Single-Step Full-Face Surgical Treatment of the Facial Profile.

The present study was performed to describe how much affordable, feasible, and straightforward is the approach the authors called "single-stage full-face surgical profileplasty," tailored to greatly improve the surgery of the facial profiling setting and achieve complete profile correction at the same time. From January 2010 to May 2019, 113 patients (95 females and 18 males; aged 19 - 63 years) were surgically treated for full-face profile amelioration. Profile correction was performed by using a combination of five procedures out of other various previously experienced: forehead fat grafting, rhinoplasty, lip fat grafting, genioplasty, and submental liposuction. All patients were assessed at 1, 3, 6, and 12 months following surgery for assessing the surgical profile treatment (SPT) outcome and any possible side effects of the combined treatment. Facial profile stability at 1 year was taken as the completion point of this treatment. Arnett et al's "Soft Tissue Cephalometric Analysis" (1999) was used to clinically evaluate the soft tissues before and after the SPT. Patients' satisfaction was measured with the Client Satisfaction Questionnaire-8" at 3 and 12 months after surgery. Statistics were used for Arnett et al's evaluation. Almost all the values were consistent and reached the normal ranges indicated by Arnett et al (p < 0.001), confirming that the desired results of the surgical profileplasty have been achieved. Single-stage full-face surgical profile treatment helps in correcting faults of the global facial deformity, in every single treated area, providing an overall improvement in facial aesthetics and harmony. Obtaining the simultaneous correction in the whole face has also the advantage of avoiding multiple surgical procedures, reducing postoperative discomfort, and the overall risks for the patient due to multiple surgical and anesthetic procedures.

Role of Robotics in Neuromodulator and Filler Injections of Face.

In recent years, robots have been increasingly used in various fields of medicine, including surgery, dentistry, and ophthalmology. One of the newest and most promising applications of robotic technology in medicine is in the field of facial aesthetics, particularly in the injection of facial fillers and neuromodulators. While facial injections have traditionally been performed manually by trained physicians and nurses, the introduction of robots has the potential to revolutionize the field, offering a range of potential benefits, including increased precision, accuracy, and consistency of results. However, the significant disadvantages of robots are high cost, lack of flexibility and personal touch, limited experience, and risk of injury due to malfunction.

A Systematic Review and Meta-Analysis of Rhinoplasty Using the Rhinoplasty Outcome Evaluation Scale.

Background: The purpose was to evaluate the role and impact of the rhinoplasty outcome evaluation (ROE) in rhinoplasty. Objectives: To systematically review the ability of ROE to assess rhinoplasty outcome in the very recent surgical approaches. Data Sources: Searching MESH terms "rhinoplasty" and "rhinoplasty and ROE" on PubMed, Scopus, Embase, Google Scholar, and other major literature databases. Study Eligibility Criteria: A Preferred Reporting Items for Systematic Reviews and Meta-Analyses model was adopted for eligibility criteria. Participants and Interventions: A first large screening on 1,660 papers allowed the final retrieval of 896 reports, of which only 101 were eligible for all the inclusion criteria, which allowed finally to select a group of 12 reports published in the time range 2018-2021. Study Appraisal and Synthesis Methods: Meta-regression with Durbin-Watson test, checking of meta-analysis bias with Rosenthal's estimator, and heterogeneity through the I 2 statistics were performed. The analysis included a Mantel-Haenszel test and associated or meta-analysis. Results: Twelve eligible and qualified papers were included in the meta-analysis, out of 1,263 patients, from 1,660 papers. ROE confirmed previous reports about its ability to discriminate preoperative from postoperative outcome (50/100), as from the different rhinoplasty approaches, a value very close to the functional Nasal Obstruction Symptom Evaluation scale. This study strengthens the role of ROE in the evaluation of rhinoplasty outcomes encouraging further research to improve ROE scale on different cultural habits and geographical areas. Limitations: The main limitations were due to the weak inclusion and exclusion criteria, methodological flaws with the statistical analysis, and poor data synthesis and evaluation in many papers about ROE.

