Effect of facial and nasolabial asymmetry on perceived facial esthetics in children with non-syndromic cleft lip and palate.

OBJECTIVE: The aim of the present study was to objectively assess the degree of residual facial asymmetry after primary treatment of non-syndromic unilateral cleft lip and palate (UCLP) in children and to correlate it with subjective ratings of facial appearance. MATERIALS AND METHODS: Stereophotometry was used to record the faces of 89 children with UCLP for comparison of cleft and non-cleft sides up to 5 years after primary cleft closure. Root mean square values were calculated to measure the difference between the shape of cleft and non-cleft sides of the face and were compared to controls without a cleft lip. The Asher-McDade Aesthetic Index (AMAI) was used for subjective rating of the nasolabial area through 12 laypersons. RESULTS: Children with a cleft lip (CL) showed no significant difference in RMS values compared to controls. Significant differences occurred when the evaluation was limited to the nasolabial area, however only in patients with cleft lip alveolus (CLA) and cleft lip palate (CLAP)(p < 0.001). In contrast, subjective ratings showed significantly higher values for all three cleft severity groups (CL, CLA, CLAP) compared to controls (p < 0.001). There was a non-linear correlation between the RMS (root mean square) values and the AMAI score. CONCLUSIONS: Even non-significant discrete objective deviations from facial symmetry in children after primary closure of UCLP are vigilantly registered in subjective ratings and implemented in the judgement of facial appearance. CLINICAL RELEVANCE: 3D stereophotometry is a usefull tool in monitoring asymmetry in patients with a cleft.

What comes first: teeth or face? Recommendations for an interdisciplinary collaboration between facial esthetic surgery and dentistry.

OBJECTIVE: The aim of the present study was to provide recommendations in order to facilitate communication between dental professionals and surgeons who are collaborating in the field of dentofacial esthetics. CLINICAL CONSIDERATIONS: Smile esthetics are beyond the scope, both of the surgeons who are collaborating with facial esthetics and of the dentists, as a wide range of treatment options from both sides is available. It can be difficult for the surgeon or the dentist that first comes in contact with the patient to conduct an individualized global treatment plan, in order to find out how the various phases of the treatment can be sequenced, as a workflow for an efficient interaction between facial surgery and dentistry still does not exist in the scientific literature. CONCLUSIONS: Facial cosmetic procedures and dental treatment have to be planned as individual elements of the whole dentofacial esthetic rehabilitation. The treatment has to be initiated with the design of the smile and the intraoral mock-up, followed by the required surgical interventions, and to be finished with the delivery of the definitive dental restoration. CLINICAL SIGNIFICANCE: Dentofacial esthetics require comprehensive communication between surgeons and dentists. Following the proposed recommendations, an individualized interdisciplinary treatment plan can be conducted, defining the role of each specialty.

3-Dimensional Evaluation of Two PNAM Techniques (Modified Grayson & AlignerNAM) on Facial Soft Tissue Morphology: A Randomised Clinical Trial.

OBJECTIVE: Evaluate facial changes after Presurgical Naso-Alveolar Molding (PNAM) in unilateral cleft lip and palate (UCLP) patients treated with Modified Grayson Technique and AlignerNAM (with DynaCleft nasal elevator) using a 3D facial scan. DESIGN: Randomised clinical trial. SETTING: Institutional study. Participants: 20 UCLP patients allocated to two groups (10 patients each). INTERVENTIONS: Group A patients underwent PNAM with Modified Grayson Technique and Group B patients underwent AlignerNAM (with DynaCleft nasal elevator). Their 3D facial scans were obtained by using an iOSbased application (Bellus3D FaceApp) mounted on a novel frame. These .stl files were analysed using 3D software (GOM INSPECT) at three-time intervals; before intervention (T0), after intervention (T1) and one month after lip repair surgery (T2). MAIN OUTCOME MEASURE(S): Changes in facial and nasolabial morphology. RESULTS: Both techniques brought significant improvement in the columellar length, nasal tip projection, columella angle, nasal tip angle and a significant reduction in cleft width. At T1, a statistically significant difference in angular and linear measurements was present in both groups. At T2, no statistically significant difference in linear parameters was observed between the two groups except for the outer lateral height of the non-cleft side, basal lateral height of the non-cleft side, and philtrum width. Similar pattern was observed in angular measurements with no statistically significant difference between the two groups except in nasolabial angle, anterior nasal base triangle III, and anterior nasal root triangle. CONCLUSIONS: Aligner NAM and Modified Grayson technique are equally effective PNAM methods with similar clinical results in nasolabial morphology after lip repair surgery.

