Mastering Midface Injections.

Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.

Quantification of Facial Fat Compartment Variations: A Three-Dimensional Morphometric Analysis of the Cheek.

BACKGROUND: Cheek contour is a main determinant of facial attractiveness. The aim of this study was to evaluate the relationship between age, sex, and body mass index (BMI) and cheek fat volume in a large cohort to better understand and treat facial aging. METHODS: The authors performed a retrospective review of the archives of the Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen. Epidemiologic data and medical history were assessed. Cheek superficial and deep fat compartment volumes were measured on magnetic resonance images. Statistical analyses were performed using SPSS and SAS statistical software. RESULTS: A total of 87 patients with a mean age of 46 years (range, 18 to 81 years) were included. The superficial and deep fat compartment volumes of the cheek increased with BMI ( P < 0.001 and P = 0.005), but there was no significant relationship between age and volume. The ratio of superficial versus deep fat did not change with age. No significant difference of the superficial or deep fat compartments was found between men and women in a regression analysis ( P = 0.931 and P = 0.057). CONCLUSIONS: Cheek fat volume measurements on magnetic resonance imaging scans using reconstruction software suggest that the fat volume of the cheek increases with BMI but does not change significantly with age. Further studies are needed to elucidate the role of age-related changes of bone structures or sagging of the fat compartments.

Defining the Cervical Line in Face-Lift Surgery: A Three-Dimensional Study of the Cervical and Marginal Mandibular Branches of the Facial Nerve.

BACKGROUND: Continuous sub-superficial musculoaponeurotic system (SMAS) dissection in the cheek with subplatysmal dissection in the neck is an important feature of many face-lift techniques, yet the neural anatomy in this area remains unclear, and recommendations regarding continuous dissection of these adjacent areas vary widely. The purpose of this study was to define the vulnerability of the facial nerve branches in this transitional area from the face-lift surgeon's perspective and to specifically identify the location of the cervical branch penetration through the deep cervical fascia. METHODS: Ten fresh and five preserved cadaveric facial halves were dissected under 4× loupe magnification. The skin was reflected, followed by elevation of a SMAS-platysma flap, with identification of the location of cervical branch penetration through the deep cervical fascia. The cervical and marginal mandibular branches were then dissected retrograde through the deep cervical fascia to the cervicofacial trunk to confirm identifications. RESULTS: Cervical and marginal mandibular branch anatomy was found to be similar to that of the other facial nerve branches, all of which initially course deep to the deep fascia in their postparotid course. The emergence of the terminal branch or branches of the cervical branch through the deep cervical fascia was consistently at or distal to a line from a point 5 cm below the mandibular angle on the anterior border of the sternocleidomastoid muscle to the point where the facial vessels course over the mandibular border (cervical line). CONCLUSIONS: Continuous dissection of the SMAS in the cheek, with subplatysmal dissection in the neck crossing over the mandibular border, is possible without jeopardizing the marginal mandibular or cervical branches if done proximal to the cervical line. This study serves as the anatomical justification for continuous SMAS-platysma dissection, and has implications for all types of SMAS flap manipulations.

Finesse Buccal Fat Pad Excision.

SUMMARY: The buccal fat pad has long been noted for its complex anatomy and its significance to facial aesthetics. Its bulk is mostly deep facial fat immediately superficial to the buccinator muscle. The buccal fat pad has a main body and four extensions: buccal, pterygoid, superficial temporal, and deep temporal. It can be removed in patients with round, heavy faces and anterior buccal fullness to slim the lower face and contour the jawline. This article describes the authors' technique for buccal fat pad removal, with a goal of conservative fat pad reduction.

The Deep Fascia of the Infraorbital Region, Deep Plane, and Suprafibromuscular Facelift: New Anatomy for Safer Facelifting.

