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Background: Free muscle flaps can develop significant postoperative edema and wound exudation, thereby increasing interstitial pressure and potentially compromising microcirculation. While concerns exist regarding negative pressure wound therapy (NPWT) to compress free flaps and hinder monitoring, recent studies have indicated a reduction in edema and an increase in blood flow. Objective: To compare microcirculation in free latissimus dorsi muscle (LDM) flaps dressed with and without NPWT. Methods: This retrospective cohort study analyzed prospectively collected data of patients who received free LDM flap reconstruction. Patients were separated into two groups according to management with or without NPWT. Microcirculation was evaluated continuously for up to 72 h utilizing laser doppler flowmetry and tissue spectrometry. Results: In total, n = 61 patients (26 females, 35 males) with an average age of 56.90 (17.4) years were included. NPWT was applied in 12 patients, while a regular cotton dressing was used in 49 patients. Overall, no significant differences in the number of minor and major complications were observed between groups. Both groups showed an increase in microvascular flow over the investigated time period. The flow showed higher absolute values in the NPWT group, reaching statistical significance at 12 h post-anastomosis, p = 0.038. There was a tendency for lower rHb values in the NPWT group, without reaching statistical significance. Conclusions: The presented study confirms the increase in microvascular flow after NPWT application. Whilst ensuring continuous free flap monitoring utilizing laser doppler flowmetry and spectrometry, the data further support the safety of NPWT application without risking vascular compromise due to external compression.

Background: Neuromodulator treatments of the perioral region are increasingly popular and aim to modulate the position of the modiolus. The predominantly targeted muscle is the depressor anguli oris (DAO) which allows for the modiolus to reposition cranially once temporarily relaxed., Objectives: The aim of this study was to identify the precise anatomic position of the DAO in relation to the marionette line, thereby increasing precision and reducing adverse events during neuromodulator treatments., Methods: A total of n = 80 DAO muscles were investigated in n = 40 healthy, toxin-naïve volunteers (11 males, 29 females) with a mean [standard deviation] age of 48.15 [15] years and a mean BMI of 24.07 [3.7] kg/m2. The location of the DAO in relation to the labiomandibular sulcus, and its depth, extent, and thickness were investigated with high-frequency ultrasound imaging., Results: The skin surface projection of the labiomandibular sulcus separates the DAO into medial and lateral portions. The distance between skin surface and muscle surface was on average 4.4 mm, with males having a greater distance (P < .001) and higher BMI being an important influencing factor for a greater distance (P < .001). The thickness of the DAO was on average 3.5 mm, with a range of 2.8 to 4.8 mm and with females having thinner muscles compared with males (P < .001). The most favorable injection depth was calculated to be 6.1 mm for intramuscular product placement., Conclusions: Understanding the perioral anatomy and the influence of age, sex, and BMI will potentially allow injectors to increase the efficacy and duration of neuromodulator treatments while expertly managing adverse events., (© The Author(s) 2024. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For commercial re-use, please contact reprints@oup.com for reprints and translation rights for reprints. All other permissions can be obtained through our RightsLink service via the Permissions link on the article page on our site—for further information please contact journals.permissions@oup.com.)

Background: Aesthetic enhancements to the buttock region have grown in demand due to media influence and evolving beauty standards. Using eye-tracking technology, we sought to uncover subconscious visual preferences regarding the buttock aesthetic. The objective of this investigation was to assess visual gaze patterns in assessing female buttocks among Caucasian and Asians through eye-tracking technology., Materials and Methods: 67 participants viewed photographs of buttocks from various angles, and eye movements were analyzed using the Tobii Pro Nano eye-tracker., Results: Males fixated on the intergluteal cleft for 0.96 ± 1.1 s and the thigh gap for 0.07 ± 0.2 s; while, females fixated for 0.81 ± 0.9 s and 0.06 ± 0.2 s on the same regions, respectively. Significant gender differences were observed in the intergluteal cleft (p = 0.002) and upper lateral buttock (p < 0.001)., Conclusion: This study offers new insights into the observation of buttocks. The consistent attention toward the intergluteal cleft across demographics could be of potential significance in the aesthetic perception of buttocks. However, diverse gaze patterns also underscore the multifaceted nature of human attraction. These findings hold implications for plastic surgery, aesthetic medicine, and the sociocultural understanding of beauty. A deeper dive into aesthetic preferences is pivotal for a holistic understanding of human perceptions of attractive buttocks., Level of Evidence Iii: 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 Table of Contents or the online instructions to Authors www.springer.com/00266 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Background: Eyebrow position affects perceived facial expression and youthfulness, and its modification is a key component of facial rejuvenation., Objective: This investigation aimed to assess the preferred vertical eyebrow position, apex location, and eyebrow shape in Caucasian and Asian individuals and to analyze gaze patterns during aesthetic judgment using eye-tracking technology., Materials and Methods: The study included 76 Asian and Caucasian volunteers with no medical background. Eye movements were captured with a Tobii Pro Nano eye-tracker. Participants viewed AI-generated images of Caucasian and Asian females with varied eyebrow positions (ratios 1:1.3 to 1:2.5), shapes (angles 8° to 20°), and apex positions. Aesthetic preferences were rated on a 5-point Likert scale. Eye-tracking metrics and aesthetic ratings were statistically analyzed using ANOVA and bivariate correlations., Results: Both genders across ethnicities preferred a moderate eyebrow position ratio of 1:1.6. For eyebrow shapes, a 12° angle received the highest ratings, while extremes were less favored, indicating a preference for moderately curved eyebrows. The most appealing apex position was above the lateral canthus for Asians, and halfway between the lateral limbus and lateral canthus for Caucasians. Eye-tracking revealed longer fixations on unattractive features, suggesting more complex cognitive processing, while attractive features were processed more efficiently., Conclusion: The study revealed that aesthetic preferences for eyebrow features are influenced by both ethnic background and gender, with a general preference toward moderately curved eyebrows and subtle variations in preferred positions. These findings suggest a need for culturally sensitive approaches in facial aesthetic procedures and highlight the potential of eye-tracking technology to enhance surgical planning. Surgeons are advised to adopt a conservative, patient-centered approach when modifying eyebrow features, considering individual and cultural aesthetics to maximize patient satisfaction., Level of Evidence V: 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 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

