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Background Masseter reduction by botulinum neurotoxin A (BoNT-A) injection is a popular procedure in East Asia. Inappropriate injection can result in various complications. Objectives The aim of this study was to develop an approach for comprehensively evaluating the lower facial structure based on the shape of the mandible angle, the thickness of the masseter, and the thickness of subcutaneous fat. Methods Clinical profiles and standard ultrasound images were collected from patients seeking masseter BoNT-A injections. Lower facial structures were evaluated based on 3 aspects: mandible, masseter, and subcutaneous fat and skin. The mandibular angle was classified as extroverted, straight, or introverted. The starting point of the middle part of the masseter was recorded. The thickness of the deep inferior tendon, the superficial and deep belly of the superficial part of the masseter, and their contractility were measured. Overall thickness and the thickness of subcutaneous fat and skin were also measured. Results Eighty-four masseters from 42 patients were included. Straight mandibular angles were the most common type of angle (48.81%), followed by introverted (26.19%) and extroverted angles (25.00%). The middle part of the masseter starts from 2.33 [0.36] cm (mean [standard deviation]) above the mandible edge, which is above the usual injection points. The superficial belly was thicker than the deep belly in both static and clenching states (P = .048, P = .001) and had greater contractility. The average overall thickness was 1.87 [0.29] cm. Conclusions Comprehensive evaluation of the lower facial contour and structure based on ultrasound examination could be a reliable and replicable assessment approach. Level of Evidence: 4

We conducted a bibliometric analysis of blepharoptosis, obtained the top 100 most-cited articles, and then researched the characteristics of every article.The Web of Science Citation Index was utilized to identify articles related to blepharoptosis written in English published from 1900 to 2021 using predefined search terms. Then, the returned results were screened, and the top 100 most-cited articles were individually classified based on publication year, country of publication, source journal, total citations, authors' specialty, level of evidence, main subject, and type of study.The 100 most-cited articles were published between 1948 and 2014. The number of citations/articles ranged from 49 to 743. Ophthalmology journals made the greatest contributions to landmark literature (n=61). The primary focus of these 100 studies was the surgical technique (n=41). The majority of them (n=52) only achieved level 4 evidence, as a high proportion of these articles were case series (n=52). The most common country of publication was the United States (n=59).Our bibliometric analysis provides insight into the citation frequency of the most-cited articles on blepharoptosis. The landmark, highly cited articles that have shaped the landscape of blepharoptosis were identified. The results from these top 100 cited articles are helpful for present current surgical decision-making.

Background Standardized photographic recording and anatomic evaluation is crucial to refined and comprehensive preoperative design and enhanced aesthetic effect of female genital cosmetic surgery. Objectives The authors aim to propose a standard photographic scheme and physical examination form for the anatomical assessment of patients undergoing female genital surgery. Methods The scheme containing two positions (standing and lithotomy positions) and 11 views (one frontal and two oblique views from standing position, six frontal views with labia minora open and close, pulled to the opposite side, clitoral hood pushed up, posterior fourchette stretched, two oblique views from lithotomy position) (2P11V) is applied to record pre- and postoperative appearance of the vulva. The evaluation form is utilized to record characteristics of different anatomical subunits during photography. Results 245 patients who underwent female genital surgery were enrolled in the research from October 2018 to October 2022. All the patients received preoperative and postoperative 2P11V photography with about 5-minutes’ shooting time. Various anatomical variations containing hypertrophy and prolapse of mons pubis, redundant types of labia minora and clitoral hood, incremental exposure of clitoral glans, hypo to hypertrophy of labia majora, disappearance of interlabial groove, hypertrophy of posterior fourchette and relation of subunits were accurately documented. Conclusions 2P11V photographic scheme displays the isolated features of each organ and proportion relation among different parts of vulva. The standard photographic record and physical examination form offer detailed anatomical structure to surgeons and facilitate surgeons to carry out an accurate surgical design, which deserve to be promoted and applied.

