Journal of Clinical and Aesthetic Dermatology

AUG 2017

An evidence-based, peer-reviewed journal for practicing clinicians in the field of dermatology

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survey of their clinical experiences with these products to align their knowledge and focus subsequent discussions. Knowledge from a recently published consensus on combined methods in caucasian patients directed the formulation of recommendations discussed in this document. 1 the experts first stated whether they agreed or disagreed with a recommendation. they then discussed their relevant personal clinical experiences and their survey responses. experts without experience with a technology or topic in asian patients abstained from voting. any recommendation failing to achieve a strong or absolute consensus (agreement) was revised or refined, and voting was repeated. agreement by all experts resulted in an absolute consensus (100%). a "strong" consensus required a minimum of 90-percent agreement or approval, "moderate" consensus required 70- to 90-percent agreement or approval, and "weak" consensus required 50- to 70-percent agreement or approval (table 1). 7 two types of wording guided the voting process: "recommend" in cases where data were available and the level of consent was high or "suggest" when personal clinical experience led to a different perspective or less agreement. for consistency, early intervention/ enhancement were defined as treatments performed for prevention or restoration/rejuvenation and to improve or correct flaws and increase youthful appearance. Beautification interventions were defined as procedures performed for natural beautifying purposes (e.g., to reach the desired oval facial shape). results general recommendations. the experts l argely agreed with general recommendations proposed for asian patients; however, notable minor differences were found (table 2). part 1: combination treatment strategies for Asian patients— specific indications. Upper face indications. Interventions for upper face features discussed here included forehead volume deficiency with or without brow ptosis, forehead rhytides, lateral canthal lines, glabellar frown lines, temporalis hypertrophy, and hollows. Forehead volume deficiency without brow ptosis. the experts unanimously agreed with the use of ha filler for early intervention/enhancement and restoration (absolute consensus, table 3a). concomitant treatment with Bont-a for the frontalis and corrugator muscle could also be applied in order to prevent unevenness due to muscular activity. the use of a ha filler with projection capacity was recommended for asian patients. Forehead volume deficiency with brow ptosis. asians may naturally lack brow bone contouring or have age-related drooping of the fat pad beneath the brows; therefore, filling of this area can lift brows and "open" the eyes. however, brow ptosis is not commonly treated in asia. If present, volume deficiency is treated with ha, while eyebrow lifting is performed with Bont-a. 8 If only early intervention is required, ha treatment alone may be sufficient. Bont-a treatment is only considered to be effective for hyperactive depressor muscles. occasionally, Bont-a can be combined with energy-based devices to treat hypertonic/hyperkinetic supraciliary muscles. If performed on the same day as MfU-V, Bont-a should be applied immediately after MfU-V treatment (table 3B). filling beneath the brows can be done two weeks prior to MfU-V or immediately after MfU- V if done on the same day. Forehead rhytides. for early intervention/enhancement, the experts suggested using Bont-a followed by ha fillers (table 3c), both of which may be applied within the same treatment session. for restoration, e nergy devices can be used superficially before Bont-a and filler. to prevent further weakening of the frontalis or if volume deficiency is visible (with or without ptosis), ha could be applied first. eyebrow position (whether ptotic) may be naturally lower in asians and can impact the rhytide. 9 to preserve brow position, low-dose or diluted Bont-a was suggested for forehead rhytides, particularly if treatments for early intervention/enhancement are sufficient. 10 Lateral canthal lines. lateral canthal lines are not usually deep in asian patients, but in cases of severe volume loss, ha can be combined with Bont-a treatments. absolute consensus was reached on the recommendations to use only Bont-a for early intervention and Bont-a followed by MfU-V and/or ha fillers (to treat loose skin) for restoration. Glabellar frown lines. While Bont-a treatment was only suggested for early intervention/enhancement, Bont-a treatment for restoration received a unanimous recommendation (table 3e). the experts agreed that restoration should begin with a series of Bont-a treatments, and, if no sufficient improvement is observed, ha fillers should then be carefully injected into the superficial dermis. Temporal hollowing and temporalis hypertrophy. temple hollowing in asian patients requires more contouring than in caucasian patients. 11 for early intervention/enhancement of temporal hollows, low doses of ha filler were recommended. for beautification, the combination of ha and/or caha was recommended (table 3f). for temporalis hypertrophy, Bont-a rather than fillers was recommended for all aesthetic goals (table 3G). Mid-face indications. Mid-face indications discussed included nose shaping, cheek volume, and nasolabial folds (table 4). Cheek volume deficiency (anteromedial, submalar, and subzygomatic). Weak consensus was given for the use of MfU-V first to reposition 18 JCAD journAl oF clinicAl And Aesthetic derMAtologY august 2017 • Volume 10 • number 8 c o n s e n s U s t Able 1. Grading of voting for consensus statements aGreeMent leVel consensUs 100% absolute = "recommend" ≥90% strong = "suggest" 70–90% Moderate 50–70% Weak ≤50% disagreement

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