The use of hyaluronic acid-based soft tissue fillers has often been reported to modulate the muscle, that is, to cause myomodulation. To our knowledge, there has been so far no scientific study investigating the potential of hyaluronic acid-based soft tissue fillers to modulate or actually alter the function of facial muscles. To further assess this three-dimensional (3D) surface imaging and electromyography (EMG)-based prospective study investigated the changes of facial muscle contraction after injection of strategically placed hyaluronic acid-based soft tissue fillers to assess the actual validity of the term myomodulation. A total of 13 subjects with a mean age of 37.8 years (12 females, 1 male) were injected according to a predefined injection protocol. Surface EMG and 3D surface imaging were performed prior to the injection and 5 days after the injection. The results showed no significant change in the strength of the muscles (measured in μV) after injection of hyaluronic acid-based soft tissue fillers. However, horizontal and vertical skin displacement upon contraction of the zygomaticus major muscle changed significantly between baseline and follow-up, with a mean horizontal skin displacement increase from 3.2 to 4.1 mm. Upon contraction of the depressor anguli oris muscle, the horizontal skin displacement did not change significantly (2.15 vs. 2.05 mm), while vertical skin displacement increased significantly from 2.9 to 4.3 mm. The modification of the surrounding tissue caused an alteration of the vectorial skin displacement upon contraction of the muscle. A potential explanation could be the increased distance between the origin and insertion of the muscle due to the material deposition in the proximity of the relevant facial muscles, leading to a change of contraction vector., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Surgical, minimally-invasive, and non-invasive aesthetic procedures try to ameliorate the signs of facial aging, but also focus on enhancing various individual features of beauty in each patient. Herein, the midface plays a central role due to its location but also its importance for the aesthetic perception and facial expression., Objective: To date, no study has investigated the interplay between facial muscles and its connecting subdermal architecture during facial aging to provide a more comprehensive understanding of the middle face., Materials and Methods: A total of 76 subjects, consisting of 30 males (39.5%) and 46 females (60.5%) with a mean age of 42.2 (18.7) years [range 19-80] and a mean BMI of 24.6 (3.7) kg/m 2 [range 18-35], were enrolled in this investigation. Cutometry (skin aging), 3D skin displacement analyses (subdermal connective tissue aging), and sEMG (muscle aging) analyses were utilized., Results: The results revealed that overall skin firmness increased, and skin elasticity decreased (p < 0.001), sEMG signal of the investigated muscles decreased (p < 0.001), whereas midfacial mobility remained unaltered (p = 0.722)., Conclusion: The results of this study indicate that midfacial aging is a measurable effect when utilizing individual measurement modalities for assessing skin, subdermal fascia, and midfacial muscles. The function of midfacial muscles revealed a potential threshold effect, which is not reached during midfacial aging due to the unchanged soft tissue mobility at older age. However, to understand its clinical presentation all midfacial soft tissues need to be factored in and a holistic picture needs to be created., No Level Assigned: This journal requires that authors assign a level of evidence to each submission to which Evidence-Based Medicine rankings are applicable. This excludes review articles, book reviews, and manuscripts that concern Basic Science, Animal Studies, Cadaver Studies, and Experimental Studies. 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 ., (© 2024. Springer Science+Business Media, LLC, part of Springer Nature and International Society of Aesthetic Plastic Surgery.)

Being the green gold of the future, cyanobacteria have recently attracted considerable interest worldwide. This study investigates the adaptability and biocompatibility of the cyanobacterial strain Synechococcus sp. PCC 7002 with human dermal cells, focusing on its potential application in biomedical contexts. First, we investigated the adaptability of Synechococcus PCC 7002 bacteria to human cell culture conditions. Next, we evaluated the biocompatibility of cyanobacteria with common dermal cells, like 3T3 fibroblasts and HaCaT keratinocytes. Therefore, cells were directly and indirectly cocultured with the corresponding cells, and we measured metabolic activity (AlamarBlue assay) and proliferation (cell count and PicoGreen assay). The lactate dehydrogenase (LDH) assay was performed to determine the cytotoxic effect of cyanobacteria and their nutrition medium on human dermal cells. The cyanobacteria exhibited exponential growth under conventional human cell culture conditions, with the temperature and medium composition not affecting their viability. In addition, the effect of illumination on the proliferation capacity was investigated, showing a significant impact of light exposure on bacterial growth. The measured oxygen production under hypoxic conditions demonstrated a sufficient oxygen supply for further tissue engineering approaches depending on the number of bacteria. There were no significant adverse effects on human cell viability and growth under coculture conditions, whereas the LDH assay assessed signs of cytotoxicity regarding 3T3 fibroblasts after 2 days of coculturing. These negative effects were dismissed after 4 days. The findings highlight the potential of Synechococcus sp. PCC 7002 for integration into biomedical approaches. We found no cytotoxicity of cyanobacteria on 3T3 fibroblasts and HaCaT keratinocytes, thus paving the way for further in vivo studies to assess long-term effects and systemic reactions.

