Publications by authors named "Konstantin Frank"

128 Publications

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

Aesthet Surg J 2022 Aug 11. Epub 2022 Aug 11.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN.

Background: Adverse vascular event management following hyaluronic acid-based aesthetic injections relies on the administration of hyaluronidase which is capable to enzymatically degrade the injected product and to improve clinical symptoms. Two protocols are currently available to manage such complications: "ultrasound guided targeted" and "flooding".

Objectives: To compare the 2 protocols by means of amount of hyaluronidase volume utilized, and onset and degree of clinical improvement.

Methods: A comparative case series of 39 patients was retrospectively evaluated which were initially treated with the "flooding" protocol and then treated with the "ultrasound guided targeted" due to no or little improvement.

Results: The "ultrasound-guided targeted" protocol utilized a total of 122.5 iu (34) whereas the "flooding" protocol utilized 1519.4 iu (1137) which represents a statistically significant reduced amount of injected hyaluronidase with 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 treated with the "ultrasound-guided targeted" protocol. Ultrasound imaging revealed that the application of hyaluronidase normal blood flow was restored 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 material and restored faster clinically visible symptoms. The effect of this protocol is best explained by the perforasome concept which will need to be investigated further in future studies.
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http://dx.doi.org/10.1093/asj/sjac227DOI Listing
August 2022

[Change of Gaze Pattern depending on the Stage of DIEP Flap Breast Reconstruction: a Preliminary Eye-Tracking Investigation].

Handchir Mikrochir Plast Chir 2022 Aug 9;54(4):356-362. Epub 2022 Aug 9.

Klinikum der Universität München, LMU München Abteilung für Hand-, Plastische und Ästhetische Chirurgie.

Background: Breast reconstruction using autologous tissue is an integral part of breast cancer treatment. While many studies have elucidated the impact of breast reconstruction on patients' quality of life, self-esteem, sexuality and more, there is a lack of objective data regarding the effects on external observers. Aim of this study was to investigate the change in gaze pattern of independent observers depending on the stage of DIEP-flap breast reconstruction.

Materials And Methods: Eye-tracking technology was utilized to analyze the eye movements of 58 study participants while viewing 2 D photographs of a patient after mastectomy and different stages of DIEP-flap breast reconstruction. Time until first fixation and total time of fixation were recorded and con- secutively analyzed for the right and left breast on each image.

Results: Overall, the total time of fixation of the operated breast decreased significantly over the different stages of breast reconstruction, with p<0.001. At the same time, there was no statistically significant change in total time of fixation of the non-operated breast, with p=0.174. The time until first fixation showed a significant increase over the different stages of reconstruction for the reconstructed breast, with p<0.001, while no significant differences were found for the opposite breast, with p=0.344.

Conclusion: Mastectomy and the individual steps of breast reconstruction alter the perception of breast cancer patients. Over the course of breast reconstruction, the deviation of gaze in the direction of the affected breast is reversed.
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http://dx.doi.org/10.1055/a-1794-5951DOI Listing
August 2022

Pathogens and Shift of Resistance in Early Infections after Operative Fracture Fixation.

Surg Infect (Larchmt) 2022 Aug;23(6):583-589

Division of Hand, Plastic, and Aesthetic Surgery, Munich University Hospital, LMU, Munich, Germany.

Surgical site infections (SSIs) remain a challenge for the healthcare system. During the last 30 years, the literature has shown an increase of gram-negative bacterial strains in multiple infectious sites and that cephalosporins have replaced penicillin as the gold standard in peri-operative antibiotic prophylaxis. This study aims to examine the recent bacterial spectrum in orthopedic early SSIs and to compare it with a historical cohort. Patients in a level 1 trauma center with an SSI within six weeks after open fixation of a fracture were analyzed in two adjacent periods from 2007 to 2012 (data pool 1; DP1) and 2013 to 2017 (data pool 2; DP2), retrospectively. The detected microbiologic pathogens and the associated resistograms from both time periods were compared. Six hundred eighty-one smear tests and respective pathogens from the wounds of 463 patients (mean age, 62.6 ± 20 years) with SSIs were analyzed. The following pathogens were found most frequent: (DP1, 20.6%; DP2, 26.3%), (DP1, 27.1%; DP2, 16.5%), (DP1, 13.7%; DP2, 11.1%), . (DP1, 3.0%; DP2, 5.3%), (DP1, 5.1%; DP2, 4.1%), (DP1, 3.7%; DP2, 2.5%). In DP2, there were lower primary early infection rates with than in DP1 (p = 0.002). In DP2, showed an oxacillin resistance in 90.6% and an increased resistance (79.8%; p = 0.069) to several classes of antibiotic agents compared to DP1. No bacterial shift toward gram-negative species was observed in this investigation. However, showed an increased antibiotic resistance in the more recent patient cohort. The incidence of SSIs with decreased substantially.
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http://dx.doi.org/10.1089/sur.2022.033DOI Listing
August 2022

Invited Discussion on: A 7-Step Guide to High-Definition Liposuction.

