The Art and Science of Filler Injection: Based on Clinical Anatomy and the Pinch Technique 9811306109, 9789811306105

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The Art and Science of Filler Injection Based on Clinical Anatomy and the Pinch Technique Giwoong Hong Seungmin Oh Bongcheol Kim Yongwoo Lee

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The Art and Science of Filler Injection

Giwoong Hong Seungmin Oh Bongcheol Kim Yongwoo Lee •

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The Art and Science of Filler Injection Based on Clinical Anatomy and the Pinch Technique

123

Giwoong Hong SAMSKIN Plastic Surgery Seoul, Korea (Republic of)

Seungmin Oh ON Clinic Seoul, Korea (Republic of)

Bongcheol Kim Lamar Clinic Isu Branch Seoul, Korea (Republic of)

Yongwoo Lee LIKE Plastic Surgery Seoul, Korea (Republic of)

ISBN 978-981-13-0610-5 ISBN 978-981-13-0611-2 https://doi.org/10.1007/978-981-13-0611-2

(eBook)

© Springer Nature Singapore Pte Ltd. 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore

Preface

The pursuit of beauty has been a universal desire that transcends age, culture, and time. There are diverse approaches to beautification and the outcomes vary according to these approaches. Soft tissue filler injections are one of the most commonly performed aesthetic procedures that have shown tremendous progress in the last 10 years. However, along with this progress, the indications for filler procedures have also broadened and the efficacy of filler procedures has also advanced extensively. Fillers account for a significant portion of the medical aesthetics market but filler procedures performed indiscriminately by physicians who lack adequate medical knowledge of clinical anatomy, accurate injection techniques, and the potential complications have led to reports of many adverse events. To ensure optimal outcomes without complications, in-depth studies and discussions regarding the most appropriate procedural methods is paramount. In addition, the authors believe that the physician must assess the patient’s psychosocial, philosophical, and cultural perspectives on beauty during the initial consultation and take these factors into consideration when coming up with a treatment plan. The recent trend in filler procedures has shifted from addressing wrinkles or the appearance of the face when it is in an expressionless, static state to practical treatments that consider the dynamic nature of the facial soft tissues and wrinkle formations when making diverse facial expressions like smiling. Therefore, this book has been written for filler procedures which go beyond regional volumization or sunken wrinkle treatments; to creating a three dimensional, aesthetically pleasing face with a good impression (Fig. 1). The authors hope this book will help doctors who want to specialize in filler procedures. Even those who have previous experience in this procedure should compare and review their methods with the clinical anatomy-based

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Preface

Fig. 1 PINCH technique for filler procedure

treatments in this book to find any benefits they can apply to their practice. We sincerely hope this book will help you to perform more safe and effective filler procedures. Seoul, Korea (Republic of)

Giwoong Hong Seungmin Oh Bongcheol Kim Yongwoo Lee

Contents

1 The Art and Science of Filler Procedures for a More Attractive Face. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.1 Natural Beauty and Human Attractiveness . . . . . . . . . . . . . . 1.2 Differences Between Asian and Western Beauty Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1.3 Medical Reference Values to Create an Attractive Face . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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2 Filler Types and Characteristics . . . . . . . . . . . . . . . . . . . . . 2.1 Type of Filler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.1.1 Number of Various Fillers Used Recently . . . . . 2.2 Characteristics of Hyaluronic Acid Filler . . . . . . . . . . . 2.2.1 Hyaluronic Acid as a High Molecular Compound . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.2.2 Hyaluronic Acid Filler Manufacturing Process . 2.2.3 Rheology of Hyaluronic Acid Filler . . . . . . . . . 2.2.4 Selection of Hyaluronic Acid Filler . . . . . . . . . . 2.3 Calcium Filler . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 2.4 Polycaprolactone Filler . . . . . . . . . . . . . . . . . . . . . . . . . 2.5 Filler Selection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Anatomical Considerations for Filler Procedures . . . . . . . 3.1 Vessels and Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.2 Fat Compartments and Muscles . . . . . . . . . . . . . . . . . . 3.3 Retaining Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.4 Layer and Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3.5 Identification of SubSMAS Space for Filler Injection: Cadaver Study Using Stained Gelatin . . . . . . . . . . . . . . 3.6 SSRT (Skin and SMAS Layer Remodeling Technique) for Volumization and Lifting Effect . . . . . . . . . . . . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4 Basic Technique for Filler Procedure . . . . . . . . . . . . 4.1 Design (Method) . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.1 Frontal View-Horizontal/Vertical Ratio of the Face . . . . . . . . . . . . . . . . . . . . . . . 4.1.2 Frontal View—Heart-Shaped Midface . . .

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4.1.3 Oblique View—S-Line/Inverted S-Line/Ogee Curve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.1.4 Lateral View-Ricketts Line . . . . . . . . . . . . . . . . 4.1.5 Design for Safe Filler Injection—Mark of Dangerous Area . . . . . . . . . . . . . . . . . . . . . . . . . 4.2 Anesthesia—Nerve Block . . . . . . . . . . . . . . . . . . . . . . . 4.2.1 Supratrochlear/Supraorbital Nerve . . . . . . . . . . . 4.2.2 Zygomaticotemporal Nerve (Fig. 4.14) . . . . . . . 4.2.3 Zygomaticofacial Nerve (Fig. 4.15) . . . . . . . . . . 4.2.4 External Nasal Branch of Anterior Ethmoidal Nerve (Fig. 4.16) . . . . . . . . . . . . . . . . . . . . . . . . 4.2.5 Infraorbital Nerve (Fig. 4.17) . . . . . . . . . . . . . . 4.2.6 Mental Nerve (Fig. 4.18) . . . . . . . . . . . . . . . . . . 4.2.7 Greater Auricular Nerve (Fig. 4.19) . . . . . . . . . 4.3 Selection of Cannula or Needle . . . . . . . . . . . . . . . . . . 4.3.1 Cannula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.3.2 Characteristics of Needles . . . . . . . . . . . . . . . . . 4.4 Injection Technique . . . . . . . . . . . . . . . . . . . . . . . . . . . 4.4.1 Types of Injection Techniques. . . . . . . . . . . . . . 4.4.2 Injection Techniques for Each Area . . . . . . . . . 4.5 Basic Techniques by Region . . . . . . . . . . . . . . . . . . . . . 4.6 Filler Molding and Filler Degradation Test . . . . . . . . . . 4.6.1 Filler Molding . . . . . . . . . . . . . . . . . . . . . . . . . . 4.6.2 Filler Degradation Test . . . . . . . . . . . . . . . . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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5 Filler Procedures Based on the Facial Area . . . . . . . . . . . . . . . 5.1 Upper Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.1.1 Forehead and Glabella . . . . . . . . . . . . . . . . . . . . . . . . 5.1.2 Temple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2 Midface. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.1 Supraorbital Hollowness (Sunken Eyelid) and Flat Eyebrow . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.2 Pre-tarsal Roll (= Lower Eyelid Charming Roll, Pre-tarsal Fullness) . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.3 Infraorbital Groove and Hollowness . . . . . . . . . . . . . 5.2.4 Dark Circle (Tear Trough and Palpebromalar Groove) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.5 Midcheek Groove . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.6 Anteromedial, Buccal, and Lateral Cheek Hollow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.7 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.2.8 Nasolabial Fold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3 Lower Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.1 Lip and Philtrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 5.3.2 Marionette Line (Static Labiomandibular Fold) . . . . .

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Contents

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5.3.3 Perioral Wrinkles (Smoker’s Line) . . . . . . . . . . . . . . 166 5.3.4 Chin Augmentation and Jaw Line Contouring . . . . . . 168 Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 173 6 Complication of Filler Procedures . . . . . . . . . . . . . . . . . . . 6.1 Type and Treatment of Complication . . . . . . . . . . . . . . 6.1.1 Bruising and Hematoma . . . . . . . . . . . . . . . . . . 6.1.2 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.1.3 Neovascularization and Erythema . . . . . . . . . . . 6.1.4 PIH (Post-inflammatory Hyperpigmentation) . . . 6.1.5 Nodule and Granuloma . . . . . . . . . . . . . . . . . . . 6.1.6 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2 Treatment and Prevention of Vascular Complication . . 6.2.1 Mechanism and Classification of Vascular Complications . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.2 Skin Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . 6.2.3 Vascular Complication—Blindness . . . . . . . . . . 6.2.4 Vascular Complication—Pulmonary Embolism . 6.2.5 Prevention of Vascular Complication . . . . . . . . 6.3 Hyaluronidase Usage . . . . . . . . . . . . . . . . . . . . . . . . . . 6.3.1 Hyaluronic Acid Turnover . . . . . . . . . . . . . . . . . 6.3.2 Use of Hyaluronidase . . . . . . . . . . . . . . . . . . . . 6.4 Retrobulbar Injection Technique . . . . . . . . . . . . . . . . . . Bibliography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

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About the Authors

Giwoong Hong, M.D., Ph.D.

– Board-certified Plastic Surgeon – President of SAMSKIN Plastic Surgery Clinic – Clinical Professor, Department of Plastic Surgery, Chung-Ang University Medical Center – Member of the Korean Society of Plastic and Reconstructive Surgery – Member of the Korean Society of Aesthetic Plastic Surgery – Member of Korean Cleft Palate-Craniofacial Association – Member of Korean Society for Microsurgery – Member of Korean Association of Stem Cell Therapy – Scientific Committee of Korean Association of Minimally Invasive Plastic Surgery – Advisory Board Member of Galderma Korea – Advisory Board Member of N-FINDERS – Advisory Board Member of Hugel – Advisory Board Member of Chong Kun Dang Pharm – Restylane Filler Global Key Doctor – President of ICALA (International Clinical Aesthetic Leaders Academy) Published books – Botulinum Toxin Clinical Usage (2019) MDWORLD Medical Publishing Co. – Thread Lifting Clinical Usage (2019) MDWORLD Medical Publishing Co. xi

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About the Authors

– Practical Guidelines for Effective and Safe Filler Procedures (2018) KOONJA Publishing Inc. – Clinical Anatomy for Filler & Toxin (2018) MEDICAL Observer – Filler.Toxin Practical Knowhow (2017) MDWORLD Medical Publishing Co. Seungmin Oh, M.D. Medical M.B.A.

