Injection technique of the upper face with onabotulinumtoxinA in chronic migraine.

BACKGROUND: The objective is to review the technique of onabotulinumtoxinA injection treatment in the glabellar and frontal regions using the PREEMPT (Phase III REsearch Evaluating Migraine Prophylaxis Therapy) paradigm, with review of the aesthetic issues related to the procedure. OnabotulinumtoxinA is an effective medication for the prevention of chronic migraine. The PREEMPT injection paradigm has been validated in randomized clinical trials and real-world settings. This treatment includes injections in the forehead and glabella area. In addition, for aesthetic uses, glabella onabotulinumtoxinA injections are done in similar muscles specifically the procerus, corrugator supercilii, and frontalis muscles. Often patients who have been injected with onabotulinumtoxinA for chronic migraine have concerns about their appearance and will ask if they can see an aesthetic injector to improve this. This is a difficult issue as onabotulinumtoxinA should be injected with an interval of 10-12 weeks to avoid development of antibodies against onabotulinumtoxinA, so all injections (migraine and aesthetic) should ideally be done close together; however, if an aesthetic injection is done on the same day as a PREEMPT injection, the effect of the PREEMPT injection will not yet be visible as it takes time for onabotulinumtoxinA effects to be seen. Thus, there is a risk of a potential overdose in a particular area if aesthetic injections are done without input from the PREEMPT injector. METHODS: This is a narrative review supported by photographic documentation showing the technique of onabotulinumtoxinA injection of the upper face, considering anatomical differences between patients, and combining the needs in neurology and aesthetic medicine fields. RESULTS: Practitioners treating chronic migraine often modify some of the principles of the PREEMPT paradigm. Many practitioners are unsure about injections in the glabellar and frontal areas. The authors present a technique for using the PREEMPT protocol and adapting this to the individual patient's anatomy to prevent an unsightly appearance or ptosis. In addition, sites are provided where an aesthetic injector could inject to improve the patient's appearance without overlapping with the PREEMPT injection sites. CONCLUSION: Adherence to the PREEMPT injection protocol provides an evidence-based approach to achieving clinical benefit for patients with chronic migraine. Aesthetic elements of the treatment of the glabella and forehead require additional attention. The authors provide practical considerations and recommendations regarding this.

Mapping the Vascular and Muscular Topography of the Glabellar Region: Implication for Improving Safety and Efficacy of the Glabellar Injections.

BACKGROUND: Botulinum neurotoxin (BoNT) and filler injections into the highly vascularized glabellar region for aesthetical purposes are extremely common. Injections into the glabellar region without precise anatomical knowledge of its vascular and muscular topography may pose the risk of severe complications. OBJECTIVES: We aimed to improve the safety and efficacy of the glabellar injections by mapping the regional muscles and vasculature in relation to the medial canthus and the defined reference lines. METHODS: Meticulous dissection was performed to reveal glabellar region muscles and arteries under surgical microscope, in 16 hemifaces of whom arteries are injected with red-dyed latex. Location of the angular artery (AA) along with its branches was noted in relation to glabellar muscles. RESULTS: The AA was always located superficial to the levator labii superioris alaeque nasi muscle (LLSAN) and then coursed toward the medial canthus to anastomose with the supratrochlear artery deep to the origin of the depressor supercilii (DS). The AA gave subcutaneously located central and paracentral branches coursing close to the mid-face line in 14 out of 16 hemifaces. Variable muscular connections were also present between the LLSAN, the DS and the procerus (P) muscles. No arteries were detected at the base of the medial eyebrow to which the DS, the P, and the frontalis (F) inserted. CONCLUSIONS: This study provides a detailed map of muscular and vascular anatomy of the glabellar region to facilitate safe and efficient filler and BoNT injections without complications. NO LEVEL ASSIGNED: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Extended Suprabrow Lift with Relief of Glabellar Wrinkles.

