Applied Anatomy of the Lower Eyelid Preseptal Space for Treating Ectropion and Retraction with Soft-Tissue Fillers.

BACKGROUND: Lower eyelid malposition can result from age-related changes, such as ectropion, or postsurgical changes, such as retraction after lower lid blepharoplasty. The current accepted treatment is surgical, but soft-tissue fillers have been used as well, with good outcome. The underlying anatomy, which is incompletely described, would be useful information for practitioners desiring to provide minimally invasive injections of the lower eyelid. The authors describe a minimally invasive injection technique adjusted to the complex anatomy of the lower eyelid for the treatment of ectropion and retraction of the lower eyelid. METHODS: A total of 39 periorbital regions of 31 study participants were retrospectively analyzed using photographs before and after reconstruction of the lower eyelid with soft-tissue fillers. Two independent raters assessed the degree of ectropion and lower eyelid retraction (0 to 4, best to worst) before and after the reconstruction and the overall aesthetic improvement using the Periorbital Aesthetic Improvement Scale. RESULTS: The median degree of ectropion and lower eyelid retraction score improved statistically significantly from 3.00 (SD, 1.5) to 1.00 (SD, 1.0) ( P < 0.001). The mean volume of soft-tissue filler material applied per eyelid was 0.73 cc (SD, 0.5). The median Periorbital Aesthetic Improvement Scale score after the treatment was rated as 4.00 (SD, 0.5), indicating improvement of the periorbital functional and appearance. CONCLUSIONS: Anatomic knowledge of the lower eyelid and of the preseptal space is of clinical relevance when reconstructing the lower eyelid with soft-tissue fillers. The targeted space provides optimal lifting capacities for improved aesthetic and functional outcome. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Vascular Safe Zones for Facial Soft Tissue Filler Injections.

The number of soft tissue filler injections performed by aesthetic injectors has continued to increase over the last few years. To provide a high standard of safety and achieve individualized, reproducible, and long-lasting outcomes, aesthetic injectors must have a solid foundation in anatomy, facial biomechanics, rheology, and injection biomechanics. Adverse events associated with soft tissue filler injections can be severe, especially if the aesthetic injector unintentionally injects the soft tissue filler into the patient's arterial vascular circulation and the administered product reaches the arterial bloodstream. Although the face has a rich arterial vascular supply that may seem overwhelmingly complex, it can be broken down systematically according to its internal and external vascular territories. To provide guidance for aesthetic practitioners performing minimally invasive facial injections for aesthetic purposes, this narrative article will discuss the course, depth, and branching pattern of the facial arteries based on the most frequently injected anatomical regions. In this article, we focus on vascular safe zones rather than danger zones .

Vascular Safe Zones for Facial Soft Tissue Filler Injections.

The number of soft tissue filler injections performed by aesthetic injectors has continued to increase over the last few years. To provide a high standard of safety and achieve individualized, reproducible, and long-lasting outcomes, aesthetic injectors must have a solid foundation in anatomy, facial biomechanics, rheology, and injection biomechanics. Adverse events associated with soft tissue filler injections can be severe, especially if the aesthetic injector unintentionally injects the soft tissue filler into the patient's arterial vascular circulation and the administered product reaches the arterial bloodstream. Although the face has a rich arterial vascular supply that may seem overwhelmingly complex, it can be broken down systematically according to its internal and external vascular territories. To provide guidance for aesthetic practitioners performing minimally invasive facial injections for aesthetic purposes, this narrative article will discuss the course, depth, and branching pattern of the facial arteries based on the most frequently injected anatomical regions. In this article, we focus on vascular safe zones rather than danger zones.

Invited Discussion on: A 7-Step Guide to High-Definition Liposuction.

Athanasiou et al. present a 7-step guide to high-definition (HD) liposuction in the current issue of Aesthetic Plastic Surgery. [1] The guide was based on the authors vast experience in HD-liposuction performed in 568 patients (247 males and 321 females) with a mean age of 43 years (range, 22-64) and a mean BMI of 25.6 (range 21-29 kg/m2) over a 6-year time-period. The authors provide detailed information on their approach regarding pre-operative markings, methods of anesthesia and composition of tumescence solution, incision points and access, surgical technique, and fat transfer. In addition, they performed a time-dependent analysis of the type and quantity of observed complications over the study-period, as well as the mean surgical operative time. 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 http://www.springer.com/00266 .

