A Unified Approach to Facial Contours and Volume Correction: The Role of the Cheek and the Chin.

Background: Facial proportions and contours influence perceptions of beauty and youthfulness. In particular, the shape and definition of the midface and lower face impact the overall appearance of the face. Methods: This review provides anatomical evidence to support a holistic approach to facial analysis and rejuvenation that starts with assessment and treatment of the midface and lower face to create an aesthetically desirable facial balance. Results: The cheek and chin can be considered "anchors" or starting points within full-face treatment because of the noticeable impact of their treatment on the definition and contour of the entire face. Age-related changes in the cheek and chin affect overall facial appearance and can produce unintended facial emotional attributes such as looking tired, angry, or sad. Patients seek facial aesthetic treatment typically for a global improvement such as revitalization or genderization of facial features. Best practices in aesthetics have evolved from treatment of individual areas to a holistic paradigm that uses multimodal therapy to improve overall facial emotional attributes. Hyaluronic acid fillers are useful for volume replacement and smoothing abrupt transitions that develop with age throughout the midface, chin, and jaw. A combination of hyaluronic acid filler for volume restoration and sodium deoxycholate and/or onabotulinumtoxinA for volume reduction where appropriate may optimize lower facial contour. Conclusions: This review highlights the importance of facial angles and contours as well as the significance of panfacial assessments and treatment, focusing on the relationships within areas of the face, specifically the midface and lower face, to optimize results.

A Multicenter, Randomized, Evaluator-Blinded Study to Examine the Safety and Effectiveness of Hyaluronic Acid Filler in the Correction of Infraorbital Hollows.

BACKGROUND: Hyaluronic acid injections are increasingly administered for correction of infraorbital hollows (IOHs). OBJECTIVES: The objective of this study was to examine the effectiveness (IOH correction) and safety of Restylane Eyelight hyaluronic acid (HAEYE) injections. METHODS: Patients with moderate/severe IOHs, assessed with the Galderma infraorbital hollows scale (GIHS), were randomized to HAEYE injections (by needle/cannula) (Day 1 + optional Month 1 touch-up) or no-treatment control. The primary endpoint was blinded evaluator-reported Month 3 response, defined as ≥1-point GIHS improvement from baseline (both sides, concurrently). Other endpoints examined investigator-reported aesthetic improvement on the Global Aesthetic Improvement Scale (GAIS), patient-reported satisfaction (FACE-Q satisfaction with outcome; satisfaction questionnaire), and adverse events. RESULTS: Overall, 333 patients were randomized. Month 3 GIHS responder rate was significantly higher for HA-EYE (87.4%) vs control (17.7%; P < .001), and comparable between HA-EYE-needle and HA-EYE-cannula groups (P = .967). HAEYE GAIS responder rate was 87.5-97.7% (Months 3-12). Mean FACE-Q Rasch-transformed scores were 64.3-73.5 (HAEYE) vs 14.1-16.2 (control) through Month 12. Patients reported looking younger (≥71%) and less tired (≥79%) with reduced undereye shadows (≥76%) and recovered within 3-5 hours posttreatment. Efficacy was maintained through Month 12 (63.5% GIHS responders) and through Month 18, after Month 12 retreatment (80.3% GIHS responders; 99.4% GAIS responders; FACE-Q scores 72.5-72.8). Forty patients (12.7%) reported typically mild adverse events (4.9% HAEYE-needle; 20.9% HAEYE-cannula). CONCLUSIONS: HAEYE treatment was effective in correcting moderate/severe IOHs at the primary endpoint (Month 3). Efficacy was sustained through Month 12 after first treatment for 63.5% and through Month 18 for 80.3% (after 1 retreatment) with needle or cannula administration. Safety outcomes were reassuring.

From Nasolabial Folds to Pan-facial Rejuvenation-The Evolution of Fillers in my Career.

This is a comprehensive review of facial fillers including landmark studies and expert commentary spanning the years from 2003 (when the first hyaluronic acid [HA] dermal filler underwent Food and Drug Administration approval in United States) to present.