A Longitudinal Investigation of Nasolabial Changes With and Without Revision Surgery in Patients with Non-Syndromic Unilateral Cleft Lip and Palate.

OBJECTIVE: To determine a baseline of anticipated change in nasolabial appearance following primary repair of unilateral cleft lip/palate and evaluate the degree to which revision surgery improves nasolabial appearance. DESIGN: Retrospective chart review. SETTING: Patients treated at the Lancaster Cleft Palate Clinic interdisciplinary clinic. PATIENTS: Twenty-three patients with complete unilateral cleft lip and palate who underwent primary surgical repair and 19 additional patients who underwent subsequent revision surgery were included. INTERVENTIONS: Patients in the non-revision group underwent a Tennison-Randall triangular flap lip repair at 3mo. Patients in the revision group underwent a modification of the Nakajima straight-line repair after primary Tennison-Randall triangular flap lip repair at an average age of 141mo. MAIN OUTCOME MEASURES: A modification of the Asher-McDade Aesthetic Index was utilized to evaluate Nasolabial Frontal (NLF), Nasolabial Profile (NLP), Vermillion Border (VB), and total change in appearance. Scores for patients in the revision group were evaluated before and after revision while appearance for patients without revision was evaluated at 3 distinct ages. Scores were averaged across time-points and inter-rater reliability was assessed. RESULTS: Nasolabial appearance in the non-revision sample did not change significantly over time, except for nasal profile. Scores improved after revision surgery - NLP: 3.48 to 2.97, (p = 0.001); NLF: 3.50 to 2.95 (p = 0.001); and Total Nasolabial Score: 3.29 to 3.01 (p = 0.004), with no significant change in VB. CONCLUSION: Decisions regarding need for nasolabial revision surgery may be made as early as 5yo with successful outcomes following secondary surgery improving appearance except for vermillion border appearance.

Use of Hyaluronic Acid Filler in Patients with Secondary Cleft Lip Deformity.

METHODS: Retrospective case note review was undertaken of all patients treated in the clinic over a two-year period. RESULTS: 20 patients underwent HA filler injections to the upper lip 26 times. Most were female (F:M = 3:1) and patients were aged 18-58 years. Most patients had a unilateral cleft lip +/- palate (n = 13, 65%). The most common indication was to address upper lip volume (n = 13, 65%). Other indications included vermillion notch (n = 5, 25%), cupid bow peak height asymmetry (n = 4, 20%), scar asymmetry (n = 1, 5%) and nasal sill flattening (n = 1, 5%). Small volumes of filler were used with an average of 0.34 ml (range 0.05-1.2 ml). There were no complications and one patient reported pruritis post procedure. CONCLUSIONS: HA filler is a safe and reliable treatment for certain aspects of asymmetry following cleft lip repair. It can be used to address volume deficiency and asymmetry, cupid bow peak height discrepancies and a vermillion notch for patients who do not want surgery. Injection of HA to the lips can be performed easily, with appropriate training, in the outpatient setting.

Multidisciplinary Aesthetic Management of a Dentition in a Patient with Cleft Lip and Palate with a High Smile Line: A Clinical Report.

The aesthetic management of a case involving a high smile line in a patient with a cleft lip and palate can be difficult. In this report, we look at a complex case of a patient with a unilateral cleft lip and palate which required a multidisciplinary approach involving crown lengthening, extraction of a maxillary right central incisor and fabrication of a 4-unit fixed partial denture to replace this tooth and the adjacent absent maxillary right lateral incisor with use of gingival porcelain in order to improve the aesthetics of the patient's smile.

Evaluation of a Novel Objective Method for The Assessment of Nasal Symmetry Among Patients with Unilateral Cleft Lip.

