Esthetic considerations for treating the patient of European descent: Thriving in diversity international roundtable series

The European esthetic experience is informative for understanding both innovation as well as how to care for patients of various backgrounds and ages.

For the purposes of patient evaluation and treatment, ancestryrather than the location where the patient lives-may be used to help identify patterns of aging and guide the esthetic treatment approach.
However, as with any esthetic intervention, individual patient treatment goals are most important. The personality of the individual (e.g., whether they are more restrained or immoderate in their personal appearance), which may be further influenced by the culture of the region in which they live, can affect how the patient wishes treatment to change their personal esthetic. Importantly, even within the broad range of individual patient personalities, esthetics, and treatment goals, patients nearly universally wish to retain a natural appearance. Navigating a need for individualized treatment, in particular as society evolves and individuals see themselves more fluidly (e.g., gender identity and embracing ethnic differences), demands a firm understanding of how devices and interventions behave when applied to a range of skin types and features. Additionally, a concerted effort and ability to openly communicate with a sensitivity toward the patient's individualism are important.
In the sections below, the authors describe multiple techniques for achieving natural-looking, harmonious outcomes in a wide range of patients encountered in the European practice and internationally. Though the recommendations and procedural steps outlined here represent the most innovative and advanced thinking in esthetics today, it is important to remember that the nature of science and medicine permits ongoing refinement of technique and evolution of thought. Esthetics is a rapidly changing field, and the best clinicians are not only continually seeking improvement and a refined understanding of their craft, but are also willing to adapt their practices based on new data, changes in available technologies, and clinical experience.

| ME THODS
A continuing medical education (CME) event series of 6 international roundtable discussions focused on diversity in esthetics was conducted from August 24, 2021 to May 16, 2022 for a 2-h roundtable to discuss the impact of race and ethnicity on anatomy and the best esthetic products, techniques, and practices to achieve natural-looking results with minimal side effects. The results of the fifth roundtable in the series, the European Patient, are described here. In addition to discussions and the presentation of information, injection demonstrations served as a platform for discussion surrounding functional anatomy as well as approaches to treatment planning and injection that can not only be applied to the diverse European population, but also internationally. Each of the patients shown consented to treatment and provided permission for use of their photographs.

| RE SULTS
During the roundtable and injection demonstrations, several key features of the European demographic were discussed. First, the growing number of people over the age of 65 years in Europe represents a key patient group. Attention to the needs and treatment strategies that best suit a more mature patient demographic represents an opportunity to better serve not only European patients but also more mature patients internationally. Second, the role of functional anatomy in treating patients with both fillers and botulinum toxin was discussed. Finally, the role of ultrasound in clinical practice was reviewed, in particular for mapping vasculature prior to injection of the temple.

| The aging European demographic and management of the mature patient
While there is no single European esthetic, one important demographic change underway in many European countries is a growing number of people over the age of 65 years both in terms of sheer number as well as proportion of the total population. Within the EU, the population of people aged ≥65 years is expected to increase from 90.5 million at the start of 2019 to 129.8 million by 2050, and the median age of the EU is expected to increase to 48.2 years. 4 This trend is already resulting in a substantial increase in this population in many individual countries; in 2021, >21% of the population in Germany, Portugal, Greece, and Finland was ≥65 years of age. 5 For reference, 17.1% of the population in the United States in 2021 was over the age of 65 years, and the mean age was 38.8 years. 6 For this patient demographic, there is often a desire to be healthful and look their best. Often, these patients are made aware of esthetic procedures through digital channels, though typically not the same used by a broader audience. For these patients, the expenditure of resources is often not as problematic as for younger patients still establishing themselves financially, and many have the time and patience needed for a more intensive approach. These patients often present with a constellation of issues, most commonly loss of skin glow, laxity, midfacial soft tissue descent, jowls, lip lines, and upper face mimetic lines. More so with this patient group than any other, a multimodal approach is needed to address aging in multiple tissue layers, including tissue quality, position, volume, and impact of mimetic muscle activity. This is often an esthetically conservative age group that voices a need to simply look and feel their best for their age. These patients are often quite loyal and communicative.
While individual patient assessment is needed, Table 1 contains helpful guidance for optimal outcomes specific to a mature demographic. For the 78-year-old patient shown in Figure 1, a substantial improvement was achieved using these principles.

