Publications by authors named "Nicholas Moellhoff"

54 Publications

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

A prospective multicenter clinical trial evaluating the efficacy and safety of a hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips and the perioral area.

J Cosmet Dermatol 2022 Jun 19. Epub 2022 Jun 19.

Fillmed Laboratories, Paris, France.

Background: Age-related changes of facial soft tissue cause clinical signs of facial aging such as lip atrophy, marionette lines, and an accentuated nasolabial fold. These changes can be modified using dermal fillers.

Aims: To evaluate efficacy, longevity, and safety of a cross-linked hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips, nasolabial folds, and marionette lines.

Materials And Methods: This prospective, multi-center trial evaluated injections of three different areas (lips, nasolabial fold alone, or with marionette wrinkles) with a soft tissue filler containing 25 mg/ml cross-linked hyaluronic acid and 0.3% lidocaine. Primary endpoint was the aesthetic correction 3 weeks after one injection session without touch-up. Follow-up was 18 months. Assessments were performed using the Global Aesthetic Score (GAS), clinical scoring based on photographic scales, high-frequency ultrasound imaging, and the Global Aesthetic Improvement Scale (GAIS).

Results: In total, 100 subjects were injected. GAS improved significantly for all treatment indications at 3 weeks (p < 0.0001). Success rates were highest for nasolabial folds (98.4%), followed by marionette lines (94.4%) and lips (73.5%). After 18 months post-injection, success was observed in 91%, 88%, and 33% of subjects injected into nasolabial folds, marionette lines, and lips, respectively. GAIS scored highest for nasolabial folds (SGAIS: 71%; IGAIS: 40%), followed by marionette lines (SGAIS: 56%; IGAIS: 33%) and lips (SGAIS: 30%; IGAIS: 22%) at 18 months follow-up.

Conclusions: The filler demonstrated high efficacy and safety in all indications. Regional differences in longevity were evident. Thus, the necessity of regional retreatments should be discussed with patients before injection.
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http://dx.doi.org/10.1111/jocd.15169DOI Listing
June 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

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

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

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

Invited Discussion on: Clinical Application of Stromal Vascular Fraction Gel in Temple Augmentation Using Deep Injection and Shallow Pave Filling.

Aesthetic Plast Surg 2022 Mar 7. Epub 2022 Mar 7.

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

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http://dx.doi.org/10.1007/s00266-022-02829-3DOI 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

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

Commentary on: Facial Arterial Variations in Asians: A Study on Computed Tomographic Angiography.

Aesthet Surg J 2022 04;42(5):535-536

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

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http://dx.doi.org/10.1093/asj/sjab405DOI Listing
April 2022

Identifying the most attractive umbilical position - an eye tracking- and survey-based investigation.

J Plast Surg Hand Surg 2021 Dec 22:1-7. Epub 2021 Dec 22.

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

Abdominoplasty is a popular procedure in plastic surgery providing aesthetic, functional and psychological relief for patients suffering from excess abdominal tissue. Correct umbilical positioning is crucial for a successful aesthetic surgical outcome. This study aims to assess the most attractive position of the umbilicus by means of subjective and objective outcome measures. 58 Caucasian study participants with a mean age of 36.87 (15.6) years rated eight different umbilical positions. The various positions were determined based on the ratio of the distance between the xiphoid process and the umbilicus and the distance between the umbilicus and the infra-umbilical crease: 1:1, 1.25:1, 1.5:1, 1.75:1, 2:1, 2.5:1, 3:1 and 5.5:1. Semi-quantitative scoring of attractiveness based on a 5-point Likert scale and eye tracking analyses were utilized. The results revealed that the volunteers perceived as most attractive the ratio of 2:1 with 4.32 (out of possible 5.0). The ratio of 5.5:1 received the lowest rating with 1.8. The results of the objective eye tracking analyses confirmed the subjective rating as the 2:1 ratio was fixated last amongst all other displayed ratios with 1.85 s whereas the 5.5:1 ratio had the shortest interval between image display and first stable eye fixation with 0.94 s. The study confirms the concept of ''. Abdominoplasty procedures could rely on this easy to perform ratio by dividing the distance into thirds and using the boundary between the inferior and middle third as a clinically reliable landmark.
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http://dx.doi.org/10.1080/2000656X.2021.2017946DOI Listing
December 2021

Invited Discussion on: Prevention of Breast Implant Displacement Using the Acellular Dermal Matrix Garter Belt.

