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Hong GW, Hu H, Chang K, Park Y, Lee KWA, Chan LKW, Yi KH. Review of the Adverse Effects Associated with Dermal Filler Treatments: Part I Nodules, Granuloma, and Migration. Diagnostics (Basel) 2024; 14:1640. [PMID: 39125515 PMCID: PMC11311355 DOI: 10.3390/diagnostics14151640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2024] [Revised: 07/24/2024] [Accepted: 07/26/2024] [Indexed: 08/12/2024] Open
Abstract
The increase in the use of filler treatments within minimally invasive cosmetic surgery has correspondingly escalated the variety and frequency of associated side effects. Initially, unregulated procedures led to primary side effects such as infections, foreign body reactions, and granuloma formation. However, severe vascular complications like skin and tissue necrosis and blindness have emerged as recognized risks. Side effects from filler treatments can range from mild to life-threatening, including edema, pain, tenderness, numbness, bleeding, bruising, hematoma, redness, erythema, pigmentation, allergic reactions, itching, pruritus, the Tyndall effect, asymmetry, irregularity, migration, skin and soft tissue infections, nodules, granulomas, and vascular compromise. These side effects are categorized into early and delayed types. Many complications, particularly those related to vascular abnormalities, are frequently linked to procedural issues, emphasizing the importance of understanding filler properties, injection techniques, and facial anatomy. Preventing side effects is ideal, but early detection and treatment are crucial. Recognizing potential side effects based on their timing and understanding appropriate preemptive treatment methods is essential. This discussion addresses non-vascular side effects, highlighting their onset, symptoms, and management strategies. The comprehensive understanding and careful management of these side effects are vital for minimizing complications and ensuring patient safety in filler treatments.
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Affiliation(s)
- Gi-Woong Hong
- Samskin Plastic Surgery Clinic, Seoul 06577, Republic of Korea
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
| | | | | | | | | | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea;
- Maylin Clinic (Apgujeong), Seoul 06001, Republic of Korea
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Hong GW, Hu H, Park Y, Park HJ, Yi KH. Safe Zones for Facial Fillers: Anatomical Study of SubSMAS Spaces in Asians. Diagnostics (Basel) 2024; 14:1452. [PMID: 39001342 PMCID: PMC11241601 DOI: 10.3390/diagnostics14131452] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 07/03/2024] [Accepted: 07/05/2024] [Indexed: 07/16/2024] Open
Abstract
The study "Spaces of the Face for Filler Procedures: Identification of subSMAS Spaces Based on Anatomical Study" explores the anatomy of facial spaces crucial for safe and effective filler injections. By delineating the subSMAS (sub-superficial musculoaponeurotic system) spaces, this research highlights how these virtual compartments, bordered by fat, muscles, fascia, and ligaments, facilitate independent muscle movement and reduce the risk of damaging critical structures. The thicker and more robust skin of East Asians necessitates deeper filler injections, emphasizing the significance of accurately identifying these spaces. A cadaver study with dyed gelatin validated the existence and characteristics of these subSMAS spaces, confirming their safety for filler procedures. Key spaces, such as the subgalea-frontalis, interfascial and temporalis, and prezygomatic spaces, were examined, illustrating safe zones for injections. The findings underscore the importance of anatomical knowledge for enhancing facial aesthetics while minimizing complications. This study serves as a guide for clinicians to perform precise and safe filler injections, providing a foundation for further research on the dynamic interactions of these spaces and long-term outcomes.
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Affiliation(s)
- Gi-Woong Hong
- Sam Skin Plastic Surgery Clinic, Seoul 06577, Republic of Korea
| | - Hyewon Hu
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
| | | | - Hyun Jin Park
- Department of Anatomy, Daegu Catholic University School of Medicine, Daegu 42472, Republic of Korea
| | - Kyu-Ho Yi
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 FOUR Project, Yonsei University College of Dentistry, 50-1 Yonsei-ro, Seodaemun-gu, Seoul 03722, Republic of Korea
- Maylin Clinic (Apgujeong), Seoul 06005, Republic of Korea
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Lim TS, Wanitphakdeedecha R, Yi KH. Exploring facial overfilled syndrome from the perspective of anatomy and the mismatched delivery of fillers. J Cosmet Dermatol 2024; 23:1964-1968. [PMID: 38369859 DOI: 10.1111/jocd.16244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Revised: 02/05/2024] [Accepted: 02/09/2024] [Indexed: 02/20/2024]
Abstract
INTRODUCTION Facial fillers and injectables have transformed the landscape of cosmetic procedures, offering rejuvenation possibilities. However, the emergence of "Facial Overfilled Syndrome (FOS)" presents a concerning trend attributed to excessive filler use and suboptimal injection techniques. Understanding the interplay between facial aging and augmentation techniques is crucial in addressing and preventing FOS. MATERIAL AND METHODS Facial overfilled syndrome is characterized by the excessive use of fillers, resulting in a distorted and heavy appearance. It manifests in various forms, including 'flowerhorn' foreheads, 'sunset' eyes, 'chipmunk' cheeks, 'witch' chins, and 'pillow' faces. The syndrome arises from attempts to combat anatomical aging with dramatic filler treatments, causing rapid volume changes and skin tightening. Skeletal structures and soft tissue distribution across different ethnicities play a significant role in FOS development. RESULTS Understanding the aging process across facial tissues is essential, as fillers cannot entirely reverse aging manifestations. Tailored assessment and treatment plans should precede filler injections, involving muscle assessment, observation of facial movements during injection, and ultrasound imaging of fat layers. Attention should be given to filler pressure and migration risks, particularly in areas with elevated pressure. Additionally, alternative approaches like energy-based devices and polymer reinforcement of facial ligaments should be considered to minimize filler use. Ethnic variations in facial anatomy require careful consideration to avoid overcorrection. CONCLUSION FOS predominantly affects individuals of East Asian descent due to specific facial characteristics. Prevention strategies involve minimizing filler use, addressing underlying bone changes, and considering ethnic and gender differences in facial anatomy. Recent MRI and ultrasound studies challenge the notion of filler breakdown, emphasizing the importance of filler selection and injection techniques. Education, individualized treatments, and a holistic understanding of facial anatomy are key to preventing and managing FOS and ensuring natural and harmonious facial aesthetics.
