Combined Forehead and Temporal Lifting: An Innovative Approach to Lanluma V Treatment.

BACKGROUND: Excess skin laxity over the upper face can contribute to aging over the mid and lower face. We describe an innovative nonsurgical technique of facial rejuvenation by injecting Lanluma V over the scalp's vertex and parietal regions. Lanluma V is a poly-l-lactic acid (PLLA)-based collagen stimulator which contains 210 mg of PLLA, distributed by Sinclair Pharmaceutical. Lanluma V works by stimulating collagen regeneration to provide support for the treated area. METHOD: A retrospective review of 12 consecutive patients treated with Lanluma V over the vertex and parietal regions of the scalp to achieve nonsurgical rejuvenation of the upper, middle, and lower thirds of the face was conducted. The patients were treated over two sessions, 1 month apart. The treated patients were reviewed by a plastic surgeon and rated under the Global Aesthetic Improvement Scale (GAIS) 6 months after treatment. RESULTS: The patients achieved an overall average of 1.16 grade improvement in GAIS. The average follow-up period is 6 months following completion of treatment. There was no reported incidence of non-scarring alopecia, which has been reported in the use of other, more viscous fillers such as calcium hydroxyapatite or high G' hyaluronic acid. CONCLUSION: This innovative method of combined forehead and temporal lifting with Lanluma V allows for an average 1.16 grade improvement in GAIS. There is no reported incidence of non-scarring alopecia, which has been associated with other fillers.

The Type I+ Forehead in Facial Feminization Surgery.

BACKGROUND: Feminizing fronto-orbital reconstruction involves one of four possibilities with the Ousterhout Type III anterior table frontal sinus osteotomy and setback performed in most patients while the Type I reduction recontouring is reserved for patients without frontal sinuses or thick anterior tables. However, patients with frontal sinuses and either a moderately thick anterior table or a shallow frontal sinus in the sagittal plane represent an intermediate morphology. For such morphologies, we introduce the novel Type I+ fronto-orbital reconstruction technique, consisting of frontal bone recontouring supplemented with anterior table reconstruction and split cranial bone graft. METHODS: Transgender and gender non-conforming patients who underwent Type I+ or Type III feminizing fronto-orbital reconstruction (2019-2023) were included for retrospective review and comparison of techniques. RESULTS: In the 123 patients (mean age 32.2 ± 9.5 years) included, 6.5% underwent Type I+ and 94.5% underwent Type III feminizing fronto-orbital reconstruction. Morphologically, Type I+ patients displayed a shallower frontal sinus compared to Type III patients (median anterior to posterior table depth 4.1[interquartile range, IQR, 1.1-5.0] versus 9.8[IQR 7.5-12.0]mm, p<0.001). At the maximum prominence, Type I+ patients also demonstrated thicker anterior tables compared to Type III patients (median 6.6[IQR 5.0-8.8] versus 2.2[IQR 0.4-4.7]mm, p=0.001). Patients receiving Type I+ procedures underwent an anterior table reduction of 2.7±1.2mm versus 4.2 ± 1.2mm for Type III procedures in the sagittal plane (p=0.002). CONCLUSIONS: The current work introduces a novel solution to an intermediate frontal sinus phenotype for gender-affirming facial feminization surgery. 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 .

Soft-tissue complications after facial feminization bone surgery.

The soft tissues have a considerable impact on whether the results of facial feminization surgery are favorable. Complications or suboptimal results related to the soft tissue may be due to poor choice of surgical approach, improper execution of the surgical technique, a lack of assistance when resuspending the soft tissues during closure, or deficient readaptation of the overlying soft tissue to the new bone contour. This article identifies the possible poor soft-tissue outcomes that may occur after facial feminization bone surgery, describing strategies to prevent them and treatment alternatives.

Precise Needle and Cannula Placement in the Forehead During Aesthetic Procedures: Can Device and Angulation Influence Accuracy? A Fresh Frozen Specimen Study.

