Non-surgical rhinoplasty through minimal invasive nose thread procedures: Adverse effects and prevention methods.

BACKGROUND: This review addresses the intricacies of non-surgical rhinoplasty, particularly focusing on the utilization of absorbable sutures known as "Volumizing threads" in combination with fillers. The aim is to explore the enhanced precision of nasal contouring offered by these combined procedures compared to sole filler injections. METHODS: Through comprehensive clinical cases, this article scrutinizes the landscape of adverse effects and their prevention strategies associated with minimal invasive nose thread procedures. The discussion emphasizes various complications, including thread protrusion, migration, infections, skin dimpling, and granuloma formation, along with their respective management approaches. RESULTS: This article delineates cases of complications arising from thread placement, ranging from visibility issues to skin infections and granuloma formation. It highlights instances of thread visibility, oral mucosa protrusion, skin infections, dimpling, and granuloma formation. Additionally, it outlines the corresponding management strategies, accentuating the criticality of early intervention to preclude severe complications in non-surgical rhinoplasty involving nose threads. CONCLUSION: Non-surgical rhinoplasty, leveraging nose thread procedures, offers heightened precision compared to conventional filler injections. However, the review underscores the importance of recognizing potential risks and promptly addressing complications like thread extrusion, migration, and infections. Understanding these complexities in non-surgical rhinoplasty aids in informed decision-making and efficient patient care.

Case series of tongue necrosis from vascular complications after chin augmentation with hyaluronic acid: Potential pathophysiology and management.

BACKGROUND: Even though the chin is considered a safe injection area for facial filler augmentation, tongue necrosis is a rare complication in this area. OBJECTIVE: Our aim was to present case series of rare complications from chin filler augmentation with possible pathophysiology and management. METHODS: From our thorough literature search found only one case report of tongue necrosis from chin filler augmentation. We present case series of unilateral tongue necrosis from vascular occlusion following hyaluronic acid injection in the chin, which was successfully treated with a high-dose hyaluronidase injection resulting in complete recovery in all patients. RESULTS: Variation in vascular anastomosis leads to a possible cause of vascular occlusion. The lingual artery is the primary arterial supply for the tongue, which is an exclusive target for embolism. Two main responsible arteries and branches are the deep lingual and sublingual arteries. The submental artery variation was previously described as the cause of this event. We proposed potential pathophysiology of the occlusion, not only the variation of vasculature but bone. The midline lingual foramen, an anatomical bone variation on the surface of the midline inferior jaw, was found to be another possible cause. This foramen contains a branch of the submental and sublingual artery, which includes the perforating artery, median perforating artery, or both. Filler injection with a sharp needle on the bone can potentially increase the risk of this vascular incident. A high dose of hyaluronidase administered with multiplane injections was accomplished with complete recovery. CONCLUSIONS: Tongue necrosis from vascular complications after hyaluronic acid filler injection can occur. Not only vessels but bone variation pathology were possible causes.

The efficacy and safety of the innovative cold atmospheric-pressure plasma technology in the treatment of striae distensae: A randomized controlled trial.

BACKGROUND: Available current therapeutics modalities for striae distensae (SD) provide inconsistently effective outcomes. There is ongoing research on innovative treatment modalities to find better treatment solutions. OBJECTIVES: To evaluate the efficacy and safety of innovative cold atmospheric plasma (CAP) technology in the treatment of striae distensae. METHODS: This study includes twenty-three patients with striae distensae. The body was divided into two halves. One side was randomly treated with CAP biweekly on the same treated side for five sessions with 30 days follow-up after the last session. Another half was left untreated. Efficacy assessment was done using patient and observer scar assessment scale (POSAS), patient satisfaction scales, and Antera 3D® skin imaging system. Safety assessment was evaluated using the visual analog scale (VAS) and adverse effects monitoring. RESULTS: Patient and observer scar assessment scale, patient and observer overall opinion score, and patient and observer total score in a summary of all rated characteristics, comparing treated and untreated areas, showed a statistically significant reduction in all parameters after one treatment (*p-value <0.05). Patients rated satisfaction as a great improvement in 52.3%, moderate improvement in 39.1%, extreme improvement in 4.3%, and slight improvement in 4.3%. Adverse effects included small scabs, shallow wounds, and rash. CONCLUSION: Cold atmospheric plasma is a safe and effective, innovative treatment modality for striae distensae with minimal side effects.

