Multi-Dimensional Aesthetic Scan Assessment (MD ASA™): Initial experience with a novel

consultation, facial assessment and treatment planning tool

Accepted Article
Authors: Mauricio de Maio MD ScM, PhD1, Vandana Chatrath MD2, Sarah Hart MBChB3, Anna
Jen Shi Hoo, MD4, Alexandre Marchac MD5, Dimitris Sykianakis MD PhD6, Izzy Lung I Lee MD7

1MD Codes Institute, São Paulo, Brazil

2Vanila Dermologie, New Delhi, India
3Dr Sarah Hart, Auckland, New Zealand
4Anna Hoo Clinic, Petaling Jaya, Malaysia
5Marchac Chirurgie Plastique, Paris, France
6Well Aging Clinic, Athens, Greece
7Shang-Ho Aesthetic Medical Clinic, Kaohsiung City, Taiwan (R.O.C.)

Corresponding author: Mauricio de Maio, MD Codes Institute, Avenida Faria Lima, 4509 cj 121,
04538-133, São Paulo-SP, Brazil; e-mail: mauriciodemaio@uol.com.br; tel: +55 (11) 983208000

Short title: MD ASA™: Initial experience

Conflicts of interest: Dr de Maio, Chatrath, Hart, Hoo, Marchac, Sykianakis and Lee are
consultants and speakers for Allergan.

Acknowledgments: Writing and editorial assistance was provided to the authors by Timothy
Ryder, DPhil, of Biological Communications Limited (London, United Kingdom) and funded by
Allergan plc (now AbbVie) at the request of the investigators. The authors thank Dr Elian
Brenninkmeijer for patient recruitment and post-treatment care.

Authors’ contributions: M.d.M. developed the MD ASA tool, interviewed all the patients,
established the treatment plan, led the training session, supervised the data analysis, and
provided writing content. M.d.M., V.C., S.H., A.J.S.H., A.M., D.S. and I.L.I.L. were all involved in
treating patients and writing the paper. All authors read and approved the final manuscript.

This article has been accepted for publication and undergone full peer review but has not been
through the copyediting, typesetting, pagination and proofreading process, which may lead to
differences between this version and the Version of Record. Please cite this article as doi:
10.1111/JOCD.14216
This article is protected by copyright. All rights reserved
 DR. MAURICIO DE MAIO (Orcid ID : 0000-0001-8020-4801)
Accepted Article
Article type : Original Contribution

ABSTRACT
Background: Comprehensive patient assessment and planning are central to aesthetic
treatment with injectables. MD ASA™ (Multi-Dimensional Aesthetic Scan Assessment) is a
novel tool developed for this purpose.
Aims: To describe the MD ASA technique and present its preliminary application.
Methods: MD ASA breaks down the face into five hierarchies (H1–H5). H1 shifts patients’
focus from ‘distractions’ (individual lines and folds) towards the overall messages their face
portrays, based on eight Emotional Attributes: four negative (tired, sad, angry, saggy); four
positive (youthful, attractive, contoured, feminine/masculine). Three priority Emotional
Attributes are selected for each patient. This is followed by a process of narrowing down
through facial thirds (H2), periorbital and perioral dynamics (H3), facial units (H4), and
subunits (H5), to arrive at a final assessment. Based on the key facial signs identified, this
can be translated into MD Codes equations and thus a treatment formula. A retrospective
analysis was performed based on 12 female patients injected by expert clinicians at an
educational event. All patients were selected for, and treated using, a single MD Codes
formula derived from a common MD ASA work-up.
Results: There were substantial differences between patients and clinicians in their views of
which anatomical areas needed treatment – but good alignment on priority Emotional
Attributes. Patients were treated only for three negative Emotional Attributes, but
improvements were observed across all eight attributes.
Conclusions: MD ASA provides a practical method for translating facial messages into
actionable injectable treatment plans, and facilitates greater patient–clinician alignment.
Prospective studies are warranted.

Keywords: facial aesthetics; facial assessment; hyaluronic acid; injectables; MD ASA; MD

Codes

This article is protected by copyright. All rights reserved

 INTRODUCTION
In recent years, the field of aesthetic medicine has seen rapid increases in the use of
injectable treatments – particularly hyaluronic acid (HA) fillers and botulinum neurotoxin type
Accepted Article
A (BoNTA).1 However, patient dissatisfaction remains a common problem.2 Tools for
assessment, communication and treatment technique are becoming more and more
important for improving relationships between clinicians and patients.