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Affiliation(s)
| | | | - Kyu-Ho Yi
- Maylin Clinic (Apgujeong), Seoul, Korea
- Division in Anatomy and Developmental Biology, Department of Oral Biology, Human Identification Research Institute, BK21 PLUS Project, Yonsei University College of Dentistry, Seoul, Korea
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Ramirez S, Cullen C, Ahdoot R, Scherz G. The Primacy of Ethics in Aesthetic Medicine: A Review. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2024; 12:e5935. [PMID: 38919517 PMCID: PMC11199011 DOI: 10.1097/gox.0000000000005935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Accepted: 05/10/2024] [Indexed: 06/27/2024]
Abstract
Background The landscape of modern aesthetic medicine has witnessed a paradigm shift from traditional doctor-led care to a consumer-driven model, presenting a plethora of ethical challenges. This review discusses the ethical dimensions of medical aesthetics, exploring the implications of consumer demand, societal influences, and technological advancements on patient care and well-being. Methods Drawing upon a comprehensive analysis of existing literature, this review synthesizes evidence regarding the rise of aesthetic medicine, ethical challenges encountered in practice, and the implications of social media and marketing in shaping patient perceptions and decision-making. Results Aesthetic medicine confronts unique ethical challenges stemming from its elective nature and the pervasive influence of societal beauty standards. Concerns include the commodification of beauty, conflicts of interest, limited evidence-base of treatments, and the rise of nonphysician providers. Moreover, the evolving role of social media influencers and medical marketing raises ethical dilemmas regarding transparency, patient autonomy, and professional integrity. Conclusions The ethical landscape of aesthetic medicine necessitates a proactive approach to address emerging challenges and safeguard patient well-being. Guided by principles of autonomy, beneficence, nonmaleficence, and justice, recommendations are proposed to enhance informed consent practices, mitigate appearance anxiety, facilitate shared decision-making, and promote responsible use of social media. Professional societies are urged to establish clear ethical guidelines and standards to uphold professionalism and patient trust in the field of aesthetic medicine.
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Affiliation(s)
- Sylvia Ramirez
- From Cutis Medical Laser Clinics Pte Ltd, Singapore, Singapore
| | - Clara Cullen
- University of Michigan Medical School, Ann Arbor, Mich
| | - Rodney Ahdoot
- University of Michigan Medical School, Ann Arbor, Mich
| | - Gunther Scherz
- From Cutis Medical Laser Clinics Pte Ltd, Singapore, Singapore
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de Sanctis Pecora C. The Anatomical Layering Assessment: The Construction of Beauty. Clin Cosmet Investig Dermatol 2024; 17:605-620. [PMID: 38505808 PMCID: PMC10949303 DOI: 10.2147/ccid.s447865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 02/20/2024] [Indexed: 03/21/2024]
Abstract
Restructuring an aging face from bone structure to the surface of the skin can be metaphorically compared to building and renovating a house. While each anatomical layer of the face undergoes an aging process of its own, there is also an interdependency of superficial structures on deeper layers, so that a change in one layer may lead to changes to the adjacent layers. This interaction among the structures deep into the skin, along with the skin's ability to envelope them is what determine the aspect of the aging face. Thus, a careful assessment of all the layers is imperative and we describe herein a step-by-step facial layering assessment and facial restructuring approach from bone structure to the surface of the skin to implement a treatment plan able to deliver a harmonious rejuvenating outcome.
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Bergeret-Galley C. Invited Discussion on "Ultra-Condensed Fat: A Novel Fat Product for Volume Augmentation". Aesthetic Plast Surg 2024; 48:985-986. [PMID: 37644189 DOI: 10.1007/s00266-023-03562-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 07/31/2023] [Indexed: 08/31/2023]
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Liu X, Gao Y, Ma J, Li J. The Efficacy and Safety of Hyaluronic Acid Injection in Tear Trough Deformity: A Systematic Review and Meta-analysis. Aesthetic Plast Surg 2024; 48:478-490. [PMID: 37684413 DOI: 10.1007/s00266-023-03613-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 08/12/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND Hyaluronic acid (HA) injection is an effective method to correct tear trough deformity. Nevertheless, the quantitative data of cosmetic results and complications of HA injection in tear troughs remained unemployed. The purpose of this meta-analysis was to synthesize the current quantitative data on the aesthetic outcomes and adverse effects of tear trough deformity correction with HA injection. METHODS This meta-analysis consulted PubMed, Embase, Web of Science, Scopus and Cochrane databases based on the search terms published before September 2022. Data extracted was analyzed to evaluate the satisfaction rates and complications of HA injection. Meta-analysis was performed using the random-effect model for overall and subgroup analysis. RESULTS This meta-analysis comprised 31 reports involving 2556 participants. The pooled overall satisfaction rate was 91.0% (95% CI 84.9-95.7%). The pooled rates of swelling/edema and bruising/ecchymosis were 19.2% (95% CI 10.4-29.9%) and 18.4% (95% CI 10.1-28.4%), respectively. The pooled rates of redness/erythema, contour irregularity/lump and blue discoloration/Tyndall effect were 7.1% (95% CI 1.5-15.6%), 5.3% (95% CI 1.8-10.2%) and 0.9% (95% CI 0.0-2.5%), respectively. CONCLUSIONS The present meta-analysis manifested a low risk of complication rate and a high satisfaction rate in tear trough rejuvenation with HA injection. LEVEL OF EVIDENCE I 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 .
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Affiliation(s)
- Xuanchen Liu
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuan Gao
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jiguang Ma
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jie Li
- Department of Facial and Cervical Plastic Surgery, Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China.
