Facial Sagging Research Articles

Safety and Efficacy of an Injectable Solution Enriched With Sodium Hyaluronate, Amino Acids, and Peptides in Relation to Superficial Facial Connective Tissues (Dermis and Retinacular Cutis).

Skin aging research often focuses on the dermis, overlooking the significance of the retinacular cutis (RC) in aging. This study aimed to investigate the efficacy, safety, and effect of an injectable solution containing hyaluronic acid, amino acids, and peptides, on facial sagging and laxity by targeting the RC. This single-center observational study recruited 28 female volunteers aged 25-65 years. The participants received four monthly injections of the studied solution. Objective measures included skin hydration, elasticity, color, thickness, collagen density evaluated via DermaLab Combo and high-resolution ultrasound imaging. Subjective measures included participant satisfaction evaluated using the Global Aesthetic Improvement Scale (GAIS). Adverse effects were monitored throughout the study period. Significant improvements were observed in skin hydration, elasticity, and collagen density after treatment. Hydration increased by 25.9% at T1 (30 days after last session), sustaining a 15.9% increase at T2 (120 days after last session). Elasticity improved by 29.2% at T1 and 20.7% at T2. Collagen density increased by 20.27% at T1 and 16.71% at T2. Self-reported GAIS scores showed consistent increases. Adverse effects were minimal and included only transient ecchymosis and mild pain. Injections of the solution had a substantial hydrating effect, enhanced elasticity, and increased collagen density in the RC and dermis. Results persisted at the 120-day follow-up, indicating sustained benefits. Hence, this injectable solution may offer a safe and effective non-invasive treatment option for improving skin laxity and sagging, targeting the RC and other deep connective tissue such as retaining ligaments.

Analysis of the Effect of Zygomatic Fat Pad Lifting Combined with Ultra-High SMAS Technique on the Improvement of Nasolabial Folds (Lower Eyelid Margin Incision)

This paper aims to explore the effect of zygomatic fat pad lifting combined with ultra-high superficial muscularaponeurotic system (SMAS) technique on the improvement of nasolabial folds. From December 2021 to June 2022, 40 patients with facial sagging were selected in our hospital to perform zygomatic fat pad lifting combined with ultra-high SMAS technology for large facelift surgery. Combined with lower eyelid incision and zygomatic fat pad degloving, the middle and lower face lift surgery, the improvement of the nasolabial fold, and the reduction of the apple cheeks were evaluated to assess the surgical effect. Statistics were collected on the improvement of nasolabial folds and apple cheeks aesthetic units before and after operation in 40 follow-up patients, and the satisfaction degree of nasolabial fold elevation and apple cheeks reduction was investigated and analyzed. The facial nasolabial folds and apple cheeks aesthetic units of 40 patients were followed-up after operation and compared with those before operation, and the difference was statistically significant (P < 0.05). After surgical treatment, 95% of patients were satisfied with the improvement of nasolabial folds, and 97.5% were satisfied with the reduction of apple cheeks. Zygomatic fat pad lifting combined with ultra-high SMAS technique has a significant effect on the reduction of apple cheeks zygomatic fat pad and nasolabial fold elevation, and it has clinical application value.

Practical application of the facial fat compartments and the line of ligaments concept in achieving the lifting effect in the lower face region in female patients.

Practical application of the facial fat compartments and the line of ligaments concept in achieving the lifting effect in the lower face region in female patients.