In an attempt to provide a more consistent approach to treatment, the MD Codes™ (for

structure) and the MD DYNA Codes™ (for dynamics) were developed.3,4 These provide
specific technical guidance, including injection locations in relation to mimetic muscles,
layers, devices (needle or cannula), delivery format (bolus, fanning, linear, etc), and product
volumes (active numbers), which can be used regardless of patient ethnicity, age or gender.
Several studies have demonstrated that the MD Codes approach is safe and effective in
routine practice.5–7

It is also important to provide comprehensive methods for patient assessment and planning
prior to treatment execution. Such methods are the fundamental basis of a successful
outcome, supporting practitioners in identifying requirements and formulating an appropriate
strategy. As a result, the predictability and reproducibility of results may be improved.

Facial assessment poses numerous challenges. For example, practitioners frequently face
the dilemma of indicating treatment of an area that the patient has not expressed concern
about. Patients are often not fully aware of their needs and may require expert input.
Furthermore, clinical diagnosis is challenging in internal medicine and it appears to be the
same in aesthetic medicine. This may be due to many factors, not least the variety of
different faces that exist around the world – including diverse ethnicities, age groups and
genders. The aging process also presents a huge variety of signs with varying degrees of
severity, making it challenging for clinicians to reach an accurate diagnosis.

Moreover, it is common during consultation for patients to ask only for correction of the small
distractions they see in the mirror (eg, crow’s feet lines or nasolabial folds), which may be
referred to as ‘Patient Wants’. If only these minor imperfections are treated, it may lead to a
limited outcome, with the patient looking corrected but not necessarily good. To expand their
understanding of their own requests, we must consider what the ‘Patient Feels’, relating to
the overall messages of the face that the individual feels they want to achieve or correct.
These may be termed ‘Emotional Attributes’. Last but not least, we also need to consider
what the ‘Patient Needs’, based on the expert opinion of the clinician.

This article is protected by copyright. All rights reserved

 Many validated rating scales are available for assessing parts of the face,8–12 and these are
particularly useful for research purposes – but can be time consuming and may be of limited
Accepted Article
value in clinical practice. Other methods provide clues on ideal proportions and specific
deficits.13–17 However, should we not focus on the message of the face rather than on
correcting distractions? The objective of this paper is to introduce a novel tool known as MD
ASA™ (Multi-Dimensional Aesthetic Scan Assessment), which was developed by the first
author and may help clinicians with patient assessment and treatment planning. We will also
present the preliminary application of MD ASA, associated with relevant MD Codes-based
injections using a single formula,3 at a clinical education event.

METHODS: MD ASA: FIVE HIERARCHIES OF ASSESSMENT

Faces can be challenging for clinicians to read. As with books written in a foreign language,
we sometimes need help to ‘translate’ them. In practice, one way to do this is to divide the
face into appropriate pieces, just as a book is divided into chapters, paragraphs, sentences
and words. Rather than using only the traditional horizontal facial thirds,18 MD ASA breaks
down the face into five hierarchies (H1–H5), ranging from the full face (H1) to facial subunits
(H5) (Figure 1).

Hierarchy 1: Full face and the ‘Emotional Attributes’

Hierarchy 1 (H1) assesses the messages that the patient portrays – an overall analysis of
the full face. This is where the Emotional Attributes are found, such as the tired look, the sad
look, the angry look, or a saggy appearance. For example, with aging, patients can often
look tired without actually being tired, and this creates a discrepancy between what they feel
and how they look.

Within H1, MD ASA defines the emotional messages of the face using eight Emotional
Attributes (Table 1; Figure 2): four negatives (tiredness, sadness, angriness, and saggy
appearance); and four positives (youthfulness, attractiveness, contour, and femininity /
masculinity). The negative attributes may be considered as the patient’s ‘realities’ whereas
the positive attributes are the ‘dreams’. Although some of these are obviously physical traits
(eg, saggy appearance, contour), they have been included as Emotional Attributes because
they relate to the messages that patients often want to convey and frequently request.

