Three-Dimensional Topographic Surface Changes in Response to Compartmental Volumization of the Medial Cheek: Defining a Malar Augmentation Zone

Three-Dimensional Photography for Evaluating the Effectiveness of Botulinum Toxin Injection for Masseter Hypertrophy

BACKGROUND

Masseter hypertrophy is a common condition that causes a undesirable square face, and often treated with botulinum toxin type A (BoNTA). Subjective assessments of BoNTA effectiveness vary from physician to patient, necessitating an objective approach for evaluation. This study introduces three-dimensional photography (3DP) for the first time in clinical assessment to evaluate BoNTA treatment for masseter hypertrophy.

METHODS

Ten patients received 36U of BoNTA at three injection points on each side masseter muscle. 3DP scanner using Artec Eva® was taken at the first, third, and sixth postoperative months for objective evaluation. Patient's self-perceived prominence, patients self-rated satisfaction, and physicians provided 5-grade scores were the subjective indicators.

RESULTS

A significant decrease in left masseter volume at the sixth month (P = 0.002, P = 0.004 at rest and clenching, respectively) was observed. Patient's self-perceived prominence decreased at the first (P = 0.021) and third (P = 0.039) months. Physicians' scores significantly decreased at all postoperative months. No significant changes were noted in the right masseter volume and patients self-rated satisfaction. Patient self-rated satisfaction did not consistently correlate with objective measures, except for left masseter with clenching at the sixth month.

CONCLUSION

Three-dimensional photography accurately quantifies facial changes post-BoNTA treatment. Despite objective improvements, patient satisfaction may not align consistently. Reliable assessment tools are crucial in cosmetic surgery to manage expectations and prevent disputes.

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 .

Accuracy of Three-dimensional Scan Technology and Its Possible Function in the Field of Hand Surgery

Background

Three-dimensional (3D) technology has become a standard manufacturing element in many industries and has gained significant interest in plastic surgery. The 3D scans are widely used for patient communication, virtual surgery planning, and intraoperative tool manufacturing, providing a more comprehensive view of procedures and their outcomes compared with 2D visualization.

Methods

We evaluated the performance of six commercially available 3D scanners by acquiring 3D models of a human hand and a 3D-printed replica of a human hand. We performed objective comparisons between the 3D models of the replica using color mapping techniques. Moreover, we compared the results of the human hand 3D scans.

Results

We achieved the highest precision with the Artec Space Spider 3D scanner (Artec 3D) when scanning the 3D-printed replica. The SD was ±0.05 mm, and the scan did not have major defects that needed manual correction. On the human hand scan, we achieved the best results using the Artec Eva (Artec 3D), the resulting scan was an accurate digital representation of the scanned human hand.

Conclusions

In our study, the Artec Space Spider 3D scanner demonstrated superior precision when scanning a 3D-printed replica, deviating only slightly from the original data, making it an optimal choice for nonmoving objects such as casts or medical instruments. For scanning human hands, the Artec Eva 3D scanner exhibited the highest performance, offering accuracy comparable to the Artec Space Spider, but with the added benefit of being able to scan larger objects.

An Algorithmic Approach to Managing Parotid Duct Injury Following Buccal Fat Pad Removal

The principles of achieving an aesthetically pleasing and harmonious facial appearance are influenced by our evolving understanding of the three-dimensional topography of the face coupled with novel approaches to midface volumization and contouring. In parallel with the evolving landscape of facial aesthetic surgery, an increasing number of publications have emerged focusing on the role of intraoral buccal fat pad removal (BFPR) for the purposes of aesthetic midface contouring. The authors sought to emphasize an underreported and potentially preventable and untoward complication involving iatrogenic parotid duct injury following BFPR. The purpose of this publication is 3-fold: (1) to review the relevant anatomy and literature on intraoral BFPR, (2) to present a case example of this complication, and (3) to discuss treatment options as part of a proposed management algorithm. The authors detail the surgical indications for performing BFPR and review the relevant anatomic considerations. Complication prevention strategies are outlined, and details regarding avoidance of parotid duct injury are reviewed. The diagnostic criteria and clinical presentation of parotid duct injuries following BFPR are comprehensively outlined. The authors present a clinically actionable algorithm for managing a suspected or diagnosed parotid duct injury following BFPR. A clinical case example is discussed to highlight this complication, the diagnostic criteria, and the systematic and algorithmic approach to management. Intraoral BFPR is an incredibly valuable and powerful procedure that can improve facial contour in patients with buccal lipodystrophy or buccal fat pad pseudoherniation. The authors propose a proper diagnostic approach and treatment algorithm to manage this untoward complication.

