Understanding clinical meaningfulness when targeting the depressor anguli oris muscle (DAO) with neuromodulators: a clinical prospective interventional study.

BACKGROUND: Neuromodulator injections in the US increased by 24% from 2021 to 2022. This rise is attributed to new products and growing acceptance of minimally invasive aesthetic treatments. Recent studies emphasize the importance of facial anatomy for precision and, consequently, a higher efficacy of neuromodulator treatments. This study aims to evaluate the clinical efficacy of a novel previously proposed injection technique targeting the depressor anguli oris (DAO) muscle to improve oral commissure position. This clinical, prospective study included 34 volunteers from the Shinobu Clinic, São Paulo, Brazil. Patients received 3 units of onabotulinumtoxinA per side, injected mid-distance between the oral commissure and jawline, following the labiomandibular sulcus (LMS). Standardized photographs and assessments using the Oral Commissure Severity Scale (OCSS) and Global Aesthetic Improvement Scale (GAIS) were conducted before and 30 days post-treatment. Statistical analyses included t-tests, Wilcoxon Signed Rank test, and generalized linear models. The average increase in commissural height was 5.22% (p < 0.001). OCSS ratings improved significantly from baseline (clinician: 1.21 to 0.72, p < 0.001; patient: 0.93 to 0.69, p < 0.001). However, GAIS scores indicated no significant change (patient: 0.32, observer: 0.38; p = 0.491). The proposed injection technique improves perioral aesthetics objectively and subjectively. However, the lack of significant change in GAIS scores suggests that perceived improvements may not be clinically meaningful to patients. Future studies should focus on patient-centered evaluation methods to better assess aesthetic outcomes.

Horizontal necklines correction with absorbable braided polydioxanone threads: Case series.

INTRODUCTION: The prevalence of horizontal neck lines as a cosmetic concern is widely acknowledged, yet the available treatment options are limited, and no studies have investigated the use of polydioxanone-barbed threads. These threads, characterized by a finely braided structure, function as a scaffold to attract regenerative factors and facilitate the migration and proliferation of cells. This study aims to evaluate the outcomes of concurrent application of braided polydioxanone-barbed threads for addressing horizontal neck wrinkles. METHODOLOGY: A retrospective case series involving four female participants (aged 41, 43, 45, and 46) treated with polydioxanone-barbed threads for horizontal neck wrinkles between January 2023 and July 2023 was conducted. Adult patients were assessed at an 8-week follow-up, revealing a significant reduction in wrinkle intensity based on the Horizontal Neck Wrinkle Severity Scale. RESULTS: The analysis of horizontal neck lines demonstrated a notable decrease in wrinkle intensity according to the Horizontal Neck Wrinkle Severity Scale at the 8-week mark, and this improvement maintained statistical significance. Both patient Global Aesthetic Improvement Scale (GAIS) scores (90%-100%) and physician GAIS scores (100%) were rated as excellent. CONCLUSION: The subdermal application of polydioxanone-barbed threads for horizontal neck lines proves to be a secure and efficacious approach for treating horizontal neck wrinkles, with no observed Tyndall effect. This technique shows promise for rejuvenating the skin in the horizontal neckline region.

Investigating Facial Muscle Physiology Following Soft Tissue Filler Injections-A Surface-derived Electromyographic and Skin Vector Displacement Analytic Study.

The use of hyaluronic acid-based soft tissue fillers has often been reported to modulate the muscle, that is, to cause myomodulation. To our knowledge, there has been so far no scientific study investigating the potential of hyaluronic acid-based soft tissue fillers to modulate or actually alter the function of facial muscles. To further assess this three-dimensional (3D) surface imaging and electromyography (EMG)-based prospective study investigated the changes of facial muscle contraction after injection of strategically placed hyaluronic acid-based soft tissue fillers to assess the actual validity of the term myomodulation. A total of 13 subjects with a mean age of 37.8 years (12 females, 1 male) were injected according to a predefined injection protocol. Surface EMG and 3D surface imaging were performed prior to the injection and 5 days after the injection. The results showed no significant change in the strength of the muscles (measured in µV) after injection of hyaluronic acid-based soft tissue fillers. However, horizontal and vertical skin displacement upon contraction of the zygomaticus major muscle changed significantly between baseline and follow-up, with a mean horizontal skin displacement increase from 3.2 to 4.1 mm. Upon contraction of the depressor anguli oris muscle, the horizontal skin displacement did not change significantly (2.15 vs. 2.05 mm), while vertical skin displacement increased significantly from 2.9 to 4.3 mm. The modification of the surrounding tissue caused an alteration of the vectorial skin displacement upon contraction of the muscle. A potential explanation could be the increased distance between the origin and insertion of the muscle due to the material deposition in the proximity of the relevant facial muscles, leading to a change of contraction vector.

