Volumizing viaducts of the midface: defining the Beut techniques

A narrative-style review of non-surgical rhinoplasty: Indications, outcomes, and limitations

The aim of this narrative-style review was to evaluate non-surgical rhinoplasty in terms of indications, outcomes, and limitations. Both 'PubMed' and 'Science Direct' were reviewed by all authors, in order to reach consensus with regard to the chosen studies. Studies published from 1980 to 2023 were searched using the key terms "non-surgical rhinoplasty", "dermal filler", "thread lifting", and "botulinum toxin", and relevant papers were selected. Non-surgical rhinoplasty refers to the use of injectable temporary fillers to augment selected areas of the nose, in order to achieve improved appearance or function in select patients. It includes the use of dermal fillers, thread lifting, and botulinum toxin injections. The perfect dermal filler would be inexpensive, safe, painless to inject, hypoallergenic, and long lasting. In addition, it should produce consistent and predictable results, feel natural under the skin, take little time to inject, be ready to use, exert no downtime on the patient, and have a low risk of complications. Regions of the nose treated with filler injections include the frontonasal angle, dorsum, nasolabial angle, and columella. Thread lifting and botulinum toxin injection are the other methods of non-surgical rhinoplasty. Dermal fillers, thread lifting, and botulinum toxin injections can be used as non-surgical rhinoplasty. Dermal fillers and botulinum neurotoxin can be used alongside each other to allow minimally invasive resculpting of the nasal region and midface, compensating for a reduction in tissue volume and the formation of rhytides.

Needle versus Cannula to Treat Tear Trough: A Prospective Study Comparing both Methods

Background

We aimed to clinically compare needle and cannula techniques in vivo with ultrasound and magnetic resonance imaging, to better understand the best technique and adverse events.

Methods

Ten adults without previous fillers in the area were injected with hyaluronic acid (CPM 22.5 HA mg/mL) with a 25G cannula on one side and a Becton Dickinson syringe needle (31G 0.3 mL) on the other. The product was fractionated among two visits. Assessment was made at time 0d, 14d, 30d, 60d, 90d, 180d, and 365d with standard camera, Vectra H2, ultrasound, and magnetic resonance imaging. Level of satisfaction was also evaluated.

Results

All the patients showed natural results with both techniques and a high satisfaction index. Cannulas were minimally less traumatic in terms of bruises. However, the product was applied in a more superficial layer and in a less precise manner, despite the fact that a deep technique was used with cannulas, depositing the product on the orbital bone. Patients reported a more noticeable change immediately after the procedure on the side treated with cannulas but less edema and a more comfortable procedure on the Becton Dickinson syringe treated side. None of the patients required hyaluronidase to dissolve overcorrection of the area, and no severe complications were observed. The product remained in most of them at day 365.

Conclusions

Cannulas seem to be less traumatic regarding bruises, but less precise in vivo. Thin needles seem to be more precise with minimal trauma. However, this difference disappears during patient's evolution.

Unravelling the Complex Anatomy of the Tear Trough and Lower Eyelid Folds: A Review of Cadaveric Studies in the Literature

The lower eyelid tear trough deformity is a common cosmetic concern which is the result of multiple anatomic changes in the lower eyelid, usually resulting from age. A sound understanding of the underlying anatomy is vital to inform surgeons about the ideal treatment options for rejuvenation of this region and to minimize the risk of complications. Cadaveric studies provide unique insight into underlying anatomic changes. Here we review the relevant published cadaveric studies relating to the tear trough deformity and its treatment.

Anatomical Basis for Malar Augmentation Injection With the Zygomatic Ligamentous System

BACKGROUND

The malar augmentation injection has gained popularity in recent years, but the exact location of each injection site has not been clearly identified.

OBJECTIVE

To discover ideal injection sites by comprehensively considering the distributions of ligaments, muscles, and vessels.

