international issue of the journal kosmetische …...international issue of the journal kosmetische...

InternatIonal Issue of the Journal KosmetIsche medIzIn, Volume 3, ISSN 2366-0554

2.2017

correctIon of lower eyelId by hyaluronIc acId (ha) fIller

InternatIonal expert consensus on the use of abobotulInum toxIn a

restylane® sKInboosterstm for Improvement of the sKIn qualIty results of a consensus meetIng

C o S m e t I CMedIcIne

fIller GuIde 2017

Official publication of the following societies:European Society of Cosmetic and Aesthetic Dermatology (ESCAD)Cosmetic Dermatology Society of India (CDSI)Academy of Associated Dermatologic Institutes (AADI) Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS) Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA) German Society of Aesthetic Botulinum Toxin Therapy (DGBT) Network Globalhealth

Knowledge and skills are necessary to perform good clinical medicine. In aesthetic medicine, however, the details become very important to achieve satisfying results. In the present issue of CoSmetIC medICINe INteRNAtIoNAl we focus on details in treatment with botulinum toxin A and filler injections. these are the most frequently used techniques in facial rejuvenation. Because they look so simple, guidelines and workshops are important to transfer the knowledge of experts in the hand of trained physicians. We all know that lay persons try to use these tools as well. this can end up in disastrous situations for the patients and undermine trust in aesthetic medicine in general.

In the present issue international experts in this field report about their experience and illustrate their techniques in detail for various aesthetic indications such as eye-lid corrections, gummy smile or full face treatment to name just a few.

We proudly present the International expert Consensus on the use of AboBotuli-num toxin A for facial rejuvenation and primary hyperhidrosis. under the leadership of Professor Alessio Redaelli (milan, Italy) experts from different medical specialities and from Russian Federation, united Kingdom, Italy, Germany, Israel, Belarus, and ukraine developed these scientifically grounded recommendations for a safe and effective use of this particular botulinum toxin A.

A German expert panel under the leadership of Professor martina Kerscher (Ham-burg) prepared a consensus report on the use of skin boosters to stimulate skin reju-venation without sculpturing for face, hands, décolletage and to improve skin hydra-tion by these hyaluronic acid-based products.

the present and even more the future is combination treatment. dr. michael Wei-dmann (Augsburg, Germany) presents impressive results that have been obtained by a synergistic approach with minimal invasive procedures.

last but not least the 2017 Filler Guide is presented by douglas Grosse, who has done a tremendous work to collect all these date and details to gain a representa-tive overview on the ever enlarging field of soft tissue filler products. make your own choice!

With kind regards,

Prof. dr. uwe Wollina, dresden

edItorIal CoSmetIC medICINe 2.17 57

what we need is details and overview

58

edItorIal

uWe WollINA 57

revIew

ANNA ReZNIKcorrection of lower eyelid by hyaluronic acid (ha) filler, depending on anatomic features 60

m. I. SoYKHeR, o. R. oRloVA et. al.“gingival (gummy) smile” – diagnostic value and treatment with botulinum neurotoxin 64

orIgInal

A. RedAellI, A. SARomYtSKAYA, C. RoWlANd PAYNe et Al.International expert consensus on the use of abobotulinum toxin a (abota) for facial rejuvenation and primary hyperhidrosis 70

case report

lIA GAVASHelIdysport® full-face approach for correction of mimic lines 81

CoSmetIC medICINeINteRNAtIoNAl ISSue oF tHe JouRNAlKoSmetISCHe medIZIN

official publication of the following societies:• european Society of Cosmetic and Aesthetic dermatology (eSCAd)• Academy of Aesthetics and dermatologic Institutes (AAdI)• Austrian Academy of Cosmetic Surgery and Aesthetic medicine (AACS)• Austrian Society of dermatologic Cosmetics and Research on Aging (oGdKA)• Cosmetic dermatology Society of India (CdSI)• German Society of Aesthetic Botulinum toxin therapy (dGBt)• Network Globalhealth

editor-in-chief:Prof. dr. uwe Wollina, dresden, [email protected]

deputy editor:Prof. assoc. dr. Klaus Fritz, landau Germany

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publisher:douglas [email protected]

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therapy focus

mARtINA KeRSCHeR, HeIKe BuNtRoCK, mARtINA HuNd et Al.restylane® skinboosterstm for improvement of the skin quality results of a consensus meeting 82

mICHAel WeIdmANNsynergistic combination therapies are highlighted in 2017! 90

JöRG FAulHABeRnew patient group „men“ – hyaluronic acid as an important tool 93

IntervIew

algeness® a new polysaccharide based filler 40

fIller guIde

douGlAS GRoSSe editorial 95

Industry news

harmonyca: the synergy of calcium hydroxyapatite and hyaluronic acid 110

teosyal® rha 4* receives the anti-aging & beauty trophy as „best dermal fIller“ 111

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editorial board: Ashraf Badawi, Cairo (egypt) mohamed Amer, Cairo (egypt) Anthony V. Benedetto, Philadelphia (uSA) ulrike Blume-Peytavi, Berlin (Germany) Hong-duo Chen, Shenyang (China) Zoe draelos, High Points (uSA) Peter elsner, Jena (Germany) tanja Fischer, Potsdam (Germany) Alina Fratila, Bonn (Germany) Alberto Goldmann, Porto Alegre (Brazil) loek Habbema, Bassum (Netherlands) thomas Jansen, Bochum (Germany) Amala Kamat, margao (India) Bernd Kardorff, mönchengladbach (Germany) Andreas Katsambas, Athen (Greece) martina Kerscher, Hamburg (Germany) daisy Kopera, Graz (Austria) oliver Kreyden, muttenz (Switzerland) moshe lapidoth, Herzelia Pituach (Israel) leonardo marini, triest (Italy) thada Piamphongsant, Bangkok (thailand) Christopher Rowland Payne, london (GB) Berthold Rzany, Berlin (Germany) matthias Sandhofer, linz (Austria) Rekka Sheth, mumbai (India) George Stergiou, Zurich (Switzerland) Boris Sommer, Frankfurt/main (Germany) Shyam Verma, Vadodara (India) Ines Verner, tel Aviv (Israel) michael Weidmann, Augsburg (Germany) Johannes Wohlrab, Halle (Germany) Hanna Zelenkova, Svidnik (Slovakia) Sabine Zenker, munich (Germany) Zoran Zgaljardic, Zagreb (Croatia)

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CoSmetIC medICINe 2.17

60 CosmetiC mediCine 2.17 Reviews

IntroductIon

traditionally, a major method of a rejuvenation of the perior-bital area is surgical blepharoplasty. But its frequently limited efficiency in the long-term prospect, and the increasing interest in low-invasive procedures create injection blepharoplasty as an important method of correction of a palpebromalar groove and tear trough, an injection camouflage of prominent orbital fat of a lower eyelid.

the delayed adverse effects of correction of the tear trough and injection camouflage of prominent orbital fat of a lower eyelid are important. they include the accumulation of hyalu-ronic acid (HA)-filler out of tear trough, enlargement of hernia of a lower eyelid, puffiness of a periorbital zone, short and insufficient effect of correction [4]. All this can develop several months after the procedure.

We would like to consider options of injection correction of a lower eyelid by means of HA-filler depending on anatomic features of the patient, and specifically expression of promi-nent orbital fat of a lower eyelid to decrease the possibility of emergence of these adverse effects [1, 5, 6]. We suggest our clinical classification of aging changes in lower eyelid area for convenience correction. We mark out 3 types of a zone of a lower eyelid (Fig. 1) [5, 6].

the first type is characterized by loss of volume in lower eyelid. this type is most common in young patients or patients after surgical blepharoplasty [2, 5].

In this case we recommend to place filler in the space lim-ited from above (ranial) by bony orbital margin or septae, lower (caudal) – by oRl, deeply with periosteum and superfi-cially by SmAS (Fig. 2) [1, 5, 6].

We use microboluses fan injections by sharp needle for pre-cise injection of filler in this space (Fig. 2). dangerous zones should be marked before an injection for the prevention of their trauma by a needle. they are: zone of angular vessels and a zone of an infraorbital neurovascular fascicle [3].

After we mark space borders where we will enter filler. It is a projection of edge of an orbit and eyelid-cheek junction (oRl projection). We do a puncture of a skin 1–2 mm higher than eyelid-cheek junction, we enter a needle perpendicular to a surface of a skin and we move a needle till periosteum. then we turn a needle almost parallel to periosteum and we enter all length under the SmAS [2]. We inject filler into space limited by

correction of lower eyelid by hyaluronic acid (ha) filler,

depending on anatomic features

ANNA ReZNIK

Key wOrds:

periorbital ageing, facial rejuvenation, hyaluronic acid, fillers, danger

zones.

summary:

periorbital rejuvenation is important for facial aesthetics. according to

the type of anatomical ageing-related changes different techniques of

hyaluronic acid-based filler placement are presented for rejuvenation.

In addition, the choice of filler product is crucial for optimal outcome.

the knowledge of danger zones for filler placement increases safety

for patients.

fig. 1: three types of aging of the lower eyelid.

fig. 2: lower lid correction in case of no prominent orbital fat. fan-

technique, microboluses, supraperiosteal injections of ha-filler by sharp

needle placed between bony orbital margin and eyelid-cheek junction.

projection of angular and infraorbital vessels are marked by red.

61CosmetiC mediCine 2.17


eyelid-cheek junction and projection of edge of an orbit (1 mm above these borders) with the microboluses, retrograde fan injections. tear trough and a palpebromalar groove are cor-rected at the same time.

Filler accumulation lower (more caudal) than the tear trough can occur after correction of the tear trough by cannula with an entry point in a malar zone at this type of lower eyelid. It can be due excess amount of filler, injected to medial SooF [4]. We don‘t recommend to place filler caudal to oRl for pre-vention of accumulation it out of the tear through. It is possible to use a blunt cannula with entry point in a lateral part of an orbit (between a lateral cantus and eyelid- cheek junction) for correction of this type.

the second type of changes of a lower eyelid is prominent orbital fat of a lower eyelid in a medial part of an orbit and visualization of bony edge of an orbit in a lateral part of an orbit [1]. We also use the microboluses, retrograde fan injec-tions by needle with preliminary marking of dangerous zones for correction of this type (Fig.3) [3, 5].

Filler is injected under SmAS in lateral part of an orbit into the space limited by oRl (eyelid- cheek junction) and bony edge of orbit as well as in the first type. And in a medial part of an orbit filler is injected in a deep fatty tissue caudal to oRl and in projection of oRl fixation [1]. to avoid injection of filler

in hernia we don‘t inject filler cranial to oRl projections in a medial part of an orbit.

It is possible to use for correction of this type a blunt can-nula with entry points: in a lateral part between a lateral can-tus and eyelid-cheek junction, in a medial part in a buccal zone below eyelid-cheek junction.

the third type of changing in a zone of an upper eyelid is determined by visualization of hernias of a lower eyelid both in medial, and in a lateral part of an orbit [1]. this type is indica-tion to surgical blepharoplasty usually. If there are contrain-dications to surgery, it might be corrected by HA-filler. Incom-plete correction of the tear through and palpebromalar groove is preferable to the prevention of effect „pillow face“ in this case.

It is possible to use both a needle, and a blunt cannula in correction of this type. Filler should be injected into deep fat compartments caudal to oRl projections (eyelid-cheek junc-tion). We prefer the microboluses technique by needle (Fig. 4) [3, 5].

When correcting the lower eyelid, the right choice of filler is very important. Filler must have the necessary elasticity and plasticity to evenly fill the depression and prevent contouring. We use monophasic HA-filler of average degree of a reticula-tion – Filorga XHA-3 0.2–0.5 cc – on the side with good clini-cal effect from 10 to 18 months (Fig. 5).

We recommend to correct loss of volume of a buccal and malar zone as first procedure, and then correct zone of a lower eyelid for obtaining optimum effect in all cases [6].

fig. 3: technique for lower lid correction in case of prominent orbital fat

and visualisation of lateral portion of bony orbital margin. microboluses

supraperiosteal injection of ha filler by sharp needle. In lateral part:

between projection of orl and bony orbital margin. In medial part:

in projection of attachment of orl or more caudal.

fig. 4: technique for lower lid correction in case of prominent orbital

fat, visible in lateral and medial part. supraperiosteal microboluses

injection of ha-filler by sharp needle more caudal to projection of orl

(eyelid-cheek juncton).

fig. 5a - c: periorbital zone (types 1, 2 and 3) before correction by fil-

ler filorga xha-3 and 2 weeks after correction.


In conclusion, it is important to underline that correction with HA-filler of lower eyelid has to be performed with consid-eration of anatomic features of every patient, especially exist-ence and expression of prominent orbital fat of a lower eyelid for optimum results and decreasing risks of adverse events. It is necessary to use a filler with specific physicochemical prop-erties. In our hands, HA-filler Filorga XHA-3 is optimal for the correction of this area.

address of correspondance: dr. med. Anna Reznik

medical Center ARclinic,

Saint-Petersburg, Russia

[email protected], [email protected]

literature:1. Животкова Е, Красносельских М (2016) Коррекция периорбитальной

области: pro et contra. Журнал Облик. Esthetic Guide 2: 68-70.

2. Павленко ОЮ, Хрусталева ИЭ, Атаманов ВВ, Грищенко СВ, Стенько АГ

(2014) Возможности филлеров в коррекции нежелательных явлений

после блефаропластики и липофиллинга нижних век. Инъекционные

методы в косметологии 3: 48-54.

3. Павленко ОЮ (2015) Инъекционная блефаропластика. Журнал Облик.

Esthetic Guide 1: 78-81

4. Kohli m, davda R (2016) Complications of fillers. Complications in Cosme-

tic dermatology: Crafting Cures. pp. 90-109.

5. mendelson B, Wong CH (2013) Anatomy of the Aging Face. Plastic sur-

gery, 3rd edn. elsevier Saunders, Philadelphia/PA, pp. 78-92.

6. muzaffar AR, mendelson BC, Adams WP (2002) Surgical anatomy of the

ligamentous attachments of the lower lid and lateral canthus. Plast Recon-

str Surg 110: 873-884.

A series of standards called IdmP (Identification of medicinal Products) standards is under revision and will bring a host of benefits to patients and the healthcare community. Implement-ing these standards should simplify the exchange of information between stakeholders and enhance the interoperability of sys-tems in the medical field.

IdmP standards and technical specifications, compris-ing ISo 11616, ISo 11615, ISo/dIS 11238, ISo/tS 20451, ISo/tS 20443 and ISo/tS 19844, support the activities of medicines agencies worldwide. these cover a variety of regulatory activi-ties related to the development, registration and life-cycle man-agement of medicinal products, as well as pharmacovigilance and risk management.

Christian Clay, Senior Consultant Healthcare for GS1 Global office and Convenor of working group 6, Pharmacy and medi-cines business, of ISo technical committee ISo/tC 215, Health informatics, explains: “IdmP standards are essential for the world’s increasingly integrated healthcare. they provide the precise architecture for the computerization of information on medicinal products all around the world. When regulators adopt IdmP, their capacity to interoperate with each other makes for safer patient care; this is, for example, a huge benefit for adverse-event reporting and for documenting medication in patient records.”

“the revision has become necessary as a consequence of the development of IdmP implementation guides (which take the form of four CeN1) ISo technical specifications). the overall standard has not really changed but has gained in usability for implement-ers. By developing implementation guides, it has been possible to

shift some detailed information from the standard itself to its cor-responding implementation guide,” says Christian Hay.

“By publishing the ISo IdmP standards in 2012, the com-munity has been able to understand a potential fundamental change in each respective data model – which are currently very diverse. Having learned from users’ reactions, the IdmP project leaders have initiated an ambitious standards development pro-gramme, which consists of working on implementation guides (namely, the four CeN ISo technical specifications). Now, one can expect the creation of educational material and a uniform implementation both on the part of the manufacturer and the regulator. In parallel, IdmP provides a basis for existing or new It solutions, such as prescriptions, medication reports, medicinal product dictionaries for clinical use, and more,” he adds.

using ISo IdmP within regulatory activities brings benefits to regulators, industry and, ultimately, patients. “the trend towards global standards continues to increase. I cannot imagine the world without IdmP, whose implementation programme is going to last several years. Without IdmP, the existing information fragmentation by country or region would cause increasing risks to patients globally – not only those who travel, but those who are faced with mobile health or because of the globalization of supply chains,” explains Christian Hay.

ISo IdmP standards were developed by ISo technical commit-tee ISo/tC 215, Health informatics, whose secretariat is held by ANSI, ISo’s member for the uSA. It is now available from your national ISo member or through the ISo Store.

for more information visit: www-iso.org

revised Idmp standards to improve description of medicinal products worldwide


Key wOrds:

gummy smile, facial aesthetics, aetiology, treatment, botulinum toxin

summary:

smile is an important human facial expression of nonverbal communi-

cation. smile aesthetics represent a target for minimal invasive pro-

cedures such as botulinum neurotoxin injections for improvement and

correction. we present pathogenesis, diagnostic relevance and treat-

ment options of so-called gingival or gummy smile. the aesthetic cor-

rection of gummy smile is a multidisciplinary task.

IntroductIon

today, more and more people are striving to realize [4, 14] in their own life the motto: “everything in a human being should be perfect” [15]. mostly, we pay a lot of attention to our appear-ance and special importance is attached to our face [5, 6]. every unique human face has important personal significance for each of us. Smile and lips are the leading factors in the perception of face aesthetics. many authors like Pererverzev (1978), Khoroshilkina (1979), Persin (1988), Polma l (1996, 2010), Arsemima (1998), Ricketts (1981), Bishara (1985), Bac-ceti (2000), Sarver (2001), and Ackerman (2004) made great contributions to the study of the issue of face aesthetics and its violations.

the motivation of patients for dental treatment in recent years is increasingly aimed at obtaining an aesthetic result. Analysis of the reasons why patients turn to dentists showed [7, 11], that 23.0 % of patients want to improve the aesthetic appearance of their teeth, 71.2 % orthodontic patients want to improve face and teeth aesthetics such as reconstruction of the teeth rows. during the last years, facial aesthetics is especially associated with the smile zone. the smile zone is a special structural, a functional and aesthetically significant area. It consists of different macro- (facial and labial) and micro- (gin-gival and tooth crowning) parameters [3].

the smile formation process divides into 4 stages: 1. stage – lips are closed 2. stage – lips are ajar (half-opened) 3. stage – natural smile (three quarters opened lips) 4. stage – broad smile.

Currently, smile analysis is the key to diagnosis and planning of rehabilitation of dental patients. A smile can destroy or emphasize the face harmony. therefore, an attractive smile becomes an important indicator of successful dental reha-bilitation. the clinical value of a harmonious balance is deter-mined by the limits of the possible effect on soft tissues and the direction of orthopedic treatment, which allows to achieve the best aesthetic result.

What is “the perfect smile”? Are there any clear criteria for this concept? We can easily tell which smile is beautiful, but it is difficult for us to describe those characteristics, that cre-ates it. many investigations of the problem of aesthetic facial disorders of young patients indicates the presence of “gingival smile” in 10–15 % of cases.

Actually, smile aesthetics depends on: ratio parameters between teeth and gums, their compliance with the rules of structural beauty, the ratio between the teeth and lips param-eters and their harmonious integration with the components of the face. mimic muscles are the main component of a smile [32, 33]. Approximately 7 % of men and 14 % of women have excessive visualization of gums with a smile. excessive gum visualization is a descriptive term rather than diagnosis that involves the mandatory conduct of a specific treatment.

Gummy smile (or gingival smile) – it’s a kind of structure of tissues of the oral cavity, wherein smile occurs during dis-placement of the upper lip exposing the gums. For the correct diagnosis doctor requires knowledge in the field of facial aes-thetics. the main parameter of the estimation is the height of the face oval. the height of the middle part of the face should be equal to the height of the lower part with a relaxed state of mimic muscles. A „gummy smile“ may be a symptom of a dis-order in structures of the facial skeleton and hyperactive facial muscles (Fig. 1).

Anatomical reference point of the middle part of the face is glabella – the most prominent point of the frontal bone between the superciliary arches and the lower point of the

“gingival (gummy) smile” – diagnostic value and treatment

with botulinum neurotoxin

m.I. SoYKHeR1, o.R. oRloVA1, m.G. SoYHeR1, l.R. mINGAZoVA1, em SoYHeR2

1 first moscow state medical university named after Im sechenov, moscow.

2 center of Interdisciplinary stomatology and neurology, moscow.


nasal septum. the lower part is measured from the bottom point of the nasal septum to the lowest point of the soft tissues of the mandibula, i.e. the lower edge of the chin.

It is necessary to measure the length of the upper lip after making assessment of the height of the face. In the state of relaxation of the facial muscles length from the bottom of the nasal septum up to the lower edge of the upper lip is 20–22 mm on average for young women (Fig. 2a) and 22–24 mm for young men. In this case for women, 3–4 mm maxillary central incisors are usually visualized (Fig. 2b), and 2 mm less for men. over time, there is a trend to upper lip lengthening.

Short or hyperactive upper lip is one of the factors forming a “gummy smile”. usually, with a broad smile, teeth crowns 10–11 mm long are completely visible. However, for patient with a hyperactive upper lip these parameters can be raised in 1.5 2 times (Fig. 3).

In addition, excessive lengthening of the teeth of the frontal group of the maxilla [20] leads to a displacement of the gin-giva together with the underlying bone, and their lower posi-tion leads to the appearance of a „gummy smile“.

the reason of excessive visualization of the gum also might be an increase in the height of the mandible, which makes the lower part of the face longer relatively to the middle part [16, 18, 22]. According to Jiao Wei et al. (2015), one of the aeti-ological factors of the „gingival smile“ may be dysplasia of the nasal septum [21]. the most complicated case that require spe-cial attention – is a combination of several factors.