Deep-plane rhytidectomy, first described by Skoog, has had a resurgence in popularity and is in high demand today. We describe anatomical findings that establish the presence of a true deep fascia in the midface, we named as Chiara's fascia, like the first author's first name, which helps to form the facial ligaments and is contiguous with the superficial layer of the deep temporal fascia. This fascia inserts on the periosteum of the inferior orbital rim at the arcus marginalis and separates the suborbicularis oculi fat (SOOF) from the preperiosteal fat. This distinct fascial layer lies under the superficial fascia or superficial musculoaponeurotic system (SMAS) and represents the floor of what is commonly termed the "deep plane." When this fascial highway is identified intraoperatively, blunt dissection immediately superficial to this layer will protect facial nerve branches overlying the muscles lifting the upper lip such as the zygomaticus. Subsequent dissection over the middle and lower face can usually be performed bluntly. Over a 10-year period, a total of 100 hemifaces were dissected with a 100% success rate of identifying this fascia in all specimens. This work was further validated by examining histologic specimens that clearly demonstrate this unique fibrofatty fascial layer. These dissections and new anatomical findings were then correlated to over 300 intraoperative deep-plane facelift cases by the primary and senior authors. We term this operative technique as the suprafibromuscular facelift. Dissection in this plane allows for safe release of facial retaining ligaments with protection of facial nerve branches.

Mastering Midface Injections.

Injectable filler is one of the most common cosmetic procedures performed annually. An aging face shows a characteristic loss of volume in the deep fat pads of the midface. The goal of midfacial rejuvenation with injectable filler is to restore lost volume, with the suborbicularis fat pad and deep medial cheek fat being the most critical areas. Filler can be instilled here with a cannula or needle with successful outcomes. However, this procedure is not without complications if proper technique and underlying anatomy are not respected.

Tear Trough and Lid-Cheek Junction Anatomy: Current Understanding and Nonsurgical Treatment.

The tear trough and lower eyelid are sentinel sites of facial aging and are increasingly the target of nonsurgical aesthetic procedures. This article will review the advances that have led to our current understanding of tear trough anatomy. We propose a new functional classification of the lid-cheek junction for soft tissue filler treatment, and suggest simpler stratification of patients seeking lower eyelid treatment based on the etiology of their tear trough depression. We aim to describe a stepwise approach to management, with specific technical considerations targeting the underlying causes of lower eyelid pathology. The common complications and pitfalls of nonsurgical tear trough management will be discussed.

Relaciones anatómicas del cuerpo adiposo de la mejilla asociadas a complicaciones de bichectomía: a propósito de un caso / Anatomical relationships of the adipose buccal fat pad associated with bichectomy complications: about a case

RESUMEN: El presente estudio busca entregar conocimientos y aspectos importantes de las estructuras anatómicas asociadas al cuerpo adiposo de la mejilla (CAM), a consecuencia del reporte de un caso de complicación posterior a una bichectomía. Conocer los elementos anatómicos y sus relaciones con el CAM es de vital importancia, ya que en la actualidad son muchos los cursos y pasadas que se realizan para odontólogos generales y especialistas para el retiro del CAM, esto producto de la creciente demanda estética de las personas por presentar un perfil más fino y estilizado. El caso presentado corresponde a una mujer que consultó al servicio de urgencia por aumento de volumen facial posterior a la extracción del CAM, el cual se diagnosticó como sialocele, consecutivo a daño del conduc- to parotídeo. Al revisar la literatura y observar en nuestros preparados anatómicos se aprecia la cercanía de elementos de importancia, como son el conducto parotídeo, los ramos cigomático y bucal del nervio facial, vasos faciales como la arteria facial, vena facial y arteria transversa facial, es por esto que es necesario conocer en detalle la zona a intervenir y considerar las posibles variaciones anatómicas de estos elementos, para así evitar dañarlos durante el procedimiento, tomando una actitud preventiva. Apuntado entonces al objetivo de este estudio, fue lograr entregar información anatómica precisa y concisa de los elementos de importancia próximos o inmersos en el CAM, para prevenir la iatrogenia de estos.