INTRODUCTION: Myomodulation is a technique aimed at enhancing the dynamics of muscle contraction and relaxation through methods like hyaluronic acid (HA) injection. Achieving optimal outcomes depends on the precise placement of the injected product within the targeted anatomical plane. This is particularly important in the forehead, an area with elevated vascular risk. The selected treatment techniques must ensure both efficacy and safety. This study aims to assess the anatomical precision of HA injections in the forehead using different techniques and devices. METHODS: Four fresh frozen specimens were injected with HA by five experienced board-certified plastic surgeons using three different techniques/devices: (1) a 50 mm, 22G microcannula; (2) a 13 mm, 27G needle with the bevel down at a 45-degree angle; and (3) the same needle positioned at a 90-degree angle. Ultrasound analysis was used to evaluate the precision of each approach. RESULTS: Both the cannula technique and the needle technique with the bevel down at a 45-degree angle consistently delivered the filler to the supraperiosteal layer in 100% of cases without spreading. However, the 90-degree needle technique, despite correct placement on the periosteum, resulted in filler dispersion across multiple layers. CONCLUSION: The accuracy of filler placement in the forehead is influenced by the choice of device and its angulation. It is recommended to use a cannula with the entry point at the frontalis crest or a needle angled at 45 degrees to the skin. The use of a needle at a 90-degree angle should be avoided to ensure precise placement and avoid filler migration. NO LEVEL ASSIGNED: 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 .

Case Report: A new variant of the forehead flap for subtotal nose reconstruction in a single stage: the dragonfly flap.

Background: The forehead flap is probably the most used method for nose reconstruction after cancer resection. During the past century, this technique has been continuously refined to achieve better functional and aesthetic outcomes. Different variations have been described, with the original technique being modified based on tissue loss, the layer to be replaced, and the management of the donor area. Methods: We propose a new and innovative version of the forehead flap in which both the forehead skin and the frontal muscle are harvested simultaneously using the same vascular pedicle. Partially separating the two layers allows muscle tissue to replace the inner layer and cover the nasal septum framework, while the skin will replace the outer layer. The nostrils are reconstructed simultaneously using bilateral hinge-over lining skin flaps harvested from the nasal folds. Results: Step by step, a schematic illustration of the technique is given, followed by a complete report on a successful total nose reconstruction case. Conclusions: Despite the increasing number of techniques which have been introduced to achieve full reconstruction of the nose, including microsurgical tissue transfer, the simultaneous replacement of both the inner and outer layers continues to be an issue for the plastic surgeon. In this article, we suggest a solution for total nose reconstruction in a single-stage procedure.

Best Practices for the Use of High-Frequency Ultrasound to Guide Aesthetic Filler Injections-Part 1: Upper Third of the Face.

Filler injections in the upper face pose significant challenges due to its complex anatomy and proximity to vascular structures. High-frequency Doppler ultrasound offers real-time visualization of facial anatomy, improving both safety and aesthetic outcomes. This paper presents a detailed overview of the ultrasonographic anatomy of the temples, forehead, and glabella, along with reproducible, ultrasound-guided filler injection techniques for these areas. We use two scanning techniques previously described: "scan before injecting" and "scan while injecting", applicable to subdermal, interfascial, and supraperiosteal planes in the temporal region, as well as the glabella, forehead, and supraorbital region. Ultrasound guidance for filler injections in the upper face can enhance procedural efficacy and safety. By integrating real-time imaging, practitioners can navigate the intricate vascular anatomy more effectively, thereby minimizing the risk of complications. This study highlights the need for ongoing research and continuous education to further refine these techniques and improve patient outcomes.

Analysis of maxillary teeth and soft tissue profiles among Tibetan and Han Chinese females with facial symmetry for orthodontic treatment planning.

