1
|
Cotofana S, Gold MH, Biesman BS, Alfertshofer M. Should novice injectors treat every facial region in their first year of practice? J Cosmet Dermatol 2024; 23:2288-2289. [PMID: 38544440 DOI: 10.1111/jocd.16305] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 03/15/2024] [Indexed: 05/19/2024]
Affiliation(s)
- Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Blizard Institute, Centre for Cutaneous Research, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | | | | | - Michael Alfertshofer
- Department of Oromaxillofacial Surgery, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
2
|
Alfertshofer M, Hoch CC, Funk PF, Hollmann K, Wollenberg B, Knoedler S, Knoedler L. Sailing the Seven Seas: A Multinational Comparison of ChatGPT's Performance on Medical Licensing Examinations. Ann Biomed Eng 2024; 52:1542-1545. [PMID: 37553555 PMCID: PMC11082010 DOI: 10.1007/s10439-023-03338-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 07/28/2023] [Indexed: 08/10/2023]
Abstract
PURPOSE The use of AI-powered technology, particularly OpenAI's ChatGPT, holds significant potential to reshape healthcare and medical education. Despite existing studies on the performance of ChatGPT in medical licensing examinations across different nations, a comprehensive, multinational analysis using rigorous methodology is currently lacking. Our study sought to address this gap by evaluating the performance of ChatGPT on six different national medical licensing exams and investigating the relationship between test question length and ChatGPT's accuracy. METHODS We manually inputted a total of 1,800 test questions (300 each from US, Italian, French, Spanish, UK, and Indian medical licensing examination) into ChatGPT, and recorded the accuracy of its responses. RESULTS We found significant variance in ChatGPT's test accuracy across different countries, with the highest accuracy seen in the Italian examination (73% correct answers) and the lowest in the French examination (22% correct answers). Interestingly, question length correlated with ChatGPT's performance in the Italian and French state examinations only. In addition, the study revealed that questions requiring multiple correct answers, as seen in the French examination, posed a greater challenge to ChatGPT. CONCLUSION Our findings underscore the need for future research to further delineate ChatGPT's strengths and limitations in medical test-taking across additional countries and to develop guidelines to prevent AI-assisted cheating in medical examinations.
Collapse
Affiliation(s)
- Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University Munich, Ziemssenstrasse 5, 80336, Munich, Germany.
| | - Cosima C Hoch
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich (TUM), Ismaningerstrasse 22, 81675, Munich, Germany
| | - Paul F Funk
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Jena, Friedrich Schiller University Jena, Am Klinikum 1, 07747, Jena, Germany
| | - Katharina Hollmann
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, 02114, USA
| | - Barbara Wollenberg
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich (TUM), Ismaningerstrasse 22, 81675, Munich, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| |
Collapse
|
3
|
Armengou X, Frank K, Kaye K, Brébant V, Möllhoff N, Cotofana S, Alfertshofer M. Facial Anthropometric Measurements and Principles - Overview and Implications for Aesthetic Treatments. Facial Plast Surg 2024; 40:348-362. [PMID: 37487528 DOI: 10.1055/s-0043-1770765] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/26/2023] Open
Abstract
Facial anatomy is highly individual in each patient. Anthropometric measurements can be a useful tool to objectively analyze individual facial anatomy to allow for better comparability before and after treatments to ultimately improve standardization of facial procedures, both nonsurgical and surgical. The aim of this study was to provide a comprehensive overview over clinically relevant and feasible facial anthropometric measurements and principles for aesthetic medicine. A literature review was conducted to describe the most important and clinically relevant anthropometric measurements and principles for both the entire face and for three aesthetically relevant facial regions: the periorbital region, the nose, and the perioral region. A multitude of different anthropometric measurements and principles have been described in the literature for both the overall facial appearance and specific facial regions. Certain generally accepted anthropometric principles and proportions need to be respected to achieve aesthetic and harmonious results. For the overall facial appearance, a focus on symmetry, certain proportions, facial angles, and indices has been described. Principles and measurements were also described for the periorbital region, the nose, and the perioral region. Although attractiveness and aesthetic perception are subjective, objective evaluation of facial surface anatomy via anthropometric measurements can improve pre- and postinterventional analysis of the face and help the treating physician to individualize treatments, both nonsurgical and surgical.
Collapse
Affiliation(s)
| | - Konstantin Frank
- Centre for Plastic and Aesthetic Surgery, Ocean Clinic Marbella, Marbella, Spain
| | - Kai Kaye
- Centre for Plastic and Aesthetic Surgery, Ocean Clinic Marbella, Marbella, Spain
| | - Vanessa Brébant
- Department of Plastic, Aesthetic and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Bayern, Germany
| | - Nicholas Möllhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital Munich, Ludwig Maximilian University, Munich, Germany
| |
Collapse
|
4
|
Knoedler L, Alfertshofer M, Geldner B, Sherwani K, Knoedler S, Kauke-Navarro M, Safi AF. Truth Lies in the Depths: Novel Insights into Facial Aesthetic Measurements from a U.S. Survey Panel. Aesthetic Plast Surg 2024:10.1007/s00266-024-04022-0. [PMID: 38772944 DOI: 10.1007/s00266-024-04022-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Accepted: 03/11/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Aesthetic facial bone surgery and facial implantology expand the boundaries of conventional facial surgery that focus on facial soft tissue. This study aimed to reveal novel aesthetic facial measurements to provide tailored treatment concepts and advance patient care. METHODS A total of n=101 study participants (46 females and 55 males) were presented with 120 patient portraits (frontal images in natural head posture; 60 females and 60 males) and asked to assess the facial attractiveness (scale 0-10; "How attractive do you find the person in the image?") and the model capability score (MCS; scale 0-10; "How likely do you think the person in the image could pursue a modelling career?"). For each frontal photograph, defined facial measurements and ratios were taken to analyse their relationship with the perception of facial attractiveness and MCS. RESULTS The overall attractiveness rating was 4.3 ± 1.1, while the mean MCS was 3.4 ± 1.1. In young males, there was a significant correlation between attractiveness and the zygoma-mandible angle (ZMA)2 (r= - 0.553; p= 0.011). In young and middle-aged females, MCS was significantly correlated with facial width (FW)1-FW2 ratio (r= 0.475; p= 0.034). For all male individuals, a ZMA1 value of 171.79 degrees (Y= 0.313; p= 0.024) was the most robust cut-off to determine facial attractiveness. The majority of human evaluators (n=62; 51.7%) considered facial implants a potential treatment to improve the patient's facial attractiveness. CONCLUSION This study introduced novel metrics of facial attractiveness, focusing on the facial skeleton. Our findings emphasized the significance of zygomatic measurements and mandibular projections for facial aesthetics, with FI representing a promising surgical approach to optimize facial aesthetics. 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 .
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Benedikt Geldner
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Khalil Sherwani
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic and Reconstructive Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Ali-Farid Safi
- Faculty of Medicine, University of Bern, Bern, Switzerland.
- Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland.
| |
Collapse
|
5
|
Meneses CCB, Freitas S, Knoedler L, Knoedler S, Davidovic K, Bravo C, Pappas A, Biesman BS, Alfertshofer M, Cotofana S. Increasing precision during neuromodulator injections for frontal rhytids-Using ultrasound imaging to identify the line of convergence. J Cosmet Dermatol 2024. [PMID: 38757429 DOI: 10.1111/jocd.16368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Revised: 04/15/2024] [Accepted: 05/01/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND Recent research introduced the concept of the "line of convergence" as a guide for injectors to enhance precision and avoid complications when treating the frontalis muscle with toxins. However, currently, no pre-injection ultrasound scanning is employed to increase precision and reduce adverse events when searching for the line of convergence. OBJECTIVE To explore the feasibility and practicality of implementing pre-injection ultrasound scanning into aesthetic neuromodulator treatments of the forehead. METHODS The sample of this study consisted of n = 55 volunteers (42 females and 13 males), with a mean age of 42.24 (10.3) years and a mean BMI of 25.07 (4.0) kg/m2. High-frequency ultrasound imaging was utilized to measure the thickness, length, and contractility of the frontal soft tissue and to determine the precise location of the line of convergence during maximal frontalis muscle contraction. RESULTS The results revealed that the line of convergence was located at 58.43% (8.7) of the total forehead height above the superior border of the eyebrow cilia without a statistically significant difference between sex, age, or BMI. With frontalis muscle contraction, the forehead shortens in males by 25.90% (6.5), whereas in females it shortens only by 21.74% (5.1), with p < 0.001 for sex differences. CONCLUSION This study demonstrated the feasibility and practicality of pre-injection ultrasound scanning for facial aesthetic neuromodulator treatments. Knowing the location of the line of convergence, injectors can determine precisely and on an individual basis where to administer the neuromodulator deep or superficial or when the injection location is at risk to cause eyebrow ptosis.
Collapse
Affiliation(s)
| | | | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samuel Knoedler
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, Serbia
| | | | | | | | - Michael Alfertshofer
- Department of Oromaxillofacial Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong Province, China
| |
Collapse
|
6
|
Baecher H, Gerken M, Knoedler L, Knoedler S, Alfertshofer M, Klinkhammer-Schalke M, Berneburg M, Drexler K, Haferkamp S. Complete lymph node dissection in cutaneous melanoma patients with positive sentinel lymph node: Outcome and predictors in a retrospective cohort study over 16 years. J Plast Reconstr Aesthet Surg 2024; 92:33-47. [PMID: 38489985 DOI: 10.1016/j.bjps.2024.02.056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 01/29/2024] [Accepted: 02/22/2024] [Indexed: 03/17/2024]
Abstract
BACKGROUND In melanoma treatment, complete lymph node dissection (CLND) has been considered the therapeutic gold standard in patients with positive sentinel lymph node biopsy (SLNB). This long-held approach was revised in 2017, with recent evidence questioning the therapeutic benefit of CLND in malignant melanoma (MM) therapy. In this study, we aimed to fill this knowledge gap by retrospectively analyzing the impact of CLND on MM patients' survival. METHODS We retrospectively analyzed the multi-center population-based Clinical Cancer Registry at the Tumor Center Regensburg (TUDOK) database (2004-2020) to identify patients who had been diagnosed with SLN-positive MM and underwent (non)invasive management thereof. Patient cohorts were subdivided according to the treatment received (CLND and waiving CLND). Primary outcomes included overall survival (OS), recurrence-free survival (RFS), and cumulative recurrence rate. RESULTS We identified 1143 MM patients, of whom 126 (11.0%) had positive SLN status. CLND was waived in the majority of SLN-positive MM cases (n = 71; 56.3%), with 55 (43.7%) patients undergoing CLND. Univariable and multivariable Cox regression revealed no significant advantage for CLND patients compared to non-CLND patients in OS (HR=0.970, p = 0.915 and HR=1.295, p = 0.479, respectively), RFS (HR=1.050, p = 0.849 and HR=1.220, p = 0.544, respectively), and cumulative recurrence rate (HR=1.234, p = 0.441 and HR=1.220, p = 0.544), respectively). CONCLUSION We found that CLND had no significant impact on patient survival and MM recurrence rate, thus corroborating the validity of current clinical guidelines.
Collapse
Affiliation(s)
- Helena Baecher
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Michael Gerken
- Bavarian Cancer Registry, Regional Centre Regensburg, Bavarian Health and Food Safety Authority, 93053 Regensburg, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, 93053 Regensburg, Germany; Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Monika Klinkhammer-Schalke
- Tumor Center, Institute for Quality Management and Health Services Research, University of Regensburg, 93053 Regensburg, Germany
| | - Mark Berneburg
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Konstantin Drexler
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany
| | - Sebastian Haferkamp
- Department of Dermatology, University Hospital Regensburg, 93053 Regensburg, Germany.
| |
Collapse
|
7
|
Alfertshofer M, Kempa J, Biesman BS, Knoedler S, Knoedler L, Bravo C, Davidovic K, Antoszewski B, Timler W, Kasielska-Trojan A, Cotofana S. The "Central Tendency Bias" in the assessment of facial attractiveness in group-based and individual ratings-A survey-based study in 727 volunteers. J Plast Reconstr Aesthet Surg 2024; 92:264-275. [PMID: 38582052 DOI: 10.1016/j.bjps.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 03/09/2024] [Accepted: 03/18/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND The increasing number of esthetic procedures emphasizes the need for effective evaluation methods of outcomes. Current practices include the individual practitioners' judgment in conjunction with standardized scales, often relying on the comparison of before and after photographs. This study investigates whether comparative evaluations influence the perception of beauty and aims to enhance the accuracy of esthetic assessments in clinical and research settings. OBJECTIVE To compare the evaluation of attractiveness and gender characteristics of faces in group-based versus individual ratings. METHODS A sample of 727 volunteers (average age of 29.5 years) assessed 40 facial photographs (20 male, 20 female) for attractiveness, masculinity, and femininity using a 5-point Likert scale. Each face was digitally edited to display varying ratios in four lip-related proportions: vertical lip position, lip width, upper lip esthetics, and lower lip esthetics. Participants rated these images both in an image series (group-based) and individually. RESULTS Differences in the perception of the most attractive/masculine/feminine ratios for each lip proportion were found in both the group-based and individual ratings. Group ratings exhibited a significant central tendency bias, with a preference for more average outcomes compared with individual ratings, with an average difference of 0.50 versus 1.00. (p = 0.033) CONCLUSION: A central tendency bias was noted in evaluations of attractiveness, masculinity, and femininity in group-based image presentation, indicating a bias toward more "average" features. Conversely, individual assessments displayed a preference for more pronounced, "non-average" appearances, thereby possibly pointing toward a malleable "intrinsic esthetic blueprint" shaped by comparative context.
