Enhancing Fat Graft Survival via Upregulating Autophagy of Adipocytes.

BACKGROUND: Autophagy is a cellular self-protection mechanism. The upregulation of adipose-derived stem cells' (ADSCs) autophagy can promote fat graft survival. However, the effect of interfering with adipocyte autophagy on graft survival is still unknown. In addition, autophagy is involved in adipocyte dedifferentiation. We investigated the effect of autophagy on adipocyte dedifferentiation and fat graft survival. METHODS: The classic autophagy regulatory drugs rapamycin (100 nM) and 3-methyladenine (3-MA; 10 mM) were used to treat adipocytes, adipocyte dedifferentiation was observed, and their effects on ADSCs were detected. In our experiments, 100 nM rapamycin, 10 mM 3-MA and saline were mixed with human adipose tissue and transplanted into nude mice. At 2, 4, 8 and 12 weeks postoperatively, the grafts were harvested for histological and immunohistochemical analysis. RESULTS: Rapamycin and 3-MA can promote and inhibit adipocyte dedifferentiation by regulating autophagy. Both drugs can inhibit ADSC proliferation, and 10 mM 3-MA can inhibit ADSC adipogenesis. At weeks 8 and 12, the volume retention rate of the rapamycin group (8 weeks, 64.77% ± 6.36%; 12 weeks, 56.13% ± 4.73%) was higher than the control group (8 weeks, 52.62% ± 4.04%; P < 0.05; 12 weeks, 43.17% ± 6.02%; P < 0.05) and the rapamycin group had more viable adipocytes and better vascularization. Compared with the control group, the volume retention rate, viable adipocytes and vascularization of the 3-MA group decreased. CONCLUSIONS: Rapamycin can promote adipocyte dedifferentiation by upregulating autophagy to promote fat graft survival. 3-MA can inhibit graft survival, but its mechanism includes the inhibition of adipocyte dedifferentiation and ADSC proliferation and adipogenesis. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

A Retrospective Analysis of Upper Arm Rejuvenation Surgery in 50 Patients.

BACKGROUND: Upper arm aesthetics often suffer from aging effects such as skin laxity and sagging due to collagen and elastin depletion. Fat loss, obesity, and weight fluctuations further exacerbate these issues. Existing classification systems for upper arm excess are complex and have practical limitations. OBJECTIVES: The aim of this study was to develop a more concise and clearer classification of upper arm excess that can guide surgical interventions effectively and assess clinical outcomes. METHODS: Patients undergoing upper arm rejuvenation surgery from January 2020 to January 2023 were categorized as mild, moderate, or severe. Mild cases underwent suction-assisted liposuction (SAL), moderate cases underwent radiofrequency-assisted liposuction combined with SAL, and severe cases underwent brachioplasty combined with SAL. Arm circumferences and BODY-Q questionnaires were collected pre- and postoperatively. RESULTS: The study included 50 female patients, aged 21 to 49 years. The average follow-up time was 7.5 [2.2] months. Arm circumference reduction rates were 6.8% in mild cases, 15.1% in moderate cases, and 17.3% in severe cases. Regarding the BODY-Q questionnaire for upper arms, the average score increased by 0.9 for mild, 2.1 for moderate, and 2.9 for severe cases. Complications were minimal, including 1 seroma and 2 cases of scar widening. CONCLUSIONS: The revised classification system for upper arm excess proved effective in guiding surgical decisions. Selecting the surgical approach based on severity resulted in satisfactory outcomes based on BODY-Q scores. This system offers a concise, objective, and practical tool for plastic surgeons.

Evaluating the Efficacy of Dedifferentiated Fat Cells (DFATs) vs Adipose-Derived Stem Cells (ASCs) in Enhancing the Viability of Fat Grafts.