Smile is unique for each person. there are several classifica-tions of smiles. According to the Rubin and Philips classifica-tion, there are three basic types of smile [12, 30, 31].

the first type is a commissural smile („la Gioconda‘s smile“) – occurs in 67 % of people. When smiling, the corners of the lips move laterally upwards by 7–22 mm. the corners of the lips (commissures) occupy a position above the upper lip and the lateral part of the lips forms an angle of 40° (more often 24–38°) to the horizon. lips form two curved arcs, in the gleam of them only the upper teeth are visible, sometimes even wis-dom teeth. Zygomaticus major and minor muscles are involved in the formation of this type of smile.

the second type of smile – „canine“ or „labial“ – is observed at 31 % of people. It is formed without a significant shift up the corners of the mouth. upper lip rises upwards, exposing 6–8 upper teeth, lower teeth are closed with lower lip. the lower lip takes the form of an arch, the upper one has curves, in one of which the canines are exposed (this is the reason of the char-acteristic name). muscles lifting the upper lip and the one lift-ing the upper lip and the wing of the nose are involved in the formation of this type of smile.

the third type – „full denture“ or „complex“ smile – found at 2 % of people. With a smile, both upper and lower teeth are exposed and the lips have the form of two practically parallel lines. the maximum number of antagonist muscles of middle and lower third of the face is involved in the formation of this type of smile. therefore, the key characteristic of this smile – strong muscular tension and displacement of the lower lip down and backward [13].

multifactor analysis [10] (2009) carried out by Polma allowed to reveal a syndrome, accompanying unaesthetic types of smiles, for which patients complain. A high type of smile („gummy“ smile) is common not only due to vertical enlarge-ment of the upper jaw, or the increase in the height of the lower part of the face and the prevalence of the vertical type of growth, but also as a result of soft tissue anatomy. In 90 % of cases a straight or downward bending of the upper lip is noted. large percentage of „gummy“ smiles (90 %) arises due

fig. 1: aetiology and pathogenesis of gummy smile.

fig. 2a + b: measurements of lip harmony (see text).

fig. 3: clinical presentation of a gummy smile.


to anterior rotation of the upper jaw, and in 75 % of cases it is accompanied by a retraction of incisors of the upper jaw.

there are five variations for exposing teeth and gums in a smile:

type 1 – only the upper teeth; type 2 – upper teeth and more than 3 mm of gum; type 3 – only lower teeth; type 4 – upper and lower teeth; type 5 – neither upper nor lower teeth.

With aging, there is an elongation of the upper lip occurs with simultaneous reduction of the alveolar processes of the upper jaw and the maxillary bone in general. Against this back-ground, the exposure of the gum with a smile is leveled. maz-zuco and Hexsel suggested an aesthetic-functional classifica-tion of „gingival smile“ [23, 24] (tab. 1).

multifactorial analysis of the smile and its consistent design are the key stages of diagnosis and planning aesthetic correc-tion. diagnosis of smile aesthetics disorders should be con-ducted on an interdisciplinary basis, acknowledging the stand-ards of harmonious smile, professionally installed for different age-sex and ethnic groups.

the plan for aesthetic correction of the „gummy smile“ is devel-oped after an accurate diagnosis and includes the use of both orthodontic correction and maxillofacial surgery, also the use of botulinum neuroprotein, for mimic muscle relaxation [21] (Fig. 4).

According to various authors injections of botulinum neu-roprotein (or botulinum toxin) are necessary for patients with gingival smile for reduce hypermobility of the upper lip [8, 12, 25, 29]. the main target muscle is the one that lifts the upper lip (m. levator labii superioris) together with m. zygomaticus minor, m. zygomaticus major, m. depressor septi nasi, m. orbic-ularis oris [17, 28] (Fig. 5).

Injection of botulinum toxin into the muscle lifting the upper lip may be accompanied sometimes by ptosis of the upper lip and its excessive elongation, protrusion of the lower lip and its asymmetry [19, 32].

the mechanism of action of the botulinum neuroprotein is due to the progress of chemodenervation – direct peripheral influ-ence on motor fibers (neuromuscular transmission), binding to the presynaptic terminal and blockade of transport protein, that takes from 1 to 3 days, so the effect of muscle relaxation begins to manifest a few days after the injection of botulinum toxin into the muscles [1]. the use botulinum toxin for the correction of muscle hypertonicity is based on the following positions [3]:

1. Botulinum toxin provides long lasting muscle relaxation, that allows to break the vicious circle of muscle tension and pain, and to eliminate nerve compression by the tense muscle, if the last exists. 2. Important advantages of treating with botulinum toxin are its local, predictable, dose- dependent effect and a low risk of systemic side effects.

type of „gummy smile“

Front type

Side type

mixed type

Asymmetric type

characteristic

more than 3 mm exposure of the gum in the anterior part between the canine teeth

more than 3 mm only in the side sections

increased muscle activity in the frontal and posterior areas

only from one side

muscles

m.levator labii superioris alaeque nasi, m.levator labii superioris

m. zygomaticus minor, m. zygomaticus major

m.levator labii superioris, m. zygomaticus minor, m. zygomaticus major

m.levator labii superioris,иm. zygomaticus minor, m. zygomaticus major only on one side

table 1. classIfIcatIon of „gummy smIle“.

fig. 4: an interdisciplinary approach to gummy smile.


the purpose of this research determination of the dose of botulinum toxin and the zones of injection (muscle-targets), for the correction of the „gummy smile“, considering the functional type of the smile.

materIals and methods

Criteria for selection were complaints about aesthetic dissat-isfaction with a smile, exposure of the gum more than 3 mm.

the research included 18 patients, men 22 %, women 78 %, the average age is 29.5 years.

Attention was drawn to the following clinical signs: facial expression, the condition of the mimic musculature with a smile, degree and nature of exposure of the gum. Gingival dis-tance (Gd) Is estimated as the distance between the area of the upper lip and the border of the cutting edge of the teeth.depending on the type of „gummy smile“, all patients were divided into four groups (table 2).

the examination included: analysis of data of anamnesis, Clini-cal examination (examination of the face, oral cavity, Functional tests of mimic muscles), photoanalysis (portrait and intraoral photos). depending on the type of gingival smile all patients were classified into four groups (see table 2).

All patients were injected by botulinum toxin, injection points were selected depending on the nature of muscular hyperactivity.

methodology

In the apical area of the nasolabial fold 5–10 ed of dysport® were injected symmetrically on both sides. It is possible to determine the injection point of the drug by placing the tip of the index finger on the edge of the pear-shaped hole direct under the nasal-maxillary suture (Fig. 6). Injection sites and dose of botulinum toxin were defined depending on the type of „gingival smile“ (table 3).

the result was evaluated after 7, 14, 28 days and six months by changing the gingival distance (Gd) (table 4).

group

I

II

III

IV

type of smile

Frontal

Side

mixed

Asymmetrical

sex m/f

1/3

/2

3/7

/2

gingival distance (mm) m/f

22/20

/18.8

21.5/19

/18.5

table 2. classIfIcatIon of patIents accordIng to the type of „gIngIval smIle“.

group

I

II

III

IV

type of smile

Frontal

Side

mixed

Asymmetrical

muscle

m. levator labii superioris

m. zygomaticus minor, m. zygomaticus major

m. levator labii superioris, m. zygomaticus minor, m. zygomaticus major

m. levator labii superioris, m. zygomaticus minor, m. zygomaticus major only on one side

the dose of dysport

5–10 units

5–10 units

5–10 units

5–10 units

table 3. doses of botulInum toxIn (dysport unIts).

fig. 5: target muscles for botulinum toxin to correct gummy smile [2].


results

Analysis of clinical patient’s data demonstrated, that initial positive dynamics in the form of reduced gingival distance was noted on 7th day, and the maximum – on the 14th day after the injection. All the patients noted improvement of smile aesthet-ics. After 6 months, there was a return of muscular hyperactiv-ity and a “gummy smile”, that required a repeat of injection. In subsequent injections, the doses of botulinum toxin depend on the result of the treatment. therapy should be conducted very carefully, starting from the lowest dosage. the key to the suc-cess of the „gummy smile“ correction is the careful selection of patients and use of minimally necessary dosages of botulinum toxin

conclusIon

Since injections of the botulinum toxin are safe, reliable and reproducible [29], and the effect is reversible [26]. Botulinum therapy is an independent therapeutic effect for the temporary correction of gingival smiles, also it gives the ability to supply or postpone surgical interventions for a later period [27].

authors correspondence:m. I. Soykher, m.d.

Biotechnology and Interdisciplinary dentistry Institute

Komsomolsky Prospect 32, corpus 2

moscow, Russia

literature:1. timerbaeva Sl, ed. (2014) the alphabet of botulinum therapy: a scientific

and practical publication. moscow: Practical medicine p. 46-48.

2. Bilich Gl, Kryzhanovskiy VA (2012) Human Anatomy: Atlas. Volume 1.

musculoskeletal System. moscow: GeotAR-media.

3. Gileeva eS (2007) A comprehensive approach to assessing the aesthetics

of a smile. Perm medical Journal 24(3): 99-102.

4. Goldstein R (2005) Aesthetic dentistry. Volume 1. moscow: „Stbook“,

p. 10-14.

5. Kalyuzhny dV (1984) Physiological mechanisms of regulation of pain

sensitivity. moscow: medicine, p. 102-114.

6. Karlov VA (1991) Neurology of the face. moscow: „medicine“.

7. maksimovskaya lN (2003) Socio-economic aspects of aesthetic treatment

in therapeutic dentistry. In: maksimovskaya lN, orestova eV, umansaya NG

(eds) Proceedings of the eighth Congress of the StAR. moscow, p. 199-200.

8. orlova oR, timerbaeva Sl, et al. (2012) the use of the drug dysport

(botulinum toxin) for the treatment of local muscular hypertonia with focal

dystonia, spasticity and other muscle-tonic syndromes. medical technology.

9. orlova oR, Yakhno NN (2001) the use of Botox (botulinum toxin type A)

in clinical practice. moscow: Catalogue.

10. Polma lV (2009) diagnosis of aesthetic disorders and planning of

complex rehabilitation of patients with sagittal anomalies of occlusion.

thesis for the degree of doctor of medical Sciences. moscow, p. 17-35.

11. Petrikas oA (1999) the prevalence of aesthetic disorders of the

dentition. In: Petrikas oA, Petrikas IV (eds) New in dentistry No. 3. moscow,

pp. 21-23.

12. Razumovskaya eA (2012) „Clinical portrait“ of the lips in peace and with

a smile. optimization of aesthetic correction. Injection methods in Cosmeto-

logy. 3: 92-102.

13. Razumovskaya eA (2013) dynamic approach to conducting botulinum

therapy in the provision of botulinum therapy in the lower third of the face.

lower third of the face. Harmony of a smile. Injection methods in Cosmeto-

logy. 2: 42-50.

14. Soiher mI, Sojher mG, Rumyantseva eV (2006) Aesthetics of a smile:

an interdisciplinary approach. les nouvelles esthetiques. 5: 24-30.

15. Chekhov. A.P. „uncle Ivan“.

group

I

II

III

IV

type of smile

Frontal

Side

mixed

Asymmetrical

gd (mm) m\f after 7 days

17

14

16.5

13.5


12

10

13

10


9

9

10

9

gd (mm) m\f after 6 months

20

18

20

18

table 4. the dynamIcs of treatment response.

fig. 6: the injection technique of botulinum toxin.


16. Angelillo JC, dolan eA (1982) the surgical correction of vertical

maxillary excess (long face syndrome). Ann Plast Surg. 81: 64-70.

17. Ahn BK, Kim YS, Kim HJ, Rho NK, Kim HS (2013) Consensus recommenda-

tions on the aesthetic usage of botulinum toxin type A in asians. dermatol

Surg 39(12): 1843-1860.

18. Bell WH, Creekmore td, Alexander RG (1977) Surgical correction of the

long face syndrome. Am J orthod 71(1):40-67.

19. Carruthers J, Carruthers A (2004) Botulinum toxin A in the mid and

lower face and neck. dermatol Clin 22(2): 151-158.

20. Fish lC, Wolford lm, epker BN (1978) Surgical-orthodontic correction of

vertical maxillary excess. Am J orthod 73(3): 241-257.

21. Wei J, Herrler t, Xu H, li Q, dai C (2015) treatment of gummy smile:

Nasal septum dysplasia as etiologic factor and therapeutic target. JPRAC

68(10): 1338–1343.

22. Kawamoto HK (1982) treatment of the elongated lower face and the

gummy smile. Clin Plast Surg 94: 479-489.

23. Nasr mW, Jabbour SF, Sidaoui JA, Haber RN, Kechichian eG (2016)

Botulinum toxin for the treatment of excessive gingival display: a systematic

review. Aesthet Surg J 36(6): 629-638.

24. mazzuco R, Hexsel d (2010) Gummy smile and botulinum toxin: a new

approach based on the gingival exposure area. J Am Acad dermatol 63(6):

1042-1051.

25. Nayyar P, Kumar P, Nayyar PV, Singh A (2014) Botox: Broadening the

horizon of dentistry. J Clin diagnostic Res 8(12): Ze25-Ze29.

26. miskinyar SA (1983) A new method for correcting a gummy smile.

Plast Reconstr Surg 72(3): 397-400.

27. Niamtu J (2008) Botox injections for gummy smiles. Am J orthod

dentofac orthop 133(6): 782- 783.

28. Polo m (2008) Botulinum toxin type A (Botox) for the neuromuscular

correction of excessive gingival display on smiling (gummy smile).

Am J orthod dentofac orthop 133(2): 195-203.

29. Philips e (1999) the classification of smile patterns. J Can dent Assoc

65(5): 252–254.

30. Rubin lR (1974) the anatomy of a smile: its importance in the treatment

of facial paralysis. Plast Reconstr Surg 53: 384–387.

31. dinker S, Anitha A, Sorake A, Kumar K (2014) management of gummy

smile with botulinum toxin type-A: A case report. J Intern oral Health 6(1):

111-115.

32. Sucupira e, Abramovitz A (2012) A simplified method for smile

enhancement: botulinum toxin injection for gummy smile. Plast Reconstr

Surg 130(3): 726-728.

Scientists from the university of Würzburg have synthe-sized a complex sugar molecule which specifically binds to the tumor protein Galectin-1. this could help to recognize tumors at an early stage and to combat them in a targeted manner.

Galectins are a family of proteins that have become a prom-ising source of cancer research in recent years. A represent-ative thereof is galectin-1. It sits on the surface of all human cells; on tumor cells, however, it occurs in enormous quanti-ties. this makes it an interesting target for diagnostics and therapy.

“Among other things, it is known that galectin-1 hides the tumor cells from the immune system,” explains Professor Jürgen Seibel of the Institute of organic Chemistry at the Julius-maximilians-universität (Jmu) Würzburg in Bavaria, Germany. Recent studies have shown that when Galectin-1 is blocked, the immune system can recognize the tumor and attack it with t cells.

Sugar molecule with docking stationNo wonder, therefore, that galectin-1 has become a major focus of research. Seibel and his colleague dr. Clemens Grimm is interested in a very specific section of this pro-tein, the so-called carbohydrate recognition domain. they have now designed a complex sugar molecule that fits per-fectly into this domain, as the scientists report in journal “ChemBioChem”.

“We have equipped the sugar molecule with a docking site, for example, to connect it with a fluorescent dye or an drug,” says Seibel. In addition, the scientists have described the binding of their molecule to galectin-1 with high-resolution X-ray structure analyzes.“our findings can serve the development of high-affinity ligands of the protein Galectin-1 and thus of new drugs,” said Clemens Grimm.

quick test for galectin-1 in progressNow the Jmu scientists are working on a rapid test for the detection of galectin-1. It is designed to enable early detec-tion of tumors such as neuroblastoma. For the future, Sei-bel’s team would like to expand the sugar molecules into a kind of shuttle system that allows pharmaceutical agents to be transported directly to the tumors.

contact:Prof. dr. Jürgen SeibelInstitute of organic Chemistry, [email protected]

cancer detection with sugar molecules

70 CoSmetIC medICINe 2.17 orIgInal

a cosmetic department, visconti di mondrone medical center,

milan, Italy

b aestetical medicine clinica, volgograd, russian federation

c the london clinic, london, uK

d chief department plastic and reconstructive surgery,

pirogova n.I.moscow, Institute of plastic surgery and cosmetology,

russian federation

e aesthetic practisioner, Italy

f nice, france, ent facial plastic and maxillofacial surgery,

european academy of facial plastic surgery

g medical centre “eklan”, moscow, russian federation

h department of dermatology and allergology, academic teaching

hospital dresden-friedrichstadt, dresden, germany

I dermatology, wolfson medical center, holon, Israel

J mntK, “eye microsurgery” s.n. fyodorov fsaI of the ministry

of health care center, novosibirsk, russian federation

K clinic of youth by liya gavasheli, moscow, russian federation

l medical center of cosmetology correction eKlan, moscow,

russian federation

m clinic “vallex-med”, “nl clinic” – clinic of preventive medicine

moscow, russian federation

n I.m. sechenov first moscow state medical university, clinic

of nervous diseases, a.y. Kozhevnikov, centre of Interdisciplinary

dentistry and neurology, moscow, russian federation

o medico estetico, turin, Italy

p clinic “medclinic”,saint-petersburg, russian federation

q medical centre “arclinic”,saint- petersburg, russian federation

r belarusian state medical university, minsk, belarus

s center of aesthetic medicine “chistye prudy”, moscow,

russian federation

t clinic of youth and beauty “sl”, Kazan, russian federation

u center of laser aesthetics “romital clinic”, Kiev, ukraine

v clinic of aesthetic medicine and plastic surgery “arumed”,

alma-ata, Kazakhstan

w llc “neo-clinic”, tyumen, russian federation

x center of Interdisciplinary dentistry and neurology, moscow,

russian federation

y Institute of plastic surgery and cosmetology, moscow, russian federation.

z “estelab” clinic of aesthetic medicine, moscow

zz “aestima clinic” of aesthetic, saint-petersburg, russian federation

Key wOrds: abobotulinum toxin a, abota, botulinum toxin a,

hyperhidrosis, rejuvenation, mimics, mimical muscles

summary:

Introduction: recent developments in our understanding of facial age-

ing have led to a greater appreciation of the part played by dynamic

wrinkles. botulinum toxin is increasingly used to lessen hyperdynamic

muscular activity and to rejuvenate the ageing face.

materials and method: a group of international experts convened to

consider the literature and, in the light of their own clinical experi-

ence, discuss the optimal uses of abobotulinum toxin a (abota) for

myomodulation. to assist doctors, the international expert group

here presents consensus guidelines for the use of abota in various

clinical indications.

discussion: to achieve optimal results, the clinician requires a detailed

understanding of facial anatomy, correct dilution technique, injection

procedure and aftercare.

Conclusions: abota may be used to rejuvenate the face and other

areas. abota treatment is effective, safe, and relatively easy to per-

form and has high patient satisfaction. duration of action is up to 5 1/2

months.

IntroductIon

In modern society, beauty canon is increasingly identified with perfect symmetry and important characters. Women and men have a self-evaluation fee that is reprogrammed from time to time. Common distinctive requirements are oval face, skin compactness and uniformity, eye magnetism, and lips‘ appeal. time is inexorably affecting every single of these beauty fac-tors by marking the skin with wrinkles [1, 2] that develop even in younger persons, from habitual or dynamic muscular hyperactivity, as consequence of emotions or other stimuli. the severity and physiological changes of our body redesign the features of facial compartments, launching a big challenge to self-acceptance.

the advent of modulators for dynamic wrinkles enhance-ment has expanded rapidly by lengthening the time before resorting to surgery for facial rejuvenation [3].

International expert consensus on the use of abobotulinum toxin a (abota) for facial

rejuvenation and primary hyperhidrosis

RedAellI A.A, SARomYtSKAYA A.B, RoWlANd PAYNe C.C, mANtuRoVA N.d, BAttIStellA m.e, SABAN Y.F, PANoVA o.G, WollINA u.H, lANdAu m.I, AtAmANoV V.J, GAVASHelI l.K, SANCHeS el, GuBANoVA e.m, oRloVA o.N,

dIASPRo A.o, KoBAlAdZe N.P, ReZNIK A.Q, luKYANAu A.R, SHARoVA A.S, ZHABoeVA S.t, Holod o.u, ZHumAtoVA G.V, GoltSoVA e.W, SoIHeR m.X, CHAIKoVSKAYA e.Y, CHeBotAReVA J.Z, PARSAGASHVIlI e.ZZ


Although the law rules differently the use of botulinum toxin in each states of the world, the scientific community has uni-versally recognized this product with a high security profile for the patient and after years of research identified parameters for a correct use even in those districts considered “off-label”.

one of the most used BtA toxins is иbobotulinumtoxin A (AbotA). In Russia AbotA was approved in 1999 for neurologi-cal indications, in 2004 for aesthetic indications and in April 2009 FdA approved it also for therapeutic use. Very popular and largest used among neurologists and ophthalmologists, each area of the three-thirds of the face that present muscle hypercinetic activity can benefit from this type of treatment, starting with glabella, forehead, periorbital and perioral regions, from masseter to platysma for aesthetic and func-tional purpose too. In some countries, mainly in europe, AbotA is marketed under another trade name.

materIals and methods

In Pubmed: Abobotulinumtoxin A. Abbreviation, AbotA

AbotA is not so widely used in aesthetic medicine as it is in neurology and so we have developed guidelines with the pur-pose of sharing knowledge, experience and expertise to help enhance the quality of service provided to patients by doctors using AbotA.

these guidelines for the use of AbotA are designed to help identify and/or specify:

• Characteristics and properties of AbotA• Pre-treatment considerations• Anatomical danger areas • technical considerations• Post-treatment conclusions• Aesthetic indications for “on label indications”• Aesthetic indications for “off label indications” (according to the experience of the authors)• Anticipated results

AbotA is present into the market in vial of 300 and 500 u. the chain of BtA joined with some non-toxic accessory pro-teins (NAPs) weighs 150 kda. AbotA acts at the neuromuscu-lar junction in the targeted muscle, thereby reducing muscular contraction. this lessens muscular strength and also lessens resting tone and so achieves temporary improvement in the appearance of dynamic lines.

the mechanism of action is simple. the exocytosis of ace-tylcholine into the synaptic gap is performed by a protein complex (SNARe) that allow the consequent activation of the muscle fiber [4]. once injected, the toxin penetrates inside the cell for endocytosis, and in the presynaptic cytoplasm plays a proteolytic on the SNARe complex and then blocks the release of acetylcholine. By time, the nerve cell will synthesize and transport the SNARe complex‘s proteins again to the presynap-tic terminal. this is the reason why AbotA action can be con-sidered reversible.

the authors conducted a search in ovid medlINe, Pubmed, embase, and the Cochrane library looking for “Abobotulinum-toxinA“, “facial rejuvenation” and „lines” and they carried out a systematic review of the more recent literature, specifically from January 2010 to october 2016 (table 1).

