Identifying a safe zone for midface augmentation using anatomic landmarks for the infraorbital foramen

Morphological Measurement of Asian Osteal Nasal Base for Paranasal Augmentation

BACKGROUND

Paranasal augmentation has been a popular approach in restoring Asian patients' lateral profile. Irregular surface in the surgical area emphasizes the importance of morphological evidence for the preoperative evaluation and the design of paranasal implants.

METHODS

We retrospectively collected craniofacial computer tomography scans of patients in the department of plastic surgery from 2020 to 2022. The imaging data were imported to Mimics (version 20.0; Materialize, Leuven, Belgium) for three-dimensional reconstruction. Measurements of osteal nasal base were performed in 3-matics (version 12.0; Materialize). The severity of paranasal concavity was graded by a senior doctor to study the correlation with measured variables.

RESULTS

Fifty-seven patients with a median age of 27 years (IQR: 22-33) were included in the study. For design of paranasal implants, the lengths of both lower and lateral edge were measured for reference. In the regression analysis, the alar base-alveolar process angle was significantly associated with the degrees of paranasal concavity (OR = 1.222, p = 0.00001).

CONCLUSIONS

Morphological data of osteal nasal base were measured and presented in the current study. The analysis supported that alar base-alveolar process angle be used for preoperative grading and evaluation to help guiding treatment decisions.

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 .

Evaluation of Infraorbital Foramen Position Using Cone-Beam Computed Tomography in a Cohort of Central Gujarat, Indian Population

OBJECTIVE

The location of infraorbital foramen varies between geographic locations. Thus, population-specific information is required to facilitate the prediction of its exact location.

METHODS

 A cross-sectional study was conducted on 100 cone beam computed tomography (CBCT) sections to evaluate the distance between the infraorbital foramen and incisal edge of the maxillary central incisor, the occlusal plane of the maxillary second premolar, and the alveolar crest over the maxillary second premolar using CBCT in Central Gujarat, Indian population. Descriptive statistical analysis was performed to calculate means and standard deviations for each measured parameter. The statistical significance level was defined at p<0.05.

RESULTS

The distance between the infraorbital foramen and incisal surface of the maxillary central incisor was (mean ± standard deviation) R=49.39 ± 3.12 mm and L=49.49 ± 3.29 mm, the occlusal plane of the maxillary second premolar was R=39.02 ± 2.65 mm and L=39.49 ± 2.53 mm, and the alveolar crest over the maxillary second premolar was R=32.64 ± 2.67 mm and L=31.64 ± 2.33 mm. There was no significant difference in the mean values of all variables between genders and age groups (p>0.05). The distance between the infraorbital foramen and the alveolar crest over the maxillary second premolar was greater on the right side (p<0.05).

CONCLUSION

The results of this study were analogous to those observed in a cohort of the Turkish population but varied from those observed in a cohort of the Sri Lankan population. Hence, more population-specific studies are required.

Application of Paranasal Augmentation Rhinoplasty in Asians With Midfacial Concavity

BACKGROUND

For Asian rhinoplasty patients with midfacial concavity, the conventional method is to solve the problem by using structural rhinoplasty to increase the nasal height and length. However, the results are not satisfying, and many complications are caused.Paranasal augmentation as an adjunct to rhinoplasty can improve surgical results and increase satisfaction. However, there are limited studies focusing on the details and evaluation of this technique.

OBJECTIVES

To investigate a minimally invasive method to correct midfacial concavity simultaneously with rhinoplasty, as well as improve satisfaction and reduce complications.

MATERIALS AND METHODS

Between January 2010 and December 2019, we reviewed all rhinoplasty patient records from patients who had midfacial concavity and underwent simultaneous paranasal augmentation with our technique. The patient demographics, surgical characteristics, and outcomes were reviewed retrospectively. Satisfaction was evaluated by an independent medical staff who reviewed the preoperative and postoperative photos.

RESULTS

Sixty-seven patients were included in the study. The mean age of the patients was 28.7 ± 8.0 years, and the median follow-up time was 26 months (range, 2-60 months). Overall satisfaction was high (90%). Eight (12%) patients had complications, including 5 (7.4%) cases of implant displacement and 3 (4.4%) cases of infection. All patients healed uneventfully after revision surgery.

