Frank, Konstantin

Background: Aesthetic soft-tissue filler injections for lip enhancement are popular and performed throughout the world. When injecting lips with a cannula, as the cannula is advanced, resistance is perceived in consistent locations, potentially indicating boundaries between intralabial compartments. Objective: We aimed to investigate whether intralabial compartments exist and, if so, to describe their volumes, location, boundaries, and dimensions. Methods: This cadaveric study investigated a total of 20 human body donors (13 male, seven female) with a mean (SD) age at death of 61.9 years (23.9) and body mass index of 24.3 kg/m2 (3.7). The investigated cohort included 11 White donors, eight Asian donors, and one Black donor. Dye injections simulating minimally invasive lip treatments were conducted. Results: Independent of sex or race, six anterior and six posterior compartments in the upper and lower lip were identified, for a total of 24 lip compartments. Compartment boundaries were formed by vertically oriented septations that were found in consistent locations. The anterior compartments had volumes ranging from 0.30 to 0.39 cc; the posterior compartment volume ranged from 0.44 to 0.52 cc. The compartment volumes were larger centrally and decreased gradually toward the oral commissure. Conclusions: The volume and size of each of 24 compartments contribute to the overall appearance and shape of the lips. To achieve a natural lip shape preserving aesthetic outcome it may be preferable to administer the volumizing product using a compartment-respecting injection approach.

Background: Soft-tissue filler injections performed with a cannula are perceived to be less precise because of the length of the instrument and the blunt tip, which can deviate in any direction. Midfacial needle injections are favored despite the increased risk for intraarterial product placement. The objective of this study was to demonstrate that ultrasound-assisted cannula injections of the midface result in precise, safe, and effective volumization procedures. Methods: Midfacial injections with a 22-G cannula were performed in 188 midfaces of 94 healthy volunteers [86 women; age, 53.05 (9.9) years; 23.63 (2.1) kg/m2] under ultrasound-assisted guidance. Precision (ie, administration of product in the same plane as the location of the cannula tip), safety (ie, rate of adverse events), and aesthetic outcome (rated by the patient and the treating physician) were assessed. Results: In 100% of cases, the product was applied into the desired deep midfacial fat compartment, and the product did not migrate into more superficial layers during the injection process or at any follow-up visit. There was a statistically significant (P < 0.001) improvement in midfacial volume loss and the aesthetic outcome was rated as very much improved. No adverse events were reported throughout follow-up. Conclusions: Real-time imaging allows for visual feedback during cannula advancement and injection procedures in the midface and can help practitioners achieve safer aesthetic outcomes. It is hoped that practitioners decide to use a cannula more frequently for midfacial volumization, given the results presented in this article. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

AbstractBackgroundPrevious clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First.ObjectiveTo test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face.MethodsThis study was designed as an interventional split‐face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m2 (1.7) were studied. Follow‐up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging.ResultsDespite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow‐up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001.ConclusionApplying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness.

Abstract Background Transient swelling is common after lip injections with hyaluronic acid (HA) based fillers. Swelling and other injection‐site reactions may relate to the injection procedure itself, or to gel properties, which differ between fillers due to differences in manufacturing methods. Objectives To evaluate safety and effectiveness of lip injections with two HA fillers manufactured using different gel technologies. Methods In a study sample of 40 subjects, treatment with two soft tissue filler product (HA RK or HA JUS ) was randomly assigned. Subjects were injected with 0.5 cc per upper and lower lip using a standardized injection procedure. Early‐onset adverse events (AEs) were assessed by evaluation up to Day 14. Aesthetic improvement, subject satisfaction, and AEs post‐Day 14 were assessed up to 24 weeks. Results In subjects treated with HA RK , the intensity of early onset swelling, erythema, and pain/tenderness was lower than in subjects treated with HA JUS . Aesthetic improvement was achieved in both groups, and most subjects were satisfied with the appearance of their lips. Treatment‐related AEs post‐Day 14 mostly related to the implant site; most were mild‐to‐moderate, and none were serious. Conclusions The intensity of early‐onset swelling, and other injection‐site reactions was lower in subjects treated with HA RK than in subjects treated with HA JUS . Since both the injection volume and injection procedure were standardized, the difference in local tolerability between the two HA fillers may relate to differences in gel properties. Aesthetic improvement, subject satisfaction, and AE profiles post‐Day 14, however, were similar between filler groups.

