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The aging appearance of the lower eyelids is multifactorial, involving changes in the skin, orbital fat, orbicularis muscle, soft tissue of the midface, and tear trough. The extent of these changes differs in each case and happens in a background of volume loss that occurs with facial aging. We present the indications, advantages, and technique for volumizing transcutaneous lower blepharoplasty with fat transposition. The absolute and relative contraindications to transcutaneous surgery are discussed, and surgical details of transconjunctival blepharoplasty with fat repositioning and autologous fat grafting as alternative approaches are included.

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.

BACKGROUND There is extensive literature on different face-lift techniques; however, few articles published in the English language address the particularities of the face-lift for Chinese patients. Because of differences in facial anatomy, facial aging, and patient expectations, facial rejuvenation procedures for Chinese patients can be quite different from those of White patients. METHODS The study includes 1026 consecutive primary face-lift cases performed by the senior author (D.Y.) from 2006 to 2019. Of these, 1010 patients were female and 16 were male. The average age of the patient at the time of primary face-lift was 40.5 years. The face-lift procedures included midface lift in 108 cases, midface and lower-face lift in 882 cases, and midface and lower-face lift with brow lift in 36 cases. All patients received superficial musculoaponeurotic system (SMAS) treatment, in the form of lateral SMASectomy in 607 cases, high-SMAS technique in 84 cases, modified high-SMAS short-scar technique in 108 cases, minimal access cranial suspension technique in 38 cases, and modified minimal access cranial suspension technique in 189 cases. Photographs of patients were analyzed to assess persistent features of facial aging. Complications such as hematoma, skin slough, infection, and nerve injury were also reviewed. RESULTS Most patients obtained consistently good results with minimal risk and complications. All surgical techniques discussed were safe and reproducible, providing various options for surgeons. CONCLUSIONS Special attention should be taken when planning a facial rejuvenation procedure for Chinese patients. Anatomic variations dictate a greater emphasis on the management of tissue ptosis, particularly regarding lateral brow descent and malar fat pad descent. In our practice, various face-lift techniques can produce excellent results. Surgeons must adopt a technique that serves patients well and is, ideally, safe, consistent, easily reproducible, and applicable to various anatomic problems. In addition, every surgery is customized to the patient's anatomy and concerns. Therefore, the surgeon must adopt individualized technique according to the needs and desires of each patient.

Objective: To evaluate the effectiveness and safety of a 675 nm laser device in the treatment of facial aging. Background: Wrinkles represent a major sign of aging skin and are considered a major t...

The demand for noninvasive facial rejuvenation continues to increase as younger, well-informed patients enter the aesthetic market. We refer to a subset of these patients as “tweeners,” those who present with early signs of neck and facial aging, but who have not yet developed changes significant enough to warrant a traditional excisional surgery approach. Many of these patients are in search of a minimally invasive intervention, a bridge in between observation and surgery. The authors describe their experience with radiofrequency (RF) technology as an in-office tool to address the aging face in a select patient population. This review also attempts to comprehensively search the existing body of literature to describe the RF technologies and devices available for facial rejuvenation. The efficacy and safety profiles of the devices are discussed, and the devices are categorized by their method of RF delivery—over (contact), through (microneedle), and under (percutaneous) the skin.

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

Background: Skin aging can be delayed through therapeutic resources. In manual therapy, myofascial stretching has been used tomobilize the structures of the skin, fasciae and muscles in order to reorganize the collagen, improving the appearance of the skin.Objective: Investigate the effects of TENSI massage technique, associated or not with firming cream, on skin aging. Methods: Thesample consisted of 27 volunteers, over the age of 40, who had static and/or dynamic wrinkles caused by facial skin aging. Th eevaluation was performed using the facial evaluation protocol (FEP), photos, morphological analysis of the face by the Dolphin ImagingSoftware and questionnaires. The volunteers were divided into two subgroups: G1 - Manual therapy with 12 volunteers and G2 - Manualtherapy and cosmetics with 15 volunteers. The treatment was carried out in three cycles. Each cycle corresponded to 5 weeks, with twotreatment sessions per week for the first 3 weeks and one session per week for the 4th and 5th weeks. The protocol start ed with facecleaning, followed by cutaneous myostretching. Only the G2 used the firming cream together with the therapy. Results: The softwareanalysis showed changes in both groups, with improvement in the paralateronasal line, in the mandibular projection and in the nasolabialangle, however, these were better perceived in the volunteers of the G2. No adverse reactions were reported and few volunteersobserved hyperemia at the skin. The firmness of the skin was reported as “Much firmer” in the vast majority of volunteers, as well as theclassification in “Excellent treatment”. Conclusion: The myofascial stretch caused by the TENSI Method proved to be effective inimproving skin aging, however, its results are even more satisfactory when adding firming cosmetics

