Gravity in Midfacial Aging: A 3-Dimensional Study.

BACKGROUND: Volume loss and volume descent are complementary aspects of facial aging, although the respective contribution of each is unclear. OBJECTIVES: The aim of this study was to quantify in 3 dimensions the effects of gravity on the midface in both upright and supine positions in an older and a younger group of patients. METHODS: A prospective study was undertaken of 53 female patients who had not undergone treatment with dermal fillers or facial cosmetic surgery. Three-dimensional photography with a VECTRA H1 camera (Canfield Scientific, Fairfield, NJ) was taken in supine and sitting positions. Volume shifts and displacement of structures in 3 dimensions were measured and analyzed. RESULTS: Morphologically, upon shifting from sitting to supine position, the tail of the brow elevated, the tear trough filled, the buccal and malar fat shifted posteriosuperiorly, the earlobe decreased in height, the nasiolabial folds and marionette lines diminished, the modiolus shifted laterally, and the jowl diminished. Volumetric analysis revealed that the infraorbital region increased in volume by a mean [SD] of 0.59 [0.55] mL, the tear trough by 0.22 [0.19] mL, and the malar region by 1.2 [1.06] mL. With subjects in the supine position, all facial topographic landmarks displaced significantly from sitting position. CONCLUSIONS: Facial aging in this cohort was predominantly due to tissue descent rather than volume loss. Reversal of the gravitational force restores the 3D position of the facial subunits and leads to volumization in desirable locations that approximates a more youthful appearance. The volume restored via redistribution of facial fat is comparable to that typically injected during direct volume transfer procedures.

Observations on the Tear Trough.

BACKGROUND: The tear trough is a prominent structure of the midface. Many surgical and nonsurgical techniques have been devised to efface this feature. OBJECTIVES: The aim of this study was to define an aesthetically pleasing tear trough and understand the effect of various surgical procedures on its appearance. METHODS: We undertook a retrospective review of "ideal" subjects (ie, young men and women as well as male and female models) as well as surgical patients undergoing lower blepharoplasty with fat excision, fat transposition, erbium laser resurfacing of the eyelids and midface, or endoscopic midface lifting. Marginal reflex distance-2, lower eyelid length, and nasojugal fold depth were measured and analyzed for all patients. RESULTS: The nasojugal fold was significantly less prominent in ideal female models than in all other groups (P < 0.0001). Lower eyelid length was significantly shorter after fat excisional lower blepharoplasty, laser resurfacing, and midface lift (P < 0.0001), and did not change after fat transpositional lower blepharoplasty. Postsurgical reduction in lower eyelid length was significantly less with fat transpositional lower blepharoplasty than in all other groups (P < 0.0001). The nasojugal fold was significantly effaced after all types of procedures (P < 0.0001), but was significantly more effaced after fat transpositional lower blepharoplasty (P < 0.01) than after all other procedures. CONCLUSIONS: A slight, medial tear trough is present in youth in many patients. The clinical tear trough is a virtual topographic structure distinct from the anatomic tear trough ligament and can be altered in a variety of ways.

Effectiveness and cost of olanzapine and haloperidol in the treatment of schizophrenia: a randomized controlled trial.

CONTEXT: Although olanzapine has been widely adopted as a treatment of choice for schizophrenia, its long-term effectiveness and costs have not been evaluated in a controlled trial in comparison with a standard antipsychotic drug. OBJECTIVE: To evaluate the effectiveness and cost impact of olanzapine compared with haloperidol in the treatment of schizophrenia. DESIGN AND SETTING: Double-blind, randomized controlled trial with randomization conducted between June 1998 and June 2000 at 17 US Department of Veterans Affairs medical centers. PARTICIPANTS: Three hundred nine patients with a Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition diagnosis of schizophrenia or schizoaffective disorder, serious symptoms, and serious dysfunction for the previous 2 years. Fifty-nine percent fully completed and 36% partially completed follow-up assessments. INTERVENTIONS: Patients were randomly assigned to receive flexibly dosed olanzapine, 5 to 20 mg/d, with prophylactic benztropine, 1 to 4 mg/d (n = 159); or haloperidol, 5 to 20 mg/d (n = 150), for 12 months. MAIN OUTCOME MEASURES: Standardized measures of symptoms, quality of life, neurocognitive status, and adverse effects of medication. Veterans Affairs administrative data and interviews concerning non-VA service use were used to estimate costs from the perspective of the VA health care system and society as a whole (ie, consumption of all resources on behalf of these patients). RESULTS: There were no significant differences between groups in study retention; positive, negative, or total symptoms of schizophrenia; quality of life; or extrapyramidal symptoms. Olanzapine was associated with reduced akathisia in the intention-to-treat analysis (P<.001) and with lower symptoms of tardive dyskinesia in a secondary analysis including only observations during blinded treatment with study drug. Small but significant advantages were also observed on measures of memory and motor function. Olanzapine was also associated with more frequent reports of weight gain and significantly greater VA costs, ranging from 3000 dollars to 9000 dollars annually. Differences in societal costs were somewhat smaller and were not significant. CONCLUSION: Olanzapine does not demonstrate advantages compared with haloperidol (in combination with prophylactic benztropine) in compliance, symptoms, extrapyramidal symptoms, or overall quality of life, and its benefits in reducing akathisia and improving cognition must be balanced with the problems of weight gain and higher cost.

Risperidone in Elderly Schizophrenic Patients: An Open-Label Trial.

The authors assessed the safety and efficacy of risperidone in a group of elderly patients with chronic schizophrenia and behavioral disturbances (N = 10). There were no clinically significant changes on physical examination. Also, schizophrenic symptoms and cognitive performance improved during risperidone administration. Patients showed a sufficient improvement in both areas to warrant a larger, double-blind study assessing the effects of risperidone on cognitive and psychiatric symptoms in elderly psychotic patients.