The Surface-Volume Coefficient of the Superficial and Deep Facial Fat Compartments: A Cadaveric Three-Dimensional Volumetric Analysis

Minilifting: Short-Scar Rhytidectomy with Thread Lifting

Facelifting techniques have been developed over time to mask the aging process. However, conventional facelifts cause scarring. Because of patient demands, various noninvasive lifting techniques have been introduced, including absorbable thread lifting. Minilifting is known for its short-scar excision and is used to improve skin laxity and lifting using absorbable threads but the definition and operation techniques are not certain. In this article, we described the definition, development, and operative techniques used in minilifts. Minilifting procedures represent an added option for patients with minimal scarring and adequate lifting effects.

Ultrasound to Improve the Anatomic Approach to the Temple and a Retrospective Study on the Efficacy of Large-Volume Autologous Fat Grafting

BACKGROUND

Autologous fat grafting (AFG) has been used widely in temporal-hollowing augmentation, but its efficacy and safety are unclear. The authors examined the use of Doppler ultrasound (DUS) in large-volume lipofilling after performing an anatomic study of the temporal region.

METHODS

To clarify safe and stable levels of AFG of the temporal fat compartments, 5 cadaveric heads (10 sides) were dissected after dye was injected into targeted fat pads with DUS guidance. In addition, the authors retrospectively analyzed 100 patients with temporal fat transplantation, including groups with conventional AFG ( n = 50) and DUS-guided large-volume AFG ( n = 50).

RESULTS

The anatomic study revealed the approach of 5 injection planes and 2 fat compartments in the temporal region: the superficial and deep temporal fat pads. In the AFG study, all patients were female, and there were no statistically significant differences between the groups in age, body mass index, tobacco or steroid use, or previous filling history. Between the conventional AFG group and the DUS-guided large-volume AFG group, the average volume of temporal lipofilling per side was 10.55 ± 2.25 versus 22.32 ± 5.19 mL/side ( P < 0.001), surgeon Likert scale score was 2.86 ± 0.97 versus 4.24 ± 0.66 ( P < 0.001), and rate of satisfaction was 74% versus 92% ( P < 0.05) (statistically significant differences).

CONCLUSIONS

The anatomic approach to the main temporal fat compartment is feasible. DUS-guided large-volume AFG is an effective and safe way to improve temporal hollowing augmentation.

New Aesthetic Unit (NAU) Method: A Comprehensive Method Based on Accurate Anatomical Assessment and Precise Multilayering Panfacial Treatment for Hyaluronic Acid Fillers

BACKGROUND

Recent progress in anatomy enables a more sophisticated approach to treat patients with facial aesthetic concerns (PFAC) with HA fillers. Furthermore, advances in rheology have offered a range of HA fillers with different biomechanical properties adapted to different indications.

METHODS

Based on recent anatomical and rheological progresses, the author has developed a new methodology that couples an accurate patient assessment tool and a panfacial precise treatment instrument. In the presented method, the face is divided into 6 units called New Aesthetic Units (NAU). NAUs are classified on the extent of volume deficiency and asymmetry, ranging from none to moderate to severe deficiencies. After discussion with the patient regarding the assessment findings, a customized treatment plan, including timelines and number of sessions, is recommended. The modalities of the treatment are exhaustively described for each NAU based on multilayering, best practice medicine, and expert consensus available in the literature.

RESULTS

Before-and after-case studies are presented to illustrate how the NAU method is used in routine practice for the treatment of two patients with HA fillers.

CONCLUSION

The NAU method is not only a practical and accurate roadmap for the assessment and treatment of PFAC with HA fillers, but also facilitates communication between injectors and patients and data analysis.

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 .

The Anatomical Layering Assessment: The Construction of Beauty

Restructuring an aging face from bone structure to the surface of the skin can be metaphorically compared to building and renovating a house. While each anatomical layer of the face undergoes an aging process of its own, there is also an interdependency of superficial structures on deeper layers, so that a change in one layer may lead to changes to the adjacent layers. This interaction among the structures deep into the skin, along with the skin's ability to envelope them is what determine the aspect of the aging face. Thus, a careful assessment of all the layers is imperative and we describe herein a step-by-step facial layering assessment and facial restructuring approach from bone structure to the surface of the skin to implement a treatment plan able to deliver a harmonious rejuvenating outcome.

Expanding Treatment Indications Beyond the Tear Trough Defect: The G-Point Lift Technique to Address the Entire Eyelid-Cheek Junction

Knowledge of the anatomy of the infraorbital region is key to understanding the full extent of clinically visible infraorbital defects and the underlying structures involved to achieve optimal aesthetic results. The authors have developed a more anatomic approach to the infraorbital region, which has led to recognition of a specific anatomic area, defined previously as the aesthetic G-point. Shifting attention away from the tear trough itself and applying a surgical approach to aesthetic medicine can lead to more natural and complete results while at the same time minimizing the risk of undesired side effects and complications.