Background: Addressing neck contouring with surgical and nonsurgical aesthetic procedures includes understanding the origin of platysmal banding. A theory was postulated to explain this phenomenon by isometric vs isotonic muscular contraction patterns. However, no scientific proof had been provided to date for its correctness., Objectives: The aim of this study was to confirm the correctness of the platysmal banding theory based on isometric vs isotonic muscular contractions., Methods: Eighty platysma muscles from 40 volunteers (15 males and 25 females) were investigated (mean age 41.8; SD 15.2 years; mean BMI of 22.2; SD 2.3 kg/m2). Real-time ultrasound imaging was utilized to measure the increase in local muscle thickness inside and outside of a platysmal band as well as platysma mobility., Results: Within a platysmal band, the local thickness of the muscle increases during muscular contractions by 0.33 mm (37.9%; P < .001). Outside of a platysmal band the thickness of the platysma muscle decreased by 0.13 mm (20.3%; P < .001). It was identified that within a platysmal band no gliding was detectable, whereas outside of a band an average muscle gliding of 2.76 mm was observed., Conclusions: The results confirm the correctness of the isometric vs isotonic platysma muscle contraction pattern theory: isotonic muscle contraction (gliding without increase in tension and therefore in muscle thickness) vs isometric muscle contraction (no gliding but increase in tension and therefore in muscle thickness). These 2 types of contraction patterns occur within the platysma simultaneously and are an indicator for zones of adhesion in the neck to guide surgical and nonsurgical aesthetic procedures., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Given that scars are acknowledged as the primary cause of postoperative dissatisfaction following reduction mammoplasty, it is imperative to comprehend the patient's visual perception of different scar patterns in order to enhance patient satisfaction. To achieve this, eye-tracking technology provides an unbiased method of evaluating how observers assess breast scars., Methods: 58 participants (32 females and 26 males) between the ages of 19 and 82 years (mean age of 29.47 ± 10.98 years) were shown 18 color photographs, taken at 3 viewing angles (right 45° oblique, frontal and frontal view with arms raised), from 6 patients undergone reduction mammoplasty with the inverted T-scar technique (3 patients) or no-vertical-scar technique (3 patients). The images were presented to every participant for a fixed duration of 5 s each. Eye-tracking device was used to collect and analyze the gaze data of viewers., Results: The nipple-areola complex (NAC) and the periareolar scar captured observers' gaze faster, had longer duration and more count of eye fixation than all other parts of breast scars, regardless of the viewing angle and scar pattern. Moreover, the scar region in the inverted T-scar pattern received greater and faster visual attraction of observer's gaze than the no-vertical-scar pattern., Conclusion: The NAC and the periareolar scar seem to be perceived as the most important regions for breast aesthetics. The findings can be helpful to assist plastic surgeons in determining the most appropriate technique for reduction mammoplasty, meanwhile underlining the importance of a fine periareolar scar and symmetric NAC for excellent aesthetic outcomes. This is to our best knowledge the first study using eye-tracking technology in evaluating reduction mammoplasty outcomes. This study explored the influence of different scar patterns after reduction mammoplasty on eye movements and gaze patterns among observers. The study have validated the significance of the NAC and the periareolar scar for breast aesthetics and revealed that the scar region in the inverted T-scar pattern may be judged less visually attractive than the no-vertical-scar pattern., Level of Evidence V: 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 ., (© 2023. The Author(s).)

Background: While autologous fat grafting of the face is considered a generally safe procedure, severe complications such as arterial embolism (AE) have been reported., Objective: To summarize data on injection-related visual compromise, stroke, and death caused by arterial embolism after facial fat transplantation., Materials and Methods: Plastic surgery societies were contacted for reports on AE after autologous facial fat injection. In addition, a systematic literature review was performed. Data extracted included study design, injection site/technique, symptoms, management, outcome, and etiology., Results: 61 patients with a mean age of 33.56 ± 11.45 years were reported. Injections targeted the glabella or multiple facial regions (both n = 16/61, 26.2%) most commonly, followed by injections in the temples (n = 10/61, 16.4%) and the forehead (n = 9/61, 14.8%). The mean volume injected was 21.5 ± 21.5 ml. Visual symptoms were described most frequently (n = 24/58, 41.4%) followed by neurological symptoms (n = 20/58, 34.5%), or both (n = 13/58, 22.4%). Ophthalmic artery (OA, n = 26/60, 43.3%), anterior or middle cerebral artery (CA, n = 11/60, 18.3%) or both (n = 14/60, 23.3%) were most frequently occluded. Outcome analysis revealed permanent vision loss in all patients with OA occlusion (n = 26/26, 100%), neurological impairment in most patients with CA occlusion (n = 8/10, 80%), and vision loss in most patients suffering from both OA and CA occlusion (n = 7/11, 63.6%). Six patients died following embolisms., Conclusions: AE causes severe complications such as blindness, stroke, and death. Due to a lack of high-quality data, no evidence-based treatment algorithms exist. To increase patient safety, a database collecting cases and complications should be established., Level of Evidence Iii: 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 ., (© 2023. The Author(s).)