SUMMARY: The present study seeks to provide knowledge and important aspects of the anatomical structures associated with the buccal fat pad (BFP), as consequence of the report of a case of complication after bichectomy. Knowing the anatomical elements and their relationships with BFP is of vital importance, because nowadays there are too many BFP removal courses and internships, for general dentists and specialists, due to the increasing aesthetic demands of individuals seeking a finer and more stylized profile. The case presented is a female patient who consults the emergency department for an increase in facial volume after BFP extraction, which was diagnosed as sialocele, following damage to the parotid duct. When reviewing the literature and observing our anatomical preparations, the proximity of important elements is appreciated, such as the parotid duct, the zygomatic and buccal branches of the facial nerve, facial vessels such as the facial artery, facial vein and facial transverse artery. It is essential to know in detail the area in order to intervene and consider the possible anatomical variations of these elements to avoid injury during the procedure. The aimed objective of this study, is to provide accurate and concise anatomical information of important elements near or immersed in BFP, to prevent iatrogenesis.

Anatomic Characteristics and Treatment of the Midcheek Groove by Deep Filling.

BACKGROUND: Because the anatomic mechanisms underlying the formation of the midcheek groove are unclear, treatments to date have resulted in unsatisfactory outcomes. OBJECTIVE: This study investigated the anatomical foundation of the midcheek groove and evaluated appropriate treatment methods. MATERIALS AND METHODS: Six cadaver hemifacial specimens were subjected to gross anatomic dissection and 6 to P45 sheet plastination. Based on the anatomic results, the area under the orbicularis oculi muscle (OOM) was selected for deep filling. Patients were evaluated by measuring 3D depth, regrading, and self-assessment. RESULTS: The medial band was observed to be an important structure of the OOM, with the facial projection overlapping the midcheek groove trace. Two of the 6 P45 specimens were found to have compact fibroelastic bundles (CFBs) between the medial band and the dermis. Deep filling of the area under the OOM significantly reduced the depth of each section in all 34 patients (p < .001). Grades 3 and 4 midcheek grooves were downgraded distinctively. Most subjects expressed satisfaction with outcomes. CONCLUSION: Formation of the midcheek groove is associated with the passage of CFBs. Deep filling of the area under the OOM effectively improves the midcheek grooves.

A Cadaveric Study of the Buccal Fat Pad: Implications for Closure of Palatal Fistulae and Donor-Site Morbidity.

BACKGROUND: For the cleft surgeon, palatal fistulae after cleft palate repair remain a difficult problem, with a paucity of local tissue options to aid closure. Small clinical series have described the use of the buccal fat pad flap to repair palatal fistulae; however, there is no literature detailing the anatomical coverage of the flap. This study delineates the anatomy of the buccal fat pad flap to guide surgeons in patient selection and examines the residual buccal fat after flap harvest to provide new information with regard to possible effects on the donor site. METHODS: Buccal fat pad flaps were raised in 30 hemicadavers. The reach of the flap across the midline, anteriorly and posteriorly, was recorded. In 18 hemicadavers, the entire buccal fat pad was then exposed to determine the effects of flap harvest on movement and volume of the residual fat. RESULTS: All buccal fat pad flaps provided coverage from the soft palate to the posterior third of the hard palate and all across the midline. Approximately three-fourths of flaps would cover the mid hard palate. The flap constitutes 36 percent of the total buccal fat pad on average, and a series of retaining ligaments were identified that may prevent overresection. CONCLUSIONS: The buccal fat pad flap is a useful tool for coverage of fistulae in the soft palate to the posterior third of the hard palate. In most cases, it will also reach the middle third; however, it is not suitable for more anterior defects. On average, two-thirds of the buccal fat pad remains within the cheek after flap harvest, which may protect against unwanted alteration in aesthetics.

The bicycle wheel analogy for linear closures of small suborbital cheek defects.

Primary closure of suborbital skin defects can cause tension along the closure resulting in ectropion. The bicycle wheel analogy is a simple yet effective guide to aid in reducing tension vectors resulting in ectropion.