Efficacy and safety of the innovative cold atmospheric-pressure plasma technology in the treatment of keloid: A randomized controlled trial.

BACKGROUND: Keloid (KD) treatment is challenging for both physicians and patients. It can be functional debilitating and psychologically distressing. Available current therapeutics modalities give inconsistently effective results. OBJECTIVES: To evaluate the efficacy and safety of innovative cold atmospheric plasma (CAP) technology in the treatment of keloid. METHODS: This prospective, randomized control trial, the assessor-blinded trial, includes 18 patients with keloids. The keloid lesion was divided into two halves. One side was randomly treated with CAP technology biweekly on the same treated side for five sessions with a follow-up 30 days after finishing the final treatment. Another half was left untreated as a control. Efficacy assessment using POSAS, VSS, Patients' satisfaction scale, Antera 3D® skin imaging system. The safety assessment using VAS and adverse effects monitoring was completed. RESULTS: Objective assessment using Antera 3D® skin imaging system (Miravex, Dublin, Ireland) showed statistically significant improvement (p-value <0.05) on the treated side compared with the untreated side in all parameters, color, melanin, hemoglobin, texture, except for volume. POSAS, patient, and observer overall opinion score, and patient and observer total score in the summary of all rated characteristics, comparing the treated and untreated areas, showed a statistically significant reduction in all parameters after two treatments (*p-value <0.05). VSS showed statistically significant improvement after the second treatment and continued to the last follow-up. Most patients rated satisfaction scales up to 72.2% as moderate improvement, 11.1% as great improvement, 11.1% as slight improvement, and 5.6% as no change. The adverse effect was only a small scab in one patient. CONCLUSION: CAP technology could be considered an alternative treatment for keloid offering mild-to-moderate improvement with minimal side effects.

Current Practices in Hyaluronic Acid Dermal Filler Treatment in Asia Pacific and Practical Approaches to Achieving Safe and Natural-Looking Results.

Complications such as delayed inflammatory reactions (DIRs) and unnatural outcomes can sometimes arise from hyaluronic acid (HA) dermal filler treatments and can be challenging to address. Given the popularity of HA dermal fillers for aesthetic procedures, there is a need for preventive strategies to minimize these complications. Two hundred practitioners from 10 regions in Asia Pacific who administer HA fillers completed a survey on prevention of DIRs and unnatural outcomes. Thirteen global experts convened to evaluate the current practices and propose practical approaches for safe and appropriate use of HA dermal fillers. From the survey, the top three measures used to reduce the risk of DIRs included choosing an appropriate HA filler, aseptic technique, and patient selection. Key strategies employed to achieve natural-looking outcomes were treatment customization, understanding the rheological properties and behavior of different HA fillers, and being conservative in treatment approach. The panel developed a concise reference guide aimed at minimizing the risk of DIRs while achieving natural aesthetic outcomes. Five practical considerations were recommended: patient assessment and individualization of treatment plan, choice of an appropriate HA filler, adequate knowledge of facial anatomy, strict adherence to aseptic methods, and proper injection technique. The panel highlighted the need for education efforts to increase awareness of differential immunogenicity between HA fillers and to improve understanding on the importance of preserving aesthetic individuality for optimal results. These practical insights from the global experts support practitioners in optimizing safety and quality of aesthetic treatment with HA fillers.

A novel technique in reducing sebum production and improving atrophic acne scars.

