Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual... Abstract Background The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes. Objectives The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction. Methods An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection. Results Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days. Conclusions Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area. Level of Evidence: 4 The etiology of facial aging is complex and remains incompletely understood. Age-related changes in all anatomical layers of the face, including the underlying skeleton, soft tissues such as fat compartments and muscles, as well as the skin, interdependently contribute to the phenotype of the aging face.1-8 The perioral area (defined superiorly by the columella, laterally by the nasolabial folds and marionette lines, and inferiorly by the inferior aspect of the mental symphysis), is a region at particularly high risk for volume-loss and dynamic rhytid formation, especially in women.9-12 Our group has previously demonstrated that aging results in significantly increased dynamic perioral strain.13 Clinically, perioral aging is an increasingly frequent patient concern and one that has proven to be excessively difficult to treat in a natural manner.9-12 The most effective treatments for this region remain phenol croton oil peels, 14-17 CO2 laser resurfacing,4,16,18-22 fat grafting,23-25 and dermabrasion,26-29 all of which require significant down time for recovery. As such, efforts have focused on developing minimally invasive, low recovery, approaches to treat perioral aging.30-37 Prior studies of such approaches to the perioral area have been limited to single modality rejuvenation analyzed via subjective measurements. To address these limitations, we sought to objectively define the dynamic strain in the perioral area and evaluate the efficacy of a modest, minimally invasive, dual modality treatment to improve perioral strain with minimal patient downtime and significant patient satisfaction. We have previously pioneered and validated the use of 3-dimensional dynamic digital image correlation (DIC) to objectively and quantitatively measure dynamic facial strain and rhytids.38,39 We propose here to combine DIC perioral strain analysis with the FACE-Q survey,40-43 a validated instrument for measuring patient reported outcomes, in order to correlate objective strain measurements with patient satisfaction. Specifically, we wished to determine whether perioral aging could be significantly improved via conservative neuromodulation of the orbicularis oris muscle in combination with 1 cc of perioral hyaluronic acid filler placement and whether these treatments would result in appreciable strain and volumetric changes as well as patient satisfaction. METHODS A University of Pennsylvania IRB (Study #823351) approved prospective study of a dual modality treatment for perioral rhytids was performed. Patient Selection Female patients between the ages of 30 and 75 seeking treatment for clinically apparent perioral aging were prospectively recruited to participate in the study from February to May 2016 at the Hospital of the University of Pennsylvania, Division of Plastic Surgery. Following informed consent, baseline DIC measurements and FACE-Q evaluations were performed immediately pretreatment and repeated 14 days and 3 months after treatment. Patients who were unable to adhere to the study follow-up schedule or who received treatment outside the study protocol while in the study were excluded. Additional exclusion criteria included a history of facial neuromodulation or filler use within the past 12 months, medical contraindications to any products or materials used, as well as any patients with a history of significant facial trauma, surgery, or paralysis. FACE-Q Administration Handheld tablet devices were used to administer the FACE-Q instrument to all patientts at baseline. The individual sections of FACE-Q that were administered and scored in this study were: satisfaction with facial appearance overall; aging appearance appraisal; psychological well-being; social function; appraisal of lip lines; appraisal of marionette lines; appraisal of lines overall; satisfaction with lips; and satisfaction with lower face and jawline. Two days before the follow-up visits, all patients received an automated reminder email that also included a link for patients to repeat the FACE-Q survey prior to arriving in clinic. Patients who did not complete the survey prior to the follow up visits were provided a tablet device to do so while in the clinic waiting area during follow-up visits. The FACE-Q survey used for the 2-week and 3-month follow-up visits included four additional sections: late negative sequelae of the lips; late negative sequelae of the lower face and neck; early recovery life impact; and early recovery symptoms. These sections were used as an assessment aid for follow up care and counseling. Digital Image Correlation Following completion of the FACE-Q questionnaire, makeup was applied to the lower face of each patient. For sufficiently contrasting makers to be tracked by the ARAMIS (Trilion Quality Systems, Plymouth Meeting, PA) software, a white foundation and black speckle makeup was used (Figure 1). Airbrushed body paint was used for the white foundation. Patient positioning as well as camera setup and calibration were consistent across all patients and time points. Patients were recorded from a distance of 72 cm by two high-resolution cameras simultaneously. After a reference frame was taken with the face in a resting position, patients were instructed to smile, purse their lips, and frown over the course of 10 seconds at a rate of 10 frames per second for a total of 100 dynamic frames captured per patient at each visit. These images were directly imported into ARAMIS for data computation. The perioral area was defined by the following landmarks: columella superiorly, nasolabial folds and marionettes laterally, and mental protruberance inferiorly. ARAMIS software was used to calculate the displacement compared to the reference frame between all the speckle markers during facial animation (Video 1). ARAMIS also calculated strain as the per cent change in displacement between the markers, with the “mises” strain representing the vector sum of the strain in the x-, y-, and z-planes. Average mises strain over the oral commissures, cheeks, nasolabial folds, marionette lines, and chin, was calculated across all available frames. Changes in the magnitude of strain between day 14 and day 0 and between day 90 and day 0 were calculated for each of the study regions (Figures 2-3). Changes in facial volume were calculated in ARAMIS by overlaying the day 14 and day 90 images on the day 0 reference images for each patient (Figure 4). Volume changes were assessed with the patients at rest, making a neutral expression, and in the areas corresponding to the most common filler injection points: upper lip, nasolabial folds, marionette lines, and oral commissures. The protocol for imaging and data processing was consistent for each patient across all time points. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy060 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy060 Close Figure 1. View largeDownload slide Sample image of the perioral region after application of white foundation with black speckle makeup. The photograph is of a 47-year-old woman who presented with perioral rhytides and volume loss. Blue diamonds indicate the four Dysport injection sites to the upper and lower orbicularis oris muscle that were consistent across all patients. Each site was injected with 4.5 units of Dysport. Red X’s represent the injection sites for Restylane Silk. Figure 1. View largeDownload slide Sample image of the perioral region after application of white foundation with black speckle makeup. The photograph is of a 47-year-old woman who presented with perioral rhytides and volume loss. Blue diamonds indicate the four Dysport injection sites to the upper and lower orbicularis oris muscle that were consistent across all patients. Each site was injected with 4.5 units of Dysport. Red X’s represent the injection sites for Restylane Silk. Figure 2. View largeDownload slide A 53-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 2. View largeDownload slide A 53-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 3. View largeDownload slide A 46-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 3. View largeDownload slide A 46-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 4. View largeDownload slide A 53-year-old woman who presented with perioral rhytides and volume loss who was treated with 18 units of Dysport and 1 cc of Restylane Silk. Sample DIC image of a patient’s change in facial volume from day 0 to day 14. Areas in red indicate areas of increased facial volume, while areas in blue indicate areas of decreased facial volume. Figure 4. View largeDownload slide A 