BACKGROUND: Eyebrows define one's facial appearance; brow ptosis, which can occur with aging, can convey a negative expression. Various methods have been used to correct eyebrow position and shape. We endeavored to repair brow ptosis and glabellar wrinkles and present the outcome. METHODS: This retrospective study reviewed 40 patients who underwent extended suprabrow lift accompanied by relief of glabellar wrinkles between January 2018 and August 2020. The procedure was considered when patients exhibited brow ptosis, glabellar wrinkles, and a wide forehead. Fat graft was implemented after glabellar muscle division. The results were assessed based on measurements performed preoperatively and at 6 and 18 months postoperatively. RESULTS: Overall, patients were satisfied with the outcomes. To assess glabellar wrinkles, the Modified Fitzpatrick Wrinkle Assessment score revealed adequate correction during neutral and furrowed gazes (P < 0.05). The forehead and brow heights were also analyzed after repair, exhibiting decreased forehead height and elevated brow position (P < 0.05). At 6 and 18 months after surgery, adequate maintenance of the repair was evident (P < 0.05). A visible scar was observed in two patients, which was managed using a fractional ablative laser procedure. CONCLUSION: Extended suprabrow lift, when based on preoperative measurements, led to the correction of brow ptosis, glabellar wrinkles, and a wide forehead. For periorbital rejuvenation, it is imperative to decide locations where the skin and soft tissues should be preserved or removed. The use of fat grafts for wrinkle repair effectively maintains the repair postoperatively. 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 .

9-Year Follow-Up on Maxillofacial Implant-Supported Framework Designed to Accommodate Childhood Growth.

This clinical report focuses on the challenges and solutions for a child subjected to craniofacial trauma from a wild hyena biting off his nose and anterior maxilla. Unique considerations in prosthodontics and biomedical engineering were required based on future craniofacial growth and development of the child. The physical requirement of a maximum retentive prosthesis for an active, athletic child required unique engineering designs and executions. The sequence of treatment and prosthesis fabrication are detailed. The patient has been followed for 9 years without physiologic complications and only minor prosthodontic complications.

Laser speckle contrast imaging of forehead cutaneous blood flow during carotid endarterectomy as a potential non-invasive method for surrogate monitoring of cerebral perfusion.

Monitoring cerebral perfusion is important for goal-directed anesthesia. Taking advantage of the supply of the supraorbital region and Glabella from the internal carotid artery (ICA), we evaluated changes in cutaneous blood flow using laser speckle contrast imagining (LSCI) as a potential method for indirect real-time monitoring of cerebral perfusion. Nine patients (8 men, mean age 70 years) underwent eversion carotid endarterectomy under local anesthesia. Cutaneous blood flow of the forehead was monitored using LSCI. During clamping of the common carotid artery (CCA), ipsilateral supraorbital region and Glabellas cutaneous blood flow dropped from 334 ± 135 to 221 ± 109 AU (p = 0.023) (AU: arbitrary flux units) and from 384 ± 151 to 276 ± 107 AU (p = 0.023), respectively, whilst the contralateral supraorbital region cutaneous blood flow remained unchanged. The supraorbital cutaneous blood flow did not change significantly following reperfusion of the external carotid artery (ECA) (221 ± 109 to 281 ± 154 AU; p = 0.175) and ICA (281 ± 154 to 310 ± 184 AU; p = 01). A comparable trend for Glabella followed ECA (276 ± 107 to 342 ± 170 AU; p = 0.404) and ICA (342 ± 170 to 352 ± 191 AU; p = 01) reperfusion. In patients undergoing carotid endarterectomy under local anesthesia, LSCI of the supraorbital and Glabella regions reflected clamping of the CCA but did not distinguish reperfusion of the ICA from that of the ECA.

Lifting effect of onabotulinumtoxinA in patients treated for glabellar and crow's feet rhytids.

OnabotulinumtoxinA injection can enhance the appearance of the eyes. This study evaluated the lifting effect of onabotulinumtoxinA treatment of the eye area. A retrospective, single-center audit of patients treated for glabellar and crow's feet rhytids was undertaken. Standardized photographs taken before and 2-4 weeks after treatment were assessed. Computer-based measurements were made of the height of the visible superior tarsal plate (STP) and brow (measured from upper eyelid lash edge to eyebrow base) at rest and maximum frown. One hundred patients were included (96 females; mean age: 46.2 ± 8.8 years). Mean onabotulinumtoxinA doses were 14.95 ± 0.61 units (glabella) and 17.83 ± 2.74 units (crow's feet). There were significant post-treatment increases in mean STP height at rest (left side, 0.76 ± 0.99 mm, p = .02; right side, 0.79 ± 0.94 mm, p = .01) and maximum frown (left, 2.25 ± 1.52 mm, p < .0001; right, 1.87 ± 1.34 mm, p < .0001), and mean brow height at rest (left side, 1.54 ± 1.49 mm, p = .0006; right side, 1.47 ± 1.84 mm, p = .0009) and maximum frown (left, 4.37 ± 2.29 mm, p < .0001; right, 4.16 ± 1.88 mm, p < .0001). OnabotulinumtoxinA injection is effective for elevating brow position and increasing STP show.