Studying Dynamics of Mid-face Lifting During Hyaluronic Acid Filler Injection Using Ultrasound Imaging

BACKGROUND

The ageing in the mid-face involves volume deficiency in multiple anatomical units, including the zygomatic arch, infraorbital region, medial and lateral cheek and nasolabial fold (NLF). Hyaluronic acid (HA) is extensively used in the minimally invasive procedures of mid-face rejuvenation.

OBJECTIVES

MD CodesTM is proposed to perform combined treatment of multiple sites to reduce treatment variability and increase clinician success rates. Although the detailed procedure of this technique, aesthetic effects and complications have been disclosed, its anatomical information has yet to be discussed. This paper elaborated on the static and dynamic anatomical characteristics of MD CodesTM through cadaveric dissection and ultrasound imaging.

METHODS

Anatomical dissection and ultrasound imaging help us look back on the injection methods and anatomical principles of MD CodesTM.

RESULTS

The treatment is threefold: (1) the bolus injections, for lifting purposes, are performed at the most depressing point along the zygomatic arch, zygomatic eminence, the prominent optimal point in the zygomatic region, the most depressed point of upper NLF with 0.2-0.3 ml HA. (2) The linear injections, featuring facial contouring refinement, are performed at the deep fat pad of the medial cheek and infraorbital region with 0.4 ml HA. (3) The linear injections, featuring volume replacement, are performed at the subcutaneous fat layer of lateral cheek and NLF with 0.8 and 0.4 ml HA.

CONCLUSIONS

MD CodeTM is led by the principle of "less dosage and better effect", and a special injection sequence is formulated based on the anatomical characteristics. Ultrasound is a useful tool to make for a dynamic anatomical understanding of MD CodeTM and visualize the anatomical information such as layers and thicknesses.

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 .

Superficial versus deep injections of the upper midface-A prospective interventional split-face study

BACKGROUND

Various injection algorithms have been proposed in the past which are in line with the three aesthetic principles: upper face first, lateral face first, and deep regions first. However, increasing evidence is provided that the upper midface can be targeted with superficial soft tissue filler injections alone too.

OBJECTIVE

To investigate in a prospective split-face study design whether superficial or deep upper midfacial injections provide superior aesthetic outcomes.

METHODS

A total of n = 20 study participants (100% females; age 43.95 (11.7) years; BMI 22.92 (2.6) kg/m2 ) were treated with superficial soft tissue filler injections on side of their face and deep injections on the contralateral side with a mean volume of 0.78 cc. Outcome was evaluated at 7 weeks follow-up for midfacial, and lower facial volume, for medial and lateral facial skin vector displacement, and for improvement of nasolabial, crow's feet, and upper cheek fullness severity scores.

RESULTS

No adverse events related to safety or product tolerability were observed during the entire study period. All semiquantitative scores improved statistically significantly after the observational period (p < 0.001) but displayed no difference between the two applied injection techniques (p > 0.05).

CONCLUSION

The results of this split-face study revealed that both the superficial and the deep cannula injection technique for midface volumization statistically significantly improve the midfacial volume, reduce nasolabial fold and crow's feet severity. No statistically significant difference was observed between the two injection techniques when compared via semiquantitative and objective outcome evaluation after 7 weeks follow-up.

[Injection anatomy-a new discipline in aesthetic medicine]

The basic anatomical understanding of aesthetic medicine has changed fundamentally since the turn of the millennium. With the advent of modern minimally invasive injection procedures using botulinum toxin and hyaluronic acid fillers, anatomical structures that had previously received little attention and were not considered relevant have steadily gained in importance and moved into the scientific focus. Understanding the three-dimensional arrangement of the face with its defined anatomical layers and compartments serves the procedural dermatologist in the sense of a navigation system to optimize treatment success and patient safety when performing aesthetic injections in the facial region. The principles of the biomechanical interaction of the structures are of elementary importance in the creation of individual treatment plans for the implementation of natural and balanced therapeutic results. Modern injection anatomy as an interdisciplinary subject of the three fields of anatomy, dermatology and plastic surgery makes a decisive contribution here.

Slim the face or not: 3D change of facial soft and hard tissues after third molars extraction: a pilot study

BACKGROUND

Whether slim the face or not after removed third molars is the concern of some orthodontic treatment candidates. The aim of this article is to explore the volume changes of facial soft and hard tissues after third molars extraction, as well as develop a reproducible clinical protocol to precisely assess facial soft tissue volume change.

