Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers

Association between the three-dimensional facial shape and its color in a boundary group of young to middle-aged Asian women

Visual cues strongly influence an individual's self-esteem and have fundamental sociopsychological functions. The color and shape of the face are important information for visual cues and are hypothesized to be correlated with each other. However, few studies have examined these relationships. Thus, this study determined the association between color and shape of the face. For this purpose, we evaluated Chinese women in their 30s and 40s (n = 166). Three-dimensional (3D) image-capture devices that provide shape morphology along with standardized photographs (color information) were used to obtain 3D images of women. The coordinates and red‒green-blue color data on the 3D images were utilized to perform principal component (PC) analysis, and shape and color PCs were generated. A canonical variate analysis was then conducted to check for significant correlations between the shape and color PCs. As a result, 6 significant correlations were found (p < 0.05). In detail, in addition to the physical correlations (i.e., steric faces or faces with protrusion of the cheek showed greater shadows, retrognathism was related to a shadow under the lower lip and vice versa), biological correlations (fatty faces showed greater redness and remarkable marionette lines; faces with age-related sagging showed greater darkness, possibly related to cumulative ultraviolet radiation exposure of the skin; and robust mandibles and supraorbital ridges were related to thick eyebrows) were found. This insight can aid both medical and cosmetic practitioners in comprehending the intricate details conveyed by facial features, thereby facilitating more comprehensive diagnosis and treatment planning, including makeup.

Gender Affirming Facial Surgery-Anatomy and Procedures for Facial Masculinization

For some patients, feminine facial features may cause significant gender dysphoria. Multiple nonsurgical and surgical techniques exist to masculinize facial features. Nonsurgical techniques include testosterone supplementation and dermal fillers. Surgical techniques include soft tissue manipulation, synthetic implants, regenerative scaffolding, or bony reconstruction. Many techniques are derived from experience with cisgender patients, but are adapted with special considerations to differing anatomy between cisgender and transgender men and women. Currently, facial masculinization is less commonly sought than feminization, but demand is likely to increase as techniques are refined and made available.

Injectable Fillers for Lower Face Rejuvenation

The lower face is an integral component of a beautiful face. Age-related changes in this region are so significant that they are often easily appreciated by patients. The aging process not only includes volume loss or downward fat repositioning, but also soft tissue laxity, skin changes, and even bony resorption. In the lower face, this results in sagging of the soft tissue leading to the formation of jowling, loss of an attractive well-defined jaw line, and a retruded chin. Both surgical and non-surgical options are available to reverse the aging signs; however, the popularity of non-surgical treatment has dramatically increased in last 2 decades.

Analysis of Age-Related Changes in Lower Facial Fat Compartments and of the Course of Blood Vessels Using Computed Tomography

BACKGROUND

According to the volume restoration theory, lower facial fat compartments tend to selectively atrophy or hypertrophy with age. The aim of this study was to demonstrate age-related changes in lower facial fat compartments using computed tomography, with strict control of the body mass index and underlying diseases.

METHODS

This study included 60 adult women in three age-based categories. The thicknesses of the jowl, labiomandibular, and chin fat compartments were measured using computed tomographic images. The distribution and arrangement of facial blood vessels were further analyzed to provide evidence of the safety of rejuvenation strategies based on the facial volumetric theory.

RESULTS

The inferior part of the superficial jowl fat compartment and deep jowl fat compartment thickened with age. The deep layer of the labiomandibular fat compartment thinned with age, and the superficial layer thickened with age. The deep and superficial layers of the chin compartments thickened with age. The facial vein passes through the lower mandibular border at the anterior edge of the masseter muscle and moves upward, perpendicular to the lower mandibular border. The high-risk area of the facial artery had an angle of approximately 45 degrees to the lower mandibular border.

CONCLUSIONS

This study suggests that with age, selective thickening or thinning occurs in different lower facial fat compartments. The mandible and masseter muscle were used as reference markers to analyze the courses of the facial artery and facial vein, which can help clinicians to reduce vascular injury.

Associations between genetically predicted sex and growth hormones and facial aging in the UK Biobank: a two-sample Mendelian randomization study

Background

Aging is an inescapable process, but it can be slowed down, particularly facial aging. Sex and growth hormones have been shown to play an important role in the process of facial aging. We investigated this association further, using a two-sample Mendelian randomization study.

