The Research Trend of Soft Tissue Filler Injection from 2000 to 2022: A Bibliometric and Visualized Analysis.

Background: The demand for soft tissue filler injections has experienced a significant increase in recent years. Therefore, this study used bibliometric analysis to identify prominent research areas and emerging trends within the field. Methods: Publications concerning research on soft tissue filler injections were collected from the Web of Science Core Collection database. Subsequently, VOSviewer 1.6.18 and CiteSpace 6.2.R4 software were used to analyze the co-authorship, co-occurrence, and citations of countries, institutions, authors, hotspot keywords, and journals associated with these studies. Results: A total of 1370 records pertaining to filler injection research conducted between 2000 and 2022 were identified. The United States (524 publications) emerged as the country with the highest number of publications in this field, with Mayo Clinic (37 publications) making the most substantial contribution. Dermatologic Surgery emerged as the leading journal in this field, publishing the highest number of research articles (151 publications) and also being the most frequently co-cited. Cotofana proved to be the most prolific author with 51 publications, and Lemperle emerged as the most frequently co-cited author with 628 citations (including total link strength: 6587). The most popular keywords, in descending order of popularity, were "dermal filler," "injection," "soft-tissue augmentation," "complications," and "hyaluronic acid." Conclusions: The findings of this study offer a comprehensive overview of the main directions in filler injection research. Furthermore, they underscore the imperative of intensifying efforts to prevent complications linked to filler injections.

Use of LetibotulinumtoxinA for Aesthetic Treatment of Asians: A Consensus.

Treatment of wrinkles and dynamic lines with botulinum toxin has been a routine practice for years in aesthetic clinical settings. The effective treatment of wrinkles requires a comprehensive understanding of facial expression muscles and their interactions, the mechanism of action of botulinum toxin, and individual patient preferences. The dose adjustment practice and injection technique of physicians are affected by cultural differences; most Asian patients prefer natural-looking results. This article aims to present an expert consensus on the injection sites, doses, and levels of botulinum toxin for various indications in Asians, with the hope of providing guidance to some clinicians. This consensus paper reviews LetibotulinumtoxinA for patient evaluation, dosage, and delivery techniques in Asians from the time LetibotulinumtoxinA was approved up to December 2022. Panelists proposed individualized treatment plans for botulinum toxin type A (BTxA) treatments in 3 areas-wrinkle removal, contour adjustment, and face lifting-for Asians based on their extensive experience and knowledge of facial anatomy. When using a different BTxA, clinicians should start with a conservative dose and carefully individualize the treatment for each patient, and adjust it according to feedback to obtain a higher satisfaction level.

New Insight into Glabellar Arteries: A Three-Dimensional Computed Tomography and Dissection Study.

BACKGROUND: Vascular complications from glabellar intravascular filler injections are major safety concerns. Filler injection into the glabella without precise knowledge of its vascular topography poses a risk of severe complications. METHODS: Computed tomography was used to study 90 cadaveric heads after contrast agent and filler injection, and 15 cadaveric heads were dissected. RESULTS: Central (CAs), paracentral (PCAs), and reverse dorsal nasal arteries (rDNAs) were found in 70 (38.9%), 58 (32.2%), and 16 (8.9%) of the 180 hemifaces, respectively. Based on the presence of CAs, PCAs, and rDNAs between the bilateral supratrochlear arteries (STAs), glabellar arteries were categorized into two main patterns: in type 1 [without named arteries between bilateral STAs; 22 of 90 (24.4%)], the glabella was supplied by bilateral STAs and their branches; in type 2 [with named arteries between bilateral STAs; 68 of 90 (75.6%)], the glabella was supplied by bilateral STAs and CAs, PCAs, and rDNAs. Type 2 could be further divided into three subtypes: in type 2a [45 of 90 (50.0%)], the glabella was supplied by bilateral STAs and one of the named arteries; in type 2b [21 of 90 (23.3%)], the glabella was supplied by bilateral STAs and two of the named arteries; and in type 2c [two of 90 (2.3%)], the glabella was supplied by bilateral STAs and unilateral CA, PCA, and rDNA. CONCLUSION: This study elucidated novel arterial systems and proposed considerations for glabellar filler injection.

