb, the distributor of Thermage® in Taiwan, we conducted a study on two alternative treatment methodologies for the Thermage device (Thermage-FLX 900, Solta Medical, Hayward, CA, USA). The objective of this study was to determine whether using lower energy and multiple passes for treatment to achieve a clinical end-point of visible tightening would yield better results than the established methodology of fewer passes at higher energy levels. The superiority of the tested method was measured by patient and physician satisfaction.

The first of the two treatments we trialled targets the periorbital region of the face, and we called it the ‘true ligaments heating method’. The second treatment, which focuses on the back of the neck, we called it the ‘neckcircular tightening method’.

Patients and methods

The study took place in 2019 and involved 16 female volunteers, aged between 25–70, who received either the true ligaments heating method for the orbital region, or the full-face true ligament heating treatment combined with the neck-circular tightening method. For the purpose of the trial, the patients that had received the neck-circular tightening method, initially only had onehalf of their faces treated to create a contrast between the treated and untreated sides. The efficacy of the lower energy and multiple passes methodologies in achieving an end-point of visible tightening was assessed via pre-

KEYWORDS

Thermage, low energy, multiple passes, face, neck, tightening

WENG YU-CHING 1650 Taiwan Bo ulevard Sect. 4, Taichung, Taiwan 40705, ROC email: WwngYC@vghtc.gov.tw

Figure 1 The ‘true ligaments’ targeted during treatment

(A) Seven true ligaments in the face.

(B) Anatomy of the galea, septae, adhesions, ‘true ligaments’ and mandibular ligaments in the face.

Figure 2 Treatment areas

(A) Lateral extension of treatment at the paravertebral region of the neck, from the first cervical vertebra to the first rib. (B) Parallel lines drawn 5 mm apart from top to bottom of the paravertebral region to delineate the posterior treatment area.

Figure 3 Treatment area and direction of passes

Lower edge of the treatment area runs from C7/T1, around the neck to the junction of the sternocleidomastoid muscle (SCM) and the clavicle at the bottom. C-shaped passes were done from the lateral to the medial line (sternocleidomastoid region), without touching the vertebral area.

BSEPTAE

• SUPERIOR TEMPORAL SEPTUM

• INTERIOR TEMPORAL SEPTUM

ADHESIONS

• TEMPORAL ADHESION

• LATERAL ORBITAL THICKENING

TRUE LIGAMENTS

• ZYGOMATIC LIGAMENT

• MASSETERIC LIGAMENTS

MANDIBULAR LIGAMENTS

and post-treatment photographs. The methods’ effectiveness was measured by patient and physician satisfaction using these photographs.

Techniques

The overlying soft tissues of the face are connected to the underlying structures of the face by fibrous connective tissues known as retaining ligaments. These retaining ligaments are responsible for supporting the soft tissue in its normal anatomic position; however, with age, the ligaments loosen, while the facial soft tissues sag due to gravity.

The retaining ligaments of the face can be classified as true or false. True retaining ligaments are a series of fibrous bands that run from the periosteum to the dermis and cover the bones within these areas of the facial anatomy. False retaining ligaments tether the intervening facial tissue layers to each other5,6. The true ligaments heating method will target the ‘true ligaments’ and others.

This method uses a low energy setting (Watt µW/cm2) for a higher number of passes, focusing on seven ‘true ligaments’ in the face, the mandibular, buccal-maxillary, zygomatic, tear trough, orbital ligaments, and the superior and inferior temporal septum (Figure 1).

The neck-circular tightening method uses lower energy and an increased number of passes. This method targets the connection between the posterior neck fascia and soft tissues of the face to achieve an annular tightening of the facial contour.

Both treatments used half the energy setting used in the standard treatment modality. In the past, doctors commonly used 7 or 8 µW/cm2 for facial treatments; however, 3.5 µW/cm2 was the maximum energy used in the current study. This setting was selected due to better patient tolerance and fewer risks of side effects, such as blistering.

The treatments were administered to the areas of the face in a specific set of orders. A single-pass was first administered to the upper eyelid, followed by overlapping ‘super passes’ to the face, a multi-pass vector technique targeting the mid and lower face to improve facial laxity and, finally, the ‘true ligaments’.