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Zhu C, Li F, Tang X, Cai L, Yin B, Zhang X, Jiang C, Han X. Buccal Fat Pad Augmentation for Midfacial Rejuvenation: Modified Fat Grafting Technique and Ogee Line Remodeling. Aesthet Surg J 2024; 44:117-130. [PMID: 37418635 DOI: 10.1093/asj/sjad214] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 06/28/2023] [Accepted: 06/28/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND The volume and position of the buccal fat pad (BFP) change with age, which manifests as a hollow midface. Previous studies showed that autologous fat grafting for BFP augmentation could effectively ameliorate midfacial hollowing. OBJECTIVES The aim of this study was to introduce a modified fat grafting technique for female patients with midfacial hollowing to restore the volume of BFP, and to evaluate the safety and effectiveness of this approach. METHODS Two cadavers were used for the dissection of the BFP and to demonstrate the surgical procedures. Forty-eight patients were treated for midfacial hollowing with the modified grafting strategy. The BFP was filled through a percutaneous zygomatic incision and an immediate amelioration in the hollow area was observed. Improvements were evaluated from measurements of the ogee line and ogee angle, FACE-Q questionnaires, and 3-party satisfaction ratings. Clinical profiles were reviewed and statistically analysed. RESULTS The mean [standard deviation] ogee angle was 6.6° [1.9°] preoperatively and 3.9° [1.4°] postoperatively (average reduction, 2.7°). Patients' ogee lines were smoother postoperatively, with marked improvements in overall appearance, psychological well-being, and social confidence. Patients reported high satisfaction with decision-making and postoperative outcomes and felt 6.61 [2.21] years younger. Overall, 88%, 76%, and 83% of the cases were graded as good or excellent in improvement by surgeon, patient, and the third party, respectively. CONCLUSIONS For age-dependent midfacial hollowing in female patients, the modified percutaneous grafting technique described here was safe and efficacious in restoring BFP volume. This technique produced a smoother ogee line and a natural, younger midfacial contour. LEVEL OF EVIDENCE: 4
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Ho WWS. Achieving the Attractive Asian Midface Profile with Hyaluronic Acid-Based Fillers. Dermatol Clin 2024; 42:113-120. [PMID: 37977677 DOI: 10.1016/j.det.2023.06.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
Despite different ethnic origins among Asians, midface enhancement is the most frequent noninvasive procedure for hyaluronic acid injection either as a stand-alone treatment or as part of the pan-facial beautification strategy. Because Asians often have an aesthetically undesirable wide, flat, and short face, improving the projection of midface and midline facial structures is an indispensable aesthetic procedure in creating a smaller facial appearance with better three-dimensionality. Achieving an oval facial shape together with increased facial height is also required in most circumstances for a natural and balanced result.
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Affiliation(s)
- Wilson W S Ho
- The Specialists: Lasers, Aesthetic and Plastic Surgery, Room 601, Prosperity Tower, 39 Queen's Road Central, Hong Kong.
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Schelke L, Harris S, Cartier H, Alfertshofer M, Doestzada M, Cotofana S, Velthuis PJ. Treating facial overfilled syndrome with impaired facial expression-Presenting clinical experience with ultrasound imaging. J Cosmet Dermatol 2023; 22:3252-3260. [PMID: 37772766 DOI: 10.1111/jocd.16013] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Facial overfilled syndrome is an adverse event following minimally invasive soft tissue filler injections. It presents in most cases as excess midfacial volume and/or as unnatural smile which is difficult to detect due to the absence of standardized evaluation methods. OBJECTIVE To showcase how to identify, evaluate, and treat facial overfilled syndrome by utilizing facial ultrasound and simultaneous hyaluronidase injections. METHODS Twenty-eight consecutive patients (26 females, 2 males) were enrolled in this study in which facial ultrasound was performed to evaluate the location previously implanted filler material. The position of the oral commissure was objectively measured in relation to bony landmarks, and the severity of lateral canthal lines was assessed by independent and blinded raters. RESULTS The material was identified in 35.7% inside the subdermal fatty layer, in 28.6% inside the deep supra-periosteal fatty layer, in 10.7% inside the fibrous layer deep to the subdermal fatty layer, whereas in 25.0%, the product was not possible to locate clearly inside one specific layer. On average, 81.6 I.U. [range: 75-150] of hyaluronidase were injected. Lateral canthal line severity was before the treatment 2.28 (1.4) and was after the hyaluronidase treatment 2.02 (1.3) with p = 0.578. The position of the oral commissure increased by 0.60 cm in vertical and by 0.30 cm in horizontal directions (both p < 0.001). CONCLUSION Facial overfilled syndrome following aesthetic soft tissue filler injections can present as excess midfacial volume but also as unnatural smile. Targeted hyaluronidase injections into the culprit pockets inside the midfacial soft tissues have shown to re-establish a natural smile, to reduce excess midfacial volume, and to decrease lateral canthal line severity.
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Affiliation(s)
- Leonie Schelke
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Sebastian Cotofana
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Peter J Velthuis
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
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Germani M, Almeida CCMS, Munoz-Lora VRM, Rogério V, Moelhoff N, Freytag DL, Green JB, Alfertshofer M, Davidovic K, Cotofana S. How to improve infraorbital hollows with neuromodulators-A clinical prospective interventional study about the application of facial biomechanics. J Cosmet Dermatol 2023; 22:2950-2956. [PMID: 37632259 DOI: 10.1111/jocd.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND A previous injection algorithm termed the "Toxin Lift" was recently introduced and described volume increases in the midface following neuromodulator treatments of the jawline. Increase in midfacial volume due to soft tissue repositioning could also affect the severity of infraorbital hollows. OBJECTIVE The objective is therefore to evaluate whether the severity of infraorbital hollows can be improved by injecting neuromodulators in the supra-mandibular segment of the platysma. MATERIALS AND METHODS A total of 35 volunteers (11 males/24 females) with a mean age of 39.8 (9.6) years and a mean BMI of 25.2 (5.2) kg/m2 were investigated. Bilateral infraorbital regions were evaluated via clinical assessment and semi-quantitative 3D imaging. The applied injection technique targeted the platysma via four injection points administering 5 I.U. per injection point resulting in a total of 20 I.U. per facial side. RESULTS Volume increase of the infraorbital region was 0.13 cc at 15 days (p = 0.001) and was 0.02 cc at 30 days (p = 0.452) whereas the skin displacement in cranial direction was 0.54 mm at 15 days (p < 0.001) and was 0.31 mm at 30 days (p < 0.001). Clinical evaluation revealed a highly statistically significant improvement of the tear trough, palpaebromalar groove, and of the lid-cheek junction when compared to baseline with all p < 0.001. CONCLUSION The results of this clinical prospective interventional analysis revealed that the "Toxin Lift" injection technique is capable to improve the clinical appearance of infraorbital hollows. The effects can be explained by the concepts of facial biomechanics.