OBJECTIVE: This is a cross sectional study aimed to asses novel semi objectve compter assisted method to asses the symmetry amog unilateral cleft lip patients. DESIGN: using Standard inferior view nose photos that were uploaded to Digimizer© Version 4.6.1 (2005-2016 MedCalc Software) Image Analysis, symmetry percentage was calculated and compared between cleft and non-cleft neonates. This method was compared to two subjective methods of rating symmetry. SETTING: This a cross sectional pilot study performed in the Univresity Medical Center using standard inferior views of unilateral cleft patients which were compared to non-cleft neonates. PATIENTS: Photographs of 71 neonates with unilateral complete and incomplete cleft lip and 30 neonates without facial cleft, which were born at the university medical center, Beer Sheba, Israel, were analyzed in a standard manner to determine nasal symmetry. MAIN MEASURES: the novel method proposed produced a nominal value for percentage of symmetry. RESULTS: Using Pearson's correlation test we found intra-rater reliability of 91.2% (p < 0.001) and Inter-rater reliability of 82.9% (p < 0.001). The analysis correlated with the surgeons subjective scores in both the numerical ranking method at 73% (p < 0.001) and 72.6% (p < 0.001) and the Ordinal ranking method at 87.6% (p < 0.001) and 77.7% (p < 0.001). The ability of the method to discriminate healthy from Cleft Lip patients overall was 92.3% With high sensitivity and specificity. CONCLUSIONS: This method accurately distinguishes healthy patients from cleft lip patients. We have achieved High levels of inter and intra-rater reliability. Significant correlations were found between our semiobjective method and the subjective scores.

Drainage tube use for the reduction of postoperative ecchymosis in rhinoplasty.

BACKGROUND: Postoperative healing after rhinoplasty can have a negative impact on patient quality of life. OBJECTIVES: In our study, we aimed to reduce postoperative edema and ecchymosis by applying a minidrain system. We evaluated this intervention's benefit on postoperative morbidity by observing the patient with left and right sides, intervention side and control side respectively. METHODS: All surgeries were performed using a piezo device with an open technique septorhinoplasty. We only used a left-sided minidrain system through the osteotomy lines just in front of the piriform aperture for all patients with no other intervention on the right side of the same patient. RESULTS: Use of a drain on the left side was associated with a statistically significant decrease in ecchymosis at postoperative day 7 (P<0.05). CONCLUSIONS: We found that using a minidrain system through internal osteotomy lines was effective in reducing the amount of ecchymosis by day seven after surgery.

Mathematical Tooth Proportions: A Systematic Review.

PURPOSE: The aim of this systematic review was to evaluate and compare three commonly used proportions that include the golden proportion, golden percentage, and Recurring Esthetic Dental (RED) proportion to identify which of the mathematical formulas, if any, can be used to provide predictable and repeatable esthetic clinical outcomes. METHODS: A comprehensive search of electronic databases that included EBSCO, ProQuest, SCOPUS, Science Direct, Wiley, Google Scholar and PubMed was conducted using the terms: "golden proportion," "golden percentage," and "Recurring Esthetic Dental (RED) proportions" alone or in concurrence with one or both ensuing terms: "tooth proportions" and "esthetic tooth proportions." In addition, the following journals were hand searched for relevant articles: Journal of Prosthodontics, Journal of Prosthetic Dentistry and Journal of Esthetic and Restorative Dentistry. Related citations were also considered. RESULTS: Tooth proportions varied substantially in the natural dentition. No studies revealed findings that supported the use of one mathematical formula to predict esthetic success. The golden proportion is present between the central to lateral incisor in some cases, but rarely between the lateral incisor and the canine. When compared to the other proportions, the golden percentage provided better starting points for tooth shape and size, but only when values were adjusted to consider other factors such as ethnicity and/or facial proportions. CONCLUSION: Mathematical formulas did not provide consistent results that would allow for their use as a standardized guide for esthetically pleasing smiles. Although the golden percentage may be a good starting point if the percentages are adjusted on a case-by-case basis, generalized esthetic ideals cannot be determined by a mathematical formula and are open to interpretation by both the clinician and the patient.

Concentrated growth factors gel activated with ozone for facial aesthetics purpose after granuloma removal: a case report.

The aim of this case report was to present the management of the aesthetic consequences of the treatment for granuloma removal in the zygomatic region, with concentrated growth factors (CGF) activated by medical ozone. A 54-year-old woman presented with bilateral lesion in the zygomatic region, caused by treatment with hyaluronidase and laser for removal of a granuloma, developed after infiltration with hyaluronate. The lesion was treated by local application of platelet-rich plasma obtained with CGF centrifuge, and containing CD34+ cells, mixed and activated by ozone in a 1:1 proportion, at a concentration of 40 mg/ml for 30 sec, in a syringe. Five consecutive bilateral infiltrations were made at 3-week intervals. Lesion volume was measured, and patient's quality of life was assessed with PGWBI (Psychological General Well Being Index) questionnaire. After the third infiltration of CGF-ozone, a consistent reduction of the lesion was observed, until disappearance at the end of the treatment. The result was maintained after 4-year follow-up. Considerable improvement of patient's well-being was reported. This case report showed that CGF-ozone combined therapy may promote dermal regeneration, achieving excellent facial esthetics outcomes. This result needs to be confirmed by further studies with a larger sample size.

