Fresh Frozen, In-Alcohol, or Autologous Costal Cartilage? Analysis of Complications in Over 650 Revision Rhinoplasties.

BACKGROUND: When autologous septal cartilage is not enough or even not disposable for graft sculpting in revision rhinoplasty, valid alternatives have to be found. Both autologous and homologous costal cartilage usage has been described in scientific literature. As there is no universally accepted consensus on the cartilage choice to use in these cases, the experiences with the different types of cartilage usage assume significant importance in the rhinoplasty learning process. OBJECTIVES: This multicenter prospective study outlined an overview of the authors' experience regarding short-term and long-term complications following revision rhinoplasty procedures in which either fresh frozen (FFCC), in-alcohol (IACC) or autologous costal cartilage (ACC) was used. METHODS: 671 patients undergoing revision rhinoplasty from June 2015 to September 2020 were divided into three groups according to the type of cartilage used (Group1/FFCC with 212 patients, group2/IACC with 239 patients and group3/ACC with 202 cases). Sociodemographic and clinical characteristics and short and long-term complications were described and discussed. A statistical analysis investigating a possible significance of the differences in complication rate was conducted. RESULTS: Authors' data outlined a short-term general complication rate of 5.05%, and a long-term complication rate of 7.04%. A statistically significant difference was identified in cartilage warping rate between the homologous cartilages in comparison to ACC. CONCLUSIONS: FFCC, IACC and ACC can be safely used in revision rhinoplasty with no statistically significant differences regarding short- and long-term complications rate. Cartilage warping rate is significantly higher for ACC in comparison with FFCC and IACC.

Aesthetic Surgical Pathway in Permanent Facial Filler Removal.

Although permanent fillers have been introduced in order to get long-lasting results, many studies have shown numerous severe and disfiguring complications. Nonsurgical procedures may mitigate those adverse events but the only way to remove the filler previously injected is represented by surgical excision. We present a pathway of facial surgical accesses to be performed achieving two goals: permanent filler removal and restore facial aesthetic balance. The proposed surgical accesses are already standardized in aesthetic surgical practice in order to avoid direct excision and unpleasant facial scar. A total of 231 patients underwent surgery for permanent filler removal and aesthetic restoration of the involved facial area, represented by forehead, glabella, nose, cheeks, eyelids, chin, jawline, and lips. Magnetic resonance evaluation was performed with the exception of lip patients who were evaluated with ultrasound. Postoperative follow-up was 12 months to 6 years. Subjective and objective methods were used for outcome evaluation according to the FACE-Q questionnaire. Functional and aesthetic correction was scored using the patient-graded Global Aesthetic Improvement Scale (GAIS), overall patient satisfaction was assessed by a five-point scale questionnaire. Functional and aesthetic restoration was globally recognized as improved according to the GAIS. Patients reported high levels of satisfaction assessed by a five-point scale questionnaire. A very good satisfaction level was registered in both subjective and objective judgment scores. To the best of our knowledge, we present the largest case series regarding surgical removal of permanent facial fillers. A proper preoperative evaluation, filler removal followed by restorative facial aesthetic surgery technique is paramount to approach challenging cases.

Letter in reply to Letter to the Editor: Fat injection as a valuable tool for lower eyelid retraction management: a retrospective, observational, single blind, case-control study.

DEAR EDITOR: We have read Dr Riccardo Fondrini and Colleagues commentary on our paper, and we are grateful for their remarks. We herewith would clarify the critical points mentioned about fat reabsorption and survival, along with the risk of periorbital chronic oedema as per the recorded outcomes in the presented case series. Lastly, we have unfortunately to disagree with the commentary's point related to recommended injection depth as it is mandatory to point out that in our experience the superficial injection of nano-fat is a crucial step for lower eyelid retraction management, otherwise a retraction may persist due to the untreated scar in the anterior lamella, thus missing the therapeutic goal that we aim to achieve. 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 .

Fat Injection as a Valuable Tool for Lower Eyelid Retraction Management: A Retrospective, Observational, Single Blind and Case-Control Study.

