Investigating Facial Muscle Physiology Following Soft Tissue Filler Injections - A surface-derived Electromyographic and Skin Vector Displacement Analytic Study.

The use of hyaluronic - acid based soft - tissue fillers has often been reported to modulate the muscle i.e., to cause myomodulation. To our knowledge, there has been so far no scientific study investigating the potential of hyaluronic - acid based soft - tissue fillers to modulate or actually alter the function of facial muscles. To further assess this 3 - dimensional (3D) surface imaging and electromyography (EMG) based prospective study investigated the changes of facial muscle contraction after injection of strategically placed hyaluronic - acid based soft - tissue fillers to assess the actual validity of the term myomodulation. A total of 13 subjects with a mean age of 37.8 years (12 females, 1 male) were injected according to a predefined injection protocol. Surface electromyography and 3D surface imaging were performed prior to the injection and 5 days after the injection. The results showed no significant change in the strength of the muscles (measured in µV) after injection of hyaluronic - acid based soft - tissue fillers. However, horizontal and vertical skin displacement upon contraction of the zygomaticus major muscle changed significantly between baseline and follow - up , with a mean horizontal skin displacement increase from 3.2 mm to 4.1 mm. Upon contraction of the depressor anguli oris muscle, the horizontal skin displacement did not change significantly (2.15 mm vs. 2.05 mm), while vertical skin displacement increased significantly from 2.9 mm to 4.3 mm. The modification of the surrounding tissue caused an alteration of the vectorial skin displacement upon contraction of the muscle. A potential explanation could be the increased distance between origin and insertion of the muscle due to the material deposition in the proximity of the relevant facial muscles, leading to a change of contraction vector.

The Influence of Scar Patterns After Reduction Mammoplasty on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

BACKGROUND: Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars. METHODS: 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers. RESULTS: The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern. CONCLUSION: The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern. LEVEL OF EVIDENCE V: 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 .

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 .

Increasing Precision When Targeting the Depressor Anguli Oris (DAO) Muscle With Neuromodulators - An Ultrasound-Based Investigation.

BACKGROUND: Neuromodulator treatments of the perioral region are increasingly popular and aim to modulate the position of the modiolus. The predominantly targeted muscle is the depressor anguli oris (DAO) which allows for the modiolus to reposition cranially once temporarily relaxed. OBJECTIVES: To identify the precise anatomic position of the DAO in relation to the Marionette Line for increasing precision and reducing adverse events during neuromodulator treatments. METHODS: A total of n = 80 DAO muscles were investigated in n = 40 healthy, toxin naïve volunteers (11 males, 29 females) having a mean age of 48.15 (15) years and a mean body mass index of 24.07 (3.7) kg/m2. The location of the DAO in relation to the labiomandibular sulcus (LMS), its depth, extent, and thickness were investigated with high frequency ultrasound imaging. RESULTS: The skin surface projection of the LMS separates the DAO into medial and lateral portions. The distance between skin surface and muscle surface was on average 4.4 mm with males having a greater distance (p < 0.001) and higher BMI being an important influencing factor for a greater distance (p < 0.001). The thickness of the DAO was on average 3.5 mm with a range of 2.8-4.8 mm and with females having thinner muscles when compared to men (p < 0.001). The most favorable injection depth was calculated to be 6.1 mm for intra-muscular product placement. CONCLUSIONS: Understanding the perioral anatomy and the influence of age, sex, and BMI will potentially allow the injectors to increase efficacy and duration of neuromodulator treatments while expertly managing adverse events.

Molecular Characterization of BK Polyomavirus Replication in Allogeneic Hematopoietic Cell Transplantation Patients.

BACKGROUND: High-level BK polyomavirus (BKPyV) replication in allogeneic hematopoietic cell transplantation (HCT) predicts failing immune control and BKPyV-associated hemorrhagic cystitis. METHODS: To identify molecular markers of BKPyV replication and disease, we scrutinized BKPyV DNA-loads in longitudinal urine and plasma pairs from 20 HCT patients using quantitative nucleic acid testing (QNAT), DNase-I treatment prior to QNAT, next-generation sequencing (NGS), and tested cell-mediated immunity. RESULTS: We found that larger QNAT amplicons led to under-quantification and false-negatives results (P < .001). DNase-I reduced urine and plasma BKPyV-loads by >90% (P < .001), indicating non-encapsidated BKPyV genomes. DNase-resistant urine BKPyV-loads remained infectious in cell culture. BKPyV genome fragmentation of ≤250 bp impaired NGS coverage of genetic variation using 1000-bp and 5000-bp amplicons. Conversely, 250-bp amplicons captured viral minority variants. We identified genotype-specific and genotype-independent changes in capsid Vp1 or T-antigen predicted to escape from antibody neutralization or cytotoxic CD8 T-cells, respectively. Genotype-specific changes in immunodominant 9mers were associated with reduced or absent CD8 T-cell responses. Thus, failure to control BKPyV replication in HCT Patients may involve insufficient genotype-specific cytotoxic CD8 T-cell responses, potentially predictable by low neutralizing antibodies as well as genotype-independent immune escape. CONCLUSIONS: Our results provide new insights for patient evaluation and for designing immune protection through neutralizing antibodies, adoptive T-cell therapy, or vaccines.

