Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-Based Study.

BACKGROUND: In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amidst an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by non-academic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety. OBJECTIVES: To identify levels of competency for the aesthetic practitioner and for necessary achievement milestones during the educational path from novice to expert injector. METHODS: A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections. RESULTS: Regardless of medical specialty and experience level, an average of 3.85 (1.8) years, 786.4 (2,628) filler injections, and 549.9 (1,543) toxin injections was estimated to progress from novice to advanced injector, while an average of 6.10 (3.7) years, 1,842.2 (4,793) filler injections, and 1,308.5 (3,363) injections was estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively. CONCLUSIONS: This study establishes an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1,840 filler and 1,310 neuromodulator injections for expertise. It also identifies critical facial regions for targeted treatments by different expertise levels.

The perception of lip aesthetics in the context of facial proportions-An eye-tracking-based analysis.

BACKGROUND: Minimally invasive lip volumizing and contouring soft tissue filler procedures are frequently requested by both female and male aesthetic patients. Guidance on how to achieve the most beautiful outcome is inconsistent. OBJECTIVE: To investigate what the most beautiful proportions are in relation to vermillion thickness, the distance of the upper and lower lip in relation to nose and chin, and relation to the bigonial distance. METHODS: This study included a total of n = 101 volunteers (52 females, 49 males, 100% Caucasian) who inspected frontal images of modified facial proportions and answered a related questionnaire showcasing the same images. Image presentation followed a randomized sequence both for the eye tracking and for the survey component of this study but was equal for all observers. RESULTS: The most attractive vertical position of lips was the 1:2 ratio in which the distance between lips and chin is double the length as the distance between lips and nose. For the ratio between the width of the lips and the bigonial distance, it was the 1:2.5 ratio, whereas for the thickness of the upper lip vermilion in relation to the upper lip ergotrid it was the 1:3/1:2 (male/female) ratio and for the lower lip vermilion and lower lip ergotrid it was the 1:4 ratio for both genders. CONCLUSION: The results of this eye tracking and survey-based investigation revealed that instead of one single universal ratio, multiple facial proportions exist that are perceived as most attractive/masculine/feminine. Regarding the perception of facial aesthetics, it appears there is a distinction between attractiveness and masculinity/femininity: the most attractive male/female face is not necessarily the most masculine or feminine.

Developing Consensus-Based Guidelines for Case Reporting in Aesthetic Medicine: Enhancing Transparency and Standardization.

Clinical case reporting plays a vital role in sharing detailed patient narratives, providing insights into rare conditions, innovative treatments, and unexpected outcomes. However, existing reporting guidelines in aesthetic medicine fail to capture the specific nuances of procedures and outcomes in this field. The authors' objectives were to develop comprehensive guidelines for Case REporting in Aesthetic Medicine (CREAM). The study employed a 3-phase consensus process, including a literature review, expert interviews, and a consensus meeting. A diverse group of 10 expert participants (plastic surgeons, dermatologists, noncore specialists, evidence-based medicine expert, and research scientist) in Phase I and 30 experienced aesthetic practitioners in Phase II contributed to the research. Statistical analysis was conducted to assess agreement levels among participants and explore associations and variations within the data. The participants represented various specialties, genders, LGBTQ+ identities, and ethnic backgrounds. The research resulted in the development of the CREAM guidelines, consisting of a 16-item checklist. The guidelines covered essential aspects of case reporting, such as patient and practice information, procedure details, clinical assessment and outcomes, adverse events, and ethical considerations. Statistical analysis indicated a high level of consensus among participants, as well as significant associations between checklist items. CREAM guidelines represent a step toward enhancing transparency and standardization in case reporting in aesthetic medicine. Adhering to these guidelines will allow authors to contribute to a robust evidence base, prioritize patient safety, and drive advancements aesthetic medicine.

Decades of beauty: Achieving aesthetic goals throughout the lifespan.

