Impact of Glabellar Injection Technique With DaxibotulinumtoxinA for Injection on Brow Position.

BACKGROUND: Precise injection technique is vital for avoiding suboptimal eyebrow position when treating glabellar lines with botulinum toxin type A. OBJECTIVES: The aim of this study was to evaluate the impact of glabellar injection technique on eyebrow position in patients treated with DaxibotulinumtoxinA for Injection (DAXI). METHODS: This retrospective post hoc analysis involved 60 adults who received a single treatment with DAXI 40 U to the glabella and had standardized facial photography. Median vertical and horizontal displacement of the brows (at rest) at baseline and 2 weeks after glabellar injection were measured. Brow position outcomes were evaluated by an oculoplastic surgeon and expert anatomist. Investigators were interviewed to ascertain individual injection techniques. RESULTS: Precise injection location and depth, and median resting brow position following treatment varied between investigators. Positive brow outcomes were achieved with deep DAXI injections into the medial corrugator, superficial lateral corrugator injections placed between the midpupil and lateral limbus, and deep midline procerus injections. Glabellar injection technique that more precisely targeted the corrugator muscles resulted in longer glabellar line treatment duration compared to a less targeted technique. Medial corrugator injections above the medial brow; lateral corrugator injections administered deeply or more medially, toward the medial third of the brow; and procerus injections superior to the inferomedial brow tended to be associated with suboptimal outcomes that were more apparent during dynamic expression. CONCLUSIONS: Aesthetically pleasing brow outcomes and greater duration of efficacy can be achieved with an injection pattern that precisely treats the anatomic location of the corrugator supercilii and procerus muscles, avoiding the frontalis.

Quantifying Skin Removal During a Face-lift: Does the Approach Matter?

BACKGROUND: The purpose of this study was to measure the amount of skin removed around the ears during a face-lift procedure. The secondary metric assessed skin removal comparing different face-lift techniques of SMASectomy versus deep plane approach and lastly comparing with and without midline corset platysmaplasty (MCP). METHODS: One hundred fifty consecutive face-lift patients were measured for skin removal at 3 cardinal locations in the postauricular, preauricular, and temple regions. Measurements were quantitated and compared statistically with different face-lift techniques. RESULTS: The average skin removal in the postauricular area was 4 cm, the preauricular area was 2.4 cm, and the temple 1.9 cm. There was no difference in skin removal comparing SMASectomy and deep plane face-lift. There was a small but significant difference when MCP was performed, with more skin removal with MCP. CONCLUSION: Quantifying the amount of skin removal during a face-lift procedure provides surgeons and patients important information. There was no difference when comparing the simpler SMASectomy technique with the more invasive deep plane technique.

Stop Blaming the Septum.

PURPOSE: To identify if isolated surgical violation of the orbital septum predisposes to "middle lamellar" scarring and subsequent postblepharoplasty lower eyelid retraction. METHODS: A retrospective review of patients who underwent transconjunctival blepharoplasty in either a postseptal (orbital septum undisturbed) or preseptal (septal incision required) plane was performed. Patients undergoing skin excision, orbicularis muscle plication, and canthal suspension were excluded. The presence of clinically apparent postoperative lower eyelid retraction and limitation of forced superior eyelid excursion (forced traction testing) were assessed. RESULTS: Two hundred eighty-eight patients (576 eyelids) were evaluated. One hundred fifty-eight patients (316 eyelids, 55%) had transconjunctival blepharoplasty performed in a postseptal plane and 130 patients (260 eyelids, 45%) in a preseptal plane. Two hundred two patients (404 eyelids, 70%) had forced traction testing performed postoperatively. After surgery, there were no patient complaints of change in lower eyelid position, subjective physician assessment of clinically apparent lower eyelid retraction, and only 1 case (0.5%) of a positive forced traction test in a patient with conjunctival scarring after significant postoperative infection. CONCLUSIONS: Lower eyelid scars leading to eyelid retraction after blepharoplasty are not likely related to "isolated" orbital septal scars (middle lamellar scars). Their designation as a "multilamellar scar" is more appropriate.

Case Series of Orbital Lymphoma: Cardinal Presentations.