Truth Lies in the Depths: Novel Insights into Facial Aesthetic Measurements from a U.S. Survey Panel.

BACKGROUND: Aesthetic facial bone surgery and facial implantology expand the boundaries of conventional facial surgery that focus on facial soft tissue. This study aimed to reveal novel aesthetic facial measurements to provide tailored treatment concepts and advance patient care. METHODS: A total of n=101 study participants (46 females and 55 males) were presented with 120 patient portraits (frontal images in natural head posture; 60 females and 60 males) and asked to assess the facial attractiveness (scale 0-10; "How attractive do you find the person in the image?") and the model capability score (MCS; scale 0-10; "How likely do you think the person in the image could pursue a modelling career?"). For each frontal photograph, defined facial measurements and ratios were taken to analyse their relationship with the perception of facial attractiveness and MCS. RESULTS: The overall attractiveness rating was 4.3 ± 1.1, while the mean MCS was 3.4 ± 1.1. In young males, there was a significant correlation between attractiveness and the zygoma-mandible angle (ZMA)2 (r= - 0.553; p= 0.011). In young and middle-aged females, MCS was significantly correlated with facial width (FW)1-FW2 ratio (r= 0.475; p= 0.034). For all male individuals, a ZMA1 value of 171.79 degrees (Y= 0.313; p= 0.024) was the most robust cut-off to determine facial attractiveness. The majority of human evaluators (n=62; 51.7%) considered facial implants a potential treatment to improve the patient's facial attractiveness. CONCLUSION: This study introduced novel metrics of facial attractiveness, focusing on the facial skeleton. Our findings emphasized the significance of zygomatic measurements and mandibular projections for facial aesthetics, with FI representing a promising surgical approach to optimize facial aesthetics. 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 .

The Influence of Scar Patterns After Reduction Mammoplasty on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

BACKGROUND: Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars. METHODS: 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers. RESULTS: The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern. CONCLUSION: The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern. 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 .

Investigating the Contraction Pattern of the Zygomaticus Major Muscle and its Clinical Relevance: A Functional MRI Study.

BACKGROUND: Our understanding of facial anatomy has significantly evolved, yet the detailed contraction patterns of facial muscles and their presentation during clinical imaging remain largely unexplored. Understanding the contraction patterns and visual presentation of these muscles, particularly the zygomaticus major could enhance pre-surgical facial assessments and the development of new treatment strategies. METHODS: A total of 34 healthy young individuals (17 female, 17 male) with a mean age of 23.6 (2.4) years [range: 20-30] were investigated regarding the length, thickness, width, and angle of the zygomaticus major muscle in five different facial expressions (i.e., repose, anger, joy, surprise, and sadness) utilizing MR imaging. RESULTS: Joyful expressions caused a reduction in muscle length to 85.6% of its original length and an increase in width (103.4%), thickness (108.4%), and facial angle (2.72°) when compared to that in repose, suggesting isotonic contraction. Conversely, expressions of anger, surprise, and sadness generally led to muscle stretching, seen through changes in length (98.9%, 104.3%, and 102.7%, respectively), width (98.8%, 96.5%, and 99.4%, respectively), and thickness (91.2%, 91.0%, and 102.7%, respectively), with variable alterations in facial angle (0.55°, 1.85°, and 1.00°, respectively) depending on the specific expression. CONCLUSION: This MRI-based study indicates that the zygomaticus major muscle experiences isotonic contraction, characterized by decreased length and increased width and thickness. The findings underline the importance of muscle thickness as a reliable parameter in assessing facial muscle function and offer valuable guidance for practitioners in accurately evaluating muscle performance during different facial expressions. 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 .

Understanding the Interplay Between Skin, Fascia, and Muscles of the Midface in Facial Aging.