Methods

We analyzed genome-wide association study (GWAS) data from the UK Biobank database comprising facial aging data from 432,999 samples, using two-sample Mendelian randomization. In addition, single-nucleotide polymorphism (SNP) data on sex hormone-binding globulin (SHBG) and sex steroid hormones were obtained from a GWAS in the UK Biobank [SHBG, N = 189,473; total testosterone (TT), N = 230,454; bioavailable testosterone (BT), N = 188,507; and estradiol (E2), N = 2,607)]. The inverse-variance weighted (IVW) method was the major algorithm used in this study, and random-effects models were used in cases of heterogeneity. To avoid errors caused by a single algorithm, we selected MR-Egger, weighted median, and weighted mode as supplementary algorithms. Horizontal pleiotropy was detected based on the intercept in the MR-Egger regression. The leave-one-out method was used for sensitivity analysis.

Results

SHBG plays a promoting role, whereas sex steroid hormones (TT, BT, and E2) play an inhibitory role in facial aging. Growth hormone (GH) and insulin-like growth factor-1 (IGF-1) levels had no significant effect on facial aging, which is inconsistent with previous findings in vitro.

Conclusion

Regulating the levels of SHBG, BT, TT, and E2 may be an important means to delay facial aging.

Injectable Treatments and Nonsurgical Aspects of Gender Affirmation

Injectable treatments are valuable tools to be considered in those seeking facial gender-affirming therapies. As stand-alone procedures, they are unlikely to meet expectations, particularly in those seeking facial feminization. However, injectables can be useful for those seeking to transition into another gender role, who are not ready for more permanent surgical treatment. They are also useful to help fine-tune features to one's satisfaction. Transgender people in the United States are more likely than the general population to be impoverished, and thus the cost of injectables may be a more salient concern.

Evaluation and Treatment Planning for the Aging Face Patient

Facial aging is a multifactorial process that occurs due to alterations in the skin, soft tissue, and bony skeleton. When considering treatments for the aging face and neck, a multifaceted approach targeting each of these areas should be considered. Although surgical intervention remains a key component to the holistic care of the aging face patient, a multitude of minimally invasive techniques is now available to optimize the care of the patient seeking rejuvenation. Proper patient evaluation and counseling on realistic expectations are critical and will be discussed here. A brief overview of common minimally invasive treatments will be presented.

Assessment and Treatment Strategies for the Aesthetic Improvement of the Lower Face and Neck

Background

Interest in aesthetic rejuvenation of the lower face and neck is growing, but published expert guidance is limited.

Objective

Review aesthetic concerns of the lower face and neck and provide expert guidance on evaluation and treatment.

Methods

Twelve international experts participated in an advisory board on lower face and neck aesthetic treatment. They completed a premeeting survey and met twice, reviewing responses and discussing patient evaluation and treatment strategies. They developed decision tree algorithms on patient assessment and treatment planning and sequencing, using clinical cases as a reference.

Results

Treatment concerns include neck and lower face skin laxity, structural bone deficiency, insufficient or excess volume, submental fat, jowls, platysma bands, and masseter muscle prominence. Advisors agreed that the lower face and neck may be the most challenging areas to assess and treat; treatment goals include lower facial contour and overall facial harmony/balance. Advisors recommended first ruling out a surgical approach, then determining whether midface treatment is needed to support the lower face, and lastly evaluating the lower face for significant submental fat, excess or insufficient volume, and structural bone deficiency. To treat the lower face and neck, an anatomical layer approach, moving from deep to superficial layers, beginning with structural support, was recommended. Assessment and treatment decision trees were based on this approach.

Conclusion

The lower face and neck are important but underrecognized areas of aesthetic concern. This article provides expert guidance and a suggested algorithm for assessment and treatment aimed at achieving satisfying and harmonious facial aesthetic results.

Contouring Plus: A Comprehensive Approach of the Lower Third of the Face with Calcium Hydroxylapatite and Hyaluronic Acid

A well-defined jawline is aesthetically pleasing, so that rejuvenation of the jawline is becoming part of routine aesthetic practice. Restoring balance to the lower face without surgical intervention requires a multiple treatment approach, among which the minimally invasive injectables play a central role. Nevertheless, amidst the plethora of different injectable products available, choosing the option that best suits the patient's need can be a challenge. A panel of experts sought to describe herein 4 clinical cases, illustrating the Contouring Plus technique, which provides a practical guidance for lower third assessment, choice of products, and treatment execution, especially among hyaluronic acid and calcium hydroxylapatite, aiming for immediate, as well as mid-to-long-term results.

Evaluation of Supratrochlear, Supraorbital and Angular Artery Course Variations and Depth by Doppler Ultrasound

BACKGROUND

Supratrochlear (STA), supraorbital (SOA), and dorsal nasal artery (DNA) branches from the ophthalmic artery and angular artery (AA) from the facial artery are the primary suppliers of blood to the upper face. Filler injection without precise knowledge of its vascular topography poses a risk of severe complications.

