Investigating the Contraction Pattern of the Zygomaticus Major Muscle and its Clinical Relevance: A Functional MRI Study.

BACKGROUND: Our understanding of facial anatomy has significantly evolved, yet the detailed contraction patterns of facial muscles and their presentation during clinical imaging remain largely unexplored. Understanding the contraction patterns and visual presentation of these muscles, particularly the zygomaticus major could enhance pre-surgical facial assessments and the development of new treatment strategies. METHODS: A total of 34 healthy young individuals (17 female, 17 male) with a mean age of 23.6 (2.4) years [range: 20-30] were investigated regarding the length, thickness, width, and angle of the zygomaticus major muscle in five different facial expressions (i.e., repose, anger, joy, surprise, and sadness) utilizing MR imaging. RESULTS: Joyful expressions caused a reduction in muscle length to 85.6% of its original length and an increase in width (103.4%), thickness (108.4%), and facial angle (2.72°) when compared to that in repose, suggesting isotonic contraction. Conversely, expressions of anger, surprise, and sadness generally led to muscle stretching, seen through changes in length (98.9%, 104.3%, and 102.7%, respectively), width (98.8%, 96.5%, and 99.4%, respectively), and thickness (91.2%, 91.0%, and 102.7%, respectively), with variable alterations in facial angle (0.55°, 1.85°, and 1.00°, respectively) depending on the specific expression. CONCLUSION: This MRI-based study indicates that the zygomaticus major muscle experiences isotonic contraction, characterized by decreased length and increased width and thickness. The findings underline the importance of muscle thickness as a reliable parameter in assessing facial muscle function and offer valuable guidance for practitioners in accurately evaluating muscle performance during different facial expressions. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Understanding the Interplay Between Skin, Fascia, and Muscles of the Midface in Facial Aging.

BACKGROUND: Surgical, minimally-invasive, and non-invasive aesthetic procedures try to ameliorate the signs of facial aging, but also focus on enhancing various individual features of beauty in each patient. Herein, the midface plays a central role due to its location but also its importance for the aesthetic perception and facial expression. OBJECTIVE: To date, no study has investigated the interplay between facial muscles and its connecting subdermal architecture during facial aging to provide a more comprehensive understanding of the middle face. MATERIALS AND METHODS: A total of 76 subjects, consisting of 30 males (39.5%) and 46 females (60.5%) with a mean age of 42.2 (18.7) years [range 19-80] and a mean BMI of 24.6 (3.7) kg/m2 [range 18-35], were enrolled in this investigation. Cutometry (skin aging), 3D skin displacement analyses (subdermal connective tissue aging), and sEMG (muscle aging) analyses were utilized. RESULTS: The results revealed that overall skin firmness increased, and skin elasticity decreased (p < 0.001), sEMG signal of the investigated muscles decreased (p < 0.001), whereas midfacial mobility remained unaltered (p = 0.722). CONCLUSION: The results of this study indicate that midfacial aging is a measurable effect when utilizing individual measurement modalities for assessing skin, subdermal fascia, and midfacial muscles. The function of midfacial muscles revealed a potential threshold effect, which is not reached during midfacial aging due to the unchanged soft tissue mobility at older age. However, to understand its clinical presentation all midfacial soft tissues need to be factored in and a holistic picture needs to be created. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes review articles, book reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to authors www.springer.com/00266 .

How We Look At Mature Faces-An Eye-Tracking Investigation Into the Perception of Age.

BACKGROUND: It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses. OBJECTIVES: The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face. METHODS: Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 > 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (<40 years) and older (>40 years) gender-matched individuals were presented in a standardized setting. RESULTS: Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P < 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer's age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers. CONCLUSIONS: It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan.

Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures.

BACKGROUND: Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position. OBJECTIVE: The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions. METHODS: This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m2. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity. RESULTS: The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001. CONCLUSION: Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

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.

Treatment of Rhinophyma With Fractional CO2 Laser Resurfacing in a Woman of Color: Case Report and Review of the Literature.

Rhinophyma is a disfiguring disorder that is characterized by an erythematous, hypertrophied, and inflamed lower two-thirds of the nose. Widely accepted as the severe form of acne rosacea, rhinophyma can result in functional, aesthetic, and psychosocial concerns that require treatment in a cosmetic fashion. Rosacea should be treated in its earliest manifestations to mitigate the progression towards rhinophyma; therefore, early detection and intervention is a crucial part of treatment. Little has been written on this subject in people of color. We present the first reported case of rhinophyma in a 62-year-old Fitzpatrick V female patient who was successfully treated with one session of fractional CO2 laser resurfacing. This case highlights the successful use of the fractional CO2 laser to treat rhinophyma in darker skin types (Fitzpatrick IV–VI) and underscores the potential for future use among patients of color. J Drugs Dermatol. 2021;20(7):772-775. doi:10.36849/JDD.C702.

Global Recommendations on COVID-19 Vaccines and Soft Tissue Filler Reactions: A Survey-Based Investigation in Cooperation With the International Society for Dermatologic and Aesthetic Surgery (ISDS).

