Publications by authors named "Sebastian Cotofana"

131 Publications

Clinical Validation of Superficial Lip Injections Utilizing Cohesive Polydensified Matrix Hyaluronic Acid-Based Soft Tissue Fillers.

J Drugs Dermatol 2021 Sep;20(9):940-945

Background: A combination of optimal injection technique and dermal filler choice is key for improving lip architecture with natural and long-lasting results.

Objective: To investigate the positioning of Cohesive Polydensified Matrix™ (CPM) hyaluronic acid (HA) fillers after superficial lip injections and document their tissue integration and effects on lip architecture and shape.

Methods: Eligible patients underwent lip contouring and volumization using a superficial direct tissue action technique. All injections were performed with CPM-HA lip fillers using a 30G needle and retrograde microthreading. Total injected volume was 0.8-1.2 mL. High-resolution ultrasound (US) imaging, 3D surface scanning, and Global Aesthetic Improvement Scale (GAIS) assessments were performed before, and 1, 3 and 6 months post-injection to define the anatomy, positioning, longevity and patient satisfaction.

Results: Sixteen patients were injected (mean age, 33.2 years). US measurements revealed an increased skin–orbicularis oris muscle distance up to 1 month post-injection after which measurements returned to baseline values. This observation correlated with complete product integration into the surrounding tissue visualized by US at 3 months. An increased dry mucosa thickness (vermilion body) remained at 6 months, and GAIS scores revealed 70% of patients continued to experience visible lip improvements. 3D analyses revealed significantly increased total lip surface area at 3 months with increased Cupid’s bow distance, philtral height, and anterior upper lip projection.

Conclusion: Superficial injection of CPM-HA fillers offers an effective and safe tool for improving lip architecture and volume. Results showed homogeneous dermal integration of the product and aesthetic outcomes maintained up to 6 months. J Drugs Dermatol. 2021;20(9):940-945. doi:10.36849/JDD.6011.
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http://dx.doi.org/10.36849/jdd.6011DOI Listing
September 2021

The Anatomical Basis of Cellulite Dimple Formation: An Ultrasound-Based Examination.

Plast Reconstr Surg 2021 Sep;148(3):375e-381e

From the Division of Plastic Surgery, Albany Medical Center; Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science; and Division of Plastic Surgery, Montefiore Medical Center.

Background: Cellulite is a common aesthetic condition that affects the majority of women. It is characterized by the inhomogeneous appearance of the skin overlying the gluteal and the posterior thigh region. Despite a wide array of treatment options, little has been done to evaluate the anatomical basis of cellulite formation. This study used ultrasound to visualize subcutaneous changes of cellulite to aid with treatment guidance and complication avoidance.

Methods: Cellulite dimples were examined on the bilateral thigh and buttock regions of 50 consecutive women and each dimple was scored with the Hexsel Cellulite Scoring System based on severity. Cellulite dimples were then analyzed by ultrasound to identify the presence, orientation, and origination of subcutaneous fibrous bands and the presence of associated vascular structures.

Results: Two hundred total sites were examined, with 173 dimples identified. Of these, 169 demonstrated the presence of fibrous bands (97.6 percent). The majority of bands demonstrated an oblique (versus perpendicular) orientation to the skin (84.4 percent), with the majority (90.2 percent) taking origin from the superficial fascia (versus the deep fascia). Overall, 11 percent of bands had an associated vascular structure. When stratified by body mass index, overweight and obese patients had a higher likelihood of having an associated blood vessel visualized (p = 0.01). Results were similar for dimples in the thigh compared to those located in the buttock region.

Conclusions: Ultrasound appears to be a valid technique to image the subcutaneous architecture of cellulite. This technology can help guide surgeons in real time to improve outcomes and minimize complications while performing cellulite treatments.
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http://dx.doi.org/10.1097/PRS.0000000000008218DOI Listing
September 2021

Migration of Hyaluronic Acid-Based Soft Tissue Filler From the Temples to the Cheeks-An Anatomic Explanation.

Dermatol Surg 2021 Aug 18. Epub 2021 Aug 18.

Cosmetic Laser Dermatology, San Diego, California Private Practice, Los Angeles, California Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Rochester, Minnesota Department of Dermatology, University of California, San Diego.

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http://dx.doi.org/10.1097/DSS.0000000000003219DOI Listing
August 2021

Change in Rheologic Properties of Facial Soft-Tissue Fillers across the Physiologic Angular Frequency Spectrum.

Plast Reconstr Surg 2021 Aug;148(2):320-331

From the Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science; Division of Anatomy, Department of Medical Education, Albany Medical College; Division of Dermatology, University of Toronto; private practice; Skin Associates of South Florida, Skin Research Institute; the Erevna Innovations, Inc., Clinical Research Unit; Division of Plastic Surgery, McGill University; and the Department for Hand, Plastic and Aesthetic Surgery, Ludwig-Maximilian University.