ChatGPT's quiz skills in different otolaryngology subspecialties: an analysis of 2576 single-choice and multiple-choice board certification preparation questions.

PURPOSE: With the increasing adoption of artificial intelligence (AI) in various domains, including healthcare, there is growing acceptance and interest in consulting AI models to provide medical information and advice. This study aimed to evaluate the accuracy of ChatGPT's responses to practice quiz questions designed for otolaryngology board certification and decipher potential performance disparities across different otolaryngology subspecialties. METHODS: A dataset covering 15 otolaryngology subspecialties was collected from an online learning platform funded by the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, designed for board certification examination preparation. These questions were entered into ChatGPT, with its responses being analyzed for accuracy and variance in performance. RESULTS: The dataset included 2576 questions (479 multiple-choice and 2097 single-choice), of which 57% (n = 1475) were answered correctly by ChatGPT. An in-depth analysis of question style revealed that single-choice questions were associated with a significantly higher rate (p < 0.001) of correct responses (n = 1313; 63%) compared to multiple-choice questions (n = 162; 34%). Stratified by question categories, ChatGPT yielded the highest rate of correct responses (n = 151; 72%) in the field of allergology, whereas 7 out of 10 questions (n = 65; 71%) on legal otolaryngology aspects were answered incorrectly. CONCLUSION: The study reveals ChatGPT's potential as a supplementary tool for otolaryngology board certification preparation. However, its propensity for errors in certain otolaryngology areas calls for further refinement. Future research should address these limitations to improve ChatGPT's educational use. An approach, with expert collaboration, is recommended for the reliable and accurate integration of such AI models.

Facial Anthropometric Measurements and Principles - Overview and Implications for Aesthetic Treatments.

Facial anatomy is highly individual in each patient. Anthropometric measurements can be a useful tool to objectively analyze individual facial anatomy to allow for better comparability before and after treatments to ultimately improve standardization of facial procedures, both nonsurgical and surgical. The aim of this study was to provide a comprehensive overview over clinically relevant and feasible facial anthropometric measurements and principles for aesthetic medicine. A literature review was conducted to describe the most important and clinically relevant anthropometric measurements and principles for both the entire face and for three aesthetically relevant facial regions: the periorbital region, the nose, and the perioral region. A multitude of different anthropometric measurements and principles have been described in the literature for both the overall facial appearance and specific facial regions. Certain generally accepted anthropometric principles and proportions need to be respected to achieve aesthetic and harmonious results. For the overall facial appearance, a focus on symmetry, certain proportions, facial angles, and indices has been described. Principles and measurements were also described for the periorbital region, the nose, and the perioral region. Although attractiveness and aesthetic perception are subjective, objective evaluation of facial surface anatomy via anthropometric measurements can improve pre- and postinterventional analysis of the face and help the treating physician to individualize treatments, both nonsurgical and surgical.

Arterial Embolism After Facial Fat Grafting: A Systematic Literature Review.

