Facial Assessment and Injection Guide for Botulinum Toxin and Injectable Hyaluronic Acid Fillers

A Gaze into the Eyebrow Standards of Asian Versus Caucasian Women

BACKGROUND

Eyebrow position affects perceived facial expression and youthfulness, and its modification is a key component of facial rejuvenation.

OBJECTIVE

This investigation aimed to assess the preferred vertical eyebrow position, apex location, and eyebrow shape in Caucasian and Asian individuals and to analyze gaze patterns during aesthetic judgment using eye-tracking technology.

MATERIALS AND METHODS

The study included 76 Asian and Caucasian volunteers with no medical background. Eye movements were captured with a Tobii Pro Nano eye-tracker. Participants viewed AI-generated images of Caucasian and Asian females with varied eyebrow positions (ratios 1:1.3 to 1:2.5), shapes (angles 8° to 20°), and apex positions. Aesthetic preferences were rated on a 5-point Likert scale. Eye-tracking metrics and aesthetic ratings were statistically analyzed using ANOVA and bivariate correlations.

RESULTS

Both genders across ethnicities preferred a moderate eyebrow position ratio of 1:1.6. For eyebrow shapes, a 12° angle received the highest ratings, while extremes were less favored, indicating a preference for moderately curved eyebrows. The most appealing apex position was above the lateral canthus for Asians, and halfway between the lateral limbus and lateral canthus for Caucasians. Eye-tracking revealed longer fixations on unattractive features, suggesting more complex cognitive processing, while attractive features were processed more efficiently.

CONCLUSION

The study revealed that aesthetic preferences for eyebrow features are influenced by both ethnic background and gender, with a general preference toward moderately curved eyebrows and subtle variations in preferred positions. These findings suggest a need for culturally sensitive approaches in facial aesthetic procedures and highlight the potential of eye-tracking technology to enhance surgical planning. Surgeons are advised to adopt a conservative, patient-centered approach when modifying eyebrow features, considering individual and cultural aesthetics to maximize patient satisfaction.

LEVEL OF EVIDENCE V

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 .

Study on botulinum toxin in dermatology from 2000 to 2023: A CiteSpace-based bibliometric analyses

OBJECTIVE

Using bibliometric methods, this study analyzed and summarized the current situation and development of the global application of botulinum toxin in dermatology.

METHODS

Literature published in the Web of Science Core Collection database from January 1, 2000 to October 28, 2023 was searched for topics such as "Botulinum toxin," "Dermatology," and so forth. The number of publications, countries, institutions, journals, authors, cited literature, keywords, and so forth, were analyzed and a visual knowledge map was created using scientometric tools such as CiteSpace, VOSviewer, and Scimago Graphica.

RESULTS

A total of 2039 documents were retrieved and 1877 documents were included after de-duplication and transformation. The country with the highest number of published periodical articles was the United States; the main research institution was Yonsei University; the author with the highest number of published periodical articles was Kim, Hee Jin; and the high-frequency keywords mainly related to indications, combination therapy, and safety optimization.

CONCLUSION

The results of this study provide information on the current status and trends in clinical studies of botulinum toxin in dermatology, which will help researchers identify hotspots and explore new research directions in this field.

Singular entry point technique for forehead and temple filler augmentation: Anatomical and clinical perspectives

BACKGROUND

The depressed volume of the forehead and temple is resolved by filler injection. However, the current method has the potential to cause pain and side effects in patients, depending on the skill of the clinician. Therefore, this study proposes a new method for safer and simpler injection using only one injection entry point.

METHODS

Using the novel injection method, the filler was injected into the forehead and temple regions in three unembalmed cadavers and two healthy Korean volunteers. The cannula and filler locations were identified using dissection, ultrasonography, and three-dimensional (3D) scanning.

RESULTS

Ultrasonographic images and dissection results showed that the filler injected into the cadavers was in the target layer. The cannula and filler were located on the layer as the supraperiosteal layer on the forehead and the supra deep temporal fascia layer in the temple. Finally, 3D scanning images showed that the filler was injected precisely and effectively into the forehead and temples of the volunteer who underwent the procedure.

CONCLUSIONS

This method can reduce pain and minimize externally visible wounds caused by injections. The injected filler was naturally connected from the forehead to the temple and maintained for around 3 months. Additionally, it is possible to inject fillers into the forehead and temple at a constant and safe depth without requiring specific skills. It is expected that this method will become a universal method because it minimizes the burden on both patients and clinicians.

Application of High-Frequency Ultrasound to Evaluate Forehead Filling Materials

BACKGROUND

In recent years, soft tissue materials have been applied as forehead fillers. Some filling materials need to be removed or refilled in a timely manner in certain situations; therefore, it is important to develop a method to identify the location and type of filling materials. This study summarizes the imaging findings of different filling materials under high-frequency ultrasound, providing a reference for clinical treatment.

METHODS

We screened facial ultrasound images performed at the Plastic Surgery Hospital of the Chinese Academy of Medical Sciences from April 2015 to July 2023 and classified and summarized the types of frontal filling materials and their imaging results.

RESULTS

This study included ultrasound imaging results from 114 patients, including 39 with hyaluronic acid (HA) filling, 45 with polyacrylamide hydrogel (PAG) filling, 14 who received autologous fat transplantation, 2 who received prosthesis implantation, 2 who received both HA and PAG filling, and 12 who received silicone oil filling. HA mainly manifests as an anechoic zone on ultrasonography, with images divisible into four types. PAG primarily presents as fine punctate echoes, divisible into five types. Fat transplantation presents as a low-echo area with uneven density, divisible into five types. Finally, the silicone oil-filling material appears as a cloud-like high echo on the forehead, visible throughout the entire skin layer, and unclear imaging in deep tissues.

CONCLUSION

High-frequency ultrasound is a safe and reliable method to evaluate the type and position of forehead filling materials, which can be easily applied in clinical practice.

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 .