BACKGROUND: Several elements, including age, influence judgments of beauty and attractiveness. Aging is affected by intrinsic factors (e.g., genetics, race/ethnicity, anatomical variations) and extrinsic factors (e.g., lifestyle, environment). AIMS: To provide a general overview of minimally invasive injectable procedures for facial beautification and rejuvenation to meet the aesthetic goals of patients across their lifespan, organized by decade. METHODS: This case study review describes aesthetic considerations of females in their third to sixth decade of life (i.e., 20-60 years of age or beyond). Each case study reports the treatments, specifically botulinum toxin type A and soft tissue fillers, used to address aesthetic concerns. RESULTS: Signs of aging, as well as aesthetic goals and motivations, vary by age groups, cultures, and races/ethnicities. However, there are overarching themes that are associated with each decade of life, such as changes in overall facial shape and specific facial regions, which can be used as a starting point for aesthetic treatment planning. Appropriate patient selection, thorough aesthetic evaluation, product knowledge, and injection technique, as well as good physician-patient communication, are essential for optimal treatment outcomes. CONCLUSIONS: Nonsurgical facial injectable treatments can successfully enhance and rejuvenate facial features across different age ranges. A comprehensive understanding of facial aging and the aesthetic considerations of patients by the decade contributes to optimal treatment planning and maintenance.

Precision in Midfacial Volumization Using Ultrasound-Assisted Cannula Injections.

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/m 2 ] 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.

Early ultrasound for diagnosis and treatment of vascular adverse events with hyaluronic acid fillers.

BACKGROUND: Hyaluronic acid fillers are known for a reliable safety profile, but complications do occur, even serious vascular adverse events. OBJECTIVE: To improve the treatment outcome after a vascular adverse event with use of hyaluronic acid filler treatments. METHODS: Duplex ultrasonography is used to detect the hyaluronic acid filler causing the intra-arterial obstruction. RESULTS: If treated in time, 1 single treatment of ultrasonographically guided injections of hyaluronidase into the filler deposit will prevent skin necrosis. CONCLUSION: Because the use of duplex ultrasonography adds extra essential information, its use may become an integral part of the prevention and treatment of injection adverse events.

Ultrasound as an Educational Tool in Facial Aesthetic Injections.

Injection therapies for cosmetic enhancement, particularly antiaging treatments, are increasingly popular. However, once the needle has penetrated the skin, the injector is "blind" to the depth and exact location of the needle tip. Duplex ultrasound use before and after treatment can allow the injector to visualize in real time the individual anatomy, thereby improving and confirming the accuracy of the injections through visualization of both the target layer and the vital structures to be avoided. Previously injected permanent filler treatments can also be visualized. In this way, ultrasound use becomes an important educational tool in promoting "safer" facial injection therapy. It shifts static anatomy to mobile real-time facial anatomy, thereby establishing itself as an invaluable learning tool through follow-up imaging, with subsequent optimization in techniques and patient outcomes.

PrabotulinumtoxinA vs OnabotulinumtoxinA for the Treatment of Adult Males With Moderate to Severe Glabellar Lines: Post-hoc Analyses of the Phase III Clinical Study Data.

BACKGROUND: Despite a growing interest among men in cosmetic procedures such as botulinum toxin, comparator clinical trial data in this population are limited. OBJECTIVES: The authors sought to compare the efficacy and safety of prabotulinumtoxinA and onabotulinumtoxinA for the treatment of males with moderate to severe glabellar lines. METHODS: Post-hoc analyses were performed on the subpopulation of male patients treated with either a single dose of 20 U prabotulinumtoxinA (n = 25) or 20 U onabotulinumtoxinA (n = 31) in the EVB-003 Phase III glabellar line clinical study. One key efficacy endpoint was the proportion of responders with a ≥1-point improvement from baseline at maximum frown on the 4-point Glabellar Line Scale. RESULTS: Compared with onabotulinumtoxinA-treated males, the percentages of responders who had a ≥1-point improvement on the Glabellar Line Scale at maximum frown were higher at all postbaseline time points for prabotulinumtoxinA-treated males (P > 0.05 at all visits) by an absolute overall mean difference of 10.1% across all visits. Similar trends were observed for efficacy endpoints based on global aesthetic improvement and subject satisfaction. PrabotulinumtoxinA-treated males had a higher incidence of treatment-related headache and eyelid ptosis. CONCLUSIONS: The percentages of patients who met the definition of a responder were higher at almost all time points examined for prabotulinumtoxinA-treated males. Despite the high level of consistency across all measures, differences between the 2 treatment groups did not reach statistical significance. Further study is warranted to establish if these post-hoc analyses observations are reproducible in a larger male patient population.

