Facial Rhytides Research Articles

The Contribution of the Lower Third of the Face to Perceived Age: Do Masks Make You Appear Younger?

BackgroundThere is evidence that changes to the midface and lower third of the face in isolation contribute significantly to one’s perception of the overall facial age. Since the spread of the coronavirus disease 2019 (COVID-19), mask wearing has become commonplace. To date, there have been no studies that explore how covering the lower third of the face impacts the perception of age.ObjectivesThe authors hypothesized that covering the lower third of the face with a mask will make a person appear younger.MethodsOne hundred consecutive plastic surgery patients were photographed in a standardized fashion, both masked and unmasked. A questionnaire for factors known to contribute to facial aging was administered. These photographs were randomized to 6 judges who estimated the patients’ age and also quantified facial rhytids with the validated Lemperle wrinkle assessment score of 6. Data were analyzed using PROC MIXED analysis.ResultsMasked patients on average appeared 6.17% younger (mean difference = 3.16 years, P < 0.0001). Wrinkle assessment scores were 9.81% lower in the masked group (mean difference = 0.21, P = 0.0003). All subgroups appeared younger in a mask except for patients aged 18 to 40 years chronological age (P = 0.0617) and patients BMI > 35 (P = 0.5084).ConclusionsThe mask group appeared younger and had lower overall and visible wrinkle assessment scores when compared with the unmasked group. This has implications for our understanding of the contributions of the lower third of the face to overall perceived facial age.

BOTULINUM TOXIN (BOTOX) PRACTICE PATTERN

Botulinum toxin has found numerous uses in medicine, with new indications being continually added. This agent has become the treatment of choice for a number of movement disorders, and has been advocated for many other conditions such as aesthetic reduction of facial wrinkles. Among ophthalmic plastic surgeons, botulinum toxins are often used as the first line treatment for facial dystonias. These toxins are also efficacious for the temporary management of various other conditions including keratopathies (through so called chemo-tarsorraphy), upper eyelid retraction, orbicularis overaction-induced lower eyelid entropion, gustatory epiphora, Frey's syndrome, and dynamic facial rhytids such as lateral canthal wrinkles (crow's feet), glabellar creases and horizontal forehead lines. Four leading Oculoplasty Surgeons of India opine in our panel discussion on their preferred 'Practice Pattern' regarding use of Botox in Ophthalmology. Their immense clinical experience, outstanding body of work, deep insight in their art and unmatched academic credentials will provide an excellent learning experience for our readers. The Editorial Board of BJO is deeply indebted to them for their contribution, considering the trials and tribulations of the continuing COVID era.

Combining Laser Resurfacing and Facial Rejuvenation Surgery.

Facial aging is a multifactorial process involving skin laxity, volume loss, facial rhytids and solar elastosis. Surgical interventions can address the laxity of the skin and restore volume loss but do not fully correct the texture of the skin. Historically, there were concerns over the safety of combining laser resurfacing with facelifting procedures, but now there is much evidence to support the safe use of this combination treatment. When done appropriately, the combination of laser resurfacing with facial rejuvenation surgery can provide a synergistic effect for optimal clinical results. Here, we review the many laser options available and how they may be combined safely with surgical facial rejuvenation. We also review clinical contexts and candidate selection to provide safe, reliable results and minimize complications.

Millennials Are Interested in Botulinum Toxin Injections for Prevention of Facial Rhytids

Background: Botulinum toxin has been utilized for the treatment of facial rhytids since 2002. Since development, the indications for botulinum toxin have expanded greatly. Typically utilized in older generations for the treatment of rhytids, younger generations may be pursuing botulinum toxin injections for prevention rather than solely treatment of rhytids at a younger age. Methods: A 26-question survey was designed on Qualtrics and distributed to people through Amazon Mechanical Turk (MTurk) system. The Data was extracted from the Qualtrics website and processed with Microsoft Excel. Results: Out of 516 completed surveys, 92% of respondents were familiar with botulinum toxin injections with 21% having received botulinum toxin injections and 18% have received injections for cosmetic indications. Of those who have received botulinum toxin injections, 45% utilized injections for the treatment of wrinkles, 37% for the prevention of wrinkles, and 18% for the management of a non-cosmetic indication. When all respondents were asked the purpose of botulinum toxin injections, 11% thought they were for the prevention of wrinkles, 25% believed they were for the treatment of wrinkles, while 63% believe they are for both the prevention and treatment of wrinkles. Conclusions: Younger patients are pursuing botulinum toxin injections at an earlier initial age than their older counterparts. Significantly more people believe that these injections are intended for the prevention and treatment of facial rhytids rather than treatment alone. Plastic surgeons must be aware of the shifting landscape in order to adequately access this increasing patient population.