Positions of the Glabellar Arteries: Implications for Glabellar Injection.

BACKGROUND: Glabellar filler injection is linked to an increased risk of blindness. A thorough understanding of vascular changes in the glabellar area is critical for safety. The study's goal was to precisely determine the three-dimensional placements of the arteries in the glabellar area. METHODS: In 117 cadavers, the vascular structures in the glabellar area were examined. There were four segments (S1/S1'-S4/S4') and five points (P1-P5) specified. The number of identified arteries found in each section and at each position was tallied. Additionally, the depth of the underlying identified artery under each site was measured. RESULTS: One to three named arteries per glabellar segment were found. Each segment had at least one named artery, and the number of named arteries detected between S1/S1' and S4/S4' decreased. The chance of encountering identified arteries at the 5 designated locations, P1-P5, was 7/117 (6.0%), 6/117 (5.1%), 7/117 (6.0%), 6/117 (5.1%), and 16/117 (13.7%), respectively. At P1-P5, the major artery trunk was 1.8 ± 0.3 mm, 1.6 ± 0.3 mm, 1.4 ± 0.2 mm, 1.3 ± 0.3 mm, and 1.1 ± 0.2 mm below the skin. CONCLUSIONS: The site of the glabellar arteries was clearly shown in this investigation; these arteries were met at a rate of 14% from P1 to P5. We demonstrated that a single entry site through the glabella via cannula could readily keep the needle deep enough for safe glabellar filler injection. 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 .

Clarifying the Anatomy of the Zygomatic Cutaneous Ligament: Its Application in Midface Rejuvenation.

BACKGROUND: Anatomical knowledge of the zygomatic cutaneous ligament is crucial for rejuvenation of the anteromedial midface. However, there is a lack of satisfactory descriptions of the anatomy of the zygomatic cutaneous ligament, and the exact range and location are still controversial. The present study attempts to clarify the anatomy of the zygomatic cutaneous ligament to provide vital information for clinical operations. METHODS: Facial dissection was performed on 36 cadaver hemifaces. The location of the zygomatic cutaneous ligament was investigated and recorded relative to the Frankfort horizontal line and several vertical reference lines. The relative relationship of the zygomatic cutaneous ligament with surrounding anatomical structures was also investigated. RESULTS: The zygomatic cutaneous ligament is a septum-like osteocutaneous ligament originating from the periosteum of the maxilla and zygoma. The overall range of the zygomatic cutaneous ligament starts at the origin of the levator labii superioris and then extends laterally, following the curvature of the inferior bone margin. After merging with the ligamentous part at the origin of zygomaticus minor and zygomaticus major muscle (11.65 mm inferior to the horizontal line), it continues as the zygomatic retaining ligament on the zygomatic arch. The vertical distances between the zygomatic cutaneous ligament and horizontal line along the L1, L2, L3, L4, and L5 reference lines are 9.1, 19.5, 22.1, 21.7, and 18.7 mm, respectively. CONCLUSION: The anatomical data obtained in the present study regarding the location of the zygomatic cutaneous ligament might be valuable for understanding the appearance of the midcheek fold and be helpful for surgical procedures to rejuvenate the anteromedial midface.

Three-Dimensional Computed Tomographic Study of the Supratrochlear Artery and Supraorbital Artery to Determine Arterial Variations and Their Relationship.

BACKGROUND: The forehead has high risks associated with filler injection considering its highly complex vascular system. This study aims to thoroughly describe the anatomical variations and relationships between the supratrochlear artery (STA) and supraorbital artery (SOA). MATERIALS AND METHODS: We studied 56 cadaveric heads by computed tomography after contrast-agent injection. RESULTS: The deep branch of the STA originated in the deep superior orbital arcade and the ophthalmic artery (OA), whereas that of the SOA originated at 3 locations: the deep superior orbital arcade, deep superior orbital artery, and OA. The superficial branch of the STA also had 3 origins: the superficial superior orbital arcade, OA, and angular artery, whereas the superficial branch of the SOA had 2 origins: the superficial superior orbital arcade and OA. Based on the relationship between the STA and SOA, 2 main arterial distribution patterns were observed in both superficial and deep layer arteries: STA/SOA connected pattern and STA/SOA disconnected pattern, of which the latter pattern has 3 subtypes. CONCLUSION: The forehead arteries have complex origins. The relationship of the supratrochlear and supraorbital arteries could be categorized into 2 main patterns. The study elucidated the complexity of the forehead vasculature.