The evaluation of maxillary teeth and soft tissue profiles is a critical component of orthodontic diagnosis and treatment planning. This study aimed to evaluate the correlation between the sagittal position of maxillary anterior teeth and facial profile esthetics among Tibetan and Han Chinese adult females for optimizing orthodontic diagnosis and treatment planning. A total of 100 Tibetan Chinese and 100 Han Chinese adult females with good facial symmetry were recruited. The smiling facial profile images with the maxillary central incisors and forehead in full view were taken based totally on the same standard. The photo measurement and head position were adjusted using the picture-enhancing software. The reference traces associated with forehead inclinations were utilized to assess the anteroposterior (AP) positions of the maxillary central incisors. The results showed that a round forehead was the dominant forehead shape for Tibetan (93%) and Han (55%) Chinese females. In Tibetan females, 85% of the maxillary central incisors were found to be located between the forehead's anterior limit line (the Gall line) and the goal anterior limit line (the Fall line), with 15% located posterior to the Fall line. This distribution manifested a strong association with incisor position and forehead inclination (R2 = 0.742). In Han females, 83% of the maxillary central incisors were located between the Fall line and the Gall line, with 12% posterior to the Fall line and 5% anterior to the Gall line. The positions of the maxillary central incisors exhibited a strong relationship with forehead inclination (R2 = 0.827). The maxillary central incisors were close to the aesthetic line in both ethnic groups, while forehead inclinations were correlated with AP maxillary incisor position. These findings demonstrated that there was a close relationship between the incisor position of Tibetan and Han females with facial symmetry and the forehead FFA factor, indicating a reference in oral hard and soft tissues for optimizing orthodontic diagnosis and treatment planning in terms of facial contour.

Supraperiosteal technique protocol for forehead filling with a mixture of calcium hydroxyapatite and hyaluronic acid: Double-blind, randomized controlled clinical trial.

OBJECTIVE: The current study aims to investigate the safety and efficacy of using calcium hydroxyapatite (CaHA) versus CaHA associated with hyaluronic acid (HA) for forehead volume replacement and contour restoration without forehead irregularities. METHODS: This interventional study involved 132 participants in a two-arm, parallel, double-blind trial for forehead treatment using the supraperiosteal technique. Group A received CaHA, and Group B received a combination of CaHA and HA as filler materials. Follow-up assessments occurred at 30 and 180 days, incorporating the 5-point Global Aesthetic Improvement Scale (GAIS) and photographic analysis for forehead volume replacement, contour restoration, and without forehead irregularities. Safety assessments included monitoring adverse events, particularly nodules. RESULTS: The study included all 132 enrolled patients who completed the trial. Applying CaHA in combination with HA resulted in a statistically significant improvement in both GAIS scale scores and the reduction of forehead irregularities. The total incidence of nodules was 3.7%. Group A had four times more occurrences of nodules than Group B. Furthermore, Group B exhibited lower rates of forehead irregularities following the treatment compared to Group A. CONCLUSION: The supraperiosteal application of CaHA and HA for forehead treatment demonstrates superior efficacy in addressing signs of aging compared to the isolated use of CaHA.

Patient satisfaction after conservative treatment of anterior wall frontal sinus fractures.

This study aims to determine patient forehead aesthetics satisfaction after conservative treatment of non-dislocated and dislocated anterior wall frontal sinus fractures. Prospectively, patients older than 15 years of age with a frontal sinus fracture, treated conservatively between the period of 2010-2020, were analysed. The Face-Q questionnaire was used to assess patient satisfaction, and the fracture dimensional properties were measured using computed tomography. The results were compared with a matched non-fractured control group. The mean total Face-Q questionnaire score was 114.77 (SD = 17.38) versus 114.23 (SD = 15.23) (research-versus control group, respectively), with a mean difference of 0.55 (SD = 4.85), which was not significant (p = 0.91). The size of impression area did not appear to have a linear relationship with patient satisfaction within the entire population (p = 0.87; r = 0.00). Presence of a scar in the fracture site was a significant predictor of patient satisfaction, contributing to 31% of the entire population's overall score (p = 0.01) and 57% in the dislocated fracture population (p = 0.003). The conservatively treated patients' satisfaction score was comparable to the control group. A higher satisfaction score after a conservative treatment is associated with the absence of a scar on the fracture site, even with dislocations up to 6 mm at the deepest impression point.

[Folded paramedian forehead flap - Surgical technique: About 17 patients]. / Lambeau frontal paramédian plicaturé ­ technique chirurgicale : à propos de 17 patients.