One-Year Data on the Longevity and Safety of Hyaluronic Acid Filler for Static Horizontal Neck Rhytids.

BACKGROUND: The long-term efficacy and safety of hyaluronic acid fillers injected into the neck have yet to be analyzed in a prospective trial in the United States. OBJECTIVE: Analyze the long-term efficacy and safety of a hyaluronic acid filler for static horizontal neck rhytids. MATERIALS AND METHODS: Twenty-six subjects were enrolled in the study. Six subjects were randomized to receive saline and 20 subjects were randomized to receive HA RR. All subjects were randomized to use a cannula on 1 side and needle on the other with optional retreatment on day 30 and optional crossover treatment with different assignment on day 60. The subjects were graded using the Transverse Neck Line Scale, Canfield photography, and the Global Aesthetic Improvement Scale on day 360. RESULTS: A significant improvement from baseline on day 360 was achieved on the Transverse Neck Line Scale according to the blind evaluator, subjects, and investigator without any delayed-onset or prolonged side effects. There was no significant difference in the average improvement from the short-term analysis on day 60 to the long-term analysis on day 360. CONCLUSION: HA RR achieved significant long-term improvement in static horizontal neck rhytids without any long-term side effects.

Actinomyces: An Under Appreciated Cause of Postoperative Infection in Rhinoplasty.

OBJECTIVE: To discuss a case series of Actinomyces infection post-rhinoplasty and review the literature for correct diagnosis and management. STUDY DESIGN: Case series with chart review. METHODS: Three cases are presented of patients with a history of recurrent infectious symptoms post revision rhinoplasty later being diagnosed as Actinomyces. RESULTS: Three patients were identified having undergone revision rhinoplasty and later being diagnosed with Actinomyces infection. They initially presented with underwhelming physical exams, mild erythema, slight swelling, yet extreme pain. They also had periods of recurrent infection once antibiotics were stopped. Aerobic, anaerobic, fungal, and Actinomyces cultures were sent to pathology and returned positive for Actinomyces. Treatment typically involved a combination of prolonged antibiotics, incision and drainage, and/or surgical debridement. CONCLUSIONS: Awareness of Actinomyces as a possible cause of infection post-rhinoplasty is significant as this pathogen can lead to extensive tissue destruction and fistula formation which could be detrimental for a rhinoplasty. Duration of treatment is beyond typical lengths for other infections and a specific culture for Actinomyces is required to be sent as it isn't captured in standard aerobic/anaerobic cultures. Therefore, a high index of suspicion is required by physicians to ensure that patients are evaluated thoroughly. Laryngoscope, 133:2948-2950, 2023.

Cosmetic Filler and PET Positivity: The Risk of a False Positive.

OBJECTIVE: To discuss a case of hyaluronic acid filler displaying as PET avid resulting in a false positive for local recurrence and review of the literature of how filler presents on PET. STUDY DESIGN: Case report and literature review. METHODS: Retrospective case review of a patient with angiosarcoma with PET-MRI positivity after hyaluronic acid filler injection. Review of the literature was performed. RESULTS: A 49-year-old female with low grade angiosarcoma of the right cheek pT1N0M0 was treated with wide local excision and staged reconstruction with cervicofacial advancement flap with subsequent adjuvant radiation therapy. Surveillance PET/MRI scans were conducted every 3 months. After one year without recurrence, HA injectable filler was offered to correct resultant right facial soft tissue defect. The patient proceeded with HA filler and was counseled on the risk of local increased SUV on imaging. Her PET/MRI 3 months later revealed postsurgical changes in the right premaxillary soft tissues with associated low-grade hypermetabolism with max SUV 1.8, which elevated from prior max SUV 0.9. Contralateral left maxillary soft tissues revealed max SUV 0.8. Biopsy was initially favored for concern of local recurrence until the potential for filler to be associated with elevated SUV was discussed. Further evaluation with MRI showed diffusely increased T2 signal with some trace enhancement in the region of PET activity, confirming that findings were consistent with HA filler augmentation per the neuroradiologist team. CONCLUSIONS: Fillers, including hyaluronic acid, are associated with elevated SUV on PET-CT. Otolaryngologists should be aware of these features to improve patient counseling, avoid unnecessary procedures, and reduce patient anxiety. Laryngoscope, 133:2951-2953, 2023.

