Citations

Abstract Background Due to its arterial vasculature, the nasolabial sulcus is one of the most challenging facial regions to treat when trying to ameliorate the signs of facial aging. Objectives The aim of the present study was to provide data on the 3-dimensional course of the angular artery within the nasolabial sulcus in relation to age, gender, and body mass index to increase safety during minimally invasive treatments. Methods Thee hundred nasolabial sulci from 75 males and 75 females of Russian Caucasian ethnic background (mean [standard deviation] age, 45.7 [18.7] years; mean body mass index, 25.14 [4.9] kg/m2) were analyzed. Bilateral multiplanar measurements were based on contrast-enhanced computed tomography cranial scans. Results Up to 3 arteries could be identified within the nasolabial sulcus: ~90% contained 1 arterial trunk, ~9% had 2 trunks, and ~1% had 3 trunks; females had more arteries than men. The artery is located at mean depths of 21.6 mm at the oral commissure and 8.9 mm at the nasal ala. The angular artery was lateral to the nasolabial sulcus in 100% of cases; the smallest distance between the artery and the nasolabial sulcus was at the oral commissure (11.91 [7.9] mm) and the greatest was at the nasal ala (13.73 [3.9] mm). Conclusions In contrast to current concepts, the angular artery is not located strictly subdermal to the nasolabial sulcus but at a variable depth, and in 100% of the investigated cases lateral to the nasolabial sulcus. With increasing age, the depth and lateral distance between arteries and sulci reduces significantly, underscoring the need for special caution when injecting this site.

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.

Abstract Background Lips are considered a key element of facial attractiveness due to their central position in the face and their elemental role in verbal and nonverbal communication. Objectives The authors sought to provide clinically relevant information on the 3-dimensional pathway of the superior and inferior labial arteries within the lips to increase safety during labial soft tissue filler injections. Methods The study enrolled 41 healthy volunteers with a mean age of 26.17 ± 9.6 years and a mean body mass index of 23.09 ± 2.3 kg/m2. Ultrasound imaging was performed at 6 different locations. The position of the labial arteries within the lips, depth of the arteries, cranio-caudal location of each artery in relation to the vermilion border, and diameter of the superior/inferior labial arteries were recorded. Results The most frequent location of both the superior and inferior labial arteries was the submucosal plane (58.5%) followed by intramuscular (36.2%) and subcutaneous (5.3%) planes. The depth of the superior labial artery in the upper lip was 5.6 ± 0.13 mm, whereas the depth of the inferior labial artery in the lower lip was 5.2 ± 0.14 mm. Both arteries were more frequently located within the red lip: upper lip (83% vs 18.7%) and lower lip (86.2% vs 13.8%). In the midline, the artery coursed within the red lip in all investigated volunteers. Conclusions Clinically, results of this study favor a superficial injection plane for lip volumization procedures. A perpendicular approach to the lip (coming from the cutaneous lip) might increase safety because the artery is located most frequently within the red lip.

AbstractObjectiveThe most promising facial region for inducing pan‐facial effects is the temporal region. The temple displays signs of facial aging itself which include temporal volume loss and increased visibility of the temporal crest, the temporal vasculature, the lateral orbital rim, and the upper zygomatic arch. The objective of this article is to provide a detailed review of temple anatomy pertaining to routinely performed temporal injection techniques, their expected esthetic outcomes as well as the intendant advantages, disadvantages, and procedure pearls.Materials and MethodsThis narrative review is based on the clinical experience of the authors treating the temporal region for esthetic purposes. The postulated outcome of each technique was observed during the routine clinical practice of the authors.ResultsThe temporal region is based on a bony platform consisting of the parietal, frontal, sphenoid, and temporal bones. The overlying soft tissues are arranged in layers which contain the temporal neurovascular structures. The temporal soft tissues consist of 10 parallel layers which vary in their thickness depending on age‐related influences. Six different techniques will be addressed, which include subdermal and interfascial techniques for volumizing, low and high supraperiosteal techniques for volumizing, and supraauricular and temporal lifting techniques.ConclusionThis narrative provides a detailed anatomic overview of the temporal region and describes each commonly performed injection technique with respect to anatomy, esthetic outcome, as well as potential pearls and pitfalls. It is hoped that the description contained herein may guide esthetic practitioners toward safer and more natural outcomes when treating the face.

The aim of the study was to longitudinally investigate symptomatic and structural factors prior to total knee replacement (TKR) surgery in order to identify influential factors that can predict a patient’s need for TKR surgery. In total, 165 participants (60% females; 64.5 ± 8.4 years; 29.7 ± 4.7 kg/m2) receiving a TKR in any of both knees within a four-year period were analyzed. Radiographic change, knee pain, knee function and quality of life were annually assessed prior to the TKR procedure. Self-learning artificial neural networks were applied to identify driving factors for the surgical procedure. Significant worsening of radiographic structural change was observed prior to TKR (p ≤ 0.0046), whereas knee symptoms (pain, function, quality of life) worsened significantly only in the year prior to the TKR procedure. By using our prediction model, we were able to predict correctly 80% of the classified individuals to undergo TKR surgery with a positive predictive value of 84% and a negative predictive value of 73%. Our prediction model offers the opportunity to assess a patient’s need for TKR surgery two years in advance based on easily available patient data and could therefore be used in a primary care setting.

AbstractBackgroundTreating the lower face with neuromodulators and targeting the masseter muscle can reduce masseteric hypertrophy but can also change the facial shape. A novel observation after the treatment of the masseter muscle with incobotulinumtoxin Type A was the increase in temporal volume.AimObjectively assess temporal volume increase following treatment of masseteric hypertrophy using incobotulinumtoxin Type A.MethodsNine female patients with a mean age of 35.11 years ± 9.1 [Asian (11.1%) and Caucasian (88.9%)] were treated with incobotulinumtoxin Type A for masseteric hypertrophy. Masseteric prominence and temporal volume were assessed by two independent raters, and temporal fossa volume was measured via 3‐dimensional volumetric imaging.ResultsIndependent of the neuromodulator injection technique (ie, single‐injection versus multi‐injection), a reduction in masseteric hypertrophy occurred represented by a decrease in the masseter prominence scale. In addition, the treatment resulted in a significant improvement of the temporal volume scale and an increase in the measured volume of the temporal fossa. None of the presented measurements were statistically significantly different between the two utilized injection techniques.ConclusionsThis study supports using a full‐face approach when performing aesthetic treatments. Anatomical concepts can help to guide treatments: the compensatory increase in temporalis function after masseter muscle treatment resulted in an increased in temporal fossa volume. The findings presented herein should not be considered as a new concept for treating the temporal fossa but rather as an additional possibility for increasing the temporal volume.

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.