CONCLUSIONS

Paranasal augmentation can improve the outcome and increase satisfaction in Asian rhinoplasty patients who have midfacial concavity. Preoperative patient evaluation, surgery planning, and surgery details are crucial to ensure a favorable result. The expanded polytetrafluoroethylene implant has advantages over other materials and therefore is recommended in paranasal augmentation surgery.

Application of 3D Imaging-Assisted Precise Aesthetic Evaluation in Midfacial Depression Treatment

Most Chinese have unpleasant facial profile of midfacial depression, which could be caused by multiple reasons. In the past, LeFort osteotomy and orthodontic methods were applied for surgical treatment of midfacial concavity. As the development of plastic surgery filling techniques, nasal base filling or concurrent comprehensive rhinoplasty has been widely used to improve midfacial depression. However, most of the related studies focus on surgical techniques or filling materials, yet lack accurate and objective aesthetic evaluation. In the current study, we used 3D imaging to collect 3D facial profile of 66 patients suffering from midfacial depression. Related linear distance and angles were measured accurately using 3D software. Patient satisfaction and physician evaluation were also collected in the follow-up period. The results showed that patients' midfacial depression were significantly improved after the surgery and the overall patient satisfaction was 100%. Our study demonstrated the positive role of nasal base filling in improving the midfacial depression, and illustrated the advantages of 3D imaging technology in personalized preoperative communication, surgical simulation and postoperative effect evaluation.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 .

Usefulness of the Blink Reflex in Diagnosing Isolated Infraorbital Neuropathy Following Midface Augmentation with AlloPlastic Facial Implants: A Case Report

For the preoperative evaluation of infraorbital nerve injury, most clinicians depend on the patient’s subjective symptoms or judgements, lacking a generalized and objective evaluation method. Due to the limitations in subjective evaluations for accurate diagnosis of infraorbital nerve injury, we used the blink reflex to objectively evaluate injury to the infraorbital nerve. A 49-year-old female, who had previously undergone midface augmentation with alloplastic implants, presented with sensory loss in the left upper lip, nose tip, and lower palatal area. Physical examination revealed sensation loss in the area innervated by the infraorbital nerve. Facial three-dimensional computed tomography did not identify compression of the infraorbital nerve. The blink reflex study of the infraorbital nerve was evaluated preoperatively. After the patient was diagnosed with injury along the infraorbital nerve pathway from alloplastic facial implants, she underwent facial implant removal with decompression surgery. The patient experienced a significant decrease in hypoesthesia, and her sensory function improved. The blink reflex study was an effective method to objectively diagnose infraorbital neuropathy. Therefore, clinical use of the blink reflex study as an electrophysiological diagnostic tool is recommended to investigate infraorbital nerve injuries.

Anatomical Basis for Malar Augmentation Injection With the Zygomatic Ligamentous System

BACKGROUND

The malar augmentation injection has gained popularity in recent years, but the exact location of each injection site has not been clearly identified.

OBJECTIVE

To discover ideal injection sites by comprehensively considering the distributions of ligaments, muscles, and vessels.

MATERIALS AND METHODS

Eighteen cadaver heads were dissected to investigate the zygomatic ligamentous system and to measure the position of muscles. Sixty-six cadaver heads were subjected to computed tomographic scanning and three-dimensional vessel reconstruction. Radiological evaluation of the fillers was performed before and after experimental injection in one hemiface and dissected to confirm safe delivery. Five patients were enrolled in a prospective clinical study. 2D and 3D photographs were taken before and after the injections for comparison.

RESULTS

Site 1 was defined along the zygomatic arch, except the first 1/4 length and the midline of the arch. Site 2 was on the body of the zygoma, superior to the level of the infraorbital foramen and medial to the jugale. Site 3 was defined in the anteromedial midface approximately 30 mm below the lateral canthus.

CONCLUSION

Injections at these 3 sites can be performed within the range of the ligaments to achieve effective lifting effects and minimize potential complications.