BACKGROUND: Enhancing graft fat survival remains a paramount challenge in autologous fat transplantation surgeries. Dedifferentiated fat cells (DFATs) and adipose-derived stem cells (ASCs) represent 2 pivotal cells with potential to improve fat graft survival rates. OBJECTIVES: In this study we aimed to compare the effectiveness of DFATs and ASCs in promoting fat graft survival, emphasizing their adipogenic and angiogenic capabilities. METHODS: Both in vitro and in vivo experiments were conducted. In vitro assessments compared adipogenesis, angiogenesis, osteogenesis, chondrogenesis, cell migration abilities, and surface markers. For in vivo evaluation, a cell-assisted lipotransfer animal model was employed to gauge graft volume retention and histological morphology. Analysis techniques included hematoxylin and eosin staining, Western blotting, and real-time polymerase chain reaction. RESULTS: In vitro findings suggested a slight superiority of DFATs in adipogenesis and angiogenesis compared to ASCs. In vivo tests demonstrated both cell types surpassed the control in terms of graft volume retention, with the DFATs group marginally outperforming in retention rates and the ASC group presenting a slightly enhanced graft tissue structure. CONCLUSIONS: Our study underscores the distinct advantages of DFATs and ASCs in bolstering fat graft survival, offering potentially novel insights for plastic surgeons aiming to elevate fat graft survival rates.

Buccal Fat Pad Augmentation for Midfacial Rejuvenation: Modified Fat Grafting Technique and Ogee Line Remodeling.

BACKGROUND: The volume and position of the buccal fat pad (BFP) change with age, which manifests as a hollow midface. Previous studies showed that autologous fat grafting for BFP augmentation could effectively ameliorate midfacial hollowing. OBJECTIVES: The aim of this study was to introduce a modified fat grafting technique for female patients with midfacial hollowing to restore the volume of BFP, and to evaluate the safety and effectiveness of this approach. METHODS: Two cadavers were used for the dissection of the BFP and to demonstrate the surgical procedures. Forty-eight patients were treated for midfacial hollowing with the modified grafting strategy. The BFP was filled through a percutaneous zygomatic incision and an immediate amelioration in the hollow area was observed. Improvements were evaluated from measurements of the ogee line and ogee angle, FACE-Q questionnaires, and 3-party satisfaction ratings. Clinical profiles were reviewed and statistically analysed. RESULTS: The mean [standard deviation] ogee angle was 6.6° [1.9°] preoperatively and 3.9° [1.4°] postoperatively (average reduction, 2.7°). Patients' ogee lines were smoother postoperatively, with marked improvements in overall appearance, psychological well-being, and social confidence. Patients reported high satisfaction with decision-making and postoperative outcomes and felt 6.61 [2.21] years younger. Overall, 88%, 76%, and 83% of the cases were graded as good or excellent in improvement by surgeon, patient, and the third party, respectively. CONCLUSIONS: For age-dependent midfacial hollowing in female patients, the modified percutaneous grafting technique described here was safe and efficacious in restoring BFP volume. This technique produced a smoother ogee line and a natural, younger midfacial contour.

Increased Fat Graft Survival by Promoting Adipocyte Dedifferentiation.

BACKGROUND: Some adipocytes undergo dedifferentiation after fat transplantation, and this may affect the survival of fat grafts. However, this effect has not been adequately studied. OBJECTIVES: This study aimed to clarify the effect of promoting the dedifferentiation of mature adipocytes on the survival of fat grafts. METHODS: Mature adipocytes and adipose stem cells (ASCs) were treated with OSI-906 (a specific inhibitor of insulin receptor and insulin-like growth factor-1 receptor) in vitro, and then the dedifferentiation of mature adipocytes and the proliferation of ASCs were evaluated. In the in vivo experiment, human lipoaspirates mixed with phosphate-buffered saline (Group A) or OSI-906 (Group B) were compared in nude mice. Grafts were harvested at 2, 8, and 12 weeks, and volume retention rate, histologic, and immunohistochemical analyses were conducted. RESULTS: OSI-906 can promote the dedifferentiation of mature adipocytes and inhibit the proliferation of ASCs. At 12 weeks, Group B showed a better volume retention rate (mean [standard deviation, SD], 62.3% [7.61%]) than group A (47.75% [6.11%]) (P < .05). Moreover, viable adipocytes and vascularization showed greater improvement in Group B than in Group A. CONCLUSIONS: This study suggests that promoting the dedifferentiation of mature adipocytes can improve the survival rate and quality of fat grafts.

