Citations

AbstractBackgroundCurrent injection algorithms for treating the glabella rely on a five‐ or seven‐point injection technique with possible medial eyebrow ptosis and lateral eyebrow elevation as undesirable outcomes.ObjectiveThe objective of this study was to investigate the efficacy and safety profile of a refined 3‐point injection technique targeting horizontal and vertical glabellar lines.MethodsA total of n=105 patients (27 males and 78 females) with a mean age of 40.90 ± 9.2 years were investigated. The injection technique relied on targeting the muscular origin of the procerus and the corrugator supercilii muscles exclusively. The time of effect onset and the injection‐related outcome 120 days after the treatment was evaluated using the 5‐point glabellar line severity scale.ResultsThe onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There was no statistically significant difference in the amplitude of movement before or 14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for the lateral head of the eyebrow, respectively.ConclusionIncorporating anatomic concepts into clinical practice for glabellar frown line neuromodulator treatments with the investigated 3‐point injection technique resulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, medial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated efficacy throughout the 4‐month study period.

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

AbstractBackgroundA plethora of age‐related changes contribute to hollowing of the temples, as bone remodeling, atrophy of the temporalis muscle, thinning of the skin, and deflation of the subcutaneous and deep temporal fat create the appearance of a skeletonized face. In addition, previous studies have established a relationship between facial skeletonization, temporal hollowing, and postmenopausal sarcopenia.ObjectiveTo compare the volume change, adverse events, and patient satisfaction of soft‐tissue filler injections in the temple between young (<51) and old (>51) females.Material and MethodsA total of 30 women with a mean age of 53.1 ± 12.1 years underwent bilateral temporal volumization. Adverse events and satisfaction were assessed after 3 and 6 months. 3‐Dimensional surface imaging was performed at baseline and after 2 weeks, 3 and 6 months to assess volumetric changes.ResultsA mean volume of 5.55 ± 1.9 cc was injected into the temples. A total of 31 adverse events were observed in 13 patients. The overall satisfaction of the procedure was very high after 3 and 6 months in both patient groups, and raters showed a significant agreement in their assessment of the aesthetic improvement, while the self‐reported patient satisfaction was also substantially high. The surface‐volume coefficient differed significantly between 14 days and 3 months post‐injection only in pre‐menopausal patients, while no significant difference was detected between 3 and 6 months.ConclusionTemporal soft‐tissue filler injections are safe and provide long‐lasting aesthetic improvement both in pre‐ and postmenopausal women.

Abstract Background Since the emergence of the COVID-19 pandemic facecovers have become a common sight. The effect of facecovers on the gaze when looking at faces has not yet been assessed. Objectives The aim of the present study was to investigate any potential differences in eye movement pattern in observers exposed to images showing a face without and with a facecover to identify if there is truly a change of gaze when identifying (masked) facial features. Methods The eye movement of 64 study participants (28 males and 36 females) with a mean [standard deviation] age of 31.84 [9.0] years was analyzed in this cross-sectional observational study. Eye movement analysis was conducted based on positional changes of eye features within an x- and y-coordinate system while two images (face without/with facecover) were displayed for 8 seconds. Results The results of this study revealed that the sequence of focusing on facial regions was not altered when wearing a facecover and followed the sequence: perioral, nose, periorbital. Wearing a facecover significantly increased the time spent focusing on the periorbital region and also increased the number of repeated eye fixations during the 8-second visual stimulus presentation. No statistically significant differences were observed between male and female participants in their eye movement pattern across all investigated variables (P &gt; 0.433). Conclusions The altered eye movement pattern caused by wearing facecoverings that this study has revealed suggests that, during the COVID-19 pandemic, aesthetic practitioners might consider developing marketing and treatment strategies that principally target the periorbital area.

Abstract Background The temple has been identified as one of the most compelling facial regions in which to seek aesthetic improvement—both locally and in the entire face—when injecting soft tissue fillers. Objective The objective of this study is to identify influences of age, gender, and body mass index (BMI) on temporal parameters to better understand clinical observations and to identify optimal treatment strategies for treating temporal hollowing. Methods The sample consisted of 28 male and 30 female individuals with a median age of 53 (34) years and a median BMI of 27.00 (6.94) kg/m2. The surface area of temporal skin, the surface area of temporal bones, and the temporal soft tissue volume were measured utilizing postprocessed computed tomography (CT) images via the Hausdorff minimal distance algorithm. Differences between the investigated participants related to age, BMI, and gender were calculated. Results Median skin surface area was greater in males compared with females 5,100.5 (708) mm2 versus 4,208.5 (893) mm2 (p < 0.001) as was the median bone surface area 5,329 (690) mm2 versus 4,477 (888) mm2 (p < 0.001). Males had on average 11.04 mL greater temporal soft tissue volume compared with age and BMI-matched females with p < 0.001. Comparing the volume between premenopausal versus postmenopausal females, the median temporal soft tissue volume was 46.63 mL (11.94) versus 40.32 mL (5.69) (p = 0.014). Conclusion The results of this cross-sectional CT imaging study confirmed previous clinical and anatomical observations and added numerical evidence to those observations for a better clinical integration of the data.

