The Fascias of the Forehead and Temple Aligned-An Anatomic Narrative Review.

A thorough understanding of 3-dimensional facial anatomy and its fascial concepts is essential to allow for further development of novel surgical and nonsurgical treatment strategies to increase patient safety and effectiveness. The layered anatomy and its interconnections of the forehead, scalp, and temple is complex and is thus summarized and aligned in a unified nomenclature in this review. The scalp consists of 5 layers, which transition into 8 layers in the forehead and into a total of 13 layers in the temple.

Reevaluation of the Layered Anatomy of the Forehead: Introducing the Subfrontalis Fascia and the Retrofrontalis Fat Compartments.

BACKGROUND: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures. METHODS: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions. RESULTS: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat (deep to the orbicularis oculi muscle), and retro-frontalis fat (deep to the frontalis muscle); layer 6, subfrontalis fascia; layer 7, preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead; and layer 8, periosteum. CONCLUSIONS: The results of this study add to the current understanding of the layered arrangement of the forehead. The combination of ultrasound imaging and cadaveric dissections provided evidence for a continuous fatty layer deep to the frontalis muscle.

Development and Validation of IBSA Photographic Scale for the Assessment of Inner Upper Arm Laxity.

OBJECTIVE: To describe the development and validation of the 5-grade photographic IBSA inner upper arm scale. METHODS: From 2 real-life pictures, a scale made up of 5 morphed images showing increasing severity of inner upper arm laxity was created. For validation, a set of 50 images (half of which real and the other morphed) was developed and sent to 5 trained physicians in two rounds 30 days apart. Raters' task was to make a selection of each image according to the given scale. Inter-rater and intra-rater reliability were evaluated in both rounds. RESULTS: As to intra-rater reliability, single-rater kappa scores between 0.74 and 1.00 and a global kappa score of 0.846 were observed, while inter-rater agreement was calculated with intra-class correlation coefficient reporting scores higher than 0.91, which indicate excellent reliability. CONCLUSION: IBSA inner upper arm laxity scale proved to be a validated and reliable tool.

An Update on the Anatomy of the Forehead Compartments.

BACKGROUND: The forehead is one of the most frequent locations for neuromodulator and soft tissue filler applications; however, the underlying anatomy is still poorly understood. Thus far, the presence of deep forehead compartments has not been confirmed. METHODS: Twenty Caucasian cephalic specimens, 15 fresh frozen (six female and nine male) and five with formalin-phenol embalmment (three female and two male) were investigated using contrast-enhanced computed tomographic scans, dye injections, and anatomical dissections. RESULTS: Three superficial (one central and two lateral) and three deep (one central and two lateral) forehead compartments were identified. The superficial fat compartments were found within the subcutaneous fat tissue (layer 2) and measured 2.1 × 4.6 mm for the superficial central forehead compartments and the right superficial lateral forehead compartments and 2.6 × 3.2 cm for the left superficial lateral forehead compartments, with a mean volume of 2.5, 3.1, and 3.4 cc, respectively. The deep fat compartments were identified deep to the frontalis muscle but superficial to the periosteum with an extent of 6.4 × 5.9 cm for the deep central forehead compartments, 2.6 × 5.8 cm for the right deep lateral forehead compartments, and 2.7 × 5.8 cm for the left deep lateral forehead compartments, and a mean volume of 9.1, 1.6, and 1.4 cc, respectively. CONCLUSIONS: The results presented in this study increase the understanding of the forehead anatomy. Understanding the presence of the superficial and the deep forehead compartments allows one to change the signs of frontal aging. The deep forehead compartments are in general avascular planes and permit blunt dissection for access to the supraorbital region.

The Benslimane's Artistic Model for Females' Gaze Beauty: An Original Assessment Tool.

BACKGROUND: The aim of this paper is to analyze the aesthetic characteristics of the human females' gaze using anthropometry and to present an artistic model to represent it: "The Frame Concept." In this model, the eye fissure represents a painting, and the most peripheral shadows around it represent the frame of this painting. The narrower the frame, the more aesthetically pleasing and youthful the gaze appears. MATERIALS AND METHOD: This study included a literature review of the features that make the gaze appear attractive. Photographs of models with attractive gazes were examined, and old photographs of patients were compared to recent photographs. The frame ratio was defined by anthropometric measurements of modern portraits of twenty consecutive Miss World winners. The concept was then validated for age and attractiveness across centuries by analysis of modern female photographs and works of art acknowledged for portraying beautiful young and older women in classical paintings. RESULTS: The frame height inversely correlated with attractiveness in modern female portrait photographs. The eye fissure frame ratio of modern idealized female portraits was similar to that of beautiful female portraits idealized by classical artists. In contrast, the eye fissure frames of classical artists' mothers' portraits were significantly wider than those of beautiful younger women. CONCLUSION: The Frame Concept is a valid artistic tool that provides an understanding of both the aesthetic and aging characteristics of the female periorbital region, enabling the practitioner to plan appropriate aesthetic interventions. 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 A3 online Instructions to Authors. www.springer.com/00266 .

Face transplant graft procurement: a preclinical and clinical study.

BACKGROUND: Most articles on face composite tissue allotransplantation have considered ethical and immunologic aspects. Few have dealt with the technical aspects of graft procurement. The authors report the technical difficulties involved in procuring a lower face graft for allotransplantation. METHODS: After a preclinical study of 20 fresh cadavers, the authors carried out an allotransplantation of the lower two-thirds of the face on a patient in January of 2007. The graft included all the perioral muscles, the facial nerves (VII, V2, and V3) and, for the first time, the parotid glands. RESULTS: The preclinical study and clinical results confirm that complete revascularization of a graft consisting of the lower two-thirds of the face is possible from a single facial pedicle. All dissections were completed within 3 hours. Graft procurement for the clinical study took 4 hours. The authors harvested the soft tissues of the face en bloc to save time and to prevent tissue injury. They restored the donor's face within approximately 4 hours, using a resin mask colored to resemble the donor's skin tone. All nerves were easily reattached. Voluntary activity was detected on clinical examination 5 months postoperatively, and electromyography confirmed nerve regrowth, with activity predominantly on the left side. The patient requested local anesthesia for biopsies performed in month 4. CONCLUSIONS: Partial facial composite tissue allotransplantation of the lower two-thirds of the face is technically feasible, with a good cosmetic and functional outcome in selected clinical cases. Flaps of this type establish vascular and neurologic connections in a reliable manner and can be procured with a rapid, standardized procedure.