By texts, contents and thanks to their long experience in the use of AbotA, they summarized the found data in specific guidelines to allow doctors to have a reference point for a good use of the product regarding immunological, safety and efficacy aspects. All patients, without distinction of sex or ethnicity,can be successfully treated with AbotA in on label areas [5–8].

AbotA can also be used in other “off-label” areas affected by ageing such as neck and chest [9, 10, 28, 29] or for the treatment of masseter hypertrophy [11], as well as in other indications like hyperhidrosis [12].

crow’s feet: many studies have been conducted to assess the influence of the number of injections in this area for the distribution of the same amount of units. It has emerged that treating one side with a single injection of 36 u in the middle of central lateral at the ocular cantus does not show statistically significant differ-ences in terms of results compared to three injections of 12 u each distributed along the same area [13].

glabellar lines: other studies have been conducted to evaluate the efficacy of two different injective schemes for the treatment of glabellar wrinkles [14]. Specifically, the procerus and the two corru-gators were injected in 3 points with 10 u per point and the results were compared with the same pattner to which two injective points (one on each side at 1 cm above the corruga-tor) of 10 u were added. the researchers pointed out that the two additional points with a larger number of units are irrel-evant to the final result and that it didn’t improve efficacy.

even the best dose in effect has been studied by comparing the results obtained by injecting respectively 20, 50 and 75 u into the glabellar area to improve the appearance of wrinkles. the most tolerated, effective and safe dose was judged at 50 u.

the important factor is that all patients treated with AbotA showed high satisfaction for the type of results obtained, declaring an improvement in the quality of social life through-out the time that AbotA was active [15].

safety: the safety profile of AbotA used for facial rejuvenation is well established. Among thousands of patients treated no serious adverse events (Ae) have been observed. All reported Aes were mild or moderate in severity and are usually caused by wrong technique [16–19, 30].

In addition to being well tolerated, the safety and efficacy of AbotA for glabellar wrinkles [4, 5], universal „on label“ treat-ment, is confirmed by many researchers in international scien-tific literature.

Numerous studies have been also conducted to analyze the different results based on the dilution of AbotA. each dilution


analyzed showed rapid and long-lasting efficacy, equal to injection pain [20].

Nowadays, after years of research, it is possible to com-pare the efficacy of different toxins in other areas of the face [21–31]. the efficacy and safety of AbotA injections is similar when used with a conversion factor of 1 : 2.5 – 1 : 3 compared with onatA or IncotA [24].

dIscussIon

this expert group included dermatologists, plastic and maxillo-facial surgeons and aesthetic physicians. they gathered to dis-cuss about recognized texts in literature found through online research and to share their own knowledge. Particular atten-tion has been paid to the doses to be injected, to which specific points, with what dilutions, at which depth with emphasis on anatomical details, that are different for each individual.

the expert group reached a consensus on most issues with special recommendations for the use of AbotA in different ana-tomical areas.

the specialist’s advice to start with a set-up phases before treatment with AbotA that includes different points:

pre treatment considerationsAs in all branches of medicine:• History, clinical examination and diagnosis are necessary steps before any treatment is considered.• Absolute contraindications and relative contraindications should be excluded. • Any bleeding tendency should be considered. • Informed consent: oral, and preferably written, informed consent is desirable.• medical Record: A medical record should be kept. • Photography: Photography may be helpful.

Patients are treated in a reclining position, 30°. the skin of the patient is cleansed to remove residues, as make-up can result in post-operative complications [1, 12]. Particular atten-tion and care is taken disinfecting the anatomical area to be treated.

Following a post-treatment protocol of skin care, accord-ing to some of the experts, produced better results and a decreased rehabilitation period after procedure.

For the treatment of very sensitive anatomical areas or in patients particularly sensitive to painful stimuli, topical anes-thetic may be used.

anatomical danger areas [18] (anatomical study by saban I.)the anatomical details suggested by anatomical studies sug-gest the depth of injection and the exact injection site.

Glabellar area, 1st area of caution: Note that the procerus muscle runs from its deep bony origin on the nasal bones cau-dally to its insertion into the deep aspect of the skin in the glabellar area cephalically, superficial to and between the two frontalis muscles.

In the glabellar area, frontalis is always very superficial while the depressor muscles are deeper. For this reason, and to avoid the classical “Botox look”, it is important to inject deeply thereby only injecting the depressor muscles.

Crow’s feet inferior area, 2nd area of caution: • the finger is placed just inferior to the caudal border of the zygomatic arch; the tip of the finger is blocked anteriorly by the body of the zygomatic bone (Fig. 1a)• Just cephalic to the tip is located the bony origin of the zygomaticus major muscle [18]• the zygomatic arch and bone have been drawn on the skin (Fig. 1b)• the anterior border of the masseter m. is marked • the orbicularis oculi (pars orbitalis) is represented, following the limits of the crow’s feet wrinkles• the zygomaticus major muscle is drawn between its zygomatic bony insertion and the modiolus• the depressor anguli oris (dAo) and depressor labii inferioris (dlI) muscles are already marked (Fig. 1b)• the zygomatic area is shown, after resection of 3 first layers (Fig. 1c): - 1° the skin - 2° the malar subcutaneous fat pad - 3° the orbicularis oculi layer• the bony origins of zygomaticus major and minor muscles are exposed.

fig. 1a–c: crow’s feet inferior area, 2nd area of caution.


• the suborbicularis oculi fat (SooF) (*) is the fat pad located in the prezygomatic space, which is just cephalic to the origins of these muscles

depressor anguli oris (dAo) and depressor labii inferioris (dlI): 3rd area of caution: • dAo muscle is a triangle with its base on the mandible (ori-

gin), its anterior border running perpendicularly upwards to the oral commissure (insertion) and its posterior border running obliquely downwards and backwards from lateral to oral commissure (Fig. 2a)

• dlI is a rectangle whose infero-posterior part lies deep to dAo. It originates from the mandible and inserts into the lateral half of the lower lip.

• the blue square, 3 cm wide, represents the area of the dissection

• the * represents the foramen of the trigeminal nerve 3rd branch (Fig. 2a)

• the dAo lies deep on the caudal border of the mandible where it originates and where it is covered by the subcuta-neous fat; it becomes more superficial and inserts into the modiolus (Fig. 2b)

• the dlI and the orbicularis oris muscles have been resected (Fig. 2c)

• Note that the dlI caudal fibers are pass deep to the dAo as they run from their origin on the caudal border of the man-dible. Its fibres are oblique cephalically and medially and pass deep to the oo muscle

• the exit point of the mandibular sensory nerve (Fig. 2a): its foramen is located where dAo overlaps superficial to dlI.

• lateral to dAo, the inferior labial artery is dissected. (**)

masseter and risorius muscles: 4th area of caution.

the lateral fibres of risorius originates in the preparotid fascia. Very near, but more deeply lie the fibres of masseter muscle. to avoid asymmetries of the smile, it is important to inject mas-seter deeply.

Knowledge and understanding of these 4 areas of caution is very important in order to avoid complications and bad results.

group discussion:the optimum interval between treatments is 4 months or more. Subsequent treatments follow the same scheme or are adapted to the current situation.

It is the unanimous opinion of the international expert con-sensus group that to use AbotA the operator requires a degree in medicine and surgery. Specialization in dermatology or plastic surgery is an advantage. training in aesthetic medicine through accredited courses is helpful. the treatment should be performed in a clinical setting.

conclusIons

Innumerable scientific clinical studies and countless years of injector experience have demonstrated the efficacy and safety of AbotA as well as its action in terms of onset and duration. more-over, considering the annual cost of the treatment with AbotA instead of with other neuromodulators, it results lower [32].

the guidelines here presented by the international expert consensus group are based on our current knowledge. the guidelines reflect data obtained from reference scientific litera-ture. Subsequent studies may lead to amendments or changes to these recommendations and/or to these conclusions of this document. Compliance with the guidelines guarantees nei-ther treatment satisfaction nor a risk-free procedure. the data should always be analyzed and interpreted carefully, with proper critical analysis. All AbotA procedures should depend on the clinical assessment. the clinical experience and the clin-ical judgement of the doctor performing the treatment is much more important than any guidelines can ever be. the use of AbotA raises ethical, cultural and legal considerations both for medical users and for manufacturers.

fig.: 2a–c: depressor anguli oris (dao) and depressor labii inferioris (dlI): 3rd area of caution.


summary of the recommendatIons of the InternatIonal expert consensus – all areas

Recommendations of the AbotA international expert consensus group concerning the preparation and use of AbotA

technical considerations

Reconstitution

dilution

Storage

Product injection

Product placement for on label areas

Product amount

Conversion rate

pre-treatment considerations

Position technique

Injection technique

onset of action

dose duration

With a needle, take the necessary 9 % sterile, preservative-free saline solution. After inserting the needle into the AbotA vial, vacuum will aspirate the solution automatically while you need to manu-ally inject the remaining volume. If you do not notice the suction, do not use the vial. It is then advis-able to rotate the vial to allow mixing of the toxin in the solution. the resulting solution will be clear and colorless.

each 125 unit vial hass to be reconstituted with either 0.63 ml or 2.5 ml as regards 500 u vial or 1.5 ml as regards 300 u vial. the concentration of the resulting solution will be 20 Speywood units per 0.1 ml. It is possible to dilute more or less, based on the area to be injected and on the physician’s experience and preference.

to store AbotA after reconstitution refrigeration is needed at 2–8°C, away from light. It is forbidden to use it after the expiry date stated on the vial.In spite of company’s recommendations, once the toxin has been reconstituted and in case it is not consumed within 24 hours, the experts’ experience indicates that the drug maintains its efficacy and safety for at least one week.

After drawing up AbotA in a sterile syringe, all possible eventual air bubbles have to be eliminated.

depending on the area physician want to treat, based on patient’s desire, a dynamic patient study is performed while moving the specific muscles, palpating the strength points and mapped its with a demographic pencil

See summary of consensus recommendations for all areas below. Adjust dose to individual’s need to achieve natural or “frozen” look, based on the muscle mass and doctor-patient preference.

When calculating doses, it is not recommended to use conversion factors of activity units of the toxin in different preparations. Should be based on clinical recommendations for specific preparation BtX. After the evaluation of clinical data regarding the clinical and safety issues of Abo tA, the experts advice is to use a conversion ratio Abo:ona::2.5 : 1.0 or even lower in order to achieve equipotancy with ona.

the patient may sit, recline or lie down.

After having taken pictures and/or an animated video and disinfecting the skin, the experts suggest marking the injection points during animation.

to inject AbotA the experts suggest using a 0.5–0.3 ml insulin syringe with a bonded 8 mm 30 g needle. the needle is advanced through the skin into the underlying muscle. the depth of injections may be subcutaneous or intramuscular, according to the depth of the muscle and other anatomical details.

Some experts choose to insert the needle directly during muscular contraction and inject the muscle relaxed.

median time for initial onset of action is 2–4 days, with full effect apparent by 8–10 days.

median duration of effect assessed by experts was 120-180 days for single treatments and up to 4–6 months for repeated treatments. Cases with more than 6 months duration were reported.


disclosures:• Redaelli A, Saromytskaya A, Panova o, Atamanov V, Kobaladze N,

Gavashely l, Goltsova e, Sanches e, Gubanova e, orlova o, Reznik A,

lukyanau A, Sharova A, Zhaboeva S, Holod o, Zhumatova G, Soikher m,

Shelekhov S, Saromytskaya A are trainers and speakers for Ipsen com-

pany

• landau m, Atamanov V, Gubanova e are trainers and speakers for Gal-

derma Company

• Kobaladze N, diaspro A, Zhaboeva S, Gavasheli l are trainers for Aptos

Company

• Sanches e is medical adviser of the company oftaderm

• orlova o is trainer and speaker for Allergan, martinex, microgen and

merz Aesthetics Companies

• Reznik A is speaker and trainer for the Institute Hyalual Company

• Sharova A is trainer and speaker for Innovation and lG company

• Goltsova e is trainer and speaker for the merz Aesthetics Companies

• Redaelli A, Zhumatova G are trainers and speakers for Filorga company

• Rowland Payne C is a key opinion leader for Venn and an occasional

speaker for Ipsen & Sesderma.

• Battistella m is trainer and speaker for General Project, Wavemed,

Attiva, Venus Concept Companies

authors correspondence:Prof. Alessio Redaelli, m.d.

Via delle Repubblica 4

I-20098 San Giuliano milanese

[email protected]

post-treatment considerations

touch up

Immunogenity

In combination with other techniques

Post-treatment

Age and maximum dosage

A touch up session to perfectly refine the dose of toxin in some points, and/or to evaluate the response, is suggested at 10 days, especially for patients treated for the first time or by novice injec-tors. It is recommended touch up treatments are performed no later than one month after the initial treatment.

In the experts’ experience, the non-responder rate (possibly probably due to the development of neu-tralizing antibodies) is less than 0.1%. [25]

Very often to counteract the aging process doctors suggest an integrated protocol that includes AbotA with other injectable drugs such as hyaluronic acid or biorevitalizing products rather than with energy based devices (laser, radiofrequency, ultrasounds, ...) to try avoid surgery. [26]For example nasal improvement can be also achieved with Abota and fillers with very good outcome [27, 31].the expert committee is confident that if AbotA and HA fillers are used to treat different areas, this can be done on the same day with no increase in risk. Some of the experts believe that injecting the same area on the same day with both AbotA and HA may slightly increase the risk of product diffusion which might perhaps increase the risk of vascular compromise but, despite this, they still continue to do this.

After treatment, some of the experts advise that the patient should:• remain upright • not bend excessively • perform active facial expressions within 2 hours of the procedure • avoid alcoholic drink • avoid to wear make-up on the injection sites to avoid pigmentation• do not massage the area to avoid diffusion of the injected fluid nearby• avoid sunbath and saunas • avoid strong gym activity• avoid other treatments on the face the same day.

the experts do not consider that youth or age affect AbotA safety and efficacy. the experts suggest that 500–600 AbotA units might be a sensible upper limit for a single treatment session.


Recommendations of the AbotA international expert consensus group concerning specific anatomical areas.

Aesthetic indications fig. 3: Injection points Area of use and pattern of injections

on label

In some countries, AbotA is licensed for use in these areas.

frontal area:m. frontalisglabella:m. corrugatorm. procerusm. depressor superciliicrow’s feet:m. orbicularis oculinasal root:m.levator labii superioris alaeque nasinasalis pars transversa

lateral eyebrow lift: m. orbicularis oculi pars orbitalism. frontaliswrinkles of the nose:m. nasalis pars transversabar code wrinkless:m. orbicularis orischin:m. mentalis“bunny lines”:m. levator labii superioris alequae nasitip of the nose:m. depressor septi nasi “marionette lines”:m. depressor anguli orisquadralized face and/or bruxism:m. masseter

off label

fig. 4a: abota is not licensed

for use in these areas

fig. 4b fig. 4c


dose per injection point(Speywood units)

Number of injection points

total dose range(Speywood units)

Injection site Injection technique

Forehead and Glabella

Frontalis2–8

4–14 maximum 100

Inferior to the hairline. At least 3 cm superior to the supraorbital edge

Superficial intramuscular injections with perpendicu-lar orientation.

Intradermal injections (suggested by some authors) can be also done with more uniform muscle diffusion and reduction of asymmetries

lateral Corrugators2–4

medial Corrugator5–10

1–2 for each one

2–12 per side

4–14 per side

As shown in the picture above

Superficial intramuscular injections at an angle of 45° in a medial direction, with finger protection in orbital zone

depressor supercilii2

1 2 Superficial injection

Procerus5–16

1–2 5–32 As shown in the picture above

deep intramuscular injections with perpendicular ori-entation, until the middle 1/3 of the needle.

Crow’s feet

2–10 5 per side (3 along the lateral orbital margin and 2 in the lower eyelid if the pinch test is negative)

10–50 per side


the distance between lateral orbital margin and injection points is 1 cm and the needle is directed laterally

Nose (bunny lines)

2–8 1 per side, total 2 points

2–8 per side


Superficial injection




total dose(Speywood units)


lateral eyebrow lift

2–5 2 per side 2–5 per side

2–10 per side

one point at the pars orbitalis of orbicularis oculi at the eyebrow tail with an additional point at the exter-nal part of the frontalis.

Superficial intramuscular injections with perpendicular orientation.

Nose tip

2–10 1–21

2–54–8

Just inferior to the nasal tip at the base of the columella.

deep perpendicular injections.

Nasal flares

1 1 1 per side At the angle of flares Superficial intramuscolar injection

Perioral region

1–2 4 for upper lip and, if necessary, 2 for lower lip total 4–6 points

4–10 per side Inject at the vermillion border of the lips

Very superficial intradermal injections.

references:1. Redaelli A, Braccini F (eds).: Facial aging. medical, surgical and

odontostomatological solutions for mid & inferior part of the face.

Florence: officina editoriale oltrano: 2012.

2. Wollina u, Rowland Payne C (2010) Aging well-the role of minimally

invasive aesthetic dermatological procedures in women over 65. J

Cosmet dermatol 9(1): 50-8.

3. Wollina u. Botulinum toxins: uses in medicine. Cosmetic medicine

and surgery. ed: Andrè P, Haneke e, marini l, Rowland Payne C. Boca

Raton, Fl: CRC Press, pp 547-5.

4. Wollina u (2008) Botulinum toxin: Non-cosmetic indications and pos-

sible mechanisms of action. J Cutan Aesthet Surg 1(1): 3-6.

5. Cohen Jl, Scuderi N (2017) Safety and patient satisfaction of abobo-

tulinumtoxinA for aesthetic use: a systematic review of clinical stu-

dies. Aesthet Surg J 5: 37(suppl_1): S32-S44

6. Schlessinger J (2014) long-term safety of abobotulinumtoxinA for

the treatment of glabellar lines: results from a 36-month, multicenter,

open-label extension study. dysport Study Group. dermatol Surg.

40(2): 176-83.

7. lorenc ZP (2013) A review of AbobotulinumtoxinA (dysport). Aesthet

Surg J 33 (1 Suppl):13S-7S.

8. Fabi SG (2013) A two-center, open-label, randomized, split-face study

to assess the efficacy and safety of one versus three intradermal injec-

tion sites of abobotulinumtoxinA in the treatment of lateral periocular

rhytides. J drugs dermatol 12(8): 932-7.

9. erickson BP (2015) the role of neurotoxins in the periorbital and mid-

facial areas. Facial Plast Surg Clin North Am 23(2): 243-55.

10. Klein FH (2014) lower facial remodeling with botulinum toxin type A

for the treatment of masseter hypertrophy. An Bras dermatol. 89(6):

878-84

11. Redaelli A (2011) Botulinum toxin A in bruxers: one year experience.

Saudi med J 32(2): 156-158.

12. Redaelli A (2014) BtxA in aesthetic medicine, for hyperhidrosis and

in odontostomatology. Basic Principles and clinical practice. Second

revised edition, oeo Firenze.

13. Kiripolsky mG, Goldman mP (2011) Safety and efficacy of admini-

stering abobotulinumtoxinA through a single injection point when

treating lateral periocular rhytides. J Cosmet dermatol 10(3):

232-234

14. Rzany B (2006) efficacy and safety of 3- and 5-injection patterns (30

and 50 u) of botulinum toxin A (dysport) for the treatment of wrinkles

in the glabella and the central forehead region. Arch dermatol 142(3):

320-6.

15. Hexsel d (2013) Quality of life and satisfaction of patients after full-

face injections of abobotulinum toxin type A: A randomized, phase IV

clinical trial. J drugs dermatol 12(12): 1363-7.

16. Kim BW (2014) Adverse events associated with botulinum toxin injec-

tion: a multidepartment, retrospective study of 5310 treatments admi-

nistered to 1819 patients. J dermatolog treat 25(4):331-6.

17. Yin-Shuo Chang (2015) Nonallergic eyelid edema after botulinum

toxin type A injection. Case report and review of literature. medicine

(Baltimore). 94(38): e1610.

18. Saban I (2016) Anatomie du visage et du cou en chirurgie et cosmeto-

logy. elsevier masson.




total dose(Speywood units)


depressor anguli oris

5 1 per side 5 1 cm lateral and below the modiolus

Superficial intramuscular injections.

Chin

5–20 1–2 5–20 1 point in the middle or 2 points close to the middle at the bony jawline.

deep intramuscular injections with perpendicular orientation.

masseter hypertrophy

10–15 3–5 per side 40–100 per side

In the lower part of the muscle deep intramuscular injections when the patient relaxes the muscle after clenching. Intramuscular injection.

Platysmal bands

2–5 2–5 points for each band

maximum dose 50 per side

From the jaw line inject one point every 2 cm until the middle part of the bands. Number of points depends on the number and length of the bands but should not exceed the total maximum dose.

deep intramuscular injections into the bands in a perpendicular direction.

décolletéSome authors continue to use it, others do not find it efficacious.