METHODS

Seventy-four hemifaces from 37 subjects with a median age of 25.0 (21.0, 35.0) years and a median body mass index of 21.2 (20.0, 25.4) kg/m² underwent high-frequency ultrasound tests between March 2022 and April 2022. The bilateral location, depth, peak systolic velocity (PSV), and inner diameter (ID) of the four periorbital arteries (STA, SOA, DNA, AA) were measured.

RESULTS

The average ID ranges from 0.6~1.0 mm, and the average PSV ranges from 9.2~24.9 cm/s. All arteries detected passed through the superficial subcutaneous fascia. Most subjects' STAs traveled within 1.0 to 2.0 cm from the midline (left 96.8%, right 93.8%), while SOAs were mainly concentrated within 2.0 to 4.0 cm (left 83.9%, right 81.3%). STAs were more superficial and had a larger internal ID and PSV than SOAs (p<0.001). Except for the ID of the right SOA2 being significantly larger than that of the left SOA2 (p<0.05), no dominant side was found. The depth of STAs and SOAs was moderately correlated with BMI (p<0.05), except for STA1 on the left side. The course of AAs presented a high variability.

CONCLUSION

These findings emphasize that the periorbital arteries carry with it a likelihood of ocular complication risks during injection. Targeting the supraperiosteal layer in the STA area and the supramuscular layer in the SOA area of the inferior forehead during injection seems reasonable, and an area within 1.0~2.0 cm from the midline should be avoided. Additionally, the high variability of AAs will enhance the understanding of the anatomy of the facial artery terminals.

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 .

"Bi-Bi" technique for lip augmentation: A retrospective study on 30 cases

INTRODUCTION

Lip augmentation is achieved mainly by using hyaluronic acid (HA) fillers. The injection procedures are performed either superficially or deeply with a needle or a cannula, and only one type of hyaluronic acid is used. The authors' objective was to evaluate the feasibility, safety, and satisfaction level of a procedure combining two anatomical injection plans, two injection modes (i.e., cannula and needle), and two types of hyaluronic acid fillers.

METHOD

The retrospective study included 30 patients who underwent the following procedure: Intramuscular retro-trace injections of Stylage M (Vivacy® Laboratories) were conducted through a 27-gauge cannula at the level of the upper and lower hemi-lip. Then, intradermal injections of Stylage Lips (Vivacy® Laboratories) using a 33-gauge needle were carried out on the entire lip border as well as the cupid's bow. During a post-injection follow-up, subjects were asked to evaluate satisfaction level and the effect of fillers over time. Elastic (G') and viscosity (G″) moduli of HA fillers were measured with a rheometer (AR2000, TA Instruments) prior to and after extrusion through a 33-gauge needle.

RESULTS

Rheological assessment showed that passage through a 33-gauge needle did not alter the viscoelastic properties of HA fillers. After the clinical procedure, no side effects were observed except for standard post-treatment bruises and edema. No vascular incident occurred. Moreover, overall patient satisfaction was high (2.6/3) and there was a long-lasting perception of the effect of the filler.

CONCLUSION

The current study demonstrated that dissociating the anatomical zones of the lip during the injection procedure by means of different hyaluronic acids in the muscular and dermal planes would efficiently and safely provide both lip projection and fullness for a natural and lasting effect.

Social Profiloplasty:A Practical Assessment and Injection Guide

The trend of aesthetic medical procedures continues growing every year since decades all over the globe, especially considering minimal invasive treatments since the results are immediate and the downtime minimal. Hence, treatments with hyaluronic acid fillers have become extremely popular and routinely used in common practice. However, numerous areas of treatment were identified and described in the last years clinical training and consciousness of possibly complication remain still under represented. In the following article, we present four key treatment areas for optimal overall facial rejuvenation of what the authors define the social profile. Of each area an assessment, anatomical considerations, danger zones and the preferred personal technique of the authors are described.

Efficacy and safety of hyaluronic acid fillers for lip augmentation in a Chinese population

BACKGROUND

Hyaluronic acid (HA) is an effective dermal filler for facial rejuvenation. This study aimed to observe the clinical efficacy of HA injection for lip augmentation in Chinese patients.

METHODS

From May 2019 to April 2020, 70 patients with lip fullness scale (LPS) ≤3 underwent local HA injection using the "three-point" injection technique. All patients were followed up to observe the clinical efficacy, LPS, adverse events, and complications.

