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Background Hyaluronic acid (HA) fillers are the most popular dermal fillers for wrinkle correction and facial rejuvenation. Recently, there has been an interest toward classifying HA fillers based on the cross-linking properties into monophasic (MHA) and biphasic (BHA) fillers. We aimed to compare the efficacy and safety outcomes between MHA and BHA fillers for the correction of nasolabial folds (NLFs). Methods We searched Medline, Embase, and CENTRAL for randomized controlled trials (RCTs) that compared MHA filler to BHA filler for individuals with moderate-to-severe bilateral NLFs. We sought to evaluate the following outcomes: Wrinkle severity rating scale (WSRS), pain on visual analog scale (VAS), global aesthetic improvement scale (GAIS), and adverse events. The standardized mean difference (SMD) was used to represent continuous outcomes while risk ratio (RR) was used to represent dichotomous outcomes. Results A total of 11 RCTs that enrolled 935 participants deemed eligible. MHA filler revealed a significant improvement in the overall WSRS score and GAIS score compared to BHA filler (SMD = -0.38, 95% CI -0.49 to -0.27 and SMD = 0.34, 95% CI 0.24-0.45, respectively). No significant difference was noted between MHA and BHA fillers in terms of pain score or adverse events (SMD = -0.39, 95% CI -0.81-0.03 and RR = 1.00, 95% CI 0.89-1.12, respectively). Conclusions MHA filler showed discernable cosmetic results and comparable effective and tolerability to BHA filler.

Background A consensus on facial artery anatomy has not been established due to the discrepancies in previous studies. Objectives The authors sought to assess the branches, course, and location of the facial artery in Asians by utilizing computed tomographic angiography. Methods The computed tomographic angiography images of 300 facial arteries from 150 Asian patients were evaluated. The FA was classified as follows: type 1, facial artery terminates superior labial or inferior labial artery; type 2, facial artery terminates lateral nasal or inferior alar artery; type 3, facial artery terminates medial canthal artery; or type 4, facial artery is divided into duplex branches with dominant medial canthal artery laterally. The relationship between nasolabial fold and FA was evaluated, and the distances from anatomical landmarks to FA were measured to position the course. Results Seventy (23.3%), 163 (54.3%), 49 (16.3%), and the other 18 arteries (6.0%) were classified as type 1, 2, 3, and 4, respectively. A total 72.3% of facial arteries were located medially to the nasolabial fold, and only 14.7% of arteries were lateral to the nasolabial fold. The vertical distance between the facial artery and the inner canthus or the midpoint of the inferior orbital rim decreased from type 1 to type 4 facial artery (P < 0.0001). The 4 types did not significantly differ in distance between the mandibular angle (P = 0.1226) or oral commissure (P = 0.1030) and the facial artery at inferior of mandible. Conclusions Detailed findings of the facial artery will provide a valuable reference for filler injection in cosmetic procedures and flap design in reconstructive surgery.

Masseter injections for cosmetic or pathological reasons are increasingly common, as are filler injections using dual or multiplane techniques in the lateral facial regions or for jawline contouring. The occurrence of blindness following these procedures often remains unexplained. This study aimed to determine the anatomical explanation for this debilitating complication by investigating the transverse facial artery and its relation to the masseter. For this purpose, we dissected 35 cheek specimens with latex injections and 10 specimens without latex. The external carotid artery was dissected up to its bifurcation into the maxillary and superficial temporal arteries. Results showed that the transverse facial artery arose from the superficial temporal or external carotid artery that runs between the zygomatic arch and the parotid duct. Three types of transverse facial arteries were observed: type I: a short artery that did not extend beyond the masseter muscle; type II: a transverse artery that ran to the nasolabial fold and anastomosed to the facial artery; and type III: a sizable transverse artery that substituted the hypoplastic facial artery, continued as the angular artery, and then anastomosed to the dorsal nasal artery. Knowledge of these three types of transverse facial arteries is a prerequisite to study the vascular territory. Type III provides an explanation for the occurrence of blindness after lateral face injections. We consequently define a line that runs from the tragus to the outer quarter of the upper lip as the risk area, while the safe zone is located on either side of this line.

Objectives The use of fat grafts in maxillofacial sculpturing is currently a common technique. Unlike fillers, autologous fats unite with facial tissues, but long-term results may still be unsatisfactory. Sharing long-term follow-ups can be helpful in making outcomes more predictable. Materials and Methods The data from patients who were admitted from 2014 to 2016 for fat augmentation were collected. In all cases, fat grafts were injected by blunt cannula using a tunneling technique in different planes. A fan shape order for the malar, periorbital, nasolabial fold, mandibular angle and body, and perioral area was established. Results Autologous fat was used for different sites of the maxillofacial regions. Of 15 patients, two patients were not satisfied due to fat graft resorption. For this, further injections were performed six months after the first injection using preserved fat grafts. One patient continued to be dissatisfied. There were no other complications related to fat transplants. Conclusion Fat transplantation is a safe, reliable, and non-invasive method for facial contour and facial soft tissue defect restoration. Additional methods such as mesenchymal stem cells along with fat injection increase the survival rate of transferred fat.

BACKGROUND The reduction malarplasty has become one of the most popular esthetic surgeries among Asian women to improve facial contour. However, it is still controversial whether midfacial soft tissue changes after surgery, and more studies are needed. METHODS This retrospective observational study reviewed 30 patients who underwent L-shaped reduction malarplasty during January 2018 and August 2019. The preoperative and postoperative soft tissue thickness and the angle of nasolabial fold of the midfacial were assessed using photographs, three-dimensional skull computerized tomography images, and the Wrinkle Severity Rating Scale. RESULTS The postoperative average level of nasolabial fold angle was lower than that observed in preoperative conditions, with the difference being statistically significant (t = -10.262, P

Summary: Reconstruction following excision of skin lesions at the cosmetically sensitive junction between the alar base and upper lip continues to be challenging for surgeons. We describe an advancement flap from the nasolabial fold area to reconstruct such defects. Our case demonstrates a gentleman with a clinically diagnosed BCC between the alar base and upper lip. An advancement flap from the nasolabial area was designed to reconstruct the defect, with two Burrow's triangles excised to prevent standing cones. The scar of the two Burrow's triangles falls over the nasolabial fold, resulting in the integration of the scar within the natural line. This flap design also maintains of the level of the upper lip, the shape and position of the nostril, and minimises flattening of the philtrum. Excellent cosmetic results were seen six weeks post-op.

BACKGROUND Feeling beautiful and staying young have always been important to the people. Therefore, an extensive body of research has focused on the efforts made to remove the skin problems, especially wrinkles. Fibroblast cells of the skin are the various autologous cells currently used in repairing several wounds, scars, and skin aging. Thus, the present study was conducted to assess the efficacy of the transplantation of the fibroblast cells in eliminating the facial wrinkles using the biometric assessment and to optimize the application of this technique in this treatment. METHODS The present study was conducted on 22 male and female patients aged between 35 and 60 years old. Samples were collected from the retro-auricular region, and the fibroblast cells were isolated and cultured. Subjects received three injections with autologous fibroblasts at 2-week intervals. The patients were followed up for 6 months, and structural changes in their wrinkles were assessed by the sonography and the VisioFace software, cutometer, tewameter, and colorimeter. RESULTS The results obtained using the VisioFace software showed the significant phenotypic changes in the patients after the nasolabial injections (81.42 ± 23.97 vs. 60.91 ± 21.91, p = 0.0001). The results showed a significant increase in the total skin density (13.73 ± 6.30 vs. 26.27 ± 7.93, p = 0.0001), dermis density (11.28 ± 5.21 vs. 31.88 ± 7.96, p = 0.0001), epidermis density (27.68 ± 23.15 vs. 49.21 ± 45.68, p = 0.046), and dermis thickness (798.09 ± 133.51 μm vs. 905.59 ± 240.67 μm, p = 0.036) compared to pre-treatment. CONCLUSION The findings of the study revealed that the injection of autologous fibroblasts can be effective in restoring the aging skin, especially in the nasolabial region, and can be used as a safe rejuvenating strategy.