Simplifying the injector's armamentarium: An international consensus regarding the use of gel science to differentiate hyaluronic acid fillers and guide treatment recommendations

BACKGROUND

The Restylane portfolio of soft tissue fillers spans a wide range of indications, due in part to their complementary manufacturing technologies [non-animal stabilized hyaluronic acid (NASHA) and Optimal Balance Technology (OBT/XpresHAn)]. Using an array of products, injectors can achieve a holistic, natural looking effect for their patients. However, with a wide range of products it may be difficult to choose an optimal combination.

AIM

Simplify and align global use recommendations for NASHA versus OBT products.

METHODS

Two pre-meeting surveys were completed by 11 key opinion leaders with international representation, with the goal of collecting information regarding their current injection practices for various anatomical regions of the face (i.e., temporal region, forehead, tear trough, lateral zygoma, anteromedial cheek, nose, pyriform aperture, nasolabial fold, perioral area, lips, labiomental crease, marionette lines, chin, and jawline). The data collected from these surveys was subsequently discussed in a consensus group meeting involving 11 voting members and 3 nonvoting members.

RESULTS

Top product recommendations were identified for each anatomical area, along with secondary and tertiary recommendations that can also be used under defined circumstances. Recommendations were provided based on a consideration of elements such as patient features (e.g., skin thickness, bone structure), the desired aesthetic outcome, experience of the injector, and the preferred injection technique.

CONCLUSION

A majority consensus regarding the top NASHA versus OBT product choice for each anatomical region of the face was reached. These recommendations represent international agreement regarding the use of Restylane products.

Integrative Assessment for Optimizing Aesthetic Outcomes When Treating Glabellar Lines With Botulinum Toxin Type A: An Appreciation of the Role of the Frontalis

Despite the perception that treatment of glabellar lines with botulinum toxin A is straightforward, the reality is that the glabellar region contains a number of interrelated muscles. To avoid adverse outcomes, practitioners need to appreciate how treatment of 1 facial muscle group influences the relative dominance of others. In particular, practitioners need to understand the independent role of the frontalis in eyebrow outcomes and the potential for negative outcomes if the lower frontalis is unintentionally weakened by botulinum toxin A treatment. In addition, practitioners must recognize how inter-individual variation in the depth, shape, and muscle fiber orientation among the upper facial muscles can affect outcomes. For optimal results, treatment of the glabellar complex requires a systematic and individualized approach based on anatomical principles of opposing muscle actions rather than a one-size-fits-all approach. This review provides the anatomical justification for the importance of an integrated assessment of the upper facial muscles and eyebrow position prior to glabellar treatment. In addition, a systematic and broad evaluation system is provided that can be employed by practitioners to more comprehensively assess the glabellar region in order to optimize outcomes and avoid negatively impacting resting brow position and dynamic brow movement.

LEVEL OF EVIDENCE: 5

SAMCEP Society consensus on the treatment of upper facial lines with botulinum neurotoxin type A: A tailored approach

BACKGROUND

The safety and efficacy of botulinum neurotoxin type A (BoNTA) treatments are well established, but injection techniques, target muscles, and toxin doses continue to evolve, with each refinement producing improvements in treatment outcomes. The recommendations in this consensus move away from standard templates and illustrate how to tailor treatments to individual patterns and strengths of muscle activity, and patient preferences.

METHODS

Seventeen experts in the fields of plastic surgery, dermatology, ophthalmology, otorhinolaryngology, and neurology convened in 2022 to develop consensus-based recommendations for the use of botulinum toxin A for the treatment of horizontal forehead lines, glabellar frown lines, and crow's feet lines that reflect current clinical practice. The focus was on how to tailor injections to individual patients to optimize treatment outcomes.

RESULTS

For each upper face indication, consensus members describe how to perform a dynamic assessment to optimize the dose and injection technique for each patient. A tailored treatment protocol is presented for commonly observed patterns of dynamic lines. Units of Inco are defined and the precise location of injection points, illustrated with the use of anatomical images.

CONCLUSION

This consensus provides up-to-date recommendations on the tailored treatment of upper facial lines based on the latest research and collective clinical experience of the expert injectors. Optimal outcomes require thorough patient evaluation, both at rest and during animation, using both visual and tactile cues; detailed understanding of facial muscular anatomy and how opposing muscles interact; and use of a BoNTA with high precision to target identified zones of excess muscle activity.

Novel Validated Five-point Photonumeric Scales for Assessment of Static and Dynamic Forehead Lines

Background

The objective of this investigation was to create and validate five-point photonumeric scales which assess static and dynamic forehead lines.

Methods

Two different novel five-point photonumeric scales for the assessment of static and dynamic forehead lines were developed. Moreover, a photoguide was created, including subjects from both sexes, all age groups, and different Fitzpatrick skin types. A total of 11 raters from all over the world were involved in the digital validation, whereas four raters performed a live validation.

Results

The Croma Static Forehead Lines-Assessment Scale showed almost perfect inter and intra-rater agreement in both the digital and the live setting with inter-rater intraclass correlation coefficients of 0.86 [95% confidence interval (CI): 0.82-0.89] in the first digital rating and 0.82 [95% CI: 0.78-0.86] in the second digital rating. The Croma Dynamic Forehead Lines-Assessment Scale showed almost perfect inter and intra-rater agreement in the digital setting with inter-rater intraclass correlation coefficients of 0.83 [95% CI: 0.79-0.86] in the first digital rating and 0.80 [95% CI: 0.75-0.84] in the second rating and almost substantial agreement in the live setting.

Conclusions

The Croma Static Forehead Lines-Assessment Scale and the Croma Dynamic Forehead Lines-Assessment Scale have excellent inter and intra-rater agreements to be justifiably used in the clinical and study setting, both digitally and live across ethnic groups.

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.

Dynamic Evaluation of Skin Displacement by the Frontalis Muscle Contraction Using Three-Dimensional Skin Displacement Vector Analysis

PURPOSE

Understanding the muscle actions and resultant skin movement can enable more safe and effective botulinum toxin injection for the treatment of forehead wrinkles. We aimed to investigate skin displacement patterns of the forehead and adjacent skin due to frontalis muscle contraction using three-dimensional skin vector displacement analysis.

MATERIALS AND METHODS

Thirty healthy individuals were enrolled. Photographs of the face were taken at rest and during maximal contraction of the frontalis muscle. Each expression image was aligned to its respective static image to compute the differences in the skin position.