– – – – – – – – – – – –

Director, ON Clinic President of OK Medi. Co. Ltd. Seoul national university college of medicine Seoul national university hospital internship, Residentship Seoul national university hospital Clinical Instructor Executive board member of the Korean Association for Laser, Dermatology and Trichology Faculty member of IMCAS (International Master Course on Aging Science) Advisor, Galderma (Restylane filler) Advisor, JongKunDang (Stylage filler-VIVACY) Advisor, Medytox. Co. Ltd. (Neuramis filler) Advisor, Hugel Co. Ltd. (Blue Rose Forte thread) Advisor, Sthepharm C. Ltd. (QTL, QT cell)

Books – 『The Art and Science of Thread Lifting: Based on Pinch Anatomy』 Bongcheol Kim, Seungmin Oh, Wonsug Jung (2019, SPRINGER NATURE) – 『English version: Safe Filler Injection Technique Demonstration-using live imaging tools』Seungmin Oh, Bongcheol Kim (2017) – 『Chinese version: The art and science of the Thread lifting (埋线提升术 的定石)』 /Bongcheol Kim, Seungmin Oh, Wonsug Jung (2017) – 『Korean version: The art and science of the Thread lifting』 /Bongcheol Kim, Seungmin Oh, Wonsug Jung (2017)

About the Authors

xiii

– 『Chinese version: Safe Filler Injection Technique Demonstration-using live imaging tools (安全地注射玻尿酸以活体影像为工具)』 /Seungmin Oh, Bongcheol Kim (2015) – 『Safe Filler Injection Technique Demonstration-using live imaging tools』 /Seungmin Oh, Bongcheol Kim (2014) Bongcheol Kim, M.D.

– – – – –

Director of Lamar Isu Clinic College of Medicine, Chonnam National University Internship—Samsung Medical Center (Seoul) Residency—Samsung Medical Center (Seoul) Executive board member of the Korean Association for Laser, Dermatology and Trichology

– – – – –

KOL KOL KOL KOL KOL

of of of of of

Merz Korea (Ulthera®, Radiesse®, Belotero®, Xeomin®) Classys (Shrink®, Ultraformer®, Scizer®, Ulfit®) Sinclair Korea (Silhouette Soft® lifting) Sthepham (QT Lift®, QT cell®) DNC (Theosyal®)

Published Books – /Seungmin Oh, Bongcheol Kim (Korean version 2014, Chinese version 2015, English version 2017, Taiwanese version 2018) – /Bongcheol Kim, Seungmin Oh, Wonsug Jung (Korean version 2017, Chinese version 2017, SPRINGER NATURE 2019)

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Yongwoo Lee, M.D., Medical M.B.A.

– Board-certified Plastic Surgeon – President of LIKE Plastic Surgery Clinic – Clinical Professor, Department of Plastic Surgery, Han-Yang University Medical Center – Member of the Korean Society of Plastic and Reconstructive Surgery – Member of the Korean Society of Aesthetic Plastic Surgery – Committee of Korean Association of MIPS (Minimally Invasive Plastic Surgery) – Scientific Committee of ICALA (International Clinical Aesthetic Leaders Academy) – Advisory Board Member of Galderma Korea – Advisory Board Member of Hugel – Advisory Board Member of Medytox – Advisory Board Member of N-FINDERS Published books – Botulinum Toxin Clinical Usage (2019) MDWORLD Medical Publishing Co. – Thread Lifting Clinical Usage (2019) MDWORLD Medical Publishing Co. – Practical Guidelines for Effective and Safe Filler Procedures (2018) KOONJA – Clinical Anatomy for Filler & Toxin (2018) MEDICAL Observer

About the Authors

1

The Art and Science of Filler Procedures for a More Attractive Face

1.1

Natural Beauty and Human Attractiveness

The current trend and prevailing issue in aesthetic medicine are creating natural beauty. In addition to enhancing natural beauty with cosmetics, hair products, and fashion items, more and more people are fervently striving for healthier lifestyles and well-being. Such social and cultural changes have not only impacted the field of aesthetic medicine but have also changed how people react to facial changes related to aging. People seek to age beautifully but focus has shifted. From deliberately reverting and masking the signs of aging and inadvertently looking awkward, more and more people are pursuing beauty that is natural, graceful, and effortless. Minimally-invasive cosmetic procedures, including filler procedures, do not require the patient to go under the knife. There is less swelling and there are barely any signs of having undergone a medical aesthetic procedure. Patients can be discreet and are able to return to their daily lives with more convenience. Moreover, because minimally-invasive procedures do not cause significant changes to the facial skin and tissue, they are highly unlikely to cause any permanent side effects. Moreover, additional procedures may be performed at any time. Facial fillers are in widespread use today, and have firmly established their place in the aesthetic armamentarium among the minimallyinvasive cosmetic procedures. Unlike in the © Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_1

earlier years, the materials and manufacturing methods used to produce fillers have become much more sophisticated. The indications for filler procedure have broadened and the efficacy of filler procedures has also advanced extensively. Fillers account for a significant portion of the medical aesthetics market and filler procedures performed indiscriminately by professionals who lack adequate medical knowledge regarding clinical anatomy, accurate injection techniques, and the potential complications have led to reports of many adverse events. To ensure optimal outcomes without complications, indepth studies and discussions regarding the most appropriate procedural methods are paramount. In addition, the physician must assess the patient’s psychosocial, philosophical, and cultural perspectives on beauty during the initial consultation and take these factors into consideration when coming up with a treatment plan. Filler indications diversified significantly and injection techniques have become more sophisticated. When fillers were first introduced to Korea around 30 years ago, no one could have anticipated the current pervasiveness of filler procedures. Until the mid-1990s, collagen fillers from the United States were the only fillers available and these fillers had a duration period of only 1–2 months. Due to numerous inconveniences associated with collagen fillers, including pretreatment skin testing to check for allergic reactions, there were very few doctors at the time 1

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The Art and Science of Filler Procedures for a More Attractive …

who actually used these products at their clinical practices. Korean doctors encountered hyaluronic acid (HA) fillers for the first time in the late 1990s when Restylane® (Q-Med, Sweden) was launched in Korea. HA fillers are used currently for facial volumization but before the introduction of HA fillers, fillers were mostly used to efface superficial skin wrinkles or to correct small, regional depressions. Administration of fillers for facial contouring and full face volumization, as in fat grafting, is a practice that has become popular only within the past few years. As a member of the first generation of plastic surgeons to perform filler procedures in Korea, the author aims to delve into the following; standards of natural beauty for effective patient consultation, differences between Asian and Caucasian facial anatomy, and medical reference values to identify procedural standards and methods most suitable for Asians. The sociologist Beverley McNamara stated that people all have inner desires to look good for their age, albeit to a different degree. In addition, there are scholars who state that human health today does not simply signify physical health, but also comprises mental, sexual, and aesthetic health. An anecdote about Dr. Ivo Pitanguy, a famous Brazilian plastic surgeon, illustrates this point. In 1961, a fire broke out during a circus performance in Rio de Janeiro, Brazil, causing burns and other injuries to many children. Dr. Pitanguy treated children whose faces had been disfigured by the fire and became a national hero. After this event, he became a philanthropist who offered free cosmetic surgeries to the rich and poor and gained international acclamation. He played a pivotal role in creating a favorable public opinion toward cosmetic surgery in Brazil. Subsequently, Brazil became one of the world leaders in cosmetic surgery. Dr. Pitanguy stated that “even poor people have the right to beautiful,” suggesting that pursuit of beauty is a universally fundamental human desire and maybe one of the driving factors in people’s lives. Historically, some Western philosophers emphasized “inner beauty” or the person’s character as opposed to his or her external

appearance when discussing beauty. Likewise, up until the mid-twentieth century, Koreans, strongly influenced by Confucian philosophy, believed that they should not be reckless with the faces and bodies they had inherited from their parents. Even just few decades ago, satirical cartoons and editorials appeared in newspapers, lamenting the fact that women had received cosmetic surgery from doctors who had been trained in Japan. In this context, it is astonishing that Korea has become a leader in cosmetic surgery, surpassing even Japan. The initial surge in popularity of cosmetic surgery and introduction of Western culture coincided with patients undergoing extreme cosmetic surgeries to attain Caucasian facial characteristics. This led to numerous complications and in the disappearance of traditional Korean beauty. In the early 2000s, there was a shift from the materialistic “fast food” culture to the “slow food” movement that encompassed a return to nature. With the “slow food” movement gaining momentum, there was also a shift from drastic, artificial altering of the face to minimally-invasive cosmetic procedures that produced subtle and natural results. In addition, with increase in life expectancy, people are socially active until a later stage and more people seek to recover younger versions of themselves and do not wish to alter their faces. The shift allowed minimally-invasive cosmetic procedures to meet the patients’ desires and thus underwent tremendous advancement since 2005. According to statistics from the United States on data from 1997 to 2013, the number of people who received surgical cosmetic procedures increased by 73%, whereas the number of people who received minimally-invasive cosmetic procedures increased by 356%. Filler administration, a minimally-invasive procedure, offers the advantages of immediate results, short recovery time, high satisfaction relative to the convenience of the procedure, average results relative to ease of procedure, and ease of repeat treatments. Disadvantages include low profitability due to price competition, limitations in procedural outcomes when compared to surgery, short duration of effect, sensation of a

1.1 Natural Beauty and Human Attractiveness

foreign body, post-procedure swelling, intra- and post-procedure pain, and concerns about procedure process including anesthesia. However, filler types and quality have improved markedly and volumizing filler procedures are supplanting fat graft procedures. Fillers are used beyond the scope of merely filling out superficial wrinkles and depressions. Fillers can create facial shape harmonization and even improve skin quality. Although filler injections have become prevalent recently, the actual practice of using substances such as Vaseline to fill depressed areas was practiced as early as the 1900s. Subsequently, paraffin wax with a low-melting point was used and became very popular as a filler material for nearly 20 years. However, these substances have disappeared from the market as they caused adverse events with serious sequelae. Then during the 1940s, liquid silicone injections into the breast, hip, and face became very popular in the US. However, this too was plagued by reports of foreign body reactions and the practice of using chemical substances as fillers was discontinued. Even in Korea, there have been reports of removing foreign substances from patients who experienced adverse events. These patients had illegally received filler injections from unlicensed practitioners and the substances removed were identified as paraffin wax and industrial silicone. In 1976 collagen fillers were introduced but failed to gain much popularity for various reasons. In 1996, first-generation HA filler Hylans was introduced for the first time. That same year, second-generation HA filler Restylane entered the market. Widespread use of fillers was observed in the 2000s. Introduction of Restylane in Europe was followed by the introduction of Juvéderm in 2000. The company that manufactured Juvéderm was acquired by an American company in 2006 and is still being produced today. Subsequently, many new products have been introduced, including Teosyal (2003), Esthelis (2005), Stylage (2007), Glytone (2008), and Hylaform (2008). European countries are still producing various types of HA-based fillers. Currently, these countries have established their positions as industry leaders and produce

