Alfertshofer, Michael

AbstractBackgroundVarious injection algorithms have been proposed in the past which are in line with the three aesthetic principles: upper face first, lateral face first, and deep regions first. However, increasing evidence is provided that the upper midface can be targeted with superficial soft tissue filler injections alone too.ObjectiveTo investigate in a prospective split‐face study design whether superficial or deep upper midfacial injections provide superior aesthetic outcomes.MethodsA total of n = 20 study participants (100% females; age 43.95 (11.7) years; BMI 22.92 (2.6) kg/m2) were treated with superficial soft tissue filler injections on side of their face and deep injections on the contralateral side with a mean volume of 0.78 cc. Outcome was evaluated at 7 weeks follow‐up for midfacial, and lower facial volume, for medial and lateral facial skin vector displacement, and for improvement of nasolabial, crow's feet, and upper cheek fullness severity scores.ResultsNo adverse events related to safety or product tolerability were observed during the entire study period. All semiquantitative scores improved statistically significantly after the observational period (p < 0.001) but displayed no difference between the two applied injection techniques (p > 0.05).ConclusionThe results of this split‐face study revealed that both the superficial and the deep cannula injection technique for midface volumization statistically significantly improve the midfacial volume, reduce nasolabial fold and crow's feet severity. No statistically significant difference was observed between the two injection techniques when compared via semiquantitative and objective outcome evaluation after 7 weeks follow‐up.

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: 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.

AbstractBackgroundAn increasing demand for in‐office aesthetic procedures aiming to improve collagen stimulation has been reported.ObjectiveTo analyze the effects of combinations of different aesthetic collagen stimulation procedures using histological analysis.MethodsHistological analysis was performed on skin samples of the excess skin of a 60‐year‐old patient after sub‐superficial musculo‐aponeurotic system facelift surgery. The excess skin before facelift surgery was divided into three areas per hemiface. Each area—with exception of area A as a control—received an isolated or combined treatment of microfocused ultrasound (MFU), injections of calcium‐hydroxylapatite/hyaluronic‐acid‐based soft tissue filler, and microneedling. The effect of the treatments was analyzed using histological analysis with H&E coloration and PAS staining.ResultsA threefold increase of epidermal and dermal thickness was achieved by treating the skin with the proposed combined treatment comprising MFU and injections of calcium‐hydroxylapatite‐ and hyaluronic‐acid‐based soft tissue fillers.ConclusionThe investigated treatments act synergistically in the production of collagen and combining these treatments allows for an increase in collagen production.

Abstract Background Lip enhancement procedures involving dermal fillers are one of the most sought after nonsurgical aesthetic treatments. However, current trends are associated with unnatural results and involve increased risks of complications and compromise to normal function. It appears that lips may be classified according to the presentation of their tubercles and this may be used to guide minimally invasive techniques which aim to preserve individual lip shapes and normal function. Objectives To test the reliability of a classification system based on lip tubercle morphology, named the Lip Classification of Tubercles (LCT). Methods To test the reliability of the LCT, a total of 214 high-definition photographs of patients’ lips with no previous histories of lip treatments were classified independently by 4 experienced aesthetic practitioners on 2 separate occasions 3 months apart; the second followed a more detailed explanation of the classification. Results When inter-rater reliability was calculated for the first attempt, the results were 36% and 43% for upper and lower lips, respectively. The second attempt following an education process resulted in 79% for both lips. When 1 practitioner was considered the standard, the average score for the remaining 3 showed some individual variation but improved significantly from 58% to 85%. Conclusions The LCT is a reliable way to classify lip types based on the morphology of tubercles. Level of Evidence: 3

AbstractBackgroundDue to the great importance of the face in social interaction, minimally invasive treatments can—besides their ability to rejuvenate and enhance beauty—also change the way facial impressions of a person are perceived. In recent literature, three main character traits (attractiveness, trustworthiness, and competence) and subdomains essential for facial perception were described.ObjectiveTo investigate whether minimally invasive procedures truly influence different character traits when evaluated by independent, objective observers.MethodsPhotographs of n = 34 female faces before and after treatment with injectable fillers and botulinum toxin were rated by 393 individuals without aesthetic background with regards to different character traits on a 7‐point Likert scale. Tests for dimensionality were performed, and composite scores of the impressions underlying each of the three dimensions were created and compared using within‐subjects t tests.ResultsTreatments statistically significantly improved the overarching character trait domains attractiveness, trustworthiness, and competence in posttreatment photographs compared with pretreatment. Posttreatment ratings of the respective subdomains also showed a statistically significant difference compared with pretreatment photographs, with the exception of the subdomain dominance which failed to reach statistical significance.ConclusionImpressions of facial attractiveness, trustworthiness, and competence can be improved by injectables while the naturalness of the face is left intact. An implication is that the improvement of traits highly relevant to social interaction will accommodate the patient's desires for beautification and rejuvenation.

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