Background The superficial musculoaponeurotic system (SMAS) is an important structure to understand for face-lift surgeries. However, the detailed distribution and imaging findings of the SMAS have not been established yet. Objectives The aim of this study was to establish the accurate distribution and computed tomography (CT) imaging findings of the SMAS based on cadaveric studies. Methods This study was designed in a 3-step procedure. First, 7 cadaver faces were utilized to understand the distribution and histology of the SMAS. Second, the SMAS findings from the cadaveric studies were compared with the CT images. Third, CT images were enrolled for the SMAS interpretation. Results In 7 cadaveric studies, the SMAS was observed as a subcutaneous fibro-membranous structure extending from the galea aponeurotica to the platysma muscle and laterally connected to the parotid fascia. On the medial side, it also connects with major and minor zygomatic muscles. The SMAS consisted of muscular fibers, collagen fibers, and elastic fibers histologically. Eighteen CT images (all females; age range, 21-82 years) showed the thin linear structures corresponding to the fibro-membranous structures in the cadaveric studies. CT density of the SMAS was similar with that of the muscle, and the SMAS was recognizable in all 18 subjects. Conclusions The SMAS is a definite anatomical structure that can be demonstrated as a thin membranous structure on CT. This clinical application could be applicable to the development the cosmetic surgical procedures.

Background Microneedling in combination with the use of growth factors can help with a range of indications, including skin rejuvenation. There is an increase in request for safe minimally invasive procedures with no-to-minimal downtime. This procedure offers regeneration and is becoming popular as part of the regenerative, minimally invasive era. Aims To examine the efficacy of a course of two sessions of growth factor-induced therapy using propriety preparation of AQ recovery serum. Methods Thirty women with various ethnic backgrounds (Chinese, Caucasian and Latino) with an average age of 38 years old participated and mild-moderate visual facial aging signs Two sessions with 2-week intervals were completed using a derma stamp (transdermal drug delivery method) and 2 mL of growth factor serum (AQ Skin Solution recovery serum-contain a mixture of contains a mix of transforming growth factor beta (TGF-β), granulocyte monocyte-colony-stimulating factor, and platelets-derived growth factor with patented technology for extraction and composition at each session. The procedures were carried out for anti-aging and skin rejuvenation. Clinical assessment, VISIA photography, independent assessment of before and after photographs baseline and six weeks by two clinicians and two laypersons were carried out. The participants used FACE-Q questionnaire (outcome satisfaction) and scored changes in terms of their skin texture, radiance, pore size, wrinkles, pigmentation, tightness and overall skin appearance. Results Physician's global assessment revealed growth factor-induced therapy resulted in skin rejuvenation in all races with 95% confidence, and this increased to 98% confidence for Latinos and Caucasians within the six weeks. Participants' subjective rating revealed improvement of overall skin appearance with 95% confidence. Most noted improvements were in brightness, skin texture, and tightness. Conclusion This study revealed improvement in overall skin appearance, brightness, skin texture, and tightness. The treatment is non-invasive, safe, with no or minimal downtime and resulted in high participant satisfaction.

Background: There are many reports in the literaturedescribing how to slim down the face. These reports includediet and nutritional control, facial exercises, camouflageprocedures by makeup and hair style and facial liposuction.However, excessive slimming of the face is due to decreasedamount of subcutaneous fat cells in facial fat compartments.Slim face deformity is the term which we applied todescribe diffuse symmetrical hollowing of the face of youngpeople without any apparent cause. It may be constitutionalor due to massive weight loss in some patients. Fat graftingis one of many other techniques that were reported for correctionand enhancement of localized facial regions andtreatment of facial aging. However we could not find anyreport in the literature describing how to correct slim facedeformity.Obejective: The authors are going to describe slim facedeformity and experience in correction using fat cells transferin different facial fat compartments.Patients and Methods: Thirty five patients with slim facedeformity were treated by full face fat injection. The techniqueof fat harvesting, preparation and injection is illustrated. Thepatients were followed-up for at least six months.Results: All patients had initial dissatisfaction with earlypost-operative appearance due to the surgical edema andovercorrection. They became gradually satisfied within aperiod of three months after surgery. 80% of patients had onlyone session of fat injection and only 20% of them asked forfurther fat injection and this was usually done eight to tenmonths after surgery.Conclusion: Fat cell transfer, can be used as a safe longlasting procedure for correction of slim face deformity inpatients who need full facial augmentation. It is a more naturaland relatively cheaper technique in comparison to the use ofother dermal fillers