3 Table 1.1 History of Injectables Vaseline: 1900−1910 Paraffin: 1900−1920 Liquid injectable silicone: Early 1940−1965 Collagen: 1976−2003 PMMA (Polymethyl methacrylate): 1992−2006 PAAG (Polyacrylamide gel): 1984, 1996−2001 HA (Hyaluronic acid): 1996−2003 PTFE (Polytetrafluoroethylene): Late 1990s PLA (Polylactic acid): 1999−2009 Polyalkylimide: Early 2000s Ca–HA (Hydroxyapatite): 2001−2006

approximately 300 different filler products (Table 1.1). Patients today seek three-dimensional contouring and rejuvenation of the entire face over adding volume to a specific part of the face, removing wrinkles, or making the face look slimmer. Standards of beauty are ever-changing and relative. They are influenced by many factors including historical period, culture, and geographical location. Accordingly, there is a need for objective standards or references to define the attractive face archetype that people desire. Undertakings of this mission have persisted since ancient times. Artists and scholars historically used the concept of the “golden ratio” to define the ideal form and stated that when the face is divided into numerous compartments in relation to the eyes, nose, and mouth, the ratio of shortest and longest sides that make up each compartment should have a ratio of 1:1.618 to be considered beautiful. As an example, Dr. Stephen Marquardt, an American oral and maxillofacial surgeon, created the Marquardt mask so that individuals can measure how close his/her face was to the ideal ratio. In the Marquardt mask, ratios such as lower lip-nasal tip distance: nasal tip-sellion distance and width of the eye: sellion-lateral canthus distance are measured. Marquardt claimed that the facial ratios of people recognized around the world as being beautiful have ratios that are closer to the golden ratio masks that he created for each ethnicity.

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However, many questions have been raised as to whether Marquardt’s claim is valid. Indeed, there are counterclaims stating that when the Marquardt mask was used to create the ideal beautiful female face using 3D graphics, the resulting face had masculine characteristics. Moreover, although the golden ratio can be used as a means to assess beauty from an artistic or academic perspective, there are limitations to using this tool in clinical practice on the faces of actual patients. In addition, according to a study conducted by David Perrett, a professor of psychology at the University of St. Andrews in Scotland, there are both absolute and relative standards of beauty when determining facial attractiveness. According to his theory, absolute standards of beauty are standards that apply universally. “Left-right symmetry,” “proximity to average ratios,” “emotions and facial expressions,” “skin condition”, and “severity of wrinkles” are examples of absolute standards. Relative standards may include “similarity in appearance”, “difference,” and “differences in values,” and what is perceived as beautiful vary from individual to individual. The author agrees with this latter theory more than the golden ratio. Specifically, having a higher degree of “left-right symmetry,” which is one of the absolute standards of beauty is an indication of health and normal genes and the provision of visual harmonization enhances attractiveness. Biologically, the “average ratio” refers to the proportions of the average human face. Proportions of facial structures relative to the eyes, nose, and mouth and features such as hair, eyebrows, and mustache are considered. Faces closer to the “average ratio” are perceived to be more beautiful and associated with good health. Indeed, people perceive faces with proportions closest to the average facial ratios over faces that are unique or different to be more attractive. Proportions close to the average ratio signifies the optimum for that given physical trait. Skin color varies by race but regardless of skin color, skin quality, facial wrinkles, and degree of sagging are all absolute standards of beauty. In addition, positive emotions, bright,

and cheerful facial expressions are important factors in creating a favorable impression. People have a tendency to place importance only on the physical appearance of the face. The fact that emotions and facial expressions also play a significant role in how attractive a person is perceived to be is often overlooked. In fact, study results have shown that patients with Moebius syndrome, who are not capable of forming facial expressions, do not give a psychologically favorable impression to others due to their expressionless faces. Guillaume Duchenne, a French neurologist, stated that only a genuine true smile that involves both the contraction of the orbicularis oculi and zygomaticus major muscles is considered to be emotionally pleasing. Moreover, the Pan Am smile, which refers to a smile involving just the mouth, is perceived as a false smile and is associated with disingenuity. In his book titled “The Expression of the Emotions of Man and Animals,” Charles Darwin claimed the universal nature of expression. According to his theory, humans universally feel 6 emotional states, happiness, sadness, anger, fear, disgust, and surprise. Each emotional state is conveyed by the same facial expression. However, Paul Ekman, an American psychologist, made the argument that throughout the world a specific emotion is not communicated with the same facial expression and in fact vary depending on culture. To support this claim, he investigated the indigenous people of Papua New Guinea. As these people had lived in isolation, the way they expressed and reacted to the six major human emotions would not have been influenced by Western culture. The results showed that the indigenous people responded similarly to people from the West. Contrary to Ekman’s initial theory, the study results demonstrated that human response to the 6 universal emotional states does not vary by race or culture. The portrayal of and response to emotions was not relative but universally shared, absolute, and innate. These findings show that plastic surgeons must take natural facial expressions into consideration when performing procedures on patients. There are instances when patient expresses dissatisfaction despite successful aesthetic

1.1 Natural Beauty and Human Attractiveness

outcomes with effective correction of wrinkles and sagging. When procedure results are too drastic or cause discomfort in forming facial expressions, patients feel that their face has become abnormal. Naturally, the field has also seen an emergence of a new trend called “dynamic cosmetic surgery,” and practitioners consider aesthetic outcomes of the face in the dynamic state as well. The relative standards of beauty which are “similarity in appearance”, “difference,” and “differences in values” will be discussed. First “similarity in appearance” denotes that people will generally perceive family and friends or people with whom they have a relationship to be more attractive. The opposite, people being attracted to others who possess traits that they do not have, maybe true. However, people are predominantly attracted to familiarity. “Difference” is based on the concept that women are attracted to men who are masculine and men are attracted to women who are feminine. Men also show preferences for women with child-like appearances. In particular, women who are considered beautiful today have facial ratios similar to that of a 6–7 years old child. Lastly, beauty standards may vary by “difference in values.” Standards vary from one generation to another and are influenced by societal and cultural factors. In particular, humans have a tendency to emulate the appearance of the ruling class due to inner desires to obtain higher societal status. This is exemplified in Asia where there are both people who aspire to Asian beauty ideals but also people who, under the notion that Western culture is superior, seek Caucasian features. The four common factors identified in both the absolute and relative standards of beauty are: “factors that contribute to a youthful appearance”, “left-right symmetry”, “facial harmonization close to average ratio,” and “gender and ageappropriate characteristics.” In particular, skin quality and wrinkles affect all four factors. Skin brightness, evenness of skin tone, size of moles, and blemishes, all have a major impact on a person’s perceived age.

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According to a study, when one facial feature looks older than another, people tend to judge that person by the oldest looking feature. For example, no matter how young the person maybe, if that person is bald, people would perceive that person as being old. In addition, there are studies showing that an individual with severe wrinkles imparts a negative impression as the wrinkles serve as a distraction to the individual’s positive facial traits. As negative traits obscure positive traits, it is necessary to correct the negative trait/s. For optimal results, a comprehensive approach should be taken over partial correction. In 2011, Dr. Seung-Chul Rhee, a plastic surgeon, presented composite photographs of the archetypal attractive face by race. The aforementioned factors contributing to facial attractiveness were evident in all the faces regardless of race. As racial groups have their own distinct characteristics, cosmetic procedures appropriate for that race should be performed rather than attempting to “westernize” the appearance of Asian people (Fig. 1.1). According to Yong-Jin Cho, a face scientist, the perception of beauty has changed in Korea as a result of cultural adaptation by cultural learning. These shifts in beauty standards occur over time with changes in culture and values.

1.2

Differences Between Asian and Western Beauty Concepts

Tremendous advances in the field of cosmetic surgery using minimally-invasive techniques in recent years have led to the introduction of many different types of fillers. However, just as with cosmetic surgery, these minimally-invasive procedures first introduced from the West provided injection guidelines and protocols tailored to Caucasians. Therefore, to effectively perform these procedures on Asians, various issues had to be considered. One of the most important issues is the identification of facial features that distinguish Caucasians from Asians. To ensure the recommendation of the appropriate minimally-invasive

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Fig. 1.1 Differences in standards of beauty according to race and culture. 1. Rhee SC. The average Korean attractive face. Aesthetic Plast Surg 2006;30:729–730.