Objective: With more than 1.5 million performed procedures, liposuction was the second most performed esthetic surgical procedure all over the world in males and in females in the year 2020. The objective of this open-label, evaluator-blinded study was to assess the efficacy and safety of an energy-based device that combines multipolar radiofrequency with pulsed electromagnetic field (PEMF) in patients that underwent liposuction., Materials and Methods: A total of 30 subjects, of whom 24 were females (80%), with a mean age of 48.4 ± 11.0 years (range: 27-69 years) and a mean weight of 69.5 ± 11.7 kg underwent unilateral treatment with radiofrequency and application of PEMF after bilateral liposuction. One month after the last of a total of six weekly treatments, skin elasticity, visco-elasticity and net elasticity, as well as subject reported satisfaction on a 5-point scale ranging from -1 (worse) to 3 (very much improved) and esthetic improvement ranging from 0 (very unsatisfied) to 4 (very satisfied) rated by three independent reviewers were assessed., Results: Three independent and blinded reviewers rated the improvement of the treated side on average as 1.17 + 0.07 compared with baseline. Subjects were very satisfied with their treatment, with a mean score of 3.24 (0.03) out of 4 at the 1-month follow-up visit. Cutometer measurements showed no significant changes., Conclusion: This study revealed that the subjective satisfaction with the results of the application of RF and PEMF after liposuction is high, while at the same time the esthetic appearance as rated by independent raters improved on the treated side., (© 2023 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: The use of validated scales is still considered the gold standard for evaluating the severity of an aesthetic facial condition., Objectives: The aim of this investigation was to create and validate 5-point photonumeric scales for the assessment of perioral lines and marionette lines., Methods: A medical team created 2 different novel 5-point photonumeric scales for the assessment of perioral lines and marionette lines. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation., Results: For the Croma Static Perioral Lines-Assessment Scale, the digital interrater intraclass correlation coefficients (ICCs) were 0.88 (95% CI, 0.85-0.91) in the first rating and 0.87 (95% CI, 0.83-0.90) in the second rating. The digital intrarater ICCs were 0.90 (95% CI, 0.87-0.92). In the live rating, the interrater ICCs were 0.89 (95% CI, 0.85-0.93) in the first rating and 0.91 (95% CI, 0.87-0.93) in the second rating with an intrarater ICC of 0.91 (95% CI, 0.88-0.95). For the Croma Marionette Lines-Assessment Scale, the digital rating interrater ICCs were 0.85 (95% CI, 0.81-0.89) in the first rating and 0.87 (95% CI, 0.84-0.90) in the second rating with an intrarater ICC of 0.89 (95% CI, 0.88-0.91). In the live rating, the interrater ICCs were 0.73 (95% CI, 0.54-0.83) in the first rating and 0.79 (95% CI, 0.65-0.87) in the second rating with an intrarater ICC of 0.88 (95% CI, 0.83-0.94)., Conclusions: The Croma Static Perioral Lines-Assessment Scale and the Croma Marionette Lines-Assessment Scale have exceptional inter- and intrarater agreements that justify their use in clinical and study settings for all ethnic groups., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: The measured intraarterial volume of cadaveric ophthalmic arteries was utilized for safety recommendations during facial soft tissue filler injections. However, its clinical practicability and model applicability have become questionable., Objectives: To measure the volume of the ophthalmic artery in living individuals by utilizing computed tomography (CT) imaging technology., Methods: A total of 40 Chinese patients (23 males, 17 females) were included in this study with a mean age of 61.0 (14.2) years and a mean body mass index of 23.7 (3.3) kg/m2. Patients were investigated with CT imaging technology to evaluate the length, diameter, and volume of the bilateral ophthalmic arteries as well as the length of the bony orbits, resulting in a total of 80 investigated ophthalmic arteries and orbits., Results: Independent of gender, the average length of the ophthalmic artery was 80.6 (18.7) mm, the calculated volume of the ophthalmic artery was 0.16 (0.05) mL and the minimal and maximal internal diameter of the ophthalmic artery were 0.50 (0.05) mm and 1.06 (0.1) mm, respectively., Conclusions: Based on the results obtained from the investigation of 80 ophthalmic arteries it must be concluded that current safety recommendations should be reevaluated. The volume of the ophthalmic artery appears to be 0.2 mL rather than 0.1 mL as previously reported. In addition, it appears impractical to limit the volume of soft tissue filler bolus injections to 0.1 mL due to the aesthetic requirements of each individual patient and treatment plan., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Recent research has indicated that in the upper face a delicate arrangement exists between the muscles of facial expression and the skin. This arrangement allows for immediate transmission of movements following muscle contraction, resulting in skin movements and skin rhytid formation., Objectives: To investigate age-related changes of the biomechanical unit formed by facial muscles, their connective tissue envelope, and the skin of the upper face., Methods: A total of 76 Caucasian volunteers (30 males, 46 females) with a mean age of 42.2 years (SD 18.6) and a mean body mass index of 24.58 kg/m2 (SD 3.7) were investigated. Three upper facial regions were analyzed for skin firmness and elasticity with cutometric assessment, vertical and horizontal skin vector displacement using 3-dimensional imaging, and muscle activity with surface-derived electromyography., Results: Study participants of older age (>42.2 years), when compared with younger participants (≤42.2 years), showed increased skin firmness, at 0.20 mm vs 0.30 mm (P < .001); decreased skin elasticity at 53.2% vs 69.0% (P < .001); increased vertical (not horizontal) skin mobility at 3.56 mm vs 1.35 mm (P < .001); and decreased surface-derived electromyography (sEMG) signal of the frontalis muscle with 174 µV vs 309 µV (P = .039)., Conclusions: This study reveals that age-related changes occur in each component of the biomechanical unit formed by facial muscles, connective tissue envelope, and skin in the upper face. Knowledge and understanding of such changes can allow for more targeted and individualized surgical and nonsurgical aesthetic treatments., (© The Author(s) 2023. Published by Oxford University Press on behalf of the Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: There is a scarcity of scales that assess platysmal bands, wrinkles in the décolleté, and horizontal neck lines in the digital and live setting., Objectives: The objective of this investigation was to create and validate 5-point photonumeric scales that assess horizontal neck lines, platysmal bands, and wrinkles in the décolleté., Methods: A medical team created 3 different novel 5-point photonumeric scales for the assessment of horizontal neck lines, platysmal bands, and décolleté wrinkling. Eleven international raters were involved in the digital validation, and 4 raters performed a live validation., Results: The Croma (Leobendorf, Austria) Horizontal Neck Lines Assessment Scale showed substantial interrater agreement and almost perfect intrarater agreement in the digital and live validations, respectively. The Croma Platysmal Bands Assessment Scale showed substantial intrarater agreement in both digital and live validations. For the décolleté, a static scale and a dynamic scale were created and validated. The Croma Static Décolleté Wrinkles Assessment Scale showed substantial and almost perfect interrater agreement in the digital and live validations, respectively, and the intrarater agreement in both was almost perfect. The Croma Dynamic Décolleté Wrinkles Assessment Scale showed almost perfect agreement in both validation settings for both interrater and intrarater measures., Conclusions: The Croma Horizontal Neck Lines Assessment Scale and the Croma Static and Dynamic Décolleté Wrinkles Assessment Scales have sufficient interrater and intrarater agreement for justifiable use in clinical and research settings., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Commercial fibrin glue is increasingly finding its way into clinical practice in surgeries to seal anastomosis, and initiate hemostasis or tissue repair. Human biological glue is also being discussed as a possible cell carrier. To date, there are only a few studies addressing the effects of fibrin glue on the cell-molecular level. This study examines the effects of fibrin glue on angiogenesis and lymphangiogenesis, as well as adipose-derived stem cells (ASCs) with a focus on gene and protein expression in scaffolds regularly used for tissue engineering approaches., Methods: Collagen-based dermal regeneration matrices (DRM) were seeded with human umbilical vein endothelial cells (HUVEC), human dermal lymphatic endothelial cells (LECs), or adipose-derived stem cells (ASC) and fixed with or without fibrin glue according to the experimental group. Cultures were maintained for 1 and 7 days. Finally, angiogenic and lymphangiogenic gene and protein expression were measured with special regard to subtypes of vascular endothelial growth factor (VEGF) and corresponding receptors using Multiplex-qPCR and ELISA assays. In addition, the hypoxia-induced factor 1-alpha (HIF1a) mediated intracellular signaling pathways were included in assessments to analyze a hypoxic encapsulating effect of fibrin polymers., Results: All cell types reacted to fibrin glue application with an alteration of gene and protein expression. In particular, vascular endothelial growth factor A (VEGFA), vascular endothelial growth factor B (VEGFB), vascular endothelial growth factor C (VEGFC), vascular endothelial growth receptor 1 (VEGFR1/FLT1), vascular endothelial growth receptor 2 (VEGFR2/KDR), vascular endothelial growth receptor 3 (VEGFR3/FLT4) and Prospero Homeobox 1 (PROX1) were depressed significantly depending on fibrin glue. Especially short-term fibrin effect led to a continuous downregulation of respective gene and protein expression in HUVECs, LECs, and ASCs., Conclusion: Our findings demonstrate the impact of fibrin glue application in dermal regeneration with special regard to angiogenesis and lymphangiogenesis. In particular, a short fibrin treatment of 24 hours led to a decrease in gene and protein levels of LECS, HUVECs, and ASCs. In contrast, the long-term application showed less effect on gene and protein expressions. Therefore, this work demonstrated the negative effects of fibrin-treated cells in tissue engineering approaches and could affect wound healing during dermal regeneration.