Perception of Plastic Surgery Among Medical Students

Introduction: Misconception of plastic surgery as a purely aesthetic specialty is common among medical students and interns. This study aims to assess the perception of medical students and interns on plastic surgery in Saudi Arabia and Canada. Materials and Methods: A cross-sectional study was conducted on February 2020 targeting first to last year medical students and interns in Saudi Arabia (IAU, KAUH) and Canada (McGill). Convenient sampling technique was used. Online based and paper questionnaires consisting of 21 questions addressing participants’ demographics as well as a list of various medical scenarios that require participants to choose the most appropriate specialty to refer to. These scenarios aim to assess the broad understanding of the participants of the various pathologies treated by plastic surgeons. Results: A total of 729 students were included in this study, where 27.5% of them were second year medical student, 25.3% were third year, 14.4% fourth year, 11.2% interns and 21.6% other levels (Table 3). Geographical distribution demonstrates that 86.8% of the students were from Saudi Arabia and 13.2% were from Canada (Table 1). The data analysis demonstrated that only 3 questions of the plastic surgery were answered correctly including liposuction (73.7% correct answers), facial sagging (67.2%) and congenital adhesion (52.5%) as shown in Figure 1. The rest of the 9 questions were answered incorrectly, indicating that most of the students misinterpret the various services that plastic surgeons can offer. Conclusion: This data suggests that plastic surgery is still commonly perceived as a merely aesthetic specialty among medical students. We recommend increasing the exposure to plastic surgery for medical students during clinical years to enhance their awareness about the armamentarium of the plastic surgeon.

Novel conformation of hyaluronic acid with improved cosmetic efficacy.

Hyaluronic acid presents a valuable cosmetic ingredient that occurs naturally. Its direct links to skin aging has led to its broad application. The aim of this study was to improve the cosmetic efficacy of high molecular weight hyaluronic acid (HMWHA) without chemical modifications and evaluate such improvements through clinical and in vitro studies. A novel formulation of HMWHA (SCAI-HA) was prepared and investigated to comparatively assess 6 clinical and 2 in vitro parameters concerning its dermatological cosmetic efficacy and biological properties. The dermatological and cellular parameters examined in this study include skin hydration, transepidermal water loss (TEWL), skin elasticity, wrinkles, facial sagging, dermal density, cytotoxicity, and collagen synthesis. SCAI-HA exhibited the ability to improve the tested dermatological parameters (hydration, elasticity, wrinkles, and density) to magnitudes comparable to those of HMWHA. In addition, SCAI-HA showed notably improved capacities for attenuating facial sagging and TEWL and promoting cellular collagen synthesis in normal human dermal fibroblasts. SCAI-HA presents a novel conformation of HMWHA with improved cosmetic efficacy in mitigating (i) facial sagging, (ii) TEWL, and promoting, and (iii) collagen synthesis. These findings denote the enhancement of SCAI-HA as a cosmetic ingredient with potential anti-aging properties.

Static and dynamic high-resolution ultrasound analysis of tissue distribution of poly-L-lactic acid particles during subdermal application in two different presentations.

All the changes the skin goes through, peaking at flaccidity, occur in the dermis and hypodermis, leading to loss of support and a lower capacity to totally accommodate displacements or any loss of subjacent volume, bringing about the onset of furrows and sagging. Improvements in facial sagging may be obtained with the administrations of substances like poly-L-lactic acid (PLLA), which triggers a tissue response through a controlled inflammatory reaction. Compare the tissue distribution of the particles of PLLA of both products available in Brazil (Sculptra® and Rennova Elleva®) during and immediately after their subdermal administrations, with 22G cannulas, through high-resolution ultrasound imaging. A total of four patients aged between 18 and 64years had the inner part of the upper arms divided into eight quadrants and treated with 16ml of each product, reconstituted to correspond to 9.5mg/ml. The sites where PLLA was injected were analyzed through the high-resolution ultrasound during (dynamic imaging) and immediately after the procedures (static imaging). During Sculptra® injection, high-resolution ultrasound revealed that its distribution did not follow the trajectory of the cannula homogeneously. It was characterized by a more hyperechogenic central portion and an anechogenic peripheral portion, forming discrete posterior acoustic shadowing at times. Regarding Rennova ELLEVA® injection, the high-resolution ultrasound analysis showed a homogeneous distribution of the product across the subcutaneous tissue following the trajectory of the cannula without formation of significant interface with the surrounding tissue, maintaining the sonographic aspect of thinly granulated hyperechogenic deposits, with strong posterior acoustic shadowing during and immediately after its administration. Static and dynamic high-resolution ultrasound imaging show a more homogenous distribution of PLLA particles with the use of Rennova ELLEVA® when compared with Sculptra®, which may induce the formation of capsules and a subsequent more dispersed fibroplasia, with larger area of action and a possible better therapeutic result. The interest of this article lies in its originality, highlighting the differences in the tissue distribution of two different brands of PLLA particles, which can impact the clinical response to the two products - which we are researching and seems to interfere with the increase in dermal thickness.