RESULTS

When frontalis muscle contracts, forehead skin displacement vectors were mostly vertical (63.4%), followed by lateral oblique (33.3%) and medial oblique (3.3%). In 53.3%, only the lower part of the forehead moved upward, while 40.0% showed bidirectional skin movement with transition line at a mean distance of 59.4 mm above the pupil. Moreover, 86.7% showed asymmetric skin displacement, and 83.3% showed both glabellar and eyebrow skin displacement. Frontalis muscle contraction also induced medial 2/3 (50.0%) or entire (33.3%) skin movement of the temple.

CONCLUSION

Botulinum toxin injection into the forehead can be individualized by considering the vector and asymmetry of skin displacement. Vertical or medial vector requires more centrally located injections, while laterial vector requires more laterally located injections. The presence and location of the vertical transition line are important for preventing ptosis when treating forehead lines with botulinum toxin. Glabellar movement during frontalis contraction suggests the need for a concomitant injection into the glabella to prevent glabella wrinkle accentuation.

Eyebrow Shape Preference Across Age, Gender, and Self-reported Ethnic Group

BACKGROUND

Preference in eyebrow shape has been studied in young women, but less so in older adults, men, and a wide variety of ethnic groups.

OBJECTIVE

To identify preference in eyebrow shape across age groups, genders, and ethnic groups for both the survey responder and the observed subject.

METHODS

Digital images of subjects from 3 age groups (18-39, 40-59, and 60+ years), 2 genders (female and male), and 4 self-identified ethnic backgrounds were edited to correspond to 5 brow shapes (Anastasia, head-up, horizontal, rounded, and tail-up). Panels of images representing the same subject with different brow shapes were displayed and responders ranked them in order of attractiveness via an online survey.

RESULTS

Six hundred fifty-two responders answered the survey. Survey responders generally preferred the Anastasia shape, but not in all subgroups. Strength of preference in eyebrow shape was more marked when observing images of women and less marked when observing men.

CONCLUSION

An arched brow, such as the Anastasia shape, was the preferred eyebrow shape. This study is limited by its survey nature, underrepresentation of self-identified Black study responders, and categorization of data. Despite these findings, the authors advocate determining eyebrow shape preference individually with patients during cosmetic consultations.

Human adipose-derived stem cells can optimize the filling material in rats

BACKGROUND

Human adipose-derived stem cells have been identified as a promising candidate for cell-assisted therapy to improve graft survival.

OBJECTIVE

To objective of the study was to add human adipose-derived stem cells into filling materials.

METHODS

The filling materials were prepared and divided into 6 groups: fat particles with phosphate buffer saline or human adipose-derived stem cells; acellular dermal matrix particles with phosphate buffer saline or human adipose-derived stem cells; mixture of fat particles and acellular dermal matrix particles with phosphate buffer saline or human adipose-derived stem cells. The survival rate, vascular density and histological at 2, 6 and 12 weeks were investigated.

RESULTS

Human adipose-derived stem cells significantly improved survival rate in each group at 6 and 12 weeks, and it significantly increased the vascular density in the fat particles and porcine acellular dermal matrix combined group and porcine acellular dermal matrix group at three time points, but human adipose-derived stem cells did not have a significant effect in the fat particles group.

CONCLUSION

Human adipose-derived stem cells as assisted cells added into filling material can improve survival rate and vascular density in rats.

Cosmetic Treatment Using Botulinum Toxin in the Oral and Maxillofacial Area: A Narrative Review of Esthetic Techniques

Botulinum toxin (BoNT) is an anaerobic rod-shaped-neurotoxin produced by Clostridium botulinum, that has both therapeutic and lethal applications. BoNT injection is the most popular cosmetic procedure worldwide with various applications. Patients with dynamic wrinkles in areas such as the glabella, forehead, peri-orbital lines, nasal rhytides, and perioral rhytides are indicated. Excessive contraction of muscles or hyperactivity of specific muscles such as bulky masseters, cobble stone chins, gummy smiles, asymmetric smiles, and depressed mouth corners can achieve esthetic results by targeting the precise muscles. Patients with hypertrophic submandibular glands and parotid glands can also benefit esthetically. There are several FDA-approved BoNTs (obabotuli-numtoxinA, abobotulinumtoxinA, incobotulinumtoxinA, letibotulinumtoxinA, prabotulinumtox-inA, daxibotulinumtoxinA, rimbotulinumtoxinB) and novel BoNTs on the market. This paper is a narrative review of the consensus statements of expert practitioners and various literature on the injection points and techniques, highlighting both the Asian and Caucasian population separately. This paper can serve as a practical illustrative guide and reference for optimal, safe injection areas and effective doses for application of BoNT in the face and oral and maxillofacial area. The history of BoNT indications, contraindications, and complications, and the merits of ultrasonography (US)-assisted injections are also discussed.

Eyebrow lifting with barbed threads: A simple, safe, and effective ambulatory procedure

INTRODUCTION

Changes in brow positioning are one of the first facial aging signs. A more beautiful and younger look can be achieved by repositioning the tissues involved in brow descent and sagging eyelids.

METHODS

We report the outcome of eyebrow thread lifting in a series of patients who came to our clinic to improve their gaze. Response to treatment was assessed at 6- and 12-months using FACE-Q^™ upperlids and eyebrow/forehead scales.

RESULTS

A total of 38 patients with mild-to-moderate brow ptosis or without ptosis underwent eyebrow thread lifting (mean age 35.5, all female). No serious complications were observed during or after treatment. All patients were satisfied with the outcome of the intervention. Mean FACE-Q^™ scores improved at six months compared with baseline. A statistically significant increase in mean FACE-Q^™ scores was still seen at 12 months and was more evident in younger women. Patients were able to go back to their daily lives the day after the procedure.

CONCLUSION

Eyebrow thread lifting is a minimally invasive procedure able to overcome mild-to-moderate ptosis with excellent aesthetic results. In the absence of ptosis, thread lifting is a good choice to reposition the brow and improve the gaze. The technique is simple to perform and safe.