Collapse
Affiliation(s)
- Michael Alfertshofer
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians-University, Munich, Germany.
| | - Joanna Kempa
- Individual Course of Study in the Department of Plastic, Reconstructive and Aesthetic Surgery, Institute of Surgery, Medical University of Łódź, Poland
| | | | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kristina Davidovic
- Department of Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Belgrade, Serbia
| | - Boguslaw Antoszewski
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Institute of Surgery, Medical University of Łódź, Poland
| | - Wojciech Timler
- Department of Family Medicine, Medical University of Łódź, Poland
| | - Anna Kasielska-Trojan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Institute of Surgery, Medical University of Łódź, Poland
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands; Center for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK; Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong Province, China
| |
Collapse
|
8
|
Knoedler S, Frank K, Muehlberger T, Safi AF, Cotofana S, Perozzo FAG, Panayi AC, Guyuron B, Janis JE, Alfertshofer M. Neural Interconnections of Extracranial Nerves in Headache Surgery: Anatomical Landmarks and Clinical Implications - A Review of Literature. Plast Reconstr Surg 2024:00006534-990000000-02327. [PMID: 38684023 DOI: 10.1097/prs.0000000000011504] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/02/2024]
Abstract
Headache disorders (HD) remain a nationwide challenge for the US healthcare system affecting nearly 60% of the US population. Surgical deactivation of the peripheral trigger site, also referred to as headache surgery, represents an effective treatment for patients with refractory HD pain or non-response to pharmacological regimes. Research stemming from other surgical specialties has underlined the clinical relevance of neural interconnections in refining diagnostic algorithms, adapting surgical techniques, and improving overall patient outcomes. While different HD trigger points have been identified, there is a paucity of studies discussing these mostly sensory neural interconnections between these trigger points in a comprehensive fashion. Herein, we aim to provide an overview of the specific nerves involved in HD and synthesize the current literature on HD nerve interconnections to, ultimately, deduce clinical implications. Overall, this line of research may help refine the perioperative workflow and enhance HD patient care.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | | | | | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Filippo A G Perozzo
- Department of Plastic and Reconstructive Surgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Adriana C Panayi
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bahman Guyuron
- Zeeba Clinic, Lyndhurst, OH, USA
- School of Medicine, Case Western Reserve University, Cleveland, OH, USA
| | - Jeffrey E Janis
- Department of Plastic and Reconstructive Surgery, The Ohio State University Wexner Medical Center, Columbus, OH
| | - Michael Alfertshofer
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians University Munich, Munich, Germany
| |
Collapse
|
9
|
Knoedler L, Huelsboemer L, Hollmann K, Alfertshofer M, Herfeld K, Hosseini H, Boroumand S, Stoegner VA, Safi AF, Perl M, Knoedler S, Pomahac B, Kauke-Navarro M. From standard therapies to monoclonal antibodies and immune checkpoint inhibitors - an update for reconstructive surgeons on common oncological cases. Front Immunol 2024; 15:1276306. [PMID: 38715609 PMCID: PMC11074450 DOI: 10.3389/fimmu.2024.1276306] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 04/05/2024] [Indexed: 05/23/2024] Open
Abstract
Malignancies represent a persisting worldwide health burden. Tumor treatment is commonly based on surgical and/or non-surgical therapies. In the recent decade, novel non-surgical treatment strategies involving monoclonal antibodies (mAB) and immune checkpoint inhibitors (ICI) have been successfully incorporated into standard treatment algorithms. Such emerging therapy concepts have demonstrated improved complete remission rates and prolonged progression-free survival compared to conventional chemotherapies. However, the in-toto surgical tumor resection followed by reconstructive surgery oftentimes remains the only curative therapy. Breast cancer (BC), skin cancer (SC), head and neck cancer (HNC), and sarcoma amongst other cancer entities commonly require reconstructive surgery to restore form, aesthetics, and functionality. Understanding the basic principles, strengths, and limitations of mAB and ICI as (neo-) adjuvant therapies and treatment alternatives for resectable or unresectable tumors is paramount for optimized surgical therapy planning. Yet, there is a scarcity of studies that condense the current body of literature on mAB and ICI for BC, SC, HNC, and sarcoma. This knowledge gap may result in suboptimal treatment planning, ultimately impairing patient outcomes. Herein, we aim to summarize the current translational endeavors focusing on mAB and ICI. This line of research may serve as an evidence-based fundament to guide targeted therapy and optimize interdisciplinary anti-cancer strategies.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Lioba Huelsboemer
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Katharina Hollmann
- Department of Pathology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Faculty of Medicine, University of Wuerzbuerg, Wuerzburg, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University Munich, Munich, Germany
| | - Konstantin Herfeld
- Department of Internal Medicine III (Oncology and Haematology), University Hospital Regensburg, Regensburg, Germany
- Leibniz Institute for Immunotherapy, Regensburg, Germany
| | - Helia Hosseini
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Sam Boroumand
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Viola A. Stoegner
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Burn Center, Hannover Medical School, Hannover, Germany
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Markus Perl
- Department of Internal Medicine III (Oncology and Haematology), University Hospital Regensburg, Regensburg, Germany
- Leibniz Institute for Immunotherapy, Regensburg, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand, and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
10
|
Cotofana S, Mehta T, Davidovic K, Swift A, Rohrich RJ, Biesman BS, Gold M, Nikolis A, Dayan S, Alfertshofer M. Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-Based Study. Aesthet Surg J 2024:sjae096. [PMID: 38636497 DOI: 10.1093/asj/sjae096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Revised: 04/10/2024] [Accepted: 04/10/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amidst an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by non-academic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety. OBJECTIVES To identify levels of competency for the aesthetic practitioner and for necessary achievement milestones during the educational path from novice to expert injector. METHODS A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections. RESULTS Regardless of medical specialty and experience level, an average of 3.85 (1.8) years, 786.4 (2,628) filler injections, and 549.9 (1,543) toxin injections was estimated to progress from novice to advanced injector, while an average of 6.10 (3.7) years, 1,842.2 (4,793) filler injections, and 1,308.5 (3,363) injections was estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively. CONCLUSIONS This study establishes an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1,840 filler and 1,310 neuromodulator injections for expertise. It also identifies critical facial regions for targeted treatments by different expertise levels.
Collapse
Affiliation(s)
- Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| | | | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Belgrade, Serbia
| | - Arthur Swift
- Plastic surgeon in private practice, Montreal, Canada
| | - Rod J Rohrich
- Plastic surgeon in private practice, Dallas, TX, USA
| | | | - Michael Gold
- Dermatologist in private practice, Nashville, TN, USA
| | - Andreas Nikolis
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Steven Dayan
- Facial plastic surgeon in private practice, Chicago, IL, USA
| | - Michael Alfertshofer
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians-University Munich, Germany
| |
Collapse
|
11
|
Knoedler L, Dean J, Knoedler S, Kauke-Navarro M, Hollmann K, Alfertshofer M, Helm S, Prantl L, Schliermann R. Hard shell, soft core? Multi-disciplinary and multi-national insights into mental toughness among surgeons. Front Surg 2024; 11:1361406. [PMID: 38645505 PMCID: PMC11027567 DOI: 10.3389/fsurg.2024.1361406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2023] [Accepted: 03/15/2024] [Indexed: 04/23/2024] Open
Abstract
Background With the prevalence of burnout among surgeons posing a significant threat to healthcare outcomes, the mental toughness of medical professionals has come to the fore. Mental toughness is pivotal for surgical performance and patient safety, yet research into its dynamics within a global and multi-specialty context remains scarce. This study aims to elucidate the factors contributing to mental toughness among surgeons and to understand how it correlates with surgical outcomes and personal well-being. Methods Utilizing a cross-sectional design, this study surveyed 104 surgeons from English and German-speaking countries using the Mental Toughness Questionnaire (MTQ-18) along with additional queries about their surgical practice and general life satisfaction. Descriptive and inferential statistical analyses were applied to investigate the variations in mental toughness across different surgical domains and its correlation with professional and personal factors. Results The study found a statistically significant higher level of mental toughness in micro-surgeons compared to macro-surgeons and a positive correlation between mental toughness and surgeons' intent to continue their careers. A strong association was also observed between general life satisfaction and mental toughness. No significant correlations were found between the application of psychological skills and mental toughness. Conclusion Mental toughness varies significantly among surgeons from different specialties and is influenced by professional dedication and personal life satisfaction. These findings suggest the need for targeted interventions to foster mental toughness in the surgical community, potentially enhancing surgical performance and reducing burnout. Future research should continue to explore these correlations, with an emphasis on longitudinal data and the development of resilience-building programs.
Collapse
Affiliation(s)
- Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Jillian Dean
- University of Pittsburgh School of Medicine, Pittsburgh, PA, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, United States
| | - Katharina Hollmann
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sabrina Helm
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Rainer Schliermann
- Faculty of Social and Health Care Sciences, Regensburg University of Applied Sciences, Regensburg, Germany
| |
Collapse
|
12
|
Knoedler L, Knoedler S, Alfertshofer M, Hansen FJ, Schenck T, Sofo G, Obed D, Hollmann K, Siegwart LC, Vollbach FH, Bigdeli AK, Kauke-Navarro M, Pomahac B. Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes. Aesthetic Plast Surg 2024:10.1007/s00266-024-03927-0. [PMID: 38528130 DOI: 10.1007/s00266-024-03927-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 02/09/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. 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 .
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Samuel Knoedler
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Frederik J Hansen
- Department of Surgery, Universitätsklinikum Erlangen, Friedrich-Alexander University Erlangen-Nürnberg, Erlangen, Germany
| | | | - Giuseppe Sofo
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia Rio de Janeiro, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeriro, Brazil
| | - Doha Obed
- Department of Plastic, Aesthetic, Hand and Reconstructive Surgery, Hannover Medical School, 30625, Hannover, Germany
| | - Katharina Hollmann
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Laura C Siegwart
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Felix H Vollbach
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Amir K Bigdeli
- Department of Hand-, Plastic and Reconstructive Surgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Martin Kauke-Navarro
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Bohdan Pomahac
- Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
13
|
Alfertshofer M, Calomeni M, Welch S, Metelitsa A, Knoedler S, Frank K, Green JB, Moellhoff N, Knoedler L, Cotofana S. Increasing Precision When Targeting the Depressor Anguli Oris (DAO) Muscle With Neuromodulators - An Ultrasound-Based Investigation. Aesthet Surg J 2024:sjae067. [PMID: 38513359 DOI: 10.1093/asj/sjae067] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/12/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
BACKGROUND Neuromodulator treatments of the perioral region are increasingly popular and aim to modulate the position of the modiolus. The predominantly targeted muscle is the depressor anguli oris (DAO) which allows for the modiolus to reposition cranially once temporarily relaxed. OBJECTIVES To identify the precise anatomic position of the DAO in relation to the Marionette Line for increasing precision and reducing adverse events during neuromodulator treatments. METHODS A total of n = 80 DAO muscles were investigated in n = 40 healthy, toxin naïve volunteers (11 males, 29 females) having a mean age of 48.15 (15) years and a mean body mass index of 24.07 (3.7) kg/m2. The location of the DAO in relation to the labiomandibular sulcus (LMS), its depth, extent, and thickness were investigated with high frequency ultrasound imaging. RESULTS The skin surface projection of the LMS separates the DAO into medial and lateral portions. The distance between skin surface and muscle surface was on average 4.4 mm with males having a greater distance (p < 0.001) and higher BMI being an important influencing factor for a greater distance (p < 0.001). The thickness of the DAO was on average 3.5 mm with a range of 2.8-4.8 mm and with females having thinner muscles when compared to men (p < 0.001). The most favorable injection depth was calculated to be 6.1 mm for intra-muscular product placement. CONCLUSIONS Understanding the perioral anatomy and the influence of age, sex, and BMI will potentially allow the injectors to increase efficacy and duration of neuromodulator treatments while expertly managing adverse events.