Aesthetic Plast Surg 2021 Nov 30. Epub 2021 Nov 30.

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

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http://dx.doi.org/10.1007/s00266-021-02685-7DOI Listing
November 2021

[Development of a giant bulla under spontaneous breathing by self-inflicted lung injury in a patient with COVID-19 pneumonia].

Anaesthesist 2022 04 22;71(4):303-306. Epub 2021 Nov 22.

Intensivstation ANIS 5, Klinik für Anaesthesiologie, Klinikum der Universität München, LMU München, Nussbaumstraße 20, 80336, München, Deutschland.

The outbreak of SARS-CoV‑2 and the associated COVID-19 pandemic pose major challenges to healthcare systems worldwide. New data on diagnosis, clinical presentation and treatment of the disease are published on a daily basis. This case report describes the fatal course of severe COVID-19 pneumonia in an 81-year-old patient with no previous pulmonary disease who developed a giant bulla during non-invasive high-flow oxygen therapy. Virus-induced diffuse destruction of alveolar tissue or patient self-inflicted lung injury (P-SILI) are discussed as possible pathomechanisms. Future studies must determine whether lung-protective mechanical ventilation with high levels of sedation and paralysis to suppress spontaneous respiratory drive and to reduce transpulmonary pressure can prevent structural lung damage induced both by the virus and P‑SILI in COVID-19 patients with ARDS.
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http://dx.doi.org/10.1007/s00101-021-01072-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8608363PMC
April 2022

Reliability of 3-dimensional surface imaging of the face using a whole-body surface scanner.

J Cosmet Dermatol 2022 Apr 3;21(4):1464-1470. Epub 2021 Nov 3.

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

Objective: To the knowledge of the authors, no data about the reproducibility and accuracy of 3-dimensional surface imaging of the face using a whole-body scanner are available. Thus, the objective of this investigation was to assess the reproducibility of facial scans acquired using a whole-body imaging device.

Material And Methods: This investigation investigated 220 3-D scans of a total of 22 healthy volunteers (with a mean age of 29.36 years). Two consecutive 3-D images using a Vectra WB360 of the volunteers were obtained utilizing a whole-body imaging device. Predefined distances in the face were performed in each scan and compared. Furthermore, surface deviation between two consecutively captured scans was assessed.

Results: The distance with the smallest statistical significance was found to be at the nose with p = 0.998, while the biggest statistical significance was found in the midface with p = 0.658. The area with the biggest surface deviation between the superimposed scans was the neck with a root mean square (RMS) of 1.62 ± 1.71, and the area with the smallest surface deviation was the forehead with a RMS of 0.17 ± 0.05.

Conclusion: The whole-body imaging device investigated in this study can be utilized to capture the face and provides enough accuracy to compare scans. Even though not directly investigated, it can be hypothesized that the error caused by repositioning the patient between a baseline and a follow-up scan will not be too big to consider measurements performed with the whole-body imaging device as impractical.
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http://dx.doi.org/10.1111/jocd.14555DOI Listing
April 2022

Soft tissue filler augmentation of the orbicularis retaining ligament to improve the lid-cheek junction.

J Cosmet Dermatol 2021 Nov 22;20(11):3446-3453. Epub 2021 Oct 22.

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

Background: The orientation of facial ligaments changes with increasing age due to the loss of bony support. Soft tissue filler injections placed in close proximity to facial ligaments can alter their orientation to help achieve an improved and younger aesthetic appearance.

Objective: To assess the anatomic and aesthetic effects of a standardized injection with soft tissue filler placed directly inferior to the orbicularis retaining ligament in the infraorbital region.

