The blushing brain: neural substrates of cheek temperature increase in response to self-observation.

Darwin proposed that blushing-the reddening of the face owing to heightened self-awareness-is 'the most human of all expressions'. Yet, relatively little is known about the underlying mechanisms of blushing. Theories diverge on whether it is a rapid, spontaneous emotional response that does not involve reflection upon the self or whether it results from higher-order socio-cognitive processes. Investigating the neural substrates of blushing can shed light on the mental processes underlying blushing and the mechanisms involved in self-awareness. To reveal neural activity associated with blushing, 16-20 year-old participants (n = 40) watched pre-recorded videos of themselves (versus other people as a control condition) singing karaoke in a magnetic resonance imaging scanner. We measured participants' cheek temperature increase-an indicator of blushing-and their brain activity. The results showed that blushing is higher when watching oneself versus others sing. Those who blushed more while watching themselves sing had, on average, higher activation in the cerebellum (lobule V) and the left paracentral lobe and exhibited more time-locked processing of the videos in early visual cortices. These findings show that blushing is associated with the activation of brain areas involved in emotional arousal, suggesting that it may occur independently of higher-order socio-cognitive processes. Our results provide new avenues for future research on self-awareness in infants and non-human animals.

Age-related changes in cheek skin movement: A case study of Japanese women.

BACKGROUND: The majority of conventional studies on skin aging have focused on static conditions. However, in daily life, the facial skin we encounter is constantly in motion due to conversational expressions and changes in facial expressions, causing the skin to alter its position and shape, resulting in a dynamic state. Consequently, it is hypothesized that characteristics of aging not apparent in static conditions may be present in the dynamic state of the skin. Therefore, this study investigates age-related changes in dynamic skin characteristics associated with facial expression alterations. METHODS: A motion capture system measured the dynamic characteristics (delay and stretchiness of skin movement associated with expression) of the cheek skin in response to facial expressions among 86 Japanese women aged between 20 and 69 years. RESULTS: The findings revealed an increase in the delay of cheek skin response to facial expressions (r = 0.24, p < 0.05) and a decrease in the stretchiness of the lower cheek area with age (r = 0.60, p < 0.01). An increasing variance in delay and stretchiness within the same age group was also observed with aging. CONCLUSION: The findings of this study revealed that skin aging encompasses both static characteristics, such as spots, wrinkles, and sagging, traditionally studied in aging research, and dynamic aging characteristics of the skin that emerge in response to facial expression changes. These dynamic aging characteristics could pave the way for the development of new methodologies in skin aging analysis and potentially improve our understanding and treatment of aging impressions that are visually perceptible in daily life but remain unexplored.

Age-related changes in the fiber structure around adipocytes in the subcutaneous fat layer and their association with skin viscoelasticity.

OBJECTIVE: Age-related changes in the fiber structure around adipocytes were investigated via scanning electron microscopy (SEM) of excised skin tissues. In addition, the viscoelasticity of the subcutaneous fat layer was evaluated via elastography, and the association between the fiber structure and the viscoelastic properties was assessed. METHODS: Skin tissues excised from the facial cheek area were used. Then, SEM images of these tissues were obtained. The thickness and quantity of the fibers around adipocytes were assessed using a 5-point scale. The score was used to grade 18 tissue samples. Moreover, the viscoelasticity of the subcutaneous fat layer in the same samples was evaluated via ultrasound elastography. RESULTS: Based on the SEM image score, an association was observed between the fiber status score and age, thereby indicating a tendency toward age-related fibrosis. Fiber structures with high scores, which indicate fibrosis, had a significantly lower viscoelasticity based on ultrasound elastography. CONCLUSION: The thickness and quantity of fibrous structures around adipocytes in the subcutaneous fat layer increase with age, and these changes can be associated with decreased viscoelasticity in the subcutaneous fat layer.

An exploratory study of structural and microvascular changes in the skin following electrical shaving using optical coherence topography.