Aesthetic Plast Surg 2022 Jul 15. Epub 2022 Jul 15.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany.

Athanasiou et al. present a 7-step guide to high-definition (HD) liposuction in the current issue of Aesthetic Plastic Surgery. [1] The guide was based on the authors vast experience in HD-liposuction performed in 568 patients (247 males and 321 females) with a mean age of 43 years (range, 22-64) and a mean BMI of 25.6 (range 21-29 kg/m) over a 6-year time-period. The authors provide detailed information on their approach regarding pre-operative markings, methods of anesthesia and composition of tumescence solution, incision points and access, surgical technique, and fat transfer. In addition, they performed a time-dependent analysis of the type and quantity of observed complications over the study-period, as well as the mean surgical operative time. 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 http://www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-022-03005-3DOI Listing
July 2022

An open-label, 4-week, prospective clinical study evaluating the efficacy and safety of a novel targeted skin care line addressing five common skin conditions.

J Cosmet Dermatol 2022 Jul 10. Epub 2022 Jul 10.

Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany.

Background: Common skin conditions, such as irritated, dry, aging, and oily skin or dark eye circles with periorbital edema, usually do not require pharmaceutical therapy in form of dermatological drugs. They can, however, still affect the quality of life significantly. With the advent of newer cosmetics, a more targeted treatment of these dermatological conditions has become available to the public. There are few clinical studies investigating the efficacy and safety of cosmetics, leaving consumers exposed to potentially false claims of the cosmetic industry. This study aims to assess the efficacy and safety of a novel skin care series addressing the aforementioned five common skin conditions.

Methods: This open-label, single-center, 4-week, prospective clinical study evaluated the efficacy and safety of five novel skin care formulations, each targeting one of five common skin issues in 176 study subjects. The primary endpoint parameters for the change in irritated skin, dark and puffy eyes, dry skin, aging skin, and oily skin were assessed through validated questionnaires, scales, and biomedical devices.

Results: After 4 weeks of topical application of each formulation of a new targeted skin care, a significant improvement in all primary endpoints was detected. No undesirable effects occurred during this study.

Conclusion: This study showed a significant improvement in five common dermatological conditions with a novel targeted skin care series. Moreover, this study leads the way for an overdue critical assessment and certification of cosmetic product claims.
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http://dx.doi.org/10.1111/jocd.15223DOI Listing
July 2022

Aging of the Neck Decoded: New Insights for Minimally Invasive Treatments.

Aesthetic Plast Surg 2022 Jun 14. Epub 2022 Jun 14.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.

Background: Many signs of aging manifest in the neck region, including platysmal bands, excess skin, horizontal neck lines and decreasing contour of the neck. While the clinical signs of an aged neck are well-known, data determining the underlying aging process are limited.

Objective: To decode aging of the neck.

Materials And Methods: This prospective study investigated elasticity and firmness of skin, muscle activity and skin displacement upon muscular contraction in the neck in 77 young-, middle- and old-age individuals. Objective outcome measures, including 3-dimensional imaging, cutometry and surface electromyography, were utilized for all assessments.

Results: Mean firmness of skin decreased significantly from young to old individuals (0.37 ± 0.13 mm, 0.30 ± 0.12 mm and 0.26 ± 0.12 mm in young, middle and old subjects, respectively; p < 0.001). Gross elasticity decreased significantly from 75.1 ± 13.0% in young subjects, to 64.53 ± 15.7% in middle-aged subjects and 55.79 ± 13.0% in old subjects (p < 0.001). The mean y-axis skin displacement increased from 2.48 ± 4.33 mm in young subjects, to 3.11 ± 4.49 mm in middle-aged subjects and 3.61 ± 5.38 mm in old subjects (p = 0.006). The mean signal-to-noise ratio decreased significantly from 16.74 ± 5.77 µV in young subjects, to 14.41 ± 4.86 µV in middle-aged subjects and to 12.23 ± 5.99 µV in old subjects (p < 0.001).

Conclusion: This study provides insights into the interplay between skin elasticity, muscular activity and the reflected movement of the skin of the neck. Appreciation of these age-related changes lays the fundament for aesthetic treatments in this delicate region.

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 .
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http://dx.doi.org/10.1007/s00266-022-02961-0DOI Listing
June 2022

Visualization of the location and level of pain in common wrist pathologies using color-coded heatmaps.

Arch Orthop Trauma Surg 2022 Jun 6. Epub 2022 Jun 6.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Ziemssenstr. 5, 80336, Munich, Germany.

Background: Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon.

Objective: The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies.

Methods: This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities.

Results: 120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology.

Conclusions: Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain.
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http://dx.doi.org/10.1007/s00402-022-04479-1DOI Listing
June 2022

In Search of the Most Attractive Lip Proportions and Lip Volume: An Eye Tracking- and Survey-Based Investigation.

Plast Reconstr Surg 2022 08 6;150(2):301-308. Epub 2022 Jun 6.

From the Department for Hand, Plastic, and Aesthetic Surgery, Ludwig-Maximilian University; Westmount Institute of Plastic Surgery; Skin Associates of South Florida and Skin Research Institute; private practice; CH Dermatologia; private practice; and Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science.

