Ultrasound-Guided Targeted vs Regional Flooding: A Comparative Study for Improving the Clinical Outcome in Soft Tissue Filler Vascular Adverse Event Management

Increasing precision during neuromodulator injections for frontal rhytids-Using ultrasound imaging to identify the line of convergence

BACKGROUND

Recent research introduced the concept of the "line of convergence" as a guide for injectors to enhance precision and avoid complications when treating the frontalis muscle with toxins. However, currently, no pre-injection ultrasound scanning is employed to increase precision and reduce adverse events when searching for the line of convergence.

OBJECTIVE

To explore the feasibility and practicality of implementing pre-injection ultrasound scanning into aesthetic neuromodulator treatments of the forehead.

METHODS

The sample of this study consisted of n = 55 volunteers (42 females and 13 males), with a mean age of 42.24 (10.3) years and a mean BMI of 25.07 (4.0) kg/m2. High-frequency ultrasound imaging was utilized to measure the thickness, length, and contractility of the frontal soft tissue and to determine the precise location of the line of convergence during maximal frontalis muscle contraction.

RESULTS

The results revealed that the line of convergence was located at 58.43% (8.7) of the total forehead height above the superior border of the eyebrow cilia without a statistically significant difference between sex, age, or BMI. With frontalis muscle contraction, the forehead shortens in males by 25.90% (6.5), whereas in females it shortens only by 21.74% (5.1), with p < 0.001 for sex differences.

CONCLUSION

This study demonstrated the feasibility and practicality of pre-injection ultrasound scanning for facial aesthetic neuromodulator treatments. Knowing the location of the line of convergence, injectors can determine precisely and on an individual basis where to administer the neuromodulator deep or superficial or when the injection location is at risk to cause eyebrow ptosis.

Updated Filler Emergency Kit: Next-Generation Emergency Solution

INTRODUCTION

The rising popularity of facial filler injections has corresponded with an increase in reported complications. While a filler emergency kit was previously introduced, advancements in the field have highlighted certain limitations, prompting the development of the updated filler emergency kit (UFEK).

METHODS

The authors conducted literature research up to February 2023, focusing on PubMed and open web searches for articles referred to filler emergent complications: vascular occlusion, blindness and anaphylaxis. Approximately 1200 articles were obtained from PubMed and other sources, and 45 articles were reviewed.

RESULTS

The developed UFEK protocol delineates specific interventions meticulously tailored to address diverse emergent scenarios linked to soft tissue fillers complications. This protocol emphasizes the urgent requirement for timely and personalized interventions.

CONCLUSION

The UFEK offers a standardized, comprehensive and effective approach. This work contributes to the responsible and informed progression of the field of aesthetic medicine, providing more value and safety, both for clinicians and patients. Level of Evidence IV 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 .

Investigating the Contraction Pattern of the Zygomaticus Major Muscle and its Clinical Relevance: A Functional MRI Study

BACKGROUND

Our understanding of facial anatomy has significantly evolved, yet the detailed contraction patterns of facial muscles and their presentation during clinical imaging remain largely unexplored. Understanding the contraction patterns and visual presentation of these muscles, particularly the zygomaticus major could enhance pre-surgical facial assessments and the development of new treatment strategies.

METHODS

A total of 34 healthy young individuals (17 female, 17 male) with a mean age of 23.6 (2.4) years [range: 20-30] were investigated regarding the length, thickness, width, and angle of the zygomaticus major muscle in five different facial expressions (i.e., repose, anger, joy, surprise, and sadness) utilizing MR imaging.

RESULTS

Joyful expressions caused a reduction in muscle length to 85.6% of its original length and an increase in width (103.4%), thickness (108.4%), and facial angle (2.72°) when compared to that in repose, suggesting isotonic contraction. Conversely, expressions of anger, surprise, and sadness generally led to muscle stretching, seen through changes in length (98.9%, 104.3%, and 102.7%, respectively), width (98.8%, 96.5%, and 99.4%, respectively), and thickness (91.2%, 91.0%, and 102.7%, respectively), with variable alterations in facial angle (0.55°, 1.85°, and 1.00°, respectively) depending on the specific expression.

CONCLUSION

This MRI-based study indicates that the zygomaticus major muscle experiences isotonic contraction, characterized by decreased length and increased width and thickness. The findings underline the importance of muscle thickness as a reliable parameter in assessing facial muscle function and offer valuable guidance for practitioners in accurately evaluating muscle performance during different facial expressions.