AbstractThe evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m2). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.

Abstract Background Injecting soft tissue fillers into the deep plane of the forehead carries the risk of injection-related visual compromise due to the specific course of the arterial vasculature. Objectives The aim of this study was to investigate the 2- and 3-dimensional location of the change of plane of the deep branch of the supratrochlear and supraorbital artery, respectively. Methods A total of 50 patients (11 males and 39 females; mean age, 49.76 [13.8] years, mean body mass index, 22.53 [2.6] kg/m2) were investigated with ultrasound imaging. The total thickness and the distance of the arteries from the skin and bone surface were measured with an 18-MHz broadband compact linear array transducer. Results The deep branch of the supraorbital artery changed plane from deep to superficial to the frontalis muscle at a mean distance of 13 mm (range, 7.0-19.0 mm) in males and at 14 mm (range, 4.0-24.0 mm) in females and for the deep branch of the supratrochlear artery at a mean distance of 14 mm in males and females (range, 10.0-19.0 in males, 4.0-27.0 in females) when measured from the superior orbital rim. Conclusions Based on the ultrasound findings in this study, it seems that the supraperiosteal plane of the upper and lower forehead could be targeted during soft tissue filler injections because the deep branches of both the supraorbital and supratrochlear arteries do not travel within this plane. The superficial plane of the lower forehead, however, should be avoided due to the unpredictability and inconsistent presence of the central and paracentral arteries. Level of Evidence: 4

Abstract Background The most severe complications following soft tissue filler injections result from the intraarterial administration of the filler product. Although hyaluronic acid–based filler can be trans-arterially dissolved with hyaluronidase, no information is available on calcium hydroxylapatite (CaHA)-based fillers. Objective The authors sought to test whether CaHA-based fillers can be trans-arterially dissolved by sodium thiosulfate (STS) when evaluated in cadaveric and in vitro models. Methods Human cadaveric facial arterial segments were each filled with 0.2 cc of commercially available CaHA product and submerged for 24 hours in 4 different STS-containing solutions: 10 cc STS (300 mg/cc) (pure, 1:1 dilution, 1:2 dilution), 0.9% saline and 10 cc STS (300 mg/cc), and 300 IU (bovine) hyaluronidase in a 1:1 ratio. Results Intraarterial CaHA was detected in human facial artery segments after 24 hours independent of the STS concentration employed. Submerging the arterial segments in STS (300 mg/cc) and 300 IU (bovine) hyaluronidase (1:1 ratio) also did not dissolve the intraarterial CaHA product. Gray scale analyses did show, however, that increasing concentrations of STS resulted in increased disintegration of CaHA in an in vitro experimental setting. Conclusions The results of this study indicate that STS is limited in its potential to dissolve intraarterial CaHA of cadaveric human facial arteries, despite the fact that it appears effective when in direct contact with the CaHA. Adverse events caused by intraarterial administration of CaHA-based fillers still lack a suitable antidote.

Abstract Background Soft tissue filler injections are frequently performed with a relatively low number of severe adverse events reported. While venous complications have been described, the majority of adverse events are generally associated with the arterial vascular system. Intra‐arterial product application can present with pain, skin discoloration, and potential tissue loss and/or injection related visual compromise. Aim We present the clinical case and the consecutive symptomology of a 39‐year‐old woman injected with calcium hydroxylapatite at the zygomatic arch with five perpendicular needle (27G 12mm) supraperiosteal bolus injections of 0.2 cc per site. Methods Immediately after the injections, weakness, nausea, vomiting, and loss of consciousness occurred. Additionally, left‐sided loss of sensation of her face, scalp, oral, and nasal mucosa occurred, with absence of left corneal reflex and ipsi‐lateral ear congestion. Subsequently, left‐sided masseteric atrophy and dysphagia occurred. Results One year after the injection procedure the sensory loss of her facial skin and scalp persisted, while the other symptoms improved. Medications involved in the symptomatic (not causal) partial recovery process were Dexamethasone, Vitamin B complex, Vinpocetine, Pentoxifyllin, and Thioctic acid. Conclusion The symptoms presented and the time‐related relationship to the injection procedure increases the likeliness of an association between the administration of the calcium hydroxylapatite product and a lesion of the trigeminal ganglion. The resulting symptoms can altogether be related to the functions of the ganglion. The connecting pathway between the injection site and the ganglion can be explained by the arterial vascular pathway.