BACKGROUND: Recent research introduced the concept of the \"line of convergence\" as a guide for injectors to enhance precision and avoid complications when treating the frontalis muscle with toxins. However, currently, no pre-injection ultrasound scanning is employed to increase precision and reduce adverse events when searching for the line of convergence.
OBJECTIVE: To explore the feasibility and practicality of implementing pre-injection ultrasound scanning into aesthetic neuromodulator treatments of the forehead.
METHODS: The sample of this study consisted of n = 55 volunteers (42 females and 13 males), with a mean age of 42.24 (10.3) years and a mean BMI of 25.07 (4.0) kg/m2. High-frequency ultrasound imaging was utilized to measure the thickness, length, and contractility of the frontal soft tissue and to determine the precise location of the line of convergence during maximal frontalis muscle contraction.
RESULTS: The results revealed that the line of convergence was located at 58.43% (8.7) of the total forehead height above the superior border of the eyebrow cilia without a statistically significant difference between sex, age, or BMI. With frontalis muscle contraction, the forehead shortens in males by 25.90% (6.5), whereas in females it shortens only by 21.74% (5.1), with p < 0.001 for sex differences.
CONCLUSIONS: This study demonstrated the feasibility and practicality of pre-injection ultrasound scanning for facial aesthetic neuromodulator treatments. Knowing the location of the line of convergence, injectors can determine precisely and on an individual basis where to administer the neuromodulator deep or superficial or when the injection location is at risk to cause eyebrow ptosis.

OBJECTIVE: Development of a technique for measuring the mechanical properties of zygomaticus major (ZM) may aid advances in clinical treatments for correcting abnormal oral posture. The objective of this work was to demonstrate the feasibility of measuring the stiffness of ZM using an MR elastography technique that incorporates a custom local driver and a phase-gradient (PG) inversion.
METHODS: 2D MRE investigations were performed for 3 healthy subjects using a vibration frequency of 90 Hz to test the prediction that the stiffness of ZM would be greater in the mouth-open compared to the mouth-closed position. MRE wave images were acquired along the long axis of ZM and processed using a 2D spatial-temporal directional filter applied in the direction of wave propagation along the long axis of the muscle. Stiffness measurements were obtained by applying the PG technique to a 1D-profile drawn in the phase image of the first harmonic of the wave images and a one-tailed paired t-test was used to compare the ZM stiffness between the two mouth postures (p < 0.05).
RESULTS: The mean stiffness and standard deviation (SD) of ZM across the three participants in the mouth-closed and mouth-open postures was 6.75 kPa (SD 3.36 kPa) and 15.5 kPa (SD 5.15 kPa), respectively. Changes of ZM stiffness were significantly greater in the mouth-open than the mouth-closed posture (p = 0.038).
CONCLUSIONS: The feasibility of using the PG MRE technique to measure stiffness changes in a small muscle such as ZM for different mouth postures has been demonstrated. Further investigations are required in a larger cohort of participants to investigate the sensitivity and reproducibility of the technique for potential clinical application as well as in health and beauty related studies.

OBJECTIVE: This study aimed to assess the functional and esthetic outcomes of a chimeric innervated buccinator myomucosal-submental island flap (BMM-SIF) for large composite lower lip reconstruction.
METHODS: This retrospective study included five patients who underwent lower lip tumor resection and BMM-SIF reconstruction at the Hospital of Stomatology, Sun Yat-sen University, between August 2021 and February 2023. Lip function was evaluated using water leakage, cheek puffing tests, and superficial electromyography. Lip appearance was observed using photographs and evaluated through subjective interviews. Donor-site conditions, including facial symmetry and mouth opening, were monitored.
RESULTS: All the BMM-SIFs survived. Drooling was the main complication observed shortly after surgery. The water leakage test showed complete oral competence for liquid holding in the 7th month; however, moderate air leakage was present in two patients. Electromyography revealed myoelectric signals from the innervated buccinator at the recipient site. Facial expression and food intake were typically managed. The shape and projection of the vermilion were harmonious and satisfactory for each patient. Neither microstomia nor mouth opening limitation was observed, with an average inter-incisor distance of 37.25±4.4 mm.
CONCLUSIONS: Chimeric motor-innervated BMM-SIF effectively reconstructed large full-thickness lower-lip defects with satisfactory functional and esthetic outcomes.