Prevention and management of iatrogenic blindness associated with aesthetical filler injections.

Injectable fillers have become one of the most performed aesthetical treatments worldwide over the past two decades. They are frequently applied to the face, offering effective and safe alternatives to more invasive surgical procedures. Nevertheless, there are serious risks associated with filler-based treatment. Visual impairment stands as a rare yet catastrophic adverse event associated with intravascular embolization of injected material to the retina or other areas of the central nervous system; potentially leading to permanent visual loss. This article presents a comprehensive revision of blindness secondary to aesthetical filler injections, offering up-to-date strategies for prevention and management.

A quantitative approach for sex estimation based on cranial morphology.

OBJECTIVES: This paper proposes a method for the quantification of the shape of sexually dimorphic cranial traits, namely the glabella, mastoid process and external occipital protuberance. MATERIALS AND METHODS: The proposed method was developed using 165 crania from the documented Athens Collection and tested on 20 Cretan crania. It is based on digital photographs of the lateral view of the cranium, drawing of the profile of three sexually dimorphic structures and calculation of variables that express the shape of these structures. RESULTS: The combinations of variables that provide optimum discrimination between sexes are identified by means of binary logistic regression and discriminant analysis. The best cross-validated results are obtained when variables from all three structures are combined and range from 75.8 to 85.1% and 81.1 to 94.6% for males and females, respectively. The success rate is 86.3-94.1% for males and 83.9-93.5% for females when half of the sample is used for training and the rest for prediction. Correct classification for the Cretan material based upon the standards developed for the Athens sample was 80-90% for the optimum combinations of discriminant variables. DISCUSSION: The proposed method provides an effective way to capture quantitatively the shape of sexually dimorphic cranial structures; it gives more accurate results relative to other existing methods and it does not require specialized equipment. Equations for sex estimation based on combinations of variables are provided, along with instructions on how to use the method and Excel macros for calculation of discriminant variables with automated implementation of the optimum equations.

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.

Arterial Vascularization of the Forehead in Aesthetic Dermatology Procedures: A Review.

Background: The growing popularity of aesthetic procedures on the face raises the question of their safety. The forehead region is crucial aesthetically, but due to its abundant vascularization, it is also one of the most dangerous areas for dermatologic procedures, especially in the glabella area. The purpose of this article is to review the literature on the arterial vascularization of the forehead to identify potential high-risk zones for aesthetic dermatology procedures. Methods: A database search (PubMed, Web of Science, Scopus, and Embase) was conducted, and the titles and abstracts of all identified studies were screened, followed by full-text evaluation. Results: We identified 714 articles during the database search, and 25 articles were included in the review. The included studies used cadaveric dissection and computed tomography applied to cadavers as well as Doppler ultrasonography on volunteers to evaluate the forehead arteries (supratrochlear (STrA), supraorbital (SOA), central (CA), paracentral artery (PCA), and frontal branch of superficial temporal artery(FBSTA)). A total of 1714 cases involving the forehead arteries were analyzed. The included arteries were observed over a relatively large area, and their locations varied. The CA and PCA in cadaver studies were observed in an area of 0.2 to 10.8 mm and 0.8 to 16.2 mm, respectively, on the entire path from the glabellar point to the frontal prominence point. The distances from the midline in cadaveric studies at various measurement points ranged from 0.6 to 28.0 mm for the superficial branch of the STrA and 13.6 to 40.7 mm for the deep branch of STrA. In case of SOA, the distance from the midline ranged from 23 to 32 mm. Measurements from the midline in Doppler studies ranged from 0 to 23 mm for STrA and from 10 to 50 mm for the SOA. In studies using computed tomography, STrA was observed at a distance of 11 to 21 mm and the SOA at a distance of 21 to 32 mm, both lateral to the midline. Conclusions: Medical professionals should be aware of zones where frontal arteries are more likely to be encountered. The glabella region appears to be one of the most dangerous areas for dermatologic procedures. It is believed that the supratrochlear, supraorbital, and the paracentral arteries may cause ophthalmic complications due to occlusion of the ophthalmic artery, while this risk for the frontal branch of the superficial temporal artery seems to be low but cannot be completely excluded.

