Review Reports

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

# Peer Review Report

**Manuscript:** cosmetics-4489056 — *Planning the Surgical Correction of Age-Related Changes of the Chin Region and Neck Based on Digital and Radiological Imaging Methods: A Literature Review*
**Recommendation: Major revision**

## General comment

The topic is timely and fits the journal. The classification of imaging modalities is clear, the search strings are fully reported and reproducible, and the argument about upright versus supine positioning is clinically sound. However, the central claim — that upright CBCT is the most informative modality — is not adequately supported, and the manuscript contains one direct internal contradiction that must be resolved before publication.

## Major points

1. **Contradiction on CBCT soft-tissue performance.** Table 3 states that CBCT soft-tissue sensitivity is "low (mainly for bone)". The Abstract (l. 31–33), Table 4 and lines 334–340 claim CBCT resolves the platysma, supra- and subplatysmal fat, submandibular glands and digastric bellies. CBCT has intrinsically poor contrast resolution (scatter, no reliable HU). Please resolve this and support the position with quantitative data (CNR, measurement repeatability, inter-observer ICC).

2. **Platysmal "hypotonus vs hypertonus" (l. 334–336).** Muscle tone is a functional parameter and cannot be inferred from a single static radiological acquisition. Please provide validation (EMG, dynamic ultrasound, intraoperative correlation) or remove the claim.

3. **Self-referential evidence base.** The key conclusion rests essentially on refs [20] and [21] from the authors' own group, cited six times including in the Abstract and Conclusions; refs [19,22,23,27,28,32] are also in-group. Please acknowledge this in a limitations section, soften "is shown to be the most informative" to reflect single-centre preliminary evidence, and state whether independent confirmatory data exist.

4. **Unsupported efficacy claim.** "Reduction in complication risk" (Abstract l. 34; Table 4; Conclusions) is asserted without any cited study reporting clinical endpoints (complications, revisions, PROMs). Remove or reframe as a hypothesis.

5. **Radiation justification is absent.** The manuscript recommends ionising radiation in a purely aesthetic indication without discussing justification/ALARA, effective dose in µSv for a large-FOV facial protocol (refs [64,65] concern dentomaxillofacial dosimetry and are not equivalent), repeat imaging, or comparison with zero-dose upright ultrasound [27–32], which satisfies the same gravitational argument. A dedicated paragraph is required.

6. **The PRISMA framing overstates the method.** Only 12 of 399 full texts came from the systematic search, while 53 of 65 included works (82%) came from the "other sources" branch, which carries no screening figures. The full-text exclusion reason ("less relevant or duplicated") does not meet PRISMA 2020 requirements. Either complete the diagram and give structured exclusion reasons with a PRISMA checklist, or present this as a "structured, PRISMA-informed search" within a narrative review.

7. **No evidence table.** For 65 included works, please add a table (supplementary if needed) listing author/year, study design, sample size, modality, structure assessed and main quantitative finding, plus a brief quantitative description of the corpus.

8. **Table 3 requires revision.** Separating "CT" from "MSCT" as distinct modalities is outdated and produces the inconsistency "MSCT dose higher than CT"; "CT scan time: several minutes" is obsolete; CBCT voxel size is compared against CT slice thickness. Add rows for contrast resolution, HU availability, patient position, motion artefacts, effective dose and cost. MRI is missing from this table.

9. **Define and standardise "upright".** Seated or standing? Natural head position is not addressed, yet small changes in cervical flexion markedly alter the cervicomental angle and undermine reproducibility.

## Minor and editorial points

- Two tables are numbered "Table 1" (l. 172 should be Table 2); Conclusions are numbered 5 with no Section 4.
- Unclosed parentheses in Table 3 headers; MRI bullet (l. 219) lost its formatting; "ENT" is not in the abbreviation list.
- "Informativeness" is a calque — use *diagnostic value/performance*. "Cervicomandibular angle" (l. 339) should be *cervicomental*.
- l. 270–271: 1713 is almost certainly records screened, not studies analysed — please verify.
- Eligibility states 2020–2025, but refs [4,5,6,25,31,46,60,61] fall outside; add an explicit exception for anatomical/methodological key sources.
- "Impossible without" (l. 354) is indefensible; soften.
- Add a review limitations section (single screener, no risk-of-bias appraisal, language restriction, self-citation).