Periorbital lymphomas may present with nonspecific symptoms and may disguise as other ocular conditions, which may result in a missed diagnosis. The purpose of his case series is to add to the existing literature and raise awareness of this rare and lethal cancer so early detection and treatment can be instituted. A retrospective review of four diverse cases of periorbital lymphoma is described, highlighting the important role of plastic surgeons in early recognition and prompt diagnosis through extensive examination, imaging studies, and biopsies. The histological subtype and site of lesion play a critical role in the prognosis of patients with periorbital lymphoma. This article also underscores the significance of early detection and a multidisciplinary team approach.

The Platysma Contraction Pattern in Healthy Adults: A Vector Analysis Study.

BACKGROUND: The platysma muscle's role in lower face dynamics is complex. Multiple insertion points to soft-tissue structures at various levels in the lower face create a multifaceted contraction pattern. To avoid adverse effects in cosmetic procedures when targeting the platysma, its anatomy and physiology must be understood. Clinical observations hint at a bidirectional contraction pattern. METHODS: Eighteen healthy volunteers (13 women and five men) with a mean age of 44.2 ± 10.1 years were enrolled. Skin displacement vector analysis was used on maximal platysma contraction to characterize and calculate the movement of the neck and lower face skin. RESULTS: In all of the participants, a bidirectional movement of the skin was observed: the skin of the lower face and inferior to the jawline moved caudally, whereas the skin of the lower neck moved cephalad. Both movements converged at a line situated at 54% ± 10% and 55% ± 8% of the length between the clavicle and the inferior base of the ear lobe in men and women, respectively ( P = 0.70). CONCLUSIONS: The platysma is a bidirectional muscle with a line of convergence. Whereas the superior portion acts as lip depressor, the lower portion elevates the skin of the upper chest and lower neck. This transition can explain some of the clinically observed adverse effects of neuromodulation of the neck area. It can potentially direct neuromodulation injections to focus above the convergence line to better address lower face descent.

The sigmoid upper eyelid blepharoplasty: redefining beauty.

PURPOSE: A youthful female upper eyelid contour includes a concave medial portion of the upper eyelid along with a fuller, convex lateral eyelid. The skin in the lateral eyelid is tight without hooding. This is a sigmoid shape in 3-dimensional terms. With aging, fatty herniation medially along with redundant, hooded, ptotic lateral skin creates the exact opposite eyelid curve. The sigmoid blepharoplasty is a novel surgical technique that recreates a youthful upper eyelid. METHOD: A retrospective chart review of 142 female patients who underwent the sigmoid blepharoplasty was conducted. To recreate a youthful eyelid in 3 dimensions, the medial eyelid concavity is achieved by removing a strip of medial orbicularis oculi muscle along with selective medial fat removal. Excess skin and hooding is removed, and fat grafts from the medial eyelid are placed laterally below the muscle to achieve a fullness and tight skin. RESULTS: All patients achieved a pleasant, rejuvenated upper eyelid as assessed by photographs and chart records. The sigmoid blepharoplasty restored a youthful eyelid appearance by recreating a concave medial eyelid and fuller lateral eyelid. There were no infections, and fat grafts took uniformly. CONCLUSIONS: The sigmoid upper eyelid blepharoplasty technique recreates a truly youthful eyelid with novel eyelid concepts. The surgery is safe and reproducible, and consistent results are achievable.

Cross-linked hyaluronic acid gel occlusive device for the treatment of dry eye syndrome.