BACKGROUND: Surgical, minimally-invasive, and non-invasive aesthetic procedures try to ameliorate the signs of facial aging, but also focus on enhancing various individual features of beauty in each patient. Herein, the midface plays a central role due to its location but also its importance for the aesthetic perception and facial expression. OBJECTIVE: To date, no study has investigated the interplay between facial muscles and its connecting subdermal architecture during facial aging to provide a more comprehensive understanding of the middle face. MATERIALS AND METHODS: A total of 76 subjects, consisting of 30 males (39.5%) and 46 females (60.5%) with a mean age of 42.2 (18.7) years [range 19-80] and a mean BMI of 24.6 (3.7) kg/m2 [range 18-35], were enrolled in this investigation. Cutometry (skin aging), 3D skin displacement analyses (subdermal connective tissue aging), and sEMG (muscle aging) analyses were utilized. RESULTS: The results revealed that overall skin firmness increased, and skin elasticity decreased (p < 0.001), sEMG signal of the investigated muscles decreased (p < 0.001), whereas midfacial mobility remained unaltered (p = 0.722). CONCLUSION: The results of this study indicate that midfacial aging is a measurable effect when utilizing individual measurement modalities for assessing skin, subdermal fascia, and midfacial muscles. The function of midfacial muscles revealed a potential threshold effect, which is not reached during midfacial aging due to the unchanged soft tissue mobility at older age. However, to understand its clinical presentation all midfacial soft tissues need to be factored in and a holistic picture needs to be created. 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 .

Eye-Tracking Insights into the Perception of Buttocks.

BACKGROUND: Aesthetic enhancements to the buttock region have grown in demand due to media influence and evolving beauty standards. Using eye-tracking technology, we sought to uncover subconscious visual preferences regarding the buttock aesthetic. The objective of this investigation was to assess visual gaze patterns in assessing female buttocks among Caucasian and Asians through eye-tracking technology. MATERIALS AND METHODS: 67 participants viewed photographs of buttocks from various angles, and eye movements were analyzed using the Tobii Pro Nano eye-tracker. RESULTS: Males fixated on the intergluteal cleft for 0.96 ± 1.1 s and the thigh gap for 0.07 ± 0.2 s; while, females fixated for 0.81 ± 0.9 s and 0.06 ± 0.2 s on the same regions, respectively. Significant gender differences were observed in the intergluteal cleft (p = 0.002) and upper lateral buttock (p < 0.001). CONCLUSION: This study offers new insights into the observation of buttocks. The consistent attention toward the intergluteal cleft across demographics could be of potential significance in the aesthetic perception of buttocks. However, diverse gaze patterns also underscore the multifaceted nature of human attraction. These findings hold implications for plastic surgery, aesthetic medicine, and the sociocultural understanding of beauty. A deeper dive into aesthetic preferences is pivotal for a holistic understanding of human perceptions of attractive buttocks. LEVEL OF EVIDENCE III: 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 .

Surgical Management of Breast Capsular Contracture-A Multi-institutional Data Analysis of Risk Factors for Early Complications.

BACKGROUND: Capsular contracture (CC) is a common complication following implant-based breast surgery, often requiring surgical intervention. Yet, little is known about risk factors and outcomes following CC surgery. METHODS: We reviewed the American College of Surgeons National Surgical Quality Improvement Program database (2008-2021) to identify female patients diagnosed with CC and treated surgically. Outcomes of interest included the incidence of surgical and medical complications at 30-days, reoperations, and readmissions. Confounder-adjusted multivariable analyses were performed to establish risk factors. RESULTS: 5,057 patients with CC were identified (mean age: 55 ± 12 years and mean body mass index [BMI]: 26 ± 6 kg/m2). While 2,841 (65%) women underwent capsulectomy, capsulotomy was performed in 742 patients (15%). Implant removal and replacement were recorded in 1,160 (23%) and 315 (6.2%) cases, respectively. 319 (6.3%) patients experienced postoperative complications, with 155 (3.1%) reoperations and 99 (2.0%) readmissions. While surgical adverse events were recorded in 139 (2.7%) cases, 86 (1.7%) medical complications occurred during the 30 day follow-up. In multivariate analyses, increased BMI (OR: 1.04; p = 0.009), preoperative diagnosis of hypertension (OR: 1.48; p = 0.004), and inpatient setting (OR: 4.15; p < 0.001) were identified as risk factors of complication occurrence. CONCLUSION: Based on 14 years of multi-institutional data, we calculated a net 30 day complication rate of 6.3% after the surgical treatment of CC. We identified higher BMI, hypertension, and inpatient setting as independent risk factors of postoperative complications. Plastic surgeons may wish to integrate these findings into their perioperative workflows, thus optimizing patient counseling and determining candidates' eligibility for CC surgery. LEVEL OF EVIDENCE III: 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 .