Background Multiple muscles contribute to the formation of dorsal nasal lines (DNLs) and affect nasal aesthetics. Few attempts have been made to explore the range of distribution of DNLs in relation to injection planning. Objectives The aim of this study was to classify the distribution types of DNLs and propose a refined injection technique validated by clinical study and cadaver dissection. Methods Patients were classified into 4 types according to their DNL distribution type. Botulinum toxin type A injections were administered at 6 regular points and 2 optional points. The effect on wrinkle reduction was assessed. Patient satisfaction was recorded. Cadaver dissection was conducted to explore the anatomical evidence of DNL variation. Results The study included 349 treatments in 320 patients (269 females and 51 males), whose DNLs were classified into complex type, horizontal type, oblique type, and vertical type. The severity of DNLs was significantly reduced after treatment. Most patients were satisfied. From the cadaver study, connecting muscular fibers were clearly observed among the muscles involved in the formation of DNLs, and these muscles were collectively named the dorsal nasal complex (DNC) by the authors. Four anatomical variations of the DNC were discovered, corroborating the DNL classification system. Conclusions A novel anatomical concept, the DNC, and a classification system for DNLs were proposed. Each of the 4 distribution types of DNLs corresponds to a specific anatomical variation of the DNC. A refined injection technique for DNLs was developed, and its efficacy and safety were demonstrated.

Botulinum neurotoxin A injection is a popular noninvasive alternative for the treatment of masseter hypertrophy. This study was conducted to identify a safe injection volume to avoid sunken lateral cheek after botulinum neurotoxin A injection in the masseter muscle.One milliliter or 0.5 ml of indocyanine green was randomly injected into either side of the masseter muscles of 18 fresh cadaver heads. The bilateral spreads of indocyanine green within the masseter were observed by a fluorescence imager. The masseters were then dissected, and the spreading distance was measured.Dye spreading showed an oval shape parallel to the long axis of the masseter muscle. The lower edges of the masseters were all stained with indocyanine green. The upward spreading exceeded the mouth corner-tragus line in 94.44% (17/18) of the masseters on the 1-ml side, and 11.11% (2/18) of the masseters on the 0.5-ml side. The spreading area and upward spreading distance on the 1-ml side (9.95 ± 0.48 cmThe spread of indocyanine green within the masseter occurs in direct proportion to its volume. A bolus of 1 ml easily exceeded the mouth corner-tragus line and cause sunken cheek.

Fibrosis is the hyperactivation of fibroblasts that results in excessive accumulation of extracellular matrix, which is involved in numerous pathological changes and diseases. Adipose-derived stem cells (ASCs) are promising seed cells for regenerative medicine due to their bountiful source, low immunogenicity and lack of ethical issues. Their anti-fibrosis, immunomodulation, angiogenesis and other therapeutic effects have made them suitable for treating fibrosis-related diseases. Here, we review the literature on ASCs treating fibrosis, elaborate and discuss their mechanisms of action, changes in disease environment, ways to enhance therapeutic effects, as well as current preclinical and clinical studies, in order to provide a general picture of ASCs treating fibrotic diseases.

Summary Purpose In addition to women, men also undergo breast surgeries, and early studies on the blood supply of breasts are nearly all conducted in female subjects. The vasculature of the male breast is seldom studied. Understanding the male-specific blood supply of the breast is important for pre-operative planning and reducing complications. The purpose of this retrospective study is to fill the gap in the literature by describing the main blood supply and its orientation in the male breast. Methods We retrospectively evaluated thoracic computed tomographic angiography (CTA) data from January 1, 2017 to July 30, 2019. Single or multiple dominant arteries and their origins were traced, and the artery route and orientation related to the nipple-areola complex (NAC) were revealed through data analysis of the images. Results Totally, 284 breasts were included. Most breasts were supplied by a single dominant artery (196, 69%), among which the lateral thoracic artery (LTA; 119, 41.9%; type I) and internal thoracic artery (ITA; 63, 22.2%; type II) were the most common arteries. A minority of breasts were supplied by vascular anastomoses formed by dual arteries (17, 6.0%; type III), and in 25.0% of breasts, no specific dominant artery was found (type IV). The predominant artery distribution was evaluated. Conclusion This study cohort of male thoracic CTA provided and analysed the elaborate vascular anatomy of the NAC region. Our results favour inferior periareolar incision in regard to diminished vascular-related complications in male surgeries without pre-operative vascular evaluation. This study also suggests that super-lateral or lower-lateral-based pedicles can reserve more vasculature.