Level of Evidence 5

Measurement Method to Determine the Difference in Tear Trough and Palpebromalar Groove Distribution After Transconjunctival Fat Reposition

PURPOSE

This study designed an efficient measurement method to evaluate the outcome of transconjunctival fat reposition in the tear trough and palpebromalar groove.

METHODS AND TECHNIQUES

A total of 41 patients (82 eyes) who underwent transconjunctival fat reposition surgery between January 2016 and March 2019 were retrospectively analyzed. Preoperative and postoperative (at least six months) standardized digital images were taken from the patients. A satisfaction survey was conducted on all patients. Their images were analyzed by using the Adobe Photoshop CS5 software. Ratios of the tear trough and palpebromalar groove were calculated. These data were analyzed by SPSS 20.0.

RESULTS

The overall satisfaction rate was 90.2%. With a partition in the infraorbital region, a line graph showed that the location of the tear trough and palpebromalar groove moved to the upper squares postoperatively. The number of patients whose end points of the tear trough and palpebromalar groove located outside the midline of the pupil decreased by 30.5%. When we processed all the parameters of the preoperative and postoperative groups by profile analysis, a significant difference in the tear trough and palpebromalar groove before and after surgery was observed (right: F = 79.844, P = 0.000 < 0.01; left: F = 161.799, P = 0.000 < 0.01).

CONCLUSIONS

Digital image analysis is feasible and useful in investigating the improvement of the tear trough and palpebromalar groove. The tear trough and palpebromalar groove shifted up and became shortened, which provided a more reliable evidence for lower eyelid rejuvenation.

Three-Dimensional Facial Scanning at the Fingertips of Patients and Surgeons: Accuracy and Precision Testing of iPhone X Three-Dimensional Scanner

BACKGROUND

The iPhone X (Apple, Inc., Cupertino, Calif.) is the first smartphone to be released with a high-fidelity three-dimensional scanner. At present, half of all U.S. smartphone users use an iPhone. Recent data suggest that the majority of these 230 million individuals will upgrade to the iPhone X within 2 years. This represents a profound expansion in access to three-dimensional scanning technology, not only for plastic surgeons but for their patients as well. The purpose of this study was to compare the iPhone X scanner against a popular, portable three-dimensional camera used in plastic surgery (Canfield Vectra H1; Canfield Scientific, Inc., Parsippany, N.J.).

METHODS

Sixteen human subjects underwent three-dimensional facial capture with the iPhone X and Canfield Vectra H1. Results were compared using color map analysis and surface distances between key anatomical landmarks. To assess repeatability and precision of the iPhone X three-dimensional scanner, six facial scans of a single participant were obtained and compared using color map analysis. In addition, three-dimensionally-printed facial masks (n = 3) were captured with each device and compared.

RESULTS

For the experiments, average root mean square was 0.44 mm following color map analysis and 0.46 mm for surface distance between anatomical landmarks. For repeatability and precision testing, average root mean square difference following color map analysis was 0.35 mm. For the three-dimensionally-printed facial mask comparison, average root mean square difference was 0.28 mm.

CONCLUSIONS

The iPhone X offers three-dimensional scanning that is accurate and precise to within 0.5 mm when compared to a commonly used, validated, and expensive three-dimensional camera. This represents a significant reduction in the barrier to access to three-dimensional scanning technology for both patients and surgeons.

Expert Consensus on Hyaluronic Acid Filler Facial Injection for Chinese Patients

Supplemental Digital Content is available in the text.

Background:

Beauty standards vary by race and region, which must be accounted for in creating beauty. Chinese have unique features, including a depressed nose, flat midface, and small chin, and have different cosmetic concerns. We performed a consensus study on filler injections based on the Chinese standard of beauty due to a lack of such study.

Methods:

We organized the YVOIRE Consensus Group, including 5 plastic surgeons. We discussed common problematic areas seen in Chinese and described techniques based on our experience with hyaluronic acid fillers, while considering peer-reviewed articles, followed by multiple consensus-developing sessions.

Results:

Chinese faces are characterized by retruded forehead, chin, and low nasal bridge, with certain features believed to bring good fortune. Therefore, profiles of the forehead, nose, lip, and chin have substantial effects on attractiveness. The demand for cosmetic procedures is high among the young generation who particularly desire nose and chin augmentation. Attractive Chinese facial shapes are characterized by a long, slender facial shape and pointed chin. Lips are narrow and thick. When injecting fillers for Chinese, it is necessary to apply special methods that produce results consistent with these characteristics.

