Citations

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 The iliopsoas is a common source of anterior hip pain. Refractory cases may require surgical intervention, with reported complication rates ranging from 3% to 50%. Development of a minimally invasive, outpatient method of iliopsoas tendon release is desirable and may reduce costs, lower complications, and improve recovery time. Objective To describe and evaluate the safety and reproducibility of an ultrasound‐guided (USG) iliopsoas tendon release using a spinal needle in a cadaveric model. Design Prospective, cadaveric laboratory investigation. Setting Academic Institution Procedural Skills Laboratory. Participants Five unembalmed cadaveric specimens (three female, two male), 69 to 93 years of age (mean 83.2 years), with a mean body mass index (BMI) of 24.5 kg/m 2 (range 19.2 to 30.3 kg/m 2 ). Interventions Two operators each performed five USG iliopsoas tendon releases. Three additional investigators dissected the pelves to assess completeness of tendon release and damage to adjacent structures. Main Outcome Measures Successful transection, completeness (%) of the tendon transection, damage to adjacent structures, and procedural time. Results Nine of 10 releases achieved the target release of ≥75% tendon transection. One procedure achieved 50% tendon release. No injury to adjacent structures was identified. The mean duration of the procedure was 6.19 minutes. Conclusions USG iliopsoas tendon release can be performed in a cadaveric model, consistently achieve the desired percentage of tendon release, does not result in injury to adjacent neurovascular structures, and takes approximately 6 minutes to perform. Although results cannot be generalized to a clinical setting, due to the minimally invasive nature of the procedure, it is likely that this procedure can be performed safely in an outpatient setting under local anesthesia, will cost less, and will facilitate a more rapid recovery when compared to standard surgical procedures. Further research is warranted for clinical application.

Abstract Background Glabellar soft tissue filler injections have been shown to be associated with a high risk of causing injection-related visual compromise. Objectives The aim of this study was to identify the course of the superficial branch of the supratrochlear and of the deep branch of the supraorbital artery in relation to the ipsilateral vertical glabellar line and to test whether an artery is located deep to this line. Methods Forty-one healthy volunteers with a mean age of 26.17 [9.6] years and a mean BMI of 23.09 [2.3] kg/m2 were analyzed. Ultrasound imaging was applied to measure the diameters, distance from skin surface, distance between the midline, distance between vertical glabella lines, and the cutaneous projection of the supratrochlear/supraorbital arteries at rest and upon frowning. Results The mean distance between the superficial branch of the supratrochlear artery and the ipsilateral vertical glabellar line was 10.59 [4.0] mm in males and 8.21 [4.0] mm in females, whereas it was 22.38 [5.5] mm for the supraorbital artery in males and 20.73 [5.6] mm in females. Upon frowning, a medial shift in supratrochlear arterial position of 1.63 mm in males and 1.84 mm in females and of 3.9 mm in supraorbital arterial position for both genders was observed. The mean depth of the supratrochlear artery was 3.34 [0.6] mm at rest, whereas the depth of the supraorbital artery was 3.54 [0.8] mm. Conclusions The hypothesis that injecting soft tissue fillers next to the vertical glabellar line is safe because the supratrochlear artery courses deep to the crease should be rejected. Additionally, the glabella and the supraorbital region should be considered as an area of mobile, rather than static, soft tissues.

In recent years, the use of point of care ultrasound (POCUS) in clinical practice has increased substantially . Many medical schools have introduced ultrasound skills training into their curriculum which starts early in anatomy courses . Few, if any, of these programs assess students’ ultrasound knowledge and skills in a simulated clinical team environment. Anatomy Ultrasound Objective Structural Practical Examination (OSPE) implemented as a part of practical examination provides such an opportunity to asses both traditional and non‐traditional discipline‐independent skills, competencies and attributes. As part of the seven‐week anatomy course at Mayo Clinic Alix School of Medicine, first‐year medical students attended four ultrasound sessions. Each session included a short didactic module followed by hands‐on practice guided by near‐peer teachers. For the final examination, four‐member student teams were required to work collaboratively to perform four different scans during which students interacted with multiple standardized patients and rotated responsibility for obtaining an image, orienting the image, and identifying assigned structures. Students were graded using a rubric and received a team‐score based on tasks associated with individual roles of team members. In addition to ultrasound skills, the nature of their professional interactions with patient, communication skills, and situational awareness were assessed. The average team score was 96%. The students completed a survey at the conclusion of the anatomy course in which they rated the OSPE experience very positively. Team‐based OSPE examination was a clinically relevant and effective mechanism to simultaneously evaluate anatomic knowledge, clinical skills, and non‐traditional discipline‐independent skills that were emphasized during the anatomy course. Support or Funding Information