Rhinoplasty and brow modification: a powerful combination.

BACKGROUND: Plastic surgeons have long recognized the importance of performing chin augmentation concurrent with a rhinoplasty to achieve facial balance. However, few surgeons consider the benefits of combining a rhinoplasty with brow modification to achieve a better aesthetic result. By increasing the size of the middle third of the face, the nose will automatically appear smaller. OBJECTIVE: The authors describe anatomical dissections that provided perspective on the facial anatomy of the areas being studied and report the results of concurrent browlift and rhinoplasty procedures in a retrospective series of patients. METHODS: The present study consisted of 2 parts: anatomical dissections and a retrospective chart review. The nose and central forehead area were dissected in 7 fresh cadavers at the time of autopsy to understand the anatomical relationship between the various muscles in the radix/glabellar region and to assess the muscle resection occurring in the clinical procedures. We also reviewed the charts of 24 patients who underwent combined rhinoplasty and brow modification with the senior author (R.K.D.) during a 2-year period (July 2010 to June 2012). Younger patients underwent a central browlift (CBL) with screw fixation, while older patients (ages 34-60 years) underwent full 5-incision endoscopic forehead lifting. RESULTS: The age range for patients in this series was 14 to 60 years. Two patients were men and 22 were women. There were 12 primary and 12 secondary procedures in the series; 13 patients underwent CBL and 11 had EFL. The mean follow-up was 18 months. One patient had a persistent fluid accumulation in the glabellar region, which required drainage. One patient requested additional refinement of her nasal tip. CONCLUSION: Modification of the central brow can dramatically change the aesthetic polygons of the nose/glabellar region. A CBL with radix/glabellar muscle excision is important in younger patients who need a well-defined nasion and older secondary patients who feel that the upper third of their nose is still heavy. A full EBL can enhance the facial appearance of older patients in whom a rhinoplasty alone would have a modest impact.

Simplifying Forehead and Temple Reconstruction: A Narrative Review.

The forehead and temporal region are frequent areas of skin cancer development. After tumor removal, reconstruction must be performed, maintaining the frontal-temporal line of the scalp and symmetry of the eyebrows in an attempt to hide the scars within these marks or natural folds and wrinkles. Second wound healing and skin grafts generally do not produce an acceptable cosmetic result. When direct closure is not possible, the technique of choice is skin flaps. In the midfrontal line continuation of the glabella, there is a remnant of skin to be used as a donor area for local flaps; similarly, it occurs in the preauricular cheek, which can move toward the temple. In addition to the classic advancement and rotation flaps, the frontalis myocutaneous transposition flap is an excellent technique for closing defects which are wider than higher on the forehead. Its design is very versatile and can be performed between the two pupil lines at different heights depending on the location of the defect. On the other hand, the preauricular skin advancement flap with an infralobular Burow's triangle is also an excellent option for reconstructing tumors in the temporal area.

Comprehensive Genomic Characterization of Staphylococcus aureus Isolated from Atopic Dermatitis Patients in Japan: Correlations with Disease Severity, Eruption Type, and Anatomical Site.