Background: Despite various aesthetic trends, the ideal lip proportion and lip volume remains elusive. Thus, the aim of this study was to investigate the aesthetic perception of various lip shapes to identify the most attractive lips.

Methods: Fifty-nine White study participants with a mean age of 32.73 ± 9.4 years were asked to assess lips of various proportions and of various volumes. Gaze assessment and aesthetic rating of the same set of modified lip images were performed.

Results: The results revealed that the lip proportion that was rated to be most attractive was the 1:1.6 ratio (upper-to-lower lip, 4.21 of a possible 5). This lip proportion, however, was not the first one to be viewed on initial image display (1.20 sec) and had the shortest duration of a stable eye fixation within the 6-second image display interval (2.18 of 6 seconds). The lip volume that received the highest aesthetic rating was the 100 percent volume (original lip size), with 4.56 of a possible 5. This lip volume, however, had the third longest interval between initial image exposure and the first stable eye fixation (0.81 second) and had the shortest duration of stable eye fixations during the 6 seconds of image display (2.22 of 6 seconds).

Conclusion: The results presented could be potentially reflective of the internal cognitive processes during the involuntary and voluntary assessment of lip attractiveness.
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http://dx.doi.org/10.1097/PRS.0000000000009361DOI Listing
August 2022

Quantitative Mobility Analysis of the Face and its Relevance for Surgical and Non-surgical Aesthetic Facial Procedures.

Aesthetic Plast Surg 2022 Jun 1. Epub 2022 Jun 1.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA.

Background: Understanding the degree of facial mobility upon postural changes is of great clinical relevance especially if facial assessment, facial measurements and/or facial markings are done in an upright position, but facial procedures are performed in a supine position.

Objective: The objective of this study is to investigate regional facial skin displacement and facial volume changes in individuals between upright and supine positions.

Methods: This multi-center study analyzed a total of 175 study participants with a mean age of 35.0 (10.2) years and a mean body mass index of 24.71 (3.5) kg/m. 3D surface scanning technology with automated registration and alignment was utilized, and multivariate analyses were performed with adjustment for age, gender, body mass index, facial skin sagging and laxity.

Results: The medial face displaced less than the lateral face in both cranial (0.88 mm) and in lateral (0.76 mm) directions, and the lower face displaced more than the middle face in both cranial (1.17 mm) and lateral directions (1.37 mm). Additionally, the medial face lost, on average, 3.00cc whereas the lateral face increased by 5.86cc in volume; the middle face increased by 2.95cc, whereas the lower face decreased by 0.98cc in volume. All p < 0.001.

Conclusion: Practitioners should be mindful that there is a statistically significant change in facial soft tissues between the upright and supine positions and that the magnitude of the change does not necessarily reflect on the aging process alone but is a multi-factorial process which should be individualized for each patient's needs.

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 .
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http://dx.doi.org/10.1007/s00266-022-02921-8DOI Listing
June 2022

Applied anatomy of the layers and soft tissues of the forehead during minimally-invasive aesthetic procedures.

J Cosmet Dermatol 2022 May 30. Epub 2022 May 30.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, Munich, Germany.

Background: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region.

Objective: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments.

Methods: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues.

Results: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle.

Conclusion: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region.
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http://dx.doi.org/10.1111/jocd.15131DOI Listing
May 2022

Comparing the Time-Dependent Evolution of Microcirculation in Gracilis vs. ALT Flaps Using Laser-Doppler Flowmetry and Tissue-Spectrometry.

J Clin Med 2022 Apr 26;11(9). Epub 2022 Apr 26.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, Ludwig Maximilian University of Munich, 81377 Munich, Germany.

Postoperative free flap monitoring is considered a key component of care after microsurgical reconstruction. To achieve successful flap salvage after surgical revision, early recognition of vascular compromise is required. The aim of this study was to assess and compare the time-dependent evolution of microcirculation in gracilis muscle (GM) and anterolateral thigh (ALT) flaps. This study included continuous measurements of blood flow (flow), hemoglobin oxygenation (SO) and the relative amount of hemoglobin (rHb) using laser-doppler flowmetry and tissue-spectrometry (O2C, LEA Medizintechnik, Gießen, Germany) over a time-period of 72 h. Microcirculation was assessed in a total of 66 viable free flaps (GM = 40; ALT = 26). A statistically significant positive correlation between time post-anastomosis and microvascular flow was found for both GM and ALT flaps with r = 0.384 ( < 0.001) and r = 0.178 ( = 0.015), respectively. No significant positive or negative correlations between time post-anastomosis and SO were found for both GM and ALT flaps with r = 0.052 ( = 0.387) and r = -0.018 ( = 0.805), respectively. Overall, a significant negative correlation between time post-anastomosis and rHb was found for GM flaps with r = -0.140 ( = 0.019). For ALT flaps, no significant positive or negative correlation was found with r = -0.011 ( = 0.887). Microcirculation differs in different flap entities, and surgeons should be aware of these differences in order to correctly evaluate and classify the values of flow, SO and rHb obtained when using the O2C device for postoperative monitoring.
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http://dx.doi.org/10.3390/jcm11092425DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC9099565PMC
April 2022

Facial Recognition Pattern before and after Lower Eyelid Blepharoplasty: An Eye Tracking Analysis.