Author Response

Comment 1: Contradiction on CBCT soft-tissue performance. Table 3 states that CBCT soft-tissue sensitivity is “low (mainly for bone)”. The Abstract, Table 4 and the text claim CBCT resolves the platysma, supra- and subplatysmal fat, submandibular glands and digastric bellies. CBCT has intrinsically poor contrast resolution. Please resolve this and support the position with quantitative data (CNR, repeatability, inter-observer ICC).

Response 1: Thank you for pointing this out. We agree. We have harmonized the tables and the text so that CBCT is no longer described as resolving soft tissues as MRI does. CBCT is now presented as visualizing bony landmarks together with the position and outer contours of soft-tissue structures through bone–soft-tissue–air interfaces, whereas its intrinsic soft-tissue contrast resolution is limited and inferior to that of MRI; we also state that quantitative reproducibility data (contrast-to-noise ratio, inter-observer agreement) are currently lacking.

Comment 2: Platysmal “hypotonus vs hypertonus”. Muscle tone is a functional parameter and cannot be inferred from a single static acquisition. Provide validation or remove the claim.

Response 2: Agree. We have removed all references to platysmal tone and now refer only to the position, outer contour and ptosis of the platysma.

Comment 3: Self-referential evidence base. The key conclusion rests essentially on the authors’ own studies and is overstated. Acknowledge this in a limitations section and soften the claim.

Response 3: Agree. We have softened the conclusion to a qualified opinion (“available preliminary, predominantly single-centre evidence suggests that CBCT … may be the most informative modality”) and explicitly acknowledged the reliance on our own studies [20,21] and the lack of independent multicentre confirmation in the new Limitations section.

Comment 4: Unsupported efficacy claim. “Reduction in complication risk” is asserted without any cited study reporting clinical endpoints. Remove or reframe as a hypothesis.

Response 4: Agree. In line with the option to remove it, we have deleted the complication-risk statement entirely from the Abstract, the Conclusions and Table 4; the manuscript no longer makes any claim about complication rates.

Comment 5: Radiation justification is absent. There is no discussion of justification/ALARA, effective dose in µSv/mSv for a large-FOV facial protocol, or comparison with zero-dose upright ultrasound. A dedicated paragraph is required.

Response 5: Agree. We have added a dedicated paragraph on justification and the ALARA principle. We report the effective dose of our facial CBCT protocol — 0.135 mSv (GENORAY Volux 550, 16 × 14 cm field of view) — which is consistent with published large-field CBCT dosimetry (135 µSv for a comparable unit, new reference [66]) and an order of magnitude lower than conventional or multislice CT (new reference [67]); we also acknowledge upright ultrasound as a radiation-free alternative.

Comment 6: The PRISMA framing overstates the method. Only 12 of 399 full texts came from the systematic search, while most included works came from citation searching. Either complete the diagram or present this as a structured, PRISMA-informed search within a narrative review.

Response 6: Agree. We now explicitly specify the design as a narrative review with a structured, PRISMA-informed search and explain that most included works (53 of 65) were identified through citation searching; the flow diagram (Figure 1) is retained for transparency of the search process, and its caption has been amended.

Comment 7: No evidence table. For the included works, please add a table listing author/year, design, sample size, modality, structure assessed and main quantitative finding, plus a brief quantitative description of the corpus.

Response 7: Agree. We have added a brief quantitative description of the corpus in the text, and a complete, per-study evidence table (author, year, study design, sample size, imaging modality, structure assessed and main quantitative finding) is provided as Supplementary Table S1.

Comment 8: Table 3 requires revision. The CT/MSCT split is outdated; scan time is obsolete; voxel size is compared with slice thickness; rows for contrast resolution, HU, patient position, motion artefacts, effective dose and cost are missing; MRI is absent.

