cosmetic procedures in 2018 amounted to over 12.5 million in the US alone.11 With the inclusion of calcium hydroxylapatite and poly-L-lactic acid (31,821 and 28,036, respectively), the total amount of injectable treatments surpassed 2,671,130 procedures in 2018.11
Injectables are a further fast-expanding treatment option for signs of facial aging. The American Society for Aesthetic Plastic Surgery (ASAPS) reported that over $1 billion USD were spent on injectables in 2020. Together, botulinum toxin and soft tissue fillers such as hyaluronic acid injections made up the top two nonsurgical treatments performed in 2020, with 4.4 million and 3.4 million procedures, respectively; and with Botox® Cosmetic being the number one aesthetic procedure performed by plastic surgeons since 1999.10
Further injectable treatments include biodegradable facial lifting sutures.
Common injectable treatment-related AEs include bruising, erythema, inflammation, and pruritus.12-23 Moderate-to-severe AEs such as infection (including biofilms), granulomas, nodules, skin necrosis, scarring, and vision loss or blindness occur less; however, these serious AEs will impact a significant number of patients given the many procedures performed annually worldwide by dermatologists/plastic surgeons/ aesthetic medicine physicians.17-23 Over 5,000 patients will experience an infection per year in the US as indicated by the ASAPS and the reported infection rates (including biofilm) in the literature.11,21 Therefore, there is a need for reducing the risks of injectable-related AEs.
Guidance and consensus documents describe best practices for performing nonenergy-based and injectable procedures; however, few discuss specific pre-and post-procedure measures.4-8,12-23 Two previously published surveys reported that no guidelines or algorithms are currently available concerning pre-and post-procedure measures and agents for nonenergy-based and injectable facial treatments and their use in preventing or treating post-procedural side effects or complications.24,25
The current algorithm aims to provide clinicians with guidelines when treating patients with nonenergy-based and injectable treatments for facial rejuvenation to improve treatment outcomes.
Injectables are a further fast-expanding treatment option for signs of facial aging. The American Society for Aesthetic Plastic Surgery (ASAPS) reported that over $1 billion USD were spent on injectables in 2020. Together, botulinum toxin and soft tissue fillers such as hyaluronic acid injections made up the top two nonsurgical treatments performed in 2020, with 4.4 million and 3.4 million procedures, respectively; and with Botox® Cosmetic being the number one aesthetic procedure performed by plastic surgeons since 1999.10
Further injectable treatments include biodegradable facial lifting sutures.
Common injectable treatment-related AEs include bruising, erythema, inflammation, and pruritus.12-23 Moderate-to-severe AEs such as infection (including biofilms), granulomas, nodules, skin necrosis, scarring, and vision loss or blindness occur less; however, these serious AEs will impact a significant number of patients given the many procedures performed annually worldwide by dermatologists/plastic surgeons/ aesthetic medicine physicians.17-23 Over 5,000 patients will experience an infection per year in the US as indicated by the ASAPS and the reported infection rates (including biofilm) in the literature.11,21 Therefore, there is a need for reducing the risks of injectable-related AEs.
Guidance and consensus documents describe best practices for performing nonenergy-based and injectable procedures; however, few discuss specific pre-and post-procedure measures.4-8,12-23 Two previously published surveys reported that no guidelines or algorithms are currently available concerning pre-and post-procedure measures and agents for nonenergy-based and injectable facial treatments and their use in preventing or treating post-procedural side effects or complications.24,25
The current algorithm aims to provide clinicians with guidelines when treating patients with nonenergy-based and injectable treatments for facial rejuvenation to improve treatment outcomes.
METHODS
The Process
Following two highly successful face-to-face algorithmgenerating events in September 2018 for alignment on the current standards for procedure-based therapy and February 2020 energy-based treatments for anti-aging, in April 2021, a panel of dermatologists and plastic surgeons convened a virtual meeting to develop an algorithm on measures before and after facial nonenergy-based and injectable treatments. The panel members previously published two surveys24,25 on before and after measures for nonenergy-based and injectable facial treatments to prevent or treat post-procedural side effects or complications.
For the project, a modified Delphi, an interactive decisionmaking technique for medical projects, was applied.26,27 The method was adapted from face-to-face meetings to a virtual meeting to discuss the outcome of literature searches, including the two surveys to reach a consensus on the algorithm.26,27
Based on literature searches, including two surveys, the panel discussed the proposed design of the algorithm.24,25 After presentations of the summaries of the literature searches and the proposed algorithm, the panel worked in small groups, advising their algorithm, editing, and revising it. They then reconvened into a plenary group to reach consensus through blinded reiterations and votes to determine the final algorithm. The panel obtained consensus through unanimous votes. Reviewing, finetuning, and discussing the manuscript, took place online due to the impact of the COVID-19 pandemic and the diverse geography represented by the panel (Figure 1).
Literature Searches
Before the expert panel meeting, a systematic literature review was conducted, selecting present clinical guidelines, algorithms, and evidence-based recommendations describing the current best practice measures before/after facial nonenergy-device and injectable treatments. Additionally, review articles, clinical trials, and other studies were selected that were clinically relevant to the algorithm. Publications were in the English language dating from 2015 to March 2021 and were searched on PubMed and Google Scholar as a
secondary
Following two highly successful face-to-face algorithmgenerating events in September 2018 for alignment on the current standards for procedure-based therapy and February 2020 energy-based treatments for anti-aging, in April 2021, a panel of dermatologists and plastic surgeons convened a virtual meeting to develop an algorithm on measures before and after facial nonenergy-based and injectable treatments. The panel members previously published two surveys24,25 on before and after measures for nonenergy-based and injectable facial treatments to prevent or treat post-procedural side effects or complications.
For the project, a modified Delphi, an interactive decisionmaking technique for medical projects, was applied.26,27 The method was adapted from face-to-face meetings to a virtual meeting to discuss the outcome of literature searches, including the two surveys to reach a consensus on the algorithm.26,27
Based on literature searches, including two surveys, the panel discussed the proposed design of the algorithm.24,25 After presentations of the summaries of the literature searches and the proposed algorithm, the panel worked in small groups, advising their algorithm, editing, and revising it. They then reconvened into a plenary group to reach consensus through blinded reiterations and votes to determine the final algorithm. The panel obtained consensus through unanimous votes. Reviewing, finetuning, and discussing the manuscript, took place online due to the impact of the COVID-19 pandemic and the diverse geography represented by the panel (Figure 1).
Literature Searches
Before the expert panel meeting, a systematic literature review was conducted, selecting present clinical guidelines, algorithms, and evidence-based recommendations describing the current best practice measures before/after facial nonenergy-device and injectable treatments. Additionally, review articles, clinical trials, and other studies were selected that were clinically relevant to the algorithm. Publications were in the English language dating from 2015 to March 2021 and were searched on PubMed and Google Scholar as a
secondary