Efficacy Evaluation of a Cosmetic Product for the Periocular Area in Caucasian Women Aged Over 40 Years Old

Purpose

The present study was aimed at evaluating the efficacy of a cosmetic product in improving the appearance of periocular skin.

Patients and Methods

An open-label study on 40 female subjects showing clinical signs of skin aging in the periocular area (including bags under the eye and dark circles) was conducted. At day 0 and day 28 the bags under eye volume, dark circles color, skin texture, skin moisturization, skin elasticity, and skin radiance were measured. The instrumental measurements were integrated by clinical analysis carried out by a board-certified dermatologist and by a self-assessment questionnaire carried out by each subject participating in the study.

Results

After 28 days of product use the volume of the bags under the eye was decreased by 6.8% (p = 0.005), the dark circle color red and blue component improved by 7.1% (p = 0.001) and 4.0% (p = 0.001), respectively, wrinkle depth and skin roughness decreased by 15.8% (p = 0.001) and 6.3% (p = 0.011), respectively, skin moisturization increased by 11.7% (p = 0.000), the skin distensibility decreased by 8.9% (p = 0.000), the overall skin elasticity increased by 10.4% (p = 0.000), and the skin radiance increased by 16.3% (p = 0.000). The instrumental measured effects were also confirmed by the clinical analysis of the dermatologist and the self-assessment questionnaire output.

Conclusion

Conclusions: our results suggest that the test product is effective for periocular skin aesthetics (reduction of imperfections undermining the periocular area) and wellness.

Rhinofiller: Fat Grafting (Surgical) Versus Hyaluronic Acid (Non-Surgical)

BACKGROUND

The author presented his experience using "fat grafting" (FG) and "hyaluronic acid" (HA) techniques in nasal remodeling.

OBJECTIVES

The paper aimed to evaluate the efficacy and safety of the use of FG and HA in nasal remodeling for aesthetic improvement.

METHODS

A randomized controlled trial was conducted. 15 patients affected by soft defects of the dorsum, low and boxy nasal tip, and hidden columella, were treated with FG (study group-SG), comparing results with the control group (CG) (n = 17) treated with hyaluronic acid (HA). Post-operative follow-up took place at 1, 2, 4, weeks, 3, 6, 12 months, and then annually.

RESULTS

73.7% of SG patients showed excellent cosmetic results after 1 year compared with only 29.7% of CG patients. At one-month, major part of people who underwent the treatments (FG and HA) referred to satisfaction with the resulting volume contours (p = 0.389). 88.3% of CG patients versus 53.8% of SG described the HA and FG injection, respectively, as a very comfortable and non-invasive procedure. As expected, patient satisfaction with the appearance of nasal contouring was higher in the FG group at 1 year.

CONCLUSIONS

FG and HA were safe and effective in this series of cases performed.

LEVEL OF EVIDENCE III

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.

Evaluation of supratrochlear artery depth and course variations by Doppler ultrasonography along the glabellar frown lines for safer filler injections

PURPOSE

Hyaluronic acid (HA) injection is a popular nonsurgical, rejuvenating procedure to treat glabellar frown lines, which has devastating complications such as blindness and skin necrosis due to the arterial occlusion of supratrochlear artery (STA). Therefore, when injecting into the frown lines, knowledge of the STA's depth and plane is necessary to prevent possible adverse events. The aim of this study was to identify the depths of STA in the area of the frown lines in order to maximize safety during filler injections.

METHODS

Supratrochlear artery depth measurements were performed at the level of eyebrow and at the level of 1.5 cm above the eyebrow. Superficial duplex Doppler ultrasonography was performed of 71 cases.

RESULTS

In the eyebrow level, the epidermis-artery distance (EAD) is between 1,8 and 5.9 mm, and the artery-periost distance (APD) is between 0.7 and 3.7 mm. In the 1.5 cm superior level of the eyebrow, the EAD is between 1.8 and 5.1 mm and the APD is between 0.6 and 3.8 mm. There was no significant difference between the depth measurements of the right and left STA. At the eyebrow level, APD is greater in men than in women. As the body mass index increases, the EAD and APD depth increases. EAD depth increases with increasing age.

CONCLUSIONS

Based on the findings of this study, safe filler injections to correct the glabellar frown lines can be possible with intradermal injections just below the ryhtide. In the glabellar region, subcutaneous and supraperiosteal injections seems to be risky.

Expert Opinion on Non-Surgical Eyebrow Lifting and Shaping Procedures

Eyebrow elevation and reshaping are common concerns that we handle in everyday practice, and we have noticed that the trend is shifting from a medical concern to a cosmetic one. Several eyebrow lift methods are available, both invasive and non-surgical. The method of choice depends on several factors, such as patient expectations and beliefs, financial budget, acceptance of downtime and the available tools in the practice. In this article, we review the recent literature on non-surgical eyebrow lift methods to provide an overview of the current state of this field. We discuss seven different methods for eyebrow lift and reshaping, including botulinum toxin, dermal fillers, fractional radiofrequency, high-intensity focused ultrasound, thermo-mechanical ablation, lasers, and threads. Moreover, we provide practical insight into the procedure, injection techniques, expected results, and patient satisfaction rate.

Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures

BACKGROUND

An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region.

OBJECTIVE

To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments.

METHODS

A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m² were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues.

RESULTS

The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle.

CONCLUSION

On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.

Ultrasonographic Analyses of Crow's Feet and Novel Guideline for Botulinum Toxin Injection

BACKGROUND

Crow's feet are bilateral orbital wrinkles formed by the orbital portion of the orbicularis oculi muscle, which is the target muscle for botulinum neurotoxin (BoNT) injection.

OBJECTIVES

This study's aim was to demonstrate a novel BoNT injection guideline by assessing muscle width, thickness, and dynamic features using ultrasonography.

METHODS

Twenty healthy Korean volunteers (10 men, 10 women; mean age, 25.6) participated. The width, thickness, and dynamic movement of the orbicularis oculi muscle were measured using ultrasonography. Two volunteers were selected to receive BoNT injections. Injections were administered using a novel method with two curved reference lines passing a point 15 mm lateral to the lateral canthus (conventional injection) and a point 5 mm lateral to the lateral margin of the frontal process of zygomatic bone (additional injection).