Abstract Background Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility. Objectives The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula. Methods This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection. Results A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P &lt; .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area. Conclusions Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers. Level of Evidence: 5

Abstract Background It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses. Objectives The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face. Methods Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 &gt; 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (&lt;40 years) and older (&gt;40 years) gender-matched individuals were presented in a standardized setting. Results Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P &lt; 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer’s age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers. Conclusions It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan.

Zusammenfassung Hintergrund Die Brustrekonstruktion mittels autologem Gewebe ist fester Bestandteil eines ganzheitlichen Therapiekonzeptes bei Patientinnen mit Mammakarzinom. Während zahlreiche Studien den körperlichen und psychischen Gesundheitszustand von Patientinnen mit Brustkrebs nach Mastektomie und konsekutiver Brustrekonstruktion untersuchen, mangelt es an objektiven Daten zur Beurteilung des Einflusses von Ablatio und Brustrekonstruktion auf die Wahrnehmung von externen Beobachtern. Diese Studie untersucht die Blickmuster bei Betrachtung einer Brust in verschiedenen Stadien der Brustrekonstruktion mittels DIEP Lappenplastik. Material und Methoden Mittels Eye-Tracking-Technologie wurden die Augenbewegungen von 58 Studienteilnehmer*in- nen beim Betrachten von 2D-Fotografien einer Patientin in den verschiedenen Stadien der Brustrekonstruktion (1. Ablatio, 2. Aufbau mittels DIEP Lappenplastik, 3. MAK Rekonstruktion) analysiert. Die Zeit bis zur ersten Fixierung und die Dauer der Fixierung wurde in jedem Bild für die rechte und linke Brust aufgezeichnet. Ergebnisse Die Dauer der kompletten Fixierung der operierten Brust zeigte über die verschiedenen Stadien der Brustrekonstruktion insgesamt eine signifikante Abnahme mit p<0,001. Gleichzeitig zeigte sich keine statistisch signifikante Veränderung der Blickdauer auf der nicht-operierten Gegen- seite mit p=0,174. Die Zeit bis zur ersten Blickfixierung der betroffenen Brust zeigte eine signifikante Zunahme über die verschiedenen Rekonstruktionsschritte, mit p<0,001. Bei der Gegenseite zeigte sich kein statistisch signifikanter Unterschied in der Zeit bis zur ersten Fixierung, mit p=0,344. Schlussfolgerung Die Ablatio mammae und die einzelnen Schritte der Brustrekonstruktion verändern die äußerliche Wahrnehmung von Patientinnen. Im Laufe der einzelnen re- konstruktiven Teilschritte kommt es zu einer zunehmenden Aufhebung der Blickdeviation in Richtung erkrankte Brust.

Background: Despite various aesthetic trends, the ideal lip proportion and lip volume remains elusive. Thus, the aim of this study was to investigate the aesthetic perception of various lip shapes to identify the most attractive lips. Methods: Fifty-nine White study participants with a mean age of 32.73 ± 9.4 years were asked to assess lips of various proportions and of various volumes. Gaze assessment and aesthetic rating of the same set of modified lip images were performed. Results: The results revealed that the lip proportion that was rated to be most attractive was the 1:1.6 ratio (upper-to-lower lip, 4.21 of a possible 5). This lip proportion, however, was not the first one to be viewed on initial image display (1.20 sec) and had the shortest duration of a stable eye fixation within the 6-second image display interval (2.18 of 6 seconds). The lip volume that received the highest aesthetic rating was the 100 percent volume (original lip size), with 4.56 of a possible 5. This lip volume, however, had the third longest interval between initial image exposure and the first stable eye fixation (0.81 second) and had the shortest duration of stable eye fixations during the 6 seconds of image display (2.22 of 6 seconds). Conclusion: The results presented could be potentially reflective of the internal cognitive processes during the involuntary and voluntary assessment of lip attractiveness.