BACKGROUND: Recent reports have surfaced from the United States Food and Drug Administration hearings in December 2020 regarding the COVID-19 vaccines and study participants who developed facial and/or lip swelling after receiving the newly developed drug. Despite an incidence rate of 0.02% in the vaccine arm of the Moderna mRNA-1273 trial, concerns have been expressed about the association of adverse reactions following soft tissue filler injections and the COVID-19 vaccines. The International Society for Dermatologic and Aesthetic Surgery (ISDS) understands these concerns and has designed the following study. METHODS: A global survey was designed to capture the incidence of adverse events related to: (1) previous soft tissue filler injections, (2) soft tissue filler injections during positive testing for COVID-19, and (3) soft tissue filler injections during and after receiving any of the COVID-19 vaccines globally available. RESULTS: The information of 106 survey participants from 18 different countries was analyzed. 80.2% (n=85) never experienced any adverse reaction following their soft tissue filler injection whereas 15.1% (n=16) experienced swelling and 4.7% (n=5) experienced pain that lasted longer than two days. Of those who received at least one dose of the COVID-19 vaccine (n=78), 94.9% reported not to have experienced any adverse reaction related to their previous soft tissue filler injection, whereas 5.1% (n=4) reported to have perceived pain that lasted longer than two days. CONCLUSION: The data collected does not support the concern for an increased risk of developing adverse reactions following soft tissue filler injections associated with the COVID-19 vaccines compared to that risk associated with other previously described triggers or the default risk following soft tissue filler injections. J Drugs Dermatol. 20(4):374-378. doi:10.36849/JDD.2021.6041.

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

The 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.

Differences in Temporal Volume between Males and Females and the Influence of Age and BMI: A Cross-Sectional CT-Imaging Study.

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.

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging.

Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m2. Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both p < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.

The Course of the Angular Artery in the Midface: Implications for Surgical and Minimally Invasive Procedures.

BACKGROUND: Previous anatomic studies have provided valuable information on the 2-dimensional course of the angular segment of the facial artery in the midface and its arterial connections. The third dimension (ie, the depth of the artery) is less well characterized. OBJECTIVES: The objective of the present study was to describe the 3-dimensional pathway of the angular segment of the facial artery and its relationship to the muscles of facial expression. METHODS: The bilateral location and the depth of the midfacial segment of the facial artery was measured utilizing multi-planar computed tomographic image analyses obtained from contrast agent-enhanced cranial computed tomographic scans of 156 Caucasians aged a of 45.19 ± 18.7 years and with a mean body mass index of 25.05 ± 4.9 kg/m2. RESULTS: At the nasal ala, the mean depth of the main arterial trunk was 13.7 ± 3.7 mm (range, 2.7-25.0 mm), whereas at the medial canthus it was 1.02 ± 0.62 mm (range, 1.0-3.0 mm). This was reflected by the arteries' relationship to the midfacial muscles: at the nasal ala superficial to levator anguli oris in 62.0% but deep to the levator labii superioris alaeque nasi in 53.6%; at the medial canthus superficial to the levator labii superioris alaeque nasi in 83.1% and superficial to the orbicularis oculi in 82.7%. CONCLUSIONS: The results presented herein confirm the high variability in the course of the angular segment of the facial artery. Various arterial pathways have been identified providing evidence that, in the midface, there is no guaranteed safe location for minimally invasive procedures.

Understanding Facial Muscle Aging: A Surface Electromyography Study.

BACKGROUND: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood. OBJECTIVES: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers. METHODS: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles. RESULTS: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity). CONCLUSIONS: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.

Three-Dimensional Description of the Angular Artery in the Nasolabial Fold.

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.

Anatomy Behind the Facial Overfilled Syndrome: The Transverse Facial Septum.

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.

The Influence of the Insertion Angle on Middle and Lower Face Tissue-Mechanics When Treating the Nasolabial Folds with Facial Suspension Threads-An Experimental Split-Face Cadaveric Study.

A 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.

Influences of Age, Gender, and Body Mass Index on the Depth of the Superficial Fascia of the Arm and Thigh.

BACKGROUND: Nonsurgical skin-tightening procedures are increasing in popularity because of their noninvasiveness as the energy is transdermally applied to the subcutaneous tissues. OBJECTIVE: To provide precise data on the depth of the superficial fascia for potentially safer and better targeted treatments of arms and thighs. METHODS: One hundred fifty Caucasian individuals were investigated with an equal distribution of men and women (each n = 75) and a balanced distribution of age (n = 30 per decade). Ultrasound-based measurements were conducted, measuring the distance between skin and the superficial fascia in the posterior arm and the anterior, medial, and posterior thigh. RESULTS: Deep to the skin, 5 layers were consistently and bilaterally identified in both sexes: skin, superficial fat, superficial fascia, deep fat, and deep fascia. The overall mean distance between the skin surface and the superficial fascia was for the posterior arm 4.38 ± 0.9 mm; range (2.60-6.70), for the anterior thigh 7.90 ± 2.3 mm range (3.50-13.20), for the medial thigh 5.74 ± 1.2 mm range (3.10-8.20), and for the posterior thigh 7.77 ± 3.2 mm range (3.60-14.50). CONCLUSION: Knowing the precise depth of the superficial fascia for nonsurgical skin-tightening procedures could potentially guide practitioners toward safer and more effective outcomes.

