Traumatic hematoma-based pseudoaneurysm of the superficial temporal artery in a 7-year-old boy: a case report.

The superficial temporal artery (STA), the terminal branch of the external carotid artery, is divided into the frontal (anterior) and parietal (posterior) branches. The frontal branch of the STA is located superficially on the anterior region of the scalp, making it especially susceptible to trauma. Here, we report a traumatic pseudoaneurysm of the STA in a 7-year-old boy who was injured in a minor car accident. A physical examination showed only a small bruise on the patient's forehead, and all vital signs were stable at the emergency room of our medical center. A facial computed tomography scan showed no significant findings. However, the boy later re-visited the hospital with slight swelling on the right forehead, and an ultrasonography scan revealed a hematoma near the right temporal artery. The resected hematoma (approximately 2 cm) was diagnosed as a traumatic pseudoaneurysm. Awareness of the possibility of a traumatic pseudoaneurysm in the STA may prevent a circumspect diagnosis in the future.

Nanoparticle-Based Chimeric Antigen Receptor Therapy for Cancer Immunotherapy.

Adoptive cell therapy with chimeric antigen receptor (CAR)-engineered T cells (CAR-Ts) has emerged as an innovative immunotherapy for hematological cancer treatment. However, the limited effect on solid tumors, complex processes, and excessive manufacturing costs remain as limitations of CAR-T therapy. Nanotechnology provides an alternative to the conventional CAR-T therapy. Owing to their unique physicochemical properties, nanoparticles can not only serve as a delivery platform for drugs but also target specific cells. Nanoparticle-based CAR therapy can be applied not only to T cells but also to CAR-natural killer and CAR-macrophage, compensating for some of their limitations. This review focuses on the introduction of nanoparticle-based advanced CAR immune cell therapy and future perspectives on immune cell reprogramming.

Reprogramming the tumor microenvironment with biotechnology.

The tumor microenvironment (TME) is a unique environment that is developed by the tumor and controlled by tumor-induced interactions with host cells during tumor progression. The TME includes immune cells, which can be classified into two types: tumor- antagonizing and tumor-promoting immune cells. Increasing the tumor treatment responses is associated with the tumor immune microenvironment. Targeting the TME has become a popular topic in research, which includes polarizing macrophage phenotype 2 into macrophage phenotype 1 using Toll-like receptor agonists with cytokines, anti-CD47, and anti-SIPRα. Moreover, inhibiting regulatory T cells through blockades and depletion restricts immunosuppressive cells in the TME. Reprogramming T cell infiltration and T cell exhaustion improves tumor infiltrating lymphocytes, such as CD8+ or CD4+ T cells. Targeting metabolic pathways, including glucose, lipid, and amino acid metabolisms, can suppress tumor growth by restricting the absorption of nutrients and adenosine triphosphate energy into tumor cells. In conclusion, these TME reprogramming strategies exhibit more effective responses using combination treatments, biomaterials, and nanoparticles. This review highlights how biomaterials and immunotherapy can reprogram TME and improve the immune activity.

Biofunctional Layered Double Hydroxide Nanohybrids for Cancer Therapy.

Layered double hydroxides (LDHs) with two-dimensional nanostructure are inorganic materials that have attractive advantages such as biocompatibility, facile preparation, and high drug loading capacity for therapeutic bioapplications. Since the intercalation chemistry of DNA molecules into the LDH materials were reported, various LDH nanohybrids have been developed for biomedical drug delivery system. For these reasons, LDHs hybridized with numerous therapeutic agents have a significant role in cancer imaging and therapy with targeting functions. In this review, we summarized the recent advances in the preparation of LDH nanohybrids for cancer therapeutic strategies including gene therapy, chemotherapy, immunotherapy, and combination therapy.

Cervical chondrocutaneous remnant: a case report.

Cervical chondrocutaneous branchial remnants are very rare congenital lesions of the lateral neck; thus, our knowledge of this condition derives almost entirely from occasional case reports in the literature. They are thought to originate from the branchial arches and, therefore, can be found anywhere on the pathway along which those branchial arches migrate during embryogenesis. We report the case of a 5-year-old girl presenting with a cervical chondrocutaneous branchial remnant on the right lateral neck that had existed since birth, with no other anomalies.