The ageing in the mid-face involves volume deficiency in multiple anatomical units, including the zygomatic arch, infraorbital region, medial and lateral cheek and nasolabial fold (NLF). Hyaluronic acid (HA) is extensively used in the minimally invasive procedures of mid-face rejuvenation.MD CodesAnatomical dissection and ultrasound imaging help us look back on the injection methods and anatomical principles of MD CodesThe treatment is threefold: (1) the bolus injections, for lifting purposes, are performed at the most depressing point along the zygomatic arch, zygomatic eminence, the prominent optimal point in the zygomatic region, the most depressed point of upper NLF with 0.2-0.3 ml HA. (2) The linear injections, featuring facial contouring refinement, are performed at the deep fat pad of the medial cheek and infraorbital region with 0.4 ml HA. (3) The linear injections, featuring volume replacement, are performed at the subcutaneous fat layer of lateral cheek and NLF with 0.8 and 0.4 ml HA.MD CodeThis 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 .

Patients nowadays seek medical reduction of the upper trapezius muscle to achieve aesthetic pleasing necklines. Botulinum toxin type A (BoNT-A), a neurotoxin that reduces the force of muscle contraction, is widely used for shoulder contouring. However, detailed metrical data are lacking to guide clinical injection.Forty healthy young women were enrolled. All subjects were seated for point marking and measuring of trapezius muscle (TM) anatomical data. At marked locations, the thickness of the subcutaneous tissue, the thickness of the TM, the TM's anterior border, and the depth from the skin surface to the middle of TM were measured using a real-time ultrasound scanner. In addition, photos were taken to assess the shoulder area proportion and shoulder angle.The shoulder area size among participants was 90 ± 15.2 cmIn this study, ultrasonography and photos were applied to assess the TM's anatomical features. Trapezius hypertrophy was described on a scale from 0 to 2 based on the shoulder angle. The findings of the present study provide a practical clinical guidance for precise and efficient BoNT-A administration.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 Nipple-areola complex is a naturally hyperpigmented skin area which can be involved in vitiligo. But limited study focused on the treatment of nipple-areola complex vitiligo, and few methods were proven to be effective. In this study, we aimed to explore the feasibility and efficacy of ReCell® on vitiligo in the nipple-areola complex area. METHODS Medical records of patients with vitiligo involving nipple-areola complex and underwent ReCell® treatment from October 2016 to April 2020 were retrospectively reviewed. The repigmentation rate of the nipple-areola complex and other breast area were calculated under the Wood's light at each follow-up. The grade of repigmentation and patient-reported satisfaction rate were also evaluated to prove the effect of ReCell® on vitiligo of breast and especially in the nipple-areola complex area. RESULTS A total of 18 patients were included in this study. No surgical complications were reported. The mean postoperative repigmentation rate in the nipple-areola complex area (3rd-month, 78.7 ± 5.8%; 6th-month, 87.6 ± 5.1%; and 12th-month, 96.1 ± 3.5%) was significantly higher than that in the other breast treatment area (3rd-month, 70.4 ± 6.9%; 6th-month, 84.2 ± 5.7%, and 12th-month, 93.2 ± 3.6%). All patients showed good or excellent grades at the last follow-up, and 94.4% of them considered the overall treatment results satisfactory. CONCLUSIONS ReCell® is a feasible and efficient treatment strategy in the nipple-areola complex vitiligo.