Background: Increasing demand for minimally invasive aesthetic treatments, such as injection of biostimulator substances to induce the production of extracellular matrix, has been reported. Recent studies have reported on a variety of different product characteristics influencing the integration and distribution of biostimulator substances after injection., Objectives: The aim of this study was to analyze the ex vivo product integration and distribution behavior of 6 different biostimulator substances after injection., Methods: A total of n = 21 abdominal soft tissue flaps were analysed by real-time ultrasound imaging with regards to horizontal and vertical spread of 6 different injected biostimulator substances-based on hydroxylapatite (HA), polycaprolactone (PCL), and poly-L-lactic acid (PLLA)-immediately after injection and after massaging. The 6 different biostimulator substances were R-CaHA-based, H-CaHA-based, PCL-based, PLLA-1-based, PLLA-2-based and H-HA-based products., Results: Overall, the R-CaHA-, H-CaHA-, and PCL-based substances showed greater product spread after massaging when compared with the product distribution immediately after the injection with all P < .001 with the exception of the vertical dimension of the H-CaHA-based substance (P = .064). The PLLA-1-, PLLA-2-, and H-HA-based substances showed smaller product spread after massaging compared with the product distribution immediately after the injection with all P < .001 with the exception of the horizontal dimension of the H-HA-based substance (P = .314), indicating higher tissue integration., Conclusions: Different biostimulator substances behave differently when injected into subcutaneous soft tissues; differences exist at the level of initial product diffusion and during tissue integration., (© The Author(s) 2023. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background and Objectives : Impaired wound healing represents an unsolved medical issue with a high impact on patients' quality of life and global health care. Even though hypoxia is a significant limiting factor for wound healing, it reveals stimulating effects in gene and protein expression at cellular levels. In particular, hypoxically treated human adipose tissue-derived stem cells (ASCs) have previously been used to stimulate tissue regeneration. Therefore, we hypothesized that they could promote lymphangiogenesis or angiogenesis. Materials and Methods: Dermal regeneration matrices were seeded with human umbilical vein endothelial cells (HUVECs) or human dermal lymphatic endothelial cells (LECs) that were merged with ASCs. Cultures were maintained for 24 h and 7 days under normoxic or hypoxic conditions. Finally, gene and protein expression were measured regarding subtypes of VEGF, corresponding receptors, and intracellular signaling pathways, especially hypoxia-inducible factor-mediated pathways using multiplex-RT-qPCR and ELISA assays. Results: All cell types reacted to hypoxia with an alteration of gene expression. In particular, vascular endothelial growth factor A (VEGFA), vascular endothelial growth factor B (VEGFB), vascular endothelial growth factor C (VEGFC), vascular endothelial growth factor receptor 1 (VEGFR1/FLT1), vascular endothelial growth factor receptor 2 (VEGFR2/KDR), vascular endothelial growth factor receptor 3 (VEGFR3/FLT4), and prospero homeobox 1 (PROX1) were overexpressed significantly depending on upregulation of hypoxia-inducible factor 1 alpha (HIF-1a). Moreover, co-cultures with ASCs showed a more intense change in gene and protein expression profiles and gained enhanced angiogenic and lymphangiogenic potential. In particular, long-term hypoxia led to continuous stimulation of HUVECs by ASCs. Conclusions: Our findings demonstrated the benefit of hypoxic conditioned ASCs in dermal regeneration concerning angiogenesis and lymphangiogenesis. Even a short hypoxic treatment of 24 h led to the stimulation of LECs and HUVECs in an ASC-co-culture. Long-term hypoxia showed a continuous influence on gene expressions. Therefore, this work emphasizes the supporting effects of hypoxia-conditioned-ASC-loaded collagen scaffolds on wound healing in dermal regeneration.

Background: Research is an integral part of academic medicine. In plastic surgery, it sets the course for innovations in the specialty. The purpose of this study is to present the research performance of plastic surgeons in Germany for the period 2021/2022 and to compare it with previous periods., Materials and Methods: The directors of plastic surgical academic institutions reported all requested/approved and rejected research applications to public, non-public and industrial funding organizations. Data was gathered within an established online database. In addition, the DFG´s public database GEPRIS was screened for plastic surgical research grants. Data was also collected regarding research infrastructure and organization at the participating centers., Results: 105 applications were reported to 54 different funding agencies from 20 plastic surgery centers. 37 funding applications were submitted to the major public funding agencies DFG, BMBF, BMWi, BMG, BMVg, G-BA and EU. Of these, 59,5% (22/37) were DFG, 13,5% (5/37) each BMBF and EU, 5,4% (2/37) BMWi, and 2,7% (1/37) each BMG, BMVg, and G-BA applications. The average funding volume of these proposals was 401,515 euros. Approved DFG proposals were most frequently assigned to the review board 205-27 Orthopedics, Trauma Surgery, Reconstructive Surgery (n=10/16, 62,5%). Over time, the research registry shows an increase in the number of proposals in general and those granted. 70,0% (14/20) of participating sites had their own experimental research laboratory, while only 40,0% (8/20) had their own clinical trial center., Conclusion: The 2021/2022 Research Funding Report once again highlights the impressive research accomplishments of the plastic surgery community., Competing Interests: Die Autoren geben an, dass kein Interessenskonflikt besteht., (Thieme. All rights reserved.)