Nasal reproduction is a difficult plastic medical procedure, it is the most unmistakable and stylish component of the face. Point of work is assessment, result and complexity of the nasolabial folds in nose recreation. Strategies: This examination was done in Benha University Hospital and Benha Health Insurance Hospital on thirty patients with various nasal imperfections. Subsequent to assessing the site, size, and profundity of the imperfections, recreation was finished by nasolabial folds. The folds were planned by the deliberate nasal deformities. Results and end: The mean age of the examination members was 57 years, with a standard deviation of 10 years. As to, 76.7% were guys, while 23.3% were females. The nasolabial fold is a simple, snappy and successful methodology for treatment of more modest and average estimated imperfections of the midfacial region. This method permits collecting a wide and rich vascularized fold along the entire length of the nasolabial overlap. In blend with the wide circular segment of pivot, the fold could arrive at practically any site of centrofacial territory. The closeness to the beneficiary deformities, the best shading match and the acceptable form made from the generally bare territories used from the nasolabial overlap are the other significant benefits of the method.

Delayed inflammatory and infectious complications occurred in a 63-year-old woman after receiving AQUAfilling filler injection in the forehead and nasolabial folds. The complications were idiopathic and occurred at different time points at different sites. Her condition improved after the removal of the injected materials and capsule, and administration of intravenous antibiotics. Although injection sites differ, inflammation can occur at any site at different time points. The possibility of inflammation at other injection sites should always be considered during periodic follow-up, even if the filler injection site initially shows no signs of complications.Level of Evidence: Level IV.

Seborrheic keratoses (SK) are benign skin tumor characterized by well-demarcated and skin-colored to pigmented papules, plaques, or nodules with stuck-on appearance. Typical SKs are normally treated for cosmetic reasons. However, total excision and histopathological examination have to be considered in SK with unusual properties. The island pedicle flap (IPF) is a method of flap for defect closure, especially on the cheek. It has the capability to maintain the vascularization, thus it is also suitable in the elderly. We report a case of an SK with atypical clinical presentation in a 69-year-old female, with a solitary enlarging, hyperpigmented, verrucous, and bleeding tumor. The dermoscopic examination did not show characteristic features of SK. Total excision was performed due to its clinical properties. The histopathological examination revealed hyperkeratosis, acanthosis, hyperplasia, and papillomatosis, along with intercellular pseudo-horn cyst which confirmed the diagnosis of SK. The patient underwent total excision of the skin lesion which left a primary defect. We performed IPF procedure to reconstruct the defect after total excision of the skin lesion. After a year of follow-up, no meaningful complication was detected. The final result of the procedure was satisfying due to its ability to restore the natural contour and texture match by utilizing cheek laxity, without interfering the nasolabial fold. In conclusion, IPF is an appropriate method for defect closure in an elderly patient after facial total tumor excision.

This study aimed to evaluate satisfaction in terms of facial appearance, quality of life, and adverse effects in patients undergoing the facial thread lifting procedure using the absorbable facial threads anchored on the superficial and deep temporal fascias. The charts of patients for whom facial anchored thread lifting was performed using absorbable threads between February 2017 and September 2019 were reviewed. Demographic data including age and gender as well as data from the Face-Q scales were collected. Descriptive analysis was made for the adverse effects 1 week after the procedure. The mean value of adverse effects scales was compared 1 and 2 weeks after the procedure and also the mean values of facial appearance and quality-of-life scales were compared at baseline, 6 months, and 12 months after the procedure. All recruited subjects were females with a mean age of 43.42 years. There was a statistically significant decrease in the rate of adverse effects following the procedure between the first and second week. The mean difference in patients' perceived age 6 and 12 months after the procedure was statistically significant when compared with baseline. The psychological distress significantly decreased and the psychological function improved 6 and 12 months after the procedure. The overall satisfaction with facial appearance increased significantly after 6 months with a mean of 20.08. This was maintained at 12 months. The satisfaction in skin appearance, cheeks, nasolabial folds, marionettes, lower face, and jawline appearances improved significantly 6 months after the procedure. This was also maintained at 12 months. Face lifting using the polycaprolactone threads anchored on the temporalis fascia showed a significant improvement in the quality of life and facial appearance. The adverse effects are tolerable starting 2 weeks after the procedure.

Background Agarose gel filler is a natural hydrocolloid with a three‐dimensional structure similar to the extracellular matrix, with gel formed by hydrogen bonds and electrostatic interactions rather than through chemical cross‐linking or polymerization. Objective To determine efficacy and safety of 2.5% agarose gel filler for the correction of nasolabial folds. Methods In this split‐face study, efficacy, safety, and usability of 2.5% agarose gel were compared to those of NASHA‐L. Assessments included the nasolabial fold (NLF) Wrinkle Severity Rating Scale (WSRS), Global Aesthetic Improvement Scale (GAIS [blinded investigator]), subject satisfaction, safety (adverse events), and usability. Results Sixty‐six subjects were treated, and 46/66 (66.7%) were available for evaluation at 3 months, when mean change in WSRS was identical for both products (−1.1 ± 0.4 for 2.5% agarose; −1.1 ± 0.4 for NASHA‐L). Scores for each product remained similar across all time points and began to return to baseline between 7 and 8 months. GAIS score followed a similar pattern, rising between months 7 and 8 (2.7 ± 0.6 for 2.5% agarose at month 7‐3.3 ± 0.5 at month 8 and 2.7 ± 0.6 for NASHA‐L at month 7‐3.3 ± 0.5 at month 8). Ultrasound confirmed the longevity of both fillers between 7 and 8 months. All adverse events were transient in nature and resolved within 15 days. Most events were mild in nature, and the number of events was similar between the two fillers. Conclusion Treatment with 2.5% agarose gel resulted in improvement that persisted for between 7 and 8 months. The treatment effect was equivalent to NASHA‐L.

Upper-lip reconstruction after Mohs micrographic surgery is challenging for dermatologic surgeons. We describe a series of 15 patients (7 men and 8 women; mean age, 65.6 years) with skin cancer on the upper lip treated with Mohs surgery: 10 were basal cell carcinomas, 2 were melanomas, and 3 were squamous cell carcinomas. The resulting defects measured between 3 and 7.6cm. We used island flaps to reconstruct the defects in all cases, hiding the incisions in the nasolabial fold, at the line where the skin meets the vermillion border of the lip, and in the relaxed skin tension lines. We explain key aspects of the surgeries and design of the reconstructions, with emphasis on the importance of occasionally sacrificing small areas of healthy skin. Cosmetic and functional outcomes were satisfactory in all patients, and there were no postsurgical complications.