Response 8: Agree. Table 3 has been comprehensively revised: an MRI column and rows for patient position, contrast resolution/HU availability, effective dose, motion sensitivity and cost were added; the CT scan-time entry was corrected; MSCT is noted as comparable to CT; and the effective-dose row is referenced.

Comment 9: Define and standardise “upright”. Seated or standing? Natural head position is not addressed.

Response 9: Agree. We now define “upright” as imaging with the patient standing in a natural head position, gazing horizontally, with the face oriented vertically and without a chin rest or head restraint, following the standardized protocol previously published by our group [20].

Comment 10: Minor and editorial: duplicate “Table 1”; Conclusions numbered 5 with no Section 4; “informativeness” calque; “cervicomandibular”→“cervicomental”; “1713”; search window vs cited references; “impossible without”; “ENT” missing from abbreviations; add a limitations section.

Response 10: Agree. All minor points were addressed: tables were renumbered; a new Section 4 (Limitations) makes the numbering continuous (1–5); “informativeness” was replaced with “diagnostic value”; “cervicomandibular” was corrected to “cervicomental”; “1713 studies” was corrected to “screening of 1731 records” (verified against the source); the search window was corrected to January 2020 – June 2026; “impossible without” was softened to “benefits greatly from”; and “ENT” was added to the abbreviation list.

 

Author Response File: Author Response.pdf

Reviewer 2 Report

Comments and Suggestions for Authors

Digital and radiological imaging methods used in chin and neck rejuvenation planning are reviewed, however, there is internal inconsistency regarding CBCT, methodology reporting and the overall evidentiary base of the main conclusion.
- The data from manuscript itself does not prove CBCT conclusion. According to Table 3, soft-tissue sensitivity is low, while according to Table 4, informativeness is also low. However, CBCT assesses platysma tone, fat distribution, glandular ptosis and digastric muscles anatomy. Reconciliation is required; validation data should be provided.
- Comparatives are not quantified. Effective doses, resolutions and soft-tissue sensitivity are not quantified; no numbers and references provided. Effective doses should be in mSv, each table row should be referenced.
- Evidence base is heavily self-cited. CBCT recommendations based on refs [19-21], which are by the authors' research group. Add comparative evidence or make a qualified opinion.
- There is no limitations section. Single-reviewer screening, absence of risk-of-bias assessment, languages restriction, and self-citations should be mentioned.
- PRISMA reporting is inconsistent. Only 12 out of 399 full-texts were included. 53 records were added as a result of citation searching without going through screening process. Provide the explanation, categorize exclusions, and specify design as this is supposed to be a narrative review but PRISMA flow chart presented.
- Search window and dates mismatch. Coverage 2020-2025; search run on 18.06.2026; thus, six months period is missed and ref [31] is out of window.
- Figure 1 should be presented in journal resolution.
- Inconsistent references (PMID/DOI issues; ref [3] does not have volume/pages).
- Duplicate "Table 1" labels (pages 3 and 6); the latter is cited as Table 2.
- Ref [41] is a manufacturer webpage; should be labeled as such and access date provided.
- Duplicates in content in Tables 2 and 4; merge or clarify the differences.
- Section 4 is not provided; Conclusions is number 5.

Author Response

Comment 1: The data from manuscript itself does not prove CBCT conclusion. Table 3 says soft-tissue sensitivity is low; Table 4 says informativeness is low; yet CBCT assesses platysma tone, fat, glandular ptosis and digastric anatomy. Reconciliation is required; validation data should be provided.

Response 1: Thank you. We agree. We have reconciled Tables 3 and 4 with the text: CBCT is described as visualizing bony landmarks and the position/outer contours of soft-tissue structures, with limited contrast resolution (inferior to MRI); the platysmal-tone claim was removed; and we state that validation data are lacking (see also our response to Reviewer 1, Comment 1).

Comment 2: Comparatives are not quantified. Effective doses, resolutions and soft-tissue sensitivity are not quantified; effective doses should be in mSv, each table row referenced.