Relação anatômica da Bola de Bichat com ramos terminais do nervo facial / Anatomical Correlation among Bichat's fat pad with the Facial Nerve Terminal Branches

Introdução: A cirurgia de Bichectomia está sendo muito procurada por pessoas que visam diminuir o volume facial. O corpo adiposo da bochecha, ou bola de Bichat, possui uma complexa relação anatômica com estruturas faciais. Uma das complicações que o procedimento pode causar é a paralisia facial temporária ou permanente, em decorrência de injúrias causadas aos ramos terminais do nervo facial, devido à proximidade dessas duas estruturas anatômicas. Metodologia: O objetivo do presente artigo é enfatizar a relação anatômica da bola de Bichat com alguns ramos terminais do nervo facial através da dissecação de cadáveres. Foram feitas dissecações em três hemifaces de cadáveres humanos para a exposição do corpo adiposo da bochecha e dos ramos extracranianos do nervo facial. Resultados: A anatomia dos ramos terminais zigomáticos e bucais do nervo facial se mostrou variável em cada hemiface dissecada, mas sempre intimamente relacionados a bola de Bichat. Conclusões: O profissional que realiza a Bichectomia deve ter pleno conhecimento não só da técnica cirúrgica, mas também da variabilidade anatômica da região... (AU)

Introduction: The Buccal Fat Extraction surgery has been sought by people who aim to reduce facial volume. The Buccal fat pad has a complex anatomical correlation among the facial structures. The facial nerve paralysis is one of Bichat's fat extraction complications which might be temporary or permanent, due to the proximity of those anatomical structures. Methodology: The present article aims to emphasize the anatomical correlation between the Buccal fat pad and a few terminal branches of the facial nerve through the human cadaveric dissection. The dissection was performed on three human cadaveric hemifacial to expose the buccal fat pad body and the facial nerve extracranial branches. Results: The zygomatic and buccal terminal branches anatomy of the facial nerve has shown variables in each dissected hemifacial part. However, it has always presented closely related to Bichat's fat pad. Conclusions: The professional that performs the Buccal Fat Removal surgery must have to have the full knowledge not only about the surgical technique but the anatomical variability of the region, as well... (AU)

Facial Nerve Danger Zones.

Facial nerve injury is one of the most feared complications in surgical rejuvenation of the aging face. Understanding the three-dimensional architecture of the facial soft tissue, the fascial planes that exist within this architectural arrangement, and the danger zones where the facial nerve is situated superficial and adjacent to the planes of dissection commonly used in face-lift techniques, are the keys to safety in preventing motor branch injury. The two-dimensional branching patterns of the marginal and cervical branches of the facial nerve are variable, making it difficult to ascertain exact nerve location when dissecting within the cheek and neck. On a three-dimensional basis, the position and depth of the marginal and cervical branches are constant and predictable. Understanding the three-dimensional anatomy in terms of planes of dissection, and the danger zones where these nerve branches are vulnerable to injury, provides protection against iatrogenic injury when performing surgical rejuvenation of the aging face. These video vignettes provide an overview of the fascial anatomy of the cheek in relation to the facial nerve branches and delineate the regions of the face in which nerve branches are most likely to be injured. Methods to prevent injury are discussed. Furthermore, the vignette defines these danger zones and delineates methods to protect the nerve branches.

Anthropometric Research of Metric Characters in Zygomatic Complex Region.

OBJECTIVES: To get and analyze the metric data of zygomatic region for the plasty of zygoma. MATERIALS AND METHODS: A total of 108 dry skulls in Chinese Han population were randomly collected and measured. The metrical data were divided into 4 parts, including the relative position of contour height of zygomatic bone, the relative prominence of zygomatic bone, the relative prominence of zygomatic arch, and the angle of the zygomatic bone and arch. RESULTS: The measurements in the 4 parts showed significantly difference between male and female (P < 0.05). For relative position of contour height of zygomatic bone group, the data of male is significantly bigger than female (P < 0.05). For relative prominence of zygomatic bone/zygomatic arch group, zygoma/zygomatic arch of male significantly protruded more than female (P < 0.05). CONCLUSION: The location of male zygoma is more protruding than female. The female zygoma is squarer than male and marginal process is helpful in zygomatic plasty. CLINICAL RELEVANCE: These studies show and analyze the metric data of zygomatic region in Chinese Han population for the plasty of zygoma. These different characters between males and females could be helpful in zygomatic plasty of Chinese Han population based on this research.