Effective Locations for Injecting Botulinum Toxin into the Mentalis Muscle; Cadaveric and Ultrasonographic Study.

The mentalis muscle is now considered key structures when performing procedures for rejuvenating the lower face. The aim of this study was to determine the anatomical morphology and location of the mentalis muscle and thereby provide anatomical information for facilitating clinical procedures designed to rejuvenate the lower face. Forty-four adult hemifaces from five Thai cadavers and 21 Korean cadavers were dissected to identify the locations of the mentalis muscle. Sixty-six hemifaces from 33 healthy young Korean subjects were included in an ultrasonographic study. The depth of the mentalis muscle below the skin surface, the thickness of the mentalis muscle, and the distance from the bone to the mentalis muscle were measured at the two points that were 5 mm lateral to the most-prominent point of the chin. The mentalis muscle was classified into two types based to its shape: in type A (86.4%, 38 of the 44 cases) it was dome shaped in three dimensions, while in type B (13.6%, 6 of the 44 cases) it was flat. The mentalis muscle was present mostly at the area 5–10 mm from the midsagittal line and 20–30 mm from a horizontal line connecting the mouth corners. The mentalis muscle was present between depths of 6.7 to 10.7 mm below the skin. This new information about the location of the mentalis muscle may help when identifying the most effective and safe botulinum toxin injection points and depths during esthetic procedures for weakened facial rhytides on the lower face.

Photobiomodulation: The Clinical Applications of Low-Level Light Therapy.

Low-level light therapy (LLLT) is a recent addition to the pantheon of light-based therapeutic interventions. The absorption of red/near-infrared light energy, a process termed "photobiomodulation," enhances mitochondrial ATP production, cell signaling, and growth factor synthesis, and attenuates oxidative stress. Photobiomodulation is now highly commercialized with devices marketed directly to the consumer. In the gray area between the commercial and therapeutic sectors, harnessing the clinical potential in reproducible and scientifically measurable ways remains challenging. The aim of this article was to summarize the clinical evidence for photobiomodulation and discuss the regulatory framework for this therapy. A review of the clinical literature pertaining to the use of LLLT for skin rejuvenation (facial rhytids and dyschromias), acne vulgaris, wound healing, body contouring, and androgenic alopecia was performed. A reasonable body of clinical trial evidence exists to support the role of low-energy red/near-infrared light as a safe and effective method of skin rejuvenation, treatment of acne vulgaris and alopecia, and, especially, body contouring. Methodologic flaws, small patient cohorts, and industry funding mean there is ample scope to improve the quality of evidence. It remains unclear if light-emitting diode sources induce physiologic effects of compararable nature and magnitude to those of the laser-based systems used in most of the higher-quality studies. LLLT is here to stay. However, its ubiquity and commercial success have outpaced empirical approaches on which solid clinical evidence is established. Thus, the challenge is to prove its therapeutic utility in retrospect. Well-designed, adequately powered, independent clinical trials will help us answer some of the unresolved questions and enable the potential of this therapy to be realized.

A Randomized, Double-Blinded Study Evaluating the Safety and Efficacy of AbobotulinumtoxinA Injections for Oily Skin of the Forehead: A Dose-Response Analysis.

AbobotulinumtoxinA has been investigated for applications beyond facial rhytides, including the treatment of oily skin. The authors sought to investigate the optimal number of units and the duration of abobotulinumtoxinA for the treatment of oily skin. This randomized, double-blinded, placebo-controlled study included 50 male and female subjects that got either 0, 15, 30, or 45 units of abobotulinumtoxinA injected into their forehead. For the 6 months after treatment, subjects were evaluated for the effectiveness of the treatment in decreasing the oiliness of their skin and the duration of this effect. Subjects in the treatment groups that received either 30 or 45 units of neurotoxin experienced a significant reduction in oily skin. This effect was present for the 6-month duration of the study. No treatment-related adverse events were reported during this study, and both subjects and investigators reported a high level of satisfaction with the treatment. Thirty or 45 units of abobotulinumtoxinA are safe and effective doses in treating oily skin for improved cosmetic appearance.