All areas and tissues of the face will go through age-related changes; however, aging occurs at a faster rate in the lower third of the face than in other areas. This study presents the anatomical and physiological aspects of age-related changes in all areas and tissues of the face, mainly in the lower third, such as the skin, subcutaneous fat, muscular-aponeurotic system, deep layers of adipose tissue, and bone structures of the face. Involutional changes were differentiated by taking into account the constitutional and architectonic features of the face. Heterochronous and heterotopic characteristics of age-related changes, cutaneous, and treatment components of facial aging were identified. The most commonly used visual scales to assess cosmetic effects and determine chronological aging included global aesthetic improvement scale, Glogau scale, Fitzpatrick wrinkle classification, and Merz visual 5-point aging scale. According to the classification of age-related changes proposed by Kolgunenko, five morphotypes of aging are distinguished: tired, wrinkled, deformation, mixed, and muscular. Understanding the pathogenesis of involutional changes in the lower third of the face in patients with different morphotypes of aging allows for an objective and individualized choice of optimal therapy methods.

Aging of the face produces many changes in the structure and integrity of the skin and other anatomical aspects, the three major signs of which are volume loss, sagginess, and skin quality change. Through surgical or nonsurgical procedures, it is possible to slow or even reverse these mechanisms through artificial means, including thread lifting, radiofrequency, or filler injection. Filler injections are particularly popular in recent years, owing to their convenience, efficacy, and long-lasting results. In this minireview, the author outlines the basic mechanisms behind facial aging, discusses current literature on each aspect of facial aging, and offers injection protocol recommendations based on past literature and clinical experience.

This article provides the facial plastic surgeon with anatomic and embryologic evidence supporting use of the deep-plane technique and understanding the evolution of the technique over decades to the vertical platysma advancement for optimal treatment of facial aging. The original description of the deep-plane rhytidectomy described a basic subsuperficial musculoaponeurotic system dissection in the midface. This plane of dissection provides access to deeper anatomic structures. A detailed description of the procedure is provided to allow safe and consistent performance. Insights into anatomic landmarks, technical nuances, and alternative approaches for facial variations are presented.

Gerhard Sattler,1 Martina Kerscher,2 Ernst Magnus Noah,3 Welf Prager,4 Tanja C Fischer,5 Patricia Ogilvie,6 Matthias Hofmann,7 Hanna Dersch,7 Gemma Odena8 1Rosenparkklinik GmbH, Darmstadt, Germany; 2Division of Biochemistry and Molecular Biology, Cosmetic Science, University of Hamburg, Hamburg, Germany; 3Department of Plastic, Reconstructive, Aesthetic and Hand Surgery, Kassel, Germany; 4Prager & Partner Dermatologische Praxis, Hamburg, Germany; 5Haut- Und Lasercentrum Berlin-Potsdam, Potsdam, Germany; 6SkinConcept, Munich, Germany; 7Merz Pharmaceuticals GmbH, Frankfurt Am Main, Germany; 8Merz North America, Inc., Raleigh, NC, USACorrespondence: Gerhard Sattler Email gerhard.sattler@rosenparkklinik.deBackground: Facial aging is characterized by increased prominence of nasolabial folds (NLFs), marionette lines, and thinning of the lips. Cross-linked hyaluronic acid injection is a very effective method for the temporary correction of these areas.Objective: To confirm the clinical performance and the safety of Etermis 3 (ET3) and/or Etermis 4 (ET4) in the treatment of moderate and severe wrinkles/folds, as well as lip volume enhancement.Methods: Subjects were treated in at least two facial areas (NLFs, marionette lines, lips). ET3 was used in facial moderate wrinkles while ET4 was used in severe facial skin volume loss. An optional touch-up 1 month after treatment was possible. A blinded investigator assessed improvement on Merz Aesthetic Scales (MAS). Subjects were followed-up for 12 months after the last treatment.Results: In total, 154 healthy subjects were enrolled. The proportion of subjects achieving ≥ 1 score improvement in MAS after treatment was above 60% for ET4 (Month 6/7: NLFs 94.9% and marionette lines 81.4%, p≤ 0.0004; Month 3/4: lips 63.0%, p=0.39) and ET3 (Month 6/7: marionette lines 79.4%, p=0.0005; Month 3/4: lips 65.5%, p=0.31). Facial improvement was still visible at Month 12/13 for ET4 (NLFs ≥ 76.6%, marionette lines ≥ 61%, lips ≥ 36%) and ET3 (marionette lines ≥ 50% and lips ≥ 21.9%). No treatment-related serious AEs occurred. The most frequent AEs were injection-site reactions.Conclusion: Etermis 3 and Etermis 4 demonstrated good clinical performance and safety for NLFs and marionette lines volume enhancement for up to 12 months. Both products can also be used safely to treat lips for volume augmentation.Keywords: hyaluronic acid, wrinkles, facial volume enhancement