BACKGROUND: Consumer products such as electrical shavers exert a combination of dynamic loading in the form of pressure and shear on the skin. This mechanical stimulus can lead to discomfort and skin tissue responses characterised as "Skin Sensitivity". To minimise discomfort following shaving, there is a need to establish specific stimulus-response relationships using advanced tools such as optical coherence tomography (OCT). OBJECTIVE: To explore the spatial and temporal changes in skin morphology and microvascular function following an electrical shaving stimulus. METHODS: Ten healthy male volunteers were recruited. The study included a 60-s electrical shaving stimulus on the forearm, cheek and neck. Skin parameters were recorded at baseline, 20 min post stimulus and 24 h post stimulus. Structural and dynamic skin parameters were estimated using OCT, while transepidermal water loss (TEWL) was recorded to provide reference values for skin barrier function. RESULTS: At baseline, six of the eight parameters revealed statistically significant differences between the forearm and the facial sites, while only surface roughness (Rq) and reflectivity were statistically different (p < 0.05) between the cheek and neck. At 20 min post shaving, there was a significant increase in the TEWL values accompanied by increased blood perfusion, with varying magnitude of change dependent on the anatomical site. Recovery characteristics were observed 24 h post stimulus with most parameters returning to basal values, highlighting the transient influence of the stimulus. CONCLUSIONS: OCT parameters revealed spatial and temporal differences in the skin tissue response to electrical shaving. This approach could inform shaver design and prevent skin sensitivity.

Revisiting the Anchor Flap for Nasal Defects: How It Fits in the Current Reconstruction Paradigm.

The anchor or Peng flap, first described in 1987, has not been comprehensively discussed in the literature since 2008. The anchor flap is worth revisiting as a useful advancement-rotation flap for medium-sized defects of the distal nose. More recent variations to the flap design incorporate medial cheek advancement and allow for versatility in its use for wide defects of the nasal tip, supratip, and dorsum. The anchor flap is a suitable reconstructive option for defects for which the bilobed/trilobed flap, dorsal nasal rotation flap, or interpolated flap would be considered. We review various designs of the anchor flap and discuss how it can be considered in the modern reconstructive paradigm.  J Drugs Dermatol. 2024;23(1):1271-1273.     doi:10.36849/JDD.7532.

Effectiveness and Safety of Sculptra Poly-L-Lactic Acid Injectable Implant in the Correction of Cheek Wrinkles.

BACKGROUND: The current study evaluated the effectiveness and safety of Sculptra injectable poly-L-lactic acid (PLLA-SCA) treatment in correcting cheek wrinkles compared with a no-treatment control. METHODS: Male/female immune-competent adults (aged >21 years) with moderate/severe cheek wrinkles, graded using the Galderma Cheek Wrinkle Scale (GCWS) at rest, were randomized 2:1 to receive PLLA-SCA injections (150 mg; 8 mL reconstitution in sterile water for injection) + 1 mL lidocaine hydrochloride (2%), administered immediately after reconstitution, or no treatment (control). Up to 3 additional treatments were allowed at monthly intervals, and follow-up was at months 7, 9, and 12. The primary endpoint was 1-grade or greater improvement in GCWS at rest for both cheeks at month 12. RESULTS: GCWS at rest responder rate was significantly higher with PLLA-SCA treatment versus the no-treatment control at months 7 (66.2% versus 38.6%; P=0.0043), 9 (70.6% versus 31.1%; P<0.0001), and 12 (71.6% versus 26.1%; P<0.0001). Treating investigators reported improvements in skin radiance (>95%), tighter appearance (>88%), and jawline contour (>85%). PLLA-SCA recipients reported high satisfaction levels regarding improvements in skin radiance (90% or greater), sagging (84% or greater), and firmness (91% or greater) as well as natural-looking results (85% or greater) and a desire for repeat treatment (84% or greater). Treatment-related adverse events were mostly mild in severity with no serious events related to PLLA-SCA injections. CONCLUSION: Injectable PLLA-SCA treatments were well tolerated and significantly reduced the severity of moderate/severe cheek lines and wrinkles, while improving skin quality. Effectiveness was durable over the 12-month study period with high subject-reported satisfaction, natural-looking appearance, and enthusiasm for repeat treatments. CLINICALTRIALS: gov registry number: NCT04124692J Drugs Dermatol. 2024;23(1):1297-1305.        doi:10.36849/JDD.7729.