A split-face, blind, randomized placebo-controlled clinical trial investigating the efficacy and safety of hyaluronic acid filler for the correction of atrophic facial scars.

BACKGROUND: Hyaluronic acid fillers have been studied extensively for facial wrinkles; however, their efficacy for atrophic facial scars has yet to be analyzed in a prospective placebo-controlled study. OBJECTIVE: To analyze the efficacy and safety of a hyaluronic acid filler for atrophic facial scars. METHODS & MATERIALS: Fifteen subjects were randomized to receive up to 1 ml of VYC-17.5 L on one cheek and up to 1 ml of saline on the other side, with an optional touch-up treatment. Subjects were graded by a live blind evaluator using the Quantitative Global Scarring Grading System (QGSGS) (J Cosmet Dermatol. 2006;5:48), the Global Aesthetic Improvement Scale (GAIS), and Canfield photo-analysis. RESULTS: According to the blind evaluator, there was a significant reduction 90 days after the last treatment on the QGSGS for VYC-17.5L compared with saline (-6.6 VYC-17.5L vs -1.7 saline [t(28) = -4.3196, p = 0.008]). There was a smaller, but still significant reduction on the QGSGS for saline alone (10.4 to 8.6 [t(14) = -3.453, p = 0.004]). In addition, 93% (13/14) of subjects chose VYC-17.5L over saline treatment and reported an improvement on the GAIS. There were no serious side effects and all minor side effects resolved by Day 30. CONCLUSION: VYC-17.5L achieved significant improvements in rolling atrophic scars as compared to saline, though saline also had modest improvements.

A Randomized, Placebo-Controlled, Split-Neck Trial of Hyaluronic Acid Filler for Static Horizontal Neck Rhytides Using Either a Cannula or Needle.

BACKGROUND: Hyaluronic acid (HA) fillers have been studied extensively on the face; however, their safety and efficacy on the neck has not yet been evaluated in a prospective trial in the United States. OBJECTIVE: Analyze the efficacy and safety of a HA filler for static horizontal neck rhytides using either a cannula or needle. MATERIALS AND METHODS: Twenty-six subjects were randomized to receive up to 1 mL of the HA filler Restylane Refyne (HARR, n = 20) or saline (n = 6) using a cannula on one side and a needle on the other with optional repeat treatment. Subjects were graded using the Transverse Neck Line Scale, Canfield photography, and the Global Aesthetic Improvement Scale. RESULTS: A significant improvement 30 days after the last treatment was achieved on the Transverse Neck Line Scale when comparing HARR with saline according to the blind evaluator, subjects, and investigator without any significant side effects. In addition, the blind evaluator, subjects, and investigator rated the side of the neck injected with a needle as having significantly greater improvement than the cannula. CONCLUSION: The hyaluronic acid filler, Restylane Refyne, achieved significant improvement in static horizontal neck rhytides using either a cannula or needle without any serious side effects, although the needle was more effective.

Lip and Perioral Trauma: Principles of Aesthetic and Functional Reconstruction.

Successful management of lip and perioral trauma requires a nuanced understanding of anatomy and surgical techniques. Surgical correction is particularly challenging in instances of tissue loss, due to a narrow tolerance for aesthetic deformity and highly specialized functions of the perioral region, including facial expression, communication, and oral competence. Restoring continuity of the orbicularis oris musculature is critical for dynamic sphincter function of the upper and lower lips. Lip and perioral tissue symmetry are also critical for aesthetic balance, and failure to restore a natural appearance can adversely affect personal identity, with attendant psychological trauma. This discussion of lip and perioral trauma management encompasses lip and perioral anatomy, evaluation of injuries, reconstructive techniques, and prevention and management of complications. Perioral injuries are classified by size, depth, and extent of injury, and the corresponding reconstructive approaches are a function of complexity. These approaches proceed sequentially up rungs of the reconstructive ladder including primary repair, local flaps, grafting, regional flaps, as well as microvascular free tissue transfers. Procedures may be single stage or require multiple stages or subsequent refinement. Regardless of the defect size or location, the guiding principle of repair in the perioral region is restoring natural function and aesthetic appearance. This still-evolving area of facial plastic and reconstructive surgery lends itself to artistry and technical precision, offering opportunities for further innovation to improve the outcomes of patients with lip and perioral trauma.