Patients who received the full-face true ligaments heating method were also treated with the neck-circular tightening method to one side of the neck and jawline. A single side was treated to better assess the tightening effect through a comparison between the treated and untreated sides of the face.

The treatment involved 900 passes in total, with 100 passes being applied to the forehead, 250 passes to each cheek, 50 passes to each anterior side of the neck and 100 passes to each posterior side of the neck.

The passes to the posterior sides of the neck are to treat and tighten the investing layer, which has multiple attachment points located in the lower areas of the face and neck. The investing layer is the most superficial of the deep cervical fascia. It is a thin layer of subcutaneous connective tissue that lies between the dermis of the skin and the deep cervical fascia, and surrounds all the structures in the neck. It contains the platysma, cutaneous nerves, blood, and lymphatic vessels. The investing layer splits into two when it meets the trapezius and sternocleidomastoid muscles, completely surrounding them.

The investing fascia can be thought of as a tube; with superior, inferior, anterior, and posterior attachments:

■ Superior— attaches to the external occipital protuberance and the superior nuchal line of the skull

■ Anteriorly— attaches to the hyoid bone

■ Inferiorly— attaches to the spine and acromion of the scapula, the clavicle, and the manubrium of the sternum

■ Posterior — attaches along the nuchal ligament of the vertebral column.

Mirrored images

We worked with Bausch & Lomb’s Medical Educational department to create a unique facial data analysis software to help measure the efficacy of the treatment. The software was used to vertically divide the face into right and left, which were then mirrored to produce two perfectly symmetrical images.

The splitting and mirroring of the two halves of the face serve to emphasise the asymmetry of the face, which is a

Figure 5 Improvement in the height between the eye and the eyebrow

(A) Before treatment and (B) after 4 months of treatment. Increases in the distances between the eyes and eyebrows were noted at three different measurement points for both patients.

Figure 4 Mirrored photographs

A(A) Unaltered baseline photograph taken before treatment. (B) Left face. (C) Right face. B(i) is the mirrored left side and C(i) is the mirrored right side. Mirrored images of a photograph taken four months post-treatment are represented by B(ii) for the left side and C(ii) for the right side. The angle of tightening was clearly visible for the treated left half of the face (B(ii) and C(ii), compared to the untreated right halves B(i) and C(i).

universal occurrence. Facial asymmetry is rarely caused by genetics or a congenital factor but develops with time due to lifestyle and habits, such as chewing and sleeping. These daily practices cause one side of the face to be smaller / slimmer than the other, whereby the majority of people have a smaller / slimmer right side. The unique facial analysis eased comparisons between photos taken before treatment and after four months of treatment. When juxtaposing mirrored images of the treated half of the face with a mirrored image of the untreated half, the differences before and after treatment were strikingly visible. The area of treatment extended laterally from the paravertebral region of the neck (from the transverse process of the first cervical vertebra to the first rib)

These improved methods offer a more comfortable and safer yet effective approach.

6

BEFORE

A reduced distance as measured by angle was observed between the lower jaw and the mouth after treatment.

4 MONTH POST-TREATMENT WITH THERMAGE FLX

Discussion

Both tested methodologies appeared to be safer than the standard high-energy treatments. The low energy settings used in this study carried no risk of nerve damage, even to the superficially positioned Erb’s point, which is located behind the SCM in the posterior triangle of the neck and about 2–3 cm above the clavicle7 Additionally, no patients reported blistering or other adverse effects.

Positive changes to selected parameters of the face and neck were noted, particularly for the front-facing height between lateral and medial commissure, the thickness of the double eyelid, side-viewed height of the eye, angle and height from the ala nasi to the brow bridge, depressed eye socket, ‘Goddess Glow’, height between the lateral and medial commissure, height of the eyebrow, and height between eye and eyebrow. The data obtained and feedback gathered were encouraging to demonstrate that lower energy and more frequent passes were as effective as the previously established method.

Conclusion

(Figure 2A). Parallel lines drawn 5 mm apart from top to bottom of the paravertebral region helped delineate the posterior treatment area (Figure 2B).

A line was also drawn from the Cervical 1 (C1) vertebra to the occipital protuberance behind the ear, as the area above the treatment area. The lower edge of the treatment area runs from the Cervical 7/Thoracic 1 (C7/ T1) vertebrae, all the way around the neck to the junction of the sternocleidomastoid muscle (SCM) and the clavicle. C-shaped passes were done from the lateral to the medial line (sternocleidomastoid region) without touching the vertebral area, which are the top, middle, and bottom areas of the lower edge of treatment (Figure 3).