2. Rhee SC, Lee SH. Attractive composite faces of different races. Aesthetic Plast Surg. 2010;34(6):800–1

procedure, it is crucial to gain an accurate understanding of Caucasian and Asian facial characteristics. Caucasians who have slimmer faces with distinct contours prefer a more three-dimensional face with angled jawlines. In contrast, Asians have wider anterior malar areas, protruding lateral cheeks, square jawlines, and paranasal depressions. Consequently, Asian faces look uneven from the profile view, appear wider and flatter with rather faint contours in the frontal view. Accordingly, Asians prefer smooth threedimensional contours as opposed to Caucasians who prefer protruding, defined three-dimensional contours. In other words, Westerners prefer angular, prominent faces whereas Asians prefer slimmer, smooth contours. There are many anatomical differences in the facial skin and soft tissues as well. First, Asians have thicker, heavier, and firmer skin than

Caucasians, and as a result, they have fewer agerelated wrinkles. However, Asians have larger skin volume per surface unit area so compared to Caucasians, a greater force is needed to add overall volume to the face or lift the skin. The superficial muscular aponeurotic system (SMAS) is a layer superficial to the skin that contains superficial and deep retinacula cutis. The SMAS connects the skin to the deeper structures located by the bone. In regards to the soft tissue structure, the retinacula cutis formed by retaining ligaments is denser in Asians than in Caucasians, and as a result, the subcutaneous tissue of Asians tends to be tougher. In terms of vasculature, Caucasians have greater collateral circulation whereas Asians have more vertically running perforating vessels and blood vessels tend to be more developed. This increases the risk of bleeding and serious vascular complications such as tissue necrosis in

1.2 Differences Between Asian and Western Beauty Concepts

Asians. To prevent these accidents, it is important to locate injection sites and layers that are anatomically safe for the procedure. It is known that with aging severe depression of orbital and other facial bones that support the midface occur. In an article published in 2000, Dr. Pessa claims that to correction the depression, adequate volumization is needed in the periorbital region and midface area. Following the claim by Dr. Pessa, procedures were performed based on the assumption that such changes in facial bones occurred in Asians as well. However, recent findings indicate that unlike Caucasians, Koreans do not experience the same changes in the bones of the midface as they age. Therefore, the flat midface observed in some Asians is a trait that they were born with and not an age-related change in bone structure. For Koreans whose faces have become flatter over time, this depression has been caused by ptosis of skin and soft tissues overlaying the bones of the midface. Such differences should be taken into account when coming up with a treatment plan. Because Asians have thicker, denser, and heavier skin than Caucasians do, Asians require firmer fillers with relatively higher elasticity to enhance facial volume. Moreover, because of tougher subcutaneous tissue and well-developed vasculature, there is a higher risk of serious vascular complications due to bleeding or vascular occlusion. Therefore, it is of utmost importance to identify anatomically safe and effective injection sites and planes for each part of the face to avoid such complications. In terms of the frontal view of the face, Asians prefer facial types with appropriately sized cheeks that impart a smiling appearance, a slim and smooth facial contour, a well-balanced jawline, and a nose of suitable proportion and height. For Caucasians seeking prominent “apple cheeks,” the superolateral quadrant (quadrants defined by Hinderer’s lines) is augmented. On the other hand, because the goal is to create a smoother ogee curve in Asians, the inferomedial aspect is targeted to enhance the anterior malar area.

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Since most Asians already have wide and protruding zygomatic arches, Asians do not need zygomatic arch augmentation procedures performed on Westerners. When lateral cheek hollow is present, there is loss of smooth contours in the lateral aspect of the face due to the protruding zygomatic arch. The filler procedure is thus performed in the hollow region inferior to the zygomatic arch to create a smoother facial profile. To summarize, unlike in Caucasians who need zygomatic arch augmentation, Asians need treatment inferior to the zygomatic arch. Caucasians congenitally have a narrow lower face. As a result, they prefer procedures that create well-defined mandibular angles. Conversely, Asians, who have a wider lower face with a prominent square jawlines prefer the slim “egg-shaped” face that becomes narrower toward the bottom, similar to a kiwi or heart. Accordingly, many Asians augment just the mental region and do not receive fillers in the mandibular angle and jawline (Table 1.2). In most people, the lower face increases in volume and becomes wider with aging. This causes the face to appear wider. To create a more three-dimensional and slimmer face shape, botulinum toxin or a lipolytic agent can be used in combination with fillers. Chin augmentation with fillers and treatment with botulinum toxin/lipolytic agent in the lower cheek muscles, skin, or soft tissues decreases volume to create a slimmer lower face. In patients in whom the wide lower face is caused by sagging skin rather than skeletal structure, face-lifting with thread or laser treatment can smoothen the lower face contours. Combination treatment can maximize the effects of lower face filler procedures. In addition, procedures that are performed more commonly in Korea compared to the West are: lower eyelid charming roll formation for cuteness, paranasal augmentation to reduce protrusion of the mouth for elegance, columellar augmentation to lift the depressed nasal tip for a cat-like appearance, and sunken eyelid correction to fill the upper eyelid. The brow lift procedure, which involves volumizing the sunken region by the brows to lift them, is commonly performed in

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Table 1.2 Differences in Facial Characteristics in Caucasians and Asians ① Caucasians—Relatively prominent supraorbital ridge, high cheek bones, strong nose and chin, fully defined lips, and a square jawline ② Asians—Slightly smooth facial 4S line profile (from the forehead to chin) with balanced convexity and concavity rather than high cheek bones and strong triangle with prominent nose and chin, and small face with slim oval-shaped jawline rather than a well-defined and square jaw ③ Difficult to contour the face with only a small-particle filler—The skin of Asians is oily, rough, thick, and tight ④ Safer selection of the injection entry site and injection plane to avoid severe bleeding and vascular compromise— The subcutaneous layer is tighter and thicker with a more abundant and complex vascular plexus ⑤ Requests of Asian patients—Youthful, charming, small face with a cute and cheerful smiling appearance

Western countries. However, this procedure is not performed as much in Korea because Koreans do not prefer the strong, aggressive image that elevated eyebrows may impart (Table 1.3).

1.3

Medical Reference Values to Create an Attractive Face

As demonstrated by numerous different studies, the standards of beauty tend to be consistent, regardless of age and sex. For example, most people consider features that symbolize youthfulness to be beautiful. People are innately drawn to what is attractive and there is even a theory that even newborn infants perceive beauty. It has been experimentally shown that babies show interest in attractive faces and focus more on such faces. To ensure the attractive facial image that the patient desires is achieved, treatment approach should be based on medical references values that consider the absolute and relative standards of beauty discussed above. Generally, Asians consider a face with the following characteristics

to be an ideal face; smooth forehead with minimal curvature, appropriately sized cheekbones that give a smiling expression, sleek but smooth facial contours, full lips, bilaterally balanced jawline, nose with appropriate proportion and height, and egg-shaped or oval face. First, accurate facial analysis with knowledge in the references values of a well-balanced face with good facial proportions and harmonization is necessary. Assess patient in the upright position, aligning the Frankfort horizontal line (line that projects from the external auditory canal to the lower rim of the orbit) and the floor to be parallel. Evaluate the frontal, profile, and threequarter views of the face. The ideal reference values to create an attractive face that takes racial differences into account can be found in the facial proportions and harmonization of faces we are most familiar with. As shown in the left illustration in Fig. 1.2, when the face is divided into thirds—trichion to glabella, glabella to subnasale, and subnasale to gnathion—Westerners consider a 1:1:1 ratio to be ideal. In the past, procedures were performed

Table 1.3 Filler and Toxin Treatments Specific to Asian Patients ① Use of filler and toxin for a cheerful smiling effect ② Oval face toxin injection for a small face and slimmed jawline with filler for the stereographic T zone ③ Lower eyelid roll formation using filler for a charming eye ④ Paranasal space augmentation using filler for a smart and noble appearance ⑤ Lateral cheek and temple augmentation to smooth out irregular lateral facial contours—depressions and irregular shape due to prominent and widened zygomatic arch ⑥ Anterior nasal spine and columellar filler injection for a cat-like appearance, nasal tip elevation, and wider columello-labial angle ⑦ Correction of sunken eyelid and multiple eyelid lines to correct sleepy, tired eye appearance—Sunken eyelids make Asians’ eyes appear more ptotic with multiple eyelid lines due to small eyes and weak eyelid levator muscle function

1.3 Medical Reference Values to Create an Attractive Face

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Fig. 1.2 Ideal facial proportion and line

in Asia based on this standard. However, Asians today tend to prefer a shorter lower face, considering this facial type to be more youthful. Accordingly, procedures are performed on the chin and jawline so that the midface to lower face ratio is 1:0.8–0.9. When the face is divided into five vertical sections from the right ear to the left ear, as shown in the right illustration in Fig. 1.2, a 1:1:1:1:1 ratio is considered ideal. Asians’ faces are wider than that of Caucasians, and as a result, their eyes and nose may appear broader. Regardless of the absolute width of the nose, for a face to appear well-balanced, the intercanthal distance to width of the nose ratio should be close to one. Accordingly, filler and thread lifting procedures on the nasal tip and columellar area to make the ala nasi look narrower are becoming more popular. More favorable outcomes can be achieved by combining filler with botulinum toxin injections into the muscles responsible for dilating the nares and plunging of the nasal tip which causes the ala nasi to look flattened when smiling or making facial expressions (Fig. 1.3). The Ricketts line, which extends from the nasal tip to the mentum, is used to determine the degree of mouth protrusion and assess facial balance of the profile. Relative to the Ricketts line, which spans the nasal tip, lips, and mentum, Westerners consider the ideal location of the lower lip and upper lip to be 2 mm and 4 mm posterior to the line, respectively. To achieve this in Asians, the procedure must involve excessive

anterior projection of the nasal tip and mentum. In Asians, the lower lip located on the Ricketts line is considered appropriate. If the line extending from the nasal tip to the forehead is symmetrical with the Ricketts line, the forehead is considered to have appropriate volume (Fig. 1.4). The conditions for a three-dimensional, wellbalanced, and youthful face from the profile view can be explained using the specific values shown in Fig. 1.5. Clinically, the lines connecting the forehead to nose, nose to lips, lips to mentum, and the anterior cheek line should be S-shaped curves, as shown in Fig. 1.6. In the frontal view, the face should be eggshaped or oval. The face is youthful and slim, resembling an inverted triangle or heart, as shown in Fig. 1.7. In addition, combination treatment with other minimally-invasive procedures may be considered to eliminate wrinkles and rejuvenate the skin. Achieving facial balance to create an attractive face requires a holistic approach. Harmony in interpersonal relationships between medical professionals, hospital staff, and patients is crucial in optimizing outcomes of minimallyinvasive procedures and maximizing patient satisfaction. In line with this thought, the “Harmony Program” was recently developed in Europe. This is an advanced patient management program that provides total approach, consultation, and management services for patients undergoing minimally-invasive procedures. With respect to

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1.5

Fig. 1.3 Ideal proportion and line of nose and lip

Supraorbital ridge Tip of nose

Lower lip Tip of chin

Fig. 1.4 Difference of Ricketts line between Caucasians and Asians

the specifics of the program, the medical consultation is conducted based on medical background and patient self-assessment. The consultation is a collaborative process that actively involves the patient and the treatment plan is established based on the results of the consultation. Subsequently, the treatment plan is carried out. Lastly, plans for post-treatment

follow-up and if necessary, plans for additional procedure(s) are established. The details of the program are as follows: In Step 1, a standardized questionnaire and pretreatment interview are conducted to identify specific details about the patient; patient medical history, including previous surgery or interventions, motivation behind and desire for the