Cabozantinib-Loaded PLGA Nanoparticles: A Potential Adjuvant Strategy for Surgically Resected High-Risk Non-Metastatic Renal Cell Carcinoma.

Patients with high-risk non-metastatic renal cell carcinoma (RCC) are at risk of metastatic relapse following nephrectomy. Cabozantinib (CZ), a potent multitarget tyrosine kinase inhibitor, interferes with angiogenesis and immunosuppression associated with surgery-induced metastasis. Here, we explored the therapeutic potential of CZ-loaded poly(lactic-co-glycolic acid) (PLGA) nanoparticles (CZ-PLGA-NPs) as an adjuvant strategy for targeting post-nephrectomy metastasis. A clinically relevant subline recapitulating post-nephrectomy lung metastasis of high-risk human RCC, namely Renca-SRLu5-Luc, was established through in vivo serial selection of luciferase-expressing murine RCC Renca-Luc cells. CZ was encapsulated into PLGA-NPs via the conventional single emulsion technique. The multifaceted preclinical antimetastatic efficacy of CZ-PLGA-NPs was assessed in Renca-SRLu5-Luc cells. CZ-PLGA-NPs with a smooth surface displayed desirable physicochemical properties, good CZ encapsulation efficiency, as well as controlled and sustained CZ release. CZ-PLGA-NPs exhibited remarkable dose-dependent toxicity against Renca-SRLu5-Luc cells by inducing G2/M cell cycle arrest and apoptosis. CZ-PLGA-NPs attenuated in vitro colony formation, migration, and invasion by abrogating AKT and ERK1/2 activation. An intravenous injection of CZ-PLGA-NPs markedly reduced lung metastatic burden and prolonged lifespan with favorable safety in the Renca-SRLu5-Luc experimental lung metastasis model. The novel CZ-PLGA-NPs system with multifaceted antimetastatic effects and alleviating off-target toxicity potential is a promising adjunctive agent for patients with surgically resected high-risk RCC.

Image-guided in situ cancer vaccination with combination of multi-functional nano-adjuvant and an irreversible electroporation technique.

Cancer immunotherapy is a next-generation treatment strategy; however, its side effects limit its clinical translation. Here, a novel combination of a multi-functional nano-adjuvant (M-NA) prepared with an iron oxide/gold core and a cationic polymer shell via multilayer synthesis with CpG oligodeoxynucleotide (CpG-ODN) electrostatically complexed on its surface, and irreversible electroporation (IRE) technique was developed for effective image-guided in situ cancer vaccination. The M-NA can be retained long-term in the dense tumoral extracellular matrix after intratumoral injection and internalized by antigen-presenting cells (APCs). The IRE can induce immunogenic cell death. Indeed, in a mouse tumor model, the M-NA showed longer tumor retention time than free CpG-ODN. Compared with other treatments, the combined treatment significantly inhibited tumor growth with 100% survival rate for ∼60 days. The therapy induced the activation of cytotoxic lymphocytes and the maturation of APCs in vivo. This treatment could be effective in image-guided local cancer immunotherapy.

Usefulness of computed tomography venography in gynecologic cancer patients with lower extremity edema.

Lower extremity (LEx) edema is a common complication in gynecologic cancer patients. There are 2 main causes of edema in these patients such as deep vein thrombosis (DVT) and lymphedema. Early diagnosis and treatment of DVT are certainly important, but it is often difficult to evaluate proximal DVT by using ultrasound. The aim of this study is to demonstrate the usefulness of computed tomography venography of the lower extremity (CTV LEx) for the diagnosis of the DVT and investigate predictive factor of DVT in gynecologic cancer patients with LEx edema.The medical records of 415 gynecologic cancer patients who were referred to the department of rehabilitation medicine with LEx edema were retrospectively reviewed in this case-controlled study. We categorized CTV LEx findings as follows: DVT proximal to the inguinal ligament (inferior vena cava or iliac vein thrombosis) and DVT distal to the inguinal ligament (femoral, popliteal, or calf vein thrombosis). We also evaluated patient characteristics including D-dimer level. We analyzed the correlation of each factor with DVT frequency and used receiver operating characteristic curve analysis to determine the appropriate D-dimer threshold.Sixty-six patients were diagnosed with DVT; of them, 35 (53%) had DVT proximal to the inguinal ligament. Twenty-two patients were diagnosed with pulmonary embolism, of whom 15 had proximal DVT. Patients with proximal DVT tended to have pulmonary embolism (P < .001). Distal organ metastasis (odds ratio [OR], 2.88; P = .002) and a high D-dimer level (OR, 1.13; P = .001) were correlated with DVT.CTV LEx is a useful diagnostic tool for gynecologic cancer patients with LEx edema, particularly high-risk patients, that should be performed at the initial evaluation.