Background: The number of soft-tissue filler injections performed in the United States is constantly increasing and reflects the high demand for enhanced facial and body attractiveness. The objective of the present study was to measure the viscoelastic properties of soft-tissue fillers when subjected to different testing frequencies. The range of tested frequencies represents clinically different facial areas with more [lips (high frequency)] or less [zygomatic arch (low frequency)] soft-tissue movement.

Methods: A total of 35 randomly selected hyaluronic acid-based dermal filler products were tested in an independent laboratory for their values of G', G″, tan δ, and G* at angular frequencies between 0.1 and 100 radian/second.

Results: The results of the objective analyses revealed that the viscoelastic properties of all tested products changed between 0.1 and 100 radian/second angular frequency. Changes in G' ranged from 48.5 to 3116 percent, representing an increase in their initial elastic modulus, whereas changes in G″ ranged from -53.3 percent (i.e., decrease in G″) to 7741 percent (i.e., increase in G″), indicating both an increase and a decrease in their fluidity, respectively.

Conclusions: The increase in G' would indicate the transition from a "softer" to a "harder" filler, and the observed decrease in G″ would indicate an increase in the filler's "fluidity." Changes in the frequency of applied shear forces such as those occurring in the medial versus the lateral face will influence the aesthetic outcome of soft-tissue filler injections.
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http://dx.doi.org/10.1097/PRS.0000000000008188DOI Listing
August 2021

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

J Cosmet Dermatol 2021 Aug 8. 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
August 2021

The Layered Anatomy of the Nose: An Ultrasound-Based Investigation.

Aesthet Surg J 2021 Aug 7. Epub 2021 Aug 7.

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

Background: An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex.

Objectives: To describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement.

Methods: A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose using ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature.

Results: In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n= 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% - 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip.

Conclusions: Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared to any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.
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http://dx.doi.org/10.1093/asj/sjab310DOI Listing
August 2021

Evaluating safety in hyaluronic acid lip injections.

Expert Opin Drug Saf 2021 Aug 19:1-14. Epub 2021 Aug 19.

Division of Plastic and Reconstructive Surgery, McGill University Health Center, Montreal, Canada.

Introduction: Soft tissue filler augmentation has become increasingly popular due to its perceived ease and impressive results. Unfortunately, although the results are impressive, so are the reported complications. This article describes complications specific to peri-oral soft tissue filler injection and then discusses evidence-based, anatomic prevention and treatment guidelines.

Areas Covered: The authors aimed at providing an overview of the complications associated with peri-oral soft tissue filler. Hyaluronic Acid (H.A) fillers may have devastating complications which are oft undisclosed or published. This narrative review aims to describe the various complications and provide preventative strategies.

Expert Opinion: Given the paucity of prospective, randomized clinical trials on the subject and in light of complication underreporting, the authors believe that efficacy and safety literature on the subject is lacking. Injectors must rely on the one strength which exists in the lip literature to date, that is anatomy. The basis of all successful injections is a mandatory understanding of normal as well as variations of vital structures in an area, combined with meticulous injection techniques, deposition of small aliquots of product and the ability to recognize unwanted adverse events early enough to act on them.
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http://dx.doi.org/10.1080/14740338.2021.1962283DOI Listing
August 2021

The Impact of Breast Symmetry on Eye Movement and Gaze Pattern: An Eye-Tracking Investigation.

Aesthet Surg J 2021 Jul 17. Epub 2021 Jul 17.

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

Background: The objective assessment of beauty is challenging and subject to current research efforts. Recently, a new means of objectively determining the aesthetic appeal of body features has been investigated by analyzing gaze patterns and eye movements.

Objectives: The objective of this study was to assess differences in observers' gaze patterns presented with standardized 3-dimensional images with different degrees of breast asymmetry using objective eye-tracking technology.

Methods: A total of 83 Caucasian study participants with a mean age of 38.60 (19.8) years were presented with 5 images depicting varying degrees of breast symmetry. In addition to the assessment of eye movements, participants were asked to rate the aesthetic appeal and the asymmetry of the breasts on a 5-point Likert scale.

Results: Overall, the data show that participants rating of the breasts' aesthetic appeal was inversely related to the level of asymmetry. Time until fixation was shortest for the image depicting the greatest breast asymmetry (50 cc) with 0.77 (0.7), p <0.001. In addition, the mammary region was also viewed longest in this image with 3.76 (0.5) seconds, p < 0.001. A volume difference of 35 cc between breasts deflected the observers' gaze significantly toward the larger of the asymmetrical breasts, p<0.001.

Conclusions: Surgeons should focus on symmetrical breast volume (ie, differences < 35 cc between breasts) to avoid noticeable asymmetry with regard to breast size.
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http://dx.doi.org/10.1093/asj/sjab285DOI Listing
July 2021

After the Temporal Lifting Technique-What comes next?

J Cosmet Dermatol 2021 May 22. Epub 2021 May 22.

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

Background: The temporal lifting technique can provide lateral facial lifting when administering hyaluronic acid (HA)-based soft tissue fillers into the subdermal plane of the temple. However, the central facial oval is not influenced by this technique.

Objectives: To identify the safety and esthetic effectiveness of additional midfacial injection points (in addition to the temporal lifting technique) that can volumize the medial midface, lift the lateral face, and increase jawline contouring when included into a full-face injection algorithm.

