Lower Eyelid Dark Circles (Tear Trough and Lid-Cheek Junction): A Stepwise Assessment Framework.

BACKGROUND: Despite increasing popularity, the use of hyaluronic acid (HA) fillers for the correction of dark under-eye shadows remains challenging. Specific guidance on patient assessment is limited. OBJECTIVES: The aim of this study was to develop a stepwise assessment framework for lower eyelid dark shadows to help practitioners classify patients based on their underlying problems and facilitate a more strategic approach to treatment. METHODS: Literature review and peer collaboration informed the current availability of educational material for use by experienced injectors when assessing patients presenting with dark circles. A practitioner survey provided insight into current practices. A focus group convened to review the survey results and discuss best practice approaches to patient assessment. RESULTS: Surveyed practitioners (n = 39) reported patient concern about under-eye hollows (91%), dark eye circles (80%), and looking tired (60%). All (100%) agreed that midcheek volume was critical when treating tear-trough depression, and only 26% reported use of a tear-trough classification system. The focus group developed a framework for assessing tear-trough depression and the lid-cheek junction in patients presenting with dark circles. Key factors within this framework included the importance of appropriate lighting when conducting a visual inspection, regional inspection of the cheek and tear trough, palpation of the orbital rim and soft tissues, determination of the orbital vector, and assessment of lower eyelid pigmentation and skin quality. CONCLUSIONS: Careful step-by-step assessment can reduce the challenges of treating dark circles by identifying patients in whom dark eye circles may be improved without the need to directly inject filler into the tear trough.

Chin Microgenia: An Anthropometric Analysis on the Prevalence and Severity in a Chinese Population.

BACKGROUND: The chin is an important component of facial harmony, and deficient chins are associated with unattractiveness. Previous studies have reported microgenia as the most common subtype of chin deformities. OBJECTIVE: To investigate the prevalence and severity of microgenia in a Chinese population through facial anthropometric analysis. METHODS: A total of 800 Han Chinese adults from various age groups of both sexes were recruited for facial anthropometric measurements and photographic analysis. Chin deficiencies in both sagittal and vertical dimensions were evaluated using G-S-P angle, chin retrusion distance, and Sn-Vl/Sn-Me ratio criteria. RESULTS: In the sagittal dimension, microgenia was present in 60.7% of men and 68.6% of women according to the G-S-P angle criterion, and the angle significantly decreased with age in women (p < .05). According to the chin retrusion criterion, microgenia was present in 38.7% of men and 32.3% of women, and the retrusion distance significantly increased with age in both sexes (p < .05). Vertical microgenia was present in 69.6% of men and 81.9% of women according to the Sn-Vl/Sn-Me criterion, and the ratio gradually increased with age in both sexes (p < .05). CONCLUSION: Microgenia is common among Chinese, particularly in women, and the prevalence and severity increase with age.

Tear Trough and Lid-Cheek Junction Anatomy: Current Understanding and Nonsurgical Treatment.

The tear trough and lower eyelid are sentinel sites of facial aging and are increasingly the target of nonsurgical aesthetic procedures. This article will review the advances that have led to our current understanding of tear trough anatomy. We propose a new functional classification of the lid-cheek junction for soft tissue filler treatment, and suggest simpler stratification of patients seeking lower eyelid treatment based on the etiology of their tear trough depression. We aim to describe a stepwise approach to management, with specific technical considerations targeting the underlying causes of lower eyelid pathology. The common complications and pitfalls of nonsurgical tear trough management will be discussed.

Movement of the Syringe During Filler Aspiration: An Ultrasound Study.

