Managing the Aesthetic Patient

January 2019 | Volume 18 | Issue 1 | Original Article | 92 | Copyright © January 2019

Alessandra Haddad MD PhD,a,b Ana Paula Gomes Meski MD,c Camila Cazerta MD,d Christine Guarnieri MD,d Eliandre Palermo MD,d Juliana Sarubi MD,e Luciana Lourenço MD PhD,d Luiz Eduardo Avelar MD,e Marcus Henrique Morais MD,e Maria Alice Gabay MD,f Meire Brasil Parada MD,d Rodrigo Ferraz MD,e Rodrigo Maia MD,e Danielle Shitara MD PhDd

aPlastic Surgery Department of Universidade Federal de São Paulo, SP, Brazil bHospital Israelita Albert Einstein, São Paulo, SP, Brazil cDepartment of Dermatology, Hospital das Clínicas da Universidade de São Paulo, São Paulo, SP, Brazil dPrivate Practice, São Paulo, SP, Brazil ePrivate Practice, Belo Horizonte, MG, Brazil fPrivate Practice, Niterói, RJ, Brazil

Abstract
The number of cosmetic filler and botulinum toxin options available in the Brazilian market has increased over the past years. With a wide variety of therapeutic options, some challenges have arisen: designing an adequate treatment plan, electing the most suitable procedures for the patient, taking into consideration the rheological characteristics of the products, considering the amount needed to achieve a natural look, but also defining the safest way to deliver the treatment. Aging of the facial structural tissue layers occurs at a different pace and the requirements for the aesthetic approach of a 30-year-old patient are different from a 60-year-old patient. A group of twelve experts in minimally invasive injectable procedures sought to identify common changes observed in different age groups in order to help in establishing a plan of treatment for patients of different ages. The individualized aesthetic plan should consider the main pillars of the aesthetic treatment -- aging process, facial assessment, and facial anatomy, to identify and systematize common changes observed in different age groups, as well as the safest and most reproducible techniques, especially for new injectors. J Drugs Dermatol. 2019;18(1):92-102.

INTRODUCTION

According to the survey published by the International Society of Aesthetic Plastic Surgery, 23 million cosmetic procedures were performed in 2016, and Brazil ranked the second place worldwide. Non-surgical procedures accounted for 55% of total procedures, botulinum toxin (BT) and filler injections being the most popular totaling 65% of non-surgical procedures.1 In this scenario of a wide variety of therapeutic options some challenges have arisen: designing an adequate treatment plan, electing the most suitable procedures for the patient, taking into consideration the rheological characteristics of the products, considering the amount needed to achieve a natural look, but also defining the safest way to deliver the treatment.In 1965, Gonzalez-Ulloa and Flores2 published an article describing changes in facial skin thickness and fat at different ages. The idea that all structural tissue layers—skin, muscle, fat, and bone—should be considered in aging has been corroborated by other authors.3-5 Nevertheless, aging occurs for each structure at a different pace and the requirements for the aesthetic approach of a 30-year-old face are different from a 60-year-old face. Therefore, by means of a thorough knowledge of the aging process and anatomy, as well as the facial assessment, a group of experts in minimally invasive injectable procedures sought to identify common changes observed in different age groups, in order to help establishing an individualized plan of treatment for patients of different ages, as well as the safest and most reproducible techniques for each desirable end.

METHODOLOGY

The panel of experts consisted of twelve dermatologists and plastic surgeons, highly experienced in minimally invasive injectable procedures (ie, BT, hyaluronic acid (HA) fillers, poly-L-lactic acid (PLLA), Skinboosters™).To achieve a better understanding of the common practice of non-invasive facial aesthetic treatments in different age groups, the Expert Group members were requested to complete a pre-meeting survey. During the meeting, the results of the survey were presented and the panel was asked to reach a consensus to determine, based on the process of facial aging, (i) the most common clinical features observed in the different age groups, (ii) most common complaints among their patients in each age group, based on the total number of patients who present to them for noninvasive facial esthetic treatment, (iii) the treatment methods most used for each indication, considering only injectable procedures (abobotulinum toxin, HA fillers with non-animal stabilized hyaluronic acid (NASHA™) technology or Optimal Balance Technology (OBT™), Skinboosters™ and PLLA, (iv) treatment priorities for each age group, and (v) based upon