Rhytidectomy, or facelift in layman's terms, is performed to reverse the appearance of facial aging. A lift can improve volume shifts with age, reposition sagging tissues, and eliminate skin redundancy. There are limitations to what can be accomplished with a facelift alone. Commonly performed adjuncts including surgery to the eyelids or brows, liposuction, and even rhinoplasty can be combined to improve the result. Further options exist that are more commonly overlooked or rarely offered to patients but can greatly enhance the surgeon's ability to remove years from the face. This article will cover some additional options that every facial plastic surgeon should be familiar with and experienced to both describe and perform.

Facial aging is a multifactorial process with many articles over decades supporting various theories of varying causes. It is generally thought that aging occurs as a combination of changes in skin quality, gravitational descent of tissue with interaction of retaining ligaments on the ptotic tissue, and facial volume loss or the appearance of volume loss. The most significant cause of volume loss is skeletal remodeling and bone loss, which manifests as characteristic shadows and hollows on the face in conjunction with soft tissue changes that are yet to be completely elucidated.

Background Lip enhancement continues to be one of the most popular facial procedures. State-of-the-art lip enhancement involves sculpting of perilabial soft tissue, in particular, the philtrum, but it is unclear how patients perceive their philtral contours. Objectives The aim of this study was to test the impact of the philtrum on attractiveness, and on the perception of facial proportions and age. Methods Respondents (1100, including 50 aesthetic specialists) were presented with 2 sets of identical portraits, 1 set of a young Caucasian female and 1 set of an aged Caucasian female, with 1 portrait in each set having an upper lip lacking any philtral contours. The respondents were asked to choose which upper lip was more attractive, appeared longer, and looked older. Rankings were analyzed according to population demographics. Results Overall, most respondents considered the young face (84%) and the aged face (68%) with philtral contours to be more attractive. Moreover, the majority of respondents (81%) considered the upper lip of the young face without a philtrum to appear longer in a craniocaudal orientation (67% for the aged image), and 67% of respondents described the image of the young woman with no philtral definition as appearing older (55% for the aged face with no philtrum). Conclusions This study confirms the authors’ hypothesis that the existence of philtral contours exerts a significant impact on perioral attractiveness, and that its absence can be related to a longer appearance of the upper lip as well as an older facial appearance.

Objective The most promising facial region for inducing pan-facial effects is the temporal region. The temple displays signs of facial aging itself which include temporal volume loss and increased visibility of the temporal crest, the temporal vasculature, the lateral orbital rim, and the upper zygomatic arch. The objective of this article is to provide a detailed review of temple anatomy pertaining to routinely performed temporal injection techniques, their expected esthetic outcomes as well as the intendant advantages, disadvantages, and procedure pearls. Materials and methods This narrative review is based on the clinical experience of the authors treating the temporal region for esthetic purposes. The postulated outcome of each technique was observed during the routine clinical practice of the authors. Results The temporal region is based on a bony platform consisting of the parietal, frontal, sphenoid, and temporal bones. The overlying soft tissues are arranged in layers which contain the temporal neurovascular structures. The temporal soft tissues consist of 10 parallel layers which vary in their thickness depending on age-related influences. Six different techniques will be addressed, which include subdermal and interfascial techniques for volumizing, low and high supraperiosteal techniques for volumizing, and supraauricular and temporal lifting techniques. Conclusion This narrative provides a detailed anatomic overview of the temporal region and describes each commonly performed injection technique with respect to anatomy, esthetic outcome, as well as potential pearls and pitfalls. It is hoped that the description contained herein may guide esthetic practitioners toward safer and more natural outcomes when treating the face.