Comparison of Microfat, Nanofat, and Extracellular Matrix/Stromal Vascular Fraction Gel for Skin Rejuvenation: Basic Animal Research.

BACKGROUND: Although stromal vascular fraction (SVF) cells and adipose-derived stem cells have well-defined antiaging effects on skin, certain disadvantages have limited their clinical application. OBJECTIVES: The aim of this study was to evaluate the effects of microfat, nanofat, and SVF-gel in improving ultraviolet (UV)-induced photoaged skin injury in nude mice. METHODS: After successfully establishing a photoaging model by UVA and UVB irradiation in nude mice, the back of each mouse was divided into 2 regions and randomly injected under the dermis with 0.5 mL of microfat, nanofat, SVF-gel, and phosphate-buffered saline. Inflammatory infiltration, dermis thickness, hydroxyproline content, Type I/Type III collagen ratio, elastic fiber morphology, skin cell proliferation, and adipocyte viability were measured. The overall structure of the skin was also observed by scanning electron microscopy. RESULTS: In the microfat group, the grafts survived well, with intact structure and viable adipocytes and little infiltration of inflammatory cells. Microfat promoted skin cell proliferation, collagen content increased, the ratio of Type I and III collagen reversed, and new oxytalan fibers formed, which to some extent improved the photoaging skin. In the nanofat and SVF-gel groups, a large amount of inflammatory cell infiltration and foam cell deposition in the grafts and dermis led to fibrosis and proliferation of skin tissue. Although the skin thickness and collagen content were also increased, these factors did not improve the photoaging skin. CONCLUSIONS: Microfat survives well, and improves photoaged skin injury in nude mice by promoting skin tissue regeneration and supplementing the capacity of subcutaneous adipose tissue.

Oncological Safety of Autologous Fat Grafting in Breast Reconstruction: A Meta-analysis Based on Matched Cohort Studies.

BACKGROUND: Autologous fat grafting has become a commonly used procedure for breast reconstruction after breast cancer surgical treatment. Nevertheless, oncological considerations remain concerning autologous fat grafting after breast cancer surgery. OBJECTIVE: This meta-analysis aimed to summarize the current matched cohort studies and provide high-quality evidence-based conclusions on the oncological safety of fat grafting in breast reconstruction. METHODS: The Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines were followed. A literature search was performed on August 1, 2021, using PubMed. All relevant matched cohort studies of patients undergoing autologous fat grafting after breast cancer surgery were included. After independently screening the studies and extracting the data, pooled estimates for local and regional recurrence as well as distant metastases were conducted using Review Manager software (RevMan, version 5.3). Outcomes were expressed as odds ratios and 95% confidence intervals. RESULTS: Seventeen studies involving 7494 patients were included. The observed outcomes indicated that no significant differences existed in the risks of local and regional recurrence or distant metastases between autologous fat grafting and control groups. Also, there was no significant heterogeneity among the studies. CONCLUSION: This study provided evidence-based conclusions that support the use of autologous fat grafting in breast reconstruction. LEVEL OF EVIDENCE III: 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Washing Lipoaspirate Improves Fat Graft Survival in Nude Mice.