MATERIALS AND METHODS

Eighteen cadaver heads were dissected to investigate the zygomatic ligamentous system and to measure the position of muscles. Sixty-six cadaver heads were subjected to computed tomographic scanning and three-dimensional vessel reconstruction. Radiological evaluation of the fillers was performed before and after experimental injection in one hemiface and dissected to confirm safe delivery. Five patients were enrolled in a prospective clinical study. 2D and 3D photographs were taken before and after the injections for comparison.

RESULTS

Site 1 was defined along the zygomatic arch, except the first 1/4 length and the midline of the arch. Site 2 was on the body of the zygoma, superior to the level of the infraorbital foramen and medial to the jugale. Site 3 was defined in the anteromedial midface approximately 30 mm below the lateral canthus.

CONCLUSION

Injections at these 3 sites can be performed within the range of the ligaments to achieve effective lifting effects and minimize potential complications.

Hyaluronic Acid Gel Injection for the Treatment of Tear Trough Deformity: A Multicenter, Observational, Single-Blind Study

BACKGROUND

Hyaluronic acid (HA) gel injections were first used to treat the tear trough in 2005 and since then it has been a mainstay of the approach to lower eyelid deformities.

OBJECTIVE

The authors present this retrospective multicentric observational study based on single-blind objective and subjective evaluation and patient satisfaction in relation to the aesthetic improvement of a large group of patients treated.

METHODS AND MATERIALS

Between January 2016 and December 2019, 600 patients (468 women and 132 men), were enrolled in this study, and 1200 tear trough deformities were treated with both needle and cannula techniques.

RESULTS

Average follow-up time was 12 ± 1 months, and the outcomes were assessed both objectively and subjectively with respect to Hirmand's classification. Statistical analysis shows an inverse correlation between age and class amelioration.

CONCLUSION

HA injection of the tear trough is most effective in patients between 30 and 40 years of age, while its benefits extend to up to 50 years old; afterward, it should no longer be the treatment of choice. This confirms that correction of tear trough with hyaluronic acid injections may provide an option to achieve immediate and durable results for up to one year after the injection.

LEVEL OF EVIDENCE IV

This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Pinch Anatomy of Forehead: An Injection Guide for Forehead Filler Treatment

With the popularity of filler injections globally, more and more injectors are using them for facial shaping and reversing the aging changes of the face. Detailed knowledge of facial anatomy, especially of important vessels and tissue planes is essential for injectors. While performing filler injections, injectors tend to pinch the tissue layers with their non-dominant hand for ease of doing the procedure. Such deformational forces cause some changes in the anatomy of tissue layers held in a pinch. During a deep pinch, the important arteries in that area can get pulled up in the pinch's tissue layers, or they can stay in their position being unaffected by pinching. The 'pinch and pull' can also improve the tissue space for injections, by pulling away the mobile tissue layers from the fixed ones. Knowledge of the 'pinch anatomy' in the forehead can be used to the injector's advantage to avoid important arteries and place filler in the correct plane. By knowing the anatomical changes during the pinched state of tissue layers, filler injections in the forehead can be performed with relative safety in the correct tissue plane.

Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice

BACKGROUND

Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration.

OBJECTIVES

The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient.

METHODS

Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined.

RESULTS

The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection.

CONCLUSIONS

To prevent intravascular injection, understanding "injection anatomy" and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on.

LEVEL OF EVIDENCE: 4

Injectable Filler Technique for Face Lifting Based on Dissection of True Facial Ligaments

BACKGROUND

Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting.

OBJECTIVES

The aim of the study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection.

METHODS

Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and 3-dimensional (3D) images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of 5 patients received the injections; 3D images were taken before and after the injections for comparison and clinical outcome assessments.

RESULTS

The injection technique was designed to target 6 true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line.

CONCLUSIONS

This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.

LEVEL OF EVIDENCE: 4

Safety and efficacy of the transoral approach for cheek volumization with hyaluronic acid: A pilot study

BACKGROUND

With aging, there is a decrease in the volume of facial fat compartments, which can be restored using injectable biodegradable fillers.