Methods: A total of 163 patients with signs of infraorbital aging were treated with a standardized soft tissue filler injection into and in close proximity to the orbicularis retaining ligament (ORL). 2D frontal images of the infraorbital region were rated by eleven blinded and independent raters with regards to the aesthetic appearance of the infraorbital region before and after the standardized injection treatment.

Results: The aesthetic appearance of the entire infraorbital region (lid-cheek junction) was rated before and after the treatment. The severity of the tear trough (medial aspect of the infraorbital region) as well as the hollowing of the lateral aspect of the infraorbital region also was rated before and after the treatment. Aesthetic improvement was statistically significant when evaluated by the blinded raters, the treating physician, and the patients. All the results were "very much improved" compared to baseline.

Conclusion: The effectiveness of this injection technique is thought to be due to the strategic placement of soft tissue filler that helps to reposition facial ligaments that have changed their orientation during the aging process.
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http://dx.doi.org/10.1111/jocd.14495DOI Listing
November 2021

Real-Time Ultrasound Imaging of the Tear Trough: Lessons Learned From Functional Anatomy.

Aesthet Surg J 2022 04;42(5):518-526

Department of Clinical Anatomy, Mayo Clinic Rochester, MN, USA.

Background: The tear trough is one of the most challenging facial regions for soft-tissue filler injections. A thorough understanding of the underlying facial, muscular, and vascular anatomy is crucial to perform safe and effective tear trough injectable treatments.

Objectives: The authors sought to evaluate the location and function of the angular vein in the tear trough in 3 different facial expressions: repose, smiling, and max. orbicularis oculi contraction.

Methods: Twenty study participants with a mean age of 48.3 years and mean BMI of 24.5 kg/m2 were investigated via functional ultrasound imaging. The diameter of the angular vein and the velocity and direction of venous blood flow were analyzed in repose, smiling, and during max. orbicularis oculi contraction.

Results: The angular vein was identified in 100% of the cases to travel inside the orbicularis oculi muscle (intra-muscular course) within the tear trough, whereas the angular artery was not identified in this location. The distance between the angular vein and the inferior orbital rim was (lateral to medial): 4.6 mm, 4.5 mm, 3.9 mm, and 3.8 mm. The caudally directed blood flow was in repose 10.2 cm/s and was 7.3 cm/s at max. orbicularis oculi muscle contraction; however, no blood flow was detectable during smiling.

Conclusions: The diameter and the venous blood flow of the angular vein varied between the 3 tested facial expressions. Based on these anatomical findings, the deep injection approach to the tear trough is recommended due to the intramuscular course of the angular vein.
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http://dx.doi.org/10.1093/asj/sjab351DOI Listing
April 2022

A prospective open-label, multicentre study evaluating a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal and perioral lines.

J Cosmet Dermatol 2022 Jan 24;21(1):191-198. Epub 2021 Sep 24.

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

Objective: The aim of this investigation was to assess the effectiveness of a non-cross-linked hyaluronic acid based soft-tissue filler in the correction of lateral canthal lines and periorbital lines.

Material And Methods: A total of 59 female Caucasian patients with a mean age of 52.6 ± 9.0 years were enrolled in this prospective open-label, multicentre study and received intradermal injections of a soft-tissue filler at baseline, after 3 and 6 weeks. Aesthetic improvement and patient satisfaction, skin hydration, skin firmness and skin elasticity, as well as adverse events were assessed at 3, 6, 8, 12 and 16 weeks.

Results: At baseline, the lateral canthal skin firmness was 0.206 ± 0.07 mm and increased after 8 weeks to 0.087 ± 0.08 mm with p < 0.001, while the perioral skin firmness was 0.205 ± 0.09 mm and increased after 8 weeks to 0.116 ± 0.08 mm with p < 0.001. Increases in skin hydration were observed after 8 weeks in both areas, however, did not reach statistical significance at any point. At week 8, 12 and 16 a majority (93.1%, 91.1% and 73.7% respectively) of the patients stated that they were 'satisfied' or 'very satisfied' with the treatment.

