Freytag, David L.

Abstract Background Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral periorbital region, underscoring the versatility of neuromodulator treatments. Objectives The aim of this study was to analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. Methods Seventy-five study participants (8 males, 67 females) with a mean [standard deviation] age of 37.5 [8.5] years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement measured by 3-dimensional imaging at baseline, Day 14, and Day 30. Results Three-dimensional volume analysis revealed an increase in midfacial volume by 0.46 mL, and a decrease of the lower facial volume by 0.30 mL compared with baseline. Additionally, an improvement of midfacial fullness (by 0.13) and jawline contour (by 0.44) was reported on clinical rating scales at Day 30 compared with baseline. Conclusions Facial soft tissues can be repositioned during the 30-day follow-up period following a neuromodulator treatment; this was reflected through an increase in midfacial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone. Level of Evidence: 4

AbstractBackgroundAn increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex.ObjectivesThe authors sought to describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement.MethodsA total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose utilizing ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature.ResultsIn the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n = 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% to 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip.ConclusionsSoft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared with any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.

Abstract Background Injectable soft tissue fillers are used on a global scale for a variety of aesthetic indications. Despite their widespread use, there is a dearth of information regarding needle deformation following injection procedures. Repeated injections with the same needle could lead to progressive needle tip deformation, potentially resulting in decreased precision and increased patient discomfort. Objectives The objective of this study was to quantify the magnitude of needle tip deformation utilizing scanning electron microscopy (SEM) image analysis. Methods An observational study was performed evaluating 4 differently sized needles following soft tissue filler injections for 5 different aesthetic indications (zygomatic arch, infraorbital, midcheek, nasolabial sulcus, and perioral) in patients aged 36 to 64 years. Following treatment, each needle was visualized and imaged through SEM, and the percentage of deformation in relation to the total amount of needle tip surface was calculated. Results The factor most influencing needle tip damage was revealed to be the number of injection passes, ie, dermal transitions. Per injection procedure, an increase in needle tip damage of 4.7% occurred. Touching the bone deformed the needle tip by 9.6% and an increase in needle size resulted in 0.13% more damage. Conclusions To the authors’ knowledge, this is the first SEM investigation to provide objective evidence for the deformation of needle tips after repeated facial soft tissue filler injections. These data may help improve patient safety and comfort during these minimally invasive procedures. Level of Evidence: 3

Background: Although injectable soft-tissue fillers are frequently used for facial rejuvenation, there is a dearth of objective data evaluating the tissue-lifting effects. Current practices for efficacy evaluation include some subjectivity. This study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifiable, objective setting. Methods: Twenty fresh hemifaces obtained from 10 Caucasian body donors (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers following a predefined treatment algorithm. Three-dimensional surface scanning procedures were performed to assess postinjection effects. Results: Injections in the medial face [i.e., forehead, medial midface, and perioral (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jawline) changed the local surface volume by 0.45, 0.02, and −0.38 cc, and created local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections, however, created additional regional lifting effects by co-influencing neighboring lateral facial regions, which was not observed for medial face injections. Conclusions: This cadaveric study provides evidence that soft-tissue fillers, although typically classified as volumizers, can induce lifting effects of the face. Whereas temporal deep supraperiosteal injections have limited lifting effects, the combined effects of subdermal injections of the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, V.

Abstract 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. Level of Evidence: 4

AbstractBackgroundDifferences in the effectiveness of neuromodulator treatments for horizontal forehead lines dependent on depth of product administration have been described. However, knowledge in respect to the fascial anatomy of the forehead still remains elusive.AimsTo relate the fascial anatomy of the forehead to the effectiveness of neuromodulator treatments by conducting a clinical, prospective, interventional split‐face study in which injections for the treatment of horizontal forehead lines are performed differently between facial sides.MethodsThis study included a total of n = 14 patients with a mean age of 35.71 (7.8) years and mean body mass index of 21.9 (3.0) kg/m2. One side of the forehead was injected superficially by positioning the product in the superficial fatty layer, whereas the contralateral side was injected deep targeting the supraperiosteal plane (random selection). The treatment outcome was rated by the physician and by two independent observers according to a forehead line severity scale (0‐4) at 14 and at 30 days.ResultsAll three observers agreed in their ratings (ICC: 0.942) that the deep injection technique resulted in a superior outcome: D14 (superficial vs deep) 0.17 (0.4) vs 0.14 (0.4; P = .583) at rest and 1.26 (0.6) vs 0.43 (0.5; P < .001) for frontalis contraction; D30 0.17 (0.4) vs 0.14 (0.3) at rest (P = .583) and 1.21 (0.6) vs 0.43 (0.5; P < .001) for frontalis contraction.ConclusionThe results of this study underscore how detailed anatomic knowledge can enhance results of aesthetic interventions, in this case horizontal forehead line treatment with neuromodulators.