Facial Plast Surg Clin North Am 2022 May;30(2):271-276

Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany. Electronic address:

This study investigated eye movement patterns using eye tracking technology when looking at preoperative and postoperative images of patients that underwent bilateral periorbital cosmetic surgery. The sequence of facial recognition before surgery was periorbital-nose-perioral, whereas following surgery it was nose-periorbital-perioral. This study revealed that the sequence of facial feature recognition is influenced by the aesthetic liking of the observer and that alteration to facial features influences the sequence of facial feature recognition. The eye movement pattern, however, seems to follow the internal representation of beauty where aesthetically pleasing facial features are observed later during first image exposure and are viewed shorter.
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http://dx.doi.org/10.1016/j.fsc.2022.01.007DOI Listing
May 2022

Electrophysiologic Frontalis Muscle Response Following Neuromodulator Injections.

Facial Plast Surg Clin North Am 2022 May;30(2):225-231

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN 55905, USA. Electronic address:

Neuromodulator treatments limit the contractility of the frontalis muscle, resulting in reduced dynamic and static horizontal forehead line formation of the overlying skin. This interventional study investigated the electrophysiologic response (via signal-to-noise [SNR] ratio) and the overlying skin displacement of the frontalis muscle following neuromodulator injections in a total of 11 healthy neuromodulator-naïve volunteers. Relating SNR to the respective skin movement revealed that the higher the SNR, the more vertical the skin displacement is; this remained statistically relevant after gender stratification. These results are novel and will help the aesthetic community to understand neuromodulator effects on the frontalis muscle.
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http://dx.doi.org/10.1016/j.fsc.2022.01.010DOI Listing
May 2022

The Fascias of the Forehead and Temple Aligned-An Anatomic Narrative Review.

Facial Plast Surg Clin North Am 2022 May;30(2):215-224

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN 55905, USA. Electronic address:

A thorough understanding of 3-dimensional facial anatomy and its fascial concepts is essential to allow for further development of novel surgical and nonsurgical treatment strategies to increase patient safety and effectiveness. The layered anatomy and its interconnections of the forehead, scalp, and temple is complex and is thus summarized and aligned in a unified nomenclature in this review. The scalp consists of 5 layers, which transition into 8 layers in the forehead and into a total of 13 layers in the temple.
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http://dx.doi.org/10.1016/j.fsc.2022.01.006DOI Listing
May 2022

Superficial Nasal Filler Injections-How I do It.

Facial Plast Surg Clin North Am 2022 May;30(2):183-191

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN, 55905, USA. Electronic address:

Nasal enhancement is one of the most challenging and intriguing of aesthetic procedures. Although the nose is the most central and prominent facial feature, it should not be dominant while maintaining both a harmonious relationship with the face and its own intrinsic beauty. In this article, the first author shares his experience on how to specifically apply intradermal soft-tissue fillers (for particular indications) in nasal enhancement and incorporates patient assessment, anatomy of the nose, and injection techniques to provide guidance. Intradermal injections are required for specific regions, as for example in the treatment of internal and external valve collapse; however, several precautionary measures need to be implemented to minimize risks resulting in vascular compromise.
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http://dx.doi.org/10.1016/j.fsc.2022.01.012DOI Listing
May 2022

Effect of Surgical versus Nonsurgical Rhinoplasty on Perception of the Patient: An Eye-Tracking-Based Investigation.

Facial Plast Surg Clin North Am 2022 May;30(2):175-181

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich 80336, Germany. Electronic address:

Because of its central location in the face, the nose plays an important role in the aesthetic perception of the face. To improve the appearance of the nose, surgical and nonsurgical rhinoplasty techniques have been described, although it still remains elusive if both options show comparable results in their aesthetic perception. This study assesses the fixation pattern and duration when looking at postinterventional images compared with baseline images for surgical and nonsurgical rhinoplasty procedures. According to this study, the nasal appearance, especially in a lateral view, is more fundamentally altered when surgical rhinoplasty is performed, compared with nonsurgical rhinoplasty.
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http://dx.doi.org/10.1016/j.fsc.2022.01.004DOI Listing
May 2022

Anatomic Differences Between the Asian and Caucasian Nose and Their Implications for Liquid Rhinoplasties.

Facial Plast Surg Clin North Am 2022 May;30(2):167-173

Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Germany. Electronic address:

The demand for surgical and nonsurgical esthetic procedures in the nasal region has increased sharply in the past. Anatomic differences of the nose between different ethnicities need to be investigated thoroughly. The objective of this article is to analyze and compare morphometric features of the nose in a mixed Asian-Caucasian study population. The nasal length in Asians was statistically significantly greater than in Caucasians, also after having adjusted for facial height. The nasal dorsal bridge and the nasal base showed statistically significant differences. By keeping these anatomic differences in mind while treating patients, greater efficacy and safety can be achieved.
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http://dx.doi.org/10.1016/j.fsc.2022.01.008DOI Listing
May 2022

Accuracy Assessment of Three-Dimensional Surface Imaging-Based Distance Measurements of the Face: Comparison of a Handheld Facial Scanner and a Stationary Whole-Body Surface Imaging Device.