Consulting with the Emotional Attributes enables patients to understand that they may need
to address more than just the small distractions, such as annoying facial lines. It can also
help them to focus on the messages of their face: how they see themselves and how they

This article is protected by copyright. All rights reserved

 are perceived by others. This enhances their understanding of the possible need for a full-
face approach, which may ultimately lead to the desired outcome.
Accepted Article
During the consultation, the patient is asked to prioritize three of the eight Emotional
Attributes (in rank order), so that the clinician can better understand their treatment
expectations (Figure 2A). They are asked to do this by looking at themselves in the mirror,
as well as by looking at photographs at rest and during animation. The clinician should
always help the patient to focus on reducing unfavorable messages first and only then on
enhancing the positive attributes. To achieve the ‘dreams’, we need to fix the ‘realities’ first.
Thus, H1 is an important educational tool to improve patient awareness of the objectives of
aesthetic treatment.

H1 also assesses the overall rating of the patient on a scale of 0 to 10, where 0 signifies the
worst they can look and 10 the best they can look for their age and ethnicity (Figure 2B). As
a rule, few if any patients rate a 0 or a 10. The responsibility of the clinician is to improve the
overall rating of the patient, focusing first on the negative attributes. Ethnicity, age and
gender must be considered.

The patient is rated on a scale of 0 to 10 at rest, and also when smiling. On smiling, the
rating may upgrade, downgrade or be equivalent. If the patient’s face upgrades on smiling,
there is a high likelihood of achieving a good result. If the rating is equivalent, it is possible to
improve the patient’s look. However, if the patient’s face downgrades on smiling, the
procedure may be technically challenging.

Figure 2 provides an example based on a 51-year-old female. In this case, the patient and
injector each picked the same three Emotional Attributes – to look less saggy, less tired and
less sad – although the rank order differed. The injector considered the overall facial
appearance to be unfavorable at rest (a rating of 5 on a 0–10 scale) but this upgraded on
smiling.

Hierarchy 2: Facial thirds and neck

Based on H1 only, it would be difficult to know which parts of the face are contributing most
to a favorable or unfavorable global facial message. Hierarchy 2 (H2) therefore probes
further, splitting the face into upper, mid and lower thirds, as well as the neck. Within each,
specific key features are assessed (Table 2) and qualified (Table 3). The thirds of the face
and the neck should be rated as ideal/optimal, favorable, acceptable or unfavorable
according to key facial features, degree of severity, symmetry and proportions – always

This article is protected by copyright. All rights reserved

 taking into consideration the patient’s ethnicity, age and gender. In H2, clinicians should also
check for the presence or absence of lines and volume loss. This classification may indicate
whether treatment is a priority for correction (unfavorable) or if the patient might need
Accepted Article
beautification (favorable).

An example is provided in Figure 3. In this case, the upper third and neck were considered
‘acceptable’, whereas the mid and lower third were ‘unfavorable’ – indicating the need to
prioritize treatment of these two areas.

Hierarchy 3: Periorbital and perioral areas

The periorbital and perioral areas are the parts of the face where aging signs are most
apparent and emotion is best communicated,19,20 particularly on animation. Hierarchy 3 (H3)
focuses on assessment of periorbital and perioral dynamics. In the periorbital area, the
expressions assessed should ideally include frowning (angry), raising brows (surprise), and
smiling (happy); in the perioral area, smiling (happy), kissing (affection) and pouting (baby
cry) are assessed. The clinician should analyze whether these areas upgrade, remain
equivalent or downgrade on animation, and thus determine whether treatment is a priority or
not. For example, in Figure 4, the perioral area downgrades on kissing or pouting, and
hence addressing this area should take priority for treatment.

Hierarchy 4: Facial units

Hierarchy 4 (H4) considers the facial units and key facial signs that may lead to the negative
Emotional Attributes. In H4, the clinician identifies ‘Patient Needs’ by associating unfavorable
messages with the relevant facial units, and then starts to prepare the relevant MD Codes
equations.3 As an example, the tired look may indicate deficiencies in the cheeks, tear
troughs, and temporal areas (Table 4). On the other hand, if the patient does not present any
visible negative messages, then the clinician may focus on beautifying the patient’s
appearance. For example, a young female patient may benefit from fuller lips and greater
cheek definition.

Treatment of the patient is tailored and customized in H4. The MD Codes should be grouped
into equations according to patient needs and the MD Codes formulas are then created. It is
important to highlight that the treatment of a specific facial sign, such as low brows, may
require the treatment of adjacent areas, such as the cheeks and temples.