Methods: The patient records of nine consecutive patients (all females) with a mean age of 35.0 (8.4) years and a mean body mass index of 21.7 (2.4) kg/m were retrospectively analyzed after a full-face injection algorithm was performed using HA-based fillers. The additional injection points target the supraperiosteal plane of the medial zygomatic arch, the lateral infraorbital region, and the pyriform fossa using both needles and cannula.

Results: No adverse events were observed during the 6-month retrospective observational period. The volume of the medial midface increased, the volume of the lateral midface decreased, and the contour of the jawline improved; all effects reached a highly statistically significant level with p < 0.001.

Conclusion: Despite each individual injection is currently performed on a daily clinical basis the evaluated injection algorithm following the temporal lifting technique shows some evidence that it is safe and esthetically effective. Future studies will need to confirm the results presented herein in a larger sample and with objective outcome measures to guide safe and effective esthetic outcomes.
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http://dx.doi.org/10.1111/jocd.14247DOI Listing
May 2021

Invited Discussion on: Crushed Cartilage and Autologous Fat for Dorsal Nasal Refinement.

Aesthetic Plast Surg 2021 May 17. Epub 2021 May 17.

Private Practice, New York, NY, USA.

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http://dx.doi.org/10.1007/s00266-021-02347-8DOI Listing
May 2021

The Influence of Different Light Angles During Standardized Patient Photographic Assessment on the Aesthetic Perception of the Face.

Aesthetic Plast Surg 2021 May 13. Epub 2021 May 13.

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: 2D baseline and follow-up clinical images are potentially subject to inconsistency due to alteration of imaging parameters. However, no study to date has attempted to quantify the magnitude by which such images can be influenced.

Objective: The objective of the present study is to identify the magnitude by which images can be influenced by changing the imaging light angle.

Methods: This study is based on the evaluation of 2D frontal images of the face and included a total of 51 subjects of which n = 14 were males and n = 37 were females. Faces were photographed at 0°, 30°, and 60° light angle under identical and standardized conditions. Images were randomized and rated by 27 blinded raters for age, facial attractiveness, body mass index (BMI), temporal hollowing, lower cheek fullness, nasolabial sulcus severity, and jawline contour.

Results: Facial attractiveness decreased, facial unattractiveness increased and the evaluated BMI (based on facial assessment) increased statistically significantly at 60°. The assessment of regional facial scores, i.e., temporal hollowing, lower cheek fullness, and jawline contour, showed no statistically meaningful changes both at 30° and at 60° light angle.

Conclusion: The results indicate that there might be an observed blind range in light angle (0°-30°) which does not influence facial assessment. Increasing the light angle past the threshold value to 60° might result in a statistically significant impact on facial perception which should be accounted for when documenting and/or presenting facial 2D images.

Level Of Evidence V: This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .
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http://dx.doi.org/10.1007/s00266-021-02314-3DOI Listing
May 2021

A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 2: Vascular Mapping.

Aesthet Surg J 2021 May 5. Epub 2021 May 5.

Duplex mode ultrasound imaging can detect the course of the main vascular structures in the face, which are known to be subject to variation. Once duplex mapping has been performed, measures can be taken to prevent injection into an artery, thereby avoiding skin necrosis or, worse, vision loss. For this reason, in particular, we predict that in the coming years sonography will become standard equipment in the offices of cosmetic doctors. We discuss the basics of vascular imaging by Doppler ultrasound, both in normal and pathologic situations. Starting from the 7 basic positions for the ultrasound probe, all facial arteries relevant in cosmetic medicine can be found.
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http://dx.doi.org/10.1093/asj/sjaa411DOI Listing
May 2021

A Guide to Doppler Ultrasound Analysis of the Face in Cosmetic Medicine. Part 1: Standard Positions.

Aesthet Surg J 2021 May 5. Epub 2021 May 5.

Interest in Doppler ultrasound (DUS) analysis of the face has grown in cosmetic medicine, in particular for injectable fillers. When dealing with complications, DUS has the advantage of easily visualizing the filler and identifying the problem in relation to the patient's anatomy. When working with hyaluronic acid filler, ultrasound-guided injections with hyaluronidase can precisely target the problem. In addition, DUS can be used to study the anatomy of a patient, specifically to prevent intravascular injections. We predict that in a few years' time DUS will become standard equipment in the offices of cosmetic doctors. We discuss the basics of ultrasound imaging of different tissues with the concomitant terminology. With the use of 7 basic DUS probe positions, key anatomic reference points can be easily found. From these, all relevant anatomic structures in the face can be observed and analyzed. With some practice, physicians will ultimately be able to acquire a complete 3-dimensional mental image of a patient's face.
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http://dx.doi.org/10.1093/asj/sjaa410DOI Listing
May 2021

Deformation of Needle Tips during Facial Soft Tissue Filler Injections: An Electron-Microscopic Study.

Aesthet Surg J 2021 May 4. Epub 2021 May 4.