Background The injection of hyaluronic acid (HA) dermal fillers is a popular minimally invasive approach to improve lip volume and contour, and with improved techniques has gained popularity because full lips are often associated with beauty and youth. Patient satisfaction is a key driver for successful aesthetic procedures, influencing individual treatment plans and future recommendations. Objective To evaluate subject and partner satisfaction with the hyaluronic acid (HA) dermal filler HARK for lip enhancement at 8 weeks after the last treatment. Methods & materials Subjects in this open-label study all received HARK in the lips, and an additional group also received HARR and/or HARD in nasolabial folds (NLFs) and marionette lines (MLs). Satisfaction was assessed at Weeks 4 and 8 after the last treatment using questionnaires (FACE-Q™ [subjects] and KISSABILITY [subjects and partners]). Results Nineteen subjects received HARK only; 40 also received HARR and/or HARD . Subjects reported a high level of satisfaction with their lips following treatment. Increases from baseline in the mean total satisfaction score were statistically significant at Weeks 4 and 8 (P ≤ .001). Most subjects (≥89%) reported satisfaction on all FACE-Q questions at Week 8. Both subjects and partners were satisfied with the kissability, appearance, and natural look and feel of the post-treatment results. Conclusion This study demonstrated that HARK resulted in lip enhancement with high levels of subject and partner satisfaction, when used alone or in combination with HARR / HARD in NLFs and MLs.

Background Full-thickness skin grafts (FTSGs) have been widely used after facial skin cancer resection, for correcting defects that are too wide to be reconstructed using a local flap or if structural deformation is expected. The preauricular, posterior auricular, supraclavicular, conchal bowl, nasolabial fold, and upper eyelid skin areas are known as the main donor sites for facial FTSG. Herein, we aimed to describe the effectiveness of using infraclavicular skin as the donor site for specific cases. Methods We performed FTSG using the infraclavicular skin as the donor site in older Asian adults following skin cancer resection. Outcomes were observed for > 6 months postoperatively. The Manchester Scar Scale was used for an objective evaluation of satisfaction following surgery and scarring. Results We analyzed the data of 17 patients. During follow-up, the donor and recipient sites of all patients healed without complications. Upon evaluation, the average Manchester Scar Scale scores for the recipient and donor sites were 7.4 points and 5.7 points, respectively. Conclusion In general, conventional donor sites, such as the preauricular, posterior auricular, and supraclavicular sites, are widely used for facial FTSG because they achieve good cosmetic results. However, the infraclavicular skin may be a useful donor for facial FTSG in cases where the duration of time spent under anesthesia must be minimized due to a patient's advanced age or underlying health conditions, or when the recipient site is relatively thick area, such as the nose, forehead, or cheek.

Background Skin scarring can occur after punch biopsies, prohibiting their routine utilization, especially in the central face. Objectives This paper describes a scarless, 0.33-mm-diameter skin microbiopsy for molecular analysis of skin. Methods This is was single-center, randomized, prospective study with 15 patients receiving no biopsy or biopsy on the left or right nasolabial fold. Six blinded raters assessed participant photos at baseline, 1 month, and 3 months post biopsy to evaluate for a visualized scar. Patient and Observer Scar Assessment Scale was completed. Additionally, biopsies from various skin regions of body along with arm skin after treatment with a single Erbium-YAG laser were processed for molecular analysis. Results No patients exhibited scar formation based on evaluation of photographs and patient feedback. There was no mark at the biopsy site 7 days post-procedure. Optical coherence tomography showed a complete closing of the biopsy-punch wound 48 hours post-biopsy. One month post-biopsy, photography reviewers were unable to identify a scar, on average, 90% of the time at 3-month follow-up. Microbiopsies from various anatomical regions were successfully extracted for histology, electron microscopy, and gene expression analysis. Selected skin rejuvenation markers in the biopsies from Erbium-YAG–treated forearm skin resulted in significant gene upregulation in extracellular matrix molecules at 1 month posttreatment compared with untreated skin. Conclusions A core microbiopsy of 0.33 mm can be extracted reproducibly for histological, ultrastructural, and gene expression analysis without scarring. This allows repeated sampling for assessment of skin treatments and diseases, including aesthetics and wound-healing progress.

MRI analyzed quantitatively the HA injected into the NLF subcutaneous fat to correlate the gel diffusion and degradation with the morphological changes of the NLF appearance for twelve months. Measurements of the gel diffusion and degradation were taken by MRI as parameters to assess the clinical efficacy and long-acting of the HA in NLF rejuvenation. HA was applied into the superficial compartment of the subcutaneous fat of twenty NLFs. Each NLF received three injection points, from the nasal ala toward the oral commissure, 1.0–1.5 cm distant from each other, according to the NLF length. A bolus injection technique without retrograde backflow applied per injection point 0.15–0.20 ml of HA for moderate. NLF and 0.20–0.25 ml for severe NLF. Patients were evaluated through MRI and clinically twenty-four hours, one month and twelve months after the HA application. MRI, in T2-weighted, displayed the gel as a dense, spindle-shaped nodule as pattern of the gel diffusion, measuring its largest longitudinal and transverse axes. Twenty-four hours after HA application the longitudinal axis measured 1.79 cm, after one month 2.33 cm and at month twelve 0.91 cm. The transverse axis measured 0.92 cm at 24 hours, 1.13 cm after one month and 0.47 cm at month twelve. Despite reduction in size and denseness of the spindle-shaped nodule, the small amount of gel presenting into the subcutaneous fat after twelve months of the application evidenced the HA efficacy and long-acting in NLF rejuvenation. 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 .

Background Recently, the field of face and facial features has been progressively studied. The features of facial expression have gained increasing attention for related applications. The wrinkle is the most representative feature, and its research and applications have been topics of high interest. Wrinkles play an important role in face feature analysis. They have been widely used in applications, such as age estimation, skin texture classification, expression recognition, and simulation. Purpose Existing approaches to the image‐based analysis of wrinkles as texture not as curvilinear discontinuity and wrinkle detection mainly have focused on detecting wrinkles on forehead position, which is usually horizontal linear shapes, while the detection of the nasolabial wrinkle is not well understood due to their variety of shapes and complexity. Method In this paper, we present a nasolabial wrinkle line detecting effective algorithm based on the Active appearance model and Hessian filter to improve localization results by creating unique initial shapes of the wrinkle lines for each input face image. Results Experimental results show that the proposed method is capable of tracking curve wrinkle lines, thus allowing to detect complexly structured wrinkle lines. This work demonstrates results illustrated the competitiveness of the proposed method in detecting nasolabial wrinkle lines. Conclusion In our study, this was introduced the effectiveness of changing the structure of AAM and successfully applied in wrinkle line localizing, although competitive results are achieved by the proposed wrinkle detection method.