1–2 “meso-AbotA” technique

max 40 u diluted in 1 ml: up to 0,8 ml 0,8 % NaCl solution +/– 0,2 ml carbocaine

V-shape zone Superficial intradermal injections at 1 cm intervals in order to cover the whole area

For horizontal lines of the neck same quantity per point at 1 cm intervals in order to cover the whole area.

Axillary, plantar and palmar primary hyperhidrosis

2 the number of injections depends on the minor test and on the size of the affected area

2 to 4 u for point, 1 point for each cm2

2–5 multiple intradermal injections, “meso-AbotA” technique, is strongly suggested in order to avoid diffusion into deeper muscles


19. Wollina u (2005) managing adverse events associated with botulinum

toxin type A: a focus on cosmetic procedures. Am J Clin dermatol 6(3):

141-50.

20. Punga AR, Alimohammadi m, Fagrell d, Nyberg F, Rees d, Wong

C (2016) A randomized, comparative study to evaluate efficacy

and safety of 2 injection volumes of abobotulinumtoxinA in treatment

of glabellar lines. dermatol Surg 42(8): 967-76.

21. Frevert (2015) Pharmaceutical, biological, and clinical properties of

botulinum neurotoxin type A products. J drugs Res derm 15(1): 1-9.

22. Kassir R, Kollurur A, Kassir m (2013) triple-blind, prospective, inter-

nally controlled comparative study between abobotulinumtoxinA and

onabotulinumtoxinA for the treatment of facial rhytids. dermatol ther

3(2): 179-89.

23. Yu KC, Nettar Kd, Bapna S, Boscardin WJ, maas CS (2012) Split-

face double-blind study comparing the onset of action of onabotu-

linumtoxinA and abobotulinumtoxinA. Arch Facial Plast Surg 14(3):

198-204.

24. Scaglione F (2016) Conversion Ratio between Botox®, dysport®, and

Xeomin® in Clinical Practice. toxins (Basel) 2016 8(3).

25. Naumann m (2013) Immunogenicity of botulinum toxins. J Neural

transm (Vienna) 120(2): 275-90.

26. Rubin mG Cox Se, Kaminer mS, Solish N (2014) Correcting age-related

changes in the face by use of injectable fillers and neurotoxins. Semin

Cutan med Surg 33(4 Suppl): S81-4.

27. Redaelli A (2012) minimally invasive procedures for nasal aesthetics.

J Cutan Aesthet Surg 25(2): 115-20.

28. Rowland Payne Cme (2012) multi-mini botulinum. Chapter in: Botuli-

num toxin A in aesthetic medicine. eds. Redaelli A, Braccini F. officina

editoriale oltrarno S.r.l – Firenze, 185-198.

29. Rowland Payne Cme (2016) Cosmetic botulinum toxin treatment. In:

Andre P, Haneke e, marini l & Rowland Payne Cme, editors. Cosmetic

medicine & Surgery. 1st ed. taylor & Francis-CRC Press (london); p.

557-80.

30. Rowland Payne Cme (2016) Complications & pitfalls of cosmetic botu-

linum. In: Andre P, Haneke e, marini l & Rowland Payne Cme, editors.

Cosmetic medicine & Surgery. 1st ed. taylor & Francis-CRC Press (lon-

don); p. 581-89.

31. Rowland Payne Cme (2017) Cosmetic dermatology of the nose and

medical rhinoplasty. Aesthetic Surgery techniques – A Case Based

Approach. elsevier. In press.

32. Ravi Jandhyala

33. Jandhyala R (2012) effectiveness of type A botulinum toxins for aes-

thetic indications and their relative economic impact. J Plast Reconstr

Aesthet Surg 65(6): 720–731.

Chronic migraine patients suffer at least 15 days a month from headache that has at least half of migraine symptoms such as sensitivity to light or noise, nausea and worsen-ing with physical activity. If this disease does not respond to conventional acute or prophylaxis therapies, migraine headaches are referred to as resistant to therapy.

the aim of a study by Bratbak and colleagues (2017) was to investigate the safety of Botox treatments for therapy-resistant chronic migraine, which was carried out mainly in trondheim, Norway, in cooperation with the mayo Clinic, uSA. Botox (onabotulinumtoxinA) was injected into the sphenopalatine ganglion, a bundle of nerves with pathways to the tear glands and mucous membranes in the nose and palate. the success of the treatment was assessed accord-ing to the number and type of adverse reactions as well as the frequency of headache days before and after treatment.

10 patients with therapy-resistant chronic migraine were observed for one month and subsequently received a botox injection. After 12 weeks, the effects of the treatment were examined. All patients suffered adverse effects as a result of the treatment, but none of them were classified as serious.

typically, unpleasant sensations in the face and jaw area were reported. the number of headache days in month 2 after treatment was significantly reduced compared to the pre-treatment month: 8 out of 10 patients suffered from less than 50 % of previous headache days.

the results of the Botox injection in this small study therefore appeared promising in terms of both treatment safety and long-term efficacy. Randomized, placebo-con-trolled studies are therefore appropriate to clarify Botox‘s potential contribution to the treatment of chronic migraine, which has been resistant to therapy up to now.

reference:Bratbak dF, Nordgård S, Stovner lJ, linde m, dodick dW, Aschehoug I,

Folvik m, tronvik e. Pilot study of sphenopalatine injection of onabotu-

linumtoxinA for the treatment of intractable chronic migraine. Cephalal-

gia. 2017 Apr;37(4):356-364. doi: 10.1177/0333102416648328

source: idw-online

onabotulinum toxin a against migraine

81case report CoSmetIC medICINe 2.17

KeywOrds:

dysport, full-face correction, botulinum toxin type a

summary:

this article describes a method of full-face correction in patients with

moderate and severe wrinkles of the face.

case report

A 54-year-old patient had severe horizontal wrinkles in the frontal area, vertical wrinkles in the glabellar area and crow’s feet. In addition, there were also changes in the lower third of the face in the form of activity of m. mentalis, m. dAo, m. platy-sma. Furthermore, the patient had low tails of the eyebrows.

Patient had a porous and thick skin with a severe form of cuperose. Subcutaneous fat was expressed moderately. mus-cles did, however, not have excessive hypertonicity.

treatment regimen: dysport 500 u was dissolved with 1,25 ml of saline. m. frontalis – 7 points. In each point – 8 u. Injections were made at the top of the muscles, superficially, by V drawing. m. procerus – 8 u. m. corrugator – 8 u and 4 u on each side. m. depressor supercilii – 2 u on each side. lateral side of moo.

5 points in staggered order in two lines (1 – stepping from the edge of the orbit by 1 cm and the second by 0.2–0.3 cm from the first). At each point of the first line – 8 u. At each point of the second line – 4 u. lower eyelid – 2 points to the pupillary line of 2 u. For correction of the tail of the eyebrows – 2 points of 4 u. the first point at the intersection of the line drawn from the alae of the nose along the lateral edge to the intersection with the eyebrow. the second was at the intersection of the line drawn from the alae of the nose along the edge of the iris to the eyebrow.

the spine of the nose was injected to decompensate wrin-kles. used for 4 u in each part of m. nasalis pars transversa.

For correction of m. mentalis, at the central point – 10 u of dysport. to determine the point for correction, m. dAo – step back 2 cm from the commissure laterally and 3 cm perpendicu-lar down. A dose of dysport 4 u allowed to correct the lowered corners of the mouth. Align the oval allows injection in m. plat-ysma at 1 cm above the edge of the lower jaw. three points are used – 4 u of dysport on each side.

address of correspondence:liya Gavasheli, m.d.

Clinic of Youth by liya Gavasheli

Garibaldi, 3

moscow 119313

Russia

literature:1. Kassir R, Kolluru A, Kassir m (2013) triple-blind, prospective, internally

controlled comparative study between abobotulinumtoxin A and onabotuli-

numtoxin A for the treatment of facial rhytids. dermatol ther (Heidelb)

3: 179-189.

2. molina B, Grangier Y, mole B, Ribe N, martín diaz l, Prager W, Paliargues

F, Kerrouche N (2015) Patient satisfaction after the treatment of glabellar

lines with Botulinum toxin type A (Speywood unit): a multi-centre european

observational study. J eur Acad dermatol Venereol 29: 1382-1388.

3. Punga AR, Alimohammadi m, Fagrell d, Nyberg F, Rees d, Wong C (2016)

A randomized, comparative study to evaluate efficacy and safety of two

injection volumes of abobotulinumtoxin A in treatment of glabellar lines.

dermatol Surg 42: 967-976.

4. Schlessinger J, monheit G, Kane mA, mendelsohn N (2011) time to onset

of response of abobotulinumtoxina in the treatment of glabellar lines:

a subset analysis of phase 3 clinical trials of a new botulinum toxin type A.

dermatol Surg 37: 1434-1442.

dysport®. full-face approach for correction of mimic lines

lIA GAVASHelI

82

restylane® skinboosters™ for the improvement of the skin quality

Results of a consensus meeting

mARtINA KeRSCHeR, HeIKe BuNtRoCK, mARtINA HuNd, ANNA moKoSCH,AleXANdRA oGIlVIe, SHIRIN SAmImI-FARd, mAJA WAIBel

For every woman, beauty plays a sig-nificant role in their lives beyond the age 40. With a good constitution and an active lifestyle, women on average feel ten years younger than they are and they want to look as young as they feel. more than half of women define attractiveness through a firm, wrinkle-free skin [7, 18]. Study results from Fink et al. document that a smooth skin texture, therefore fine, tight, full skin without wrinkles, as well as a healthy skin tone with a special glow significantly influences perceived attrac-tiveness. As a result, female attractive-ness is assessed higher if the skin shows less blemishes [4, 12, 13]. In our society, youthfulness and beauty are positively attributed and also determine interac-tions and positioning in the social as well as the professional environment [2, 6, 10, 14, 17]. therefore, the need for attractiveness is quite understandable. But with increasing age, the quality of the skin changes. Histological studies, for example, show a reduction and incor-rect cross-linkage of the elastin fibers and a decreasing hyaluronic acid (HA) syn-thesis with reduced water binding (50% reduced HA concentration in 60-year-old women) [21]. the reduced number and activity of fibroblasts additionally leads to a reduced collagen synthesis and a decrease of dermal collagen I and III. Vis-ible signs of the intrinsic aging process include dehydration, loss of tissue tight-ness and elasticity, wrinkle formation as well as a thinning of the skin and can be superimposed by extrinsic skin aging (especially uV-induced photo aging).

minimally invasive aesthetic treat-ments intended to delay the skins aging

process are increasing in demand. today, patients want an out-patient aesthetic treatment with little side effects and a long-term outcome, leading to effective but also natural results with minimal recovery time. Accordingly, the substitu-tion of HA by means of intradermal injec-tions is an established anti-ageing meas-ure, with proven, evidence-based efficacy and safety.

In principle, injectable HA products can be classified into two groups with different therapeutic goals. Whereas HA-fillers are used for targeted wrinkle aug-mentation and volume substitution, skin boosters are injected superficially for the revitalization of the skin. they improve the signs of skin aging through stimula-tion of the extraellular matrix (eCm) [5, 22, 26]. the biological significance of HA for the skin as well as its excellent physic-ochemical properties, especially its high water-binding capacity, determine inject-able HA based skinboosters for improve-ment of skin quality. Although native HA is ubiquitous in the human body, the larg-est amount is located in the skin. With 7-8 g of HA, the skin contains approximately 50-56% of the total body content. HA is a significant stabilizing component of the eCm, can bind large amounts of water and is essential for hydration homeosta-sis. Apart from its significance as a struc-ture substance, HA is also an important functional tissue component, because extracellular substance transport (diffu-sion of electrolytes, nutrients and decom-position products in the tissue) as well as the activity of the immune system are associated with the hydration sta-tus of the eCm. In addition to this, HA is

pivotal for cellular processes such as pro-liferation, differentiation and migration. Amongst other processes, it stimulates fibroblast proliferation and activity with an increased biosynthesis of collagen and other components of the eCm. Apart from regenerative tasks such as improved wound healing under HA, it also has cell protecting properties against external noxious substances. In current studies, it is being discussed whether HA itself fulfills the function of a radical catcher for the deactivation of RoS or whether a reaction with free radicals attacks and leads to it’s destruction [11, 28].

the efficacy and safety of the widely applicable Restylane® Skinboosterstm are excellently proven on the basis of current data. According to these findings, they ensure an improvement of skin quality without significant volume changes. the skin is hydrated [8, 15, 27], its elasticity increased [8, 15, 16, 20, 23, 27], the skin surface smoothened [8, 16, 20, 27] and fine lines and wrinkles are reduced [16]. Restylane® Skinboosterstm are injected subcutaneously and have a clinically proven effect duration of up to 12 months [16]. the long lasting and significant effect is due to the use of non-animal stabilized hyaluronic acid (NASHA), espe-cially in direct comparison with non-sta-bilized hyaluronic acid. this was proven by a number of studies including Carru-thers et al. (2014) as well as Williams et al. (2009) [5, 27]. the substitution leads to a stimulation of fibroblast proliferation and activity with new synthesis of col-lagen, elastin and other extracellular components such as HA, leading to more skin elasticity, skin tension and moisture

CoSmetIC medICINe 2.17 therapy focus


[5, 25, 26]. the positive study results are supported by high patient satisfaction. According to blinded live-rating, skin quality improved in more than 80% of the patients. 85% assessed the therapeu-tic success positively and stated that they would repeat the treatment. Furthermore, patients as well as blinded evaluators indicated significant aesthetic improve-ments on the basis of the Global Aesthetic Improvement Scale (GAIS).

For the standardization of therapy protocols, a consensus meeting with six experts from the field of aesthetic der-matology took place (committee mem-bers see Appendix). the objective of the scientific expert committee was the com-pilation of an updated guideline for the application of Restylane® Skinboosterstm. Current evidence-based studies and the expertise of the committee members were included in the new standardized treatment protocols for the various indi-cations, which through clear recommen-dations (e.g. injection depth, application intervals) are intended to guide novices as well as experienced users towards Restylane® Skinboosterstm and provide support for the application in everyday practice. For the indication-appropriate application, the treatment protocols define the respective treatment area, the target group and indications, the protocol selection and injection amount, technique, points and volumes for every indication.

product selectIon

the target group for Restylane® Skin-boosterstm are patients who want an improved skin structure. In the past, the choice for the correct Restylane® Skin-boosterstm has been individually made for every patient based on the Glogau Scale (classification of akin aging in skin types I-IV). However, since this clas-sification method is very complex, the Glogau Scale is now being replaced by a simpler system. this updated classifica-tion is supposed to help even novices to easily arrive at the correct product selec-tion for their patients. It will also help experienced practitioners improve day-to-day efficiency.

First, the skin in the treatment area should be defined. the new classifica-tion differentiates between more mature, thicker, partially light-damaged skin with more covering tissue (type A skin, e.g. cheeks) and younger, thinner, more sen-sitive skin with less covering tissue (type B skin, e.g. neck). For type A skin, the

use of Restylane® Skinboosterstm Vital is suitable with strong tissue coverage and low lifting capacity. For type B skin, the practitioner can select Restylane® Skinboosterstm Vital light with low tis-sue coverage and very low lifting capac-ity (table 1). Special challenges could be posed by thick photo-aged skin, mature and thin or sensitive skin, although even younger skin can be associated with less tissue coverage in certain areas. Here, the success of the treatment is closely associated with the expertise of the prac-titioner, whose patient-individual choices are decisive for treatment results. For example, with an optimal treatment, skin aging symptoms (e.g. dehydration, loss of tissue tightness and elasticity, wrinkle formation, atrophy and photo aging) as well as deep acne scars can be reduced and skin quality can thereby be visibly improved. With uV-damaged skin, a more conservative application of Restylane® Skinboosterstm should be considered. the stronger the uV-damage, the more diffi-cult it is to activate the fibroblasts. In this

table 1: product recommendations.

general treatment references vital vital light

Ingredients 20 mg/ml stabilized hyalurone with 12 mg/ml stabilized hyalurone with or without 0.3 % lidocaine or without 0.3 % lidocaine

lifting capacity low Very low

technologiy NASHAtm NASHAtm

skin quality Aged or thicker skin Younger or thin or sensitive skin

treatment areas Face, neck, hands, décolletage, upper arms Face, neck, hands, décolletage, upper arms

tissue coverage Strong Weak

Injection depth Subcutaneous Subcutaneous

figure 1: revised treatment protocol for restylane® skinboosterstm.

84

case, combination treatments or alterna-tive treatments are preferred. especially with uV-damaged skin, exclusive therapy with laser has been regarded as helpful. However, prior to laser treatment with a fractioned ablative Co

2-laser, Angelis and

tretti recommend the injection of stabi-lized hyaluronic acid [1]. the Restylane® Skinboosterstm stimulate the fibroblasts, which should then respond better to the thermal stimulation of the laser.

restylane® sKInboosterstm InJectIon

on recommendation of the experts and based on the current state of research, the injection of Restylane® Skinboost-erstm should generally be performed superficially in the subcutaneous tissue. It is important not to equate Skinboost-ers treatment with mesotherapy. Whereas with mesotherapy non-stabilised hyalu-ronic acid and diverse other substances

are injected into various skin layers, the efficacy and safety of the Restylane® Skinboosterstm, which exclusively contain non-animal stabilised HA, is clinically proven [19, 20, 23, 24, 27] and must be performed in the area of the deep dermis and subcutis.

unwanted effects and results – apart from local injection-related reactions such as short-term erythemas or hemato-mas – usually occur due to incorrect treat-ment, for example by injecting the Skin-boosters too superficially. If Skinboosters are applied too superficially and the skin is too thin, there is a risk for nodules/papules formation and an accumulation of the injected material. this undesirable effect can be prevented with injections into the correct skin layer. Nevertheless, if it occurs the committee recommends the application of the enzyme hyaluronidase. Another safety issue besides the defined injection depth is the selection of a suit-able cannula. depending on the expertise

of the practitioner the injection can be performed with blunt cannulas or with sharp needles. Blunt cannulas are prin-cipally associated with lower side-effects and are therefore usually preferred by the patients. Blunt ending cannulas (Pix’l23G - 50 mm to 25G - 40 mm) have been clini-cally proven to reduce injection-related reactions [3, 9]. With less penetration points and a reduced risk of hematoma formation, patient comfort is increased. Furthermore, the lateral outlet of the cannula ensures a more even distribu-tion of the Skinboosters and the treat-ment is experienced as being less painful. through the optional SmartClick™ Sys-tem, application safety can additionally be increased: for each 10 µl injected, a click is triggered, enabling the practi-tioner to completely focus on the injec-tion and attend to the patient while the product is evenly delivered.

For an indication-conforming appli-cation, the injection amount, technique,


table 2: consensus – Indication cheeks.

IndIcatIon cheeKs

definition cheek area treatment area upper cheek: Zygomatic region bordering below the orbital rim; the periorbital region (crow’s feet) is assigned to the upper cheek area. treatment area lower cheek + chin: hollow cheek, tragus, chin

target group Patients with aged skin and younger patients

Indications younger patients: prophylaxis, dry skin, fine lines

product selection Vital or Vital light (see below CAVe)

Injection volume (per treatment upper cheek area: 0.5 mlarea and per side) lower cheek area + chin: 0.5 ml

Injection technique Blunt; sharp

Injection points and volumes blunt: 1. Approx. 0.5 ml lateral and approx. 2–3 mm above the corner of the mouth (to be able to treat the perioral region from here as well) 2. In a line between the corner of the mouth and the tragus, medial to the m. masseter 3. optional point for beginner practitioners: on the zygomatic arch (to better cover the complete region (incl. distal)sharp: • Injection points see figure• Approx. 10 ul per Injection point• Bolus-technique

CAVe: For younger/thinner/sensitive skin the use of Vital light is also possible.


points and volumes are recommended in the treatment protocols for the respective treatment area (tables 2-5, figure 2).

applIcatIon Intervals

So far, the treatment regimen for Resty-lane® Skinboosterstm recommends three build-up treatments at an interval of four weeks and two repeated treatments after six months respectively. As Resty-lane® Skinboosterstm are medicinal prod-ucts, deviations can be made from the described treatment scheme in clinical practice if safety is ensured.

Results from current studies and the experience of the experts suggest a reorientation in the recommendation on application intervals. the expert commit-tee agreed that two applications lead to very good results and a current investiga-tion from Kerscher et al. substantiates this [19]. the new treatment protocol (figure 1) recommends two, optionally three ini-tial treatments at an interval of respec-tively four weeks. In everyday practice however, patient-individual decisions are recommendable: for patients who wish for less treatments, longer intervals can be planned between the appoint-ments. Although a few days after the first treatment an increasing amount of water is bound in the patient’s skin and a visible effect is achieved, only repetitive

treatment can stimulate the fibroblasts and instigate a collagen biosynthesis. For high patient satisfaction and a long-term relationship to the treating physi-cian patient education is paramount, especially regarding the expectations towards the delayed occurring effect. Fur-thermore, the revised treatment protocol is based on current research on the effect duration of the Restylane® Skinbooster-stm: for Restylane® Skinboosterstm Vital light [24] a duration of the aesthetic effect of nine months was substantiated,

for Restylane Skinbooster Vital even up to 12 months [16]. Subsequent to the two to three initial treatments, two repeated treatments are only recommended after respectively 9-12 months (figure 1).

figure 2 : consensus – restylane® skinboosterstm volume per Indication.

table 3: consensus – Indication perioral (smoker’s lines).