Objective analysis of the effectiveness of facial massage using breakthrough computed tomographic technology: A preliminary pilot study.

Facial massage is empirically known to be associated with morphological changes, such as improvements in facial sagging. However, quantified objective evaluations of massage-induced changes have not been performed to date. This preliminary pilot study aimed to verify the effectiveness of facial massages by using breakthrough computed tomographic technology. Five healthy adult volunteers (three women and two men; age, 29-37 years) were enrolled, and computed tomography (CT) examinations using a 320 detectors-spiral CT system known as 320-multidetector-row CT (MDCT) were performed before and after facial massages. Each participant performed a self-massage twice daily for 2 weeks. Massage-induced changes in the cheeks and the superficial musculoaponeurotic system (SMAS) were analyzed by two radiologists on a workstation with a high-accuracy imaging analysis system. After facial massage, the malar top became thinner by -0.8% ± 0.45% and shifted cranially and horizontally over a distance of 3.9 ± 1.94mm. The SMAS-height, defined as the highest vertical distance of the SMAS, increased by 2.6% ± 2.6%. The change rate in cheek thickness and SMAS-height showed a significant correlation (r=-0.63; P<0.05). These changes were attributed to the lifting and tightening effects of facial massage. We conducted a detailed analysis of the effects of facial massages by using the breakthrough CT technology. Our results provide useful information for beauty treatments and could contribute to the collection of objective scientific evidence for facial massages.

Quantitative evaluation of facial sagging in different body postures using a three‐dimensional imaging technique

The possible contribution of head flexion posture while using a smartphone to the formation of "smartphone face," is an increasing concern. Smartphone face describes the facial changes in a stooped posture receiving more gravitational pull on the jowl area. In this study, we quantified facial sagging in different postural changes using a three-dimensional imaging technique. Faces of 21 young (30.45±2.81yo, n=11) and old (59.50±3.37yo, n=10) Korean female subjects were scanned in different body postures including standing, supine, and head flexion (30°, 45°). The landmark displacements and volumetric changes in facial areas were assessed and correlated with skin elasticity. In addition, 22 Korean female subjects (45.45±3.81yo) were recruited to test the anti-gravity effect of facial cream A, which was formulated with Stem III complex™, for 8weeks. The landmarks shifted inferior-laterally with the supine posture, while the upper face shifted more laterally and the lower face shifted more inferiorly. With a head flexion posture, facial sagging occurred mainly toward the anterior direction with more prominent changes in the lower face. The changes were greater in the older group, and skin elasticity exhibited negative correlation with the shifting distances. A significant decrease in facial sagging was noted after an 8-week treatment of facial cream A. The use of a three-dimensional imaging technique could accurately assess the gravity-induced facial changes in different postures. The head flexion posture particularly gives more gravitational pull to the lower face, which could contribute to the drooping jawline.

Manual therapy in the treatment of facial wrinkles and sagging: a quantitative-qualitative randomized clinical trial

Background: Manual therapy has emerged as an option for facial rejuvenation treatment due to its effects on connective tissue. Objectives: The aim of the study was to verify the effectiveness of the manual therapy protocol in attenuating wrinkles and facial sagging. Methods: This is a quantitative-qualitative, randomized clinical trial. The study included female volunteers, aged between 40 and 50 years, distributed in 2 groups: Manual therapy group (MTG) and Control group (CG). The protocol used consisted of: lymph node decongestion, sliding massages, fast and vigorous movements, and traction on the fasciae. The evaluation instrument was through photos, in which they were analyzed by Dermato-functional specialists through a scale that graduates the wrinkles. The Shapiro-Wilk normality test was used to analyze the symmetry of the results by the Gauss curve. Pre- and post-intervention differences between the groups were determined using the non-parametric Wilcoxon test. Results: The average score obtained in the graduation of wrinkles and signs of aging in the manual therapy group showed significant differences in all regions of the face before and after treatment. And there was a decrease in the score, which shows improvement in the reduction of wrinkles and signs of aging, especially in the upper third. In contrast, in the control group, the average remained before and after the follow-up by the research, showing that there were no significant changes in this group. Conclusion: The manual therapy protocol showed significant results in reducing the signs of aging, such as fine lines and wrinkles, being another option to be applied in clinics.