53-year-old woman who presented with perioral rhytides and volume loss who was treated with 18 units of Dysport and 1 cc of Restylane Silk. Sample DIC image of a patient’s change in facial volume from day 0 to day 14. Areas in red indicate areas of increased facial volume, while areas in blue indicate areas of decreased facial volume. Injection Technique Following baseline FACE-Q and DIC measurements, patients were evaluated by a single plastic surgeon (I.P.) for Glogau score and Fitzpatrick skin type. Each patient was then injected by a single surgeon (I.P.) with a total of 18 units of abobotulinumtoxinA (Dysport; Galderma Pharma S.A., Lausanne, Switzerland), followed by 1 cc of hyaluronic acid (HA) filler (Restylane Silk; Galderma Pharma S.A., Lausanne, Switzerland). Each patient was injected in the same manner with a total of 18 units of Dysport, diluted per standard manufacturer instructions. There were 4 injection points: left upper, right upper, left lower, and right lower cutaneous lip. All injection points were 2 to 3 mm away from the white roll. A total of 4.5 units (18/4) were injected into each of the 4 points at the depth of the orbicularis oris muscle. This injection pattern was the same for all patients regardless of their facial anatomy and degree of rhytid formation (Figure 1). Each patient was also subsequently injected with 1 cc of Restylane Silk, undiluted, to the perioral region. Each patient’s treatment was individualized to address the perioral site(s) most severely affected by volume loss, as determined by the single injector (I.P.). Potential injection sites included the nasolabial folds, lips, oral commissures, mental crease, and marionette lines. Similarly, the amount of filler injected into each site was tailored to each patient, while maintaining a total amount of 1 cc of HA injected to the perioral region (Figure 1). Each patient was evaluated before treatment as well as 2 weeks and 3 months after treatment. Statistical Methods Data were deidentified and entered into JMP (SAS Institute, Inc., Cary, NC) for analysis. Descriptive statistics were computed for the study population including mean (interquartile range) for continuous data and frequency (percentage) for categorical data. Per cent differences between pre- and posttreatment strain were compared using paired t tests. Comparisons were between postinjection day 0 and day 14 as well as between day 0 and day 90. ANOVA was used to determine if patient age, Glogau score, Fitzpatrick score, education level, or income level were associated with changes in strain, volume, or satisfaction. All tests were two-sided. A value of P ≤ .05 was utilized to determine statistical significance. RESULTS Demographics Thirty-two female patients participated in this study. The average age at time of injection was 51.7 years (range, 28.8-72.4 years). Two patients (6%) were classified as Fitzpatrick class I, eight (25.0%) as class II, fourteen (43.8%) as class III, seven (21.9%) as class IV, one (3.1%) as class V, and none as class VI. No patients were classified as Glogau class I, ten (31.3%) as class II, thirteen (40.6%) as class III, and nine (28.1%) as class IV. No patients had any complications or complaints as a result of the neurotoxin or filler injections. Fourteen days postinjection, the Glogau scale of patients were again evaluated by the senior author. None of the patients had a change in their Glogau class 14 days postinjection. DIC: Perioral Strain Reduction Of the 32 patients who presented for initial imaging and treatment, 29 (90.6%) returned for reimaging on day 14, and 25 (78.1%) returned for reimaging on day 90. Fourteen days postinjection, patients demonstrated statistically significant reductions in the magnitude of facial strain. Strain in the cheek decreased by 12.0% (P = 0.001), in the chin by 7.8% (P = 0.022), in the marionette lines by 17.0% (P < 0.001), in the nasolabial folds by 5.9% (P = 0.057), in the upper lip by 6.3% (P = 0.001), and in the perioral region as a whole by 9.3% (P = 0.001). The day 0 to day 14 reductions in strain were not associated with age (P = 0.596), Fitzpatrick score (P = 0.475), Glogau score (P = 0.144), education level (P = 0.201), or income level (P = 0.336). Strain reductions in each of the study regions varied among facial expressions but were most significant for small smile with a 15.6% reduction (P < 0.001). In addition to strain reduction, perioral rejuvenation was associated with a trend toward improved facial symmetry from day 0 to day 14. Facial strain symmetry improved by 1.3% in the cheek (P = 0.272), 0.5% in the chin (P = 0.378), 3.2% in the marionette lines (P = 0.008), 4.6% in the nasolabial folds (P = 0.010), 0.1% in the upper lip (P = 0.272), and 1.6% in the perioral region as a whole (P = 0.095) (Figure 5). Figure 5. View largeDownload slide Graphical depiction of facial strain from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Strain was significantly lower at day 14 in all study regions except the nasolabial folds (P = 0.057). Strain was significantly lower at day 90 in all study regions. Figure 5. View largeDownload slide Graphical depiction of facial strain from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Strain was significantly lower at day 14 in all study regions except the nasolabial folds (P = 0.057). Strain was significantly lower at day 90 in all study regions. Ninety days postinjection, patients continued to demonstrate statistically significant reductions in the magnitude of strain. Strain in the cheek decreased by 22.9% (P < 0.001), in the chin by 12.9% (P < 0.001), in the marionette lines by 17.2% (P < 0.001), in the nasolabial folds by 8.3% (P = 0.042), in the upper lip by 12.4% (P < 0.001), and in the perioral region by 15.0% (P < 0.001). The day 0 to day 90 reductions in strain trended with increasing age (P = 0.022), increasing level of income (P = 0.052), and increasing level of education (P = 0.095). Glogau (P = 0.109) and Fitzpatrick (P = 0.146) scores were not associated with strain reduction. Strain reductions in each of the study regions varied among facial expressions but were most significant for small smile with a 30.7% reduction (P < 0.001). There were no significant changes in facial strain symmetry from day 0 to day 90. Facial strain symmetry improved by 2.6% in the cheek (P = 0.137), 2.0% in the chin (P = 0.133), 0.2% in the marionette lines (P = 0.464), 2.5% in the nasolabial folds (P = 0.115), 0.8% in the upper lip (P = 0.137), and 1.7% in the perioral region (P = 0.175) (Figure 5). DIC: Volume Enhancement Fourteen days postinjection, patients demonstrated statistically significant increases in perioral volume. Volume increased in the nasolabial folds by 151.45 mm3 (P = 0.004), in the marionette lines by 138.29 mm3 (P = 0.006), in the upper lip by 98.10 mm3 (P = 0.004), and in the oral commissures by 362.26 mm3 (P < 0.001). Changes in volume were not associated with age (P = 0.327), Glogau score (P = 0.139), Fitzpatrick score (P = 0.149), education level (P = 0.115), or income level (P = 0.290) (Figure 6). Figure 6. View largeDownload slide Graphical depiction of facial volume changes from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Facial volume was significantly higher at day 14 in all study regions but returned to baseline by day 90. Figure 6. View largeDownload slide Graphical depiction of facial volume changes from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Facial volume was significantly higher at day 14 in all study regions but returned to baseline by day 90. Ninety days postinjection, only the increase in volume in the marionette lines remained statistically significant, with volumes in the other three regions returning close to baseline levels. Relative to baseline volume, the volume in the marionette lines increased by 91.59 mm3 (P = 0.039) and in the oral commissures by 154.30 mm3 (P = 0.071). The volume in the nasolabial folds decreased by 8.51 mm3 (P = 0.545) and in the upper lip by 5.56 mm3 (P = 0.541), relative to baseline. Changes in volume were not associated with age (P = 0.192), Glogau score (P = 0.320), Fitzpatrick score (P = 0.849), education level (P = 0.792), or income level (P = 0.438) (Figure 6). FACE-Q: Patient Satisfaction Of the 32 patients who completed the baseline FACE-Q, 29 (90.6%) completed the FACE-Q on day 14, and 28 (87.5%) completed it on day 90. Following perioral rejuvenation, patients were statistically significantly more satisfied with their overall facial appearance, both at day 14 and at day 90. Fourteen days posttreatment, patients on average were 22.2% (P = 0.014) more satisfied with their overall facial appearance as compared to baseline. In particular, patients were statistically significantly more satisfied with their appearance at end of day (36.8%, P < 0.001), freshness (48.9%, P < 0.001), restfulness (45.4%, P < 0.001), profile appearance (25.9%, P = 0.010), appearance in photos (40.2%, P = 0.003), appearance when waking up (37.9%, P = 0.006), and