Background Autologous platelet-derived preparations have been used in many surgical fields to improve healing outcomes, with benefits reported in several aesthetic indications. Aims This single-center, prospective, uncontrolled study evaluated the efficacy of injectable platelet-rich fibrin (i-PRF) for facial skin rejuvenation using an objective skin analysis system and validated patient-reported outcome measures. Patients/methods PRF® PROCESS system technology was used to prepare i-PRP. Eleven healthy female individuals were included in the study and over 3-months received monthly intradermal injections of i-PRF in 3 facial regions: malar areas (1 mL each side), nasolabial fold (0.5 mL each side), and upper lip skin above the vermilion border (1 mL). The efficacy of the procedures was assessed by objective skin analysis (VISIA® ) and a subjective patient-reported outcome (FACE-Q) assessment at baseline and after 3 months. Results A significant improvement in skin surface spots (P = .01) and pores (P = .03) was seen at 3-months follow-up. Other variables, such as skin texture, wrinkles, ultraviolet spots, and porphyrins, showed a numerical improvement. FACE-Q scales that measure satisfaction with appearance all showed a significant improvement from baseline, including satisfaction with skin (P = .002), satisfaction with facial appearance (P = .025), satisfaction with cheeks (P = .001), satisfaction with lower face and jawline (P = .002), and satisfaction with lips (P = .04). No major adverse effects were reported. Conclusions A series of three i-PRF injections resulted in significant rejuvenation of the face skin at 3-month follow-up, as shown by improved skin analysis parameters and patient self-assessment scores.

We present reconstruction of a gunshot-caused mouth floor defect using a nasolabial flap and a de-epithelialized V-Y advancement flap.A 58-year-old man presented 14 days after bullet injury passed from anterior chin to the right postauricular area. Upon examination, the central incisors, alveolar bones, and soft tissues of the mouth floor were lost. Bone fragments and failed miniplates were exposed. Pus discharge filled the defect.On the 23rd post-trauma day, right unilateral nasolabial flap was used to cover the oral side of the mouth floor. This flap was centered on the nasolabial fold and its base was situated on the commissure of the lips. The flap was raised in the soft tissue, just superficial to the facial muscles, transferred into the oral cavity through an incision made in the cheek mucosa, and sutured to the margin of the defect. A de-epithelialized dermal and subcutaneous flap was used to reconstruct the deep portion of the mouth floor through the V-Y advancement method. At the lower border of the mandible, a 3-cm-wide V-Y advancement flap was designed. The de-epithelized portion was inserted into the mouth floor and sutured to the defect margin. On 30th post-trauma day, left commissure-based buccal mucosal flap was used for the gingivobuccal sulcus defect. The apex was near the retromolar trigone. The elevated flap was transferred to the lower gingivobuccal sulcus defect. On POD 28, the nasolabial flap and commissure-based buccal myomucosal flap was divided and inset respectively.These flaps can be used for moderate-sized mouth floor defects.

Background Despite the increasingly popular use of platelet-rich fibrin matrix (PRFM) for facial rejuvenation, no studies have evaluated its effects on skin. Objectives The aim of this study was to determine the effect of PRFM on skin quality as measured by the Canfield VISIA Complexion Analysis System. Methods This was a 12-week randomized, placebo-controlled trial conducted at a single center comparing 2 groups. Thirty patients received a PRFM injection in the mid-cheek region and nasolabial fold on one side of the face and saline on the contralateral side. The primary outcome measure was the difference between pre- and posttreatment total VISIA skin scores for each group at 6 and 12 weeks. The change in subscores for each skin parameter was also calculated. Results There were 30 participants, with a mean [standard deviation] age of 49.9 [13.9] years. At 6 weeks, the median change in total VISIA score (interquartile range) was –1.77 (2.36) in the PRFM group and –0.73 (2.09) in the saline group (P = 0.003). The only skin parameter that had a significantly different change in score between the groups was texture (P = 0.004). At 12 weeks, the change in median score was –1.31 (3.26) in the PRFM cohort and –0.76 (2.21) in the saline cohort (P = 0.34). There was no statistical significance in the change in score for any of the individual skin parameters. Conclusions PRFM can objectively improve skin quality compared with placebo. Texture was the only skin parameter that significantly improved, which is consistent with PRFM’s role as a filler agent. The results appear to persist for at least 6 weeks. Level of Evidence: 1

Background The facial artery is a high-risk structure when performing filler injections at the nasolabial fold, buccal, and mandibular regions. Objectives This study aimed to establish reference landmarks locating the course of the facial artery and its essential branches. Methods Thirty-one embalmed cadavers were enrolled in this study. The course of the facial artery was observed in regard to the following reference points: masseter insertion, oral commissure, and common bony landmarks. The corner of the mouth was utilized as the landmark to measure the turning point of the facial artery. Results Seven points were established to identify the course and turning point of the facial artery. These included the anterior masseteric, lateral mental, infraorbital, medial canthal, basal alar, post-modiolar (PMP), and supra-commissural (SCP) points. The course of the facial artery deviates at least twice at the lateral mental points and at the SCP or PMP. The facial artery appeared more medially when the artery turned at the PMP and SCP. It presented through the lateral channel if the turning point was solely at the PMP. Wherever the facial artery deviates, it can be divided into 3 segments: the mandibular, buccal, and nasolabial segments. The arterial course may deviate laterally from the mouth corner towards PMP. The nasolabial segment may also deviate laterally to the basal alar point at the alar grove for 0.5 to 1 cm. Conclusions The deviation of facial artery closely relates with mandibular, buccal, and nasolabial segments. It is essential in avoiding arterial injury for physicians and surgeons who perform procedures in these areas.

Background Recently, light-emitting diode (LED) devices are among those mostly preferred for esthetic application because they improve the appearance of photoaged skin characterized by wrinkles, sagginess, pigmented lesions, and others. In addition, the use of hyaluronic acid (HA) for skin rejuvenation is already well proven. Aims This study aims to evaluate the synergistic effects of using home-use LED mask device with HA ampoule. Methods The total number of recruited subjects was 48:24 in Group A treated with both home-use LED mask device and HA ampoule and 24 in Group B treated with HA ampoule only, for 4 weeks. To assess the efficacy of the treatment, the following were used: Antera 3D CS, EOS 800D with Image-Pro Plus, DUB-USB, VisioFace Quick, and Visioscan VC98. Results After treatment, the volume measurement (mm3 ) for prejowl sulci and nasolabial fold flattening as well as the area measurement (pixel) for lower chin firmness improvement was significantly reduced, and the number of pores (ea) for enlarged pores as well as the desquamation index (%) for the amount of corneocytes significantly decreased in both Group A and Group B. Moreover, the percentage of skin density significantly improved. Furthermore, Group A showed a significantly faster and higher rate of improvement than Group B. Conclusion The use of 660- and 850-nm home-use LED mask device can generate synergistic effects on home-use topical applications like HA on photoaged face, and such device can be safely and efficiently used daily in personal environments.

Introduction The nasolabial fold (NLF) causes particular concern during aging in the middle face region. However, arterial complications of filler injections at this site have been continually reported during recent years. The aim of this study was to investigate the arterial locations and their anastomotic pathways related to filler injection sites in the NLF. Materials and methods Thirty hemi-faces of 15 embalmed Thai cadavers were dissected. Three anatomical landmarks of NLFs were assigned: the inferior margin level (NLF1), the mid-philtral horizontal line level (NLF2), and the inferior alar level (NLF3). Ten hemi-faces of five soft embalmed Thai cadavers underwent a modified Sihler's staining procedure to investigate the arterial anastomoses. Results The artery closest to all of the landmarks was the facial artery. It was located inferomedial to NLF1 in 28%, and the mean distances along the X- and Y-axes were 3.53 ± 2.11 mm and 3.53 ± 1.75 mm, respectively. It was also located medial to NLF2 in 52.1% with an X-axis distance of 4.93 ± 1.53 mm. Several arteries were located close to NLF3, including the facial (33.3%), lateral nasal (33.3%), and infraorbital (30.0%) arteries. Anastomoses of the nasolabial arteries served to connect both the external-external and internal-external carotid systems. Conclusions Several arteries are located close to NLF1-NLF3. To prevent arterial injury, the locations and anastomotic pathways, as possible sources of severe complications, should be recognized prior to NLF filler injection.