Atopic dermatitis (AD) shows frequent recurrence. Staphylococcus aureus is the primary microbial component in AD and is associated with disease activity. However, traditional typing methods have failed to characterize virulent AD isolates at the clone level. We conducted a comprehensive genomic characterization of S. aureus strains isolated from the skin of AD patients and healthy donors, comparing the whole-genome sequences of the 261 isolates with anatomical and lesional (AD-A)/nonlesional (AD-NL)/healthy sites, eruption types, clinical scores, virulence, and antimicrobial resistance gene repertoires in Japan. Sequence type (ST) diversity was lost with worsening disease activity; ST188 was the most frequently detected ST in AD-A and had the strongest correlation with AD according to the culture rate and proportion with worsening disease activity. ST188 and ST20 isolates inhabited all skin conditions, with significantly higher proportions in AD skin than in healthy skin. ST8, ST15, and ST5 proportions were equivalent for all skin conditions; ST30 was detected only in healthy skin; and ST12 was detected only in AD skin. ST97 detected in AD-A and healthy skin was clearly branched into two subclades, designated ST97A and ST97H. A comparison of two genomes led to the discovery that only ST97A possessed the complete trp operon, enabling bacterial survival without exogenous tryptophan (Trp) on AD skin, where the Trp level was significantly reduced. Primary STs showing an AD skin inhabitation trend (ST188, ST97A, ST20, and ST12) were all trp operon positive. The predominant clones (ST188 and ST97) possessed almost no enterotoxin genes, no mecA gene, and few other antimicrobial resistance genes, different from the trend observed in Europe/North America. IMPORTANCE While Staphylococcus aureus is a member of the normal human skin flora, its strong association with the onset of atopic dermatitis (AD) has been suggested. However, previous studies failed to assign specific clones relevant to disease activities. Enterotoxins produced by S. aureus have been suggested to aggravate and exacerbate the inflammation of AD skin, but their role remains ambiguous. We conducted a nuanced comprehensive characterization of isolates from AD patients and healthy donors, comparing the whole-genome sequences of the isolates with anatomical and lesional/nonlesional/healthy sites, eruption types, clinical scores, virulence, and antimicrobial resistance gene repertoires in Japan. We demonstrate that specific clones are associated with disease severity and clinical manifestations, and the dominant clones are devoid of enterotoxin genes and antimicrobial resistance genes. These findings undermine the established notion of the pathophysiological function of S. aureus associated with AD and introduce a new concept of S. aureus colonization in AD.

Ophthalmic artery occlusion after glabellar hyaluronic acid filler injection.

PURPOSE: Filler injections for aesthetic purposes are very popular, but can have far-reaching and irreversible consequences. This report describes the course of a patient with devastating complications after glabellar hyaluronic acid injection, their pathomechanism, management and outcome. OBSERVATIONS: A healthy, 43-year-old woman underwent her first hyaluronic acid injection in the glabella and went blind on her left eye immediately thereafter. Massaging of the injection area and observation were performed, before she presented with swelling of the left forehead and upper lid, ptosis, complete ophthalmoplegia and blindness in our hospital. Immediate massaging of the globe and systemic therapy including acetylsalicylic acid, tinzaparin sodium and cortisone was initiated and hyaluronidase injections in the injection area were performed. In the further course, the patient developed necrotic and hemorrhagic skin and mucosal lesions, lagophthalmos, anterior and posterior segment ischemia and globe hypotonia with consecutive globe deformation. In the follow-up of 2.5 months, lid swelling, lagophthalmos and ptosis resolved and keratopathy improved but blindness, skin lesions and strabismus with reduced eye motility were still present and madarosis and early enophthalmos were detected. CONCLUSIONS AND IMPORTANCE: The outcome of ophthalmic artery occlusion after hyaluronic acid filler injection is poor. Sufficient knowledge about facial anatomy, the implementation of filler injections and the management of complications is essential for the practitioner. The patient should be clarified about potential and even rare risks of these procedures.

Aesthetic implications of depressor supercilii muscle block with botulinum toxin type A.

INTRODUCTION: When applying botulinum toxin in the upper third of the face, it is important to consider the balance between the elevator and depressor muscles of the eyebrows. Depressor supercilii muscle block leads to elevation of the medial portion of the eyebrow and correction of the oblique lines in the frown. OBJECTIVES: The intention is to highlight the importance of the depressor supercilii muscle block as a useful tool to reposition the medial portion of the eyebrow. PATIENTS AND METHODS: Three cases are presented, in whom botulinum toxin is applied conventionally and subsequently on the depressor supercilii muscle after the subjective sensation of flattening of the glabella and increasing distance between the eyebrows referred by the patients. RESULTS: The application of botulinum toxin type A on the depressor supercilii muscle is an effective measure to facilitate the elevation of the medial portion of the eyebrow, after the conventional application in between the eyebrows treating the orbicularis, corrugator, and procerus muscles. CONCLUSIONS: Depressor supercilii muscle block can be considered when applying botulinum toxin type A in the upper third of the face, in cases where there is loss of facial aesthetic harmony. This is given by the subjective perspective of the patient due to a change in the natural expression of their face with a sensation of flattening of the glabella and distancing of the medial portion of the eyebrows, occurring after the use of a conventional technique at that anatomical level, where patients may report a "feline" or "avatar" appearance.