Collapse
Affiliation(s)
- Michael Alfertshofer
- Research fellow, Department of Oromaxillofacial Surgery, University Hospital, LMU Munich, Munich, Germany
| | | | - Scott Welch
- Aesthetic practitioner in private practice, Newport Beach, CA, USA
| | - Andrei Metelitsa
- Dermatologist, Department of Dermatology, University of Calgary, Calgary, Canada
| | - Samuel Knoedler
- Medical student, Department of Surgery, Division of Plastic Surgery, Yale School of Medicine, New Haven, CT, USA
| | | | - Jeremy B Green
- Dermatologist in private practice, Coral Gables, FL, USA
| | - Nicholas Moellhoff
- Plastic surgeon, Department of Hand-, Plastic and Aesthetic Surgery, University Hospital Munich, Munich, Germany
| | - Leonard Knoedler
- Medical student, Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Sebastian Cotofana
- Professor, Department of Dermatology, Erasmus Medical Centre, Rotterdam, The Netherlands
| |
Collapse
|
14
|
Knoedler S, Knoedler L, Geldner B, Ghanad I, Kim BS, Alfertshofer M, Machens HG, Broer PN, Pomahac B, Kauke-Navarro M, Paik AM. Isolated and combined breast augmentation in transgender patients: Multi-institutional insights into early outcomes and risk factors. J Plast Reconstr Aesthet Surg 2024; 90:149-160. [PMID: 38367411 DOI: 10.1016/j.bjps.2024.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Revised: 01/23/2024] [Accepted: 01/29/2024] [Indexed: 02/19/2024]
Abstract
BACKGROUND The increasing demand for gender-affirming surgery (GAS) in transgender and gender-diverse healthcare highlights the importance of breast augmentation surgery (BAS) for transfeminine patients. Despite its significance, there is a lack of research on postoperative outcomes of BAS. METHODS We analyzed the multi-institutional American College of Surgeons (ACS) National Surgical Quality Improvement Program (NSQIP) (2008-2021) database to identify female transgender individuals (TGIs) who underwent BAS surgery, both isolated and combined with concurrent GAS procedures. We evaluated 30-day outcomes, including the incidence of mortality, reoperation, readmission as well as surgical and medical complication occurrence. RESULTS Of 1699 female TGIs, 92% underwent isolated BAS and 7.7% underwent combined BAS. The mean age and body mass index (BMI) were 36 ± 12 years and 27 ± 6.6 kg/m2, respectively. Isolated BAS showed a 2.8% complication rate, while combined BAS had a higher rate with 9.1%. Specifically, all complications occurred in patients undergoing BAS with concurrent genitourinary surgery (n = 85; 14%), whereas no adverse events were recorded after combined BAS and facial feminization (n = 19) or chondrolaryngoplasty (n = 19). In patients seeking combined BAS, advanced age (p = 0.05) and nicotine abuse (p = 0.004) were identified as risk factors predisposing to adverse events, whereas American Society of Anesthesiology class 1 was found to be protective (p = 0.02). CONCLUSIONS Isolated BAS in TGIs demonstrates a positive safety profile. Combined surgeries, particularly with genitourinary procedures, pose higher risks. Identifying risk factors such as smoking and advanced age is crucial for patient selection and surgical planning. These findings can aid in refining patient eligibility and inform surgical decision-making for BAS.
Collapse
Affiliation(s)
- Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA; Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA
| | - Benedikt Geldner
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Iman Ghanad
- Department of Hand-, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Center Ludwigshafen, University of Heidelberg, Ludwigshafen, Germany
| | - Bong-Sung Kim
- Department of Plastic Surgery and Hand Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Hans-Guenther Machens
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany
| | - Peter Niclas Broer
- Department of Plastic, Reconstructive, Hand and Burn Surgery, Bogenhausen Academic Teaching Hospital, Munich, Germany.
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| | - Angie M Paik
- Division of Plastic Surgery, Department of Surgery, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
15
|
Yi K, Kim S, Chua D, Stefanelli MB, Alfertshofer M, Vachiramon V. Horizontal necklines correction with absorbable braided polydioxanone threads: Case series. Skin Res Technol 2024; 30:e13617. [PMID: 38444188 PMCID: PMC10915367 DOI: 10.1111/srt.13617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2024] [Accepted: 02/05/2024] [Indexed: 03/07/2024]
Abstract
INTRODUCTION The prevalence of horizontal neck lines as a cosmetic concern is widely acknowledged, yet the available treatment options are limited, and no studies have investigated the use of polydioxanone-barbed threads. These threads, characterized by a finely braided structure, function as a scaffold to attract regenerative factors and facilitate the migration and proliferation of cells. This study aims to evaluate the outcomes of concurrent application of braided polydioxanone-barbed threads for addressing horizontal neck wrinkles. METHODOLOGY A retrospective case series involving four female participants (aged 41, 43, 45, and 46) treated with polydioxanone-barbed threads for horizontal neck wrinkles between January 2023 and July 2023 was conducted. Adult patients were assessed at an 8-week follow-up, revealing a significant reduction in wrinkle intensity based on the Horizontal Neck Wrinkle Severity Scale. RESULTS The analysis of horizontal neck lines demonstrated a notable decrease in wrinkle intensity according to the Horizontal Neck Wrinkle Severity Scale at the 8-week mark, and this improvement maintained statistical significance. Both patient Global Aesthetic Improvement Scale (GAIS) scores (90%-100%) and physician GAIS scores (100%) were rated as excellent. CONCLUSION The subdermal application of polydioxanone-barbed threads for horizontal neck lines proves to be a secure and efficacious approach for treating horizontal neck wrinkles, with no observed Tyndall effect. This technique shows promise for rejuvenating the skin in the horizontal neckline region.
Collapse
Affiliation(s)
- Kyu‐Ho Yi
- Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 FOUR ProjectYonsei University College of DentistrySeodaemun‐guSeoulSouth Korea
- Maylin Clinic (Apgujeong)Gangnam‐guSeoulSouth Korea
| | - Soo‐Bin Kim
- Division in Anatomy and Developmental BiologyDepartment of Oral BiologyHuman Identification Research InstituteBK21 FOUR ProjectYonsei University College of DentistrySeodaemun‐guSeoulSouth Korea
| | | | | | - Michael Alfertshofer
- Department of Plastic and Aesthetic SurgeryTechnical University MunichMunichGermany
| | - Vasanop Vachiramon
- Department of Internal MedicineFaculty of MedicineRamathibodi HospitalMahidol UniversityBangkokThailand
| |
Collapse
|
16
|
Rams DJ, Alfertshofer M, Batko J, Gotkin RH, Perdikis G, Szczepanek E, Urbanik A, Koziej M, Ostrogórska M, Cotofana S. Investigating the Contraction Pattern of the Zygomaticus Major Muscle and its Clinical Relevance: A Functional MRI Study. Aesthetic Plast Surg 2024:10.1007/s00266-024-03876-8. [PMID: 38413445 DOI: 10.1007/s00266-024-03876-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Accepted: 01/25/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Our understanding of facial anatomy has significantly evolved, yet the detailed contraction patterns of facial muscles and their presentation during clinical imaging remain largely unexplored. Understanding the contraction patterns and visual presentation of these muscles, particularly the zygomaticus major could enhance pre-surgical facial assessments and the development of new treatment strategies. METHODS A total of 34 healthy young individuals (17 female, 17 male) with a mean age of 23.6 (2.4) years [range: 20-30] were investigated regarding the length, thickness, width, and angle of the zygomaticus major muscle in five different facial expressions (i.e., repose, anger, joy, surprise, and sadness) utilizing MR imaging. RESULTS Joyful expressions caused a reduction in muscle length to 85.6% of its original length and an increase in width (103.4%), thickness (108.4%), and facial angle (2.72°) when compared to that in repose, suggesting isotonic contraction. Conversely, expressions of anger, surprise, and sadness generally led to muscle stretching, seen through changes in length (98.9%, 104.3%, and 102.7%, respectively), width (98.8%, 96.5%, and 99.4%, respectively), and thickness (91.2%, 91.0%, and 102.7%, respectively), with variable alterations in facial angle (0.55°, 1.85°, and 1.00°, respectively) depending on the specific expression. CONCLUSION This MRI-based study indicates that the zygomaticus major muscle experiences isotonic contraction, characterized by decreased length and increased width and thickness. The findings underline the importance of muscle thickness as a reliable parameter in assessing facial muscle function and offer valuable guidance for practitioners in accurately evaluating muscle performance during different facial expressions. NO LEVEL ASSIGNED This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .
Collapse
Affiliation(s)
- Daniel J Rams
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Michael Alfertshofer
- Department of Oromaxillofacial Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Jakub Batko
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | | | - Galen Perdikis
- Department of Plastic Surgery, Vanderbilt University, Nashville, TN, USA
| | - Elżbieta Szczepanek
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Andrzej Urbanik
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Mateusz Koziej
- Department of Anatomy, Jagiellonian University Medical College, Kraków, Poland
| | - Monika Ostrogórska
- Department of Radiology, Jagiellonian University Medical College, Kraków, Poland
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus University Medical Center, Dr. Molewaterplein 40, 3015 GD, Rotterdam, The Netherlands.
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK.
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong Province, China.
| |
Collapse
|
17
|
Calomeni M, Alfertshofer M, Moellhoff N, Freytag DL, Nikolis A, Biesman B, Davidovic K, Schelke L, Velthuis PJ, Cotofana S. Understanding Platysma Muscle Contraction Pattern and Its Relationship to Platysmal Banding: A Real-Time Ultrasound Study. Aesthet Surg J 2024; 44:233-239. [PMID: 37418617 DOI: 10.1093/asj/sjad216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 07/01/2023] [Accepted: 07/03/2023] [Indexed: 07/09/2023] Open
Abstract
BACKGROUND Addressing neck contouring with surgical and nonsurgical aesthetic procedures includes understanding the origin of platysmal banding. A theory was postulated to explain this phenomenon by isometric vs isotonic muscular contraction patterns. However, no scientific proof had been provided to date for its correctness. OBJECTIVES The aim of this study was to confirm the correctness of the platysmal banding theory based on isometric vs isotonic muscular contractions. METHODS Eighty platysma muscles from 40 volunteers (15 males and 25 females) were investigated (mean age 41.8; SD 15.2 years; mean BMI of 22.2; SD 2.3 kg/m2). Real-time ultrasound imaging was utilized to measure the increase in local muscle thickness inside and outside of a platysmal band as well as platysma mobility. RESULTS Within a platysmal band, the local thickness of the muscle increases during muscular contractions by 0.33 mm (37.9%; P < .001). Outside of a platysmal band the thickness of the platysma muscle decreased by 0.13 mm (20.3%; P < .001). It was identified that within a platysmal band no gliding was detectable, whereas outside of a band an average muscle gliding of 2.76 mm was observed. CONCLUSIONS The results confirm the correctness of the isometric vs isotonic platysma muscle contraction pattern theory: isotonic muscle contraction (gliding without increase in tension and therefore in muscle thickness) vs isometric muscle contraction (no gliding but increase in tension and therefore in muscle thickness). These 2 types of contraction patterns occur within the platysma simultaneously and are an indicator for zones of adhesion in the neck to guide surgical and nonsurgical aesthetic procedures. LEVEL OF EVIDENCE: 4
Collapse
|
18
|
Frank K, Zeng R, Sedlbauer S, Prantl L, Giunta R, Cotofana S, Moellhoff N, Alfertshofer M, Kaye K, Brébant V. The Influence of Scar Patterns After Reduction Mammoplasty on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation. Aesthetic Plast Surg 2024; 48:250-258. [PMID: 37853080 PMCID: PMC10917861 DOI: 10.1007/s00266-023-03689-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 09/13/2023] [Indexed: 10/20/2023]
Abstract
BACKGROUND Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars. METHODS 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers. RESULTS The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern. CONCLUSION The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern. 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 .