Bellafill (Suneva Medical Inc) is a semipermanent injectable soft tissue filler composed of smooth and uniform polymethylmetacrylate (PMMA) microspheres suspended in a bovine collagen gel. It is a third generation PMMA filler, with more uniform shapes and sizes of the PMMA microspheres, which has been purported to decrease the incidence of granuloma formation.We performed a retrospective review of our clinical experience from 2014 to 2017 with Bellafill as a soft tissue injectable filler in the following clinical scenarios: deep nasolabial folds, depressed facial acne scars, malar volume loss, temporal wasting, tear trough deformity, chin augmentation, angle of jaw augmentation, and lip augmentation. The primary outcome is the rate of adverse events, and the secondary outcome is subjective patient satisfaction.From 2014 to 2017, 842 syringes of Bellafill were administered to 212 patients, for a total of 417 procedures. Of the 417 procedures, 96 (23.0%) were for acne scars, 82 (19.7%) malar volume restorations, 65 (15.6%) nasolabial fold augmentations, 45 (10.8%) chin augmentations, 42 (10.1%) tear trough volume restorations, 28 (6.7%) temple volume restorations, 25 (6.0%) rhinoplasty touch-ups for small areas of nasal depression, 22 (5.3%) lip augmentations, and 12 (2.9%) jaw angle augmentations were performed. A range of 1 to 12 syringes were injected into each patient, over 1 to 3 sessions; 6 cases of adverse events occurred (1.4%). There were 4 cases of solitary nodules in the injection site, 1 case of lower eyelid oedema which persisted for 3 months and 1 case of lower lip oedema which resolved within hours. Patient satisfaction rates ranged from 83.3% for angle of jaw augmentation to 99.0% for improvement of acne scars.Bellafill is a safe and effective option for a semipermanent soft tissue filler, with high patient satisfaction and a good safety profile.Le Bellafill (Suneva Medical Inc.) est un produit de comblement injectable semi-permanent des tissus mous, composé de microsphères de polyméthymétracylate (PMMA) lisses et uniformes, suspendues dans un gel de collagène bovin. Il s’agit d’un produit de comblement de PMMA de troisième génération, dont les microsphères de PMMA, de formes et de dimensions plus uniformes, réduiraient l’incidence de granulomes.Les chercheurs ont procédé à une analyse rétrospective de leur expérience clinique du Bellafill utilisé comme produit de comblement injectable des tissus mous dans les scénarios cliniques suivants entre 2014 et 2017: sillons nasogéniens profonds, cicatrices déprimées d'acné facial, perte de volume de l’os malaire, émaciation des tempes, dépression du rebord orbital inférieur, augmentation du menton, augmentation de l’angle des mâchoires et augmentation des lèvres. Le résultat primaire était le taux de réactions indésirables et le résultat secondaire, la satisfaction subjective des patients.Entre 2014 et 2017, les plasticiens ont injecté 842 seringues de Bellafill à 212 patients, pour un total de 417 interventions. De ce nombre, 96 (23,0 %) visaient des cicatrices d'acné, 82 (19,7 %), la restauration du volume de l’os malaire, 65 (15,6 %), l’augmentation des sillons nasogéniens, 45 (10,8 %), l’augmentation du menton, 42 (10,1 %), la restauration du volume du rebord orbital inférieur, 28 (6,7 %), la restauration du volume des tempes, 25 (6,0 %), les retouches des petites zones de dépression nasale après une rhinoplastie, 22 (5,3 %), l’augmentation des lèvres, 12 (2,9 %), l’augmentation de l’angle de la mâchoire. Chaque patient s’est fait injecter de une à 12 seringues, réparties entre une et trois séances. Six cas de réactions indésirables se sont produits (1,4 %), soit quatre cas de nodules solitaires au point d’injection, un cas cas d’œdème de la paupière inférieure qui a persisté trois mois et un cas d’œdème de la lèvre inférieure qui a disparu en quelques heures. Le taux de satisfaction des patients a oscillé entre 83,3 % pour l’augmentation de l’angle de la mâchoire et à 99,0 % pour l’atténuation des cicatrices d’acnén.Le Bellafill est un produit de comblement des tissus mous à la fois sécuritaire et efficace, qui suscite une satisfaction élevée de la part des patients et possède un bon profil d’innocuitfi.

Background Injection of hyaluronic acid filler, a common procedure for nasolabial fold correction, poses a risk of vascular compromise, which can result in skin necrosis and blindness. Objectives The aim of this study was to examine the facial arterial pathway in real time by Doppler ultrasound to avoid arterial complications during filler injections. Methods The facial artery pathway of 40 patients (80 nasolabial folds; 2 men and 38 women; mean age, 46.5 years; range, 28-72 years) was examined by Doppler ultrasound before hyaluronic acid filler injection. On the basis of this ultrasound evaluation, the filler injection targeted the subdermal, subcutaneous, and deep to submuscular layers by bypassing the facial artery. The efficacy of the filler injection was evaluated for each patient. Results The facial artery was detected lateral to the nasolabial fold in 31% of patients; it was detected beneath the nasolabial fold in the other patients as follows: subdermal layer, 13%; subcutaneous layer, 29%; muscular layer, 24%; and submuscular layer, 4%. The mean [standard deviation] Wrinkle Severity Rating Scale score was 3.68 [0.76] before injection and 2.28 [0.78] at 3 months after injection. Two patients experienced unilateral bruising of the nasolabial fold, which resolved after 2 weeks without treatment. Conclusions Doppler ultrasound can be considered as pretreatment tool for the prevention of vascular complications during filler injections to correct nasolabial folds. Level of Evidence: 4

A novel treatment approach to address the nasolabial fold is the insertion facial suspension threads. However, there is a paucity of data available to guide insertion techniques and material selection. Three female and two male cephalic specimens of Caucasian ethnicity (73.6 ± 6.5 years; 21.41 ± 2.2 kg/m2) were included into this experimental split-face study. One facial side was treated with polycaprolactone (PCL) thread: 180 mm, bidirectional, 18G 100 mm cannula, 20 degrees trajectory, preauricular approach whereas the contralateral side was treated with polydioxanone (PDO) thread: 100 mm, bidirectional, 19G, 60 mm cannula, 50 degrees trajectory, infraorbital approach. Three-dimensional imaging outcome measures included vertical and horizontal skin displacement and volume changes at the nasolabial sulcus, at the labiomandibular sulcus, and along the jawline. Comparing PCL 180 mm 20 degrees to PDO 100 mm 50 degrees: vertical lifting effect 1.42 ± 2.63 mm versus 1.24 ± 1.88 mm (p = 0.906); horizontal lifting effect 3.42 ± 1.44 mm versus –2.02 ± 1.84 mm (p = 0.001); nasolabial volume change –0.80 ± 0.65 mL versus –0.52 ± 0.17 mL (p = 0.367); labiomandibular volume change –0.45 ± 0.42 mL versus –0.16 ± 0.16 mL (p = 0.191); jawline volume change 0.02 ± 0.43 mL versus –0.01 ± 0.21 mL (p = 0.892). The study provides objective evidence for the short-term effectiveness of facial suspension threads in treating the nasolabial folds. The results point toward a better aesthetic outcome when utilizing long facial suspension threads that can effect full-face changes as compared with short facial suspension threads.