In Search of the Most Attractive Lip Proportions and Lip Volume: An Eye Tracking- and Survey-Based Investigation.

BACKGROUND: Despite various aesthetic trends, the ideal lip proportion and lip volume remains elusive. Thus, the aim of this study was to investigate the aesthetic perception of various lip shapes to identify the most attractive lips. METHODS: Fifty-nine White study participants with a mean age of 32.73 ± 9.4 years were asked to assess lips of various proportions and of various volumes. Gaze assessment and aesthetic rating of the same set of modified lip images were performed. RESULTS: The results revealed that the lip proportion that was rated to be most attractive was the 1:1.6 ratio (upper-to-lower lip, 4.21 of a possible 5). This lip proportion, however, was not the first one to be viewed on initial image display (1.20 sec) and had the shortest duration of a stable eye fixation within the 6-second image display interval (2.18 of 6 seconds). The lip volume that received the highest aesthetic rating was the 100 percent volume (original lip size), with 4.56 of a possible 5. This lip volume, however, had the third longest interval between initial image exposure and the first stable eye fixation (0.81 second) and had the shortest duration of stable eye fixations during the 6 seconds of image display (2.22 of 6 seconds). CONCLUSION: The results presented could be potentially reflective of the internal cognitive processes during the involuntary and voluntary assessment of lip attractiveness.

Superficial Nasal Filler Injections-How I do It.

Nasal enhancement is one of the most challenging and intriguing of aesthetic procedures. Although the nose is the most central and prominent facial feature, it should not be dominant while maintaining both a harmonious relationship with the face and its own intrinsic beauty. In this article, the first author shares his experience on how to specifically apply intradermal soft-tissue fillers (for particular indications) in nasal enhancement and incorporates patient assessment, anatomy of the nose, and injection techniques to provide guidance. Intradermal injections are required for specific regions, as for example in the treatment of internal and external valve collapse; however, several precautionary measures need to be implemented to minimize risks resulting in vascular compromise.

Tips and Tricks for Facial Toxin Injections with Illustrated Anatomy.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Recognize facial muscle contraction direction and muscle morphology based on skin surface movements and facial rhytides. 2. Classify different muscle contraction patterns and target respectively with the recommended dosage and injection technique. 3. Apply the presented injection techniques to the patients' individual anatomy with greater precision and without affecting adjacent muscles or causing other adverse events. SUMMARY: Facial muscular anatomy has recently gained increased attention, with new investigative methodologies and new injection techniques arising on the market. These recent advancements have increased our understanding about the functional anatomy of facial muscles and have changed the way health care professionals see and understand their interplay during various facial expressions and in determining facial shape. This new anatomical understanding of facial muscles and their interaction has resulted in superior neuromodulator treatment outcomes with fewer side effects and with increased precision. The latter is of greatest importance, as all facial muscles act as a unit and connect with each other. It is therefore paramount to target during neuromodulator treatments only the muscle responsible for the aesthetic effect desired and not other adjacent muscles, which can have different or even antagonistic effects. Conventional anatomy was previously limited to two-dimensional explanations of muscle locations without incorporating their detailed action or their three-dimensional location of extent. The "new" anatomy incorporates those novel concepts and, once understood, will help health care providers to understand better and to "read" the underlying muscular anatomy based on the wrinkle status and based on the change in skin surface landmarks based on the actions of the underlying musculature. The following article summarizes tips and tricks, pearls and pitfalls, and dos and don'ts during facial neuromodulator injections along with a guide toward adverse event management and patient outcome assessment with special focus on the underlying anatomy.

Facial Aesthetic Priorities and Concerns: A Physician and Patient Perception Global Survey.