Botulinum toxin (BoNT) injection is the most commonly performed procedure in cosmetic surgery. However, blind injection is unable to take individual anatomical variations into consideration, which is the main contributing factor to complications. Ultrasound (US) imaging was introduced to reduce complications and improve effects. This article will review uses of US in aesthetic BoNT injection. A systematic electronic search was performed using the PubMed, MEDLINE, Web of science. Search terms were set to focus on aesthetic BoNT injection. Two independent reviewers subsequently reviewed the resultant articles based on strict inclusion and exclusion criteria. Selected manuscripts were analysed and grouped by procedure categories. Clinical cases were all performed by one plastic surgeon in our department. The search finally retained 24 articles. Five procedural categories were identified, including masseter (n = 16), frontalis (n = 2), glabella complex (n = 2), trapezius (n=1), and gastrocnemius (n = 3). US imaging is practical and instructive for pre-operative assessments as in needle-type selection, injection point localization and depth setting, as well as post-operative follow-ups regarding injection feedback (for instance, the extent of muscle volume decreases). What's more, ultrasound-guided injection makes needle trajectory visualized so as for the needle to reach the target muscle in avoidance of potential damage to neurovascular bundle, gland or adjacent muscle. Muscles, such as masseter, frontalis, glabella complex, trapezius and gastrocnemius, and their adjacent structures can be well visualized using US, and as such, US can be a useful tool for a variety of pre-operative, intra-operative and post-operative procedures. 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 .

Wenyun Ting,1,&ast; Yuming Chong,1,2,&ast; Jing Xu,2 Jiuzuo Huang,1 Nanze Yu,1 Zhifei Liu1 1Department of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China; 2Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Zhifei LiuDepartment of Plastic and Aesthetic Surgery, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing, People’s Republic of ChinaEmail liuzfpumch@163.comPurpose: Keloids are caused by uncontrolled excessive proliferation of fibrous tissue. Multiple treatment strategies including steroid injection, surgical excision, laser therapy and radiation therapy have been reported. Few studies have evaluated the performance of plasma skin regeneration (PSR) in the treatment of keloid. This study aimed to evaluate the effectiveness of PSR combined with radiation therapy for keloids on different body parts.Patients and Methods: A total of 71 patients with 98 keloids were enrolled in this study. Keloids < 4 mm thick underwent single-dose PSR, while keloids ≥ 4 mm thick were administered compound betamethasone injection beforehand. Radiation therapy was administered after 24 hours and again 7 days later after PSR. The outcome was evaluated using the patient and observer scar assessment scale at 12 months post-treatment.Results: Patient-reported average scores for all keloids significantly decreased from 35.05± 9.94 to 21.84± 7.04 (p < 0.05). Keloids on face and neck, chest, and back responded better than those on shoulders and limbs. The recurrence rate was observed to be 15.3% (15 out of 98). Adverse effects were mild.Conclusion: PSR combined with radiation therapy is an effective and safe strategy to treat keloids. Location could be a factor that affects curative effects.Keywords: keloid, plasma skin regeneration, radiation therapy, POSAS, recurrence rate

The inframammary approach is one of the most commonly used incisions in breast augmentation. There are many suture methods for inframammary incisions; however, no one method has proven optimal. We modified the traditional three-layer suture method according to the inframammary fold (IMF) cadaver dissection results. This study aims to investigate whether using a modified suture method can improve postoperative outcomes.Cadaver dissections were performed in order to clarify the anatomy of the IMF. From June 2013 to December 2017, a retrospective study of primary breast augmentation patients subjected to the inframammary approach was conducted. Patients were divided into two cohorts: the traditional suture method and the modified suture method. The patient's demographics, specifics of breast augmentation procedures, complications, and scar assessment were analyzed. Univariate and multivariable analyses were used to determine differences between the two cohorts.One hundred eighty-four patients were included: 75 patients were subjected to the traditional suture method, and 109 patients were subjected to the modified suture method. Wound-related adverse events (p = 0.026) and IMF-indented scarring (p = 0.014) were significantly different between the two groups. Multivariable analysis showed that the suture method was the most influential factor related to IMF-indented scarring (OR = 16.9), followed by BMI (OR = 2.9).We defined a new suture method for the inframammary incision in primary breast augmentation. This modified suture method reduces the occurrence of wound-related adverse events and IMF-indented scarring.