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

Background: Injectable soft tissue fillers are used on a global scale for a variety of aesthetic indications. Despite their widespread use, there is a dearth of information regarding the potential repeated injections into tissue have to cause needle deformation. Repeated injections with the same needle result in an increase in force used by the injector to achieve dermal penetration, potentially resulting in decreased precision and increased patient discomfort.

Objectives: The objective of this study is to quantify the magnitude of needle tip deformation utilizing Scanning Electron Microscopy (SEM) image analysis.

Methods: An observational study was performed evaluating four differently sized needles following soft tissue filler injections for five different aesthetic indications (zygomatic arch, infraorbital, mid cheek, nasolabial sulcus and perioral) in patients aged 36-64 years old. Following treatment, each needle was visualized and imaged through SEM, and the percentage of deformation in relation to the total amount of needle tip surface was calculated.

Results: The most influencing factor for needle tip damage was revealed to be the number of injection passes, ie, dermal transitions. Per injection procedure, an increase in needle tip damage of 4.7% occurred. Touching the bone deformed the needle tip by 9.6% and the increase in needle size allowed for 0.13% more damage.

Conclusions: To the authors' knowledge, this is the first SEM investigation to provide objective evidence for the deformation of needle tips after repeated facial soft tissue filler injections. This data may help improve patient safety and comfort during these minimally invasive procedures.
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http://dx.doi.org/10.1093/asj/sjab211DOI Listing
May 2021

Understanding Facial Muscle Aging: A Surface Electromyography Study.

Aesthet Surg J 2021 Aug;41(9):NP1208-NP1217

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

Background: Facial aging is a multifactorial process that involves all tissues of the face, including skin, muscles, fat, ligaments, and bone. Whereas robust evidence is available for age-related changes of bone and facial fat, the influence of age on facial muscle activity is poorly understood.

Objectives: The objective of this study was to investigate the motor unit action potential of facial muscles by utilizing surface-derived, noninvasive electromyography in young and old healthy volunteers.

Methods: The study investigated a total of 32 healthy volunteers with a mean [standard deviation] age of 42.6 [19.6] years (range, 21-82 years) and a mean BMI of 23.9 [2.7] kg/m2 (range, 18.5-29.7 kg/m2) by performing surface-derived, noninvasive facial electromyography. Nine facial muscles were investigated bilaterally, resulting in a total of 1632 measurements of the signal, baseline noise, and signal-to-noise ratio of these muscles.

Results: The results of the study revealed that age does not significantly influence the signal (P = 0.234), the baseline noise (P = 0.225), or the signal-to-noise ratio (P = 0.432) of younger individuals (<30 years) vs older individuals (>50 years) in a gender- and BMI-matched statistical model. Exceptions were the zygomaticus major muscle (reduced activity), procerus muscle (increased activity), and corrugator supercilii muscle (increased activity).

Conclusions: The results of this facial electromyography study may help to increase the understanding of facial aging. Future studies need to reproduce the results presented herein to further increase our understanding of facial aging.
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http://dx.doi.org/10.1093/asj/sjab202DOI Listing
August 2021

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

J Drugs Dermatol 2021 May;20(5):498-502

Background: To date no precise data are available for extrusion forces related to the G-prime and G-double-prime of fillers in combination with different 27G and 30G needles. Therefore, the objective of this study was to analyze extrusion forces of various product-needle-combinations containing two different 27G and two different 30G needles in combination with fillers of a wide range of elastic moduli starting from 2.0 – 166.0 Pa.

Material And Methods: Four different fillers with the following elastic moduli 1.87, 11.65, 61.80, 165.50 Pa were combined with four different needles: 27G ½”, internal diameter: 0.300 μm; 27G ½”, internal diameter: 0.241 μm; 30G ½”, internal diameter: 0.241 μm and 30G ½“, internal diameter: 0.240 μm. Product-needle-combination were subjected to uni-axial mechanical testing and the respective extrusion force was measured.

Results: The results of this study revealed that the G-prime and the G-double-prime of a product are statistically significantly related to their extrusion force, with higher G-prime/G-double-prime products requiring higher extrusion forces. The results additionally revealed that whether the size of the needle was described as 27G or 30G by the respective manufacturer statistically significant differences between the measured extrusion forces were detected.

Conclusion: Injectors need to be aware that not every 27G/30G needle has the same extrusion force even though the external diameter is similar (27G or 30G); this might additionally influence the ability to withdraw blood during a pre-injection aspiration manoeuvre. J Drugs Dermatol. 20(5): doi:10.36849/JDD.5237.
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http://dx.doi.org/10.36849/JDD.5237DOI Listing
May 2021

Quantitative Analysis of the Lifting Effect of Facial Soft-Tissue Filler Injections.

Plast Reconstr Surg 2021 May;147(5):765e-776e

From private practice; the Department for Hand, Plastic, and Aesthetic Surgery, Ludwig Maximilian University; the Division of Anatomy, Department of Medical Education, Albany Medical College; Skin Associates of South Florida; and the Department of Clinical Anatomy, Mayo Clinic College of Medicine and Science, Mayo Clinic.

