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Background: Aesthetic soft-tissue filler injections for lip enhancement are popular and performed throughout the world. When injecting lips with a cannula, as the cannula is advanced, resistance is perceived in consistent locations, potentially indicating boundaries between intralabial compartments., Objective: We aimed to investigate whether intralabial compartments exist and, if so, to describe their volumes, location, boundaries, and dimensions., Methods: This cadaveric study investigated a total of 20 human body donors (13 male, seven female) with a mean (SD) age at death of 61.9 years (23.9) and body mass index of 24.3 kg/m 2 (3.7). The investigated cohort included 11 White donors, eight Asian donors, and one Black donor. Dye injections simulating minimally invasive lip treatments were conducted., Results: Independent of sex or race, six anterior and six posterior compartments in the upper and lower lip were identified, for a total of 24 lip compartments. Compartment boundaries were formed by vertically oriented septations that were found in consistent locations. The anterior compartments had volumes ranging from 0.30 to 0.39 cc; the posterior compartment volume ranged from 0.44 to 0.52 cc. The compartment volumes were larger centrally and decreased gradually toward the oral commissure., Conclusions: The volume and size of each of 24 compartments contribute to the overall appearance and shape of the lips. To achieve a natural lip shape preserving aesthetic outcome it may be preferable to administer the volumizing product using a compartment-respecting injection approach., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Background: Demand for lip filler injection continues to increase. Despite the current literature's acknowledgement of the role both venous and arterial vasculature play in minor and major side effects, research addressing the venous vasculature of the lower one-third of the face is scarce., Methods: A photographic analysis of the venous vasculature of 26 participants was performed using a vein transilluminator to display the venous flow around the perioral region. The data were analyzed for commonalities among participants and then compared with common lip filler injection techniques and locations., Results: Venous tributaries were identified in all patients, with slight variation in pattern, superior to the upper vermilion border between the nasolabial fold and philtral column on each side of the mouth. Venous tributaries were noted approximately 1 to 1.5 cm lateral to the oral commissures extending inferiorly to the chin and along the labiomental crease. Four areas of venous pooling were deemed significant: a small area approximately 2 mm superior to the Cupid's bow, along the middle tubercle of the upper lip, along the wet-dry line of the lower lip; and centrally along the vermilion border between the lower lip tubercles., Conclusions: Perioral venous mapping provides a guide for injectors performing lip enhancement procedures in identifying areas at risk for injury because of venous pooling. Avoiding these anatomically vulnerable regions can minimize the potential for inflammation and ecchymosis associated with intravenous injection and prevent dissatisfactory aesthetic results because of lumps, excessive bruising, swelling, or asymmetry., (Copyright © 2023 by the American Society of Plastic Surgeons.)

Strong command of facial anatomy is paramount for all facelift surgeons. A comprehensive understanding of how aging impacts facial anatomy is equally important for effective preoperative evaluation of the patient undergoing facelift surgery. Key areas for assessment of the patient undergoing facelift surgery are addressed. This article highlights and summarizes the high-yield anatomic pearls in facelift surgery, particularly in sub-SMAS (superficial musculoaponeurotic system) dissection techniques. Emphasis is placed on the depth and transitions of the facial nerve branches and the sub-SMAS potential spaces and their role in deep plane facelift dissection. Key anatomic structures in the deep neck are described., (Copyright © 2022 Elsevier Inc. All rights reserved.)