BACKGROUND: The aim of this study was to evaluate the use of autologous fat graft injection to correct lower eyelid position METHODS: A retrospective, observational, single blind, case-control study was carried out on 94 patients, presenting with lower eyelid retraction in 159 eyes. In the sub-population with monolateral eyelid retraction, the not affected site has been considered as a control and compared with the outcomes recorded after treatment of the contralateral side Follow-up at 12 months was performed with a subjective assessment carried out by a questionnaire administered to patients while objective result assessment was performed 12 months after surgery by two independent blind examiners. RESULTS: The eyelid upward reposition has improved one year after fat grafting in both bilateral (1,52 mm) and unilateral (1,7 mm) population: the latter allowed to statistically validate (P<0.05) the result with respect to the not affected site. CONCLUSIONS: This is the first paper that highlights the outcomes of sole fat injection in the treatment of lower eyelid retraction: blind objective evaluation of surgical outcomes along with a patient assessment of both functional and aesthetic improvement one year after surgery confirm its efficacy and reliability along with the first case/control outcome evaluation of the technique carried on in the sub-population of 29 patients affected by unilateral lower eyelid retraction that validate the average improvement of the retracted eyelid one year after fat grafting as statistically significant. Nevertheless, longer follow-up periods and a larger sample size are needed to thoroughly confirm surgical outcomes and statistical results. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266.

The Temporal Subcutaneous Brow Lift with Orbicularis Oculi Muscle Elastic Flap: Technical Considerations, Systematic Review, and Terminology Standardization.

OBJECTIVES: As the face ages, cosmetic changes in the periorbital region including eyebrow ptosis, sagging in the lateral temporo-orbital region with superior eyelid hooding, ptosis of orbicularis oculi muscle associated with drooping of the malar area with multiple "crow feets", a deeper lid-cheek junction, and malar festoons also occur. All these periorbital structures should be considered as a single anatomical entity. METHODS: Numerous techniques have been described to correct brow aesthetics in facial rejuvenation. We report the senior author's (M.P.) current approach utilizing a temporal subcutaneous brow lift (TSBL) associated with an orbicularis oculi muscle (OOM) elastic flap. Furthermore, a systematic review of the literature was performed comparing the different surgical approaches striving to clarify its terminology. A total of 298 patients underwent this procedure in 4 years period. Of these, 230 patients, with at least 12 months of follow-up, were submitted to subjective and objective methods to evaluate the self-perception of scar and their overall aesthetic satisfaction. A committee of experts, blinded to each other's assessment, evaluated the same outcomes. Total eyebrow's tail lift was measured and recorded for each patients. RESULTS: The most satisfying aspect of these techniques is the dramatic periorbital rejuvenation and preservation of the patient's original youthful identity. In fact, the postoperative results appear very natural and do not suffer from an "operated" look. This aspect is noticeable from both the surgeon's and the patient's perceptions. There were no major complications in any of the cases. CONCLUSIONS: The proposed TSBL with OOM elastic flap technique, in the hands of senior author (M.P.) has emerged as a reliable, effective, and highly reproducible method to treat sagging and aging of the lateral region of the orbit, even without associated blepharoplasties.

An Italian Online Survey Regarding the Use of Hyaluronidase in Previously Hyaluronic Acid-Injected Noses Looking for Surgical Rhinoplasty.

Background: Nonsurgical nasal reshaping (nSNR) with hyaluronic acid (HA) filler is a well-established procedure performed to ameliorate nasal appearance and is considered a valid alternative to surgical rhinoplasty in selected patients. Objectives: The aim of our study is to evaluate the decision-making process and management of patients undergoing rhinoplasty, with previous HA filler injection, and evaluate if consensus could be achieved to recommend guidelines. Methods: Between April and May 2021, an online survey was sent to 402 Italian surgeons of different specialties. The survey collected information regarding the types of treatment of patients who have previously undergone nSNR, who should undergo surgical rhinoplasty. For those surgeons using hyaluronidase, an additional information was collected. Results: In a range of time of 2 months (April and May 2021), a total of 72 surgeons replied and completed the survey: out of the 402 questionnaires sent, the response rate was approximately 18%. The majority of respondents (61.5%) replied to inject hyaluronidase (HYAL) in patients who had to undergo a rhinoplasty but reported previous nSNR. Of the surgeons who use HYAL, 70% performed rhinoplasty after a waiting time of 3 to 4 weeks. Conclusions: Either direct surgical approach or hyaluronidase injection first seems to be a viable options. The use of HYAL before surgery is the choice with the broadest consensus in our survey. However, a larger case-control study with long follow-ups is necessary to understand if in patient seeking surgical rhinoplasty who already received nSNR, the injection of hyaluronidase before surgery is mandatory, recommended, or not.

