Background The arrangement of the facial soft tissue layers is different with respect to the line of ligaments: medially oblique and laterally in parallel. Aims This split‐face study was designed to investigate the effects on midfacial volumization if the same medial vs lateral injection points are targeted in various sequences. Methods Twelve patients (3 males, 9 females; 46.67 years ± 4.5) were included in this interventional study. On the right side of the face, lateral injection points were performed first, whereas on the left side, medial injection points were executed first. The infraorbital hollowness score, the upper cheek fullness score, the global aesthetic improvement scale, and the injected volume were assessed. Results No side differences were observed after the intervention with P = 1.00 for all scores. When the lateral injection points were performed first, the volume injected into the medially located injection points (0.46 ± 0.26 cc vs 0.73 ± 0.31 cc [P = .037]), into the lateral injection points (0.79 ± 0.40 cc vs 1.15 ± 0.28 cc [P = .017]), and overall (1.26 ± 0.64 cc vs 1.88 ± 0.57 cc [P = .02]) was significantly reduced. Conclusion The results of the present study emphasize the importance of respecting the layered arrangement of the facial soft tissues when performing minimally invasive soft tissue filler injections. Targeting injection points lateral to the line of ligaments first reduces the volume needed to symmetrically and aesthetically appealing manner and volumizes the infraorbital and upper cheek regions.

Background: Cosmetic treatment of the forehead using neuromodulators is challenging. To avoid adverse events, the underlying anatomy has to be understood and thoughtfully targeted. Clinical observations indicate that eyebrow ptosis can be avoided if neuromodulators are injected in the upper forehead, despite the frontalis muscle being the primary elevator. Methods: Twenty-seven healthy volunteers (11 men and 16 women) with a mean age of 37.5 ± 13.7 years (range, 22 to 73 years) and of diverse ethnicity (14 Caucasians, four African Americans, three Asians, and six of Middle Eastern descent) were enrolled. Skin displacement vector analyses were conducted on maximal frontalis muscle contraction to calculate magnitude and direction of forehead skin movement. Results: In 100 percent of investigated volunteers, a bidirectional movement of the forehead skin was observed: the skin of the lower forehead moved cranially, whereas the skin of the upper forehead moved caudally. Both movements converged at a horizontal forehead line termed the line of convergence, or C-line. The position of the C-line relative to the total height of the forehead was 60.9 ± 10.2 percent in men and 60.6 ± 9.6 percent in women (p = 0.941). Independent of sex, the C-line was located at the second horizontal forehead line when counting from superior to inferior (men, n = 2; women, n = 2). No difference across ethnicities was detected. Conclusions: The identification of the C-line may potentially guide practitioners toward more predictable outcomes for forehead neuromodulator injections. Injections above the C-line could mitigate the risk of neuromodulator-induced brow ptosis.

Background While the temporal lifting technique has gained increasing attention, there is a dearth of objective and reliable evidence of its effects. Aim The objective of the present study is to analyze the ability of the temporal lifting technique to reduce the midfacial volume by soft tissue repositioning and to achieve an improved pan‐facial appearance by targeting exclusively the subdermal plane of the posterior and superior temple with soft tissue fillers. Methods A total of 12 patients (1 male and 11 females) with a mean age of 36.75 ± 6.6 years and a mean body mass index of 23.04 ± 1.3 kg/m2 were included in this prospective clinical single‐center interventional study. Injection‐related outcome was evaluated utilizing 3D skin vector displacement and surface volume analyses and scoring based on five different evaluators. Results Three months after the treatment, the global esthetic improvement scale rating showed an improved outcome (3.08) when evaluated by the independent observers, very improved outcome when evaluated by the treating physician (4.33), and exceptional improvement when rated by the patient (4.83). Temporal volume improved by 0.36 (P < .001), lower cheek fullness by 0.47 (P < .001), and jawline contouring by 0.51 (P < .001). No major adverse events were reported during the 3‐month observational period. Conclusion Objective outcome measures have provided evidence that by augmenting the posterior superior temple the volume of the middle face can be reduced and the contour of the jawline can be accentuated; this is due to the underlying fascial anatomy and the resulting soft tissue re‐position.