In particular, the focus should be on the areas rated as unfavorable or acceptable in H2 and
those that downgrade in H3. The ultimate objective of treatment is to improve the ratings of

This article is protected by copyright. All rights reserved

 these areas to favorable or ideal/optimal. For the example patient, this meant a focus on the
lower and mid thirds and the perioral area (Figure 5). Areas rated at unfavorable include the
lips, jowls and jawline, as well as the tear troughs.
Accepted Article
Hierarchy 5: Facial subunits
There are usually specific problems (distractions) that the patient sees when looking at
themselves in the mirror, such as fine lines and folds, which trigger them to seek aesthetic
treatment. In H5, these distractions are grouped as ‘Patient Wants’ and may include
forehead lines, glabellar lines, crow’s feet, tear troughs, nasolabial folds, perioral lines,
marionette lines, etc. However, these are only the tip of the iceberg. The challenge for the
clinician is that if they only focus on these distractions, it may lead to patient dissatisfaction.
Hence, it is crucial to highlight the importance of H1 – the message of the face. Nonetheless,
to address H1 and improve the message of the face, the clinician should take all of the
hierarchies into consideration (Table 5).

For the example patient, the three areas that she selected in her self-assessment were the
eyebags, jowls, and downturn of the mouth (Figure 6). All three of these distractions were
rated as moderate in severity. In this instance, they largely align with the key facial signs
selected by the clinician in H4.

Formulating the treatment plan

Based on what the ‘Patient Wants’, ‘Patient Feels’, and ‘Patient Needs’, the clinician should
apply the analysis of the five hierarchies of MD ASA. They can then start to prepare the
treatment plan using the key facial signs of each Emotional Attribute, and translate these
into MD Codes equations (Table 4). Algorithms to correlate the facial signs with the MD
Codes have been published previously to identify ‘Patient Needs’.3

By combining relevant MD Codes equations, a systematic ‘formula’ for each Emotional

Attribute is then designed. This basic formula contains the potential facial signs for each
Emotional Attribute. It must be customized for each patient, which means that some codes
may be excluded from the formula. At this point, it is the responsibility of the clinician to
make the relevant clinical judgments. The formula provides the MD Codes to be injected for
the specific patient, and hence the clinician may estimate the volume of filler required to
achieve the desired outcome; because each code has an active number,3 the total amount
of product needed is easily calculated. If larger volumes are required, some clinicians may
prefer to deliver this across multiple sessions, although we typically advise a minimum of 4
mL per session to achieve an optimal result.

This article is protected by copyright. All rights reserved

 To illustrate how this works in practice, the MD ASA assessment for the example patient is
summarized in Table 6, and the matching MD Codes equations and final treatment plan are
Accepted Article
shown in Figure 7. Although Figure 7A shows a number of different equations, many are
overlapping, and hence the final formula given in Figure 7B is not excessively complicated.

METHODS: INITIAL EXPERIENCE

The experience presented here is from a training and mentoring event on the MD ASA and
MD Codes techniques held in Amsterdam, Netherlands (10 February 2019). This is a
retrospective analysis of data from a group of 12 female patients who were treated by 12
expert clinicians (one patient per clinician) as part of that event. The training was led by the
first author. Clinicians came from different medical specialties and from multiple countries
and territories (Table 7).

Patients
Twelve patients were included in the training event. They were selected by the lead author
based on their appropriateness for training on the MD ASA / MD Codes formula already
described. Thus, to be included in the event, patients were required to present the facial
signs listed in Table 8. The degree of severity of these facial signs ranged from mild to
severe. Individuals were excluded from the training session if they had ever previously
received a permanent filler and/or had received an HA filler or BoNTA in the past 6 months.

All signed informed consent for treatment and for use of their photographs, and each was
personally assessed by the lead author and their clinician. All parties agreed on the final
treatment plan.

Prior to consultation, patients were photographed from five angles (frontal; left and right
oblique; left and right profile) at rest, smiling, kissing and pouting.

Consultation
The first consultation was carried out by the lead author to ensure that all patients were
eligible for the training session. Patients were asked to prioritize the top three anatomical
areas of their face that they wanted to improve or correct both in the mirror and then looking
at their photographs (‘Patient Wants’). Based on H1 of MD ASA, patients were also
presented with the Emotional Attributes chart (Table 1) and asked to prioritize the top three
Emotional Attributes that they would like to achieve with aesthetic treatment (‘Patient Feels’).
Again, this was done both by self-examination in the mirror and then using photographs.