Anthropometric analysis of the eyeball exposure area in Koreans.

BACKGROUND: Eyelids vary in morphology and structure depending on age, sex, and race. Usually, one-dimensional measurements are used to evaluate blepharoplasty outcomes. However, in recent years, three- or four- directional enlargements of the eyelid have been used for blepharoplasty in Asian patients, and the outcomes of techniques such as lateral canthoplasty or canthotomy and medial epicanthoplasty with increased scleral area cannot be analyzed using marginal reflex distance 1 or the area of corneal exposure. Therefore, we describe the use of a measurement method based on the eyeball exposure area (EEA). METHODS: To obtain normal EEA values by age and sex, 320 individuals were recruited. The participants were divided into eight age groups (n=40 in each group: female subjects, n=20; male subjects, n=20): 10-19, 20-29, 30-39, 40-49, 50-59, 60-69, 70-79, and 80-89 years. The EEA value was obtained by dividing the exposed area by the total eyeball area. The normal EEA values and differences in EEA according to age and sex were calculated. RESULTS: The mean EEA values for male and female subjects were 66.86% ±9.20% and 71.48%±10.48%, respectively. In each age group, the EEA values of females were higher than those of males. EEA decreased significantly with age in both male and female subjects (P<0.05). CONCLUSIONS: We determined normal EEA values according to age and sex. EEA can be used as an indicator of the outcome of blepharoplasty.

Measurement of the Area of Corneal Exposure Using Digital Image and Its Application During Assessment for Blepharoplasty.

BACKGROUND: The normal morphological and functional values of orbits vary according to race, sex, and age. We measured the palpebral fissure using the marginal reflex distance (MRD1), marginal limbal distance (MLD), and vertical height of the palpebral fissure (VHPF). Unfortunately, these measurements are all one-dimensional figures that measure the distance between two points; they have limitations when it comes to measuring the three-dimensional ocular surface. Therefore, this study used the area of corneal exposure (ACE), which shows a two-dimensional area, to measure changes between the sizes of eyes according to age. MATERIALS AND METHODS: This study was conducted using preoperative photographs of Koreans in Daegu city, Korea, who underwent plastic surgery in our department except for eyelid surgery. We divided the subjects into eight groups, including ten males and ten females in each decade of age, from age 10 to over 80 years. A total of 160 people were recruited who were followed up for photograph analysis using Adobe Photoshop 7.0 software. RESULTS: In terms of the mean value, the ACEs were 73.3 ± 2% in male subjects and 77.1 ± 2% in female subjects, and values for female subjects were greater than those for male subjects (p < 0.05). Significant differences in ACEs were observed according to age. The peak level of growth in the ACE was reached between 20 and 29 years of age. After the 20 s, a gradual decrease was observed (p < 0.05). CONCLUSION: The peak level of growth in the ACE was reached between 20 and 29 years of age. The growth pattern can be classified as continuously decreasing after reaching the peak level. The data from this study are significant in that they can be used as comprehensive data for normal eyelid values according to age. 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Prevalence and risk factors of adhesive capsulitis of the shoulder after breast cancer treatment.