Conclusion: Overall, the skin firmness and skin visco-elasticity showed significant increases in the lateral canthal and perioral region. Moreover, albeit not statistically significant, skin hydration increased in both areas after 8 weeks. The procedure has been shown to be safe and satisfactory for the treated patients; however, emergence of oral herpes should be added to the safety profile of intradermally applied hyaluronic acid treatments.
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http://dx.doi.org/10.1111/jocd.14460DOI Listing
January 2022

Longevity and subject-reported satisfaction after minimally invasive jawline contouring.

J Cosmet Dermatol 2022 Jan 18;21(1):199-206. Epub 2021 Sep 18.

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

Background: Minimally invasive treatments as soft tissue filler injections can enhance the appearance of the jawline. This prospective, single-center study investigated aesthetic outcome, patient satisfaction, adverse events, and volume changes after jawline contouring using standardized reporting scales and objectifiable 3D surface analysis.

Methods: A total of 30 patients (1 male and 29 females, mean age: 57.2 (±8.7) years) were investigated. Patients underwent jawline augmentation using a highly cross-linked hyaluronic acid-based soft tissue filler. Three-dimensional surface imaging was performed after 2 weeks, and 3, 6, 9, and 12 months. Furthermore, the aesthetic results and the occurrence of complications were investigated after two weeks, and 3, 6, 9, and 12 months.

Results: The surface-volume coefficient (SVC) had an average of 1.10 ± 0.2 after 14 days, 0.95 ± 0.1 after 3 months, 0.83 ± 0.1 after 6 months, 0.74 ± 0.1 after 9 months, and 0.63 ± 0.1 after 12 months. A significant correlation was revealed between time of measurement and measured SVC with r  = -0.761, p < 0.001. Multivariate analysis revealed a significant difference between the measured SVC and the different time points of measurement with p < 0.001. The data revealed strong aesthetic improvement with results most often reported as "very much improved" according to the 5-point GAIS after 3, 6, and 9 months, both by the investigator and by the patients. A 12-month follow-up analysis showed "much improved" results in a majority of cases.

Conclusion: The result of this investigation showed that jawline enhancement using minimally invasive soft tissue filler injections produces durable, safe results that are generally rated as very satisfying from a patient's and investigator's perspective over a time period of 12 months.
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http://dx.doi.org/10.1111/jocd.14410DOI Listing
January 2022

The mobility of the superficial and deep midfacial fat compartments: An ultrasound-based investigation.

J Cosmet Dermatol 2021 Dec 8;20(12):3849-3856. Epub 2021 Aug 8.

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

Background: Understanding the mobility of the midface and the separate contributions of the superficial and deep fat compartments is essential for natural esthetic outcomes following soft tissue filler or fat grafting procedures. A study was designed that used ultrasound imaging to demonstrate in vivo visualization and quantification of distances and movements in the midface.

Methods: A total of 48 midfaces of 24 healthy Caucasian volunteers, all naïve of esthetic procedures, (22 females; 46.85 (9.8) years; 22.83 (3.1) kg/m ) were scanned using 18 MHz ultrasound imaging. Distances between bony landmarks (inferior orbital rim, infraorbital foramen) were used as markers to measure the cranial movement of the superficial (superficial nasolabial and superficial medial cheek fat compartment) and the deep (deep pyriform space, deep medial check fat compartment, deep lateral cheek fat compartment) midfacial fat compartments between resting and smiling facial position.

Results: The superficial midfacial fat compartment moved, on average, 3.7 mm (p < 0.001) cranially, whereas the deep midfacial fat compartments moved, on average, 0.1 mm (p > 0.05) during smiling. No gender differences in mobility were identified (p > 0.05).

Conclusion: The results obtained are in line with previous cadaveric investigations and revealed, in a highly statistically significant fashion, that the superficial midfacial fat compartments move in cranial direction whereas the deep fat compartment did not display similar positional changes. These results help to guide facial injectable treatments and to understand why, in the midface, a deep supraperiosteal approach should be favored when augmenting the deep midfacial fat compartments.
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http://dx.doi.org/10.1111/jocd.14374DOI Listing
December 2021
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