NO LEVEL ASSIGNED

This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes Review Articles, Book Reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 .

Reticulated livedoid skin patterns after soft-tissue filler-related vascular adverse events

BACKGROUND

For the treatment of vascular adverse events caused by filler injections, duplex ultrasound imaging may be used. The findings of duplex ultrasound examination and the clinical features of reticulated livedoid skin patterns were compared with the hemifaces anatomy.

OBJECTIVE

The objective of this study was to link the reticulated livedoid skin patterns to the corresponding duplex ultrasound findings and the facial perforasomes.

METHODS

Duplex ultrasound imaging was used for the diagnosis and treatment of vascular adverse events. The clinical features and duplex ultrasound findings of 125 patients were investigated. Six cadaver hemifaces were examined to compare the typical livedo skin patterns with the vasculature of the face.

RESULTS

Clinically, the affected skin showed a similar reticulated pattern in each facial area corresponding with arterial anatomy and their perforators in the cadaver hemifaces. With duplex ultrasound, a disturbed microvascularization in the superficial fatty layer was visualized. After hyaluronidase injection, clinical improvement of the skin pattern was seen. Normalization of blood flow was noted accompanied by restoration of flow in the corresponding perforator artery. The skin patterns could be linked to the perforators of the superficial fat compartments.

CONCLUSION

The livedo skin patterns seen in vascular adverse events may reflect the involvement of the perforators.

Cosmetic Filler-Induced Vascular Occlusion: A Rising Threat Presenting to Emergency Departments

Vascular emergencies from cosmetic filler-induced vascular occlusion represent an iatrogenic etiology that poses a threat to patients, with sequelae that range from disfiguring skin necrosis to blindness and stroke. As cosmetic fillers continue to grow in popularity, the importance of early identification, triaging, and management of these rare but potentially disabling injuries has motivated efforts to educate the public and professional audiences. In this practice review article, we outline components of acute care pertaining to these injuries based on evolving practice guidelines and best evidence recommendations.

Personalization of Minimally-Invasive Aesthetic Procedures with the Use of Ultrasound Compared to Alternative Imaging Modalities

Ultrasonography is a well-tolerated procedure that aids in the targeted esthetic therapies of special cutaneous regions, as well as in the prevention (vascular mapping, identification of previous filler, and others) and management of potential complications (vascular occlusion, external vascular compression, product misplacement or migration, inflammatory reactions, and others). It has lately been promoted as the first-line imaging tool to address injectables. In this article, we aim to review the evolving role of ultrasonography in cosmetic filler procedures, from the fundamental ultrasound characterization of cosmetic fillers to the ultrasound-enhanced detection and management of cosmetic filler complications, including ultrasound's role in hyaluronidase-guided injections for cosmetic filler dissolution. Furthermore, the paper explores the integral role played by ultrasound in enhancing the precision, efficacy, and safety of additional minimally invasive aesthetic techniques such as mesotherapy, radiofrequency, cryolipolysis, and polydioxanone procedures.

A Computed Tomographic Investigation of the Ophthalmic Artery Volume and Its Relevance to Soft Tissue Filler Injections

BACKGROUND

The measured intraarterial volume of cadaveric ophthalmic arteries was utilized for safety recommendations during facial soft tissue filler injections. However, its clinical practicability and model applicability have become questionable.

OBJECTIVES

To measure the volume of the ophthalmic artery in living individuals by utilizing computed tomography (CT) imaging technology.

METHODS

A total of 40 Chinese patients (23 males, 17 females) were included in this study with a mean age of 61.0 (14.2) years and a mean body mass index of 23.7 (3.3) kg/m2. Patients were investigated with CT imaging technology to evaluate the length, diameter, and volume of the bilateral ophthalmic arteries as well as the length of the bony orbits, resulting in a total of 80 investigated ophthalmic arteries and orbits.

RESULTS

Independent of gender, the average length of the ophthalmic artery was 80.6 (18.7) mm, the calculated volume of the ophthalmic artery was 0.16 (0.05) mL and the minimal and maximal internal diameter of the ophthalmic artery were 0.50 (0.05) mm and 1.06 (0.1) mm, respectively.

CONCLUSIONS

Based on the results obtained from the investigation of 80 ophthalmic arteries it must be concluded that current safety recommendations should be reevaluated. The volume of the ophthalmic artery appears to be 0.2 mL rather than 0.1 mL as previously reported. In addition, it appears impractical to limit the volume of soft tissue filler bolus injections to 0.1 mL due to the aesthetic requirements of each individual patient and treatment plan.