Three-Dimensional Arterial Distribution Over the Midline of the Nasal Bone.

BACKGROUND: A comprehensive understanding of arterial variations around the midline of the nose is of great importance for the safety of filler injection. OBJECTIVES: The aim of the study was to clearly define the 3-dimensional location of the arteries along the midline of the nasal bone. METHODS: The arterial structures overlapping the nasal bone along the midline were observed in 79 cadavers. RESULTS: The present study found that 0 to 3 named arteries per nose segment could be identified. All the arterial structures were located in or above the superficial musculoaponeurotic system layer overlapping the nasal bone. The probability of encountering named arteries at 5 defined points, P1 to P5, was 5/79 (6.3%), 4/79 (5.1%), 1/79 (1.3%), 6/79 (7.6%), and 9/79 (11.4%), respectively. The depth of the main arterial trunk was 1.2 ± 0.4 mm, 1.6 ± 0.6 mm, 1.8 ± 0 mm, 1.0 ± 0.4 mm, and 0.9 ± 0.5 mm below the skin at P1 to P5, respectively. CONCLUSIONS: The authors confirmed that sub-superficial musculoaponeurotic system injection along the midline through a needle is anatomically reliable and that a technique with 1 entry point through the rhinion via a cannula can easily keep the needle sufficiently deep for safe nasal filler injection.

Three-Dimensional Computed Tomography of the Detoured Facial Artery: Variations and Implications for Nasojugal Groove Correction.

BACKGROUND: When performing filler injection procedures to the nasojugal groove, there is the risk of iatrogenic damage to the detoured facial artery. OBJECTIVE: To determine the 3-dimensional location of the detoured facial artery. MATERIALS AND METHODS: The branches of the facial arteries from 118 cadaveric hemifaces were scanned using computed tomography and reconstructed using the Mimics software program. RESULTS: Detoured facial arteries were found in 47 of the 118 hemifaces (39.8%). Two main arterial patterns were identified: in Type I (29 of 47 cases), there were both detoured and nasolabial trunks where the facial artery originated, whereas in Type II (18 of 47 cases), there was only a detoured trunk. The detoured trunk originated 32.0 ± 5.3 mm from the midsagittal line, 5.0 ± 2.8 mm from the occlusion plane, and 5.9 ± 3.5 mm below the skin layer; the inflection of the detoured trunk was located 30.0 ± 5.6 mm laterally, 26.2 ± 4.4 mm superiorly, and 5.7 ± 2.6 mm deep. The meeting point with the inferior orbital rim plane was located 17.1 ± 3.4 mm laterally, 43.4 ± 3.1 mm superiorly, and 2.8 ± 1.7 mm deep. CONCLUSION: The 3-dimensional location of the detoured facial artery as reported here will help clinicians to avoid iatrogenic damage when they are performing filler injection procedures.

Three-Dimensional Computed Tomography Scanning of Temporal Vessels to Assess the Safety of Filler Injections.

BACKGROUND: Temple filler injection is one of the most common minimally invasive cosmetic procedures involving the face; however, vascular complications are not uncommon. OBJECTIVES: This study aimed to investigate the anatomy of the temporal vessels and provide a more accurate protocol for temple filler injection. METHODS: Computed tomography (CT) scans of 56 cadaveric heads injected with lead oxide were obtained. We then used Mimics software to construct 3-dimensional (3D) images of the temporal vessels described by a coordinate system based on the bilateral tragus and right lateral canthus. RESULTS: In the XOY plane, the superficial temporal artery (STA), middle temporal artery (MTA), zygomatico-orbital artery (ZOA), posterior branch of the deep temporal artery (PDTA), and lateral margin of the orbital rim divide the temple into 4 parts (A, B, C, and D). The probabilities of the STA, MTA, ZOA, and PDTA appearing in parts A, B, C, and D were 30.73%, 37.06%, 39.48%, and 77.18%, respectively. In 3D images, these vessels together compose an arterial network that is anastomosed with other vessels, such as the external carotid, facial, and ocular arteries. CONCLUSIONS: 3D CT images can digitally elucidate the exact positions of temporal vessels in a coordinate system, improving the safety of temple filler injections in a clinical setting.