appearance under bright lights (51.7%, P < 0.001). Patients continued to be satisfied with their overall facial appearance 90 days posttreatment as the overall section score was 21.2% (P = 0.009) higher at day 90 than at day 0 (Table 1, Figure 7). Table 1. Patient Satisfaction With Facial Appearance as Measured by the FACE-Q at Day 14 and Day 90 (the overall domain score is depicted as well as the individual components of that domain) Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 View Large Table 1. Patient Satisfaction With Facial Appearance as Measured by the FACE-Q at Day 14 and Day 90 (the overall domain score is depicted as well as the individual components of that domain) Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 View Large Figure 7. View largeDownload slide Graphical depiction of patient satisfaction changes according to the FACE-Q from day 0 to day 14 to day 90 as a result of perioral rejuvenation. Figure 7. View largeDownload slide Graphical depiction of patient satisfaction changes according to the FACE-Q from day 0 to day 14 to day 90 as a result of perioral rejuvenation. Patients were also significantly more satisfied with specific areas of their facial appearance following perioral rejuvenation. Fourteen days posttreatment, patients were 38.7% (P = 0.018) more satisfied with the appearance of their lip lines, 59.7% (P = 0.001) more satisfied with the appearance of their marionette lines, 46.1% (P = 0.006) more satisfied with their overall lines, 23.4% (P = 0.098) more satisfied with their lips, and 44.0% (P = 0.021) more satisfied with their lower face and jawline, relative to pre-treatment. The average increase in patient satisfaction persisted 90 days posttreatment, but due to the variability in patient responses, the increases were not statistically significant (Table 1, Figure 7). In contrast, there were no significant differences in patients’ satisfaction with age appearance at day 14, 13.9% (P = 0.205), or at day 90, 3.7% (P = 0.715). There were no significant differences in patients’ psychological well-being at day 14, 4.5% (P = 0.491), or at day 90, −5.0% (P = 0.461). There were no significant differences in patients’ social function at day 14, 3.6% (P = 0.614), or at day 90, −3.7% (P = 0.602) (Table 1, Figure 7). At day 14, significant improvement in satisfaction with lower face and jawline was associated with increasing age (P = 0.020), education level (P = 0.048), and income level (P = 0.044) but not with Glogau (P = 0.747) or Fitzpatrick (P = 0.389) score. None of the demographic factors were significant predictors for the other FACE-Q sections. There were no significant associations between demographic factors and patient satisfaction at 90 days. DISCUSSION The perioral area is unique anatomical region of bony and soft tissue elements subject to dynamic forces resulting in complex rhytid formation and soft tissue atrophy with aging. Perioral rejuvenation remains one of the most challenging, complex, and controversial aspects of aesthetic surgery. Despite a strong demand and many proposed treatments for perioral rejuvenation, very little quantitative evidence exists for the directed treatment of this region. Skin resurfacing via ablative CO2 laser and deep chemoexfoliation treatments has been demonstrated to significantly improve perioral rhytids.44,45 However, the downtime associated with these procedures is substantial, and recovery can be complicated by persistent erythema, dyspigmentation and scarring, especially in darker Fitzpatrick skin types.44,45 While neuromodulation and HAs have been independently demonstrated to improve perioral rhytids, these procedures have largely been evaluated using subjective measurements.46-55 We previously demonstrated that digital image correlation allows for precise, quantifiable, and reproducible perioral strain measurements.38,39 This study expands our prior work by analyzing a specific dual injection therapy for improving dynamic perioral rhytid strain and volume by quantifying these dynamic variables during common facial expressions. Further, while Carruthers et al have previously reported success with combined neurotoxin and filler treatment of the lower face, this dual approach has yet to be analyzed in the objective, quantitative approach taken by this study.56 When applying DIC to study the dynamic face, it is important to understand the principle of strain. Strain is the percentage of change in the distance between two points that occurs with facial animation. This change is calculated by the Aramis system for every combination of black paint speckled points demarcated on the face during animation. The software allows the user to calculate the average strain associated with a given anatomic area. Strain is a vector measurement with two directions—positive or negative—and magnitude. Positive strain, an increase in the distance between the soft tissues, is termed stretch. Negative strain, a decrease in the distance between the soft tissues, is termed compression. The strain observed in the perioral region is largely negative because, during facial motion, the dynamic rhytids produced reflect the compression of skin and subcutaneous tissues secondary to mimetic muscle contraction. A patient with more prominent rhytids will have a greater magnitude of strain, as the increased compression of the tissues produces a deeper rhytid. The data reported here therefore describe reductions in the magnitude of strain secondary to neurotoxin and filler injection, or alternatively, the reduction in compression so that what is being captured clinically is the decrease in rhytid formation. Our previous study using DIC to assess reduction in glabellar rhytids following neuromodulator treatment also assessed reductions in the magnitude of the negative strain, or compression, observed in the glabella.39 The significant value of DIC in assessing outcomes following neuromodulator and filler treatment of the aging face is that it is a quantitative and objective assessment tool that can detect subtle but significant clinical improvements that may be appreciated by the naked eye, but missed by subjective scales. For example, none of the patients experienced an improvement in their Glogau class postinjection, which is not surprising given that there are only four broad, nonspecific, Glogau classes, with significant differences between them. The demographic factors assayed in this study included patient age, education level, income level, Glogau class, and Fitzpatrick class. The education and income levels were collected primarily to determine if they correlate with degree of patient satisfaction. The other three demographic factors were identified as potential predictors of the outcome metrics: patient satisfaction, strain reduction, and volume enhancement. To make our analyses consistent, we included regression analysis results for all the collected demographic factors for all three outcome metrics. Using DIC to quantitate perioral strain before and after conservative dual neuromodulation (18 units of abobotulinumtoxinA [Dysport]) and HA filler treatment (1 cc of Restylane Silk), we demonstrated a significant decrease in strain in the entire perioral region, upper lip vertical rhytids, marionette lines, and mental crease at both 14 and 90 days postinjection. The day 0 to day 90 strain reductions trended with increasing patient age (P = 0.022). These data confirm that older patients who experience more soft tissue atrophy and rhytid formation benefit more from the dual treatment than younger patients presenting with more subtle age-related changes. Strain reduction was accompanied by significant increases in perioral volume at day 14, which was only significantly maintained in the marionette lines at day 90. These result suggest that an HA filler may be metabolized more slowly in the marionettes than in other perioral sites, perhaps due to less direct mimetic activity in this region as compared to other perioral regions. Finally, patients of all ages were statistically significantly more satisfied with their overall facial appearance, at both day 14 and day 90, though patient satisfaction became increasingly variable at 90 days. This study demonstrates that neuromodulation in combination with conservative HA filler placement is effective in treating perioral aging with significant patient satisfaction. The importance of this study is multifold. The work demonstrates for the first time that: (1) even without complete correction, a significant and quantifiable improvement can be achieved in the perioral region with combined conservative injectables; (2) older patients may experience a more measurable correction than younger patients who present with a more mild age-related phenotype; and (3) HA volume may be better maintained in the marionettes as opposed to other perioral areas that may therefore require more frequent injections for consistent correction. The study is limited in part by the number of patients participating as