Response 2: Agree. We revised Table 3 to give numerical, referenced effective doses (CBCT 0.135 mSv; CT ~1.5–2 mSv; MSCT ~1–2 mSv; MRI none), each referenced ([66,67]), and added rows for patient position, contrast resolution/HU, motion and cost.

Comment 3: Evidence base is heavily self-cited. CBCT recommendations based on refs [19-21] by the authors’ group. Add comparative evidence or make a qualified opinion.

Response 3: Agree. We made the conclusion a qualified opinion and acknowledged the self-citation in the new Limitations section (see also our response to Reviewer 1, Comment 3).

Comment 4: There is no limitations section. Single-reviewer screening, absence of risk-of-bias assessment, language restriction and self-citations should be mentioned.

Response 4: Agree. We added a dedicated Limitations section (Section 4) covering the narrative design, single-reviewer selection without duplicate screening, absence of a formal risk-of-bias appraisal, the Russian/English language restriction, and reliance on the authors’ own studies.

Comment 5: PRISMA reporting is inconsistent. Only 12 of 399 full-texts were included; 53 records added via citation searching without screening. Explain, categorize exclusions, and specify design.

Response 5: Agree. We specify the design as a narrative review with a structured, PRISMA-informed search and explain the 12/53 split; the flow diagram is retained for transparency (see also our response to Reviewer 1, Comment 6).

Comment 6: Search window and dates mismatch. Coverage 2020-2025; search run on 18.06.2026; ref [31] is out of window.

Response 6: Agree. We corrected the search window to January 2020 – June 2026, consistent with the search date (18 June 2026); this now includes reference [31].

Comment 7: Figure 1 should be presented in journal resolution.

Response 7: Agree. Figure 1 has been prepared at 600 dpi (raster) and as vector files (PDF/EPS) and is uploaded separately with this revision.

Comment 8: Inconsistent references (PMID/DOI issues; ref [3] does not have volume/pages).

Response 8: Agree. Reference [3] now includes the full citation (J Cosmet Dermatol. 2022;21(10):4160–4170); reference [65] now includes pages (214–222) and reference [53] the article number (46(1):29); the DOI of reference [15] was corrected (10.1055/s-0043-1777409); and author lists of references [18], [22], [23], [29], [51] and [64] were corrected.

Comment 9: Duplicate “Table 1” labels; the latter is cited as Table 2.

Response 9: Agree. All tables have been renumbered consistently and are cited correctly in order of appearance.

Comment 10: Ref [41] is a manufacturer webpage; should be labeled as such and access date provided.

Response 10: Agree. Reference [41] is now formatted per journal style as a manufacturer’s website: “VECTRA M3 3D Imaging System; Canfield Scientific: Parsippany, NJ, USA. Available online: … (accessed on 15 June 2026).”

Comment 11: Duplicates in content in Tables 2 and 4; merge or clarify the differences.

Response 11: Agree. We clarified the distinct purpose of each table in their captions: Table 2 classifies the method groups and their principal role, whereas Table 4 provides a detailed advantages/limitations appraisal complementing Table 2.

Comment 12: Section 4 is not provided; Conclusions is number 5.

Response 12: Agree. A new Section 4 (Limitations) has been added, making the section numbering continuous (1. Introduction; 2. Materials and Methods; 3. Results and Discussion; 4. Limitations; 5. Conclusions).

We hope that the revised manuscript now meets the standards of Cosmetics, and we thank the Editor and both Reviewers again for their valuable input.

On behalf of all authors,

Sergey Yu. Golovanov (corresponding author)

Author Response File: Author Response.pdf

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

Accept after minor revision

The authors have responded thoroughly and in good faith. The four principal concerns of the first round — the contradiction over CBCT soft-tissue performance, the claim about platysmal tone, the reliance on single-centre evidence from the authors' own group, and the absence of any radiation-justification discussion — have all been properly resolved, and the new Limitations section is commendably candid. Three points remain before publication.