The nasoseptal flap is a well‐recognized “work‐horse” flap for anterior skull base reconstruction. The sphenopalatine artery (SPA), which accounts for a large portion of the arterial supply in the nasal cavity, forms a basis for the flap pedicle. In addition, the identification of the SPA as it emerges from the pterygopalatine fossa into the nasal cavity via the sphenopalatine foramen (SPF) is useful during the transpterygoidal approach to the infratemporal fossa. This identification is also useful for treatment of epistaxis in the nasal cavity, and aids in the prevention of vascular complications in a surgical setting. Previous studies have shown the relationship of the sphenopalatine foramen to the floor of the nasal cavity, choanal arch, and maxillary line. To enhance endoscopic visualization this study set out to identify the relationship of the anteroinferior bony border of the sphenoid sinus, the superior nasal concha, and the middle nasal concha as anatomical landmarks to the SPF. A total of n = 33 cadaveric hemisections were studied. In addition, the SPF was identified in coronal computerized tomography (CT) scans of the dissected cadavers acquired from the Anatomical Bequest Program at the Mayo Clinic (IRB approval #19‐010471), n = 8. Nasal mucosa was reflected from the lateral nasal wall where the SPF was located. The exit of the SPA’s main arterial trunk at the SPF was measured in relation to the sphenoid sinus, superior nasal concha, and middle nasal concha and the number of branches was recorded. Measurements on CT imaging were taken posterior to the ostiomeatal unit and maxillary sinus at initial visualization of the sphenoid sinus. Measurements of the SPF in relation to the inferior bony boundary of the sphenoid sinus were recorded (mm). All radiologic images were collected, and measurements were taken using Association for Quality Imaging (AQI) software. Images were analyzed and processed using Fiji ImageJ software. Results of this study showed the immediate surgical relationship of the sphenoid sinus, superior nasal concha, and middle nasal concha to the SPA as it traverses the SPF into the nasal cavity. Average distance from the SPF to the anterior‐inferior bony boundary of the sphenoid sinus was 2.5mm, the superior nasal concha was 4.12mm, and the middle nasal concha was 2.86mm. Radiological measurements taken in coronal CT images from the inferior bony boundary of the SPF to the inferior bony boundary of the sphenoid sinus was on average 4.94mm. Number of primary branches off of the SPA arterial trunk, and branching patterns varied between 2–3 with instances of a single long SPA arterial trunk traveling more than 3 mm followed by two small branches inferiorly. These relationships can be used to safely identify the SPA as it exits the SPF during surgery to prevent vascular complications due to occluded visualization of the region. Support or Funding Information American Association of Anatomists Short‐Term Visiting Scholarship Award

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.

BACKGROUND The midface is an area of high demand for minimally invasive cosmetic procedures, that is, soft-tissue filler injections. OBJECTIVE To investigate the functional anatomy behind the facial overfilled syndrome observed after soft-tissue filler injections. MATERIALS AND METHODS The clinical part of the study enrolled 25 volunteers (12 men and 13 women, Caucasians); the anatomical part included 72 fresh frozen cephalic specimens obtained from 32 male and 40 female body donors. 3D surface scanning procedures were applied to calculate the maximal anterior projection of the midface. RESULTS Upon smiling, the point of maximal anterior projection shifted cranially in men by 12.43 ± 8.8 mm (difference between resting and smiling; p < .001) and by 8.75 ± 4.1 mm in women (p < .001). Cadaveric dissections identified a septum originated from the underside of the zygomaticus major muscle forming a transversely running boundary between the buccal space and the deep midfacial fat compartments. CONCLUSION Facial overfilled syndrome can potentially be explained by the presence of the transverse facial septum. Dynamic filling—injecting small amounts of filler and asking the patient to smile repeatedly during the procedure—seems to be a viable way to avoid this adverse event during soft-tissue filler injection.

Abstract Background The arrangement of the facial soft tissue layers is different with respect to the line of ligaments: medially oblique and laterally in parallel. Aims This split‐face study was designed to investigate the effects on midfacial volumization if the same medial vs lateral injection points are targeted in various sequences. Methods Twelve patients (3 males, 9 females; 46.67 years ± 4.5) were included in this interventional study. On the right side of the face, lateral injection points were performed first, whereas on the left side, medial injection points were executed first. The infraorbital hollowness score, the upper cheek fullness score, the global aesthetic improvement scale, and the injected volume were assessed. Results No side differences were observed after the intervention with P = 1.00 for all scores. When the lateral injection points were performed first, the volume injected into the medially located injection points (0.46 ± 0.26 cc vs 0.73 ± 0.31 cc [ P = .037]), into the lateral injection points (0.79 ± 0.40 cc vs 1.15 ± 0.28 cc [ P = .017]), and overall (1.26 ± 0.64 cc vs 1.88 ± 0.57 cc [ P = .02]) was significantly reduced. Conclusion The results of the present study emphasize the importance of respecting the layered arrangement of the facial soft tissues when performing minimally invasive soft tissue filler injections. Targeting injection points lateral to the line of ligaments first reduces the volume needed to symmetrically and aesthetically appealing manner and volumizes the infraorbital and upper cheek regions.

Background: The purpose of this article is to provide a comprehensive review based on images and discussion of the current understanding of the arterial supply of the face to facilitate safe minimally invasive antiaging procedures. Methods: Contrast-enhanced computed tomographic scans of 40 fresh frozen heads from 17 male and 23 female Caucasian body donors with a mean age of 76.9 ± 13.1 years and a mean body mass index of 23.6 ± 5.3 kg/m2 were retrospectively analyzed and compared to cadaveric dissections performed in more than 400 fresh cephalic specimens. Results: This review presents the current understanding of the facial arteries based on existing literature, direct observation from cadaveric dissection, and the dissection experience of the two authors of the study. It reveals the constant three-dimensional locations of the facial and angular arteries: mandible, modiolus, and medial canthus as compared to their unpredictable course in other facial regions. In addition, the anatomy of the ophthalmic and central retinal arteries is discussed in the context of current treatment strategies in cases of blindness following facial soft-tissue filler injections. Conclusions: The arterial supply of the face exhibits high variability in branching patterns, course (two-dimensional), and depth (three-dimensional). Because of the lack of predictability of the vascular anatomy, it is impossible to absolutely guarantee safety when performing minimally invasive injectable procedures. Injectors should understand the potential for adverse vascular events, communicate this risk appropriately to patients, and be properly trained and equipped to treat any such complication.