Understanding Platysma Muscle Contraction Pattern and Its Relationship to Platysmal Banding: A Real-Time Ultrasound Study.

BACKGROUND: Addressing neck contouring with surgical and nonsurgical aesthetic procedures includes understanding the origin of platysmal banding. A theory was postulated to explain this phenomenon by isometric vs isotonic muscular contraction patterns. However, no scientific proof had been provided to date for its correctness. OBJECTIVES: The aim of this study was to confirm the correctness of the platysmal banding theory based on isometric vs isotonic muscular contractions. METHODS: Eighty platysma muscles from 40 volunteers (15 males and 25 females) were investigated (mean age 41.8; SD 15.2 years; mean BMI of 22.2; SD 2.3 kg/m2). Real-time ultrasound imaging was utilized to measure the increase in local muscle thickness inside and outside of a platysmal band as well as platysma mobility. RESULTS: Within a platysmal band, the local thickness of the muscle increases during muscular contractions by 0.33 mm (37.9%; P < .001). Outside of a platysmal band the thickness of the platysma muscle decreased by 0.13 mm (20.3%; P < .001). It was identified that within a platysmal band no gliding was detectable, whereas outside of a band an average muscle gliding of 2.76 mm was observed. CONCLUSIONS: The results confirm the correctness of the isometric vs isotonic platysma muscle contraction pattern theory: isotonic muscle contraction (gliding without increase in tension and therefore in muscle thickness) vs isometric muscle contraction (no gliding but increase in tension and therefore in muscle thickness). These 2 types of contraction patterns occur within the platysma simultaneously and are an indicator for zones of adhesion in the neck to guide surgical and nonsurgical aesthetic procedures.

A Computed Tomographic Investigation of the Ophthalmic Artery Volume and Its Relevance to Soft Tissue Filler Injections.

BACKGROUND: The measured intraarterial volume of cadaveric ophthalmic arteries was utilized for safety recommendations during facial soft tissue filler injections. However, its clinical practicability and model applicability have become questionable. OBJECTIVES: To measure the volume of the ophthalmic artery in living individuals by utilizing computed tomography (CT) imaging technology. METHODS: A total of 40 Chinese patients (23 males, 17 females) were included in this study with a mean age of 61.0 (14.2) years and a mean body mass index of 23.7 (3.3) kg/m2. Patients were investigated with CT imaging technology to evaluate the length, diameter, and volume of the bilateral ophthalmic arteries as well as the length of the bony orbits, resulting in a total of 80 investigated ophthalmic arteries and orbits. RESULTS: Independent of gender, the average length of the ophthalmic artery was 80.6 (18.7) mm, the calculated volume of the ophthalmic artery was 0.16 (0.05) mL and the minimal and maximal internal diameter of the ophthalmic artery were 0.50 (0.05) mm and 1.06 (0.1) mm, respectively. CONCLUSIONS: Based on the results obtained from the investigation of 80 ophthalmic arteries it must be concluded that current safety recommendations should be reevaluated. The volume of the ophthalmic artery appears to be 0.2 mL rather than 0.1 mL as previously reported. In addition, it appears impractical to limit the volume of soft tissue filler bolus injections to 0.1 mL due to the aesthetic requirements of each individual patient and treatment plan.

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.

3D Anthropometric Facial Imaging - A comparison of different 3D scanners.

Facial measurements serve as a valuable tool in the treatment planning of facial plastic surgery. The aim of this study was to evaluate the accuracy and reliability of standard 3D anthropometric measurements of the face made with one low-cost handheld 3D scanner and one industrial-type mobile 3D scanner. There are clear potential benefits of using 3D measurements by means of new handheld mobile scanners. However, the Sense scanner from the class of inexpensive scanners showed significant limitations in more complex areas such as the lip and nose, whereas proportions could be measured satisfactorily.

Facial Soft Tissue Repositioning With Neuromodulators: Lessons Learned From Facial Biomechanics.

BACKGROUND: Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral periorbital region, underscoring the versatility of neuromodulator treatments. OBJECTIVES: The aim of this study was to analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. METHODS: Seventy-five study participants (8 males, 67 females) with a mean [standard deviation] age of 37.5 [8.5] years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement measured by 3-dimensional imaging at baseline, Day 14, and Day 30. RESULTS: Three-dimensional volume analysis revealed an increase in midfacial volume by 0.46 mL, and a decrease of the lower facial volume by 0.30 mL compared with baseline. Additionally, an improvement of midfacial fullness (by 0.13) and jawline contour (by 0.44) was reported on clinical rating scales at Day 30 compared with baseline. CONCLUSIONS: Facial soft tissues can be repositioned during the 30-day follow-up period following a neuromodulator treatment; this was reflected through an increase in midfacial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.

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.

Deformation of Needle Tips During Facial Soft Tissue Filler Injections: An Electron-Microscopic Study.