well as the common cosmetic study patient drop-out rate, though the loss-to-follow-up rate in our study was lower than most. Further, although there was also no negative control group that received no treatment, we consider that the pretreatment assessment of patients served, in part, as their own controls to determine if the described technique for perioral rejuvenation is effective. This work is similarly limited in that we selected to investigate a single defined treatment for each patient rather than treat the area to full correction with more volume or additional classes of HA fillers. We elected to do this in order to ascertain whether a quantifiable correction could be achieved with minimal treatment, as “full correction” would certainly result in a predictable measurable change, though not necessary represent a financially feasible option for most patients. Finally, this study was limited to the use of a single neuromodulator and HA filler and thus additional work with different products will be required in order to determine whether other injectables may provide a more robust outcome. CONCLUSIONS This is the first study objectively measuring and defining an effective dual treatment modality for the perioral region. The combination of orbicularis oris neuromodulation and hyaluronic acid filler placement demonstrates objective improvement of perioral strain and volume as well as increased patient satisfaction that was maintained at 90 days. These data confirm that injectable therapy for the complex perioral region is effective and should be tailored to the needs of each patient. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Acknowledgments We would like to acknowledge Trilion Quality Systems for their support and assistance in conducting the DIC component of this study. We would like to acknowledge the Center for Human Appearance at the University of Pennsylvania for their support of our research study. Disclosures The authors declared no potential conflicts of interest with respect to the research, authorship, and publication of this article. Funding The authors received no financial support for the research, authorship, and publication of this article. Presented at: The 34th Annual Northeastern Society of Plastic Surgery (NESPS) Meeting in Newport, RI in September 2017. REFERENCES 1. Gilchrest BA . Skin aging and photoaging: an overview . J Am Acad Dermatol . 1989 ; 21 ( 3 Pt 2 ): 610 - 613 . Google Scholar Crossref Search ADS PubMed 2. Montagna W , Carlisle K . Structural changes in ageing skin . Br J Dermatol . 1990 ; 122 ( Suppl 35 ): 61 - 70 . Google Scholar Crossref Search ADS PubMed 3. Bolognia JL . Dermatologic and cosmetic concerns of the older woman . Clin Geriatr Med . 1993 ; 9 ( 1 ): 209 - 229 . Google Scholar Crossref Search ADS PubMed 4. Alster TS , Garg S . Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser . 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Perioral rejuvenation with a range of customized hyaluronic acid fillers: efficacy and safety over six months with a specific focus on the lips . J Drugs Dermatol . 2012 ; 11 ( 1 Suppl ): s17 - s26 . Google Scholar PubMed 36. Fabi SG , Champagne JP , Nettar KD , Maas CS , Goldman MP . Efficacy and safety of and patient satisfaction with injectable hyaluronic acid with 0.3% lidocaine hydrochloride for the treatment of superficial perioral lines or superficial lateral canthal lines . Dermatol Surg . 2013 ; 39 ( 11 ): 1613 - 1620 . Google Scholar Crossref Search ADS PubMed 37. Beer K , Glogau RG , Dover JS , et al. A randomized, evaluator-blinded, controlled study of effectiveness and safety of small particle hyaluronic acid plus lidocaine for lip augmentation and perioral rhytides . Dermatol Surg . 2015 ; 41 ( Suppl 1 ): S127 - S136 . Google Scholar Crossref Search ADS PubMed 38. Wilson AJ , Chin BC , Hsu VM , Mirzabeigi MN , Percec I . Digital image correlation: a novel dynamic three-dimensional imaging technique for precise quantification of the dynamic rhytid and botulinum toxin type a efficacy . Plast Reconstr Surg . 2015 ; 135 ( 5 ): 869e - 876e . Google Scholar Crossref Search ADS PubMed 39. Wilson AJ , Chang B , Taglienti AJ , et al. A quantitative analysis of OnabotulinumtoxinA, AbobotulinumtoxinA, and IncobotulinumtoxinA: a randomized, double-blind, prospective clinical trial of comparative dynamic strain reduction . Plast Reconstr Surg . 2016 ; 137 ( 5 ): 1424 - 1433 . Google Scholar Crossref Search ADS PubMed 40. Klassen AF , Cano SJ , Scott A , Snell L , Pusic AL . Measuring patient-reported outcomes in facial aesthetic patients: development of the FACE-Q . Facial Plast Surg . 2010 ; 26 ( 4 ): 303 - 309 . Google Scholar Crossref Search ADS PubMed 41. Pusic AL , Klassen AF , Scott AM , Cano SJ . Development and psychometric evaluation of the FACE-Q satisfaction with appearance scale: a new patient-reported outcome instrument for facial aesthetics patients . Clin Plast Surg . 2013 ; 40 ( 2 ): 249 - 260 . Google Scholar Crossref Search ADS PubMed 42. Panchapakesan V , Klassen AF , Cano SJ , Scott AM , Pusic AL . Development and psychometric evaluation of the FACE-Q aging appraisal scale and patient-perceived age visual analog scale . Aesthet Surg J . 2013 ; 33 ( 8 ): 1099 - 1109 . Google Scholar Crossref Search ADS PubMed 43. Chang BL , Wilson AJ , Taglienti AJ , Chang CS , Folsom N , Percec I . Patient perceived benefit in facial aesthetic procedures: FACE-Q as a tool to study botulinum toxin injection outcomes . Aesthet Surg J . 2016 ; 36 ( 7 ): 810 - 820 . Google Scholar Crossref Search ADS PubMed 44. Alster TS , Garg S . Treatment of facial rhytides with a high-energy pulsed carbon dioxide laser . Plast Reconstr Surg . 1996 ; 98 ( 5 ): 791 - 794 . Google Scholar Crossref Search ADS PubMed 45. Hedelund L , Bjerring P , Egekvist H , Haedersdal M . Ablative versus non-ablative treatment of perioral rhytides. A randomized controlled trial with long-term blinded clinical evaluations and non-invasive measurements . Lasers Surg Med . 2006 ; 38 ( 2 ): 129 - 136 . Google Scholar Crossref Search ADS PubMed 46. Cohen JL , Dayan SH , Cox SE , Yalamanchili R , Tardie G . OnabotulinumtoxinA dose-ranging study for hyperdynamic perioral lines . Dermatol Surg . 2012 ; 38 ( 9 ): 1497 - 1505 . Google Scholar Crossref Search ADS PubMed 47. Carruthers A , Carruthers J , Monheit GD , Davis PG , Tardie G . Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation . Dermatol Surg . 2010 ; 36 ( Suppl 4 ): 2121 - 2134 . Google Scholar Crossref Search ADS PubMed 48. Gordon RW . BOTOX cosmetic for lip and perioral enhancement . Dent Today . 2009 ; 28 ( 5 ): 94 - 97 . Google Scholar PubMed 49. Perkins SW , Balikian R . Treatment of perioral rhytids . Facial Plast Surg Clin North Am . 2007 ; 15 ( 4 ): 409 - 414 , v. Google Scholar Crossref Search ADS PubMed 50. Carruthers J , Carruthers A . Aesthetic botulinum A toxin in the mid and lower face and neck . Dermatol Surg . 2003 ; 29 ( 5 ): 468 - 476 . Google Scholar PubMed 51. Chiu A , Fabi S , Dayan S , Nogueira A . Lip injection techniques using small-particle hyaluronic acid dermal filler . J Drugs Dermatol . 2016 ; 15 ( 9 ): 1076 - 1082 . Google Scholar PubMed 52. Dayan S , Bruce S , Kilmer S , et al. Safety and effectiveness of the hyaluronic acid filler, HYC-24L, for lip and perioral augmentation . Dermatol Surg . 2015 ; 41 ( Suppl 1 ): S293 - S301 . Google Scholar Crossref Search ADS PubMed 53. Narurkar VA , Cohen JL , Dayan S , et al. A comprehensive approach to multimodal facial aesthetic treatment: injection techniques and treatment characteristics from the HARMONY study . Dermatol Surg . 2016 ; 42 ( Suppl 2 ): S177 - S191 . Google Scholar Crossref Search ADS PubMed 54. Gilbert E , Calvisi L . Midface and perioral volume restoration: a conversation between the US and Italy . J Drugs Dermatol . 2014 ; 13 ( 1 ): 67 - 74 . Google Scholar PubMed 55. Park TH , Seo SW , Kim JK , Chang CH . Clinical experience with hyaluronic acid-filler complications . J Plast Reconstr Aesthet Surg . 2011 ; 64 ( 7 ): 892 - 896 . Google Scholar Crossref Search ADS PubMed 56. Carruthers A , Carruthers J , Monheit GD , Davis PG , Tardie G . Multicenter, randomized, parallel-group study of the safety and effectiveness of onabotulinumtoxinA and hyaluronic acid dermal fillers (24-mg/ml smooth, cohesive gel) alone and in combination for lower facial rejuvenation . Dermatol Surg . 2010 ; 36 ( Suppl 4 ): 2121 - 2134 . Google Scholar Crossref Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model) http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Aesthetic Surgery Journal Oxford University Press

Perioral Rejuvenation: A Prospective, Quantitative Dynamic Three-Dimensional Analysis of a Dual Modality Treatment

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Oxford University Press
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© 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com
ISSN
1090-820X
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1527-330X
D.O.I.