Ideal Facial Relationships and Goals.

Analysis of the face is an essential component of facial plastic surgery. In training, we are taught standards and ideals based on neoclassical models of beauty from Greek and Roman art and architecture. In practice, we encounter a wide range of variation in patient desires and perceptions of beauty. Our goals seem to be ever shifting, yet our education has provided us with a foundation from which to draw ideals of beauty. Plastic surgeons must synthesize classical ideas of beauty with patient desires, cultural nuances, and ethnic considerations all the while maintaining a natural appearance and result. This article gives an overview of classical models of facial proportions and relationships, while also discussing unique ethnic and cultural considerations which may influence the goal for the individual patient.

The Orbital Oval Balance Principle: A Morphometric Clinical Analysis.

BACKGROUND: The aim of this study was to test the validity of the "orbital oval balance principle," a system of analysis and guideline that is used among aestheticians, artists, and makeup artists to create and design aesthetically pleasing eyebrows for optimal upper facial appearance. According to this principle, a face is optimally attractive when the eye is centered in an "oval" defined by the lid-cheek junction and the eyebrow. METHODS: One hundred participants were asked to rank digital morphed images of four female models with four different periorbital proportions: higher or lower lid-cheek junction versus higher or lower eyebrow position. In addition, the participants were asked to quantify seven emotions on these morphed images. RESULTS: A higher lid-cheek junction was rated as significantly more attractive with a lower eyebrow position, and a lower lid-cheek junction was regarded far more attractive in combination with a higher eyebrow position. Moreover, a higher lid-cheek junction was rated as more attractive than a lower lid-cheek junction, and elevation of the lid-cheek junction improved the perception of emotions such as tiredness and sadness. CONCLUSIONS: This study lends support to the orbital oval balance principle that can provide important insight into facial attractiveness to surgeons undertaking procedures intended to improve and rejuvenate facial appearance. Moreover, this study has also shown not only that a high(er) lid-cheek junction is regarded as more youthful and attractive, but that it also may reduce the appearance of tiredness and sadness.

The Changes of Cheek Line (Lateral) and Face Line (Frontal) after Correction of Mandibular Prognathism.

OBJECTIVE: The purpose of the present study was to investigate the improvements of facial profile and postoperative stability by single mandibular setback surgery. MATERIALS AND METHODS: The study included twenty-seven patients who underwent mandibular prognathism correction by sagittal split ramus osteotomy (SSRO). Cephalometric radiograms (lateral and frontal) were collected and analyzed at three intervals: preoperatively (T1), immediately postoperatively (T2), and final follow-up postoperatively (T3). The lateral and frontal cephalometric parameters were measured. The immediate postoperative change (T21), postoperative stability (T32), and final surgical change (T31) were calculated and analyzed. The null hypothesis is that postoperative stability (T32) was not significantly correlated to amount of mandibular setback (T21). RESULTS: The immediate postoperative change (T21) of menton (Me) was significantly backward 8.7 mm. In the final postoperative change (T31), average chin points anterior movements were approximately 0.32 mm. Investigating frontal appearance, inter ramus posterior (InterRp) and intergonion (InterGo) widths were significantly increased with 1.8 and 2.2 mm, respectively. Bilateral ramus angles were not significantly increased, about 1°. The horizontal Me (T32) had significant correlation (p = 0.028) with amount of setback (T21). Therefore, null hypothesis is rejected. CONCLUSION: Postoperative relapse was significantly correlated to the amount of setback. The frontal transverse changes (InterRp and InterGo) were significantly increased.