IndIcatIon perIoral (smoKer’s lInes)

definition perioral area distal border: A few cm around the border of the vermilion around the vertically running smoker's lines

target group Younger patients (preventive treatment) as well as patients with loss of elasticity

Indications Wrinkles and perioral loss of elasticity

product selection Vital light or Vital (see below CAVe)

Injection volume 0.25–0.5 ml(complete treated area per session)


Injection points and volumes See figure "Indication cheek"

cave: use of Vital possible, if the region above the lip is sunken in (use marginal injection volume)

86

treatment protocols for face, décolletage and hands

consensus – faceIndication cheek / indication periorbital (crow‘s feet):the indication cheek includes the upper and the lower cheek area. the indication periorbital (crow‘s feet) is allocated to the treatment area „upper cheek“ (table 2).Indication perioral (smoker’s wrinkles):(table 3)

consensus – indication décolletage (table 4)

consensus – Indication hands(table 5)

the indications forehead, temples and neck are expert indications for Resty-lane® Skinboosterstm treatment. therefor no recommendations are given in this consensus.

summary

Restylane® Skinboosterstm are outstand-ingly suitable for deep hydration of the skin, and their effect is long-term and safe. Natural treatment results fulfil the needs of the patients and increase the patient-practitioner relation. In the new guidelines on the optimal applica-tion of Restylane® Skinboosterstm Vital light and Vital the indications, applica-tion intervals, injection technique and compliance are addressed in detail. Fur-thermore, illustrated application recom-mendations (e.g. injection amount, tech-nique, points and volumes) for different target groups and treatment areas such as face, décolleté and hands will pro-vide the practitioner security in handling Restylane® Skinboosterstm.

literature1. de Angelis F, tretti Clementoni m (2014)

Klinische erfahrungen bei kombinierten

Behandlungen mit Skin-boostern und laser.

Anwendungsgebiete, einsatzmöglichkeiten und

Abläufe. Ästhetische dermatologie 6: 6–9.

2. de Aquino mS, Haddad A, Ferreira lm (2013)

Assessment of quality of life in patients who

underwent minimally invasive cosmetic pro-

cedures. Aesthetic Plast Surg 37: 497–503.

3. Berros P, dreissigacker K (2010) optimizing

the aesthetic results, combining the prod-

ucts within the Restylane portfolio. Vorges-

tellt auf dem International mastercourse on

Aging Skin (ImCAS), Paris, Frankreich.

4. Borelli C, Berneburg m (2010) Beauty lies in

the eye of the beholder. Aspects of beauty and

attractiveness. J dtsch dermatol Ges 8: 326–330.

5. Carruthers Jd, Carruthers JA, Humphrey S

(2014) Fillers and neocollagenesis. dermatol

Surg 40(12): 134–136.

6. dayan SH, Arkin, JP, Patel AB, Gal tJ (2010)

A double-blind, randomized, placebo-con-

trolled health-outcomes survey of the effect

of botulinum toxin type a injections on qual-

ity of life and self-esteem. dermatol Surg

36(4): 2088–2097.

7. deutsche Gesellschaft für Ästhetische

Botulinumtoxin-therapie e.V. (2016) ergeb-

nisbericht zur umfrage der Gesellschaft

für Konsumforschung (GfK) im Auftrag der

dGBt: einstellung deutscher Frauen zum

thema Altern und Schönheit.


IndIcatIon décolletage [1]

definition décolletage area upper border: Clavicula lower border: Breast fold lateral border: 2 treatment areas, see orange resp. grey shaded area (see also CAVe1 below)

target group mostly patients with aged skin

Indications loss of elasticity/ decreasing skin quality

product selection Vital light (thin skin) and Vital (thicker skin)

Injection volume (complete 1–2 ml depending on the treated area treated area per session) (s. figure above and CAVe2 below)


Injection points and volumes blunt: • Injection points depending on desired treatment area, to treat the complete area • Retrograde injection

cave 1. depending on choice of clothes and individual patient wishes (no precise anatomical definition of the region)cave 2. too superficial application may result in nodules.

table 4: consensus – Indication décolletage.


IndIcatIon hands

definition hand area

target group

Indications

product selection

Injection volume (per treatment area and per side)

Injection technique

Injection points and volumes

distal border: only dorsum of the hand (no fingers)proximal border: wrist

mostly patients above 30 years; seldom younger (25–30 years)

younger patients (approx. ≥ 30 years): prophylaxis; dry skin, hands with clearly visible sinews (thin hypodermic tissue, bulging veins and sinews)

Vital or Vital light for dry, thin skin

0.5 ml (for 3 treatments) (see CAVe below)

depending on expertisechoice: blunt; 2. choice: sharp (bolus technique)

blunt – possibility no. 1: Four points: between the finger joints, Retrograde injection 1. Injection of multiple, small boli or 2. Injection of few, larger boli (0.1–0.2 ml, see figure) followed by distribution of depots (massage)

blunt – possibility no. 2: • one point: dorsum, proximal • Retrograde injection • 1. Injection of multiple, small boli or • 2. Injection of few, larger boli (0.1–0.2 ml, see figure) followed by distribution of depots (massage) sharp: (bolus technique): • Four points: between the finger joints – Retrograde injection• 1. Injection of multiple, small boli (0.1–0.2 ml, see figure)or • 2. Injection of few, bigger Bolifollowed by distribution of depots (0.1–0.2 ml, see figure) followed by distribution of depots in direction of the arrows (massage)

cave: Small depots to avoid nodules.

table 5: consensus – Indication hands.

the commIttee members

dr. med. maja waibel, berlin – After working at the Benjamin Franklin clinic in Berlin, dr. Waibel established herself in her own practice in Berlin as an expert for aesthetic dermatology, laser medicine and melanoma prevention.dr. med. martina hund, berlin – dr. Hund is specialist for dermatology and venerology in her own practice in Berlin. She is co-author of several dermatology reference books and has long-term experience working at the skin tumour centre of the Charité Berlin.dr. med. alexandra ogilvie, munich – As a senior physician of the skin clinic at the university clinic erlangen, dr. ogilvie was involved in various scientific advisory boards. She is a specialist for dermatology and allergology and works in her own practice in munich.shirin samimi-fard, gladbeck – Shirin Samimi-Fard is a specialist for dermatology and venerology, allergology and has a diploma in estethic laser medicine. She is the head of the derma loft.prof. dr. med. martina Kerscher, hamburg – Prof. Kerscher heads the cosmetic science workgroup at the university Hamburg. She is a specialist for dermatology and venerology and expert for skin physiology; skin ageing and minimal invasive cosmetic procedures.dr. med. anna mokosch, düsseldorf – dr. mokosch is a specialist for dermatology and venerology in düsseldorf. She is also a lecturer at the academy for cosmetic medicine in düsseldorf.

88

8. distante F, Pagani V, Bonfi gli A (2009) Sta-

bilized hyaluronic acid of non-animal origin

for rejuvenating the skin of the upper arm.

dermatol Surg 35(1): 389–393.

9. dreissigacker K (2009) Individual Face Bal-

ance (IFB) minimalinvasiver großfl ächiger

Volumenaufbau mit neuer Kanülentechnolo-

gie auf Hyaluronsäurebasis. Face 3: 42–45.

10. dubois m, Pansu P (2004) Facial attractive-

ness, applicants’ qualifi cations, and judges’

expertise about decisions in preselective

recruitment. Psychol Rep 95: 1129–1134.

11. entwistle J, Hall Cl, turley eA (1996) HA

receptors: regulators of signalling to the

cytoskeleton. J Cell Biochem61: 569–577.

12. Fink B, matts PJ (2008) the eff ects of skin

colour distribution and topography cues

on the perception of female facial age and

health. J eur Acad dermatol Venereol 22:

493–498.

13. Fink B, Neave N (2005) the biology of facial

beauty. Int J Cosmet Sci 27: 317–325.

14. Fink B, Prager m (2014) the eff ect of incobotu-

linumtoxin a and dermal fi ller treatment on

perception of age, health, and attractiveness of

female faces. J Clin Aesthet dermatol 7: 36–40.

15. Gubanova eI, dyachenko YY, Rodina mY,

Koliyeva mK (2010) New hydrobalance tech-

nology based on stabilized hyaluronic acid

for long term skin hydration. esteticheskaya

meditsina. Aesthetic medicine 1: 94–1098.

16. Gubanova eI et al.(2015) Injections of stabi-

lized hyaluronic acid with a sharp needle com-

pared with a blunt microcannula for facial skin

rejuvenation: 12-month results. Poster Präsen-

tation auf dem International mastercourse on

Aging Skin (ImCAS), Paris, Frankreich.

17. Gupta mA, Gilchrest BA (2005) Psychosocial

aspects of aging skin. dermatol Clin 23:

643–648.

18. Institut für demoskopie Allensbach. Generali

Zukunftsfonds (2012) Generali Altersstudie

2013: Wie ältere menschen leben, denken

und sich engagieren, Fischer taschenbuch,

Frankfurt am main.

19. Kerscher m (2017) Restylane Skinboosters

for improved facial skin quality using two

treatment sessions.

20. Kerscher m, Bayrhammer J, Reuther t (2008)

Rejuvenating infl uence of a stabilized hyalu-

ronic acid-based gel of nonanimal origin on

facial skin aging. dermatol Surg 34: 720–726.

21. longas mo, Russell CS, He XY (1987) evi-

dence for structural changes in dermatan

sulfate and hyaluronic acid with aging.

Carbohydr Res 159: 127–136.

22. Reuther t, Bayrhammer J, Kerscher m (2007)

einsatz biophysikalischer messverfahren

zur untersuchung der hautphysiologischen

Wirkung injizierbarer Hyaluronsäure.

Hautarzt 58: 1046–1050.

23. Reuther t, Bayrhammer J, Kerscher m (2010)

eff ects of a three-session skin rejuvena-

tion treatment using stabilized hyaluronic

acid-based gel of non-animal origin on skin

elasticity: a pilot study. Arch dermatol Res

302: 37–45.

24. Streker m, Reuther t, Krueger N, Kerscher m

(2013) Stabilized hyaluronic acid-based gel

of non-animal origin for skin rejuvenation:

face, hand, and décolletage. J drugs derma-

tol 12: 990–994.

25. turlier V, delalleau A, Casas C, Rouquier

A, Bianchi P, Alvarez S, Josse G, Briant

A, dahan S, Saint-martory C, theunis J,

Bensafi -Benaouda A, degouy A, Schmitt

Am, Redouès d(2013) Association between

collagen production and mechanical stretch-

ing in dermal extracellular matrix: in vivo

eff ect of cross-linked hyaluronic acid fi ller.

A randomised, placebo-controlled study. J

dermatol Sci 69: 187–194.

26. Wang F, Garza lA, Kang S, Varani J, orrin-

ger JS, Fisher GJ, VoorheesJJ (2007) In vivo

stimulation of de novo collagen production

caused by cross-linked hyaluronic acid der-

mal fi ller injections in photodamaged human

skin. Arch dermatol 143: 155–163.

27. Williams S, tamburic S, Stensvik H, Weber

m (2009) Changes in skin physiology and

clinical appearance after microdroplet

placement of hyaluronic acid in aging hands.

J Cosmet dermatol 8: 216–225.

28. Wohlrab W, Neubert RRH, Wohlrab J (2004)

trends in Clinical and experimental der-

matology, Vol. 3 Hyaluronsäure und Haut,

Shaker Verlag, Aachen.

CAVe: the presented treatment scheme has proven (itself) to be evidence based, very eff ective and safe in most patients. there are, however, individual devia-tions of volume, frequency and injection time intervals, but their eff ectiveness is not scientifi cally proven.


acknowledgements: the consensus meeting was supported by Galderma laboratorium GmbH (düsseldorf, Germany).

6th annual meeting world academy of cosmetic surgery

august 30 – september 1, 2018 – hotel park royal palace, vienna (austria)

august 28th & 29th, 2018Pre-Conference Workshop: Cosmetic Breast Surgery live-Hands-on Workshop

september 2nd, 2018Post-Conference Workshop: Sculpting the Human Form: “Connecting Art + Science”

further Informationprogramme: tel. +43 677 62414784, [email protected]

exhibition: Gmc GmbH, douglas Grosse, tel. +49 (0)30 52664885, [email protected]

89CoSmetIC medICINe 1.15

Labial angle - before Labial angle - after 14 days

Scars treatment - before Scars treatment - after 14 days

Anzeige_280x210mm_fillerguide_en_1017.indd 1 02.11.17 16:59

90 CoSmetIC medICINe 2.17 therapy focus

listening to lectures on the International Congresses and visit-ing the booths of diff erent producers I was really disappointed about the progress in single therapy advantages. maybe I am wrong, but there is really nothing which I would call a „hot topic“ in 2017 … except … the discussion about synergies we are able to produce by combining diff erent therapy options. the discussion about this topic still is on a low level, the speak-ers presented single cases with – sometimes – good results, studies are diffi cult to manage and therefore few, coopera-tion amongst colleagues with diff erent therapy options seems necessary.

Steff en Giesse, one of our Network speakers, and I have published a fi rst proposal to create a system of good and even bad synergies we can produce based on publications for single combinations and our own experiences with the combinations we use until now [1]. But this systematization could only be a fi rst step in a right direction, not more.

In my opinion the synergistic view on the patient becomes more and more necessary, and some combinations I use today produce amazing results. Inside the Academy we have the opportunity to invite volunteers to many diff erent training ses-sions like injection-lipolysis, fi llers, botulinum toxin (BtX), threads, needling, lasers, mesotherapy or PRP. therefore we have the chance which sometimes is rare in the doctor’s offi ce to discuss together the progress of each single therapy step and to propose further treatments to the volunteer who does not have to look at the economic frame conditions during a training ses-sion. In other words, we are free to optimize the results step by step, and we are free to discuss bad results as well.

We are working on this project since 2014 which we call compositional aesthetics, and we are able to present some interim results which we can recommend as synergistic optimization.

body contourIng

the body contouring market is divided at the moment into 4 groups: group one uses the cryo devices, group two uses injectables for fat pad reduction like PC/dC for injection lipoly-sis (Il), group three treats with „soft“ lasers like the Sculpsure® system from Cynosure, and group 4 is still off ering surgical procedures like invasive lasers and liposuction with its diff er-ent technologies (ultrasound assisted, tumescent, …).

synergistic combination therapies are highlighted in 2017!

mICHAel J. WeIdmANN, md1

1 medical director globalhealth academy for aesthetic medicine

fig 1 a+b: 1 treatment by J. faulhaber cryo+Il combination.

fig 2 a+b: 1 treatment by m. sandhofer cryo+Il combination.

fig. 3 a+b: 1 treatment of the jowls by J. mueller-steinmann with Il,

patient is waiting for fi ller.

fig. 4 a+b: 1 treatment of nasolabial region by J. mueller-steinmann

with Il, patient is waiting for fi ller.


the use of PC/dC injectables to correct the results of sur-gical procedures has been used since a decade nearly, and it really was helpful for surgeons as the need to correct occurring dents by a second liposuction has not longer been a necessity.

2014 a half side comparison study of I. tausch and I. Krug-likov has been published using on one side the single therapy with PC/dC, and on the other side a combination of PC/dC and dual Frequency ultrasound (ldm) with an increase of volume reduction of about 65 % [2].

In 2016 a workgroup with the cryo specialist matthias Sandhofer from linz, Austria and the PC/dC specialist Joerg Faulhaber from Schwaebisch-Gmuend, Germany has combined Cryolipolysis together with Il in a single treatment session on 22 patients. their results were overwhelming and we really can state a synergistic increase of fat reducing eff ects [3]. We still have to rise the number of treatments to present a standard-ized protocol for such a combination, but the fi rst results are more than promising (Fig. 1 a+b, 2 a+b).

face composItIon

during the last decades the number of treatment options for the face has been tremendously snowballed, especially on the minimal invasive level. Analyzing (reading) the anatomic struc-tures of the face to know what aging has caused to the skin and the fat compartments is not longer a luxury but belongs to the standards of today’s high quality treatments, and the patients want it more and more. But do we really know already, which combinations in which sequence – following or parallel – should be chosen to arrive at the horizon of a better effi cacy? It seems we are not at the end but still at the beginning.

Nevertheless we already have experiences, and some combi-nations we already can recommend to our colleagues as there are:

• Il and fillers for the jowls, the submandibular shadow line (chin-line) correction and the nasolabial fold (Fig. 3 a+b and 4 a+b))• prp and needling for the treatment of acne scars (Fig. 5 a+b)• btx (masseter) and Il for the correction of moonfaced contours (Fig. 6 a–d)• Il, fillers, btx, mesolift (Fig. 7 a+b)• Il, fillers, btx and threads for more or less declined facial structures (Figure 8a+b)• mesotherapy and prp for the treatment of hair loss

1+1 = 3 = synergy

there are surely more combinations which raise the effi cacy scale like lasers and PRP, lasers and threads, HiFu ultrasound and Fillers, Radiofrequency and mesotherapy, but a lot of work still has to be done to fi nd optimal combinations which have a high potential for synergies and therefore create results better than the addition of the single therapies.

fig. 5 a+b: combination treatment of acne scars with needling (4x)

and prp (2x) by K. rezai.

fig. 7 a+b: combination treatments btx, fillers, Il and mesotherapy

by m. lettko.

fig. 6 a-d: treatment of moonface contour during traing sessions with

Il and btx.

92 CoSmetIC medICINe 2.17 therapy focus

the conclusion of three years of experience with combinations is simply that this will be the next bigger step to optimize treat-ment results, more than any new single therapy will bring us.

Non disclosure. No conflict of interest.

address of correspondence:michael Weidmann, m.d.

Willy-Brandt-Platz 3

d-86153 Augsburg

[email protected]

literature:1. Giesse S, Weidmann m (2017) Kombinationstherapien in der Ästhetik.

Spitzenforschung in der Ästhetischen dermatologie und dermatochirurgie

pp 40–43.

2. tausch I., Kruglikov I. (2015). the benefit of dual-frequency ultrasound in

patients treated by injection lipolysis. J Clin Aesthet dermatol 8: 42–46.

3. Sandhofer m, Schauer P, Faulhaber J (2016) effektives nicht-operatives

Bodycontouring mittels Kombination aus Kryolipolyse, Injektionslipolyse

und Stoßwelle. Kos med 37(4): 136–139.

fig. 8 a+b: slow improvement during trainings (Il 2x, fillers, btx,

threads), 6 months post thread insertion.

Researchers at the university of Witten/Herdecke present detailed figures on medical device monitoring for the first time. they see potential for improvement in the use of prod-uct-specific data from clinical practice.

medical technology manufacturers are legally obliged to continue to systematically monitor the safety of their prod-ucts even after market introduction - but how the industry actually fulfils this obligation has been largely unknown to date. Prof. dr. Sabine Bohnet-Joschko and dr. Claus Zippel from the university of Witten/Herdecke have now published data on the use of appropriate monitoring instruments by medical device companies operating in Germany for the first time.

overall, manufacturers are relatively broadly positioned in this area,“ summarizes dr. Claus Zippel, the results of the nationwide expert survey. Safety-relevant product informa-tion is particularly frequently obtained through company-internal sources of knowledge as well as literature screen-ing, monitoring and reporting systems, customer contact and market analyses. In the industry, on the other hand, there is room for improvement in the use of data on the use of products in patient care, for example by means of clinical medical device studies or registers.

the higher the risk class, the higher the level of market observation due to the large differences within the indus-try, researchers have analysed the results by company size and risk group. Another result of the Witten scientists is that the higher the risk class of the manufactured products, the more intensively the manufacturers use the instruments for market observation on average. this makes sense - after all, more risky products such as artificial hip and knee joints, cardiac pacemakers or implantable defibrillators are sub-ject to stricter legal requirements to ensure product safety and performance than those from the group with the lowest risk, such as surgical textiles or dressing materials. For the first time, the data provide detailed insights into how knowl-edge about the use of the products is gained in practice. Companies can use our results to compare their quality and risk management methods with the industry average,“ said Zippel. the results were determined by a nationwide survey of quality management experts from the medical technol-ogy sector.

source:idw-online

new eu regulation tightens market surveillance of medical devices


In our dermatology practice we use increasingly cross-linked fillers in men, such as Z FIll deep2 for regenerative augmenta-tion. on behalf of a 47 year old man, the approach and the pleasing results after three months are exemplified.

A 47 year old man without preceeding diseases introduced himself in our practice for aesthetic treatment of his facial wrinkles. After a thorough anamnesis and questioning to his personal attitude and desires, augmentation of the nasolabial folds was performed (Fig. 1).

For such treatments we use the Z Fill series of the company Zimmer medizinSysteme (Neu-ulm, Germany). modern fillers, such as Z Fill contour2 and Z Fill deep2 with their cross-linked HA for regenerative augmentation, are ideal materials with long durability.

Hyaluronic acids initiate on the one hand biologic pro-cesses for tissue regeneration and on the other hand have a high moisture-binding capacity. this treatment enables a more fresh appearance, without being noticable and it is also well suited for male patients, to treat deep and distinct folds. that is why we decided in this case, to use the newly developed compound Z Fill deep2. the cross-linked monophasic HA shows very good filling and volumizing effects, as well as an excellent tissue integration. In addition, this HA is easily implanted and easy to mold.

Z Fill deep2 was injected employing the tower technique according to Gerhard Sattler, into both nasolabial folds and sub-sequently molded. the volumina amounted to 1 ml on each side.

Although the lifting effect, directly after implantation of Z Fill deep2, was not so much pronounced, a very nice result with great volume effect was visible after the 3 month control examination (Fig. 2). one can see nicely, that besides the tis-sue regeneration, a distinct mouisture binding capacity con-tributed to the treatment results.

In a further treatment, one could augment the cheek region with Z Fill deep2. this sequence one could have treated before augmentation of the nasolabial folds, but was not desired by the patient at that point. more and more male patients turn to aes-thetic dermatology and the average age will decline.

We also observe a trend to low-level invasive treatments. Here, the different HA products of the Z Fill series are an excel-lent instrument to fulfill patient demands in the field of wrinkle reduction. the Z Fill series of Zimmer medizinSysteme offers for each treatment area the appropriate product with the respective properties.