Background: Although injectable soft-tissue fillers are frequently used for facial rejuvenation, there is a dearth of objective data evaluating the tissue-lifting effects. Current practices for efficacy evaluation include some subjectivity. This study seeks to evaluate the lifting effects of facial soft-tissue fillers in a quantifiable, objective setting.

Methods: Twenty fresh hemifaces obtained from 10 Caucasian body donors (seven women and three men) with a mean age of 83.5 ± 6.8 years and a mean body mass index of 25.3 ± 4.3 kg/m2 were injected with soft-tissue fillers following a predefined treatment algorithm. Three-dimensional surface scanning procedures were performed to assess postinjection effects.

Results: Injections in the medial face [i.e., forehead, medial midface, and perioral (chin and labiomandibular sulcus)] increased the local surface volume by 0.67, 0.56, and 0.87 cc and created local (but not regional) lifting effects of 1.11, 0.11, and 0.74 mm. Injections in the lateral face (temple, lateral midface, and jawline) changed the local surface volume by 0.45, 0.02, and -0.38 cc, and created local lifting effects of 0.57, 0.81, and 0.29 mm, respectively. Lateral face injections, however, created additional regional lifting effects by co-influencing neighboring lateral facial regions, which was not observed for medial face injections.

Conclusions: This cadaveric study provides evidence that soft-tissue fillers, although typically classified as volumizers, can induce lifting effects of the face. Whereas temporal deep supraperiosteal injections have limited lifting effects, the combined effects of subdermal injections of the temple, lateral midface, and mandibular angle can induce lifting effects of the total lateral face.

Clinical Question/level Of Evidence: Therapeutic, V.
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http://dx.doi.org/10.1097/PRS.0000000000007857DOI Listing
May 2021

Global Recommendations on COVID-19 Vaccines and Soft Tissue Filler Reactions: A Survey-Based Investigation in Cooperation With the International Society for Dermatologic and Aesthetic Surgery (ISDS).

J Drugs Dermatol 2021 Apr;20(4):374-378

Background: Recent reports have surfaced from the United States Food and Drug Administration hearings in December 2020 regarding the COVID-19 vaccines and study participants who developed facial and/or lip swelling after receiving the newly developed drug. Despite an incidence rate of 0.02% in the vaccine arm of the Moderna mRNA-1273 trial, concerns have been expressed about the association of adverse reactions following soft tissue filler injections and the COVID-19 vaccines. The International Society for Dermatologic and Aesthetic Surgery (ISDS) understands these concerns and has designed the following study.

Methods: A global survey was designed to capture the incidence of adverse events related to: (1) previous soft tissue filler injections, (2) soft tissue filler injections during positive testing for COVID-19, and (3) soft tissue filler injections during and after receiving any of the COVID-19 vaccines globally available.

Results: The information of 106 survey participants from 18 different countries was analyzed. 80.2% (n=85) never experienced any adverse reaction following their soft tissue filler injection whereas 15.1% (n=16) experienced swelling and 4.7% (n=5) experienced pain that lasted longer than two days. Of those who received at least one dose of the COVID-19 vaccine (n=78), 94.9% reported not to have experienced any adverse reaction related to their previous soft tissue filler injection, whereas 5.1% (n=4) reported to have perceived pain that lasted longer than two days.

Conclusion: The data collected does not support the concern for an increased risk of developing adverse reactions following soft tissue filler injections associated with the COVID-19 vaccines compared to that risk associated with other previously described triggers or the default risk following soft tissue filler injections. J Drugs Dermatol. 20(4):374-378. doi:10.36849/JDD.2021.6041.
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http://dx.doi.org/10.36849/JDD.2021.6041DOI Listing
April 2021

Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique.

J Cosmet Dermatol 2021 Jun 16;20(6):1625-1633. Epub 2021 Apr 16.

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

Background: Current injection algorithms for treating the glabella rely on a five- or seven-point injection technique with possible medial eyebrow ptosis and lateral eyebrow elevation as undesirable outcomes.

Objective: The objective of this study was to investigate the efficacy and safety profile of a refined 3-point injection technique targeting horizontal and vertical glabellar lines.

Methods: A total of n=105 patients (27 males and 78 females) with a mean age of 40.90 ± 9.2 years were investigated. The injection technique relied on targeting the muscular origin of the procerus and the corrugator supercilii muscles exclusively. The time of effect onset and the injection-related outcome 120 days after the treatment was evaluated using the 5-point glabellar line severity scale.

Results: The onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There was no statistically significant difference in the amplitude of movement before or 14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for the lateral head of the eyebrow, respectively.

Conclusion: Incorporating anatomic concepts into clinical practice for glabellar frown line neuromodulator treatments with the investigated 3-point injection technique resulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, medial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated efficacy throughout the 4-month study period.
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http://dx.doi.org/10.1111/jocd.14133DOI Listing
June 2021

The Difference in Facial Movement Between the Medial and the Lateral Midface: A 3D Skin Surface Vector Analysis.

Aesthet Surg J 2021 Mar 30. Epub 2021 Mar 30.