Background: Current techniques for temple volumization primarily focus on deep or superficial targets. Further anatomical exploration of intermediate injection targets is warranted., Objectives: The purpose of this study was to examine the anatomy of the intermediate temporal fat pad (ITFP) as it relates to filler injection procedures and to explore the utilization of ultrasound technology for clinical localization., Methods: Ultrasound technology was utilized to identify and inject red dyed hyaluronic acid filler into the ITFP in 20 hemifacial fresh cadavers. Cross-sectional dissection was performed to confirm injection accuracy and document pertinent anatomical relationships. The same technique was performed in a single clinical patient case employing ultrasound guidance and injectable saline., Results: The ITFP is a quadrangular structure located in the anterior-inferior bony trough. The ITFP is supplied by a middle temporal artery branch and encased between the superficial and deep layers of deep temporal fascia. In 18 of 20 (90%) injections performed under ultrasound guidance, the injected product was accurately delivered to the substance of the ITFP, and in 2 of 20 (10%), the product was found immediately below the deep layer of deep temporal fascia within the temporalis muscle. In the single clinical case, saline was successfully injected in the ITFP under ultrasound guidance., Conclusions: The ITFP is a consistent anatomical structure in the anterior-inferior trough of the temporal fossa. Ultrasound technology can be utilized to identify and inject the fat pad. Further clinical evaluation will determine the role of this fat pad as a potential intermediate injection target for temple volumization procedures., (© 2021 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: The marginal mandibular branch (MMBr) of the facial nerve is the least likely to recover from injury due to infrequent anastomosis with other branches. The MMBr has been described as coursing superior to the inferior border of the mandible. However, studies have reported variations in its location in embalmed and fresh specimens. It has been postulated that the embalming process may effect its anatomic position., Objectives: The aim of this study was to re-evalulate the location of the MMBr relative to the inferior border of the mandible in both fresh and embalmed cadavers, and investigate variation in its position with sex, side of the face, and age., Methods: Superficial fascial planes were dissected to reveal the MMBr and its anatomic relations. Distance between the most inferior branch of the MMBr and the antegonial notch were measured bilaterally. The most inferior position of the MMBr between the antegonial notch and gonion was measured. Fresh heads were used as a comparison, with an additional measurement taken of the distance between the MMBr and the gonial angle., Results: The MMBr was located inferior to the border of the mandible (90.3%) more often than above (9.6%). No significant differences were found between fresh and embalmed cadavers, sex, side of body, or age (P > 0.05). No significant difference was found between intact cadavers and fresh heads (P > 0.05)., Conclusions: This study confirms and describes reliable landmarks for safety zones for the MMBr during plastic and reconstructive surgery of the lower face and upper neck. These data add reliability to studies that have investigated nerve locations in embalmed cadavers., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: The anterior or submental necklift has been well described. Long-term results have been demonstrated in patients with minimal, mild, and moderate skin excess. It relies on the skin's unique ability to contract once separated from its attachments and further enhances the surgical result with treatment of the intermediate layer- subplatysmal fat, anterior digastric, submandibular gland, and platysma. Treatment of this layer differentiates this operation from liposuction and offers benefits beyond liposuction alone., Objectives: The authors sought to assess the long-term success of the anterior necklift for neck rejuvenation and determine its utility in patients with severe cervicomental angles., Methods: This was a single-surgeon, retrospective review of patients who underwent an isolated anterior necklift with no additional procedures between 1998 and 2017. Pre- and postprocedure photographs were scrambled and examined by independent evaluators grading the change in cervicomental angle based on the Knize scale. The reduction in apparent age was calculated utilizing the validated apparent age assessment scale., Results: Twenty-seven patients were evaluated (42% mild and 58% moderate to severe necks preoperatively). The average follow-up was 24.7 months. There was an average 3.6-year age reduction and 1.0-grade improvement in all patients. In moderate to severe necks, there was a 3.9-year age reduction and 1.4-grade improvement in the cervicomental angle following surgery., Conclusions: This study demonstrates the effectiveness of the operation in improving the cervicomental angle and reducing the overall apparent age of patients, even more so in severe cases. The operation is an option for patients who desire neck improvement but are unwilling to undergo a facelift., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Background: Masculinization of the face is a common finding in facelift patients. It is attributed to deflation and decent of the midface-jowls coupled with skin laxity. Fullness is evident lateral to the jowl in a small percentage due to prominent buccal fat pad (BFP)., Objectives: The authors sought to examine the anatomy of the BFP, triangulate the prominent BFP with surgical landmarks, and describe an external approach to excise the BFP during facelift surgery., Methods: Eighteen cadaveric dissections were performed. Facelift flap was elevated and the prominent buccal extension of the BFP protruding through the superficial-musculo-aponeurotic-system was identified. Measurements were taken from the BFP to surgical landmarks: zygomatic arch, tragus, and gonial angle. The locations of the facial nerve, parotid duct, and vascular pedicle relative to the BFP were calculated., Results: BFP was 4.1 cm inferior to the zygomatic arch, 7.5 cm anterior the tragus, and 4.5 cm medial the gonial angle. The middle facial artery supplied the BFP on the inferior-lateral quadrant in 61% and inferior-medial quadrant in 39% of specimens . In all specimens, the parotid duct traversed the BFP superiorly, and the buccal branches of the facial nerve traversed the capsule superficially., Conclusions: The buccal extension of the BFP can pseudoherniate in the aging face. Excision may improve lower facial contour. Measurements from facial landmarks may help surgeons identify the buccal extension of the BFP intraoperatively. The surgeon must be careful of the vascular pedicle, parotid duct, and the facial nerve. The external approach safely excises buccal fat during facelift dissection while avoiding intraoral incisions and unnecessary contamination., (© 2020 The Aesthetic Society. Reprints and permission: journals.permissions@oup.com.)

