Quantifying Soft Tissue Loss in Facial Aging: A Study in Women Using Magnetic Resonance Imaging

Evaluation of Facial Aging in Different Age and Gender Groups With Computed Tomography-Based Calvarium and Face Measurements

BACKGROUND

The human face is a complex area formed by the combination of many different components and varies among individuals according to gender, age, and ethnicity.

OBJECTIVE

The aim of this study was to evaluate age-related changes in the facial and calvarial bones in a large sample of both genders.

METHODS

The retrospective study included nontraumatic brain computed tomography scans of 280 Turkish adults. Participants were divided into 7-decade groups with the age ranging from 20 to 89 years. Measurements of the face and calvaria were recorded, and calvarial volume was calculated. The relationship of these parameters with age and gender was examined.

RESULTS

Statistically significant differences were observed in all the facial and calvarial measurements, except the transverse diameter of the head, with increasing age in both genders. Regardless of age, no significant differences were found in facial and calvarial measurements between genders. In addition, there was a significant decrease in the calvarial volume in both genders after the seventh decade of life.

CONCLUSION

The structure of the face and calvarium continues to change and differentiate throughout life. Taking these changes into account during surgical and facial rejuvenation procedures can help predict outcomes and avoid the use of incorrect techniques.

Using a structured light scanner to evaluate 3-dimensional soft-tissue changes after extracting 4 premolars in young adult female patients

INTRODUCTION

Facial esthetics have always received much attention in orthodontic treatment, especially in young adult female patients. Three-dimensional (3D) soft-tissue changes after orthodontic extraction have not been fully explained. This study evaluated the 3D morphologic changes after orthodontic extraction in young female patients using a structured light scanner.

METHODS

Forty-five adult female patients aged 20-25 years were enrolled in our study. The treatment group consisted of patients who received orthodontic treatment with 4 premolar extractions, and the control group was composed of young female volunteers who had not undergone any orthodontic treatment. To monitor the soft-tissue changes, 9 morphologic regions and 12 landmarks were identified for the 3D deviation analyses. The spatial deviations of landmarks and regions in the x, y, and z directions were constructed for quantitative analysis. Color map images were constructed to visualize soft-tissue displacement as a qualitative evaluation. The paired sample test was used to compare differences at the beginning of the experiment (T0) and after 24 months (T1) in both groups. An independent t test with Bonferroni correction was performed to compare differences between the treatment and control groups. A linear regression test was performed between incisor retraction and changes in the perioral tissues.

RESULTS

Subtracting the effect of aging from the lip changes in the control group, the treatment group showed a statistically significant difference in the displacement of labrale superius (-1.37 mm), labrale inferius (-1.89 mm), the upper lip region (-0.98 mm), and the lower lip region (-1.36 mm) along the z-axis. No significant differences were found between the treatment and control groups in the temporal, parotideomasseteric, and buccal regions. Pearson correlation tests indicated a positive correlation between incisor tip retraction and changes in soft tissues (two-dimensional cephalometric analysis, 3D landmark measurements, and 3D regional measurements). The correlation coefficient ranged between 0.45 and 0.55.

CONCLUSIONS

Three-dimensional soft-tissue changes were mainly concentrated in the upper and lower lip regions in adult female patients after the 4 premolars were extracted. For female patients aged 20-25 years with 4 extracted premolars, soft-tissue changes in the temporal, parotideomasseteric, and buccal regions were not clinically significant.

Cone-Beam Computed Tomography for Objective Diagnosis of Age-Related Soft Tissue Changes in Lower Face and Neck

BACKGROUND

An objective assessment of the causes of age-related contour deformities of the soft tissues of the face and neck is very important in esthetic surgery, especially as minimally invasive techniques gain increasing popularity.

METHODS

To visualize the tissues that cause age-related soft tissue changes, we performed cone-beam computed tomography (CBCT) in 37 patients who underwent facial and neck rejuvenation procedures in 2021-2022.

RESULTS

Vertical CBCT enabled visualization of the causes and degree of tissue involvement in age-related changes in the lower third of the face and neck. CBCT showed the location and condition of the platysma (hypo- [ptosis], normo-, or hyper-tonus), position, thickness, and location (above and/or below the platysma) of fat tissue, presence of ptosis of the submandibular salivary glands, condition of the anterior bellies of the digastric muscles, and the degree of their participation in contours of the cervicomandibular angle, and location of the hyoid bone. Moreover, CBCT enabled demonstrating for the patient the facial and neck contour deformations and discussing the suggested corrective methods using a clear objective visual image.

CONCLUSIONS

CBCT in the upright position enables objective assessment of each soft tissue in the age-related deformity of the cervicofacial region and provides an opportunity to plan the appropriate impact on the particular anatomical structures during rejuvenation procedures and estimate their results. This is the only study to date to objectively and clearly visualize the entire topographic anatomy of the soft tissues of the face and neck vertically for plastic surgeons 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 .

Quantification of Facial Fat Compartment Variations: A Three-Dimensional Morphometric Analysis of the Cheek

BACKGROUND

Cheek contour is a main determinant of facial attractiveness. The aim of this study was to evaluate the relationship between age, sex, and body mass index (BMI) and cheek fat volume in a large cohort to better understand and treat facial aging.

METHODS

The authors performed a retrospective review of the archives of the Department of Diagnostic and Interventional Radiology, University Hospital of Tübingen. Epidemiologic data and medical history were assessed. Cheek superficial and deep fat compartment volumes were measured on magnetic resonance images. Statistical analyses were performed using SPSS and SAS statistical software.

RESULTS

A total of 87 patients with a mean age of 46 years (range, 18 to 81 years) were included. The superficial and deep fat compartment volumes of the cheek increased with BMI ( P < 0.001 and P = 0.005), but there was no significant relationship between age and volume. The ratio of superficial versus deep fat did not change with age. No significant difference of the superficial or deep fat compartments was found between men and women in a regression analysis ( P = 0.931 and P = 0.057).

CONCLUSIONS

Cheek fat volume measurements on magnetic resonance imaging scans using reconstruction software suggest that the fat volume of the cheek increases with BMI but does not change significantly with age. Further studies are needed to elucidate the role of age-related changes of bone structures or sagging of the fat compartments.

The effect of sex and age on facial shape directional asymmetry in adults: A 3D landmarks-based method study

OBJECTIVES

Facial directional asymmetry research, including age-related changes, is crucial for the evaluation of treatment of craniofacial malformations/trauma in orthodontics, facial surgery and forensic sciences. The aim was to describe facial directional asymmetry (DA) in different age categories of adults using 3D methods. According to our hypothesis, facial shape DA (1) depends on sex; (2) differs among age groups; and (3) has wider variability in older age.

MATERIAL AND METHODS

A cross-sectional sample of healthy Czech adults without craniofacial trauma or anomalies consisted of 300 3D facial models (151 females). The age-range in the study was between 20-80 years. The shape asymmetry of 28 3D landmarks was evaluated using geometric morphometrics and multivariate statistics.

RESULTS

The manifestation of DA was similar in both sexes and in each age category; however, there were some statistical differences. In contrast to the ideal symmetrical face, the mean asymmetrical faces tended to create a slightly bent "C" shape of the midline. Therefore, the upper face was rotated slightly clockwise and the lower face counter-clockwise. The right eye was located slightly higher, with the nasal tip and mandibular region tilting to the left. Sex differences in facial DA were significant before the age of 40. DA was more significant in the youngest males than in the oldest, while the women's DA did not change.

CONCLUSIONS

The DA patterns were similar in both sexes and in all age categories (a slightly bent C shape of the midline); however, some significant local differences between male age groups were found. A significantly more pronounced asymmetry compared to other age groups was found only in the youngest males from 20 to 40 years. Moreover, significant sexual dimorphism of DA rapidly decreased after middle age, likely caused by the same age-related changes of the face during aging.