| Functional anatomy and treatment plan development
Irrespective of age, nearly all patients prioritize natural-looking results as a treatment goal. An important first step is to proactively manage skin quality. Excellent skin quality is not only a "certificate of health" 7 and important for the overall esthetic, but can reduce the amount of filler needed for optimal outcomes. 7,8 An optimally managed patient will appear a refreshed and more relaxed version of themselves, never unfamiliar or "cheeky" looking. One example in which excess filler volume in the medial face leads to unnaturallooking outcomes is facial overfilled syndrome, which occurs when excess volume is placed in the superficial fat pads of the cheek. At rest, excessive volume may or may not be apparent, but an unnatural look is obvious when the patient smiles and the transverse facial septum, which runs under the zygomaticus muscle, lifts the facial fat pads up to the zygomaticus cutaneous ligament, which then pushes the volume outward. 9 In support of a natural-looking outcome, doses of botulinum toxin (BoNT-A) should be administered according to individual patient anatomy inferred from patterns of dynamic lines.
Further, a holistic approach is needed: BoNT-A can be used to relax muscles in the upper face and to create lift in the lower face through relaxation of depressor muscles. In particular, an everted "lip lift" showing increased red fullness of the vermillion can be achieved via injection into the superficial orbicularis muscle at the cutaneous mucosal lip border. 10,11 In parallel, relaxation of the platysma can lift the jowls and define the mandible. 12 Inclusion of the lower face in a treatment plan is critical for a balanced and harmonious outcome.
Key treatment strategies to achieve natural-looking results are described below, including the injection itself and the anatomic reasoning for individual techniques.

| Natural-looking outcomes through indirect effects of filler
In order to achieve a natural-looking outcome with fillers, the face should be treated from top to bottom and from lateral to medial, taking advantage of indirect effects that can be achieved by injecting filler into specific layers within lateral facial compartments. The layer and location of product placement impacts efficiency, and surface volume coefficient (the percentage of the injected product that TA B L E 1 Guidance for nonsurgical management of mature patients.

Treating the mature patient
Avoid changes to brow shape • Lateral elevation of the eyebrow is characteristic of the aging face. In more mature patients, additional lateral elevation makes the patient appear exaggerated or older • When treating forehead lines with BoNT-A, it is important NOT to change the lateral position of the brow or to exacerbate lateral frontalis lines • Remember that personalized assessment and treatment with BoNT-A is key to treatment success. An unnatural look in the upper face can jeopardize the patient's overall esthetic Avoid overcorrection • Do not attempt to use filler to elevate the tissues beyond what looks natural • Avoid excessive volume to the midface and anteromedial cheek filling • Treat the infraorbital hollows after the midface and cheeks have been appropriately managed • Treat to smooth the lips. Avoid significant changes to lip volume and shape. Overfilling radial lip lines looks especially awkward in mature patients, as it distorts the natural convexity of the upper cutaneous lip • Sagging of the midface and loss of definition along the jawline cannot be corrected by injecting the midface alone. Include the lower face and jawline in the treatment plan. In more severe cases, injection of the lower posterior temporal fossa with a high G′ product can provide mild tissue repositioning of the mid and lower face • Allow adequate time for integration of fillers following injection and adequate time for biostimulatory activity to peak Be mindful of swelling • When treating mature patients, it is important to avoid using highly hygroscopic fillers • Use smaller volumes for treating the infraorbital hollows in particular A holistic approach is needed • Mature patients, especially those who have not been previously treated, require multiple modalities. Optimal correction takes time • Do not neglect the lower face; the chin and the jawline must be treated to achieve a more defined look and harmonious outcome. Be sure to assess and treat the jawline and chin together • The esthetic of the neck must be in balance with the face and appear of similar age • Photo documentation permits the patient to see treatment success over time and is particularly important if the patient has issues with vision. This group does not have the same degree of exposure to before and after images on social media and may need support understanding the nature of results Skin quality is key • Every mature patient should be evaluated for cumulative actinic damage, and treatment plans should include options for management of skin quality • Skin quality should be assessed and addressed before adding volume to any region on the face (except the posterior temple) • A careful clinical assessment for precancerous lesions and malignancies (actinic keratosis, basal cell carcinoma, lentigo maligna) should precede any esthetic intervention translates into surface projection) is a useful consideration. 13 More structural fillers placed lateral to the line of true ligaments (e.g., lateral orbital, zygomatic, masseteric, and mandibular ligaments), provide projection and lift to adjacent medial tissues and pull the skin superiorly along the vectors where a series of small boluses (~0.2 cc) has been placed. [13][14][15] Thus, product rheology is an important consideration when attempting to provide lift. An awareness of product lifting capacity (also understood as G′, or product "stiffness"), moldability, and hygroscopy is necessary for appropriate selection. 16,17 The need to consider indirect effects first, rather than focusing on local increases in volume, is applicable to multiple areas of the face, but is particularly important for the infraorbital hollows temple has the greatest effect on apparent cheek fullness and jawline contour. 22 The order in which injections are performed is also relevant. By injecting the posterior temporal fossa first, the amount of filler needed to restore volume in the midface is significantly reduced. 18 Following lateral treatment, it is best to inject the deeper medial (less mobile) fat compartments should the patient require volume in the midface.
Excellent resources detailing safe injection approaches are available for the temple, but it is an advanced technique due to the potential for inadvertent arterial injection. 18,19 During this CME activity, the authors discussed anatomy relevant to this injection. Key