There is no accurate visual representation of the aging process, one that visually shows how the shape of the face changes with age in a rigorous and three-dimensional way.A total of 594 subjects were studied. Two hundred eighty three-dimensional images of male faces and 305 three-dimensional images of female faces were categorized into "young" and "old" groups by sex. The mean age of the younger men was 33.6, and the mean age of the older men was 70.3. The mean age of the younger women was 24, and the mean age of the older women was 74. Landmarks were placed on all images, and in the male groups the distances between these landmarks were analyzed with an independent t test to compare the differences between age groups. These measurements were then used to develop validated three-dimensional averaged models of the different groups. These averages were formed into comparative image transitions and studied.The comparative image transitions of the average young and old faces in this series show accurate and registered age and shape changes. The faces of men and women age in almost identical ways. The images imply that the aging process is not solely along the surface planes of the face but at right angles to it, that is, many of the changes are in and out, not up and down. Males and females seem to age in quantitatively similar ways.These images are unique in the facial aging literature. The main points and conclusions of this article are derived from and only visible in the comparative image transitions included in this article as supplemental digital content. The reader is encouraged to study them because the side-by-side still images do not show the changes.

Facial aging is a consequence of the face’s unique adaptions for the mobility needed for facial expression. This chapter describes the soft tissue construct of the face as being in five concentric layers. Movement originates in the middle layer, which for the most part is muscular and closely bound to the overlying dermis. Stability is provided in key immobile areas around the orbital and oral cavities, by a system of facial retaining ligaments. The ligaments effectively bind the layers by attaching the dermis to the skeleton. While facial movement occurs primarily over the bony cavities, it also occurs adjacent to them in a series of soft tissue glide plane spaces. These sub-SMAS facial soft tissue spaces are located between the ligaments. Being areas that facilitate mobility, they are also areas of inherent weakness. This is where aging originates anatomically. The 3-dimensional course of the facial nerve after it exits the stylomastoid foramen and travels towards the muscles of facial expressions is related predictably and consistently with this five-layered anatomy, being initially deep to the deep fascia (layer 5) as it exits the parotid gland, transitions through layer 4 to innervate the muscle of facial expressions in layer 3. Understanding the transition of the facial nerve from deep to superficial is important as the are the locations where the nerves are susceptible to injury during sub-SMAS facelift procedures.

The field of cosmetic dermatology has recently witnessed unbridled growth in the past several years. Part of this has been due to the increasing popularity of aesthetic treatments in men, who represent a growing patient population. Men tend to have higher levels of collagen density and greater skin thickness, but these begin to decrease earlier on. They can also more frequently have severe photodamage. Their clinical presentations can affect the selection of treatments. Physicians should be familiar with the subtle differences between treating men and women. Early studies and literature are beginning to shed more light on these important distinctions. We have reviewed the notable differences in facial aging, pathophysiology, and patient selection, as well as discussing available treatment options with these factors in mind.

Conjoint measurement was used to investigate the joint influence of facial gender and facial age on perceived gender (Experiment 1) and perceived age (Experiment 2). A set of 25 faces was created, covarying independently five levels of gender (from feminine to masculine) and five levels of age (from young to old). Two independent groups of observers were presented with all possible pairs of faces from this set and compared which member of the pair appeared as more masculine (Experiment 1) or older (Experiment 2). Three nested models of the contribution of gender and age to judgment (i.e., independent, additive, and saturated) were fit to the data using maximum likelihood. The results showed that both gender and age contributed to the perceived gender and age of the faces according to a saturated observer model. In judgments of gender (Experiment 1), female faces were perceived as more masculine as they became older. In judgments of age (Experiment 2), young faces (age 20 and 30) were perceived as older as they became more masculine. Taken together, the results entail that: (a) observers integrate facial gender and age information when judging either of the dimensions, and that (b) cues for femininity and cues for aging are negatively correlated. This correlation exerts stronger influence on female faces, and can explain the success of cosmetics in concealing signs of aging and exaggerating sexually dimorphic features.