RESULTS

All 70 patients were followed up for 12 months. Statistically significant improvements were observed in the height of lips within 6-9 months post-treatment (p < 0.05). The LFS improved significantly at follow-up compared with baseline (p < 0.05). Local redness occurred in two patients, and serious swelling occurred in three patients. These adverse events were generally tolerated and disappeared gradually within 1 week. No other serious adverse events and complications were reported in the remaining patients.

CONCLUSIONS

Hyaluronic acid injection can be used for lip augmentation in the Chinese population. The "three-point" technique is simple, safe, and effective and does not cause serious complications.

Endolift laser for jowl fat reduction: clinical evaluation and biometric measurement

Recently, jawline rejuvenation and jowl fat treatment methods have received a lot of attention. Many people are extremely upset and complain about the excess fat under the chin or neck and jowl. The study suggests a new procedure for targeting the jowl fat using Endolift laser, highlighting on the feasibility, convenience, and safety of the technique. Nine patients with pinchable fat on the jawline were enrolled in the study. The Endolift laser was performed for jowl fat treatment for each patient. The results of the treatment were measured by biometric assessment. Also the results were evaluated by 3 board-certified dermatologists (blind). Furthermore, patients' satisfaction was appraised at the end of the treatment. The biometric results showed that Endolift laser can increase the thickness, density, and elasticity of the skin in the jowl area. The patients' satisfaction results showed good and very good improvement in all of the patients (90%). The results by the dermatologist displayed good and very good improvement in about 90% of the patients. The outcomes of this experience displayed that Endolift laser is a safe and effective nonsurgical method for jowl reduction.

Treating Aging Changes of Facial Anatomical Layers with Hyaluronic Acid Fillers

The aging process affects every anatomical layer of the face. Improved knowledge of how aging occurs in each anatomical layer of the face has helped evolve the facial rejuvenation strategies with HA fillers. Understanding the age-related changes in the anatomical facial layers, including their time of onset and how the changes occur in the different tissue layers, an injector can provide much more targeted and refined HA filler treatments. As fillers’ use has increased, there has been a distinct shift away from procedures lifting the skin and SMAS. We can selectively target the anatomical facial layers with HA fillers for more refined and predictable outcomes. An extensive range of HA filler variants is now available. Each filler type is optimized and designed to be injected into specific tissue planes for the best results. Knowing the predictable aging changes in the different tissue layers of the face is crucial as this guides the optimum filler choice. Working knowledge of the individual characteristics of the numerous HA-based products allows for their effective placement in the correct layer. Familiarity with the correct HA product may also help to minimize the downtime and risk of adverse events.

Understanding Facial Muscle Aging: A Surface Electromyography Study

BACKGROUND

Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood.

OBJECTIVES

The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers.

METHODS

The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles.

RESULTS

The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity).

CONCLUSIONS

The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.

Nonsurgical Redefinition of the Chin and Jawline of Younger Adults With a Hyaluronic Acid Filler: Results Evaluated With a Grid System Approach

BACKGROUND

Aesthetic treatment of the lower face is increasingly in demand, particularly owing to age-related changes in appearance. VYC-25L is a novel hyaluronic acid filler with high G' and high cohesivity, specifically designed for sculpting and contouring of the chin and jaw.

OBJECTIVES

The aim of this study was to assess the use of a grid traced onto the chin and jaw for guiding treatment with VYC-25L.

METHODS

This was a retrospective, single-center analysis of data from adult patients undergoing treatment of the lower third of the face with VYC-25L. A grid system of horizontal and vertical lines was used to systematize the process of treatment planning and performance.

RESULTS

Thirty subjects were enrolled (53.3% female; mean [standard deviation] age, 34.4 [2.8] years). The mean quantity of VYC-25L used was 4.0 [0.8] mL. Based on the 5-point Global Aesthetic Improvement Scale, 29 patients (96.7%) rated their appearance at 20 days posttreatment as "much improved" or "very much improved." The only complications recorded were early transient soft-tissue edema (n = 14; 46.7%) and bruising (n = 6; 20.0%). There were no cases of infection, paresthesia, asymmetry, hematoma, necrosis, or skin discoloration.

CONCLUSIONS

Treatment of the chin and jawline with VYC-25L, with injection locations determined by a standardized grid-based approach, appears to be effective and safe with high rates of patient satisfaction. Injection of this filler offers a potentially high-impact approach for patients across a variety of biological and economic circumstances.