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Affiliation(s)
| | | | | | | | - Nicholas Moelhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - David L Freytag
- Department of Plastic Surgery, Gemeinschaftsklinikum Havelhöhe, Berlin, Germany
| | - Jeremy B Green
- Skin Associates of South Florida and Skin Research Institute, Coral Gables, Florida, USA
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade, Belgrade, Serbia
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
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Martín JM, Revelles JM, Aznar NM, Jiménez LM, Orellana JB, Gomariz MÁ, Alfertshofer M, Cotofana S. Superficial versus deep injections of the upper midface-A prospective interventional split-face study. J Cosmet Dermatol 2023; 22:2940-2949. [PMID: 37594172 DOI: 10.1111/jocd.15795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/16/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND Various injection algorithms have been proposed in the past which are in line with the three aesthetic principles: upper face first, lateral face first, and deep regions first. However, increasing evidence is provided that the upper midface can be targeted with superficial soft tissue filler injections alone too. OBJECTIVE To investigate in a prospective split-face study design whether superficial or deep upper midfacial injections provide superior aesthetic outcomes. METHODS A total of n = 20 study participants (100% females; age 43.95 (11.7) years; BMI 22.92 (2.6) kg/m2 ) were treated with superficial soft tissue filler injections on side of their face and deep injections on the contralateral side with a mean volume of 0.78 cc. Outcome was evaluated at 7 weeks follow-up for midfacial, and lower facial volume, for medial and lateral facial skin vector displacement, and for improvement of nasolabial, crow's feet, and upper cheek fullness severity scores. RESULTS No adverse events related to safety or product tolerability were observed during the entire study period. All semiquantitative scores improved statistically significantly after the observational period (p < 0.001) but displayed no difference between the two applied injection techniques (p > 0.05). CONCLUSION The results of this split-face study revealed that both the superficial and the deep cannula injection technique for midface volumization statistically significantly improve the midfacial volume, reduce nasolabial fold and crow's feet severity. No statistically significant difference was observed between the two injection techniques when compared via semiquantitative and objective outcome evaluation after 7 weeks follow-up.
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Affiliation(s)
| | | | | | | | | | | | - Michael Alfertshofer
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munchen, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
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Eid L, Mao X, Zhao B, Mao J, Qian S, Zhang Y, Zhang Y, Zhang L, Cheng L, Zhang Y, Sun X. Fat Compartment Gliding Theory - A Novel Technique for the Repositioning of Superficial Fat Compartments for Facial Rejuvenation. Clin Cosmet Investig Dermatol 2023; 16:3077-3090. [PMID: 37908409 PMCID: PMC10614658 DOI: 10.2147/ccid.s415467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 10/03/2023] [Indexed: 11/02/2023]
Abstract
Background Facial fat compartments and their role in facial aging have gained increased recognition and are playing a significant role in facial rejuvenation. The superficial fat compartments glide inferiorly during the aging process, leading to the flattening and elongation of the face and the appearance of facial bulges, folds, and grooves. Patients and Methods Ultrasound imaging of the facial soft tissues was performed on nine female volunteers to demonstrate the change in superficial facial fat compartments from an upright to supine position. The net suture jowl and medial cheek fat compartment repositioning technique was operated on 165 Asian patients between September 2020 and July 2021. Volume and projection change of malar and jowl regions, as well as change in elevation of malar protrusion were measured 1, 3, and 6 months postoperatively using a three-dimensional imaging system. Results Ultrasound measurements confirmed the medial and middle cheek, nasolabial, and jowl fat compartments changed in thickness during positional changes with age-related differences. Postoperative three-dimensional imaging showed volume and projection increase in the malar region (2.23mL and 1.11mm) and decrease in the jowl region (-0.18mL and -0.52mm) by the 6-month follow-up date, and malar projection saw a superior displacement of 3.08mm. Conclusion The superficial fat glide inferiorly within their compartments under the force of gravity and naturally reposition themselves when the effect of gravity is reversed. The net suture technique offers a minimally invasive method for lifting the jowl fat, volumizing the mid-cheek and achieving facial rejuvenation by repositioning the superficial fat compartments.
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Affiliation(s)
- Loy Eid
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Xiyuan Mao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Binfan Zhao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Jiayi Mao
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Shutong Qian
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Yuyu Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Ying Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Lu Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Liying Cheng
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Yuguang Zhang
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
| | - Xiaoming Sun
- Department of Plastic and Reconstructive Surgery, Shanghai Ninth People’s Hospital, Shanghai, People’s Republic of China
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Wu W, Bi X, Zhao J, Lin Z, Lu F, Dong Z, Li Y. Ultra-condensed Fat: A Novel Fat Product for Volume Augmentation. Aesthetic Plast Surg 2023; 47:2074-2083. [PMID: 37227488 DOI: 10.1007/s00266-023-03383-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Accepted: 04/26/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Fat transplantation retention rate is individualized and unpredictable. The presence of blood components and oil droplets in the injected lipoaspirate increases inflammation and fibrosis in a dose-dependent manner, and is probably the key factor associated with poor retention. OBJECTIVES This study describes a volumetric fat grafting strategy based on optimization of grafts via screening intact fat particles and absorbing free oil droplets and impurities. METHODS Centrifuged fat components were analyzed by n-hexane leaching. A special device was applied to de-oil intact fat components and obtain ultra-condensed fat (UCF). UCF was evaluated by scanning electron microscopy, particle size analysis, and flow cytometric analysis. Histological and immunohistochemical changes were investigated in a nude mouse fat graft model over 90 days. RESULTS The lower 50% of centrifuged fat was concentrated to 40% of the original volume to obtain UCF. In UCF, the free oil droplet content was less than 10%, more than 80% of particles were larger than 1000 µm, and architecturally important fat components were present. The retention rate of UCF was significantly higher than that of Coleman fat on day 90 (57.5 ± 2.7% vs. 32.8 ± 2.5%, p < 0.001). Histological analysis detected small preadipocytes with multiple intracellular lipid droplets on day 3 in UCF grafts, indicative of early adipogenesis. Angiogenesis and macrophage infiltration were observed in UCF grafts soon after transplantation. CONCLUSION Adipose regeneration with UCF involves rapid macrophage infiltration and exit, resulting in angiogenesis and adipogenesis. UCF may serve as a lipofiller which is beneficial for fat regeneration. 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 http://www.springer.com/00266 .
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Affiliation(s)
- Weizi Wu
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Xin Bi
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Jing Zhao
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Zhousheng Lin
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China
| | - Feng Lu
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China.
| | - Ziqing Dong
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China.
| | - Ye Li
- Department of Plastic and Cosmetic Surgery, Nanfang Hospital, Southern Medical University, 1838 Guangzhou North Road, Guangzhou, 510515, Guangdong, People's Republic of China.