The diagnosis of aging based on the morphogeometric changes experienced by the face, measured by the application of facial stratigraphic semiology by thirds, could become a novel approach that guarantees an efficient replacement of aged tissues through minimally invasive aesthetic medicine strategies. Facial aging should be analyzed by thirds, because not all thirds grow old at the same time. Owing to this is necessary go giving solve the aging problems each one of them, by means of therapies of the facial restructuring into sequential treatment appointments, with the purpose of being go giving time to the tissues rearrangement of the face, so that it is perceived as a subtle progressive reversal of aging and so generate a comfortable social acceptance of the resulting changes of said facial rejuvenation. This article intends to present the practical approach of the concepts and guidelines illustrated in the routine aesthetic diagnosis, the anatomical changes in the various tissue layers that are externally appreciated, but detailing them under a regional approach (upper, middle, and lower thirds). Our paradigm seeks that as professionals of aesthetic and regenerative medicine we identify facial aging not only as the obvious wrinkles and other changes in the skin, but that we diagnose according to the proposed parameters, so that when considering the rejuvenation treatment, we identify which are facial tissues that have changed due to aging and must therefore be restored to harmonize the face according to the ideal forms and proportions that must prevail (morphometry).

Background Nasolabial fold (NLF) is an important anatomic sign of facial aging. However, the dynamic biomechanical relationships between the facial mimetic muscles (FMMs) and the NLF remain unclear. Objective This study aimed to investigate the dynamic biomechanical relationships between the FMM and various NLF by finite-element analysis (FEA). Methods The 3-dimentional computer-aided design (3D CAD) model of the skin-muscle-maxillofacial bone in the NLF was established by using the engineering design module of the Computer-Aided 3-dimensional Interactive Application (CATIA) software. This CAD model was then imported into the Hypermesh software to set element type, mesh, and material properties. Finally, the 3D FEA model of the skin-muscle-maxillofacial bone in the NLF was generated, and then exported and uploaded into the Abaqus software with HM format for mechanical force loading and biomechanical analysis. Results A 3D FEA model of the skin-muscle-maxillofacial bone in the NLF was successfully established by using the Mimics, Geomagic Studio, CATIA, Hypermesh, and Abaqus softwares. This FEA model had a good geometrical resemblance and good biomechanical properties. This provided an ideal biomechanical model for the study of deformation and the biomechanics of soft tissues, such as the NLF. The FEA was applied to the biomechanical simulation of the NLF. We established five effective FEA models to study the dynamic biomechanical relationships between the NLF and the FMM. The dynamic biomechanical relationships between the NLF and the FMM were preliminarily determined by computer simulating different types of mechanical force loadings. Conclusion The FEA is an effective method to simulate the dynamic biomechanical relationships between the NLF and the FMM. Through the FEA simulation described in this study, we could preliminarily conclude that the formation of different types of NLF is mainly due to the coordinated contraction of various FMM. Moreover, not all FMM are involved in all types of NLF. According to the results of the FEA simulations in this study, it is worthwhile considering investigating the role of botulinum toxin in improving the morphology of the NLF in the near future.

Fat grafting is one of the most prevalent fields in facial rejuvenation at present. The procedures include the evaluation of recipient and donor areas, as well as fat harvesting, processing, and reinjection. Inappropriate treatment of each link may affect the final effect on the whole. The authors believe that understanding of facial anatomy and personalized therapy are the key to successful operation.

Purpose Nasolabial folds (NLFs) are one of the most noticeable signs of facial aging. NLFs negatively affect self-confidence and social acceptance often leading to a person's desire to improve their appearance using dermal fillers. The hyaluronic acid injectable gel implant Princess® FILLER Lidocaine (PFL) is a minimally invasive easy to administer the product. In this investigation, we assessed the safety and efficacy of PFL to correct moderate to severe NLFs over a 36-week period. Methods Adult women and men with moderate to severe NLFs received one injection of PFL to both NLFs. After 2 weeks, a touch-up treatment could be performed, if deemed necessary by the investigator. The change in NLF severity was assessed using the Nasolabial Fold Severity Rating Scale (NFL-SRS) developed by Croma-Pharma and the Global Aesthetic Improvement Scale (GAIS). Results Out of 60 analyzed subjects, 59 (98.3%) had improved their NLF severity by at least 1 grade on the NFL-SRS at week 4, 58 subjects (96.7%) at weeks 24 and 36. All subjects showed aesthetic improvement (GAIS), at weeks 4 and 24. The investigator judged the aesthetics as very much improved (score of 1) in 45 (75.0%) at week 4, 48 (80.0%) at week 24, and in 39 of 60 subjects, respectively (65.0%) at week 36. Thirty-six weeks post-initial treatment, 56 of 60 subjects (93.3%) were very satisfied or satisfied with the treatment. Adverse device effects (ADEs) were mild or moderate and resolved at latest 25 days post-onset. The most commonly reported ADEs were injection site hematoma and injection site pain. Conclusion PFL was safe and effective in reducing the severity of NLFs. Most subjects were (very) satisfied with the treatment outcome throughout a 36 weeks investigation period.

