JUL-AUG 2018

MedEsthetics—business education for medical practitioners—provides the latest noninvasive cosmetic procedures, treatment trends, product and equipment reviews, legal issues and medical aesthetics industry news.

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Page 35 of 68 | JULY/AUGUST 2018 33 Increased strain or compression in the perioral region among older patients changes the appearance of this area, causing more dynamic lines and visible muscle movement, according to a University of Pennsylvania study published in September 2014 in PRS Global Open. "With expressions like lip pursing, strain in the nasolabial fold increases along with asymmetry compared to younger patients," says study co-author Ivona Percec, MD, PhD, assistant professor of plastic surgery, associate director of cosmetic surgery and director of basic science research in the division of plastic surgery at the University of Pennsylvania. In April, Dr. Percec presented data from a new study at The Aesthetic Meeting 2018 in New York City. This study compared the naturalness of expression in 30 patients (40- 65 years of age) before and after treatment to the nasola- bial folds and marionette lines with Galderma's Refyne and Defyne HA fi llers. She and her colleagues found that fol- lowing treatment, the strain in the perioral area decreased, and they were able to provide a more youthful contour to the face that preserved natural expressions when patients pursed their lips, grimaced and smiled. "Using just 1cc of fi ller to that region in combination with a few units of neurotoxin can dramatically decrease the amount of strain in that area and increase patient satisfac- tion," says Dr. Percec. "In addition, with the Defyne and Refyne fl exible gels, we can maintain and/or improve the dynamic motion and naturalness of expression." Gauging Satisfaction For years, practitioners have reported high satisfaction rates with full-face injectable treatments. That anecdotal evidence is supported by fi ndings of the HAR- MONY study (Aesthetic Surgery, April 2018). "This was the fi rst prospective study to objec- tively analyze satisfaction," says study co-author Vic Narurkar, MD, founder of the Bay Area Laser Institute in San Francisco. "We looked at the face as a whole and treated the full face with a combination of Botox and fi llers. We used Voluma in the mid-cheek; Juvéderm Ultra and Ultra Plus in the lower face, and then we used Botox in the upper face." At four months, 99 percent of patients rated themselves as "improved" or "much improved" on the Global Aesthetic Improvement Scale, and self-perceived age decreased from 0.2 years older than actual age at baseline to 4.6 years younger at month 4. But safely achieving natural-looking outcomes requires experience, a keen aesthetic eye and a good understanding of how these individual products behave and interact with one another. "We have been using HA fi llers for 14 years and we cer- tainly have evolved from just fi lling the nasolabial folds," says Susan Weinkle, MD, a dermatologist in Bradenton, Florida, and co-author of the HARMONY study. "We've learned to treat the overall volume and shape of the face, but in doing so we have learned some lessons about making sure that all of the units of the face remain in balance." Maintaining Balance A rush to try new treatment options has, at times, left pa- tients with less-than-stellar outcomes. "We've sent people out with cheek bones that were way too prominent, be- cause we failed to recognize that if you overinfl ate one area, it can have a negative effect on another area," says Dr. Weinkle. "For example, if you overbuild that zygomatic area of the cheek, the eyes look much smaller." To achieve natural-looking results, injectors need to re- member the golden ratio. "Your face should be fi ve eyes wide, and the distance and the width of the face should be greatest among the zygomatic arch region," says Dr. Weinkle. "You always have to keep your eye on those pro- portions—upper third, middle third, lower third—and you have to look at the face dynamically and adynamically as you inject. "When you're doing a neuromodulator, you also have to look at the face dynamically so you see where the maximum muscle activity is. This is particularly true in the

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