Introduction: Patients who have previously undergone superficial parotidectomy may also seek facelift surgery for facial aging and rejuvenation. These patients present unique challenges compared to a standard facelift patient. Most concerning is the location of facial nerve branches, which may be superficial and displaced. In addition, significant contour deformities and abnormal scar patterns may be present. The purpose of the study is to review our series of patients and assess potential morbidity and safety of facelift surgery in superficial parotidectomy patients., Methods: A retrospective case series was performed reviewing all patients who underwent facelift surgery following superficial parotidectomy from 2000 to 2017. Data were collected for: postoperative facial nerve deficit, soft tissue contour and scar deformities, facelift technique, ancillary soft tissue augmentation procedures and pre- and postoperative photographs. An evidence-based treatment algorithm to address specific problems in this patient population was developed., Results: A total of seven patients were identified who underwent facelift surgery following parotidectomy. Patients underwent one of the standard SMAS procedure on the non-parotidectomy side, and surgical modifications were made to address the parotidectomy side; soft tissue augmentation was performed in two patients. Precautions to identify the facial nerve and prevent injury, including nerve monitoring and stimulation, were utilized in all seven patients. No permanent postoperative facial nerve injury was noted., Conclusion: Facelift following superficial parotidectomy was safely performed in all cases. Special consideration should be given to contour deformities, facial nerve location and scar placement. However, if approached properly, these patients can still be considered as suitable candidates for facelift surgery., Level of Evidence Iv: 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.

Background: Anatomy of the frontal branch of the facial nerve relative to the zygomatic arch and the superficial musculoaponeurotic system (SMAS) has been well described. The variability centers on the location where the frontal branch traverses from a deeper to more superficial plane in the SMAS. The goal of this study is to examine the depth transition of the frontal branch of the facial nerve relative to the zygomatic arch with hopes of pinpointing a caution zone for dissection to avoid nerve injury., Methods: The frontal branch of the facial nerve was dissected in 36 hemifacial fresh cadaver specimens. Pitanguy's line, the zygomatic arch, and temporal crest were marked. Measurements were taken from the zygomatic arch to the location where the frontal branch pierced the temporoparietal fascia. Locations of the superficial temporal artery (STA), the frontal branch cross relative to the lateral orbital rim and frontalis muscle were also measured., Results: In 94.4% ( n  = 36) of the specimens, the frontal branch was found to transition to an intra-SMAS plane approximately 9.6 mm above the zygomatic arch. In all specimens, the frontal branch transitioned to an intra-SMAS plane approximately 12.2 mm posterior to Pitanguy's line., Conclusions: This study describes a surgical "caution zone" centered on a point 9.6 mm above the arch and 12.2 mm posterior to Pitanguy's line, and related to the anterior branch of the STA. We hope this anatomical detail will help to decrease the likelihood of intraoperative injury to the frontal branch of the facial nerve., Competing Interests: Dr. Surek is a consultant for Galderma, Allergan, and Cypris Medical., (© 2019 Published by Elsevier Ltd on behalf of British Association of Plastic, Reconstructive and Aesthetic Surgeons.)