Understanding Facial Aging Through Facial Biomechanics: A Clinically Applicable Guide for Improved Outcomes.

Understanding the relevance of anatomic and biomechanical principles is crucial when treating the face with soft tissue fillers to achieve a symmetric, soft, and natural-looking result while mitigating the risk of adverse events. The objective of this study is to summarize facial age-related effects, to relate them to facial biomechanics, and to establish guidelines for safe, effective, and esthetically pleasing full-face treatment following 3 basic principles while incorporating the latest scientific developments. This narrative review summarizes the current understanding of facial aging and its implications for facial biomechanics deduced from the authors' experience and research.

Ultrasound Anatomy of the Dorsal Nasal Artery as it Relates to Liquid Rhinoplasty Procedures.

Nonsurgical rhinoplasty procedures using soft tissue fillers have gained popularity. With the increasing frequency of such procedures, the incidence of intra-arterial injection of soft tissue filler material and subsequent ischemia has also risen. This article analyzes the topographic anatomy of the dorsal nasal artery in the nasal soft tissue to potentially enhance patient safety in nonsurgical rhinoplasty procedures. The dorsal nasal artery shows a variable topographic course, especially in relationship to the procerus muscle. By understanding the topographic courses of the dorsal nasal artery, aesthetic practitioners may be able to perform nonsurgical rhinoplasty procedures with increased safety and efficacy.

3D Anthropometric Facial Imaging - A comparison of different 3D scanners.

Facial measurements serve as a valuable tool in the treatment planning of facial plastic surgery. The aim of this study was to evaluate the accuracy and reliability of standard 3D anthropometric measurements of the face made with one low-cost handheld 3D scanner and one industrial-type mobile 3D scanner. There are clear potential benefits of using 3D measurements by means of new handheld mobile scanners. However, the Sense scanner from the class of inexpensive scanners showed significant limitations in more complex areas such as the lip and nose, whereas proportions could be measured satisfactorily.

Accuracy Assessment of Three-Dimensional Surface Imaging-Based Distance Measurements of the Face: Comparison of a Handheld Facial Scanner and a Stationary Whole-Body Surface Imaging Device.

Three-dimensional surface imaging (3DSI) has been shown to be a useful tool for plastic surgeons in the preoperative, intraoperative, and postoperative setting. The objective of this investigation was to compare the accuracy of facial surface distance measurements using both a handheld facial 3DSI device and a stationary whole-body 3DSI device. Users should be aware of deviations when obtaining 3DSI using the presented imaging devices but should not refrain from using them, as the absolute differences might be too small to play a role in both, clinical and research, settings.

Anatomic Differences Between the Asian and Caucasian Nose and Their Implications for Liquid Rhinoplasties.

The demand for surgical and nonsurgical esthetic procedures in the nasal region has increased sharply in the past. Anatomic differences of the nose between different ethnicities need to be investigated thoroughly. The objective of this article is to analyze and compare morphometric features of the nose in a mixed Asian-Caucasian study population. The nasal length in Asians was statistically significantly greater than in Caucasians, also after having adjusted for facial height. The nasal dorsal bridge and the nasal base showed statistically significant differences. By keeping these anatomic differences in mind while treating patients, greater efficacy and safety can be achieved.

Effect of Surgical versus Nonsurgical Rhinoplasty on Perception of the Patient: An Eye-Tracking-Based Investigation.

Because of its central location in the face, the nose plays an important role in the aesthetic perception of the face. To improve the appearance of the nose, surgical and nonsurgical rhinoplasty techniques have been described, although it still remains elusive if both options show comparable results in their aesthetic perception. This study assesses the fixation pattern and duration when looking at postinterventional images compared with baseline images for surgical and nonsurgical rhinoplasty procedures. According to this study, the nasal appearance, especially in a lateral view, is more fundamentally altered when surgical rhinoplasty is performed, compared with nonsurgical rhinoplasty.

The Deep Columellar Approach for Liquid Rhinoplasty - A Case Series of 511 Procedures over 16 years.

