Histological effects of a combined collagen stimulation procedure consisting of microfocused ultrasound, soft tissue filler, and Ca-HA injections.

BACKGROUND: An increasing demand for in-office aesthetic procedures aiming to improve collagen stimulation has been reported. OBJECTIVE: To analyze the effects of combinations of different aesthetic collagen stimulation procedures using histological analysis. METHODS: Histological analysis was performed on skin samples of the excess skin of a 60-year-old patient after sub-superficial musculo-aponeurotic system facelift surgery. The excess skin before facelift surgery was divided into three areas per hemiface. Each area-with exception of area A as a control-received an isolated or combined treatment of microfocused ultrasound (MFU), injections of calcium-hydroxylapatite/hyaluronic-acid-based soft tissue filler, and microneedling. The effect of the treatments was analyzed using histological analysis with H&E coloration and PAS staining. RESULTS: A threefold increase of epidermal and dermal thickness was achieved by treating the skin with the proposed combined treatment comprising MFU and injections of calcium-hydroxylapatite- and hyaluronic-acid-based soft tissue fillers. CONCLUSION: The investigated treatments act synergistically in the production of collagen and combining these treatments allows for an increase in collagen production.

Vascular Safe Zones for Facial Soft Tissue Filler Injections.

The number of soft tissue filler injections performed by aesthetic injectors has continued to increase over the last few years. To provide a high standard of safety and achieve individualized, reproducible, and long-lasting outcomes, aesthetic injectors must have a solid foundation in anatomy, facial biomechanics, rheology, and injection biomechanics. Adverse events associated with soft tissue filler injections can be severe, especially if the aesthetic injector unintentionally injects the soft tissue filler into the patient's arterial vascular circulation and the administered product reaches the arterial bloodstream. Although the face has a rich arterial vascular supply that may seem overwhelmingly complex, it can be broken down systematically according to its internal and external vascular territories. To provide guidance for aesthetic practitioners performing minimally invasive facial injections for aesthetic purposes, this narrative article will discuss the course, depth, and branching pattern of the facial arteries based on the most frequently injected anatomical regions. In this article, we focus on vascular safe zones rather than danger zones .

Vascular Safe Zones for Facial Soft Tissue Filler Injections.

The number of soft tissue filler injections performed by aesthetic injectors has continued to increase over the last few years. To provide a high standard of safety and achieve individualized, reproducible, and long-lasting outcomes, aesthetic injectors must have a solid foundation in anatomy, facial biomechanics, rheology, and injection biomechanics. Adverse events associated with soft tissue filler injections can be severe, especially if the aesthetic injector unintentionally injects the soft tissue filler into the patient's arterial vascular circulation and the administered product reaches the arterial bloodstream. Although the face has a rich arterial vascular supply that may seem overwhelmingly complex, it can be broken down systematically according to its internal and external vascular territories. To provide guidance for aesthetic practitioners performing minimally invasive facial injections for aesthetic purposes, this narrative article will discuss the course, depth, and branching pattern of the facial arteries based on the most frequently injected anatomical regions. In this article, we focus on vascular safe zones rather than danger zones.

Invited Discussion on: A 7-Step Guide to High-Definition Liposuction.

Athanasiou et al. present a 7-step guide to high-definition (HD) liposuction in the current issue of Aesthetic Plastic Surgery. [1] The guide was based on the authors vast experience in HD-liposuction performed in 568 patients (247 males and 321 females) with a mean age of 43 years (range, 22-64) and a mean BMI of 25.6 (range 21-29 kg/m2) over a 6-year time-period. The authors provide detailed information on their approach regarding pre-operative markings, methods of anesthesia and composition of tumescence solution, incision points and access, surgical technique, and fat transfer. In addition, they performed a time-dependent analysis of the type and quantity of observed complications over the study-period, as well as the mean surgical operative time. 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 http://www.springer.com/00266 .

Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures.

BACKGROUND: Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position. OBJECTIVE: The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions. METHODS: This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m2. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity. RESULTS: The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001. CONCLUSION: Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs. 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 .

Understanding Facial Aging Through Facial Biomechanics: A Clinically Applicable Guide for Improved Outcomes.

Understanding the relevance of anatomic and biomechanical principles is crucial when treating the face with soft tissue fillers to achieve a symmetric, soft, and natural-looking result while mitigating the risk of adverse events. The objective of this study is to summarize facial age-related effects, to relate them to facial biomechanics, and to establish guidelines for safe, effective, and esthetically pleasing full-face treatment following 3 basic principles while incorporating the latest scientific developments. This narrative review summarizes the current understanding of facial aging and its implications for facial biomechanics deduced from the authors' experience and research.

Ultrasound Anatomy of the Dorsal Nasal Artery as it Relates to Liquid Rhinoplasty Procedures.

Nonsurgical rhinoplasty procedures using soft tissue fillers have gained popularity. With the increasing frequency of such procedures, the incidence of intra-arterial injection of soft tissue filler material and subsequent ischemia has also risen. This article analyzes the topographic anatomy of the dorsal nasal artery in the nasal soft tissue to potentially enhance patient safety in nonsurgical rhinoplasty procedures. The dorsal nasal artery shows a variable topographic course, especially in relationship to the procerus muscle. By understanding the topographic courses of the dorsal nasal artery, aesthetic practitioners may be able to perform nonsurgical rhinoplasty procedures with increased safety and efficacy.

The subjectively perceived injectability as an early indicator for adverse events?

BACKGROUND: With an increasing demand of aesthetic soft-tissue filler treatments, the occurrence of adverse events rises likewise. An optimized injection algorithm adapted to product characteristics (eg, rheology) of the soft-tissue filler is crucial in order to ensure satisfying clinical outcomes and high patient safety. OBJECTIVE: To identify a subjective feedback mechanism for the avoidance of adverse events after soft-tissue filler injection procedures. METHODS: A retrospective data analysis of n = 387 aesthetic treatments performed on n = 291 patients (4 males, 287 females) with different soft-tissue fillers with regard to loss of volume (filling effect), injected layer, injectability ("ease of injection"), injected volume, and injection technique was conducted. RESULTS: The subjectively perceived injectability during the injection process was statistically significantly related to G-Prime value with rs = 0.101 with p = 0.048, indicating an increased difficulty while injecting products with higher G-Prime. The occurrence of adverse events was also statistically significantly related to the injectability: injections with increased subjectively perceived difficulty showed increasing odds of developing adverse events by OR 0.157 with p = 0.002. CONCLUSION: Injections that were subjectively more difficult to perform are more likely to develop adverse events. Respecting the layered arrangement of the face, the recommended and approved depth and facial region for each specific treatment enable practitioners to achieve satisfying outcomes while keeping the rate of adverse events low.