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

BACKGROUND: Strengthening weakened ligament tissues with injectable fillers to improve their supportive effect may achieve the aesthetic goal of face lifting. OBJECTIVES: The aim of the study was to design an injectable technique for enhancing the true facial ligaments and dissect the ligaments to provide anatomical guidance for effective injection. METHODS: Six true facial ligaments were chosen as target anatomical sites for injection. Specimens were dissected, and 3-dimensional (3D) images were reconstructed to confirm the exact location of each injection site and to confirm that the proposed injection routes will not cause dangerous vascular damage. A total of 5 patients received the injections; 3D images were taken before and after the injections for comparison and clinical outcome assessments. RESULTS: The injection technique was designed to target 6 true facial ligaments, as follows. Site 1 targeted the temporal ligamentous adhesion region to lift the lateral ends of the eyebrows. Site 2 targeted the region of the lateral orbital thickening to lift the lateral canthus. Site 3 and site 4 targeted the zygomatic retaining ligaments and zygomatic cutaneous ligaments, respectively, to augment the soft tissues of the midface. Site 5 targeted the region of the maxillary ligament to lessen the nasolabial folds, and site 6 targeted the mandibular ligament to reduce the marionette line. CONCLUSIONS: This site-specific injection technique targeting the true ligaments may lead to increased efficiency and accuracy of face rejuvenation and exert a lifting effect.

A case series: 3-dimensional computed tomographic study of the superior orbital vessels: Superior orbital arcades and their relationships with the supratrochlear artery and supraorbital artery.

BACKGROUND: Vascular complications from periorbital intravascular filler injection are major safety concerns. OBJECTIVE: To thoroughly describe the superior orbital vessels near the orbital rim and propose considerations for upper eyelid and forehead injections. METHODS: Fifty-one cadaver heads were infused with lead oxide contrast media through the external carotid artery, internal carotid artery, and facial and superficial temporal arteries. Computed tomography (CT) images were obtained after contrast agent injection, and 3-dimensional CT scans were reconstructed by using a validated algorithm. RESULTS: Eighty-six qualified hemifaces clearly showed the origin, depth, and anastomoses of the superior orbital vessels, which consistently deployed 2 distinctive layers: deep and superficial. Of all hemifaces, 59.3% had deep superior orbital vessels near the orbital rim, including 44.2% with deep superior orbital arcades and 15.1% with deep superior orbital arteries, which originated from the ophthalmic artery. Additionally, 97.7% of the hemifaces had superficial superior orbital arcades, for which 4 origins were identified: ophthalmic artery, superior medial palpebral artery, angular artery, and anastomosis between the angular and ophthalmic arteries. LIMITATIONS: The arterial depth estimated from 3-dimensional CT needs to be confirmed by standard cadaver dissection. CONCLUSION: This study elucidated novel arterial systems and proposed considerations for upper eyelid and forehead injections.

Effective botulinum toxin injection guide for treatment of cervical dystonia.

The aim of this study was to elucidate the distribution of the accessory nerve within the sternocleidomastoid muscle (SCM) to aid identifying the optimum sites for botulinum neurotoxin (BoNT) injections and applying chemical neurolysis. Thirty SCM specimens from 15 Korean cadavers were used in this study. Sihler's staining was applied to 10 of the SCM specimens. Transverse lines were drawn in 20 sections to divide the SCM into 10 divisions vertically, and a vertical line was drawn into the medial and lateral halves from the mastoid process to the sternoclavicular joint. The most densely innervated areas were 5/10-6/10 and 6/10-7/10 along the lateral and medial parts of the muscle, respectively. We suggest injecting BoNT in the medial region 6/10-7/10 along the SCM prior to injecting in the lateral region 5/10-6/10 along the muscle to ensure safe and effective treatment. Clin. Anat. 33:192-198, 2020. © 2019 Wiley Periodicals, Inc.