Z Fill is – considering our experience – an excellent filler for volume and lifting, with which lost volumina can be replaced by a remarkable lifting effect and receding contours can be tightend, resulting in a fine aesthetic result.

address of correspondence: Prof. dr. med.

Jörg Faulhaber

dermatologische Practice

Kalter markt 27

d-73525 Schwäbisch Gmünd

www.hautarzt-gmuend.de

new patient group „men“ – hyaluronic acid as an important tool

fig. 1: 47 year old man before augmentation of the nasolabial fold.

fig. 2: 47 year old man after augmentation of the nasolabial fold.

algeness a new polysaccharide based filler

INteRVIeW WItH RICHARd F. BuRtt, eXeCutIVe CHAIRmAN oF AdVANCed AeStHetIC teCHNoloGIeS INC. CoNCeRNING AlGeNeSS® A NeW BIomAteRIAl CoNSIStING oF A PuRIFIed AGARoSe Gel (PolYSACCHARIde),

deRIVed FRom A SPHIStICAted ANd PAteNt PeNdING mANuFACtuRING PRoCeSS.

Km: Richard Burtt, your company devel-oped and brought to market a new pol-sysaccharide based filler under the name Algeness®. What is the story behind the filler?

rb: An all-natural alternative to Hyalu-ronic acid fillers has been the dream of many clinicians, including our leonard miller, md, a noted plastic surgeon in the uS. As a result of his research of pub-lished papers and aesthetic contacts, dr. miller discovered the wealth of data and information on agarose gels derived from red algae. Armed with this knowledge and data, he identified the manufacturer of this filler composed of highly purified agarose in an all natural formulation. We then formed Advanced Aesthetic tech-nologies, Inc. to acquire this technology in late 2014 and launched Algeness® to a limited test market in 2015. Based on trh success of the test market in the uK, Italy and Colombia, we are now scaling up our disitrbution to bring Algeness® to the entire europeean union, eastern europe, middle east, and Asia.

Km: What is the difference to other fill-ers on the market and how is the feed-back from practitioners and patients?

rb: Algeness® is distinguished by its ability to instantly volumize soft tis-sue for a more defined natural look with a technique we call,“master Your Resultstm“. Additionally, unlike all HA fillers, Algeness® is full biodegradable and biocompatible. In our “master Your Results“ program, we instruct practi-tioners in the art of the technique to maximize the unique properties of Alge-ness® for consistent excellent outcomes that are achieved immediately with lit-tle to no migration over time. All unique capabilities.

Km: In which countries is Algeness avail-able and in which countries will it be available soon?

rb: By the end of June of this year, Alge-ness® will be available throughout the european union and eastern europe. then subject to registration time middel

east and Asia countries will come on line.

Km: Are there any evidence based data available?

rb: Yes. We have a data package of pre-clincial studies conducted by Wake Forest Research Institute in the uS, 3 post-market comparative clinical stud-ies of over 150 subjects, and 3 com-pataive studies in process. our intent is to make theses data available to all including published papers as they come available.

Km: How are the results?

rb: We are delighted with the results in all studies completed to-date. these data have shown Algeness® to be safe, efficacious, nominal to no adverse effects, and offering excellent persis-tence and low migration.

Km: Which indications is Algeness® approved for?

rb: Algeness® holds a Ce mark certifica-tion for implantation in soft facial tissue.

Km: Can we expect an extension of the Algeness range?

rb: our intent is to offer a full range of dermal products for all facial applica-tions and other soft tissue anatomical areas that can benefit from this all natu-ral biomaterial.

dear mr. Burtt, we thank you for this interview.

94 CoSmetIC medICINe 2.17 IntervIew

the filler guide 2017

dear readers,

the number of fillers, especially those based on hyaluronic acid, has risen sharply in recent years. this is due to the trend towards non-invasive procedures and the increasing ageing population, as well as to the meanwhile high acceptance of such interventions in the population.

In 2011, sales of botulinum toxin and fillers in europe amounted to € 544 mil-lion and in 2016 to around € 830 million. the estimated annual growth rate is approximately 9.5% per annum.

the idea to publish a Filler Guide came from the book „Illustrated Guide to Aes-thetic Botulinum toxin Injections“ by KVm Publications, which contains a Filler overview. Publisher dr. Bernard Kolster gave us permission to build on their table. many thanks for that at this point. We have been able to extend the table with some products and we would like to thank the companies who supported us with this project.

We do not claim to be complete with regard to the data listed. For current and further information, please refer to the websites of the manufacturers listed in the back of this issue. Further information on indications and contraindications can be found in the product descriptions of the preparations, which are to be regarded as a primary source in any case.

We hope we have provided you with a good source of information and hope you enjoy studying the list.

Kind regards

douglas Grosse



Product name Company IndicationsApplication depth

Material i.e. hyaluronic acid concentration and crosslinkage

Needle and/or cannula size Special material properties

belotero® soft merz aesthetics Correction of superficial wrinkles

upper dermis 20 mg/ml dynami-cally multi-cross-linked HA (CPm®-technology)

Needle: 30 G 1/2

Poly densified, cohesive gel, very good tissue integration, low water retention. estimated duration: 6–9 months. Very well tolerated, available with lidocaine

hyabell® lips + lidocaine

adoderm gmbh lip contouring, lip augmentation

lip muscle 12 mg/ml cross-linked hyaluronic acid plus 0,3 % lidocaine.

Needle: 27 G

exceptionally soft injection: intermediate value of 10 N at G‘ and G‘‘ with 0.1 Hz is lower than 35 Pa; for excellent properties in shaping and distribution of the filler; for natural and elegant apperance of lip volume, low water uptake

hyal®-acp merz aesthetics Improvement of skin resili-ence and elasticity

Intra dermal ACP (Auto-Cross-linked Polymer) = auto-crosslinked HA

Needle: 30 G 1/2

Stabil without adding adjuvants, long lasting bio stimulation. documented proliferation of fibroblasts and keratinocytes

hydryalix gentle luminera derm ltd.

the product is indicated for superficial lines, fine to moderate wrinkles and minor skin damages. the product can be used onwrinkles, lines and creases around the mouth.

Superficial and mid dermis

20 mg/ml HA, cross-linked (Bdde < 2 ppm). Presentation of 1.25 ml in each syringe. two syringes in a box.

Needle: 27 G or 30 G, thin-wall

In our Hybrid moBitm technology, the gel is monophasic, fully homogenous, smooth and easy to inject. the particle nature of the gel gives the ability to mold the injected material to the desired shape in the tissue and gives the product its firmness. All the products are available with lidocaine as well.

Juvéderm® ultra 2

Allergan Inc. Correction of fine lines and wrinkles

mid dermis 24 mg/ml crosslinked HA (HYlACRoSS-technology™).

Needle: 30 G 1/2

Smooth gel, well tolerated, long lasting, with lidocaine (0.3 %)

Juvéderm® volbella

allergan Inc. Fine lines, ideal for treat-ment of the tear trough

superficial 15 mg/ml crosslinked HA (VYCRoS-technology™)

Needle:30 G 1/2

Good duration, good dispersion (reason: low cohesion), with lidocaine (0.3 %)

Juvéderm® HYDRATE

allergan Inc. Improvement of skin mois-ture and elasticity

upper dermis 13.5 mg/ml cross-linked HA with 0.9 % manitol

Needle: 30 G 1/6; 32 G

Good water absorption, low durability

Juvéderm VOLITE – Skin Juvénizer


Intra dermal 12.5 mg/ml slightliy crossinked with VYCRoSS -techno-logy™

Needle: 32 G 1/2

e-Brid™-technology; easily injectable, well tolerated, slight lifting capability, with lidocaine (0.3 %)

Restylane® Fynesse

galderma Superficial wrinkles (especially perioral and periorbital)

Superficial dermis

20 mg/ml HA, gel with low crosslinage and calibration grade (Balance tech-nology)

Needle: 30 G 1/2

Very soft gel with moderate lifting capacity

PERFECTHA® Finelines

sinclair pharma Superficial facial lines and skin depressions, periorbi-tal lines, perioral lines

Superficial dermis

20 mg/g hyaluronic acid, cross linking agent Bdde (< 1 % )

Needle: 30 G * 1/2''

e-Brid™-technology; safe, well tolerated, easy to inject, high lifting and volumizing capacity, long lasting

fIllers for superfIcIal augmentatIon





belotero® soft merz aesthetics Correction of superficial wrinkles


Needle: 30 G 1/2


hyabell® lips + lidocaine

adoderm gmbh lip contouring, lip augmentation

lip muscle 12 mg/ml cross-linked hyaluronic acid plus 0,3 % lidocaine.

Needle: 27 G

exceptionally soft injection: intermediate value of 10 N at G‘ and G‘‘ with 0.1 Hz is lower than 35 Pa; for excellent properties in shaping and distribution of the filler; for natural and elegant apperance of lip volume, low water uptake



Needle: 30 G 1/2


hydryalix gentle luminera derm ltd.

the product is indicated for superficial lines, fine to moderate wrinkles and minor skin damages. the product can be used onwrinkles, lines and creases around the mouth.

Superficial and mid dermis



In our Hybrid moBitm technology, the gel is monophasic, fully homogenous, smooth and easy to inject. the particle nature of the gel gives the ability to mold the injected material to the desired shape in the tissue and gives the product its firmness. All the products are available with lidocaine as well.

Juvéderm® ultra 2

Allergan Inc. Correction of fine lines and wrinkles

mid dermis 24 mg/ml crosslinked HA (HYlACRoSS-technology™).

Needle: 30 G 1/2

Smooth gel, well tolerated, long lasting, with lidocaine (0.3 %)



superficial 15 mg/ml crosslinked HA (VYCRoS-technology™)

Needle:30 G 1/2


Juvéderm® HYDRATE


upper dermis 13.5 mg/ml cross-linked HA with 0.9 % manitol

Needle: 30 G 1/6; 32 G

Good water absorption, low durability

Juvéderm VOLITE – Skin Juvénizer


Intra dermal 12.5 mg/ml slightliy crossinked with VYCRoSS -techno-logy™

Needle: 32 G 1/2

e-Brid™-technology; easily injectable, well tolerated, slight lifting capability, with lidocaine (0.3 %)

Restylane® Fynesse

galderma Superficial wrinkles (especially perioral and periorbital)

Superficial dermis

20 mg/ml HA, gel with low crosslinage and calibration grade (Balance tech-nology)

Needle: 30 G 1/2

Very soft gel with moderate lifting capacity

PERFECTHA® Finelines

sinclair pharma Superficial facial lines and skin depressions, periorbi-tal lines, perioral lines

Superficial dermis


Needle: 30 G * 1/2''





PERFECTHA® Complement

sinclair pharma Superficial facial lines and skin depressions, forehead finelines

Superficial dermis


Needle: 30 G * 1/2''


STYLAGE® S laboratoires vIvacy

Correction of first wrinkles and for filling of small and mid-deep wrinkles

upper to middle dermis

16 mg IPN cross-linked HA with added antioxidant mannitol

Needles: 4 x 30 G 1/2‘‘

IPN crosslinked HA with double 3d-matrix and antioxidant for reduction of possible swelling and hematomas. Also available with lidocaine (0.3 %)

TEOSYAL® “Redensity [I]”

teoxane Beauty booster for redensi-fication and hydration of the skin as well as preven-tion of the signs of ageing (face, neck and decolleté)

Intradermal (superficial to mid dermis)

15 mg/g non-cross-linked HA combined with 8 amino acids, 3 antioxidants, zink, copper and vitamin B6 (patented "nutri-ents supplemented buffer")

Needle: 30 G 1/2

Well tolerated, with lidocaine

TEOSYAL® RHA 1

teoxane Fine and superficial dyna-mic wrinkles and folds, perioral wrinkles

mid dermis A mixture of 15 mg/g crosslinked and non-crosslinked HA (RHA®-technology), Bdde crosslinker only 1.9 %

Needle: 30 G 1/2

especially for dynamic regions (face, neck, decolleté); with lidocaineestimated duration 9–12 months

Z Fill contour2 zimmer medizin-systeme

forehead wrinkles, gla-bella, nasolabial folds, marionette lines and men-tolabial folds; lip contour and lip volume

Superficial til mid dermis

23 mg/ml crosslinked HA with Bdde

Needle: 27 G 1/2

estimated duration: 6–9 months

Z Fill refresh2 zimmer medizin-systeme

mesotherapy of the face, neck, decolleté, dorsum oth the hands and upper arm

upper dermis 18 mg/ml non-cross-linked HA. Stabilizer: Glycerin

Needle: 30 G 1/2

this with the additional actve ingredient glycerin enriched HA produces a long-lasting increase of skin moisture. estimated duration: 3 –4 months




algeness® hl 1.5 %

advanced aes-thetic techno-logies

marionette lines, fine wrinkles, lip augmentation and contouring, oral com-missures, oro-mandibular wrinkles

Immediately subcutaneous

1.5 % Agarose (low density), 98.5 % sterile saline solution

Needle: 30 G

100 % Natural and biodegradable injectable implant; Algeness® is composed of an Agarose gel, totally biocompatible to the human body and does not containing cross-linked synthetic chemicals (BBde) associated with Hyaluronic Acid (HA) fillers. durabilty: 4–8 months and longer

fIllers for medIum deep augmentatIon





BELOTERO® Balance

merz aesthetics mid-deep wirnkles, lip aug-mentation and lip contour

mid dermis 22.5 mg/ml dyna-mically multi-cross-linked HA (CPm®-technology)

Needle: 27 G 1/2; 30 G 1/2

medium viscose poly-densified cohesive gel. Very good tissue integration, almost no water retention. estimated duration: 12 months. Very well tolerated, available with lidocaine

harmonyca luminera derm ltd.

designed to restore facial volume and correct facial deficiencies by promoting the generation of natural endogenous collagen.Based on a composite matrix of cross-linked Hyaluronic Acid embedding Calcium Hydroxyapatite microspheres, HArmonyCa provides a strong volumi-zing, lifting effect.

deep dermal and sub-der-mal layers

Calcium Hydroxyapa-tite (55.7 %) micros-pheres of a diameter of 25–45 microns in a cross-linked HA gel 20 mg/ml

Needle: 25 G or 27 G, thin wall

Collagen stimulation increases due to the combination of both active ingredients. Calcium Hydroxyapatite stimulates new natural collagen production, while Hyaluronic Acid forms a supporting extracellular matrix, which modulates fibroblasts proliferation. the presence of Hyaluronic Acid elevates skin hydration and moisture. Susceptible to Hyaluro-nidase, physiological osmolarity level. Available with lidocaine as well.

hyabell® basic + lidocaine

adoderm gmbh Correction of medium wrinkles. lip volume and lip correction.

medium to deep dermis

16 mg/ml cross-linked hyaluronic acid plus 0.3 % lidocaine

Needle: 27 G

exceptionally soft injection; and G‘ with 1 Hz is lower than 70 Pa; for excellent properties in shaping and distribution, for stronger volume in the lips

hydryalix deep luminera derm ltd.

the product is indicated for the correction of deep facial wrinkles and folds such as nasolabial folds and marionette lines.

deep dermis 20 mg/ml HA, cross-linked (Bdde < 2 ppm). Presen-tation of 1.25 ml in each syringe. two syringes in a box.


In our Hybrid moBitm technology, the gel is monophasic, fully homogenous, smooth and easy to inject. the particle nature of the gel gives the ability to mold the injected material to the desired shape in the tissue and gives the product its firmness. All the products are availa-ble with lidocaine as well.

hydryalix volume

luminera derm ltd.

the product is indicated for volume augmentation and facial shape restoration. the product can be used on severe wrinkles.

deep dermis or subcutane-ously

20 mg/ml HA, cross-linked (Bdde < 2 ppm). Presen-tation of 1.25 ml in each syringe. three syringes in a box.



Juvéderm® ultra 3

allergan mid and deep wrinkles, lip contour and lip volume

medium/ deep dermis

" Needle: 25 G or 27 G, thin

Smooth gel, duration nasolabial 12 months, with lidocaine (0.3 %)

Juvéderm® ULTRA 4

allergan deep wrinkles, volume creation in lips and cheeks

deep dermis 24 mg/ml crosslinked HA (HYlACRoSS-technology™

Needle: 27 G 1/2

Smooth gel, long duration with lidocaine (0.3 %)

Juvéderm® ULTRA SMILE

allergan mid and deep wrinkles, lip contour and lip volume

medium/ deep dermis

24 mg/ml crosslinked HA (HYlACRoSS-technology™

Needle: 30 G 1/2


Juvéderm® VOLBELLA

allergan Fine lines, ideal for treat-ment of the tear trough

mid-dermis 15 mg/ml crosslinked HA (HYlACRoSS-technology™

Needle: 30 G 1/2


Juvéderm® VOLIFT

allergan Inc. mid and deep wrinkles deep dermis (Recommen-dation: not intra dermal)

17.5 mg/ml cross-linked HA (VYCRoSS-technology™)

Needle: 30 G 1/2

Good duration, good dispersion, excellent tissue integration and collagen neogenesis, with lidocaine (0.3 %)

PERFECTHA® Derm

sinclair pharma medium facial lines and skin depressions, glabellar lines, lip contour

mid-dermis 20 mg/g hyaluronic acid, cross linking agent Bdde (< 1 % )

Needle: 30 G * 1/2''






PRINCESS® FILLER

croma pharma Correction of superficial and moderate deep facial wrinkles as well as perioral wrinkles, lip contours and increase of lip volume

middle to deep dermis

2.3 % HA (23 mg/ml), also available with 0.3 % lidocaine

Needle: 2 x 27 G terumo 1/2", thin walled

Princess® Filler is a sterile, viscoelastic, completely clear, colourless, isotone, homogenised gel implant

Restylane® Refyne

galderma mid-deep wrinkles (especially nasolabial folds and & marionette lines, tear trough, cheek and lid folds)

mid dermis 20 mg/ml HA, gel with moderate crosslinkage and low calibration grade (Balance techno-logy)

Needle: 30 G 1/2 (utWN)

Soft gel with moderate lifting capacity, available with lidocaine

Restylane® Kysse

galderma lip volume, lip contour lip vermilion, submucosa

20 mg/ml HA, gel with moderate crosslinkage and low calibration grade (Balance techno-logy)

Needle: 30 G 1/2

moderate soft gel with moderate lifting capacity, available with lidocaine

Restylane® galderma mid-deep wrinkles (espe-cially nasolabial folds, marionette lines, oral commissure)

mid dermis 20 mg/ml stabilized HA (NASHA tech-nology)

Needle:29 G 1/2; Canula:27 G Pixltm, 28 G Pixl+

Firm gel with moderate lifting capacity, available with lidocaine

Restylane® Lyft galderma deep wrinkles, light to moderate facial contouring (especially zygomatic bone, chin, mandibular contour)

deep dermis or superficial subcutis

20 mg/ml stabilized HA (NASHA tech-nology)

Needle:29 G 1/2; Canula:23–25 G Pixltm, 25 G Pixl+

Firm gel with high lifting capacity, available with lidocaine

STYLAGE® M laboratoires vIvacy

Correction of mid to deep wrinkles in the Nasolabial region and the cheek and chin region as well as the forehead

mid to deep dermis

20 mg IPN cross-linked HA with anti-oxidant mannitol

Needles: 4 x 30 G 1/2‘‘


TEOSYAL® RHA 2

teoxane moderate dynamic wrink-les, also universally for all indications, except tear trough

mid-dermis 23 mg/g cross-linked HA (RHA®-technology), Bdde crosslinker only 3.1 %

Needle: 30 G 1/2

especially for dynamic regions (forehead, glabella); with lidocaine. estimated duration: 9–18 months

TEOSYAL® Global Action

teoxane moderate wrinkles, also universally for all indica-tions, except tear trough

mid-dermis 25 mg/g crosslinked HA

Needle: 30 G 1/2

moderate viscous gel, also available with lidocaine. estimated duration up to 9 months

VARIODERM Lips & Medium

adoderm gmbh lip contours, lip volume, moderate facial wrinkles


16 mg/ml cross-linked hyaluronic acid plus 0.3 % lidocaine

Needle: 27 G

Without lidocaine, exceptionally soft injection: intermediate value of 9N at G' and G'' lower than 50 Pa at 0.1 Hz. For moderate volume in the lips.

VARIODERM Basic

adoderm gmbh medium facial folds in all areas, lip contouring


12 mg/ml cross-linked hyaluronic acid. Approximate duration in the skin: 6–12 months

Needle: 27 G

Without lidocaine, exceptionally soft injection: intermediate value of 9 N at G‘ more than 250 Pa at 0.1 Hz. For a higher volume with less injection quantity.