OBJECTIVE: In this article, we present our academic experience with the reconstruction of the dorsum and nasal tip by folded paramedian forehead flap described by F.J. Ménick (LFPP). We take a closer look at the technical aspects of this surgical technique and the aesthetic results at the donor sites. We compare our surgical technique with those reported in the literature. MATERIAL AND METHOD: A monocentric retrospective study was carried out on patients operated on by LFPP for surgical reconstructions of the nasal dorsum and nasal tip between January 2017 and December 2022. In each case, we analysed the typology of the type of substance loss for reconstruction, the type of reconstruction and the aesthetic result of reconstruction. A satisfaction survey on the aesthetic and functional results was sent to patients who had undergone LFPP reconstruction at 6 months post-op. RESULTS: There was no necrosis, even partial in any of the 17 cases of LFPP reconstruction. The average size of the substance loss was 3.5±0.6cm [2.5-5]. The number of aesthetic subunit (SUE) to be reconstructed was 2.6±0.9 [1-4]. The etiologies of substance loss were mainly related to skin tumors, including 58% basal cell carcinoma basal cell carcinoma (n=10), 24% squamous cell carcinoma (n=4), 6% adenoid cystic carcinoma adenoid cystic carcinoma (n=1) and 12% melanoma (n=2). The patients were very satisfied overall, both from a functional point of view with a questionnaire result of 89% (8.94±1.98 [2-10]), aesthetic, with a result of 87% (8.76±1.75 [3-10]). CONCLUSION: Among the various techniques for reconstructing the nasal pyramid, including paramedian 2-stage paramedian forehead flaps combined with a local flap of the internal lining, the technique of reconstruction described by J.F. Menick using a 3-stage paramedian folded flap is the most reliable option for complex nasal reconstructions with low donor-site morbidity.

Fully Endoscopic Resection of Frontal Osteomas.

BACKGROUND: Osteomas are the most common primary bone tumors of the calvaria, with an incidence of less than 0.5%. In skull vault osteomas, the exostotic form that grows from the outer table is more common than the enostotic ones which arise from the inner table and grow intracranially. Osteomas of the forehead are very noticeable and disfiguring; patients usually seek medical advice for cosmetic reasons. Forehead osteomas were traditionally excised via either a direct incision over the lesion using the naturally occurring creases or a conventional bicoronal flap. More recently, endoscopic approaches for excision of forehead osteomas were introduced. The results were very encouraging and the technique was adopted by many groups worldwide yet with many technical variations. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic resection of frontal osteomas. METHODS: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases of forehead osteomas were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS: The surgical technique of the fully endoscopic resection of frontal osteomas was formulated. CONCLUSION: The endoscopic technique has many advantages over the conventional procedures. In our hands, the technique has proven to be less time-consuming, efficient, and minimally invasive with excellent cosmetic results.

Using dermal filler to camouflage forehead osteoma: A case report.

OBJECTIVE: To review the technique and outcomes of using dermal filler to camouflage forehead osteoma, providing a minimally invasive alternative to surgical excision. BACKGROUND: Forehead osteoma, commonly known as a forehead bump or bone spur, can be a cosmetic concern. Surgical excision, while effective, carries risks of scarring and postoperative complications. An innovative approach using dermal filler offers a potential solution. METHODS: A hyaluronic acid­based filler is injected into the deep subcutaneous plane over the bony prominence using a cannula. The fanning technique ensures even distribution of the filler. The procedure's safety, patient selection, and communication between the injector and patient are emphasized to achieve optimal results. RESULTS: The technique provides immediate aesthetic improvement with results that can last up to 12 months, depending on the filler used. While generally safe, potential complications include infections, swelling, asymmetry, and lumpiness. Proper technique, patient selection, and good communication between the injector and patient are critical to achieving optimal outcomes. CONCLUSION: Using dermal filler to camouflage forehead osteoma is a minimally invasive alternative to surgical excision, offering immediate and long­lasting results with minimal downtime and fewer risks. Further studies are needed to refine the technique and optimize outcomes.