Adjuncts to Facial Rejuvenation

The preferred methods for facial rejuvenation have been changing over the past decade, with operative procedures on the decline and minimally invasive, office-based procedures on the rise. As a result, it is critical for plastic surgery practitioners to understand the intricacies of the use of neuromodulators and soft tissue fillers in this milieu. While these procedures are usually performed in an office, without general anesthesia, the risk of significant complications still exists. The knowledge of facial anatomy, techniques, and pitfalls is essential for achieving high quality, predictable, and reproducible results. Likewise, when a complication arises, prompt recognition and appropriate treatment is paramount. In this chapter, the history, purpose, technical guidelines, and complications of adjunctive techniques for facial rejuvenation are reviewed in detail. This review contains 2 tables, and 52 references. Keywords: facial rejuvenation, neuromodulator, soft tissue filler, botulinum toxin, dermal filler, aging face, facial rhytids, filler complications, glabellar lines, nasolabial fold

Fractional radiofrequency microneedling for skin rejuvenation

AbstractPatients continue to seek aesthetic procedures that treat intrinsic aging, progressive photodamage, skin laxity, and facial rhytids. Using the latest generation of radiofrequency microneedling (RFM) technology, it is possible to achieve elegant results when treating these concerns. In this article, we will discuss the mechanism of RFM, review the improvements in the latest generation of this technology, and consider applications of this device in aesthetic practice.

Demographics of Men and Minorities in Cosmetic Clinical Trials of Botulinum Toxin and Hyaluronic Acid Fillers.

The demographics of men and minorities in clinical studies of nonsurgical cosmetic procedures have not been well described. There is a growing interest in nonsurgical cosmetic procedures. The patients studied in clinical trials may not be reflective of the real-world demographic of patients seeking nonsurgical cosmetic procedures. To examine the demographics of men and minorities in clinical studies of nonsurgical cosmetic procedures. A systematic review of clinical trials of botulinum toxin A (BTX-A) for facial rhytides and hyaluronic acid (HA) injectable fillers for soft-tissue augmentation was performed. Data on ethnicity and sex were collected and examined. Nineteen randomized controlled trials (RCTs) on BTX-A and 22 RCTs on HA were included for analysis. Men represented 11.8% of all participants. Men were more represented in the BTX-A RCTs (13.9%) compared with the HA RCTs (6.4%). Caucasian patients represented 67.1% of the total patients. Asian, Hispanic, and black patients represented 16.8%, 6.5%, and 5.4% of study participants, respectively. The proportion of men in clinical trials of BTX-A and HA reflects the real-world demographics of men undergoing these procedures. Hispanic and black patients were underrepresented in clinical trials.

Diode Laser and Fractional Laser Innovations.

Laser technology continues to increase in popularity and expand treatment options for patients with common but challenging skin conditions including facial telangiectasias, facial aging, striae distensae, and acne scars. Facial telangiectasias have been estimated to occur in tens of millions of people worldwide. The 585-nm laser was the first to follow the principle of selective photothermolysis for the treatment of cutaneous vascular lesions, but it caused significant postoperative purpura. Newer diode lasers target superficial and deep telangiectasias without the side effects of the 585-nm laser. Ablative resurfacing was introduced in the 1990s with the carbon dioxide laser to address facial rhytids and photoaging. While effective, the risks and downtime were significant. The newest fractionated nonablative lasers are demonstrating impressive results, with decreased risks and downtime. This new generation of lasers is being used extensively and in unique combinations for facial aging, striae, and acne scars.

Digital Image Speckle Correlation to Optimize Botulinum Toxin Type A Injection: A Prospective, Randomized, Crossover Trial.

Historically, physicians have relied on their subjective measures when determining the site and dosages for botulinum toxin type A injections. Digital image speckle correlation is a technology that tracks pore movement from rest to maximal exertion, allowing for the determination of the optimal sites of injection. In this prospective, randomized, crossover trial, the efficacy of using digital image speckle correlation was compared to physician assessment in choosing botulinum toxin type A injection sites. Ten female patients were analyzed in this blinded crossover study. Subjects were randomized to either injections based on digital image speckle correlation analysis or injections based on the 2004 facial aesthetics consensus recommendations. All patients received 20 U of botulinum toxin type A in the glabellar region and were crossed over and reinjected after 6 months. Follow-up was completed with the Facial Line Outcomes 11-item survey and repeated imaging with digital image speckle correlation, to measure patient satisfaction and degree of paralysis, respectively. Statistical comparison was completed by means of matched sample t test. On average, the digital image speckle correlation analysis provided 4.8 injection sites, whereas the practitioner chose five injections sites. Patients receiving digital image-directed injections had higher rates of satisfaction on the Facial Line Outcomes instrument (p = 0.0003) and a larger degree of paralysis (p = 0.003). Furthermore, muscle function returned to normal later in patients injected with digital image speckle correlation (17.9 weeks versus 20 weeks; p = 0.03). This study demonstrates the benefits of using digital image speckle correlation in determining optimal botulinum toxin type A injection location. Digital analysis allows practitioners to better treat facial rhytides by eliminating subjective decisions regarding dose and site of injection. Therapeutic, II.