METHODS

A non-randomized, non-blind, self-controlled pilot study was conducted. 24 adults aged 18-30 had ipsilateral third molars extracted. The body weight change was controlled within 2 kg. Structured light scans were taken under a standardized procedure pre-extraction (T0), three (T1), and six (T2) months post-extraction; CBCTs were taken at T0 and T2. The projection method was proposed to measure the soft tissue volume (STV) and the soft tissue volume change (STVC) by the Geomagic software. The hard tissue volume change (HTVC) was measured in the Dragonfly software.

RESULTS

The final sample size is 23, including 5 males (age 26.6 ± 2.5 years) and 18 females (age 27.3 ± 2.5 years). The HTVC was - 2.33 ± 0.46ml on the extraction side. On the extraction side, the STV decreased by 1.396 (95% CI: 0.323-2.470) ml (P < 0.05) at T1, and increased by 1.753 (95% CI: -0.01-3.507) ml (P = 0.05) at T2. T2 and T0 had no difference (P > 0.05). The inter and intra-raters ICC of the projection method was 0.959 and 0.974. There was no correlation between the STVC and HTVC (P > 0.05).

CONCLUSIONS

After ipsilateral wisdom teeth extraction, the volume of hard tissue on the extraction side reduces, and the volume of facial soft tissue does not change evidently. However, further research with large sample size is still needed. The STV measurement has excellent repeatability. It can be extended to other interested areas, including forehead, nose, paranasal, upper lip, lower lip and chin, which is meaningful in the field of orthodontics and orthopedics.

TRIAL REGISTRATION

ChiCTR, ChiCTR1800018305 (11/09/2018), http://www.chictr.org.cn/showproj.aspx?proj=28868 .

Mastering Midface Injections

Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.

Three-dimensional Quantitative Standards for Assessing Outcomes of Facial Lipotransfer: A Review

BACKGROUND

Reliable quantitative data are required to address the unpredictability of facial autologous fat grafting (AFG). Facial evaluation by 3D scanning technology is getting popular. However, this process lacks unified standards and the reliability assessments. This study aimed to summarize a set of standards to improve the 3D quantified reliability of AFG outcomes.

METHODS

A systematic review was used to collect the differences in and limitations of 3D assessments and analyze the effect of the quantification process on the AFG outcomes. Healthy subjects undergoing only one facial structural AFG and 3D assessments were included. The revealed specific issues guided the subsequent narrative review that involves 3D measurement and fat volume retention rate (FVRR) analysis. Criteria were formulated based on the narrative review.

RESULTS

The systematic review revealed the quantitative process to be operator-dependent. The intra-group FVRR in the postoperative 11+ month group varied significantly (P=.03). The review identified a set of 3D measurement standards, including two optimal software products, two necessary steps for preprocessing, and four testing criteria. We proposed a new calculation formula and parameter and recommended a segmental area analysis for assessing the outcomes of full-face fat grafting.

CONCLUSIONS

As far as the 3D evaluation of AFG outcomes is concerned, this is the first study to comprehensively analyze the process and set quantitative criteria. These standards would not only guide future research more reliably, but also provide fresh insight into the review of the past research. 3D measurement standards also apply to all face-related studies requiring 3D registration.

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 .

Aesthetic considerations for treating the Middle Eastern patient: Thriving in Diversity international roundtable series

BACKGROUND

The Middle East has a significant influence on the global aesthetic market. Within the United States and globally, patients with Middle Eastern heritage have a wide range of ethnic and cultural backgrounds that affect their perceptions of beauty and motivations to seek cosmetic treatment.

AIMS

The aim of this roundtable was to discuss similarities and differences in anatomy and treatment preferences of Middle Eastern patients and explore how these differences may influence aesthetic practices.

PATIENTS/METHODS

In support of clinicians who wish to serve a diverse patient population, a 6-part international roundtable series focused on diversity in aesthetics was conducted from August 24, 2021, to May 16, 2022.

RESULTS

The results of the fourth roundtable in the series, the Middle Eastern Patient, are described here. A discussion of treatment preferences is included, and specific procedural information is provided for  commonly treated areas in this population (forehead, infraorbital area, and jawline).

CONCLUSIONS

Middle Eastern patients have a variety of aesthetic preferences, which are influenced by a wide range of cultural backgrounds, making it difficult to develop general statements about this demographic. There is an unmet need for research into this diverse group of patients to help physicians understand and incorporate their unique needs and desires into clinical practice.

The Utilization Of Poly-L-Lactic Acid As A Safe And Reliable Method For Volume Maintenance After Facelift Surgery With Fat Grafting

Background

For age-related volume loss, fat grafting is now recognized as an integral adjunctive procedure with facelift surgery. However, when there is continued and unpredicted volume loss postoperatively, the surgeon has limited options for restoring this lost volume.