Background Soft tissue filler injections are performed using either sharp‐tip needles or blunt‐tip cannulas. Product can change planes in an uncontrolled manner during needle injections, potentially leading to unintentional intra‐arterial placement. There is a paucity of data on the influence of injection angle on the dispersion patterns of soft tissue fillers. Materials and Methods A total of 126 injection procedures were conducted in seven Caucasian body donors (four males, three females) with a mean age of 75.29 ± 4.95 years and a mean body mass index of 23.53 ± 3.96 kg/m2. Injection procedures were performed in various facial regions (forehead, scalp, zygomatic arch, mandibular angle), utilizing different needle sizes (25G, 27G, 30G) and different angles (90°, 45°, 10°). Layer‐by‐layer dissections were performed to verify the location of the injected product. Dissections were facilitated by the colored material. Results Utilizing a 30G needle (compared to a 25G needle) reduces the superficial spread with OR 0.70 (95% CI, 0.48‐0.99) and P = 0.049, whereas injecting at 90° (vs 10° with the bevel down) increases the odds for superficial spread with OR 10.0 (95% CI, 7.11‐14.09) and P < 0.001. Conclusion Precision during soft tissue filler injections, defined as the product remaining in the plane of intended implantation, can be enhanced by changing the needle size and the injection angle. Utilizing a 30G needle and injecting at a 10° angle with bevel facing down reduces the uncontrolled product distribution into superficial fascial layers.

Background Most injection techniques utilizing hyaluronic acid–based soft tissue fillers have predictable outcomes at the location injected. However, the temporal region has been identified to have aesthetic effects beyond the temple. Aims To identify and quantify the panfacial aesthetic effects of three different temporal injection techniques. Patients/Methods The medical records of nine female and five male Caucasian patients with a mean age of 50.9 ± 11.9 years were retrospectively reviewed for the effects of these techniques: supraperiosteal, interfascial, and subdermal. Panfacial effects were evaluated by the semiquantitative assessment of aesthetic scores for the temple volume, the temporal crest visibility, the lateral orbital rim visibility, the position of the eyebrows, the severity of lateral canthal lines, the midfacial volume, and the contour of the jawline. Results The supraperiosteal injection technique had the greatest influence on improving the temporal volume (25.0%), the temporal crest (33.3%), and the lateral orbital rim visibility (31.0%) scales but had no effects in other facial regions. The interfascial injection technique revealed good effects on improving temporal hollowing (23.3%) but had an even greater effect on the crow's feet (26.8%) and on the position of the eyebrow (33.3%). The subdermal injection technique had its greatest effects in the lower face by improving the contour of the jawline (26.8%) followed by the improvement of the lower cheek fullness scale (14.3%). Conclusion Future injection algorithms could utilize all three injection techniques together as one multi‐layer injection approach with a tailored proportion of each technique based on the aesthetic needs of the patient.

Recent advances in facial anatomy have increased our understanding of facial aging [1][2][3][4][5] and where to best position facial soft tissue fillers. 6 The description of the layered arrangement of the facial soft tissues has introduced the 3-dimensional perspective into minimally invasive treatments as layers were identified with greater or reduced effectiveness 7 and which layers inherit a greater risk for adverse vascular events. 8 The description of the facial fat compartments is guiding practitioners toward more precise injections as compartment

Objective: Neuromodulator injections of the forehead are often performed using standardized protocols. This study was designed to identify the individual skin motion pattern of the forehead and to relate this pattern to the underlying frontalis muscle morphology to offer guidance for neuromodulator placement.

Background An increasing number of soft tissue filler procedures in the nasal region has been reported. Concomitant with demand, the number of complications has risen due to the difficulty in administering filler in a region where soft tissue layering is complex. Objectives To describe the layered soft tissue arrangement of the nose as it relates to the underlying arterial vasculature and to define safer zones for nasal filler enhancement. Methods A total of 60 (28 males and 32 females) study participants were investigated with respect to their layered anatomy in the midline of the nose using ultrasound imaging. The presence and extent of the layered arrangement was examined as well as the depth of the arterial vasculature. Results In the mid-nasal dorsum, a 5-layer arrangement was observed in 100% (n= 60) of all investigated cases, whereas it was found to be absent in the nasal radix and tip. The 5-layer arrangement showed an average extent of 26.7% - 67.5% in relation to nasal length. The nasal arteries coursed superficially in 91.7% of all cases in the nasal radix, in 80% in the mid-nasal dorsum, and in 98.3% in the nasal tip. Conclusions Soft tissue filler administration in the nose carries the highest risk for irreversible vision loss compared to any other facial region. The safety of soft tissue filler rhinoplasty procedures is enhanced by knowledge of the layered anatomy of the nose, the location and depth of the major nasal vasculature, and employment of maneuvers to decrease the risk of blindness.