AbstractBackgroundMost injection techniques utilizing hyaluronic acid–based soft tissue fillers have predictable outcomes at the location injected. However, the temporal region has been identified to have aesthetic effects beyond the temple.AimsTo identify and quantify the panfacial aesthetic effects of three different temporal injection techniques.Patients/MethodsThe medical records of nine female and five male Caucasian patients with a mean age of 50.9 ± 11.9 years were retrospectively reviewed for the effects of these techniques: supraperiosteal, interfascial, and subdermal. Panfacial effects were evaluated by the semiquantitative assessment of aesthetic scores for the temple volume, the temporal crest visibility, the lateral orbital rim visibility, the position of the eyebrows, the severity of lateral canthal lines, the midfacial volume, and the contour of the jawline.ResultsThe supraperiosteal injection technique had the greatest influence on improving the temporal volume (25.0%), the temporal crest (33.3%), and the lateral orbital rim visibility (31.0%) scales but had no effects in other facial regions. The interfascial injection technique revealed good effects on improving temporal hollowing (23.3%) but had an even greater effect on the crow's feet (26.8%) and on the position of the eyebrow (33.3%). The subdermal injection technique had its greatest effects in the lower face by improving the contour of the jawline (26.8%) followed by the improvement of the lower cheek fullness scale (14.3%).ConclusionFuture injection algorithms could utilize all three injection techniques together as one multi‐layer injection approach with a tailored proportion of each technique based on the aesthetic needs of the patient.

AbstractBackgroundWhile the temporal lifting technique has gained increasing attention, there is a dearth of objective and reliable evidence of its effects.AimThe objective of the present study is to analyze the ability of the temporal lifting technique to reduce the midfacial volume by soft tissue repositioning and to achieve an improved pan‐facial appearance by targeting exclusively the subdermal plane of the posterior and superior temple with soft tissue fillers.MethodsA total of 12 patients (1 male and 11 females) with a mean age of 36.75 ± 6.6 years and a mean body mass index of 23.04 ± 1.3 kg/m2 were included in this prospective clinical single‐center interventional study. Injection‐related outcome was evaluated utilizing 3D skin vector displacement and surface volume analyses and scoring based on five different evaluators.ResultsThree months after the treatment, the global esthetic improvement scale rating showed an improved outcome (3.08) when evaluated by the independent observers, very improved outcome when evaluated by the treating physician (4.33), and exceptional improvement when rated by the patient (4.83). Temporal volume improved by 0.36 (P < .001), lower cheek fullness by 0.47 (P < .001), and jawline contouring by 0.51 (P < .001). No major adverse events were reported during the 3‐month observational period.ConclusionObjective outcome measures have provided evidence that by augmenting the posterior superior temple the volume of the middle face can be reduced and the contour of the jawline can be accentuated; this is due to the underlying fascial anatomy and the resulting soft tissue re‐position.

AbstractA novel treatment approach to address the nasolabial fold is the insertion facial suspension threads. However, there is a paucity of data available to guide insertion techniques and material selection. Three female and two male cephalic specimens of Caucasian ethnicity (73.6 ± 6.5 years; 21.41 ± 2.2 kg/m2) were included into this experimental split-face study. One facial side was treated with polycaprolactone (PCL) thread: 180 mm, bidirectional, 18G 100 mm cannula, 20 degrees trajectory, preauricular approach whereas the contralateral side was treated with polydioxanone (PDO) thread: 100 mm, bidirectional, 19G, 60 mm cannula, 50 degrees trajectory, infraorbital approach. Three-dimensional imaging outcome measures included vertical and horizontal skin displacement and volume changes at the nasolabial sulcus, at the labiomandibular sulcus, and along the jawline. Comparing PCL 180 mm 20 degrees to PDO 100 mm 50 degrees: vertical lifting effect 1.42 ± 2.63 mm versus 1.24 ± 1.88 mm (p = 0.906); horizontal lifting effect 3.42 ± 1.44 mm versus –2.02 ± 1.84 mm (p = 0.001); nasolabial volume change –0.80 ± 0.65 mL versus –0.52 ± 0.17 mL (p = 0.367); labiomandibular volume change –0.45 ± 0.42 mL versus –0.16 ± 0.16 mL (p = 0.191); jawline volume change 0.02 ± 0.43 mL versus –0.01 ± 0.21 mL (p = 0.892). The study provides objective evidence for the short-term effectiveness of facial suspension threads in treating the nasolabial folds. The results point toward a better aesthetic outcome when utilizing long facial suspension threads that can effect full-face changes as compared with short facial suspension threads.

Background: Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator. Methods: Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement. Results: In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 ± 10.2 percent in men and 60.6 ± 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2; women, n = 2). No difference across ethnicities was detected. Conclusions: The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.