Injecting soft-tissue fillers in the nose requires a very specific approach, as vascular-related adverse events are a pivotal concern. This study describes a novel standardized 4-step treatment algorithm for safe, reproducible, and effective liquid rhinoplasty procedures using a "deep columellar approach." Medical records of n = 511 treatments were retrospectively analyzed with respect to the occurrence and severity of adverse events. The low rate and severity reported for such incidents can be correlated to a precise and verifiable filler placement in the deep, supraperiosteal, and supraperichondrial layers, using blunt cannulas.

The Fascias of the Forehead and Temple Aligned-An Anatomic Narrative Review.

A thorough understanding of 3-dimensional facial anatomy and its fascial concepts is essential to allow for further development of novel surgical and nonsurgical treatment strategies to increase patient safety and effectiveness. The layered anatomy and its interconnections of the forehead, scalp, and temple is complex and is thus summarized and aligned in a unified nomenclature in this review. The scalp consists of 5 layers, which transition into 8 layers in the forehead and into a total of 13 layers in the temple.

Electrophysiologic Frontalis Muscle Response Following Neuromodulator Injections.

Neuromodulator treatments limit the contractility of the frontalis muscle, resulting in reduced dynamic and static horizontal forehead line formation of the overlying skin. This interventional study investigated the electrophysiologic response (via signal-to-noise [SNR] ratio) and the overlying skin displacement of the frontalis muscle following neuromodulator injections in a total of 11 healthy neuromodulator-naïve volunteers. Relating SNR to the respective skin movement revealed that the higher the SNR, the more vertical the skin displacement is; this remained statistically relevant after gender stratification. These results are novel and will help the aesthetic community to understand neuromodulator effects on the frontalis muscle.

The subjectively perceived injectability as an early indicator for adverse events?

BACKGROUND: With an increasing demand of aesthetic soft-tissue filler treatments, the occurrence of adverse events rises likewise. An optimized injection algorithm adapted to product characteristics (eg, rheology) of the soft-tissue filler is crucial in order to ensure satisfying clinical outcomes and high patient safety. OBJECTIVE: To identify a subjective feedback mechanism for the avoidance of adverse events after soft-tissue filler injection procedures. METHODS: A retrospective data analysis of n = 387 aesthetic treatments performed on n = 291 patients (4 males, 287 females) with different soft-tissue fillers with regard to loss of volume (filling effect), injected layer, injectability ("ease of injection"), injected volume, and injection technique was conducted. RESULTS: The subjectively perceived injectability during the injection process was statistically significantly related to G-Prime value with rs = 0.101 with p = 0.048, indicating an increased difficulty while injecting products with higher G-Prime. The occurrence of adverse events was also statistically significantly related to the injectability: injections with increased subjectively perceived difficulty showed increasing odds of developing adverse events by OR 0.157 with p = 0.002. CONCLUSION: Injections that were subjectively more difficult to perform are more likely to develop adverse events. Respecting the layered arrangement of the face, the recommended and approved depth and facial region for each specific treatment enable practitioners to achieve satisfying outcomes while keeping the rate of adverse events low.

The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis.

BACKGROUND: Our understanding of the functional anatomy of the face is constantly improving. To date, it is unclear whether the anatomic location of the line of ligaments has any functional importance during normal facial movements such as smiling. OBJECTIVES: The authors sought to identify differences in facial movements between the medial and lateral midface by means of skin vector displacement analyses derived from 3-dimensional (3D) imaging and to further ascertain whether the line of ligaments has both a structural and functional significance in these movements. METHODS: The study sample consisted of 21 healthy volunteers (9 females and 12 males) of Caucasian ethnic background with a mean age of 30.6 (8.3) years and mean BMI of 22.57 (2.5) kg/m2. 3D images of the volunteers' faces in repose and during smiling (Duchenne type) were taken. 3D imaging-based skin vector displacement analyses were conducted. RESULTS: The mean horizontal skin displacement was 0.08 (2.0) mm in the medial midface (lateral movement) and was -0.08 (1.96) mm in the lateral midface (medial movement) (P = 0.711). The mean vertical skin displacement (cranial movement of skin toward the forehead/temple) was 6.68 (2.4) mm in the medial midface, whereas it was 5.20 (2.07) mm in the lateral midface (P = 0.003). CONCLUSIONS: The results of this study provide objective evidence for an antagonistic skin movement between the medial and lateral midface. The functional boundary identified by 3D imaging corresponds to the anatomic location of the line of ligaments.