This study underscores the paramount importance of facial expressions in pigs, serving as a sophisticated mode of communication to gauge their emotions, physical well-being, and intentions. Given the inherent challenges in deciphering such expressions due to pigs\' rudimentary facial muscle structure, we introduced an avant-garde pig facial expression recognition model named CReToNeXt-YOLOv5. The proposed model encompasses several refinements tailored for heightened accuracy and adeptness in detection. Primarily, the transition from the CIOU to the EIOU loss function optimized the training dynamics, leading to precision-driven regression outcomes. Furthermore, the incorporation of the Coordinate Attention mechanism accentuated the model\'s sensitivity to intricate expression features. A significant innovation was the integration of the CReToNeXt module, fortifying the model\'s prowess in discerning nuanced expressions. Efficacy trials revealed that CReToNeXt-YOLOv5 clinched a mean average precision (mAP) of 89.4%, marking a substantial enhancement by 6.7% relative to the foundational YOLOv5. Crucially, this advancement holds profound implications for animal welfare monitoring and research, as our findings underscore the model\'s capacity to revolutionize the accuracy of pig facial expression recognition, paving the way for more humane and informed livestock management practices.

OBJECTIVE: In order to make the postoperative effect of open double eyelid more close to the physiological and anatomical structure of double eyelid, we improved the traditional open double eyelid operation according to the anatomical characteristics of the upper eyelid. We fixed part of the orbicularis oculi muscle above the incisal margin with the orbital septum flap to make the double eyelid formed after surgery more natural and beautiful.
METHODS: A total of 76 patients who received open double blepharoplasty in department of plastic surgery from February 2019 to May 2022 were selected as this study objects, all of whom were female. Their ages ranged from 18 to 32 years, with a mean of (23.6 ± 5.2) years. The surgical method is open double blepharoplasty by fixing part of the orbicularis oculi muscle above the incisal margin with the flap of the orbital septum.
RESULTS: In this study, all 76 patients underwent successful surgery, with an average operation time of (1.5 ± 0.2) h. The postoperative double eyelid curvature was smooth and the double eyelid width was basically symmetrical. In terms of the doctors\' satisfaction evaluation of the postoperative effect, 64 cases were very satisfied and 12 cases were satisfied. In terms of patients\' satisfaction evaluation of the postoperative effect, 60 patients were very satisfied, 15 patients were satisfied and 1 patient was dissatisfied.
CONCLUSIONS: Through this study, we found that this surgical method invented by us has short operation time, good operation effect, few postoperative complications and high patient satisfaction, which is worthy of promotion and application in plastic surgery clinical practice.
METHODS: 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 www.springer.com/00266 .

Existing Transformer-based models have achieved impressive success in facial expression recognition (FER) by modeling the long-range relationships among facial muscle movements. However, the size of pure Transformer-based models tends to be in the million-parameter level, which poses a challenge for deploying these models. Moreover, the lack of inductive bias in Transformer usually leads to the difficulty of training from scratch on limited FER datasets. To address these problems, we propose an effective and lightweight variant Transformer for FER called VaTFER. In VaTFER, we firstly construct action unit (AU) tokens by utilizing action unit-based regions and their histogram of oriented gradient (HOG) features. Then, we present a novel spatial-channel feature relevance Transformer (SCFRT) module, which incorporates multilayer channel reduction self-attention (MLCRSA) and a dynamic learnable information extraction (DLIE) mechanism. MLCRSA is utilized to model long-range dependencies among all tokens and decrease the number of parameters. DLIE\'s goal is to alleviate the lack of inductive bias and improve the learning ability of the model. Furthermore, we use an excitation module to replace the vanilla multilayer perception (MLP) for accurate prediction. To further reduce computing and memory resources, we introduce a binary quantization mechanism, formulating a novel lightweight Transformer model called variant binary Transformer for FER (VaBTFER). We conduct extensive experiments on several commonly used facial expression datasets, and the results attest to the effectiveness of our methods.