AIMS

The objective of this study was to assess the efficacy and safety of an ultrasound-guided transoral injection versus the traditional percutaneous approach for cheek volumization with hyaluronic acid.

PATIENTS/METHODS

This is a pilot, single-center, comparative, prospective study conducted in Spain in which the hemifaces were randomized to receive an injection with each technique, and the duration of follow-up was 1 year. Results were assessed using the GAIS and the procedure satisfaction survey. The degree of pain experienced was evaluated using a VAS for pain.

RESULTS

This study included 20 women with a mean age of 45.3 years (SD 5.1, range of 38-53). No significant differences were observed in esthetic improvement scores or in the satisfaction surveys. There were significant differences in the transoral approach assessment at V3 (p = 0.0362) and in both procedures at V6 (p = 0.0026) between patients and evaluators. Of all patients, 55% (n = 11/20) reported less pain with the transoral approach, and 15% (n = 3/20) did not perceive pain with any techniques. No side effects different than those expected were observed, and they all resolved without the need for treatment.

CONCLUSION

The transoral approach for cheek volumization with hyaluronic acid was shown as a safe, effective technique that provides more comfort and minor sensation of pain than the traditional percutaneous approach but with equivalent esthetic outcomes.

Enhancing the Lateral Orbital "C-Angle" With Calcium Hydroxylapatite: An Anatomic and Clinical Study

BACKGROUND

Deliberate injection of specific facial subunits may improve aesthetic outcomes in facial rejuvenation. We contend that the lateral orbital area (LOA) is a key anatomic subunit in the perception of eye attractiveness, with a C-shaped distribution of fat contributing to the formation of a distinct angle in the lateral orbit.

OBJECTIVES

The aim of this study was to describe the anatomy of the LOA that constitutes the C-shaped angle and to investigate the safety and cosmetic outcomes of nonsurgical enhancement of that area with calcium hydroxylapatite (CaHA).

METHODS

Four injected fresh-frozen cadaver heads were dissected. Twenty patients were enrolled in a prospective clinical study. Participants were seen on the day of injection, and at 2 weeks and 3 months postinjection. Two-dimensional and 3D photographs were analyzed to quantify the volumetric changes between pretreatment and postinjection time points. Secondary outcomes included Global Aesthetic Improvement Scale score and subject satisfaction at 3 months.

RESULTS

Cadaver dissections revealed distinct fat compartments and a zone of adhesion forming the C-shaped area around the lateral orbit. In the clinical study, a mean of 1.88 mL of CaHA was injected into each lateral periorbital region. There was 97% and 76% volume retention at 2 weeks and 3 months, respectively, with 70% of patients being "very satisfied" at 3 months. The average Global Aesthetic Improvement Scale rating at 3 months was 3.95. There were no complications.

CONCLUSIONS

The LOA is a distinct facial subunit that can be enhanced safely by CaHA injection with good cosmetic outcomes. Focusing on the C-angle can improve periorbital aesthetics.

LEVEL OF EVIDENCE: 4

Facial vascular danger zones for filler injections

Filler injections are widely used for facial rejuvenation. The technique is safe as long as some precautions are respected. In this review we will focus on vascular anatomy in the upper, middle and lower face. We performed a PUBMED research on "facial danger zones" and "filler injections" and "hyaluronic acid" and "vascular compromise" with a focus on the last decade. This is of particular importance since vascular compromise is one of the most severe adverse events possibly leading to tissue necrosis and in rare cases to loss of vision. We describe the danger zones in these esthetic units and provide recommendations how to avoid severe adverse events. We report on temporal region, glabella and nose, infraorbital region, nasolabial folds and nasal triangle, lips, and chin. Although we focus on hyaluronic acid fillers, our recommendations will also scope other filler types and autologous adipose tissue transfer. We also take a closer look on innovations to improve the safety of facial filler injections. Facial rejuvenation with hyaluronic acid fillers is a popular method. It is safe if the facial danger zones are recognized and proper injection techniques and fillers are used.