Puzzle Facelift: A Nonsurgical, Whole Treatment for Facial Modeling and Rejuvenation.

The assessment of correct anatomy of face and the evaluation of the dynamic interplay between anatomy and function, to get an overall improvement, is a leading topic in aesthetic surgery and has increased its impact in recent years. A nonsurgical impact technique reduces both post-treatment discomfort and the overall cost. Obtaining the simultaneous correction in forehead, nose, lips, and chin means obtaining an overall improvement in face view. Likewise, the high predictability of the procedure and the absence of alloplastic implant, bone re-absorption, and scars have to be considered in nonsurgical aesthetic medicine. In conclusion, a single session of profile correction using hyaluronic acid filler should be proposed to patients, every time the aesthetic practitioner sees a coexistence of forehead, nose lips, and chin defects.

Treating Aging Changes of Facial Anatomical Layers with Hyaluronic Acid Fillers.

The aging process affects every anatomical layer of the face. Improved knowledge of how aging occurs in each anatomical layer of the face has helped evolve the facial rejuvenation strategies with HA fillers. Understanding the age-related changes in the anatomical facial layers, including their time of onset and how the changes occur in the different tissue layers, an injector can provide much more targeted and refined HA filler treatments. As fillers' use has increased, there has been a distinct shift away from procedures lifting the skin and SMAS. We can selectively target the anatomical facial layers with HA fillers for more refined and predictable outcomes. An extensive range of HA filler variants is now available. Each filler type is optimized and designed to be injected into specific tissue planes for the best results. Knowing the predictable aging changes in the different tissue layers of the face is crucial as this guides the optimum filler choice. Working knowledge of the individual characteristics of the numerous HA-based products allows for their effective placement in the correct layer. Familiarity with the correct HA product may also help to minimize the downtime and risk of adverse events.

The 10-Point Plan 2021: Updated Concepts for Improved Procedural Safety During Facial Filler Treatments.

Dermal filler treatments require constant reassessment for improving and safeguarding the rapidly evolving aesthetic field. Suboptimal injection technique, patient selection and product knowledge have touted a concerning increase in filler complications, with new challenges such as the COVID-19 pandemic leading to new paradigms in the understanding, prevention, diagnosis and treatment of complications. The updated 10-point plan has been developed to curtail complications through consideration of causative factors, categorized as patient, product, and procedure-related. Patient-related factors include a preprocedural consultation with careful elucidation of skin conditions (acne, rosacea, dermatitis), systemic disease (allergies, autoimmune disease, underlying bacterial and viral disease (herpes simplex virus, COVID-19 infection), medications (antineoplastic drugs, recreational drugs) and previous cosmetic procedures (including fillers and energy-based devices). Patient assessment should include standardized photography and also evaluate the role of social media, ethnicity, gender, generational, and LGBTQ+ needs. Specified informed consent for both adverse events and their treatment is essential due to the increase in vascular complications, including the risk of blindness. Product-related factors include the powerful advantage of reversibility when using hyaluronic acid (HA) products. Product characteristics such as molecular weight and filler degradation should be understood. Product layering over late or minimally degradable fillers is still inadvisable due to the initial filler being teased into reactivity. Procedural factors such as consistent photographic documentation, procedural planning, aseptic non-touch technique (ANTT), knowledge of topographical anatomy and angiosomes, and technical dexterity including pinch anatomy and needle skills are of pivotal importance. The final section is dedicated to algorithms and checklists for managing and treating complications such as allergic hypersensitivity reactions, vascular events, infection, edema and late-onset adverse events (LOAEs). The updated 10-point plan is a methodical strategy aimed at further minimising the risk of dermal filler complications.

Factors influencing pre-injection aspiration for hyaluronic acid fillers: A systematic literature review and meta-analysis.