Efficacy and safety of fractional micro-needling radiofrequency for the treatment of enlarged pores on the cheeks of a chinese cohort: a retrospective study.

To explore the efficacy and safety of fractional micro-needling radiofrequency (FMRF) in the treatment of enlarged pores on the cheek in a Chinese cohort. Patients with enlarged facial pores who underwent FMRF between January 2020 and December 2022 were included in this study. Blinded clinical assessments were performed by two independent dermatologists using a six-grade photographic enlarged pore scale and a quartile grading scale. Patients were asked to rate the degree of pain related to treatment on a visual analog scale (VAS), with scores ranging from 0 (no pain) to 10 (worst pain ever). A paired t-test was used to analyze the six-grade photographic enlarged pore scores. A total of 22 patients received three consecutive sessions of FMRF treatment, with intervals of 1-3 months, and underwent follow-up as scheduled. The mean six-grade photographic enlarged score was 3.55 ± 0.96 at baseline, while the score decreased significantly to 2.59 ± 0.59 after three treatment sessions (P < 0.05). The improvement score of the patients, assessed by two independent dermatologists, was 2.31 ± 0.71, according to the quartile grading scale. The mean VAS score was 6.42 ± 1.44. FMRF is effective and safe for the treatment of enlarged facial pores after three sessions.

Surgery or Not? A Systematic Review of Facial Congenital Melanocytic Nevi Treatment Patterns and Outcomes.

BACKGROUND: Treatment management for congenital melanocytic nevi (CMN) on the face (FCMN) is highly variable and requires a thorough assessment of multiple factors. To date, a systematic review of FCMN treatment is lacking. The purpose of the present study was to elucidate the frequency, variety, and outcomes of treatment modalities for FCMN with different levels of complexity. METHODS: A comprehensive review of Pubmed, Embase, and Google Scholar databases from 1950 to 2022 was conducted using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Articles reporting on FCMN treatment approaches, outcomes, and associated complications were screened and data were extracted according to inclusion criteria. Data were tabulated for thematic analysis of FCMN treatment types, anatomic locations, outcomes, and complications. RESULTS: Of the 561 studies retrieved, 34 met inclusion criteria including 19 surgical treatments, 14 nonsurgical treatments, and one combined surgical and nonsurgical treatment study, totaling 356 patients. The majority of treated FCMN were small-to-medium-sized (56%). Facial CMN treated conservatively were mostly located on the cheek (27%) and/or perinasal region (21%), whereas FCMN treated with surgery were primarily located in the periorbital region (44%) and/or the cheek (17%). Across all treatment cohorts, 22% of patients experienced at least one complication, with 12% of complications experienced by patients treated by surgery. CONCLUSIONS: There is a greater need for standardized FCMN nomenclature that encompasses nevi pattern, dimensions, anatomical coverage, and quantitative measurements of treatment outcome. Future studies should focus on identifying anatomic locations of FCMN that are more prone to complications and determine which treatment approach optimizes outcomes.

Complications of Fat Grafting and Repositioning for Correction of Lower Eyelid Pouch With Tear Trough Deformity or Lid-Cheek Junction: A Systematic Review.

BACKGROUND: Fat grafting and repositioning may serve as a convenient, economical, and effective surgical method for correcting lower eyelid pouch with a tear trough deformity or lid-cheek junction. However, comprehensive systematic reviews and meta-analyses investigating the complications associated with this technique are lacking. OBJECTIVE: This study aimed to summarize and gather data on complications related to fat grafting and repositioning for the correction of tear trough deformity or lid-cheek junction in lower eyelid blepharoplasty. METHODS: A thorough search was performed across multiple databases including PubMed, Cochrane, Embase, ProQuest, Ovid, Scopus, and Web of Science. Specific inclusion and exclusion criteria were applied to screen the articles. The occurrence of complications was analyzed using a random-effects model. RESULTS: A total of 33 studies involving 4671 patients met the criteria for systematic evaluation and were included in this meta-analysis. The overall complication rates were 0.112 (95% confidence interval [CI]: 0.060-0.177) for total complications, 0.062 (95% CI: 0.003-0.172) for unsatisfactory correction or contour irregularity, 0.062 (95% CI: 0.009-0.151) for hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and 0.024 (95% CI: 0.013-0.038) for reoperation. CONCLUSIONS: Fat grafting and repositioning for correcting a lower eyelid pouch with tear trough deformity or lid-cheek junction was associated with high rates of complications. Therefore, it is crucial to closely monitor the rates of unsatisfactory correction or contour irregularity, hematoma, swelling (not specified as bulbar conjunctiva), ecchymosis, or oozing of blood, and reoperation. In addition, effective communication with patients should be prioritized.