Consensus on Current Injectable Treatment Strategies in the Asian Face.

BACKGROUND: The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience. RESULTS: The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to[55 years are presented. CONCLUSIONS: In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages. LEVEL OF EVIDENCE V: This journal requires that the 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 .

Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty.

BACKGROUND: Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations. RESULTS: Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty. CONCLUSIONS: Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. Level of Evidence V 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 Table of Contents or the online Instructions to Authors www.springer.com/00266 .

The dental esthetic screening index: A new tool for assessment of dento-facial esthetics in restorative dentistry.

OBJECTIVES: There is a lack of comprehensive indexes, which can measure conditions or changes in dento-facial esthetics before and after treatment. Therefore, the 12-item Dental Esthetic Screening Index (DESI) was developed and validated. MATERIALS AND METHODS: Reliability was tested by five dental professionals, who evaluated 30 standardized patient photographs baseline and after 14 days. Clinical validation was done on 52 patients before and after restorative treatment. For subjective assessment, patients completed a validated questionnaire before and after treatment. Statistical analysis included inter and intrarater reliability, Wilcoxon test and linear regression analysis. RESULTS: The single item analysis identified two weak extraoral items (κ = 0.15; κ = -0.05), that were removed from the DESI. After this modification, both inter- (κ = 0.83-0.86) and intrarater reliability (ICC1-5 = 0.75-0.86) were in excellent to good agreement. In the clinical validation, the DESI was significantly lower after restorative treatment (P < .0001). The patients' perception questionnaires showed significant improvement after restorative therapy (P < .0001). A correlation of the DESI and the results of patients' perception questionnaires could be assumed (P < .0001; R2 = 0.32). CONCLUSIONS: The DESI was found to be a reliable and valid instrument for the quantitative assessment of dento-facial esthetics. It correlated well with the subjective assessment of the patients. CLINICAL SIGNIFICANCE: This comprehensive index would allow for objective quantification of clinical situations, for reliable baseline and outcome assessment in esthetic dentistry. As patients' esthetic feelings and sensations are subjective, this objective index is also proven to be congruent to patients' individual subjective assessment of dento-facial esthetics.

Perception of Facial Esthetics by Laypersons, Dental Assistants, General Dental Practitioners and Dental Specialists.

AIM: This study sought to assess perception of facial esthetics by laypersons and dental professionals. MATERIALS AND METHODS: Three standard photographs were digitally manipulated involving three facial characteristics; facial symmetry, facial profile and facial vertical proportions. A sample of 465 [142 laypersons (LP), 97 dental assistants (DA), 152 general dental practitioners (GDP) and 74 dental specialists (DS)] evaluated the standard and the manipulated images on a visual analogue scale ranging from 1 (the less pleasant image) to 5 (the standard image). The responses were analyzed using Kruskal-Wallis and Mann-Whitney tests. A p value of <0.05 was considered significant. RESULTS: The overall score was 61.29 ± 16.19% with no statistical difference by gender. GDP showed significantly higher perception score than LP, DA and DS did. Regarding the individual facial esthetic components, females showed significantly better perception for "facial profile", while males showed significantly better perception for "facial symmetry" and "facial vertical proportions". Facial symmetry and facial vertical proportions were perceived differently with the higher perception score for the GDP and the lowest perception scores were for LP. CONCLUSION: Remarkable variations do exist with regard to facial esthetic perception by LP, DA, GDP and DS, with GDP showed more favorable perception. CLINICAL SIGNIFICANCE: Perception of facial esthetics by laypersons and dental practitioners with a different level of dental education and clinical experience gives an indication about the difference between the patients' desire and the practitioners' perception of such esthetic demands.

A Cone-beam Computed Tomography Interpretation of Malar Bone Changes in Skeletal Malocclusion.