Pre-injection aspiration of hyaluronic acid filler is a well-recognized yet controversial safety technique. Many consider aspiration to be an important safety measure to prevent inadvertent intravascular filler injection. To assess factors influencing pre-injection aspiration by understanding the relationship between aspiration time and a range of product, needle, and procedural characteristics. We conducted a systematic review and meta-analysis of data, adopting the preferred reporting items for systematic reviews and metaanalyses guidelines. Our literature search identified four articles presenting data on variables associated with aspiration time for different HA filler brands. Statistical models pooling data from the four articles suggest a robust association between aspiration time and a filler's elastic modulus (G'), drop weight (cohesivity), and cross-sectional area of the needle lumen. However, there is insufficient evidence to confirm a robust association between aspiration time and HA concentration, viscous modulus (G″), needle length, and pullback volume. A deeper understanding of the relationship between product, needle, and procedural characteristics, and aspiration time can provide a sound base for discussing the role of pre-injection negative aspiration as a safety measure. The understanding of the effect of various factors on preinjection aspiration would further benefit from studies under clinical conditions.

Pinch anatomy: An injection guide for temple filler injections.

Filler injections have become exceedingly popular in the last decade, and injectors across the globe are using them for facial contouring and reversing the age-related changes. Thorough knowledge about the anatomy of important vessels and tissue planes is essential for injectors. During filler injections, injectors generally tend to pinch or pull the tissues with the nondominant hand for the ease of the procedure. These deformational forces lead to some changes in the anatomy of tissue layers held in a pinch. During pinch maneuver, the important arteries in that region can get pulled up in the tissue layers held in a pinch or stay in their position unaffected. The pinch can also increase the tissue space for injections by moving the mobile tissue layers away from the fixed ones. Knowledge of this "pinch anatomy" in the temple can be used to the injector's advantage to avoid important arteries and to place filler in the correct plane.

Non surgical facial reshaping using MD Codes.

BACKGROUND: Both age-related and congenital volume deficiencies may be addressed through the injection of hyaluronic acid (HA) fillers. Deep injection provides structural support, more superficial fat-tissue injection mediates contouring, and superficial intradermal use of HA filler and/or onabotulinumtoxinA may be used for refinement. AIMS: To evaluate the clinical efficacy, patient satisfaction, and safety of the MD Codes approach as a proposed standardized methodology for full-face rejuvenation. METHODS: This was a retrospective, single-center study of 250 consecutive adult patients undergoing full-face rejuvenation with HA fillers (Vycross) and onabotulinumtoxinA based on the MD Codes approach. RESULTS: The mean age was 39.4 ± 11.6 years, and 80.4% were female. All patients were treated with HA filler in the midface; 89.6% were also treated in the upper face, and 63.2% in the lower face. The mean number of syringes used was 14 ± 4 (range 4-25), with more syringes typically required in older versus younger patients. All patients received onabotulinumtoxinA treatment. Mean FACE-Q Appearance-Related Psychosocial Distress score decreased from 54.3 ± 9.3 pretreatment to 36.1 ± 8.9 at 3 months post-treatment (P < .05). The most common complications were bruising (35.2%), transient soft-tissue edema (14.0%), and prolonged periorbital edema (3.6%). CONCLUSIONS: Full-face rejuvenation based on the MD Codes approach provides significant esthetic improvements, with no major safety issues observed.

Safety guidelines for nonsurgical facial procedures during COVID-19 outbreak.

BACKGROUND: The novel coronavirus (COVID-19) pandemic is expected to last for an extended time, making strict safety precautions for office procedures unavoidable. The lockdown is going to be lifted in many areas, and strict guidelines detailing the infection control measures for aesthetic clinics are going to be of particular importance. METHODS: A virtual meeting was conducted with the members (n = 12) of the European Academy of Facial Plastic Surgery Focus Group to outline the safety protocol for the nonsurgical facial aesthetic procedures for aesthetic practices in order to protect the clinic staff and the patients from SARS-CoV-2 infection. The data analysis was undertaken by thematic and iterative approach. RESULTS: Consensus guidelines for nonsurgical facial aesthetic procedures based on current knowledge are provided for three levels: precautions before visiting the clinic, precautions during the clinic visit, and precautions after the clinic visit. CONCLUSIONS: Sound infection control measures are mandatory for nonsurgical aesthetic practices all around the world. These may vary from country to country, but this logical approach can be customized according to the respective country laws and guidelines.