10.1093/asj/sjy060
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Abstract

Abstract Background The perioral region is the most dynamic anatomic area of the face and subject to complex and dramatic changes during aging. Successful treatment for perioral rejuvenation has yet to be identified, and prior studies have reported only subjective outcomes. Objectives The purpose of this study was to utilize our validated dynamic 3-dimensional imaging technology to determine whether conservative neuromodulation combined with hyaluronic acid filler volumization can decrease perioral strain and increase volume with significant patient satisfaction. Methods An IRB-approved prospective study of a dual modality treatment for perioral rhytids was performed on females with perioral aging who had not had prior facial treatment within the past year. Eighteen (18) units of Dysport were injected into the upper and lower orbicularis oris and 1 cc of Restylane Silk was injected in volume-depleted perioral regions in each patient. Each patient underwent imaging with digital image correlation (DIC) and completed the FACE-Q survey prior to injection and at 14 days and 90 days postinjection. Results Thirty-two female patients were recruited. A significant reduction in perioral strain was observed at both day 14 and day 90. This was concomitant with a significant increase in perioral volume at day 14 that at 90 days was significantly retained in the marionette lines. Further, there was a significant improvement in patient satisfaction with overall facial appearance at day 14 that was maintained at 90 days. Conclusions Conservative neuromodulation and hyaluronic acid filler volumization of the perioral region produces a significant reduction in strain correlating with high patient satisfaction, even at 90 days. This dual modality treatment is effective in rejuvenating the perioral region, and its future optimization will provide greater therapeutic options for this anatomically complex area. Level of Evidence: 4 The etiology of facial aging is complex and remains incompletely understood. Age-related changes in all anatomical layers of the face, including the underlying skeleton, soft tissues such as fat compartments and muscles, as well as the skin, interdependently contribute to the phenotype of the aging face.1-8 The perioral area (defined superiorly by the columella, laterally by the nasolabial folds and marionette lines, and inferiorly by the inferior aspect of the mental symphysis), is a region at particularly high risk for volume-loss and dynamic rhytid formation, especially in women.9-12 Our group has previously demonstrated that aging results in significantly increased dynamic perioral strain.13 Clinically, perioral aging is an increasingly frequent patient concern and one that has proven to be excessively difficult to treat in a natural manner.9-12 The most effective treatments for this region remain phenol croton oil peels, 14-17 CO2 laser resurfacing,4,16,18-22 fat grafting,23-25 and dermabrasion,26-29 all of which require significant down time for recovery. As such, efforts have focused on developing minimally invasive, low recovery, approaches to treat perioral aging.30-37 Prior studies of such approaches to the perioral area have been limited to single modality rejuvenation analyzed via subjective measurements. To address these limitations, we sought to objectively define the dynamic strain in the perioral area and evaluate the efficacy of a modest, minimally invasive, dual modality treatment to improve perioral strain with minimal patient downtime and significant patient satisfaction. We have previously pioneered and validated the use of 3-dimensional dynamic digital image correlation (DIC) to objectively and quantitatively measure dynamic facial strain and rhytids.38,39 We propose here to combine DIC perioral strain analysis with the FACE-Q survey,40-43 a validated instrument for measuring patient reported outcomes, in order to correlate objective strain measurements with patient satisfaction. Specifically, we wished to determine whether perioral aging could be significantly improved via conservative neuromodulation of the orbicularis oris muscle in combination with 1 cc of perioral hyaluronic acid filler placement and whether these treatments would result in appreciable strain and volumetric changes as well as patient satisfaction. METHODS A University of Pennsylvania IRB (Study #823351) approved prospective study of a dual modality treatment for perioral rhytids was performed. Patient Selection Female patients between the ages of 30 and 75 seeking treatment for clinically apparent perioral aging were prospectively recruited to participate in the study from February to May 2016 at the Hospital of the University of Pennsylvania, Division of Plastic Surgery. Following informed consent, baseline DIC measurements and FACE-Q evaluations were performed immediately pretreatment and repeated 14 days and 3 months after treatment. Patients who were unable to adhere to the study follow-up schedule or who received treatment outside the study protocol while in the study were excluded. Additional exclusion criteria included a history of facial neuromodulation or filler use within the past 12 months, medical contraindications to any products or materials used, as well as any patients with a history of significant facial trauma, surgery, or paralysis. FACE-Q Administration Handheld tablet devices were used to administer the FACE-Q instrument to all patientts at baseline. The individual sections of FACE-Q that were administered and scored in this study were: satisfaction with facial appearance overall; aging appearance appraisal; psychological well-being; social function; appraisal of lip lines; appraisal of marionette lines; appraisal of lines overall; satisfaction with lips; and satisfaction with lower face and jawline. Two days before the follow-up visits, all patients received an automated reminder email that also included a link for patients to repeat the FACE-Q survey prior to arriving in clinic. Patients who did not complete the survey prior to the follow up visits were provided a tablet device to do so while in the clinic waiting area during follow-up visits. The FACE-Q survey used for the 2-week and 3-month follow-up visits included four additional sections: late negative sequelae of the lips; late negative sequelae of the lower face and neck; early recovery life impact; and early recovery symptoms. These sections were used as an assessment aid for follow up care and counseling. Digital Image Correlation Following completion of the FACE-Q questionnaire, makeup was applied to the lower face of each patient. For sufficiently contrasting makers to be tracked by the ARAMIS (Trilion Quality Systems, Plymouth Meeting, PA) software, a white foundation and black speckle makeup was used (Figure 1). Airbrushed body paint was used for the white foundation. Patient positioning as well as camera setup and calibration were consistent across all patients and time points. Patients were recorded from a distance of 72 cm by two high-resolution cameras simultaneously. After a reference frame was taken with the face in a resting position, patients were instructed to smile, purse their lips, and frown over the course of 10 seconds at a rate of 10 frames per second for a total of 100 dynamic frames captured per patient at each visit. These images were directly imported into ARAMIS for data computation. The perioral area was defined by the following landmarks: columella superiorly, nasolabial folds and marionettes laterally, and mental protruberance inferiorly. ARAMIS software was used to calculate the displacement compared to the reference frame between all the speckle markers during facial animation (Video 1). ARAMIS also calculated strain as the per cent change in displacement between the markers, with the “mises” strain representing the vector sum of the strain in the x-, y-, and z-planes. Average mises strain over the oral commissures, cheeks, nasolabial folds, marionette lines, and chin, was calculated across all available frames. Changes in the magnitude of strain between day 14 and day 0 and between day 90 and day 0 were calculated for each of the study regions (Figures 2-3). Changes in facial volume were calculated in ARAMIS by overlaying the day 14 and day 90 images on the day 0 reference images for each patient (Figure 4). Volume changes were assessed with the patients at rest, making a neutral expression, and in the areas corresponding to the most common filler injection points: upper lip, nasolabial folds, marionette lines, and oral commissures. The protocol for imaging and data processing was consistent for each patient across all time points. Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy060 Video 1. Watch now at https://academic.oup.com/asj/article-lookup/doi/10.1093/asj/sjy060 Close Figure 1. View largeDownload slide Sample image of the perioral region after application of white foundation with black speckle makeup. The photograph is of a 47-year-old woman who presented with perioral rhytides and volume loss. Blue diamonds indicate the four Dysport injection sites to the upper and lower orbicularis oris muscle that were consistent across all patients. Each site was injected with 4.5 units of Dysport. Red X’s represent the injection sites for Restylane Silk. Figure 1. View largeDownload slide Sample image of the perioral region after application of white foundation with black speckle makeup. The photograph is of a 47-year-old woman who presented with perioral rhytides and volume loss. Blue diamonds indicate the four Dysport injection sites to the upper and lower orbicularis oris muscle that were consistent across all patients. Each site was injected with 4.5 units of Dysport. Red X’s represent the injection sites for Restylane Silk. Figure 2. View largeDownload slide A 53-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 2. View largeDownload slide A 53-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 3. View largeDownload slide A 46-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 3. View largeDownload slide A 46-year-old woman presented with perioral rhytides and volume loss who was treated with 18 units of Dysport to the upper and lower orbicularis oris and 1 cc of Restylane Silk to the perioral region. Sample DIC image of a patient’s change in facial strain from (A) day 0 to (B) day 14. Areas in red indicate areas of high facial strain, while areas in green indicate areas of low facial strain. Images are taken in partial open smile. Figure 4. View largeDownload slide A 53-year-old woman who presented with perioral rhytides and volume loss who was treated with 18 units of Dysport and 1 cc of Restylane Silk. Sample DIC image of a patient’s change in facial volume from day 0 to day 14. Areas in red indicate areas of increased facial volume, while areas in blue indicate areas of decreased facial volume. Figure 4. View largeDownload slide A 53-year-old woman who presented with perioral rhytides and volume loss who was treated with 18 units of Dysport and 1 cc of Restylane Silk. Sample DIC image of a patient’s change in facial volume from day 0 to day 14. Areas in red indicate areas of increased facial volume, while areas in blue indicate areas of decreased facial volume. Injection Technique Following baseline FACE-Q and DIC measurements, patients were evaluated by a single plastic surgeon (I.P.) for Glogau score and Fitzpatrick skin type. Each patient was then injected by a single surgeon (I.P.) with a total of 18 units of abobotulinumtoxinA (Dysport; Galderma Pharma S.A., Lausanne, Switzerland), followed by 1 cc of hyaluronic acid (HA) filler (Restylane Silk; Galderma Pharma S.A., Lausanne, Switzerland). Each patient was injected in the same manner with a total of 18 units of Dysport, diluted per standard manufacturer instructions. There were 4 injection points: left upper, right upper, left lower, and right lower cutaneous lip. All injection points were 2 to 3 mm away from the white roll. A total of 4.5 units (18/4) were injected into each of the 4 points at the depth of the orbicularis oris muscle. This injection pattern was the same for all patients regardless of their facial anatomy and degree of rhytid formation (Figure 1). Each patient was also subsequently injected with 1 cc of Restylane Silk, undiluted, to the perioral region. Each patient’s treatment was individualized to address the perioral site(s) most severely affected by volume loss, as determined by the single injector (I.P.). Potential injection sites included the nasolabial folds, lips, oral commissures, mental crease, and marionette lines. Similarly, the amount of filler injected into each site was tailored to each patient, while maintaining a total amount of 1 cc of HA injected to the perioral region (Figure 1). Each patient was evaluated before treatment as well as 2 weeks and 3 months after treatment. Statistical Methods Data were deidentified and entered into JMP (SAS Institute, Inc., Cary, NC) for analysis. Descriptive statistics were computed for the study population including mean (interquartile range) for continuous data and frequency (percentage) for categorical data. Per cent differences between pre- and posttreatment strain were compared using paired t tests. Comparisons were between postinjection day 0 and day 14 as well as between day 0 and day 90. ANOVA was used to determine if patient age, Glogau score, Fitzpatrick score, education level, or income level were associated with changes in strain, volume, or satisfaction. All tests were two-sided. A value of P ≤ .05 was utilized to determine statistical significance. RESULTS Demographics Thirty-two female patients participated in this study. The average age at time of injection was 51.7 years (range, 28.8-72.4 years). Two patients (6%) were classified as Fitzpatrick class I, eight (25.0%) as class II, fourteen (43.8%) as class III, seven (21.9%) as class IV, one (3.1%) as class V, and none as class VI. No patients were classified as Glogau class I, ten (31.3%) as class II, thirteen (40.6%) as class III, and nine (28.1%) as class IV. No patients had any complications or complaints as a result of the neurotoxin or filler injections. Fourteen days postinjection, the Glogau scale of patients were again evaluated by the senior author. None of the patients had a change in their Glogau class 14 days postinjection. DIC: Perioral Strain Reduction Of the 32 patients who presented for initial imaging and treatment, 29 (90.6%) returned for reimaging on day 14, and 25 (78.1%) returned for reimaging on day 90. Fourteen days postinjection, patients demonstrated statistically significant reductions in the magnitude of facial strain. Strain in the cheek decreased by 12.0% (P = 0.001), in the chin by 7.8% (P = 0.022), in the marionette lines by 17.0% (P < 0.001), in the nasolabial folds by 5.9% (P = 0.057), in the upper lip by 6.3% (P = 0.001), and in the perioral region as a whole by 9.3% (P = 0.001). The day 0 to day 14 reductions in strain were not associated with age (P = 0.596), Fitzpatrick score (P = 0.475), Glogau score (P = 0.144), education level (P = 0.201), or income level (P = 0.336). Strain reductions in each of the study regions varied among facial expressions but were most significant for small smile with a 15.6% reduction (P < 0.001). In addition to strain reduction, perioral rejuvenation was associated with a trend toward improved facial symmetry from day 0 to day 14. Facial strain symmetry improved by 1.3% in the cheek (P = 0.272), 0.5% in the chin (P = 0.378), 3.2% in the marionette lines (P = 0.008), 4.6% in the nasolabial folds (P = 0.010), 0.1% in the upper lip (P = 0.272), and 1.6% in the perioral region as a whole (P = 0.095) (Figure 5). Figure 5. View largeDownload slide Graphical depiction of facial strain from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Strain was significantly lower at day 14 in all study regions except the nasolabial folds (P = 0.057). Strain was significantly lower at day 90 in all study regions. Figure 5. View largeDownload slide Graphical depiction of facial strain from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Strain was significantly lower at day 14 in all study regions except the nasolabial folds (P = 0.057). Strain was significantly lower at day 90 in all study regions. Ninety days postinjection, patients continued to demonstrate statistically significant reductions in the magnitude of strain. Strain in the cheek decreased by 22.9% (P < 0.001), in the chin by 12.9% (P < 0.001), in the marionette lines by 17.2% (P < 0.001), in the nasolabial folds by 8.3% (P = 0.042), in the upper lip by 12.4% (P < 0.001), and in the perioral region by 15.0% (P < 0.001). The day 0 to day 90 reductions in strain trended with increasing age (P = 0.022), increasing level of income (P = 0.052), and increasing level of education (P = 0.095). Glogau (P = 0.109) and Fitzpatrick (P = 0.146) scores were not associated with strain reduction. Strain reductions in each of the study regions varied among facial expressions but were most significant for small smile with a 30.7% reduction (P < 0.001). There were no significant changes in facial strain symmetry from day 0 to day 90. Facial strain symmetry improved by 2.6% in the cheek (P = 0.137), 2.0% in the chin (P = 0.133), 0.2% in the marionette lines (P = 0.464), 2.5% in the nasolabial folds (P = 0.115), 