Evaluating New Technology.

There are multiple complex issues to consider when evaluating any new technology. First evaluate the efficacy of the device. Then considering your patient population decide whether this technology brings an added benefit to your patients. If it meets these 2 criteria, then proceed to the financial analysis of acquiring this technology. The complete financial analysis has several important components that include but are not limited to cost, value, alternatives, return on investment, and associated marketing expense.

Split face evaluation of long-pulsed non-ablative 1,064 nm Nd:YAG laser for treatment of direct browplasty scars.

PURPOSE: To investigate 1,064 nm long-pulse Nd:YAG laser for postoperative treatment of direct browplasty scars. METHODS: Nine patients who underwent direct browplasty were enrolled in this prospective study. Subjects were randomized to unilateral laser treatment at 2-week intervals for six total treatments, with the contralateral scar used as a control. Prior to each treatment, subjects rated treated and control scars on overall cosmesis. Post-treatment, subjects rated each for erythema, swelling, discomfort, and perceived hair loss. Finally, examiners masked to treatment side were asked to judge side-by-side photographs of first and final visits for improvement and side effects. RESULTS: Subjects rated the overall appearance of the treated scar significantly higher at the time of treatment number 5 (mean score 5.13 ± 2.03, P = 0.008) and treatment number 6 (6.25 ± 1.98, P = 0.005) compared to treatment 1 (3.75 ± 2.12); by contrast, they failed to rate the control scar more highly. On masked examination of photographs, the treated scar was selected as most improved 50.0 ± 12.5% of the time. Both subjects and graders reported side effects as transient and mild to moderate (mean score 1-4), with no reports of hair loss from either subjects or observers. CONCLUSIONS: The 1,064 nm Nd:YAG laser provided significant improvement in scar cosmesis after direct browplasty, as rated by subject self-report, but not by masked observers, and appears to be a useful tool for increasing satisfaction among those dissatisfied with direct browplasty scars. Side effects-including erythema, edema, and discomfort-were transient and universally rated as mild to moderate. Lasers Surg. Med. 48:742-747, 2016. © 2016 Wiley Periodicals, Inc.

The role of neurotoxins in the periorbital and midfacial areas.

Initially popularized for the treatment of strabismus and blepharospasm, injection of botulinum neurotoxin has become the most commonly performed cosmetic treatment in the United States. Injection techniques have been particularly well-studied in the midface and periocular region, and patient satisfaction tends to be very high. We review the salient differences among available neurotoxins, how to optimally reconstitute them, how to inject the forehead, glabella, lateral canthal lines ("crow's feet"), infralid region, and transverse nasal lines ("bunny lines"), how to sculpt the brow, and how to manage potential complications.

Safety and efficacy of 2,790-nm laser resurfacing for chest photoaging.

Chest photodamage is a common cosmetic complaint. Laser treatment of the chest may be higher risk than other areas. The objective of this study was to assess the safety and efficacy of 2,790-nm chest resurfacing for photodamage. Twelve patients with Fitzpatrick skin types I-III were enrolled in this university IRB-approved study. Photo documentation was obtained at baseline and each visit. A test spot with the 2,790-nm resurfacing laser was performed on the chest. Patients who did not have adverse effects from the test spot went on to have a full chest resurfacing procedure. Patients were instructed on standardized aftercare, including sunscreen. A 5-point healing and photodamage improvement scale was used to rate improvement by both investigators and the patients and was obtained at 2 weeks, 1 month, 2 months, and 3 months. One pass chest treatment with the 2,790-nm resurfacing laser at fluences greater than or equal to 3.0 mJ with 10% overlap leads to unacceptable rates of hyperpigmentation. Double pass chest treatment at fluences less than or equal to 2.5 mJ with 10% overlap leads to mild improvement in chest photodamage parameters without significant or persistent adverse effects. Laser treatment of aging/photodamaged chest skin remains a challenge due to the delicacy of chest skin. Mild improvement may be obtained with double pass resurfacing with the 2,790-nm wavelength.