A Systematic Literature Review of the Middle Temporal Vein Anatomy: 'Venous Danger Zone' in Temporal Fossa for Filler Injections.

BACKGROUND: Treatment of a sunken appearance of the temporal region using injectable fillers is a popular procedure. The temporal fossa has very complex anatomy due to multiple vessels running in the different tissue layers. A severe complication in the form of non-thrombotic pulmonary embolism (NTPE) can occur as a result of an inadvertent injection in the middle temporal vein (MTV) while performing temporal fossa filler procedures. Therefore, in-depth knowledge and understanding of the MTV anatomy are essential for successful and safer injectable procedures of the temporal fossa. OBJECTIVES: While there have been many studies to describe the arteries in this region, there is limited information about the location and course of the middle temporal vein. This literature review is aimed at providing detailed information about the course, depth, and size of the MTV to help aesthetic practitioners in performing safer temporal fossa filler injections. This information is imperative to delineate the 'venous danger zone' in the temple region. METHODS: The preferred reporting items for systematic reviews and meta-analyses guidelines were used for this review. A literature search was performed to find the articles providing details about the MTV anatomy and the measurements related to its course and size. RESULTS: A review of the literature showed that the MTV displays a consistent course and depth in the temporal region, with high variability in its diameter. The middle temporal vein width varied between 0.5 and 9.1 mm in various studies. The middle temporal vein receives many subfascial tributaries from the surface of the temporalis muscle, and for most of its course runs in the fat pad enclosed between superficial and deep layers of the deep temporal fascia. A 'venous danger zone,' in the interfascial planes of the temporal fossa, which contain the main part of the MTV and its tributaries, has been proposed in this paper. CONCLUSIONS: The temporal fossa filler procedures need great caution, and knowledge of the depth and course of the MTV is essential for avoiding NTPE. 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 .

Management of noninflammatory nodule in chin after a large volume bolus injection of hyaluronic acid filler.

As most Asian women desire to have an "inverted triangle" appearance for face, there is an increasing trend to give a large volume bolus (LVB) injection in the submental region of the chin for its lengthening. Hyaluronic acid (HA) dermal fillers are very popular for facial contouring and reshaping, including the chin area. Filler injection in the submental area has been a popular method to lengthen the chin. Placing an LVB of HA filler material at one place can present as the formation of lump or nodule after injection. We present a case of formation of a nodule in the submental area after injection of a single LVB of filler. The nodule was injected with hyaluronidase 3 months after its formation, and a near-complete resolution was seen immediately. Complete disappearance of the nodule was found at follow-up after 10 days. LVB of HA filler can give rise to the formation of noninflammatory nodules after filler injection in the immediate post-injection period. Knowledge of the type of filler material and presenting features can help in instituting the correct line of treatment for the resolution of signs and symptoms. Also 0.5 mL of filler can be recommended as maximum size of single LVB, based on the mathematical calculations.

Vision Loss Associated with Hyaluronic Acid Fillers: A Systematic Review of Literature.