Background: Hand injuries compose up to 30% of all injuries in emergency care. However, there is a lack of epidemiological data reflecting patient or accident-related variables, injury types, injured anatomical structures or trauma localization., Objective: The objective of this study is (1) to provide epidemiological information on hand injuries and their patterns and (2) to visualise the frequencies of affected areas of the hand in relation to the most common trauma mechanisms using color-coded heatmaps., Methods: This prospective single-center observational trial conducted at a surgical emergency department in Germany collected data of hand trauma patients using a standardized documentation form. Demographic data, trauma-related data, diagnostic and therapeutic measures were analyzed. Color-coded heatmaps were generated marking anatomic danger zones., Results: 435 patients with a mean age of 39.5 were included. Most patients admitted on their own initiative (79%). Leisure and sport injuries were most frequent (75%). Digiti II-V were injured most commonly (43%), followed by metacarpals (19%) and the thumb (14%). Blunt trauma and cuts accounted for most injuries (74%). Hand-graphics depicted color-coded frequencies of the affected areas of the palmar and dorsal aspect of the hand for the most common types of injury, as well as the most frequent circumstances of accident. Elective surgery was recommended in 25% of cases, and hand surgical follow-up was proposed in over 50% of cases., Conclusions: The dorsal aspect of the hand including the 5th metacarpal, the radial wrist and thenar region, as well as the fingertips of Digiti II/III represent anatomic danger zones to injury of the hand. Due to the large variety of potentially injured structures, diagnosis and treatment is not trivial. Specific training is required for all surgical specialties in emergency care, to increase quality of diagnostic work-up and management of hand injuries., (© 2022. The Author(s).)

Background: Uncontrolled product spread is an important issue to consider in facial filler injections. Lack of precision can result in reduced effectiveness and surface projection, as well as irregularities and product visibility., Objectives: The authors sought to assess the precision of soft-tissue filler injections in the face by employing a cannula., Methods: This single-center observational study investigated soft-tissue filler distribution utilizing real-time non-invasive ultrasound imaging. Outcome parameters included (1) the tissue plane of product distribution, (2) the extent of horizontal as well as vertical product spread at the injection site, and (3) the product surface area taking into account the multifactorial influence of several independent variables. Participants were followed up to 30 days post-injection., Results: A total 100 facial injections were performed in 8 patients (2 males, 6 females) with a mean age of 37.20 (±6.34) years and a mean BMI of 22.21 (±1.39) kg/m.2. The plane of product distribution remained constant in approximately 90% of cases at day 0 (d0), d14, and d30. Mean horizontal product spread was higher compared with vertical spread, and both significantly decreased over all time points (P < .001). Mean product surface area was 22.51 ± 16.34 mm2 at d0, 15.97 ± 11.28 mm2 at d14, and 12.9 ± 9.15 mm2 at d30. Analysis employing generalized linear models revealed that injection volume and injection depth significantly influenced product surface area., Conclusions: Injection of soft-tissue filler employing a cannula allows precise application of the product within the intended tissue plane. Precision can be improved by injecting less product into deeper tissue layers., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: It is still unclear which facial region contributes most to the perception of an aged face when evaluated by eye-tracking analyses., Objectives: The authors sought to apply eye-tracking technology to identify whether mature faces require longer fixation durations than young faces and which facial region contributes most to the perception of a mature face., Methods: Eye-tracking analyses were conducted in 74 volunteers (37 males, 37 females; 43 ≤ 40 years, 31 > 40 years) evaluating their gaze pattern and the fixation durations for the entire face and 9 facial subregions. Frontal facial images of 16 younger (<40 years) and older (>40 years) gender-matched individuals were presented in a standardized setting., Results: Independent of age or gender of the observer, a younger stimulus image was viewed shorter than an older stimulus image with 0.82 (0.63) seconds vs 1.06 (0.73) seconds with P < 0.001. There was no statistically significant difference in their duration of a stable eye fixation when observers inspected a male vs a female stimulus image [0.94 (0.70) seconds vs 0.94 (0.68) seconds; P = 0.657] independent of the observer's age or gender. The facial image that captured the most attention of the observer (rank 9) was the perioral region with 1.61 (0.73) seconds for younger observers and 1.57 (0.73) seconds for older observers., Conclusions: It was revealed that the perioral region attracts the most attention of observers and contributes most to an aged facial appearance. Practitioners should be mindful of the importance of the perioral region when designing an aesthetic treatment plan., (© The Author(s) 2022. Published by Oxford University Press on behalf of The Aesthetic Society. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Background: Previous clinical and anatomic investigations have identified the clinical relevance of facial biomechanics. Based on this new understanding, principles for facial aesthetic procedures were established: Lateral Face First, Deep Layers First, and Upper Face First., Objective: To test the upper face first principle by showing that an injection sequence, starting in the upper face is superior to an injection sequence starting in the lower face., Methods: This study was designed as an interventional split-face study administering the same amount and type of soft tissue filler for the upper, middle, and lower face but in a different sequence: upper, middle, lower face versus lower, middle, and upper face. A total of 15 patients (5 males and 10 females) with a mean age of 39.4 years (9.6) and a mean BMI of 23.4 kg/m 2 (1.7) were studied. Follow-up at D0, D30, and D90 was conducted utilizing semiquantitative scores and objective 3D imaging., Results: Despite not reaching statistical significance, midfacial volume and jawline contouring were rated better at every follow-up visit (D0, D30, D90) when treated with the upper versus the lower face first injection algorithm. The global aesthetic improvement scale showed statistically significantly better values for the upper face first algorithm when compared to the lower face first algorithm at all evaluated time points with all p < 0.001., Conclusion: Applying the upper face first injection algorithm seems to result in better aesthetic outcomes when directly compared to the lower face first algorithm. Semiquantitative and objective outcome measurements confirm its clinical effectiveness., (© 2022 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Background: Pain of the hand and wrist affects a large patient population. If the onset is unrelated to recent trauma, the first medical contact is rarely established with a specialized hand surgeon., Objective: The objective of this investigation was to (1) visualize the localization of hand pain using pain-related heatmaps in common wrist pathologies, (2) to test whether differences between these pathologies exist with regard to sociodemographic and pain-related aspects, and (3) to evaluate the major patient-reported complaints associated with the pathologies., Methods: This observational cross-sectional study included patients suffering from: thumb basal joint arthritis (CMC-1-OA), dorsal wrist ganglions, and TFCC tears. Patients marked the location of maximum pain projection on hand graphics depicting the outline of the palmar and dorsal hand. Color-graded frequency heat maps were generated for the wrist pathologies investigated. Daily life impairments were assessed and clustered into groups of functions/activities., Results: 120 patients with a mean age of 44.3 years were investigated. The diagnostic groups showed significant differences regarding the level and location of pain, as well as daily life impairments. Patients with CMC-1-OA presented with increased pain levels compared to patients with dorsal wrist ganglions and TFCC tears. Daily life impairment was rated highest when household chores were adversely affected, and sport activities were symptomatic/painful. All groups showed significant skin surface pain projection, which was visualized in heatmaps. While general trends in pain localization were visible, pain levels were also reported distal/proximal and palmar/dorsal to the pathology., Conclusions: Knowledge of main demographic parameters, pain projection, and degree of impairment in daily activities can help physicians to narrow differential diagnosis of wrist pain during first patient contact. Patients should then be referred to hand surgeons for specialist examination, to further differentiate the origin of the pain., (© 2022. The Author(s).)