Objectives

Poly-l-lactic acid (PLLA) is a proven biostimulator that creates volumetric enhancement. This study is undertaken to demonstrate that PLLA is a safe and efficacious option for maintenance of post-facelift volume loss.

Methods

A retrospective review was conducted to identify all patients who underwent facelift surgery with fat grafting and postoperative PLLA injections from 2010 to 2018 by a single surgeon. Demographic and clinical data were collected and analyzed.

Results

This review identified a total of 241 patients who had undergone a facelift with fat grafting and PLLA injections. Of these, 190 patients were treated with PLLA after facelift and fat grafting, while 51 patients received PLLA injections before their operation. We identified 5 common indications for use of PLLA after facelift surgery and fat grafting. These included unexplained early fat graft loss, significant weight loss in the postoperative period, normal aging process, and patients who had a high perioperative lean body mass. Additionally, PLLA was found to be an effective volumizer for site-specific areas that did not undergo fat grafting during the initial operation. There were no complications reported from the PLLA injections related to nodule formation, papules, or granulomas.

Conclusions

The high degree of variability in the survival of fat grafts with facelift surgery is an accepted reality. PLLA represents a safe and highly effective solution to restore volume loss in patients who have undergone facelifts with fat grafting.

The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis

BACKGROUND

Our understanding of the functional anatomy of the face is constantly improving. To date, it is unclear whether the anatomic location of the line of ligaments has any functional importance during normal facial movements such as smiling.

OBJECTIVES

The authors sought to identify differences in facial movements between the medial and lateral midface by means of skin vector displacement analyses derived from 3-dimensional (3D) imaging and to further ascertain whether the line of ligaments has both a structural and functional significance in these movements.

METHODS

The study sample consisted of 21 healthy volunteers (9 females and 12 males) of Caucasian ethnic background with a mean age of 30.6 (8.3) years and mean BMI of 22.57 (2.5) kg/m2. 3D images of the volunteers' faces in repose and during smiling (Duchenne type) were taken. 3D imaging-based skin vector displacement analyses were conducted.

RESULTS

The mean horizontal skin displacement was 0.08 (2.0) mm in the medial midface (lateral movement) and was -0.08 (1.96) mm in the lateral midface (medial movement) (P = 0.711). The mean vertical skin displacement (cranial movement of skin toward the forehead/temple) was 6.68 (2.4) mm in the medial midface, whereas it was 5.20 (2.07) mm in the lateral midface (P = 0.003).

CONCLUSIONS

The results of this study provide objective evidence for an antagonistic skin movement between the medial and lateral midface. The functional boundary identified by 3D imaging corresponds to the anatomic location of the line of ligaments.

LEVEL OF EVIDENCE: 4

Injection techniques for midface volumization using soft tissue hyaluronic acid fillers designed for dynamic facial movement

Volume loss of the face occurs over time; thus, volume enhancement of the midface can counteract the effects of aging. Hyaluronic acid (HA) fillers are often used for facial revolumization for a more youthful appearance due to their favorable outcomes and safety profiles. A patient‐centric approach, in which dynamic facial expressions are considered, is needed for optimal aesthetic results. In addition, injectors must be familiar with midface anatomy, how it is affected by the aging process, and must also consider the rheological and physical properties of fillers, including their stretch and dynamic strength.

In this article, optimal injection techniques are described for a new range of HA‐based fillers for midface revolumization using a needle, cannula, or both. The layering technique involves product placement in both the deep and superficial fat compartments to achieve natural‐looking outcomes at rest and during motion.

The Resilient Hyaluronic Acid (RHA^®) line of fillers was designed to maintain their durability and integrity while adapting to the dynamic movements of the face. RHA 2 is applicable for superficial placement, whereas the balanced stretch and dynamic strength of RHA 3 render it more versatile. The novel rheological properties of RHA 4, with the highest dynamic strength and sufficient stretch, allow it to be injected superficially and into deep facial compartments.

Depending on patient characteristics, the appropriate RHA filler can be chosen to reach the goal of a natural, younger appearance and avoid overfilling.

Reliability of 3-dimensional surface imaging of the face using a whole-body surface scanner

OBJECTIVE

To the knowledge of the authors, no data about the reproducibility and accuracy of 3-dimensional surface imaging of the face using a whole-body scanner are available. Thus, the objective of this investigation was to assess the reproducibility of facial scans acquired using a whole-body imaging device.

MATERIAL AND METHODS

This investigation investigated 220 3-D scans of a total of 22 healthy volunteers (with a mean age of 29.36 years). Two consecutive 3-D images using a Vectra WB360 of the volunteers were obtained utilizing a whole-body imaging device. Predefined distances in the face were performed in each scan and compared. Furthermore, surface deviation between two consecutively captured scans was assessed.