Mohs Micrographic Surgery for Dermatofibrosarcoma Protuberans in 15 Patients: The University of Arkansas for Medical Sciences Experience.

BACKGROUND: Dermatofibrosarcoma protuberans (DFSP) is an uncommon, locally aggressive malignancy with wide local excision (WLE) or Mohs micrographic surgery (MMS) representing the treatment of choice. This article illustrates the experience of a single academic institution in treating DFSP with MMS and adds two particularly large, difficult closures of the glabella/central forehead and sternum to the body of literature. OBJECTIVE: To report the results of 15 patients with DFSP treated with MMS over a five-year period by a single Mohs surgeon at the University of Arkansas for Medical Sciences (UAMS). METHODS: A total of 15 patients between the ages of 16 and 80 years were diagnosed with DFSP and treated with MMS and were contacted in October 2021 to assess for recurrence. RESULTS: None of the 15 patients had a recurrence of DFSP following MMS, with a mean follow-up interval of 22.4 months and an average of 1.93 Mohs layers required for tumor clearance. CONCLUSION: This experience reaffirms that MMS is an effective treatment for DFSP and adds additional examples of closure techniques of large, ovoid surgical defects on the glabella/central forehead and sternum to the literature.

Evaluation of supratrochlear artery depth and course variations by Doppler ultrasonography along the glabellar frown lines for safer filler injections.

PURPOSE: Hyaluronic acid (HA) injection is a popular nonsurgical, rejuvenating procedure to treat glabellar frown lines, which has devastating complications such as blindness and skin necrosis due to the arterial occlusion of supratrochlear artery (STA). Therefore, when injecting into the frown lines, knowledge of the STA's depth and plane is necessary to prevent possible adverse events. The aim of this study was to identify the depths of STA in the area of the frown lines in order to maximize safety during filler injections. METHODS: Supratrochlear artery depth measurements were performed at the level of eyebrow and at the level of 1.5 cm above the eyebrow. Superficial duplex Doppler ultrasonography was performed of 71 cases. RESULTS: In the eyebrow level, the epidermis-artery distance (EAD) is between 1,8 and 5.9 mm, and the artery-periost distance (APD) is between 0.7 and 3.7 mm. In the 1.5 cm superior level of the eyebrow, the EAD is between 1.8 and 5.1 mm and the APD is between 0.6 and 3.8 mm. There was no significant difference between the depth measurements of the right and left STA. At the eyebrow level, APD is greater in men than in women. As the body mass index increases, the EAD and APD depth increases. EAD depth increases with increasing age. CONCLUSIONS: Based on the findings of this study, safe filler injections to correct the glabellar frown lines can be possible with intradermal injections just below the ryhtide. In the glabellar region, subcutaneous and supraperiosteal injections seems to be risky.

Sudden vision loss and neurological deficits after facial hyaluronic acid filler injection.

BACKGROUND: The ongoing expansion of the cosmetic armamentarium of facial rejuvenation fails to uncover the inherent risks of cosmetic interventions. Informed consent to all risks of cosmetic filler injections and potential sequelae, including ocular and neurological complications, should be carefully ensured. We present two cases of complications following facial hyaluronic acid filler injections. CASE PRESENTATIONS: Case 1: A 43-year-old woman presented with monocular vision loss of the left eye, associated ptosis, ophthalmoplegia, periocular pain and nausea, cutaneous changes of the glabella region and forehead, and sensory impairment in the left maxillary branch dermatome (V2) after receiving a hyaluronic acid (HA) filler injection into the left glabellar area. On ophthalmological examination, an ophthalmic artery occlusion (OAO) was diagnosed upon identification of a "cherry-red spot". Magnetic resonance imaging (MRI) revealed a left ischemic optic neuropathy. Supportive therapy and hyaluronidase injections were initiated. A follow-up MRI of the head performed two months after presentation corresponded to stable MRI findings. The patient had irreversible and complete vision loss of the left eye, however, the ptosis resolved. Case 2: A 29-year-old woman was admitted to hospital a few hours after a rhinoplasty and cheek augmentation with hyaluronic acid, presenting with acute monocular vision loss in the right eye, retrobulbar pain, fatigue and vomiting. In addition, the patient presented a harbinger of impending skin necrosis and a complete oculomotor nerve palsy on the right side, choroidal ischemia and vision impairment. Supportive treatment and hyaluronidase injections into the ischemic tissue were initiated. A small scar at the tip of the nose, vision impairment and an irregular pupillary margin on the right side persisted at follow-up. CONCLUSION: These two case reports and the literature review emphasize the pathophysiological mechanisms leading to potentially devastating complications. In order to reduce the risk of vision loss secondary to cosmetic filler injections, practitioners should possess a thorough knowledge of anatomy and preventive strategies.

A practical approach to orofacial rehabilitation in a patient after inferior maxillectomy and rhinectomy with mono framework construction supported on a zygomatic implant placed in the glabella: a case report.

BACKGROUND: In the field of craniofacial tumor surgery, an adequately performed excision, despite being a life-saving procedure, is only a first step to successful treatment. During such a procedure, the main goal is to completely remove the lesion, paying less attention to factors contributing to future rehabilitation possibilities. One ty 2of the possibilities for prosthetic rehabilitation of such cases is utilizing one-piece implants with bicortical anchorage. CASE PRESENTATION: This case report presents a case of a 48-year-old patient with oral squamous cell carcinoma (OSCC). The treatment protocol consisted of radical surgery to remove the tumor, and intraoral and extraoral rehabilitation with a single framework prosthesis anchored with one-piece implants. Moreover, the intraoral stomatognathic deformity was corrected with a fixed implant-retained prosthesis, and the extraoral defect was covered with a removable epithesis. CONCLUSIONS: The use of one-piece implants with bicortical anchorage may be an additional tool in reconstructing maxillofacial defects. Properly executed treatment may improve the esthetics, speech, masticatory function, muscle support, and the overall quality of life of patients with extensive defects in the maxillofacial region.

The One21 Technique: An Individualized Treatment for Glabellar Lines Based on Clinical and Anatomical Landmarks.

PURPOSE: Botulinum toxin type A is an effective treatment for glabellar dynamic wrinkles. As the muscular group involved in the contraction of the glabella varies among people, individualized treatment can achieve optimal results. This study evaluates a customized assessment for the treatment of glabellar lines with Incobotulinumtoxin-A, leading to an individualized points distribution and dosage. PATIENTS AND METHODS: A single-center, evaluator-blinded, therapeutic cohort study enrolled 130 women with moderate or severe glabellar wrinkles. They underwent Incobotulinumtoxin-A injection following the standard 5-point injection at the glabellar muscles (n = 65) or an individualized assessment and scheme treatment based on anatomical references of contraction, the One21 technique (n = 65). All the patients were photographed under maximum contraction before treatment (T0) and after 4 weeks (T28). The photos were randomly assessed by two blinded, experienced raters to consensually grade the severity according to the Merz Aesthetics Scales (MAS). The primary clinical efficacy was defined as a 2-point reduction in the MAS score, on Day 28. RESULTS: The groups were homogeneous regarding age, phototype, and baseline MAS scores. On Day 28 (T28), 64 (98.5%) patients from the One21 group and 52 (80%) from the 5-point group reduced the MAS score by at least two points (p < 0.01). When adjusted by age and phototype, both groups reduced the MAS score at T28 (p < 0.01); nevertheless, patients from the One21 group significantly performed better (p < 0.01), with a much higher rate response rate at T28, in comparison to the 5-point group. Of patients enrolled in the 5-point group, 83.1% utilized muscle groups other than the procerus and corrugator in glabellar wrinkle formation, and 17 (24.6%) presented asymmetrical contraction. Patients from the 5-point group with glabellar asymmetry and those who utilized the frontalis and orbicularis presented inferior performance (p < 0.05), reinforcing the importance of an individualized assessment and treatment plan. CONCLUSION: The One21 technique yielded better results than the standard 5-point treatment in reducing glabellar dynamic lines with Incobotulinumtoxin-A, especially for asymmetric lines of the glabella or the involvement of muscle groups other than the procerus and corrugator.