Background: Age-related changes of facial soft tissue cause clinical signs of facial aging such as lip atrophy, marionette lines, and an accentuated nasolabial fold. These changes can be modified using dermal fillers., Aims: To evaluate efficacy, longevity, and safety of a cross-linked hyaluronic acid-based filler with Tri-Hyal technology in the treatment of lips, nasolabial folds, and marionette lines., Materials and Methods: This prospective, multi-center trial evaluated injections of three different areas (lips, nasolabial fold alone, or with marionette wrinkles) with a soft tissue filler containing 25 mg/ml cross-linked hyaluronic acid and 0.3% lidocaine. Primary endpoint was the aesthetic correction 3 weeks after one injection session without touch-up. Follow-up was 18 months. Assessments were performed using the Global Aesthetic Score (GAS), clinical scoring based on photographic scales, high-frequency ultrasound imaging, and the Global Aesthetic Improvement Scale (GAIS)., Results: In total, 100 subjects were injected. GAS improved significantly for all treatment indications at 3 weeks (p < 0.0001). Success rates were highest for nasolabial folds (98.4%), followed by marionette lines (94.4%) and lips (73.5%). After 18 months post-injection, success was observed in 91%, 88%, and 33% of subjects injected into nasolabial folds, marionette lines, and lips, respectively. GAIS scored highest for nasolabial folds (SGAIS: 71%; IGAIS: 40%), followed by marionette lines (SGAIS: 56%; IGAIS: 33%) and lips (SGAIS: 30%; IGAIS: 22%) at 18 months follow-up., Conclusions: The filler demonstrated high efficacy and safety in all indications. Regional differences in longevity were evident. Thus, the necessity of regional retreatments should be discussed with patients before injection., (© 2022 The Authors. Journal of Cosmetic Dermatology published by Wiley Periodicals LLC.)

Abdominoplasty is a popular procedure in plastic surgery providing aesthetic, functional and psychological relief for patients suffering from excess abdominal tissue. Correct umbilical positioning is crucial for a successful aesthetic surgical outcome. This study aims to assess the most attractive position of the umbilicus by means of subjective and objective outcome measures. 58 Caucasian study participants with a mean age of 36.87 (15.6) years rated eight different umbilical positions. The various positions were determined based on the ratio of the distance between the xiphoid process and the umbilicus and the distance between the umbilicus and the infra-umbilical crease: 1:1, 1.25:1, 1.5:1, 1.75:1, 2:1, 2.5:1, 3:1 and 5.5:1. Semi-quantitative scoring of attractiveness based on a 5-point Likert scale and eye tracking analyses were utilized. The results revealed that the volunteers perceived as most attractive the ratio of 2:1 with 4.32 (out of possible 5.0). The ratio of 5.5:1 received the lowest rating with 1.8. The results of the objective eye tracking analyses confirmed the subjective rating as the 2:1 ratio was fixated last amongst all other displayed ratios with 1.85 s whereas the 5.5:1 ratio had the shortest interval between image display and first stable eye fixation with 0.94 s. The study confirms the concept of ' internal representation of beauty '. Abdominoplasty procedures could rely on this easy to perform ratio by dividing the distance into thirds and using the boundary between the inferior and middle third as a clinically reliable landmark.

Background: Microsurgical tissue transfer revolutionized reconstructive surgery after extensive trauma, oncological resections, and severe infections. Complex soft tissue reconstructions are increasingly performed in multimorbid and elderly patients. Therefore, it is crucial to investigate whether these patients benefit from these complex procedures., Objective: To evaluate the outcome for multimorbid patients who underwent microsurgical soft tissue reconstruction and to identify potential risk factors that may increase mortality., Methods: This single-center study retrospectively analyzed prospectively collected data of patients receiving free gracilis (GM) or latissimus dorsi muscle (LDM) flap reconstruction between September 2017 and December 2021. Cases were divided into two groups (dead vs. alive), depending on patient survival. Patient demographics, comorbidities and medication, perioperative details, free flap outcome, as well as microcirculation were determined., Results: A total of 151 flaps (LDM, n = 67; GM, n = 84) performed in 147 patients with a mean age of 61.15 ± 17.5 (range 19-94) years were included. A total of 33 patients (22.45%) passed away during the study period. Deceased patients were significantly older (Alive: 58.28 ± 17.91 vs. Dead: 71.39 ± 11.13; p = 0.001), were hospitalized significantly longer (Alive: 29.66 ± 26.97 vs. Dead: 36.88 ± 15.04 days; p = 0.046) and suffered from cardiovascular (Alive: 36.40% vs. Dead: 66.70%; p = 0.002) and metabolic diseases (Alive: 33.90% vs. Dead: 54.50%; p = 0.031) more frequently, which corresponded to a significantly higher ASA Score ( p = 0.004). Revision rates (Alive: 11.00% vs. Dead: 18.20%; p = 0.371) and flap loss (Alive: 3.39% vs. Dead: 12.12%; p = 0.069) were higher in patients that died by the end of the study period., Conclusions: Free flap transfer is safe and effective, even in multimorbid patients. However, patient age, comorbidities, preoperative ASA status, and medication significantly impact postoperative patient survival in the short- and mid-term and must, therefore, be taken into account in preoperative decision-making and informed consent.