Performance Investigation of Somfit Sleep Staging Algorithm.

Purpose: To investigate accuracy of the sleep staging algorithm in a new miniaturized home sleep monitoring device - Compumedics® Somfit. Somfit is attached to patient's forehead and combines channels specified for a pulse arterial tonometry (PAT)-based home sleep apnea testing (HSAT) device with the neurological signals. Somfit sleep staging deep learning algorithm is based on convolutional neural network architecture. Patients and Methods: One hundred and ten participants referred for sleep investigation with suspected or preexisting obstructive sleep apnea (OSA) in need of a review were enrolled into the study involving simultaneous recording of full overnight polysomnography (PSG) and Somfit data. The recordings were conducted at three centers in Australia. The reported statistics include standard measures of agreement between Somfit automatic hypnogram and consensus PSG hypnogram. Results: Overall percent agreement across five sleep stages (N1, N2, N3, REM, and wake) between Somfit automatic and consensus PSG hypnograms was 76.14 (SE: 0.79). The percent agreements between different pairs of sleep technologists' PSG hypnograms varied from 74.36 (1.93) to 85.50 (0.64), with interscorer agreement being greater for scorers from the same sleep laboratory. The estimate of kappa between Somfit and consensus PSG was 0.672 (0.002). Percent agreement for sleep/wake discrimination was 89.30 (0.37). The accuracy of Somfit sleep staging algorithm varied with increasing OSA severity - percent agreement was 79.67 (1.87) for the normal subjects, 77.38 (1.06) for mild OSA, 74.83 (1.79) for moderate OSA and 72.93 (1.68) for severe OSA. Conclusion: Agreement between Somfit and PSG hypnograms was non-inferior to PSG interscorer agreement for a number of scorers, thus confirming acceptability of electrode placement at the center of the forehead. The directions for algorithm improvement include additional arousal detection, integration of motion and oximetry signals and separate inference models for individual sleep stages.

LANMAO sleep recorder versus polysomnography in neonatal EEG recording and sleep analysis.

BACKGROUND: The field of neonatal sleep analysis is burgeoning with devices that purport to offer alternatives to polysomnography (PSG) for monitoring sleep patterns. However, the majority of these devices are limited in their capacity, typically only distinguishing between sleep and wakefulness. This study aims to assess the efficacy of a novel wearable electroencephalographic (EEG) device, the LANMAO Sleep Recorder, in capturing EEG data and analyzing sleep stages, and to compare its performance against the established PSG standard. METHODS: The study involved concurrent sleep monitoring of 34 neonates using both PSG and the LANMAO device. Initially, the study verified the consistency of raw EEG signals captured by the LANMAO device, employing relative spectral power analysis and Pearson correlation coefficients (PCC) for validation. Subsequently, the LANMAO device's integrated automated sleep staging algorithm was evaluated by comparing its output with expert-generated sleep stage classifications. RESULTS: Analysis revealed that the PCC between the relative spectral powers of various frequency bands during different sleep stages ranged from 0.28 to 0.48. Specifically, the correlation for delta waves was recorded at 0.28. The automated sleep staging algorithm of the LANMAO device demonstrated an overall accuracy of 79.60 %, Cohen kappa of 0.65, and F1 Score of 76.93 %. Individual accuracy for Wake at 87.20 %, NREM at 85.70 %, and REM Sleep at 81.30 %. CONCLUSION: While the LANMAO Sleep Recorder's automated sleep staging algorithm necessitates further refinement, the device shows promise in accurately recording neonatal EEG during sleep. Its potential for minimal invasiveness makes it an appealing option for monitoring sleep conditions in newborns, suggesting a novel approach in the field of neonatal sleep analysis.

[Forehead burns]. / Les brûlures du front.