Collapse
Affiliation(s)
| | - Rui Zeng
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Stephanie Sedlbauer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany
| | - Riccardo Giunta
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Vanessa Brébant
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauß-Allee 11, 93053, Regensburg, Germany.
| |
Collapse
|
19
|
Knoedler L, Alfertshofer M, Knoedler S, Hoch CC, Funk PF, Cotofana S, Maheta B, Frank K, Brébant V, Prantl L, Lamby P. Pure Wisdom or Potemkin Villages? A Comparison of ChatGPT 3.5 and ChatGPT 4 on USMLE Step 3 Style Questions: Quantitative Analysis. JMIR Med Educ 2024; 10:e51148. [PMID: 38180782 PMCID: PMC10799278 DOI: 10.2196/51148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/30/2023] [Accepted: 10/20/2023] [Indexed: 01/06/2024]
Abstract
BACKGROUND The United States Medical Licensing Examination (USMLE) has been critical in medical education since 1992, testing various aspects of a medical student's knowledge and skills through different steps, based on their training level. Artificial intelligence (AI) tools, including chatbots like ChatGPT, are emerging technologies with potential applications in medicine. However, comprehensive studies analyzing ChatGPT's performance on USMLE Step 3 in large-scale scenarios and comparing different versions of ChatGPT are limited. OBJECTIVE This paper aimed to analyze ChatGPT's performance on USMLE Step 3 practice test questions to better elucidate the strengths and weaknesses of AI use in medical education and deduce evidence-based strategies to counteract AI cheating. METHODS A total of 2069 USMLE Step 3 practice questions were extracted from the AMBOSS study platform. After including 229 image-based questions, a total of 1840 text-based questions were further categorized and entered into ChatGPT 3.5, while a subset of 229 questions were entered into ChatGPT 4. Responses were recorded, and the accuracy of ChatGPT answers as well as its performance in different test question categories and for different difficulty levels were compared between both versions. RESULTS Overall, ChatGPT 4 demonstrated a statistically significant superior performance compared to ChatGPT 3.5, achieving an accuracy of 84.7% (194/229) and 56.9% (1047/1840), respectively. A noteworthy correlation was observed between the length of test questions and the performance of ChatGPT 3.5 (ρ=-0.069; P=.003), which was absent in ChatGPT 4 (P=.87). Additionally, the difficulty of test questions, as categorized by AMBOSS hammer ratings, showed a statistically significant correlation with performance for both ChatGPT versions, with ρ=-0.289 for ChatGPT 3.5 and ρ=-0.344 for ChatGPT 4. ChatGPT 4 surpassed ChatGPT 3.5 in all levels of test question difficulty, except for the 2 highest difficulty tiers (4 and 5 hammers), where statistical significance was not reached. CONCLUSIONS In this study, ChatGPT 4 demonstrated remarkable proficiency in taking the USMLE Step 3, with an accuracy rate of 84.7% (194/229), outshining ChatGPT 3.5 with an accuracy rate of 56.9% (1047/1840). Although ChatGPT 4 performed exceptionally, it encountered difficulties in questions requiring the application of theoretical concepts, particularly in cardiology and neurology. These insights are pivotal for the development of examination strategies that are resilient to AI and underline the promising role of AI in the realm of medical education and diagnostics.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University Munich, Munich, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Cosima C Hoch
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich, Munich, Germany
| | - Paul F Funk
- Department of Otolaryngology, Head and Neck Surgery, University Hospital Jena, Friedrich Schiller University Jena, Jena, Germany
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Bhagvat Maheta
- College of Medicine, California Northstate University, Elk Grove, CA, United States
| | | | - Vanessa Brébant
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Philipp Lamby
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| |
Collapse
|
20
|
Knoedler S, Sofo G, Kern B, Frank K, Cotofana S, von Isenburg S, Könneker S, Mazzarone F, Dorafshar AH, Knoedler L, Alfertshofer M. Modern Machiavelli? The illusion of ChatGPT-generated patient reviews in plastic and aesthetic surgery based on 9000 review classifications. J Plast Reconstr Aesthet Surg 2024; 88:99-108. [PMID: 37972444 DOI: 10.1016/j.bjps.2023.10.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2023] [Revised: 10/18/2023] [Accepted: 10/23/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Online patient reviews are crucial in guiding individuals who seek plastic surgery, but artificial chatbots pose a threat of disseminating fake reviews. This study aimed to compare real patient feedback with ChatGPT-generated reviews for the top five US plastic surgery procedures. METHODS Thirty real patient reviews on rhinoplasty, blepharoplasty, facelift, liposuction, and breast augmentation were collected from RealSelf and used as templates for ChatGPT to generate matching patient reviews. Prolific users (n = 30) assessed 150 pairs of reviews to identify human-written and artificial intelligence (AI)-generated reviews. Patient reviews were further assessed using AI content detector software (Copyleaks AI). RESULTS Among the 9000 classification tasks, 64.3% and 35.7% of reviews were classified as authentic and fake, respectively. On an average, the author (human versus machine) was correctly identified in 59.6% of cases, and this poor classification performance was consistent across all procedures. Patients with prior aesthetic treatment showed poorer classification performance than those without (p < 0.05). The mean character count in human-written reviews was significantly higher (p < 0.001) that that in AI-generated reviews, with a significant correlation between character count and participants' accuracy rate (p < 0.001). Emotional timbre of reviews differed significantly with "happiness" being more prevalent in human-written reviews (p < 0.001), and "disappointment" being more prevalent in AI reviews (p = 0.005). Copyleaks AI correctly classified 96.7% and 69.3% of human-written and ChatGPT-generated reviews, respectively. CONCLUSION ChatGPT convincingly replicates authentic patient reviews, even deceiving commercial AI detection software. Analyzing emotional tone and review length can help differentiate real from fake reviews, underscoring the need to educate both patients and physicians to prevent misinformation and mistrust.
Collapse
Affiliation(s)
- Samuel Knoedler
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts der Isar, Technical University of Munich, Munich, Germany; Division of Plastic Surgery, Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA; Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil.
| | - Giuseppe Sofo
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Barbara Kern
- Department of Plastic Surgery, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Germany
| | | | - Sebastian Cotofana
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK; Department of Dermatology, Erasmus Hospital, Rotterdam, the Netherlands
| | - Sarah von Isenburg
- Private Practice, Plastische Chirurgie München Dres. Neuhann-Lorenz & v. Isenburg, Munich, Germany
| | - Sören Könneker
- Department of Plastic Surgery and Hand Surgery, University Hospital Zürich, Zurich, Switzerland
| | - Francesco Mazzarone
- Instituto Ivo Pitanguy, Hospital Santa Casa de Misericórdia, Pontifícia Universidade Católica do Rio de Janeiro, Rio de Janeiro, Brazil
| | - Amir H Dorafshar
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, IL, USA
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| |
Collapse
|
21
|
Knoedler L, Alfertshofer M, Simon S, Prantl L, Kehrer A, Hoch CC, Knoedler S, Lamby P. Diagnosing lagophthalmos using artificial intelligence. Sci Rep 2023; 13:21657. [PMID: 38066112 PMCID: PMC10709577 DOI: 10.1038/s41598-023-49006-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 12/02/2023] [Indexed: 12/18/2023] Open
Abstract
Lagophthalmos is the incomplete closure of the eyelids posing the risk of corneal ulceration and blindness. Lagophthalmos is a common symptom of various pathologies. We aimed to program a convolutional neural network to automatize lagophthalmos diagnosis. From June 2019 to May 2021, prospective data acquisition was performed on 30 patients seen at the Department of Plastic, Hand, and Reconstructive Surgery at the University Hospital Regensburg, Germany (IRB reference number: 20-2081-101). In addition, comparative data were gathered from 10 healthy patients as the control group. The training set comprised 826 images, while the validation and testing sets consisted of 91 patient images each. Validation accuracy was 97.8% over the span of 64 epochs. The model was trained for 17.3 min. For training and validation, an average loss of 0.304 and 0.358 and a final loss of 0.276 and 0.157 were noted. The testing accuracy was observed to be 93.41% with a loss of 0.221. This study proposes a novel application for rapid and reliable lagophthalmos diagnosis. Our CNN-based approach combines effective anti-overfitting strategies, short training times, and high accuracy levels. Ultimately, this tool carries high translational potential to facilitate the physician's workflow and improve overall lagophthalmos patient care.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany.
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Lukas Prantl
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Andreas Kehrer
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Cosima C Hoch
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich (TUM), 81675, Munich, Germany
| | - Samuel Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| | - Philipp Lamby
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Franz-Josef-Strauss-Allee 11, 93053, Regensburg, Germany
| |
Collapse
|
22
|
Schelke L, Harris S, Cartier H, Alfertshofer M, Doestzada M, Cotofana S, Velthuis PJ. Treating facial overfilled syndrome with impaired facial expression-Presenting clinical experience with ultrasound imaging. J Cosmet Dermatol 2023; 22:3252-3260. [PMID: 37772766 DOI: 10.1111/jocd.16013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 08/26/2023] [Accepted: 09/19/2023] [Indexed: 09/30/2023]
Abstract
BACKGROUND Facial overfilled syndrome is an adverse event following minimally invasive soft tissue filler injections. It presents in most cases as excess midfacial volume and/or as unnatural smile which is difficult to detect due to the absence of standardized evaluation methods. OBJECTIVE To showcase how to identify, evaluate, and treat facial overfilled syndrome by utilizing facial ultrasound and simultaneous hyaluronidase injections. METHODS Twenty-eight consecutive patients (26 females, 2 males) were enrolled in this study in which facial ultrasound was performed to evaluate the location previously implanted filler material. The position of the oral commissure was objectively measured in relation to bony landmarks, and the severity of lateral canthal lines was assessed by independent and blinded raters. RESULTS The material was identified in 35.7% inside the subdermal fatty layer, in 28.6% inside the deep supra-periosteal fatty layer, in 10.7% inside the fibrous layer deep to the subdermal fatty layer, whereas in 25.0%, the product was not possible to locate clearly inside one specific layer. On average, 81.6 I.U. [range: 75-150] of hyaluronidase were injected. Lateral canthal line severity was before the treatment 2.28 (1.4) and was after the hyaluronidase treatment 2.02 (1.3) with p = 0.578. The position of the oral commissure increased by 0.60 cm in vertical and by 0.30 cm in horizontal directions (both p < 0.001). CONCLUSION Facial overfilled syndrome following aesthetic soft tissue filler injections can present as excess midfacial volume but also as unnatural smile. Targeted hyaluronidase injections into the culprit pockets inside the midfacial soft tissues have shown to re-establish a natural smile, to reduce excess midfacial volume, and to decrease lateral canthal line severity.
Collapse
Affiliation(s)
- Leonie Schelke
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | | | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | | | - Sebastian Cotofana
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Peter J Velthuis
- Department of Dermatology, Erasmus University Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
23
|
Zhang Z, Wang R, Xue H, Knoedler S, Geng Y, Liao Y, Alfertshofer M, Panayi AC, Ming J, Mi B, Liu G. Phototherapy techniques for the management of musculoskeletal disorders: strategies and recent advances. Biomater Res 2023; 27:123. [PMID: 38017585 PMCID: PMC10685661 DOI: 10.1186/s40824-023-00458-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2023] [Accepted: 10/28/2023] [Indexed: 11/30/2023] Open
Abstract
Musculoskeletal disorders (MSDs), which include a range of pathologies affecting bones, cartilage, muscles, tendons, and ligaments, account for a significant portion of the global burden of disease. While pharmaceutical and surgical interventions represent conventional approaches for treating MSDs, their efficacy is constrained and frequently accompanied by adverse reactions. Considering the rising incidence of MSDs, there is an urgent demand for effective treatment modalities to alter the current landscape. Phototherapy, as a controllable and non-invasive technique, has been shown to directly regulate bone, cartilage, and muscle regeneration by modulating cellular behavior. Moreover, phototherapy presents controlled ablation of tumor cells, bacteria, and aberrantly activated inflammatory cells, demonstrating therapeutic potential in conditions such as bone tumors, bone infection, and arthritis. By constructing light-responsive nanosystems, controlled drug delivery can be achieved to enable precise treatment of MSDs. Notably, various phototherapy nanoplatforms with integrated imaging capabilities have been utilized for early diagnosis, guided therapy, and prognostic assessment of MSDs, further improving the management of these disorders. This review provides a comprehensive overview of the strategies and recent advances in the application of phototherapy for the treatment of MSDs, discusses the challenges and prospects of phototherapy, and aims to promote further research and application of phototherapy techniques.
Collapse
Affiliation(s)
- Zhenhe Zhang
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Rong Wang
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
| | - Hang Xue
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Samuel Knoedler
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02152, USA
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Max-Lebsche-Platz 31, 81377, Munich, Germany
| | - Yongtao Geng
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Yuheng Liao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Adriana C Panayi
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02152, USA
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071, Ludwigshafen, Rhine, Germany
| | - Jie Ming
- Department of Breast and Thyroid Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
| | - Bobin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, 1277 Jiefang Avenue, Wuhan, 430022, China.