Localized scleroderma (LoS) is an autoimmune connective tissue disorder leading to serious long-term aesthetic impairment on patients. Objective evaluation methods are badly needed to facilitate the evaluation of the surgical treatment on individual patients and clinical studies. To develop and assess the reliability and validity of Peking Union Medical College LoS facial aesthetic index (PUMC LoSFAI). Twelve experts devoted their time and resources in the development and validation. LoS patients in the stable phase were recruited. Reliability and validity was then assessed. LoS patients were evaluated by two plastic surgeons using PUMC LoSFAI and LoS skin damage index (LoSDI). The PUMC LoSFAI comprises 4 domains for the local assessment (surface area of lesion, dyspigmentation, skin thickness and soft tissue atrophy) and 3 domains for the overall assessment (facial symmetry, proportion and profile) to describe LoS facial aesthetic impairment. Face-Q was completed by patients at each visit. Thirty-two LoS patients had 96 visits, during which 138 lesions were assessed. PUMC LoSFAI and 7 domains demonstrated substantial to excellent inter- and intra-rater reliability (ICC 0.995, κw 0.72-0.91, r 0.85–0.99, respectively). Seven domains considered to be important to extremely important variables (mean rank 3.2–3.8) had high I-CVI (> 0.78) and S-CVI (0.93). PUMC LoSFAI correlated excellently with LoSDI (r = 0.933, P

Background The emergence of COVID-19 has become a global health emergency. The transmissibility of the disease is of great interest to healthcare workers and scientists alike. The primary route of transmission is via respiratory droplets, but viral RNA has also been found in feces and body fluids such as urine, serum, and semen. So far, there has been no report on whether SARS-CoV-2 is present in the exudates of cutaneous lesions. This study was designed to investigate whether SARS-CoV-2 can be found in the pressure injury exudates in patients with severe COVID-19 infections. Methods 46 critically ill COVID-19 patients who were admitted to the ICU of the Sino-French New City Branch of Tongji Hospital in Wuhan between February 4 and April 12 developed pressure injuries. 22 patients with pressure injuries had wound exudates. Wound and pharyngeal swabs of the 22 patients were collected and RT-PCRs were conducted to detect SARS-CoV-2 viral RNA. Results At the time of pressure injury, 5 patients still tested positive by pharyngeal swabs, the rest of the 17 patients tested negative. However, none of the wound exudate swabs from the participants tested positive for SARS-CoV-2 by RT-PCR. Conclusion Our study suggests that it is rather unlikely that COVID-19 can be transmitted via pressure injury exudates, but we still recommend standardized personal protective equipment, face shield and an additional pair of gloves when treating pressure injuries.

BACKGROUND: Due to adipose-derived stem cells (ASCs) being easy to obtain, their rapid proliferation rate, and their multidirectional differentiation capabilities, they have been widely used in the field of regenerative medicine. With the progress of decellularized adipose tissue (DAT) and adipose tissue engineering research, the role of DAT in promoting angiogenesis has gradually been emphasized. METHODS: We examined the biological characteristics and biosafety of DAT and evaluated the stem cell maintenance ability and promotion of growth factor secretion through conducting in vitro and in vivo studies. RESULTS: The tested ASCs showed high rat:es of proliferation and adhered well to DAT. The expression levels of essential genes for cell stem maintenance, including OCT4, SOX2, and Nanog were low at 2–24 h and much higher at 48 and 96 h. The Adipogenic expression level of markers for ASCs proliferation including PPARγ, C/EPBα, and LPL increased from 2 to 96 h. Co-culture of ASCs and DAT increased the secretion of local growth factors, such as VEGF, PDGF-bb, bFGF, HGF, EGF, and FDGF-bb, and secretion gradually increased from 0 to 48 h. A model of full-thickness skin defects on the back of nude mice was established, and the co-culture of ASCs and DAT showed the best in vivo treatment effect. CONCLUSION: The application of DAT promotes wound healing, and DAT combined with ASCs may be a promising material in adipose tissue engineering and regenerative medicine.