Key points

The lower energy and multiple passes treatments were better tolerated by the patients, compared to the previously established method, while still being efficacious. All 16 patients were quite satisfied with the treatment outcomes and typically perceived their faces to have a more youthful appearance after treatment. These improved methods offer a more comfortable and safer yet effective approach.

Results

Figure 4 demonstrates the mirroring effect of photographs. The photograph on the left is the unaltered baseline image taken before treatment (4A). The two photographs in the middle show the two halves of the pre-treated face, mirrored with the left side (B(i)) and the right side (C(i)). The two photographs on the right are mirrored images of a photograph taken four months post-treatment, with B(ii) being the left side and C(ii) the right side. In the posttreatment photographs, the angle of tightening was clearly visible for the treated left half of the face (B(ii) and C(ii), compared to the untreated right half (B(i) and C(i)).

Figure 5 shows photographs of two patients who demonstrated visible and measured improvements in the height between the eye and the eyebrow after treatment. Figure 6 shows visible and measured improvement in the distance between the lower jaw and mouth of a patient post-treatment.

Monopolar radiofrequency treatment administered with more passes at a lower energy setting offers safer facial and neck rejuvenation, compared to the standard high-energy setting with a lower number of passes

Lower maximum energy settings led to better patient tolerance and fewer risks of side effects

Multiple passes with a lower energy setting resulted in visible and measured improvements in the height between the eye and the eyebrow, the distances between the lower jaw and mouth, and the angle of tightening

Declaration of interest The author thanks the Medical Educational department of Bausch & Lomb for the collaboration to generate an improved facial data analysis software and Bausch & Lomb, Taiwan for sponsoring the sponsored handpiece and treatment tips. Gratitude is also extended to the patient volunteers for their participation in the study.

Figures 1–6 © Weng Yu-Ching

References

with different fibrous septa architectures to RF heating: numerical study. Lasers Surg Med 2015;47(2):18395.

5. LaTrenta, GS. Atlas of Aesthetic Face and Neck Surgery. Saunders, 2004.

6. Ozdemir R, Kilinç H, Unlü RE et al. Anatomicohistologic study of the retaining ligaments of the face and use in face lift: retaining ligament correction and SMAS plication. Plast Reconstr Surg 2002;110(4):1134-47.

Suárez A, Gutierrez Herrera E, Berjano E et al. Thermal and elastic response of subcutaneous tissue

7. Brummer G, Troxel J & Peterson SR. Cover Story: Five Tips in Anatomical Dermatologic Surgery. The Dermatologist 2013. Available at: https:// www.hmpgloballearningnetwork.com/ site/thederm/site/cathlab/event/ five-tips-anat-omical-dermatologicsurgery. [Last accessed April 2022]

Figure

Improvements in the distance between the lower jaw and mouth

These improved methods offer a more comfortable and safer yet effective approach.

SECRETS OF SUCCESSFUL DRIP CAMPAIGNS TO KEEP PATIENTS ENGAGED

DRIP CAMPAIGNS ARE ONE OF THOSE ‘OLDIES BUT goodies’ in the realm of digital marketing strategies that sometimes gets overlooked. The secret sauce to effective campaigns is getting the right messages to the right customers through the right vehicle with the right look and feel, and at the right time.

On a personal note, drip campaigns bring out the amateur psychologist in me. I enjoy the challenge of taking a deep dive into people’s predispositions and figuring out what makes them tick.

The architecture of a drip campaign

Drip marketing is all about anticipating consumer behaviour patterns.

To be effective, you need to understand the patients you are most eager to reach in a deeper way than just by standard demographics. You will have to get into their heads a little, such as what they are most likely to respond

Wendy Lewis offers effective strategies for turning leads into loyal patients

The secret sauce to effective campaigns is getting the right messages to the right customers through the right vehicle with the right look and feel, and at the right time.

to, what turns them off, the best taglines to get their attention, and ideal intervals to reach out.

What is unique about drip campaigns is that they can be structured to anticipate and follow the user’s actions through automated workflows. For example, if someone just subscribed to your newsletter, you may start a sequence by sending a welcome email. Then, after a few days to a week, you could deliver the most popular content on your blog to keep them engaged.