OBJECTIVE: Fractional microneedling radiofrequency (FMR) has gained popularity for the treatment of acne scars, owing to favorable outcomes and short downtimes. This study aimed to investigate FMR use in reducing facial sebum production and treating acne scars. MATERIALS AND METHODS: This single-center, prospective, evaluator-blinded trial compared sebum production after three sessions of FMR (Fractora® 24-pin coated tip) performed one-month apart. Results were evaluated with a sebumeter (Cutometer®), sebaceous gland histology, and subjects' assessment. Acne scars were graded according to the Echelle d'Evaluation clinique des Cicatrices d'acné scale, Goodman and Baron's qualitative grading system, acne scar volume measurement, and subjects' assessments. RESULTS: Sebumeter results revealed a significantly decreased (p < 0.05) sebum production since the first treatment, sustained throughout the study period. Histological assessment showed decreased density and size of sebaceous glands. The mean acne scar volume decreased significantly, without a significant increase in the mean melanin levels. CONCLUSION: Fractora® 24-pin coated tip can be used as an alternative for patients with acne scars, who wish to concomitantly reduce their facial oiliness. A significant decrease in facial oiliness and acne scars' volume can be seen after a single treatment session, with up to 15.48% decrease in facial oil production.

Outcomes of 1064-nm picosecond laser alone and in combination with fractional 1064-nm picosecond laser in tattoo removal.

BACKGROUND: Removal of the unwanted tattoo was initially focused treatment of picosecond laser in the setting of the unfractionated beam, whereas the fractionated 1064-nm picosecond lasers (Fr-Pico) has been successfully utilized in various skin conditions, including scar and benign pigmented lesions. However, no studies compared the combination of Fr-Pico and unfractional 1064-nm picosecond laser (UFr-Pico) and UFr-Pico alone in tattoo removal. OBJECTIVE: This study aims to compare the efficacy and safety of the combination of Fr-Pico and UFr-Pico and the UFr-Pico and in tattoo removal. MATERIALS AND METHODS: Nineteen black tattoos in 11 patients were treated with UFr-Pico on one half and in combination with Fr-Pico on another half over three sessions with 4-week intervals and 4-week follow-up after the last session. Treatment efficacy was assessed using digital photographs, skin imaging analysis, and patient satisfaction. RESULTS: After three treatments, tattoo clearance scores revealed that greater than 50% clearance was achieved in 11 (84.6%) tattoos treated with combination side and 9 (69.2%) tattoos with UFr-Pico alone. Significant differences were observed between the groups at 8 and 12 weeks. Skin textural changes also demonstrated significant improvements in the combination side at Week 12. Adverse events, such as blistering and textural changes, were fewer in the combination side. CONCLUSION: The combination of 1064 nm Fr-Pico and UFr-Pico may be more effective and safer in tattoo removal than UFr-Pico alone.

Validated 5 - Point photonumeric scales for the assessment of hand atrophy.

OBJECTIVE: Quantifying the degree of dorsal hand atrophy is a challenging endeavor, but often necessary, in both the clinical and the research setting. The aim of this investigation was to create and consecutively validate a 5-point photonumeric scale for assessment of dorsal hand atrophy. MATERIAL AND METHODS: A medical team created a novel 5-point photonumeric scale. Twelve international raters were involved in the digital validation, while five raters performed a live validation. RESULTS: For the digital validation of the Croma Hand Atrophy Assessment Scale, a total of 72 subjects (58 females, 14 males) with a mean age of 43.0 ± 14.4 years [18-73 years] were assessed. For the live validation, 88 subjects (73 females, 15 males) with a mean age of 45.0 ± 14.1 years [20-73 years] were rated. The results revealed almost perfect intra-rater (ICC: 0.90 [95% CI: 0.88-0.92]) and inter-rater agreements (ICC: 0.85 [95% CI: 0.81-0.89] and 0.86 [95% CI:0.82-0.89]) in the digital validation and substantial intra-rater (ICC: 0.79 [95% CI: 0.75-0.82]) and inter-rater agreements (ICC: 0.75 [95% CI: 0.68-0.81] and ICC: 0.67 [95% CI: 0.54-0.77]) in the live validation. CONCLUSION: The created scale to assess dorsal hand atrophy has been shown to provide substantial-to-almost perfect agreement in the digital and live validation cycles and reached comparable intra-rater and inter-rater agreement to already published and validated scales. It is expected that the created scale will help physicians and researchers in the assessment of hand atrophy in the clinical and research setting in the future.

