Facial aesthetics and rejuvenation are evolving rapidly due to changes in products, procedures, and patient demographics. Clinicians can benefit from ongoing guidance on products, tailoring treatments to individual patients, treating multiple facial areas, and using combinations of products and ways to optimize outcomes. A multidisciplinary group of aesthetic treatment experts convened to review the properties and uses of botulinum toxin type A (BoNTA) and hyaluronic acid fillers and to update consensus recommendations for facial rejuvenation using these two types of products. The group considered paradigm shifts in facial aesthetics; optimal techniques for using BoNTA and hyaluronic acid fillers alone and in combination; the influence of patient sex, ethnicity, cultural ideals, and skin color on treatment; general techniques; patient education and counseling; and emerging trends and needs in facial rejuvenation. The group provided specific recommendations by facial area, focusing on relaxing musculature, restoring volume, and recontouring using BoNTA and hyaluronic acid fillers alone and in combination. For the upper face, BoNTA remains the cornerstone of treatment, with hyaluronic acid fillers used to augment results. These fillers are central to the midface because of the need to restore volume. BoNTA and hyaluronic acid in combination can improve outcomes in the lower face. Optimal outcomes in facial aesthetics require in-depth knowledge of facial aging and anatomy, an appreciation that rejuvenation is a three-dimensional process involving muscle control, volume restoration, and recontouring, and thorough knowledge of properties and techniques specific to each product in the armamentarium.

Until relatively recently, restoration of appearance by replacement of lost facial volume and muscular relaxation has been an illusory goal. With advances in the commercial availability of newer filling agents and a better understanding of the clinical esthetic effects of botulinum toxin A, remarkably sophisticated and refined results can now be achieved by using these noninvasive techniques. The combined use of BTX-A and filling agents, such as collagen and hyaluronic acid, can restore facial appearance by the dual mechanisms of reflation and relaxation. In addition, their combined use appears to increase the longevity of tissue dwell time of the filling agent. Current practices now strive to correct wrinkles by restoring volume and also relaxing the pull of muscles that create negative facial expressions such as glabellar folds, mouth frown, crow's feet, horizontal forehead lines, and perioral and cervical rhytides. As with any of the new technological innovations currently available, understanding of the differing properties of the agents used and education in optimal technique is essential to clinical and esthetic success.

BACKGROUND With the increasing popularity of three dimensional filler treatments, the tip of the injecting needle or cannula is subdermal, often adjacent to the facial vasculature. Inadvertent canalization of these vessels can rarely result in vascular occlusion with consequent blindness or stroke. OBJECTIVE The goal was to demonstrate a technique of retro or peribulbar injection of hyaluronidase should such an emergency arise if no ophthalmologist was immediately available. The treatment is needed urgently because the retina can only withstand up to 90 minutes of hypoxia. MATERIALS AND METHODS We present verbal and diagrammatic instructions for this treatment and videos of both the retrobulbar technique (courtesy of Dr. D. Maberley) and peribulbar technique (courtesy of Dr. S. Fagien). RESULTS None of us have yet used this technique to treat iatrogenic filler induced blindness but we present the information for the benefit of patient safety, given the limited time the retina can survive vascular occlusion. CONCLUSION Inadvertent canalization of facial vessels can cause embolic occlusion of retinal vasculature because of the anastomotic nature of the facial vasculature and the end artery morphology of the retinal circulation. Embolism from 3-dimensional hyaluronic acid filler use is potentially reversible if hyaluronidase is injected into the adjacent tissue.

Background. Until recently, deep facial sculpting was exclusively the domain of surgical interventions. Recent advances in the available array of dermal and subdermal fillers combined with an esthetic appreciation by both surgeons and nonsurgeons alike of the positive effect of filling the volume‐depleted face have led to an expansion in the indications for the use of soft tissue augmenting agents. Method. Subdermal support of the lateral two‐thirds of the brow, the nasojugal fold, the malar and buccal fat pads, the lateral lip commissures, and the perioral region, including the prejowl sulcus, all restore youthful facial contour and harmony. An important advance in technique is the subdermal rather than the intradermal injection plane. Results. “Instant” facial sculpting giving a brow‐lift, cheek‐lift, lip expansion, and perioral augmentation is possible using modern soft tissue augmenting agents. The softer, more relaxed appearance contrasts to the somewhat “pulled” appearance of subjects who have had surgical overcorrections. Treatments can be combined with botulinum toxin and other procedures if required. Conclusion. Newer advances in the use of fillers include the use of fillers injected in the subdermal plane for “lunchtime” facial sculpting. Using the modern esthetic filler compounds, which are biodegradable but longer lasting, subjects can have a “rehearsal” treatment or make it ongoing. Some individuals, such as those with human immunodeficiency virus (HIV)‐related lipoatrophy or those who desire to obtain a longer‐lasting effect, may elect to use a nonbiodegradable filling agent.