Lateral SOOF injection
In clinical practice, the lateral lid-cheek junction is a high-impact area to treat and is a relatively safe area to inject; however, it is often neglected. To improve the infraorbital area and medial cheek, place a high G′ filler under the lateral SOOF (prezygomatic space;  Figure 4 shows a patient who has been injected on one side of the face with the injection points shown in Figure 3B. The patient treated during the roundtable is shown in Figure 4 with the left side of the face injected in the superior portion of the posterior temple and under the lateral SOOF. Note the rounder, rather than triangular, shape under the eye, the canthal axis elevation, and wider eye. Full treatment plans for these patients are shown in Figure 3, and before and after images are shown in Figures 5 and 6.  (Video S1), and depth can also be affected by patient BMI and thickness of the subdermal fatty layer.

| Ultrasound mapping of vasculature for informing injection approach in the temple
The one-up-one-over technique, a popular technique for temple injection, touts that the safest point for injecting is 1 cm up from the lateral orbital rim and 1 cm lateral to the temporal suture line, deep onto bone, with the bevel pointed downward. 23 Despite the reported lack of major vessels in the area, aspiration for 10 s and injection of small volumes are recommended. Importantly, this technique is restricted to injection within a single plane and does not necessarily prevent transecting vasculature, but rather seeks to ensure that F I G U R E 7 In the ultrasound image (A), the superficial temporal artery is 2.9 mm from the surface within the fascia. The location of the artery within the fascia is illustrated in 2 views of a cadaver dissection (B, C; Cadaver dissection courtesy of Sebastian Cotofana, MD).
the injection itself does not deposit product inside a vessel. For the patient shown in Figure 5, who was treated during the live demonstration portion of the course, the superficial temporal artery was closer to the orbit than in most patients, and in this case the one-upone-over technique could have resulted in an arterial puncture. This highlights that no technique is fool-proof and that each injection must be approached with care. Ultrasound guidance is becoming increasingly popular as a valuable tool for mapping vasculature in the temple prior to injection.
The utility of ultrasound devices in clinical practice is contingent upon the quality of the image, which is largely a function of the device itself. The ultrasound images shown in Video S1 and Figure 7 are • If the patient experiences pain, stop injecting! Withdraw the needle or cannula and asses prior to starting again. Pain can be a sign that the needle or cannula is in the incorrect plane.
• Be gentle! Injections should never be rushed, and the resistance felt by the injector provides valuable information for understanding the plane of injection and the location of anatomic structures.
• Use small volumes. Not only is this practice important for an artistic approach, but it supports safe injection.
• Gently rolling the cannula forward can help to move vessels out of the way.
There is no single best approach for temple injection, only a need to understand the rationale and expected outcomes and risks associated with each technique. However, the authors recognize that because the aging process affects all layers and that injec- The masseter muscle, one of the 4 muscles of mastication, is one of the largest muscles in the lower face. It has a significant influence on overall facial shape, and injecting it can reduce its volume and slim and feminize the lower face. For those with bruxism, there may be secondary benefits, such as the reduction of teeth grinding, less temporal mandibular joint pain, and/or the alleviation of headaches.
To properly inject the masseter and reduce the risk of negatively influencing the smile, it is best to stay posterior and lateral. Keep injections below the line that extends from the lobule of the ear to the oral commissure and 1 cm lateral to the palpable anterior boundary of the masseter muscle in a 3-point injection in a triangular pattern

| CON CLUS ION
While there is no typical European face, there is much to be learned from thoughtful consideration of how to best manage mature patients as well as how to use minimally invasive modalities to efficiently to achieve natural-looking results. Europe, with its extensive geographical dimension and significant migratory movements over the course of human history and into the present day, is the epitome of multiethnic diversity. The European experience treating a diverse patient group highlights the importance of diligent communication and treating each patient as an individual, which are critical approaches across the globe.

ACK N OWLED G M ENTS
Medical writing assistance was provided by Ginny Vachon, PhD of Principal Medvantage, LLC, Atlanta, Georgia, under the direction of the authors. Funding for this support was provided by a CME grant funded by Abbvie, Galderma, Merz, and Evolus.

FU N D I N G I N FO R M ATI O N
Funding for this CME event was provided by Abbvie, Galderma, Merz, and Evolus.

DATA AVA I L A B I L I T Y S TAT E M E N T
Data sharing is not applicable to this article as no new data were created or analyzed in this study.