RESULTS

The distance with the smallest statistical significance was found to be at the nose with p = 0.998, while the biggest statistical significance was found in the midface with p = 0.658. The area with the biggest surface deviation between the superimposed scans was the neck with a root mean square (RMS) of 1.62 ± 1.71, and the area with the smallest surface deviation was the forehead with a RMS of 0.17 ± 0.05.

CONCLUSION

The whole-body imaging device investigated in this study can be utilized to capture the face and provides enough accuracy to compare scans. Even though not directly investigated, it can be hypothesized that the error caused by repositioning the patient between a baseline and a follow-up scan will not be too big to consider measurements performed with the whole-body imaging device as impractical.

Regen Fat Code: A Standardized Protocol for Facial Volumetry and Rejuvenation

BACKGROUND

Facial aging is a degenerative process that impairs contour and angle prominence. Rejuvenation is based on tissue replacement, volumization of the atrophic areas, and improving flaccidity and cutaneous photoaging.

OBJECTIVES

The aim of this study was to apply structural fat grafting to manage volumetric deficits of the face, following a new systematic protocol called "Regen Fat Code" (RF Code) that was created to standardize structural lipotransfer methods.

METHODS

This is a prospective clinical trial involving 80 healthy candidates for facial rejuvenation who were split into 2 groups. Group A underwent only structural lipotransfer; Group B underwent replacement of deep facial structures by face-lifting plus structural lipotransfer. Structural lipotransfer followed the protocol "RF Code" and 3 clinical tools were adopted for pre- and postoperative facial volumetric analysis.

RESULTS

Total volume (mL) of lipotransfer in Groups A and B ranged between 1 and 20 mL (mean [standard deviation], 12 [5] mL), distributed to the different areas as follows: nasolabial fold, 3.32 [0.92] mL; superior lip, 2.0 [0.62] mL; inferior lip, 2.76 [0.71] mL; malar, 8.51 [5.25] mL; inferior eyelid, 1.2 [0.54] mL; and chin, 7.18 [1.99] mL. Areas with less mobility showed a lower absorption index than dynamic areas.

CONCLUSIONS

The development of the RF Code protocol demonstrated the potential of grouping many parameters based on the lipotransfer method used to volumize and regenerate atrophic areas of the face. The protocol is easy to apply, and allows different volumizing and regenerative effects to be proposed, according to the demands of each surgical area.

LEVEL OF EVIDENCE: 4

Digital Leg Volume Quantification: Precision Assessment of a Novel Workflow Based on Single Capture Three-dimensional Whole-Body Surface Imaging

Whole-body three-dimensional surface imaging (3DSI) offers the ability to monitor morphologic changes in multiple areas without the need to individually scan every anatomical region of interest. One area of application is the digital quantification of leg volume. Certain types of morphology do not permit complete circumferential scan of the leg surface. A workflow capable of precisely estimating the missing data is therefore required. We thus aimed to describe and apply a novel workflow to collect bilateral leg volume measurements from whole-body 3D surface scans regardless of leg morphology and to assess workflow precision. For each study participant, whole-body 3DSI was conducted twice successively in a single session with subject repositioning between scans. Paired samples of bilateral leg volume were calculated from the 3D surface data, with workflow variations for complete and limited leg surface visibility. Workflow precision was assessed by calculating the relative percent differences between repeated leg volumes. A total of 82 subjects were included in this study. The mean relative differences between paired left and right leg volumes were 0.73 ± 0.62% and 0.82 ± 0.65%. The workflow variations for completely and partially visible leg surfaces yielded similarly low values. The workflow examined in this study provides a precise method to digitally monitor leg volume regardless of leg morphology. It could aid in objectively comparing medical treatment options of the leg in a clinical setting. Whole-body scans acquired using the described 3DSI routine may allow simultaneous assessment of other changes in body morphology after further validation.

Longevity and subject-reported satisfaction after minimally invasive jawline contouring

BACKGROUND

Minimally invasive treatments as soft tissue filler injections can enhance the appearance of the jawline. This prospective, single-center study investigated aesthetic outcome, patient satisfaction, adverse events, and volume changes after jawline contouring using standardized reporting scales and objectifiable 3D surface analysis.

METHODS

A total of 30 patients (1 male and 29 females, mean age: 57.2 (±8.7) years) were investigated. Patients underwent jawline augmentation using a highly cross-linked hyaluronic acid-based soft tissue filler. Three-dimensional surface imaging was performed after 2 weeks, and 3, 6, 9, and 12 months. Furthermore, the aesthetic results and the occurrence of complications were investigated after two weeks, and 3, 6, 9, and 12 months.

