Background:The aging process of the face comprises all layers: skin, subcutaneous fat, muscles, and skeleton, and the signs of aging depend mainly on which layer is mostly affected.Objective:To evaluate the aging facial skeleton, as well as establish the sexual differences, areas with a strong predisposition to resorption, and aesthetic repercussion for better treatment approach.Methods:Skulls from the Forensic Anthropology Department of the Institute of Forensic Medicine of Belo Horizonte, Brazil, were classified according to gender and age group (i.e., <20 years, 20–50 years, >50 years). Structural changes were classified according to gender and age group.Results:Of the 241 skulls included, 192 were male skulls and 49 female. Sexual dimorphism and age-related peculiarities are described herein.Conclusions:The knowledge of the anatomy of the aging face, taking into consideration all the layers (skin, fat pads, muscles, and bones), as a whole, for the treatment of folds and shadows is vital for a better and more natural final aesthetic outcome.

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Background Neuromodulators have proven efficacy in reducing facial rhytides and have also been reported to improve jawline contour and the appearance of platysmal bands. Lifting effects of the tail of the eyebrow are expected outcomes when targeting the lateral peri-orbital region underscoring the versatility of neuromodulator treatments. Objective To analyze the clinical effectiveness of a novel neuromodulator-based injection algorithm with regards to its ability to reposition the middle and lower facial soft tissues. Methods Seventy-five study participants (8 males, 67 females) with a mean age of 37.5 (8.5) years were injected with neuromodulators in the subdermal plane of the mandibular soft tissues following a standardized algorithm. Live rating of clinical appearance was performed, as well as volume change and skin vector displacement using 3-dimensional imaging at baseline, day 14 and day 30. Results 3-dimensional volume analysis revealed an increase in midfacial volume by 0.46 cc, and a decrease of the lower facial volume by 0.30 cc compared to baseline. Additionally, an improvement of midfacial fullness (change of 0.13) and jawline contour (change of 0.44) was reported on clinical rating scales at day 30 compared to baseline. Conclusions Facial soft tissues can be repositioned during the 30 days follow-up period following a neuromodulator treatment; this was reflected through an increase in middle facial volume as well as through a decrease in lower facial volume. The novel injection algorithm presented can provide a safe and effective option for patients desiring improvement of midfacial fullness and jawline contour with neuromodulator treatment alone.

Background: Current injection algorithms for treating the glabella rely on a five-or seven-point injection technique with possible medial eyebrow ptosis and lateral eyebrow elevation as undesirable outcomes.Objective: The objective of this study was to investigate the efficacy and safety profile of a refined 3-point injection technique targeting horizontal and vertical glabellar lines.Methods: A total of n=105 patients (27 males and 78 females) with a mean age of 40.90 ± 9.2 years were investigated. The injection technique relied on targeting the muscular origin of the procerus and the corrugator supercilii muscles exclusively. The time of effect onset and the injection-related outcome 120 days after the treatment was evaluated using the 5-point glabellar line severity scale. Results:The onset of the neuromodulator effect was on average 3.5 ± 1.5 days. There was no statistically significant difference in the amplitude of movement before or 14 days after the treatment with 2.99 ± 4.4 mm vs. 3.39 ± 3.6 mm (p = 0.149) for the medial head of the eyebrow and with 3.18 ± 4.7 mm vs. 3.33 ± 4.3 mm (p = 0.510) for the lateral head of the eyebrow, respectively. Conclusion:Incorporating anatomic concepts into clinical practice for glabellar frown line neuromodulator treatments with the investigated 3-point injection technique resulted in the absence of adverse events like eyebrow ptosis, upper eyelid ptosis, medial eyebrow ptosis, and lateral frontalis hyperactivity. This technique demonstrated efficacy throughout the 4-month study period. K E Y W O R D S abobotulinum toxin, corrugator supercilii muscle, glabellar frown lines, incobotulinum toxin, onabotulinum toxin, procerus muscle How to cite this article: Cotofana S, Pedraza AP, Kaufman J, et al. Respecting upper facial anatomy for treating the glabella with neuromodulators to avoid medial brow ptosis-A refined 3-point injection technique.

Background: The lips and perioral region are a highly dynamic anatomic area of the face and its anatomy and measurements will vary from patient to patient. In many years of clinical practice and as trainers for other injectors we have noticed that the assessment of this region is also very variable regardless of the experience of the injector. Objectives: The goal of this article is to provide a tool for assessment of the lower face and perioral area in other to simplify cosmetic treatments and help injectors identify what needs to be addressed in each patient. Methods: Over the last few years, weanalyzed the most common concerns of every patient presenting for treatment of the lips and perioral area and the most frequent areas addressed in the treatment of the lower face, and organized them into a tool that was able to systematize the different levels of attention needed in each particular area, guiding injectors towards a better final result. As trainers for other injectors, we also analyzed the most difficult aspects of the perioral assessment and simplified them into this tool that can help even novice injectors to do the correct diagnosis and therefore achieve better results while treating the perioral area. Conclusions: We believe that this tool will help both experienced and young injectors in the assessment of the lips and perioral area prior to treatment and in doing so, will provide a better outcome and cosmetic result.

Background and Objective Poly-L-lactic acid (PLLA) has been used in various medical applications for decades, including aesthetic ones. The use of a cannula technique in injecting PLLA has been proposed in order to lower the incidence rate of adverse events (AEs) following treatment. Such AEs include nodule formation, which may occur less frequently by fanning the product with a cannula, thus creating a more uniform product placement compared to that resulting from the use of a needle. Currently, however, there is a lack of comparative research regarding the safety of cannulas versus needles for PLLA injections, as the selection of either remains highly subjective. Therefore, the objective of our study was to investigate the safety of cannula use in the administration of PLLA, in order to report safety outcomes. Materials and Methods A single-center, retrospective chart review was conducted to examine the data of patients who had previously undergone treatment with PLLA in the form of Sculptra ® Aesthetic™ in the face and/or neck regions. Twenty-seven subject charts met eligibility. Descriptive data regarding treatment and follow-up visits were collected and analyzed. Results A total of seven AEs resulted from eighty-two treatment sessions (8.54%), with 6/27 patients having experienced at least one AE (22.22%). Mild bruising was the most commonly reported AE (57.14%). The majority of the AEs were mild and transient in nature, with one moderate AE being a nodule that was possibly related to a concomitant treatment. All AEs were resolved with follow-up care. Conclusion Mild AEs such as bruising, swelling and pain should be expected following the use of a cannula for PLLA injections. However, the incidence rates of AEs following treatment can remain low if proper product preparation and treatment techniques are utilized.

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