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15
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Lots TCC. Effect of pdo facelift threads on facial skin tissues: An ultrasonographic analysis. J Cosmet Dermatol 2023; 22:2534-2541. [PMID: 37128828 DOI: 10.1111/jocd.15761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 03/06/2023] [Accepted: 03/21/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Recent studies demonstrate that PDO threads, after being introduced into the facial skin, provide benefits due to collagen formation around the thread and improved vascularization. AIMS This work aims to report the ultrasound and photographic follow-up after the execution of the facelift thread technique, thus evaluating the anti-aging treatment that PDO threads will provide for human facial skin. METHODS The facelift will be performed using PDO thread 18G cannulated Sculpt i- Thread FML 100 × 185 mm, and 29G PDO thread Needled Flat i-Thread 38 × 50 mm. A total of 10 patients were selected for the study; all of them had medium-grade facial ptosis and aged 40-50 years old. In order to control tissue changes after thread, insertion ultrasound measurements will be made with Philips ultrasound 12 MHz linear probe at maximum resolution, initial evaluations and control of 30, 60, 90, and 120 days, measuring the skin layers: epidermis\dermis and hypodermis. Photographic control was performed before and after 120 days of intrusion of the PDO threads. RESULTS The formation of collagen around the PDO thread was evidenced through ultrasound images in all patients in this study, as well as improvement in the appearance of the skin and sagging, evaluated by photographic control. CONCLUSIONS We can define that the PDO threads used for the facelift are effective in the formation of collagen around the thread (observed through the increase in the dermal layer), and improvement of the condition of the anti-aging factor through sagging skin, vascularization and thinning of the superficial fat layer (observed through the reduction of the subcutaneous or hypodermis layer).
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16
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Philipp-Dormston WG, Weinmann C, Frank K. [Injection anatomy-a new discipline in aesthetic medicine]. DERMATOLOGIE (HEIDELBERG, GERMANY) 2023; 74:621-631. [PMID: 37460865 DOI: 10.1007/s00105-023-05185-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 06/02/2023] [Indexed: 07/25/2023]
Abstract
The basic anatomical understanding of aesthetic medicine has changed fundamentally since the turn of the millennium. With the advent of modern minimally invasive injection procedures using botulinum toxin and hyaluronic acid fillers, anatomical structures that had previously received little attention and were not considered relevant have steadily gained in importance and moved into the scientific focus. Understanding the three-dimensional arrangement of the face with its defined anatomical layers and compartments serves the procedural dermatologist in the sense of a navigation system to optimize treatment success and patient safety when performing aesthetic injections in the facial region. The principles of the biomechanical interaction of the structures are of elementary importance in the creation of individual treatment plans for the implementation of natural and balanced therapeutic results. Modern injection anatomy as an interdisciplinary subject of the three fields of anatomy, dermatology and plastic surgery makes a decisive contribution here.
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Affiliation(s)
- Wolfgang G Philipp-Dormston
- Hautzentrum Köln, Schillingsrotter Str. 39-41, 50996, Köln, Deutschland.
- Department of Dermatology, Faculty of Health, Universität Witten/Herdecke, Witten, Deutschland.
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17
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Newsome HA, Chi JJ. Mastering Midface Injections. Clin Plast Surg 2023; 50:437-446. [PMID: 37169409 DOI: 10.1016/j.cps.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.
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Affiliation(s)
- Hillary A Newsome
- Division of Facial Plastic & Reconstructive Surgery, Washington University Facial Plastic Surgery Center, Washington University in St. Louis-School of Medicine, 660 S Euclid AveCampus Box 8115St. Louis, MO 63110, USA
| | - John J Chi
- Division of Facial Plastic & Reconstructive Surgery, Washington University Facial Plastic Surgery Center, Washington University in St. Louis-School of Medicine, 660 S Euclid AveCampus Box 8115St. Louis, MO 63110, USA.
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18
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Cotofana S, Ziebart R, Chaney GK, Alfertshofer MG, Frank K, Freytag L, Moellhoff N. Discussion: Zygomatico-Orbital Artery: A Reevaluation of the Temporal Blood Vessels. Plast Reconstr Surg 2023; 151:1186-1188. [PMID: 37224340 DOI: 10.1097/prs.0000000000010113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2023]
Affiliation(s)
- Sebastian Cotofana
- From the Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science
| | - Rachel Ziebart
- From the Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science
| | - Grace K Chaney
- From the Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science
| | - Michael G Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig Maximilian University of Munich
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig Maximilian University of Munich
| | | | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig Maximilian University of Munich
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19
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Hernandez CA, Zapata DEU, Bermudez MP, Frank K, Moellhoff N, Alfertshofer M, Gotkin RH, Davidovic K, Cotofana S. Clinical validation of the upper face first principle-A clinical, prospective, interventional split-face study. J Cosmet Dermatol 2023; 22:418-425. [PMID: 36573471 DOI: 10.1111/jocd.15563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/03/2022] [Accepted: 11/29/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First. OBJECTIVE To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face. METHODS This study was designed as an interventional split-face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m2 (1.7) were studied. Follow-up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging. RESULTS Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow-up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001. CONCLUSION Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.
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Affiliation(s)
| | | | | | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | | | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Belgrade, Serbia
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
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20
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Fabi SG, Callender VD, Lee WW, Dayan S. Aesthetic considerations for treating the North American multi-ethnic patient: Thriving in diversity international roundtable series. J Cosmet Dermatol 2022; 21:6976-6984. [PMID: 36176035 DOI: 10.1111/jocd.15422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 09/27/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND The United States is becoming increasingly diverse, and between 2016 and 2019, an increase of 945 832 aesthetic procedures was recorded for Hispanic, African American, and Asian American patients combined. In aesthetics, where outcomes are technique dependent and tied to the clinician's ability to tailor treatment to the needs of individual patients, a knowledge of ethnic differences in anatomy and how aesthetic issues can be safely and effectively addressed in different groups is paramount. AIMS To discuss similarities and difference in anatomy and treatment preferences of patients from a variety of ethnic and racial backgrounds and how these differences may influence the products or techniques utilized to achieve natural-looking results and minimize side effects. PATIENTS/METHODS In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022. RESULTS The results of the first roundtable in the series, the North American Multiethnic Patient, are described here. CONCLUSIONS A diverse range of patients can benefit from the tailored use of fillers, fat transfer, neuromodulators, lasers, and energy-based devices, as long as differences in structural support, skin, and aging patterns, are appreciated.