BACKGROUND: While autologous fat grafting of the face is considered a generally safe procedure, severe complications such as arterial embolism (AE) have been reported. OBJECTIVE: To summarize data on injection-related visual compromise, stroke, and death caused by arterial embolism after facial fat transplantation. MATERIALS AND METHODS: Plastic surgery societies were contacted for reports on AE after autologous facial fat injection. In addition, a systematic literature review was performed. Data extracted included study design, injection site/technique, symptoms, management, outcome, and etiology. RESULTS: 61 patients with a mean age of 33.56 ± 11.45 years were reported. Injections targeted the glabella or multiple facial regions (both n = 16/61, 26.2%) most commonly, followed by injections in the temples (n = 10/61, 16.4%) and the forehead (n = 9/61, 14.8%). The mean volume injected was 21.5 ± 21.5 ml. Visual symptoms were described most frequently (n = 24/58, 41.4%) followed by neurological symptoms (n = 20/58, 34.5%), or both (n = 13/58, 22.4%). Ophthalmic artery (OA, n = 26/60, 43.3%), anterior or middle cerebral artery (CA, n = 11/60, 18.3%) or both (n = 14/60, 23.3%) were most frequently occluded. Outcome analysis revealed permanent vision loss in all patients with OA occlusion (n = 26/26, 100%), neurological impairment in most patients with CA occlusion (n = 8/10, 80%), and vision loss in most patients suffering from both OA and CA occlusion (n = 7/11, 63.6%). Six patients died following embolisms. CONCLUSIONS: AE causes severe complications such as blindness, stroke, and death. Due to a lack of high-quality data, no evidence-based treatment algorithms exist. To increase patient safety, a database collecting cases and complications should be established. LEVEL OF EVIDENCE III: 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 .

Epidemiology of hand injuries that presented to a tertiary care facility in Germany: a study including 435 patients.

BACKGROUND: Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization. OBJECTIVE: The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps. METHODS: This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones. RESULTS: 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases. CONCLUSIONS: The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries.

Visualization of the location and level of pain in common wrist pathologies using color-coded heatmaps.

BACKGROUND: Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon. OBJECTIVE: The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies. METHODS: This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities. RESULTS: 120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology. CONCLUSIONS: Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain.

Multimodal Analyses of the Aging Forehead and Their Clinical Implications.

BACKGROUND: Recent research has indicated that in the upper face a delicate arrangement exists between the muscles of facial expression and the skin. This arrangement allows for immediate transmission of movements following muscle contraction, resulting in skin movements and skin rhytid formation. OBJECTIVES: To investigate age-related changes of the biomechanical unit formed by facial muscles, their connective tissue envelope, and the skin of the upper face. METHODS: A total of 76 Caucasian volunteers (30 males, 46 females) with a mean age of 42.2 years (SD 18.6) and a mean body mass index of 24.58 kg/m2 (SD 3.7) were investigated. Three upper facial regions were analyzed for skin firmness and elasticity with cutometric assessment, vertical and horizontal skin vector displacement using 3-dimensional imaging, and muscle activity with surface-derived electromyography. RESULTS: Study participants of older age (>42.2 years), when compared with younger participants (≤42.2 years), showed increased skin firmness, at 0.20 mm vs 0.30 mm (P < .001); decreased skin elasticity at 53.2% vs 69.0% (P < .001); increased vertical (not horizontal) skin mobility at 3.56 mm vs 1.35 mm (P < .001); and decreased surface-derived electromyography (sEMG) signal of the frontalis muscle with 174 µV vs 309 µV (P = .039). CONCLUSIONS: This study reveals that age-related changes occur in each component of the biomechanical unit formed by facial muscles, connective tissue envelope, and skin in the upper face. Knowledge and understanding of such changes can allow for more targeted and individualized surgical and nonsurgical aesthetic treatments.

Ex Vivo Product Distribution of Injectable Biostimulator Substances.

BACKGROUND: Increasing demand for minimally invasive aesthetic treatments, such as injection of biostimulator substances to induce the production of extracellular matrix, has been reported. Recent studies have reported on a variety of different product characteristics influencing the integration and distribution of biostimulator substances after injection. OBJECTIVES: The aim of this study was to analyze the ex vivo product integration and distribution behavior of 6 different biostimulator substances after injection. METHODS: A total of n = 21 abdominal soft tissue flaps were analysed by real-time ultrasound imaging with regards to horizontal and vertical spread of 6 different injected biostimulator substances-based on hydroxylapatite (HA), polycaprolactone (PCL), and poly-L-lactic acid (PLLA)-immediately after injection and after massaging. The 6 different biostimulator substances were R-CaHA-based, H-CaHA-based, PCL-based, PLLA-1-based, PLLA-2-based and H-HA-based products. RESULTS: Overall, the R-CaHA-, H-CaHA-, and PCL-based substances showed greater product spread after massaging when compared with the product distribution immediately after the injection with all P < .001 with the exception of the vertical dimension of the H-CaHA-based substance (P = .064). The PLLA-1-, PLLA-2-, and H-HA-based substances showed smaller product spread after massaging compared with the product distribution immediately after the injection with all P < .001 with the exception of the horizontal dimension of the H-HA-based substance (P = .314), indicating higher tissue integration. CONCLUSIONS: Different biostimulator substances behave differently when injected into subcutaneous soft tissues; differences exist at the level of initial product diffusion and during tissue integration.

Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management.

BACKGROUND: Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable of enzymatically degrading the injected product and improving clinical symptoms. Two protocols are currently available to manage such complications: "ultrasound-guided targeted" and "flooding". OBJECTIVES: The aim of this study was to compare the 2 protocols in terms of the volume of hyaluronidase utilized, and the onset and degree of clinical improvement. METHODS: A comparative case series of 39 patients was retrospectively evaluated. The patients were initially treated with the "flooding" protocol and then treated with the "ultrasound-guided targeted" protocol due to no or little improvement. RESULTS: The "ultrasound-guided targeted" protocol utilized a mean [standard deviation] total of 122.5 [34] IU of hyaluronidase, whereas the "flooding" protocol utilized 1519.4 [1137] IU, which represents a statistically significant reduced amount of injected hyaluronidase (P = 0.028). There was no clinical improvement in 92.3% and only little improvement in 7.7% of the treated patients following the first applied "flooding" protocol, but there was a 100% immediate improvement when subsequently treated with the "ultrasound-guided targeted" protocol. Ultrasound imaging revealed that the application of hyaluronidase restored normal blood flow both in the perivascular space and in the superficially located subdermal soft tissues. CONCLUSIONS: Despite its limitations in study design, this retrospectively evaluated case series revealed that the "ultrasound-guided targeted" protocol utilized less hyaluronidase and restored clinically visible symptoms faster. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies.

Precision of Soft-Tissue Filler Injections: An Ultrasound-Based Verification Study.

BACKGROUND: Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility. OBJECTIVES: The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula. METHODS: This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection. RESULTS: A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area. CONCLUSIONS: Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers.

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.

Novel, Validated 5-Point Photonumeric Scales for Assessment of the Neck and Décolleté.

BACKGROUND: There is a scarcity of scales that assess platysmal bands, wrinkles in the décolleté, and horizontal neck lines in the digital and live setting. OBJECTIVES: The objective of this investigation was to create and validate 5-point photonumeric scales that assess horizontal neck lines, platysmal bands, and wrinkles in the décolleté. METHODS: A medical team created 3 different novel 5-point photonumeric scales for the assessment of horizontal neck lines, platysmal bands, and décolleté wrinkling. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation. RESULTS: The Croma (Leobendorf, Austria) Horizontal Neck Lines Assessment Scale showed substantial interrater agreement and almost perfect intrarater agreement in the digital and live validations, respectively. The Croma Platysmal Bands Assessment Scale showed substantial intrarater agreement in both digital and live validations. For the décolleté, a static scale and a dynamic scale were created and validated. The Croma Static Décolleté Wrinkles Assessment Scale showed substantial and almost perfect interrater agreement in the digital and live validations, respectively, and the intrarater agreement in both was almost perfect. The Croma Dynamic Décolleté Wrinkles Assessment Scale showed almost perfect agreement in both validation settings for both interrater and intrarater measures. CONCLUSIONS: The Croma Horizontal Neck Lines Assessment Scale and the Croma Static and Dynamic Décolleté Wrinkles Assessment Scales have sufficient interrater and intrarater agreement for justifiable use in clinical and research settings.

Novel, Validated, 5-Point Photonumeric Scales for Assessment of the Perioral Region.

BACKGROUND: The use of validated scales is still considered the gold standard for evaluating the severity of an aesthetic facial condition. OBJECTIVES: The aim of this investigation was to create and validate 5-point photonumeric scales for the assessment of perioral lines and marionette lines. METHODS: A medical team created 2 different novel 5-point photonumeric scales for the assessment of perioral lines and marionette lines. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation. RESULTS: For the Croma Static Perioral Lines-Assessment Scale, the digital interrater intraclass correlation coefficients (ICCs) were 0.88 (95% CI, 0.85-0.91) in the first rating and 0.87 (95% CI, 0.83-0.90) in the second rating. The digital intrarater ICCs were 0.90 (95% CI, 0.87-0.92). In the live rating, the interrater ICCs were 0.89 (95% CI, 0.85-0.93) in the first rating and 0.91 (95% CI, 0.87-0.93) in the second rating with an intrarater ICC of 0.91 (95% CI, 0.88-0.95). For the Croma Marionette Lines-Assessment Scale, the digital rating interrater ICCs were 0.85 (95% CI, 0.81-0.89) in the first rating and 0.87 (95% CI, 0.84-0.90) in the second rating with an intrarater ICC of 0.89 (95% CI, 0.88-0.91). In the live rating, the interrater ICCs were 0.73 (95% CI, 0.54-0.83) in the first rating and 0.79 (95% CI, 0.65-0.87) in the second rating with an intrarater ICC of 0.88 (95% CI, 0.83-0.94). CONCLUSIONS: The Croma Static Perioral Lines-Assessment Scale and the Croma Marionette Lines-Assessment Scale have exceptional inter- and intrarater agreements that justify their use in clinical and study settings for all ethnic groups.