Facial volumization with filler and/or fat has become an integral part of global facial rejuvenation and provides a finishing touch to harmonize the face after surgical repositioning of soft tissue. However, facial injection is not devoid of complications that can lead to suboptimal outcomes. This article journeys through the facial anatomy for the injector emphasizing the superficial musculoaponeurotic system as a centralized depth gauge facilitating navigation into deep and superficial injection targets. Based on this principle, the fat compartments, ligaments, potential spaces, and neurovascular structures are categorized into planes to assist the injector in performing safe and accurate volume correction., (Copyright © 2019 Elsevier Inc. All rights reserved.)

While blindness after hyaluronic acid gel filler injection occurs only very rarely, it represents a devastating complication for the patient and the surgeon. Retrobulbar injection with hyaluronidase is the only known potential means of reversing this adverse event. However, positive outcomes remain anecdotal. We have attempted to review the current literature regarding possible efficacy and detail the indications and technique to be utilized, if hyaluronidase retrobulbar injection is to be attempted. 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 .

Background: Current literature suggests that preserving the lobular branch of the great auricular nerve has greater impact on sensory function of the auricle than preservation of the posterior branch during rhytidectomy. However, no methodology exists to efficiently and accurately determine the topographic location of the lobular branch. This study describes the branching characteristics of the lobular branch and algorithmic surface markings to assist surgeons in preservation of the great auricular nerve during rhytidectomy flap elevation., Methods: The lobular branch was dissected in 50 cadaveric necks. Measurements were taken from the lobular branch to conchal cartilage, tragus, and antitragus. The anterior branch was measured to its superficial musculoaponeurotic system insertion, and the posterior branch was measured to the mastoid process. The McKinney point was marked and the great auricular nerve diameter was recorded. Branching pattern and location of branches within the Ozturk 30-degree angle were documented. Basic statistics were performed., Results: The lobular branch was present in all specimens and distributed to three regions. In 85 percent of specimens, the lobular branch resided directly inferior to the antitragus; in the remaining specimens, it was located directly inferior to the tragus. Preoperative markings consisting of two vertical lines from the tragus and antitragus to the McKinney point can be used to outline the predicted location of the lobular branch., Conclusions: This study delineates the location of the lobular branch of the great auricular nerve. The authors translate these findings into a quick and simple intraoperative marking, which can assist surgeons in avoiding lobular branch injury during rhytidectomy dissection.

Background: The purpose of this study was to examine the anatomical principles of lip structure as they relate to individualized lip enhancement procedures and to describe a technique that does not violate lip mucosa during injection., Methods: A retrospective analysis of patients undergoing lip enhancement procedures between 2001 and 2014 was performed. Preprocedural and postprocedural photographs were analyzed for lip subunit changes. A stepwise treatment algorithm targeting specific anatomical subunits of lip is described., Results: Four hundred ten patients were treated with a "no-touch" technique for lip enhancement. Lip profile is determined by the position of the white roll. The white roll is accessed by a 30-gauge needle at a point 5 mm lateral to the oral commissure and at the base of the philtral columns. Lip projection is established by vermilion formation contributing to the arc of the Cupid's bow. To improve projection, the labial commissure is entered with a 25-gauge cannula and tunneled into the submucosal space between the white and red rolls. Lip augmentation is a direct reflection of the prominence of the red line and can be approached in a perpendicular fashion with a needle or cannula descending to the level of the wet-dry junction., Conclusions: Accurate assessment of the white and red rolls, arc of Cupid's bow, philtrum, and gingival show can guide the injector on the proper enhancement that individual patients require. The no-touch technique minimizes mucosal trauma. Tailoring treatment toward lip profile, projection, and/or augmentation can yield predictable and reproducible outcomes in this commonly performed cosmetic procedure.

