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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.

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.

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

Nasolabial folds are caused by loss of deep fat and subsequent loss of muscle contour in the midface, leading to sagging which forms cosmetic issues in some cases when they are otherwise overly pronounced. Various treatment procedures have been developed to reduce their appearance. The objective of this study is to compare the efficacy of hyaluronic acid (HA) cheek fillers injection and thread lifting in improving the nasolabail folds. Twenty cases presenting with prominent nasolabial folds were randomly divided into two groups; group A underwent HA fillers for cheek lifting and group B underwent thread lifting for the cheek. Only one session was done for each case, and then they were followed up after 1 and 2 months. Statistical significant difference after treatment for both groups was detected using the wrinkle severity rating scale (WSRS) and the modified Fitzpatrick wrinkle scale (MFWS). The average global aesthetic improvement scale (GAIS) was 2.2 ± 0.79 for the fillers group and 3.2 ± 0.92 for the threads group, showing a statistical significant improvement with a p value less than 0.05 favoring the fillers group. 70% of fillers cases were satisfied and only 30% of threads cases. Fillers cheek injection is recommended for patients with sagged thin face to improve the nasolabial folds as well as giving volume and contour. Threads would do better for patients desiring an oval, less wide face shape. Combining threads with other cosmetic procedure would give a better holistic appearance.

Calcium hydroxylapatite filler is a popular dermal filler, as it provides long-lasting results. However, it sometimes undergoes unexpected early volume loss, due to rapid gel absorption before neocollagenesis. To compensate for this phenomenon, hyaluronic acid filler was added to calcium hydroxylapatite filler for injection as a mixture. Twenty-five patients who scored 1 or 2 on the Merz 5-point scale for the nasolabial fold and jawline were injected with 3.0 mL of the mixture. The mixture was prepared with 1.0 mL of hyaluronic acid filler, 0.5 mL of lidocaine, and 1.5 mL of calcium hydroxylapatite filler. A visual analog scale (VAS) and the 5-point global satisfaction scale (GSS) were used for objective and subjective assessments. In a subset of patients, for histologic analysis, 0.1 mL of the mixture and 0.1 mL of only calcium hydroxylapatite filler were injected into the right and left postauricular areas, respectively. The histologic analysis was performed 6 months after implantation. The mean VAS and GSS scores for both sets of wrinkles were above "fair" at every follow-up, including at short-term and long-term periods. The skin biopsies from both postauricular areas from selected patients showed increased dermal collagen bundles without inflammation. The mixture of calcium hydroxylapatite filler and hyaluronic acid filler maintained constant volume with high satisfaction, as hyaluronic acid filler compensated for the unexpected early volume loss of calcium hydroxylapatite filler. This procedure can be applied safely, and it is also convenient, because no retouching procedure is needed.

The nasolabial fold is known to be a challenging midface feature for aesthetic physicians. However, the steric conformation of the structures related to the nasolabial fold has remained undefined because the composition and topography of this region are highly intricate. Therefore, this study aimed to clarify the three-dimensional structures of the nasolabial fold using micro-computed tomography and verify their detailed composition by means of histologic observation.Twenty-four specimens were collected from the area beside the alae nasi to the area above the oral angle of 12 cadavers (mean age, 80.3 years) bilaterally. Twelve specimens were evaluated by means of phosphotungstic acid contrast staining, and the rest were evaluated by means of histologic staining. All specimens were divided into three regions and analyzed comprehensively.The medial region of the nasolabial fold had dense irregular connective tissue intermingled with muscle fibers; the lateral region of the nasolabial fold had numerous fibrous septa with abundant adipose tissue. The levator labii alaeque nasi and the zygomaticus minor were attached to the medial part of the nasolabial fold, and the fascial septa were intermittently tethered to the dermis, lateral to the nasolabial fold. The extension of the adipose tissue within the fascial septa was limited by the lateral border of the muscle attachment.Dimensional and distributional alterations of the adipose tissues with senescence could render the nasolabial fold deeper by increasing the depth of the subcutaneous layer, lateral to the fold. Thus, to ameliorate the fold, the adipose tissue, lateral to the fold, or the muscle traction, medial to the fold, should be altered.

Aim and objective To determine the effect of botulinum toxin type-A (BTX-A) in reducing gummy smile. Materials and methods This was an interventional case series conducted at a tertiary care setting in Mangaluru, Karnataka, India. Twenty patients with the gingival display of >3 mm were selected through convenience sampling technique. 2.5 units of BTX-A were injected under sterile conditions on either side of the face. The effect of the injection on gingival display was measured at the interval of 2, 4, 12, and 24 weeks. At the end of the treatment, the patient was asked to smile and was photographed and was compared to pretreatment photo. Repeated measures analysis of variance (ANOVA) was used to detect the change at each interval and intergroup comparisons were performed using post hoc Bonferroni test. Results The mean gingival exposure reduction from 4.93 to 3.705 mm at week 2. At the end of 24 weeks, the evaluation showed the mean gingival display of 4.755 mm on administration of 2.5 units on either side. The photographs also showed the change in smile at the end of the treatment. Conclusion From the study, it was inferred that botulinum toxin was effective in eliminating gummy smile along with noticeable decrease in the nasolabial fold despite for the effect lasting only about 24 weeks. Clinical significance A nonsurgical method of correction of gummy smiles when compared to surgical intervention is readily accepted by patients. Botulinum toxin type-A for gummy smiles is an effective, conservative, and satisfactory technique.

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.

Polycaprolactone (PCL)-based fillers are widely used for skin rejuvenation and wrinkle reduction. The objective of this study is to compare the efficacy and safety of newly developed PCL-based fillers (SYB filler®; SF-01) and widely used existing PCL-based fillers (Ellansé-M®) for correction of moderate-to-severe nasolabial folds. In a randomized, participant-and evaluator-blinded, matched-pair, prospective study, participants were randomized for injections of SF-01 or Ellansé-M® in both nasolabial folds. Efficacy was evaluated using the Wrinkle Severity Rating Scale (WSRS), Global Esthetic Improvement Scale (GAIS), and a three-dimensional (3D) scanner. All adverse events (AEs) were examined and reported. At month 12, both SF-01-and Ellansé-M®-treated groups showed statistically significant improvements in the WSRS, GAIS, and 3D scanner scores compared to baseline. The difference in changes in WSRS scores at month 12 between the two groups was 0.08 ± 0.34 compared to baseline. The upper limit of the 95.0% confidence interval was 0.0031, which was lower than the predefined margin for non-inferiority (0.35). All AEs were injection site-related (swelling, pain, and erythema) and disappeared within 30 min after the procedure. SF-01 was non-inferior to Ellansé-M® and demonstrated favorable efficacy and safety at 12 months after correcting moderate-to-severe nasolabial folds.

The therapeutic effects of hyaluronic acid dermal fillers to correct facial wrinkles and folds usually last up to 6-12 months. Few studies have evaluated their long-term safety.To evaluate the long-term safety and biodegradability of two hyaluronic acid dermal fillers (YVOIRESubjects scheduled to receive the injections of YVOIREComplete clinical biodegradation was observed in 93.5% [95% CI 91.0%-95.5%] of 494 assessable YVOIREYVOIRE