Kinetic energy-assisted delivery of hyaluronic acid for skin remodeling in middle and lower face.

Kinetic energy of a liquid jet has been demonstrated to achieve clinical efficacy by injecting hyaluronic acid for skin thickening and improving facial sagging. A pneumatically accelerated jet penetrates the epidermis leaving HA particles spherically spread in the dermis and initiating microtraumatic wound healing. We reported retrospective analysis of our successful experience in improving rhytidosis and skin remodeling in the middle and lower facial regions by pneumatically administered HA filler. Subjects seeking correction of facial wrinkles in middle and lower face were treated in 3 monthly sessions with computerized jet-injection device and assessed 6months thereafter for perception of the wrinkles, rhytidosis burden, and treatment satisfaction. Thirty-four female patients (average age 42years) with age-related rhytidosis in perioral, cheek, and neck areas received the treatment. The treatments had short downtime, minimal pain, and no side effects. Mean Lemperle Rating Scale score decreased in all treated areas by one full degree and was maintained for 6months after the treatments. Patients and investigators independently scored the wrinkles as "improved" per Global Aesthetic Improvement Scale. Mean treatment satisfactory score was 4.0±1.4 (out of 5). Retrospective data showed successful implementation of liquid jet injections of HA in correction of aging middle and lower facial regions.

Clinical impacts of sun exposures on the faces and hands of Japanese women of different ages

To assess the impacts of sun exposures on some skin signs on the faces and hands of differently aged Japanese women, according to their distinct behaviours towards vis à vis sun exposure. Two comparable cohorts of Japanese women (aged 18-83years) were created according to their usual behaviour towards sun exposure i.e. non-sun-phobic (N=495) and sun-phobic (N=516) and through their regular use(s) of a photo-protective product. Standard photographs (full-face and 45° lateral) allowed to focus on 18 facial signs that were graded by 15 experts, using a referential skin ageing Atlas. From these two cohorts, two sub-cohorts (114 and 122 women) were created with regard to the similar clinical aspects of the dorsal side of their hands (Left vs. Right) that were further graded. Absolute differences in the scores of each sign were used (non-sun-phobic minus sun-phobic), by age-ranges, to better ascertain the impact of sun exposures and photo-protection. Facial signs related to skin wrinkles/texture and pigmentary spots were found significantly more accentuated among non-sun-phobic women and show an early onset (20-30years). Facial sagging and crow's feet wrinkles appear delayed (30-40years). The severity of vascular disorders was found to be similar in the two cohorts. The absolute differences in the grading's of almost all signs were unsurprisingly found increased with advancing ages, illustrating the combination of chronological and photo-ageing processes. With regard to hands, differences in skin texture and pigmentary disorders are of a late onset (40-50years) and were found much increased at older ages. The cutaneous signs of the hands of Japanese women can hardly be taken as reliable markers of their photo-ageing status. The present work illustrates, for the first time, some specificities of the impact of sun exposures on the facial skin of Japanese women, pinpointing the fact that some facial signs are of an early onset. Results significantly confirm the importance of both sun avoidance coupled with photo-protective measures.

BTX-A Rejuvenation: Regional Botulinum Toxin-A Injection of the Platysma in Patients with Facial Sagging.