This article is protected by copyright. All rights reserved

 Treatment
The MD Codes formula that was selected for this training event, with respective codes and
Accepted Article
active numbers, is shown in Figure 7B. All treatments were performed using the Vycross™
range of HA fillers (Juvéderm Voluma [VYC-20], Volift [VYC-17.5], Volbella [VYC-15];
Allergan, Dublin, Ireland). Post-treatment photographs were taken immediately after
injection. Patients were asked to look at these photographs and describe which Emotional
Attributes had been achieved.

Assessments
As part of the training event, patients and clinicians were asked to look at the patient
photographs. All 12 clinicians were also asked to rate all 12 patients for the following: top
three anatomical areas needing improvement (pre-treatment); top three Emotional Attributes
to address (pre-treatment); and the impact of treatment on all eight Emotional Attributes. The
12 clinicians then recruited three further groups, who were each asked to make the same
assessments of all 12 patients using pre- and post-treatment photographs: 12 other
experienced clinicians; 12 aesthetic clinic staff; and 12 laypeople.

RESULTS
Patients and treatment plans
Twelve female patients were included with a mean age of 48.7 ± 6.3 years (range: 42–55
years). All were Caucasian. They were assessed and treated using MD ASA and the MD
Codes by 12 expert clinicians (one patient per clinician) with a mean duration of aesthetic
medicine experience of 13.2 ± 3.9 years.

For all 12 patients, the same three (negative) Emotional Attributes were selected by their
clinician: saggy, tired and sad. All were treated with the MD Codes formula selected for the
training event (Figure 7B), and each of the 12 clinicians injected a single patient using the
prescribed points within this treatment plan. In all cases, this involved 13–14 mL of Vycross
HA fillers injected in a single treatment session. No BoNTA was used. Before-and-after
images of the example patient demonstrate the effectiveness of the method (Figure 8).

Patient self-assessment and comparison with other assessors

Patients made pre- and post-treatment assessments of themselves. In addition, all 12
clinicians and all 12 members of each of the three additional groups (other experienced
clinicians; clinic staff; and laypeople) made assessments of all 12 patients. The ‘other

This article is protected by copyright. All rights reserved

 experienced clinicians’ group had a mean duration of aesthetic medicine experience of 9.5 ±
5.1 years.
Accepted Article
Prior to treatment, patients selected specific anatomical areas of their face that they wished
to improve – the ‘Patient Wants’. The majority of patients (n=8/12; 67%) changed their
mirror-based selections after viewing themselves in photographs (Table 9). The most
common choices using photographs were jowls (n=6; 50%), nasolabial folds (n=6; 50%),
and marionette lines (n=5; 42%). When patient selections were compared with those of other
assessors, there were wide variations. For example, the most commonly selected priority
areas among clinicians were tear troughs (n=57; 40%), nasolabial folds (n=55; 38%), and
saggy cheeks (n=49; 34%).

Patients also selected the key Emotional Attributes that they wished to address – the ‘Patient
Feels’ – both in the mirror and with photographs (Table 10). Ten of the 12 patients changed
their mind to some degree after viewing themselves in photographs compared with the
mirror. Nonetheless, irrespective of whether a mirror or photographs were used, the most
common selections were the same three (negative) attributes: saggy, tired and sad. In
photographs, these were selected by 9 (75%), 8 (67%) and 7 (58%) patients, respectively.
There was good alignment between patients and the other groups of assessors. Indeed, the
three most frequently selected Emotional Attributes were the same among clinicians, other
experienced clinicians, aesthetic clinic staff and laypeople as they were among the patients:
saggy, tired and sad (Table 11).

After treatment, 11 of the 12 patients rated themselves as having improved in all eight
Emotional Attributes based on photographs (Table 12); the other patient indicated
improvements in seven of the eight attributes. Furthermore, the majority of assessors in all
four of the other groups (clinicians, other experienced clinicians, clinic staff, and laypeople)
felt that each of the eight Emotional Attributes – whether negative or positive – was
improved, even though the patients had only been specifically treated for three negative
attributes.

DISCUSSION
The MD ASA tool is a novel systematic method for consultation, facial assessment and
treatment planning with HA fillers and BoNTA that aims to go beyond the treatment of
‘distractions’. The overall messages of the face play a central role in social interaction.
Indeed, emotions are a key factor in human communication and a powerful source of
influence, having a significant impact on the attitudes of others.21–23 Thus, MD ASA focuses

This article is protected by copyright. All rights reserved

 on addressing the Emotional Attributes rather than merely focusing on lines or folds. In
addition, a successful outcome may be more readily achieved if practitioners inspire their
patients to be involved in treatment planning.24 Clinicians should help patients to see beyond
Accepted Article
small lines and folds or the improvement of a single facial area.