Treatment for benign skin lesion in zygomatic-infraorbital region by the expanded multi-lobe cervicofacial advancement rotation flap in pediatric patients.

PURPOSE: Benign skin lesions in zygomatic-infraorbital regions severely influence pediatric patients' appearance as well as mental health. Treatments are difficult for the high requirements of patients' guardians in both function and aesthetics. The present study aims to introduce a surgical method, Expanded Multi-Lobe Cervicofacial Flap, which combines the advantages of the classical cervicofacial advancement rotation flap and the tissue expansion technique. METHODS: A total of 21 pediatric patients were enrolled. The treatment process included 2 stages: implantation of the skin tissue expander and flap transfer. The excessive skin created by tissue expansion extended the coverage area of the multi-lobe flap. RESULTS: In this retrospective study, follow-up periods were all more than 12 months (20.8 ± 6.7). In the last follow-ups, the flaps were all in good condition, and No facial organ displacement was observed. The patients' guardians were satisfied with the outcomes. CONCLUSIONS: Using the expanded multi-lobe cervicofacial flap for the zygomatic-infraorbital benign skin lesion repair is effective, and this method is especially applicable to the pediatric population.

Correlation between oral muscle pressure and malocclusion in mixed dentition: a cross-sectional study.

OBJECTIVE: To investigate the relationship between oral muscle pressure and malocclusion in the mixed dentition. MATERIALS AND METHODS: Maximum tongue, lip and cheek pressure was measured using the Iowa Oral Performance Instrument (IOPI) in 3 patient cohorts: patients with (1) posterior crossbite, (2) class II relationship and (3) a control group of patients without malocclusion. Linear models were used to compare the mean differences in muscle pressure between groups, with correction for age and gender. The imbalance between lips and tongue and between lips and cheeks was calculated by the Delta z-scores of each group. RESULTS: A total of 146 participants were included, 46 (mean age 8.71±0.85), 41 (mean age 11.74±1.17) and 35 (mean age 10.71±1.92) in groups 1, 2 and 3 respectively. Patients with malocclusion showed significantly higher lip and lower cheek pressure and imbalance favouring the lips over the tongue compared to controls. Class II,1 patients showed significantly higher tongue pressure than Class II,2. No differences were found in muscle pressure or imbalance between crossbite and Class II nor between crossbite types. CONCLUSION AND CLINICAL RELEVANCE: These findings suggest that oral muscle pressure may be associated with malocclusion. This highlights the importance of functional diagnosis and its implications on the prevention and treatment of malocclusion, as well as on orthodontic stability.

Use of the pedicle of previously harvested pectoral myocutaneous flap as a recipient for free flaps in head and neck reconstruction.