BACKGROUND: Aspiration prior to hyaluronic acid filler injection is often taught as a safety maneuver to minimize the risk of intravascular injection; however, the validity of this technique in aesthetic practice is being increasingly challenged. One key assumption underpinning the validity of the aspiration test is that the needle tip does not move during the aspiration and subsequent injection of filler. OBJECTIVES: The aim of this study was to visualize and measure needle tip movement in real time during aspiration and injection of filler. Secondary objectives were to assess the impact of injector experience and double-handed versus single-handed aspiration technique in maintaining stability of the syringe. METHODS: Under real-time ultrasound visualization, 3 injectors with different levels of experience injected hyaluronic acid filler into pork belly tissue utilizing both double-handed and single-handed aspiration techniques. Needle tip movements were recorded and measured by means of ultrasound and video. RESULTS: The aspiration maneuver is in all cases associated with retrograde movement of the needle tip, ranging from 1.1 to 5.3 mm (mean, 2.9 mm), whereas injection leads to anterograde movement ranging from 0.6 to 4.1 mm (mean, 1.9 mm). Double-handed aspiration is associated with less needle tip movement than single-handed aspiration (P = 0.037). Greater experience is also associated less movement of the needle tip (P < 0.0001). CONCLUSIONS: In all cases, the aspiration and injecting maneuver is associated with micromovements of the needle tip, of a magnitude consistently significant relative to the typical size of facial vessels. Although needle tip movement is only a single factor limiting the usefulness of the aspiration test, the results of this study suggest that it is not advisable to rely only on aspiration as a method to prevent intravascular injection.

Aspiration Before Tissue Filler-An Exercise in Futility and Unsafe Practice.

BACKGROUND: Aesthetic physicians rely on certain anecdotal beliefs regarding the safe practice of filler injections. These include a presumed safety advantage of bolus injection after a negative aspiration. OBJECTIVES: The authors sought to review and summarize the published literature on inadvertent intravascular injection of hyaluronic acid and to investigate whether the technique of aspiration confers any safety to the practitioner and the patient. METHODS: Pertinent literature was analyzed and the current understanding of the safety of negative and positive aspiration outlined. RESULTS: The available studies demonstrate that aspiration cannot be relied on and should not be employed as a safety measure. It is safer to adopt injection techniques that avoid injecting an intravascular volume with embolic potential than utilize an unreliable test to permit a risky injection. CONCLUSIONS: To prevent intravascular injection, understanding "injection anatomy" and injection plane and techniques such as slow, low-pressure injection are important safety measures. Assurance of safety when delivering a bolus after negative aspiration does not appear to be borne out by the available literature. If there is any doubt about the sensitivity or reliability of a negative aspiration, there is no role for its utilization. Achieving a positive aspiration would just defer the risk to the next injection location where a negative aspiration would then be relied on.

Influence of Rheological Properties and Needle Size on Extrusion Forces of Hyaluronic Acid Based Soft Tissue Fillers.

BACKGROUND: To date no precise data are available for extrusion forces related to the G-prime and G-double-prime of fillers in combination with different 27G and 30G needles. Therefore, the objective of this study was to analyze extrusion forces of various product-needle-combinations containing two different 27G and two different 30G needles in combination with fillers of a wide range of elastic moduli starting from 2.0 – 166.0 Pa. MATERIAL AND METHODS: Four different fillers with the following elastic moduli 1.87, 11.65, 61.80, 165.50 Pa were combined with four different needles: 27G ½”, internal diameter: 0.300 μm; 27G ½”, internal diameter: 0.241 μm; 30G ½”, internal diameter: 0.241 μm and 30G ½“, internal diameter: 0.240 μm. Product-needle-combination were subjected to uni-axial mechanical testing and the respective extrusion force was measured. RESULTS: The results of this study revealed that the G-prime and the G-double-prime of a product are statistically significantly related to their extrusion force, with higher G-prime/G-double-prime products requiring higher extrusion forces. The results additionally revealed that whether the size of the needle was described as 27G or 30G by the respective manufacturer statistically significant differences between the measured extrusion forces were detected. CONCLUSION: Injectors need to be aware that not every 27G/30G needle has the same extrusion force even though the external diameter is similar (27G or 30G); this might additionally influence the ability to withdraw blood during a pre-injection aspiration manoeuvre. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5237.

The Facial Aging Process From the "Inside Out".