Objective To clinically evaluate the impacts of sun exposures on some facial signs of differently aged Chinese men with a distinct behavior vis a vis sun exposures. Methods Two comparable cohorts of Chinese men (aged 18-75 years old), living in two cities (Shanghai, Hong Kong) were created according to their usual behavior towards sun exposure and through their variable use(s) of a photo-protective product, i.e. non-sun-phobic (N = 127) and sun-phobic (N = 134). Standard photographs (full-face and 45° lateral) allowed to focus on 13 facial signs that were further graded by 15 experts and dermatologists, using a referential Skin Aging Atlas. Absolute differences in the scores of each sign were used (non-sun-phobic minus sun-phobic), by age-classes, to better ascertain the impact of sun exposures and a photo-protecting product, when used. Results Most facial signs, particularly wrinkles and skin texture, differentiated the two cohorts. Some others showed some erratic changes with age, albeit more pronounced at older ages. In contrast with previous results obtained in Chinese women, the changes observed in men were not only of a lessened severity but were undetected at early ages (

The focus of modern face-lifting has shifted from isolated superficial musculoaponeurotic system (SMAS) manipulation to providing necessary volume restoration and overall facial shaping. Volume deflation is a major component of facial aging but cannot be corrected solely by rhytidectomy. This article presents a detailed overview of facial fat compartment anatomy and examines its role in facial rejuvenation. A good understanding of facial fat compartment anatomy cannot be overemphasized. In combination with methodical preoperative visual analysis, this allows surgeons to target the specific areas that have undergone deflation with fat grafting before selective SMAS manipulation.

This article discusses the various nonsurgical treatments that can be performed in combination with facelift surgery to provide patients with a more complete facial rejuvenation. Nonsurgical adjuncts focus on facial volume enhancement, skin resurfacing, intense pulsed light for pigmentary changes, neuromodulators, and skin care in addition to the surgical techniques used to combat facial aging. Several options exist for skin resurfacing, including dermabrasion, chemical peels, and lasers; the advantages and limitations of each are discussed. Photographs demonstrating the effectiveness of nonsurgical treatments to facelift patients are displayed as examples of their powerful adjunctive effect.

Background: Face-lifting procedures are often performed to hide the effects of aging. Thread-lifting, a minimally invasive technique for the correction of facial aging, has become increasingly popular, and various materials for the procedure have been developed. Objective: This study compared tissue responses to two types of threading sutures placed under rat skin: polypropylene (PP) monofilament mesh suspension thread (a novel face-lifting material) and polydioxanone (PDO) barbed thread. Methods: Eight rats each were assigned to the PP monofilament mesh suspension, PDO barbed thread, and control groups. Tissue reactions were evaluated 28 days after subcutaneous loading of the materials. Results: Significant increases in tensile strength and the mean area occupied by collagen fibers were evident in skin loaded with PDO barbed thread and PP monofilament mesh suspension thread compared to control skin (p＜0.05). Compared to sites loaded with PDO barbed thread, those loaded with PP monofilament mesh suspension thread showed a significant increase in the number of collagen fibers and a lower grade of inflammation (p＜0.05). Conclusion: PP monofilament mesh suspension thread has skin-rejuvenating effects comparable to those of PDO barbed thread, but induces a less severe inflammatory response. This indicates that it is a safe and effective material for use in thread-lifting procedures on aging skin. (Ann Dermatol 31(6) 645∼653, 2019)

The minimal access cranial suspension (MACS) facelift is a minimally invasive face and neck lift that uses the understanding of the changes in facial anatomy as it relates to facial aging. The MACS facelift uses a shorter incision with limited subcutaneous undermining. It achieves a resuspension of the underlying neck and midface soft tissues with the use of looped, purse-string sutures in the superficial musculoaponeurotic system and platysma. These attenuated structures are anchored to the deep temporal fascia. In the properly selected patient, the MACS facelift is an effective technique with high levels of physician and patient satisfaction.