PURPOSE: The present study investigated the prevalence and risk factors of adhesive capsulitis of the shoulder in breast cancer patients between 13 and 18 months after surgery. METHODS: This study included 271 women who underwent surgery for breast cancer with a postoperative period of 13-18 months. Current adhesive capsulitis was defined as restriction of external rotation and one or more additional directional restrictions with history of shoulder pain. Cumulative adhesive capsulitis was defined as current adhesive capsulitis or a previous history of adhesive capsulitis after breast cancer surgery. Multivariate logistic regression analysis was performed to examine associations between current or cumulative adhesive capsulitis and potential risk factors. RESULTS: Among the 271 study patients, 28 (10.3%) and 21 (7.7%) had cumulative or current adhesive capsulitis, respectively. The incidences of cumulative and current adhesive capsulitis were higher in those aged 50-59 years (odds ratio [OR], 9.912; 95% confidence interval [CI], 1.790-54.880; and OR, 12.395; 95% CI, 1.187-129.444, respectively) and those who underwent mastectomy (OR, 6.805; 95% CI, 1.800-25.733; and OR, 9.645; 95% CI, 2.075-44.829, respectively) or mastectomy with reconstruction (OR, 13.122; 95% CI, 2.488-69.218; and OR, 20.075; 95% CI, 2.873-140.261, respectively). CONCLUSIONS: Adhesive capsulitis of the shoulder is a common problem after breast cancer treatment. An age of 50-59 years and mastectomy are major risk factors for adhesive capsulitis, and breast reconstruction additionally increases the risk. Patients with these risk factors require greater attention for early diagnosis and proper treatment.

Comparison of Saccharina japonica-Undaria pinnatifida Mixture and Minoxidil on Hair Growth Promoting Effect in Mice.

BACKGROUND: Algae have traditionally been used for promotion of hair growth. Use of hair regrowth drugs, such as minoxidil, is limited due to side effects. The aim of this study was to examine a mixture of Saccharina japonica and Undaria pinnatifida (L-U mixture) on hair growth and to compare the promoting effect of hair growth by a 3% minoxidil and a L-U mixture. METHODS: To evaluate the hair growth-promoting activity, saline, 50% ethanol, 3% minoxidil, and the L-U mixture were applied 2 times a day for a total of 14 days on the dorsal skin of C57BL/6 mice after depilation. Analysis was determined by using a high-resolution hair analysis system, real-time polymerase chain reaction, and H&E staining. RESULTS: On day 14, the hair growth effect of the L-U mixture was the same as that of the 3% minoxidil treatment. The L-U mixture significantly (P<0.05) stimulated hair growth-promoting genes, as vascular endothelial growth factor (VEGF) and insulin-like growth factor -1. Increase of VEGF was observed in the L-U mixture group compared with minoxidil and the negative control. In contrast, the L-U mixture suppressed the expression of transforming growth factor-ß1, which is the hair loss-related gene. In histological examination in the L-U mixture and minoxidil groups, the induction of an anagen stage of hair follicles was faster than that of control groups. CONCLUSIONS: This study provides evidence that the L-U mixture can promote hair growth in mice, similar to the effect from minoxidil, and suggests that there is potential application for hair loss treatments.

Ten Years of Results of Modified Frontalis Muscle Transfer for the Correction of Blepharoptosis.

BACKGROUND: Conventional frontalis transfer may cause a range of complications. In order to overcome complications, we made modifications to the surgical technique, and compared the outcomes of patients who underwent conventional frontalis transfer with those of patients who underwent modified frontalis transfer. METHODS: We conducted a retrospective study of 48 patients (78 eyes) who underwent conventional frontalis transfer between 1991 and 2003 (group A) and 67 patients (107 eyes) who underwent modified frontalis transfer between 2004 and 2014 (group B). The frontalis transfer procedures were modified conform to the following principles. The tip of the frontalis muscle flap included soft tissue that was as thick as possible and the soft tissue on the tarsal plate was removed to the greatest extent possible. A double fold was created in cases of unilateral ptosis. In order to evaluate the objective effects of modification, preoperative and postoperative values of the marginal distance reflex 1 (MRD1), the corneal exposure area, and the decrease in eyebrow height were compared between the two groups. RESULTS: In group A, patients showed an improvement of 1.19 mm in the MRD1, a 6.31% improvement in the corneal exposure area, and a 7.82 mm decrease in eyebrow height. In group B, patients showed an improvement of 2.17 mm in the MRD1, an 8.39% improvement in the corneal exposure area, and an 11.54 mm decrease in eyebrow height. The improvements in group B were significantly greater than those in group A. CONCLUSIONS: Modified frontalis transfer showed better results than the conventional procedure and provided satisfactory outcomes.

Biodegradable Inorganic Nanovector: Passive versus Active Tumor Targeting in siRNA Transportation.