LEVEL OF EVIDENCE: 4

Combination of hyaluronic acid fillers and personalized skincare as a perfect tool in aesthetic medicine

Nowadays the desire to look younger has increased. The most popular noninvasive rejuvenation method is hyaluronic acid (HA) filler injection. However, aging of the skin involves multiple pathological processes, which can be managed by using topical formulations with sophisticated active agents addressing problems such as extracellular matrix degradation, textural variances, and dyschromias. A single site experience trial was conducted to assess the efficacy of HA dermal filler injections combined with personally prepared, bespoke formulations on epidermis and dermis condition. A total of 15 female participated in the study. Mid and lower face were treated with Saypha® HA fillers injection with volume chosen by the investigator performed with 25G/50mm cannula. The formulations for topical skincare consisted of substances chosen from 19 active agents, which were scientifically proven. The subjects were supposed to use them for 6 weeks. Fourteen subjects completed the study, and one subject was lost to follow-up. The age of the study population ranged from 36 to 58 years. The average amounts of Saypha volume plus, Saypha volume, and Saypha filler used per subject were 2.8 ml, 2.25 ml and 1.7 ml, respectively. The most typical skin dysfunctions were loss of elasticity (12 subjects), hyperpigmentation (nine subjects), erythema (eight subjects), and hyperseborrhea with enlarged pores (five subjects). After completing the study all subjects were satisfied. Combined therapies based on HA fillers and personalized skincare with Universkin™ products show promising results in patients with skin problems due to aging.

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

Mucomuscular Elastic Flap for Lower Lip Vermilion Reconstruction: Experience in a Series of Cases in Pediatric Patients

ABSTRACT

The mucocutaneous line and the lip vermilion are important structures from an esthetic standpoint but also in relation to the functionality of the mouth. In the literature, several types of flaps have been described for reparation of labial defects in adults. In this study, the authors analyze results of surgical reconstruction of the lower lip in the pediatric population using unilateral or bilateral mucomuscular elastic flaps for labial reconstruction. A retrospective analysis of 10 patients operated between 2003 and 2018 at our institution was made. The following demographic and clinical data were collected: age, sex, diagnosis, type of flap, follow-up, results, and complications. The Strasser scale was chosen for assessment of postoperative photographic results. Average age was 8.1 years (range 3-18). The most frequent etiology was arteriovenous malformation seen in 60% of cases. All cases corresponded to a defect of the lower lip. The average percentage of lip compromised was 44% and the largest length of compromise observed was 60% of the lip. Follow-up was on average 2.4 years. Esthetic results according to the Strasser method were as follows: 1 patient presented an excellent esthetic result, 5 good, 4 regular, and 0 poor.Considering the esthetic outcomes and low incidence of complications of the mucomuscular elastic flap, it is an acceptable and recommended technique of choice for lip vermilion reconstruction.

Anatomy and Aging of the Perioral Region

Perioral region, although severely impacted by facial aging, is often overlooked in texts on facial rejuvenation. Sun exposure, bone resorption, dynamic contraction of the sphincteric and nonsphincteric oral musculature, gravitational pull, histological changes of the skin, and unhealthy habits all take their toll in this area. Fine wrinkling on the lips, deep nasolabial and mentolabial folds, elongation and flattening of the upper lip, downturned corners of the mouth, marionette lines, diminished vermillion and upper teeth show and chin irregularities are the main signs of this process, raising great concern amongst patients and making the perioral region the most demanded area for facial rejuvenation treatment. A huge armamentarium of surgical and nonsurgical techniques, with or without complex technology, are available to tailor patient's specific needs, from chemodenervation and mild chemical peels to operations designed to restore the size and shape of the lips. In this article we perform a comprehensive review of the contemporary treatment of the aging perioral area, detailing the most common techniques and their nuances.

Whole-Face Approach with Hyaluronic Acid Fillers

The use of hyaluronic acid fillers in aesthetic medicine has changed over the years and the procedure became one of the most common in the world. Understanding the ageing process of the face and the anatomical interrelationships in the face have dramatically influenced the use of the hyaluronic acid fillers and the assessment of the patient. It was supported by a new technology of products and by the delivery of tools (eg, blunt cannulas), face imaging, and innovative injection techniques. The whole-face approach challenges the practitioner to look at the face as a whole, and the patient to trust and rely on the treatment plan. Over the years, we have understood, that the most important outcome of aesthetic procedures is what does the whole face look like not static but in motion, and how do people read emotions from it. Nowadays, the result changes "the face information" and makes aesthetic procedures more satisfactory. In this manuscript, we reviewed essentials of the current treatment approach including patient's consultations, product selection and injection techniques used in different parts of the face. One size fits none; thus, we provided a general overview of hyaluronic acid fillers used in different indications and presented several treatment approaches to each region of the face.