RESULTS

The surface-volume coefficient (SVC) had an average of 1.10 ± 0.2 after 14 days, 0.95 ± 0.1 after 3 months, 0.83 ± 0.1 after 6 months, 0.74 ± 0.1 after 9 months, and 0.63 ± 0.1 after 12 months. A significant correlation was revealed between time of measurement and measured SVC with r_p  = -0.761, p < 0.001. Multivariate analysis revealed a significant difference between the measured SVC and the different time points of measurement with p < 0.001. The data revealed strong aesthetic improvement with results most often reported as "very much improved" according to the 5-point GAIS after 3, 6, and 9 months, both by the investigator and by the patients. A 12-month follow-up analysis showed "much improved" results in a majority of cases.

CONCLUSION

The result of this investigation showed that jawline enhancement using minimally invasive soft tissue filler injections produces durable, safe results that are generally rated as very satisfying from a patient's and investigator's perspective over a time period of 12 months.

Paradoxical Temporal Enlargement: An Expansion of Superficial Temporal Fat Pad Following Interfacial Technique for Pterional Craniotomy

OBJECTIVE

Contour irregularities in the temporal region have been reported previously after procedures involving temporal dissection. In this study, we report paradoxical temporal enlargement (PTE) following interfascial pterional craniotomy.

METHODS

A retrospective review of patients who underwent a unilateral transcranial procedure with frontotemporal approach at our institution between September 2013 and December 2017 was performed. Patients with a previous craniotomy or bilateral craniotomy were excluded. Radiological imaging series including computed tomography and magnetic resonance imaging were utilized to calculate temporal soft tissue volumes both preoperatively and postoperatively by using advanced software technology. Relative soft tissue volume differences between the operative side and the contralateral side were calculated at different time-points including preoperative, 3-months follow-up (3M), 12-months (12M) follow-up, and the last follow-up (LFU, over 1-year).

RESULTS

Forty-three patients were included. Mean age was 52.7 ± 4.5 years. Mean follow-up was 27.9 ± 15.8 months. Significant changes of temporal fat pad relative-volume difference were observed between the preoperative and the corresponding 3M (t [82] = -2.8865, P = 0.0050); 12M (t [77] = -4.4321, P < 0.0001), and LFU (t [74] = -4.9862, P < 0.0001) postoperative time points. No significant change of the temporalis muscle was observed between the preoperative and the corresponding 3M (P = 0.3629), 12M (P = 0.1553), or LFU (P = 0.0715). Soft tissue volume showed a significant increase on the operative side between the preoperative and the corresponding LFU (t [74] = -2.5866, P =  0.0117).

CONCLUSIONS

Paradoxical temporal enlargement with more than 10% volumetric change was observed in 24% of the patients at their LFU (>1-year). This change was not due to temporalis muscle changes. Paradoxical temporal enlargement was due to hypertrophy of the superficial temporal fat pad. Before surgical correction of postoperative temporal contour changes, it is important to obtain imaging and characterize the etiology of the deformity.

After the Temporal Lifting Technique-What comes next?

BACKGROUND

The temporal lifting technique can provide lateral facial lifting when administering hyaluronic acid (HA)-based soft tissue fillers into the subdermal plane of the temple. However, the central facial oval is not influenced by this technique.

OBJECTIVES

To identify the safety and esthetic effectiveness of additional midfacial injection points (in addition to the temporal lifting technique) that can volumize the medial midface, lift the lateral face, and increase jawline contouring when included into a full-face injection algorithm.

METHODS

The patient records of nine consecutive patients (all females) with a mean age of 35.0 (8.4) years and a mean body mass index of 21.7 (2.4) kg/m² were retrospectively analyzed after a full-face injection algorithm was performed using HA-based fillers. The additional injection points target the supraperiosteal plane of the medial zygomatic arch, the lateral infraorbital region, and the pyriform fossa using both needles and cannula.

RESULTS

No adverse events were observed during the 6-month retrospective observational period. The volume of the medial midface increased, the volume of the lateral midface decreased, and the contour of the jawline improved; all effects reached a highly statistically significant level with p < 0.001.

CONCLUSION

Despite each individual injection is currently performed on a daily clinical basis the evaluated injection algorithm following the temporal lifting technique shows some evidence that it is safe and esthetically effective. Future studies will need to confirm the results presented herein in a larger sample and with objective outcome measures to guide safe and effective esthetic outcomes.

Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections

BACKGROUND

Although injectable soft-tissue fillers are frequently used for facial rejuvenation, there is a dearth of objective data evaluating the tissue-lifting effects. Current practices for efficacy evaluation include some subjectivity. This study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifiable, objective setting.

METHODS

Twenty fresh hemifaces obtained from 10 Caucasian body donors (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers following a predefined treatment algorithm. Three-dimensional surface scanning procedures were performed to assess postinjection effects.