Neurotoxins.

Botulinum toxin is integral to the practice of facial plastic surgery. Since it was approved by the U.S. Food and Drug Administration for the temporary improvement of glabellar rhytids in 2002, botulinum toxin has achieved a growing number of off-label clinical applications. These include the management of facial rhytids, brow ptosis, excessive gingival display, masseteric hypertrophy, platysmal banding, facial nerve paralysis, hypertrophic scars, and keloids. Many forms of botulinum toxin have been developed, and their safety and efficacy have been thoroughly established. This article will review the aesthetic and functional uses of botulinum toxin as it relates to the field of facial plastic and reconstructive surgery. In addition, the authors will discuss the suggested quantity of units per injection site based on onabotulinumtoxinA.

Jessner's Solution with Trichloroacetic Acid Chemical Peel: Optimizing Outcomes and Safety.

Trichloroacetic acid (TCA) is a versatile agent, efficacious in treating a spectrum of facial rhytids and dyschrommias at varying concentrations. TCA is commonly used in a 30%-35% concentration to achieve a medium-depth peel into the upper reticular dermis. The addition of Jessner's solution before the TCA peel application leads to partial removal of epidermis, allowing for deeper penetration of the TCA. This combination is beneficial, as lower concentrations of TCA can be used for the same depth of peel, minimizing complications such as scarring.

614 Investigation of the efficacy and safety of topical vibration anesthesia to reduce pain from cosmetic botulinum toxin A injections in Chinese patients

Vibration anesthesia has been proved to be effective to reduce pain during facial cosmetic injections, but it has not been studied in Chinese patients and anatomic sites other than face. This study was to investigate the efficacy and safety of vibration anesthesia for pain reduction associated with cosmetic botulinum toxin A (BTX-A) injections in Chinese patients and anatomic sites other than face. In this prospective, randomized, split-face, self-controlled study, 53 patients received BTX-A injections for facial rhytids reduction, lower face, shoulder, or posterior leg contour reshaping. A vibration stimulus was co-administered with the BTX-A injections on one side (treatment), whereas the other side received the BTX-A injections only (control). Immediately after treatment, the patients completed a questionnaire composed of a visual analogue scale of pain sensation (VAS), a preference question, and a statement of the feelings and/or questions they might have about the vibration treatment. The patients were also followed up two weeks later. The patients experienced both clinically and statistically significant pain reduction when a vibration was co-administered with injections. The mean patient-reported VAS scores were 3.6 ± 1.3 for the vibration-treated side and 5.6 ± 1.8 for the control side (p = 0.000). No difference was found between the patients receiving two different BTX-A products injection. No difference was found between the treatment-naïve patients and repeated patients. Overall, 75% of patients preferred to receive vibration for their next treatment. Positive feedback, psychological benefits, and needs for optimizing vibration parameters were identified in the paitents’ statement. No adverse events and no delayed or declined toxin effect were reported. Topical vibration anesthesia during cosmetic BTX-A injections had a beneficial effect that was statistically and clinically significant in terms of patients’ assessment of pain. It may have applications in other cosmetic procedures.

String Fat/Dermis Graft for Correction of Wrinkles and Scars

Established creases and wrinkles do not predictably respond to the fat injection technique. The authors describe a minimally invasive yet simple technique to address recalcitrant facial rhytides and minor depressed scars. This technique optimally requires a concomitant procedure whereby suitable fat or dermis graft could be available for grafting without having to make another incision. However, if needed, the graft can be harvested from an easily concealed area such as postauricular sulcus. Preferably, dermis or a combination of fat and dermis is harvested in the form of strings using a pair of straight iris scissors. The sharp end of an 18-gauge needle is then used to create a tunnel in the subcutaneous plane beneath each line while releasing any fibrous bands. The string of dermis/fat is then engaged at the end of the 18-gauge needle and delivered into the subcutaneous tunnel with rotation and advancement of the needle. The authors have used this graft on 49 sites on 39 patients. The mean age of the patients was 57.6 years, with eight male and 31 female patients. The sites included rhytides in upper and lower lips, oral commissure, labial mental groove, and frown lines, and scars in the forehead, nasal dorsum, nasal tip, and eyebrows. String fat grafting is a simple and reliable method to address limited rhytides or depressed scars. CLINICAL QUESTION/LEVEL OF EVIDENCE:: Therapeutic, V.