BACKGROUND: Injectable soft tissue fillers are used on a global scale for a variety of aesthetic indications. Despite their widespread use, there is a dearth of information regarding needle deformation following injection procedures. Repeated injections with the same needle could lead to progressive needle tip deformation, potentially resulting in decreased precision and increased patient discomfort. OBJECTIVES: The objective of this study was to quantify the magnitude of needle tip deformation utilizing scanning electron microscopy (SEM) image analysis. METHODS: An observational study was performed evaluating 4 differently sized needles following soft tissue filler injections for 5 different aesthetic indications (zygomatic arch, infraorbital, midcheek, nasolabial sulcus, and perioral) in patients aged 36 to 64 years. Following treatment, each needle was visualized and imaged through SEM, and the percentage of deformation in relation to the total amount of needle tip surface was calculated. RESULTS: The factor most influencing needle tip damage was revealed to be the number of injection passes, ie, dermal transitions. Per injection procedure, an increase in needle tip damage of 4.7% occurred. Touching the bone deformed the needle tip by 9.6% and an increase in needle size resulted in 0.13% more damage. CONCLUSIONS: To the authors' knowledge, this is the first SEM investigation to provide objective evidence for the deformation of needle tips after repeated facial soft tissue filler injections. These data may help improve patient safety and comfort during these minimally invasive procedures.

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.

The Bidirectional Movement of the Frontalis Muscle: Introducing the Line of Convergence and Its Potential Clinical Relevance.

BACKGROUND: Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator. METHODS: Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement. RESULTS: In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 ± 10.2 percent in men and 60.6 ± 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2; women, n = 2). No difference across ethnicities was detected. CONCLUSIONS: The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.

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.

Influences of Age, Gender, and Body Mass Index on the Thickness of the Abdominal Fatty Layers and its Relevance for Abdominal Liposuction and Abdominoplasty.

BACKGROUND: Liposuction and lipoabdominoplasty procedures frequently involve the treatment of the superficial and deep fatty layers of the abdomen. OBJECTIVES: The aim of the present investigation was to provide comprehensive data on the thickness of the abdominal fatty layers in relation to age, gender, and body mass index (BMI). METHODS: The study investigated 150 Caucasian individuals; there was an equal distribution of males and females (each n = 75) and a balanced distribution of age (n = 30 per decade: 20-29, 30-39, 40-49, 50-59, and 60-69 years) and BMI (n = 50 per group: BMI ≤24.9, 25.0-29.9, and ≥30 kg/m2). Ultrasound-based measurements of the superficial and deep abdominal fatty layers were performed. RESULTS: An increase in BMI was associated with an increase in total abdominal wall fat thickness. The measured increase was related more to the thickness of the deep fatty layer than to the thickness of the superficial fatty layer (Z = 1.80, P = 0.036). An increase in age was associated with a decrease in thickness of the superficial fatty layer (rp = -0.104, P = 0.071) but with an increase in thickness of the deep fatty layer (rp = 0.197, P = 0.001). CONCLUSIONS: Age and BMI can change the thickness of both the superficial and deep fatty layers of the anterior abdominal wall, thus influencing the plan and conduct of cosmetic surgical procedures. Knowledge of the layered anatomy of the anterior abdominal wall, as well as its associated blood supply, is important for surgeons performing procedures in this area.

Treating the Lips and Its Anatomical Correlate in Respect to Vascular Compromise.

Treating the lips to increase facial attractiveness and youthfulness is challenging when trying to consider ethnic differences in an increasingly more diverse society. Multiple injection techniques are currently available for treating lip contour and volume, but a validation in the cadaveric model under the aspects of safety has not been performed yet. The injection techniques presented in this study are based on the experience and personal selection of the authors. The authors have assessed, treated, and evaluated for more than 20 years patients from the Middle East and Central Europe. Cadaveric verification was performed for each of the presented techniques to identify the positioning of the injected product inside the lips and its relation to the superior/inferior labial arteries. The results of the anatomic analyses revealed that in 58.3% of the performed injections, the product was placed close to the superior/inferior labial arteries. In 60.0% of the cases, applications using a needle placed the injected product in endangered locations, whereas 57.1% of the cases using cannulas placed the product in endangered locations (i.e., in the vicinity of the superior/inferior labial arteries). This anatomic study revealed that injected material into the lips is frequently placed in close proximity to labial arteries representing a high risk for intra-arterial applications, leading to tissue loss (necrosis) and potential end-arterial embolism (potential blindness). Nevertheless, treatment of the lips should be a multistep approach focusing first on the far (upper and middle face) and close (labiomandibular and labiomental) perioral regions.

Influence of Age, Sex, and Body Mass Index on the Depth of the Superficial Fascia in the Face and Neck.

BACKGROUND: Nonsurgical skin-tightening procedures are increasing in popularity, as patients seek aesthetic interventions that are safe with minimal downtime. OBJECTIVE: This study was designed to provide precise data on the depth of the superficial fascia-the structure of action-of the face and neck. METHODS: One hundred fifty Caucasian individuals (75 men and 75 women) were investigated with a balanced distribution of age (n = 30 per decade: 20-29, 30-39, 40-49, 50-59, and 60-69 years) and body mass index (BMI) (n = 50 per group: BMI ≤ 24.9 kg/m, BMI between 25.0 and 29.9 kg/m, and BMI ≥ 30 kg/m). The distance between skin surface and the superficial fascia was measured through ultrasound in the buccal region, premasseteric region, and lateral neck. RESULTS: The mean distance between skin surface and superficial fascia was for the buccal region 4.82 ± 0.9 mm, range (2.60-6.90); for the premasseteric region 4.25 ± 0.6 mm, range (2.60-5.80); and for the lateral neck 3.71 ± 0.5 mm, range (2.0-5.0). The depth of the superficial fascia increased with increasing BMI, whereas it decreased with advanced age. CONCLUSION: Knowing the precise depth of the superficial fascia for nonsurgical skin-tightening procedures will guide practitioners toward safer and more effective outcomes.