If you wait to re-engage in two weeks or more, it may be too long depending on your primary target. Most people are bombarded with information coming at them from every direction, so they have limited attention spans. They may forget why they subscribed to your content in the first place and ignore it, or worse, opt-out.

Think of the first email you send to a new subscriber as a valuable one-time opportunity. If you blow it with the wrong messaging or graphics or come across as too much of a hard sell, there may not be a second chance to engage with that subscriber. If you lose them, they may move on and forget about you.

Regulations for direct mail campaigns

Although there may be opportunities in the future to reengage with those who opted out in a different way, it is imperative to respect subscribers’ wishes to avoid being flagged to the platform you use for your eblasts.

The U.S. Congress passed the CAN-SPAM Act to address the problem of unwanted commercial electronic mail messages. The CAN-SPAM Act requires the Federal Communications Commission to issue rules with regard to commercial email and some text messages sent to wireless devices such as cell phones — not email in general1

CAN-SPAM covers all commercial messages, which the law defines as ‘any electronic mail message the primary purpose of which is the commercial advertisement or promotion of a commercial product or service,’ including email that promotes content on commercial websites. The law makes no exception for business-to-business email. That means all emails — for example, a message to former customers announcing a new product line — must comply with the law2

Similar regulations apply to many countries, including the U.K., Canada, Australia, and Germany. There is also an EU Directive on Privacy that applies to all members of the EU that states that you must have prior explicit consent before sending any commercial email, an opt-out or unsubscribe option must be easy and clear for recipients of commercial messages, and you must be in compliance with each country’s additional rules3

If you are unfamiliar with the specific regulations in your country, please consult with the local agency that may be charged with this task or with an attorney to be sure that you are in compliance before you launch an email or text drip campaign.

WHAT’S THE IDEAL FREQUENCY?

More is not more Aim for selective eblasts that are educational and interesting Make sure every eblast adds value for the recipients

If you have the bandwidth, informative monthly eblasts are a good cadence

Some practices opt for longer eblasts every other month or quarterly, with shorter messages in between as needed Selective short eblasts with a single message may be helpful for timely info

Avoid bombarding patients with white noise— they get enough of that already!

Marketing automation

When they are well thought out and flawlessly activated, email drip campaigns can drive repeat treatments, increase client retention, and stimulate more skincare sales and packages. By carefully automating the process, you can make sure that the goals for your practice or medspa will align with your customers’ behaviour patterns.

According to Ran Berkman, President of Webtools, a global digital marketing agency, ‘More of our practices and medspa clients are interested in drip campaigns. This tactic can create marketing automations that deliver results with the right planning.’

He continues, ‘We often use tools like Klaviyo to set up a combination of text and email messages that are being sent based on a logic we develop. For example, when a potential patient who has been to their website, left their contact information, and inquired about a specific procedure but has not booked an appointment, we will add them to a drip campaign. These campaigns typically include videos, before and after photos, relevant webinars, and special promotions to maximise the return on their investment that was already spent on obtaining those leads. This strategy has been very effective to keep those customers interested in what our clients offer.’

Staying connected

Theda Kontis, M.D., F.A.C.S., President of the American Academy of Facial, Plastic and Reconstructive Surgery, uses email marketing to keep in touch with her current patients. ‘We also use this method to keep them informed about our practice and when we are looking for patients to be clinical trial subjects,’ she says. Their platform of choice is Weave.

WENDY LEWIS is President of Wendy Lewis & Co Ltd, Global Aesthetics Consultancy, a marketing communications group in New York. An award-winning writer, her textbook. Aesthetic Clinic Marketing in the Digital Age. (CRC Press) will have a second edition in 2022. She is a frequent presenter at virtual and live conferences worldwide. contact wl@wlbeauty.com

‘We use Weave for appointment confirmation, patient communication, and for patients to send photos with clinical concerns, especially if they can’t make it into the office to be checked, as in post-op patients with concerns, those with possible reactions to a procedure, or who have questions about whether something is a normal consequence after surgery, for example. We also use this platform for nurses to communicate directly with patients,’ she explains. ‘It’s fast and patients love using it.’