Nonprescription topical treatments for skin rejuvenation.

Topical skin care regimens are a mainstay treatment for aging skin. All patients seeking skin rejuvenation can benefit from this low-risk intervention. This article reviews available nonprescription topical treatments for rejuvenation including moisturizers, antioxidants, retinols, and sunscreen.

Neurotoxins and fillers for skin rejuvenation.

The ephemeral effects of neurotoxins and fillers are well described for facial remodeling and rejuvenation. Less is known about their long-term effects on skin rejuvenation and neocollagenesis. This article aims to review current available science and literature to support the use of these cosmetic procedures as lasting antiaging treatments.

Cosmeceuticals for recurrence prevention after prior skin cancer: an overview.

INTRODUCTION: Skin cancer is the most common form of cancer in the United States. According to the World Health Organization, the incidence of both nonmelanoma and melanoma skin cancers has increased over the past few decades. OBJECTIVE: The objective of this article is to review studies about cosmeceuticals that can be used by people who previously had skin cancer and may work as agents that help in some way to prevent new skin cancer lesions. CONCLUSION: Cosmeceuticals are antiaging skin products that overlap cosmetics and pharmaceuticals and are commonly available over the counter. This article reviewed several substances used in cosmeceuticals formulations that could be useful for individuals who have had previous skin cancers and need to prevent possible new lesions. Further studies are needed to better evaluate these products and their skin cancer preventive properties.

Photoaging.

Treatments for photoaging are commonly requested by cosmetic patients. Laser resurfacing treatment addresses the myriad aspects of photoaging, including fine rhytides, dyspigmentation, and abnormal texture. Recent developments in laser medicine--such as fractional resurfacing in both ablative and non-ablative wavelengths--have improved the safety and side effect profile of laser resurfacing. Both ablative and non-ablative wavelengths are effective. The use of lasers should be limited to experienced practitioners to minimize the risks of scarring, pigment alterations, and other unwanted effects.

Laser treatment of skin texture and fine line etching.

Modern cosmetic medicine requires accurate recognition of all types of rhytids and their molecular causes such that treatments may be tailored for improving skin appearance for each unique patient. This article examines the causes and treatment of fine rhytids. Laser rejuvenation therapies that affect the epidermis, dermis or both and induce neocollagenesis and dermal remodeling can be effective against the stigmata of mature skin.

Effects of lavender olfactory input on cosmetic procedures.

OBJECTIVES: To evaluate the effects of the aroma of essential oil of lavender against placebo on subjects' pain perceptions and levels of anxiety when undergoing elective cosmetic facial injections of botulinum toxin type A (BOTOX(®) COSMETIC) for the correction of glabellar wrinkles. METHODS: Subjects (N=30) who had not previously received any cosmetic facial injections were randomized to essential oil of lavender aroma exposure or to placebo during elective cosmetic facial injections of BOTOX(®) (12 U) for the correction of glabellar wrinkles. Evaluations of subjects' pain perceptions and levels of anxiety assessed by the Spielberger State-Trait Anxiety Inventory, heart rate (HR), and blood pressure (BP) measurements were taken at baseline, before, and after injections. RESULTS: Subjects exposed to essential lavender oil showed a significant reduction in HR after the injection as compared to the pre-injection HR. Subjects exposed to the placebo did not show any significant difference in BP or HR between pre-injection and postinjection. CONCLUSIONS: Although essential oil of lavender did not have an effect on the subjects' perception of pain during a facial injection, subjects showed significant increases in parasympathetic activity when exposed to the lavender aroma. Lavender aromatherapy has the potential to ease anxiety in patients undergoing minimally invasive facial cosmetic procedures.