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan, 430022, China.
| |
Collapse
|
24
|
Davidovic K, Cotofana S, Heisinger S, Savic S, Alfertshofer M, Antonić T, Jovanović S, Ercegovac M, Muto M, Jeremić D, Janićijević A, Rasulić L, Janošević V, Šarić L, Chua D, Masulovic D, Maksimović R. Percutaneous Computed Tomography-Guided Oxygen-Ozone (O 2O 3) Injection Therapy in Patients with Lower Back Pain-An Interventional Two-Year Follow-Up Study of 321 Patients. Diagnostics (Basel) 2023; 13:3370. [PMID: 37958266 PMCID: PMC10650810 DOI: 10.3390/diagnostics13213370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 10/27/2023] [Accepted: 10/31/2023] [Indexed: 11/15/2023] Open
Abstract
OBJECTIVES To assess the effect of oxygen-ozone therapy guided by percutaneous Computed Tomography (CT) compared to corticosteroids in individuals experiencing lower back pain (LBP) not attributed to underlying bone-related issues. METHODS A total of 321 patients (192 males and 129 females, mean age: 51.5 ± 15.1 years) with LBP were assigned to three treatment groups: group A) oxygen-ozone only, group B) corticosteroids only, group C) oxygen-ozone and corticosteroids. Treatment was administered via CT-guided injections to the intervertebral disc (i.e., intradiscal location). Clinical improvement of pain and functionality was assessed via self-reported pain scales and magnetic resonance (MR) and CT imaging. RESULTS At all follow-up times, the mean score of the numeric rating scale and the total global pain scale (GPS) of study groups receiving oxygen-ozone (groups A and C) were statistically significantly lower than the study group receiving corticosteroids only (group B), with p < 0.001. There was a statistically significant difference between groups A and C at 30 days for the numeric rating scale. CONCLUSIONS The percutaneous application of oxygen-ozone in patients with LBP due to degeneration of the lumbosacral spine showed long-lasting significant pain reduction of up to two years post-treatment when compared to corticosteroids alone. Combination therapy of oxygen-ozone and corticosteroids can be useful as corticosteroids showed statistically significant improvement in LBP earlier than the oxygen-ozone-only treatment.
Collapse
Affiliation(s)
- Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (K.D.)
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Medical Centre, 3015 GD Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London E1 4NS, UK
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou 510317, China
| | - Stephan Heisinger
- Department of Orthopedics and Trauma Surgery, Medical University of Vienna, 1090 Vienna, Austria
| | - Slavica Savic
- Medical Faculty, University of Belgrade, 11120 Belgrade, Serbia
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, 80336 Munich, Germany
| | - Tatjana Antonić
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (K.D.)
| | | | - Marko Ercegovac
- Clinic of Neurology, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Mario Muto
- Neuroradiology Department, Ospedale Cardarelli Napoli, 80131 Napoli, Italy
| | - Danilo Jeremić
- Institute for Orthopedic Surgery “Banjica”, 11000 Belgrade, Serbia
| | | | - Lukas Rasulić
- Clinic of Neurosurgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Vesna Janošević
- Clinic of Neurosurgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | - Lidija Šarić
- Clinic of Neurosurgery, University Clinical Centre of Serbia, 11000 Belgrade, Serbia
| | | | - Dragan Masulovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (K.D.)
| | - Ružica Maksimović
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, 11000 Belgrade, Serbia; (K.D.)
| |
Collapse
|
25
|
Gonchar IV, Alfertshofer M, Nikolis A, Hong WJ, Biesman B, Cotofana S. Is constant needle motion during soft tissue filler injections a safer procedure? A theoretical mathematical model for evaluating patient safety. J Cosmet Dermatol 2023; 22:2964-2970. [PMID: 37712576 DOI: 10.1111/jocd.15998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 09/04/2023] [Indexed: 09/16/2023]
Abstract
BACKGROUND The safety rationale behind the constant needle motion injection technique is based on the assumption that due to the constant needle motion and simultaneous soft tissue filler material administration a smaller amount of product per area may be injected into an artery if an artery within the range of the moving needle is inadvertently entered. OBJECTIVE To perform mathematical calculations for determining the probability for causing intra-arterial product administration when constantly moving the needle during facial aesthetic soft tissue filler injections. METHODS This study was designed as a theoretical investigation into the probabilities for causing adverse events due to intravascular injection of soft tissue filler material when constantly moving a 27-G needle during facial soft tissue filler administration. RESULTS It was revealed that with a higher number of conducted injection passes a greater soft tissue area can be covered by the needle. The odds of encountering an artery within the covered soft tissue volume and the odds of injecting any volume greater than zero into the arterial blood stream increases with the number of performed injection passes. This increase is greatest between 1 and 10 performed injection passes. CONCLUSION This model demonstrates that the constant needle motion technique increases the probability of encountering an artery within the treatment area and thus increases the odds for intra-arterial product administration. The constant needle motion technique does not increase safety but rather may increase the odds of causing intra-arterial product administration with the respective adverse consequences for the patient.
Collapse
Affiliation(s)
- Ivan V Gonchar
- Department of Discrete Mathematics, Moscow Institute of Physics and Technology, Moscow, Russia
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Nikolis
- Clinical Research Unit, Erevna Innovations Inc, Montreal, Quebec, Canada
- Division of Plastic Surgery, McGill University, Montreal, Quebec, Canada
| | - Wei-Jin Hong
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, China
| | | | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| |
Collapse
|
26
|
Germani M, Almeida CCMS, Munoz-Lora VRM, Rogério V, Moelhoff N, Freytag DL, Green JB, Alfertshofer M, Davidovic K, Cotofana S. How to improve infraorbital hollows with neuromodulators-A clinical prospective interventional study about the application of facial biomechanics. J Cosmet Dermatol 2023; 22:2950-2956. [PMID: 37632259 DOI: 10.1111/jocd.15970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 06/28/2023] [Accepted: 08/13/2023] [Indexed: 08/27/2023]
Abstract
BACKGROUND A previous injection algorithm termed the "Toxin Lift" was recently introduced and described volume increases in the midface following neuromodulator treatments of the jawline. Increase in midfacial volume due to soft tissue repositioning could also affect the severity of infraorbital hollows. OBJECTIVE The objective is therefore to evaluate whether the severity of infraorbital hollows can be improved by injecting neuromodulators in the supra-mandibular segment of the platysma. MATERIALS AND METHODS A total of 35 volunteers (11 males/24 females) with a mean age of 39.8 (9.6) years and a mean BMI of 25.2 (5.2) kg/m2 were investigated. Bilateral infraorbital regions were evaluated via clinical assessment and semi-quantitative 3D imaging. The applied injection technique targeted the platysma via four injection points administering 5 I.U. per injection point resulting in a total of 20 I.U. per facial side. RESULTS Volume increase of the infraorbital region was 0.13 cc at 15 days (p = 0.001) and was 0.02 cc at 30 days (p = 0.452) whereas the skin displacement in cranial direction was 0.54 mm at 15 days (p < 0.001) and was 0.31 mm at 30 days (p < 0.001). Clinical evaluation revealed a highly statistically significant improvement of the tear trough, palpaebromalar groove, and of the lid-cheek junction when compared to baseline with all p < 0.001. CONCLUSION The results of this clinical prospective interventional analysis revealed that the "Toxin Lift" injection technique is capable to improve the clinical appearance of infraorbital hollows. The effects can be explained by the concepts of facial biomechanics.
Collapse
Affiliation(s)
| | | | | | | | - Nicholas Moelhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - David L Freytag
- Department of Plastic Surgery, Gemeinschaftsklinikum Havelhöhe, Berlin, Germany
| | - Jeremy B Green
- Skin Associates of South Florida and Skin Research Institute, Coral Gables, Florida, USA
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade, Belgrade, Serbia
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| |
Collapse
|
27
|
Gelezhe P, Frank K, Casabona G, Kaye KO, Kassirer S, Moelhoff N, Freytag DL, Gotkin RH, Alfertshofer M, Cotofana S. Safety considerations for treating the parotid and submandibular glands with neuromodulators for facial slimming. J Cosmet Dermatol 2023; 22:2957-2963. [PMID: 37602962 DOI: 10.1111/jocd.15973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 08/13/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND Neuromodulators have predominantly been used for the treatment of upper facial lines, but their use has expanded to include lower face and neck treatments. However, the injection sites for these treatments are based on skin surface landmarks, which may pose risks to nearby structures and result in undesired outcomes. OBJECTIVE To investigate the spatial relationship between the FDA-approved skin surface landmarks for neuromodulator injections in the parotid and submandibular glands and the topographical anatomy of critical facial structures such as the facial artery, facial vein, external carotid artery, and retromandibular vein. MATERIALS AND METHODS A cross-sectional retrospective analysis was conducted on contrast-enhanced cranial CT scans. The scans were analyzed for the morphology and location of the parotid and submandibular glands. Measurements were taken for gland volume, craniocaudal extent, anterior-posterior extent, and distances between the skin surface and gland capsule or nearby structures such as arteries. RESULTS The study sample consisted of 53 subjects, including 7 males and 46 females, with a mean age of 36.91 years and a mean BMI of 23.28 kg/m2 . The mean volume of the parotid gland was 31.9 ± 3.0 cc in males and 28.5 ± 3.6 cc in females with p < 0.001, while the mean volume of the submandibular gland was 18.2 ± 2.0 cc in males and 14.5 ± 3.4 cc in females with p < 0.001. The mean distances between skin surface and the gland capsule were 5.98 ± 2.2 and 8.84 ± 4.0 mm for the parotid and submandibular gland, respectively. This distance increased with higher age and higher BMI values in a statistically significant manner with p < 0.001. CONCLUSION The distances between FDA-approved skin surface landmarks and the parotid and submandibular glands varied significantly depending on gender, age, and BMI. Optimal injection depth and location for neuromodulator treatments cannot be generalized based on these landmarks alone, emphasizing the need for real-time ultrasound imaging guidance.
Collapse
Affiliation(s)
- Pavel Gelezhe
- Research and Practical Center of Medical Radiology, Department of Health Care of Moscow, Moscow, Russia
| | | | | | | | - Samuel Kassirer
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Nicholas Moelhoff
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - David L Freytag
- Department of Plastic Surgery, Gemeinschaftsklinikum Havelhöhe, Berlin, Germany
| | | | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| |
Collapse
|
28
|
Martín JM, Revelles JM, Aznar NM, Jiménez LM, Orellana JB, Gomariz MÁ, Alfertshofer M, Cotofana S. Superficial versus deep injections of the upper midface-A prospective interventional split-face study. J Cosmet Dermatol 2023; 22:2940-2949. [PMID: 37594172 DOI: 10.1111/jocd.15795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/16/2023] [Indexed: 08/19/2023]
Abstract
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.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Michael Alfertshofer
- Department of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munchen, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic School of Medicine, Rochester, Minnesota, USA
| |
Collapse
|
29
|
Knoedler L, Knoedler S, Allam O, Remy K, Miragall M, Safi AF, Alfertshofer M, Pomahac B, Kauke-Navarro M. Application possibilities of artificial intelligence in facial vascularized composite allotransplantation-a narrative review. Front Surg 2023; 10:1266399. [PMID: 38026484 PMCID: PMC10646214 DOI: 10.3389/fsurg.2023.1266399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 09/26/2023] [Indexed: 12/01/2023] Open
Abstract
Facial vascularized composite allotransplantation (FVCA) is an emerging field of reconstructive surgery that represents a dogmatic shift in the surgical treatment of patients with severe facial disfigurements. While conventional reconstructive strategies were previously considered the goldstandard for patients with devastating facial trauma, FVCA has demonstrated promising short- and long-term outcomes. Yet, there remain several obstacles that complicate the integration of FVCA procedures into the standard workflow for facial trauma patients. Artificial intelligence (AI) has been shown to provide targeted and resource-effective solutions for persisting clinical challenges in various specialties. However, there is a paucity of studies elucidating the combination of FVCA and AI to overcome such hurdles. Here, we delineate the application possibilities of AI in the field of FVCA and discuss the use of AI technology for FVCA outcome simulation, diagnosis and prediction of rejection episodes, and malignancy screening. This line of research may serve as a fundament for future studies linking these two revolutionary biotechnologies.