Three dimensional quantitative study of soft tissue changes in nasolabial folds after orthodontic treatment in female adults

BACKGROUND

With the popularity of medical aesthetic programs, some female adults who will or are undergoing orthodontic treatment often wonder whether orthodontic treatment has adverse effects on the nasolabial folds (NLFs). The aims of the study were to investigate any potential changes in the NLFs and associated peripheral soft tissues after orthodontic treatment of female adults.

METHODS

This study compared changes in the NLFs and peripheral soft tissues in female adults undergoing orthodontic treatment using the 3dMD Face system (3dMD, Atlanta, Ga). A total of 52 adult female patient cases (24 teeth extraction, 28 non-teeth extraction) were included to evaluate the effects of different orthodontic treatment regimens on the NLFs and peripheral soft tissues.

RESULTS

In the NLFs area, the landmarks of the extraction group were all significantly negatively changed (P < 0.001; the NLF2s average value was - 0.72 mm), and the upper and middle parts of the landmarks were negatively changed in the non-extraction group (P < 0.05; the NLF2s average value was - 0.22 mm). Compared to the non-extraction group, the negative changes in the extraction group were more pronounced (P < 0.005). In the lip region, all landmarks in the extraction group were negative changes (P < 0.05; upper lip (ULP) = - 0.93 mm, lower lip (LLP) = - 1.46 mm), and most landmarks in the non-extraction group were positive changes (P < 0.01; ULP = 0.55 mm). In the cheek area, the left and right buccal of the extraction and non-extraction groups were all negatively changed (P < 0.05), and there was no significant difference between the two groups.

CONCLUSION

After orthodontic treatment, the NLFs showed negative changes, which were more obvious in the extraction group. The lip soft tissue had a negative change in the extraction group and a positive change in the non-extraction group, indicating that orthodontic treatment affected the soft tissue around the nasolabial sulcus, and that tooth extraction would lead to more negative changes.

Benefit of Hyaluronic Acid to Treat Facial Aging in Completely Edentulous Patients

Hyaluronic acid (HA) is widely used in aesthetic medicine for its moisturizing and anti-aging action. This molecule, which is naturally present in the body, has an interesting response to aging, accentuated in totally edentulous patients. While its aesthetic benefits for facial rejuvenation are well-documented, there is a lack of description and investigation on its therapeutic usefulness for edentulous patients. The management of completely edentulous patients is a daily reality in dental practice and requires specific attention. The aesthetic and functional challenge is considerable. The displacement of the bone base, which is often marked, and lack of soft tissue support are sometimes difficult to correct with prosthetic reconstruction. This review aims to present the physiological processes appearing in completely edentulous patients and prosthetic solutions available to recreate oral functions and counteract facial aging. As prosthetic rehabilitations are not fully satisfying for counterbalancing the impression of excessive facial aging, we investigated the applications of HA injection in the perioral area, in order to improve edentulism treatment, and discussed the advantages and disadvantages, compared to other dermal fillers and rejuvenation therapies. Considering the specific situations of edentulous patients, dermal HA injections help to correct uncompensated bone losses and mucous volume losses and appear to be a therapeutically beneficial for treating completely edentulous patients, without the requirement to full rejuvenation therapy.

Use of Facial Morphology to Determine Nutritional Status in Older Adults: Opportunities and Challenges

Undiagnosed malnutrition is a significant problem in high-income countries, which can reduce the quality of life of many individuals, particularly of older adults. Moreover, it can also inflate the costs of existing health care systems because of the many metabolic complications that it can cause. The current methods for assessing malnutrition can be cumbersome. A trained practitioner must be present to conduct an assessment, or patients must travel to facilities with specialized equipment to obtain their measurements. Therefore, digital health care is a possible way of closing this gap as it is rapidly gaining traction as a scalable means of improving efficiency in the health care system. It allows for the remote monitoring of nutritional status without requiring the physical presence of practitioners or the use of advanced medical equipment. As such, there is an increasing interest in expanding the range of digital applications to facilitate remote monitoring and management of health issues. In this study, we discuss the feasibility of a novel digital remote method for diagnosing malnutrition using facial morphometrics. Many malnutrition screening assessments include subjective assessments of the head and the face. Facial appearance is often used by clinicians as the first point of qualitative indication of health status. Hence, there may be merit in quantifying these subtle but observable changes using facial morphometrics. Modern advancements in artificial intelligence, data science, sensors, and computing technologies allow facial features to be accurately digitized, which could potentially allow these previously intuitive assessments to be quantified. This study aims to stimulate further discussion and discourse on how this emerging technology can be used to provide real-time access to nutritional status. The use of facial morphometrics extends the use of currently available technology and may provide a scalable, easily deployable solution for nutritional status to be monitored in real time. This will enable clinicians and dietitians to keep track of patients remotely and provide the necessary intervention measures as required, as well as providing health care institutions and policy makers with essential information that can be used to inform and enable targeted public health approaches within affected populations.

Age-Related Changes in Facial Soft Tissue of Han Chinese: A Computed Tomographic Study

BACKGROUND

Facial lifting and volume restoration are the major strategies of facial rejuvenation, but the aging of facial soft tissues has not been sufficiently explored.

OBJECTIVE

This study aimed to reveal the age-related changes in full facial soft tissue of Han Chinese by using computed tomography.

MATERIALS AND METHODS

The measurements were performed on head computed tomographic images of 200 Han Chinese subjects (100 men and 100 women). The thickness of facial soft tissue was measured at 20 anthropological landmarks of the skull.

RESULTS

The thickness at rhinion was increased, whereas the thickness at midphiltrum, supradentale, and infradentale was decreased, indicating the significant differences in both sexes. Besides, the thickness at glabella, nasion, supramentale, and menton was decreased significantly in women. The thickness at supraorbital and lateral orbit was increased with aging in either sex. The thickness at frontal eminence, infraorbital, supraglenoid, and gonion showed significant age-related increases in women, and the thickness at zygomatic arch, supra M2, and infra M2 was significantly decreased in men.

CONCLUSION

These results suggest that soft tissues in different areas of the face are selectively thickened or thinned with aging, thus providing a reference for rejuvenation procedures.

Perceived Age and Personality Profiling after Orthognathic Surgery

BACKGROUND

Recent studies suggest that orthognathic surgery can improve facial age and personality profiling. The authors expand on these findings by assessing the role of patient facial profile and sociodemographics on perceived changes following surgery.

METHODS

Preoperative and postoperative images of 65 patients operated on by a single surgeon were randomly assorted and rated by 30 respondents. Patient facial profiles were categorized as convex, concave, or straight. Paired and unpaired t tests were used to assess differences preoperatively and postoperatively. Multivariate regression and post hoc receiver operating characteristic curve analyses were used to quantify the influence of various patient factors.

RESULTS

Significant decreases in perceived age were seen following orthognathic surgery overall (-1.31 years; p < 0.01) and in the straight (-1.10 years; p = 0.02) and convex (-1.80 years; p ≤ 0.01) subgroups. After controlling for patient sociodemographics, there were no significant differences in age change based on facial profile. Older age at the time of surgery was independently associated with greater perceived age changes ( p = 0.04); older patients (>26.5 years, determined by receiver operating characteristic curve) experienced greater net decreases in perceived age in comparison to younger patients (-2.0 years versus -1.2 years; p < 0.01). Improvements were seen in overall attractiveness ( p < 0.01) and in each tested personality characteristic following surgery ( p < 0.01). These differences were not significantly associated with different patient sociodemographics or facial profile.