Positional Variation of the Infraorbital Foramen in Caucasians and Black Africans from Britain: Surgical Relevance and Comparison to the Existing Literature

BACKGROUND

Midface augmentation and orbital surgery carry an inherent risk of injury to the infraorbital vascular bundle, especially the infraorbital nerve where it exits the infraorbital foramen (IOF). This can result in significant morbidity for the patient, including paresthesia and neuralgia. Studies report significant heterogeneity in IOF position according to gender, ethnicity, and laterality. A knowledge of the relationship of the IOF to regional soft tissue, bony landmarks, and its variation among ethnicities is likely to reduce iatrogenic injuries.

METHODS

A single-center retrospective computed tomography (CT)-based study was conducted. Twenty Caucasians and 20 Black Africans patients were selected from an existing radiologic database at Moorfields Eye Hospital, London, UK. DICOM image viewing software (Syngo, Siemens Healthineers) was used to record the position of the IOF using standardized sagittal and axial views.

RESULTS

There was a statistically significant difference in the horizontal position of the IOF in the 2 races (P = 0.00). The combined measurements were used to derive a rectangular zone of variability measuring 14.30 mm by 10.60 mm. This zone was found to lie 3.50 mm below the infraorbital rim, 7.10 mm medial to the piriform aperture, and 11.60 mm from the lateral orbital rim.

CONCLUSION

A sound knowledge of key facial landmarks is necessitated when performing midface augmentation and orbital surgery. An anatomical safe zone depicting the variation of the IOF will help reduce iatrogenic injury to the infraorbital nerve and prevent patient morbidity.

The Infraorbital Foramen in a Sample of the Lebanese Population: A Radiographic Study

Purpose

The infraorbital foramen (IOF) is an important structure in the maxillofacial region through which important structures pass. Wide variability in the shape and location of the infraorbital foramen among different populations and ethnic groups is present. So we conducted this study to specify the IOF shape, the presence of accessory foramina, and the IOF location with respect to anatomic landmarks in the Lebanese population.

Patients and method

A cross-sectional retrospective study was conducted on cone-beam computed tomography (CBCT) scans of 105 Lebanese adult patients. Images were reviewed and the shape, diameter, and location of the IOF were recorded. The presence of an accessory foramen was also noted. Then, SPSS version 21 (IBM Corp., Armonk, NY, US) was used for the statistical analysis.

Results

Concerning the distances from the IOF to the anatomic landmarks, the distance from the IOF to the infraorbital margin measured 7.98 ± 1.41 mm, to the lateral nasal wall 10.61 ± 2.39 mm, and to the midline 24.71 ± 2.09 mm. When distances were compared, a statistical difference was only identified in the distance between the IOF and the lateral nasal wall (p=0.00), and the distance between the IOF and the middle of the face (p=0.016) between genders. For the shape of the IOF, 54.8% of the IOF were circular in shape, and this shape was the most common shape in females. An accessory foramen was present in 8.6% of the cases. Finally, the mean diameter of the foramina measured 3.71 ± 0.63 mm.

Conclusion

The IOF shows a lot of variability between different populations. Thus, the exact location should always be remembered during an infraorbital nerve (ION) block, during maxillofacial surgeries, and during esthetic procedures involving the facial region in order to prevent unnecessary complications.

Anatomy of Infraorbital Foramen: Influence of Sex, Side, and Cranium Size

Several researchers have analyzed the collocation of infraorbital foramen, but no study has so far considered the possible influence of cranial size.Three measurements (distances from anterior nasal spine, inferior orbital rim, angle at the intersection between the line from anterior nasal spine and the transversal plane parallel to the Frankfurt plane) were taken on 100 skulls belonging to a contemporary skeletal collection. In addition, maximum cranial length, maximum cranial breadth, cranial height, and bizygomatic breadth were measured, together with 2 indices (horizontal cephalic index and Giardina Y-index). Differences according to sex and side were assessed through 2-way analysis of variance test (P <0.05). Measurements showing statistically significant differences according to sex were further assessed through 1-way analysis of covariance test including cranial measurements and indices as covariates (P <0.05).Statistically significant differences according to sex and side were found respectively for the distance from anterior nasal spine and the angle at infraorbital foramen (P <0.05). One-way analysis of covariance test verified that the sexual dimorphism of infraorbital foramen- anterior nasal spine distance was independent from the general measurements of cranium.The present study first proved that sexually dimorphic parameters useful for the localization of infraorbital foramen do not depend upon the cranium size.