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Affiliation(s)
| | - Valerie D Callender
- Dermatologist at Callender Dermatology & Cosmetic Center, Glenn Dale, Maryland, USA.,Howard University College of Medicine, Washington, District of Columbia, USA
| | - Wendy W Lee
- Bascom Palmer Eye Institute, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Steven Dayan
- Division of Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, University of Illinois at Chicago, Chicago, Illinois, USA
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21
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Soares DJ, Zuliani GF. Orbital post-septal hyaluronic acid: An iatrogenic etiology compounding lower eyelid steatoblepharon. JPRAS Open 2022; 34:173-177. [PMID: 36325377 PMCID: PMC9618635 DOI: 10.1016/j.jpra.2022.09.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Accepted: 09/30/2022] [Indexed: 11/06/2022] Open
Abstract
The stark rise in the incidence of dermal filler-related adverse sequelae has given rise to a variety of cosmetic distortions related to improper filler placement that include dynamic and static contour deformities of the face. In this article, we describe two instances of post-septal hyaluronic acid filler aggravating existing steatoblepharon and outline potential causative mechanisms responsible for this condition.
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Affiliation(s)
- Danny J. Soares
- American Foundation for Aesthetic Medicine (AFFAM), Fruitland Park, FL 34731, United States
- University of Central Florida, College of Medicine, Orlando, FL 32827, United States
| | - Giancarlo F. Zuliani
- Wayne State University, School of Medicine, Department of Otolaryngology Head & Neck Surgery, Detroit MI 48201, United States
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22
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Newsome HA, Chi JJ. Mastering Midface Injections. Facial Plast Surg Clin North Am 2022; 30:347-356. [DOI: 10.1016/j.fsc.2022.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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23
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Hernandez CA, Alfertshofer M, Frank K, Freytag L, Gavril DL, Davidovic K, Gotkin RH, Mercado-Perez A, Mardini S, Cotofana S. Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures. Aesthetic Plast Surg 2022; 46:2237-2245. [PMID: 35648191 DOI: 10.1007/s00266-022-02921-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position. OBJECTIVE The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions. METHODS This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m2. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity. RESULTS The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001. CONCLUSION Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs. 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 .
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Affiliation(s)
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Lysander Freytag
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | | | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Arnaldo Mercado-Perez
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA
| | - Samir Mardini
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.
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24
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Cotofana S, Kaminer MS. Anatomic Update on the
3‐Dimensionality
of the Subdermal Septum and its Relevance for the Pathophysiology of Cellulite. J Cosmet Dermatol 2022; 21:3232-3239. [DOI: 10.1111/jocd.15087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2022] [Revised: 05/05/2022] [Accepted: 05/11/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Sebastian Cotofana
- Department of Clinical Anatomy Mayo Clinic College of Medicine and Science Rochester MN USA
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25
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Freytag L, Alfertshofer MG, Frank K, Moellhoff N, Helm S, Redaelli A, Voropai D, Hernandez CA, Green JB, Cotofana S. Understanding Facial Aging Through Facial Biomechanics. Facial Plast Surg Clin North Am 2022; 30:125-133. [DOI: 10.1016/j.fsc.2022.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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26
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Hernandez CA, Davidovic K, Avelar LET, Alfertshofer M, Freytag DL, Frank K, Moellhoff N, Bihun R, Green JB, Cotofana S. Facial Soft Tissue Repositioning With Neuromodulators: Lessons Learned From Facial Biomechanics. Aesthet Surg J 2022; 42:1163-1171. [PMID: 35416929 DOI: 10.1093/asj/sjac090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral peri-orbital region underscoring the versatility of neuromodulator treatments. OBJECTIVE To analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. METHODS Seventy-five study participants (8 males, 67 females) with a mean age of 37.5 (8.5) years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement using 3-dimensional imaging at baseline, day 14 and day 30. RESULTS 3-dimensional volume analysis revealed an increase in midfacial volume by 0.46 cc, and a decrease of the lower facial volume by 0.30 cc compared to baseline. Additionally, an improvement of midfacial fullness (change of 0.13) and jawline contour (change of 0.44) was reported on clinical rating scales at day 30 compared to baseline. CONCLUSIONS Facial soft tissues can be repositioned during the 30 days follow-up period following a neuromodulator treatment; this was reflected through an increase in middle facial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.
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Affiliation(s)
| | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade , Belgrade, Serbia
| | | | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - David L Freytag
- Department of General Surgery, Community Hospital Havelhöhe , Berlin , Germany
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - Rebekah Bihun
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Jeremy B Green
- Skin Associates of South Florida and Skin Research Institute , Coral Gables, FL , USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
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27
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Calomeni M, Alfertshofer MG, Frank K, Moellhoff N, Dennison R, Bravo B, Schelke L, Velthuis P, Green JB, Cotofana S. Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned From Functional Anatomy. Aesthet Surg J 2022; 42:518-526. [PMID: 34610093 DOI: 10.1093/asj/sjab351] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying facial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments. OBJECTIVES The authors sought to evaluate the location and function of the angular vein in the tear trough in 3 different facial expressions: repose, smiling, and max. orbicularis oculi contraction. METHODS Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m2 were investigated via functional ultrasound imaging. The diameter of the angular vein and the velocity and direction of venous blood flow were analyzed in repose, smiling, and during max. orbicularis oculi contraction. RESULTS The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (intra-muscular course) within the tear trough, whereas the angular artery was not identified in this location. The distance between the angular vein and the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/s and was 7.3 cm/s at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling. CONCLUSIONS The diameter and the venous blood flow of the angular vein varied between the 3 tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein.