RESULT

At the lateral canthus level, the distance between the lateral margin of the frontal process and the most lateral margin of the orbicularis oculi muscle was 12.5±1.3 mm. The thickness of the orbicularis oculi muscle at the midpoint of the frontal process, the lateral marginal of the frontal process, and 5 mm lateral to the lateral marginal of the frontal process was 0.7±0.3 mm, 1.1±0.3 mm, and 1.2±0.3 mm, respectively. The crow's feet of the two volunteers began to disappear from day 3 and completely disappeared on day 7 after the injection.

CONCLUSION

The novel injection technique based on the ultrasonographic anatomy resulted in improvements in the appearance of crow's feet.

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.

Application of Nonsurgical Modalities in Improving Facial Aging

Objective. This review aims to summarize different kinds of applications of minimally invasive surgery in improving facial aging to provide a comprehensive and accurate introduction on the issue of esthetic treatment of facial skin. Overview. In the twentieth century, facial rejuvenation has become a new beauty trend. Facial cosmetology has entered a period of antiaging and rejuvenation therapies and microplastic surgery. The pursuit of beauty has promoted the development of minimally invasive plastic surgery. This review introduces the possible causes of facial aging and its related topics with a focus on facial injectable drugs, such as botulinum toxin, main filler materials (hyaluronic acid, calcium hydroxyapatite, poly L-lactic acid, collagen, autologous fat, and polymethyl methacrylate), and some current antiwrinkle technologies, such as thread lift and radiofrequency rhytidectomy. Conclusions. Despite the difference in mechanisms of action, each technique can address facial aging involving the loss of collagen, displacement and enlargement of fat, and muscle relaxation. Combinations of these treatments can provide patients with reasonable, comprehensive, and personalized treatment plans.

Avoiding Complications on the Upper Face Treatment With Botulinum Toxin: A Practical Guide

BACKGROUND

Currently, botulinum toxin (BoNT) injections are the most commonly performed non-invasive procedure for rejuvenation on the upper face. The therapeutic use of botulinum toxin has generally been safe and well tolerated. Adverse effects are considered mild, transient, and self-limited. However, as with all other injectable procedures, this one is also susceptible to adverse events and complications. When the safety zones are respected, the chance of any of these complications is practically null. Thus, this review aims to describe the main complications of treatment with BoNT on the upper face and to present a practical guide based on current evidence on how to avoid them.

METHODS

The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles.

RESULTS

The main complications secondary to BoNT injections on the upper face are: ptosis of eyelid or eyebrow, eyebrow asymmetry, diplopia, Lakeophthalmos, Palpebral ectropion, and prominence of the palpebral bags. To avoid such complications, it is necessary to have knowledge of the anatomy of this region and adequate and individualized planning based on the existing patterns of the frontalis muscle, glabella, and crow's feet. This review presents the specificities of each of these regions and practical suggestions to obtain satisfactory results, avoiding complications.

CONCLUSION

Particularly on the upper face treatment with BoNT offers predictable results, has few adverse effects, and is associated with high patient satisfaction. However, it is suggested that the commented parameters and safety areas be incorporated into daily practice so that the possibilities of complications are minimized as much as possible.

LEVEL OF EVIDENCE III

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 .

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

BACKGROUND

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE: 4

Periorbital Filling With The MD Codes™ Algorithm: A Narrative Review and a Practical Guide

INTRODUCTION

The hyaluronic acid dermal fillers are employed to bring balance and facial harmony, improving the proportions and asymmetries of the structures, besides acting to reverse the signs of facial aging. The periorbital region is one of the first to show the signs of aging with periocular wrinkles, deepening of the nasojugal and palpebromalar folds, prolapse of the fat bags, excess palpebral skin, ptosis of the eyelashes, disappearance of the upper eyelid crease due to excess skin and hollowing of the upper eyelid.

AIMS

To describe the lines and grooves of the periorbital region and present a practical guide to the MD CODES™ algorithm for filling this region based on a narrative review of the literature.

METHODS

The literature research considered published journal articles (clinical trials or scientific reviews). Studies were identified by searching electronic databases (MEDLINE and PubMed) and reference lists of respective articles.

RESULTS

MD CODES™ algorithm maps anatomical points of the face (anatomical codes) that, when treated with fillers, promote instantaneous lifting and rejuvenation. In addition to defining the points for treatment, this method identified the order of the points to be treated, that is, which points should be prioritized to cause greater aesthetic impact. The MD CODES aim to standardize facial rejuvenation and is of particular interest for young as well as more experienced physicians.

CONCLUSION

Was presented in detail the regions, the aesthetic effects of the application, the technique, the volume, and the target structure undertaken in the remodeling of the tear trough, periorbital, temporal, brow, and frontal regions.

Current Use of Cosmetic Toxins to Improve Facial Aesthetics

LEARNING OBJECTIVES

After studying this article, the participant should be able to: 1. Compare and contrast the various types of botulinum toxin on the market. 2. Appropriately select patients for treatment with cosmetic botulinum toxin. 3. Understand the common injection patterns for treating various regions of the face with cosmetic botulinum toxin. 4. List the complications associated with treating various regions of the face with cosmetic botulinum toxin.

SUMMARY

Nonsurgical rejuvenation of the face with botulinum toxin is one of the most commonly performed procedures in the United States. This article reviews the current evidence in treating different regions of the face: upper face, lower face, masseter, and platysma. Dosing and complications associated with different facial regions are reviewed.

Multi-Dimensional Aesthetic Scan Assessment (MD ASA™): Initial experience with a novel consultation, facial assessment, and treatment planning tool

BACKGROUND

Comprehensive patient assessment and planning are central to esthetic treatment with injectables. MD ASA™ (Multi-Dimensional Aesthetic Scan Assessment) is a novel tool developed for this purpose.

AIMS

To describe the MD ASA technique and present its preliminary application.