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

Background: Our understanding of the functional anatomy of the face is constantly improving. To date, it is unclear whether the anatomic location of the line of ligaments has any functional importance during normal facial movements such as smiling.

Objectives: It is the objective of the present study to identify differences in facial movements between the medial and lateral midface by means of skin vector displacement analyses derived from 3D imaging and to further ascertain whether the line of ligaments has both a structural and functional significance in these movements.

Methods: The study sample consisted of 21 healthy volunteers (9 females & 12 males) of Caucasian ethnic background with a mean age of 30.6 (8.3) years and a mean BMI of 22.57 (2.5) kg/m 2. 3D images of the volunteers' faces in repose and during smiling (Duchenne type) were taken. 3D imaging-based skin vector displacement analyses were conducted.

Results: The mean horizontal skin displacement was 0.08 (2.0) mm in the medial midface (lateral movement) and was -0.08 (1.96) mm in the lateral midface (medial movement) (p = 0.711). The mean vertical skin displacement (cranial movement of skin toward the forehead/temple) was 6.68 (2.4) mm in the medial midface whereas it was 5.20 (2.07) mm in the lateral midface (p = 0.003).

Conclusions: The results of this study provide objective evidence for an antagonistic skin movement between the medial and the lateral midface. The functional boundary identified by 3D imaging corresponds to the anatomic location of the line of ligaments.
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http://dx.doi.org/10.1093/asj/sjab152DOI Listing
March 2021

Volumization of the young and the old temple using a highly cross-linked HA filler.

J Cosmet Dermatol 2021 Jun 28;20(6):1634-1642. Epub 2021 Apr 28.

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

Background: A plethora of age-related changes contribute to hollowing of the temples, as bone remodeling, atrophy of the temporalis muscle, thinning of the skin, and deflation of the subcutaneous and deep temporal fat create the appearance of a skeletonized face. In addition, previous studies have established a relationship between facial skeletonization, temporal hollowing, and postmenopausal sarcopenia.

Objective: To compare the volume change, adverse events, and patient satisfaction of soft-tissue filler injections in the temple between young (<51) and old (>51) females.

Material And Methods: A total of 30 women with a mean age of 53.1 ± 12.1 years underwent bilateral temporal volumization. Adverse events and satisfaction were assessed after 3 and 6 months. 3-Dimensional surface imaging was performed at baseline and after 2 weeks, 3 and 6 months to assess volumetric changes.

Results: A mean volume of 5.55 ± 1.9 cc was injected into the temples. A total of 31 adverse events were observed in 13 patients. The overall satisfaction of the procedure was very high after 3 and 6 months in both patient groups, and raters showed a significant agreement in their assessment of the aesthetic improvement, while the self-reported patient satisfaction was also substantially high. The surface-volume coefficient differed significantly between 14 days and 3 months post-injection only in pre-menopausal patients, while no significant difference was detected between 3 and 6 months.

Conclusion: Temporal soft-tissue filler injections are safe and provide long-lasting aesthetic improvement both in pre- and postmenopausal women.
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http://dx.doi.org/10.1111/jocd.14109DOI Listing
June 2021

Commentary on: A New Target for Temple Volumization? A Pilot Anatomical and Ultrasound-Guided Study of the Intermediate Temporal Fat Pad.

Aesthet Surg J 2021 Mar 16. Epub 2021 Mar 16.

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

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http://dx.doi.org/10.1093/asj/sjab022DOI Listing
March 2021

Performing Distance Measurements in Curved Facial Regions: A Comparison between Three-Dimensional Surface Scanning and Ultrasound Imaging.

Facial Plast Surg 2021 Jun 11;37(3):395-399. Epub 2021 Mar 11.

Department of Medical Education, Albany Medical College, Albany, New York.

Facial flap surgery depends strongly on thorough preoperative planning and precise surgical performance. To increase the dimensional accuracy of transferred facial flaps, the methods of ultrasound and three-dimensional (3D) surface scanning offer great possibilities. This study aimed to compare different methods of measuring distances in the facial region and where they can be used reliably. The study population consisted of 20 volunteers (10 males and 10 females) with a mean age of 26.7 ± 7.2 years and a mean body mass index of 22.6 ± 2.2 kg/m. Adhesives with a standardized length of 20 mm were measured in various facial regions through ultrasound and 3D surface scans, and the results were compared. Regardless of the facial region, the mean length measured through ultrasound was 18.83 mm, whereas it was 19.89 mm for 3D surface scans, with both  < 0.0001. Thus, the mean difference was 1.17 mm for ultrasound measurements and 0.11 mm for 3D surface scans. Curved facial regions show a great complexity when it comes to measuring distances due to the concavity and convexity of the face. Distance measurements through 3D surface scanning showed more accurate distances than the ultrasound measurement. Especially in "complex" facial regions (e.g., glabella region and labiomental sulcus), the 3D surface scanning showed clear advantages.
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http://dx.doi.org/10.1055/s-0041-1725166DOI Listing
June 2021

How Does Wearing a Facecover Influence the Eye Movement Pattern in Times of COVID-19?