Validated 5-point photonumeric scales for the assessment of the periorbital region.

OBJECTIVE: The objective of this investigation was to create and validate 5-point photonumeric scales for the assessment of dynamic crow's feet, static crow's feet, and infraorbital hollows. MATERIAL AND METHODS: Three novel 5-point photonumeric scales were created by a medical team. A total of 12 raters from all over the world performed a digital validation, and a total of 5 raters a live validation of the created scale. RESULTS: The statistical analysis revealed almost perfect intra-rater and inter-rater reliability in the digital validation of the scales for the assessment of static and dynamic crow's feet as well as infraorbital hollows. In the live validation, both crow's feet scales showed almost perfect intra-rater reliability, while the Croma Infraorbital Hollow Assessment Scale showed substantial intra-rater reliability. Inter-rater reliability was substantial for all three scales in the live validation. All three scales, the Croma Dynamic Crow's Feet Assessment Scale, Croma Static Crow's Feet Assessment Scale, and Croma Infraorbital Hollow Assessment Scale, were validated digitally and in a live setting. CONCLUSION: The created scales to assess infraorbital hollowing, dynamic and static crow's feet have been shown to provide substantial to almost perfect agreement in the digital and live validation and can thus be considered as helpful tools in the clinical and research setting. While technical methods and appliances to assess the degrees of severity of age-dependent features are advancing, validated scales are of great importance due to their ease of use and, as shown by the validations, reliability, and reproducibility.

Validated 5-point photonumeric scales for the assessment of the jowls and chin.

OBJECTIVE: The objective of this investigation was to create and to examine the reproducibility and validity of 5-point photonumeric assessment scales that allow objective assessment of chin retrusion and jawline sagging using a digital and a live validation. MATERIAL AND METHODS: Two new 5-point photonumeric scales created to assess chin projection and jawline sagging were validated by 12 experts in a digital validation and by 5 experts in a live validation setting. Intra-rater agreement and inter-rater agreement were assessed. RESULTS: For the digital validation, an almost perfect intra-rater (Kappa: 0.89 [95% CI: 0.86-0.91]) and almost perfect inter-rater agreement in both sessions (Kappa: 0.80 [95% CI: 0.74-0.86] and 0.80 [95% CI: 0.74-0.86]) was achieved for the Croma Chin Projection Assessment Scale, while intra-rater agreement (Kappa: 0.88 [95% CI: 0.85-0.91]) was almost perfect for the Croma Jawline Sagging Assessment Scale and inter-rater agreement being substantial in the first session (Kappa: 0.76 [95% CI: 0.71-0.81]) and almost perfect in the second session (Kappa: 0.81 [95%CI: 0.76-0.85]). For the live validation, intra-rater agreement was almost perfect for the Croma Chin Projection Assessment Scale (Kappa: 0.82 [95%CI: 0.74-0.90]) and the Croma Jawline Sagging Assessment Scale (Kappa: 0.83 [95%CI: 0.77-0.89]), while inter-rater agreement was substantial in both sessions for both scales. CONCLUSION: The created chin and jawline photonumeric grading scales are valid and reliable tools for assessing chin projection and jawline sagging. The scales will be of value for standardized chin evaluation and quantifying outcomes in clinical research and daily practice.

Customized Treatment Using Microfocused Ultrasound with Visualization for Optimized Patient Outcomes: A Review of Skin-tightening Energy Technologies and a Pan-Asian Adaptation of the Expert Panel's Gold Standard Consensus.