1. Residual inconsistencies left over from the revision. Table 3 gives the CBCT patient position as "upright (seated)", while the new positioning paragraph states the patient was standing. Similarly, the softened description of CBCT has not been carried through everywhere: Section 3.2 still reads "detailed assessment of bony structures and facial soft tissues", the text still claims an objective assessment of "each soft-tissue structure", and Table 4 still calls CBCT the "optimal method" of preoperative planning. Please harmonise these with the qualified wording now used in the Abstract and Discussion. The unclosed parenthesis in the Table 3 header ("CT (Computed Tomography") also remains.

2. Abstract and two residual efficacy statements. The Abstract still describes the work as "conducted in accordance with the PRISMA methodology", although the Methods now correctly present it as a narrative review with a structured, PRISMA-informed search. The complication-risk claim, stated as deleted, still appears in the Introduction ("minimize the risk of adverse outcomes") and in Section 3 ("reductions in surgical risk in complex, repeat, and combined interventions").

3. Reported data. The modality breakdown sums to 68 rather than the stated 65 included works — please correct or footnote the overlap. The newly reported effective dose is the authors' own measurement, which sits awkwardly with the Data Availability Statement ("No new data were created in this study"); please reconcile. Reference [66] covers three devices with substantially different doses, so specify which unit the 135 µSv figure refers to. Finally, the reference list still requires conversion to MDPI style.

Author Response

Comment 1: Residual inconsistencies left over from the revision. Table 3 gives the CBCT patient position as “upright (seated)”, while the new positioning paragraph states the patient was standing. Section 3.2 still reads “detailed assessment of bony structures and facial soft tissues”, the text still claims an objective assessment of “each soft-tissue structure”, and Table 4 still calls CBCT the “optimal method” of preoperative planning. The unclosed parenthesis in the Table 3 header (“CT (Computed Tomography”) also remains.

Response 1: Thank you for catching these. We have harmonised all of them. In Table 3 the CBCT position now reads “upright (standing)”, consistent with the positioning paragraph. In Section 3.2 the CBCT description was softened to match the qualified wording used elsewhere. The phrase “objective assessment of each soft-tissue structure” was changed to “assessment of the position and contours of each soft-tissue structure”. In Table 4, “optimal method” was changed to “a promising method”. The unclosed parenthesis in the Table 3 header was corrected to “CT (computed tomography)”.

Comment 2: Abstract and two residual efficacy statements. The Abstract still describes the work as “conducted in accordance with the PRISMA methodology”, although the Methods now correctly present it as a narrative review with a structured, PRISMA-informed search. The complication-risk claim, stated as deleted, still appears in the Introduction (“minimize the risk of adverse outcomes”) and in Section 3 (“reductions in surgical risk in complex, repeat, and combined interventions”).

Response 2: Agree. The Abstract now states that the work is “a narrative review based on a structured, PRISMA-informed search”, consistent with the Methods. We have also removed the two residual complication-risk statements: the Introduction no longer mentions minimizing adverse outcomes, and the corresponding clause in Section 3 has been deleted. The manuscript now makes no claim about complication rates anywhere.

Comment 3: Reported data. The modality breakdown sums to 68 rather than the stated 65 included works — please correct or footnote the overlap. The newly reported effective dose is the authors’ own measurement, which sits awkwardly with the Data Availability Statement (“No new data were created in this study”); please reconcile. Reference [66] covers three devices with substantially different doses, so specify which unit the 135 µSv figure refers to. Finally, the reference list still requires conversion to MDPI style.

Response 3: Agree on all four points. The modality breakdown was recomputed and now sums exactly to 65. We also clarify that the two additional dosimetric references [66,67], added during revision to substantiate the dose figures, fall outside the search-derived corpus. The Data Availability Statement was revised to reconcile it with the reported dose: the review analyzed only previously published data, and the single primary value (the 0.135 mSv effective dose of our facial CBCT protocol) was taken from the scanner’s dose report and is available from the corresponding author on request.  Reference [66] reports three devices; we now specify that the 135 µSv figure refers to the large field-of-view i-CAT unit.  The reference list has been converted to MDPI style throughout.

We are grateful for the Reviewer’s careful reading, which has further improved the manuscript.