Severe burns on the forehead are rare; well-conducted initial surgical treatment also limits the occurrence of sequelae. Therefore, indications for repairing the forehead arise from complex burns often extending to adjacent units. Repair techniques depend on the location and size of the lesions, associated nearby damage, and the patient's ability to withstand the burden of treatment. Management at the acute stage determines the sequelae; excision-grafting is the standard treatment, but it yields good results only if the fundamental principles of repair are respected: intervention within the 10th and 15th days post-burn, graft harvesting from the cephalic extremity or the upper part of the thorax and arms, and respect for the frontal unit. Sequelae management follows the same imperatives and typically requires skin expansion: front expansion for skin flaps if enough frontal skin is still available, upper thorax expansion for full thickness skin grafts if the frontal scar is too extensive. However, the excellent results obtained should not conceal the significant constraints associated with skin expansion.

[The useful forehead, the impaired forehead, but the forehead repaired!] / Le front utilisé, le front traumatisé, mais le front réparé !

The forehead, although sometimes hidden by a fringe, is a major region of the face revealing many expressions such as fatigue, surprise, concern, anger… In reconstructive surgery, the forehead is frequently used as a donor site. This article looks at three aspects: the used, traumatised and repaired forehead. The forehead, with its high-quality hairless skin and proximity to the noble structures of the face, is a central donor site. The forehead flap is commonly used for nasal reconstruction, with several variations to meet different needs. Other pedicled flaps, such as the supra-eyebrow flap and the crane flaps, are also used for various facial reconstructions. The forehead can be affected by trauma, burns, vascular lesions and skin tumours. We are particularly interested "en coup de sabre" linear scleroderma, an autoimmune disease that causes cutaneous and subcutaneous fibrosis, sometimes associated with Parry Romberg syndrome. In addition, lesions of the temporal branch of the facial nerve lead to muscular paralysis, affecting the aesthetics and function of the frontal region. Precise knowledge of the anatomy of the nerve pathway is crucial to avoid iatrogenic lesions. The entire arsenal of reconstructive surgery is useful for repairing the forehead. Controlled wound healing, tension suturing and the use of local flaps are key techniques for repairing the forehead. Tension sutures are particularly effective for small losses of substance, and their orientation depends on the location. Advancement, rotation and transposition flaps are used for larger losses of substance. Skin grafts, although less aesthetic, are sometimes necessary. Skin expansion, although socially restrictive, is used to treat congenital giant nevi and increase the surface area of forehead flaps.

[Forehead injections: Anatomy, technics, products]. / Les injections du front : anatomie, techniques, produits.

Knowledge of anatomy not only allows optimal treatment and therefore full satisfaction of our patients, but is also fundamental in the prevention of complications. A thorough understanding of aging allows for effective treatments, as most patients demand a natural result, removing the inevitable signs of aging, which can only be understood by considering their aging. Facial aging is a natural but complex multifactorial process, particularly for the forehead. In this article, we will focus on botulinum toxin as well as fillers in aging.

[Anatomy of the frontal region]. / Anatomie de la région frontale.

The forehead is an anatomic region located between the frontal hairline cranially, the eyebrow and the glabella caudally, and the anterior border of the temporal fossa laterally on both sides. Its vertical situation, due to the telencephalon growth, is specific of the human species. From surface to deep planes, the skin and sub-cutaneous fat pads are described first. The muscular plane is constituted of the frontal muscles elevators of the forehead and the eyebrow, and the depressors which are the procerus and orbicularis oculi muscles superficially, the depressor supercilii muscle, and the corrugator supercilii in a deep plane. The galea aponeurotica, located deep to the frontal muscles, is a fibrous lamina on which the muscles of the skull insert. There is a sexual dimorphism of the frontal bone. The male forehead has extensive supraorbital bossing, and above this there is often a flat area, in teh femalethe supraorbital bossing is often nonexistent and above, there is a continous mild curvature. Blood supply to the forehead is given by an anterior pedicle constituted by the supraorbital and supratrochlear vessels and a lateral pedicle made of the anterior branches from the superficial temporal vessels. The sensory innervation of the forehead is given by the ophtalmic nerve which divides in frontal, nasociliar and lacrymal nerves. The motor innervation is given by the temporal ramus of the facial nerve which passes laterally to the zygomatic arch, and gives the innervation of the frontal, corrugator supercilii and procerus muscles.