1.3 Medical Reference Values to Create an Attractive Face

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Fig. 1.5 Conventional criteria for ideal facial profile 1. The arc of forehead, convexities of the temples 2. The concavity between the glabella and the nasal root area (135‚) 3. Strong nose and nasal tip projection (30‚-45‚) 4. Ideal columello-labial angle (90‚-100‚) 5. Anterior cheek projection, extending as an unbroken convex line from the lower eyelid to the cheek 6. Not depressed paranasal space 7. Upper and lower lip fullness 8. Sharp well-defined arc of the jawline

Fig. 1.6 Facial 4S lines for ideal facial profile

The youthful face : balanced harmony of convexity and concavity

S

From forehead to nose

S

From nose to upper lip

S

From lower lip to chin

S

Apple cheek (Anterior malar area) for ogee curve

procedures, self-assessment of patient face, specific requests, personality, and current financial situation. In Step 2, the medical professional evaluates the patient’s face based on the aforementioned standards of beauty including, facial symmetry, facial volume, degree of sagging, wrinkles, and skin condition. Based on the findings, an individually tailored treatment plan for the facial region to be treated, necessary procedure/s, degree of correction possible, and which combination of treatments should be attempted to optimize outcomes is established. Ultimately, the treatment method and cost are determined through the final consultation. When establishing an individually tailored treatment plan, the physician must comprehensively consider both patient-related and clinical factors. The physician must think about the following: the type of change the patient desires and to what extent; any procedure-related concerns the patient may have,

including pain, bleeding, swelling, and bruising; the affordable amount of filler, toxin, and thread that can be used based on patient’s financial status; product selection; and if alternative procedure options are available. Step 3 is the actual treatment stage. The goal should be to achieve overall harmony in the face in line with the aforementioned beauty standards of improving facial proportions and balance. In cases when patient expectations exceed what is feasible with injectable fillers, it is important to inform the patient about this. Doing so will build a trusting relationship and encourage the patient to come in for subsequent treatments. Step 4 includes follow-up planning. Typically, a follow-up visit for evaluation and correction two weeks after the procedure is recommended. Additional procedure(s) for harmony and balance or combination treatment using other procedures are discussed and a longterm treatment plan reflecting the expectations of

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Fig. 1.7 Inverted triangle or heart shape

the patient is established. The follow-up visit is also an opportunity for business-related aspects, such as introduction of potential patients, continuous visits for additional treatment, and sales of cross-treatment and other products. One of the procedures that have been used recently in combination treatment with filler procedures is egg injection. Filler injections add volume to the entire face whereas egg injections reduce the volume of bulging soft tissue in the lateral border of the face to create a slimmer face type. Egg injection, which consists of a cocktail solution mixed with botulinum toxin, is injected into the muscles, skin, and soft tissues in the cheek and chin area to inhibit excessive contraction of the masseter muscle, tighten the skin of the cheeks, and reduce volume of soft tissue including the skin and subcutaneous fat. In combination, the egg injection has the effect of both slimming the face and maximizing the three-dimensional volumization of the filler. While excessive dieting can lead to hollowness and dry, flakey skin, egg injection is effective in creating a slim face that is natural and healthy looking. The slimming effects vary depending on individual differences in skeletal size, amount of soft tissue, and skin condition. However, unlike PPC injections which have been banned, egg injection is a safe and effective treatment option without major discomfort and adverse events (Fig. 1.8).

Lastly, the future directions physicians should pursue when performing minimally-invasive procedures, including filler procedures, will be discussed. First, with the full face approach, the primary goal should be to achieve balance and overall harmony, including left-right symmetry. With this approach, even patients who have received prior cosmetic surgery or aesthetic procedures can expect some degree of correction and improvement through minimally-invasive procedures. In the full face approach, the focus shifts from assessing the facial wrinkles and shape in the expressionless, static state. In clinical practice, it is important to take into consideration the dynamic nature of soft tissues and wrinkles, which change with smiling and the formation of facial expressions. Second, more emphasis should be placed on soft tissues. Compared to Caucasians, ageinduced facial skeletal changes tend to be less pronounced in Asians. Therefore, it is important to consider the anatomical location and configuration of the soft tissue covering the facial bones, rather than merely focusing on the location of and changes in the skeletal structure Lastly, beauty standards should shift from traditional, definitive standards of the past to beauty standards that encompass patients’ personality, race, culture, geographical region, and aspirations/goals for treatment.

Bibliography

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Fig. 1.8 Before (left) and after (middle, right) treatment of oval face injection

Bibliography 1. Bray D, et al. A review of dermal fillers in facial plastic surgery. Curr Opin Otolaryngol Head Neck Surg. 2010;18:295–302. 2. Edsman K, et al. Gel properties of hyaluronic acid dermal fillers. Dermatol Surg. 2012;38:1170–9. 3. Kablik J, et al. Comparative physical properties of hyaluronic acid dermal fillers. Dermatol Surg. 2009;35:302–12. 4. Matarasso SL, et al. Consensus recommendations for soft-tissue augmentation with nonanimal stabilized hyaluronic acid (Restylane). Plast Reconstr Surg. 2006;117(3):3S–34S;discussion 35S. 5. Cohen SR, et al. Facial Rejuvenation with Fillers by Elsevier Limited, 2009. 6. Kim P, et al. Structured nonsurgical asian rhinoplasty. Aesthetic Plast Surg. 2012;36:698. 7. Liew S. Ethnic and gender considerations in the use of facial injectables: Asian patients. Plast Reconstr Surg. 2015;136(5):22S–7S. 8. Pierre S, et al. Basics of dermal filler rheology. Dermatol Surg. 2015;41(1):120S–6S. 9. Tezel A, et al. The science of hyaluronic acid dermal fillers. J Cosmet Laser Ther. 2008;10:35–42. 10. Gold MH. Use of hyaluronic acid fillers for the treatment of the aging face. Clin Interv Aging. 2007;2(3):369–76. 11. Sundaram H, et al. Comparison of the rheological properties of viscosity and elasticity in two categories of soft tissue fillers: calcium hydroxylapatite and hyaluronic acid. Dermatol Surg. 2010;36:1859–65. 12. Casabona G, et al. Microfocused ultrasound with visualization and fillers for increased neocollagenesis: Clinical and histological evaluation. Dermatol Surg. 2014;40:194S–8S. 13. Kenner JR. Hyaluronic acid filler and botulinum Neurotoxin delivered simultaneously in the same syringe for effective and convenient combination aesthetic therapy. J Drugs Dermatol. 2010;9:1135–8. 14. Lee, et al. Rejuvenating effects of facial hydrofilling using Restylane Vital. Arch Plast Surg. 2015;42 (3):232–87. 15. Kim, et al. Development of facial rejuvenation procedures: thirty years of clinical experience with face lifts. Arch Plast Surg. 2015;42:521–31.

16. Flynn TC, et al. Ultrastructural analysis of 3 hyaluronic acid soft-tissue fillers using scanning electron microscopy. Dermatol Surg. 2015;41:143S–52S. 17. Narurkar V, et al. Facial treatment preferences in aesthetically aware women. Dermatol Surg. 2015;41:153S–60S. 18. Kim J. Effects of injection depth and volume of stabilized hyaluronic acid in human dermis on skin texture, hydration, and thickness. Arch Aesthetic Plast Surg. 2014;20:97–103. 19. Carruthers J, et al. Introduction to fillers. Plast Reconstr Surg. 2015;136:120S–31S. 20. Friedman PM, et al. Safety data of injectable nonanimal stabilized hyaluronic acid gel for soft tissue augmentation. Dermatol Surg. 2002;28:491–4. 21. Ablon Glynis. Understanding how to prevent and treat adverse events of fillers and neuromodulators. Plast Reconstr Surg Glob Open. 2016;4(12S):e1154. 22. Perrett D. In your face: the new science of human attraction; 2012. 23. Ioi H, et al. Influence of facial convexity on facial attractiveness in Japanese. Orthod Craniofac Res. 2007;10(4):181–6. 24. Pessa JE, Rohrich RJ. Facial topography: clinical anatomy of the face. St. Louis: Quality Medical Publishing; 2012. 25. Farkas LG, et al. Is photogrammetry of the face reliable? Plast Reconstr Surg. 1980;66:346. 26. Park HS, et al. Harmonized profiloplasty using balanced angular profile analysis. Aesthetic Plast Surg. 2004;28:89–97. 27. Mendelson B. In your face: the hidden history of plastic surgery and why looks matter. Hardie Grant Books; 2013. 28. Pearson DC, et al. The ideal nasal profile: rhinoplasty patients vs the general public. Arch Facial Plast Surg. 2004;6(4):257–62. 29. Jones BC, et al. When facial attractiveness is only skin deep. Perception. 2004;33(5):569–76. 30. Kaipainen Anu E, et al. Regional facial asymmetries and attractiveness of the face. Eur J Orthodont. 2015;13:1–7. 31. Berneburg M, et al. Changes in esthetic standards since 1940. Am J Orthod Dentofacial Orthop. 2010;137(4):450. 32. Lee HB, et al. Evaluation of influence of individual facial aesthetic subunits on the cognition of facial

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attractiveness in public. J Korean Soc Plast Reconstr Surg. 2010;37(4):361–8. Meneghini, et al. Clinical facial analysis: elements, principles, and techniques.Berlin: Springer; 2012. Rhee SC, et al. Balanced angular profile analysis. Plast Reconstr Surg. 2004;114(2):535–44. Liew S, et al. Consensus on changing trends, attitudes, and concepts of Asian beauty. Aesthetic Plast Surg. 2016;40:193–201. Zhuang Z, et al. Facial anthropometric differences among gender, ethnicity, and age groups. Ann Occup Hyg. 2010;54(4):391–402. Swift A, et al. Beautiphication: a global approach to facial beauty. Clin Plast Surg. 2011;38:347–77. Farkas LG, et al. International anthropometric study of facial morphology in various ethnic groups/races. J Craniofac Surg. 2005;16(4):615–46. Narins RS, et al. Validated assessment scales for the lower face. Dermatol Surg. 2012;38:333–42. Soh J, et al. Professional assessment of facial profile attractiveness. Am J Orthod Dentofacial Orthop. 2005;128(6):690–6. Choe KS, et al. The Korean American woman’s face: anthropometric measurements and quantitative analysis of facial aesthetics. Arch Facial Plast Surg. 2004; 6(4):244–52. Farkas JP, et al. The science and theory behind facial aging. Plast Reconstr Surg Global Open. 2013;1:e8–15. Ek Chan, et al. Esthetic evaluation of Asian-Chinese profiles from a white perspective. Am J Orthod Dentofacial Orthop. 2008;133(4):532–8. Sadick NS, et al. A novel approach to structural facial volume replacement. Aesthetic Plast Surg. 2013;37:266–76.

