Facial Hypertrophy as a Complication of Weight Gain in Autologous Fat Graft Patients: Considerations and Recommendations.

Fat grafting can restore facial volume for reconstructive and cosmetic indications. Common practice often involves extracting lipoaspirate from the most abundant anatomic location. However, grafted fat retains the phenotypic characteristics of its original location and can undergo exaggerated hypertrophy with patient weight fluctuations. The aim of this study was to systematically assess the literature to summarize the reported effects of postoperative weight gain on facial hypertrophy in patients after facial fat grafting and to determine potentially avoidable factors. A search through PubMed/MEDLINE was conducted on October 4, 2022, to identify relevant articles with appropriate search terms. No lower date limit was applied and all eligible nonanimal clinical articles in English were included for review. Reports were summarized and presented as descriptive statistics. The search generated 714 articles. After abstract and full-text review of the initial set of articles, 6 were included in our analysis. All articles described poor cosmetic outcomes resulting from nonanatomic hypertrophy of the grafted fat. None of the articles reported a thorough methodology for selecting the donor site to minimize fat hypertrophy with potential future weight fluctuations. Grafted facial fat is susceptible to exaggerated hypertrophy as a result of changes in patient weight. Specifically, harvesting lipoaspirate from maximally abundant areas of the body may increase this risk. Individualizing the area of fat donation may attenuate unwanted fat growth and further contribute to increased patient quality of life.

Orbital Volume Increases With Age: A Computed Tomography-Based Volumetric Study.

OBJECTIVE: The aim of the study was to determine whether the bony orbital volume (BOV) changes with age in males and females. METHODS: This case-control study reviewed high-resolution (<1-mm slices) computed tomography (CT) scans of consecutive patients seen for 4 years. The scans were requested as part of the patient's routine care for symptoms related to sinus symptoms. Eligible participants were adults aged between 18 and 30 years and 60 and 75 years. Exclusion criteria included previous surgery, any medical conditions that might affect the bone or soft tissue of the orbit, and any abnormalities seen on imaging. Male patients aged between 18 and 30 years were compared with males aged 60 to 75 years. The same was done for females. The main outcome measure was measurement of the BOV. Both orbits of each patient were included using the generalized estimating equation, to avoid any bias from correlation between 2 orbits of the same patient. RESULTS: A total of 240 orbits from 120 patients were used for this study. Each age group contained 30 patients. There were no significant differences in the ages between males and females in each age category (P = 0.88 for ages 20-30 years and P = 0.74 for ages 60-75 years). The mean (SD) BOV for females aged between 20 and 30 years was 19,153.69 mm (3776.21), whereas that for females aged between 60 and 75 years was 20,939.38 mm (2837.34). The difference between the groups was significant (Pr(>|W|) = 0.05). The mean (SD) BOV for males aged between 20 and 30 years was 22,2721 mm (2977.35), whereas that for males aged between 60 and 75 years was 22,892.92 mm (2389.46) (Fig. 1). The difference between these 2 groups was not significant (Pr(>|W|) = 0.40). The mean BOV was significantly greater for males than females (P ≤ 0.01) across both age groups. CONCLUSIONS: This study found that female orbits expand with age, whereas male orbits showed no significant changes. Changes to the orbital volume in females may contribute to the appearance of aging.

Relationship Between Midface Volume Deficits and the Appearance of Tear Troughs and Nasolabial Folds.

BACKGROUND: Understanding interrelationships among aging facial features is important in facial aesthetics as a global treatment approach becomes standard. OBJECTIVE: Examine empirical relationships between midface volume deficit and severity of tear troughs (TTs) and nasolabial folds (NLFs) in women and men of different racial/ethnic groups. METHODS: A web-based study was administered to health panel members (aged 18-75 years). Participants compared their midface volume, TTs, and NLFs against photonumeric scales depicting degrees of severity. Linear regressions were conducted to assess the relationship of midface volume on severity of TTs and NLFs, controlling for demographic factors. RESULTS: Of 4,086 participants (80.0% female), 3,553 had complete data. Increasing severity of midface volume deficit was associated with increasing severity of TTs and NLFs in both sexes (all p < .001). Race/ethnicity was associated with differences in severity in all 3 facial areas, although specific differences between races/ethnicities varied for women and men. Progression rates of severity differed between racial/ethnic groups. Correlations between midface volume deficit, TTs, and NLFs were positive and significant (all p < .001). CONCLUSION: Midface volume deficit was associated with severity of TT deformity and NLFs after controlling for age and other demographic variables.