Collapse
Affiliation(s)
- Leonard Knoedler
- Department of Plastic, Hand- and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Omar Allam
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Katya Remy
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Maximilian Miragall
- Department of Oral and Maxillofacial Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians University Munich, Munich, Germany
| | - Bohdan Pomahac
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
30
|
Baecher H, Hoch CC, Knoedler S, Maheta BJ, Kauke-Navarro M, Safi AF, Alfertshofer M, Knoedler L. From bench to bedside - current clinical and translational challenges in fibula free flap reconstruction. Front Med (Lausanne) 2023; 10:1246690. [PMID: 37886365 PMCID: PMC10598714 DOI: 10.3389/fmed.2023.1246690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2023] [Accepted: 09/29/2023] [Indexed: 10/28/2023] Open
Abstract
Fibula free flaps (FFF) represent a working horse for different reconstructive scenarios in facial surgery. While FFF were initially established for mandible reconstruction, advancements in planning for microsurgical techniques have paved the way toward a broader spectrum of indications, including maxillary defects. Essential factors to improve patient outcomes following FFF include minimal donor site morbidity, adequate bone length, and dual blood supply. Yet, persisting clinical and translational challenges hamper the effectiveness of FFF. In the preoperative phase, virtual surgical planning and artificial intelligence tools carry untapped potential, while the intraoperative role of individualized surgical templates and bioprinted prostheses remains to be summarized. Further, the integration of novel flap monitoring technologies into postoperative patient management has been subject to translational and clinical research efforts. Overall, there is a paucity of studies condensing the body of knowledge on emerging technologies and techniques in FFF surgery. Herein, we aim to review current challenges and solution possibilities in FFF. This line of research may serve as a pocket guide on cutting-edge developments and facilitate future targeted research in FFF.
Collapse
Affiliation(s)
- Helena Baecher
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Cosima C. Hoch
- Medical Faculty, Friedrich Schiller University Jena, Jena, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
- Division of Plastic Surgery, Department of Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, United States
- Department of Plastic Surgery and Hand Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Bhagvat J. Maheta
- College of Medicine, California Northstate University, Elk Grove, CA, United States
| | - Martin Kauke-Navarro
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| | - Ali-Farid Safi
- Craniologicum, Center for Cranio-Maxillo-Facial Surgery, Bern, Switzerland
- Faculty of Medicine, University of Bern, Bern, Switzerland
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Leonard Knoedler
- Department of Plastic, Hand and Reconstructive Surgery, University Hospital Regensburg, Regensburg, Germany
- Division of Plastic Surgery, Department of Surgery, Yale New Haven Hospital, Yale School of Medicine, New Haven, CT, United States
| |
Collapse
|
31
|
Hoch CC, Wollenberg B, Lüers JC, Knoedler S, Knoedler L, Frank K, Cotofana S, Alfertshofer M. ChatGPT's quiz skills in different otolaryngology subspecialties: an analysis of 2576 single-choice and multiple-choice board certification preparation questions. Eur Arch Otorhinolaryngol 2023; 280:4271-4278. [PMID: 37285018 PMCID: PMC10382366 DOI: 10.1007/s00405-023-08051-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 43.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Accepted: 05/26/2023] [Indexed: 06/08/2023]
Abstract
PURPOSE With the increasing adoption of artificial intelligence (AI) in various domains, including healthcare, there is growing acceptance and interest in consulting AI models to provide medical information and advice. This study aimed to evaluate the accuracy of ChatGPT's responses to practice quiz questions designed for otolaryngology board certification and decipher potential performance disparities across different otolaryngology subspecialties. METHODS A dataset covering 15 otolaryngology subspecialties was collected from an online learning platform funded by the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, designed for board certification examination preparation. These questions were entered into ChatGPT, with its responses being analyzed for accuracy and variance in performance. RESULTS The dataset included 2576 questions (479 multiple-choice and 2097 single-choice), of which 57% (n = 1475) were answered correctly by ChatGPT. An in-depth analysis of question style revealed that single-choice questions were associated with a significantly higher rate (p < 0.001) of correct responses (n = 1313; 63%) compared to multiple-choice questions (n = 162; 34%). Stratified by question categories, ChatGPT yielded the highest rate of correct responses (n = 151; 72%) in the field of allergology, whereas 7 out of 10 questions (n = 65; 71%) on legal otolaryngology aspects were answered incorrectly. CONCLUSION The study reveals ChatGPT's potential as a supplementary tool for otolaryngology board certification preparation. However, its propensity for errors in certain otolaryngology areas calls for further refinement. Future research should address these limitations to improve ChatGPT's educational use. An approach, with expert collaboration, is recommended for the reliable and accurate integration of such AI models.
Collapse
Affiliation(s)
- Cosima C Hoch
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich (TUM), Ismaningerstrasse 22, 81675, Munich, Germany.
| | - Barbara Wollenberg
- Department of Otolaryngology, Head and Neck Surgery, School of Medicine, Technical University of Munich (TUM), Ismaningerstrasse 22, 81675, Munich, Germany
| | - Jan-Christoffer Lüers
- Department of Otorhinolaryngology, Head and Neck Surgery, Medical Faculty, University of Cologne, 50937, Cologne, Germany
| | - Samuel Knoedler
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, 02152, USA
- Department of Plastic Surgery and Hand Surgery, Klinikum Rechts Der Isar, Technical University of Munich, Munich, Germany
| | - Leonard Knoedler
- Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, 02115, USA
| | | | - Sebastian Cotofana
- Department of Dermatology, Erasmus Hospital, Rotterdam, The Netherlands
- Centre for Cutaneous Research, Blizard Institute, Queen Mary University of London, London, UK
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| |
Collapse
|
32
|
Li XR, Hong WJ, Luo SK, Zhang YL, Li WM, Moellhoff N, Freytag DL, Nikolis A, Alfertshofer M, Cotofana S. A Computed Tomographic Investigation of the Ophthalmic Artery Volume and Its Relevance to Soft Tissue Filler Injections. Aesthet Surg J 2023; 43:1025-1032. [PMID: 36866393 DOI: 10.1093/asj/sjad051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND The measured intraarterial volume of cadaveric ophthalmic arteries was utilized for safety recommendations during facial soft tissue filler injections. However, its clinical practicability and model applicability have become questionable. OBJECTIVES To measure the volume of the ophthalmic artery in living individuals by utilizing computed tomography (CT) imaging technology. METHODS A total of 40 Chinese patients (23 males, 17 females) were included in this study with a mean age of 61.0 (14.2) years and a mean body mass index of 23.7 (3.3) kg/m2. Patients were investigated with CT imaging technology to evaluate the length, diameter, and volume of the bilateral ophthalmic arteries as well as the length of the bony orbits, resulting in a total of 80 investigated ophthalmic arteries and orbits. RESULTS Independent of gender, the average length of the ophthalmic artery was 80.6 (18.7) mm, the calculated volume of the ophthalmic artery was 0.16 (0.05) mL and the minimal and maximal internal diameter of the ophthalmic artery were 0.50 (0.05) mm and 1.06 (0.1) mm, respectively. CONCLUSIONS Based on the results obtained from the investigation of 80 ophthalmic arteries it must be concluded that current safety recommendations should be reevaluated. The volume of the ophthalmic artery appears to be 0.2 mL rather than 0.1 mL as previously reported. In addition, it appears impractical to limit the volume of soft tissue filler bolus injections to 0.1 mL due to the aesthetic requirements of each individual patient and treatment plan.
Collapse
|
33
|
Chu X, Xiong Y, Knoedler S, Lu L, Panayi AC, Alfertshofer M, Jiang D, Rinkevich Y, Lin Z, Zhao Z, Dai G, Mi B, Liu G. Immunomodulatory Nanosystems: Advanced Delivery Tools for Treating Chronic Wounds. Research (Wash D C) 2023; 6:0198. [PMID: 37456931 PMCID: PMC10348408 DOI: 10.34133/research.0198] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 07/02/2023] [Indexed: 07/18/2023]
Abstract
The increasingly aging society led to a rise in the prevalence of chronic wounds (CWs), posing a significant burden to public health on a global scale. One of the key features of CWs is the presence of a maladjusted immune microenvironment characterized by persistent and excessive (hyper)inflammation. A variety of immunomodulatory therapies have been proposed to address this condition. Yet, to date, current delivery systems for immunomodulatory therapy remain inadequate and lack efficiency. This highlights the need for new therapeutic delivery systems, such as nanosystems, to manage the pathological inflammatory imbalance and, ultimately, improve the treatment outcomes of CWs. While a plethora of immunomodulatory nanosystems modifying the immune microenvironment of CWs have shown promising therapeutic effects, the literature on the intersection of immunomodulatory nanosystems and CWs remains relatively scarce. Therefore, this review aims to provide a comprehensive overview of the pathogenesis and characteristics of the immune microenvironment in CWs, discuss important advancements in our understanding of CW healing, and delineate the versatility and applicability of immunomodulatory nanosystems-based therapies in the therapeutic management of CWs. In addition, we herein also shed light on the main challenges and future perspectives in this rapidly evolving research field.
Collapse
Affiliation(s)
- Xiangyu Chu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Yuan Xiong
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Samuel Knoedler
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02152, USA
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Max-Lebsche-Platz 31, 81377 Munich, Germany
| | - Li Lu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Adriana C Panayi
- Division of Plastic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02152, USA
- Department of Hand, Plastic and Reconstructive Surgery, Microsurgery, Burn Center, BG Trauma Center Ludwigshafen, University of Heidelberg, Ludwig-Guttmann-Strasse 13, 67071 Ludwigshafen/Rhine, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Dongsheng Jiang
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Max-Lebsche-Platz 31, 81377 Munich, Germany
| | - Yuval Rinkevich
- Institute of Regenerative Biology and Medicine, Helmholtz Zentrum München, Max-Lebsche-Platz 31, 81377 Munich, Germany
| | - Ze Lin
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Zhiming Zhao
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Orthopedics, Suizhou Hospital, Hubei University of Medicine, Suizhou 441300, China
| | - Guandong Dai
- Pingshan District People's Hospital of Shenzhen, Pingshan General Hospital of Southern Medical University, Shenzhen, Guangdong 518118, China
| | - Bobin Mi
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| | - Guohui Liu
- Department of Orthopedics, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Hubei Province Key Laboratory of Oral and Maxillofacial Development and Regeneration, Wuhan 430022, China
| |
Collapse
|
34
|
Cotofana S, Hong WJ, Horne J, Harris S, Surek CC, Frank K, Alfertshofer M, Kattil PK, Sakuma T, Onishi EC, Bertucci V, Green JB, Smith MP, Khan A, Lowry N. Intralabial Lip Compartments and their Potential Clinical Relevance. Plast Reconstr Surg 2023:00006534-990000000-01982. [PMID: 37314374 DOI: 10.1097/prs.0000000000010820] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
BACKGROUND Aesthetic soft tissue filler injections for lip enhancement are highly popular and are performed throughout the world. When injecting lips with cannulas, as the cannula is advanced, resistance is perceived in consistent locations potentially indicating boundaries between intralabial compartments. OBJECTIVE To investigate whether intra-labial compartments exist and (if so) to describe their volumes, location, boundaries, and dimensions. METHODS This cadaveric study investigated a total of n = 20 (13 males, 7 females) human body donors with a mean age at death of 61.9 (23.9) years and a mean body mass index of 24.3 (3.7) kg/m 2. The investigated cohort included n = 11 Caucasian, n = 8 Asian, and n = 1 African American donors. Dye injections simulating minimally invasive lip treatments were conducted. RESULTS Independent of gender or race, 6 anterior and 6 posterior compartments in the upper and lower lip were identified, for a total of 24 lip compartments. Compartment boundaries were formed by vertically oriented septations that were found in consistent locations. The anterior compartments had volumes ranging from 0.30 - 0.39 cc whereas the posterior compartment volume ranged from 0.44 - 0.52 cc. Centrally, the compartment volumes were larger and decreased gradually towards the oral commissure. CONCLUSION The volume and the size of each of the 24 compartments contribute to the overall appearance and shape of the lips. To achieve a natural and lip-shape preserving aesthetic outcome it may be preferable to administer the volumizing product using a compartment-respecting injection approach.