This study provides preliminary evidence that use of the eight Emotional Attributes during
consultation may help to create a more aligned and therefore more effective practitioner–
patient discussion. When the 12 patients were asked to list the key anatomical areas
needing treatment, these were typically different from those identified by clinicians. By
contrast, there was generally good alignment between patients and clinicians with regard to
Emotional Attributes (Table 11).

MD ASA encourages clinicians to assess the face in detail via the five hierarchies and to
deliver a full-face approach. In addition, MD ASA can guide clinicians to prepare a
comprehensive treatment plan with the MD Codes3 – which have proven safety and
effectiveness in several real-world studies.5–7

Photographs as a consultation device

There were substantial differences in how patients saw themselves in the mirror versus
photographs. Indeed, most changed their minds on priority anatomical areas and Emotional
Attributes when using photographs versus a mirror (Tables 9 and 10). In practice, mirrors
only allow for a very restricted frontal (and reversed) view, from which the key features of
facial aging may be poorly discernible; by contrast, photographs provide a more objective
self-examination and allow patients to see themselves from multiple angles.25 Consulting
with photographs may facilitate better communication of patients’ aesthetic goals without the
distraction of features seen in the mirror that do not contribute to the overall facial message.
Given that almost all practitioners and patients now have a handheld camera phone,
consultation using photographs should be as practical and simple as consulting with mirrors.

Treat negative before positive

The three Emotional Attributes most commonly selected by patients prior to treatment were
all negative (saggy, tired and sad). This is not the ‘rule’ and may differ based on cultural and
demographic factors. For example, Latin and Middle Eastern women tend to focus more on
positive attributes, as do younger patients (who typically show less evidence of negative
messages).

The present group was demographically homogenous (Caucasian females from the

This article is protected by copyright. All rights reserved

 Netherlands aged 42–55 years), but it is nonetheless striking that they focused on the same
three negative attributes. The other four assessor groups also most frequently chose these
three attributes. This suggests that – irrespective of background and training – observers
Accepted Article
often tend to select negative facial aspects to improve before selecting positive
characteristics to enhance. This emphasizes the importance of eliminating negative signs as
a treatment priority.

Interestingly, when patients and assessors were asked to analyze post-treatment

photographs, they judged that there were improvements in positive Emotional Attributes
(younger, more attractive, more contoured, more feminine) as commonly as improvements in
the negative attributes that had actually been treated (Table 12). It may be that treating
negative Emotional Attributes should be prioritized in most cases, allowing for concomitant
enhancement of positive attributes. Further studies are warranted.

Treating all patients alike

Once the priority Emotional Attributes are established for a given patient, the MD ASA facial
assessment hierarchy helps to identify the key facial signs that contribute to this
appearance. The process establishes a series of MD Codes equations delineating a
systematic treatment plan. For example, within the ‘less saggy’ module, a commonly
observed key facial sign is the presence of jowls. To improve the appearance of jowls,
selected MD Codes for the cheek, chin and jawline are needed. Additionally, a saggy
appearance may involve other key facial signs, such as nasolabial folds and marionette
lines. MD Codes equations can be created for each key facial sign; by combining these MD
Codes and eliminating those that repeat, a final ‘formula’ is reached.

Of course, not all patients that have a saggy look will show the same set of contributing key
facial signs. Thus, even though the underlying MD Codes equations for each Emotional
Attribute are the same, some individualization of the treatment plan will still be required to
achieve optimal correction.

Nonetheless, a key benefit of MD ASA and the MD Codes is that substantial systematization
is achieved. We believe that, in general, greater systematization of methodology leads to
improved predictability of outcomes and a reduced likelihood of significant complications.3–7

Furthermore, because each Emotional Attribute has a systematic set of underlying equations
based on the key facial signs contributing to that attribute, it can potentially be applied to all
patients, irrespective of demographic characteristics – such as ethnicity, age or gender. The

This article is protected by copyright. All rights reserved

 patient group analyzed in the present work was relatively homogenous in this regard.
Indeed, a lack of demographic diversity was a key limitation, along with the small size of the
group. Further validation of MD ASA will therefore be required, incorporating larger,
Accepted Article
multicenter, prospectively assessed studies in more heterogenous patient populations.

