Midface Multilayering Filler Injection Technique: Understanding of the Dynamic Facial Anatomy Through a "Smiling Cadavers" Anatomical Study.

BACKGROUND: Understanding age-related changes in compartmentalized facial fat and their role in facial dynamics and aesthetics is essential to target filler injections for midface rejuvenation. METHODS: A novel anatomical approach ("smiling cadavers") was used to identify the main midface fat compartments involved during muscular contraction when smiling and their motion and behavior with and without filler injections. Based on these insights and the literature, a multilayering filler injection approach was developed to optimize midface rejuvenation by restoring fat volumes using rheologically different products injected into different fat compartments. RESULTS: Twenty-four hemifacial dissections confirmed the presence of two fat compartment layers, separated by the orbicularis oculi muscle in the horizontal plane and by the septa in the vertical plane, and revealed the anatomical effects of facial movement. The midface is composed of deep static fat compartments and a superficial dynamic adipose layer that follows the facial movements, creating a natural dynamic appearance. A proof-of-concept study involved 130 White patients (36 to 56 years; 91 percent women). After the procedure, 95 percent of patients and 98 percent of practitioners rated facial appearance as "improved" or "much/very much improved." No major complications were reported. CONCLUSIONS: The smiling cadavers method enhances understanding of dynamic facial anatomy by showing the superficial and deep fat compartments of the midface at rest and their motion during a procedure to represent a smile. The multilayered injection technique takes into account these anatomical findings to rejuvenate the midface, achieving a natural appearance at rest and during motion.

French Kiss Technique: An Anatomical Study and Description of a New Method for Safe Lip Eversion.

BACKGROUND: To minimize complications with injectable fillers, aesthetic practitioners need a detailed knowledge of facial anatomy. OBJECTIVE: To describe a novel approach ("subtractive anatomy") to identify locations where lip eversion using filler injections would be well tolerated and to evaluate the "French kiss technique" (FKT) to enhance the length of the lips using a low cohesivity hyaluronic acid filler. MATERIALS AND METHODS: Twenty hemifaces were dissected from 10 nonembalmed, nonfrozen Caucasian cadavers to assess subtractive anatomy. The FKT "proof-of-concept" evaluation enrolled 120 patients (114 women; mean age 42 years). RESULTS: The arterial supply of the lips shows marked anatomical variations between patients and when comparing sides of the face in the same person. The dissections revealed a "safe area" for filler injections in the submucosal plane 3 to 4 mm above the vermilion-mucosa junction of the upper lip and 3 to 5 mm below the vermilion-mucosa junction of the lower lip. Preliminary results suggest that FKT is associated with very good cosmetic outcomes and no major complications. CONCLUSION: Based on our anatomical studies and the literature, we developed the novel FKT for the injection of lip fillers, which produced a marked natural lip plumping effect. Further evaluation is underway.

Surgical Denervation of Platysma Bands: A Novel Technique in Rhytidectomy.

Prominent platysma bands in the neck are one of the first signs of aging. There is increasing demand for surgical facial rejuvenation, including procedures to tighten skin and muscle in the neck; however, obtaining long-lasting results is a challenge. The aim of this study was to characterize the efficacy and safety of platysma muscle denervation for this indication. The authors performed surgical platysma denervation, involving selective cervical branch section simultaneously performed with rhytidectomy, in eight patients with unilateral facial paralysis (as a solution for visible platysma bands on the unaffected side of the face) and in one patient requiring aesthetic rhytidectomy (bilateral surgery). Patients were monitored for at least 3 months after surgery (in some cases, for up to 21 months). There were no major postoperative complications. Eight of the patients were unable to contract the platysma following surgery, leading to an improvement in the platysma band appearance. This study demonstrated the effectiveness and safety of the platysma denervation technique. Sectioning the cervical branch of the facial nerve provides a permanent solution to improve the cosmetic appearance of platysma bands and can be combined with rhytidectomy. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, IV.

Platysma Bands: Is a Change Needed in the Surgical Paradigm?

BACKGROUND: Platysma bands are one of the first signs of aging of the neck. Current theories suggest that these bands develop because of skin sagging followed by loss of muscle tone. Treatment strategies therefore aim to tighten skin and muscle. The aim of the present study was to demonstrate that platysma bands are caused by muscular activity during the aging process and are not secondary to skin sagging. This suggests a new approach to managing platysma bands. METHODS: The authors conducted a descriptive, prospective clinical study of 25 patients who presented with definitive, unilateral, facial palsy following otoneurosurgical treatment. The authors targeted their observations on anterior neck bands. Patients were followed for up to 10 years. RESULTS: Of the 25 patients, 76 percent had visible platysma bands on the healthy side, but not on the paralyzed side, of their face. Platysma bands were present on both sides in the 12 percent of patients who had a spastic form of facial paralysis. There was no worsening of the platysma band appearance in any patient. No ptosis of the neck skin on the paralyzed side was observed. CONCLUSIONS: This study demonstrated that platysma bands are not related to relaxation of the platysma and skin laxity, but are caused by activity of the platysma muscle. The skin follows the muscle. These observations support a change in surgical management of the aging neck, moving from tightening the skin to denervating the platysma muscle. Further studies need to fully characterize the efficacy and safety of platysma muscle denervation in this indication.

Lower Face: Clinical Anatomy and Regional Approaches with Injectable Fillers.

The use of injectable fillers enables facial sculpting through treatment of volume depletion and modeling of facial contours. Injectable fillers are among the most frequently performed minimally invasive cosmetic procedures.However, treatment of the lower third of the face can be challenging and requires expertise in facial anatomy. In this article, the authors provide a comprehensive review of the anatomy of the lower third of the face, highlighting danger zones. In addition, the authors describe their preferred approach and detailed technique used in the treatment of each specific area, namely the jawline, prejowl sulcus, melomental folds, and lips.

Newer Understanding of Specific Anatomic Targets in the Aging Face as Applied to Injectables: Facial Muscles--Identifying Optimal Targets for Neuromodulators.

The muscular anatomy of the face is complex. Animation patterns of facial muscles vary significantly among individuals. Activity of facial muscles determines expression and emotion and affects the eyes aperture and the amount and extent of facial rhytids. Injection of botulin toxin for facial rejuvenation has become a very popular procedure and allows the practitioner the ability to modulate facial expression and to decrease the amount of facial rhytids. A thorough knowledge of the variant facial anatomy is necessary to maximize the efficiency of botulin toxin injection. This knowledge will also aid in minimizing complication an untoward side effect.

Anatomy of the Lower Face and Botulinum Toxin Injections.

The use of botulinum toxin in the lower face is more complex and less reliable than its use in the upper face. Use in the lower face is also fraught with more adverse events. The anatomy of the lower face is complex, as the muscles of this region are very close together and interface at different levels and depths to perform heterogeneous functions, such as talking, eating, drinking, and expressivity of the face. This article, based on the anatomical knowledge of each muscle of the lower face, provides recommendations and guidelines to perform botulinum toxin injection safely. The review of each muscle with its relevant anatomy and relationship of this three-dimensional anatomy with the cutaneous plane gives the exact position of injectable locations. For each muscle, the number of points related to the motor end plate location and the exact dose related to the muscular mass are indicated. Summary tables are provided.