To establish botulinum toxin-A (BTX-A) rejuvenation as an innovative technique to treat facial sagging with descent of the mid and lower face in Asian females. Between March 2016 and March 2017, 512 female patients with facial sagging were treated with regional platysma BTX-A injection. Droplet injection into the dermis was performed. Among the patients, 192 were recruited into our retrospective study. Eligible patients were divided into a pre-senile group (28-39years old) and a senile group (> 40years old). We analyzed the patient/physician-graded improvement, the mean scores of the 5-point improvement scale, and any reported complications. The overall degree of both patient- and physician-graded mid-face aesthetic improvement was very high. Improvement ratings reached 97.92% for patients and 94.79% for physicians. Improvement ratings were significantly greater in the pre-senile group compared to the senile group (p < 0.001), suggesting that the pre-senile patients were more satisfied with their improvement. Moreover, the percent of patients who reported as "much improved" was significantly higher than the percent of physicians (p < 0.05), suggesting that patients felt more positively about their aesthetic results than the physicians. No severe side effects were reported. Our results demonstrated that regional BTX-A injection in the dermis for the purpose of aesthetical platysma rejuvenation is safe and effective in patients with facial sagging with descent of the mid and lower face. Specifically, regional platysma injections of BTX-A (BTX-A rejuvenation) can correct descent of the mid and lower face in Asian females, demonstrating clinical utility of this treatment strategy. 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 .

Mandibular Rim Trilogy with Botulinum Toxin Injection: Reduction, Projection, and Lift.

"Onabotulinum toxin A (Botox) revolution" has brought the fundamental change in the facial rejuvenation as well as the concept of microinjection. The aesthetic standard tends to be the "globalization"; however, Asians have different aesthetic cultures and unique facial features compared with Caucasians. A new rejuvenation concept is proposed during our practice; the Asian face should preserve the original facial identity during Botox treatments. The lower face is treated with botulinum toxin to achieve a harmonious facial profile. Twenty young females ranging in age from 30 to 45 years consented and received the three-pronged procedure from March 2014 to April 2015; photography at baseline and follow-up visit were taken and analyzed. After posttreatment for 2 months, significant improvement was observed compared with the baseline. And the reduced masseter prominence and prominent chin were obtained, showing a favorable facial contour and harmonious appearance during the follow-up. The novel three-pronged approach to lower facial rejuvenation was aimed at the Asian characteristic of hypertrophic masseter, chin retrusion, and the facial sagging during the aging process. Botox treatment was a quite effective and safe strategy to improve the appearance and contour of the lower face in Asian patients.

Clinical efficacy of autologous fat grafting with platelet-rich plasma for facial rejuvenation

Objective This single-center prospective, case-controlled study was carried out to investigate clinical effects on patients with aging face who underwent facial autologous fat grafting with platelet-rich plasma (PRP). Methods Thirty patients with facial sagging or partial depression and requiring autologous fat grafting were randomly selected for the study. Photograph and 3D scanning were taken before and 3-month after the operation. Patient and physician satisfaction was rated using Visual Analogue Scale (VAS) ranging from 1 (most unsatisfactory) to 10 (most satisfactory) 3 months after the operation. Statistical difference between the patient and physician satisfactory scores was analyzed. Results The average physician VAS score was 7.9±1.0 while the average patient VAS score was 8.0±1.2. The scores between two groups had no significant difference (P> 0.05). Four patients developed bruising and swelling postoperatively that disappeared less than 7 days later. There was no feed back of serious complications from patients. Further investigation of patients with scores less than 7 showed the main reason of low patient satisfaction was that the improvement of facial depression did not meet the requirements of the patient, and fat absorption led to unsatisfactory filling. Conclusions The high satisfactory scores indicate good aesthetic result of facial autologous fat grafting with PRP. PRP may lead to higer survival rate of fat and satisfaction. Key words: Fat granule; Fat grafting, autologous; Platelet-rich plasma; Soft tissue; Facial rejuvenation

Investigation of postoperative satisfaction of facial autologous fat grafting with platelet-rich plasma