BACKGROUND: The optimal fat processing technique of fat grafting has not been determined. We have proved the importance of washing lipoaspirate to remove blood, but the necessity of washing when there is no obvious bleeding during liposuction is not clear. OBJECTIVES: The purpose of this study is to further investigate the effect of washing on fat graft survival and the underlying mechanisms, from the perspective of inflammation, oxidative stress and apoptosis. METHODS: To exclude the influence of blood, de-erythrocyte infranatant (dEI) isolated from lipoaspirate was obtained. Purified fat processed by cotton pad filtration mixed with dEIs after sedimentation (sedimentation group), washing (washing group) or phosphate buffer solution (control group) was transplanted to nude mice subcutaneously. Samples were harvested at 1 day and 1, 3, 8 weeks after transplantation. Volume and weight retention, histologic examination, immunostaining of perilipin-1, CD31, CD45 and Ly6g, mRNA expression of PPAR-γ, C/EBPα, VEGF, bFGF, IL-6, IL10, TNF-α, TGF-ß, Bax and Bcl-2, and protein contents of 8-iso-PGF2α, IL-6, IL10, TNF-α and TGF-ß were all compared among groups. RESULTS: After transplantation, volume and weight retention, histologic scores, viable adipocytes and vascularization were all improved in the washing group, with increased expression of adipogenic and angiogenic genes. Compared with the sedimentation group, the washing group had milder inflammation, lower levels of oxidative stress and apoptosis. CONCLUSIONS: Washing lipoaspirate to eliminate mixed components can improve fat graft survival and promote adipogenesis and angiogenesis, possibly by relieving inflammation, reducing oxidative stress injury and inhibiting apoptosis. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. For a full description of 47 these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors http://www.springer.com/00266 .

Low Negative Pressure Combined With Supertumescence Microliposuction as a New Method for Repairing Facial Fat Overfilling: A Case Series of 32 Patients.

BACKGROUND: Face fat overfilling sometimes occurs and is unfortunately very difficult to repair. OBJECTIVES: The aim of this study was to report initial experience of microliposuction with low negative pressure combined with supertumescence (LNPST) in a case series of 32 patients. METHODS: The LNPST microliposuction was performed in 32 patients aged 22 to 41 years (mean [standard deviation] age, 29.6 [4.9] years) with facial overfilling. Discomfort and bleeding were monitored intraoperatively by 2 independent plastic surgeons, who used a grading system to record the results. All patients were followed-up for hematoma within 1 week postoperatively and for skin numbness and muscle paralysis at 1 week and 3 months postoperatively. In addition, at 6 months postoperatively, patient satisfaction with the postoperative aesthetic effects was analyzed by FACE-Q questionnaire. RESULTS: All patients successfully completed the operation under local anesthesia. The mean intraoperative discomfort and blood-loss scores were 1.69 [0.62] and 1.22 [0.41], respectively. The hematoma score was 1.13 [0.34] within 1 week. Other scores included postoperative skin numbness (1 week, 1.96 [0.62]; 3 months, 1.13 [0.33]) and postoperative muscle paralysis (1 week, 1.22 [0.51]; 3 months, 1.0 [0]). Overall, neither skin necrosis nor serious complications requiring revision surgery occurred. Seventy-two percent of the patients (n = 23) answered the FACE-Q questionnaire and the score was 21.8 (1.7), covering satisfaction with the outcome score into a standard score (81.7 [15.1], from 0 to 100), which verified the high satisfaction rate. CONCLUSIONS: LNPST technology is a safe and effective method for repair of facial fat overfilling, with less bleeding, less nerve injury, fewer complications, and high patient satisfaction.

Dedifferentiation of Human Adipocytes After Fat Transplantation.

BACKGROUND: Fat transplantation is a common method employed to treat soft-tissue defects. The dedifferentiation of mature adipocytes has been well documented, but whether it occurs after fat transplantation remains unclear. OBJECTIVES: The major purpose of this project was to investigate the dedifferentiation of mature adipocytes after fat transplantation. METHODS: Human lipoaspirate tissue was obtained from 6 female patients who underwent esthetic liposuction. Mature adipocytes were extracted and labeled with PKH26, mixed with lipoaspirate, and injected into nude mice. In addition, PKH26+ adipocytes were subjected to a ceiling culture. Grafted fat was harvested from nude mice, and stromal vascular fragment cells were isolated. The immunophenotype of PKH26+ cells was detected by flow cytometry analysis at 2 days and 1 week. The PKH26+ cells were sorted and counted at 2 and 4 weeks to verify their proliferation and multilineage differentiation abilities. RESULTS: Two days after transplantation, almost no PKH26+ cells were found in the stromal vascular fragment cells. The PKH26+ cells found 1 week after transplantation showed a positive expression of cluster of differentiation (CD) 90 (CD90) and CD105 and a negative expression of CD45. This indicates that the labeled adipocytes were dedifferentiated. Its pluripotency was further demonstrated by fluorescent cell sorting and differentiation culture in vitro. In addition, the number of live PKH26+ cells at week 4 [(6.83 ± 1.67) × 104] was similar with that at week 2 [(7.11 ± 1.82) × 104]. CONCLUSIONS: Human mature adipocytes can dedifferentiate into stem cell-like cells in vivo after fat transplantation.