Facial Plast Surg Clin North Am 2022 May;30(2):159-166

Department for Hand, Plastic and Aesthetic Surgery, Ludwig - Maximilian University Munich, Munich, Germany. Electronic address:

Three-dimensional surface imaging (3DSI) has been shown to be a useful tool for plastic surgeons in the preoperative, intraoperative, and postoperative setting. The objective of this investigation was to compare the accuracy of facial surface distance measurements using both a handheld facial 3DSI device and a stationary whole-body 3DSI device. Users should be aware of deviations when obtaining 3DSI using the presented imaging devices but should not refrain from using them, as the absolute differences might be too small to play a role in both, clinical and research, settings.
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http://dx.doi.org/10.1016/j.fsc.2022.01.009DOI Listing
May 2022

3D Anthropometric Facial Imaging - A comparison of different 3D scanners.

Facial Plast Surg Clin North Am 2022 May;30(2):149-158

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany.

Facial measurements serve as a valuable tool in the treatment planning of facial plastic surgery. The aim of this study was to evaluate the accuracy and reliability of standard 3D anthropometric measurements of the face made with one low-cost handheld 3D scanner and one industrial-type mobile 3D scanner. There are clear potential benefits of using 3D measurements by means of new handheld mobile scanners. However, the Sense scanner from the class of inexpensive scanners showed significant limitations in more complex areas such as the lip and nose, whereas proportions could be measured satisfactorily.
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http://dx.doi.org/10.1016/j.fsc.2022.01.003DOI Listing
May 2022

Ultrasound Anatomy of the Dorsal Nasal Artery as it Relates to Liquid Rhinoplasty Procedures.

Facial Plast Surg Clin North Am 2022 May;30(2):135-141

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA. Electronic address:

Nonsurgical rhinoplasty procedures using soft tissue fillers have gained popularity. With the increasing frequency of such procedures, the incidence of intra-arterial injection of soft tissue filler material and subsequent ischemia has also risen. This article analyzes the topographic anatomy of the dorsal nasal artery in the nasal soft tissue to potentially enhance patient safety in nonsurgical rhinoplasty procedures. The dorsal nasal artery shows a variable topographic course, especially in relationship to the procerus muscle. By understanding the topographic courses of the dorsal nasal artery, aesthetic practitioners may be able to perform nonsurgical rhinoplasty procedures with increased safety and efficacy.
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http://dx.doi.org/10.1016/j.fsc.2022.01.002DOI Listing
May 2022

Understanding Facial Aging Through Facial Biomechanics: A Clinically Applicable Guide for Improved Outcomes.

Facial Plast Surg Clin North Am 2022 May;30(2):125-133

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic, Stabile Building 9-38, 200 First Street, Rochester, MN 55905, USA. Electronic address:

Understanding the relevance of anatomic and biomechanical principles is crucial when treating the face with soft tissue fillers to achieve a symmetric, soft, and natural-looking result while mitigating the risk of adverse events. The objective of this study is to summarize facial age-related effects, to relate them to facial biomechanics, and to establish guidelines for safe, effective, and esthetically pleasing full-face treatment following 3 basic principles while incorporating the latest scientific developments. This narrative review summarizes the current understanding of facial aging and its implications for facial biomechanics deduced from the authors' experience and research.
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http://dx.doi.org/10.1016/j.fsc.2022.01.001DOI Listing
May 2022

Facial Soft Tissue Repositioning With Neuromodulators: Lessons Learned From Facial Biomechanics.

Aesthet Surg J 2022 Apr 13. Epub 2022 Apr 13.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral peri-orbital region underscoring the versatility of neuromodulator treatments.

Objective: To analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues.

Methods: Seventy-five study participants (8 males, 67 females) with a mean age of 37.5 (8.5) years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement using 3-dimensional imaging at baseline, day 14 and day 30.

Results: 3-dimensional volume analysis revealed an increase in midfacial volume by 0.46 cc, and a decrease of the lower facial volume by 0.30 cc compared to baseline. Additionally, an improvement of midfacial fullness (change of 0.13) and jawline contour (change of 0.44) was reported on clinical rating scales at day 30 compared to baseline.

Conclusions: Facial soft tissues can be repositioned during the 30 days follow-up period following a neuromodulator treatment; this was reflected through an increase in middle facial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.
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http://dx.doi.org/10.1093/asj/sjac090DOI Listing
April 2022

Upper Facial Anastomoses Between the External and Internal Carotid Vascular Territories - A 3D Computed Tomographic Investigation.

Aesthet Surg J 2022 Mar 19. Epub 2022 Mar 19.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, MN, USA.