CONCLUSIONS

The authors' data add to the growing base of evidence that orthognathic surgery improves patient-perceived age and personality. Significant decreases in perceived age are more likely to be gained by patients undergoing surgery at an older age.

CLINICAL QUESTION/LEVEL OF EVIDENCE

Risk, II.

Profiles of facial soft tissue changes during and after orthodontic treatment in female adults

Background

Some female adults who received orthodontic treatment often complain about thinner faces, protruding cheekbones and sunken temples, even at the beginning of treatment. The present research aimed to explore facial soft tissue changes during and after orthodontic treatment, as well as the related factors affecting facial soft tissue changes.

Methods

This study used 3dMD stereo photography technology to compare facial soft tissue changes among adult females who received orthodontics. A total of 52 adult females (24 teeth extraction, 28 non-teeth extraction cases) were included and potential correlations between related factors (facial morphology features, the change of occlusal height and dental arch width) were evaluated during different treatment periods.

Results

Overall, 3D-negative soft tissue changes of the buccal region moderately correlated with distances of nasion-menton and subnasale-menton (both rs = 0.30, P < 0.05) as well as the ratio of subnasale-menton/right gonion-left gonion (rs = 0.33, P < 0.05) and nasion-menton/right zygomatic point-left zygomatic point (rs = 0.30, P < 0.05). Among the 3D angle measurements, the right chelion-median upper lip point-left chelion angle was found to have a moderate correlation with 3D negative changes of the upper cheilion region (rs = 0.31, P < 0.01). Analysis of occlusal height changes revealed that an increase in the posterior facial height (nasion-gonial distance) may be a risk factor for negative changes in the zygomatic arch area. In addition, a moderate positive correlation between the maxillary first molar width changes and 3D-negative changes of the lower cheek region was found (rs = 0.41, P < 0.05).

Conclusions

After orthodontic treatment, adult females with wide and short faces may be prone to negative soft tissue changes. Changes of posterior facial height and arch width between the first molars were also risk factors for negative changes of facial soft tissues. Extraction is not a major factor producing facial soft tissue changes.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12903-022-02280-5.

Design of an elastic porous injectable biomaterial for tissue regeneration and volume retention

Soft tissue reconstruction currently relies on two main approaches, one involving the implantation of external biomaterials and the second one exploiting surgical autologous tissue displacement. While both methods have different advantages and disadvantages, successful long-term solutions for soft tissue repair are still limited. Specifically, volume retention over time and local tissue regeneration are the main challenges in the field. In this study the performance of a recently developed elastic porous injectable (EPI) biomaterial based on crosslinked carboxymethylcellulose is analyzed. Nearly quantitative volumetric stability, with over 90% volume retention at 6 months, is observed, and the pore space of the material is effectively colonized with autologous fibrovascular tissue. A comparative analysis with hyaluronic acid and collagen-based clinical reference materials is also performed. Mechanical stability, evidenced by a low-strain elastic storage modulus (G') approaching 1kPa and a yield strain of several tens of percent, is required for volume retention in-vivo. Macroporosity, along with in-vivo persistence of at least several months, is instead needed for successful host tissue colonization. This study demonstrates the importance of understanding material design criteria and defines the biomaterial requirements for volume retention and tissue colonization in soft tissue regeneration. STATEMENT OF SIGNIFICANCE: We present the design of an elastic, porous, injectable (EPI) scaffold suspension capable of inducing a precisely defined, stable volume of autologous connective tissue in situ. It combines volume stability and vascularized tissue induction capacity known from bulk scaffolds with the ease of injection in shear yielding materials. By comparative study with a series of clinically established biomaterials including a wound healing matrix and dermal fillers, we establish design rules regarding rheological and compressive mechanical properties as well as degradation characteristics that rationally underpin the volume stability and tissue induction in a high-performance biomaterial. These design rules should allow to streamline the development of new colonizable injectables.

Three-Dimensional Geometric Morphometry of Facial Soft Tissue Changes After Bilateral Sagittal Split Ramus Osteotomy

ABSTRACT

This study aimed to evaluate the performance of geometric morphometry (GM) to assess the changes in facial soft tissue after orthognathic surgery. Subjects were 27 patients (skeletal class III) who underwent bilateral sagittal split ramus osteotomy and 27 volunteers as a control group. Computed tomography images of each patient were obtained before surgery (T0) and 6 months after surgery (T1). Computed tomography images of 27 volunteers (skeletal class I) were also obtained as a control group. Using a three-dimensional (3D) modeling software, 3D models were created and exported to a 3D surface analyzing software for geometric morphometry and principal component (PC) analysis. Significant differences in facial soft tissue were found in the first and second of 15 PC. The first PC represented variation in the lower facial height, and the second PC represented variation in the anterior-posterior position of the chin. Comparing the pre- and post-operative images, they illustrated that lower facial height was decreased, and the chin and lower lip moved posteriorly. Geometric morphometry showed to be a successful tool to isolate surgery-related changes from interindividual morphological variations.

Onabotulinumtoxin Type A Dosage for Upper Face Expression Lines in Males: A Systematic Review of Current Recommendations

BACKGROUND

Botulinum toxin injection is the most commonly performed minimally invasive aesthetic procedure in men. Despite various recommendations by experts on the use of onabotulinumtoxin type A in the literature, distinct guidelines for its use in males and females do not exist.

OBJECTIVES

The aim of this study was to delineate safe and effective doses for the use of onabotulinumtoxin type A in males for correction of upper facial expression lines.

METHODS

PubMed (MEDLINE), Embase, the Cochrane database, and Google Scholar were searched from 2002 to 2019 inclusive. Three researchers independently assessed trials for inclusion, extracted data, checked for accuracy, and assessed the evidence with AGREE II.

RESULTS

Average dosing recommended for the treatment of upper face expression lines was specific to glabellar frown lines, crow's feet, and horizontal forehead lines. Changing trends and gender variation was noted in each of the studies. Six of the 11 recommendations suggest the need to alter dosing in male patients, although do not give separate recommendations.

CONCLUSIONS

There is an urgent need for up-to-date recommendations for the use of onabotulinumtoxin type A in upper face expression lines of male patients.

Hybrid Implant and Grafted Fat Breast Augmentation: Designing the Pathway to a Future With Breasts Free of Silicone Breast Implants

BACKGROUND

Fat grafting in breast augmentation surgery is becoming increasingly popular, allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one of the current issues surrounding fat grafting is the lack of standardization.

OBJECTIVES

The objective of this study was to validate and summarize expert-based advice to help plastic surgeons better understand the benefits of utilizing fat grating to reduce implant size in their surgical planning.

METHODS

This was a prospective study of fat grafting in 56 patients who underwent fat transfer together with silicone breast implants. A 3-dimensional planning system was used to plan the procedure and also to analyze the fat retention and resorption rates. Pictures served as a basis for a questionnaire in which both patients and physicians were asked to rate their satisfaction.

RESULTS

Patients reported a satisfaction rate of "excellent" in 83.3% of cases and "good" in 16.7%. Physician satisfaction was rated as "excellent" in 84.5% of cases, "good" in 13.3%, and "fair" in 4.2% of cases. The mean fat volume grafted per breast was 113.63 mL. The mean absorption rate was 4.53%.

CONCLUSIONS

The procedure presented consistent and reproducible results. Hybrid breast augmentation can help design a pathway for a future with breasts free of silicone. This information is particularly relevant for women who have their first breast augmentation at an early age and will probably have 2 to 5 additional surgeries in their lifetime due to the nature of current silicone breast technology.