On behalf of all authors,

Sergey Yu. Golovanov (corresponding author)

Reviewer 2 Report

Comments and Suggestions for Authors

Thank you for addressing the issues in a careful and comprehensive manner, which has significantly improved the manuscript and addressed my previous concerns. There are some more clarifications needed:

- Narrative review with PRISMA-informed search, not a systematic review with protocol registration, screening duplication, or risk-of-bias assessment or meta-analysis. Full search strategy, number of records retrieved per database (Table 1), and the revised flow diagram (Figure 1) with “other sources” branch guarantee replicability. Numbers in Figure 1 correspond internally (1010 → 717 → 399 → 12 + 53 = 65).

- Upright CBCT claim has been toned down. Evidence presented as preliminary and largely single center in the abstract, Results and Conclusions. Mention the reduced soft tissue contrast of CBCT compared to MRI and the lack of information on the reproducibility of findings (CNR, inter-rater reliability).

- Definition of “upright” imaging (natural head position, chin not resting on the device, muscle relaxation, relevant anatomical reference lines) in order to increase reproducibility and minimize variability of cervicomental angle.

- Distinction between Tables 2 and 4. Supplementary Table S1 and the new Limitations section.

Author Response

Comment 1: Narrative review with PRISMA-informed search, not a systematic review with protocol registration, screening duplication, or risk-of-bias assessment or meta-analysis. Full search strategy, number of records retrieved per database (Table 1), and the revised flow diagram (Figure 1) with “other sources” branch guarantee replicability. Numbers in Figure 1 correspond internally (1010 → 717 → 399 → 12 + 53 = 65).

Response 1: Thank you. We confirm that the manuscript is now explicitly presented as a narrative review with a structured, PRISMA-informed search, and that it does not claim protocol registration, duplicate screening, formal risk-of-bias assessment, or meta-analysis — these are listed as limitations in the new Section 4. The full search strategy, the per-database record counts (Table 1) and the revised flow diagram (Figure 1, with the “other sources” branch) are retained for replicability, and the internal figures correspond as the Reviewer notes (1010 → 717 → 399 → 12 + 53 = 65). No further change was required for this point; the related wording is marked in the revised manuscript.

Comment 2: Upright CBCT claim has been toned down. Evidence presented as preliminary and largely single center in the abstract, Results and Conclusions. Mention the reduced soft tissue contrast of CBCT compared to MRI and the lack of information on the reproducibility of findings (CNR, inter-rater reliability).

Response 2: Agree. The upright-CBCT claim is now presented as preliminary and predominantly single-centre in the Abstract, Results and Conclusions. As requested, the manuscript now explicitly states that the intrinsic soft-tissue contrast resolution of CBCT is limited and inferior to that of MRI, and that quantitative reproducibility data (contrast-to-noise ratio, inter-observer agreement) are currently lacking.

Comment 3: Definition of “upright” imaging (natural head position, chin not resting on the device, muscle relaxation, relevant anatomical reference lines) in order to increase reproducibility and minimize variability of cervicomental angle.

Response 3: Agree. We now define “upright” imaging explicitly: the patient standing in a natural head position, gazing horizontally, with the face oriented vertically and the chin not resting on the device; the mimic and cervical muscles relaxed; and the scanning planes oriented to defined anatomical reference lines (the lip-closure line horizontally and the tragus vertically), following the standardized protocol previously published by our group [20]. This is intended precisely to improve reproducibility and minimize variability of the cervicomental angle.

Comment 4: Distinction between Tables 2 and 4. Supplementary Table S1 and the new Limitations section.

Response 4: Thank you. The distinct purpose of the two tables is now stated in their captions: Table 2 classifies the method groups and their principal role, whereas Table 4 provides a detailed advantages/limitations appraisal that complements Table 2. A complete, per-study evidence table (Supplementary Table S1) and the new Limitations section (Section 4) have been added, as acknowledged by the Reviewer.

 

We thank the Reviewer again for the constructive comments, which have strengthened the manuscript.

On behalf of all authors,

Sergey Yu. Golovanov (corresponding author)