Pinch anatomy: An injection guide for temple filler injections

Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age-related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane.

Three-Dimensional Topographic Surface Changes in Response to Volumization of the Lateral Suborbicularis Oculi Fat Compartment

BACKGROUND

Autologous fat grafting is an increasingly preferred method for aesthetic facial rejuvenation. The authors' group previously described the concept of "lipotopography" as topographic surface changes that occur with fat grafting to discrete facial fat compartments. The purpose of this study was to define the "augmentation zone" of the lateral suborbicularis oculi fat compartment to understand the topographical surface changes following augmentation.

METHODS

Nine cadaver hemifaces were injected with fat analogue at intervals from 1 to 4 cc. Three-dimensional photographs were taken at baseline and following each 1-cc incremental injection. The interval surface changes were calculated using three-dimensional software including perimeter, diameter, and projection.

RESULTS

The augmentation zone of the lateral suborbicularis oculi fat compartment was characterized by a consistent shape and boundary. The shape was an elongated oval bound superiorly by the lid-cheek junction and inferiorly at the level of the zygomaticocutaneous ligament. Vertical and horizontal diameter and perimeter showed initial increases between 1 and 2 cc and then a plateau between 2 and 3 cc. Projection changes demonstrated an initial slow increase from 1 to 2 cc injection followed by nearly linear growth from 2 to 4 cc.

CONCLUSIONS

Three-dimensional photography and computer analysis provide tools to understand the surface anatomy change in response to fat grafting specific facial fat compartments. Targeted volumization of the lateral suborbicularis oculi fat compartment also results in a unique surface change with consistent shape and anatomical boundaries. The lid-cheek junction and zygomaticocutaneous ligament were observed to restrict the expansion of fat analogue for all injection volumes.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Injectable Tissue Replacement and Regeneration: Anatomic Fat Grafting to Restore Decayed Facial Tissues

Aging is a dynamic process that can be modeled and understood tissue by tissue and cell by cell. Numerous authors have helped us understand the anatomy of facial fat compartments and the effects of aging on our facial tissues such as skin, fat, bone and fibrous ligaments. Injectable tissue replacement and regeneration (ITR2) is a method to replace decayed tissues of the face using “like tissues” in an effort to delay or slow the rate of tissue decay seen in facial aging. Facial topography and proportion analysis are performed to diagnose individual-specific losses of facial fat. The degree of sun damage and skin thinning is noted as is the degree of loss in the superficial fat compartment. Deep compartment fat loss is evaluated as is pyriform aperture, orbital, mandibular ramus, mandibular body, and chin resorption. From this analysis, a detailed treatment plan is formulated. Using a mechanical device, 3 different fat grafts are created: 2 mm (millifat), 1 mm (microfat), and 500 microns (cell optimized, matrix rich nanofat); anatomic replacement of all areas of tissue loss is carried out. Millifat is used for deep compartment and bone losses, microfat for superficial fat losses above the facial musculature and nanofat is used intradermally and as a biological cream for topical application. The rationale behind this standardized approach is explained and the scientific foundations for the idea are presented. Reduction in tissue decay appears to be a valid observation, but awaits others confirmation.

An approach to structural facial rejuvenation with fillers in women

Newer understanding of volume loss as a critical component of facial aging and the integration of volume replacement into the surgical and nonsurgical therapeutic algorithm is arguably the most significant recent development in the field of facial rejuvenation. As all structural tissues play a role in the aging face, restoring youthful characteristics (or establishing them where they are congenitally absent) starts from the skeletal framework and builds progressively to the canvas of the face. The purpose of this article is to provide an introduction and brief summary of some of the current concepts concerning facial anatomy and the anatomy of facial aging, which serve as the basis for predictable and reproducible results with the use of injectable fillers. This article does not include the various types of fillers or techniques of filler injection, but covers how to decide where to use the filler and why, in different faces, as a result of the recognition and targeted correction of currently recognized specific anatomic deficiencies.