Background: An increasing demand of minimally-invasive aesthetic procedures of the forehead concomitantly leads to higher numbers of adverse events. Adequate application of anatomical knowledge is required to increase safety and efficacy of different minimally-invasive aesthetic procedures in this anatomical region., Objective: To describe the layered anatomy of the forehead soft tissues with respect to their thicknesses and how they relate to different minimally-invasive aesthetic treatments., Methods: A total of n = 85 healthy study participants (69 females and 16 males) with a mean age of 40.84 ± 10.9 years and a mean body mass index of 22.65 ± 2.6 kg/m 2 were investigated with ultrasound-based imaging to measure the thickness of different forehead soft tissues., Results: The mean overall soft tissue thickness of the forehead was measured to be 4.18 ± 0.7 mm for the entire study population. Increasing BMI values correlated statistically significantly with increasing thickness of all measured forehead soft tissues with exception of the frontalis muscle. On a statistically significant level, males showed thicker forehead soft tissues than females, with exception of the retrofrontalis fat and the frontalis muscle., Conclusion: On basis of the findings obtained in this study, basic treatment principles can be derived and improved for the injection of neuromodulators, hyaluronic acid as well as the application of polydiaxonane (PDO) threads and micro-focused ultrasound. Precise knowledge and thorough understanding of the layers and soft tissues of the forehead is required to guarantee safe and effective procedures in this aesthetically important facial region., (© 2022 Wiley Periodicals LLC.)

Background: Polyurethane film dressings are commonly applied for coverage of split-thickness skin graft donor sites, although previous studies have suggested reduced morbidity using a polylactic acid membrane. To further investigate the optimal treatment approach, the authors compared outcomes of donor sites in patients receiving either polylactic acid membrane or polyurethane film., Methods: This randomized clinical trial allocated patients requiring split-thickness skin grafting to receive either polylactic acid membrane or polyurethane film at the donor site. The primary endpoint was difference in donor-site scar appearance between groups 3 months postoperatively, using the Vancouver Scar Scale. Secondary endpoints included pain, number of and time required for wound dressing changes, and costs related to the wound dressing., Results: Thirty patients were allocated to each group. The median Vancouver Scar Scale score was lower for patients receiving polylactic acid membrane [polyurethane film, 3 (interquartile range, 2 to 4); polylactic acid membrane, 2 (interquartile range, 1 to 3); p = 0.049]. Pain during change of wound dressing (polyurethane film, 2.0 ± 0.2; polylactic acid membrane, 0.5 ± 0.2; p < 0.001) and mobilization (polyurethane film, 0.8 ± 0.2; polylactic acid membrane, 0.3 ± 0.1; p = 0.032) were reduced in the polylactic acid membrane group. Patients with polylactic acid membrane required fewer dressing changes per day of hospital stay (polyurethane film, 0.44 ± 0.06; polylactic acid membrane, 0.28 ± 0.02; p = 0.015). Mean time for wound dressing changes per patient was higher in the polyurethane film group (polyurethane film, 74.50 ± 5.72 minutes; polylactic acid membrane, 21.43 ± 2.61 minutes; p < 0.001). Costs were higher in the polylactic acid membrane group (polyurethane film, €67.83 ± €5.56; polylactic acid membrane, €162.79 ± €21.76; p < 0.001)., Conclusion: Polylactic acid membrane improves outcome of split-thickness skin grafting donor sites; however, higher treatment costs must be taken into consideration., Clinical Question/level of Evidence: Therapeutic, II., Competing Interests: Disclosure:The authors have no commercial associations or financial disclosures that might pose or create a conflict of interest with the methods applied or the results presented in this article ., (Copyright © 2022 by the American Society of Plastic Surgeons.)

Background:  The risk for vascular complications is the highest within the first 24 hours after free flap transfer. Clinical signs of critical perfusion are often recognized with time delay, impeding flap salvage. To detect failing flaps as soon as possible and to prevent persisting microvascular impairments, knowledge of physiological perfusion dynamics in free flaps is needed. Aim of this study was to investigate the physiological perfusion dynamics of viable free flaps using the Oxygen to See (O2C) device for continuous monitoring., Methods:  Microcirculation was continuously monitored in 85 viable free flaps over a period of up to 72 hours following microvascular anastomosis using tissue spectrophotometry and laser Doppler flowmetry (O2C, LEA Medizintechnik, Gießen, Germany). The parameters investigated included capillary-venous blood flow (flow), oxygen saturation (SO 2 ), and relative amount of hemoglobin (rHB)., Results:  Microcirculatory blood flow increased significantly overall, especially within the first 18 hours after microsurgical anastomosis, after which peak formation was occurred. Mean values of SO 2 showed a decreasing trend and the steepest decrease of SO 2 (slope: 1.0) occurred during the steepest increase of flow between 3 and 6 hours (slope: 4.7) postanastomosis. The rHB values remained fairly constant throughout the study period., Conclusion:  Hyperemia after free flap transfer accounts for a significant increase of microvascular flow. Tissue oxygenation is reduced, likely due to an increase of oxygen consumption after anastomosis. A better understanding of physiological perfusion dynamics in free flaps can aid surgeons in recognizing compromised vasculature earlier and improve free flap salvage., Competing Interests: None declared., (Thieme. All rights reserved.)

The number of soft tissue filler injections performed by aesthetic injectors has continued to increase over the last few years. To provide a high standard of safety and achieve individualized, reproducible, and long-lasting outcomes, aesthetic injectors must have a solid foundation in anatomy, facial biomechanics, rheology, and injection biomechanics. Adverse events associated with soft tissue filler injections can be severe, especially if the aesthetic injector unintentionally injects the soft tissue filler into the patient's arterial vascular circulation and the administered product reaches the arterial bloodstream. Although the face has a rich arterial vascular supply that may seem overwhelmingly complex, it can be broken down systematically according to its internal and external vascular territories. To provide guidance for aesthetic practitioners performing minimally invasive facial injections for aesthetic purposes, this narrative article will discuss the course, depth, and branching pattern of the facial arteries based on the most frequently injected anatomical regions. In this article, we focus on vascular safe zones rather than danger zones ., Competing Interests: The authors declare no potential conflicts of interest with respect to the research, authorship, and publication of this article., (Copyright © 2022 International Society of Plastic and Aesthetic Nurses. All rights reserved.)