Background: Facial regions with a high risk for causing injection-related visual comprise are dual-supply vascular areas like the nose, glabella, and forehead. These regions have in common that they receive arterial blood supply both by branches of the internal (ICA) and the external carotid artery (ECA).

Objective: To investigate the anastomotic pathways between ICA and ECA branches in the upper face.

Methods: Post-mortem computed tomographic angiographic (CTA) scans of n = 38 Chinese non-embalmed hemifaces (25 males, 13 females; mean age 37.79 [11.8] years; mean BMI 21.90 [2.3] kg/m 2) were conducted. Data analysis relied on the calculation of depth, distances, and pathways of forehead and temporal arteries to investigate the number of anastomotic connections, the connecting branches, and the layer of connection between ICA and ECA territories.

Results: In 57.9% only one connection, in 31.6% two connections, in 5.3% three connections, and in 2.6% four and five connections each between ICA and ECA territories were identified. A superficial connection was observed in 15.8% whereas in 84.2% the anastomotic connection was identified to be both superficial and deep.

Conclusions: Adverse events following facial minimally invasive soft tissue filler injections for aesthetic purposes are not frequent but devastating if they occur. Anatomic knowledge as presented in this study can help to increase awareness of 3-dimensional vascular anastomotic pathways and to identify safer injection zones and safer fascial planes. Evidence-based injection techniques should be followed, and safety aspects should be placed over the aesthetic outcome.
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http://dx.doi.org/10.1093/asj/sjac060DOI Listing
March 2022

The 72-Hour Microcirculation Dynamics in Viable Free Flap Reconstructions.

J Reconstr Microsurg 2022 Feb 14. Epub 2022 Feb 14.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU Munich, Munich, Germany.

Background:  The risk for vascular complications is the highest within the first 24 hours after free flap transfer. Clinical signs of critical perfusion are often recognized with time delay, impeding flap salvage. To detect failing flaps as soon as possible and to prevent persisting microvascular impairments, knowledge of physiological perfusion dynamics in free flaps is needed. Aim of this study was to investigate the physiological perfusion dynamics of viable free flaps using the Oxygen to See (O2C) device for continuous monitoring.

Methods:  Microcirculation was continuously monitored in 85 viable free flaps over a period of up to 72 hours following microvascular anastomosis using tissue spectrophotometry and laser Doppler flowmetry (O2C, LEA Medizintechnik, Gießen, Germany). The parameters investigated included capillary-venous blood flow (flow), oxygen saturation (SO), and relative amount of hemoglobin (rHB).

Results:  Microcirculatory blood flow increased significantly overall, especially within the first 18 hours after microsurgical anastomosis, after which peak formation was occurred. Mean values of SO showed a decreasing trend and the steepest decrease of SO (slope: 1.0) occurred during the steepest increase of flow between 3 and 6 hours (slope: 4.7) postanastomosis. The rHB values remained fairly constant throughout the study period.

Conclusion:  Hyperemia after free flap transfer accounts for a significant increase of microvascular flow. Tissue oxygenation is reduced, likely due to an increase of oxygen consumption after anastomosis. A better understanding of physiological perfusion dynamics in free flaps can aid surgeons in recognizing compromised vasculature earlier and improve free flap salvage.
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http://dx.doi.org/10.1055/s-0042-1742733DOI Listing
February 2022

The subjectively perceived injectability as an early indicator for adverse events?

J Cosmet Dermatol 2022 Feb 6. Epub 2022 Feb 6.

Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota, USA.

Background: With an increasing demand of aesthetic soft-tissue filler treatments, the occurrence of adverse events rises likewise. An optimized injection algorithm adapted to product characteristics (eg, rheology) of the soft-tissue filler is crucial in order to ensure satisfying clinical outcomes and high patient safety.

Objective: To identify a subjective feedback mechanism for the avoidance of adverse events after soft-tissue filler injection procedures.

Methods: A retrospective data analysis of n = 387 aesthetic treatments performed on n = 291 patients (4 males, 287 females) with different soft-tissue fillers with regard to loss of volume (filling effect), injected layer, injectability ("ease of injection"), injected volume, and injection technique was conducted.

Results: The subjectively perceived injectability during the injection process was statistically significantly related to G-Prime value with r = 0.101 with p = 0.048, indicating an increased difficulty while injecting products with higher G-Prime. The occurrence of adverse events was also statistically significantly related to the injectability: injections with increased subjectively perceived difficulty showed increasing odds of developing adverse events by OR 0.157 with p = 0.002.

Conclusion: Injections that were subjectively more difficult to perform are more likely to develop adverse events. Respecting the layered arrangement of the face, the recommended and approved depth and facial region for each specific treatment enable practitioners to achieve satisfying outcomes while keeping the rate of adverse events low.
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http://dx.doi.org/10.1111/jocd.14697DOI Listing
February 2022

Efficacy and Safety of Letibotulinumtoxin A in the Treatment of Glabellar Lines: A Randomized, Double-Blind, Multicenter, Placebo-Controlled Phase 3 Study.