The Effects of Lipoaspirate-Derived Fibrous Tissue on Survival Quality and Mechanical Property of Fat Grafts.

BACKGROUND: Fibrous connective tissue (referred to as fiber) in lipoaspirates would be discarded before lipotransfer in case of cannula blockage. However, the fiber contains extracellular matrix which provide structure support and is rich in stromal vascular fractions (SVFs). Removal of the fiber might theoretically affect the survival quality and mechanical properties of fat grafts. But there is few evidence in vivo and vitro about how the fiber affects the fat grafts. OBJECTIVE: To assess the effect of fibers on the survival quality and mechanical property of fat grafts. METHODS: The SVFs in both fat and fiber were obtained by collagenase digestion for cells counting and comparison. Three groups were designed according to the different proportions of fat and fiber: the fat group (100% fat), the mixed group (50% fat, 50% fiber in volume ratio), and the fiber group (100% fiber). Three groups of grafts were transplanted in vivo to evaluate the differences in volume retention rate, histological characteristics and mechanical properties. RESULTS: The amount of SVF cells in fibers (3.47 ±â€Š1.49 × 104 cells/mL) was significantly lower than that in fat (12.3 ±â€Š4.95 × 104 cells/mL) (P < 0.05). Grafts in the mixed group and the fiber group showed an increase of volume retention at week 4, but the fiber content showed no significant effects on the volume retention of grafts in three groups at week 12. Elasticity modulus of grafts in the fat group was higher than that in the fiber group and the mixed group at week 4 and 8, the fiber content showed no significant effects on the elasticity modulus of grafts in three groups at week 12. The addition of the fiber reduced the inflammation, cysts, fibrosis, and capillaries density of the grafts. CONCLUSIONS: There were few SVF cells in the fiber. When it was mixed with fat in different proportions and transplanted in vivo, the content of fiber showed no significantly different effects on the long-term volume retention and mechanical property of fat grafts. Due to the risk of blockage, it is recommended to discard the fiber in lipoaspirates.

Blood Impairs Viability of Fat Grafts and Adipose Stem Cells: Importance of Washing in Fat Processing.

BACKGROUND: Fat processing plays a pivotal role in graft survival. Each component of the blood in lipoaspirate affects fat survival in different ways, but the mechanisms are not clear. OBJECTIVES: The aim of this study was to investigate, by various experimental methods, the effect of blood on the viability of fat grafts and adipose stem cells (ASCs). METHODS: Blood and fat samples were obtained from 6 female patients undergoing aesthetic liposuction. For the in vivo experiment, we compared fat mixed with normal saline or various ratios of blood in nude mice. The samples were explanted at 2 and 8 weeks to evaluate the gross volume retention and histologic and immunohistochemical characteristics. For in vitro experiments, ASCs were pretreated with hemoglobin at different concentrations and for different times. We then assessed the proliferation, migration, adipogenesis, and reactive oxygen species production of ASCs. RESULTS: Blood in the graft led to a decrease in graft viability, as evaluated by general observation and histologic and immunohistochemical morphology in vivo. In vitro experiments showed inhibited proliferation, migration, and adipogenesis, and increased reactive oxygen species production in ACSs, after hemoglobin treatment, suggesting impaired ASC viability. CONCLUSIONS: This study suggests that blood impairs the viability of fat grafts and ASCs and provides evidence that washing to remove blood is important in fat processing.