‘Text messaging has had high patient satisfaction in our practice. It is very convenient for patients, and they can receive quick replies. My only concern at the outset was the patients may try to use this method in an emergency and we do not monitor it 24/7. However, this has not been a problem to date.’

What is unique about drip campaigns is that they can be structured to anticipate and follow the user’s actions through automated workflows.

re-engage

welcome email

to our clients year-round. We keep the copy short and sincere, and make sure that it provides some value to the recipients. We like to start with content that is educational, timely and interesting so we are teaching them something before we present specials, new treatments and product highlights.’

right time eblasts

right customers

marketing drip consumer behaviour patterns

She continues, ‘How-to videos and before and after photos of real patients have been great additions to increase our open rates because they serve as examples of what we offer. In my experience, patients relate best to images of others who resemble them in terms of age, skin type, and the conditions they are concerned about. This strategy has been working well for us to avoid clients dropping off. They are hungry for information and curious about what is the latest and greatest. Through this tailored programme, clients have come to expect that they will learn something of interest from each Anushka Spa email that turns up on their phones,’ she adds.

‘Adding Weave has been an excellent decision for our practice. They installed a new phone system, and their software integrated well with our EMR, Nextech. On the Weave app, I can access my schedule as well as demographics for all patients in the practice. I can also call or text patients from my phone using Caller ID that only shows the office phone number.’

Educate first, promote second

With all marketing campaigns, the more personalised the messaging and graphics are, the higher the engagement is likely to be. Targeted drip campaigns can generate customer engagement by providing an easy and consistent flow of communication from your practice.

Bonnie Marting, A.R.N.P., of Anushka Spa in West Palm Beach, FL, has seen an uptick in their medical aesthetic clients from their eblast campaigns. ‘We have been very successful with drip campaigns to introduce special offers

Sending emails at consistent intervals can be an effective strategy to keep your brand top of mind. These are also a vehicle to gently remind current patients to

Targeted drip campaigns can generate customer engagement by providing an easy and consistent flow of communication from your practice.

refer your practice to their friends and family who may be looking for the aesthetic services you offer. It makes more potential customers aware of your practice and, thus, increases your reach.

There may be some patients who are interested in coming in for a treatment or service but need more information and nurturing to take the plunge. A targeted campaign may trigger a potential customer to spend

INS & OUTS OF TEXT MESSAGING TO AVOID GETTING BLOCKED

Nail the subject line to catch the reader’s attention for them to want to read more Every word and image counts— you’re competing with a steady stream of messages in consumer’s inboxes

To get more eyes on your content, keep it short, sweet, and upbeat like a teaser Whenever possible, starting with the person’s name is a plus

Remember to include contact information to get a response

Don’t bombard your list despite them having

tailored promotions automated workflows text messaging PRACTICE MANAGEMENT | MARKETING | 40 ❚ November/December 2022 | prime-journal.com

opted in; start at a reasonable interval and keep the messages relevant to specific recipients

Start with monthly messaging to bi-weekly; weekly may be risky and cause opt-outs Auto-correct is NOT your friend; double check to avoid sending weirdly distorted texts

It’s hard to convey emotions and humour via texts, so avoid phrasing that could be misinterpreted

Never use all caps it may come across like

YOU’RE MAD OR SCREAMING!

Succinct messages are easier to read, understand, and reply to Avoid emojis and abbreviations that may be conveyed as unprofessional or not serious You can add GIFs, hyperlinks, images, or PDFs to text messages, depending on the intended audience

Ideally your list should be segmented so you are sending the right messages to the right people at the right time— make it your #1 goal

10 WAYS TO IMPLEMENT DRIP MARKETING STRATEGIES

1Fill open appointment slots via automated marketing messages to promote last-minute openings on your social media channels

2Send ‘welcome’ emails or texts to introduce every new subscriber to what you have to offer. Welcome emails give a personal touch to your business and let customers know what to expect from your emails

3Offer new subscribers a one-time code they can apply to first-time services or products to incentivise them to join

Utilise ‘onboarding’ emails to share a deeper introduction to your practice or medspa, the medical team, specialty treatments, and signature packages or bundles featured

5For subscribers who have not responded to previous campaigns, try to renew their interest by re-targeting them with a campaign to drive engagement. For example, use a subject line like ‘We miss you!’ or ‘We want you back’ or ‘Where have you gone?’