Clinical Validation of the Surface Volume Coefficient for Minimally Invasive Treatment of the Temple

Objective: The aim of the present study is to compare the temporal surface volume coefficient obtained in the cadaveric model from subdermal and supraperiosteal injections to the clinical setting when treating temporal hollowing. Material and Methods: A total of 36 subjects were included in this investigation, 17 patients (16 females, 1 male; 46.3 ± 8.9 years; 25.5 ± 2.8 kg/m2) and 19 cadaveric specimens (11 females, 8 males; 76.4 ± 11.5 years; 24.0 ± 5.1 kg/m2). Subdermal and supraperiosteal injections were performed and live subjects were evaluated and followed for 12 months. The surface volume coefficients were calculated using 3D surface volume scanning and compared for validity. Results: No statistically significant difference was detected between the clinical outcome scores of the subdermal vs supraperiosteal injection technique. The supraperiosteal injection technique utilized significantly more product 1.20 ± 0.5 cc [range: 0.50 ­ 2.6 cc] compared to the subdermal 0.71 ± 0.2 cc [range: 0.30 ­ 1.20 cc] vs with P< 0.001. This difference was consistent with the different values of the cadaveric surface volume coefficient (subdermal vs supraperiosteal): 1.00 ± 0.2 vs 0.70 ± 0.2. At 12-month follow-up, the product loss was 19% for the subdermal injection and 21% for patients treated with supraperiosteal injections. Conclusion: The results of the study support the clinical validity of the surface volume coefficient. They demonstrate that the different injection volumes necessary to deliver aesthetically appealing results when utilizing the subdermal vs the supraperiosteal technique can be explained by the region-specific surface volume coefficient. J Drugs Dermatol. 2019;18(6):533-540.

Are Cosmetic Procedures Comparable to Antidepressive Medication for Quality-of-Life Improvements? A Systematic Review and Controlled Meta-Analysis.

Cosmetic procedures, especially cosmetic minimally invasive treatments, are rising in popularity, despite societal perception that these procedures may not improve patient health. The purpose of this study was to conduct a systematic review and controlled meta-analysis to compare the effects of cosmetic procedures and antidepressant treatment on health-related quality-of-life improvement. The PubMed database was queried in two independent searches to identify peer-reviewed cosmetic and antidepressant articles published between 1996 and 2017 that prospectively assessed the impact of the treatment on quality of life. All results were screened using defined exclusion and inclusion criteria and data were extracted using a standardized protocol. The meta-analysis was performed using a random-effects model. Five of 2,788 cosmetic studies and eight of 2,312 antidepressant studies met all inclusion criteria and utilized the 36-Item Short Form Health Survey (SF-36) measure. Except for the physical functioning scale, when compared with the cosmetic studies, antidepressant studies had significantly lower median baseline and post-treatment follow-up scale scores with larger median score improvement (p < 0.05). Positive effect sizes following treatment were observed for all eight SF-36 scales (range: 0.32-1.16; p < 0.05). This meta-analysis provides evidence that cosmetic procedures objectively improve a patient's health-related quality of life. While antidepressant studies exhibited greater SF-36 score improvement except for the physical functioning scale, both treatment groups demonstrated the greatest improvement in mental health and role emotional scales. As previously suggested, a disconnect exists between score improvement and clinical improvement due to baseline severity, ceiling effect, and regression to the mean effects.

Age and Gender Differences of the Frontal Bone: A Computed Tomographic (CT)-Based Study.

BACKGROUND: Age-related changes of the frontal bone in both males and females have received limited attention, although understanding these changes is crucial to developing the best surgical and nonsurgical treatment plans for this area. OBJECTIVES: To investigate age-related and gender-related changes of the forehead. METHODS: Cranial computed tomographic images from 157 Caucasian individuals were investigated (10 males and 10 females from each of the following decades: 20-29 years, 30-39 years, 40-49 years, 50-59 years, 60-69 years, 70-79 years, 80-89 years, and of 8 males and 9 females aged 90-98 years). Frontal bone thickness and forehead distance measurements were carried out to analyze age and gender differences. RESULTS: With increasing age, the size of a male forehead reduces until no significant differences to a female forehead is present at old age (P = 0.307). The thickness of the frontal bone of the lower forehead (≤4 cm cranial to the nasal root) increased slightly in both genders with increasing age. In the upper forehead (≥4 cm cranial to the nasal root), frontal bone thickness decreased significantly (P = 0.002) in males but showed no statistically significant change in thickness in females (P = 0.165). CONCLUSIONS: The shape of the frontal bone varies in young individuals of different genders and undergoes complex changes with age because of bone remodeling. Understanding these bony changes, in addition to those in the soft tissues, helps physicians choose the best surgical and nonsurgical treatment options for the forehead.