CosmetiC mediCine 2.17100




Z Fill contour2 zimmer medizin-systeme




Needle: 27 G 1/2


Z Fill deep2 zimmer medizin-systeme

Cheeks, nasolabial folds, marionette lines and men-tolabial folds. Improvement of facial contours and for volume expansion

mid and deep dermis

23 mg/ml highly crosslinked HA with Bdde

Needle: 27 G 1/2

thanks to the excellent visco-elastic properties, the gel can be injected with ease through a thin needle with utmost precision. estimated dura-tion: 8–12 months




algeness® vl 2.5 %


medium-deep volumizingWrinkles, furrows and folds Cheeks, jawline and chin Nasolabial foldsmalar and SubmalarNon-surgical rhinoplasty

Subcutane-ous

2.5 % Agarose (High density)0.5 % non crossed-linked HA97 % sterile saline

Needle: 27 G

100 % Natural and biodegradable injectable implant; Algeness® is composed of an Agarose gel, totally biocompatible to the human body. Instant volume: "What you see, is what you get". Algeness® does not containing cross-linked synthetic chemicals (BBde) associated with Hyaluronic Acid (HA) fillers. durabilty: 8–12 months and longer

algeness® df 3.5 %


deep volumetric fillingCheeks , jawline and chinNasolabial foldsmalar-zygomatic archSubmalarNon surgicalnose rhinoplasty

deep soft tissuesupra-perio-steal

3.5 % Agarose (High density)0.4 % non crossed-linked HA96.1 % sterile saline

Needle: 27 G

100 % Natural and biodegradable injectable implant; Algeness® is composed of an Agarose gel, totally biocompatible to the human body. Instant volume: „What you see, is what you get“. Algeness® does not containing cross-linked synthetic chemicals (BBde) associated with Hyaluronic Acid (HA) fillers. durabilty: 8–12 months and longer

BELOTERO® Intense

merz aesthetics deep wrinkles, volume creation, contour compen-sation

mid and deep dermis

25.5 mg/ml dyna-mically multi-cross-linked HA (CPm®-technology)

Needle: 27 G 1/2

highly viscose gel, well tolerated, available with lidocaine

crystalys luminera derm ltd.

designed to restore facial volume and natural contours by promoting generation and deposition of natural collagen, the body‘s physiological soft tissue filler.

deep dermis Calcium Hydroxya-patite (55.7%) microspheres of a diameter of 25–45 microns

Needle: 25 G or 27 G thin-wall

the calcium hydroxyapatite microspheres form a scaffold supportive of fibroblast ingrowth,which, in turn, produces and deposits new collagen, a natural volumizing agent in facial regions. Calcium hydroxyapatite degradation is synchronous with neo-collagen deposition at the injection site, providing a lasting, natural, full and youthful look.Available with lidocaine as well.

fIllers for deep augmentatIon











hyabell® deep + lidocaine

adoderm gmbh Correction of deep folds deep dermis 20 mg/ml cross-linked hyaluronic acid plus 0.3 % lidocaine.

Needle:27 G

exceptionally soft injection: 12 N at G‘ with more than 300 Pa at 0.1 Hz.For a strong volume effect with medium aged patiens.

hydryalix deep luminera derm ltd.

Correction of deep facial folds, such as nasolabial and marionette folds

lower dermis 20 mg/ml HA, cross-linked (Bdde < 2 ppm). Presen-tation of 1.25 ml in each syringe.

Needle: 25 G or 27 G, thin

In our Hybrid moBitm technology, the gel is monophasic, fully homogenous, smooth and easy to inject. the particle nature of the gel gives the ability to mold the injected material to the desired shape in the tissue and gives the product its firmness. Also available with lidocaine

Juvéderm® ultra 4

allergan Inc. deep wrinkles, volume creation in lips and cheeks

deep dermis 24 mg/ml crosslinked HA (HYlACRoSS-technology™

Needle: 27 G 1/2


Juvéderm® VOLUMA

allergan Inc. Volume creation in the mid-face

upper peri-ostea

20 mg/ml cross-linked HA (VYCRoSS-technology™)

Needle: 27 G 1/2

Very long efficacy up to 24 months, excellent tissue integration and collagen neogenesis with lidocaine (0.3 %)

Juvéderm®

VOLIFTallergan Inc. mid and deep wrinkles deep dermis

(Recommen-dation: not intra dermal)

17.5 mg/ml cross-linked HA (VYCRoSS-technology™)

Needle: 30 G 1/2


PERFECTHA® Deep

sinclair pharma deep facial lines and skin depressions, lip volume, nose correction, nasolabial folds, marionette lines, oral commissures, cheekbones and chin moderate aug-mentation

deep dermis 20 mg/g hyaluronic acid, cross linking agent Bdde (< 1 % )

Needle: 27 G * 1/2''


PRINCESS®

VOLUMEcroma pharma Corection of deep wrinkles

and folds as well as sun-ken-in facial areas, facial contouring and volume expansion

deep dermis 2.3 % HA (23 mg/ml), also available with 0.3 % lidocaine

Needle: 27 G terumo 1/2", thin walled

Also applicable for reconstructive rteatments, i.e. lipoatrophy of the face, debilitating scars and morphologic asymmetry

Radiesse® merz aesthetics deep folds, volume crea-tion and contour definition, collagen stimulation

Subdermal, sub cutane-ous, supra periostal

Filler on Basis 70 % gel-matrix, 30 % microspheres, 25-45 µm

Needle: 27 G 1 1/4, 28 G 3/4, 25 G 1

low water retention, skin tightening





restylane® defyne

galderma deep wrinkles, light to moderate facial contouring (especially zygomatic bone, chin, mandibular contour)


20 mg/ml HA, gel with very high crosslinage and high calibration grade (Balance techno-logy)


moderate firm gel with high lifting capacity, available with lidocaine

restylane® lyft galderma deep wrinkles, light to moderate facial contouring (especially zygomatic bone, chin, mandibular contour)



Needle:29 G 1/2; Canula:23–25 G Pixl™, 25 G Pixl+

Firm gel with high lifting capacity, available with lidocaine

stylage® l laboratoires vIvacy

Correction of very deep and pronounced wrinkles in the entire region of the face

lower dermis 24 mg IPN cross-linked HA with anti-oxidant mannitol

Needles: 4 x 27 G 1/2‘‘


teosyal® deep lines

teoxane deep wrinkles and folds deep dermis 25 mg/g crosslinked HA

Needle: 27 G 1/2

moderate viscous gel, also available with lidocaine. estimated duration: 9 months

teosyal® rha 3

teoxane deep dynamic wrinkles deep dermis 23 mg/g cross-linked HA (RHA®-technology), Bdde crosslinker only 3.6 %

Needle: 27 G 1/2

especially for dynamic regions (nasolabial folds, marionette lines); with lidocaineestimated duration: 12–20 months

teosyal® ultimate

teoxane Volume recovery for wide areas (oval of the face, cheeks, temples)

Subcutane-ous and pre-periosteum

22 mg/g crosslinked HA

Needle: 27 G 1/2

moderate viscous volumizer, with good material distribution, also available with lidocaineestimated duration: up to 18 months

varIoderm plus

adoderm gmbh Strongly defined facial folds. moderate Volumi-sing.

deep dermis 18 mg/ml cross-linked hyaluronic acid. Approximate duration in the skin: 12-14 months.

Needle:27 G

exceptionally soft injection: 12 N at G´over = 600 Pa at 0.1Hz to give great volume effect over 12–14 months.

z fill deep2 zimmer medizin-systeme

Cheeks, nasolabial folds, marionette lines and men-tolabial folds. Improvement of facial contours and for volume expansion

mid and deep dermis

23 mg/ml highly crosslinked HA with Bdde

Needle: 27 G 1/2

thanks to the excellent visco-elastic properties, the gel can be injected with ease through a thin needle with utmost precision. estimated dura-tion: 8–12 months


fIllers for maxImum deep augmentatIon




algeness® df 3.5 %

advanced aesthetic technologies

deep volumetric filling Deep soft tissuesupra-perio-steal

3.5 % Agarose (High density)0.4 % non crossed-linked HA96.1 % sterile saline

Needle: 27 G

100 % Natural and biodegradable injectable implant; Algeness® is composed of an Agarose gel, totally biocompatible to the human body. Instant volume: „What you see, is what you get“. Algeness® does not containing cross-linked synthetic chemicals (BBde) associated with Hyaluronic Acid (HA) fillers. durabilty: 8–12 months and longer

BELOTERO® Volume

cheeks , jawline and chin

Volume creation Deep dermal, subcutane-ous, supra periostal

26 mg/ml dynamically multi-crosslinked HA (CPm®-technology)

Needle: 30 G 1/2; 27 G 1/2 Canula: 27 G/ 37 mm

Poly-densified, ductile gel. moderlieren. In comparison to other volumizers, well moldable. estimated duration: up to 18 months. Very well tolerated. Available with lidocaine

crystalys luminera derm ltd.

designed to restore facial volume and natural contours by promoting generation and deposition of natural collagen, the body‘s physiological soft tissue filler.

deep dermis Calcium Hydroxyapa-tite (55.7%) micros-pheres of a diameter of 25–45 microns

Needle: 25 G or 27 G thin-wall

the calcium hydroxyapatite microspheres form a scaffold supportive of fibroblast ing-rowth, which, in turn, produces and deposits new collagen, a natural volumizing agent in facial regions. Calcium hydroxyapatite degra-dation is synchronous with neo-collagen depo-sition at the injection site, providing a lasting, natural, full and youthful look. Available with lidocaine as well.

ellansé® s sinclair pharma For the lasting correction of wrinkles and facial aging. treatment areas: forehead, temple, brow area, nose sha-ping, malar augmentation, cheek, nasolabial folds, oral commissures, marionette lines, prejowl sulcus, mental crease, chin definition and jaw line

Subcutane-ous layer,supra-perios-teal layer

70 % Carboxyme-thylcellulose (CmC),30 % Polycaprolac-tone (PCl)

Needle: 27 G 3/4“

StAt technology™ – Sustained performance, tunable longevity and total bioresorbability. Collagen stimulator with instant correction and subsequent volume creation through neocolla-genesis; estimated duration of 1 year

ellansé® m sinclair pharma For the lasting correction of wrinkles and facial aging. treatment areas: forehead, temple, brow area, nose shaping, malar augmen-tation, cheek, nasolabial folds, oral commissures, marionette lines, prejowl sulcus, mental crease, chin definition and jaw line

Subcutaneous,supra peri-ostal


Needle: 27 G 3/4“

StAt technology™ – Sustained performance, tunable longevity and total bioresorbability. Collagen stimulator with instant correction and subsequent volume creation through neocolla-genesis; estimated duration of 2 years

ellansé® l sinclair pharma For the lasting correction of wrinkles and facial aging. treatment areas: forehead, temple, brow area, nose shaping, malar augmen-tation, cheek, nasolabial folds, oral commissures, marionette lines, prejowl sulcus, mental crease, chin definition and jaw line

Subcutaneous layer, supra-periosteal layer


Needle: 27 G 3/4“


ellansé® e sinclair pharma For the lasting correction of wrinkles and facial aging. treatment areas: forehead, temple, brow area, nose shaping, malar augmen-tation, cheek, nasolabial folds, oral commissures, marionette lines, prejowl sulcus, mental crease, chin definition and jaw line

Subcutaneous layer, supra-periosteal layer

70 % Carboxymethyl-cellulose (CmC),30 % Polycaprolac-tone (PCl)

Needle: 27 G 3/4“












hyabell® ultra + lidocaine

adoderm gmbh Volumising and correction of deep folds

subcutaneous 24 mg/ml cross-linked hyaluronic acid plus 0.3 % lidocaine.

Needle: 27 G

exceptionally soft injection: 19N at G´more than 700 Pa. to achieve an exellent volume effect and lifting features of the skin.

hydryalix ultra deep

luminera derm ltd.

the product is indicated for the correction of deep facial wrinkles and folds such as nasolabial folds and for facialcontours remodeling.

deep dermis, subcutaneous and/or at the pre-periosteal area




perfectha® subskin

sinclair pharma Volume creation, facial contours, malar areas, chin and cheeks, nose bridge, hands

Subcutaneous or supraperi-osteal


Needle: 21 G x 50 mm needle + 21 G x 50 mm cannula


radiesse® merz aesthetics deep folds, volume crea-tion and contour definition, collagen stimulation

Subdermal, sub cutane-ous, supra periostal

Filler on Basis 70 % gel-matrix, 30 % microspheres, 25–45 µm

Needle: 27 G 1 1/4, 28 G 3/4, 25 G 1

low water retention, skin tightening

Juvéderm® ultra 4

allergan Inc. deep wrinkles, volume creation in lips and cheeks

Deep dermis 24 mg/ml crosslinked HA (HYlACRoSS-technology™)

Needle: 27 G 1/2


Juvéderm® VOLUMA

allergan Inc. Volume creation in the mid-face

upper peri-ostea

20 mg/ml cross-linked HA (VYCRoSS-technology™)

Needle: 27 G 1/2

Very long efficacy up to 24 months, excellent tissue integration and collagen neogenesis with lidocaine (0.3 %)

Juvéderm® VOLIFT

allergan Inc. mid and deep wrinkles Deep dermis (Recommen-dation: not intra dermal)

15 mg/ml crosslinked HA (VYCRoSS-technology™)

Needle: 30 G 1/2


Restylane® Volyme

galderma Volume creation (espe-cially in the temporal and zygomatic bone region, mandibular contour)

Subcutaneous to supra peri-ostal

20 mg/mlHA with high crosslinkage and high calibration grade (Balance tech-nology)


moderate soft gel with very high lifting capacity, available with lidocaine

Restylane® SubQ galderma Volume creation and strong facial contouring (chin an cheeks)

Subcutaneous to supra peri-ostal


Needle: 21 G; Canula: 21 G Pixltm

Strong lifting effect, available with lidocaine

SCULPTRA® sinclair pharma Volume creation of caved in areas, especially for correction of skin depressi-ons such as lines wrinkles and scars

Subcutane-ous,supra peri-ostal

150 mg Poly-l-lactic acid (PllA), 90 mg sodium car-boxymethyl cellulose, 127.5 mg progene free mannitol

Needle:26 G

Collagen stimulator with duration of up to 2 years





STYLAGE® XL laboratoires vIvacy

For volumetric lifting, volume extension of the cheek bones, treatment of facial contours and for treatment of fallen-in temples

Lower dermis til subcuta-neous

26 mg IPN cross-linked HA with anti-oxidant mannitol

Needle: 2 x 27 G 1/2‘‘,2 x 23 G 11/4‘‘


STYLAGE® XXL laboratoires vIvacy

For volumetric lifting of large and very large volu-mene defects as well as lipoathropy

Subcutaneous 21 mg IPN cross-linked HA with anti-oxidant mannitol, also available with lidocaine (0.3 %)

Needle:2 x 21 G 1 1/2‘‘;1 x 21 G / 50blunt canula, pricker

Highly cohesive and viscose for treatment of lipoatrophy and for volumetry

TEOSYAL® Ultimate

teoxane Volume recovery for wide areas (oval of the face, cheeks, temples)

Subcutaneous (superficial fat compart-ments)


Needle: 27 G 1/2

moderate viscous gel, volumizer with good material distribution, also available with lido-caine. estimated duration: up to 18 months

TEOSYAL® RHA 4

teoxane Volume in extended dynamic areas + cheeks + contours of the face

Subcutaneous and pre-periosteum

23 mg/g cross-linked HA (RHA®-technology), Bdde crosslinker only 4 %

Needle: 27 G 1/2

especially for volume creation in larger dynamic regions (cheeks, facial contouring); with lido-caine. estimated duration: 12–22 months

TEOSYAL® Ultra Deep

teoxane Volume in targeted areas + cheekbones + chin

Subcutaneous (pre-perios-teal)


Needle: 25 G 1

Firm gel with extra-long duration and excellent lifting effect, also available with lidocaine.estimated duration: 9–20 months

VARIODERM Subdermal

adoderm gmbh For optimum volumising at very deep folds. Ideal for dorsum, facial contouring and male patients.

Subdermal 27 mg/ml cross-linked hyaluronic acid. Approximate duration in the skin 14–18 months.

Needle: 27 G

exceptionally soft injection: 19 N at G‘more than 2000 Pa. longest duration volume effec with all fillers, more than 14 months with less injected product compared. Ideal when high volume is needed, male patients and facial contouring.





belotero® soft

merz aesthetics Correction of superficial wrinkles


Needle: 30 G 1/2


desIrIal® laboratoires vIvacy

For intradermal injectionen in the genital area and for treatment of vaginal dry-ness and other symptoms of vulvo-vaginal atrophy

depending on indication

IPN corsslinked HA Needle:2 x 30 G 1/2‘‘ 2 x 27 G 1/2‘‘

desirial is the first worldwide HA product licensed for intradermal injectionen in the genital area and for treatment of vaginal dryness and other symptoms of vulvo-vaginal atrophy (Ce)



Needle: 30 G 1/2


hydryal luminera derm ltd.

designed to enhance skin hydration and restore skinvitality, improve skin elas-ticity and achieve a natural glowing look.

According to the HA percentage-epidermal to mid-dermis*

non-cross linked hyaluronic acid in different concentra-tions: 20, 30 or 40 mg/ml hyaluro-nic acid. Contains mannitol.Presentation of 1.25 ml in each syringe. three syringes in a box.

Needle: 27 G thin-wall or 30 G thin-wall

Hydryal contains high concentration of hyaluro-nic acid that allows significant rehydration and revitalization.

*According to the HA percentage:Hydryal 2 %-dermal epidermal junction and the superficial dermisHydryal 3 %-superficial and mid-dermisHydryal 4 %-mid-dermis

Juvéderm® hydrate


upper dermis 13.5 mg/ml non-crosslinked HA with 0.9 % manitol

Needle: 30 G 1/6; 32 G

Good water binding capability, short duration

princess® rIch croma pharma enhancement of tonus and elasticity of the skin

Superficial dermis

2.3 % HA (18 mg/ml), 2 % glycerole (20 g/ml) non-crosslinked

Needle: 2 x 30 G 1/2, thin walled

Viscoelastic solution that replaces age-related loss of HA and enhances tonus and elasticity of the skin, and fills up fine wrinkles such as crows feet, laugh lines or smoker's lines around the mouth

restylane® skinbooster™

vital

galderma Improvement of skin mois-ture, skin texture and skin elasticity; especially for mature and actinic skin


29 G tWN Smart Click System; 30 G Pixl™ or Injector

Strong water retention capability, well tolerated

restylane® skinbooster™ vital light

galderma Improvement of skin moisture, skin texture and skin elasticity; especially younger and thin, sensitive skin

Subcutaneous 12 mg/ml stabilized HA (NASHA tech-nology)

29 G tWN Smart Click System; 30 G Pixl™ or Injector

Strong water retention capability, well tolerated

stylage® hydro laboratoires vIvacy

For mesotherapeutic treatments and restora-tion of skin moisture and improvement elasticity and firmness of the tissue

Superficial dermis

14.0 mg non-cross-linked HA

Needle:2 x 30 G 1/8‘‘

Very long molecule chains (ca. 1.0 mdalton) for long durability

stylage® hydromax

laboratoires vIvacy

For mesotherapy and intense hydration of the skin. longlasting (4–6 months)

mid dermis 12.5 mg lightly crosslinked HA with antioxidant sorbitol

Needle:2 x 30 G 1/8‘‘

Very long molecule chains (ca. 1.0 mdalton) for long durability

teosyal® meso teoxane Hydration of the face, neck and decolleté

epidermal und intrader-mal

15 mg/g non-cross-linked HA

Needle: 30 G 1/2

Soft gel with recommended treatment protocol

specIal IndIcatIon: sKInsurface, mesotherapy and sKInboosters


specIal IndIcatIon: lIps




algeness® hl 1.5 %


marionette lines, fine wrinkles, lip augmentation and contouring, oral com-missures, oro-mandibular wrinkles

Immediately subcutaneous

1.5 % Agarose (low density), 98.5 % sterile saline solution

Needle: 30 G

100 % Natural and biodegradable injectable implant; Algeness® is composed of an Agarose gel, totally biocompatible to the human body and does not containing cross-linked synthetic chemicals (BBde) associated with Hyaluronic Acid (HA) fillers. durabilty: 4–8 months and longer

belotero® balance

merz aesthetics mid-deep wirnkles, lip aug-mentation and lip contour

mid dermis 22.5 mg/ml dynamically multi-crosslinked HA (CPm®-technology)

Needle: 27 G 1/2; 30 G 1/2

medium viscose poly-densified cohesive gel. Very good tissue integration, almost no water retention. estimated duration: 12 months. Very well tolerated, available with lidocaine

belotero® Intense

merz aesthetics deep wrinkles, volume creation, contour compen-sation

mid and deep dermis

25.5 mg/ml dyna-mically multi-cross-linked HA (CPm®-technology)

Needle: 27 G 1/2

highly viscose gel, well tolerated, available with lidocaine

hydryalix lips luminera derm ltd.

the product is indicated for lips contour and volume.

mid and deep dermis

20 mg/ml HA, cross-linked (Bdde < 2 ppm). Presentation of 1.25 ml in each syringe.two syringes in a box.






TEOSYAL® “Redensity [I]”

teoxane Beauty booster for redensi-fication and hydration of the skin as well as preven-tion of the signs of ageing (face, neck and decolleté)

epidermal and intra dermal

15 mg/g non-cross-linked HA combined with 8 amino acids, 3 antioxidants, zink, copper and vitamin B6 (patented "nutri-ents supplemented buffer")

Needle: 30 G 1/2

Well tolerated, with lidocaine

VARIODERM Mesolift

adoderm gmbh skinbooster, superficial folds, face, neck, decolleté, back of hand

superficial dermis

12,8 mg/ml not-cross-linked hyalu-ronic acid, approxi-mate duration in the skin 3 months.