Sleep Wrinkles: Facial Aging and Facial Distortion During Sleep.

Wrinkles are just one indicator of facial aging, but an indicator that is of prime importance in our world of facial aesthetics. Wrinkles occur where fault lines develop in aging skin. Those fault lines may be due to skin distortion resulting from facial expression or may be due to skin distortion from mechanical compression during sleep. Expression wrinkles and sleep wrinkles differ in etiology, location, and anatomical pattern. Compression, shear, and stress forces act on the face in lateral or prone sleep positions. We review the literature relating to the development of wrinkles and the biomechanical changes that occur in response to intrinsic and extrinsic influences. We explore the possibility that compression during sleep not only results in wrinkles but may also contribute to facial skin expansion.

The plunging tip: analysis and surgical treatment.

BACKGROUND: The plunging tip refers to a deformity in which the nasal tip plunges on smiling. OBJECTIVES: To understand the plunging tip, we have updated our series of 25 cosmetic rhinoplasty patients who complained of a plunging tip with a focus on the anatomic changes of the nose on smiling. METHODS: Twenty-five female cosmetic primary rhinoplasty patients who complained of a nasal tip that plunged on smiling were photographed in static and smiling sequences preoperatively and one year postoperatively. Different nasal angles and landmarks were measured to study changes of the nose. RESULTS: Pre- and postoperatively, there was no statistically significant difference in the changes in the nasal angles and landmarks on smiling. At one year postoperatively, 2 patients had nasal tips that continued to plunge on smiling; these patients had requested no increase in tip rotation preoperatively. Only 2 patients had columellar base muscles cut for reasons other than treating the plunging tip. CONCLUSIONS: This is the first prospective, evidence-based study on the plunging tip. Measurements of the nose before and after surgery demonstrate that the nasal tip moves less than 1 mm and 1 degree on smiling. Treatment of the plunging tip illusion was effective by increasing the tip angle in repose. No columellar base muscles were cut to treat the plunging tip, and the nose moved just as much after surgery as before. Cutting or manipulating muscles is not necessary for treatment. To treat the illusion, the surgeon must increase tip rotation.

Treatment of Hyaluronic Acid Filler-Induced Impending Necrosis With Hyaluronidase: Consensus Recommendations.

Injection-induced necrosis is a rare but dreaded consequence of soft tissue augmentation with filler agents. It usually occurs as a result of injection of filler directly into an artery, but can also result from compression or injury. We provide recommendations on the use of hyaluronidase when vascular compromise is suspected. Consensus recommendations were developed by thorough discussion and debate amongst the authors at a roundtable meeting on Wednesday June 18, 2014 in Las Vegas, NV as well as significant ongoing written and verbal communications amongst the authors in the months prior to journal submission. All authors are experienced tertiary care providers. A prompt diagnosis and immediate treatment with high doses of hyaluronidase (at least 200 U) are critically important. It is not felt necessary to do a skin test in cases of impending necrosis. Some experts recommend dilution with saline to increase dispersion or lidocaine to aid vasodilation. Additional hyaluronidase should be injected if improvement is not seen within 60 minutes. A warm compress also aids vasodilation, and massage has been shown to help. Some experts advocate the use of nitroglycerin paste, although this area is controversial. Introducing an oral aspirin regimen should help prevent further clot formation due to vascular compromise. In our experience, patients who are diagnosed promptly and treated within 24 hours will usually have the best outcomes.

The plunging tip: illusion and reality.