BACKGROUND: Noninvasive facial-rejuvenation devices, such as nonablative radiofrequency (RF) and laser-assisted technology, are increasingly replacing higher-risk surgeries for face and body skin laxity. OBJECTIVE: We sought to review published information on noninvasive energy device safety and efficacy in aesthetic skin tightening, compare these with our experiences in Asian patients, and disseminate a consensus for optimizing microfocused ultrasound with visualization (MFU-V) in Asian patients. METHODS: A broad, nonexhaustive, nonsystematic literature search of published studies indexed in PubMed was performed to compare selected energy technologies to MFU-V for noninvasive face and body skin tightening, in particular, among Asian patients. This was supplemented with internal documents to provide evidence and support arguments if no peer-reviewed data were available. RESULTS: We highlighted the differences between devices and platforms and identified factors requiring attention and caution. Due to the increase in new devices lacking strong supporting clinical evidence of both safety and efficacy in Asia, it is necessary to convene physicians with substantial experience in MFU-V and devise a consensus on Asian patient selection, treatment planning, and customization. CONCLUSION: Many platforms duplicate or claim similar technologies, efficacy, or safety without significant peer-reviewed scientific or clinical evidence. We showed that MFU-V satisfies this clinical imperative. Further, the patented DeepSEE® technology allows users to noninvasively "see" through the skin to ensure treatment precision, facilitate optimal skin lifting and tightening, and enhance patient comfort and safety. Therefore, we believe that MFU-V is the gold standard for nonsurgical lifting and skin tightening.

Case Report: The role of intradermal micro-droplet hyaluronic acid injection in the correction of filler nodules complication.

Filler injection has been widely used as a non-surgical intervention for skin rejuvenation and augmentation for the past decade. Hyaluronic acid (HA) is considered the most common treated material with high safety profile. Various mechanisms, including promoting collagen synthesis are postulated the efficacy of this powerful skin rejuvenation. The greater number of its used, the more complications were seen. Among the non-vascular complications from filler injection, the most frequent one is nodule formation. It could occur as early or late onset even with HA injection. One of the causes of these nodule formation is from poor injection technique leading to visible skin beads and lumps. The current treatments of these filler side effects mainly aim to remove or reduce excessive or displaced filler product. To the best of our knowledge, there has been no report of using the intradermal injection of the micro-droplet HA to correct filler nodule and simultaneously revitalize the skin quality. This novel treatment technique could be a safe alternative for nodule formation correction.

Delayed Inflammatory Reactions to Hyaluronic Acid Fillers: A Literature Review and Proposed Treatment Algorithm.

BACKGROUND AND OBJECTIVES: There is a wide diversity of opinions regarding the management of delayed inflammatory reactions (DIRs) secondary to hyaluronic acid (HA)-based fillers. The plethora of approaches has led the authors to conduct a review regarding management and treatment of DIRs as well as establish therapeutic guidelines for this purpose. MATERIALS AND METHODS: A review of the literature was performed through databases such as PubMed using keywords including HA-fillers and complications, delayed HA filler sequelae and therapy, soft tissue and dermal filler reactions and management. Additionally, a survey comprised of questions regarding the management and treatment of DIRs was sent to 18 physicians highly experienced with soft-tissue filler injections in 10 countries. Their answers and recommendations were analyzed and debated amongst these panelists. RESULTS: Sixteen panelists favored antibiotic therapy as first-line treatment for DIRs, specifically dual antibiotic therapy consisting of a fluoroquinolone along with a tetracycline or macrolide for a period of 3-6 weeks. The majority refrained from the use of intralesional (IL) or systemic steroids except in the case of disfiguring or recalcitrant reactions. IL hyaluronidase was recommended by 13 panelists; however, some preferred a watchful waiting approach for a period of 48 hours to 2 weeks prior to IL hyaluronidase, and in cases where antibiotics did not lead to improvement. CONCLUSION: A consensus was reached and summarized to propose a clear, easy-to-follow, stepwise algorithm for the treatment of DIRs.

The six different injection techniques for the temple relevant for soft tissue filler augmentation procedures - Clinical anatomy and danger zones.