Objective We retrospectively evaluated the efficacy and safety of keystone-designed perforator island flaps for chest keloid reconstruction. Methods We reviewed consecutive patients who received keystone flap reconstruction after chest keloid resection between January 2017 and February 2018. The patient demographic data, defect size, flap size, complications, and recurrence were recorded. Results Thirty-eight patients were evaluated in this retrospective case series. After keloid resection, dimension of wound defects was 5.5-9.5 cm × 9.5-12.5 cm, with an average dimension of 7.3 cm × 10.7 cm. The dimension of keystone flaps was between 6-10 cm × 20-34.5 cm, with an average dimension of 7.5 cm × 25.5 cm. The flaps healed smoothly without any complication. There was no keloid recurrence with 15 months of follow-up. 89.4% of the patients had good outcome with no apparent scarring, and 10.6% patients had satisfactory outcome with localized scarring. Conclusions Keystone-designed perforator island flap is an effective and reliable method for reconstruction following chest keloid resection.

Background Lymphedema is a chronic, debilitating and incurable disease that affects 0.13%-2% of the global population. Emerging evidence indicates that adipose-derived stem cells (ADSCs) might serve as suitable seed cells for lymphatic tissue engineering and lymphedema therapy. Aim To summarize applications of ADSCs for treating lymphedema in both animal studies and clinical trials. Methods A systematic search was performed on four databases - PubMed, Clinicaltrials.gov, the evidence-based Cochrane Library, and OVID - using the following search string: ("lymphedema" or "lymphoedema" or "lymphangiogenesis") and ("adipose-derived stem cells" or "adipose-derived stromal cells" or "adipose-derived regenerative cells"). A manual search was performed by skimming the references of relevant studies. Animal studies and clinical trials using adipose-derived cells for the treatment of any kind of lymphedema were included. Results A total of eight research articles published before November 2019 were included for this analysis. Five articles focused on animal studies and another three focused on clinical trials. ADSC transplantation therapy was demonstrated to be effective against lymphedema in all studies. The animal studies found that coadministration of ADSCs and controlled-release vascular endothelial growth factor-C or platelet-rich plasma could improve the effectiveness of ADSC therapy. Three sequential clinical trials were conducted on breast cancer-related lymphedema patients, and all showed favorable results. Conclusion ADSC-based therapy is a promising option for treating lymphedema. Large-scale, multicenter randomized controlled trials are needed to develop more effective and durable therapeutic strategies.

BACKGROUND: High-riding nipple is one of the common complications after mastopexty and breast reconstruction. However, to date, a limited number of techniques have concentrated on how to lower the high-riding nipple with enlarged areola. CASE SUMMARY: This is a case report describing a combination of surgical techniques to decrease high-riding nipple. A 26-year-old woman, who previously underwent several breast operations, sought correction for high-riding nipple with enlarged areola. Expanders were used and multi-stage techniques were performed. After one year of follow-up, lowered nipple, reduced areola size, ensured nipple blood supply, and improved breast ptosis were achieved, and the patient was satisfied with the breast contour. CONCLUSION: The proposed technique offers a feasible treatment option for postoperative nipple over-elevation combined with areola dilation.

Background Botulinum toxin type A (BTA) injection is a widely-used procedure to correct cosmetic problems caused by muscular hyperactivity. "Cobblestone chin" refers to the appearance of remarkable chin creases caused by mentalis contraction. Aims The aim of this case report is to raise the awareness of paradoxical bulging after BTA injection in mentalis. Patient/methods A 26-year-old female asked for cosmetic correction of the "cobblestone chin". BTA injection was performed routinely to the mentalis muscle. However, on the second day after injection, an unusual paradoxical bulging at chin was presented. Results We speculated that the imbalanced relaxation of mentalis caused by improper injection and uneven diffusion of BTA is responsible for the bulging. After a supplementary injection of BTA in the remaining hyperactive muscle fibers based on the ultrasound examination, the bulging was relieved and chin contour improved significantly. Conclusion Injection of BTA in mentalis should cover the whole thickness of the muscle to prevent imbalanced paralysis and paradoxical chin bulging, especially in severe mentalis hyperactivity cases.