IMPORTANCE: Glabellar wrinkling is a critical component of upper facial aging. OBJECTIVE: To compare the long-term outcomes on the wrinkle lines of the glabella and forehead following browlifts with vs without corrugator and procerus muscle resection. DESIGN, SETTING, AND PARTICIPANTS: A prospective cohort comparative trial was conducted of 23 patients who underwent browlift procedures by a single surgeon at a single institution (16 with glabellar muscle resection and 7 without muscle resection) between May 1, 2016, and July 1, 2017. All analysis took place between May 1, 2016, and May 14, 2018. The mean follow-up period was 16 months (range, 12-21 months). Sixteen of the 23 patients underwent a browlift with muscle resection procedure alone or in combination with other facial rejuvenation procedures to the brow, midface, jowl, and neck. Four of the 23 patients underwent browlifts only, and 19 had browlifts with other procedures. Seven of the 23 patients had browlift procedures without muscle resection and were designated as controls. INTERVENTIONS: Endoscopic browlift surgery was performed either with procerus and corrugator muscle resection or without muscle resection. MAIN OUTCOMES AND MEASURES: Neutral gaze and dynamic photographs of the upper face obtained preoperatively and after the 1-year postoperative mark were reviewed and scored in a blinded fashion by 2 physicians not affiliated with the study team using a modified Fitzpatrick Wrinkle Assessment score (FWA; from 0 [no wrinkling] to 5 [deep wrinkling with redundant skin]). RESULTS: The 23 study patients had a mean age of 60 years (range, 48-74 years); 21 were women, and 2 were men. There was a significant difference between the myectomy and control groups in the 12-month postoperative improvement in dynamic glabellar FWA scores (2.56 vs 1.07, P = .01). There was a difference between the myectomy and control groups in the improvements in resting glabellar FWA scores at 12-month follow-up, but it did not reach statistical significance (1.28 vs 1.00, P = .38). The 12-month postoperative improvements in dynamic (1.19 vs 1.29, P = .86) and resting forehead (1.0 vs 1.1, P = .70) FWA scores were not significantly different. CONCLUSIONS AND RELEVANCE: In this study, the use of procerus and corrugator myectomy techniques appeared to achieve a superior long-term reduction in glabellar wrinkles vs forehead rejuvenation techniques without muscle resection. LEVEL OF EVIDENCE: 3.

Facial fat transfer has evolved from simple grafting techniques to smaller lobule (microfat) and adipose-derived stem cell (nanofat) injection techniques. These new methods look to overcome the early limitations of facial fat transfer while meeting increased demand and understanding of the role of volume loss in facial aging. The purpose of this article is to review basic principles of microfat and nanofat and demonstrate one technique for their application.

There are multiple surgical and non-surgical ways to treat the nasolabial fold. Traditionally, the non-surgical way of treating nasolabial folds was through careful placement of hyaluronic acid fillers directly to the fold. Our understanding of the facial ageing process and facial anatomy has enabled us to evolve our technique so that nasolabial fold treatments are safer for patients and deliver better clinical outcomes. By treating nasolabial folds indirectly, by addressing the changes that occur through aging, the aesthetic practitioner can achieve more natural and effective reduction in the fold. Indirect treatment of the nasolabial fold requires addressing the bony resorption, deep fat and superficial fat volume loss. Through better understanding of the facial aging process, we are entering an era where more practitioners are treating the cause of a particular line than treating it directly. This has the benefit of creating a more balanced and natural result with longer lasting rejuvenation.

The malaris muscle has long been described as one of the facial muscles. Numerous studies have attempted to define and examine the malaris muscle owing to its clinical implications related to the facial aesthetic concept. In the anatomical context, however, the concept of the malaris muscle remains ambiguous. This review article proposes a reconsideration of the malaris muscle. The article focuses on the anatomical concept of the malaris muscle from previous studies to the current studies as well as the conceptual changes in the malaris muscle. To improve understanding of the role of the malaris muscle in the facial aesthetic aspects, here the article reviews the role of the malaris muscle in facial aging appearance and discusses the practical clinical applications surrounding this aging gradation.