Background: Given the widespread use of facial fillers and recent identification of distinct facial fat compartments, a better understanding of three-dimensional surface changes in response to volume augmentation is needed. Advances in three-dimensional imaging technology now afford an opportunity to elucidate these morphologic changes for the first time., Methods: A cadaver study was undertaken in which volumization of the deep medial cheek compartment was performed at intervals up to 4 cc (n = 4). Three-dimensional photographs were taken after each injection to analyze the topographic surface changes, which the authors define as the "augmentation zone." Perimeter, diameter, and projection were studied. The arcus marginalis of the inferior orbit consistently represented a fixed boundary of the augmentation zone, and additional cadavers underwent similar volumization following surgical release of this portion of the arcus marginalis (n = 4). Repeated three-dimensional computer analysis was performed comparing the augmentation zone with and without arcus marginalis release., Results: Volumization of the deep medial cheek led to unique topographic changes of the malar region defined by distinct boundaries. Interestingly, the cephalic border of the augmentation zone was consistently noted to be at the level of the arcus marginalis in all specimens. When surgical release of the arcus marginalis was performed, the cephalic border of the augmentation zone was no longer restricted., Conclusions: Using advances in three-dimensional photography and computer analysis, the authors demonstrate characteristic surface anatomy changes in response to volume augmentation of facial compartments. This novel concept of the augmentation zone can be applied to volumization of other distinct facial regions., Clinical Question/level of Evidence: Therapeutic, V.

Background: The study was conducted to construct an anatomically inspired midfacial analysis facilitating safe, accurate, and dynamic nonsurgical rejuvenation. Emphasis is placed on determining injection target areas and adverse event zones., Methods: Twelve hemifacial fresh cadavers were dissected in a layered fashion. Dimensional measurements between the midfacial fat compartments, prezygomatic space, mimetic muscles, and neurovascular bundles were used to develop a topographic analysis for clinical injections., Results: A longitudinal line from the base of the alar crease to the medial edge of the levator anguli oris muscle (1.9 cm), lateral edge of the levator anguli oris muscle (2.6 cm), and zygomaticus major muscle (4.6 cm) partitions the cheek into two aesthetic regions. A six-step facial analysis outlines three target zones and two adverse event zones and triangulates the point of maximum cheek projection. The lower adverse event zone yields an anatomical explanation to inadvertent jowling during anterior cheek injection. The upper adverse event zone localizes the palpebral branch of the infraorbital artery. The medial malar target area isolates quadrants for anterior cheek projection and tear trough effacement. The middle malar target area addresses lid-cheek blending and superficial compartment turgor. The lateral malar target area highlights lateral cheek projection and locates the prezygomatic space., Conclusions: This stepwise analysis illustrates target areas and adverse event zones to achieve midfacial support, contour, and profile in the repose position and simultaneous molding of a natural shape during animation. This reproducible method can be used both procedurally and in record-keeping for midface volumizing procedures.

Cervical esophageal perforation is a rare and life-threatening condition. Its prompt diagnosis and treatment require a high index of suspicion. Cervical spine hardware is an uncommon cause of posterior esophageal perforation. Management has included a variety of musculofascial flaps for surgical repair. We present 2 cases of cervical esophageal perforation induced by spinal hardware that were repaired with a superior omohyoid muscle (SOM) flap for closure and/or primary closure reinforcement. Advantages and techniques of the SOM flap are discussed.