LEVEL OF EVIDENCE: 4

An Injectable Meta-Biomaterial: From Design and Simulation to In Vivo Shaping and Tissue Induction

A novel type of injectable biomaterial with an elastic softening transition is described. The material enables in vivo shaping, followed by induction of 3D stable vascularized tissue. The synthesis of the injectable meta-biomaterial is instructed by extensive numerical simulation as a suspension of irregularly fragmented, highly porous sponge-like microgels. The irregular particle shape dramatically enhances yield strain for in vivo stability against deformation. Porosity of the particles, along with friction between internal surfaces, provides the elastic softening transition. This emergent metamaterial property enables the material to reversibly change stiffness during deformation, allowing native tissue properties to be matched over a wide range of deformation amplitudes. After subcutaneous injection in mice, predetermined shapes can be sculpted manually. The 3D shape is maintained during excellent host tissue integration, with induction of vascular connective tissue that persists to the end of one-year follow-up. The geometrical design is compatible with many hydrogel materials, including cell-adhesion motives for cell transplantation. The injectable meta-biomaterial therefore provides new perspectives in soft tissue engineering and regenerative medicine.

The Facial Aging Process From the "Inside Out"

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

Evaluation of aging changes of the superficial fat compartments of the midface over time: A computed tomography study

BACKGROUND

Previous studies on alterations in superficial fat compartments with age yielded contradictory results; the superficial fat tissue volume or thickness was reported to increase, decrease, or remain unchanged.

AIMS

To investigate volumetric and dimensional changes in superficial midfacial fat tissue retrospectively in patients who underwent a repeated computed tomography (CT).

METHODS

A total of 262 patients (mean age, 46 years; median elapsed time between two CT imagings, 56 months) were included. Axial and sagittal planes were used for measurements of the medial part of the superficial cheek fat (SCF), which is divided into three compartments. The thickness, width, and height of each compartment were measured, and volumes were calculated for both hemifaces. Additionally, results were compared between males and females, and between three age groups: <45, 45-54, and ≥55 years.

RESULTS

The total volume of SCF and inferior compartment was significantly increased compared with the first CT findings (p < 0.05). Upper and middle compartment volumes were found to decrease with age (p < 0.05). Thickness was decreased in the upper and middle compartments but not in the lower compartment. The width of the lower and middle compartments increased (p < 0.05), while the upper compartment did not show a significant change with age (p > 0.05). The height of the superficial fat layer was significantly increased at follow-up (p < 0.05). The results were similar for both sexes and all age groups (p > 0.05).

CONCLUSIONS

SCF undergoes significant volume and dimensional changes with aging. Therefore, superficial fat tissue should be considered for enhancement of cosmetic treatments.

Thread Lifting of the Jawline: A Pilot Study for Quantitative Evaluation

Introduction

The facial aging process produces changes that are characteristic of the superficial and deep fat framework and skin layers. Subdermal suspension with threads enables the sagging tissues to be lifted by means of a minimally invasive, closed procedure without surgical dissection. This observational study has been carried out on the basis of standardized tridimensional photographic analysis and measurement, aimed at determining objective, repetitive, and reliable evaluation of the soft tissue suspension technique.

Materials and Methods

Eight participants were enrolled in this pilot study presenting with mild to moderate ptosis of the jawline tissues. Patient photographs were taken before (t0), immediately after threads implantation (t1), and at the following visit (t2). Each image captured before thread insertion was registered by the software and surface linear lengths in between the mentioned points were calculated.

Results

The result showed an overall average improvement in the "tragus-to-marionette distance" (C-A) and the "tragus-to-jowl distance" after a mean follow-up time of 8.16 months (t0-t2). All analyzed parameters improved significantly (P < 0.05) at t1 and at t2 with respect to t0.

Conclusions

This pilot study suggest that facial tissue suspension by means of poli-lactic/poli-caprolactone threads is safe and effective in treating skin flaws that affect mild-to-moderate ptosis of the jawline up to 8 months.

Aging Process of Lateral Facial Fat Compartments: A Retrospective Study

BACKGROUND

Since 2007, when the anatomy of facial fat compartment was described, an increasing number of studies on the aging process of the compartment of cadavers has emerged.

OBJECTIVES

The authors evaluated the aging changes of lateral facial fat compartments on the same person.

METHODS

Sixty-three patients were included in this retrospective study. All patients had magnetic resonance imaging scans with at least 4 years apart. The authors targeted the fat compartments of the superficial temporal, subcutaneous temporal, and buccal fat pad, comparing the data on different time points.

RESULTS

The thickness of the subcutaneous temporal fat did not change significantly. The 3 diameters of the superficial temporal fat compartment all became thinner on the axial view (P < 0.05). On the sagittal view, the superficial temporal fat elongated from 38.89 mm to 43.74 mm (P < 0.05). The buccal fat compartment also lengthened from 68.73 mm to 74.39 mm (P < 0.05) and had a positive correlation with follow-up duration only.

CONCLUSIONS

The study revealed the fat compartment change on the same person with time. The temporal hollow mainly originates from the thinner part of the superficial temporal fat. The descending of the buccal fat pad aggravates the labiomandibular fold. By understanding the aging process more fully, we can rejuvenate our patients more naturally.

Considerations for the Use of Minimally Invasive Aesthetic Procedures for Facial Remodeling in Transgender Individuals

There is increasing demand among transgender individuals for minimally invasive aesthetic procedures, such as injectable facial fillers and neurotoxins, for facial remodeling and transformation. These procedures may increase transgender individuals’ satisfaction with their appearance and allow them to more effectively harmonize their physical appearance with their perception of self. There is currently a lack of information in the medical literature regarding guidelines for the use of these products in transgender patients. In this report, the authors provide experience-based treatment considerations and recommendations for use of minimally invasive facial aesthetic procedures in transgender patients, including case studies illustrating the use of these procedures for both male-to-female and female-to-male transitioning patients. This report highlights the success of minimally invasive methods for assisting transgender patients in achieving their facial remodeling goals. Clinicians play an integral role in the transitioning process for transgender patients, and facial transformation is a key element of this process. When conducted with sensitivity and attention to individual patient goals at varying stages of transition, facial procedures can be of great benefit in enhancing patients’ self-perception and overall quality of life.

Thread lifting of the midface: A pilot study for quantitative evaluation

Volume restoration remains the principal target to be addressed when approaching midface rejuvenation, and absorbable sutures can create a suspension system that addresses ptotic skin located primarily in the midface. The aim of this pilot study was to investigate the effectiveness in lifting sagging tissue and to determine the outcome of thread lifting procedures of the midface. Six participants were enrolled and treated with suspension threads to correct mild to moderate ptosis of the flabby tissues of the midface. Volumetric changes were calculated at t0 (pretreatment), t1(120 days) and t2 (365 days), with a mean follow-up time of 349.64 days, (range from 304 to 380.5 days). Results showed an overall average improvement of 5.59 mL at 120 days (t0-t1) after thread implantation, up to a mean value of 4.16 mL at the end of the 350 days follow up (t0-t2). A comparison was made in between and statistical analysis was performed with level of significance set at P < .05. The records shown suggest that it is possible to achieve volume restoration which lasts up to 12 months as all parameters improved significantly (P < .05) at t1 and at t2 with respect to t0. Facial tissues suspension by means of threads is therefore safe and effective, as it is possible to achieve tissue repositioning which lasts up to 12 months for the correction of mild to moderate ptosis of the midface.

Aging Changes of the Superficial Fat Compartments of the Midface Over Time: A Magnetic Resonance Imaging Study

BACKGROUND

Studies involving superficial facial fat compartments are few in number with conflicting results. Most of them involved small study groups and compared measurements between different populations of young and old subjects either on cadavers or living subjects.

OBJECTIVE

To clarify volumetric and dimensional changes in midfacial superficial fat compartment retrospectively in patients who underwent a repeat magnetic resonance imaging (MRI) without gross pathology.