Transverse facial artery: Its role in blindness after cosmetic filler and botulinum toxin injections

Masseter injections for cosmetic or pathological reasons are increasingly common, as are filler injections using dual or multiplane techniques in the lateral facial regions or for jawline contouring. The occurrence of blindness following these procedures often remains unexplained. This study aimed to determine the anatomical explanation for this debilitating complication by investigating the transverse facial artery and its relation to the masseter. For this purpose, we dissected 35 cheek specimens with latex injections and 10 specimens without latex. The external carotid artery was dissected up to its bifurcation into the maxillary and superficial temporal arteries. Results showed that the transverse facial artery arose from the superficial temporal or external carotid artery that runs between the zygomatic arch and the parotid duct. Three types of transverse facial arteries were observed: type I: a short artery that did not extend beyond the masseter muscle; type II: a transverse artery that ran to the nasolabial fold and anastomosed to the facial artery; and type III: a sizable transverse artery that substituted the hypoplastic facial artery, continued as the angular artery, and then anastomosed to the dorsal nasal artery. Knowledge of these three types of transverse facial arteries is a prerequisite to study the vascular territory. Type III provides an explanation for the occurrence of blindness after lateral face injections. We consequently define a line that runs from the tragus to the outer quarter of the upper lip as the risk area, while the safe zone is located on either side of this line.

Anatomy of the Superior and Inferior Labial Arteries Revised: An Ultrasound Investigation and Implication for Lip Volumization

BACKGROUND

Lips are considered a key element of facial attractiveness due to their central position in the face and their elemental role in verbal and nonverbal communication.

OBJECTIVES

The authors sought to provide clinically relevant information on the 3-dimensional pathway of the superior and inferior labial arteries within the lips to increase safety during labial soft tissue filler injections.

METHODS

The study enrolled 41 healthy volunteers with a mean age of 26.17 ± 9.6 years and a mean body mass index of 23.09 ± 2.3 kg/m2. Ultrasound imaging was performed at 6 different locations. The position of the labial arteries within the lips, depth of the arteries, cranio-caudal location of each artery in relation to the vermilion border, and diameter of the superior/inferior labial arteries were recorded.

RESULTS

The most frequent location of both the superior and inferior labial arteries was the submucosal plane (58.5%) followed by intramuscular (36.2%) and subcutaneous (5.3%) planes. The depth of the superior labial artery in the upper lip was 5.6 ± 0.13 mm, whereas the depth of the inferior labial artery in the lower lip was 5.2 ± 0.14 mm. Both arteries were more frequently located within the red lip: upper lip (83% vs 18.7%) and lower lip (86.2% vs 13.8%). In the midline, the artery coursed within the red lip in all investigated volunteers.

CONCLUSIONS

Clinically, results of this study favor a superficial injection plane for lip volumization procedures. A perpendicular approach to the lip (coming from the cutaneous lip) might increase safety because the artery is located most frequently within the red lip.

"WAY": A practical means to identify and treat the aging process

Background

Many patients consult a specialist in esthetics to improve certain aspects of their face that are altered by aging. To ensure optimal results and to define the best approach for such interventions, it is important that specialists have a comprehensive understanding of facial anatomy and of the aging process in the regions of interest.

Aims

The main purpose of this article was to provide a practical approach for managing aging process in the mid‐ and lower face. Additionally, this paper also aimed to describe the processes associated with aging that may affect the morphology and the appearance of jaw contour (“W”); prejowl (“A”); tear trough, palpebromalar area, and nasojugal groove (“Y”) (“WAY”) signs.

Methods

The Current paper combined the authors experience with the currently available scientific evidence.

Results

In this study, the anatomy and the changes associated with aging of the mandibular line and that of the tear trough, palpebromalar area, and nasojugal groove was described. The important anatomical changes in these facial regions can be considered through the “WAY” paradigm, signs of aging that can be treated through a variety of surgical and nonsurgical approaches. Although surgical procedures may obtain good results, patients generally prefer less invasive treatments, which have a good efficacy profile, but are safer and have a shorter recovery time.

Conclusions

The “WAY” signs identify anatomical changes in the mandibular line and tear trough, palpebromalar area, and nasojugal groove associated with aging that can be corrected by different procedures, preferably minimally invasive ones.

Reshaping the Lower Face Using Injectable Fillers

The lower third is very important for the pleasant appearance of the face. A well-contoured jawline is desirable in men and women, giving a perception of beauty and youth. It is also key to sexual dimorphism, defining masculine and feminine characteristics. The nonsurgical rejuvenation and beautification of the lower third of the face is becoming more frequent. Injectable fillers can reshape the jawline, lift soft tissues, and improve facial proportions, effectively improving the appearance of the area.