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Affiliation(s)
| | - Michael G Alfertshofer
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Konstantin Frank
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Nicholas Moellhoff
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | | | | | - Leonie Schelke
- Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands
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28
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Freytag DL, Alfertshofer MG, Frank K, Melnikov DV, Moellhoff N, Swift A, Heisinger S, Gotkin RH, Ehrl D, Cotofana S. The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis. Aesthet Surg J 2022; 42:1-9. [PMID: 33784397 DOI: 10.1093/asj/sjab152] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Our understanding of the functional anatomy of the face is constantly improving. To date, it is unclear whether the anatomic location of the line of ligaments has any functional importance during normal facial movements such as smiling. OBJECTIVES The authors sought to identify differences in facial movements between the medial and lateral midface by means of skin vector displacement analyses derived from 3-dimensional (3D) imaging and to further ascertain whether the line of ligaments has both a structural and functional significance in these movements. METHODS The study sample consisted of 21 healthy volunteers (9 females and 12 males) of Caucasian ethnic background with a mean age of 30.6 (8.3) years and mean BMI of 22.57 (2.5) kg/m2. 3D images of the volunteers' faces in repose and during smiling (Duchenne type) were taken. 3D imaging-based skin vector displacement analyses were conducted. RESULTS The mean horizontal skin displacement was 0.08 (2.0) mm in the medial midface (lateral movement) and was -0.08 (1.96) mm in the lateral midface (medial movement) (P = 0.711). The mean vertical skin displacement (cranial movement of skin toward the forehead/temple) was 6.68 (2.4) mm in the medial midface, whereas it was 5.20 (2.07) mm in the lateral midface (P = 0.003). CONCLUSIONS The results of this study provide objective evidence for an antagonistic skin movement between the medial and lateral midface. The functional boundary identified by 3D imaging corresponds to the anatomic location of the line of ligaments. LEVEL OF EVIDENCE: 4
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Affiliation(s)
- David L Freytag
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig–Maximilian University, Munich, Germany
| | | | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig–Maximilian University, Munich, Germany
| | - Dmitry V Melnikov
- Plastic Surgery Department, I.M. Sechenov First Moscow State Medical University, Moscow,Russia
| | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig–Maximilian University, Munich, Germany
| | | | - Stephan Heisinger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, Vienna,Austria
| | | | - Denis Ehrl
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig–Maximilian University, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Galadari H, Weinkle SH. Injection techniques for midface volumization using soft tissue hyaluronic acid fillers designed for dynamic facial movement. J Cosmet Dermatol 2021; 21:924-932. [PMID: 34964234 PMCID: PMC9303613 DOI: 10.1111/jocd.14700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 12/10/2021] [Indexed: 12/01/2022]
Abstract
Volume loss of the face occurs over time; thus, volume enhancement of the midface can counteract the effects of aging. Hyaluronic acid (HA) fillers are often used for facial revolumization for a more youthful appearance due to their favorable outcomes and safety profiles. A patient‐centric approach, in which dynamic facial expressions are considered, is needed for optimal aesthetic results. In addition, injectors must be familiar with midface anatomy, how it is affected by the aging process, and must also consider the rheological and physical properties of fillers, including their stretch and dynamic strength. In this article, optimal injection techniques are described for a new range of HA‐based fillers for midface revolumization using a needle, cannula, or both. The layering technique involves product placement in both the deep and superficial fat compartments to achieve natural‐looking outcomes at rest and during motion. The Resilient Hyaluronic Acid (RHA®) line of fillers was designed to maintain their durability and integrity while adapting to the dynamic movements of the face. RHA 2 is applicable for superficial placement, whereas the balanced stretch and dynamic strength of RHA 3 render it more versatile. The novel rheological properties of RHA 4, with the highest dynamic strength and sufficient stretch, allow it to be injected superficially and into deep facial compartments. Depending on patient characteristics, the appropriate RHA filler can be chosen to reach the goal of a natural, younger appearance and avoid overfilling.
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Affiliation(s)
- Hassan Galadari
- College of Medicine and Health Sciences, United Arab Emirates University, Al Ain, United Arab Emirates
| | - Susan H Weinkle
- Department of Dermatology and Cutaneous Surgery, University of South Florida, Tampa, Florida, USA
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Xu Y, Frank K, Kohler L, Ehrl D, Alfertshofer M, Giunta RE, Moellhoff N, Cotofana S, Koban KC. Reliability of 3-dimensional surface imaging of the face using a whole-body surface scanner. J Cosmet Dermatol 2021; 21:1464-1470. [PMID: 34731521 DOI: 10.1111/jocd.14555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 08/11/2021] [Accepted: 09/27/2021] [Indexed: 02/01/2023]
Abstract
OBJECTIVE To the knowledge of the authors, no data about the reproducibility and accuracy of 3-dimensional surface imaging of the face using a whole-body scanner are available. Thus, the objective of this investigation was to assess the reproducibility of facial scans acquired using a whole-body imaging device. MATERIAL AND METHODS This investigation investigated 220 3-D scans of a total of 22 healthy volunteers (with a mean age of 29.36 years). Two consecutive 3-D images using a Vectra WB360 of the volunteers were obtained utilizing a whole-body imaging device. Predefined distances in the face were performed in each scan and compared. Furthermore, surface deviation between two consecutively captured scans was assessed. RESULTS The distance with the smallest statistical significance was found to be at the nose with p = 0.998, while the biggest statistical significance was found in the midface with p = 0.658. The area with the biggest surface deviation between the superimposed scans was the neck with a root mean square (RMS) of 1.62 ± 1.71, and the area with the smallest surface deviation was the forehead with a RMS of 0.17 ± 0.05. CONCLUSION The whole-body imaging device investigated in this study can be utilized to capture the face and provides enough accuracy to compare scans. Even though not directly investigated, it can be hypothesized that the error caused by repositioning the patient between a baseline and a follow-up scan will not be too big to consider measurements performed with the whole-body imaging device as impractical.
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Affiliation(s)
- Ya Xu
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Lukas Kohler
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Denis Ehrl
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Riccardo Enzo Giunta
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Konstantin Christoph Koban
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
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Schelke L, Velthuis PJ, Lowry N, Rohrich RJ, Swift A, Gotkin RH, Moellhoff N, Frank K, Dumbrava M, Cotofana S. The mobility of the superficial and deep midfacial fat compartments: An ultrasound-based investigation. J Cosmet Dermatol 2021; 20:3849-3856. [PMID: 34365716 DOI: 10.1111/jocd.14374] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Understanding the mobility of the midface and the separate contributions of the superficial and deep fat compartments is essential for natural esthetic outcomes following soft tissue filler or fat grafting procedures. A study was designed that used ultrasound imaging to demonstrate in vivo visualization and quantification of distances and movements in the midface. METHODS A total of 48 midfaces of 24 healthy Caucasian volunteers, all naïve of esthetic procedures, (22 females; 46.85 (9.8) years; 22.83 (3.1) kg/m2 ) were scanned using 18 MHz ultrasound imaging. Distances between bony landmarks (inferior orbital rim, infraorbital foramen) were used as markers to measure the cranial movement of the superficial (superficial nasolabial and superficial medial cheek fat compartment) and the deep (deep pyriform space, deep medial check fat compartment, deep lateral cheek fat compartment) midfacial fat compartments between resting and smiling facial position. RESULTS The superficial midfacial fat compartment moved, on average, 3.7 mm (p < 0.001) cranially, whereas the deep midfacial fat compartments moved, on average, 0.1 mm (p > 0.05) during smiling. No gender differences in mobility were identified (p > 0.05). CONCLUSION The results obtained are in line with previous cadaveric investigations and revealed, in a highly statistically significant fashion, that the superficial midfacial fat compartments move in cranial direction whereas the deep fat compartment did not display similar positional changes. These results help to guide facial injectable treatments and to understand why, in the midface, a deep supraperiosteal approach should be favored when augmenting the deep midfacial fat compartments.