Aesthet Surg J 2021 07;41(8):NP1118-NP1124

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

Background: Since the emergence of the COVID-19 pandemic facecovers have become a common sight. The effect of facecovers on the gaze when looking at faces has not yet been assessed.

Objectives: The aim of the present study was to investigate any potential differences in eye movement pattern in observers exposed to images showing a face without and with a facecover to identify if there is truly a change of gaze when identifying (masked) facial features.

Methods: The eye movement of 64 study participants (28 males and 36 females) with a mean [standard deviation] age of 31.84 [9.0] years was analyzed in this cross-sectional observational study. Eye movement analysis was conducted based on positional changes of eye features within an x- and y-coordinate system while two images (face without/with facecover) were displayed for 8 seconds.

Results: The results of this study revealed that the sequence of focusing on facial regions was not altered when wearing a facecover and followed the sequence: perioral, nose, periorbital. Wearing a facecover significantly increased the time spent focusing on the periorbital region and also increased the number of repeated eye fixations during the 8-second visual stimulus presentation. No statistically significant differences were observed between male and female participants in their eye movement pattern across all investigated variables (P > 0.433).

Conclusions: The altered eye movement pattern caused by wearing facecoverings that this study has revealed suggests that, during the COVID-19 pandemic, aesthetic practitioners might consider developing marketing and treatment strategies that principally target the periorbital area.
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http://dx.doi.org/10.1093/asj/sjab121DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7989657PMC
July 2021

Differences in Temporal Volume between Males and Females and the Influence of Age and BMI: A Cross-Sectional CT-Imaging Study.

Facial Plast Surg 2021 Mar 8. Epub 2021 Mar 8.

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

Background:  The temple has been identified as one of the most compelling facial regions in which to seek aesthetic improvement-both locally and in the entire face-when injecting soft tissue fillers.

Objective:  The objective of this study is to identify influences of age, gender, and body mass index (BMI) on temporal parameters to better understand clinical observations and to identify optimal treatment strategies for treating temporal hollowing.

Methods:  The sample consisted of 28 male and 30 female individuals with a median age of 53 (34) years and a median BMI of 27.00 (6.94) kg/m. The surface area of temporal skin, the surface area of temporal bones, and the temporal soft tissue volume were measured utilizing postprocessed computed tomography (CT) images via the Hausdorff minimal distance algorithm. Differences between the investigated participants related to age, BMI, and gender were calculated.

Results:  Median skin surface area was greater in males compared with females 5,100.5 (708) mm versus 4,208.5 (893) mm ( < 0.001) as was the median bone surface area 5,329 (690) mm versus 4,477 (888) mm ( < 0.001). Males had on average 11.04 mL greater temporal soft tissue volume compared with age and BMI-matched females with  < 0.001. Comparing the volume between premenopausal versus postmenopausal females, the median temporal soft tissue volume was 46.63 mL (11.94) versus 40.32 mL (5.69) ( = 0.014).

Conclusion:  The results of this cross-sectional CT imaging study confirmed previous clinical and anatomical observations and added numerical evidence to those observations for a better clinical integration of the data.
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http://dx.doi.org/10.1055/s-0041-1725201DOI Listing
March 2021

Signal-To-Noise Ratio Calculations to Validate Sensor Positioning for Facial Muscle Assessment Using Noninvasive Facial Electromyography.

Facial Plast Surg 2021 Mar 5. Epub 2021 Mar 5.

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

The evaluation of neuromodulator treatment outcomes can be performed by noninvasive surface-derived facial electromyography (fEMG) which can detect cumulative muscle fiber activity deep to the skin. The objective of the present study is to identify the most reliable facial locations where the motor unit action potentials (MUAPs) of various facial muscles can be quantified during fEMG measurements. The study population consisted of five males and seven females (31.0 [12.9] years, body mass index of 22.15 [1.6] kg/m). Facial muscle activity was assessed in several facial regions in each patient for their respective muscle activity utilizing noninvasive surface-derived fEMG. Variables of interest were the average root mean square of three performed muscle contractions (= signal) (µV), mean root mean square between those contraction with the face in a relaxed facial expression (= baseline noise) (µV), and the signal to noise ratio (SNR). A total of 1,709 processed fEMG signals revealed one specific reliable location in each investigated region based on each muscle's anatomy, on the highest value of the SNR, on the lowest value for the baseline noise, and on the practicability to position the sensor while performing a facial expression. The results of this exploratory study may help guiding future researchers and practitioners in designing study protocols and measuring individual facial MUAP when utilizing fEMG. The locations presented herein were selected based on the measured parameters (SNR, signal, baseline noise) and on the practicability and reproducibility of sensor placement.
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http://dx.doi.org/10.1055/s-0041-1725168DOI Listing
March 2021

The Change of Plane of the Supratrochlear and Supraorbital Arteries in the Forehead - An Ultrasound-Based Investigation.

Aesthet Surg J 2021 Feb 28. Epub 2021 Feb 28.

Private Practice, Amsterdam, Netherlands & Department of Dermatology, Erasmus MC, University Medical Centre, Rotterdam, Netherlands.