BACKGROUND: With the global increase in the use of injectable fillers, more cases with serious adverse events such as skin ischemia and vision loss are being reported. This article aims to review the role of HA fillers, as a subgroup separate from fat graft and non-HA fillers, in causing vision loss and to elucidate various features and outcomes of post-HA filler vision loss. METHODS: The preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines were used to report this review. A total of 29 articles presenting 60 unique cases of post-HA filler vision loss were identified in the literature. Based on various inclusion and exclusion criteria, 26 articles with details of 44 cases were included in this study. RESULTS: The majority of cases were seen in women and in the 20-40 years age group. The maximum number of cases was reported from Korea, followed by China. Nearly half of the cases reported after HA filler-related visual complications had partial loss of sight, hence 'partial vision loss' and 'complete vision loss' were used as differentiating descriptive terms to the degree of 'blindness.' Nearly all the cases were unilateral, with immediate onset of visual signs and symptoms. The nose, glabella, and forehead were the most commonly implicated areas, while no cases of post-HA filler vision loss were reported from lower face anatomical areas, including the chin, jawline, and lips. Partial vision loss after HA filler has a better prognosis than complete vision loss. HA filler volumes as low as 0.2 ml can cause permanent, complete vision loss, which is suggestive of the embolic nature of HA filler blockage. Ophthalmic artery occlusion (OAO) and central retinal artery occlusion (CRAO) were the two most commonly involved arterial obstruction patterns followed by branch retinal artery occlusion (BRAO). BRAO is the most favorable involved arterial pattern for a chance of recovery after HA filler-related vision loss while CRAO and OAO patterns carry a very poor prognosis. CONCLUSION: Post-HA filler vision loss is nearly always of immediate onset. Partial vision loss after HA filler injection with the involvement of smaller branches of the retina, other than central retinal artery or ophthalmic artery, has more favorable visual outcomes. 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.

A Consensus on Minimizing the Risk of Hyaluronic Acid Embolic Visual Loss and Suggestions for Immediate Bedside Management.

BACKGROUND: Hyaluronic acid fillers have a satisfactory safety profile. However, adverse reactions do occur, and rarely intravascular injection may lead to blindness. Currently there is no internationally recognized consensus on the prevention or management of blindness from hyaluronic acid filler. OBJECTIVES: The authors sought to give guidance on how to minimize the risk and optimize the management of this rare but catastrophic adverse reaction. METHODS: A multinational group of experts in cosmetic injectables from multiple disciplines convened to review current best practice and develop updated consensus recommendations for prevention and bedside intervention if visual loss occurs after cosmetic injection of hyaluronic acid filler. RESULTS: The consensus group provided specific recommendations focusing on the consenting process, prevention, and early management of visual impairment related to intravascular hyaluronic acid filler injection. CONCLUSIONS: Although visual loss due to filler injections is rare, it is important that both patient and physician be aware of this risk. In this paper the authors describe methods and techniques available to reduce the risk and also document suggested initial management should a clinician find themselves in this situation.

Reversal of Post-filler Vision Loss and Skin Ischaemia with High-Dose Pulsed Hyaluronidase Injections.

Nose filler injections are very popular in many Asian countries to improve nose shape and projection. However, due to the vascular supply of nose from the ophthalmic artery and its communication with branches of the facial artery in this region, there could be a possibility of ophthalmic complications in case of an accidental intra-arterial injection of filler material. This may cause devastating complications of partial or complete vision loss with or without associated cutaneous ischaemic changes. We present a case report of a patient who developed features of vascular involvement after two ml of HA filler injection in the nasal dorsum, tip and columella. The patient initially developed tell-tale signs of impending skin necrosis in the nasal and forehead skin followed by ptosis, severe pain and progressive vision loss in the right eye until a point where the patient could only perceive light. The patient was managed with multiple doses of hyaluronidase in the involved skin and two doses of retrobulbar injection for vision loss. Significant recovery in the skin and ophthalmic components occurred within 20 days of filler injection. This case demonstrates that recovery of the ischaemic ophthalmic and cutaneous changes secondary to probable intra-arterial injection could be accomplished using combined retrobulbar and periorbital intracutaneous injections of high-dose pulsed hyaluronidase. 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 .

Managing Complications of Submental Artery Involvement after Hyaluronic Acid Filler Injection in Chin Region.