Endoscopic Browlift in Patients With Receding Hairlines.

ABSTRACT: Patients with receding or high hairlines have traditionally been considered unfavorable candidates for endoscopic brow lift as this can further lengthen the hairline. We analyzed outcomes in patients that underwent a novel endoscopic brow lift technique with placement of incisions and anchoring Endotine Forehead Devices (CoApt Systems Inc, Palo Alto, CA, USA) directly at the natural forehead crease lines, in an effort to minimize elevation of the hairline, whereas providing well-hidden scars. We retrospectively reviewed all patients who underwent this new Endotine and incision placement between 2016 and 2020. Preoperative and postoperative photographs of all patients were analyzed to determine the postoperative changes in brow elevation and forehead length proportion (defined as length from cranium to chin).The forehead length proportion was unchanged pre- and post-operatively, with no statistically significant differences noted (P = 0.48). The average brow position elevation ranged from 2.78 mm in the medial location to 5.05 mm in the lateral location. All patients were happy with their appearance and had improved visual fields postoperatively. The forehead scars healed well and were well hidden in forehead rhytids at long term follow-up.This novel endoscopic brow lift technique provides an option to utilize a minimally invasive approach in patients with receding hairline. With this technique, visible scars were minimized, whereas still being able to achieve reasonable brow elevation. Thus, our approach enables long term maintenance of brow elevation with inconspicuous scars in the forehead.

Reproducibility of Novel Soft-Tissue Landmarks on Three-Dimensional Human Facial Scan Images in Caucasian and Asian.

BACKGROUND: Three-dimensional surface imaging is established in many disciplines for objective facial acquisition regarding anthropometry. Former studies addressed the validation of landmark-based measurements for single race. In order to distinguish racial difference, the reproducibility of the landmark measurements must first be validated. OBJECTIVES: Our purpose is to validate the reproducibility of 46 facial soft-tissue landmarks on x, y, z axes to prove their reliability as 3D reference points. METHODS: The study included 80 European Caucasian and 80 Chinese volunteers. Standardized 3D surface imaging was performed using Vectra 3D system. Two raters identified and defined 46 landmarks (138 coordinates), then repeatedly 3D-imaged volunteers' facial region in separate sessions. Coordinates' reproducibility of landmarks is divided into three categories (< 0.5 mm, < 1 mm, and >1 mm) for intra- and inter-rater reproducibility assessments. RESULTS: Coordinates' reproducibility of 160 samples was distributed as follows: Intra-rater: < 0.5 mm (45%), < 1 mm (42%), >1 mm (13%); inter-rater: < 0.5 mm (31.2%), < 1 mm (42%), > 1 mm (26.8%). The reproducibility of landmarks in nasal tip region differs slightly between Caucasians and Asians. Compared to females, males typically have higher landmark reproducibility in lip and chin region. However, there were no differences in the reproducibility ranking of landmarks by gender. CONCLUSION: The majority of the 46 landmarks in the 3D plane are reproducible to 1 mm, which is clinically acceptable. All selected landmarks showed strong consistency across race and gender, suggesting their potential use as reference points in prospective clinical practice. 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 .

Invited Discussion on: A 7-Step Guide to High-Definition Liposuction.

Athanasiou et al. present a 7-step guide to high-definition (HD) liposuction in the current issue of Aesthetic Plastic Surgery. [1] The guide was based on the authors vast experience in HD-liposuction performed in 568 patients (247 males and 321 females) with a mean age of 43 years (range, 22-64) and a mean BMI of 25.6 (range 21-29 kg/m2) over a 6-year time-period. The authors provide detailed information on their approach regarding pre-operative markings, methods of anesthesia and composition of tumescence solution, incision points and access, surgical technique, and fat transfer. In addition, they performed a time-dependent analysis of the type and quantity of observed complications over the study-period, as well as the mean surgical operative time. 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 http://www.springer.com/00266 .