Comparison of Microfat, Nanofat, and Extracellular Matrix/Stromal Vascular Fraction Gel for Skin Rejuvenation: Basic Research and Clinical Applications.

BACKGROUND: Over the past 2 decades, fat grafting has been extensively applied in the field of tissue regeneration. OBJECTIVES: The aim of this study was to investigate the therapeutic potential of microfat, nanofat, and extracellular matrix/stromal vascular fraction gel (SVF-gel) in skin rejuvenation. METHODS: Microfat was harvested by a cannula with multiple 0.8-mm smooth side holes and processed with a fat stirrer to remove fibers. Nanofat and SVF-gel were prepared according to previously reported methods, and their structure and viability were evaluated. Then, SVF cells from the 3 types of samples were isolated and characterized, and the cell viability was compared. RESULTS: The microstructure of the 3 samples showed distinct differences. The microfat group showed a diameter of 100 to 120.0 µm under the microscope and presented a botryoid shape under calcein acetoxymethyl (calcein-AM)/propidium iodide staining. Scanning electron microscopy analysis showed that the microfat maintained an integral histologic structure. In the nanofat group, no viable adipocytes and no normal histologic structure were observed, but high levels of free lipids were noted. The SVF-gel group showed uniform dispersion of cells with different sizes and parts of the adipose histologic structure. Cell count and culture revealed that the number of viable SVF cells decreased distinctly in the nanofat group compared with the microfat group. In contrast, the number of viable SVF cells in the SVF-gel group increased moderately. Clinical applications with microfat showed marked improvements in skin wrinkles. CONCLUSIONS: Microfat can preserve the integrity of the histologic structure and presents the advantages of subcutaneous volumetric restoration and improvement of skin quality in skin rejuvenation compared with the nanofat and SVF-gel.

Individual Factors of Botulinum Type A in Treatment of Gummy Smile: A Prospective Study.

BACKGROUND: Botulinum type A (BTX-A) injection is a promising treatment for gummy smile (GS), although its effects are varied and inconsistent. OBJECTIVES: The aim of this study was to explore the effect of individual factors on BTX-A treatment for GS, and to establish treatment expectations. METHODS: In this prospective clinical study, a standardized technique comprising bilateral single-point injections of 2 U BTX-A (total, 4 U) was administered to all GS patients. Data were collected at baseline and after 4, 12, and 32 weeks of follow-up. Twenty-nine potential individual factors were analyzed by correlation and regression analysis to exclude confounding bias. RESULTS: Ninety-four patients completed the BTX-A treatment. After adjusting for potential confounding factors, the correlation and regression analysis confirmed the following formula: anterior gingival exposure (GE) at 4 weeks = 1.44 + (0.94 × baseline anterior GE) - (1.88 × sex) (where male = 1 and female = 2). The confidence interval (CI) of the prediction showed that for all female participants with baseline anterior GE <5.3 mm, the 95% CI of anterior GE was 0.3 to 3.0 mm after 4 weeks of treatment, and 3.0 to 8.9 mm with baseline anterior GE ≥6 mm. For male patients with baseline anterior GEs of 3 and ≥4.6 mm, the 95% CIs were 1.5 to 3.3 mm and 3.2 to 8.9 mm, respectively. CONCLUSIONS: The effect of average-dose BTX-A treatment for GS depended on GS severity and patient's sex, rather than GS etiology and other factors. Female participants with baseline anterior GE <5.3 mm were more likely to show complete improvement after 4 weeks of treatment. However, female participants with baseline anterior GE ≥6.0 mm or male participants were less likely to show complete improvement at 4 weeks.

The Efficacy and Safety of Subcutaneous Radiofrequency After Liposuction: A New Application for Face and Neck Skin Tightening.