Anatomical Characterization and Three-Dimensional Modeling of the Muscles at the Corner of the Mouth: An Iodine Staining Technique Based on Micro-Computed Tomography.

The anatomy of the modiolus and surrounding muscles is complicated and contributes to the morphology of the mouth corner. The authors used iodine staining and micro-computed tomography to observe the anatomy of the modiolus and surrounding muscles. Based on the micro-computed tomographic images and the three-dimensional model construction, the authors found that the muscle fibers in the modiolus were oriented continuously in the running direction of the muscle itself and that there were no chaotic clumps in the region of muscle fiber convergence. The pars marginalis of the orbicularis oris muscle connects with the deep buccinator muscle, which may account for how the pars marginalis fibers act to press the upper lip against the maxillary teeth or invert it closer to the oral cavity. These findings may be helpful for plastic surgeons who perform commissuroplasty.

[Three-dimensional study of facial soft tissue changes in patients with skeletal Class â ¢ malocclusion before and after orthognathic surgery].

Objective: To investigate the changes of facial soft tissue before and after orthognathic surgery in patients with skeletal Class Ⅲ malocclusion. Methods: Between August 2016 and April 2017, 30 patients with skeletal Class Ⅲ malocclusion who underwent maxillary LeFort Ⅰ osteotomy and sagittal split mandible osteotomy were selected as study subjects. Among them, 11 were male and 19 were female with an average age of 22.6 years (range, 18-35 years). Full head CT scan and facial soft tissue three-dimensional image scan were performed within 2 weeks before surgery and at 6 months after surgery. A three-dimensional facial image model was established using Artec Studio 11.0 and CMF Proplan 3.0 software to analyze the facial soft tissue changes before and after surgery. The soft tissue anatomical landmarks in each area of the face were measured and compared before and after surgery. Results: The area of facial soft tissue change after surgery was the maxillary nose and the lower jaw area, and the two sides did not exceed the vertical boundary of the outer canthus. After surgery, the horizontal points of bilateral alar bases and bilateral cheeks changed significantly ( P<0.05). The sagittal points of subnasale, pronasale, bilateral alar bases, upper lip margin significantly forwarded ( P<0.05); the sagittal points of the bilateral cheilions, lower lip margin, midpoint of chin-lip groove, pogonion, and menton significantly backwarded ( P<0.05). The vertical points of the upper lip margin, bilateral cheilions, lower lip margin, bilateral cheeks, and bilateral inner canthus points significantly descended ( P<0.05), and the vertical point of the menton significantly elevated ( P<0.05). After surgery, the nasal column was significantly shortened, the upper lip got longer and the alar base widened when compared with those before surgery ( P<0.05). Conclusion: The overall change of face after double jaw surgery is shorter and fuller, and the mandible of facial soft tissue change is larger than that of maxillary, which suggests that the postoperative facial changes should be taken into account in the surgical design.

[Progress of midfacial fat compartments and related clinical applications].

Objective: To review the research progress of midfacial fat compartments, and to thoroughly understand its current state of the anatomy and the aging morphologic characters of midfacial fat compartments, as well as the current status of clinical applications. Methods: The recent literature concerning the midfacial fat compartments and related clinical applications were extensively reviewed and analyzed. Results: Midfacial fat layer has been considered as a fusion and a continuous layer, experiencing a global atrophy when aging. As more anatomical researches have done, recent studies have shown that midfacial fat layer is broadly divided into superficial and deep layers, which are both divided into different fat compartments by fascia, ligaments, or muscles. Midfacial fat compartments tend to atrophy with age, specifically in the deep fat compartments while hypertrophy in the superficial fat compartments. Clinical applications show that fat volumetric restoration with deep medial cheek fat and Ristow's space can restore the appearance of midface effectively. Conclusion: In recent years, the researches of midfacial fat compartments have achieved obvious progress, which will provide new ideas and basis for fat volumetric restoration. Corresponding treatments are selected based on different sites and different layers with different aging changes, reshaping a more youthful midface.