METHODS

MD ASA breaks down the face into five hierarchies (H1-H5). H1 shifts patients' focus from "distractions" (individual lines and folds) toward the overall messages their face portrays, based on eight Emotional Attributes: four negative (tired, sad, angry, and saggy); four positive (youthful, attractive, contoured, and feminine/masculine). Three priority Emotional Attributes are selected for each patient. This is followed by a process of narrowing down through facial thirds (H2), periorbital and perioral dynamics (H3), facial units (H4), and subunits (H5), to arrive at a final assessment. Based on the key facial signs identified, this can be translated into MD Codes equations and thus a treatment formula. A retrospective analysis was performed based on 12 female patients injected by expert clinicians at an educational event. All patients were selected for, and treated using, a single MD Codes formula derived from a common MD ASA work-up.

RESULTS

There were substantial differences between patients and clinicians in their views of which anatomical areas needed treatment-but good alignment on priority Emotional Attributes. Patients were treated only for three negative Emotional Attributes, but improvements were observed across all eight attributes.

CONCLUSIONS

MD ASA provides a practical method for translating facial messages into actionable injectable treatment plans and facilitates greater patient-clinician alignment. Prospective studies are warranted.

Recommendations for the use of corrective makeup after dermatological procedures

Introduction

The number of dermatological or cosmetic procedures carried out has continuously increased over the last decades. Almost all may cause transient local skin reactions such as erythema, blistering, crusts, scaling, hypo‐ or hyperpigmentation, or hemorrhagic lesions. One issue of dermatological procedures is the downtime, during which patients need to hide their skin, due to these local reactions.

Aim

To provide dermatologists with easy‐to‐follow recommendations for the right timing of use of corrective makeup for patients who have undergone or who plan to undergo dermatological procedures, according to the invasiveness of the dermatological procedure chosen.

Methodology

A group of experts in dermatological procedures met in 2019 and at the beginning of 2020 to discuss the different procedures, their local reactions and downtime, and the opportunities to use specific corrective makeup in order to hide these transient reactions.

Results

As a result of the discussions, the experts proposed a tabulated algorithm of use based on a classification of the different dermatological procedures according to their invasiveness and recommended timing of the first post‐procedure corrective makeup application.

Conclusion

Corrective makeup may be considered as a complement to certain dermatological procedures in order to minimize downtime. However, its use is conditioned by the correct understanding of skin barrier alteration and recovery time. The proposed algorithm of use of corrective makeup after procedures may help the practitioner to indicate his patient the right moment for applying corrective makeup in order to avoid local tolerance issues and post‐procedure complications.

Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals

There is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodeling and transformation. These procedures may increase transgender individuals’ satisfaction with their appearance and allow them to more effectively harmonize their physical appearance with their perception of self. There is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. In this report, the authors provide experience-based treatment considerations and recommendations for use of minimally invasive facial aesthetic procedures in transgender patients, including case studies illustrating the use of these procedures for both male-to-female and female-to-male transitioning patients. This report highlights the success of minimally invasive methods for assisting transgender patients in achieving their facial remodeling goals. Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process. When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients’ self-perception and overall quality of life.

Management of Tear Trough with Hyaluronic Acid Fillers: A Clinical-Practice Dual Approach

INTRODUCTION

Tear trough deformity (TTD) is currently a major concern for many individuals that seek periorbital rejuvenation. Among the different options currently available for treating TTD, hyaluronic acid (HA) filler injections have become increasingly popular.

PURPOSE

To provide a dual approach, direct and indirect strategies for treating TTD with HA fillers according to patient facial structure.

METHODS

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

RESULTS

The current study presents the authors clinical experience regarding TTD treatment and serves as a guide on the best therapeutic approach with HA fillers. For achieving good aesthetic outcomes, especially in TTD, it is crucial to have a detailed understanding of both facial anatomy and the individual characteristics of the HA fillers. Proper management of full-face facial rejuvenation should have into consideration three main pillars: structure, contour, and refinement.

CONCLUSION

Treatment of TTD should be addressed from a comprehensive perspective, including potential lack of structural support, as well as interventions on the dynamic processes involved in the problem. Additionally, HA fillers can be used to modulate mechanically muscle movement by either facilitating their action or decreasing contractility by reducing their movement. Clinicians can benefit from ongoing guidance on the use of these products in order to tailor and optimize treatments to patient's requirements. Although HA filler injections have low rates of side effects, TTD was listed as the most challenging area to treat with HA. Therefore, TTD treatment should be performed only by well-trained and experienced specialists.

Complications of Botulinum toxin A: An update review

Cosmetic surgery procedures have increased manifolds all over the world owing to the ever-increasing demand of people to look beautiful and young. Injectable treatments like botulinum toxin are becoming more popular owing to their rapid, well-defined, and lasting results for the reduction of facial fine lines, wrinkles, and facial rejuvenation. These emerging treatments are quite safe but can have certain adverse effects. In this article, we have highlighted the complications and side effects of botulinum toxin based on the anatomical location. The possible causes and precautions to prevent these complications are also discussed. The search of literature included peer-reviewed articles including clinical trials and scientific reviews. Literature was identified from electronic databases (MEDLINE/PubMed) through January 2021 and references of respective articles and only the articles published in English language were included.

Eyelid and Periorbital Dermal Fillers: Products, Techniques, and Outcomes

A retrospective observational case study and a literature review were conducted to evaluate how anatomic findings, especially those related to the periorbital zone, serve as a guiding compass for injectable implants. Treatment techniques and product selection will be discussed for patients with negative vector, shallow orbit, and deep set eyes. Versatility of injectables will be demonstrated on patients with peanut face, iatrogenically altered anatomy (after surgery), and trauma.

Hyaluronic acid in vulvar and vaginal administration: evidence from a literature systematic review

Vulvovaginal pathology impairs the quality of life of both women in menopause and those who are not. Different therapies have been proposed, mainly related to estrogen therapy in postmenopausal women. However, some contraindications limit its use, and different moisturizers or lubricants have been tested. Hyaluronic acid is a promising and widely used vaginal medical treatment with a moisturizing action and appears to provide a solution. For this reason, we performed a systematic review of the literature. We searched for original articles without date restriction until 30 April 2020. We included all clinical trials which administered local hyaluronic acid in the vulva or vagina. Only English studies and those performed in humans were eligible. Seventeen original studies were included in the review (from randomized controlled trials to longitudinal studies). Hyaluronic acid was generally found to be effective in improving vulvovaginal symptoms (dyspareunia, itching, burning, dryness) and signs (bleeding, atrophy, vaginal pH). In conclusion, hyaluronic acid has the properties to be an efficient moisturizer for women suffering from vulvovaginal atrophy who have contraindications for estrogen therapy and for vulvovaginal signs and symptoms affecting sexual well-being. However, a well-designed randomized controlled trial is needed in order to clarify its efficacy and safety profile.