It is paramount to understand the facial anatomy and perform a good facial assessment in order to propose a proper aesthetic treatment plan. The aesthetic goal of the rejuvenation approach is to redefine the mandibular angle and line. In young patients, beautification can be achieved through correction of constitutional deficit or enhancement of the contour of the face, improving the facial shape. It is very important to possess knowledge of facial anatomy and of the aging process in order to deliver effective and safe results.

In this article, we discuss the anatomy of the lower third of the face, facial assessment, aging process, and treatments of the chin, prejowls and mandibular line and angle with injectable fillers. The authors’ experience in the approach of this area is discussed.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

Management of noninflammatory nodule in chin after a large volume bolus injection of hyaluronic acid filler

As most Asian women desire to have an "inverted triangle" appearance for face, there is an increasing trend to give a large volume bolus (LVB) injection in the submental region of the chin for its lengthening. Hyaluronic acid (HA) dermal fillers are very popular for facial contouring and reshaping, including the chin area. Filler injection in the submental area has been a popular method to lengthen the chin. Placing an LVB of HA filler material at one place can present as the formation of lump or nodule after injection. We present a case of formation of a nodule in the submental area after injection of a single LVB of filler. The nodule was injected with hyaluronidase 3 months after its formation, and a near-complete resolution was seen immediately. Complete disappearance of the nodule was found at follow-up after 10 days. LVB of HA filler can give rise to the formation of noninflammatory nodules after filler injection in the immediate post-injection period. Knowledge of the type of filler material and presenting features can help in instituting the correct line of treatment for the resolution of signs and symptoms. Also 0.5 mL of filler can be recommended as maximum size of single LVB, based on the mathematical calculations.

Jowl Reduction With Deoxycholic Acid

BACKGROUND

The study proposes a novel protocol for targeting the jowls using deoxycholic acid (DCA) injections, with emphasis on safety and feasibility of the procedure.

METHODS

This prospective study was conducted at a cosmetic practice between June 2016 and May 2017. Twelve consecutive patients seeking reduction/improvement in mild/moderate jowl fat were injected with DCA subcutaneously in a predefined circular area 1.0 cm above the mandibular border. Treatment response was assessed using physician-evaluated Global Aesthetic Improvement Scale (GAIS) and Subject GAIS.

RESULTS

Twelve patients (11 women and 1 man) with mild (n = 8) or moderate (n = 4) jowls were treated. After the first treatment, GAIS responses for 24 jowls showed 5 jowls with vast improvement, 15 with moderate improvement, and 4 with no change. After the second session for 5 jowls in 3 patients, GAIS responses showed vast improvement in 4 jowls and moderate improvement in 1. Adverse events included induration (n = 4), bruising (n = 6), numbness (n = 2), pain (n = 5), redness (n = 3), edema (n = 9), and dysphagia (n = 1).

CONCLUSION

Results of this early experience showed that DCA injections were safe and effective for nonsurgical jowl reduction.

Nonsurgical jawline rejuvenation using injectable fillers

BACKGROUND

A well-defined jawline is a critical component in the perception of facial attractiveness in both men and women. Dermal fillers offer a nonsurgical, temporary method of correcting mild-to-moderate mandibular bone resorption.

AIMS

The authors discuss pertinent aspects of anatomy, pathophysiology of aging, patient evaluation, gender considerations, injection technique, and complications in jawline augmentation using injectable fillers.

METHODS

A brief review of the literature surrounding jawline augmentation using injectable fillers in both men and women, as well as the authors' experience in this area, is provided.

RESULTS

Nonsurgical jawline augmentation using injectable fillers can be performed effectively and safely with adequate background knowledge of the regional anatomy and appropriate patient selection. The authors discuss both injection techniques in the published literature and their own approach. Potential complications are also reviewed.

CONCLUSION

Jawline rejuvenation is a key component to global facial aesthetic rejuvenation. Therefore, it is important for physicians to understand how to safely and effectively perform nonsurgical jawline rejuvenation using injectable fillers.

Nonsurgical Management of Facial Masculinization and Feminization

BACKGROUND

Transgender patients may seek nonsurgical methods for facial masculinization and feminization as an adjunct or alternative to undergoing surgical procedures.

OBJECTIVES

The authors reviewed the existing literature regarding this topic and provided an overview of nonsurgical techniques for facial masculinization and feminization.

METHODS

A comprehensive literature search of the PubMed and MedLine databases was conducted for studies published through December 2017 for techniques and outcomes of nonsurgical facial masculinization and feminization. Keywords were used in performing the search. Data on techniques, outcomes, complications, and patient satisfaction were collected.

