Sentimos muito, mas esse site sé funciona com Javascript. Impresso por Princesss, CPF 053.150.176-05 para uso pessoal e privado. Este material pode ser protegido por direitos autorais ¢ no pode ser reproduzido ou repassado para terceiros. 10/12/2020 22:45:04 Anatomy Behind the Facial Overfilled Syndrome: The Transverse Facial Septum Sepastian CoTorana, MD, PuD,** Roserr H, Gorxiy, MD,' Konstantin Frank, MD,‘ ‘Nirusa Lacuman, PuD,! an Tuto L. Scuencx, MD, PHD‘ BACKGROUND The midface is an area of high demand for minimally invasive cosmetic procedures, that is, softtissue filler injections. OBJECTIVE To investigate the functional anatomy behind the facial overfilled syndrome observed after soft- tissue filler injections. MATERIALS AND METHODS The clinical part of the study enrolled 25 volunteers (12 men and 13 women, Caucasians); the anatomical part included 72 fresh frozen cephalic specimens obtained from 32 male and 40 female body donors. 3D surface scanning procedures were applied to calculate the maximal anterior projection of the midtface. RESULTS Upon smiling, the point of maximal anterior projection shifted cranially in men by 12.43 + 8.8 mm (difference between resting and smiling; p < 001) and by 8.75 + 4.1 mm in women (p < .001). Cadaveric dissactions identified a septum originated from the underside of the 2ygomaticus major muscle forming a transversely running boundary between the buccal space and the deep midfacial fat compartments. CONCLUSION Facial overfilled syndrome can potentially be explained by the presence of the transverse facial septum. Dynamic filling—injecting small amounts of filler and asking the patient to smile repeatedly during the procedure—seems to be a viable way to avoid this adverse event during soft-tissue filler injection, The authors have indicated no significant interest with commercial supporters. the number of cosmetic surgical and minimally _In 2016, Pessa reported on adhesions of the superfi- invasive cosmetic procedures performed in the United States is constantly growing. According to the 2018 ASDS procedures survey statistics, the number cof minimally invasive cosmetic procedures increased by 78% from 2012, reaching 1.6 million procedures performed in the US in 2018.! Patients desire a younger look without the telltale signs of any cosmetic intervention, and they expect a natural appearance that doesnot alter their facial expression2-*The gap between patient expectations and the ability of physicians to deliver a realistic cosmetic result is sometimes large, but recent advances in knowledge of functional facial anatomy is helping to narrow this gap.*” cial musculoaponeurotic system with deeper planes when trying to highlight the importance of anatomy for facial aging, Three vertically oriented, that is, from bone to skin oriented, “membranes” that cross the midface were mentioned: the upper boundary of the of the suborbicularis oculi fat (SOOF?**°—correspond- ing to the orbicularis retaining ligament," the inferior boundary of the SOOF—corresponding to the zyg0- maticocutaneous ligament—and a third “membrane” separating the deep midfacial fat compartments" from the buccal space.* In the same year, the latter membrane was also mentioned in a commentary by Kim and Hwang,” and this membrane was *Division of Anatom, Department of Medical Education, Albany Medical College, Albany, New York ‘Divison of Plastic Surgery, Department of Surgery, Albany Medical Center, Albany, New Yorks ‘Private Practice, New York City, New York; Department for Hand, Plastic and Aesthetic Surgery, Ludwig—Maximilian University, Munich, Germany; | Mayo. Clinic College of Medicine and Science, Mayo Clinic, Rochester, Minnesota (© 2019 by the American Society for Dermatologic Surgery, Ine. Published by Wolters Kkaver Heal, Inc. All rights reserved, ISSN: 1076-0512 © Dermatol Surg 2019;00:1-8 © DOI: 10.1097/DSS,0000000000002236Impresso por Princesss, CPF 053.150.176-08 para uso pessoal e privado. Este material pode ser protegido por direitos autorais e no pode ser reproduzido ou repassado para terceiros. 10/12/2020 22:45:04 additionally described to have connections to the zygomaticus major muscle." ‘The current understanding of facial anatomy is based on the concept of 5 different and distinct anatomic layers, parallel tothe skin surface, which form the fatty and fascial soft-tissue envelope of the face.” Verti- cally oriented septae or “membranes” that cross the midface and run perpendicular to the regular S layers are not new to the scientific community. They have been introduced previously*"*"* but have not been incorporated into a general concept which includes ‘muscles, fat, ligaments, and skin. Incorporating these vertically oriented structures into a general concept of facial anatomy would increase the authors? under. standing, especially as it relates to the biomechanics of facial expression. This anatomical understanding is needed to guide minimally invasive cosmetic proce- dures toward more natural outcomes with less telltale signs of any type of intervention. ‘Therefore, the aim of this study is to objectively investigate the biomechanics of vertically oriented structures of the midace with a specific emphasis on °2 This aesthetic the facial overfilled syndrome. condition can be classified as an adverse event after excessive soft-tissue filler injection into the midface leading to an unbalanced alteration of 0 facial anatomy.?" The goal of erie study is to inerease the understanding of facial e functional is clinical and cadav- biomechanics and to guide health care professionalsin their surgical and nonsurgical techniques. Material and Methods Study Sample ‘The clinical part of the study enrolled 25 volunteers, and patients of the Department for Hand, Plastic, and Aesthetic Surgery, Ludwig- Maximilian University Munich, Germany. All were of Caucasian ethnic background (12 men and 13 women) and had a mean age of 41.0 + 14.1 years. Written informed consent and approval from the Ethies Committee of the Ludwig-Maximilian University Munich (Reference Number 266-13) was obtained before start of the study. The measurements were conducted in accor- dance with the Declaration of Helsinki protocols (1996) and with the regional laws and good clinical practice, Individuals were not included in the study if any type of previous trauma, surgery, irradiation, or any other intervention affected the anatomical integ- rity of the face The anatomicalicadaveric part of the study was con ducted in 72 fresh frozen cephalic specimens obtained from 32 male and 40 female body donors having a mean age of 75.2 + 10.9 years.” Informed consent was obtained from each body donor while alive, including permission for use in medical and scientific studies. Cephalic specimens were not included in the study ifrecords indieated any type of previous trauma surgery, irradiation, or any other intervention affect ing the anatomical integrity of the face. The method- ology applied conforms to the laws of the country where this part ofthe study was conducted (Austria). Clinical Imaging Midfacial surface scanning was performed applying 3D surface scanning procedures using the Vectra X3 tific, Inc. Fairfield, NJ). Con- secutive photographs of faces of study participants were taken at rest (baseline image) and when smiling {follow-up image). Differences in surface projection between the baseline image and the follow-up image were calculated using the surface-to-surface root mean square analysis and the iterative closest point algo rithm inchuded in the Mirror Software Suite (Canfield Scientific, Ine, Fairfield, NJ}. A.maximal mean surface deviation of 0.1 mm was tolerated. All surface scan ning procedures were conducted by the same investi- gator (K.P). camera (Canfield Sci Anatomical Dissection Cephalic specimens were dissected and objectively investigated at che Surgical Course Center, Salzburg, Austria. The dissection procedure was based on layer- by-layer identification of facial structures. ‘The zyg0- maticus major muscle was identified, and relationships with surrounding structures, especially the deep facial fat compartments and motor branches of the facial nerve and the parotid duct, were analyzed,