Some might argue that applying the same MD Codes formula across multiple patients
detracts from their individuality and risks making them all look the similar. However, the
starting point is always different based personal characteristics (e.g. ethnicity, age and
gender). Use of the same formula puts the focus on the overlapping unfavorable messages
that patients present – but the results are always individual. An analogy would be use of the
same broad-spectrum antibiotic to reduce infections in diverse patient populations.

CONCLUSIONS
MD ASA is a novel clinical tool for patient consultation, facial assessment, and treatment
planning with HA fillers and BoNTA. It was developed with the aim of facilitating greater
systematization of these processes, leading directly to MD Codes-based treatment plans
designed to achieve predictable and reproducible aesthetic outcomes and minimize the risk
of major complications.3–7 This system can be used to ‘transform the message of the face’
regardless of patient ethnicity, age or gender. It provides a practical method for clinicians at
all levels – from novices through to highly experienced practitioners – to translate facial
messages into actionable treatment plans.

Within the consultation process, MD ASA helps to bridge the gap between what patients
want and what they actually need. Consulting with fewer initial variables (eight Emotional
Attributes rather than many different anatomical areas) facilitates greater clarity and
alignment between patient and clinician. Improved communication may result in better
outcomes and greater patient satisfaction.24 In addition, the use of photographs during
consultation (rather than only a mirror) may catalyze improved patient understanding of their
needs.

Rates of satisfaction with outcomes were high in the initial group of 12 patients. Further
prospective studies and greater application in routine practice are needed to better
understand the potential of this novel tool.

This article is protected by copyright. All rights reserved

 REFERENCES
1. American Society of Plastic Surgeons. Plastic surgery statistics report 2019.
Available at: www.plasticsurgery.org/documents/News/Statistics/2019/plastic-
Accepted Article
surgery-statistics-full-report-2019.pdf. Accessed April 6, 2021.
2. Watchmaker LE, Watchmaker JD, Callaghan D, et al. The unhappy cosmetic patient:
Lessons from unfavorable online reviews of minimally and noninvasive cosmetic
procedures. Dermatol Surg. 2020;46:1191-1194.
3. de Maio M. MD Codes™: A methodological approach to facial aesthetic treatment
with injectable hyaluronic acid fillers. Aesthetic Plast Surg. 2021;45:690-709.
4. de Maio M. Myomodulation with injectable fillers: An update. Aesthetic Plast Surg.
2020;44:1317-1319.
5. Bertossi D, Nocini PF, Rahman E, et al. Non-surgical facial reshaping using MD
Codes. J Cosmet Dermatol. 2020;19:2219-2228.
6. Saliani MT. Full-face rejuvenation with hyaluronic acid fillers based on the MD Codes
technique: A retrospective, single-center study. J Clin Exp Dermatol Res.
2020;11:523.
7. Farolch-Prats L, Nome-Chamorro C. Facial contouring by using dermal fillers and
botulinum toxin A: A practical approach. Aesthetic Plast Surg. 2019;43:793-802.
8. Carruthers J, Flynn TC, Geister TL, et al. Validated assessment scales for the mid
face. Dermatol Surg. 2012;38:320-332.
9. Flynn TC, Carruthers A, Carruthers J, et al. Validated assessment scales for the
upper face. Dermatol Surg. 2012;38:309-319.
10. Hersant B, Abbou R, Sidahmed-Mezi J, Meningaud JP. Assessment tools for facial
rejuvenation treatment: A review. Aesth Plast Surg. 2016;40:556-565.
11. Narins RS, Carruthers J, Flynn TC, et al. Validated assessment scales for the lower
face. Dermatol Surg. 2012;38:333-342.
12. Rzany B, Carruthers A, Carruthers J, et al. Validated composite assessment scales
for the global face. Dermatol Surg. 2012;38:294-308.
13. de Maio M, Swift A, Signorini M, et al. Facial assessment and injection guide for
botulinum toxin and injectable hyaluronic acid fillers: Focus on the upper face. Plast
Reconstr Surg. 2017;140:265e-276e.
14. de Maio M, DeBoulle K, Braz A, et al. Facial assessment and injection guide for
botulinum toxin and injectable hyaluronic acid fillers: Focus on the midface. Plast
Reconstr Surg. 2017;140:540e-550e.
15. de Maio M, Wu WTL, Goodman GJ, et al. Facial assessment and injection guide for
botulinum toxin and injectable hyaluronic acid fillers: Focus on the lower face. Plast
Reconstr Surg. 2017;140:393e-404e.