The normal course of aging alters the harmonious, symmetrical, and balanced facial features found in youth, not only impacting physical attractiveness but also influencing self-esteem and causing miscommunication of affect based on facial miscues. With this evidence-based paper, the authors aim to provide a comprehensive overview of the latest research on the etiology and progression of facial aging by explaining the aging process from the "inside out," that is, from the bony platform to the skin envelope. A general overview of the changes occurring within each of the main layers of the facial anatomy is presented, including facial skeleton remodeling, fat pad atrophy or repositioning, changes in muscle tone and thickness, and weakening and thinning of the skin. This is followed by an in-depth analysis of specific aging regions by facial thirds (upper, middle, and lower thirds). This review may help aesthetic physicians in the interpretation of the aging process and in prioritizing and rationalizing treatment decisions to establish harmonious facial balance in younger patients or to restore balance lost with age in older patients.

Comparison of Single- Versus Dual-Vector Technique Using Facial Suspension Threads: A Cadaveric Study Using Skin Vector Displacement Analysis.

BACKGROUND: Facial suspension threads have been successfully used for facial soft-tissue repositioning. When using facial suspension threads, it is unclear which technique and/or material has the greatest lifting effect for the middle and lower face or which technique/material best reduces the appearance of the jowls. MATERIAL AND METHODS: Three female and 2 male cephalic specimens of Caucasian ethnicity (65.2 ± 8.3 years; 20.72 ± 2.6 kg/m) were analyzed in an upright secured position. Polydioxanone and polycaprolactone bidirectional barbed facial suspension threads were introduced by an 18 G, 100 mm cannula. The single-vector technique aimed toward the labiomandibular sulcus, and the dual-vector technique aimed toward the labiomandibular sulcus and the mandibular angle. Computation of vertical lifting, horizontal lifting, and volume reduction at the jowls and along the jawline were calculated using 3D imaging. RESULTS: The dual-vector technique effected a greater vertical lifting effect (4.45 ± 2.78 mm vs 2.99 ± 2.23 mm) but a reduced horizontal lifting effect (0.33 ± 1.34 mm vs 0.49 ± 1.32 mm). The dual-vector technique effected less volume reduction at the jowls 0.32 ± 0.24 cc versus 0.41 ± 0.46 cc and less volume reduction along the jawline 0.46 ± 0.48 cc versus 0.87 ± 0.53 cc (dual-vector vs single-vector). CONCLUSION: This study provides evidence resulting from cadaveric observations for the overall nonsuperiority of the dual-vector technique compared with the single-vector technique.

Facial aesthetic injections in clinical practice: Pretreatment and posttreatment consensus recommendations to minimise adverse outcomes.

Facial aesthetic treatment with injectable neuromodulators and hyaluronic acid fillers is well established, with favourable safety profiles and consistent outcomes. As with any medical treatment, adverse events and complications may occur. Adverse events associated with these products are typically transient and mild to moderate in severity. Serious adverse events, such as infection and intravascular occlusion, are rare. Proper patient selection, consent and counselling, preparation and impeccable injection technique are important risk reduction strategies. Both clinicians and patients must be alert to the signs and symptoms of complications so that appropriate treatment can be started promptly. In this article, the authors review the current literature and provide their consensus recommendations for minimising adverse outcomes when treating patients with botulinum toxin or hyaluronic acid fillers.

Re Facial aesthetic injections in clinical practice: Pretreatment and post-treatment consensus recommendations to minimise adverse outcome Region-specific changes in line with the Covid-19 pandemic.

Despite the recent publication in March 2020 of guidelines for facial injectable treatments, the speed of the COVID-19 pandemic and its safety implications necessitate changes to these guidelines The authors described what would constitute safest practice in the provision of facial injectable treatments and summarised these in table form. Adherence to a high standard of asepsis and infectious disease precautions remain a key patient safety requirement when performing facial aesthetic injections. A revision and update of these guideline summary tables follows. Changes made should enhance both patient and staff safety regarding COVID-19/SARS-CoV-2, a highly infective respiratory pathogen transmitted by respiratory droplets, respiratory/mucosal secretions and contaminated fomites. Some of the additions are COVID-19 specific and are likely to evolve and change, particularly should serological tests determining acquired immunity become available. Other additions represent further tightening of our infection control precautions.