Turn Your Vision into Reality-AI-Powered Pre-operative Outcome Simulation in Rhinoplasty Surgery.

BACKGROUND: The increasing demand and changing trends in rhinoplasty surgery emphasize the need for effective doctor-patient communication, for which Artificial Intelligence (AI) could be a valuable tool in managing patient expectations during pre-operative consultations. OBJECTIVE: To develop an AI-based model to simulate realistic postoperative rhinoplasty outcomes. METHODS: We trained a Generative Adversarial Network (GAN) using 3,030 rhinoplasty patients' pre- and postoperative images. One-hundred-one study participants were presented with 30 pre-rhinoplasty patient photographs followed by an image set consisting of the real postoperative versus the GAN-generated image and asked to identify the GAN-generated image. RESULTS: The study sample (48 males, 53 females, mean age of 31.6 ± 9.0 years) correctly identified the GAN-generated images with an accuracy of 52.5 ± 14.3%. Male study participants were more likely to identify the AI-generated images compared with female study participants (55.4% versus 49.6%; p = 0.042). CONCLUSION: We presented a GAN-based simulator for rhinoplasty outcomes which used pre-operative patient images to predict accurate representations that were not perceived as different from real postoperative outcomes. LEVEL OF EVIDENCE III: 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 .

Gynecomastia Surgery in 4996 Male Patients Over 14 Years: A Retrospective Analysis of Surgical Trends, Predictive Risk Factors, and Short-Term Outcomes.

BACKGROUND: The high prevalence of benign male breast tissue enlargement (gynecomastia) has resulted in a marked increase of gynecomastia cases. While about one third of male adults experience some form of gynecomastia, gynecomastia surgery (GS) outcome research is limited to small study populations and single-center/-surgeon databases. In this study, we aimed to access the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database to identify preoperative risk factors for complications and investigate postoperative outcomes of GS. METHODS: In this retrospective study, we queried the ACS-NSQIP database from 2008 to 2021 to identify male adult patients who underwent GS. Postoperative outcomes involved the occurrence of any, surgical and medical complications, as well as reoperation, readmission, and mortality within a 30-day postoperative time period. Univariable and multivariable assessment were performed to identify risk factors for complications while adjusting for possible confounders. RESULTS: The study included 4,996 GS patients with a mean age of 33.7 ± 15 years and BMI of 28.2 ± 5.1 kg/m2. White patients constituted 54% (n = 2713) of the cohort, and 27% (n = 1346) were obese. Except for 2020, there was a steady increase in GS cases over the study period. Outpatient surgeries were most common at 95% (n = 4730), while general surgeons performed the majority of GS (n = 3580; 72%). Postoperatively, 91% (n = 4538) of patients were discharged home; 4.4% (n = 222) experienced any complications. Multivariable analysis identified inpatient setting (p < 0.001), BMI (p = 0.023), prior sepsis (p = 0.018), and bleeding disorders (p = 0.047) as independent risk factors for complications. CONCLUSION: In this study, we analyzed 4996 male adult GS patients from the ACS-NSQIP database, revealing an increased caseload and significant general surgeon involvement. Risk factors like bleeding disorders, inpatient status, and prior sepsis were linked to postoperative complications, while BMI was crucial for predicting adverse events. Overall, our findings may aid in enhancing patient care through advanced preoperative screening and closer perioperative management. LEVEL OF EVIDENCE III: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Understanding Platysma Muscle Contraction Pattern and Its Relationship to Platysmal Banding: A Real-Time Ultrasound Study.