Background: Injecting soft tissue fillers into the deep plane of the forehead carries the risk of injection related visual compromise due to the specific course of the arterial vasculature.

Objectives: To investigate the 2- and 3-dimensional location of the change of plane of the deep branch of the supratrochlear and supraorbital artery, respectively.

Methods: A total of 50 patients (11 males and 39 females, mean age: 49.76 (13.8) years, mean body mass index of 22.53 (2.6) kg/m 2) were investigated with ultrasound imaging. The total thickness, and the distance of the arteries from the skin and bone surface were measured using a 15-7 MHz broadband compact linear array transducer.

Results: The deep branch of the supraorbital artery changed plane from deep to superficial to the frontalis muscle at a mean distance of 13 mm [range: 7.0 - 19.0] in males and at 14 mm [range: 4.0 - 24.0] in females and for the deep branch of the supratrochlear artery at a mean distance of 14 mm in males and females [range: 10.0 - 19.0 in males, 4.0 - 27.0 in females} when measured from the superior orbital rim.

Conclusions: Based on the ultrasound findings in this study, it seems that the supraperiosteal plane of the upper and lower forehead could be targeted during soft tissue filler injections as the deep branches of both the supraorbital and supratrochlear arteries do not travel within this plane. The superficial plane of the lower forehead, however, should be avoided due to the unpredictability and inconsistent presence of the central and paracentral arteries.
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http://dx.doi.org/10.1093/asj/sjaa421DOI Listing
February 2021

Acute isolated trigeminal neuropathy following calcium hydroxylapatite-based soft tissue filler injection: A case report.

J Cosmet Dermatol 2021 May 6;20(5):1505-1511. Epub 2021 Feb 6.

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

Background: Soft tissue filler injections are frequently performed with a relatively low number of severe adverse events reported. While venous complications have been described, the majority of adverse events are generally associated with the arterial vascular system. Intra-arterial product application can present with pain, skin discoloration, and potential tissue loss and/or injection related visual compromise.

Aim: We present the clinical case and the consecutive symptomology of a 39-year-old woman injected with calcium hydroxylapatite at the zygomatic arch with five perpendicular needle (27G 12mm) supraperiosteal bolus injections of 0.2 cc per site.

Methods: Immediately after the injections, weakness, nausea, vomiting, and loss of consciousness occurred. Additionally, left-sided loss of sensation of her face, scalp, oral, and nasal mucosa occurred, with absence of left corneal reflex and ipsi-lateral ear congestion. Subsequently, left-sided masseteric atrophy and dysphagia occurred.

Results: One year after the injection procedure the sensory loss of her facial skin and scalp persisted, while the other symptoms improved. Medications involved in the symptomatic (not causal) partial recovery process were Dexamethasone, Vitamin B complex, Vinpocetine, Pentoxifyllin, and Thioctic acid.

Conclusion: The symptoms presented and the time-related relationship to the injection procedure increases the likeliness of an association between the administration of the calcium hydroxylapatite product and a lesion of the trigeminal ganglion. The resulting symptoms can altogether be related to the functions of the ganglion. The connecting pathway between the injection site and the ganglion can be explained by the arterial vascular pathway.
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http://dx.doi.org/10.1111/jocd.13959DOI Listing
May 2021

Intraarterial Degradation of Calcium Hydroxylapatite Using Sodium Thiosulfate - An In Vitro and Cadaveric Study.

Aesthet Surg J 2021 04;41(5):NP226-NP236

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

Background: The most severe complications following soft tissue filler injections result from the intraarterial administration of the filler product. Although hyaluronic acid-based filler can be trans-arterially dissolved with hyaluronidase, no information is available on calcium hydroxylapatite (CaHA)-based fillers.

Objective: The authors sought to test whether CaHA-based fillers can be trans-arterially dissolved by sodium thiosulfate (STS) when evaluated in cadaveric and in vitro models.

Methods: Human cadaveric facial arterial segments were each filled with 0.2 cc of commercially available CaHA product and submerged for 24 hours in 4 different STS-containing solutions: 10 cc STS (300 mg/cc) (pure, 1:1 dilution, 1:2 dilution), 0.9% saline and 10 cc STS (300 mg/cc), and 300 IU (bovine) hyaluronidase in a 1:1 ratio.

Results: Intraarterial CaHA was detected in human facial artery segments after 24 hours independent of the STS concentration employed. Submerging the arterial segments in STS (300 mg/cc) and 300 IU (bovine) hyaluronidase (1:1 ratio) also did not dissolve the intraarterial CaHA product. Gray scale analyses did show, however, that increasing concentrations of STS resulted in increased disintegration of CaHA in an in vitro experimental setting.

Conclusions: The results of this study indicate that STS is limited in its potential to dissolve intraarterial CaHA of cadaveric human facial arteries, despite the fact that it appears effective when in direct contact with the CaHA. Adverse events caused by intraarterial administration of CaHA-based fillers still lack a suitable antidote.
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http://dx.doi.org/10.1093/asj/sjaa350DOI Listing
April 2021
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