0.8% in the upper lip (P = 0.137), and 1.7% in the perioral region (P = 0.175) (Figure 5). DIC: Volume Enhancement Fourteen days postinjection, patients demonstrated statistically significant increases in perioral volume. Volume increased in the nasolabial folds by 151.45 mm3 (P = 0.004), in the marionette lines by 138.29 mm3 (P = 0.006), in the upper lip by 98.10 mm3 (P = 0.004), and in the oral commissures by 362.26 mm3 (P < 0.001). Changes in volume were not associated with age (P = 0.327), Glogau score (P = 0.139), Fitzpatrick score (P = 0.149), education level (P = 0.115), or income level (P = 0.290) (Figure 6). Figure 6. View largeDownload slide Graphical depiction of facial volume changes from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Facial volume was significantly higher at day 14 in all study regions but returned to baseline by day 90. Figure 6. View largeDownload slide Graphical depiction of facial volume changes from day 0 to day 14 to day 90 in each of the study regions as a result of perioral rejuvenation. Facial volume was significantly higher at day 14 in all study regions but returned to baseline by day 90. Ninety days postinjection, only the increase in volume in the marionette lines remained statistically significant, with volumes in the other three regions returning close to baseline levels. Relative to baseline volume, the volume in the marionette lines increased by 91.59 mm3 (P = 0.039) and in the oral commissures by 154.30 mm3 (P = 0.071). The volume in the nasolabial folds decreased by 8.51 mm3 (P = 0.545) and in the upper lip by 5.56 mm3 (P = 0.541), relative to baseline. Changes in volume were not associated with age (P = 0.192), Glogau score (P = 0.320), Fitzpatrick score (P = 0.849), education level (P = 0.792), or income level (P = 0.438) (Figure 6). FACE-Q: Patient Satisfaction Of the 32 patients who completed the baseline FACE-Q, 29 (90.6%) completed the FACE-Q on day 14, and 28 (87.5%) completed it on day 90. Following perioral rejuvenation, patients were statistically significantly more satisfied with their overall facial appearance, both at day 14 and at day 90. Fourteen days posttreatment, patients on average were 22.2% (P = 0.014) more satisfied with their overall facial appearance as compared to baseline. In particular, patients were statistically significantly more satisfied with their appearance at end of day (36.8%, P < 0.001), freshness (48.9%, P < 0.001), restfulness (45.4%, P < 0.001), profile appearance (25.9%, P = 0.010), appearance in photos (40.2%, P = 0.003), appearance when waking up (37.9%, P = 0.006), and appearance under bright lights (51.7%, P < 0.001). Patients continued to be satisfied with their overall facial appearance 90 days posttreatment as the overall section score was 21.2% (P = 0.009) higher at day 90 than at day 0 (Table 1, Figure 7). Table 1. Patient Satisfaction With Facial Appearance as Measured by the FACE-Q at Day 14 and Day 90 (the overall domain score is depicted as well as the individual components of that domain) Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 View Large Table 1. Patient Satisfaction With Facial Appearance as Measured by the FACE-Q at Day 14 and Day 90 (the overall domain score is depicted as well as the individual components of that domain) Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 Day 0 to day 14 P-value Day 0 to day 90 P-value Satisfaction with Facial Appearance Total Score 22.2% 0.014 21.2% 0.009  Symmetry 2.6% 0.620 8.9% 0.117  Balance 2.6% 0.706 7.7% 0.170  Proportionality 12.1% 0.038 8.3% 0.125  Appearance at the end of day 36.8% < 0.001 32.1% 0.002  Freshness 48.9% < 0.001 48.8% < 0.001  Restfulness 45.4% < 0.001 36.3% 0.001  Appearance of profile 25.9% 0.010 35.7% 0.001  Appearance in photos 40.2% 0.003 29.2% 0.017  Appearance when waking up 37.9% 0.006 36.3% 0.005  Appearance under bright lights 51.7% < 0.001 42.3% 0.007 Aging Appearance Appraisal Total Score 13.9% 0.205 3.7% 0.715  Don’t recognize self 8.6% 0.272 3.9% 0.531  Don't like self 20.4% 0.150 16.7% 0.171  Bothered 17.5% 0.026 8.0% 0.290  Look older 28.4% 0.004 16.1% 0.043  Worried 28.4% 0.008 19.6% 0.033  Reminded 30.7% 0.007 18.2% 0.084  Photos 49.1% < 0.001 38.1% 0.002 Psychological Well-Being Total Score 4.5% 0.491 -5.0% 0.461  Feel okay 2.3% 0.624 -0.6% 0.918  Self-acceptance 10.6% 0.024 8.9% 0.109  Self-comfort 10.3% 0.219 3.0% 0.760  Feel good 18.4% 0.024 9.5% 0.150  Self like 2.6% 0.526 0.0% 1.000  Feel positive 0.6% 0.899 -4.8% 0.352  Feel happy 6.6% 0.206 -3.3% 0.565  Feel attractive 4.0% 0.433 -10.7% 0.014  Feel confident 12.6% 0.026 -0.3% 0.949  Feel great 2.3% 0.677 -3.3% 0.508 Social Function Total Score 3.6% 0.614 -3.7% 0.602  Comfortable meeting new people 5.5% 0.304 3.3% 0.508  Confident meeting new people 3.4% 0.430 -0.3% 0.945  Make good first impression 2.0% 0.613 -0.3% 0.947  Relaxed around others 2.0% 0.676 1.8% 0.747  Confident in group situations -1.4% 0.791 -4.2% 0.516  Easy to make friends 10.9% 0.042 8.6% 0.107  Confident in new social situations 7.5% 0.155 2.4% 0.641  Confident in a room of people you don't know 8.3% 0.183 3.0% 0.706 Appraisal of Lip Lines Total Score 38.7% 0.018 20.9% 0.243  Number of lines 49.1% < 0.001 21.7% 0.003  Depth of lines 38.8% < 0.001 13.4% 0.087  Noticeability of lines 36.2% < 0.001 9.2% 0.152  Lines in comparison to others 24.1% 0.013 9.2% 0.166  How old lines make you look 31.0% 0.002 13.4% 0.073  Appearance of lines with puckered lips 33.9% 0.013 12.2% 0.186 Appraisal of Marionette Lines Total Score 59.7% 0.001 19.2% 0.301  Depth of lines 50.9% < 0.001 30.7% 0.011  Noticeability of lines 50.3% < 0.001 30.1% 0.008  Appearance when face is relaxed 56.3% < 0.001 22.3% 0.004  How old lines make you look 49.1% < 0.001 24.7% 0.005  How tired lines make you look 67.0% < 0.001 36.0% 0.001  How angry lines make you look 57.2% < 0.001 26.5% 0.009  How sad lines make you look 50.3% < 0.001 21.7% 0.011 Satisfaction with Lips Total Score 23.4% 0.098 14.4% 0.330  Shape of upper lip 31.3% 0.001 11.9% 0.082  Shape of lower lip 24.7% 0.023 18.8% 0.120  Fullness of upper lip 33.3% 0.002 3.6% 0.571  Fullness of lower lip 26.4% 0.008 13.7% 0.257  Size of lips 32.8% 0.001 13.1% 0.076  Appearance when smiling 46.0% 0.001 8.6% 0.317  Appearance when turning upper lip 37.1% 0.005 6.3% 0.366  Appearance of outer corners when relaxed 40.8% 0.005 6.0% 0.247  Suitability of lips to face 35.1% 0.007 10.1% 0.173  Style of lips 39.1% 0.005 15.5% 0.046 Satisfaction with Lower Face and Jawline Total Score 44.0% 0.021 34.0% 0.083  Prominence of jawline 35.6% 0.007 27.7% 0.003  Sculptedness of jawline 28.7% 0.022 15.8% 0.094  Profile of jawline 28.7% 0.037 17.6% 0.064  Niceness of lower face 37.4% 0.001 21.7% 0.019  Smoothness of lower face 35.6% 0.007 17.7% 0.035 View Large Figure 7. View largeDownload slide Graphical depiction of patient satisfaction changes according to the FACE-Q from day 0 to day 14 to day 90 as a result of perioral rejuvenation. Figure 7. View largeDownload slide Graphical depiction of patient satisfaction changes according to the FACE-Q from day 0 to day 14 to day 90 as a result of perioral rejuvenation. Patients were also significantly more satisfied with specific areas of their facial appearance following perioral rejuvenation. Fourteen days posttreatment, patients were 38.7% (P = 0.018) more satisfied with the appearance of their lip lines, 59.7% (P = 0.001) more satisfied with the appearance of their marionette lines, 46.1% (P = 0.006) more satisfied with their overall lines, 23.4% (P = 0.098) more satisfied with their lips, and 44.0% (P = 0.021) more satisfied with their lower face and jawline, relative to pre-treatment. The average increase in patient satisfaction persisted 90 days posttreatment, but due to the variability in patient responses, the increases were not statistically significant (Table 1, Figure 7). In contrast, there were no significant differences in patients’ satisfaction with age appearance at day 14, 13.9% (P = 0.205), or at day 90, 3.7% (P = 0.715). There were no significant differences in patients’ psychological well-being at day 14, 4.5% (P = 0.491), or at day 90, −5.0% (P = 0.461). There were no significant differences in patients’ social function at day 14, 3.6% (P = 0.614), or at day 90, −3.7% (P = 0.602) (Table 1, Figure 7). At day 14, significant improvement in satisfaction with lower face and jawline was associated with increasing age (P = 0.020), education level (P = 0.048), and income level (P = 0.044) but not with Glogau (P = 0.747) or Fitzpatrick (P = 0.389) score. None of the demographic factors were significant predictors for the other FACE-Q sections. There were no significant associations between demographic factors and patient