AIM: The purpose of this cross-sectional study is to signify malar bone anatomy and to obtain linear correlation with varied skeletal pattern by utilizing cone beam computed tomographic views. MATERIALS AND METHODS: The experimental sample consisted of cone-beam computed tomography (CBCT) scans of 30 patients taken for the purpose of orthodontic treatment and peri implant planning (16 males and 14 females), 11-30 years of age (mean, 23.4 years). The sex and age were documented for all samples and nine landmarks were evaluated. The various CBCT were categorized into different malocclusions based on wits appraisal. Its prevalence was collated with age, sex and various malocclusion by Chi-square test. RESULTS: Age and gender altogether influenced M1. The mean posterior zygomatic bone width (M1) for all sample was 63.7 mm. For M1 estimations, no huge contrast was observed among left and right side (p = 0.915). The mean anteriorzygomatic bone width (M2) was 51.8 mm. No noteworthy contrast amongst two sides (p = 0.995) or age (p = 0.067) was seen. Although sex altogether influenced M3 variety (p = 0.003), the mean greatest cortical thickness (max CT) (M4) was 9.36 mm, significant difference was observed between the minimum cortical thickness of skeletal class I and skeletal class III malocclusion design. CONCLUSION: Detailed evaluation of malar bone should be performed prior to any ortho-surgical procedure using CBCT. CLINICAL SIGNIFICANCE: Our study signifies the importance of consideration of zygoma during any pre-treatment evaluation of skeletal malocclusion. It also marks the pivotal role of zygoma while considering gross facial esthetics. Precise assurance of zygomatic bone size may likewise aid the choice of fitting surgeries and determination of zygomatic implant area. How to cite this article: Dash BP, Reddy R, Mohanty P, et al. A Cone-beam Computed Tomography Interpretation of Malar Bone Changes in Skeletal Malocclusion. J Contemp Dent Pract 2019;20(11):1319-1322.

Differences in Lip Support with and without Labial Flanges in a Maxillary Edentulous Population. Part 2: Blinded Subjective Analysis.

PURPOSE: To study the subjective differences in facial esthetics evaluations among lay people, general dentists, and prosthodontists, when evaluating images of patients wearing a maxillary denture with a labial flange in comparison to an experimental flangeless denture. MATERIALS AND METHODS: A random sample of 20 maxillary edentulous patients from the original sample of 31 patients described in part 1 of the study was selected for this study. A total of 60 judges comprising 15 general dentists, 15 prosthodontists, and 30 lay people were recruited for subjective analysis. The judges were blinded about the objectives of the study and were asked to rate the facial esthetics of each image using a 100 mm visual analog scale (VAS) instrument. Four digital images per subject (total of 80 images) were evaluated in a random order, twice by all 60 judges. A repeated measures general linear mixed modeling method using restricted maximum likelihood estimation was performed using mixed procedure in a statistical software package to study the differences in evaluations. RESULTS: The overall VAS ratings of facial esthetics for images with flangeless dentures were slightly lower compared to images with labial flanges, and this difference was statistically significant (p < 0.05). This was true for both profile and frontal images; however, the magnitude of the difference was too small (no greater than 4 mm on a 100 mm scale) to be clinically significant. There were no statistically significant differences in facial esthetics ratings irrespective of the background or gender of the judges. CONCLUSIONS: Flangeless dentures resulted in slightly lower ratings of facial esthetics compared to images with a labial flange, but the differences were clinically insignificant. This was true for all judges comprising general dentists, prosthodontists, and lay people and for both frontal and profile images.

Differences in Lip Support with and without Labial Flanges in a Maxillary Edentulous Population. Part 4: Patient-Centered Analysis.

PURPOSE: To study the subjective differences in facial esthetics evaluations and the ability to distinguish facial changes due to changes in lip support, when evaluated by patients themselves. An additional objective was to study the differences between patients' self-evaluation versus evaluation of other patients. MATERIALS AND METHODS: A total of 22 maxillary edentulous patients from the original sample of 31 patients described in Part 1 of the study, returned to participate in this part of the study. The 22 patients acted as judges for all images in this study, and were therefore un-blinded to the objectives and details of the study. Patients first completed evaluation of facial esthetics on a visual analog scale (VAS). Four digital images per patient (total of 88 images) were evaluated in a random order, twice by all 22 patients. The mean scores from all judgments were used as the outcomes to be analyzed. All patients then took a discriminatory sensory analysis test (triangle test) where they were required to correctly identify the image with a flangeless denture out of a set of 3 images. Both the VAS and triangle test ratings were conducted twice in a random order, and mean ratings were used for all analyses. RESULTS: For VAS analysis, there were no statistically significant or clinically significant differences in facial esthetics ratings between flange and flangeless dentures (p < 0.05). This was true for both profile and frontal images, irrespective of self-evaluation versus evaluation of other patients, years of patient edentulism, and judge (patient) gender. For the triangle test, frontal images had a correct identification rate of 50.2% and profile images of 50.4%, and the difference was not significant. There were no significant differences in triangle test results with respect to self-evaluation versus evaluation of other patients and judge (patient) gender. For all patients, the likelihood of correctly identifying images with flangeless dentures was significantly greater than 1/3, which was the minimum chance for correct identification (p < 0.0001). CONCLUSIONS: Flangeless dentures resulted in no differences in facial esthetics ratings for frontal and profile images, when evaluated by patients. When patients were forced to look for differences, flangeless dentures were detected in half of the image sets. These findings were similar for self-evaluation versus evaluation of other patients and for both patient genders.