Anatomy of the Superficial Venous Structures of the Neck: A Cadaveric Study to Guide Superficial Injections.

BACKGROUND: Minimally invasive aesthetic procedures of the neck are becoming more popular. However, anatomical studies on the venous structures of the neck in relation to these procedures are lacking. OBJECTIVE: The aims of this study were to identify the locations and communication patterns of the anterior jugular vein and external jugular vein (AJV and EJV) and the communicating vein (CV) based on superficial anatomical landmarks and to determine dangerous areas for dermal filler injections into the neck. MATERIALS AND METHODS: Thirty sides of the neck from Korean adult cadavers were dissected for this study. RESULTS: Four anatomical variants were identified. In Type Ia, the CV ran along the anterior border of the sternocleidomastoid muscle (SCM) (33.4%); in Type Ib, a single vein was observed connecting the CV and the EJV at the level of laryngeal prominence (23.3%); in Type Ic, the CV proceeded separately from the medial side of the anterior border of the SCM (13.3%); and in Type II, the CV was absent while the EJV and AJV were observed (30%). CONCLUSION: Given the 4 anatomical variants identified in this study, the authors recommend exerting caution when performing dermal filler injections approximately 10, 30, and 60 mm lateral to the midsagittal line to avoid iatrogenic side effects.

Three-Dimensional Topography of the Emerging Point of the Ophthalmic Artery.

BACKGROUND: During periorbital noninvasive and surgical procedures, there is the risk of iatrogenic injury to the emerging point of the ophthalmic artery. This study aimed to determine the three-dimensional location of the emerging point of the ophthalmic artery and to provide clinicians with anatomical information that would help them to avoid associated complications. METHODS: Seventeen hemifaces of the emerging point of the ophthalmic artery from 10 Korean and seven Thai cadavers were dissected and scanned by a three-dimensional scanner. The emerging points of the ophthalmic artery of 30 healthy Korean volunteers were also detected using an ultrasound imaging system. RESULTS: The transverse distance from the medial canthus to the emerging of the ophthalmic artery was 3.8 ± 1.0 mm medially, and the vertical distance was 14.0 ± 2.9 mm superiorly. The transverse distance from the midline was 16.5 ± 1.7 mm to the emerging point of the ophthalmic artery and 20.0 ± 2.0 mm to the medial canthus. The measured depth from the skin surface to the emerging point of the ophthalmic artery was 4.8 ± 1.7 mm by means of three-dimensional scanning and 4.5 ± 1.1 mm using ultrasound detection. The vertical distance from the inferior margin of the superior orbital rim to the emerging point of the ophthalmic artery was 5.3 ± 1.4 mm. CONCLUSION: These data inform clinicians about the anatomical three-dimensional location of the emerging point of the ophthalmic artery, which will help them to avoid iatrogenic injury when they are performing periorbital clinical procedures.

Topographic Analysis of the Supratrochlear Artery and the Supraorbital Artery: Implication for Improving the Safety of Forehead Augmentation.

BACKGROUND: The supratrochlear and supraorbital artery branches from the ophthalmic artery are the primary suppliers of blood to the forehead. Filler injection into the forehead without precise knowledge of its vascular topography poses a risk of severe complications. METHODS: Twenty hemifaces from 11 cadavers were dissected. RESULTS: Based on the presence of the deep branch of the supratrochlear artery, two main arterial distribution patterns of the forehead were observed. Type I (deep branch of the supratrochlear artery-present pattern) was classified into two subtypes: type Ia, in which the layer superficial to the frontalis was supplied medially by the superficial branch of the supratrochlear artery and laterally by the superficial branch of the supraorbital artery, and the deep branch of the supratrochlear artery and the deep branch of the supraorbital artery were distributed deep to the frontalis; and type Ib, in which the layer superficial to the frontalis was supplied by the superficial branch of the supratrochlear artery and the superficial branch of the supraorbital artery in addition to the central artery or the paracentral artery, and the layer deep to the frontalis was supplied the same with type Ia. For type II (deep branch of the supratrochlear artery-absent pattern), the layer superficial to the frontalis was supplied the same with type Ia; only the deep branch of the supraorbital artery supplied the layer deep to the frontalis. CONCLUSION: This study yielded novel arterial systems of the forehead and provided guidance for the safe forehead augmentation.