The biodegradable inorganic nanovector based on a layered double hydroxide (LDH) holds great promise for gene and drug delivery systems. However, in vivo targeted delivery of genes through LDH still remains a key challenge in the development of RNA interference therapeutics. Here, we describe in vivo and in vitro delivery system for Survivin siRNA (siSurvivin) assembled with passive LDH with a particle size of 100 nm or active LDH conjugated with a cancer overexpressing receptor targeting ligand, folic acid (LDHFA), conferring them an ability to target the tumor by either EPR-based clathrin-mediated or folate receptor-mediated endocytosis. When not only transfected into KB cells but also injected into xenograft mice, LDHFA/siSurvivin induced potent gene silencing at mRNA and protein levels in vitro, and consequently achieved a 3.0-fold higher suppression of tumor volume than LDH/siSurvivin in vivo. This anti-tumor effect was attributed to a selectively 1.2-fold higher accumulation of siSurvivin in tumor tissue compared with other organs. Targeting to the tumor with inorganic nanovector can guide and accelerate an evolution of next-generation theranosis system.

Medial epicanthoplasty without a vertical scar.

BACKGROUND: The epicanthal fold (Mongolian fold) in Asians reduces the aesthetic results of eyelid surgery, and thus, medial epicanthoplasty is commonly performed in combination with a double fold operation or blepharoptosis correction. Epicanthoplasty is one of the most popular cosmetic operations conducted in Asia, but scarring is a common problem. METHODS: From December of 2006 to July of 2011, we treated 60 cases using our epicanthoplasty method, which was designed to reduce scarring. A double fold operation and blepharoptosis correction was performed along with epicanthoplasty in 54 cases and an epicanthoplasty without a double fold operation in the remaining 6 cases. Follow-up periods ranged from 6 months to 4 years and 10 months. Previously, we used an elliptical excision epicanthoplasty method, which was simple and practical. However, the elliptical excision method leaves a vertical scar on the nasal side of the upper and lower eyelids. To avoid this scar, we placed an additional incision parallel with the ciliary margin of the lower and/or upper eyelids. The results of epicanthoplasty were evaluated by asking the patients and the surgeon involved to allocate visual analog scale scores. RESULTS: With the exception of 1 case of hypertrophic scarring and 4 cases of undercorrection, patients were satisfied with their results. Mean patient and surgeon visual analog scale scores were 4.6 and 4.2, respectively. The advantages of the described procedure are its simplicity and the minimal scarring caused in the epicanthal area. CONCLUSIONS: This method could become an effective means of removing the Asian epicanthal fold and minimizing vertical scars.

Comparison of swallowing functions between brain tumor and stroke patients.

OBJECTIVE: To compare the swallowing functions according to the lesion locations between brain tumor and stroke patients. METHODS: Forty brain tumor patients and the same number of age-, lesion-, and functional status-matching stroke patients were enrolled in this study. Before beginning the swallowing therapy, swallowing function was evaluated in all subjects by videofluoroscopic swallowing study. Brain lesions were classified as either supratentorial or in-fratentorial. We evaluated the following: the American Speech-Language-Hearing Association (ASHA) National Outcome Measurement System (NOMS) swallowing scale, clinical dysphagia scale, functional dysphagia scale (FDS), penetration-aspiration scale (PAS), oral transit time, pharyngeal transit time, the presence of vallecular pouch residue, pyriform sinus residue, laryngopharyngeal incoordination, premature spillage, a decreased swal-lowing reflex, pneumonia, and the feeding method at discharge. RESULTS: The incidence of dysphagia was similar in brain tumor and stroke patients. There were no differences in the results of the various swallowing scales and other parameters between the two groups. When compared brain tumor patients with supratentorial lesions, brain tumor patients with infratentorial lesions showed higher propor-tion of dysphagia (p=0.01), residue (p<0.01), FDS (p<0.01), PAS (p<0.01), and lower ASHA NOMS (p=0.02) at initial evaluation. However, there was no significant difference for the swallowing functions between benign and malig-nant brain tumor patients. CONCLUSION: Swallowing function of brain tumor patients was not different from that of stroke patients according to matching age, location of lesion, and functional status. Similar to the stroke patients, brain tumor patients with infratentorial lesions present poor swallowing functions. However, the type of brain tumor as malignancy does not influence swallowing functions.

Hollow fibers networked with perovskite nanoparticles for H2 production from heavy oil.