Liporeduction: A Faster and Safer Breast Remodeling Technique.

BACKGROUND: Breast reduction is a time-consuming procedure with a relatively high complication rate. Furthermore, recurrent breast enlargement can occur in case of postoperative weight gain. The authors describe a breast reduction technique based on liposuction, followed mostly by skin resection alone, which makes this operation easier, faster, and safer, with more stable results. METHODS: Two hundred thirty-three patients were treated by breast liporeduction between 2006 and 2017, with an age range of 18 to 70 years (average age, 42 years). The patients were selected after careful clinical and instrumental assessment among those in whose breasts the fat component was prevalent over the gland. Most of the soft-tissue reduction consisted of fat aspiration. The follow-up ranged from 12 months to 9 years (average, 4.5 years). RESULTS: The results of this study have been extremely satisfactory. Most of the patients healed uneventfully and were happy with the final outcome. Very few complications were encountered, among which were small steatonecroses and partial nipple-areola complex necroses. CONCLUSIONS: For the past 15 years, all four authors have preferred this breast reduction technique over others. Fat only is selectively removed by aspiration with a blunt cannula, sparing the vascular network and easily mobilizing the nipple-areola complex. Liporeduction provides a good stable result because any postoperative weight variation will not change the volume of a breast consisting mainly of glandular and fibrous tissue. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Facial Aging Surgery: Healing Time, Duration Over the Years, and the Right Time to Perform a Facelift.

BACKGROUND: The "time variable" assumes paramount importance, especially regarding facial rejuvenation procedures. Questions regarding the length of recovery time before returning to work, how long the results will last, and the ideal time (age) to undergo this particular type of surgery are the most commonly asked by patients during the initial consultation. OBJECTIVES: The authors endeavored to determine the healing time, optimal age to perform the surgery, and duration of the results after cosmetic face surgery. METHODS: A 35-year observational study of 9313 patients who underwent facial surgeries was analyzed. The principal facial rejuvenation interventions were divided into 2 subgroups: (1) eyelid and periorbital surgery, including eyebrow lift, blepharoplasty, and its variants and midface lift; and (2) face and neck lift. Significant follow-ups were conducted after 5, 10, and 20 years. To evaluate the course of convalescence, the degree of satisfaction with the intervention, and the stability of the results, a questionnaire survey was administered to a sample of 200 patients who underwent face and neck lifts. RESULTS: The answers given indicated that surgery performed according to rigorous standards allowed for a relatively rapid recovery, and the positive results were stable up to 10 years after surgery. The level of patient satisfaction also remained high even after 20 years. CONCLUSIONS: The "right time" for a facelift, taking into account age, recovery time, and the longevity of the results, is an important consideration for both the patient and the cosmetic surgeon.

The Rhino-Lip-Lifting: A Novel Proposal for Midface Profileplasty Performed as a Single Surgical Procedure.

As facial aging occurs, aesthetic changes of the nasal tip and the senile upper lip include tip ptosis, increase in skin length, loss of vermillion height and Cupid's bow, and vertical wrinkles.Regardless of the rejuvenation procedure, the lips are not to be considered as a single anatomical entity, instead they should be placed in a strong correlation with the nose. The aim of this study is therefore to demonstrate the effectiveness of the association of primary closed rhinoplasty together with indirect subnasal lip-lifting technique.A total of 45 patients were enrolled in this study and underwent primary closed rhinoplasty with indirect subnasal lip-lifting. The result showed an overall average nasolabial angle width reduction of 10.9% and lip length shortening of 23.5%, as assessed 1 year after the surgical procedure. When comparing before and after photographs and using the Subjective Global Aesthetic Improvement Scale (sGAIS), the overall satisfaction was rated 4.4 on 5, as "much improved."The authors show that lips should not be considered as a single anatomical entity but that they indeed must be placed in a strong correlation with the nose since a droopy nasal tip is likely to be considered unattractive and is often associated with the appearance of a long nose with covered philtrum and upper lip.Tip rotation to a normal nasolabial angle width could grant a beneficial impact on overall nose aesthetics; however, it may not fully balance the midface profile as it is the "lip position-to-incisal show" ratio that defines beauty, whereas the balance among forehead, nasal tip, upper lip, and chin is what defines the contour of harmonious profiles.This is the first patient series to show that the combination of closed rhinoplasty and indirect lip-lifting is a highly effective, safe, and reliable procedure to address profile rejuvenation.