BACKGROUND: Minimally invasive and noninvasive facial aesthetic treatments are increasingly popular, and a greater understanding of patient perspectives on facial aesthetic priorities is needed. OBJECTIVES: The authors surveyed facial aesthetic concerns, desires, and treatment goals of aesthetically conscious men and women, and physicians, in 18 countries. METHODS: This was a global, internet-based survey on desired appearance and experiences with, or interest in, facial aesthetic treatments. Eligible respondents were aesthetically conscious adults (21-75 years). Eligible aesthetic physicians were required to see ≥30 patients per month for aesthetic reasons, have 2 to 30 years of experience in clinical practice, and spend ≥70% of their time in direct patient care. RESULTS: A total of 14,584 aesthetically conscious adults (mean age, 41 years; 70% women) and 1315 aesthetic physicians (mean age, 45 years; 68% men) completed the survey. Most respondents (68%) reported that aesthetic procedures should be sought in their 30s to 40s; physicians recommended patients seek treatment earlier. Respondents expressed greatest concern over crow's feet lines, forehead lines, facial skin issues, hair-related concerns, and under-eye bags or dark circles; in contrast, physicians tended to underestimate concerns about under-eye bags or dark circles, mid-face volume deficits, and skin quality. Although both physicians and respondents cited cost as a major barrier to seeking aesthetic treatments, respondents also emphasized safety, fear of injections or procedure-related pain, and concern about unnatural-looking outcomes. CONCLUSIONS: This global survey provides valuable insight into facial aesthetic concerns and perspectives that may be implemented in patient education and consultations to improve patient satisfaction following aesthetic treatments.

The Layered Anatomy of the Nose: An Ultrasound-Based Investigation.

BACKGROUND: An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex. OBJECTIVES: The authors sought to describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement. METHODS: A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose utilizing ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature. RESULTS: In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n = 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% to 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip. CONCLUSIONS: Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared with any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.

The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3-Dimensional Skin Surface Vector Analysis.

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.

The mobility of the superficial and deep midfacial fat compartments: An ultrasound-based investigation.

BACKGROUND: Understanding the mobility of the midface and the separate contributions of the superficial and deep fat compartments is essential for natural esthetic outcomes following soft tissue filler or fat grafting procedures. A study was designed that used ultrasound imaging to demonstrate in vivo visualization and quantification of distances and movements in the midface. METHODS: A total of 48 midfaces of 24 healthy Caucasian volunteers, all naïve of esthetic procedures, (22 females; 46.85 (9.8) years; 22.83 (3.1) kg/m2 ) were scanned using 18 MHz ultrasound imaging. Distances between bony landmarks (inferior orbital rim, infraorbital foramen) were used as markers to measure the cranial movement of the superficial (superficial nasolabial and superficial medial cheek fat compartment) and the deep (deep pyriform space, deep medial check fat compartment, deep lateral cheek fat compartment) midfacial fat compartments between resting and smiling facial position. RESULTS: The superficial midfacial fat compartment moved, on average, 3.7 mm (p < 0.001) cranially, whereas the deep midfacial fat compartments moved, on average, 0.1 mm (p > 0.05) during smiling. No gender differences in mobility were identified (p > 0.05). CONCLUSION: The results obtained are in line with previous cadaveric investigations and revealed, in a highly statistically significant fashion, that the superficial midfacial fat compartments move in cranial direction whereas the deep fat compartment did not display similar positional changes. These results help to guide facial injectable treatments and to understand why, in the midface, a deep supraperiosteal approach should be favored when augmenting the deep midfacial fat compartments.

Evaluating safety in hyaluronic acid lip injections.

INTRODUCTION: Soft tissue filler augmentation has become increasingly popular due to its perceived ease and impressive results. Unfortunately, although the results are impressive, so are the reported complications. This article describes complications specific to peri-oral soft tissue filler injection and then discusses evidence-based, anatomic prevention and treatment guidelines. AREAS COVERED: The authors aimed at providing an overview of the complications associated with peri-oral soft tissue filler. Hyaluronic Acid (H.A) fillers may have devastating complications which are oft undisclosed or published. This narrative review aims to describe the various complications and provide preventative strategies. EXPERT OPINION: Given the paucity of prospective, randomized clinical trials on the subject and in light of complication underreporting, the authors believe that efficacy and safety literature on the subject is lacking. Injectors must rely on the one strength which exists in the lip literature to date, that is anatomy. The basis of all successful injections is a mandatory understanding of normal as well as variations of vital structures in an area, combined with meticulous injection techniques, deposition of small aliquots of product and the ability to recognize unwanted adverse events early enough to act on them.

Influence of Rheological Properties and Needle Size on Extrusion Forces of Hyaluronic Acid Based Soft Tissue Fillers.