MATERIALS AND METHODS

A total of 70 patients with a mean age of 60 years (range: 33-82 years) and a median elapsed time of 44.5 months (range: 32-64 months) between 2 MRIs were included. Magnetic resonance imaging scans were analyzed in the axial and sagittal planes to obtain measurements of the medial part of the superficial cheek fat. Superficial cheek fat was divided into 3 compartments. Thickness, width, and height were measured, and volumes were calculated for each compartment on both hemifaces.

RESULTS

Volume and thickness were decreased significantly in all compartments (p < .05). The width was decreased in superior and middle compartments, whereas increased in lower compartment indicating dislocation of the fat tissue (p < .05). Height was also significantly increased (p < .05). A subgroup analysis has shown that there was no significant difference between men and women.

CONCLUSION

This study clarifies that aging is associated with a significant decrease in superficial midfacial fat tissue volume and thickness both in women and men. The decrease in width in upper and middle compartments, but increase in lower compartment suggests a volume shift within superficial fat tissue.

Three-Dimensional Photogrammetric Study on Age-Related Facial Characteristics in Korean Females

Background

Understanding the age-related morphological changes of facial soft tissue is fundamental in achieving improved outcomes of rejuvenating procedures. Three-dimensional (3D) photogrammetry is a reliable and convenient anthropometric tool to assess facial soft tissue.

Objective

The aim of this study was to establish age-related facial soft tissue morphology in Korean adult females using non-invasive 3D photogrammetry.

Methods

One hundred and ninety-two female participants were divided into three groups based on age: the younger group (aged 20~39 years), middle group (40~59 years), and older group (60~79 years). Thirty-six landmarks were identified via 3D photogrammetric scanning (Morpheus 3D, Morpheus Co., Ltd., Seongnam, Korea). Forty-one facial dimensions were analyzed using the imaging software to find significance between the age groups.

Results

Smaller upper-facial volume (p=0.019) and shorter upper-facial height (p=0.034) were observed in the older group than in the younger group. In the mid-face, narrowed palpebral fissure (p<0.001) with elongated upper eyelid height (p<0.001) and widened nose (p<0.001) were observed in the older group compared with the younger group. Longer lower-facial height (p<0.001) with longer and wider philtrum (p<0.001, p=0.004, respectively), shorter lower vermilion height (p<0.001), wider mouth width (p<0.001), and smaller lower vermilion angle (p<0.001) were seen in the older group when compared with the younger group. Moreover, greater angles of nasofrontal, nasomental, and labiomental angle (p=0.015, p=0.015, p=0.080, respectively), and smaller nasofacial angle (p=0.034) were observed in the older group than in the younger group.

Conclusion

Our results provide clues of aging-related facial morphological characteristics in Korean female population.

Application of intraoral scanner to identify monozygotic twins

BACKGROUND

DNA base identification is a proper and high specificity method. However, identification could be challenged in a situation where there is no database or the DNA sequence is almost identical, as in the case of monozygotic (MZ) twins. The aim of this study was to introduce a novel forensic method for distinguishing between almost identical MZ twins by means of an intraoral scanner using the 3D digital pattern of the human palate.

METHODS

The palatal area of 64 MZ twins and 33 same-sex dizygotic (DZ) twins (DZSS) and seven opposite-sex dizygotic twins (DZOS) were scanned three times with an intraoral scanner. From the scanned data, an STL file was created and exported into the GOM Inspect® inspection software. All scans within a twin pair were superimposed on each other. The average deviation between scans of the same subject (intra-subject deviation, ISD) and between scans of the two siblings within a twin pair (intra-twin deviation, ITD) was measured. One-sided tolerance interval covering 99% of the population with 99% confidence was calculated for the ISD (upper limit) and the ITD (lower limit).

RESULTS

The mean ISD of the palatal scan was 35.3 μm ± 0.78 μm. The calculated upper tolerance limit was 95 μm. The mean ITD of MZ twins (406 μm ± 15 μm) was significantly (p < 0.001) higher than the ISD, and it was significantly lower than the ITD of DZSS twins (594 μm ± 53 μm, p < 0.01) and the ITD of DZOS twins (853 μm ± 202 μm, p < 0.05).

CONCLUSION

The reproducibility of palatal intraoral scans proved to be excellent. The morphology of the palate shows differences between members of MZ twins despite their almost identical DNA, indicating that this method could be useful in forensic odontology.

Correction of temporal wasting using calcium hydroxylapatite with integral lidocaine: An underused procedure for enhancing overall facial appearance

BACKGROUND

Hollowing of the temple area is an early sign of aging that is often overlooked, but when corrected, can lead to significant subject and physician satisfaction.

AIMS

To assess physician and subject awareness of the impact of temporal hollowing on appearance and to evaluate treatment satisfaction following injection of calcium hydroxylapatite with integral lidocaine (CaHA(+)).

PATIENTS/METHODS

Subjects with temporal depression grade ≥2 on a validated Temple Hollowing Scale were recruited. CaHA(+) was injected supraperiosteally using a bolus technique. Photographs were taken prior to treatment and 30 days, and graded by three evaluating physicians using the Global Aesthetic Improvement Scale (GAIS) and Temple Hollowing Scale. The same physicians estimated subjects' age before and after treatment. Photographs were graded by patients as part of a satisfaction questionnaire.

RESULTS

The study enrolled 10 subjects aged 32-68 years old. Physician GAIS scores of subject appearance at 1 month were rated as "very much improved" in 80% and "much improved" in 20% of subjects. Temple hollows were graded as 1 after treatment in 90% of subjects. Following blinded review of patients' true ages, estimates for subjects' perceived age were on average 4 years younger than their actual age. Most subjects had not been aware of temple hollowing prior to treatment, but nine out of 10 were very to extremely satisfied with results, and all were willing to repeat treatment. No treatment complications were observed.

CONCLUSION

Treatment of the temple area can have a dramatic aesthetic effect and should not be neglected when addressing facial rejuvenation. CaHA(+) is an effective and well-tolerated product for use in the temple area and is associated with a high degree of subject and physician satisfaction.

Three-Dimensional Analysis of Age-Related Orbital and Midfacial Bone Remodeling in Asians

BACKGROUND

Facial bony changes vary among races, yet few studies have been conducted in Asians.

OBJECTIVE

To analyze the aging of orbital and midfacial bones in Asians.

METHODS

Based on the two-dimensional data obtained from the computed tomography scanner of imaging department, 3D reconstructions were conducted to take measurements (orbital diagonal diameter, orbital width, orbital area, maxillary angle, midfacial height, pyriform angle, pyriform width, and pyriform area).

RESULTS

In this retrospective study of 261 subjects, a significant decrease in the orbital diagonal diameter, orbital width, and midfacial height was found in men, whereas women displayed a significant increase in the pyriform width and a significant decrease in maxillary angle and midfacial height by three-dimensional analysis.

CONCLUSION

This study verifies the minor female changes in the orbital region and less dramatic male changes in the midfacial region compared with that in Caucasians. Individualized treatment should be performed according to different genders and races. Further exploration of facial bone metabolism may have valuable implications for Asians.

Analysis of age-related changes in midfacial fat compartments in Asian women using computed tomography

BACKGROUND

Volume restoration is no more a fresh theory for midfacial rejuvenation. However, lack of knowledge regarding the natural ageing process of fat compartments often leads to an insufficient or excessive clinical result. The aim of this study is to reveal the age-related changes in midfacial fat compartments and the correlation between midfacial grooves and the related fat compartments.

METHODS

This study included 60 Asian females in defined age-based categories. The thickness of the infraorbital fat compartment, the nasolabial fat compartment, and the cheek fat compartments were measured using computed tomography (CT) images. Analysis of correlations between midfacial grooves and the related fat compartments was performed using the SPSS software.

RESULTS

A tendency of thickening in the infraorbital fat and nasolabial fat compartments with age was observed. The superficial layer of cheek fat compartments was found to be thinner, and a similar tendency was observed in the medial part of deep medial cheek fat. However, it was thicker in the lateral part of deep medial cheek fat. There was a negative correlation between the fat thickness of deep medial cheek fat and both the severity of tear trough deformity and the nasolabial fold. A positive correlation between the lower third of the nasolabial fat compartment and the severity of the nasolabial fold was found as well.

CONCLUSION

Different midfacial fat compartments tended to undergo selective hypertrophy or atrophy with ageing. The findings of this study suggested that augmentation of the deflated fat compartment and liposuction of the hypertrophic fat compartment can provide a more natural effect in facial rejuvenation.

Facial aging trajectories: A common shape pattern in male and female faces is disrupted after menopause

Objectives

Despite variation in lifestyle and environment, first signs of human facial aging show between the ages of 20–30 years. It is a cumulative process of changes in the skin, soft tissue, and skeleton of the face. As quantifications of facial aging in living humans are still scarce, we set out to study age‐related changes in three‐dimensional facial shape using geometric morphometrics.

Materials and methods

We collected surface scans of 88 human faces (aged 26–90 years) from the coastal town Split (Croatia) and neighboring islands. Based on a geometric morphometric analysis of 585 measurement points (landmarks and semilandmarks), we modeled sex‐specific trajectories of average facial aging.

Results

Age‐related facial shape change was similar in both sexes until around age 50, at which time the female aging trajectory turned sharply. The overall magnitude of facial shape change (aging rate) was higher in women than men, especially in early postmenopause. Aging was generally associated with a flatter face, sagged soft tissue (“broken” jawline), deeper nasolabial folds, smaller visible areas of the eyes, thinner lips, and longer nose and ears. In postmenopausal women, facial aging was best predicted by the years since last menstruation and mainly attributable to bone resorption in the mandible.

Discussion

With high spatial and temporal resolution, we were able to extract a shared facial aging pattern in women and men, and its divergence after menopause. This fully quantitative three‐dimensional analysis of human facial aging may not only find applications in forensic and ancient human facial reconstructions, but shall include lifestyle and endocrinological measures, and also reach out to studies of social perception.

Patterns of Superficial Midfacial Fat Volume Distribution Differ by Age and Body Mass Index

BACKGROUND

The changes that occur to midfacial fat with increasing age and BMI are poorly understood. The aim of this study was to determine how superficial cheek fat volume and distribution are differentially predicted by changes in BMI versus age.

METHODS

We conducted a retrospective observational study of patients with facial computed tomography scans. Superficial cheek fat volumes were measured, and multiple linear regression analysis was performed to model the relationships between cheek fat and corresponding sex, age, and BMI data.

RESULTS

A total of 109 patients were included in our analysis (51 male, 58 female). The subjects' ages ranged from 21.7 to 91.1 years with a mean (SD) age of 59.7 (15.0) years. The mean (SD) superficial cheek volume of the subjects was 10.46 (2.57) cc. Female subjects had a significantly greater mean total superficial cheek fat volume compared to male subjects (11.18 cc vs. 9.64 cc; P < 0.001). The results of multiple linear regression analysis indicated that together, age, sex, and BMI explained 50.8% of the variance in cheek fat volumes (R² = 0.51, P < 0.001). BMI significantly predicted total cheek fat volume (β = 0.239, P < 0.001), in addition to age (β = 0.029, P < 0.017) and sex (β = - 1.183, P = 0.001; female = 0, male = 1). Age predicted the greatest gain of fat in the caudal subdivision of cheek (β = 0.015, P < 0.001), whereas BMI predicted the greatest gain in the cephalad subdivision (β = 0.106, P < 0.001).

CONCLUSIONS

Age, sex, and BMI are important predictors of midfacial fat volume. This study shows that increases in age and BMI differentially predict the distribution of superficial cheek fat.

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 .

Fat Injection: A Systematic Review of Injection Volumes by Facial Subunit

BACKGROUND

Fat grafting to the aging face has become an integral component of esthetic surgery. However, the amount of fat to inject to each area of the face is not standardized and has been based mainly on the surgeon's experience. The purpose of this study was to perform a systematic review of injected fat volume to different facial zones.

METHODS

A systematic review of the literature was performed through a MEDLINE search using keywords "facial," "fat grafting," "lipofilling," "Coleman technique," "autologous fat transfer," and "structural fat grafting." Articles were then sorted by facial subunit and analyzed for: author(s), year of publication, study design, sample size, donor site, fat preparation technique, average and range of volume injected, time to follow-up, percentage of volume retention, and complications. Descriptive statistics were performed.

RESULTS

Nineteen articles involving a total of 510 patients were included. Rhytidectomy was the most common procedure performed concurrently with fat injection. The mean volume of fat injected to the forehead is 6.5 mL (range 4.0-10.0 mL); to the glabellar region 1.4 mL (range 1.0-4.0 mL); to the temple 5.9 mL per side (range 2.0-10.0 mL); to the eyebrow 5.5 mL per side; to the upper eyelid 1.7 mL per side (range 1.5-2.5 mL); to the tear trough 0.65 mL per side (range 0.3-1.0 mL); to the infraorbital area (infraorbital rim to lower lid/cheek junction) 1.4 mL per side (range 0.9-3.0 mL); to the midface 1.4 mL per side (range 1.0-4.0 mL); to the nasolabial fold 2.8 mL per side (range 1.0-7.5 mL); to the mandibular area 11.5 mL per side (range 4.0-27.0 mL); and to the chin 6.7 mL (range 1.0-20.0 mL).

CONCLUSIONS

Data on exactly how much fat to inject to each area of the face in facial fat grafting are currently limited and vary widely based on different methods and anatomical terms used. This review offers the ranges and the averages for the injected volume in each zone.

LEVEL OF EVIDENCE III

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 .

Signs of Facial Aging in Men in a Diverse, Multinational Study: Timing and Preventive Behaviors

BACKGROUND

Men are a growing patient population in aesthetic medicine and are increasingly seeking minimally invasive cosmetic procedures.

OBJECTIVE

To examine differences in the timing of facial aging and in the prevalence of preventive facial aging behaviors in men by race/ethnicity.

METHODS

Men aged 18 to 75 years in the United States, Canada, United Kingdom, and Australia rated their features using photonumeric rating scales for 10 facial aging characteristics. Impact of race/ethnicity (Caucasian, black, Asian, Hispanic) on severity of each feature was assessed. Subjects also reported the frequency of dermatologic facial product use.

RESULTS

The study included 819 men. Glabellar lines, crow's feet lines, and nasolabial folds showed the greatest change with age. Caucasian men reported more severe signs of aging and earlier onset, by 10 to 20 years, compared with Asian, Hispanic, and, particularly, black men. In all racial/ethnic groups, most men did not regularly engage in basic, antiaging preventive behaviors, such as use of sunscreen.

CONCLUSION

Findings from this study conducted in a globally diverse sample may guide clinical discussions with men about the prevention and treatment of signs of facial aging, to help men of all races/ethnicities achieve their desired aesthetic outcomes.

Patterns of Change in Facial Skeletal Aging

Importance

Research in facial aging has focused on soft-tissue changes rather than bony changes despite evidence of the importance of underlying bony structural changes. Research has also been limited by comparing different patients in separate age groups rather than the same patients over time.

Objective

To longitudinally document patterns of change in the facial skeleton and determine a consistent methodology for measuring these changes.

Design, Setting, and Participants

Case series study of university hospital system records using facial computed tomographic (CT) images timed at least 8 years apart in adults initially aged 40 to 55 years with no history of facial surgery who required repeated facial imaging that included the entire midface and cranium.

Main Outcomes and Measures

Face CTs were analyzed for 3-dimensional constructions and 2-dimensional measurements to document changes in glabellar, piriform, and maxillary angles and piriform height and width.

Results

Fourteen patients (5 men, 9 women; mean [SD] age, 51.1 [5.8] years) with mean (SD) follow-up of 9.7 (1.4) years were eligible for 2-dimensional analysis, which revealed statistically significant decreases in mean (SD) glabellar angles (from 68.8° [7.6°] to 66.5° [8.6°]) and maxillary angles on both the right (from 82.5° [6.3°] to 81.0° [7.1°]) and left (from 83.0° [5.8°] to 81.0° [7.0°]), as well as increases in mean (SD) piriform width (from 24.5 [1.6] mm to 25.5 [1.3] mm). Nine patients (3 men, 6 women; mean [SD] age, 51.4 [6.3] years) with mean (SD) follow-up imaging at 9.6 (1.5) years were eligible for 3-dimensional analysis, which revealed statistically significant decreases in mean (SD) maxillary angles (from 56.5° [6.6°] to 51.6° [7.6°]) and piriform angles (from 50.8° [3.4°] to 49.1° [3.4°]). Statistically significant differences between the sexes were also noted: Initial mean (SD) glabellar angle for men was 61.7° (5.7°) vs 72.7° (5.4°) for women, with final values of 57.9° (4.9°) vs 71.2° (6.0°). Mean (SD) maxillary angle initial values were 87.8° (6.1°) (right) and 87.1° (4.9°) (left) for men, with 79.6° (4.3°) and 80.6° (5.0°) for women, respectively. Final values were 87.0° (4.4°) and 86.9° (4.1°) for men and 77.7° (6.1°) and 77.7° (6.2°) for women, respectively. Mean (SD) piriform height for men was 35.0 (2.0) mm initially and 35.5 (2.1) mm finally, vs 31.3 (2.8) and 31.6 (3.0) mm for women, respectively.

Conclusions and Relevance

Our pilot study of repeated CT images of patients over several years supports previous studies of bony facial aging and further characterizes these changes. This study is the first, to our knowledge, to document bony changes of the face in the same group of patients at different time points to better characterize facial aging. We also detail an improved methodology to study bony aging to contribute to additional research in the field.

Level of Evidence

NA.

[The third dimension of the face aging, improvement of its understanding]

OBJECTIVES

Over the past 30 years, surface imaging has made tremendous progress. Surgical management has also been subject of numerous technical and strategic developments. For a better understanding of the curative strategies of face aging, the authors have put into perspective the three-dimensional data acquired up to date.

METHOD

A review of the literature focused on the three-dimensional study of facial aging was carried out.

RESULTS

Thanks to the precision of new surface acquisition systems and larger patient cohorts, our understanding of surfaces and volumes is now much more accurate. 3D, particularly highlights the major impact of aging on the perioral area, which was up to now neglected compared to other facial areas.

CONCLUSION

A technical discussion is needed to identify the best techniques to correct the defects and provide a natural result for those anatomical areas that are heavily impacted by aging but not corrected in the final.

Aging in the Male Face: Intrinsic and Extrinsic Factors

BACKGROUND

Gender is one of the most significant factors that influence facial anatomy and behavior, both key factors in the aging process.

OBJECTIVE

To review male facial anatomy, physiology, and behavior and how it contributes to sexual dimorphism in facial aging.

METHODS

A MEDLINE search was performed for publications on gender differences in facial anatomy, aging, cutaneous physiology, and behavior.

RESULTS

There are differences in both intrinsic and extrinsic aging factors in men. Men have a thicker epidermis and dermis with more active cutaneous appendages including hair growth. Male skin has a reduced antioxidant capacity and increased ultraviolet-induced immunosuppression. The male face is larger and has a unique square shape with less subcutaneous soft tissue, especially at the medial cheek. Men are also more prone to smoking and exhibiting poor sun-protective behavior. The differences in intrinsic and extrinsic aging factors contribute to poor facial aging in men. Men develop more severe rhytides in a unique pattern, show increased periocular aging changes, and are more prone to hair loss.

CONCLUSION

This review provides insight into the factors contributing to accelerated male facial aging. Understanding gender differences in aging will help physicians tailor cosmetic treatments for men and minimize extrinsic aging factors.

Literature Review of Cosmetic Procedures in Men: Approaches and Techniques are Gender Specific

The proportion of men receiving non-surgical cosmetic procedures has risen substantially in recent years. Various physiologic, anatomic, and motivational considerations differentiate the treatments for male and female patients. Nevertheless, research regarding approaches to the male cosmetic patient is scarce. We sought to provide an overview and sex-specific discussion of the most popular cosmetic dermatologic procedures pursued by men by conducting a comprehensive literature review pertaining to non-surgical cosmetic procedures in male patients. The most common and rapidly expanding non-surgical interventions in men include botulinum toxin, filler injection, chemical peels, microdermabrasion, laser resurfacing, laser hair removal, hair transplantation, and minimally invasive techniques for adipose tissue reduction. Important sex-specific factors associated with each of these procedures should be considered to best serve the male cosmetic patient.

A Preliminary Assessment of the Predictability of Fat Grafting to Correct Silicone Breast Implant-Related Complications

BACKGROUND

Fat grafting in breast augmentation surgery is becoming increasingly popular and is allowing surgeons to fill the gaps that implant augmentation alone cannot. However, one current issue surrounding fat grafting is resorption.

OBJECTIVES

In this prospective study, the authors present their experience of fat grafting and resorption in 26 patients who had fat transfer to correct deformities or asymmetries following primary breast enlargement surgery.

METHODS

The fat utilized was harvested and processed using the Puregraft system. Fat grafting was performed until the problem was visually corrected, followed by an additional 30% overcorrection. Photographs were taken preoperatively and 1 year postoperatively, and analyzed utilizing cloud-based 3-dimensional imaging software to measure the breast volumes and calculate 1-year resorption rates. Both patients and physicians were asked to rate their satisfaction.

RESULTS

The total volume of fat transferred ranged from 160 cc to 360 cc, with an average of 280 cc per procedure. The absolute volume of tissue resorption showed considerable variation (median, 42.6 mL; range, 5.5-62 mL). However, there was a very close correlation between the volume resorbed and the volume implanted: the more volume injected, the more volume absorbed. When expressed as a percentage of implanted tissue, the resorption rate was 27.5 ± 0.8% (mean ± standard deviation) with a very narrow range (25.7%-28.9%). Patients and physicians reported a satisfaction rate of "excellent" in 83.3% and 75% of cases, respectively.

CONCLUSIONS

At 1 year, 25.7% to 28.9% of the injected fat had been resorbed in a predictable, reproducible, and effective manner.

LEVEL OF EVIDENCE

4 Therapeutic.

Consensus Recommendations for Optimal Augmentation of the Asian Face with Hyaluronic Acid and Calcium Hydroxylapatite Fillers

BACKGROUND

Although the use of filling agents for soft-tissue augmentation has increased worldwide, most consensus statements do not distinguish between ethnic populations. There are, however, significant differences between Caucasian and Asian faces, reflecting not only cultural disparities, but also distinctive treatment goals. Unlike aesthetic patients in the West, who usually seek to improve the signs of aging, Asian patients are younger and request a broader range of indications.

METHODS

Members of the Asia-Pacific Consensus group-comprising specialists from the fields of dermatology, plastic surgery, anatomy, and clinical epidemiology-convened to develop consensus recommendations for Asians based on their own experience using cohesive polydensified matrix, hyaluronic acid, and calcium hydroxylapatite fillers.