Design of catalytic materials has been highlighted to build ultraclean use of heavy oil including liquid-to-gas technology to directly convert heavy hydrocarbons into H2-rich gas fuels. If the H2 is produced from such heavy oil through high-active and durable catalysts in reforming process that is being constructed in hydrogen infrastructure, it will be addressed into renewable energy systems. Herein, the three different hollow fiber catalysts networked with perovskite nanoparticles, LaCr(0.8)Ru(0.2)O3, LaCr(0.8)Ru(0.1)Ni(0.1)O3, and LaCr(0.8)Ni(0.2)O3 were prepared by using activated carbon fiber as a sacrificial template for H2 production from heavy gas oil reforming. The most important findings were arrived at: (i) catalysts had hollow fibrous architectures with well-crystallized structures, (ii) hollow fibers had a high specific surface area with a particle size of ≈50 nm, and (iii) the Ru substituted ones showed high efficiency for H2 production with substantial durability under high concentrations of S, N, and aromatic compounds.

Combined epicanthoplasty and blepharoptosis correction in Asian patients.

BACKGROUND: In ptosis surgery, not addressing the epicanthal fold leaves a persistent rounded nasal scleral triangle, which blunts the effect of ptosis repair and leads to patient dissatisfaction. To achieve satisfactory results, epicanthoplasty is usually performed with ptosis correction. Furthermore, surgeons usually choose epicanthoplasty methods based on personal preference, and no guideline exists for selecting optimal methods. The aim of this study was to demonstrate the usefulness of a concomitant procedure (ptosis correction and epicanthoplasty) and to provide recommendations for the selection of epicanthoplasty. METHODS: The medical records of 99 patients that underwent simultaneous ptosis correction and epicanthoplasty from September of 2003 to January of 2011 were reviewed. Differences between preoperative and postoperative interepicanthal distances were analyzed by using patient photographs, and interepicanthal distance changes were evaluated for each epicanthoplasty. RESULTS: Epicanthoplasty was performed in the 99 patients using elliptical excision epicanthoplasty in 24 cases, periciliary epicanthoplasty in 12 cases, half-Z epicanthoplasty in eight cases, and V-W epicanthoplasty in 55 cases. Some changes in interepicanthal distances were observed after epicanthoplasty. Interepicanthal distance changes depended on the method used (elliptical excision epicanthoplasty, 3.1 mm; half-Z epicanthoplasty, 4 mm; periciliary epicanthoplasty, 5.3 mm; and V-W epicanthoplasty, 5.4 mm). The greatest differences between preoperative and postoperative interepicanthal distance values were found for periciliary and V-W epicanthoplasty, and these differences were statistically significant. No revision operations were conducted, and most patients were satisfied with results. CONCLUSIONS: In general, concurrent ptosis and epicanthus should be corrected to provide optimal cosmetic benefit. Periciliary or V-W epicanthoplasty is indicated when epicanthal folds are severe. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

Analysis of the patterns of lateral canthal rhytids and reference for botulinum toxin treatment in orientals.

BACKGROUND: One of the earliest signs of aging is the appearance of wrinkles in the skin at the outer corners of the eyes (lateral canthal rhytids). The purpose of this study was to divide the lateral canthal rhytids into classified groups and describe their clinical characteristics and suitable treatments. METHODS: A total of 525 patients were included in the study. These patients were groups according to age and sex. Digital photographs of the subject's lateral canthal rhytids (lateral view) were taken and classified as to type (upper, lower, and bidirectional) and degree of direction. RESULTS: A total of 425 patients (81 %) exhibited the bidirectional type of lateral canthal rhytids. The lower directional type was noted on 75 patients (14.3 %), while only 25 patients (4.7 %) exhibited the upper directional type. In the 30s age group, only 50 % exhibited the bidirectional type. However, this rate increased to a 100 % in the 60 year-old and above group. There seems to be no relationship between the type of lateral canthal rhytids and sex. The degrees of the angle of wrinkles were statistically significant only in the 30s and 40s age groups. CONCLUSIONS: We classified lateral canthal rhytids into three groups. This classification helps to decrease the complications of botulinum toxin by associating different treatments with the type of lateral canthal rhytids. LEVEL OF EVIDENCE IV: This journal requires that authors assign a level of evidence to each article.