6For example, add some patient photos or a video of your practice, or

more time on your website and social channels to get the additional information they may need to make the decision to move forward.

According to plastic surgeon Adam J Rubinstein, M.D, F.A.C.S. in Aventura, FL, ‘Keeping in touch with your existing patient base is an often-neglected marketing strategy. They are already part of your family, so they are interested and motivated. Most of them have had services so they also tend to be loyal. There is no better group to send information about your practice because they already know you.’

He continues, ‘Drip campaigns are a great way to get touch points without being perceived as overbearing. I like to send emails once or twice a month. The most effective cadence is to reach out at reasonable intervals to avoid being bothersome. We frequently use this method to share interesting news about the practice or present new technology or treatments. We also send our current patients good wishes for holidays.’

Purchasing funnel

There are countless benefits to utilising drip campaigns to increase brand awareness, engage with new patients and re-engage with previous patients. Along the way, you have the opportunity to gather data on what they are interested in, how they want to be contacted, how frequently, and in what forms. For example, Gen Y patients may prefer to use their phones for text messages and appointment scheduling, whereas more mature patients may prefer emails or speaking to a live person rather than a chatbot.

The key to successful campaigns is to make sure your

recycle snippets from a consumer-focused webinar. Most people need to see an offer several times before they make a purchasing decision

7Introduce your most popular content from blogs, newsletters, before and after photos, or videos of a hot new treatment. Allow recipients to ask questions directly from the platform they are reading it from through a live link

8Shopping cart abandonment, when a visitor adds a product or treatment to their shopping cart and then leaves the site without completing the purchase, lends

itself well to drip campaigns. Automate an email or text to the visitor to re-engage their interest in the items they were looking at

9Try building your client list by targeting new visitors to your website who have not signed up and ask them to opt-in to receive news from your practice

10Boost client engagement by making it personal. Your clients will feel that you are speaking directly to them and understand their interests so they will be more likely to read your content and then hopefully take action.

list is constantly updated. One way to do this is for the staff member who checks each patient in to confirm their address, cell phone number, and email. If your patients are scheduling their appointments online, you may be able to implement a way to confirm this information at that time in your system.

One of the most significant benefits of a well-designed drip campaign is the potential to move patients through the purchasing funnel. Campaigns can be set up in advance to be released on a specified date and time so there is minimal staff time required.

Don’t get discouraged if your campaigns are not delivering results quickly enough or you are getting too many opt-outs. Analyse what may need improvements or adjustments in terms of messages, images, format, length, frequency, and call to action. Get advice from your marketing team to make it work for your practice. You may try again after improvements have been made at a reasonable interval until you achieve more satisfactory results.

Each market and facility is unique and may need a different programme to meet its needs. Make sure you are choosing the best vehicle, format, verbiage, tone, and frequency that will deliver success for your practice. Try to avoid irritating your bread-and-butter patients with frequent emails that are neither clever nor helpful.

As Dr. Rubinstein explains, ‘Don’t try to sell because it is not necessary. Staying in touch with your patients is the primary goal. They will come back when they are ready.’

One of the most significant benefits of a well-designed drip campaign is the potential to move patients through the purchasing funnel.

SUPER VELOCE FOR THE TREATMENT OF VASCULAR LESIONS AND SKIN FIRMING

AGEING RESULTS IN collagen damage, which is manifested by collagen fibre fragmentation and solar elastosis. This occurs as a result of external damage, such as sun exposure and smoking, as well as internal factors, including genetics. Photoaging leads to thinning of the skin, wrinkles, pigmentary changes, and telangiectasias. Although invasive surgical procedures remain in demand, more and more patients are seeking non-invasive procedures to tighten the skin and slow the ageing process due to minimal recovery time, achieving a natural appearance, and time and financial affordability.

Mechanism of action

The principle of skin firming using SUPER VELOCE is that the heating of collagen fibres with high light energy, which leads to their contraction and improvement of skin texture.