BACKGROUND: Cheek drooping after reduction malarplasty remains a concern for patients.
OBJECTIVE: To evaluate the anti-drooping effectiveness of the bracing system technique with the preservation of the zygomaticus major muscle (ZMj) bony attachment and to determine the role of ZMj in anti-drooping.
METHODS: A retrospective analysis was conducted of patients who accepted this method in our department from February 2016 to May 2021. Patients\' subjective evaluation and two plastic surgeons\' objective assessment of photographs were performed. The pre- and postoperative three-dimensional (3D) ZMj models were reconstructed and compared. ZMj length and tortuosity were also measured from 3D models.
RESULTS: Twenty-two patients (44 ZMjs) met the inclusion criteria. Most patients (21/22, 95.45%) were satisfied with the postoperative appearance without ageing after reduction malarplasty, except for one feeling slightly older after the operation. The objective scoring results showed no deepening of the nasolabial fold in the majority (20/22, 90.91%) of patients. Two patients were one-grade worse, from score 1 to 2. Upward movement of the postoperative ZMj bony attachment was clearly observed compared with the preoperative 3D model. The significantly reduced ZMj tortuosity (p < 0.001) and the slightly increased ZMj length (not significant) after surgery supported the straightening of the ZMj which was also seen in the 3D comparison.
CONCLUSIONS: The bracing system technique with preservation of the bony attachment of the ZMj is an effective and cost-effective anti-sagging method for reduction malarplasty. The ZMj was lifted and straightened after reduction malarplasty, which helped to prevent sagging.
METHODS: 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: Incisional double-eyelid blepharoplasty is the main surgical technique to obtain an artificial crease. Postoperative complications decrease patients\' satisfaction, and patients with prominent depressed groove and persistent pretarsal swelling (sausage phenomenon) usually need revision surgery. To resolve the sausage phenomenon after blepharoplasty, we adopt Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach to create natural double eyelids.
METHODS: We included 68 patients in the study. The inclusion criteria for revision surgery were as follows: (1) pretarsal OOM remained after primary surgery, (2) prominent depressed surgical scar/groove and persistent pretarsal bulge (sausage phenomenon), (3) postsurgical abnormally wide crease. The surgical procedure involved releasing the pretarsal OOM, forming OFOOM-OOM flap, and OFOOM-OOM flap fixed with aponeurosis. Outcome observations were assessed using the FACE-Q questionnaire, and the follow-up period ranged from 6 to 36 months (mean=18 months).
RESULTS: The depressed groove and pretarsal bulge showed significant improvements, and FACE-Q scores of the 68 patients before surgery (mean scores=66) compared with those after surgery (mean scores=90) were significantly different (P<0.01). Four patients with palpebral fold asymmetry and two patients with shallow eyelids received revision surgery, and patients were satisfied with the secondary surgery effects. Six patients presented with unnatural curves of folds and revision surgery alleviated these situations.
CONCLUSIONS: Outer Fascia of Orbicularis Oculi Muscle (OFOOM)-Orbicularis (OOM)-Aponeurosis Fixation Approach is an effective way to resolve the sausage phenomenon. The OFOOM-OOM flap is a reliable and flexible structure to create natural double eyelids.
METHODS: 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 .