ABSTRACT Objectives: This single-center prospective, case-controlled study investigated satisfaction and esthetic results as rated by the physician and patient, respectively, by following up thirty patients with aging face, who underwent facial autologous fat grafting with platelet-rich plasma (PRP). Materials and Methods: A retrospective review of thirty patients, who were suffering from facial sagging or partial depression and requiring autologous fat grafting between February 2012 and September 2015. Photograph was taken before and 3-month after the operation. Patient and physician satisfaction was rated using visual analog scale (VAS) ranging from 1 (least satisfied) to 10 (most satisfied) 3 months after the operation. Statistical difference between the patient and physician satisfaction scores was analyzed by SPSS 17.0 software. Results: The patients' average age was 34.5 ± 1.2 years. The average VAS score of physician satisfaction was 7.9 ± 1.0, and the average VAS score of patient satisfaction was 8.0 ± 1.2. There was no statistically significant difference between the two groups in scores (P = 0.859; P &gt; 0.05). Conclusion: There is no evidence that different donor sites or different donor-site preparation will lead to different outcomes. Multilevel injection is recommended for autologous fat injection. The high satisfaction scores indicated a good esthetic result of facial autologous fat grafting with PRP. Autologous fat as one of the popular soft tissue fillers is durable and safe. The biggest challenge is the high variation in absorption rate. PRP may lead to higher survival rate of fat and satisfaction level. The stability of survival rate of autologous fat grafting with PRP and the connection between complications and PRP technique need further study.

Influence of facial skin ageing characteristics on the perceived age in a Russian female population.

The desire for a youthful look remains a powerful motivator in the purchase of cosmetics by women globally. To develop an anti-ageing solution that targets the need of end consumers, it is critical to understand which signs of ageing really matter to them and which influence their age perception. To date, such research has not been performed in a Russian population. The aim of this work was to identify the signs of ageing that contribute the most to an 'older' or 'younger' look for Russian women aged 40 years old and above. The age of 203 Russian female volunteers was estimated from their standard photographs by a total of 629 female naïve assessors aged 20-65 years old. Perceived age data were related to 23 facial skin features previously measured using linear correlation coefficients. Differences in average severity of the correlating skin ageing features were evaluated between women perceived older and women perceived younger than their chronological age. Volunteers' responses to a ranking question on their key ageing skin concerns previously collected were analysed to provide an additional view on facial ageing from the consumer perspective. Nine facial skin ageing features were found to correlate the most with perceived age out of the 23 measured. Such results showed the importance of wrinkles in the upper part of the face (crow's feet, glabellar, under eye and forehead wrinkles), but also wrinkles in the lower half of the face associated with facial sagging (upper lip, nasolabial fold). Sagging was confirmed of key importance to female volunteers aged 41-65 years old who were mostly concerned by the sagging of their jawline, ahead of under eye and crow's feet wrinkle. The severity of hyperpigmented spots, red and brown, was also found to contribute to perceived age although to a weaker extent. By providing a clear view on the signs of ageing really matter to Russian women who are aged 40 years old and above, this research offers key information for the development of relevant anti-ageing solutions specifically targeting their needs and their desire to achieve younger-looking skin.

顔面たるみの二次元簡易的測定法の開発

これまでに顔のたるみの定量的測定方法として，二次元解析，三次元解析が報告されているが，それぞれ，測定点の三次元的な移動距離を顔の奥行きを反映して直接的に測定できない，あるいはたるみ量の定義が困難であるといった理由から，たるみの絶対量を測定することができなかった。そこで，二次元解析法のもと，顔の奥行きや頬の膨らみ等を反映した測定法の開発を試みたところ，同心円状の目盛付シールを用いることで安価で簡便に測定点の三次元的な移動距離，つまりたるみの絶対量を測定することが可能となった。本法を用いた女性頬部の解析の結果，20～50歳代全年代を通して顔面中央部よりもフェイスライン側のたるみ量が多く，このフェイスライン側のたるみがほうれい線の形成に深く関与している可能性が示唆された。また，長期製剤塗布の結果，目視のほうれい線スコアでは改善効果は認めなかったが，本法ではフェイスライン側下方のたるみ量の有意な改善を認めたことから，本法は化粧品のわずかなたるみ改善効果をも感度良く捉えることが可能だと見受けられた。

Comparison of Three Techniques of Reduction Malarplasty in Zygomaticus and Massateric Biomechanical Changes and Relevant Complications