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Affiliation(s)
- Leonie Schelke
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands.,Private Practice, Amsterdam, The Netherlands
| | - Peter J Velthuis
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Natalia Lowry
- Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, NY, USA
| | | | - Arthur Swift
- Westmount Institute of Plastic Surgery, Montreal, Quebec, Canada
| | | | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Mihai Dumbrava
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
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Lim T, Frank K, Hadjab B. Target-Specific Sandwich Technique: Facial rejuvenation leveraging CPM technology. J Cosmet Dermatol 2021; 21:207-219. [PMID: 34255904 DOI: 10.1111/jocd.14342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/01/2021] [Indexed: 11/27/2022]
Abstract
Injectable rejuvenation treatments used in Caucasians might not always suit Asians as the visible signs of aging manifest differently, underscoring a need for Asian-specific strategies that correct underlying structural deficiencies and cumulative age-related changes. The presented Target-Specific Sandwich Technique (TSST) aims to simultaneously restore, rejuvenate, and enhance faces through the distribution of minute amounts of different fillers with different rheologies, using a minimal number of entry points in strategic facial areas and different soft tissue layers in Asians. A total of 14 patients underwent the presented TSST and were subsequently assessed for satisfaction with the treatment and the outcome of the treatment. With 3 cc of fillers, patients experienced a rejuvenated appearance with brow support, brow ridge softening, less severe nasolabial folds, and corrected tear trough hollows. Fillers in the lateral canthal and mandibular angles lifted mouth corners, improved submandibular jowls, and defined the lower face. Although the prejowl sulcus received minimal filler, it appeared subtler, relaxed, and had fewer lines visible while smiling. Overall, patients appeared less tense, rejuvenated, and had improved light reflection and firmer skin. These were due to tissues being supported upward and laterally by fillers in areas of bone resorption-induced volume loss.
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Diaspro A, Rossini G. Thread lifting of the midface: A pilot study for quantitative evaluation. Dermatol Ther 2021; 34:e14958. [PMID: 33840127 DOI: 10.1111/dth.14958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 03/12/2021] [Accepted: 04/09/2021] [Indexed: 11/28/2022]
Abstract
Volume restoration remains the principal target to be addressed when approaching midface rejuvenation, and absorbable sutures can create a suspension system that addresses ptotic skin located primarily in the midface. The aim of this pilot study was to investigate the effectiveness in lifting sagging tissue and to determine the outcome of thread lifting procedures of the midface. Six participants were enrolled and treated with suspension threads to correct mild to moderate ptosis of the flabby tissues of the midface. Volumetric changes were calculated at t0 (pretreatment), t1(120 days) and t2 (365 days), with a mean follow-up time of 349.64 days, (range from 304 to 380.5 days). Results showed an overall average improvement of 5.59 mL at 120 days (t0-t1) after thread implantation, up to a mean value of 4.16 mL at the end of the 350 days follow up (t0-t2). A comparison was made in between and statistical analysis was performed with level of significance set at P < .05. The records shown suggest that it is possible to achieve volume restoration which lasts up to 12 months as all parameters improved significantly (P < .05) at t1 and at t2 with respect to t0. Facial tissues suspension by means of threads is therefore safe and effective, as it is possible to achieve tissue repositioning which lasts up to 12 months for the correction of mild to moderate ptosis of the midface.
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Affiliation(s)
- Alberto Diaspro
- Maxillofacial Surgeon at Rigeneralab Centre for Regenerative Medicine, Turin, Italy
| | - Gabriele Rossini
- Department of Surgical Sciences, University of Turin, Turin, Italy
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Cotofana S, Gaete A, Hernandez CA, Casabona G, Bay S, Pavicic T, Coimbra D, Suwanchinda A, Swift A, Green JB, Nikolis A, Frank K. The six different injection techniques for the temple relevant for soft tissue filler augmentation procedures – Clinical anatomy and danger zones. J Cosmet Dermatol 2020; 19:1570-1579. [DOI: 10.1111/jocd.13491] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2020] [Revised: 05/07/2020] [Accepted: 05/11/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Sebastian Cotofana
- Department of Clinical Anatomy Mayo Clinic College of Medicine and Science Rochester MN USA
| | | | | | | | - Shino Bay
- Shino Bay Cosmetic Dermatology & Laser Institute in Fort Lauderdale Fort Lauderdale FL USA
- Department of Dermatology at Nova Southeastern University College of Osteopathic Medicine in Fort Lauderdale Fort Lauderdale FL USA
| | - Tatjana Pavicic
- Private Practice for Dermatology & Aesthetics Munich Germany
| | - Daniel Coimbra
- Department of Cosmetic Dermatology at Santa Casa de Misericórdia Rio de Janeiro Brazil
| | - Atchima Suwanchinda
- Department of Dermatology School of Anti‐Aging and Regenerative Medicine Mae Fah Luang University Bangkok Thailand
- Ramathibodi University Hospital Mahidol University Bangkok Thailand
| | - Arthur Swift
- Westmount Institute of Plastic Surgery Montreal QC Canada
| | - Jeremy B. Green
- Skin Associates of South Florida and Skin Research Institute Coral Gables FL USA
| | - Andreas Nikolis
- Clinical Research Unit Erevna Innovations Inc Montreal QC Canada
- Division of Plastic Surgery McGill University Montreal QC Canada
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery Ludwig – Maximilian University Munich Munich Germany
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