Nedle: 30 G

not-cross-linked HA for hydrating skin

Z Fill refresh2 zimmer medizin-systeme

mesotherapy of the face, neck, decolleté, dorsum oth the hands and upper arm

upper dermis 18 mg/ml non-crosslinked HA. Stabilizer: Glycerin

Needle: 30 G 1/2

this with the additional actve ingredient glycerin enriched HA produces a long-lasting increase of skin moisture. estimated duration: 3 –4 months





Juvéderm® ultra 3

allergan Inc. mid and deep wrinkles, lip contour and lip volume

lips mucosa 24 mg/ml crosslinked HA (HYlACRoSS-technology™)

Needle: 27 G 1/2

Smooth gel, duration nasolabial 12 months, with lidocaine (0.3 %)

Juvéderm®

ultra 4allergan Inc. deep wrinkles, volume

creation in lips and cheekslips mucosa 24 mg/ml crosslinked

HA (HYlACRoSS-technology™)

Needle: 27 G 1/2


Juvéderm® ultra smIle

allergan Inc. mid and deep wrinkles, lip contour and lip volume


Needle: 30 G 1/2





Needle: 30 G 1/2


perfectha® derm

sinclair pharma medium facial lines and skin depressions, glabellar lines, lip contour

mid-dermis 20 mg/g hyaluronic acid, cross linking agent Bdde (< 1 % )

Needle: 30 G * 1/2''


perfectha®

deepsinclair pharma deep facial lines and skin

depressions, lip volume, nose correction, nasolabial folds, marionette lines, oral commissures, cheekbones and chin moderate aug-mentation

deep dermis 20 mg/g hyaluronic acid, cross linking agent Bdde (< 1 % )

Needle: 27 G * 1/2''


prIncess® fIller

croma pharma Correction of superficial and moderate deep facial wrinkles as well as perioral wrinkles, lip contours and increase of lip volume

middle to deep dermis

2.3 % HA (23 mg/ml), also available with 0.3 % lidocaine

Needle: 2 x 27 G terumo 1/2", thin walled

Princess® Filler is a sterile, viscoelastic, completely clear, colourless, isotone, homogenised gel implant

restylane® Kysse

galderma lip volume, lip contour lip vermilion, submucosa

20 mg/ml HA, gel with moderate crosslinkage and low calibration grade (Balance techno-logy)

Needle: 30 G 1/2

moderate soft gel with moderate lifting capacity, available with lidocaine

stylage® lIps laboratoires vIvacy

lip volume, correction of disproportional upper and lower lips, definition and/or correction of lip contour, filling of fine lines above the upper lip, restoration of lip moisture

lip mucosa 18.5 mg IPN cross-linked HA with added antioxidans manni-tol, also available with lidocaine (0.3 %)

Needle: 2 x 30 G 1/2‘‘

estimated duration: ca. 12 months

teosyal® Kiss teoxane Harmonization of lip volume, lip contour and hydration of the lips

labial mucosa


Needle: 27 G 1/2

moderate viscous gel, estimated duration: up to 9 months

teosyal® rha 2

teoxane moderate dynamic wrink-les, also universally for all indications, except tear trough

mid-dermis 23 mg/g cross-linked HA (RHA®-technology), Bdde crosslinker only 3.1 %

Needle: 30 G 1/2

especially for dynamic regions (forehead, glabella); with lidocaine. estimated duration: 9–18 months

teosyal® rha 3

teoxane deep dynamic wrinkles deep dermis 23 mg/g cross-linked HA (RHA®-technology), Bdde crosslinker only 3.6 %

Needle: 27 G 1/2

especially for dynamic regions (nasolabial folds, marionette lines); with lidocaineestimated duration: 12–20 months

z fill contour2 zimmer medizin-systeme




Needle: 27 G 1/2



specIal IndIcatIon: vagInal reJuvenatIon




desIrIal® laboratoires vIvacy

For intradermal injectionen in the vaginal area and for treatment of vaginal dry-ness and other symptoms of vulvo-vaginal atrophy

Depending on indication

19 mg IPN corss-linked HA

Needle:2 x 30 G 1/2‘‘, 2 x 27 G 1/2‘‘

desirial is the first worldwide HA product licensed for intradermal injectionen in the genital area and for treatment of vaginal dryness and other symptoms of vulvo-vaginal atrophy (Ce)

DESIRIAL® PLUS laboratoires vIvacy

Certified for vaginal surgi-cal, volumetric treatments (i.e. clitoris and g-spot injections, labial modelling

Depending on indication

21 mg IPN corss-linked HA

Needle:2 x 30 G 1/2‘‘,1 x 18 G 80 blunt canula

Polydensified, plastic gel. Compared to other volumizers, well modable

specIal IndIcatIon: under eye/teartrough




TEOSYAL® “Redensity [II]”

teoxane tear trough and eye circle Pre-periostal, deep sub-orbicular

Semi-crosslinked HA 15 mg/g. A mix of crosslinked and non-crosslinked HA (added with paten-ted "nutrients sup-plemented buffer")

Needle: 30 G 1/2

especially developed for the eye region, low water retention. estimated duration: 9–12 months, with lidocaine

110 CoSmetIC medICINe 2.17 Industry news

harmonyca: the synergy of calcium hydroxyapatite and hyaluronic acid

In addition to cosmetic use, filler mate-rials are frequently employed for recon-struction of contour defects. Scars and tissue defects after accidents, surgery and irradiation are also ideal indications for injectables. the ideal filler should be easy to inject, easy to form, and should have a long lasting effect. Syn-thetic fillers such as calcium hydroxya-patite (CaHA), provide initial volume replacement but have an additional biostimulatory effect to supplement facial volumization and lifting.

HArmonyCa is one of the few resorb-able fillers on the market that imme-diately replenishes lost volume while at the same time stimulating the pro-duction of the skin’s natural collagen for long-lasting results. HArmonyCa is a unique product because it provides both replacement volume and collagen biostimulation as a primary mechanism of action. In addition, it is biodegradable and reabsorbed naturally by the host’s metabolic processes.

HArmonyCa is based on a composite matrix of cross-linked hyaluronic acid embedding calcium hydroxyapatite micro-spheres, thus providing a strong volumiz-ing, lifting effect. the synergy of two in one HArmonyCa combines hydroxyapatite and hyaluronic acid dermal fillers in one syringe.

Calcium hydroxyapatite is added dur-ing the cross-linking process, generating a stable, inseparable gel. due to both cal-cium hydroxyapatite and hyaluronic acid properties, HArmonyCa provides a syner-gistic effect with long lasting results. due to the combination of both active ingredi-ents, collagen stimulation is higher than the use of each ingredient alone. Calcium hydroxyapatite stimulates new natural collagen production, while hyaluronic acid forms a supporting extracellular matrix, modulating proliferation of the fibroblasts.

the presence of hyaluronic acid elevates skin hydration and moisture, while also embedding the calcium hydroxyapatite, which can prevent microspheres aggregation and disper-sion, keeping the microspheres within their desired location.

addItIonal advantages

HArmonyCa is susceptible to hyaluroni-dase. the hyaluronic acid gel component can be completely dissolved thus break-ing the composite matrix infrastructure, which is 70 % of the compound’s vol-ume. Compared to other fillers, there are reduced side effects, such as burning sensation, edema and erythema thanks to the unique qualities and low level of osmolarity.

morphology

the hyaluronic acid is of non-animal ori-gin, biocompatible and biodegradable. consisting of 55.7 % CaHA microspheres (diameter of 25–45 µm), that are strongly embedded within high-quality cross linked Hyaluronic Acid (Bdde < 2 ppm) as well as a phosphate buffer. the micro-sphere size and smoothness enable easy extrusion and reduced friction flow from the syringe into the treated site.

the microsphere diameter mini-mizes risk of particle migration and

phagocytosis, which, in addition to the microspheres’ integration within a net of cross-linked Hyaluronic Acid, ensures a smooth appearance.

Sea water osmolarity is ~ 1000 mosm/kg, and the osmolarity of CaHA dermal fillers reaches ~2000 mosm/kg, a trait that generates a strong burning sensa-tion. In comparison, HArmonyCa osmo-larity is ~300 mosm/kg, similar to that of physiological saline at ~250 mosm/kg, this allows us to minimize pain and side effects.

HArmonyCa is produced in a manu-facturing facility operating under strict ISo9001 & ISo13485 conditions and is provided in a 1.25 ml prefilled graduated syringe, it is also available with lidocaine. It is a patent pending promising product and is considered to be the new genera-tion of dermal fillers.

Besides the immediate filling effect, HArmonyCa has the exceptional capa-bility to trigger the creation of collagen fibres. these fibres not only lead to a fill-ing effect, as with usual fillers, but also lead to lifting effect over a very long period.

further Information: luminera derm ltd

1 Bat Sheva St., lod, Israel

[email protected]

www.luminera.com

save the date!

3rd escad sprIng course

Saturday May 5th 2018, Budva - MontenegroWe will meet again after the end of the eAdV Spring Symposium in Budva

For further Information: the offi ce, via San Nicolò, 14, 34121 trieste (tS) Italy

tel. +39 040 368343eSCAdsecretariat@theoffi ce.it, www.escad.org


teosyal® rha 4* receives the anti-aging & beauty trophy as

„best dermal fIller“

We are delighted to receive this award and would like to thank our excellent research and development department in Geneva,” said Carolin marx, manag-ing director of teoXANe lABoRAtoRIeS Germany.

teoSYAl® RHA4* from teoXANe is a highly cross-linked hyaluronic acid of the next generation, which for the fi rst time supports the skin and tissue in every movement and thus preserves vitality and elasticity. Behind this is the realization that not only static features, but also the dynamics of a face contrib-ute signifi cantly to its attractiveness and uniqueness. teoSYAl® RHA4 is specially designed for volume build-up in certain regions such as the chin, zygomatic bone, temples or jawline. the results are natu-ral and immediately visible. once injected by the doctor, the hyaluron gel smoothes wrinkles from the inside, supports the tis-sue and restores the skin’s elasticity. the face gets a new elasticity and at the same time preserves its liveliness and natural radiance. Another plus point: the prod-uct is not perceptible and palpable, but becomes one with the dermal structure.

teoXANe has developed four products for diff erent facial areas and indications with its teoSYAl®RHA line. the fi ll-ers are particularly suitable for dynamic areas such as the mouth region, cheeks, nasolabial folds, forehead, crow’s feet,

but also for the neck and décolleté. the line comprises four diff erently cross-linked products: RHA1 for superfi cial and fi ne wrinkles, RHA2 for moderate wrinkles and the mouth region, RHA3 for deep wrinkles and RHA4 for volume in extended areas.

teoXANe laboratories, based in Geneva, specializes in the development and manufacture of hyaluronic acid-based products for aesthetic medicine and is now one of the market leaders in this fi eld/innovative products for wrinkle treatment.

further Information: For further Information:

teoXANe deutschland GmbH

Am lohmühlbach 17

85356 Freising

www.teoxane.com

*teosyal rha® 4 is a medical device (class

III) with ce certifi cation (ce0086) according

to this regulation.

CoSmetIC medICINe 2.17 calendar 112

11th annual atlanta oculoplastIc symposIum

18. January, 2018, atlanta ga –usa

for further information: SeSPRS Southeastern Society of Plastic and Reconstructive Surgeons Phone: +1 (435)901 2544 [email protected] www.sesprs.org

34th annual 2018 atlanta breast surgery symposIum

19.–21. January 2018, atlanta ga – usa

for further information: SeSPRS Southeastern Society of Plastic and Reconstructive Surgeons Phone: +1 (435) 901 2544 [email protected] www.sesprs.org

aacs annual meetIng 2018

1.–3. february 2018, las vegas nv – usa

for further information: American Academy of Cosmetic Surgery Phone: +1 312 981 6760 www.cosmeticsurgery.org

Imcas world congress 2018

1.–3. february 2018, paris – france

for further information: ImCAS C/o Check-up SANte Phone: +33 1 40 73 82 82 www.imcas.com

76th annual meetIng aad

16.–20. february 2018, san dIega ca – usa

for further information: American Academy of dermatology Phone: +1-847-330-0230 [email protected] www.aad.org

3rd InternatIonal dermato-logy and cosmetology congress (Indercos 2018)

14.–17. march 2018, Istanbul – turkey

for further information:Figür Kongre & organsasyon Phone: + 90 212 381 46 00 [email protected]

Imcas amerIcas 2018

15.–17. march 2018, cartagena – colombia

for further information: ImCAS C/o Check-up SANte Phone: +33 1 40 73 82 82 www.imcas.com

16th aesthetIc & antI-agIng medIcIne world congress – amwc

4.–7. april 2018, monaco

for further Information: euromediCom Phone: +33(0)1 56 83 78 00 v1.euromedicom.com

38th aslms annual conference on energy-based medIcIne & scIence

11.–15. april 2018, dallas, tx – usa

for further Information: American Society for laser medicine and Surgery Phone: +1 (715) 845-9283 [email protected] www.aslms.org

the aesthetIc meetIng 2018

26. april – 1. may 2018, new york, ny – usa

for further Information:ASAPS American Society for Aesthetic Plastic Surgery Phone: +1 800 364 2147 [email protected]

Website: www.surgery.org

15tH eAdV SPRING SYmPoSIum3. - 6. may 2018, Budva - montenegro

For further Information: european Academy of dermatology and Venerology Website: www.eadv.org

outlook next issue:

Spider veins: the art of sclerotherapy

Controversies in aesthetic medicine1. the frame conditions: Society and identity of the aesthetic working doctor

Guide of energy-Based-devices

Adoderm GmbHHaaslacher Weg 12bd-51063 Kölntel.: +49 (0)2173 1019180www.adoderm.de

Advanced Aesthetic technologies Inc. one Brookline Place, Suite 427Brookline, mA 02445, uSAwww.algeness.com

Allergan Inc.morris Corporate Center III 400 Interpace Parkway Parsippany, NJ 07054 tel.: +1 (862)261 7000www.juvederm.com

Croma Pharma GmbH Cromazeile 2 A-2100 leobendorftel.: +43 (0)2262 68468www.at.croma.at

Galderma International S.A.S.Galderma-Q-med S.A.S.tour europlaza – la défence 420, Avenue André ProthinF-92927 la defense Cedextel.: +33 (0)1588 64500www.galderma.comwww.restylane.com

laboratoires VIVACY44, rue Paul ValéryF-75116 Paristel.: +33 (0)156 900808www.vivacy.eu

luminera derm ltd.1 Bat Sheva Streetlod, Israeltel.: 972 722 744141www.luminera.com

merz Pharmaceuticals GmbHeckenheimer landstrasse 100d-60318 Frankfurt am maintel.: +49 (0)69 1503 -0www.merz-aesthetics.de

Sinclair Pharma GmbH44-46 rue de la BienfaisanceF-75008 Paristel: +33 (0)173 283400www.sinclairpharma.dcom

teoxane France25 Boulevard malesherbesF-75008 Paristel.: +33 (0)144 408890www.teoxane.com

Zimmer medizinSysteme GmbHJunkersstraße 9d-89231 Neu-ulmtel.: +49 (0)731 9761-0www.zimmer.de

“Cosmetic Medicine” is the new English language journal of it’s sister „Kosmetische Medizin“, the leading publication in Aesthetic Derma-tology and it’s neighboring fi elds in the German speaking countries and offi cial publication of 6 societies. „Cosmetic Medicine“ is publis-hed quarterly under the auspices of Prof. Uwe Wollina and distributed as PDF via e-mail, as well as online. The members of CDSI – Cosme-tic Dermatology Society of India and Network GlobalHealth including Network Lipolysis and Network Meso receive the journal automati-cally. The printed version can also be obtained against a surcharge plus postage and handling.

We have also unlocked the homepage www.cosmeticmedicine-online.com. So, please have a look at that as well.

We hope to bring you many new ideas and trends and with our articles give you new insights and support for your daily work. We also invite you to submit articles thus sharing your knowledge with colleagues around the world. Do let us know your opinion on the contents and give us some feedback.

I invite you to register to receive your free subscription.Please visit www.cosmeticmedicine-online.com

Yours sincerely,

Douglas GrossePublisher

Offi cial publication of the following societies:Academy of Associated Dermatologic Institutes (AADI)Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS)Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA)Federation of Aesthetic Dermatology and Laser Medicine (VDL) German Society of Aesthetic Botulinum Toxin Therapy (DGBT)German Society of Aesthetic Dermatology (DGAED)Network Globalhealth

INTERNATIONAL ISSUE OF THE JOURNAL KOSMETISCHE MEDIZIN, 36. JAHRGANG, 2015, ISSN 1430-4031

1.2015

NEW TRENDS IN RHINOPLASTY

ETHNIC CONSIDERATIONS FOR THE FACIAL AESTHETIC USES OF BOTULINUM TOXIN:

AN ASIAN PERSPECTIVE

BODY DYSMORPHIC DISORDERS: AN UNDERESTIMATED PROBLEM WITHIN

AESTHETIC DERMATOLOGY PATIENTS

C O S M E T I CMEDICINE

I invite you to register to receive your free subscription.

Academy of Associated Dermatologic Institutes (AADI)Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS)Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA)Federation of Aesthetic Dermatology and Laser Medicine (VDL) German Society of Aesthetic Botulinum Toxin Therapy (DGBT)

2015

KosmetischeMEDIZIN Organschaften: arbeitsgemeinschaft Kosmetik und Dermatologische Institute e.V.

austrian academy of cosmetic surgery & aesthetic Medicinecosmetic Dermatology society of IndiaDeutsche gesellschaft für Ästhetische Botulinumtoxin-therapie e.V.

Deutsche gesellschaft augmentation und faltentherapie e.V.

network-globalhealthÖsterreichische gesellschaft für Kosmetische Dermatologie und altersforschung

Vereinigung für ästhetische Dermatologie und Lasermedizin e.V.

CosmetiC mediCine, 36. Jahrgang, 2015, issn 1430-4031

1.15

HautkarotINoIDE als MarkErsubstaNZEN fur ErNäHruNg uND strEssraDIalE stosswEllEN-tHErapIE bEI CEllulItE uND lyMpHöDEMEN

DIE soZIalE MaCHt DEr sCHöNHEIt

tHErapEutIsCHE aspEktE voN vItaMIN a als HautpflEgE-prograMM

CO

SM

ET

ICM

EDIC

INE

www.kosmetischemedizin-online.de www.cosmeticmedicine-online.com

KM_Abstacts_2016.indd 3 04.04.17 13:53

“Cosmetic Medicine” is the new English language journal of it’s sister „Kosmetische Medizin“, the leading publication in Aesthetic Derma-tology and it’s neighboring fi elds in the German speaking countries and offi cial publication of 6 societies. „Cosmetic Medicine“ is publis-hed quarterly under the auspices of Prof. Uwe Wollina and distributed as PDF via e-mail, as well as online. The members of CDSI – Cosme-tic Dermatology Society of India and Network GlobalHealth including Network Lipolysis and Network Meso receive the journal automati-cally. The printed version can also be obtained against a surcharge plus postage and handling.

We have also unlocked the homepage www.cosmeticmedicine-online.com. So, please have a look at that as well.

We hope to bring you many new ideas and trends and with our articles give you new insights and support for your daily work. We also invite you to submit articles thus sharing your knowledge with colleagues around the world. Do let us know your opinion on the contents and give us some feedback.

I invite you to register to receive your free subscription.Please visit www.cosmeticmedicine-online.com

Yours sincerely,

Douglas GrossePublisher

Offi cial publication of the following societies:Academy of Associated Dermatologic Institutes (AADI)Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS)Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA)Federation of Aesthetic Dermatology and Laser Medicine (VDL) German Society of Aesthetic Botulinum Toxin Therapy (DGBT)German Society of Aesthetic Dermatology (DGAED)Network Globalhealth

INTERNATIONAL ISSUE OF THE JOURNAL KOSMETISCHE MEDIZIN, 36. JAHRGANG, 2015, ISSN 1430-4031

1.2015

NEW TRENDS IN RHINOPLASTY

ETHNIC CONSIDERATIONS FOR THE FACIAL AESTHETIC USES OF BOTULINUM TOXIN:

AN ASIAN PERSPECTIVE

BODY DYSMORPHIC DISORDERS: AN UNDERESTIMATED PROBLEM WITHIN

AESTHETIC DERMATOLOGY PATIENTS

C O S M E T I CMEDICINE

I invite you to register to receive your free subscription.

Academy of Associated Dermatologic Institutes (AADI)Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS)Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA)Federation of Aesthetic Dermatology and Laser Medicine (VDL) German Society of Aesthetic Botulinum Toxin Therapy (DGBT)

2015

KosmetischeMEDIZIN Organschaften: arbeitsgemeinschaft Kosmetik und Dermatologische Institute e.V.

austrian academy of cosmetic surgery & aesthetic Medicinecosmetic Dermatology society of IndiaDeutsche gesellschaft für Ästhetische Botulinumtoxin-therapie e.V.

Deutsche gesellschaft augmentation und faltentherapie e.V.

network-globalhealthÖsterreichische gesellschaft für Kosmetische Dermatologie und altersforschung

Vereinigung für ästhetische Dermatologie und Lasermedizin e.V.

CosmetiC mediCine, 36. Jahrgang, 2015, issn 1430-4031

1.15

HautkarotINoIDE als MarkErsubstaNZEN fur ErNäHruNg uND strEssraDIalE stosswEllEN-tHErapIE bEI CEllulItE uND lyMpHöDEMEN

DIE soZIalE MaCHt DEr sCHöNHEIt

tHErapEutIsCHE aspEktE voN vItaMIN a als HautpflEgE-prograMM

CO

SM

ET

ICM

EDIC

INE

www.kosmetischemedizin-online.de www.cosmeticmedicine-online.com

KM_Abstacts_2016.indd 3 04.04.17 13:53

The new website with current trends in aesthetic dermatology and surgery is now online.

Best practice and innovations in research, practice and industry are now retrievable. You

also have access when travelling, because the pages are customized for tablet

and smartphone.

For members of our societies and subscribers registration and use are free of charge.

Register now:

www.cosmeticmedicine-online.com

gmc – Gesundheitsmedien und Congress GmbHBrandenburgische Straße 46, 10707 Berlintel.: +49 (0)30 52664885, Fax: +49 (0)30 52667191

Official publication of the following societies:Academy of Associated Dermatologic Institutes (AADI) Austrian Academy of Cosmetic Surgery and Aesthetic Medicine (AACS) Austrian Society of Dermatologic Cosmetics and Research on Aging (OGDKA) Federation of Aesthetic Dermatology and Laser Medicine (VDL) German Society of Aesthetic Botulinum Toxin Therapy (DGBT) German Society of Aesthetic Dermatology (DGAED) Network Globalhealth

InternatIonal Issue of the Journal KosmetIsche medIzIn, Volume 3, ISSN 2366-0554

1.2017

cellulIte treatment usIng an nd:Yag

10 Years aesthetIc mesotherapY of the networK-aesthetIcmeso

epIdermal and dermal hIstologIcal characterIstIcs In response to hYdroporatIon

C o S m e t I CMedIcIne

laser GuIde 2017

onlIne

international issue of the journal kosmetische …...international issue of the journal kosmetische...

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