BACKGROUND: Minimally invasive or noninvasive skin-tightening procedures have become trends in facial and neck rejuvenation. Radiofrequency-assisted liposuction (RFAL) is a new choice for the treatment of skin relaxation that is more effective than noninvasive surgery without surgical incision. OBJECTIVES: The authors recommend a 2-step method in which radiofrequency is applied after appropriate liposuction is performed. This approach is safer and more effective than traditional RFAL, and the authors detail the safety guidelines, operative techniques, postoperative satisfaction results, and complications. METHODS: A total of 227 patients with lower face and neck skin laxity underwent RFAL between April 2012 and June 2019. The following data were collected: age, body mass index, operative duration, volume of fat aspirated, amount of energy delivered, and number and type of complications. Patient satisfaction was surveyed postoperatively and assessed by third-party surgeons at 3 and 6 months. RESULTS: At 6 months after operation, 78.8% of patients considered the results moderate to excellent, whereas 21.2% of the patients considered the results to be poor or thought there was no change. The photograph evaluation performed by independent plastic surgeons showed moderate to excellent results in 89.1% of patients. There were no major complications that required further medical or surgical intervention. CONCLUSIONS: This 2-step method is a safe and effective improvement in the application of radiofrequency for face and neck skin tightening. Patients can achieve significant contour correction via minimally invasive surgery with a lower risk of side effects.

Hyaluronic Acid Filler Injections for Nasolabial Folds in Asian Patients: A Treatment Plan Based on a Practical Nasolabial Assessment Method.

BACKGROUND: There are multiple techniques used to inject hyaluronic acid to minimize the appearance of nasolabial folds. These techniques vary in accordance with the etiology of the nasolabial folds. Based on our understanding of nasolabial anatomy and our experience with the injection of hyaluronic acid fillers, we herein summarize a systemic treatment plan based on a practical nasolabial fold assessment method. METHODS: From November 2015 to December 2017, 180 patients received hyaluronic acid injections in our clinic to improve the appearance of nasolabial folds. All patients were followed up for at least 1 month. All patients underwent our nasolabial fold assessment and were then treated with an appropriate plan. The therapeutic effect was assessed via the photonumeric wrinkle assessment scale. Patients with complications were monitored for up to 1 year. A follow-up survey was performed 1 month postoperatively, with the outcome rated as excellent, satisfactory, moderate, or unsatisfactory. RESULTS: Patients demonstrated a significant improvement in the appearance of the nasolabial folds. No infection or vascular complications occurred. The 1-month follow-up survey revealed that the patient satisfaction rate was 96.7% (excellent or satisfactory outcome). CONCLUSION: This systemic treatment method for nasolabial folds is effective, safe, and practical.

Botulinum Toxin to Treat Horizontal Forehead Lines: A Refined Injection Pattern Accommodating the Lower Frontalis.

BACKGROUND: When treating horizontal forehead lines with botulinum toxin type A the traditional approach requires that injection points should stay 1.5 to 2 cm above the orbital rim to avoid brow ptosis. Failure to treat the lower frontalis may potentially cause worse rhytides in the lower forehead. OBJECTIVES: The aim of this study was to present a refined injection pattern accommodating the lower frontalis and evaluate its clinical efficacy and safety. METHODS: Patients were categorized into 4 types according to the patterns of their forehead wrinkles. Moderate and severe wrinkles in the upper forehead were treated by the "safe zone" technique. Mild wrinkles and rhytides in the lower forehead were treated by the Microbotox technique. Standard photographs and measurements were taken before and after treatment. The effect on wrinkle reduction and changes in brow heights were assessed. RESULTS: In total, 330 treatments were followed up in the clinic, and 246 treatments were followed up by telephone. Among the 330 treatments, 213 were evaluated in our clinic 2 to 4 weeks later, and the patients who received these treatments were recruited for effect evaluation and brow height measurements. The posttreatment severity of forehead wrinkles was significantly reduced (P < 0.05), and brow heights remained unchanged (P > 0.05). No severe adverse events were documented. Patient satisfaction was quite high. CONCLUSIONS: The refined injection pattern is an effective and safe technique to treat horizontal forehead lines. The Microbotox technique enables treatment of the lower frontalis without changes in brow position.