The anterior cruciate ligament (ACL) of the knee and the function of its anteromedial (AM) and posterolateral (PL) bundles are a focus of orthopedic research. Because of the probability that third-year and fourth-year osteopathic medical students will encounter ACL injuries during clinical rotations, it is of paramount importance that students fully understand the functions of the AM and PL bundles as 2 distinct functional components of the ACL. The authors assess the degree to which the AM and PL bundles are discussed within basic science curricula at colleges of osteopathic medicine (COMs). In September 2008, a 6-question survey addressing various aspects of ACL education was mailed to instructors of lower-extremity anatomy at all 28 COMs that existed at that time. Nine of the 21 responding institutions (42.9%) indicated that both the AM and PL bundles of the ACL are discussed within their basic science curricula. Four of these 9 COMs indicated that their instruction mentions that the bundles are parallel in extension and crossed in flexion. Nine of the 21 responding COMs (42.9%) indicated that they instruct students that the AM bundle is a major anterior-posterior restrictor, and 12 (57.1%) indicated that they instruct students that the PL bundle is the major rotational stabilizer of the ACL. In 7 of the 21 responding COMs (33.3%), the AM and PL bundles are identified via direct visualization during anatomic dissection of the ACL. The authors conclude that their findings suggest the need for enhanced presentation of the AM and PL bundles within the basic science curricula at COMs to provide osteopathic medical students with a more comprehensive education in anatomy.

The cerebellopontine angle (CPA) poses a surgical challenge due to the complexity and variation of its associated structures. This study examined the relationship between the glossopharyngeal nerve (CN IX) and the acousticofacial complex (AFC). Retrosigmoid suboccipital dissections were preformed on 10 cadaveric specimens. A triangle formed by the AFC, CN IX, and the skull base was consistently observed. The cisternal portions of the AFC and CN IX formed two sides of the triangle. The base was formed by a line traversing the respective dural portals of these nerves at the skull base. Triangular proportions were utilized to predict distances from five points along the course of CN IX to a corresponding point along the course of the AFC. Predicted distances were not statistically different when compared with cadaveric measurements in all 10 specimens (p > 0.05). A table of predicted distances between CN IX and the AFC at all five points along CN IX was developed, revealing a quantitative model to predict the native location of the AFC in the lateral pontine cistern. The triangle and predicted location of the AFC can serve as points of reference for the identification and preservation of these structures in CPA surgery.

The purpose of this study was to locate the infraorbital, supraorbital, and mental foramina by using palpable anatomical landmarks that are conducive to surgical use. Fourteen embalmed cadavers (27 sides) were dissected to expose the supraorbital, infraorbital, and mental foramina. Measurements were made from the lateral orbital rim at the zygomaticofrontal (ZF) suture to both the supraorbital and infraorbital foramina. The distance from the inferior orbital rim at the zygomaticomaxillary (ZM) suture to both foramina was also measured. The distance to the mental foramen was measured from the angle and the inferior border of the mandible. The supraorbital foramen was located 26.2 +/- 2.8 mm medial and 13.5 +/- 3.7 mm superior to the ZF suture. The infraorbital foramen was located 23.8 +/- 3.1 mm medial and 30.9 +/- 3.8 mm inferior to the ZF suture, on average. Vertical measurements made from the ZM suture to the supraorbital foramen averaged 34.4 +/- 3.6 mm and from the ZM suture to the infraorbital foramina averaged 7.6 +/- 2.2 mm. The mental foramen was 64.2 +/- 6.4 mm medial to the angle of the mandible and 12.9 +/- 1.6 mm superior to the inferior border of the mandible. This study provides data that may be useful in predicting the location of the supraorbital, infraorbital, and mental foramina using palpable landmarks. These data may be particularly helpful for surgery in patients with missing teeth or fractures of the maxillary bone. Clin. Anat., 2010. (c) 2009 Wiley-Liss, Inc.