OBJECTIVE: The most promising facial region for inducing pan-facial effects is the temporal region. The temple displays signs of facial aging itself which include temporal volume loss and increased visibility of the temporal crest, the temporal vasculature, the lateral orbital rim, and the upper zygomatic arch. The objective of this article is to provide a detailed review of temple anatomy pertaining to routinely performed temporal injection techniques, their expected esthetic outcomes as well as the intendant advantages, disadvantages, and procedure pearls. MATERIALS AND METHODS: This narrative review is based on the clinical experience of the authors treating the temporal region for esthetic purposes. The postulated outcome of each technique was observed during the routine clinical practice of the authors. RESULTS: The temporal region is based on a bony platform consisting of the parietal, frontal, sphenoid, and temporal bones. The overlying soft tissues are arranged in layers which contain the temporal neurovascular structures. The temporal soft tissues consist of 10 parallel layers which vary in their thickness depending on age-related influences. Six different techniques will be addressed, which include subdermal and interfascial techniques for volumizing, low and high supraperiosteal techniques for volumizing, and supraauricular and temporal lifting techniques. CONCLUSION: This narrative provides a detailed anatomic overview of the temporal region and describes each commonly performed injection technique with respect to anatomy, esthetic outcome, as well as potential pearls and pitfalls. It is hoped that the description contained herein may guide esthetic practitioners toward safer and more natural outcomes when treating the face.

Platelet-rich plasma treatment for melasma: A pilot study.

BACKGROUND: Melasma treatments have varying success and are associated with some complications. AIMS: To assess the effectiveness of platelet-rich plasma (PRP) treatment for melasma. METHODS: Ten female patients with bilateral mixed-type melasma were enrolled in our randomized, split-face, single-blinded prospective trial. Over 4 treatment sessions that each took place every 2 weeks, PRP was injected intradermally on one side of the face (PRP condition) and normal saline on the other (control condition). PRP was prepared by using the YCELLBIO Kit® . Outcomes were evaluated with the modified Melasma Area and Severity Index (mMASI), Mexameter® , and Antera® 3D. Patient satisfaction was also assessed at baseline, at 2, 4, and 6 weeks, and 1 month after treatment completion. RESULTS: mMASI score and Antera® 3D-assessed melanin levels show significant improvement in the PRP condition than control condition between baseline and week 6, while patient satisfaction significantly increased over time. However, Mexameter® -assessed erythema and melanin indices did not significantly differ between the control and PRP conditions, though there was a trend toward reduced pigmentation in the latter. Finally, side effects of treatment were mild and resolved spontaneously within a few days. CONCLUSION: This is the first randomized, placebo-controlled trial study using PRP for treatment of melasma. PRP injection significantly improved melasma within 6 weeks of treatment in terms of mMASI scores, patient satisfaction, and Antera® -assessed melanin levels. Hence, intradermal PRP injection could be used as an alternative or adjuvant therapy for melasma. However, additional trials are needed for more rigorous evaluation of its long-term efficacy and safety.

Validated Assessment Scales for the Female Asian Calf.

BACKGROUND: Clinical photonumeric scales have been developed and validated to objectively measure the effectiveness of aesthetic treatments in specific anatomical areas; however, these are based on the typical features of Caucasian patients. No clinical scale for Asian calf appearance currently exists. OBJECTIVE: To develop and validate a calf assessment scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed calf images of female Asian subjects (N = 35) viewed from behind with feet flat on the floor (at rest) and on tiptoes (dynamic). Images were rated from 0 (very slim, linear profile) to 4 (very severe convex profile). RESULTS: Inter-rater and intra-rater reliability were "substantial" (≥0.6, intraclass correlation coefficient [ICC] and weighted kappa) for the calf-at rest, calf-dynamic, and calf summary score. Reliability was "substantial" for calf-at rest and calf-dynamic (≥0.6, ICC and weighted kappa) and "almost perfect" (0.85) for the calf summary score. BMI and calf circumference were highly correlated with scale ratings, and calf circumference was a significant predictor. CONCLUSION: This new photonumeric assessment scale has value for assessing the female Asian calf, providing a standardized measure of calf appearance in clinical practice and clinical research settings.