Aesthet Surg J 2022 05;42(6):677-688

Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA, USA.

Background: Letibotulinumtoxin A (Hugel, Inc., Chuncheon, Republic of Korea and CROMA Pharma, Leobendorf, Austria) is a newly manufactured neurotoxin derived from Clostridium botulinum strain CBFC26.

Objectives: The aim of this study was to assess the efficacy and safety of letibotulinumtoxin A in reducing glabellar line severity (GLS) and to evaluate long-term safety and efficacy following repeated injections.

Methods: In this prospective, randomized, parallel-group, double-blind, multicentre, placebo-controlled Phase III clinical trial, 355 subjects with moderate to severe glabella frown lines received injections of 20 U of letibotulinumtoxin A or placebo. GLS, onset and duration of effect, time to retreatment, and adverse events were evaluated. Response to treatment was defined as a GLS score of 0 or 1 (assessed by the subject and the investigator) and an improvement at Week 4 of ≥2 points in GLS score relative to baseline.

Results: At 4 weeks, 78.6% of the active treatment subjects were responders based on the investigator's assessment and 68.8% based on the subject's assessment, resulting in a composite responder rate of 64.7% for the active treatment group, whereas the corresponding rate was 0.0% in the placebo group (P < 0.001). Subjects noted a substantial improvement in GL severity as early as Day 2, with the median time to onset of effect being 3 days. The mean [standard deviation] time until first retreatment for the letibotulinumtoxin A group was 127.26 [65.6] days. Letibotulinumtoxin A was well tolerated.

Conclusions: Letibotulinumtoxin A demonstrates high efficacy and a convincing safety profile in the treatment of glabellar lines.

Level Of Evidence: 2:
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http://dx.doi.org/10.1093/asj/sjac019DOI Listing
May 2022

Tips and Tricks for Facial Toxin Injections with Illustrated Anatomy.

Plast Reconstr Surg 2022 Feb;149(2):303e-312e

From the Westmount Institute of Plastic Surgery; Skin Associates of South Florida and Skin Research Institute; CH Dermatologia; Shino Bay Cosmetic Dermatology & Laser Institute; Department of Dermatology, Nova Southeastern University College of Osteopathic Medicine; private practice; Gold Skin Care Center, Tennessee Clinical Research Center; Ocean Clinic; Department for Hand, Plastic, and Aesthetic Surgery, Ludwig Maximilian University of Munich; Clinical Research Unit, Erevna Innovations, Inc.; Division of Plastic Surgery, McGill University; and Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science.

Learning Objectives: After studying this article, the participant should be able to: 1. Recognize facial muscle contraction direction and muscle morphology based on skin surface movements and facial rhytides. 2. Classify different muscle contraction patterns and target respectively with the recommended dosage and injection technique. 3. Apply the presented injection techniques to the patients' individual anatomy with greater precision and without affecting adjacent muscles or causing other adverse events.

Summary: Facial muscular anatomy has recently gained increased attention, with new investigative methodologies and new injection techniques arising on the market. These recent advancements have increased our understanding about the functional anatomy of facial muscles and have changed the way health care professionals see and understand their interplay during various facial expressions and in determining facial shape. This new anatomical understanding of facial muscles and their interaction has resulted in superior neuromodulator treatment outcomes with fewer side effects and with increased precision. The latter is of greatest importance, as all facial muscles act as a unit and connect with each other. It is therefore paramount to target during neuromodulator treatments only the muscle responsible for the aesthetic effect desired and not other adjacent muscles, which can have different or even antagonistic effects. Conventional anatomy was previously limited to two-dimensional explanations of muscle locations without incorporating their detailed action or their three-dimensional location of extent. The "new" anatomy incorporates those novel concepts and, once understood, will help health care providers to understand better and to "read" the underlying muscular anatomy based on the wrinkle status and based on the change in skin surface landmarks based on the actions of the underlying musculature. The following article summarizes tips and tricks, pearls and pitfalls, and dos and don'ts during facial neuromodulator injections along with a guide toward adverse event management and patient outcome assessment with special focus on the underlying anatomy.
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http://dx.doi.org/10.1097/PRS.0000000000008708DOI Listing
February 2022

Investigating the Reliability of Novel Nasal Anthropometry Using Advanced Three-Dimensional Digital Stereophotogrammetry.

J Pers Med 2022 Jan 6;12(1). Epub 2022 Jan 6.

Division of Hand, Plastic and Aesthetic Surgery, University Hospital, LMU, 80336 Munich, Germany.

