Background Inadvertent intra‐arterial injection of dermal fillers including calcium hydroxylapatite (CaHA) can result in serious adverse events including soft tissue necrosis, permanent scarring, visual impairment, and blindness. When intra‐arterial injection occurs, immediate action is required for optimal outcomes, but the infrequency of this event means that many physicians may never have experienced this scenario. The aim of this document is to provide evidence‐based and expert opinion recommendations for the recognition and management of vascular compromise following inadvertent injection of CaHA. Methods An international group of experts with experience in injection of CaHA and management of vascular complications was convened to develop a consensus on the optimal management of vascular compromise following intra‐arterial CaHA injection. The consensus members were asked to provide preventative advice for the avoidance of intravascular injection and to produce a treatment protocol for acute and delayed presentation. To ensure all relevant treatment options were included, the recommendations were supplemented with a PubMed search of the literature. Results For prevention of intra‐arterial CaHA injection, consensus members outlined the importance of a thorough knowledge of facial vascular anatomy and patient history, as well as highlighting potential risk zones and optimal injection techniques. Individual sections document how to recognize the symptoms of vascular occlusion leading to vision loss and tissue necrosis as well as detailed treatment protocols for the management of these events. For impending tissue necrosis, recommendations are provided for early and delayed presentations with treatment protocols for acute and follow‐up treatment. A separate section details the treatment options for open and closed wounds. Conclusions All physicians should be prepared for the eventuality of intra‐arterial injection of a dermal filler, despite its rarity. These consensus recommendations combine advice from aesthetic experts with the latest reports from the published literature to provide an up‐to‐date office‐based protocol for the prevention and treatment of complications arising from intra‐arterial CaHA injection.

Background As the treatment indications for the Cohesive Polydensified Matrix ® hyaluronic acid (CPM-HA) portfolio continue to expand and diversify, injectors new to the range or those who are expanding the treatments they offer may be unsure of the optimal product and injection technique for specific facial areas. Each product in the CPM-HA portfolio has been intentionally designed to provide the best physical properties for a specific indication and target tissue. This document has been developed to provide a comprehensive, one-stop reference for clinicians using the portfolio. Methods An international panel of experts in the field of aesthetic medicine convened to develop guidelines on effective and safe injection technique when performing treatments with the CPM-HA range of soft-tissue fillers. Results Consensus members considered treatment indications in the upper, middle and lower face. Landmark deficiencies and anatomical considerations are described for each indication and consensus recommendations provided on the optimal product, injection depth and treatment technique. This is supplemented by the experts advice on avoidance of complications. Throughout, an evidence-based approach to selection of products and injection techniques is provided. The result is a fully tailored approach to a range of indications covering the full portfolio of CPM-HA products, including the newest addition for skin revitalization. Conclusion The recommendations in this consensus document are provided to assist clinicians in the selection of CPM-HA products, administration techniques and depths of injection with the aim of providing seamless and natural treatment results, enhanced safety and patient satisfaction.

Calcium hydroxylapatite (CaHA) is a commonly used soft tissue filler for aesthetic facial improvement, in particular for the lower and mid-face. The golden standard for upper facial filler indications is hyaluronic acid (HA) injection. In this report we investigate the safety, efficacy and complication rates after injections of CaHA to the upper third of the face using a variety of different techniques. This was a retrospective analysis performed on patients who had received CaHA in 2016 and 2017 at various dilutions in the upper third of the face (frontal area, eyebrows and temporal hollows) using a number of injection techniques and both blunt-tipped cannulas as well as sharp needles. Records of adverse events and side effects were studied. Seventy patients had been injected with CaHA in the upper third of the face. There were 36 treatments to the frontal area, most with a cannula in the subgaleal space with standard dilution of CaHA (16.7% lidocaine containing epinephrine). There were 13 treatments to the brow, mostly with a cannula and multilevel technique, and 66 treatments to the temporal hollows, mostly with a cannula in the interfascial space with standard CaHA dilution. No serious complications were recorded. CaHA was effective and well-tolerated for a range of upper-face indications. More (prospective) research is required to further determine the value of CaHA treatments in these areas.

Background Relaxation of depressor muscles in the lower face with botulunim toxin A (BoNT-A) can create a lifting effect and dramatically improve jawline contour and resting facial expression. Even with the recent increase in interest in lower face rejuvenation, BoNT-A is a relatively under-recognized tool for treatment of this area. When treating the lower face, an understanding of anatomy and the relationship between the facial muscles is especially important, as injection patterns must be customized for consistently positive outcomes. Objectives To provide basic knowledge of the activities of the muscles in the lower face and neck and to describe the basis for injecting BoNT-A to create lift in this area. Expert guidance for injection is also provided. Methods As part of a continuing medical education (CME) course on differentiating botulinum toxin products, a panel of 4 expert physician injectors participated in a live webinar to discuss the implications of increasing toxin use. Results The practical guidance in this manuscript is based upon the most frequently requested information by audience members and the information considered critical for success by the authors. The authors outline the functional anatomy of the lower face most relevant for BoNT-A treatment and case studies as well as methods for patient evaluation and injection technique are also provided. Videos to show treatment planning and injection technique for the lower face and neck are included. Conclusions BoNT-A is an important non-surgical tool for creating lift in the lower face.

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