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.

The One21 Technique: An Individualized Treatment for Glabellar Lines Based on Clinical and Anatomical Landmarks

PURPOSE

Botulinum toxin type A is an effective treatment for glabellar dynamic wrinkles. As the muscular group involved in the contraction of the glabella varies among people, individualized treatment can achieve optimal results. This study evaluates a customized assessment for the treatment of glabellar lines with Incobotulinumtoxin-A, leading to an individualized points distribution and dosage.

PATIENTS AND METHODS

A single-center, evaluator-blinded, therapeutic cohort study enrolled 130 women with moderate or severe glabellar wrinkles. They underwent Incobotulinumtoxin-A injection following the standard 5-point injection at the glabellar muscles (n = 65) or an individualized assessment and scheme treatment based on anatomical references of contraction, the One21 technique (n = 65). All the patients were photographed under maximum contraction before treatment (T0) and after 4 weeks (T28). The photos were randomly assessed by two blinded, experienced raters to consensually grade the severity according to the Merz Aesthetics Scales (MAS). The primary clinical efficacy was defined as a 2-point reduction in the MAS score, on Day 28.

RESULTS

The groups were homogeneous regarding age, phototype, and baseline MAS scores. On Day 28 (T28), 64 (98.5%) patients from the One21 group and 52 (80%) from the 5-point group reduced the MAS score by at least two points (p < 0.01). When adjusted by age and phototype, both groups reduced the MAS score at T28 (p < 0.01); nevertheless, patients from the One21 group significantly performed better (p < 0.01), with a much higher rate response rate at T28, in comparison to the 5-point group. Of patients enrolled in the 5-point group, 83.1% utilized muscle groups other than the procerus and corrugator in glabellar wrinkle formation, and 17 (24.6%) presented asymmetrical contraction. Patients from the 5-point group with glabellar asymmetry and those who utilized the frontalis and orbicularis presented inferior performance (p < 0.05), reinforcing the importance of an individualized assessment and treatment plan.

CONCLUSION

The One21 technique yielded better results than the standard 5-point treatment in reducing glabellar dynamic lines with Incobotulinumtoxin-A, especially for asymmetric lines of the glabella or the involvement of muscle groups other than the procerus and corrugator.

Histological and Clinical Appraisal of Distribution and Long Acting New Hyaluronic Acid into the Subcutaneous Fat of the Forehead to Improve Horizontal Lines

BACKGROUND

A new hyaluronic acid (HA) was appraised to improve forehead horizontal lines (FHL). Histological analysis correlated the gel distribution with clinical findings and also with wrinkle depth, 48 h and 12 months after HA application.

METHODS

The new filler composed by 24 mg/ml of HA cross-linked with BDDE 2.0 ppm was injected into the subcutaneous fat, just beneath the dermis, through a retrograde backflow injection technique applied in sequence. Biopsies were taken with a 3.0-mm-diameter skin punch before HA application, 48 h and 12 months after HA application for histological evaluation.

RESULTS

Subcutaneous application created a compact cylindrical filament as pattern of gel distribution, which acted as strut raising the FHL to the level of the surrounding tissues. Diameter average of the filament 48 h after HA application was 1.18 mm and at month twelve 0.34 mm. The residual amount of the gel at month twelve ensured the long acting of the HA into the subcutaneous fat. FHL depth of 251.83 µm before HA application and 190.20 µm after 12 months indicated that the residual amount of gel at month twelve still projected FHL.

CONCLUSION

High cohesivity of HA and low density of forehead subcutaneous fat caused the gel to take the form of a compact cylindrical filament. The small amount of gel still presenting into the subcutaneous fat 12 months after application validated the long acting of the HA. Evidence-based analysis showed that this new filler might be considered a safe alternative for improvement in the FHL.

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 .

Hyaluronic Acid Filler in the Treatment for Drooping Tip: Anatomical Concepts and Clinical Results

The plunging nasal tip is a challenging condition because, although it is predominantly a dynamic deformity which occurs during smiling, it also indicates a structural problem. When a person smiles, the paired depressor septi nasi muscles pull the tip caudally at the same time as the levator labii superioris alaeque nasi muscles pull the alar base and lateral lip cephalically. This movement causes straightening of the alar rim. Even though surgical rhinoplasty is the gold standard to restore nasal appearance, the procedure may fail to treat the dynamic cause of the drooping tip. This article outlines the anatomical concepts that lead to a drooping tip and presents a technique that can treat both the dynamic and structural causes of the drooping tip using hyaluronic acid filler. Cases are also presented that illustrate these concepts. 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 .

"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.

Factors influencing pre-injection aspiration for hyaluronic acid fillers: A systematic literature review and meta-analysis

Pre-injection aspiration of hyaluronic acid filler is a well-recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre-injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta-analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G'), drop weight (cohesivity), and cross-sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre-injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions.

Better Results in Facial Rejuvenation with Fillers

Facial rejuvenation is a rapidly advancing field in aesthetic medicine. Minimally invasive techniques represent a powerful tool for rejuvenation, and fillers are a popular modality with which to restore and optimize facial proportions. Currently, our filler armamentarium is characterized by products with an increasing variety of biochemical compositions warranting tailored injection approaches. An intimate knowledge of anatomy, product characteristics, and appropriate injection techniques is essential to achieve optimal results while maintaining patient safety. Here, we review facial anatomy, structural changes secondary to aging, appropriate filler selection, safe injection techniques, and complications.

Tomography of the Forehead Arteries and Tailored Filler Injection for Forehead Volumizing and Contouring

BACKGROUND

The forehead is a challenging area for filler injection because of the risk of serious complications. Anatomy-based filler injection techniques help to avoid severe vascular complications.