Collapse
Affiliation(s)
- Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Wei-Jin Hong
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou City, People's Republic of China
| | | | | | | | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Punnose K Kattil
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | | | - Emy C Onishi
- Department of Dermatology, University of the Philippines, Philippine General Hospital, Manila, Philippines
| | | | - Jeremy B Green
- Skin Associates of South Florida, Skin Research Institute, Miami, FL, USA
| | - Michael P Smith
- Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, NY, USA
| | - Amanda Khan
- Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, NY, USA
| | - Natalia Lowry
- Division of Anatomy, Department of Medical Education, Albany Medical College, Albany, NY, USA
| |
Collapse
|
35
|
Casabona G, Kaye K, Cotofana S, Davidovic K, Alfertshofer M, Freytag L. Histological effects of a combined collagen stimulation procedure consisting of microfocused ultrasound, soft tissue filler, and Ca-HA injections. J Cosmet Dermatol 2023; 22:1724-1730. [PMID: 37073423 DOI: 10.1111/jocd.15770] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 03/06/2023] [Accepted: 03/30/2023] [Indexed: 04/20/2023]
Abstract
BACKGROUND An increasing demand for in-office aesthetic procedures aiming to improve collagen stimulation has been reported. OBJECTIVE To analyze the effects of combinations of different aesthetic collagen stimulation procedures using histological analysis. METHODS Histological analysis was performed on skin samples of the excess skin of a 60-year-old patient after sub-superficial musculo-aponeurotic system facelift surgery. The excess skin before facelift surgery was divided into three areas per hemiface. Each area-with exception of area A as a control-received an isolated or combined treatment of microfocused ultrasound (MFU), injections of calcium-hydroxylapatite/hyaluronic-acid-based soft tissue filler, and microneedling. The effect of the treatments was analyzed using histological analysis with H&E coloration and PAS staining. RESULTS A threefold increase of epidermal and dermal thickness was achieved by treating the skin with the proposed combined treatment comprising MFU and injections of calcium-hydroxylapatite- and hyaluronic-acid-based soft tissue fillers. CONCLUSION The investigated treatments act synergistically in the production of collagen and combining these treatments allows for an increase in collagen production.
Collapse
Affiliation(s)
| | | | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, Serbia
| | - Michael Alfertshofer
- Division of Hand-, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Lysander Freytag
- Department of Plastic Surgery, Community Hospital Havelhöhe Berlin, Berlin, Germany
| |
Collapse
|
36
|
van den Elzen HE, Barends AJ, van Vugt M, Biesman BS, Alfertshofer M, Cotofana S, Velthuis PJ. Facial aesthetic minimally invasive procedure: More than just vanity, a social-psychological approach. J Cosmet Dermatol 2023. [PMID: 36852750 DOI: 10.1111/jocd.15678] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 01/07/2023] [Accepted: 01/30/2023] [Indexed: 03/01/2023]
Abstract
BACKGROUND Due to the great importance of the face in social interaction, minimally invasive treatments can-besides their ability to rejuvenate and enhance beauty-also change the way facial impressions of a person are perceived. In recent literature, three main character traits (attractiveness, trustworthiness, and competence) and subdomains essential for facial perception were described. OBJECTIVE To investigate whether minimally invasive procedures truly influence different character traits when evaluated by independent, objective observers. METHODS Photographs of n = 34 female faces before and after treatment with injectable fillers and botulinum toxin were rated by 393 individuals without aesthetic background with regards to different character traits on a 7-point Likert scale. Tests for dimensionality were performed, and composite scores of the impressions underlying each of the three dimensions were created and compared using within-subjects t tests. RESULTS Treatments statistically significantly improved the overarching character trait domains attractiveness, trustworthiness, and competence in posttreatment photographs compared with pretreatment. Posttreatment ratings of the respective subdomains also showed a statistically significant difference compared with pretreatment photographs, with the exception of the subdomain dominance which failed to reach statistical significance. CONCLUSION Impressions of facial attractiveness, trustworthiness, and competence can be improved by injectables while the naturalness of the face is left intact. An implication is that the improvement of traits highly relevant to social interaction will accommodate the patient's desires for beautification and rejuvenation.
Collapse
Affiliation(s)
| | - Ard J Barends
- Department of Experimental and Applied Psychology, Institute for Brain and Behaviour, Amsterdam, The Netherlands
| | - Mark van Vugt
- Department of Experimental and Applied Psychology, Institute for Brain and Behaviour, Amsterdam, The Netherlands
| | | | - Michael Alfertshofer
- Department of Hand-, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Peter J Velthuis
- Department of Dermatology, Erasmus Medical Center, Rotterdam, The Netherlands
| |
Collapse
|
37
|
Calomeni M, Bravo BSF, Schelke LW, Velthuis PJ, Schalet G, Frank K, Guertler A, Alfertshofer M, Cotofana S, Moellhoff N. Precision of Soft-Tissue Filler Injections: An Ultrasound-Based Verification Study. Aesthet Surg J 2023; 43:353-361. [PMID: 36281772 DOI: 10.1093/asj/sjac272] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 10/14/2022] [Accepted: 10/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility. OBJECTIVES The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula. METHODS This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection. RESULTS A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area. CONCLUSIONS Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers. LEVEL OF EVIDENCE: 5
Collapse
Affiliation(s)
- Mariana Calomeni
- Dermatology Department, Bravo Private Clinic, Rio de Janeiro, Brazil
| | - Bruna S F Bravo
- Dermatology Department, Bravo Private Clinic, Rio de Janeiro, Brazil
| | - Leonie W Schelke
- Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Peter J Velthuis
- Department of Dermatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Grant Schalet
- Department of Surgery, Broward Health Medical Center, Ft. Lauderdale, FL, USA
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Anne Guertler
- Department of Dermatology and Allergy, University Hospital, LMU Munich, Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
38
|
Frank K, Ehrl D, Bernardini F, Walbrun A, Moellhoff N, Alfertshofer M, Davidovic K, Mardini S, Gotkin RH, Cotofana S. How We Look At Mature Faces-An Eye-Tracking Investigation Into the Perception of Age. Aesthet Surg J 2023; 43:115-122. [PMID: 36099471 DOI: 10.1093/asj/sjac251] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Revised: 09/06/2022] [Accepted: 09/06/2022] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses. OBJECTIVES The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face. METHODS Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 > 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (<40 years) and older (>40 years) gender-matched individuals were presented in a standardized setting. RESULTS Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P < 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer's age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers. CONCLUSIONS It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan.
Collapse
Affiliation(s)
- Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Denis Ehrl
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | | | - Alina Walbrun
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Kristina Davidovic
- Department of Radiology and Medical School, University of Belgrade, Belgrade, Serbia
| | - Samir Mardini
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | | | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| |
Collapse
|
39
|
Hernandez CA, Zapata DEU, Bermudez MP, Frank K, Moellhoff N, Alfertshofer M, Gotkin RH, Davidovic K, Cotofana S. Clinical validation of the upper face first principle-A clinical, prospective, interventional split-face study. J Cosmet Dermatol 2023; 22:418-425. [PMID: 36573471 DOI: 10.1111/jocd.15563] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 11/03/2022] [Accepted: 11/29/2022] [Indexed: 12/28/2022]
Abstract
BACKGROUND Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First. OBJECTIVE To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face. METHODS This study was designed as an interventional split-face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m2 (1.7) were studied. Follow-up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging. RESULTS Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow-up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001. CONCLUSION Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.
Collapse
Affiliation(s)
| | | | | | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, LMU University Hospital, Munich, Germany
| | | | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, Clinical Center of Serbia, Belgrade, Serbia
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
40
|
Casabona G, Alfertshofer M, Kaye K, Frank K, Moellhoff N, Davidovic K, Cotofana S. Ex-Vivo Product Distribution of Injectable Biostimulator Substances. Aesthet Surg J 2023; 43:NP348-NP356. [PMID: 36662772 DOI: 10.1093/asj/sjad014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 01/17/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
BACKGROUND Previously, an increasing demand for minimally invasive aesthetic treatments such as injection of biostimulator substances to induce the production of extracellular matrix (ECM) has been reported. Recent studies have reported on a variety of different product characteristics influencing the integration and distribution of biostimulator substances after injection. OBJECTIVES To analyze ex-vivo product integration and distribution behavior of six different biostimulator substances after injection. METHODS A total of n = 21 abdominal soft tissue flaps were analyzed with regards to horizontal and vertical spread of six different injected biostimulator substances immediately after injection and after massaging using real-time ultrasound imaging. The six different biostimulator substances were: R-CaHA-based, H-CaHA-based, PCL-based, PLLA-1-based, PLLA-2-based and H-HA-based products. RESULTS Overall, the R-CaHA-, H-CaHA- and PCL-based substances showed greater product spread after massaging when compared to the product distribution immediately after the injection with all p < 0.001 with exception for the vertical dimension of the H-CaHA-based substance with p = 0.064. The PLLA-1-, PLLA-2- and H-HA-based substances showed smaller product spread after massaging when compared to the product distribution immediately after the injection with all p < 0.001 with exception for the horizontal dimension of the H-HA-based substance with p = 0.314 indicating higher tissue integration. CONCLUSIONS Different biostimulator substances behave differently when injected into subcutaneous soft tissues while differences exist at the level of initial product diffusion and during tissue integration.
Collapse
Affiliation(s)
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Kai Kaye
- Physicians in private practice in Marbella, Spain
| | | | | | - Kristina Davidovic
- Center for Radiology and Magnetic Resonance Imaging, University Clinical Center of Serbia, Belgrade, Serbia
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN
| |
Collapse
|
41
|
Alfertshofer M, Engerer N, Frank K, Moellhoff N, Freytag DL, Cotofana S. Multimodal Analyses of the Aging Forehead and Their Clinical Implications. Aesthet Surg J 2023:6988321. [PMID: 36647564 DOI: 10.1093/asj/sjad009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Recent research has indicated that in the upper face a delicate arrangement exists between the muscles of facial expression and the skin. This arrangement allows for immediate transmission of movements following muscle contraction which results in skin movements and skin rhytid formation. OBJECTIVES To investigate age-related changes to the biomechanical unit formed between facial muscles, connective tissue envelope, and skin in the upper face. METHODS A total of n = 76 Caucasian volunteers (30 males, 46 females) with a mean age of 42.2 (18.6) years and a mean body mass index of 24.58 (3.7) kg/m2 were investigated. Three upper facial regions were analyzed for skin firmness and elasticity via cutometry, vertical and horizontal skin vector displacement via 3D-imaging, and muscle activity via surface-derived electromyography. RESULTS Study participants of older age (> 42.2 years) (when compared to younger participants; ≤ 42.2 years) showed increased skin firmness with 0.20 mm vs 0.30 mm with p < 0.001, decreased skin elasticity with 53.2% vs 69.0% (p < 0.001), increased vertical (not horizontal) skin mobility with 3.56 mm vs 1.35 mm (p < 0.001), and decreased muscle sEMG derived signal of the frontalis muscle with 309 µV vs 174 µV (p = 0.039). CONCLUSIONS This study reveals that age-related changes occur in each of the components of the biomechanical unit formed between facial muscles, connective tissue envelope, and skin in the upper face. Knowledge and understanding of such changes can allow for more targeted and individualized surgical and non-surgical aesthetic treatments.
Collapse
Affiliation(s)
- Michael Alfertshofer
- Physicians, Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - Nina Engerer
- Medical student, Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | | | - Nicholas Moellhoff
- Physicians, Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Germany
| | - David L Freytag
- Physician, Department of Plastic Surgery, Gemeinschaftsklinikum Havelhoehe, Berlin, Germany
| | - Sebastian Cotofana
- Associate professor of anatomy, Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN
| |
Collapse
|
42
|
Schelke LW, Velthuis PJ, Decates T, Kadouch J, Alfertshofer M, Frank K, Cotofana S. Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management. Aesthet Surg J 2023; 43:86-96. [PMID: 35951759 DOI: 10.1093/asj/sjac227] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 07/31/2022] [Accepted: 08/01/2022] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable of enzymatically degrading the injected product and improving clinical symptoms. Two protocols are currently available to manage such complications: "ultrasound-guided targeted" and "flooding". OBJECTIVES The aim of this study was to compare the 2 protocols in terms of the volume of hyaluronidase utilized, and the onset and degree of clinical improvement. METHODS A comparative case series of 39 patients was retrospectively evaluated. The patients were initially treated with the "flooding" protocol and then treated with the "ultrasound-guided targeted" protocol due to no or little improvement. RESULTS The "ultrasound-guided targeted" protocol utilized a mean [standard deviation] total of 122.5 [34] IU of hyaluronidase, whereas the "flooding" protocol utilized 1519.4 [1137] IU, which represents a statistically significant reduced amount of injected hyaluronidase (P = 0.028). There was no clinical improvement in 92.3% and only little improvement in 7.7% of the treated patients following the first applied "flooding" protocol, but there was a 100% immediate improvement when subsequently treated with the "ultrasound-guided targeted" protocol. Ultrasound imaging revealed that the application of hyaluronidase restored normal blood flow both in the perivascular space and in the superficially located subdermal soft tissues. CONCLUSIONS Despite its limitations in study design, this retrospectively evaluated case series revealed that the "ultrasound-guided targeted" protocol utilized less hyaluronidase and restored clinically visible symptoms faster. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies. LEVEL OF EVIDENCE: 4
Collapse
|
43
|
Hilton S, Frank K, Alfertshofer M, Cotofana S. Clinical outcomes after lip injection procedures-Comparison of two hyaluronic acid gel fillers with different product properties. J Cosmet Dermatol 2023; 22:119-127. [PMID: 36459413 DOI: 10.1111/jocd.15548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Revised: 11/02/2022] [Accepted: 11/21/2022] [Indexed: 12/03/2022]
Abstract
BACKGROUND Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection-site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods. OBJECTIVES To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies. METHODS In a study sample of 40 subjects, treatment with two soft tissue filler product (HARK or HAJUS ) was randomly assigned. Subjects were injected with 0.5 cc per upper and lower lip using a standardized injection procedure. Early-onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post-Day 14 were assessed up to 24 weeks. RESULTS In subjects treated with HARK , the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HAJUS . Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment-related AEs post-Day 14 mostly related to the implant site; most were mild-to-moderate, and none were serious. CONCLUSIONS The intensity of early-onset swelling, and other injection-site reactions was lower in subjects treated with HARK than in subjects treated with HAJUS . Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post-Day 14, however, were similar between filler groups.