Hyaluronic acid dermal fillers are becoming popular all over the world, but due to the presence of many blood vessels in the face, there is always a small possibility of vascular complications. We present a case with the ischemic involvement of chin and neck skin after accidental submental artery involvement after hyaluronic acid filler injection for chin region. Impending skin necrosis on the chin and upper neck on the right side was diagnosed quickly by observing the skin changes in the immediate postfiller phase. Pain in the mandible and in the muscles during swallowing due to possible ischemia of muscles supplied by submental artery was another crucial diagnostic feature. All parts of the affected zone were treated with high-dose pulsed hyaluronidase protocol using 4 pulses of hyaluronidase injection in first 24 hours after filler injection. Complete resolution of cutaneous ischemic changes and painful swallowing was achieved within days after treatment. Knowledge of presenting features of postfiller vascular complications and the extent of vascular territory of the involved artery is quite helpful in quickly instituting treatment leading to the near-complete recovery with minimal sequelae.

Successfully Managing Impending Skin Necrosis following Hyaluronic Acid Filler Injection, using High-Dose Pulsed Hyaluronidase.

Facial fillers are becoming increasingly popular as aesthetic procedures to temporarily reduce the depth of wrinkles or to contour faces. However, even in the hands of very experienced injectors, there is always a small possibility of vascular complications like intra-arterial injection of filler substance. We present a case report of a patient who developed features of vascular obstruction in right infraorbital artery and tell-tale signs of impending skin necrosis, after hyaluronic acid filler injection by an experienced injector. The diagnosis of a vascular complication was made quickly with the help of clinical features like blanching, livedo reticularis, and poor capillary refill. Patient was treated promptly with "high-dose pulsed hyaluronidase protocol" comprising three 1,000-unit pulses of hyaluronidase, administered hourly. There was no further increase in size of the involved area after the first dose of hyaluronidase. All of the involved area, along with 1 cm overlapping in uninvolved skin area, was injected during each injection pulse, using a combination of cannula and needle. Complete reperfusion and good capillary filling were achieved after completion of 3 pulses, and these were taken as the end-point of high-dose pulsed hyaluronidase treatment. Immediate skin changes after filler injections, as well as after hyaluronidase injections and during the 3-week recovery period, were documented with photographs and clinical notes. Involved skin was found to have been fully recovered from this vascular episode, thus indicating that complete recovery of the ischemic skin changes secondary to possible intra-arterial injection could be achieved using high-dose pulsed hyaluronidase protocol.

Consensus Recommendations for Treatment Strategies in Indians Using Botulinum Toxin and Hyaluronic Acid Fillers.

BACKGROUND: Indians constitute one of the largest population groups in the world. Facial anthropometry, morphology, and age-related changes in Indians differ from those of other ethnic groups, necessitating a good understanding of their facial structure and the required aesthetic treatment strategies. However, published recommendations specific to Indians are few, particularly regarding combination treatment. METHODS: The Indian Facial Aesthetics Expert Group (19 dermatologists, plastic surgeons, and aesthetic physicians with a mean 15.5 years' aesthetic treatment experience) met to develop consensus recommendations for the cosmetic facial use of botulinum toxin and hyaluronic acid fillers, alone and in combination, in Indians. Treatment strategies and dosage recommendations (agreed by ≥ 75% of the group) were based on results of a premeeting survey, peer-reviewed literature, and the experts' clinical experience. RESULTS: The need for combination treatment increases with age. Tear trough deficiency is the most common midface indication in Indian women aged 20-40 years. In older women, malar volume loss and jowls are the most common aesthetic concerns. Excess medial soft tissue on a relatively smaller midface precedes age-related sagging. Hence, in older Indians, fillers should be used peripherally to achieve lift and conservatively in the medial zones to avoid adding bulk medially. The shorter, wider lower face requires 3-dimensional correction, including chin augmentation, to achieve increased facial height and the oval shape desired by most Indian women. CONCLUSIONS: These recommendations give physicians treating Indians worldwide a better understanding of their unique facial characteristics and provide treatment strategies to achieve optimal aesthetic outcomes.