PURPOSE: A new cross-linked hyaluronic acid (xlHA) gel occlusive device was assessed for safety and efficacy in the treatment of dry eyes. METHODS: This was an institutional review board-approved, single-site, open-label, prospective study to assess the efficacy and safety of placing the xlHA gel in the lower canaliculus. Seventy-four participants aged 25-95 years with dry eyes, who failed treatment with artificial tears, were included. Patients were assessed with corneal slit lamp examination with fluorescein staining and with Schirmer's test, breakup time (TBUT), and tear meniscus height (TMH) at baseline, 1 month, and 3 months. Patients were followed at 6 months with a telephone questionnaire. The procedure entailed inserting ~0.2 mL of xlHA gel into each lower lid canaliculus with a syringe and lacrimal irrigator. Patients were followed for adverse events. RESULTS: Sixty-three patients completed the study (48 females, 15 males), with an average age of 67 years. Slit lamp demonstrated improved corneal fluorescein staining. Schirmer's tests demonstrated an average increase over baseline of 3.67 mm after 3 months. TBUT improved 87% and TMH increased by 57% at 3 months over baseline. All objective measures were statically significant. There was one case of conjunctivitis that resolved and was felt to be an incidental viral infection. CONCLUSION: The xlHA Occlusive Device offers a new, safe, and effective method to treat dry eyes. It appears to have efficacy for at least 3 months on clinical examination. The xlHA gel demonstrated a good tolerance and safety profile.

Lower Eyelid Length.

BACKGROUND: A numerical measurement of the length of the lower eyelid is valuable in understanding the aging process of the lower lid. This study recorded multiple values for the lower lid length to provide average values in each age group. This measurement will allow surgeons to better assess and treat the lower lid. METHODS: Female patients were studied in age groups every decade starting in the 20- to 29-year-old group and ending in the 90- to 99-year-old group. Twenty patients were assessed in each age group for a total of 160 patients. In each age group, an average measurement was recorded for the lower lid length. RESULTS: The lid length average was 10.4 mm in the 20- to 29-year-old group and increased to 18.6 mm in the 90- to 99-year-old group. A steady increase in lower lid measurements numerically confirms that lower lid length increases with age. For each decade, there was an almost linear increase in lower lid length, with the greatest increase in the 40- to 49-year-old group. CONCLUSIONS: This study numerically confirmed that the lower eyelid length vertically increases with age. Documenting that the lower lid does lengthen every decade of life and obtaining average numerical values of lower lid length allows physicians insight into the expected aging changes and typical amount of lower lid lengthening at each decade. This also provides blepharoplasty surgeons another tool to more accurately define the aging process and creates a baseline and a potential goal in restoring a more youthful lid.

A Prospective, Split-Face, Randomized, Double-Blind Study Comparing OnabotulinumtoxinA to IncobotulinumtoxinA for Upper Face Wrinkles.

BACKGROUND: The authors sought to compare the newest U.S. Food and Drug Administration-approved botulinum toxin type A product, incobotulinumtoxinA, to onabotulinumtoxinA for upper face wrinkles. This is the first prospective, split-face, randomized, double-blind study addressing three types of facial wrinkles using a 1:1 dose ratio. METHODS: The study was designed, institutional review board approval was obtained, and 45 patients were enrolled. A three-judge independent reviewer panel compared photographs of patients to the upper face validated assessment scales, selecting a grade ranging from 0 (no lines) to 4 (very severe) for the degree of glabellar lines, crow's feet, and forehead lines for each side of the face for photographs taken before treatment and 3 days, 2 weeks, 3 months, and 4 months after treatment. For toxin comparison, the difference in the magnitude of the degree of wrinkle scale at each period compared to before treatment was calculated and statistical analysis performed. Individual wrinkle types and all three wrinkle types combined were analyzed. RESULTS: Both products offered significant reduction in individual and combined wrinkles at comparable time points; however, onabotulinumtoxinA had significantly greater combined dynamic wrinkle reduction at 3 days (p < 0.010), 2 weeks (p < 0.008), 3 months (p < 0.013), and 4 months (p < 0.045). CONCLUSIONS: For identical dosage, both onabotulinumtoxinA and incobotulinumtoxinA are safe and effective in reducing dynamic wrinkles in the upper face; however, for the authors' dosages, onabotulinumtoxinA had statistically greater efficacy at 3 days, 2 weeks, 3 months, and 4 months. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

The use of aerosolized fibrin glue in face-lift surgery.