Conclusions:

Understanding the concept and demand of beauty depending on race and region is important. Patients should be evaluated before aesthetic procedures. Maintaining hygiene during the procedure is crucial. Moreover, methods for preventing pain are essential. Fillers should be injected into the correct anatomical site and layer to minimize side effects and maximize effectiveness.

Hyaluronic acid-based two-stage medical therapy to unfold the aged face: The centrifugal approach

BACKGROUND

Facial aging is a multifactorial process characterized by structural changes to the dermis and ligaments, lipoatrophy in the fat pads and hypodermis, remodeling of the bony skeleton, change in muscle tonicity and tissue descent.

AIMS

The purpose of this study is to evaluate the efficacy of a hyaluronic acid-based treatment for the aging face that addresses all its causes in a caudal to cranial and medial to lateral direction: the centrifugal technique.

METHODS

Between March 2015 and January 2018, 187 patients were treated with a high G' hyaluronic acid in two sessions, one/two weeks apart, to improve signs of facial aging, starting from the lower centrofacial area and progressing laterally and cranially. Results were assessed using a Global Aesthetic Improvement Scale (GAIS) judging pre- and post-treatment (32 weeks) pictures.

RESULTS

The technique effectively treated the aging face. The investigator and all patients evaluated the results improved or very much improved and agreed that the results were very natural looking.

CONCLUSION

Use of a systematic centrifugal technique to address the signs of facial aging resulted in significant and long-lasting improvement, as judged by the investigator and high patient acceptance and satisfaction.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Blepharoplasty: Anatomy, Planning, Techniques, and Safety

Blepharoplasty is one of the most commonly performed cosmetic surgical procedures. To date it remains the most powerful method of periorbital rejuvenation when compared to other nonsurgical modalities, especially in the aging face. Despite that, the procedure has its shortcomings that include a steep learning curve, prolonged recovery, and potential for appearance and life-changing complications. Attaining successful outcomes relies on a solid understanding of facial topography, patient and technique selection, and, when appropriate, following a conservative approach. Modern blepharoplasty relies on tissue conservation and volume enhancement rather than aggressive removal. This concept was conceived after the realization that older techniques resulted in a hollowed appearance, which accentuated the aging process. It was further reinforced by advances in knowledge of periorbital anatomy and aging changes. This Continuing Medical Education article will detail periorbital surgical anatomy, preoperative planning, and varied blepharoplasty approaches and techniques, with an emphasis on safety and tailoring the procedure to the patient's anatomy.

Definitions of groove and hollowness of the infraorbital region and clinical treatment using soft-tissue filler

Clarification is needed regarding the definitions and classification of groove and hollowness of the infraorbital region depending on the cause, anatomical characteristics, and appearance. Grooves in the infraorbital region can be classified as nasojugal grooves (or folds), tear trough deformities, and palpebromalar grooves; these can be differentiated based on anatomical characteristics. They are caused by the herniation of intraorbital fat, atrophy of the skin and subcutaneous fat, contraction of the orbital part of the orbicularis oculi muscle or squinting, and malar bone resorption. Safe and successful treatment requires an optimal choice of filler and treatment method. The choice between a cannula and needle depends on various factors; a needle is better for injections into a subdermal area in a relatively safe plane, while a cannula is recommended for avoiding vascular compromise when injecting filler into a deep fat layer and releasing fibrotic ligamentous structures. The injection of a soft-tissue filler into the subcutaneous fat tissue is recommended for treating mild indentations around the orbital rim and nasojugal region. Reducing the tethering effect of ligamentous structures by undermining using a cannula prior to the filler injection is recommended for treating relatively deep and fine indentations. The treatment of mild prolapse of the intraorbital septal fat or broad flattening of the infraorbital region can be improved by restoring the volume deficiency using a relatively firm filler.

A Novel and More Aesthetic Injection Pattern for Malar Cheek Volume Restoration

The loss of superior midface contour and projection can be corrected with the use of injectable hyaluronic acid (HA) dermal fillers, however, the most frequently used injection pattern employs a technique which was originally designed for malar implant surgery. Here we describe a novel injection pattern for restoring facial contours with a HA dermal filler inspired by traditional make-up artistry, which includes greater superolateral positioning of injection sites. Importantly, this technique helps injectors avoid creating an excess of volume in the anterior portion of the malar complex. Contributing authors/injectors, who now use this technique exclusively, have found that it has so far provided optimal aesthetic results for hundreds of patients with no observables complications. The malar cheek contributes much to the aesthetic curvature of the face and deserves a thoughtful update for injectable HA, as the traditional technique has never actually been aligned with its medium. In the experience of the contributing authors, this technique helps achieve a greater aesthetic outcome in the correction of midface contour deficiencies and has consistently resulted in high patient satisfaction. 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 .