BACKGROUND: The plunging tip is defined as a nasal deformity where the nasal tip descends or "plunges" during smiling. OBJECTIVE: The authors prospectively measure a series of 25 patients with a focus on the anatomic changes of the nose before and after the patient smiles. METHODS: Twenty-five women who presented for cosmetic primary rhinoplasty and complained of a plunging tip were included in the study. Three angles were measured on lateral view (tip angle, nasolabial angle, and columella inclination angle), along with changes in tip, subnasale, and alar crease. The Simon tip rotation angle (STRA) measured tip position in relation to the static tragus. The alar rim angle measured the angle of the alar rim at the nostril. Changes in static and smiling positions were compared. RESULTS: Tip, nasolabial, and the columella inclination angles decreased between static and smiling positions by 10.9, 11.8, and 11.9 degrees, respectively. Tip position dropped by 0.9 mm, while the subnasale and alar crease junction elevated by 1.3 and 3.7 mm, respectively. The STRA, an angle independent of alar base movement, decreased by less than 1 degree. The alar rim angle increased by 9.9 degrees. CONCLUSIONS: Our data demonstrate that the nasal tip changes its position less than 1 mm with a full smile. The concept of a "plunging tip" is an optical illusion. In reality, the alar crease and subnasale elevate and the alar rim straightens, while the tip position changes minimally. Objectively, the tip moves less than 1 mm and less than 1 degree using the STRA.

Orbital Aging: A Computed Tomography-Based Study of 240 Orbits.

BACKGROUND: Previous studies have attempted to explain age-related changes to the orbit in isolation, often producing conflicting results. The authors used highly accurate imaging software to analyze computed tomographic scans to characterize changes related to age objectively. METHODS: In this case-control study, patients seen in an ear, nose, and throat clinic were screened for study entry. Male and female participants were divided into two age groups (20 to 30 years and 60 to 75 years). Primary outcomes included measurement of bony orbital dimensions, volume of soft tissues (muscle and fat volume), and anterior globe position. Three-dimensional reconstructions were created of each orbit allowing these measurements. The generalized estimating equation was used so that both orbits from each patient could be included without any bias. RESULTS: The final sample included 240 orbits from 120 patients. There were 30 patients in each age group. Among female participants, the bony orbital volume ( p < 0.05), fat volume ( p < 0.01), and central width ( p < 0.001) of the bony orbit increased with age. The anterior globe position was significantly greater in older female participants ( p < 0.01). For male participants, the fat volume ( p < 0.0001) and central height ( p < 0.03) increased with age; the lateral rim moved posteriorly with age ( p < 0.007). The anterior globe position was not different between the age groups in male participants ( p = 0.56). CONCLUSION: The female bony orbit expands with age and is associated with a more anterior position of the globe; the male bony orbital volume remains the same and the lateral rim moves posteriorly.

A technique for filling the temples with highly diluted hyaluronic acid: the "dilution solution".

BACKGROUND: Hollow temples are a common sign of aging, contributing to the upper face appearing "pinched" and the brows appearing short and ptotic. Many treatments have been described for this area, including fat injections and implants. However, traditional injection techniques have not proven entirely satisfactory in correcting the problem without resulting irregularities. OBJECTIVES: The author describes a technical refinement wherein diluted hyaluronic acid (HA) fillers are injected into the temple. METHODS: Thus far, a series of 40 patients has been treated over 18 months with the author's technique, which involves diluting the HA filler by a ratio of approximately two to one (diluent to filler) and injecting the temple as evenly as possible. As the saline component absorbs, the filling material is distributed more evenly in the temple than with undiluted filler. RESULTS: Patients experienced improved results, with a smoother appearance to the brow. There were no instances of complications requiring dissolution of the product with hyaluronidase. Irregularities proved minor and easily correctable; no intravascular complications were noted in this series of patients. Clinical photographs demonstrate improvement in the "pinched" upper face and an apparent elongation of the brows. The author estimates, based on prior experience, that duration of effect will be approximately two to three years. CONCLUSIONS: Dilution of the HA fillers administered for brow treatment results in a more even distribution of the product and a lower morbidity than previously described techniques, making temple treatment far easier than in the past.

Facial Aging: A 54-Year, Three-Dimensional Population Study.

BACKGROUND: There is no accurate visual representation of the aging process, one that visually shows how the shape of the face changes with age in a rigorous and three-dimensional way. METHOD: A total of 594 subjects were studied. Two hundred eighty three-dimensional images of male faces and 305 three-dimensional images of female faces were categorized into "young" and "old" groups by sex. The mean age of the younger men was 33.6, and the mean age of the older men was 70.3. The mean age of the younger women was 24, and the mean age of the older women was 74. Landmarks were placed on all images, and in the male groups the distances between these landmarks were analyzed with an independent t test to compare the differences between age groups. These measurements were then used to develop validated three-dimensional averaged models of the different groups. These averages were formed into comparative image transitions and studied. RESULTS: The comparative image transitions of the average young and old faces in this series show accurate and registered age and shape changes. The faces of men and women age in almost identical ways. The images imply that the aging process is not solely along the surface planes of the face but at right angles to it, that is, many of the changes are in and out, not up and down. Males and females seem to age in quantitatively similar ways. CONCLUSIONS: These images are unique in the facial aging literature. The main points and conclusions of this article are derived from and only visible in the comparative image transitions included in this article as supplemental digital content. The reader is encouraged to study them because the side-by-side still images do not show the changes.