RESULTS

Injections in the medial face [i.e., forehead, medial midface, and perioral (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jawline) changed the local surface volume by 0.45, 0.02, and -0.38 cc, and created local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections, however, created additional regional lifting effects by co-influencing neighboring lateral facial regions, which was not observed for medial face injections.

CONCLUSIONS

This cadaveric study provides evidence that soft-tissue fillers, although typically classified as volumizers, can induce lifting effects of the face. Whereas temporal deep supraperiosteal injections have limited lifting effects, the combined effects of subdermal injections of the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Differences in Temporal Volume between Males and Females and the Influence of Age and BMI: A Cross-Sectional CT-Imaging Study

BACKGROUND

 The temple has been identified as one of the most compelling facial regions in which to seek aesthetic improvement-both locally and in the entire face-when injecting soft tissue fillers.

OBJECTIVE

 The objective of this study is to identify influences of age, gender, and body mass index (BMI) on temporal parameters to better understand clinical observations and to identify optimal treatment strategies for treating temporal hollowing.

METHODS

 The sample consisted of 28 male and 30 female individuals with a median age of 53 (34) years and a median BMI of 27.00 (6.94) kg/m². The surface area of temporal skin, the surface area of temporal bones, and the temporal soft tissue volume were measured utilizing postprocessed computed tomography (CT) images via the Hausdorff minimal distance algorithm. Differences between the investigated participants related to age, BMI, and gender were calculated.

RESULTS

 Median skin surface area was greater in males compared with females 5,100.5 (708) mm² versus 4,208.5 (893) mm² (p < 0.001) as was the median bone surface area 5,329 (690) mm² versus 4,477 (888) mm² (p < 0.001). Males had on average 11.04 mL greater temporal soft tissue volume compared with age and BMI-matched females with p < 0.001. Comparing the volume between premenopausal versus postmenopausal females, the median temporal soft tissue volume was 46.63 mL (11.94) versus 40.32 mL (5.69) (p = 0.014).

CONCLUSION

 The results of this cross-sectional CT imaging study confirmed previous clinical and anatomical observations and added numerical evidence to those observations for a better clinical integration of the data.

Photographic Comparison of Malar Projection in 100 Facelift Patients Treated with and without Fat Injection

Facelifts are frequently combined with fat injection to restore volume. However, the efficacy of simultaneous fat grafting has not been objectively evaluated in a large number of patients that includes a control group. This study was undertaken to fill this gap in our knowledge base.

A randomized, split-face, double-blind, comparative study of the safety and efficacy of small- and large-particle hyaluronic acid fillers for the treatment of nasolabial folds

BACKGROUND

Injections of hyaluronic acid (HA) for tissue augmentation are one of the most common aesthetic treatments performed worldwide. However, few studies have compared the safety and efficacy of small- and large-particle HA (SP-HA; LP-HA).

AIM

To assess and compare the safety and efficacy of SP-HA and LP-HA for the correction of nasolabial folds (NLFs).

METHODS

A prospective, split-face, triple-blind study design was used. Ten female subjects were recruited. Patients underwent treatment at baseline, an optional touch up at Week 2, and a follow-up visit at Week 4. At weeks 2 and 4, a blinded reviewer assessed the patients using the Global Aesthetic Improvement Scale (GAIS) and Wrinkle Severity Rating Scale (WSRS); and subjects completed the Patient Satisfaction Questionnaire (PSQ). At all visits, 3-dimensional imagery and ultrasonography of patients' NLFs were captured. Adverse events (AEs) were evaluated by the Investigator and recorded by subjects in diaries.

RESULTS

The GAIS response rate, defined as ≥ "improved" from baseline, was between 90 (2 weeks) and 100% (1 month) for SP-HA and was 100% for LP-HA, at both visits. Paired-samples t tests revealed significant differences in the change in WSRS scores between groups, at both visits (P < .01). Differences in the clinical effect and lifting capacity of both products were observed in 3-dimensional imagery and ultrasonography. Treatment volumes varied, with 61.32% more SP-HA being required than LP-HA for achieving a ≥ one-grade WSRS improvement. There were no severe AEs throughout the trial, nor AEs related to the investigational device.

CONCLUSIONS

LP-HA demonstrates better efficacy for correcting bony resorption in the nasal pyriform region.

Temporal volume increase after reduction of masseteric hypertrophy utilizing incobotulinumtoxin type A

BACKGROUND

Treating the lower face with neuromodulators and targeting the masseter muscle can reduce masseteric hypertrophy but can also change the facial shape. A novel observation after the treatment of the masseter muscle with incobotulinumtoxin Type A was the increase in temporal volume.

AIM

Objectively assess temporal volume increase following treatment of masseteric hypertrophy using incobotulinumtoxin Type A.