BACKGROUND: Addressing neck contouring with surgical and nonsurgical aesthetic procedures includes understanding the origin of platysmal banding. A theory was postulated to explain this phenomenon by isometric vs isotonic muscular contraction patterns. However, no scientific proof had been provided to date for its correctness. OBJECTIVES: The aim of this study was to confirm the correctness of the platysmal banding theory based on isometric vs isotonic muscular contractions. METHODS: Eighty platysma muscles from 40 volunteers (15 males and 25 females) were investigated (mean age 41.8; SD 15.2 years; mean BMI of 22.2; SD 2.3 kg/m2). Real-time ultrasound imaging was utilized to measure the increase in local muscle thickness inside and outside of a platysmal band as well as platysma mobility. RESULTS: Within a platysmal band, the local thickness of the muscle increases during muscular contractions by 0.33 mm (37.9%; P < .001). Outside of a platysmal band the thickness of the platysma muscle decreased by 0.13 mm (20.3%; P < .001). It was identified that within a platysmal band no gliding was detectable, whereas outside of a band an average muscle gliding of 2.76 mm was observed. CONCLUSIONS: The results confirm the correctness of the isometric vs isotonic platysma muscle contraction pattern theory: isotonic muscle contraction (gliding without increase in tension and therefore in muscle thickness) vs isometric muscle contraction (no gliding but increase in tension and therefore in muscle thickness). These 2 types of contraction patterns occur within the platysma simultaneously and are an indicator for zones of adhesion in the neck to guide surgical and nonsurgical aesthetic procedures.

Increasing Precision When Targeting the Depressor Anguli Oris Muscle With Neuromodulators: An Ultrasound-Based Investigation.

BACKGROUND: Neuromodulator treatments of the perioral region are increasingly popular and aim to modulate the position of the modiolus. The predominantly targeted muscle is the depressor anguli oris (DAO) which allows for the modiolus to reposition cranially once temporarily relaxed. OBJECTIVES: The aim of this study was to identify the precise anatomic position of the DAO in relation to the marionette line, thereby increasing precision and reducing adverse events during neuromodulator treatments. METHODS: A total of n = 80 DAO muscles were investigated in n = 40 healthy, toxin-naïve volunteers (11 males, 29 females) with a mean [standard deviation] age of 48.15 [15] years and a mean BMI of 24.07 [3.7] kg/m2. The location of the DAO in relation to the labiomandibular sulcus, and its depth, extent, and thickness were investigated with high-frequency ultrasound imaging. RESULTS: The skin surface projection of the labiomandibular sulcus separates the DAO into medial and lateral portions. The distance between skin surface and muscle surface was on average 4.4 mm, with males having a greater distance (P < .001) and higher BMI being an important influencing factor for a greater distance (P < .001). The thickness of the DAO was on average 3.5 mm, with a range of 2.8 to 4.8 mm and with females having thinner muscles compared with males (P < .001). The most favorable injection depth was calculated to be 6.1 mm for intramuscular product placement. CONCLUSIONS: Understanding the perioral anatomy and the influence of age, sex, and BMI will potentially allow injectors to increase the efficacy and duration of neuromodulator treatments while expertly managing adverse events.

Identifying Levels of Competency in Aesthetic Medicine: A Questionnaire-based Study.

BACKGROUND: In 2022, the US experienced a significant increase in demand for minimally invasive aesthetic procedures, underscoring its rising acceptance amid an unregulated educational environment for practitioners. The absence of standardized educational pathways and quality control in aesthetic medicine, primarily provided by nonacademic institutions, highlights a critical need for establishing educational standards to ensure practitioner competence and patient safety. OBJECTIVES: The aim of this study was to identify levels of competency for the aesthetic practitioner and necessary achievement milestones during the educational path from novice to expert injector. METHODS: A total of n = 386 international study participants responded to an online questionnaire regarding their experience in aesthetic medicine practice. The questionnaire comprised 58 questions focusing on professional data, the perceived difficulty of injection, and risk for the occurrence of adverse events for specific facial regions in soft tissue filler and toxin injections. RESULTS: Regardless of medical specialty and experience level, averages of 3.85 (1.8) years, 786.4 (2628) filler injections and 549.9 (1543) toxin injections were estimated to progress from novice to advanced injector, while averages of 6.10 (3.7) years, 1842.2 (4793) filler injections, and 1308.5 (3363) toxin injections were estimated to advance from advanced to expert injector. The nose and the perioral region have been ranked as the facial regions where it is most difficult to achieve a perfect aesthetic outcome and with the greatest risk for the occurrence of adverse events for filler and toxin injections, respectively. CONCLUSIONS: In this study we establish an educational framework in aesthetic medicine by defining the progression from novice to competent and expert injector levels, suggesting 4 years of practice and over 790 filler and 550 neuromodulator injections for competence, and at least 6 years with 1840 filler and 1310 neuromodulator injections for expertise. We also identify critical facial regions for targeted treatments by different expertise levels.

The perception of lip aesthetics in the context of facial proportions-An eye-tracking-based analysis.