For Asians, prominent zygomatic region is a sign of masculinity; therefore, reduction malarplasty is becoming more and more popular in Asian women. The purpose of this study is to analyze the biomechanical changes of zygomaticus and masseter, and to explore the underlying causes of relevant complications using the 3 popular techniques of reduction malarplasty. From May 2000 to August 2009, 259 female patients underwent traditional osteotomy through coronary incision, malomaxillary suture with L-shaped osteotomy through intraoral approach, and the modified X.M.'s technique. The mechanical and anatomical causes of the relevant complications such as facial asymmetry caused by detachment of zygomaticus and masseter, facial sagging, and downward movement of malar point in 3 surgical procedures were analyzed and compared postoperatively among the 3 procedures. In the traditional osteotomy through coronary incision, the inside cheek fat pad moved interoinferiorly because the greater and lesser zygomatic muscles were stripped from the attachment points, whereas masseter was relatively less stripped from its attachment point, which affects mechanical direction and contraction strength less, which possibly leads to the downward movement of the fractured extremity of zygomatic bone. In the L-shaped osteotomy, the zygomatic arch slided interoinferiorly because of the operative design, and masseter's strong extroinferior traction often caused fixation loosening between the former and latter bone margin. As a result, the fractured zygomatic bone moved downward along with zygomaticus, masseter, and fat pad. In the modified X.M.'s technique, complications were relatively fewer, which may be related to less injury to the fixation system of zygomatic bone and less biomechanical changes in masseter and zygomatic muscles. Surgeons should base their choice of reduction malarplasty not only on thoroughness of the operation but also on biomechanical changes in the zygomatic region and patients' individual conditions.

Consideration of Facelift Methods and Facial Retaining Ligaments in Asians

The demand for facelifts is rapidly increasing in Asia because of economic development as well as the aging of the population. It is difficult to achieve satisfactory results, because of the facial characteristics of Asians. The goal of the facelift is to improve facial sagging. During initial stages, facelifts focused on the lower face. Various approaches, such as the extended superficial musculoaponeurotic system (SMAS) facelift, the finger-assisted malar fat elevation (FAME) facelift, and the high SMAS facelift, were designed to improve facial sagging in the midand lower face with the development of advanced facial surgical procedures [1-5]. Retaining ligaments is important for facelifts and was described by Furnas in 1989, because these ligaments support the soft tissue in its normal anatomical position and resist gravitational effects [6]. These structures attach the dermis, SMAS, and subcutaneous tissues to deep structures such as underlying muscle, bone, and parotid glands. There are two ligament systems. The first comprises true osteocutaneous ligaments: the orbital, zygomatic, and mandibular ligaments. The second involves tethering structures that do not originate from bone but attach the SMAS layer to the deep fascia: the parotid cutaneous and masseteric cutaneous ligaments. With aging, attenuation of retaining ligaments leads to the gravitational Min-Hee Ryu

Will nonablative rejuvenation replace ablative lasers? Facts and controversies

Since the early 1980s, the field of skin rejuvenation has evolved rapidly. Traditional ablative resurfacing with carbon dioxide and Er:YAG lasers offered dramatic improvement of the skin tone and texture, but prolonged postoperative period and an increased risk for side effects and complications were unacceptable for the majority of patients. It prompted the development of nonablative lasers and non-laser systems, which stimulate dermal neocollagenesis without epidermal disruption, and therefore, produce less adverse effects with little or no healing time. Recently, fractional nonablative and ablative lasers have been introduced, employing a completely new concept of fractional photothermolysis, which ensures high efficacy and fewer risks. Ablative laser resurfacing still remains the gold standard for treating advanced and severe photoaging providing excellent results in experienced hands. Alternatively, ablative fractional resurfacing can be used, with the results, which are comparable to fully ablative lasers with better standard of safety. Nonablative resurfacing is ideal for patients under the age of 50 years with minimal facial sagging, and for those who are unwilling to undergo expensive and demanding ablative procedures. It can be concluded that the key of therapeutic success is in proper patient selection, setting appropriate expectations and combining different rejuvenation technologies with other therapeutic modalities, such as botulinum toxin and fillers.