45. Fitzgerald R, et al. Update on facial aging. Aesthet Surg J. 2010;30(Suppl):11S–24S. 46. Farkas LG, et al. Anthropometric measurements of the facial framework in adulthood: age-related changes in eight age categories in 600 healthy white North Americans of European ancestry from 16 to 90 years of age. J Craniofac Surg. 2004;15:288–98. 47. Oh HS, et al. Correlations between cepharometic and photographic measurements of facial attractiveness in Chinese and US patients after orthodontic treatment. Am J orthod Dentofacial Orthop. 2009; 136(6):762. e1–14:discussion 762–3. 48. Kahn DM, et al. Overview of current thoughts on facial volume and aging. Facial Plast Surg. 2010;26:350–5. 49. Radlanski RJ, et al. The face: pictorial atlas of clinical anatomy. Quintessence Publishing; 2012. 50. Ekman P, et al. Facial signs of emotional experience. J Pers Soc Psychol. 1980;39:1125–34. 51. Krumhuber EG, et al. Can Duchenne smiles be feigned? New evidence on felt and false smiles. Emotion. 2009; 807–20. 52. Surakka V, et al. Facial and emotional reactions to Duchenne and non-Duchenne smiles. Int J Psychophysiol. 1998;29:23–33. 53. Talarico S, et al. High patient satisfaction of a hyaluronic acid filler producing enduring full-facial volume restoration: An 18-month open multicenter study. Dermatol Surg. 2015;41(12):1361–9. 54. Budai M, et al. Relation between anthropometric and cepharometric measurements and proportions of the face of healthy young white adult men and women. J Craniofac Surg. 2003;14(2):154–61.

2

Filler Types and Characteristics

2.1

Type of Filler

It is a long wish of people to recover the volume reduction of the face caused by aging. Even before officially licensed filler products were developed, people put something other materials on their faces. However, these substances caused serious side effects. Nowadays, there are fewer cases where Vaseline or paraffin is used as filler materials because of the improvement of people’s intellectual level. Fillers can be classified according to the raw materials. The most widely used are hyaluronic acid fillers. In addition, there are calcium, PMMA, PLLA, collagen, poly-acryl amide, and polycaprolactone fillers. However, from a clinician’s point of view, it is useful to distinguish between two types of fillers. In one type, it is possible to dissolve the filler immediately in case of side effects or dissatisfaction. In another type, it is impossible to dissolve the filler. In the former type of filler, the problem can be usually solved by dissolving the filler material, but in the latter type, surgical removal is required (Fig.2.1). Dissolvable fillers are hyaluronic acid fillers. Despite its many disadvantages, it is currently the

© Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_2

most widely used ingredient due to its incomparable advantage of being able to dissolve in case of problems. All other ingredients except hyaluronic acid filler are classified as fillers that cannot be dissolved. There are many reasons why this property is important. One of the things to think about is that it affects the setup of your clinic system. Even with good products and good skills, complications of filler procedures may be inevitable. It is important to be able to solve the problems yourself. You may not be able to solve all the possible problems yourself, but you should still be able to solve most of them. Not all aesthetic physicians have a hospital operating system. Therefore, if you can’t solve the side effects of using a particular product, it would be better not to select it as one of your offered treatments.

2.1.1 Number of Various Fillers Used Recently There are hundreds of fillers on the market today. There are more than 300 products registered in Korea. Therefore, it is difficult for the clinician to choose the filler that is right for them based on their own experience and preference.

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2.2

Characteristics of Hyaluronic Acid Filler

2.2.1 Hyaluronic Acid as a High Molecular Compound Hyaluronic acid is a constituent of the skin that is present in the human body with high molecular weight compound. About 50% of the hyaluronic acid in the human body is present in the skin, and it is present in the dermis at a concentration of about 0.5–1 mg/g. The total amount of hyaluronic acid in the body is about 15 g in a 70 kg adult, and about 5 g per day is dissolved by hyaluronidase. That is, the half-life is only about 1-2 days and all disappears within a week. Therefore, resynthesis of hyaluronic acid occurs continuously in the human body. Hyaluronic acid decreases as aging progresses. As a result, skin moisture and elasticity are reduced. Hyaluronic acid is synthesized not only in dermal fibroblasts but also in keratinocytes of the epidermis. The molecular structure of hyaluronic acid is a disaccharide, mainly in combination with sodium (Fig. 2.2). N-acetyl–d-glycosamine and D-glucuronic acid bond between b-1.4 and b-1.3 glycosidic.

Is it a filler that can be dissolved?

Hyaluronic acid filler

Other fillers

Fig. 2.1 Filler division

Fig. 2.2 The molecular structure of hyaluronic acid (redrawing)

Filler Types and Characteristics

These disaccharides exist in a combined form repeatedly and have the same structure in animals and bacteria (Fig. 2.3). Therefore, fillers are manufactured using hyaluronic acid extracted from animals or bacteria.

2.2.2 Hyaluronic Acid Filler Manufacturing Process An important part of understanding the hyaluronic acid filler manufacturing process is how each process plays a role in producing a good product. At the same time, it is important to understand what problems arise when the process is flawed.

2.2.2.1 Preparation of Raw Materials of Hyaluronic Acid Manufacturers should use good quality raw materials. Friedman et al. have found that the use of high quality raw materials significantly reduces the frequency of side effects when preparing fillers under the same conditions. In conclusion, clinicians should check where the raw material of the filler originates from. 2.2.2.2 Dissolution with Strong Base (NaOH) The pH should be maintained above 10 for effective BDDE binding. NaOH which is a strong base used for dissolution, must be thoroughly removed during the manufacturing process (Fig. 2.4). 2.2.2.3 Cross-Linking Process As mentioned above, the half-life of hyaluronic acid in the body is 1–2 days. However, hyaluronic acid fillers made from hyaluronic acid are stabilized through cross-linking and have a longer half-life. Filler manufacturers have their own cross-linking technology, which is the company’s core technology. As binding materials, BDDE, PAG, and DVS are used and called “cross-linkers” (Fig. 2.5). These cross-linkers are highly toxic. Therefore, it would be most desirable if a minimum amount of cross-linker could be used while obtaining the desired physical

2.2 Characteristics of Hyaluronic Acid Filler

17

Fig. 2.3 Hyaluronic acid polymer structure (redrawing)

properties. In general, fillers with low crosslinking ratio and stable properties are good fillers. Fillers with too high cross-linking ratios are possibly dangerous. At the end of the crosslinking process, hyaluronic acid aggregates into several masses (Fig. 2.6a, b).

2.2.2.4 Dialysis or Washing Depending on the company, dialysis or washing may be performed. However, the purpose of this manufacturing process is the same which is removal and neutralization of toxic and foreign substances. Previously utilized NaOH is removed by pH and osmotic pressure adjustment. In

addition, the remaining BDDE is removed during this process (Fig. 2.7). Dialysis is generally a two-step process. Primary dialysis is performed using NaCl solution, and secondary dialysis is performed using PBS (phosphate buffer solution). This process is closely related to the safety of the product. In general, to be licensed as a filler product, the amount of endotoxin and residual BDDE should be below a certain level. However, empirically, we can’t be absolutely sure that those standards are met even if the product is licensed. Problems can still arise with products

Fig. 2.4 Dissolution of hyaluronic acid (with kind permission of S. THEPHARM)

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2

Fig. 2.5 BDDE cross-linking process (with kind permission of S. THEPHARM) Fig. 2.6 a, b State after completion of cross-linking (with kind permission of S. THEPHARM)

(a)

(b)

Filler Types and Characteristics

2.2 Characteristics of Hyaluronic Acid Filler

19

Fig. 2.7 Dialysis (with kind permission of S. THEPHARM)

that were determined to be safe during the approval/inspection process. This is one of the reasons why choosing a good filler is very difficult. It is expensive to go through a sufficient dialysis process. Nevertheless, a company’s products which have been designed with sufficient dialysis processes are naturally safe and have fewer side effects. Since the manufacturing process is kept confidential by each company, it is difficult to know the exact process which is used. However, it is not difficult to understand why it is important to wash for a sufficient time. It is essential to wash for a sufficient period until no BDDE is detected. Although different from manufacturer to manufacturer, they usually have a cleansing period of 10 days or more. In conclusion, it would be advisable to enquire about the cleaning or dialysis process and confirm the results of BDDE and endotoxin tests.

2.2.2.5 Cutting The cutting process will change the filler to the appropriate size (Fig. 2.8). There is no major difference in the cutting process depending on the filler line-up. Filler line-up is determined by dissolving and cross-linking hyaluronic acid. If the cutting process is insufficient, the extrusion force is not uniform during filler injection. If the cutting period is too long, thermal damage may occur to the filler, which may change the rheology of the product. It is important to find appropriate process conditions to produce appropriate rheology for the intended use of the product. The validation of cutting should optimize the manufacturing process. Depending on the company, the cutting and sieving process may be separated or be done simultaneously. This is because manufacturing know-how varies from company to company. The sieving process is mainly used in making biphasic fillers.

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2

Filler Types and Characteristics

2.2.3 Rheology of Hyaluronic Acid Filler Measured values used as objective indicators to determine filler rheology are as follows: (1) (2) (3) (4) (5)

G*: complex modulus G′: elastic modulus = storage modulus G′′: viscous modulus = loss modulus Tangent d Phase angle

To understand these indicators, we need to understand the external force the filler undergoes in the body after injected. There are four external forces that the filler undergoes (Fig. 2.12): (1) (2) (3) (4)

Fig. 2.8 Cutting process (with kind permission of S. THEPHARM)

2.2.2.6 Filling This is the process of inserting the completed filler product into the syringe. Contamination is the main issue needed to be controlled in this step (Figs. 2.9 and 2.10). 2.2.2.7 Sterilization Process In general, hyaluronic acid fillers are produced in single batches (i.e., LOT). Then there is a sterilization process after product filling. If it is sterilized into two separate processes, there may be a difference in the rheology of the product because the filler is affected by the minute environmental differences in the sterilization process. Cross-linking may be destroyed or viscoelastic values may be lowered (Fig. 2.11).