Introduction Intradermal injection of botulinum toxin type A (BoNT/A) has been used off-label by many clinicians for face-lifting. Previous studies on abobotulinumtoxinA (ABO) (Dysport®; Ipsen Biopharm Ltd.) have demonstrated clinical efficacy in face-lifting when compared to normal saline solution (NSS). However, few clinical studies have evaluated ABO in terms of duration of sustained effects for face-lifting. Methods Thirty subjects were enrolled, and their face was injected with ABO at a dilution of 1 vial:7 mL (500 U in 7 mL of NSS) using an intradermal injection technique. Standardized photographic documentation was obtained using a two-, and three-dimensional imaging system (Vectra H1, Canfield Scientific, Inc, Fairfield, NJ) at baseline, immediately after injection, 2 weeks after injection and at 1 , 2 , 3 , 4 , 5 and 6 months of follow-up after treatment. The face-lifting effects were graded by both the subjects and two blinded dermatologists who compared photographs taken at the different time points. Side effects were also recorded at the end of the study. Results Of the 30 subjects, 28 completed treatment and attended every follow-up visit. All subjects were female with Fitzpatrick skin type II to IV. The average age of the subjects was 27.6 ± 3.4 (range 22–34) years. The total number of ABO units used varied for each subject (range 200–250 U), with the average (± standard deviation) dose being 237 ± 19 units. Most of the subjects reported significant face-lifting up to 3 months post-procedure. However, face-lifting assessed by blinded dermatologists was notably lower than that of each patient’s evaluation. The difference in the facial contouring volume of the nasolabial fold and jawline, as measured by the Vectra H1 imaging system, was statistically significant from baseline up until 3 months after injection (p = 0.001 and p = 0.001, respectively). The only side effect found in this study was minimal bruising, which was seen in 13.8% of subjects. None of the subjects reported facial asymmetry, either at rest or during facial expression. Conclusion The results of this study demonstrate the face-lifting effect of ABO intradermal injection. The results show sustained effects up to 3 months after injection.

Background Suspension of the superficial muscular aponeurotic system (SMAS) is generally believed to be necessary in facelift surgery. Although many techniques have been suggested, all rely on the viscoelastic properties of the SMAS Objectives The aim of this study was to determine the viscoelastic properties of bursting strength, stress relaxation, and creep in the lateral, mid-cheek, and medial regions of the SMAS. Methods The viscoelastic properties of the SMAS were determined in 12 cadaveric hemifaces. Lateral SMAS was classified as the SMAS overlying the parotid gland; mid-cheek SMAS as anterior to the parotid and overlying the masseter muscle; and medial SMAS as including tissue extending medial from the lateral canthus and ending at the nasolabial fold. Results The 3 SMAS regions showed significantly different bursting strengths: 38.9 N for the lateral SMAS, 26.7 N for the mid-cheek SMAS, and 11.9 N for the medial SMAS (P Conclusions The lateral SMAS has a stronger bursting strength than the mid-cheek and medial SMAS. Creep appears to be lower in the lateral and mid-cheek SMAS. Stress relaxation appears to be similar in all 3 vertical regions.

Various techniques have been described for the reconstruction of surgical defects of the upper lip after skin cancer. Here, we propose a technique for reconstructing medium or large defects located at the junction of the nasogenian and nasolabial folds with a hatchet flap. We report on three patients treated with this technique, describing the surgical procedure and some interesting caveats. Two patients reconstructed with direct closure in this location are described in order to emphasize the better aesthetic result achieved with the hatchet flap, especially in terms of symmetry. While direct closure tends to decrease the ipsilateral nasolabial fold, the hatchet flap extends the scar to the fold below the commissure in a natural wrinkle, becoming symmetrical and much less noticeable after a few months. We conclude that the hatchet flap is technically easy and rapidly implemented for defects in the apical triangle of the upper lip, and achieves better results in terms of facial symmetry than direct closure.

Background: To investigate the efficacy and safety of Dermalax in the correction of moderate to severe nasolabial folds (NLFs) compared to Restylane.Methods: A total of 324 subjects with moderate to severe NLFs were enrolled in this multicenter, randomized, double-blind, active-controlled clinical study. Eligible subjects were randomly assigned to the test group received Dermalax injection (n = 162) or control group received Restylane injection (n = 162). Clinical efficacy and safety were assessed based on the Wrinkle Severity Rating Scale (WSRS) and the Global Esthetic Improvement Scale(GAIS) at weeks 2, 8, 16, 24, 36 and 48 weeks after injection.Results: At week 24, similar improvements of effective rate were obtained on the Dermalax group (93.75%) and Restylane group (89.44%). Significances were found at 36 weeks and 48 weeks after injection, Dermalax seemed be better than Restylane in maintaining the effect in the later period. The improvement of mean WSRS score for test group was superior to that of control group with significance. GAIS scores rated at week 24 were 1.65 VS 1.94 (p < .001) and 2.10 VS 2.27 (p = .060), seperately.Conclusions: Dermalax was no inferior to or better than that of the control filler Restylane in correcting of moderate to severe NLFs in Chinese subjects.

Lengthening temporalis myoplasty (LTM) is a unique and definite facial reanimation procedure that involves inserting the whole temporal tendon directly into the nasolabial fold. However, the nasolabial fold incision remains one of the difficulties of this procedure, particularly in young or female patient. To avoid the need for this incision, the authors developed an intraoral approach to manipulate the temporal muscle tendon toward the nasolabial fold. in this study, we describe the details of this procedure.The authors performed their intraoral approach procedure in 5 patients with established complete facial paralysis. instead of making an incision at the nasolabial fold to approach the coronoid process, the authors made the incision at the buccal mucosa. The results were evaluated both subjectively and objectively.The authors achieved facial reanimation without leaving any obvious scar on the face or neck and the effect of static reconstruction is obvious, even immediately after the surgery. All the patients obtained good facial movement within 4 months (2.5 months in average), and improved all evaluated parameters postoperatively. No infections or other major complications were reported following surgery; however, 1 patient developed a slight dimple that required revision.The authors could advance temporal tendon toward nasolabial fold firmly obtaining sufficient surgical field similar to that of nasolabial fold incision, and achieved fairly good results without an obvious scar on the face.Establishing LTM without nasolabial fold incision, we could expand the indication of LTM more widely, and it could be more familiar procedure for smile reanimation in all generation.

The use of hyaluronic acid (HA) fillers in lip augmentation represents today 1 of the most widely used nonsurgical aesthetic procedures in the world. Regarding the severe complications are rare, insufficient professional experience for recognizing signs of vascular impairment and inadequate technique could lead to severe lip skin necrosis complications. Several of existing treatment protocols in the literature to treat vascular complication are mainly based on the use of hyaluronidase. Nevertheless, there is no consensus on dosage, interval between doses and complementary protocol among the aforementioned studies. This case aims to present a conservative approach for the clinical management of serious vasculature complications with HA injection. A high dose of hyaluronidase(11500 IU) with additional multimodal treatment was performed to the upper lip, nasolabial fold, and nose that successfully reversed a vascular complication process. The present findings suggest that the use of high doses of hyaluronidase with the complementary protocol used herein might be a promising approach in the treatment of severe vascular complication in the lips caused by HA filling.