Neuromuscular structure of the tibialis anterior muscle for functional electrical stimulation.

PURPOSE: This study describes the nerve entry points and intramuscular nerve branching of the tibialis anterior, providing essential information for therapeutic functional electrical stimulation and botulinum toxin injection. METHODS: One hundred and ten legs from Korean and Thai cadavers were dissected. Ten specimens were harvested and subjected to modified Sihler's staining. RESULTS: The average total length from the lateral malleolus to the fibular head was 32.0 cm (SD 1.9). The nerve entry points were densely distributed between 86.5 and 90.6 % of the reference length, where the first and second nerve entry points were observable. A densely arborizing area of the intramuscular nerve branches was observed at 70-80 % of the reference length. CONCLUSIONS: Based on the results of this study, clinicians can increase the effectiveness of therapeutic functional electrical stimulation and identify the ideal sites for botulinum toxin injection to the tibialis anterior muscle.

Topographic Anatomy of the Inferior Medial Palpebral Artery and Its Relevance to the Pretarsal Roll Augmentation.

BACKGROUND: A detailed analysis of the topography of the inferior medial palpebral artery is needed to optimize the safety and efficacy of pretarsal roll augmentation. METHODS: Thirty-one hemifaces from 13 Korean and 8 Thai cadavers (15 male and six female cadavers) were dissected. The distributions of the inferior medial palpebral artery were determined with respect to the superior medial palpebral artery and the supratrochlear artery. RESULTS: Four distribution patterns were observed. The inferior and superior medial palpebral arteries branched individually from the ophthalmic artery, with the ophthalmic artery terminating as the supratrochlear artery on the forehead (type I); a short trunk branched from the ophthalmic artery and divided into the inferior medial palpebral artery and superior medial palpebral artery, and the ophthalmic artery terminated as the supratrochlear artery (type II); the inferior and superior medial palpebral arteries arose together from the ophthalmic artery, and the ophthalmic artery terminated as the supratrochlear artery (type III); or the inferior and superior medial palpebral arteries were the terminal branches of the ophthalmic artery, with the supratrochlear artery arising from the angular artery (type IV). The diameter of the artery was 0.94 ± 0.22 mm at the entry point and 0.37 ± 0.11 mm at the lateral canthus. CONCLUSIONS: The inferior medial palpebral artery was located along the tarsal plate deep to the pretarsal part of the orbicularis oculi in the lower eyelid. Injections to augment the pretarsal roll should be made between the subcutaneous tissue and this pretarsal part of the orbicularis oculi.

Intramuscular nerve distribution pattern of ankle invertor muscles in human cadaver using sihler stain.

INTRODUCTION: We sought to the ideal sites for botulinum toxin injection by examining the intramuscular nerve patterns of the ankle invertors. METHODS: A modified Sihler method was performed on the flexor hallucis longus, tibialis posterior, and flexor digitorum longus muscles (10 specimens each). The muscle origins, nerve entry points, and intramuscular arborization areas were measured as a percentage of the total distance from the most prominent point of the lateral malleolus (0%) to the fibular head (100%). RESULTS: Intramuscular arborization patterns were observed at 20-50% for the flexor hallucis longus, 70-80% for the tibialis posterior, and 30-40% for the flexor digitorum longus. CONCLUSIONS: These findings suggest that treatment of muscle spasticity of the ankle invertors involves botulinum toxin injections in specific areas. These areas, corresponding to the areas of maximum arborization, are recommended as the most effective and safest points for injection.