satisfaction at 90 days. DISCUSSION The perioral area is unique anatomical region of bony and soft tissue elements subject to dynamic forces resulting in complex rhytid formation and soft tissue atrophy with aging. Perioral rejuvenation remains one of the most challenging, complex, and controversial aspects of aesthetic surgery. Despite a strong demand and many proposed treatments for perioral rejuvenation, very little quantitative evidence exists for the directed treatment of this region. Skin resurfacing via ablative CO2 laser and deep chemoexfoliation treatments has been demonstrated to significantly improve perioral rhytids.44,45 However, the downtime associated with these procedures is substantial, and recovery can be complicated by persistent erythema, dyspigmentation and scarring, especially in darker Fitzpatrick skin types.44,45 While neuromodulation and HAs have been independently demonstrated to improve perioral rhytids, these procedures have largely been evaluated using subjective measurements.46-55 We previously demonstrated that digital image correlation allows for precise, quantifiable, and reproducible perioral strain measurements.38,39 This study expands our prior work by analyzing a specific dual injection therapy for improving dynamic perioral rhytid strain and volume by quantifying these dynamic variables during common facial expressions. Further, while Carruthers et al have previously reported success with combined neurotoxin and filler treatment of the lower face, this dual approach has yet to be analyzed in the objective, quantitative approach taken by this study.56 When applying DIC to study the dynamic face, it is important to understand the principle of strain. Strain is the percentage of change in the distance between two points that occurs with facial animation. This change is calculated by the Aramis system for every combination of black paint speckled points demarcated on the face during animation. The software allows the user to calculate the average strain associated with a given anatomic area. Strain is a vector measurement with two directions—positive or negative—and magnitude. Positive strain, an increase in the distance between the soft tissues, is termed stretch. Negative strain, a decrease in the distance between the soft tissues, is termed compression. The strain observed in the perioral region is largely negative because, during facial motion, the dynamic rhytids produced reflect the compression of skin and subcutaneous tissues secondary to mimetic muscle contraction. A patient with more prominent rhytids will have a greater magnitude of strain, as the increased compression of the tissues produces a deeper rhytid. The data reported here therefore describe reductions in the magnitude of strain secondary to neurotoxin and filler injection, or alternatively, the reduction in compression so that what is being captured clinically is the decrease in rhytid formation. Our previous study using DIC to assess reduction in glabellar rhytids following neuromodulator treatment also assessed reductions in the magnitude of the negative strain, or compression, observed in the glabella.39 The significant value of DIC in assessing outcomes following neuromodulator and filler treatment of the aging face is that it is a quantitative and objective assessment tool that can detect subtle but significant clinical improvements that may be appreciated by the naked eye, but missed by subjective scales. For example, none of the patients experienced an improvement in their Glogau class postinjection, which is not surprising given that there are only four broad, nonspecific, Glogau classes, with significant differences between them. The demographic factors assayed in this study included patient age, education level, income level, Glogau class, and Fitzpatrick class. The education and income levels were collected primarily to determine if they correlate with degree of patient satisfaction. The other three demographic factors were identified as potential predictors of the outcome metrics: patient satisfaction, strain reduction, and volume enhancement. To make our analyses consistent, we included regression analysis results for all the collected demographic factors for all three outcome metrics. Using DIC to quantitate perioral strain before and after conservative dual neuromodulation (18 units of abobotulinumtoxinA [Dysport]) and HA filler treatment (1 cc of Restylane Silk), we demonstrated a significant decrease in strain in the entire perioral region, upper lip vertical rhytids, marionette lines, and mental crease at both 14 and 90 days postinjection. The day 0 to day 90 strain reductions trended with increasing patient age (P = 0.022). These data confirm that older patients who experience more soft tissue atrophy and rhytid formation benefit more from the dual treatment than younger patients presenting with more subtle age-related changes. Strain reduction was accompanied by significant increases in perioral volume at day 14, which was only significantly maintained in the marionette lines at day 90. These result suggest that an HA filler may be metabolized more slowly in the marionettes than in other perioral sites, perhaps due to less direct mimetic activity in this region as compared to other perioral regions. Finally, patients of all ages were statistically significantly more satisfied with their overall facial appearance, at both day 14 and day 90, though patient satisfaction became increasingly variable at 90 days. This study demonstrates that neuromodulation in combination with conservative HA filler placement is effective in treating perioral aging with significant patient satisfaction. The importance of this study is multifold. The work demonstrates for the first time that: (1) even without complete correction, a significant and quantifiable improvement can be achieved in the perioral region with combined conservative injectables; (2) older patients may experience a more measurable correction than younger patients who present with a more mild age-related phenotype; and (3) HA volume may be better maintained in the marionettes as opposed to other perioral areas that may therefore require more frequent injections for consistent correction. The study is limited in part by the number of patients participating as well as the common cosmetic study patient drop-out rate, though the loss-to-follow-up rate in our study was lower than most. Further, although there was also no negative control group that received no treatment, we consider that the pretreatment assessment of patients served, in part, as their own controls to determine if the described technique for perioral rejuvenation is effective. This work is similarly limited in that we selected to investigate a single defined treatment for each patient rather than treat the area to full correction with more volume or additional classes of HA fillers. We elected to do this in order to ascertain whether a quantifiable correction could be achieved with minimal treatment, as “full correction” would certainly result in a predictable measurable change, though not necessary represent a financially feasible option for most patients. Finally, this study was limited to the use of a single neuromodulator and HA filler and thus additional work with different products will be required in order to determine whether other injectables may provide a more robust outcome. CONCLUSIONS This is the first study objectively measuring and defining an effective dual treatment modality for the perioral region. The combination of orbicularis oris neuromodulation and hyaluronic acid filler placement demonstrates objective improvement of perioral strain and volume as well as increased patient satisfaction that was maintained at 90 days. These data confirm that injectable therapy for the complex perioral region is effective and should be tailored to the needs of each patient. Supplementary Material This article contains supplementary material located online at www.aestheticsurgeryjournal.com. Acknowledgments We would like to acknowledge Trilion Quality Systems for their support and assistance in conducting the DIC component of this study. We would like to acknowledge the Center for Human Appearance at the University of Pennsylvania for their support of our research study. 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Google Scholar Crossref Search ADS PubMed © 2018 The American Society for Aesthetic Plastic Surgery, Inc. Reprints and permission: journals.permissions@oup.com This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)

Journal

Aesthetic Surgery JournalOxford University Press

Published: Oct 15, 2018

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