Torsion Lateral shear Compression Stretching

The filler’s response to external forces is driven by the three rheological properties of the filler. These are viscoelasticity, cohesiveness and complex viscosity, and their characteristics are as follows: (1) Viscoelasticity When an external force is applied to the filler, the filler exhibits both viscous and elastic responses. Purely viscous material remains deformed even when the external force is disappeared. Pure elastic materials, on the other hand, return to their original shape when external forces disappear. Fillers have both of these properties. Deformation occurs when an external force is applied. If you apply an external force below a certain level and then remove it, filler will recover its original appearance. However, if you apply an external force above a certain level to the filler,

2.2 Characteristics of Hyaluronic Acid Filler

Fig. 2.9 Filling system (with kind permission of S. THEPHARM)

Fig. 2.10 Product filling system (with kind permission of S. THEPHARM)

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Filler Types and Characteristics

Fig. 2.11 Sterilizing process using autoclave (with kind permission of S. THEPHARM)

the filler will not return to its original shape even if the external force disappears—only part of the original shape is restored. Four parameters are used to describe this viscoelastic property, which is described above as G*, G′, G′′, d. G* is the total energy required to deform a material using shear stress. This is typically used to express how “hard” the filler is. The formula qffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffiffi for this value is jG
j ¼ ððG0 Þ2 þ ðG00 Þ2 Þ and

Fig. 2.12 4 Types of external force applied to the filler

the value is calculated from the values of G′ and G′′. G′ is expressed as storage/elastic modulus. It is the energy stored in the gel during the deformation of the gel by an external force and then used to return to the original shape when the external force disappears. In other words, it is the ability to return to its original state after a change by external force. Thus, a filler with a large G′ value can be understood as a filler with good ability to return to its original shape. G′′ is expressed as loss/viscous modulus, and means the energy lost during the deformation of the gel by an external force. G′′ is not the same as viscosity. It means the ability to prevent filler from returning to its original form even if the external force disappears after deformation caused by an external force. Understanding G′ and G′′ is important. When we say elasticity in general, it means G*, which is the sum of the energy conserved (G′) and the energy lost (G′′) in relation to an external force.

2.2 Characteristics of Hyaluronic Acid Filler

d (delta) is an index indicating the elasticity of the material. The ratio of G′ and G′′ is used to calculate G*. Tangent d = G′′/G′ and tan d > 1 means G′′ > G′, which means that the viscous energy is larger than the elastic energy (i.e., it is close to a viscous liquid). Tan d < 1 means G′′ < G′, that is, elastic energy is larger than viscous energy (i.e., it is more of a gel-like form). During a filler procedure, the filler material in the syringe is injected into the tissue via a narrow needle or cannula. During this process, the filler material must be deformed to pass through a thin tube from the total mass in the syringe and this is only possible via viscous characteristics. After injection into the tissue, the filler must clump together again to form a mass and this is possible only via elastic characteristics. Therefore, a filler is a viscoelastic material with both properties.

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(2) Cohesiveness Cohesiveness is a characteristic of how well cross-linked filler materials aggregate together like jelly. The magnitude of cohesiveness is achieved by HA concentrations, cross-linking techniques, and other manufacturing processes. The filler can be split by applying a certain level of external force vertically to the filler. After the external force is removed, the fillers with low cohesiveness do not merge again when the filler molecules are “cracked”, but the fillers with high cohesiveness will reassemble (Figs. 2.13–2.15). This is an important property to consider when selecting the area to inject the filler. Cohesiveness is less important when the filler injection area is hard enough to prevent spread to the side (ex. Dermis), or in deep layers that are

Fig. 2.13 a, b, c In low cohesiveness fillers, when the filler is pressed and released by the tongue, the cracked filler in the pressed area remains as a hole without sticking to each other. (with kind permission of DAEHAN medbook)

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2

Filler Types and Characteristics

Fig. 2.14 a, b, c In high cohesiveness fillers, when the filler is pressed and released by the tongue, the cracked filler in the pressed area recombines (with kind permission of DAEHAN medbook)

Fig. 2.15 The structure of BDDE

far from external forces such as the Indian band area. However, migration is likely to occur when fillers with low cohesiveness are used in areas where the filler injection site is weak and can easily spread laterally, or where the distance from the skin is short as in the forehead. (3) Complex viscosity Complex viscosity means the resistance to flow when exerting a filler to create a flow. Higher complex viscosity results in greater extrusion

force. It is more difficult to inject and requires high injection force. Won Lee et al. calculated the injection pressure for various filler products. Depending on the product, the injection force may vary up to 2–3 times. In the future, when using certain products, filler products with information about the injection force can be helpful for safer procedures. In general, clinicians select products based on the clinical outcomes of the patient after the procedure. It is more common to choose products from colleague/mentor advice or empirical choices without proper knowledge and information of rheology. However, it is important for clinicians to have prior knowledge of filler rheology. One should go beyond just judging which fillers are good, bad, and appropriate. It is necessary to have a

2.2 Characteristics of Hyaluronic Acid Filler

rationale for selecting fillers with specific rheology for specific sites. You should be able to explain the results of your procedure in conjunction with rheology values. This knowledge can reduce trial and error in selecting the optimal filler.

2.2.4 Selection of Hyaluronic Acid Filler Before choosing a hyaluronic acid filler, here’s what you need to know (Table 1.1). In fact, when I see a new filler, I check it out. My personal opinion is included. In addition to the commonly used rheologyrelated physical figures, several other selection criteria are listed. Let’s talk about these things one by one. (1) Cross-linking BDDE, PAG, and DVS are used as crosslinkers nowadays.

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These substances are all chemically reactive and toxic. The most commonly used BDDE (1,4butanediol diglycidyl ether) has the following structure (Fig. 2.15 Drawing). Epoxy groups are present at both ends, forming an ether bond with a hydroxyl group (−OH) of hyaluronic acid (Fig. 2.16). Free-form BDDE is toxic, but BDDE crosslinked with hyaluronic acid is considered safe. It does not cause chemical reactions when injected into the body. During the process of degradation in the body, it is known that BDDE is safely removed without reactivation. Free BDDE that is not combined with hyaluronic acid should be thoroughly removed down to undetectable levels through cleaning and dialysis in the filler manufacturing process. If unremoved free BDDE is injected into the body, the epoxy groups of the BDDE will cause intense chemical reactions with body tissues. This is why one needs to look closely at the residual BDDE concentration when choosing a filler product and why the results should be monitored carefully.

Table 2.1 Considerations when choosing a filler Item

Contents

Way

1

Cross-linking

Check the cross-linker

Product brochure

2

MOD

Cross-linking ratio

Article or company internal data request

3

Monophasic versus biphasic

Filler physical property

Cohesiveness test product brochure

4

G*

Hardness

Company internal data request

5

Cohesiveness

Aggregation property

Direct test

6

Raw material

Good and qualified raw material

Company internal data request

7

Molecular weight of HA

Is it generic or of a different molecular weight that has not been used before?

Company internal data request

8

Additional additives

Lidocaine, mannitol, vitamin et al.

Product brochure

9

Washing

Refining process

Company internal data request

10

Injection force

Magnitude and constant of pressure

Company internal data request and direct test

11

Safety

Unwanted tissue reaction

Long term follow up at least 6 months

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2

Filler Types and Characteristics

Fig. 2.16 Linkage of BDDE and hyaluronic acid

Fig. 2.17 Cross-linked modification versus pendent modification

When a BDDE is bonded to a specific molecule but remains unbonded on one side, it is called a mono-linked BDDE. When both ends of BDDE are bonded, they are called double-linked BDDE. In the case of hyaluronic acid fillers, the state in which both epoxy groups of BDDE are combined is called a cross-linking modification (or cross-linking type), and the state in which

only one side of epoxy group is bound is called a pendent modification (or pendent type) (Fig. 2.17). One-sided pendent type BDDE is present in greater quantities than the both-sided combined BDDE. According to previous research, pendent type BDDE is known to lose toxicity by unreacted epoxy groups immediately reacting with water when exposed to the body.

2.2 Characteristics of Hyaluronic Acid Filler

However, many clinicians still suspect that pendent type BDDE may be associated with side effects such as a delayed immune response to the filler. Further research is needed. Many clinicians, including the author, know that products with the least amount of cross-links are relatively safer in making fillers with the same degree of viscoelasticity. In the past, products that promoted more solid products by increasing cross-linking rates caused problems. (2) MOD(degree of modification) (= crosslinking ratio) The cross-linking ratio refers to the ratio of how many of 100 hyaluronic acid monomers are cross-linked (Fig. 2.18). However, the MOD value is the sum of cross-linking modified BDDE and pendent modified BDDE. That is, MOD = cross-linked MOD (cMOD) + pendent MOD

27

(pMOD). MOD values are measured using Nuclear Magnetic Resonance (NMR). Indeed, the ability to support the structure of hyaluronic acid fillers through cross-linking is achieved by the cross-linking modified BDDEs. Pendent modified BDDEs do not provide support for filler structures. Therefore, the SEC/MS method is used to calculate the cross-linked MOD value rather than the NMR method. MOD values vary according to product. Filler companies will produce similar products with a certain level of G′, G′′, G* values, but the amount of cross-linkers used depends on the manufacturing process. In general, the MOD value is about 1–10%. The MOD values of the products used in aesthetic medicine are as follows (Fig. 2.19). As shown in Fig. 2.19, the difference of MOD value is very variable depending on the product.

Fig. 2.18 Cross-linking ratio (with kind permission of DAEHAN medbook)

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2

Filler Types and Characteristics

Fig. 2.19 MOD value of various filler products

In other words, products with low MOD values have similar viscoelasticity despite the use of small amounts of cross-linkers. Despite the difference in MOD values, the viscoelastic properties of the products do not differ significantly. Companies can produce similar rheology fillers with different MOD values. This is because the function of supporting the structure of a hyaluronic acid filler is achieved by cross-linked modification. MOD varies by product, but cMOD values do not differ significantly. As a result, the difference in MOD values can be attributed to pMOD, a pendent type BDDE with only one side combined with hyaluronic acid. Cross-linkers are basically toxic substances and there is a continuing debate about the safety of pendent type BDDEs. Naturally, products of Fig. 2.20 MoE of various filler products

similar viscoelasticity using a smaller amount of cross-linkers will be safer. This is where the concept of MoE (= Modification efficiency) is useful. MoE (= Modification efficiency) = gel strength/MOD That is, how much MOD value is needed to produce a certain strength of filler. High MoE products have a low MOD. In other words, it is a product made with a small amount of cross-linkers. The MoE values of the products used in the market are as follows (Fig. 2.20). (3) Biphasic versus monophasic filler Hyaluronic acid fillers can also be classified into biphasic fillers and monophasic fillers.