The purpose of this study was to report the use of aerosolized fibrin glue in face-lift surgery. A prospective study was conducted of 48 patients undergoing face-lift surgery sequentially assigned into two groups. The first 24 patients underwent face lifts without glue and the next 24 patients with the use of aerosolized fibrin glue. One surgeon (J.P.F.) performed all the face lifts using the same technique. Drains were only used in those patients who did not receive fibrin glue. The amount of bruising and edema was compared in the two groups, as was the incidence of complications, such as hematomas. Operating time was also assessed in the two groups. The patients in whom glue was used had significantly less bruising and swelling (p < 0.0001), with a more rapid healing response. The risk of hematoma was also less with the use of glue (0 percent) than without glue (8.3 percent), but this was not statistically significant (p = 0.489). Another benefit was that drains were not needed when glue was used. Operating times were shorter by 13.3 minutes with the use of glue (p < 0.0001). Aerosolized fibrin glue has great promise in improving face-lift results, with excellent outcomes and fewer complications. The added cost of the glue is partially offset by an expedited patient recovery period without the need for drains.

Nonsurgical treatment of cicatricial ectropion with hyaluronic acid filler.

BACKGROUND: Cicatricial lower eyelid ectropion is caused by a shortening of the anterior lamella, with resultant eversion of the eyelid away from the globe. Treatment is typically surgical; however, the author hypothesized that a nonsurgical injection of hyaluronic acid filler could stretch the tethered skin and act as a tissue expander to correct the lid. METHODS: Fifteen patients with lower eyelid cicatricial ectropion were injected with a hyaluronic acid filler below the surface of the affected eyelid skin. The patients were followed prospectively for over 1 year for outcomes and complications. RESULTS: All patients achieved immediate and dramatic correction of their ectropion with a single injection. Eleven patients (73 percent) had complete correction lasting more than 1 year and four had partial correction. No major complications were observed; however, temporary bruising and a Tyndall effect was evident in a majority of patients. CONCLUSIONS: Hyaluronic acid filler injections can successfully treat cicatricial ectropion by expanding the tethered anterior lamella of the skin. This provides an effective alternative to surgical correction of the lid. The treatment is quick, safe, and easy to learn.

Laserbrasion: the combination of carbon dioxide laser and dermasanding.

BACKGROUND: The purpose of this study was to assess the efficacy of laserbrasion (the combination of carbon dioxide laser and dermasanding) in the removal of heavy perioral wrinkles. METHODS: Ninety patients underwent laserbrasion for treatment of heavy perioral wrinkles. They were assessed clinically by the surgeon and staff for wrinkle reduction, healing, and complications. A subset of 26 patients was followed for more than 1 year to assess long-term effects, especially hypopigmentation. RESULTS: Laserbrasion was successful in reducing 95 percent of heavy perioral wrinkles as compared with 75 percent seen previously with laser alone. No complications were noted with laserbrasion, and there was no significant long-term hypopigmentation. Healing time was quicker for laserbrasion (9 days) than for laser alone (12 days). CONCLUSIONS: Laserbrasion is an effective and safe method of reducing deep perioral wrinkles. The technique is easy to perform and inexpensive for the laser surgeon. Laserbrasion can yield better results than the laser alone and has the added benefit of a shorter healing time.

Advanta implants.

Advanta is a new expanded polytetrafluoroethylene implant with dual porosity that can be used to enhance facial features. It is marketed for use in the areas of the nasolabial folds, marionette lines, and glabella and also to augment lips. Advanta implants provide a quick and effective method for facial augmentation. The implants feel soft and natural and the complication rate is low.

Lip augmentation using eyelid tissue from upper blepharoplasty surgery.

PURPOSE: To study the efficacy of eyelid tissue removed during upper eyelid blepharoplasty as a filler graft to augment lips. METHODS: A prospective study involving 14 female patients who underwent lip enhancement with eyelid tissue. All patients underwent CO2 laser upper eyelid blepharoplasty and desired fuller lips. The eyelid tissue was deepithelialized with the CO2 laser before implantation in the lips. Patients were followed for 6 months, and an objective grading scale based on photographs was used to assess outcomes. RESULTS: In each case, the patient's lips were substantially fuller at 6 months after surgery. Patients were pleased with the natural feel and appearance of their lips. One patient had a bacterial infection, which was successfully treated with oral antibiotics. CONCLUSIONS: Eyelid tissue from upper blepharoplasty surgery provides a quick, economical and natural method to enhance lip volume.