INTRODUCTION: The pectoral myocutaneous flap (PMF) is a workhorse regional reconstructive option for head and neck defects. It is commonly used for primary reconstructions due to its advantages or as a life-boat flap in the salvage of failed reconstructions of free flaps. However, it also has intrinsic drawbacks, such as perfusion problems and partial or complete flap loss. Although there are many studies about the advantages and use of PMF in the literature, the number of studies about salvage of this workhorse flap is inadequate. We aimed to present the use of the pedicle of previously performed PMF as a recipient for free flaps in head and neck reconstruction. METHODS: Between January 2022 and August 2023, 10 free flaps were used in nine patients (three females and six males) who had previously undergone head and neck reconstruction with PMF. The age of the patients ranged from 54 to 74 years. Seven out of the nine PMFs were previously performed by different surgical teams. Squamous cell carcinoma (SCC) was the reason for primary surgeries in all patients and the PMFs were used for right lower lip and right submandibular defect, left lower lip and mentum defect, lower lip defect, right lower lip and right submandibular defect, right retromolar trigone defect, right buccal defect, left anterolateral esophageal defect, right retromolar trigone defect and left anterolateral pharyngoesophageal defect reconstructions. The problems were partial skin island necrosis and wound dehiscence in six patients and total skin necrosis in three patients. The partial skin island necroses already showed that the pedicles were unproblematic. For patients with total skin island necrosis the muscle stalks so the pedicles were also unproblematic which were confirmed by physical examination and Doppler device. After complications, the finally defects were located in the lower lip, left lower lip and mentum, right lower lip and right submandibular area, left anterolateral esophageal area and left neck, right buccal area, right retromolar trigon, left anterolateral pharyngoesophageal fistula and left neck. The sizes of the defects were between 3 × 4 cm and 11 × 17 cm. For all patients, the pedicle of the previously harvested PMF was used as a recipient for free flaps. Since the PMF was flipped over the clavicula for the reconstruction previously, the pedicle was so close to skin or skin graft which was used for coverage of the muscle stalk. The Doppler device was used first over the clavicle where the PMF was flipped for vessel identification. After marking the vessels, a vertical zigzag incision was made on the skin or skin graft. The perivascular fatty tissue and the pedicle were encountered with minimal dissection by the guidance of Doppler. After meticulous microscopic dissection, the pedicle of PMF was prepared for anastomoses as usual. Six radial forearm free flap (RFFF) and four anterolateral thigh flap (ALT) flaps were used in the head and neck reconstructions for the nine patients. RESULTS: The sizes of the flaps were between 4 × 5 cm and 12 × 17 cm. The diameters of the recipient arteries were between 0.9 and 1.2 mm. Recipient veins were approximately the same diameter as the arteries. In one patient, two vein grafts were used for lengthening both the artery and vein to reach recipient vessels. End-to-end anastomoses without vein grafts were performed in the remaining patients. One arterial thrombosis that manifested on the first postoperative day was salvaged successfully. Hematoma was seen in two patients and wound dehiscence was seen in three patients. There was no partial or total flap necrosis and all flaps survived. The follow-up period ranged from 2 to 12 months. Despite successful reconstructions, two patients died during the follow-up period due to unrelated conditions. Functional results were acceptable in the remaining patients. CONCLUSION: The pedicle of previously used pectoral myocutaneous flaps may be a useful alternative option as the recipient for free flaps in head and neck reconstruction.

Analysis of Anatomy and Age-related Changes in Infraorbital Cheek Using Computed Tomography.

BACKGROUND: There is no consensus regarding age-related facial anatomical changes. In this study, aging-related changes in soft and hard cheek tissues were quantitatively analyzed using computed tomography. METHODS: We performed a retrospective study of 90 Asian females who underwent facial computed tomography. Three-dimensional model of soft tissue in apple zone was reconstructed, and age-related changes in fat volume and pyriform aperture area were quantified using Mimics software. RESULTS: The apple zone is an aesthetic unit of the infraorbital cheek, with soft tissue located between the lateral wall of the pyriform aperture and the zygomatic major muscle. The superficial fat volume significantly decreased with age (P < 0.05). In contrast, a significant decrease in total fat volume was only observed between the young and old groups (P < 0.05). In linear regression modeling, age was a significant predictor of pyriform aperture area (R2 = 0.194, P < 0.001). CONCLUSIONS: These results suggest that superficial fat atrophy and bone remodeling in the cheek with age, and both of which combine to contribute to an aging facial appearance. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Volume Redistribution of the Buccal Fat Pad After Reduction Malarplasty.