Facial Shape, Size, and Gender.

Traditional ways of visualizing the differences between male and female faces are often based on single-subject exemplars or artist depictions of hypermasculine and hyperfeminine faces. By equalizing the sizes of male and female facial averages, the authors analyzed the influences of intrinsic shape and size on the architecture of the face.

Volumizing the brow with hyaluronic acid fillers.

BACKGROUND: Aging eyes often are treated by excision of apparent excess skin and fat and, in some instances, by elevation of the brow. The result of these traditional approaches is increased definition of the orbit, which is not of benefit for all patients. In some cases, the addition of volume in the periorbital area may provide a better-looking result than traditional surgical alternatives. OBJECTIVE: The author describes the use of hyaluronic acid (HA) fillers for improvement of the periorbital region. METHODS: Using local anesthetic, patients are provided with a preview of the aesthetic result of treatment with HA fillers to add volume to the brow. Most treatments are performed using HA fillers, which have the benefit of results that are both reversible and long-lasting. The author uses a fanning technique to inject small quantities of material. RESULTS: The use of these techniques results in a high degree of patient satisfaction. Occasional minor irregularities may occur, but these can be smoothed out by massage or blended by further injection. Results lasting two years are common and we have observed longevity of three years or more in some patients. Some brow configurations that falsely project emotional states, such as anxiety, may also be corrected. CONCLUSIONS: As in other types of cosmetic surgery, patient selection is key. In properly selected patients, increased fullness of the upper lids is preferable to the greater definition of the lids resulting from traditional surgical techniques. The longevity of treatment and reversibility of changes to the upper lids with HA fillers render this approach both cost-effective and safe.

Effective Rejuvenation with Hyaluronic Acid Fillers: Current Advanced Concepts.

LEARNING OBJECTIVES: After studying this article, the participant should be able to: 1. Process several patient-specific factors before reaching an optimal treatment strategy with appreciation for facial balance. 2. Define the advantages and disadvantages of various hyaluronic acid preparations and delivery techniques, to achieve a specific goal. 3. Perform advanced facial rejuvenation techniques adapted to each facial zone, combining safety considerations. 4. Prevent and treat complications caused by inadvertent intraarterial injections of hyaluronic acid. SUMMARY: The growing sophistication and diversity of modern hyaluronic acid fillers combined with an increased understanding of various delivery techniques has allowed injectable filler rejuvenation to become a customizable instrument offering a variety of different ways to improve the face: volume restoration, contouring, balancing, and feature positioning/shaping-beyond simply fading skin creases. As more advanced applications for hyaluronic acid facial rejuvenation are incorporated into practice, an increased understanding of injection anatomy is important to optimize patient safety.

Cheek Volumization and the Nasolabial Fold.

BACKGROUND: The impression that cheek filling results in longitudinal shortening ("lift") of the skin and elevation of the nasolabial crease or nasolabial fold has become common within the facial injection community but remains unsubstantiated. METHODS: In this study, 77 patients were evaluated before and after injection of the cheeks with a hyaluronic acid filler using a three-dimensional camera system. RESULTS: A constant pattern of skin expansion away from the center of the injection and perpendicular to the surface of the skin was observed. A subgroup of 37 patients without differences in their preinjection and postinjection facial expression were analyzed by direct comparison and failed to demonstrate lateral traction (or "pull") on the intervening skin from the cheek injection site to the nasolabial crease. Furthermore, there was no photographic difference in the nasolabial fold or nasolabial crease. The only patients who demonstrated photographic improvement of the medial face were those who had filler placed directly in the transition between the lateral nasolabial fold and cheek (nasojugal crease). CONCLUSIONS: Filling the cheek with 3 cc of volume does not create traction forces or move the skin between the site of injection and the nasolabial crease. It is likely that expanding the nasojugal crease is the direct visual cue that leads to perceived improvement in the nasolabial fold.