This article is protected by copyright. All rights reserved

 16. Swift A, Remington K. BeautiPHIcation™: A global approach to facial beauty. Clin
Plastic Surg. 2011;38:347-377.
17. Bertossi D, Mortellaro C, Nocini PF. Facial filler grid (FAFI GRID): A new method of
Accepted Article
facial analysis. J Craniofac Surg. 2015;26:860-862.
18. Fitzgerald R, Carqueville J, Yang PT. An approach to structural facial rejuvenation
with fillers in women. Int J Womens Dermatol. 2018;5:52-67.
19. Eisenbarth H, Alpers GW. Happy mouth and sad eyes: Scanning emotional facial
expressions. Emotion. 2011;11:860-865.
20. Vernon RJW, Sutherland CAM, Young AW, Hartley T. Modeling first impressions from
highly variable facial images. Proc Natl Acad Sci U S A. 2014;111:E3353-E3361.
21. van Doorn EA, van Kleef GA, van der Pligt J. Deriving meaning from others’
emotions: Attributions, appraisal, and the use of emotions as social information. Front
Psychol. 2015;6:1077.
22. Van Kleef GA. How emotions regulate social life: The emotions as social information
(EASI) model. Curr Dir Psychol Sci. 2009;18:184-188.
23. Van Kleef GA, van der Berg H, Heerdink MW. The persuasive power of emotions:
Effects of emotional expressions on attitude formation and change. J Appl Psychol.
2015;100:1124-1142.
24. Stewart MA. Effective physician–patient communication and health outcomes: A
review. CMAJ. 1995;152:1423-1433.
25. Glasgold MJ, Glasgold RA, Lam SM. Volume restoration and facial aesthetics. Facial
Plast Surg Clin North Am. 2008;16:435-442.

This article is protected by copyright. All rights reserved

 Figure 1. The five hierarchies of MD ASA (H1–H5)
Overview of the five hierarchies (A) and a pictorial representation (B). MD ASA, Multi-
Dimensional Aesthetic Scan Assessment.
Accepted Article
Figure 2. Hierarchy 1: Example patient
The three most important Emotional Attributes in rank order, as assessed by the patient and
clinician (A), and the clinician rating of her full facial appearance (B).

Figure 3. Hierarchy 2: Example patient

Figure 4. Hierarchy 3: Example patient

Assessment of the impact of animation on the periorbital area (A) and the perioral area (B).
Images of the periorbital area during frowning and brow raising are not available for this
patient.

Figure 5. Hierarchy 4: Example patient

Figure 6. Hierarchy 5: Example patient

Figure 7. Treatment planning: Example patient

The MD Codes equations for key facial signs within the three selected Emotional Attributes
(A), and the final treatment plan based on these equations (B). C, chin; Ck, cheek; Jw, jaw;
Lp, lip; NL / NLF, nasolabial fold; SOOF, sub-orbicularis oculi fat; T, temple; Tt, tear trough;
VB, Volbella (VYC-15); VL, Volift (VYC-17.5); VM, Voluma (VYC-20).

Figure 8. Facial assessment using MD ASA and treatment with MD Codes

A 51-year-old female before (A–D) and immediately after (E–H) treatment. Within Hierarchy
1 of MD ASA, the patient wanted to look less tired, less sad, and less saggy. The clinician
selected the same three Emotional Attributes. The treatment plan for this patient is provided
in Figure 7, and she was injected with 14 mL of HA filler in a single session. After treatment,
the patient rated herself as improved on all eight Emotional Attributes. HA, hyaluronic acid;
MD ASA, Multi-Dimensional Aesthetic Scan Assessment.

This article is protected by copyright. All rights reserved

 Table 1. The eight Emotional Attributes: What would you like to achieve with treatment?
Negative attributes (realities) Positive attributes (dreams)
Look less tired Look younger
Accepted Article
Look less sad Look more attractive
Look less angry Look more contoured
Look less saggy Look more feminine / masculine

This article is protected by copyright. All rights reserved

ted A
ed
ted A
ted
pted A
ted A
cepted Arti
pted A
ted A
pted A
epted Arti
Accepted Article
Accepted Article
Accepted Article
Accepted Article
Accepted Article
Accepted Article
Accepted Article
Accepted Article