Enhancing Facelift With Simultaneous Submalar Implant Augmentation

BACKGROUND

The midface is particularly prone to the senescent changes of soft tissue ptosis and volume loss, which in individuals with aging or low adiposity can manifest as submalar hollowing. Facelift alone in those with submalar hollowing inadequately addresses the volume loss and may result in a gaunt appearance postoperatively. Submalar implant augmentation is a powerful tool for permanent midface volume restoration for a more youthful and natural contour, as opposed to soft tissue fillers that diminish over time. When performed together, submalar augmentation and facelift synergistically enhance facial rejuvenation results.

OBJECTIVES

Determine the long-term safety and efficacy of submalar implant augmentation as an adjunct to facelift.

METHODS

Retrospective review evaluating results and complications in all consecutive patients who had submalar implant augmentation with SMAS-plication facelift in a single surgeon private practice setting from January 1, 1991, to December 31, 2017.

RESULTS

Forty-eight patients underwent submalar augmentation with simultaneous facelift with an overall satisfaction rate of 95.7%. Complications included 2.1%transient infraorbital hypoesthesia, 1.1% prolonged swelling, and 1.1% capsular contraction that required a minor adjustment under local anesthesia. No infection, implant migration, or extrusion or facial nerve injury occurred.

CONCLUSIONS

Submalar implant augmentation is a safe and effective means of enhancing facelift results through midface volume restoration, subperiosteal release, and improved soft tissue suspension in a more favorable vector. Submalar implant augmentation performed simultaneously with facelift may be an attractive alternative to repeated soft tissue filler or fat injections for patients with submalar hollowing who are interested in facial rejuvenation surgery.

The infraorbital artery: Clinical relevance in esthetic medicine and identification of danger zones of the midface

BACKGROUND

Over the past decade, cosmetic injections of dermal fillers or fat have become a popular procedure in facial rejuvenation in an overconsuming society. However, complications such as arterial embolism and occlusion can occur even with experienced injectors, especially in high-risks zones namely the glabella, the nasal dorsum or the nasolabial fold. The aim of this study was to define the vascular danger zones of the infraorbital area in order to provide guidelines helping avoid them.

MATERIALS AND METHODS

The infraorbital artery, its main branches and their anastomoses with neighbouring vessels were studied in 18 fresh cadavers. Mimetic injections of inked hyaluronic acid were performed in the infraorbital area in the interest of analyzing its distribution and to determine potential vascular risks towards the infraorbital artery and its branches.

RESULTS

The infraorbital artery and its branches were located in common injection regions and anastomosed to the supratrochlear artery, the dorsal nasal artery and the angular artery through the nasal branch of the infraorbital artery. Two danger zones could be depicted: injections can be risky when performed too superficially in the midcheek area, and likewise risky when performed in a periosteal layer in infraorbital hollow or tear-trough correction, because of an obvious possibility of retrograde embolism.

CONCLUSION

The infraorbital artery can be involved in anatomic mechanism of arterial occlusion, further blindness and stroke, among the related neighbouring arteries. Based on the findings of this study, injections to the periosteum layer in tear-trough correction and above the periosteum on the zygomatic arch is not advised.