BACKGROUND: Minimally invasive lip volumizing and contouring soft tissue filler procedures are frequently requested by both female and male aesthetic patients. Guidance on how to achieve the most beautiful outcome is inconsistent. OBJECTIVE: To investigate what the most beautiful proportions are in relation to vermillion thickness, the distance of the upper and lower lip in relation to nose and chin, and relation to the bigonial distance. METHODS: This study included a total of n = 101 volunteers (52 females, 49 males, 100% Caucasian) who inspected frontal images of modified facial proportions and answered a related questionnaire showcasing the same images. Image presentation followed a randomized sequence both for the eye tracking and for the survey component of this study but was equal for all observers. RESULTS: The most attractive vertical position of lips was the 1:2 ratio in which the distance between lips and chin is double the length as the distance between lips and nose. For the ratio between the width of the lips and the bigonial distance, it was the 1:2.5 ratio, whereas for the thickness of the upper lip vermilion in relation to the upper lip ergotrid it was the 1:3/1:2 (male/female) ratio and for the lower lip vermilion and lower lip ergotrid it was the 1:4 ratio for both genders. CONCLUSION: The results of this eye tracking and survey-based investigation revealed that instead of one single universal ratio, multiple facial proportions exist that are perceived as most attractive/masculine/feminine. Regarding the perception of facial aesthetics, it appears there is a distinction between attractiveness and masculinity/femininity: the most attractive male/female face is not necessarily the most masculine or feminine.

ChatGPT's quiz skills in different otolaryngology subspecialties: an analysis of 2576 single-choice and multiple-choice board certification preparation questions.

PURPOSE: With the increasing adoption of artificial intelligence (AI) in various domains, including healthcare, there is growing acceptance and interest in consulting AI models to provide medical information and advice. This study aimed to evaluate the accuracy of ChatGPT's responses to practice quiz questions designed for otolaryngology board certification and decipher potential performance disparities across different otolaryngology subspecialties. METHODS: A dataset covering 15 otolaryngology subspecialties was collected from an online learning platform funded by the German Society of Oto-Rhino-Laryngology, Head and Neck Surgery, designed for board certification examination preparation. These questions were entered into ChatGPT, with its responses being analyzed for accuracy and variance in performance. RESULTS: The dataset included 2576 questions (479 multiple-choice and 2097 single-choice), of which 57% (n = 1475) were answered correctly by ChatGPT. An in-depth analysis of question style revealed that single-choice questions were associated with a significantly higher rate (p < 0.001) of correct responses (n = 1313; 63%) compared to multiple-choice questions (n = 162; 34%). Stratified by question categories, ChatGPT yielded the highest rate of correct responses (n = 151; 72%) in the field of allergology, whereas 7 out of 10 questions (n = 65; 71%) on legal otolaryngology aspects were answered incorrectly. CONCLUSION: The study reveals ChatGPT's potential as a supplementary tool for otolaryngology board certification preparation. However, its propensity for errors in certain otolaryngology areas calls for further refinement. Future research should address these limitations to improve ChatGPT's educational use. An approach, with expert collaboration, is recommended for the reliable and accurate integration of such AI models.

Facial Anthropometric Measurements and Principles - Overview and Implications for Aesthetic Treatments.

Facial anatomy is highly individual in each patient. Anthropometric measurements can be a useful tool to objectively analyze individual facial anatomy to allow for better comparability before and after treatments to ultimately improve standardization of facial procedures, both nonsurgical and surgical. The aim of this study was to provide a comprehensive overview over clinically relevant and feasible facial anthropometric measurements and principles for aesthetic medicine. A literature review was conducted to describe the most important and clinically relevant anthropometric measurements and principles for both the entire face and for three aesthetically relevant facial regions: the periorbital region, the nose, and the perioral region. A multitude of different anthropometric measurements and principles have been described in the literature for both the overall facial appearance and specific facial regions. Certain generally accepted anthropometric principles and proportions need to be respected to achieve aesthetic and harmonious results. For the overall facial appearance, a focus on symmetry, certain proportions, facial angles, and indices has been described. Principles and measurements were also described for the periorbital region, the nose, and the perioral region. Although attractiveness and aesthetic perception are subjective, objective evaluation of facial surface anatomy via anthropometric measurements can improve pre- and postinterventional analysis of the face and help the treating physician to individualize treatments, both nonsurgical and surgical.

Multimodal Analyses of the Aging Forehead and Their Clinical Implications.