Face Lifting in Bald Male Patients: New Trends and Specific Needs.

BACKGROUND: Aesthetic surgery has recently become popular also among men. The ever-increasing number of bald men wishing to undergo facial surgery represents a challenge for the surgeon, as the scars cannot be hidden in the hair and must therefore be as short as possible. The authors present their experience in face lifting in bald male patients and propose an innovative technique to handle the skin excess to achieve practically invisible scars. METHODS: A 10-year observational study was carried out on 68 bald male face-lift patients. All patients underwent deep plane lifting with a specific method for handling skin excess. This technique is the innovation presented in this article. Subjective and objective methods were used to evaluate the results. The well-known FACE-Q questionnaire was sent to all the patients together with an explanatory letter. Three ad hoc questions were added to the questionnaire to assess the degree of satisfaction with the scars. The objective method involved the evaluation of preoperative and postoperative photographs by a three-member jury. The average follow-up period was 12 months. RESULTS: All patients showed a high degree of satisfaction with the final appearance of the surgical scars and appreciation of the overall quality of the result, 1 year after face-lift surgery. No patient expressed regret about choosing to undergo this type of surgery. Very high scores were registered for the overall facial appearance and for the various critical areas examined, including scars, from patients and experts alike. CONCLUSION: The face-lifting technique for bald men proposed by the authors, involving a peculiar and innovative way of handling the skin excess, has proven to be reliably effective in obtaining virtually invisible scars.

Fluid Cartilage as New Autologous Biomaterial in the Treatment of Minor Nose Defects: Clinical and Microscopic Difference Amongst Diced, Crushed, and Fluid Cartilage.

Developing cartilage constructs with injectability, appropriate matrix composition, and persistent cartilaginous phenotype remains an enduring challenge in cartilage repair. Fourteen patients with minor contour deformity were treated with fluid cartilage filler gently injected as autologous fluid graft in deep planes of defect of the nose that were close to the bone or the cartilage. A computerized tomographic scan control was performed after 12 months. Pearson's Chi-square test was used to investigate differences in cartilage density between native and newly formed cartilages. The endpoints were the possibility of using fluid cartilage as filler with aesthetic and functional improvement and versatility. Patients were followed up for two years. The constructs of fluid cartilage graft that were injected in the deep plane resulted in a persistent cartilage tissue with appropriate morphology, adequate central nutritional perfusion without central necrosis or ossification, and further augmented nasal dorsum without obvious contraction and deformation. This report demonstrated that fluid cartilage grafts are useful for cartilage regeneration in patients with outcomes of rhinoplasty, internal nasal valve collapse, and minor congenital nose aesthetics deformity.

Filling Procedures for Lip and Perioral Rejuvenation: A Systematic Review.

The ideal perioral and lip rejuvenation technique provides the longest period of efficacy, lowest complication rate, and best esthetic results. Genetics, intrinsic aging, sun exposure, and repetitive muscle twitching of the orbicularis oris produce angular, radial, and vertical lines of the perioral lines and, for this reason, the needs of patients in the treatment of this anatomical area can range from simple lip enhancement to a broader and more comprehensive treatment with simultaneous correction of perioral wrinkles. A myriad of materials have been described for rejuvenation of this area. At present, the most popular and commonly used lip enhancers are dermal fillers, but there is still no agreement on what the best material for filling soft tissue of the face and in particular of the perioral region is. This systematic review will focus on the various dermal fillers, of different materials approved by the US Food and Drug Administration (FDA) namely poly-L-lactic acid, calcium hydroxylapatite, and hyaluronic acid and also different grafts, for perioral rejuvenation, with the goal of determining the optimal approach. A systematic search for English studies involving perioral rejuvenation was performed using these databases: PubMed, Google Scholar, and Ovid, using a combined keyword search or medical subject headings. At the end of our study selection process, 17 relevant publications were included. For each study, year of publication, type of material used for filling, number of patients, subject of study assessment, and efficacy of the filler procedure for lip rejuvenation were analyzed.