The Infraorbital Foramen Is Located Midway Between the Nasospinale and Jugale: Considerations for Infraorbital Nerve Block and Maxillofacial Surgery

Identification of the infraorbital foramen is important in infraorbital nerve block and the prevention of iatrogenic injury of the infraorbital nerve in maxillofacial surgeries. This study assessed the location of 887 infraorbital foramina from 518 adult crania of varied sex and population. The study assessed the midpoint of a line segment spanning from nasospinale to jugale (NS-J) relative to the infraorbital foramen. The mean distance of the NS-J midpoint from the infraorbital foramen was 2.1 ± 1.9 mm (mean ± SD) with a mode of 0 mm (266:887; 30%). The NS-J midpoint was located in the same plane or inferior to the infraorbital foramen in 98.4% of sides (873:887). There were no significant differences between sexes, populations, or sides with regard to the NS-J midpoint to infraorbital foramen distance. The NS-J midpoint can be used to locate the infraorbital foramen in both females and males of varied populations regardless of craniofacial diversity. The results of this study will aid in infraorbital nerve block procedures and maxillofacial surgery.

Facial Danger Zones: Techniques to Maximize Safety during Soft-Tissue Filler Injections

Given the short recovery and immediate results, facial fillers have become a popular alternative to surgical rejuvenation of the face. Reported complications arising from facial filler injections include erythema, tissue loss, blindness, stroke, and even death. In this article, the authors describe their anatomically based techniques to minimize risk and maximize safety when injecting in the facial danger zones, including the glabella/brow, temporal region, perioral region, nasolabial fold, nose, and infraorbital region. Complications generally arise secondary to vasculature injury and/or cannulation with filler. The authors have outlined their preferred injection techniques in the facial danger zones with respect to the pertinent anatomy in an attempt to minimize risk and maximize results. Most importantly, the practitioner should be able to recognize complications and address them immediately.

Improvement of Infraorbital Rim contour Using Medpor

BACKGROUND

Asymmetry of the infraorbital rim can be caused by trauma, congenital or acquired disease, or insufficient reduction during a previous operation. Such asymmetry needs to be corrected because the shape of the infraorbital rim or midfacial skeleton defines the overall midfacial contour.

METHODS

The study included 5 cases of retruded infraorbital rim. All of the patient underwent restoration of the deficient volume using polyethylene implants between June 2005 and June 2011. The infraorbital rim was accessed through a subciliary approach, and the implants were placed in subperiosteal space. Surgical outcomes were evaluated using preoperative and postoperative computed tomography studies.

RESULTS

Implant based augmentation was associated with a mean projection of 4.6 mm enhancement. No postoperative complications were noted during the 30-month follow-up period.

CONCLUSION

Because of the safeness, short recovery time, effectiveness, reliability, and potential application to a wide range of facial disproportion problems, this surgical technique can be applied to midfacial retrusion from a variety of etiologies, such as fracture involving infraorbital rim, congenital midfacial hypoplasia, lid malposition after blepharoplasty, and skeletal changes due to aging.

Surgical anatomy relevant to the transpalpebral subperiosteal elevation of the midface

BACKGROUND

The surgical anatomy of the midface relevant to its subperiosteal elevation and repositioning is assessed.

OBJECTIVES

The aim of this study is to give more details on the anatomy relevant to the midface lift.

METHODS

Twenty hemifacial dissections were performed. The location of the zygomatic branches of the facial nerve (ZBFN) and the terminal branches of the infraorbital nerve (ION) were dissected. The location of the masseteric and zygomatic ligaments and the elevation of midface following their release were documented.

RESULTS

On average, there were 3 branches of the facial nerve innervating the zygomatic major muscle and 1.8 branches entering the muscle superior to the caudal origin of the zygomaticomaxillary (ZM) suture. The most superior ZBFN was found to lie at an average of 6.2 ± 1.6 mm cranial to ZM suture and 1.4 ± 0.4 mm superficial to the bone. The most inferior branch was at a mean of 4.8 ± 3.3 mm inferior to ZM suture. On average the ION had 5.2 branches that traveled for 10.2 mm above the periosteum before they passed into a superficial plane. Division of the zygomatico-masseteric retaining ligaments allowed for elevation of the midface by 4.8 ± 1.0 mm medially and 5.5 ± .9 mm laterally.

CONCLUSIONS

Branches of the ZBFN and ION lie in close proximity to the subperiosteal plane in the midface. These branches are at risk for damage during release of the upper zygomatic ligaments and placement of the periosteal suspension sutures during midface elevation procedures.