BACKGROUND: Recent research has indicated that in the upper face a delicate arrangement exists between the muscles of facial expression and the skin. This arrangement allows for immediate transmission of movements following muscle contraction, resulting in skin movements and skin rhytid formation. OBJECTIVES: To investigate age-related changes of the biomechanical unit formed by facial muscles, their connective tissue envelope, and the skin of the upper face. METHODS: A total of 76 Caucasian volunteers (30 males, 46 females) with a mean age of 42.2 years (SD 18.6) and a mean body mass index of 24.58 kg/m2 (SD 3.7) were investigated. Three upper facial regions were analyzed for skin firmness and elasticity with cutometric assessment, vertical and horizontal skin vector displacement using 3-dimensional imaging, and muscle activity with surface-derived electromyography. RESULTS: Study participants of older age (>42.2 years), when compared with younger participants (≤42.2 years), showed increased skin firmness, at 0.20 mm vs 0.30 mm (P < .001); decreased skin elasticity at 53.2% vs 69.0% (P < .001); increased vertical (not horizontal) skin mobility at 3.56 mm vs 1.35 mm (P < .001); and decreased surface-derived electromyography (sEMG) signal of the frontalis muscle with 174 µV vs 309 µV (P = .039). CONCLUSIONS: This study reveals that age-related changes occur in each component of the biomechanical unit formed by facial muscles, connective tissue envelope, and skin in the upper face. Knowledge and understanding of such changes can allow for more targeted and individualized surgical and nonsurgical aesthetic treatments.

Ex Vivo Product Distribution of Injectable Biostimulator Substances.

BACKGROUND: Increasing demand for minimally invasive aesthetic treatments, such as injection of biostimulator substances to induce the production of extracellular matrix, has been reported. Recent studies have reported on a variety of different product characteristics influencing the integration and distribution of biostimulator substances after injection. OBJECTIVES: The aim of this study was to analyze the ex vivo product integration and distribution behavior of 6 different biostimulator substances after injection. METHODS: A total of n = 21 abdominal soft tissue flaps were analysed by real-time ultrasound imaging with regards to horizontal and vertical spread of 6 different injected biostimulator substances-based on hydroxylapatite (HA), polycaprolactone (PCL), and poly-L-lactic acid (PLLA)-immediately after injection and after massaging. The 6 different biostimulator substances were R-CaHA-based, H-CaHA-based, PCL-based, PLLA-1-based, PLLA-2-based and H-HA-based products. RESULTS: Overall, the R-CaHA-, H-CaHA-, and PCL-based substances showed greater product spread after massaging when compared with the product distribution immediately after the injection with all P < .001 with the exception of the vertical dimension of the H-CaHA-based substance (P = .064). The PLLA-1-, PLLA-2-, and H-HA-based substances showed smaller product spread after massaging compared with the product distribution immediately after the injection with all P < .001 with the exception of the horizontal dimension of the H-HA-based substance (P = .314), indicating higher tissue integration. CONCLUSIONS: Different biostimulator substances behave differently when injected into subcutaneous soft tissues; differences exist at the level of initial product diffusion and during tissue integration.

Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management.

BACKGROUND: Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable of enzymatically degrading the injected product and improving clinical symptoms. Two protocols are currently available to manage such complications: "ultrasound-guided targeted" and "flooding". OBJECTIVES: The aim of this study was to compare the 2 protocols in terms of the volume of hyaluronidase utilized, and the onset and degree of clinical improvement. METHODS: A comparative case series of 39 patients was retrospectively evaluated. The patients were initially treated with the "flooding" protocol and then treated with the "ultrasound-guided targeted" protocol due to no or little improvement. RESULTS: The "ultrasound-guided targeted" protocol utilized a mean [standard deviation] total of 122.5 [34] IU of hyaluronidase, whereas the "flooding" protocol utilized 1519.4 [1137] IU, which represents a statistically significant reduced amount of injected hyaluronidase (P = 0.028). There was no clinical improvement in 92.3% and only little improvement in 7.7% of the treated patients following the first applied "flooding" protocol, but there was a 100% immediate improvement when subsequently treated with the "ultrasound-guided targeted" protocol. Ultrasound imaging revealed that the application of hyaluronidase restored normal blood flow both in the perivascular space and in the superficially located subdermal soft tissues. CONCLUSIONS: Despite its limitations in study design, this retrospectively evaluated case series revealed that the "ultrasound-guided targeted" protocol utilized less hyaluronidase and restored clinically visible symptoms faster. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies.