Management of the Heavy Neck in the Ethnic Patient.

To study the hard and soft tissue volume after placing immediate (IMI) or delayed implants (DLI) with a triangular coronal macro-design (Test/T) or a conventional cylindrical design (Control/C). T/C implants were inserted in healed ridges or in fresh extraction sockets of eight beagle dogs. Biopsies were processed for Micro-CT analysis and dental stone casts were optically scanned to obtain STL files revealing the soft tissue contours at 12weeks. Image analysis software was utilized to match common landmarks superimposing the two sets of data. Three distinct volumes were calculated; buccal bone volume (B-BV), soft tissue volume below the implant shoulder (EC-STV), and the soft tissue volume above the implant shoulder (SC-STV). Using linear measurements, the soft tissue height (STH), the mucosal thickness (MT-IS), and the distance from the implant shoulder to the bone crest (I-BC) were assessed in the digital images and in conventional histology to assess the concordance, reproducibility, and reliability. There were no significant differences between test and control implants regarding the buccal bone volume, although test implants had greater B-BV in all locations except for PM2. The soft tissue volume was similar at T/C implants. The surgical approach influenced the distribution of the total tissue volume. In the IMI, a low position of the bone crest was correlated with low values of B-BV, SC-STV, MT-IS, and STH. Linear measurements showed a high correlation between the histology and digital measurements and high inter and intra examiner agreement. The superimposition of Micro-CT/STL allowed the analysis of soft and hard tissue volumes. Reduction of the implant buccal aspect resulted in nonsignificant higher bone volume although similar soft tissue volume while the surgical approach influenced soft tissue response.

Cumulative long-term exposure to solar ultraviolet radiation promotes premature skin aging characterized by wrinkle formation and reduced skin elasticity. In this study, we assessed whether microfat transfer could improve dermal and subcutaneous tissue thickness loss associated with photoaging. Twenty-one patients affected by facial photoaging (photodamage grade II-IV; age range 35-62 years; 19 females, 2 males; all of Caucasian origin) were treated using minimally invasive autologous dermal white fat transfer harvested with a recently designed microcannula. The results were determined by clinical assessment and patient self-evaluation and quantified by the Antera 3D® dermal digital device for noninvasive, objective, reliable, and accurate assessment of facial skin texture, color, and wrinkle characteristics. Compared with the pretreatment condition, the increment in soft tissue volume and improvement in skin quality and texture were assessed by a dermatologist after treatment. In addition, instrumental evaluation by digital skin profilometry of the treated areas revealed a 41% reduction in average wrinkle depth (7.29±1.04×10-2mm pretreatment vs. 4.31±1.16×10-2mm at 90 days posttreatment; p<0.001), improved skin texture, more homogeneous and uniform skin color, and declined facial hemoglobin and melanin concentrations. The majority of patients (above 90%) reported improvements in self-perception. No significant complications were reported throughout the study. In conclusion, by using digital profilometry analysis as an objective and innovative tool to determine the outcome of treatment, we demonstrated that autologous microfat transfer is a safe and well-tolerated procedure with measurable beneficial effects on facial skin aging.

Nonexcisional, Minimally Invasive Rejuvenation of the Neck

Research Type: Level 3 - Retrospective cohort study, Case-control study, Meta-analysis of Level 3 studies Introduction/ Purpose: Post-operative swelling (POS) is a significant concern in forefoot surgery, potentially contributing to complications such as persistent pain, stiffness, or wound breakdown. Accurate assessment of swelling could improve post-operative monitoring and guide rehabilitation. Traditional volumetric methods, such as water displacement or optoelectronic techniques, require additional equipment and can be impractical in routine clinical settings. Cone-beam weightbearing CT (WBCT) is increasingly used for pre- and post-operative radiographic evaluation, offering a potential opportunistic approach for swelling assessment without added technical burden. However, its role in quantifying soft tissue changes post-surgery remains unexplored. This study aimed to evaluate post-operative edema using WBCT in patients undergoing forefoot surgery. We hypothesized that swelling would increase from pre-op to 1 month post-op, followed by a decrease at 3 months. Methods: This IRB-approved, retrospective, single-center, paired comparative study included 29 feet with available WBCT imaging pre-operatively, at 1 month, and at 3 months post-operatively. Surgery consisted of a mini-open Chevron osteotomy, with 17.2% undergoing additional lesser toe realignment via percutaneous osteotomy and 58.6% undergoing distal metatarsal metaphyseal osteotomies (DMMO) of the 2nd-4th metatarsals. CubeVue software (CurveBeamAI, Hatfield, PA, USA) was used for standard Hallux Valgus (HV) measurements, including first metatarsophalangeal (MPA), sesamoid rotation (SRA), and intermetatarsal (IMA) angles. Slicer 3D (slicer.org) was used to segment bone and soft tissue volumes, with soft tissue (ST) defined by a Hounsfield Unit (HU) threshold of -500 to +500 and bone and soft tissue (BST) by -500 to +3000. Normality was assessed using the Shapiro-Wilk test. Friedman’s test was used for repeated-measures comparisons, with post-hoc pairwise analyses performed using Nemenyi’s test. Significance was set at α=0.05. Results: Mean age was 58.5 ± 14.2 years. Preoperative IMA, HVA, and SRA were 14.52 ± 2.16, 29.1 ± 7.92, and 25 ± 9.98, respectively. Soft tissue (ST) volume increased by 9.25% (95% CI 6.37–12.14) at 1 month, then decreased by - 4.02% (95% CI -6.7 to -1.33) at 3 months (overall change: 4.58%, 95% CI 1.88–7.28, p &lt; 0.001). Volume increase was highest in DMMO cases (12.4% ± 7.6) vs. toe realignment (5.3% ± 2.7) and isolated 1st ray (4.3% ± 6.2, p = 0.02). At 3 months, patients with IMA ≥ 14° had a significantly greater soft tissue volume increase at whilst those &lt; 14° had a volume decrease (3.7 ± 4.75 vs. -1.31 ± 7.98, p = 0.046). Conclusion: WBCT-based soft tissue volume measurements showed a significant 69 cm³ increase at 1 month, followed by an ∼50% decrease at 3 months. Swelling was greater in combined 1st ray + DMMO cases than in isolated 1st ray cases. At 3 months, cases with IMA &gt;14° had more residual swelling than IMA &lt; 14°. These findings align with prior literature. Compared to optical methods, WBCT enables objective swelling assessment without additional devices or radiation exposure when already used for follow-up. This opportunistic use may improve post-operative monitoring in forefoot surgery.

The aging of the face is a multifaceted phenomenon characterized by substantial modifications in different facial structures. Alterations in the skin, including diminished collagen and depletion of subcutaneous fat, coupled with changes in the facial skeleton and soft tissues, collectively contribute to this evolutionary process.1-4 Currently, there is a diverse range of facial rejuvenation techniques accessible to counteract the effects of aging. These popular procedures, encompassing fillers, toxins, thread lifting, lipofilling, and laser treatments, are in high demand.5, 6 Within these minimally invasive interventions, thread lifting emerges as a popular modality for facial rejuvenation. Originally conceived as a facelift technique, thread lifting is now widely recognized as a creative and practical approach to skin rejuvenation by practitioners.7-10 Current research underscores the dependability of thread lifting as a minimally invasive approach, highlighting prompt recovery, elevated patient contentment, and minimal risk of adverse effects.9-14 The aging process is marked by a noticeable reduction in facial volume, which significantly influences the definition of the jawline. This phenomenon results in skin sagging, the formation of jowls, and the emergence of prominent marionette lines. Given the pivotal role of the jawline in facial attractiveness, especially in adults, a holistic approach to facial rejuvenation is imperative. This approach involves a thorough assessment and targeted interventions to address concerns related to the jawline. In cosmetic procedures, a common goal is to address the aging effects, particularly evident in facial features, like marionette lines. Also referred to as melomental folds, these lines are a consequence of facial aging, presenting as downward-curving wrinkles originating from the corners of the mouth. Traditionally, marionette lines were associated with repetitive facial movements and the impact of gravity on less elastic skin tissue. The cosmetic treatment of well-established marionette lines has historically posed challenges. However, there is a noticeable shift away from employing more invasive volumizing thread methods to address these lines, with a preference for less invasive procedures that demonstrate increased efficacy. The utilization of threads has exhibited promise in improving the appearance of marionette lines. The marionette line becomes apparent as the lengthening of the nasolabial fold occurs, typically characterized by a reduction in subcutaneous fat beneath the inner lower aspect of the fold and the accumulation of fat (jowl fat) above the outer upper aspect. This results in a distinct demarcation, facilitated by the mandibular ligament at the lowermost point of the marionette line, which tightens the tissues within the fold, restricting their movement and accentuating the boundary (Figure 1). In such cases, correction of volume asymmetry is often addressed through procedures such as liposuction, transplantation, or filler injections. Specifically, introducing volumizing agents into the vertical direction of the marionette line can mitigate the visibility of the boundary between the two fat layers. The technique involves placing volumizing threads perpendicular to the marionette line, strategically positioned to minimize the visibility of the boundary between the two layers of fat (Figure 2). While conventional multi-threads, composed of numerous monothreads, experience diminished volumizing efficacy due to compression by surrounding tissues upon insertion. Volumizing threads, characterized by multiple monothreads that contribute to reduced pain during procedures and mitigate damage to surrounding blood vessels and tissues, consequently minimizing bruising, swelling, and pain. For the cross technique utilizing volumizing threads, entry points are established inside or outside the marionette line, with specific locations determined by the length of the volumizing threads being used. Inserting the threads across the marionette line along the entry points result in the volumizing thread section within the thick tissue beneath the marionette line providing support, while the upper portion of the thread above the marionette line compresses and pushes the loose skin tissue, creating a lifting effect. This method of inserting volumizing threads vertically along the marionette line promotes collagen growth along the thread direction, tightening the loose skin tissues above the marionette line. Consequently, it reduces the degree to which the skin around the mouth is pressed and folded by facial muscles during expressions. Caution is advised against inserting the threads too deeply, as it may potentially lead to protrusion of the threads into the oral cavity. To employ the cross technique using volumizing threads, an entry point is established inside the marionette line, and its specific location is determined based on the length of the volumizing threads to be used. Inserting the volumizing threads across the marionette line, from bottom to top, through the entry point, the section of the volumizing thread beneath the marionette line enters the thick tissue, providing a supportive base. Simultaneously, the upper part of the volumizing thread exerts pressure on and pushes the loose skin tissue above the marionette line. Placing volumizing threads vertically along the marionette line prompts collagen growth along the thread direction, firming the loose skin tissues above the marionette line. Consequently, when facial muscles move the area around the mouth, the skin around the corner of the mouth is pressed and folded to a lesser extent. When inserting volumizing threads inside the marionette line, care must be taken to avoid injuring the mental artery and nerve emanating from the mental foramen below the corner of the mouth. The mental foramen often lies approximately midway along a vertical line drawn from the corner of the mouth to the mandible's border. In elderly patients with sagging lower facial skin and associated tissues, the prejowl sulcus may accompany the marionette line, causing the area beneath the wrinkle line to appear compressed, resulting in an uneven jawline. The outer region beyond the jaw's tip has a thin subcutaneous fat layer compared to the jaw's tip, and the mandibular ligament along the bone's jawline attaches to the skin, providing a firm pull (Figure 3). Due to this fibrous tissue, if the prejowl sulcus appears significantly compressed, achieving smooth restoration with fillers alone can be challenging. In such cases, combining volumizing threads and fillers can yield more effective results. During the procedure, pre-tunneling between firm fibrous tissues is recommended to create space for the adequate insertion of volumizing threads and fillers, facilitating a smooth advancement of the cannula for their insertion. The cannula entry point is located approximately at the border between the chin and the mandible body, around the visibly depressed area's anterior boundary. Needle puncture is performed at this site, followed by lateral insertion of the cannula, guiding the volumizing thread along the depressor anguli oris and platysma muscles, or the subcutaneous fat layer. After inserting the volumizing thread, any uneven areas are addressed by injecting filler into the dermal or subcutaneous tissue through the same puncture site, ensuring a smoother appearance. By lifting the sagging tissues outside the marionette line and revitalizing the depressed area in front of the wrinkle line, the overall contour around the corner of the mouth improves. For achieving a softer transition between firm and lax tissue boundaries and reducing the folded lines at the border of these tissues, a more supple volumizing thread or monofilament can be employed. When inserting threads parallel to the wrinkle line, placing them slightly inside the wrinkle line can mitigate differences in the skin layer caused by the depressed area. Placing volumizing threads or monofilaments along the wrinkle line encourages collagen growth along the thread direction, firming the skin tissues and reducing symptoms of skin compression and folding in the area in front of the wrinkle line. In elderly patients, sagging of the lower facial skin and connective tissues contributes not only to the marionette line itself but also to the concurrent presence of the prejowl sulcus. This results in the area below the wrinkle line appearing compressed, giving an uneven appearance to the jawline, with the region above the wrinkle line appearing more pronounced. The outer region beyond the jawline tends to have thinner subcutaneous fat layers compared to the chin tip, and the mandibular ligament, running along the bone's jawline, attaches firmly to the skin. This ligament pulls and tightens the skin, creating a firm grip. To address the displaced fat contributing to jowling and achieve a more harmonious result, it is advisable to perform oblique cog thread lifting in conjunction with vertical lifting along the wrinkle line, directing the threads towards the ear region (Figure 4). This simultaneous approach helps target the specific fat deposits responsible for jowling, providing a comprehensive solution for a more aesthetically pleasing outcome. In cases where the prejowl sulcus itself appears significantly compressed due to ligamentous tissues, achieving a more favorable outcome can be facilitated by concurrently employing volumizing threads and fillers in the affected area (Figure 5). During the procedure, it is essential to pre-tunnel the firm ligamentous tissues, creating adequate space for the insertion of volumizing threads and fillers. The cannula entry point is typically situated around the border area between the chin tip and mandible body, where the region appears compressed and receded. Following needle puncture at the front boundary of the compressed area, the cannula is inserted outwardly to place volumizing threads along the depressor anguli oris and platysma m. or the submuscular fat layer. Irregularities post volumizing thread insertion can be addressed by injecting fillers into the dermal or subcutaneous tissue through the same puncture site, promoting a smoother appearance. In essence, it is crucial to recognize that employing diverse threads beyond simple single vectors and threads allows for longer lasting thread lifting (Figure 6). Particularly, the insertion of cross-pattern volumizing threads that traverse both tissues reduces the disparity between sagging tissue with jowling on one side, inducing adhesion and significantly extending the duration. Additionally, for refining the overall contour after repositioning sagging tissues beyond the marionette line and revitalizing the depressed areas in front of the wrinkle line, a softer form of volumizing threads or monofilaments may be utilized. When inserting threads parallel to the wrinkle line, placing them slightly inward compared to the wrinkle line helps improve the difference in skin layers due to the compressed areas. The insertion of volumizing threads or monofilaments along the wrinkle line encourages collagen growth in the thread direction, tightening the skin tissues and reducing symptoms of skin folding in front of the wrinkle line. The utilization of various threads aims to induce synergy among the inserted threads, enhancing overall effectiveness. A 53-year-old female presented with a concern related to the marionette line. Comparative images were captured in both the pre-procedural and 4-month post-procedural stages (Figure 7). The intervention involved the vertical insertion of two lines of 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) along the marionette line wrinkle. This placement strategically stimulated collagen production along the thread direction, leading to the tightening of skin tissues and the amelioration of symptoms associated with skin compression and folding. 0.1 cc of dental lidocaine was injected at the entry site prior to the insertion of the thread. The threads were precisely introduced into the subcutaneous layer, facilitated by an 18G needle following an initial puncture. The thread was inserted into the subcutaneous layer (layer II) while pressing the jowl flat with the palm. Cannula was retracted with rotating the cannula at the end of the insertion. A 55-year-old woman expressed a marionette line-related concern. Comparative photographs were taken before the procedure and 2 months after the procedure (Figure 8). In the anterior cheek area, 21G volumizng polydioxanone threads (LVDR Volume, Sihler, Korea) were introduced, and along the marionette line wrinkle, two sets of 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) were vertically inserted. Before inserting the thread, 0.1 cc of dental lidocaine was administered at the entry site. A puncture was then created with an 18G needle and the thread was placed at the subcutaneous level (layer II). The cannula was retracted by rotating it at the end of the insertion. Evident enhancements were observed in both the volumizing effects of the anterior cheek and the refinement of the marionette line. A 46-year-old female patient, with a history of facelift surgery several years ago, sought thread lifting for correction of the marionette line and prejowl sulcus. For this purpose, 27G volumizng polydioxanone threads (LVDR Volume, Sihler Inc., South Korea and Volume S Secret, Hyundaimeditech Inc., South Korea) were inserted vertically along the marionette line in two lines, and one line each was inserted directly into the prejowl sulcus. Prior to threading, 0.1 cc of dental lidocaine was injected at the entry point. An 18 G needle was used to create a puncture and the thread was then inserted into the subcutaneous layer (layer II). The cannula was retracted by rotating it at the end of the insertion. Improvement in both areas was observed. Post-procedure photos were taken 6 months later. Typically, the reduction of fat occurs on the inner lower side of the wrinkle line, while fat (jowl fat) accumulates on the outer upper side, creating a distinct boundary. Additionally, the presence of the mandibular ligament at the lowest point of the marionette line causes the tissues on the inner side of the wrinkle line to contract, preventing them from moving and resulting in a clear demarcation.15 In such cases, correction is achieved through procedures like liposuction, grafting, or filler injections to address the asymmetry in volume. This involves elevating the cheek area as much as possible, reducing volume, creating elasticity, and augmenting volume on the medial side. Contemporary aesthetic clinics have witnessed a surge in the popularity of knotless thread lifting devices utilizing absorbable threads. Despite its widespread adoption, a notable drawback of this procedure lies in its applicability to only a moderate degree of facial tissue laxity.16-18 The development of marionette lines, influenced by facial anatomy and aging dynamics, manifests as visible sagging around the mouth. These lines, influenced by factors like muscle composition and tissue depth variations, contribute to a downturned appearance reminiscent of a marionette puppet's mouth. Effectively addressing these lines often involves a comprehensive approach, employing minimally invasive procedures like thread lifting and fillers to mitigate sagging and enhance facial aesthetics. Techniques emphasizing specific anatomical considerations and precise thread insertion have demonstrated promise in effectively treating and minimizing these lines, thereby reducing risks and improving outcomes. Favorable anatomical characteristics for absorbable thread lifting include a low body mass index, minimal soft tissue fullness, robust underlying bony structures providing support, and good skin quality. Conversely, individuals with obesity and thicker soft tissues may yield less favorable results, underscoring the importance of meticulous patient selection for optimal outcomes. To combat significant skin sagging, the strategic insertion of 1–3 additional cog threads along the cheek has proven effective. Concurrently, addressing additional marionette lines and lifting the chin involves using 3–5 extra cog threads perpendicular to the chin line, resulting in more favorable outcomes. The thread technique boasts advantages such as avoiding general anesthesia and scarring due to its incision-free nature. It has demonstrated efficacy in treating uneven facial textures, midface slackness, and mild to moderate jowls in specific patient groups. Complications associated with this procedure are infrequent and generally minor, establishing the utilization of threads for aesthetic facial rejuvenation and lifting as a safe method. All authors have reviewed and approved the article for submission. Conceptualization: Kyu-Ho Yi and Soo Yeon Park. Writing—original draft preparation: Kyu-Ho Yi and Soo Yeon Park. Writing—review and editing: Kyu-Ho Yi and Soo Yeon Park. Visualization: Kyu-Ho Yi and Soo-Yeon Park. Supervision: Hong, Kyu-Ho Yi and Soo-Yeon Park. This study was conducted in compliance with the principles set forth in the Declaration of Helsinki. There is no financial disclosure to report. I acknowledge that I have considered the conflict of interest statement included in the "Author Guidelines." I hereby certify that, to the best of my knowledge, that no aspect of my current personal or professional situation might reasonably be expected to significantly affect my views on the subject I am presenting. This study was performed in line with the principles of the Declaration of Helsinki. The data that support the findings of this study are available from the corresponding author upon reasonable request.

Mandibular advancement splints (MAS) are an effective treatment for obstructive sleep apnoea (OSA). However, MAS are not equally efficacious across all patients and the reasons are not well understood. Craniofacial and upper airway structure individually influence MAS response. We aimed to assess anatomical balance, defined as the ratio of upper airway soft tissue (ST) volume to maxillomandibular enclosure volume, between MAS treatment responders and non-responders. OSA patients (apnoea-hypopnea index (AHI) >10h(-1)) were recruited for MAS treatment. Magnetic resonance imaging of the upper airway was performed during wakefulness without and with MAS in situ. Images were processed for volumetric analysis of upper airway soft tissues (tongue, soft palate, paraphayrngeal fat pads and lateral pharyngeal walls) and three-dimensional cephalometry to acquire intra-mandibular space area (IMA) and total maxillomandibular (Mm) volume. Anatomical balance ratios were compared between MAS treatment responders (AHI <10h(-1) + 50% reduction) and non-responders. Image analysis was completed in 69 patients (68% male, age 50.5 ± 10.1years, BMI 29.6 ± 5.0kgm(2), AHI 27.0 ± 14.7h(-1)) including 36 responders. Soft tissue volumes did not differ between MAS responders and non-responders. Non-responders had increased ST/IMA compared to responders (4.9 ± 0.6 vs. 4.6 ± 0.6, p = 0.031). In multivariate logistic regression with AHI and BMI, ST/IMA was the only predictive variable (p = 0.036, ROC AUC 0.7). However, changes in ST/Mm did not directly relate to treatment response. Anatomical imbalance assessed by intra-mandibular space area was associated with poor MAS treatment response. However, changes in anatomical balance with mandibular advancement did not reflect treatment outcome as static imaging may not adequately capture improvements in upper airway function.

Teprotumumab, a novel IGF-1R antibody has been shown to reduce proptosis in patients with thyroid eye disease (TED) in 2 randomized controlled trials. At present, it is unclear whether the reduction in proptosis is related to a decrease in extraocular muscle or orbital fat tissue. In this prospective longitudinal study, we reviewed the changes to orbital fat and muscle, and compared them, in consecutive patients with TED, who had completed treatment with teprotumumab (8 infusions). The primary outcome was change in orbital fat and muscle volume within 6 weeks of starting and completing therapy. Secondary outcome measures included change in proptosis and the clinical activity score (CAS). All patients had either CT or MRI with ≤ 1 mm slice thickness. Three-dimensional volumetric analysis of the orbital fat and muscle volume was performed using the previously validated 3D image analysis software, MIMICS (Materialise, Leuven, Belgium). Hounsfield units of fat and muscle were defined manually. All extraocular muscle tissue and fat between the orbital septum (eyelid) and the orbital outlet of the optic canal was included. A 3D model created by voxel addition was expressed in millimeters cubed. Segmentation and measurements were performed independently by two graders to review repeatability and observer variability. In line with previous clinical trials, the orbit with the most proptosis was defined as the study orbit and the contralateral orbit was designated the fellow orbit. Twenty-one patients (15 females and 6 males) met the inclusion criteria. Mean (SD) age was 55 (16), while mean (SD) duration of TED was 71 (46) months. There was a reduction of 3 mm in both; study and fellow orbits following treatment (p < 0. 01 for both). Compared to baseline, there was a mean (SD) CAS reduction of 4 (1) in the study orbit and 2.4 (1.1) in the fellow orbit (p < 0. 01 for both). Following therapy, mean (SD) reduction in muscle tissue was 1691 mm3 (1358) in the study orbit and 1714 mm3 (1927) in the fellow orbit (p < 0. 01 when compared to baseline for each). The mean (SD) reduction of fat volume was 1382 mm3 (1318) in the study orbit and 933 mm3 (1699) in the fellow orbit (p < 0. 01 when compared to baseline for each). There was no difference between fat and muscle reduction for the study orbit (p = 0.4) or fellow orbit (p = 0.2). There was a significant correlation between a reduction in proptosis and reduction in orbital soft tissue (fat and muscle) volume. The results of this study suggest that following treatment with teprotumumab, there is a significant decrease in orbital fat and muscle volume. This reduction in soft tissue volume likely drives the reduction in proptosis.Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

The purpose of this study was to simulate first aid by mechanical use of a limb tourniquet on a thigh with and without bone to better understand best caregiving practices. Two investigators studied simulated first aid on a new pool "noodle," a plastic cylinder with a central air tunnel into which we inserted a wood dowel to simulate bone. Data were gathered by group (study and control, n = 12 each). The control group comprised data collected from simulated tourniquet use on the model with bone present. The study group comprised data from simulated tourniquet use on the model without bone. Comparing compression with and without bone, the mean volumes of compressed soft tissues alone were 303mL and 306mL, respectively. When bone was present, the volume of soft tissues was squeezed more, yielding a smaller size by 3mL (1%). The bone had a volume of 41mL and pressed statically outward with an equal force oppositely directed to the inward compression of the overlying soft tissues. With bone removed and compression applied, the mean residual void was 16mL, because 25mL (i.e., 41mL minus 16mL) of soft tissues had collapsed inward. The volume of the limb under the tourniquet with and without bone was 344mL and 322mL, respectively. The collapse volume, 25mL, was 3mL more than the difference of the mean volume of the limb under the tourniquet. More limb squeeze (22mL) looked like better compression, but it was actually worse-an illusion created by collapse of the hidden void. In simulated first aid, mechanical modeling demonstrated how tourniquet compression applied to a limb squeezed the soft tissues better when underlying bone was present. Bone loss altered the compression profile and may complicate control of bleeding in care. This knowledge, its depiction, and its demonstration may inform first-aid instructors.

It is generally considered that patients with obstructive sleep apnea syndrome (OSAS) at increased perioperative risk should be placed in nonsupine positions throughout the recovery process; however, not all patients with OSAS show positional dependence. The authors hypothesized that morphological differences exist in three-dimensional (3D) soft tissue and craniofacial structures of the pharyngeal airway between positional and nonpositional OSAS. The subjects of the study were body mass index-matched, age-matched, and apnea hypopnea index-matched positional (n = 10) and nonpositional (n = 10) Japanese OSAS patients and body mass index-matched Japanese control subjects (n = 10). Pharyngeal magnetic resonance imaging and cephalometric radiography were performed during wakefulness. The patients with positional OSAS had a smaller volume of the pharyngeal lateral wall soft tissues, larger maxilla-nasion-mandible angle, and smaller lower facial height than the nonpositional OSAS and the control subjects. The patients with positional OSAS showed a significantly steeper sella-nasion-mandible angle and smaller craniofacial volume than the control subjects. There were no significant differences in tongue volume and 3D pharyngeal anatomical balance between positional and nonpositional OSAS. Multivariate stepwise regression for positional dependence showed that the dominant determinant was the volume of the lateral pharyngeal wall, followed by lower facial height and maxilla-nasion-mandible angle. Patients with positional OSAS have wider airways in the lateral parts, lower facial height, and more backward position of the lower jaw, which may explain differences in the maintenance of pharyngeal airway patency in the lateral sleep position.

PurposeSkin and soft tissue aging has been an important topic of discussion among plastic surgeons and their patients. While botulinum toxin, facial fillers, chemical peels, and surgical lifts preside as the mainstay of treatment to restore appearance of youth, emergent technologies, such as CRISPR-Cas9, proteostasis, flap biology, and stem cell therapies, have gained traction in addressing the aging process of skin and soft tissue. Several studies have introduced these advancements, but it remains unclear how safe and effective these therapeutics are in facial rejuvenation, and how they may fit in the existent treatment workflow for soft tissue aging.Materials/MethodsA systematic literature review was conducted to identify and assess therapeutics utilized in addressing skin and soft tissue aging. Variables collected included year of publication, journal, article title, organization of study, patient sample, treatment modality, associated outcomes. In addition, we performed a market analysis of companies involved in promoting technologies and therapeutics within this space. PitchBook (Seattle, WA), a public market database, was utilized to classify companies, and record the amount of venture capital funding allocated to these categories.ResultsInitial review yielded four hundred and two papers. Of these, thirty-five were extracted after applying inclusion and exclusion criteria. Though previous literature regards CRISPR-Cas9 technology as the most favorable anti-aging innovation, after reviewing the current literature, stem cell therapies utilizing recipient chimerism appeared to be the superior skin anti-aging technique when accounting for possible disadvantages of various techniques. The psychosocial and cosmetic outcomes from using cell therapy to modulate allograft survival and tolerance may confer more long-term proposed benefits than the technologies in CRISPR-Cas9, flap biology innovations, and autologous platelet-rich plasma use. Market analysis yielded a total of 87 companies, which promoted innovations in technology, biotechnology, biopharmaceuticals, cell-based therapies, and genetic therapy.ConclusionThis review provides physicians and patients with relevant, usable information regarding how therapeutics can impact treatment regimen for facial aesthetics and skin rejuvenation. Furthermore, the goal of this research is to elucidate the varying therapeutics to restore appearance of youth, present associated outcomes, and in doing so, present plastic surgeons and their colleagues with greater insight on the role of these therapeutics and technologies in clinical practice. Future studies can further assess the safety and efficacy of these innovations and discuss how these may fit within surgical plans among patients seeking rejuvenation procedures.Level of Evidence IIIThis 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.

The present study evaluated the clinical and radiological stability of hard and soft tissues following alveolar socket preservation (ASP) procedure with a follow-up of 5 year from implant insertion. The initial sample consisted of seven patients who underwent single tooth extraction and ASP procedure by means of demineralized bovine bone mineral particles covered with a porcine-derived non-cross-linked collagen matrix (CM). Each patient received a submerged single implant in the healed site. Mesial and distal peri-implant marginal bone resorption (MBR) rates were assessed radiographically at 1 year (T1) and 5 years (T2) after implant placement (baseline value). No dropouts occurred up to 5 years. At T1, the MBR was 0.08 ± 0.16 mm at the mesial aspect and 0.1 ± 0.12 mm at the distal aspect. This difference was not statistically significant (P = 0.867). At T2, the mesial MBR was 0.15 ± 0.17 mm and the distal MBR was 0.11 ± 0.14 mm, with a non-statistically significant difference (P = 0.532). Therefore, no statistically significant differences were detected comparing mesial and distal MBR at any time point. With respect to the intra-group comparisons, no differences were observed comparing the different study periods within each variable. Indeed, the comparison between T0, T1 and T2 was non-statistically significant at both mesial (P = 0.06) and distal (P = 0.06) aspects. After 5 years, the volume of the soft tissues appeared clinically well maintained with a natural aspect around dental implants and adjacent teeth. ASP using demineralized bovine bone mineral in combination with CM proved to be an effective technique to maintain stable dimensional volumes of both hard and soft tissues.

Developmental changes of skin quality from breast, back, and thigh of Pekin ducks from 1 to 6 weeks of age.

Summary:Facial skin quality profoundly influences an individual’s perceived appearance and is an important aspect of facial rejuvenation. Facial pore enlargement is one of the most common concerns among Asian individuals that adversely impacts perceived skin surface evenness and affects overall skin quality. One of the major causes of enlarged pores is facial skin laxity. Microfocused ultrasound with visualization (MFU-V; Ultherapy; Merz North America, Inc., Raleigh, N.C.) is indicated for lifting and tightening of the face and neck, and improving the appearance of wrinkles on the décolletage. In addition, it is useful for addressing several aspects of facial rejuvenation, including facial pores, skin laxity, skin unevenness, etc., but there is limited literature on these applications. Thus, we present our proposed MFU-V treatment protocol for achieving a harmonious outcome for attractive skin, along with practical strategies for its application, illustrated in patients presenting with enlarged pores as their main concern. Drawing on our collective experience in using MFU-V for facial rejuvenation and the recently published skin quality framework that advocates addressing interrelated attributes of skin quality for optimal outcomes, we developed a treatment protocol for improving skin quality using MFU-V. This MFU-V treatment protocol reliably improves overall skin quality in patients presenting with enlarged pores, through MFU-V’s effects on skin lifting and tightening, and consequent improvement in facial pores and skin texture. This treatment protocol can be readily used as part of a multimodal layering approach to yield successful outcomes in patients with various facial skin concerns.

Introduction: The use of soft tissue grafts has been a key component in periodontal and implant surgeries for the past five decades, aiming to increase the width of keratinized tissue and soft tissue volume. Objectives: This study evaluates the efficacy of a three-dimensional volume-stable collagen matrix (VCMX) compared to subepithelial connective tissue grafts (SCTG) in increasing soft tissue thickness and volume during multiple implant placements. Methods: A randomized controlled clinical trial was conducted with four patients and eight implants. Patients were allocated to the SCTG or VCMX group, with soft tissue augmentation performed simultaneously with implant placement. Outcome measurements included soft tissue thickness, keratinized tissue height, surgical time, and histological analysis. Results: Results indicated no statistically significant differences between the two groups over three months in keratinized mucosa height (KMH) and mucosal thickness (MT). However, the VCMX group showed reduced surgical time. Histological analysis demonstrated mature collagen and connective tissue integration in both groups. Conclusions: Despite the small sample size, the study suggests that both SCTG and VCMX effectively improve mucosal thickness, with VCMX offering reduced surgical time and lowered morbidity and discomfort for the patient due to the absence of connective tissue harvesting from the palate.

Rationale: Obesity is the primary risk factor for obstructive sleep apnea (OSA). Tongue fat is increased in obese persons with OSA, and may explain the relationship between obesity and OSA. Weight loss improves OSA, but the mechanism is unknown.Objectives: To determine the effect of weight loss on upper airway anatomy in subjects with obesity and OSA. We hypothesized that weight loss would decrease soft tissue volumes and tongue fat, and that these changes would correlate with reductions in apnea-hypopnea index (AHI).Methods: A total of 67 individuals with obesity and OSA (AHI ≥ 10 events/h) underwent a sleep study and upper airway and abdominal magnetic resonance imaging before and after a weight loss intervention (intensive lifestyle modification or bariatric surgery). Airway sizes and soft tissue, tongue fat, and abdominal fat volumes were quantified. Associations between weight loss and changes in these structures, and relationships to AHI changes, were examined.Measurements and Main Results: Weight loss was significantly associated with reductions in tongue fat and pterygoid and total lateral wall volumes. Reductions in tongue fat were strongly correlated with reductions in AHI (Pearson's rho = 0.62, P < 0.0001); results remained after controlling for weight loss (Pearson's rho = 0.36, P = 0.014). Reduction in tongue fat volume was the primary upper airway mediator of the relationship between weight loss and AHI improvement.Conclusions: Weight loss reduced volumes of several upper airway soft tissues in subjects with obesity and OSA. Improved AHI with weight loss was mediated by reductions in tongue fat. New treatments that reduce tongue fat should be considered for patients with OSA.