MATERIALS AND METHODS

Sixty-six cadaver heads were infused with adequate lead oxide contrast through the external carotid arteries, internal carotid arteries, facial artery, and superficial temporal artery. Three-dimensional computed tomography scans were reconstructed using validated algorithms. We measured the length and arc length of "beautiful" foreheads evaluated by 3 skilled surgeons.

RESULTS

The frontal branch of the superficial temporal artery (FBSTA) was classified based on the main trunk as follows: Type I FBSTA (89.72%) took a sudden turn (89.56° ± 11.76°) once passing through the temporal crest, whereas Type II FBSTA (10.28%) barely turned (52.26° ± 6.81°) at the temporal crest. A total of 319 arteries passed through the midline in 48 cadaver heads. There were more superficial arteries (292 of 319) than deep arteries (27 of 319). The difference in the length and arc length of the forehead was 19.66 ± 4.35 mm.

CONCLUSION

This study introduces an effective technique for forehead filler injection that minimizes the risk of filler injection and improves patient satisfaction.

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.

Pinch anatomy: An injection guide for temple filler injections

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

A Novel Way for Upper Eyelid Rejuvenation by Combination of Local Fat-Fascia-Muscle Flap Repositioning for Middle-Aged Asian Women

BACKGROUND

Upper eyelid aging is common among middle-aged Asians. Apart from skin aging, there has been an increasing recognition for the role of sunken eyelid playing in upper eyelid aging. Various methods have been developed to deal with the upper eyelid volume deflation. However, autologous fat tissue could not achieve stable and satisfying rejuvenation results, especially for middle-aged patients who have established extremely low adipose tissue survival rates. Therefore, efficient rejuvenation methods with consistent long-term improvement are needed, especially for middle-aged patients.

METHODS

A retrospective study was conducted of 248 middle-aged patients who underwent the upper eyelid tightening and local fat-fascia-muscle flap reposition for upper eyelid rejuvenation in our department between 2015 and 2017. A precise sunken upper eyelid calculation method was used to evaluate the patients' upper eyelid sunken volume prior to the operation for the guidance of sunken correction. The same method was also used to calculate the post-operation upper eyelid sunken volume to evaluate the operation efficiency.

RESULTS

The average age of the patients who underwent the surgery was 49.5±7 years-old. The fat-fascia-muscle flap was repositioned according to each patient's pre-operation sunken upper eyelid evaluation result, and precise and satisfying immediate sunken correction was observed after the surgery. Long-term consistent improvement was achieved. Compared to the pre-operation evaluation, the upper eyelid sunken correction ratio was nearly 90% in one year's follow-up, and no major complication occurred.

CONCLUSIONS

The fat-fascia-muscle flap reposition combined with sunken upper eyelid calculation has been proved efficient and consistent for middle-aged Asians upper eyelid rejuvenation.

The Bidirectional Movement of the Frontalis Muscle: Introducing the Line of Convergence and Its Potential Clinical Relevance

BACKGROUND

Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator.

METHODS

Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement.

RESULTS

In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 ± 10.2 percent in men and 60.6 ± 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2; women, n = 2). No difference across ethnicities was detected.

CONCLUSIONS

The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.

Expert Consensus on Injection Technique and Area-Specific Recommendations for the Hyaluronic Acid Dermal Filler VYC-12L to Treat Fine Cutaneous Lines

Background

VYC-12L is a hyaluronic acid (HA) injectable gel designed to treat fine cutaneous lines and improve skin quality attributes such as hydration and elasticity.

Objective

Expert consensus was sought on VYC-12L injection technique and primary treatment target areas.

Methods

A multinational group of aesthetic medicine clinicians (n = 128) attended product training and each identified ~10 patients for VYC-12L. After treating their first and last patients, the clinicians completed a survey on preferred injection methodology/technique, including injection angle, volume, and spacing. An expert panel (n = 12) discussed survey results and their clinical experiences to obtain consensus on VYC-12L technique and appropriate treatment areas.

Results

Recommendations included micro-depot injections of VYC-12L into the deep dermis with a 32G ½ inch needle inserted at <45º to the skin, spaced 0.5‒1.0 cm apart, with 0.01‒0.05 mL volume per injection (full-face total volume: ~2 mL). Recommended primary treatment areas were the malar, perioral, neck, and décolletage regions. Injection techniques for different treatment areas/demographic characteristics were similar, with some variability in treatment approach. Patient selection criteria, pre- and post-treatment guidelines, and managing patient expectations are important components of treatment.

Conclusion

These consensus recommendations may assist clinicians in optimizing the treatment of fine lines with VYC-12L.

Techniques of Eyebrow Lifting: A Narrative Review

None of brow lift techniques are completely satisfactory because of their limited effectiveness, lack of longevity, and potential complications. The aim of this study was to provide a comprehensive review of the literature on the pros and cons of the most popular techniques in brow and forehead lift. Relevant original articles in the PubMed database (English language) were sought using the search terms “eyebrow lift", “forehead lift", "periorbital rejuvenation", "eyebrow ptosis", "blepharoplasty and eyebrow change", "surgical eyebrow lift", and "non-surgical eyebrow lift", No date limitation was considered. Titles and abstracts were scanned to include the most pertinent articles. Subsequently, full texts of included articles (111 articles) were skimmed and finally 56 references were selected for the review. A narrative synthesis of data was finally undertaken with particular attention to the indications, techniques, and common complications of the eyebrow lift procedures. Ten popular techniques including two non-surgical methods (Botulinum toxin A and soft tissue fillers) were reviewed in this article. In general, non-surgical methods of forehead/brow lift are temporary, need less experience and correction would be easier should any complication occur. Surgical methods are divided into three categories: trans-blepharoplasty eyebrow lift, direct eyebrow lift, and trans-forehead eyebrow/forehead lift. Currently, the most popular method is the endoscopic forehead lift approach even though its longevity is limited. Direct brow-lift is particularly useful in patients with facial palsy and those who are more likely to be accepting of the scar (male gender, high forehead hair line).