BACKGROUND: During reduction malarplasty, cheek bulging could be found immediately after zygomatic complex is moved inwards, backwards and upwards. As patient is in the supine position during surgery, the effect of gravity is eliminated, so the only reason for the bulge is the redistribution of the soft tissue in the deep facial spaces. The buccal fat pad, with its main body behind the zygomatic arch and buccal extension in the cheek area, is most likely to be responsible for the bulge. METHODS: 3D buccal extension models were reconstructed from preoperative and long-term follow-up CT images and the volume measured. By comparing the pre- and postoperative 3D models, the shape deviation of the buccal extension and facial soft tissue can be identified. RESULTS: Eleven patients (22 buccal extensions) met the inclusion criteria. Compared with the preoperative buccal extension volume, the postoperative volume increased significantly. By comparing the reconstructed models, the buccal extension volume increase with anteroinferior protrusion can be visually detected, and cheek bulging was clearly identified on the lower face. The bulging area coincided with the projection of the buccal extension on the skin surface. CONCLUSIONS: Reduction malarplasty may cause volume redistribution of the buccal fat pad. Therefore, preoperative assessment of the size of the buccal fat pad based on CT images is recommended. The buccal extension volume increase with anteroinferior protrusion is an important cause of postoperative cheek bulging and should be considered during treatment. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Lower Blepharoplasty with Mid-Face Elevation: A Polydioxanone (PDO) Barbed Suture Loop for Lid-Cheek Junction Blending.

BACKGROUND: Anti-aging in the lower eyelid-cheek junction area has always been the most widely sought cosmetic surgery. However, orbital fat removal or a midcheek fat pad lift alone does not achieve the best results. This study describes a new technique of lower blepharoplasty combined with a midcheek lift performed using a polydioxanone barbed suture loop based on the entire anatomy of the lower eyelid-cheek junction area. METHODS: We report our experience with lower blepharoplasty combined with a midcheek lift, covering 38 procedures performed over the past 3 years. We reviewed the technique and results and described the various indications for which the new technique is suitable. The efficacy of the surgeries was delineated using both 3D volume calculation and graphic pictures. RESULTS: All patients demonstrated significant rejuvenation of the lower eyelid with the elimination of the eyebags, elevation of the lid-cheek junction, and improvement of the nasolabial folds. All the patients were satisfied with the procedure. Complication rates were low, and lower lid retraction temporarily occurred in 3% of patients. CONCLUSIONS: This new method of lower blepharoplasty with midcheek elevation is safe, effective, convenient, and long-lasting. The technique is more doctor-friendly, recovery is quick, and complications are minimized. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Anti-sagging Method in Reduction Malarplasty: Application of the Bracing System with the Preservation of the Zygomaticus Major Muscle Bony Attachment.

BACKGROUND: Cheek drooping after reduction malarplasty remains a concern for patients. OBJECTIVES: To evaluate the anti-drooping effectiveness of the bracing system technique with the preservation of the zygomaticus major muscle (ZMj) bony attachment and to determine the role of ZMj in anti-drooping. METHODS: A retrospective analysis was conducted of patients who accepted this method in our department from February 2016 to May 2021. Patients' subjective evaluation and two plastic surgeons' objective assessment of photographs were performed. The pre- and postoperative three-dimensional (3D) ZMj models were reconstructed and compared. ZMj length and tortuosity were also measured from 3D models. RESULTS: Twenty-two patients (44 ZMjs) met the inclusion criteria. Most patients (21/22, 95.45%) were satisfied with the postoperative appearance without ageing after reduction malarplasty, except for one feeling slightly older after the operation. The objective scoring results showed no deepening of the nasolabial fold in the majority (20/22, 90.91%) of patients. Two patients were one-grade worse, from score 1 to 2. Upward movement of the postoperative ZMj bony attachment was clearly observed compared with the preoperative 3D model. The significantly reduced ZMj tortuosity (p < 0.001) and the slightly increased ZMj length (not significant) after surgery supported the straightening of the ZMj which was also seen in the 3D comparison. CONCLUSIONS: The bracing system technique with preservation of the bony attachment of the ZMj is an effective and cost-effective anti-sagging method for reduction malarplasty. The ZMj was lifted and straightened after reduction malarplasty, which helped to prevent sagging. 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 the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Cheeklift With and Without Posterior Lamellar Spacer Grafts for Treatment of Lower Eyelid Retraction.