Crushed Cartilage: A Rescue Procedure in Rhinoplasty.

While the use of crushed cartilage is now universally recognized as a valid procedure in rhinoplasty to mask irregularities and eliminate slight deficits, there is still no consensus as to the optimal degree of crushing and the rate of graft resorption over time. With a view to casting light on these 2 important aspects and providing some guidelines, the authors present a study of 123 patients subjected to grafts of cartilage with different degrees of crushing in the different areas of the nasal pyramid: upper third (45 patients), middle third (40), and lower third (38). The degree of crushing was medium for 95 patients and high for 28 who presented thinner and less elastic skin. Comparison of the performance over time of the cartilage grafts inserted in the same areas but with different degrees of crushing provides important indications as regard the best way of preparing the material. The results proved satisfactory with improvements for all of the 95 patients subjected to grafts of moderately crushed cartilage. The initial defect was instead still present, albeit with some partial improvement, at a distance of 12 months in 17 of the 28 patients where highly crushed cartilage was used. The study suggests that a moderate degree of crushing offers better results as regard flexibility and stability over time.

Tear Trough Deformity: Study of Filling Procedures for Its Correction.

The aim of this work is to discuss the anatomy of the tear trough region with relative danger areas, and to describe 2 different options to correct this deformity.The tear trough is a concave deformity of the orbital fat that is noticeable as a result of inherited anatomic differences and aging. However, the periorbital region is a complex area with its own septa and ligaments, fat compartments, muscles, vascularization, and lymphatic drainage and presents anatomic characteristics that must be taken into account in order to achieve good results and avoid complications.The use of hyaluronic acid gel or autologous fat for soft tissue correction is a good option.A total of 96 patients with periorbital hollowing were divided into 2 groups; each group received a different treatment, from December of 2013 to December of 2015, with hyaluronic- or lipo-filling.

Vertical Midface Lifting with Periorbital Anchoring in the Management of Lower Eyelid Retraction: A 10-Year Clinical Retrospective Study.

BACKGROUND: Lower eyelid retraction can be the unfortunate result of aesthetic surgery, trauma, disease, or the aging processes. The purpose of this article is to assess whether midface lifting based on purely vertical repositioning constitutes an effective procedure for its correction. METHODS: A retrospective study was carried out on 199 patients (311 eyelids) operated on between January of 2004 and January of 2014. The various causes of eyelid retraction in this population included cosmetic blepharoplasty (56.8 percent), involutional ectropion (23.1 percent), tumor resection (9.5 percent), facial nerve paralysis (8.5 percent), and trauma and related surgery (2 percent). The study was restricted exclusively to cases of moderate and severe lower eyelid retraction addressed by means of midface lifting. The mean follow-up time was 16.8 months. All of the patients were subjected to midface lifting with strengthening of the lateral canthus. A spacer graft was also used in 37.7 percent of the cases. RESULTS: One hundred ninety-five patients (97.9 percent) displayed objective improvement of the eyelid retraction and a marked degree of improvement both in aesthetic terms and as regards the functional disorders reported. Only four patients (2 percent) presented complications such as needing another operation. CONCLUSION: Midface lifting based on purely vertical repositioning makes it possible to recruit a considerable amount of "new" skin at the lower eyelid, thus ensuring a decrease in vertical distraction and correct recovery of the height of the external lamellar plane. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Treatment of the Crooked Nose: The Final Steps to Perfection.