Introduction The tricarboxylic acid (TCA) cycle is a key metabolic pathway for driving the generation of mitochondrial energy in all oxidative organisms. Alpha-ketoglutarate (Alpha-KG), a precursor of glutamine, is known as a crucial intermediate of the TCA cycle and plays a pivotal role in multiple metabolic processes. As a precursor of glutamate and glutamine, AKG acts as an antioxidant agent as it directly reacts with hydrogen peroxide with formation of succinate, water, and carbon dioxide; meanwhile, it discharges plenty of ATP by oxidative decarboxylation. Several studies reported that Alpha-KG is a key participant in the detoxification of reactive oxygen species and acts as an integral part of the oxidative defense machinery. However, few studies have been reported on the efficacy of Alpha-KG in the maintenance of skin functions. This study demonstrated that Alpha-KG has beneficial effects on skin hydration and barrier function and that fermentation is an effective way to enhance the synthesis of Alpha-KG in yeast, which possesses mitochondria. Methods Evaluation of promoting effects on epidermal keratinocyte proliferation: Keratinocytes were incubated with a test sample, and the degree of proliferation was determined by MTT [3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide] assay. Evaluation of promoting effects on mRNA expression of genes related to skin hydration and barrier function: Keratinocytes were incubated with a test sample, and gene expression levels of filaggrin (FLG), serine palmitoyltransferase (SPT), and involucrin (IVL) were analyzed by real-time RT-PCR. Analysis of Alpha-KG in rice fermented liquid: Alpha-KG in rice fermented liquid was quantitatively analyzed by capillary electrophoresis time-of-flight mass spectrometry (CE-TOF-MS). Clinical study testing methods and VISIA testing: After 28 days of treatment use the cream with Alpha-KG and control sample without Alpha-KG, instrumentation measurements were adopted to assess skin wrinkles, texture, elasticity, and firmness, tested by the VISIA-CR. Results Immediately after using the sample for D0, the skin wrinkles were significantly reduced by 23.64%. After using the sample for D7, the average clinical score of outer corner wrinkles was significantly reduced by 15.23%, and nasolabial groove wrinkles were significantly reduced by 25.68%. After using the sample for D56, the mean clinical evaluation score of crow's feet decreased significantly by 25.42%; the average score of clinical evaluation of skin firmness increased significantly by 41.40%; the skin gloss increased significantly by 28.67%. Conclusion It was demonstrated that Alpha-KG is expected to promote skin hydration and barrier function by the activation of cell proliferation and the up-regulation of mRNA expression of genes related to the maintenance of epidermal function in in vitro tests. In order to develop a cosmetic ingredient including Alpha-KG, we focused on fermentation with yeast as an efficient production method of Alpha-KG and found that fermentation of rice with yeast efficiently produced Alpha-KG. Taken together, it is considered that rice fermented liquid containing Alpha-KG could be a promising ingredient for skin care products. Through the clinical testing, rice fermented liquid containing Alpha-KG could be a promising cosmetic ingredient for skin care products.

Introduction: The Oriental nose differs from the Caucasian nose in terms of size, subunit definition, texture, and thickness of the skin [1]. Zitelli’s bilobed flap enables aesthetic reconstruction in Caucasian noses but in smaller Oriental noses the outcomes are less desirable with nasal alar retraction commonly seen [2]. Hence, we describe a modification of Zitelli’s bilobed flap incorporating nasolabial skin for a single stage nasal reconstruction with reduced nasal alar retraction [3]. Methods: We modified the bilobed flap based on Zitelli’s bilobed flap and the aesthetic subunit principle, as modified for Orientals by Yotsuyanagi in 2000 [4]. The primary lobe was located between the defect and the cheek and the second lobe was located on the cheek, above the nasolabial fold. The modification of the bilobed flap was designed to have a primary lobe that was 10% longer than the length of the distal defect edge from the flap’s pivot point, and the width of the primary lobe was equal to the width of the defect. The length of the secondary lobe was 130% of the length of the distal defect edge to the flap’s pivot point, and the width of the secondary lobe was two-thirds the width of the primary lobe. Results: Satisfactory alar reconstruction was achieved from the viewpoint of the patient and surgeon. There was good nasal contour and appropriate symmetry of the nasal tip with reduced nasal alar retraction. Conclusion: The modification of Zitelli’s bilobed flap to have a longer primary lobe and include nasolabial skin, results in reduced nasal alar retraction.

The aim of this study was to elucidate the relationships between the nasolabial fold and superficial fascia on histology and P45 sheet plastination.Two centimeter width specimen of the nasolabial area were harvested from the skin to periosteum. Then, 10-μm sections were made, stained with Masson trichrome, and observed under a light microscope. Three head and neck specimens were sliced in horizontal sections (46 slices) using P45 sheet plastination (polyester resin corrosion-resistant method designed to preserve biological sectional specimens in situ). Through slicing, bleaching, dehydration, casting, forced impregnation, curing, cutting, and sanding the molds, P45 plastination provided good light transmission, allowing the internal structures within the sheet to be revealed clearly in their intact form.The observations on histology and P45 sheet plastination correlated well. The nasolabial fold consisted of the superficial fatty layer of superficial fascia (SFS). At the beginning of the alar groove level, the nasolabial groove was located on the point where the medial limit of SFS met the levator labii superioris. At the alar base level, the nasolabial groove was located where the medial limit of the SFS met levator labii superioris. At the mouth corner level, the nasolabial groove was located where the medial limit of the SFS met the modiolus, including the orbicularis oris. The superficial fascia became scanty near the nasolabial groove, and the SFS comprised the nasolabial fold.The results of the present study may be helpful for applying subcutaneous dissection or sub-superficial muscular aponeurotic system dissection in rejuvenation of the nasolabial area.

Platelet-rich plasma has become one of the most widely used facial cosmetics fillers. We evaluated four patients treated by cosmetologists with platelet-rich plasma injections who developed irreversible blindness due to iatrogenic occlusion of the ophthalmic artery; immediately after the injection in the glabellar area in three cases and in the nasolabial fold in one case. Early after the injections the fundi of all patients demonstrated central retinal artery and choroidal occlusions. Later, two patients developed retinal pigment dispersion and one of them a pigmented optic disc. The scars on the skin showed similar characteristics in all patients, which could constitute an important marker in the presumptive diagnosis of platelet-rich plasma injection associated complications.