Consensus on Current Injectable Treatment Strategies in the Asian Face.

BACKGROUND: The desire for and use of nonsurgical injectable esthetic facial treatments are increasing in Asia. The structural and anatomical features specific to the Asian face, and differences from Western populations in facial aging, necessitate unique esthetic treatment strategies, but published recommendations and clinical evidence for injectable treatments in Asians are scarce. METHOD: The Asian Facial Aesthetics Expert Consensus Group met to discuss current practices and consensus opinions on the cosmetic use of botulinum toxin and hyaluronic acid (HA) fillers, alone and in combination, for facial applications in Southeastern and Eastern Asians. Consensus opinions and statements on treatment aims and current practice were developed following discussions regarding pre-meeting and meeting survey outcomes, peer-reviewed literature, and the experts' clinical experience. RESULTS: The indications and patterns of use of injectable treatments vary among patients of different ages, and among Asian countries. The combination use of botulinum toxin and fillers increases as patients age. Treatment aims in Asians and current practice regarding the use of botulinum toxin and HA fillers in the upper, middle, and lower face of patients aged 18 to >55 years are presented. CONCLUSIONS: In younger Asian patients, addressing proportion and structural features and deficiencies are important to achieve desired esthetic outcomes. In older patients, maintaining facial structure and volume and addressing lines and folds are essential to reduce the appearance of aging. This paper provides guidance on treatment strategies to address the complex esthetic requirements in Asian patients of all ages. LEVEL OF EVIDENCE V: This journal requires that the 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.

Consensus on Changing Trends, Attitudes, and Concepts of Asian Beauty.

BACKGROUND: Asians increasingly seek non-surgical facial esthetic treatments, especially at younger ages. Published recommendations and clinical evidence mostly reference Western populations, but Asians differ from them in terms of attitudes to beauty, structural facial anatomy, and signs and rates of aging. A thorough knowledge of the key esthetic concerns and requirements for the Asian face is required to strategize appropriate facial esthetic treatments with botulinum toxin and hyaluronic acid (HA) fillers. METHODS: The Asian Facial Aesthetics Expert Consensus Group met to develop consensus statements on concepts of facial beauty, key esthetic concerns, facial anatomy, and aging in Southeastern and Eastern Asians, as a prelude to developing consensus opinions on the cosmetic facial use of botulinum toxin and HA fillers in these populations. RESULTS: Beautiful and esthetically attractive people of all races share similarities in appearance while retaining distinct ethnic features. Asians between the third and sixth decades age well compared with age-matched Caucasians. Younger Asians' increasing requests for injectable treatments to improve facial shape and three-dimensionality often reflect a desire to correct underlying facial structural deficiencies or weaknesses that detract from ideals of facial beauty. CONCLUSIONS: Facial esthetic treatments in Asians are not aimed at Westernization, but rather the optimization of intrinsic Asian ethnic features, or correction of specific underlying structural features that are perceived as deficiencies. Thus, overall facial attractiveness is enhanced while retaining esthetic characteristics of Asian ethnicity. Because Asian patients age differently than Western patients, different management and treatment planning strategies are utilized. LEVEL OF EVIDENCE V: 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 Table of Contents or the online Instructions to Authors www.springer.com/00266.

Use of Platelet Preparations in Facial Rejuvenation and Wound Healing Remains Unproven.

UNLABELLED: There is growing interest in the use of platelet derivatives in facial aesthetic surgery and wound healing. Sclafani et al. have concluded from their review of the literature that the vast majority of studies show a significant and measurable effect on facial aesthetic outcomes with the use of these platelet preparations. We suggest that an alternative review of the same literature may well have produced a different set of conclusions. LEVEL OF EVIDENCE V: 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.