A Validated Assessment Scale for Asian Chin Projection.

BACKGROUND: As the number of different aesthetic treatments increase, numerous photonumeric assessment scales have been developed and validated to measure the effectiveness of these new treatments and techniques. Photonumeric rating scales have been developed to objectively assess improvements in anatomical areas; however, these have been based on the features of Caucasian patients. OBJECTIVE: To develop and validate a Chin Projection Scale for use in the female Asian patient population. METHODS AND MATERIALS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial views of 50 Asian subjects and also estimated their age and the aesthetic treatment effort required for each subject. Chin projection was rated on a scale from 0 (optimal) to 4 (very severely receding). RESULTS: Inter-rater reliability was 0.80 (substantial) for Validation Session 1 and 0.83 (almost perfect) for Validation Session 2. The results for Estimated Age and Estimated Treatment Effort were essentially the same. CONCLUSION: This study demonstrated the validity of the first photonumeric assessment scale for assessing the appearance of the female Asian chin. This new scale will provide a standardized measure of chin projection for Asian patients in clinical practice and clinical research settings.

Validation of a Photonumeric Assessment Scale for Grading the Slope of the Asian Forehead.

BACKGROUND: As the number of aesthetic treatments has grown, so have the number of photonumeric assessment scales used to compare the effectiveness of these aesthetic treatments in specific anatomical areas; however, these are primarily based on Caucasian features. OBJECTIVE: To assess the validity of the first aesthetic scale for assessing the slope of the Asian forehead. A secondary objective was to correlate this scale with subject demographics and baseline characteristics. METHODS: During 2 validation sessions, 13 raters assessed full frontal and lateral facial images of female (n = 28; 56.0%) and male (n = 22; 44%) subjects. For each subject, the severity of forehead sloping was graded from 0 (convex forehead, optimal forehead volume) to 4 (concave forehead, very severe sloping). Raters also assessed the age of each subject and the estimated aesthetic treatment effort required to treat each subject. RESULTS: Inter-rater reliability was "substantial" with scores of 0.67 and 0.68 for the first and second validation sessions, indicating high reliability. BMI showed the highest correlation with the scale and was a significant predictor in the final regression model. CONCLUSION: This photonumeric assessment scale will be useful for assessing the slope of the Asian forehead in both clinical and research settings.

The study of histological changes of the arterial vascular structure after hyaluronidase exposure.

BACKGROUND: Hyaluronic acid (HA) filler injection is commonly used for soft tissue augmentation. Uncommon but serious complication from filler injection is vascular occlusion. Hyaluronidase enzyme can be used to dissolve HA filler. Evidence demonstrates that hyaluronidase can penetrate through vessel wall after incubation. However, studies regarding effects of hyaluronidase on vessel wall after intraluminal injection are limited. The objective of this study is to evaluate histological changes of postmortem arteries after intravascular injection of hyaluronidase enzyme. METHODS: This was an ex vivo experiment including arterial specimens from four cadavers which recently deceased within 24 hours. All vessels were examined at baseline and then were divided into two groups. The first was the control group treated with normal saline and the second hyaluronidase-treated group was intra-luminally injected with hyaluronidase enzyme (1500 IU/mL). Gross and histological examination was performed at baseline, 30-minutes and 4 hours after. RESULTS: Gross examination of vessels revealed no significant difference at baseline, 30 minutes and 4 hours after injection in both groups. Histological examinations at baseline and 30 minutes after injection revealed viable endothelial cells in both experimental and NSS-control group. At 4 hours after hyaluronidase injection, two of the four arterial specimens had degeneration of endothelial cell, and one artery showed separation of tunica intima from tunica media. CONCLUSION: There were endothelial injuries in the arterial specimens after intravascular concentrated hyaluronidase injection.