METHODS

Nine female patients with a mean age of 35.11 years ± 9.1 [Asian (11.1%) and Caucasian (88.9%)] were treated with incobotulinumtoxin Type A for masseteric hypertrophy. Masseteric prominence and temporal volume were assessed by two independent raters, and temporal fossa volume was measured via 3-dimensional volumetric imaging.

RESULTS

Independent of the neuromodulator injection technique (ie, single-injection versus multi-injection), a reduction in masseteric hypertrophy occurred represented by a decrease in the masseter prominence scale. In addition, the treatment resulted in a significant improvement of the temporal volume scale and an increase in the measured volume of the temporal fossa. None of the presented measurements were statistically significantly different between the two utilized injection techniques.

CONCLUSIONS

This study supports using a full-face approach when performing aesthetic treatments. Anatomical concepts can help to guide treatments: the compensatory increase in temporalis function after masseter muscle treatment resulted in an increased in temporal fossa volume. The findings presented herein should not be considered as a new concept for treating the temporal fossa but rather as an additional possibility for increasing the temporal volume.

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

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

Three-dimensional surface imaging in breast cancer: a new tool for clinical studies?

Background

Three-dimensional Surface Imaging (3DSI) is a well-established method to objectively monitor morphological changes in the female breast in the field of plastic surgery. In contrast, in radiation oncology we are still missing effective tools, which can objectively and reproducibly assess and document adverse events in breast cancer radiotherapy within the framework of clinical studies. The aim of the present study was to apply structured-light technology as a non-invasive and objective approach for the documentation of cosmetic outcome and early effects of breast radiotherapy as a proof of principle.

Methods

Weekly 3DSI images of patients receiving either conventionally fractionated radiation treatment (CF-RT) or hypofractionated radiation treatment (HF-RT) were acquired during the radiotherapy treatment and clinical follow-up. The portable Artec Eva scanner (Artec 3D Inc., Luxembourg) recorded 3D surface images for the analysis of breast volumes and changes in skin appearance. Statistical analysis compared the impact of the two different fractionation regimens and the differences between the treated and the contralateral healthy breast.

Results

Overall, 38 patients and a total of 214 breast imaging sessions were analysed. Patients receiving CF-RT showed a significantly higher frequency of breast erythema compared to HF-RT (93.3% versus 34.8%, p = 0.003) during all observed imaging sessions. Moreover, we found a statistically significant (p < 0.05) volumetric increase of the treated breast of the entire cohort between baseline (379 ± 196 mL) and follow-up imaging at 3 months (437 ± 224 mL), as well as from week 3 of radiotherapy (391 ± 198 mL) to follow-up imaging. In both subgroups of patients undergoing either CF-RT or HF-RT, there was a statistically significant increase (p < 0.05) in breast volumes between baseline and 3 months follow-up. There were no statistically significant skin or volumetric changes of the untreated healthy breasts.

Conclusions

This is the first study utilizing 3D structured-light technology as a non-invasive and objective approach for the documentation of patients receiving breast radiotherapy. 3DSI offers potential as a non-invasive tool to objectively and precisely monitor the female breast in a radiooncological setting, allowing clinicians to objectively distinguish outcomes of different therapy modalities.

Influence of needle size and injection angle on the distribution pattern of facial soft tissue fillers

BACKGROUND

Soft tissue filler injections are performed using either sharp-tip needles or blunt-tip cannulas. Product can change planes in an uncontrolled manner during needle injections, potentially leading to unintentional intra-arterial placement. There is a paucity of data on the influence of injection angle on the dispersion patterns of soft tissue fillers.

MATERIALS AND METHODS

A total of 126 injection procedures were conducted in seven Caucasian body donors (four males, three females) with a mean age of 75.29 ± 4.95 years and a mean body mass index of 23.53 ± 3.96 kg/m² . Injection procedures were performed in various facial regions (forehead, scalp, zygomatic arch, mandibular angle), utilizing different needle sizes (25G, 27G, 30G) and different angles (90°, 45°, 10°). Layer-by-layer dissections were performed to verify the location of the injected product. Dissections were facilitated by the colored material.

RESULTS

Utilizing a 30G needle (compared to a 25G needle) reduces the superficial spread with OR 0.70 (95% CI, 0.48-0.99) and P = 0.049, whereas injecting at 90° (vs 10° with the bevel down) increases the odds for superficial spread with OR 10.0 (95% CI, 7.11-14.09) and P < 0.001.

CONCLUSION

Precision during soft tissue filler injections, defined as the product remaining in the plane of intended implantation, can be enhanced by changing the needle size and the injection angle. Utilizing a 30G needle and injecting at a 10° angle with bevel facing down reduces the uncontrolled product distribution into superficial fascial layers.