Collapse
Affiliation(s)
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| |
Collapse
|
44
|
Harris S, Alfertshofer M, Allen R, Castellari F, Othoro D, Bran G, Cotofana S. Introduction of the Lip Classification of Tubercles: A Novel Approach to Minimally Invasive Aesthetic Lip Treatments. Aesthet Surg J Open Forum 2023; 5:ojad007. [PMID: 36937993 PMCID: PMC10016322 DOI: 10.1093/asjof/ojad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2023] Open
Abstract
Background Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic treatments. However, current trends are associated with unnatural results and involve increased risks of complications and compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function. Objectives To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification of Tubercles (LCT). Methods To test the reliability of the LCT, a total of 214 high-definition photographs of patients' lips with no previous histories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions 3 months apart; the second followed a more detailed explanation of the classification. Results When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was considered the standard, the average score for the remaining 3 showed some individual variation but improved significantly from 58% to 85%. Conclusions The LCT is a reliable way to classify lip types based on the morphology of tubercles. Level of Evidence 3
Collapse
Affiliation(s)
- Steven Harris
- Corresponding Author: Dr Steven Harris, 48 Crouch Hall Road, London N8 8HJ, UK. E-mail: ; Instagram: drharrisclinic
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilians-University Munich, Germany
| | - Rory Allen
- Department of Psychology, Goldsmiths, University of London, UK
| | | | | | | | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| |
Collapse
|
45
|
Bravo BSF, de Melo Carvalho R, Penedo L, de Bastos JT, Calomeni Elias M, Cotofana S, Frank K, Moellhoff N, Freitag L, Alfertshofer M. Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures. J Cosmet Dermatol 2022; 21:5864-5871. [PMID: 35634970 DOI: 10.1111/jocd.15131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 04/21/2022] [Accepted: 05/25/2022] [Indexed: 12/27/2022]
Abstract
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.
Collapse
Affiliation(s)
| | | | - Lais Penedo
- Dermatology Department, Bravo Private Clinic, Rio de Janeiro, Brazil
| | | | | | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany
| | - Lysander Freitag
- Department of General Surgery, Community Hospital Havelhöhe, Berlin, Germany
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany
| |
Collapse
|
46
|
Li ZH, Alfertshofer M, Hong WJ, Li XR, Zhang YL, Moellhoff N, Frank K, Luo SK, Cotofana S. Upper Facial Anastomoses Between the External and Internal Carotid Vascular Territories - A 3D Computed Tomographic Investigation. Aesthet Surg J 2022; 42:1145-1151. [PMID: 35305018 DOI: 10.1093/asj/sjac060] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Facial regions with a high risk for causing injection-related visual comprise are dual-supply vascular areas such as the nose, glabella, and forehead. These regions have in common that they receive arterial blood supply both by branches of the internal (ICA) and the external carotid artery (ECA). OBJECTIVE The authors sought to investigate the anastomotic pathways between ICA and ECA branches in the upper face. METHODS Postmortem computed tomographic angiographic scans of n = 38 Chinese non-embalmed hemifaces (25 males, 13 females; mean age, 37.79 [11.8] years; mean BMI, 21.90 [2.3] kg/m2) were conducted. Data analysis relied on the calculation of depth, distances, and pathways of forehead and temporal arteries to investigate the number of anastomotic connections, the connecting branches, and the layer of connection between ICA and ECA territories. RESULTS Between ICA and ECA territories, only 1 connection in 57.9%, 2 connections in 31.6%, 3 connections in 5.3%, and 4 and 5 connections in 2.6% each were identified. A superficial connection was observed in 15.8% whereas in 84.2% the anastomotic connection was identified to be both superficial and deep. CONCLUSIONS Adverse events following facial minimally invasive soft-tissue filler injections for aesthetic purposes are not frequent but devastating if they occur. Anatomic knowledge as presented in this study can help to increase awareness of 3-dimensional vascular anastomotic pathways and identify safer injection zones and safer fascial planes. Evidence-based injection techniques should be followed, and safety aspects should be placed over the aesthetic outcome.
Collapse
Affiliation(s)
- Zhen-Hao Li
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University, Munich, Germany
| | - Wei-Jin Hong
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Xin-Rui Li
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - You-Liang Zhang
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University, Munich, Germany
| | | | - Sheng-Kang Luo
- Department of Plastic and Reconstructive Surgery, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA
| |
Collapse
|
47
|
Kantelhardt C, Frank K, Kohler L, Cotofana S, Alfertshofer M, Hagen CS, Walbrun A, Karcz K, Giunta RE, Möllhoff N. [Change of Gaze Pattern depending on the Stage of DIEP Flap Breast Reconstruction: a Preliminary Eye-Tracking Investigation]. HANDCHIR MIKROCHIR P 2022; 54:356-362. [PMID: 35944538 DOI: 10.1055/a-1794-5951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Breast reconstruction using autologous tissue is an integral part of breast cancer treatment. While many studies have elucidated the impact of breast reconstruction on patients' quality of life, self-esteem, sexuality and more, there is a lack of objective data regarding the effects on external observers. Aim of this study was to investigate the change in gaze pattern of independent observers depending on the stage of DIEP-flap breast reconstruction. MATERIALS AND METHODS Eye-tracking technology was utilized to analyze the eye movements of 58 study participants while viewing 2 D photographs of a patient after mastectomy and different stages of DIEP-flap breast reconstruction. Time until first fixation and total time of fixation were recorded and con- secutively analyzed for the right and left breast on each image. RESULTS Overall, the total time of fixation of the operated breast decreased significantly over the different stages of breast reconstruction, with p<0.001. At the same time, there was no statistically significant change in total time of fixation of the non-operated breast, with p=0.174. The time until first fixation showed a significant increase over the different stages of reconstruction for the reconstructed breast, with p<0.001, while no significant differences were found for the opposite breast, with p=0.344. CONCLUSION Mastectomy and the individual steps of breast reconstruction alter the perception of breast cancer patients. Over the course of breast reconstruction, the deviation of gaze in the direction of the affected breast is reversed.
Collapse
Affiliation(s)
- Chiara Kantelhardt
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Konstantin Frank
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Lukas Kohler
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Sebastian Cotofana
- Mayo Clinic College of Medicine and Science, Department of Clinical Anatomy
| | - Michael Alfertshofer
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Christine Sophie Hagen
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Alina Walbrun
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Konrad Karcz
- Klinikum der Universität München, Klinik für Allgemeine-, Viszeral-, und Transplantationschirurgie
| | - Riccardo E Giunta
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| | - Nicholas Möllhoff
- Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie
| |
Collapse
|
48
|
Engerer N, Frank K, Moellhoff N, Alfertshofer M, Giunta RE, Green JB, Lorenc PZ, Chaney GK, Ehrl D, Cotofana S. Aging of the Neck Decoded: New Insights for Minimally Invasive Treatments. Aesthetic Plast Surg 2022; 46:1698-1705. [PMID: 35701594 DOI: 10.1007/s00266-022-02961-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/17/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Many signs of aging manifest in the neck region, including platysmal bands, excess skin, horizontal neck lines and decreasing contour of the neck. While the clinical signs of an aged neck are well-known, data determining the underlying aging process are limited. OBJECTIVE To decode aging of the neck. MATERIALS AND METHODS This prospective study investigated elasticity and firmness of skin, muscle activity and skin displacement upon muscular contraction in the neck in 77 young-, middle- and old-age individuals. Objective outcome measures, including 3-dimensional imaging, cutometry and surface electromyography, were utilized for all assessments. RESULTS Mean firmness of skin decreased significantly from young to old individuals (0.37 ± 0.13 mm, 0.30 ± 0.12 mm and 0.26 ± 0.12 mm in young, middle and old subjects, respectively; p < 0.001). Gross elasticity decreased significantly from 75.1 ± 13.0% in young subjects, to 64.53 ± 15.7% in middle-aged subjects and 55.79 ± 13.0% in old subjects (p < 0.001). The mean y-axis skin displacement increased from 2.48 ± 4.33 mm in young subjects, to 3.11 ± 4.49 mm in middle-aged subjects and 3.61 ± 5.38 mm in old subjects (p = 0.006). The mean signal-to-noise ratio decreased significantly from 16.74 ± 5.77 µV in young subjects, to 14.41 ± 4.86 µV in middle-aged subjects and to 12.23 ± 5.99 µV in old subjects (p < 0.001). CONCLUSION This study provides insights into the interplay between skin elasticity, muscular activity and the reflected movement of the skin of the neck. Appreciation of these age-related changes lays the fundament for aesthetic treatments in this delicate region. 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 .
Collapse
Affiliation(s)
- Nina Engerer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Nicholas Moellhoff
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Riccardo E Giunta
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Jeremy B Green
- Skin Associates of South Florida and Skin Research Institute, Coral Gables, Florida, USA
| | | | - Grace K Chaney
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA
| | - Denis Ehrl
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University Munich, Munich, Germany
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.
| |
Collapse
|
49
|
Hernandez CA, Alfertshofer M, Frank K, Freytag L, Gavril DL, Davidovic K, Gotkin RH, Mercado-Perez A, Mardini S, Cotofana S. Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures. Aesthetic Plast Surg 2022; 46:2237-2245. [PMID: 35648191 DOI: 10.1007/s00266-022-02921-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2022] [Accepted: 04/16/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position. OBJECTIVE The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions. METHODS This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m2. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity. RESULTS The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001. CONCLUSION Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs. 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 .
Collapse
Affiliation(s)
| | - Michael Alfertshofer
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Konstantin Frank
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | - Lysander Freytag
- Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany
| | | | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade, Belgrade, Serbia
| | | | - Arnaldo Mercado-Perez
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA
| | - Samir Mardini
- Department of Plastic and Reconstructive Surgery, Mayo Clinic, Rochester, MN, USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.
| |
Collapse
|
50
|
Hernandez CA, Davidovic K, Avelar LET, Alfertshofer M, Freytag DL, Frank K, Moellhoff N, Bihun R, Green JB, Cotofana S. Facial Soft Tissue Repositioning With Neuromodulators: Lessons Learned From Facial Biomechanics. Aesthet Surg J 2022; 42:1163-1171. [PMID: 35416929 DOI: 10.1093/asj/sjac090] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023] Open
Abstract
BACKGROUND Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral peri-orbital region underscoring the versatility of neuromodulator treatments. OBJECTIVE To analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. METHODS Seventy-five study participants (8 males, 67 females) with a mean age of 37.5 (8.5) years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement using 3-dimensional imaging at baseline, day 14 and day 30. RESULTS 3-dimensional volume analysis revealed an increase in midfacial volume by 0.46 cc, and a decrease of the lower facial volume by 0.30 cc compared to baseline. Additionally, an improvement of midfacial fullness (change of 0.13) and jawline contour (change of 0.44) was reported on clinical rating scales at day 30 compared to baseline. CONCLUSIONS Facial soft tissues can be repositioned during the 30 days follow-up period following a neuromodulator treatment; this was reflected through an increase in middle facial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.
Collapse
Affiliation(s)
| | - Kristina Davidovic
- Department of Radiology & Medical School, University of Belgrade , Belgrade, Serbia
| | | | - Michael Alfertshofer
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - David L Freytag
- Department of General Surgery, Community Hospital Havelhöhe , Berlin , Germany
| | - Konstantin Frank
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - Nicholas Moellhoff
- Division of Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich , Munich , Germany
| | - Rebekah Bihun
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| | - Jeremy B Green
- Skin Associates of South Florida and Skin Research Institute , Coral Gables, FL , USA
| | - Sebastian Cotofana
- Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science , Rochester , MN , USA
| |
Collapse
|