BACKGROUND: To date no precise data are available for extrusion forces related to the G-prime and G-double-prime of fillers in combination with different 27G and 30G needles. Therefore, the objective of this study was to analyze extrusion forces of various product-needle-combinations containing two different 27G and two different 30G needles in combination with fillers of a wide range of elastic moduli starting from 2.0 – 166.0 Pa. MATERIAL AND METHODS: Four different fillers with the following elastic moduli 1.87, 11.65, 61.80, 165.50 Pa were combined with four different needles: 27G ½”, internal diameter: 0.300 μm; 27G ½”, internal diameter: 0.241 μm; 30G ½”, internal diameter: 0.241 μm and 30G ½“, internal diameter: 0.240 μm. Product-needle-combination were subjected to uni-axial mechanical testing and the respective extrusion force was measured. RESULTS: The results of this study revealed that the G-prime and the G-double-prime of a product are statistically significantly related to their extrusion force, with higher G-prime/G-double-prime products requiring higher extrusion forces. The results additionally revealed that whether the size of the needle was described as 27G or 30G by the respective manufacturer statistically significant differences between the measured extrusion forces were detected. CONCLUSION: Injectors need to be aware that not every 27G/30G needle has the same extrusion force even though the external diameter is similar (27G or 30G); this might additionally influence the ability to withdraw blood during a pre-injection aspiration manoeuvre. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5237.

The Change of Plane of the Supratrochlear and Supraorbital Arteries in the Forehead-An Ultrasound-Based Investigation.

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.

Ultrasound to Improve the Safety and Efficacy of Lipofilling of the Temples.

BACKGROUND: Autologous fat is known for a reliable and natural safety profile, but complications do occur-even serious vascular adverse events. OBJECTIVES: The authors sought to examine doppler-ultrasound (DUS) imaging for the harvesting and subsequent facial implantation of autologous fat tissue. METHODS: All patients underwent lipofilling treatment of the temporal fosse of the face. DUS examination was performed for preprocedural vascular mapping and imaging of previously injected (permanent) fillers. In addition, the injection of autologous fat was performed DUS-guided. RESULTS: Twenty patients (all female; mean age, 57.9 years; range, 35-64 years). DUS examination showed that 16 of the 20 patients (80%) had been injected with resorbable or nonresorbable fillers elsewhere in the past. The temporal artery could be visualized and avoided in all cases. An average of 1.1 cc of autologous fat was injected in the temporal fossa per side. One case of edema and nodules was described, but no other adverse events were reported. CONCLUSIONS: The utilization of DUS can add valuable information to a lipofilling procedure and should be considered an integral part of a safe lipofilling treatment.

Descriptive Analysis of 213 Positive Blood Aspiration Cases When Injecting Facial Soft Tissue Fillers.

BACKGROUND: Pre-injection aspiration procedures could increase safety during soft tissue filler injections. However, various influencing factors have been detected in vitro that could result in false negative aspiration results. OBJECTIVE: A case series was retrospectively investigated to identify factors contributing to positive blood aspiration procedures in vivo. METHODS: This study evaluated 213 clinical cases positive for blood aspiration documented in an Asian population: 208 females (43.8 ±â€…7.2 years old) and 5 males (46.8 ±â€…7.8 years old) during soft tissue filler injections. Injection location, layer (depth) of injection, product injected, size of utilized needle (gauge), length of needle (inch), priming of needle (yes/no), injection angle (degree), and time until blood was visible in the needle hub (seconds) were evaluated. RESULTS: The most frequent location where a positive aspiration was observed was the pyriform fossa (n = 56; 26.3%), the most frequent plane was the supra-periosteal plane (n = 195; 91.5%), and the most frequent needle utilized was a 27G needle (n = 125; 58.7%). Statistically significantly more positive cases were identified when the needle was primed compared with an unprimed needle (P < 0.001, which was independent of the product). The estimated incidence rate was 0.04% to 0.9% for having positive aspiration procedures per total performed injection procedures. CONCLUSIONS: Pre-injection aspiration could be a valuable tool to prevent accidental intravascular injection of soft tissue filler. The results of the present investigation show that aspiration can be performed with an acceptable aspiration time, that is, less than 2 seconds, if a suitable product/needle combination is chosen.