Collagen denaturation is time and temperature dependent, with higher temperatures being associated with shorter treatment times, but with greater patient discomfort and a higher risk of thermal damage. Lower temperatures require longer exposure but are safer, with similar effectiveness. At the same time, thermal stimulation of dermal fibroblasts at higher wavelengths results in the synthesis of extracellular matrix proteins, which leads to partial restoration of lost dermal volume due to ageing caused by intrinsic and extrinsic factors. Specifically, the

1200 nm wavelength is absorbed by water in the dermis, and its absorption triggers a cytokine reaction that leads to the formation of new collagen and elastin. The result is a firming of the skin and reduction of fine lines and wrinkles.

In addition to facial treatments, it is also important to pay attention to the neck and chest to avoid visible differences between treated and untreated areas. The neck and décolletage area is more susceptible to photodamage due to a thinner epidermis, dermis, and the lower number of pilosebaceous units compared to the face. SUPER VELOCE technology could represent the method of first choice in this indication due to its potential to simultaneously treat telangiectasias, erythema, pigmented lesions, and skin texture using a broad spectrum of wavelengths. It represents a quick and effective treatment for poikiloderma

Civatte. Fluence depends on the phototype of the skin, and with darker skin it is necessary to reduce fluence to prevent epidermal damage.

Conclusion

The goal is to tighten the skin through controlled dermal heating to stimulate collagen remodeling and neocollagenesis with subsequent rejuvenation of facial and body skin. Effective epidermal cooling ensures patient safety and comfort during treatment SUPER VELOCE unique multi-pulse technology achieve convincing results with a good safety profile and a minimum of adverse effects. The greatest benefit with noninvasive skin tightening can be achieved in patients with mild to moderate skin laxity and realistic expectations, so careful patient selection and education is very important.

SUPER VELOCE multi-pulse technology achieves convincing results with a good safety profile and minimum adverse effects

MEČIAROVÁ PETRA, MD, Clinic of Aesthetic and Corrective, Dermatology MEDERMIS, s.r.o, Slovakia

Figure 1 (A) Before and (B) after 4 treatments to the mandibular area and neck with SUPER VELOCE NT Mode-Remodeling, 40,000 J in 2 weeks

MY CLINICAL EXPERIENCE USING SYLFIRM X

IN GENERAL, THE radiofrequency (RF) needling device is widely used, in that it can treat various skin concerns and problems, such as large pores, wrinkles, sagging skin, acne scars and others, and is a great help in running a clinic. However, it is unfortunate that it cannot be applied to patients with melasma and facial redness. In that sense, SYLFIRM X developed and manufactured by ViOL, South Korea, is a revolutionary device because it can be applied to treat melasma and redness as well as other skin conditions.

Our clinic used other brands of RF needling devices in the past. In conventional RF microneedling, RF is delivered through the needles to cause thermal coagulation with strong heat to induce collagen and elastin production and a healing response. Therefore, it improves overall skin firmness and elasticity, and is effective for skin rejuvenation and as a treatment for scarring. I also achieved good results in treating large pores, fine lines, and acne scars. However, I could not use them for patients with melasma, facial redness or pigmented or vascular conditions as the symptoms often worsen.

In 2021, SYLFIRM, the previous version of SYLFIRM X, was first introduced to our clinic. What was very interesting about SYLFIRM was that it is equipped with a method that delivers multiple short pulses of radiofrequency to the skin (pulsed wave, PW), unlike other RF microneedling devices that deliver a single long pulse of radiofrequency to

the skin (continuous wave, CW). PW mode stimulates the skin tissues that affect melasma or/and facial redness, ultimately improving the lesion and I along with my patients with melasma or redness and all the other doctors I work with, were satisfied with the SYLFIRM treatment. In particular, procedural pain and downtime were very little and short, and in the case of facial redness, a noticeable outcome was seen even after 2–3 treatments. Since then, SYLFIRM X, the latest version of RF microneedling equipped with both PW and CW, was released, and so far, a total of 25 branches of our group, including our clinic, have purchased SYLFIRM X and are using it on a daily basis.

Melasma

Melasma is a pigmented lesion that appears mainly in women in their 30s to 50s and appears symmetrically primarily on the cheekbones. It has many similarities to senile lentigo,

such as appearance or the effects of ultraviolet exposure, so it is often misclassified or misdiagnosed. However, melasma is caused by more diverse and more complex causes and factors, including hormonal imbalance. Controlling the activity of melanocytes is very important in melasma treatment, and conservative therapy is commonly used. That is, by oral or topical administration of tranexamic acid, hydroquinone or other substances, leading to cytokines inhibited or melanocyte activity suppressed. However, it cannot be used for patients with some medical diseases and there are concerns about side effects like depigmentation due to long-term use.