Histological analysis of hyaluronic acid (HA) applied in the nasolabial fold (NLF) studied gel distribution into the dermis and subcutaneous fat, correlating density of NLF tissues, with cohesivity, concentration and degradation of HA. Ten patients received two injection points on each NLF. They were intradermal near the nasal ala and subcutaneous near the oral commissure. Injection points received 0.1 ml of 24 mg/ml HA cross-linked by BDDE 2.0 ppm through a bolus technique injection without retrograde backflow. Biopsies were taken 72 h and 9 months after application to histological analysis. Dermis density fragmented the gel into small nodules, spreading it into the reticular dermis. Seventy-two hours after application, average diameter of the small nodules was 0.30 mm and at month nine 0.05 mm. Softness of the subcutaneous fat and high concentration of HA created a single and compact nodule. Seventy-two hours after application, average of nodule diameters was 1.05 mm and at month nine 0.49 mm. HA biodegradation occurred on the external surface of the gel. The single nodule offered small contact surface to enzymes, slowing gel degradation. The sum average of the diameters of the small nodules offered a large contact surface to enzymes, accelerating gel degradation. Permanence of the HA into the tissues depended on the relationship between the gel distribution and its degradation. Due to the small contact surface of the single nodule to enzymes, permanence of the HA into the subcutaneous fat was more extended than into the dermis. 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 .

Background Though the collagen-stimulating capacity of poly-L-lactic acid (PLLA) is well established, no data are available on collagen stimulation by the PLLA/PLGA within absorbable suspension sutures used for tissue repositioning. Aims To characterize collagen stimulation by absorbable suspension sutures through examination of patient biopsies and assess severity of nasolabial folds (NLF) over time. Patients/methods Single-center, open-label, prospective study of 25 healthy volunteers treated with absorbable suspension sutures for descent of midface tissues. Punch biopsies were collected and evaluated for total collagen content. Subject and investigators evaluated NLF severity using the Nasolabial Fold Wrinkle Assessment Score (NLF-WAS). Seventeen of 25 patients completed the collagenesis portion of the study. Results Collagen deposition was apparent at day 90 and increased significantly compared with baseline at days 180 and 270 and between days 90 and 180. Subject- and investigator-reported NLF-WAS were significantly improved at all post-treatment time points through day 270. Conclusions Absorbable suspension sutures stimulate collagen in areas immediately adjacent to the path of the PLLA/PLGA monofilament and cones, providing mechanistic support for improvement in appearance observed in clinical studies. This neocollagenesis, coupled with repositioning by the suture's cones, makes absorbable suspension sutures a valuable tool for patients seeking facial rejuvenation.

Despite successfully gaining excursion after free muscle transfer for facial palsy, soft tissue asymmetry, especially around the nasolabial fold (NLF) and medial cheek, is a troublesome problem in elderly patients. An NLF reset technique that enhances midface lifts has been introduced to overcome this problem. Our study included 43 consecutive patients who underwent facial reanimation surgery with free functional muscle transfer between March 2015 and July 2017. Of these, 20 patients underwent conventional procedures and 23 underwent our NLF reset technique. Postoperative oral commissure excursion and symmetry at rest and while smiling were quantified using FACEgram (Facial Assessment by Computer Evaluation) software. To detect soft-tissue changes after surgery, three-dimensional analysis was performed using Morpheus®, a 3D, LED-based, white-structured-light scanner. The NLF group had a significantly larger postoperative mean excursion at rest (control 25.32 ± 2.80 mm vs NLF 27.42 ± 3.60 mm; p = 0.047). The mean horizontal length ratios (affected-to-healthy) revealed better symmetry in the NLF group (resting 1.05 ± 0.22, smiling 0.97 ± 0.19; p = 0.201). The three-dimensional midface volume difference was significantly lower in the NLF group. The NLF reset technique produced improved surgical outcomes. An incision made along a mirrored NLF can influence midface lifting in patients with facial palsy, with the soft tissue concentrated in the lower face mobilized superomedially.

Background Subcision, also known as subcutaneous incisionless surgery, is a surgical intervention used to treat a variety of skin conditions including atrophic acne scars, depressed scars, cellulite, and wrinkles. Aims We plan to prepare a review article about the indications of subcision, its adverse reactions, and pearls. Patients/methods We searched the literature for the information about subcision and its applications from papers published up to March 2019. The search was performed through the databases of the National Library of Medicine. Results After a thorough review of the published papers about subcision, we finally chose to review 40 articles that had proper sample size and design to prepare this review article. Twenty-one papers were related to the application of subcision in the treatment of acne scar and other scars. Four articles were about the application of subcision to treat cellulite, and eight articles were related to other applications of subcision such as the treatment of striae or nasolabial fold. The remaining seven articles include published review papers about subcision or acne scar classification. Conclusion Subcision seems to be effective on various skin conditions including acne scar, other depressed scars, and cellulite. It is easy to apply and inexpensive with short downtime and no significant complications. Subcision needs proper technique and adequate experience.

Background Recently, many compounds or extracts from natural sources are used for reducing facial aging and wrinkles. Objective This study investigates the preparation and evaluation of the safety and efficacy of saffron extract and avocado oil used for anti-wrinkle topical cream. Methods and materials Oil in water cream was prepared containing avocado oil and the saffron extract. Accelerated stability tests were carried out due to 6 months accordingly through the International Council for Harmonization (ICH) guideline. For clinical studies, topical cream was applied by twenty healthy volunteers daily, for 12 weeks. Improvement in wrinkle grading by a Global Aesthetic Improvement Scale (GIAS), depth and volume of the nasolabial fold, thickness, and density of dermis, and determination of the skin biophysical parameters were evaluated at the baseline, 6th and 12th week. Result During the period of storage, the formulation showed no variation in physicochemical properties. The clinical evaluation showed at least one-grade improvement in GIAS in 30% and 45% of participants, after 6 and 12 weeks, respectively. Subjects were "moderately satisfied" with the treatment. In addition, the area and volume of nasolabial folds were significantly reduced. Moreover, net elasticity (R5) and gross elasticity (R2) showed a significant increase after 12 weeks of treatment. There was no report of allergic reactions, and no changes in skin hydration occurred during the treatment. Conclusion The results of this study showed that saffron extract and avocado oil anti-wrinkle topical cream is an efficient and safe treatment for facial skin rejuvenation.

Background Autologous fat grafting is a helpful supplement to facelift surgery that helps to combat age-related volume loss of facial structures. Despite the widespread prevalence of combined facelift and fat-grafting, significant procedural variation exists between providers. Objectives The primary purpose of this systematic review was to study the efficacy and complication rates of facelift with lipofilling compared with facelift alone. Methods A systematic review of the Cochrane Library and MEDLINE databases as completed was undertaken to identify all clinical reports of fat grafting combined with facelift surgery based on the following key terms: (“fat grafting” OR “lipotransfer” OR “lipofilling” OR “fat transfer”) AND (“facelift” OR “rhytidectomy” OR “SMASectomy” OR “facial rejuvenation”). Data on techniques, outcomes, complications, and patient satisfaction were collected. Results The systematic review was performed in April 2017. In total, 248 articles were identified for review. After application of exclusion criteria, 15 primary studies were included in this review. Various facelift techniques were reported, including deep-plane or sub–superficial musculoaponeurotic system (SMAS) facelift, SMAS facelift, modified minimal access cranial suspension lift, component facelift, midface lift, SMAS plication, SMAS-stacking/SMASectomy, and SMASectomy. The most common locations of fat graft injection included the nasolabial folds, tear troughs, temporal regions, midface/cheek/malar eminence, marionette groove, lips, and ear lobes. The addition of fat grafting to facelift surgery resulted in significant improvements in facial volume and aesthetic assessments. Conclusions Combined facelift and fat grafting is a safe and efficacious means to simultaneously address age-related ptosis and volume loss. Further research is required to validate and improve existing treatment modalities. Level of Evidence: 3