RESULTS

Four articles fit our inclusion criteria. Given the lack of published literature describing facial injectables in transgender patients, data from the literature describing techniques in cisgender patients were utilized to supplement our review.

CONCLUSIONS

Facial feminization can be achieved through injectables such as neurotoxin and fillers for lateral brow elevation, lip augmentation, malar augmentation, and improvement of rhytids. Facial masculinization can be achieved with injectables used for genioplasty, jawline augmentation, and supraorbital ridge augmentation. One must develop best practices for these techniques in the transgender patient population and increase awareness regarding nonsurgical options.

LEVEL OF EVIDENCE: 4

The Avoidance and Management of Complications, and Revision Surgery of the Lower Face and Neck

Complications are an inherent occurrence in surgery. In rhytidectomy, many complications are avoidable with thorough preoperative assessment and optimal intraoperative and postoperative care. Nevertheless, complications do occur. In certain situations, avoidance of risks is the best way to decrease the occurrence. Once complications do occur, there is a large body of literature to aid in the correction.

Composite Facial Volumization With Calcium Hydroxylapatite (CaHA) for the Treatment of Aging

Paradigms in the treatment of aging have evolved to address volume loss as a central and primary hallmark of the aging face. The concept of "composite volumization" was recently proposed by Dr. Z. Paul Lorenc to describe the effect of Radiesse (Merz Aesthetics, Inc., Raleigh, NC), when placed on bone in the supraperiosteal plane, on all overlying tissues (skin, superficial and deep fat compartments, and muscle). The physiochemical properties of Radiesse make it especially well suited for efficient and effective volumization of areas especially prone to volume loss; the temple, zygomatic arch, anterior cheek, pyriform aperture, and prejowl sulcus. Placement of Radiesse on bone in these areas creates a scaffold upon which additional restoration of fine lines and wrinkles may be accomplished, restoring a youthful appearance.

Development of "Core Syllabus" for Facial Anatomy Teaching to Aesthetic Physicians: A Delphi Consensus

Background:

A detailed understanding of facial anatomy, specifically the vascular framework, is crucial for delivering safe nonsurgical aesthetic procedures. To date, there is no core document based on consensus for the teaching of facial anatomy to aesthetic physicians exists. The aim of this study was to ascertain the most critical anatomical structures for avoiding disastrous complications during nonsurgical aesthetic procedures.

Methods:

After a detailed literature review, Delphi questionnaire was developed listing 154 anatomical structures of the face and neck for consensus review. Thirty-five international experts in surgical and nonsurgical facial aesthetics were invited to complete an online survey designed to rank the relevance of each anatomical element on a Likert scale from 1 (not at all important) to 4 (very important) or 5 (no opinion). Consensus for items included in the core syllabus was predefined as achieving a Cronbach’s α ≥ 0.90 and an agreement score of ≥ 80%.

Results:

Thirty-four international experts (97.14%) completed the iterative online Delphi survey. The consensus among the specialists polled was achieved after 1 round of the survey (Cronbach’s α = 0.94). The expert panel reached an agreement score of ≥ 80% on 137 of the 154 anatomical structures listed.

Conclusion:

The outcome of this Delphi study represents an essential first step in systematizing an evidence-based facial anatomy “Core Syllabus” for the teaching of aesthetic physicians and practitioners. This “Core Syllabus” will act as a blueprint for the educators while crafting a program.

Lip Repair after Mohs Surgery for Squamous Cell Carcinoma by Bilateral Tissue Expanding Vermillion Myocutaneous Flap (Goldstein Technique Modified by Sawada)

Squamous cell carcinoma is the most common malignancy of the lower lip. Environmental factors such as ultraviolet light exposure, arsenic and smoking are contributing factors to the increasing incidence. Mohs surgery is the treatment of choice ensuring the lowest recurrence rates. The closure of the surgical defects, however, can be a challenge. Multiple and versatile methods of reconstructing vermilion defects have been described. Among these options, Goldstein developed the adjacent ipsilateral vermilion flap based on an arterialized myocutaneous flap. The original technique was modified by Sawada based on bilateral adjacent vermilion advancement flap for closure of central vermilion defects. We report the use of bilateral flaps - Sawada’s technique (instead of unilateral as suggested by Goldstein) in medium (2 cm of extension) to large defects (> 2 cm) to achieve an effective and functional reconstruction of vermillion defects after Mohs surgery for lip cancer.

Consensus Recommendations for Treatment Strategies in Indians Using Botulinum Toxin and Hyaluronic Acid Fillers

BACKGROUND

Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment.

METHODS

The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience.

RESULTS

The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20-40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women.

CONCLUSIONS

These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.