That is why lasers are used to treat melasma or in conjunction with conservative therapy. Laser toning (low fluence of a Q-switched Nd:YAG laser or a picosecond laser) is usually used, but even this can cause

Dr. Ayaka Nishikawa shares her clinical experience using SYLFIRM X to treat melasma and rosacea

AYAKA NISHIKAWA , MD, Director of Dermatology Department of Shonan Beauty Clinic Group, Japan

Figure 1 Rosacea patient, (A) before and (B) 1 month after 5 treatments

hyperfunction of melanocytes that worsen pigmentation or damage melanocytes that create mottled hypopigmentation. Among the numerous indications, what makes melasma really difficult to treat is not only that melasma is a recalcitrant lesion, but also that there is a big gap between what the patient wants and what the doctor can actually do. This is because patients with melasma want to see fast and dramatic results with intensive and frequent treatment using any methods, including energy-based devices (EBDs), and doctors need to take safe and careful treatment methods to treat melasma that easily recur or worsen due to various stimuli and there are not many options to choose from.

SYLFIRM X’s PW mode is very helpful in this situation. This is because an additional treatment option is given to melasma patients who want an EBD treatment, but for whom conservative therapy is the only option considering their skin and melasma condition. The PW mode selectively stimulates the highly conductive skin tissue. It is suitable for treating melasma as it improves by stimulation, rather than damaging the skin like a laser.

Several clinical papers have confirmed that PW stimulates and improves melasma-related skin tissues and components, such as the basement membrane, which is the foundation of the epidermis, vascular endothelial growth factor (VEGF) and senescent fibroblasts that are associated with pigmentation production.

Rosacea

PW is also effective in the treatment of facial redness and rosacea due to its stimulation of capillaries and VEGF.

For this reason, in patients with melasma accompanied by redness, both pigmented and vascular conditions are improved and satisfaction is doubled. My experience of treating numerous patients with melasma or/and redness in the clinic has shown noticeable results are seen after 3–5 treatments without any complications. In addition, PW mode of SYLFIRM X is not an aggressive treatment due to the abovementioned features, so it can be used concurrently with conservative therapy or/and other EBD treatment. This is a suitable treatment approach for patients with melasma who need to treat various factors or for patients who want to see fast and dramatic outcomes.

SYLFIRM X

Our clinic is visited not only by patients with melasma or redness, but also by patients with acne vulgaris or acne scars. For acne and acne scars, CO2 fractional laser or conventional RF microneedling is usually used, but it is not appropriate for use when the lesion is accompanied by post-inflammatory hyperpigmentation (PIH) or postinflammatory erythema (PIE) since excessive heat worsens the lesion as well as the accompanying symptoms.

In other words, while the above devices can be applied only to lesions without PIH or PIE, SYLFIRM X with dual RF waveform can safely and effectively treat the indications with or without the symptoms.

Furthermore, patients rarely visit the clinic with only one lesion, they usually have multiple skin concerns and problems that they want to treat.

Since SYLFIRM X is dual wave, it has the great advantage of being

able to treat multiple indications and symptoms at once by applying different modes for each indication and each symptom.

Therefore, patients with melasma who are worried about enlarged pores or wrinkles can be treated simultaneously with a single device, SYLFIRM X, which ultimately improves the overall skin and appearance desired by patients.

In summary, SYLFIRM X can treat various skin concerns and indications, and doctors as well as patients show high satisfaction in terms of procedural pain, downtime, and clinical outcomes.

For more information, visit www.violmedical.com

References

1. Cho, S. B., et al. (2018). In vivo skin reaction from pulsed-type, bipolar, alternating current radiofrequency treatment using invasive noninsulated electrodes. Skin Research and Technology, 24(2), 318-325.

2. Kim, Misun, et al. (2019). Senescent fibroblasts in melasma pathophysiology. Experimental Dermatology, 28(6), 719-722.

Figure 2 Melasma patient, (A) before and (B) 3 months after 4 treatments

“Since SYLFIRM X is dual wave, it has the great advantage of being able to treat multiple indications and symptoms at once by applying different modes for each indication and each symptom.”

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