Perfection is sometimes approached in treatment of the crooked nose today but not fully achieved due to the continued existence of flaws. While the traditional surgical algorithm envisages the use of 2 series of procedures to straighten the nasal bones and cartilaginous septum, the addition of a third appears very useful with a view to obtaining truly excellent results, above all in the case of marked deviation. The authors present their experience in the use of certain procedures designed to correct asymmetry of the upper lateral and lower lateral cartilages, as well as the soft covering tissues where necessary.A retrospective study was carried out on 105 patients treated for crooked nose over a 3-year period, 90% of the patients being due to trauma and the remaining 10% to congenital malformation. All the patients involved severe deviation of the nasal pyramid.The mean follow-up period was 18 months (range: 8-36 months). The use of these additional surgical procedures made it possible to obtain excellent final results in 83 (97.6%) patients with crooked nose of traumatic origin and in 17 (85%) patients with crooked nose due to congenital malformation. No major complication was registered, although 3 patients did present minor complications not connected with the nasal deviation.In conclusion, more modern approach to correction of the crooked nose should involve not only realignment of the osteocartilaginous axis but also treatment of the neighboring structures.

Tarsal Strip Versus Tarsal Belt in Ectropion Correction: A Statistical Evaluation.

Two surgical procedures for ectropion correction are compared: the widespread "lateral tarsal strip" and the more recently introduced "tarsal belt" techniques. A retrospective interventional patient series of 40 patients with mono or bilateral ectropion are investigated.Distances of lower lid margin from interpupillary line before surgery and after 1, 6, 12, and 24 months in tarsal belt and lateral tarsal strip surgical procedure are compared. The postoperative distance is reduced in both the groups of patients, but as regard the tarsal belt the amount of correction is greater and more stable over time and this difference is statistically significant.The ideal surgical technique for ectropion's correction must be focused simultaneously on the lid and on the canthal region because it is mandatory to tight and elevate the lower lid, rotate the tarsal plate, lift the lateral canthal ligament fixing it in a sure fashion. The tarsal strip technique can result in a more vulnerability to relapse. In fact, all the lower eyelid is maintained through the little strip that is assured with a single stitch to the orbital rim periosteum.The tarsal belt technique allows a more uniform distribution of the tissue excess. The suture, with its multiple intratarsal stitches, produces a real reinforcement of the eyelid. The double passage is an added value because it is the element that assures a precise regulation of the tarsal plate rotation. Thus, the tarsal belt technique guarantees a better result over time.

Dome Division: A Viable Technique Today?

Dome division can still be regarded as a valid surgical procedure today in some particular cases of revision rhinoplasty where the scarring is so extensive as to make precise isolation of the alar cartilages impossible. The presence of asymmetry of the nasal tip, a recurrent feature in the results of rhinoplasty, constitutes the primary indication, as division makes it immediately possible to restore balance between the two domes in such cases. The technique also proves useful in cases of overprojection of the tip as a result of rhinoplasty. Moreover, the procedure has been improved by precise suturing of the cartilaginous stumps so as to avoid its frequently reported complications, arising essentially from the vulnerability of the domal arch to the distorting forces of cicatricial retraction and its resulting lack of stability over time. In this connection, the authors attach crucial importance to direct suturing of the cartilaginous stumps in accordance with a now standardized method that is easy to execute and offers lasting, stable results. This approach makes it possible to re-establish continuity of the cartilaginous domal arch in a form unquestionably closer to the physiological anatomical conformation.

Reshaping of the Anterior Nasal Spine: An Important Step in Rhinoplasty.

The importance of analysis of the nasal spine should not be underestimated in the correct planning of rhinoplasty. Deformations in position with respect to the midline and/or in size are often present, and their correction to ensure harmony between the spine and the other components of the nasal pyramid constitutes a key step in rhinoplasty that can lead to excellent results. METHODS: The study includes 160 patients who underwent surgical treatment of the anterior nasal spine with or without other techniques of nasal reshaping. Eighty-seven of these patients presented with hyperplasia of the nasal spine, 43 with hypoplasia, and 30 with deviation. A combination of deviation and hyperplasia was present in 15 cases. RESULTS: No patients developed postoperative complications. Five patients who underwent anterior nasal spine reduction reported postoperative numbness in the premaxillary area, but sensitivity was fully regained within 4 months after surgery in these patients. All the patients reported postoperative improvement of nasal airflow. A total of 142 patients considered their postoperative aesthetic result as excellent and 18 as good. CONCLUSION: The simplicity of the surgical procedures performed on the nasal spine and the marked aesthetic improvements thus achieved suggest that greater attention should be paid to this anatomical region.