Objective: To analyze genioglossus (GG) activation responses to the negative pressure of upper airway cavity during awake and different sleep stages in patients with different obstructive sleep apnea (OSA) graduation. Methods: This prospective cohort study started from August 2019 to January 2021, recruited 42 male OSA patients aged from 21 to 59 (38.77±8.42) years. After completing whole night polysomnography (PSG) and upper airway CT, each subject underwent drug-induced sleep with simultaneous monitoring of genioglossal electromyography (GGEMG) and pressure of epiglottis (Pepi). Subjects were divided into three groups of mild OSA(7 males), moderate OSA(12 males), and severe OSA(23 males). The differences in upper airway CT measurements, parameters of GGEMG and Pepi during awake and induced sleep were compared. Statistical analysis was conducted by SPSS 21.0. Results: There was no significant difference in the GGEMG parameters between the mild and moderate groups. In wakefulness, the peak phasic GGEMG of the severe group was higher than the mild group (t=1.249, P=0.025), with no statistically difference in the corresponding Pepi. In the sleep onset, the GGEMG parameters and Pepi in severe group were higher than the other two groups. Linear regression analysis of the maximum GGEMG and maximum Pepi at the end of obstructive apnea (OA) in all moderate plus severe patients (n=35) was shown nonlinear correlation (r=0.28, P=0.694). The airway length of the glossopharyngeal cavity was linearly correlated with the maximum Pepi of OA (r=0.468, R2=0.219, P=0.005). Conclusions: The individual difference of GG activation in OSA patients is related to the severity of the disease (frequency of respiratory events) and negative pressure stimulation. In moderate and severe OSA patients, GG activity is not in harmony with the corresponding negative pressure stimulation, which may be one of the mechanisms leading to the aggravation of OSA.
目的： 分析比较不同患病程度的阻塞性睡眠呼吸暂停（OSA）患者清醒、入睡初期以及睡眠状态下颏舌肌（genioglossus，GG）随腔内负压变化的活性差异及变化规律。 方法： 该前瞻性研究纳入2019年8月至2021年1月就诊于北京清华长庚医院的OSA男性患者共42例，年龄21~59（38.77±8.42）岁。每例研究对象完成整夜多导睡眠监测（PSG）及上气道CT后，均进行药物诱导睡眠下的口内表面颏舌肌肌电（GGEMG）同步会厌水平咽内压力（Pepi）监测。根据整夜PSG数据将患者分为轻度组（7例）、中度组（12例）、重度组（23例），对比组间患者上气道CT测量值以及在清醒及诱导睡眠状态下GGEMG各参数值和对应状态下Pepi的变化差异。采用SPSS 21.0进行统计学分析。 结果： 轻度组和中度组的GGEMG各参数值的差异无统计学意义。清醒期仅有重度组的清醒峰值肌电较轻度组偏高（t=1.249，P=0.025），组间同步监测的对应Pepi水平差异无统计学意义。入睡初期重度组的肌电参数值均分别较轻、中度组偏高，且同步监测的对应Pepi水平也较高。将所有中重度OSA患者（35例）的阻塞性呼吸暂停（OA）末期的最大GGEMG肌电值和最大Pepi进行线性回归分析发现，二者不符合线性相关关系（r=0.28，P=0.694）。而舌咽腔的长度与OA最大Pepi存在线性相关（r=0.468，R2=0.219，P=0.005）。 结论： OSA患者睡眠期间GG活性与患病严重程度（呼吸事件频次）相关。尤其在中度以上OSA患者，GG活性与对应腔内负压刺激存在不协调的表现，这可能是导致OSA加重的机制之一。.

BACKGROUND: The long-term postoperative outcomes of two different orbicularis oris muscle reconstruction techniques in patients with unilateral incomplete cleft lip were compared.
METHODS: Forty-seven patients with unilateral incomplete cleft lip were assessed in this study, where 23 underwent a traditional method of reconstruction and 24 underwent a novel method. Preoperative measurements, postoperative results, and 3-year follow-up outcomes were measured by photographic anthropometric analysis. Five upper lip measurement indices and 8 nostril indices were included.
RESULTS: The postoperative outcomes showed that the shape of the lip and nose was more symmetric with the new surgical method compared with the conventional technique. Long-term outcomes after 3 years, although characterized by minimal changes during maxillofacial development, showed better maintenance of lip and nostril symmetry in the novel-method group.
CONCLUSIONS: The novel technique seeks to balance the perinasal and perioral muscles, resulting in improved symmetry compared with the traditional reconstruction technique.
METHODS: Therapeutic, III.