Three-dimensional surface imaging systems (3DSI) provide an effective and applicable approach for the quantification of facial morphology. Several researchers have implemented 3D techniques for nasal anthropometry; however, they only included limited classic nasal facial landmarks and parameters. In our clinical routines, we have identified a considerable number of novel facial landmarks and nasal anthropometric parameters, which could be of great benefit to personalized rhinoplasty. Our aim is to verify their reliability, thus laying the foundation for the comprehensive application of 3DSI in personalized rhinoplasty. We determined 46 facial landmarks and 57 anthropometric parameters. A total of 110 volunteers were recruited, and the intra-assessor, inter-assessor, and intra-method reliability of nasal anthropometry were assessed through 3DSI. Our results displayed the high intra-assessor reliability of MAD (0.012-0.29, 0.003-0.758 mm), REM (0.008-1.958%), TEM (0-0.06), rTEM (0.001-0.155%), and ICC (0.77-0.995); inter-assessor reliability of 0.216-1.476, 0.003-2.013 mm; 0.01-7.552%, 0-0.161, and 0.001-1.481%, 0.732-0.985, respectively; and intra-method reliability of 0.006-0.598°, 0-0.379 mm; 0 0.984%, 0-0.047, and 0-0.078%, 0.996-0.998, respectively. This study provides conclusive evidence for the high reliability of novel facial landmarks and anthropometric parameters for comprehensive nasal measurements using the 3DSI system. Considering this, the proposed landmarks and parameters could be widely used for digital planning and evaluation in personalized rhinoplasty, otorhinolaryngology, and oral and maxillofacial surgery.
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http://dx.doi.org/10.3390/jpm12010060DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8777712PMC
January 2022

Validated 5 - Point photonumeric scales for the assessment of hand atrophy.

J Cosmet Dermatol 2022 Mar 28;21(3):933-939. Epub 2022 Jan 28.

Private Practice, New York, USA.

Objective: Quantifying the degree of dorsal hand atrophy is a challenging endeavor, but often necessary, in both the clinical and the research setting. The aim of this investigation was to create and consecutively validate a 5-point photonumeric scale for assessment of dorsal hand atrophy.

Material And Methods: A medical team created a novel 5-point photonumeric scale. Twelve international raters were involved in the digital validation, while five raters performed a live validation.

Results: For the digital validation of the Croma Hand Atrophy Assessment Scale, a total of 72 subjects (58 females, 14 males) with a mean age of 43.0 ± 14.4 years [18-73 years] were assessed. For the live validation, 88 subjects (73 females, 15 males) with a mean age of 45.0 ± 14.1 years [20-73 years] were rated. The results revealed almost perfect intra-rater (ICC: 0.90 [95% CI: 0.88-0.92]) and inter-rater agreements (ICC: 0.85 [95% CI: 0.81-0.89] and 0.86 [95% CI:0.82-0.89]) in the digital validation and substantial intra-rater (ICC: 0.79 [95% CI: 0.75-0.82]) and inter-rater agreements (ICC: 0.75 [95% CI: 0.68-0.81] and ICC: 0.67 [95% CI: 0.54-0.77]) in the live validation.

Conclusion: The created scale to assess dorsal hand atrophy has been shown to provide substantial-to-almost perfect agreement in the digital and live validation cycles and reached comparable intra-rater and inter-rater agreement to already published and validated scales. It is expected that the created scale will help physicians and researchers in the assessment of hand atrophy in the clinical and research setting in the future.
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http://dx.doi.org/10.1111/jocd.14776DOI Listing
March 2022

Reevaluation of the Layered Anatomy of the Forehead: Introducing the Subfrontalis Fascia and the Retrofrontalis Fat Compartments.

Plast Reconstr Surg 2022 Mar;149(3):587-595

From private practice; the Department for Hand, Plastic and Aesthetic Surgery, Ludwig Maximilian University of Munich; Division of Plastic and Reconstructive Surgery, Mayo Clinic; CH Dermatologia; Department of Radiology and Medical School, University of Belgrade; and Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science.

Background: Novel imaging methods have provided new insights into the layered anatomy of the forehead. This study seeks to critically reevaluate the layered anatomy of the forehead by using ultrasound imaging and cadaveric dissection to provide an accurate anatomical description that can be used to guide safer surgical and minimally invasive frontal procedures.

Methods: This study used ultrasound imaging in a sample of 20 volunteers (12 female and eight male volunteers; aged 35.25 ± 4.2 years; body mass index, 24.28 ± 3.5 kg/m2) and cadaveric dissections of 16 body donors (12 female and four male body donors; aged 72.76 ± 9.5 years) to reevaluate the layered anatomy of the forehead. Layer-by-layer dissections and ultrasound-based measurements of the frontal structures guided conclusions.

Results: The following layered arrangement was identified: layer 1, skin; layer 2, superficial fatty layer; layer 3, suprafrontalis fascia; layer 4, orbicularis oculi and frontalis muscle (same plane); layer 5, a homogenous layer of fat [preseptal fat (in the upper eyelid), retro-orbicularis fat (deep to the orbicularis oculi muscle), and retro-frontalis fat (deep to the frontalis muscle); layer 6, subfrontalis fascia; layer 7, preperiosteal fat within the prefrontal space in the lower forehead and deep compartments in the upper forehead; and layer 8, periosteum.

Conclusions: The results of this study add to the current understanding of the layered arrangement of the forehead. The combination of ultrasound imaging and cadaveric dissections provided evidence for a continuous fatty layer deep to the frontalis muscle.
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http://dx.doi.org/10.1097/PRS.0000000000008826DOI Listing
March 2022
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