BACKGROUND: To compare outcomes of lower eyelid retraction repair using a subperiosteal midface lifting technique with and without posterior lamellar grafts. METHODS: Charts of patients undergoing a sub-periosteal midface lift for treatment of lower eyelid retraction using 4 techniques for posterior lamellar reconstruction were reviewed. Thirty patients were included in each of the groups: midface with hard palate graft (HPG), midface lift with acellular cadaveric graft (ADG), midface lift with retractor disinsertion (RD) and midface lift alone (NG). Measurements of distance from pupil center to lower lid margin (MRD2) and from lateral limbus to lower lid margin (MRD2limbus) were taken from pre- and postoperative photographs and compared. Secondary outcomes included rates of reoperation, major and minor complications, resolution of symptoms and keratopathy. RESULTS: One hundred twenty operations were assessed (n = 30 for each surgical group). The average follow-up time was 20 weeks. The median MRD2 elevation was 0.95 mm (NG), 0.85 mm (HPG), 1.59 mm (ADG) and 1.02 mm (RD). The median MRD2limbus elevation was 1.06 mm (NG), 0.92 mm (HPG), 1.45 mm (ADG) and 1.12 mm (RD). There were no significant differences in MRD2 or MRD2limbus between the 4 groups (p = 0.06 and 0.29, respectively). Reoperation rates were highest with in the hard palate graft group (33%) compared to other techniques (p = 0.0006). CONCLUSIONS: Similar degrees of lower eyelid elevation were achieved with all the midface lifting techniques, and complication rates did not significantly differ between techniques. However, the higher reoperation rates with the use of spacer grafts suggest that a no-graft technique may be preferable. 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 .

The influence of different cheek and lip retractors and emissivity on intraoral infrared thermography.

OBJECTIVES: To assess the influence of two conventional and one adapted cheek and lip retractors and three emissivity setting values on intraoral infrared thermography (IT) temperature values. METHODS: The sample was composed by 50 volunteers. Three cheek and lip retractors were tested: Group 1-flex retractor (FR); Group 2-FR adapted with Styrofoam; Group 3-U-type retractor (UR) for cheek and lip. All thermograms were acquired using FLIR T650 infrared camera. A set of three thermograms in frontal norm were acquired for each lip and cheek retractor at 0.91, 0.96, and 0.98ε, with an interval of 15 min between each set of images to avoid thermal interference. All images were assessed by two observers. The ROIs' mean temperature of the four upper incisors was recorded. Two-way ANOVA and Sidak post-test were used for data assessment with a significance level of 5%. RESULTS: Group 3 showed higher mean temperature than Groups 1 and 2 at all emissivity settings for all assessed teeth (P < .05). 0.91ε showed higher temperature than 0.96ε and 0.98ε for all assessed variables (P < .01). Contralateral teeth assessed using Group 3 at 0.91ε showed statistical differences between each other (P < .05). No statistical difference was observed between contralateral teeth assessed using Groups 1 and 2 at 0.96ε and 0.98ε (P > .05). CONCLUSIONS: The choice of cheek and lip retractor and emissivity setting can interfere on intraoral IT temperature values. U-type cheek and lip retractor and 0.91ε setting should not be used for IT image acquisition when assessing dental tissues.

A novel description of the supporting system of the orbicularis oculi muscle in the infraorbital area: Tear trough muscle fiber.

BACKGROUND: The aim of this study was to elucidate the anatomical structures of supporting system of the infraorbital area. MATERIALS AND METHODS: Forty-four hemifaces from eleven Korean and eleven Thai cadavers were used to dissect the infraorbital area. Based on the dissection and previous histologic results, they were analyzed. RESULTS: The orbicularis oculi muscle (OOc) had two portions (palpebral and orbital portion) and four subparts (pretarsal, preseptal, prezygomatic, and premaxillary part). The elliptical muscle fiber of OOc was supported by circumferential connective tissue including skin ligament, orbicularis retaining ligament, zygomatic ligament, and zygomatic cutaneous ligament. The vertical muscle fiber, the tear trough muscle fiber, and medial muscular band directly attached to the skin. CONCLUSION: Full of subcutaneous tissue in the tear trough groove, strong attachment to the bone by tear trough ligament and to the skin by tear trough muscle fiber would multiply result in the tear trough on the face.

Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework.

BACKGROUND: Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited. OBJECTIVES: The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment. METHODS: Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment. RESULTS: Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality. CONCLUSIONS: Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.