RESULTS

The Asian face demonstrates differences in facial structure and cosmetic ideals. Improving the forward projection of the "T zone" (i.e., forehead, nose, cheeks, and chin) forms the basis of a safe and effective panfacial approach to the Asian face. Successful augmentation may be achieved with both (1) high- and low-viscosity cohesive polydensified matrix/hyaluronic acid and (2) calcium hydroxylapatite for most indications, although some constraints apply.

CONCLUSION

The Asia-Pacific Consensus recommendations are the first developed specifically for the use of fillers in Asian populations.

CLINCIAL QUESTION/LEVEL OF EVIDENCE

Therapeutic, V.

Evaluation of Facial Volume Changes after Rejuvenation Surgery Using a 3-Dimensional Camera

BACKGROUND

Surgical rejuvenation alters facial volume distribution to achieve more youthful aesthetic contours. These changes are routinely compared subjectively. The introduction of 3-dimensional (3D) stereophotogrammetry provides a novel method for measuring and comparing surgical results.

OBJECTIVES

We sought to quantify how specific facial areas are changed after rejuvenation surgery using the 3D camera.

METHODS

Patients undergoing facial rejuvenation were imaged preoperatively and postoperatively with 3D stereophotogrammetry. Images were registered using facial surface landmarks unaltered by surgery. Colorimetric 3D analysis depicting postoperative volume changes was performed utilizing the 3D imaging software and quantitative volume measurements were constructed.

RESULTS

Nine patients who underwent combined facelift procedures and fat grafting were evaluated. Median time for postoperative imaging was 4.8 months. Positive changes in facial volume occurred in the forehead, temples, and cheeks (median changes, 0.9 mL ± 4.3 SD; 0.8 mL ± 0.47 SD; and 1.4 mL ± 1.6 SD, respectively). Negative changes in volume occurred in the nasolabial folds, marionette basins, and neck/submental regions (median changes, -1.0 mL ± 0.37 SD; -0.4 mL ± 0.9 SD; and -2.0 mL ± 4.3 SD, respectively).

CONCLUSIONS

The technique of 3D stereophotogrammetry provides a tool for quantifying facial volume distribution after rejuvenation procedures. Areas of consistent volume increase include the forehead, temples, and cheeks; areas of negative volume change occur in the nasolabial folds, marionette basins, and submental/chin regions. This technology may be utilized to better understand the dynamic changes that occur with facial rejuvenation and quantify longevity of various rejuvenation techniques.

LEVEL OF EVIDENCE

4 Diagnostic.

Complete biodegradable nature of calcium hydroxylapatite after injection for malar enhancement: an MRI study

Background

Radiesse^® (Calcium hydroxylapatite [CaHA]) is a biocompatible, injectable gel for facial soft tissue augmentation. It is a completely biodegradable filler and this is well documented, but objective imaging methods to confirm this property are scarce.

Methods

We present a case report in which CaHA was injected into the midface of a 50-year-old woman for volume restoration and shaping of the cheek region. On the right side of the face, 1.6 mL CaHA was injected as several (5−7) small depots (0.1−0.2 mL) using a 28G 3/4 inch needle and the vertical supraperiosteal depot technique. On the contralateral side of the face, the subject received 1.6 mL CaHA over three entry points using a 27G 1 1/2 inch blunt cannula and the fanning technique. CaHA location and degradation were assessed using magnetic resonance imaging (MRI).

Results

CaHA appears as low-to-intermediate signal intensity on MRI images taken immediately after injection for malar enhancement with a symmetrical distribution. On MRI images taken 2.5 years after injection, no CaHA was visible but tissue volume remained increased, indicating a collagen-stimulating effect. The treatment was well tolerated.

Conclusion

In addition to producing long-lasting aesthetic and collagen-stimulating effects, MRI images confirm that CaHA is completely biodegradable with no product remaining 2.5 years after injection.

Three-dimensional analyses of aging-induced alterations in facial shape: a longitudinal study of 171 Japanese males

We sought to generate data to facilitate forensic facial comparisons. Specifically, we conducted a longitudinal study of alterations in face shape induced by aging. We obtained two three-dimensional facial shape measurements in 171 Japanese males at intervals of approximately 10 years. With this data, we created a homologous model consisting of 10,741 data points for each face based on 33 anatomical landmarks. We averaged the movements of corresponding data points between the two homologous models for each individual and used this data to predict up to 30 years of face aging in an average Japanese male. We clearly identified aging-induced shape changes, such as drooping and denting of the facial folds, drooping of the upper lip, and projection of the lower eyelid, in the virtually aged model. A quantitative comparison of aging-induced shape alterations among three age groups (individuals in their 20's, 30's, and 40-50's) showed that these alterations accelerated more quickly as age increased. Using our predictive model, we conducted a preliminary study focused on facial shape alterations induced by reductions in body weight. Our findings indicated that our proposed method would also be valid for this purpose.

Stimulated skin wrinkling as an indicator of limb sympathetic function

Skin wrinkling upon water immersion has been used as an indicator of limb nerve function for more than 80years. Until recently, routine use of the test has been hampered by a poor understanding of the physiology and lack of standardization. The process underlying stimulated skin wrinkling has been recently identified as dependent on digital vasoconstriction mediated via sympathetic nerve fibers. Vasoconstriction is postulated to drive wrinkling through loss of digit volume, which induces a negative pressure in the digit pulp and exerts a downward pull on the overlying skin and ultimately results in wrinkles. Improved test standardization has been achieved through substituting water with EMLA for inducing skin wrinkling. This has made testing much easier and has helped implement stimulated skin wrinkling as a practical routine clinical bedside test. A literature search identified 10 studies of sufficient quality for evaluating stimulated skin wrinkling as a diagnostic test of sympathetic under or over function. Seven studies provide level 1 or 2 evidence as a diagnostic test of small fiber neuropathy and three provide level 1 or 2 evidence for cystic fibrosis. There is reasonable evidence allowing the test to be employed as a simple and effective marker for small fiber neuropathy and cystic fibrosis.

Long-term volumetric retention of autologous fat grafting processed with closed-membrane filtration

BACKGROUND

Some practitioners have criticized the unpredictable retention associated with autologous fat transfer. Potential causes of variations in predictability include intrinsic (patient-related) or extrinsic factors, such as harvesting, processing, and graft-delivery technique.

OBJECTIVES

The authors sought to determine the long-term retention of autologous fat graft processed with a closed-membrane filtration system, to compare this retention with centrifuge-processed fat, and to analyze factors that affect graft retention.

METHODS

This was a prospective analysis of 26 female patients (representing 52 hemi-midfaces) who underwent autologous fat transfer to the midface via the closed-membrane filtration system. The Vectra 3D camera and software were employed for all photography, which was then analyzed to compare immediate preoperative images with long-term follow-up images (obtained at least 10 months postprocedure). The authors compared the findings with data from their previous study of centrifuge-processed fat grafts (historical controls).

RESULTS

Mean values were as follows: age, 55 years; follow-up period, 17 months; amount of autologous fat injected, 8.88 mL; absolute volume augmentation measured at the last postoperative visit, 3.71 mL; and retention, 41.2%. Results of Welch's t test, in which the membrane-filtration data were compared with the previous centrifuge data (31.8% long-term retention), showed a significant difference (P=.03). Retention in this study was significantly higher in patients younger than 55 years (53.0% vs 31% for older patients; P=.001) and lower in patients who underwent rhytidectomy (23.8% vs 47.6% for nonrhytidectomy patients; P<.001).

CONCLUSIONS

Autologous fat processed by closed-membrane filtration had a significantly higher long-term retention rate than did centrifuged-processed fat injected by the same surgeons.

LEVEL OF EVIDENCE

3.