A Comparison of Alpha-Adrenergics (Anticholinesterases) in the Treatment of Eyelid Ptosis After Botulinum Toxin A Administration to the Glabellar Region: A Case Study

In 2013, there were over 9.5 million nonsurgical cosmetic procedures performed; of these, over 3.7 million were botulinum toxin A injections. Treatment of dynamic facial rhytides with botulinum toxin, in particular the glabellar region, is not without complication. One of the complications of botulinum toxin A injection is paralysis of neighboring muscles to the target muscle(s) of the treatment area such as levator muscles yielding upper eyelid ptosis. Treatment of upper eyelid ptosis with phenylephrine 2.5% ophthalmic solution at 1 drop to the affected left eye every 8 hours versus apraclonidine 0.5% ophthalmic solution at 1 drop to the affected eye every 8 hours was evaluated. Both apraclonidine and phenylephrine are alpha-adrenergic agonists, more specifically apraclonidine is an alpha-2 adrenergic agonist and thus stimulates the Müller’s muscle providing temporary relief of the upper eyelid ptosis. To decrease the risk of an adverse event of upper eyelid ptosis, it is important to avoid crossing the midpupillary line and to stay 1 cm above the eyebrow. Our experience in the treatment of upper eyelid ptosis with the combination of apraclonidine 0.5% and phenylephrine 2.5% yielded improvement of the adverse event. These findings are similar to those reported by Sharma and Shocker; however, in the current case study discussed, a lesser percentage ophthalmic solution achieved satisfactory results.

Cosmetic Concerns Among Men.

Men are interested in reducing signs of aging, while maintaining a masculine appearance. A chief concern among men is maintenance of scalp hair. Men are also concerned with reducing under eye bags and dark circles. The concern of feminization is of significant importance. Neuromodulators remain the most common cosmetic procedure performed in men. Men often prefer a reduction in facial rhytids, as opposed to elimination of the lines. Softening facial lines in men is meant to maintain an appearance of wisdom, without appearing fragile. Men also wish to maintain a taut jawline and a slim waist and reduce breast tissue.

Partial Facial Paralysis as a Model for Prophylactic Botulinum Toxin Use for the Prevention of Facial Rhytides.

Partial Facial Paralysis as a Model for Prophylactic Botulinum Toxin Use for the Prevention of Facial Rhytides.

Forehead Line Treatment With OnabotulinumtoxinA in Subjects With Forehead and Glabellar Facial Rhytids: A Phase 3 Study

Effacement of horizontal forehead lines (FHL) with onabotulinumtoxinA has not been investigated in prospective Phase 3 studies. To evaluate safety and efficacy of onabotulinumtoxinA treatment of FHL together with glabellar lines (GL). A 12-month, Phase 3 study randomized subjects with moderate-to-severe FHL and GL to onabotulinumtoxinA 40 U or placebo, distributed between the frontalis (20 U) and glabellar complex (20 U). After Day 180, subjects could receive up to 2 additional open-label onabotulinumtoxinA treatments. Efficacy was assessed using the Facial Wrinkle Scale (FWS) and Facial Line Outcomes questionnaire. The intent-to-treat (ITT) population included 391 subjects, and the modified ITT (mITT) population (subjects with psychological impact) included 254 subjects. After 30 days, onabotulinumtoxinA significantly improved the investigator- and subject-assessed appearance of FHL severity by at least 2 FWS grades in 61.4% of ITT subjects versus 0% of placebo subjects (p < .0001). In the mITT population, 94.8% of onabotulinumtoxinA subjects and 1.7% of placebo subjects achieved investigator- and subject-assessed FWS ratings of none/mild (p = .0003). Patient-reported outcomes were consistent with FWS ratings. OnabotulinumtoxinA was well tolerated. OnabotulinumtoxinA 40 U distributed between the frontalis and glabellar complex was safe and effective for treatment of moderate-to-severe FHL.