2.2 Characteristics of Hyaluronic Acid Filler

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In the biphasic filler manufacturing process, case of monophasic filler than biphasic filler. the hyaluronic acid gel is produced after cross- However, maintaining the shape and volume after linking and then sifted into particles of a specific the procedure involves various factors. size. Afterwards, non-cross-linked free HA is mixed into the particles as a lubricant. The word D. Cohesiveness “biphasic” is used because it contains a mixture This is where the difference between the biphasic of cross-linked and non-cross-linked filler and the monophasic filler is the most components. obvious. Cohesiveness is more superior in Monophasic filler is a filler prepared by monophasic than biphasic fillers. grinding and cutting the solid hyaluronic acid gel. In addition, since there is no process to add E. Injection force free HA, it is called monophasic. The line-ups of biphasic fillers are classified The injection force is relatively constant for according to the size of filler particles. Small par- monophasic fillers and less constant for biphasic ticle size fillers are used for shallow wrinkles and fillers. pre-tarsal roles, on the other hand larger particle (4) G*, G′, G′′ size fillers are used for volumizing purposes. The line-ups of monophasic fillers are classi- These determine the firmness and viscoelasticity fied according to difference in concentration of of the filler. You can check the value of G′ or G′′ hyaluronic acid components. Low concentration via the product information leaflet or from the fillers are used for shallow wrinkles and high company’s internal data. concentration fillers are used for volumization. The differences in rheology of biphasic and (5) cohesiveness monopahsic fillers are as follows. In recent years, as manufacturing technology has become more Cohesiveness is important in selecting the treatdeveloped and diversified, the difference between ment site. The cohesiveness of biphasic fillers and monophasic fillers are quite different. the two has decreased. It is not a good idea to inject a low cohesiveness filler to the forehead. Since the soft A. Gel strength tissue of the forehead is thin, the external force Biphasic fillers have higher G* values than applied to the skin is easily transmitted to the monophasic fillers. That is, because it is hard, its filler. Thus, when a large external force is applied shape is maintained well after injection. to the treatment site, the filler may be deformed from its original shape, or the filler may be easily B. MOD split inside the treatment site. Fillers with low The MOD value of a biphasic filler is small since cohesiveness cannot recover their original they use a relatively small amount of cross- appearance. linkers. (6) Raw material C. Maintenance of volume after injection It is necessary to use high quality raw materials. Free HA is added to the biphasic filler, which acts as a lubricant. Within days of filler injection, free HA is absorbed. This is because the half-life of free HA is as short as 1 day. When the same amount of HA filler is injected, the amount of hyaluronic acid filler remaining in the body after several days would be higher in

Previous research has revealed the importance of raw materials. When the quality of raw materials was different among the products produced through the same production process, the frequency of side effects after the procedure was low in products using high quality raw materials. By requesting internal company data, one needs

30

to make sure that the filler products one uses are made from good raw materials. (7) Molecular weight and concentration of hyaluronic acid There are hundreds of hyaluronic acid fillers. However, the molecular weight of the hyaluronic acid used as a material or the concentration of the product does not vary greatly from product to product. Currently used bacterial hyaluronic acid has a molecular weight of 1.5 million to 2.5 million Da. Generally, higher molecular weight hyaluronic acid is used for biphasic fillers. The concentration of the product is typically 15– 25 mg/ml, most of which are 20 mg/ml. Many years of manufacturing experience have established the basic manufacturing methods for producing safe products. Of course, each company has its own know-how. When a new product with a large difference from the conventional method is introduced, it is recommended to observe for at least 6 months to confirm the safety of the product. A conservative approach is recommended for products that represent new manufacturing methods. (8) Additives: antioxidant material Additional effects may be created by adding ingredients to the filler. It is most common to mix 3% lidocaine for anesthetic effects. In addition,

Fig. 2.21 Action of hyaluronidase and free radical

2

Filler Types and Characteristics

vitamins and antioxidants may be mixed together also. Fillers with antioxidants are noteworthy. Filler injection causes some tissue damage, resulting in free radicals. The degradation of the filler consists of two steps. Initially, this is done by free radicals. Free radicals are so small that they can move freely into pores that naturally exist between filler materials. This can cause structural damage to the filler. Hyaluronic acid fillers are secondarily degraded by hyaluronidase. Since hyaluronidase is an enzyme with a large molecule size, it is impossible to enter into spaces naturally present in the filler. Therefore it acts only on the outer surface of the filler where direct contact is made (Fig. 2.21 Drawing). This is why inhibiting free radical activity during initial filler injections could extend filler duration. In fact, there are fillers that contain antioxidants that scavenge free racial. Based on clinical experience, it is found to have a relatively long duration period (Fig. 2.22). In general, mannitol is added to the filler as an antioxidant additive. Antioxidants such as mannitol have these characteristics. a. Antioxidant function prevents the loss of fillers caused by free radicals at the beginning of the procedure, thereby increasing filler retention period. b. Antioxidants have an anti-bacterial effect.

2.2 Characteristics of Hyaluronic Acid Filler

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Fig. 2.22 The effect of antioxidant to filler duration (with the kind permission of VIVACY, Chong Keun Dang company. DAEHAN Medbook)

c. Mannitol is a polymeric substance that attracts water. After the procedure, the volume of the filler will be slightly larger than the amount actually injected. (9) Dialysis or washing

In case of infection, hypersensitivity or severe tissue reaction after filler procedure, I check these four steps as follows: a. Check for similar cases after the same procedure at our hospital. b. Check for similar cases in the same product line at our hospital. c. Check with nearby hospitals for similar reactions in the same product family.

Dialysis or washing is the removal of toxic substances such as NaOH, BDDE residue, and endotoxins that are necessary or inevitable in the cross-linking process. It takes a long time to remove toxic substances inside the hyaluronic acid gel, which is made in solid form. Each d. Contact the manufacturer and check for company has its own method of cleaning or similar reactions in products with the same batch dialysis. Typically, dialysis or washing throughnumber. out the day is counted as 1 cycle. There is no standard protocol, and each company’s process is (10) Injection force kept secret in regard to the method and duration of cleaning, making it difficult to obtain accurate When a product is used for the first time, the operator needs to experience the injection force information. Unfortunately, we have no choice but to rely of the product. After opening the package, connect the on data from companies in regard to BDDE residues and endotoxin levels. Therefore, side included needles and squeeze the filler with effects can occur with filler products that are minimal pressure. Check how much force is licensed to be safe and should be proactively required until the initial filler is seen extruded from the needle and whether the injection force is addressed when problems arise. constant or jagged after the extrusion begins.

32

Fillers injected at a constant pressure appear as A in Fig. 2.26, while fillers not at a constant pressure appear as B in Fig. 2.23. (11) Safety check Although the side effects of filler procedures vary, they can be divided into immediate and delayed side effects based on the time of occurrence. Immediate side effects can be described as side effects that occur immediately after the procedure. These include allergic reactions and blindness due to intravascular injection. On the other hand, an unknown inflammatory response one month after the filler injection and even 3– 4 months later is a delayed side effect. It is difficult to pinpoint just one cause for delayed side effects. This may be due to a problem with the patient’s immune system or latent infection. It can also be caused by problems with the product itself. When these delayed side effects occur, both the medical staff and the patient are embarrassed. If delayed side effects occur in a particular product, the clinician should immediately stop using the product and perform a check. Check for similar problems in other patients who had the same product at the same time. Check if there are frequent side effects at the same time, regardless of the product. Check closely for similar symptoms in nearby hospitals that use products from

2

Filler Types and Characteristics

the same manufacturer that caused the problem in your hospital. If the cause is determined to be by the physician, the procedure should be improved. If you think there is a problem with the product, you should talk to the company about the recovery and exchange of the product produced in the same batch. If you use the product on a large scale before checking the safety of a particular product, It is difficult to cope with delayed side effects. Therefore, for newly developed products, you should take sufficient time to observe the occurrence of side effects. A minimum observation period of six months is recommended.

2.3

Calcium Filler

There are two components of a calcium filler. The first is Calcium hydroxyl-apatite (CaHA)– Ca10 (PO4) 6 (OH) 2 and the second is the gel carrier. CaHA is a biocompatible material and used in the medical field for several decades Calcium hydroxyl-apatite accounts for 30% of the filler volume (Fig. 2.24). It is a component present in the human body and consists of particles 20–45 lm in size. After injection into the body, it stimulates the surrounding tissues over time to promote collagen formation. It is then

Fig. 2.23 The comparison of injection force (with kind permission of S. THEPHARM)

B product

A product

2.3 Calcium Filler

33

carboxymethylcellulose, glycerin, and sterile water. Its high molecular weight and viscoelasticity make it more attractive to maintain shape than hyaluronic acid fillers (Fig. 2.25). The metabolic process after injection of calcium filler into the tissue is as follows (Fig. 2.26 a, b). The difference between calcium fillers and HA fillers are as follows:

Fig. 2.24 Calcium hydroxyl-apatite

degraded and removed through metabolic processes in the body. Gel carriers make up 70% of the calcium filler volume and consists of sodium

a. The duration of calcium filler is longer than that of hyaluronic acid filler. b. New collagen grows into the empty space created by the absorption of the gel carrier. c. Calcium filler cannot be dissolved. d. Because of the higher viscoelasticity of the calcium filler, it is suitable for use on areas of low satisfaction after treatment with hyaluronic acid filler (e.g., nose, etc.) e. In addition to volumizing, it is widely used for the purpose of improving skin texture.

Fig. 2.25 Calcium filler (with kind permission of DAEHAN medbook)

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2

Filler Types and Characteristics

Fig. 2.26 a Metabolism of calcium filler, b metabolism of calcium filler (with kind permission of Merz company)

2.4

Polycaprolactone Filler

Among the various polymers, there are materials that have been proven safe for medical use. These polymers are used in various applications such as PCL fillers, PDO threads, and scaffolds for nasal or breast implants. Polycaprolactone fillers consist of 30% polycaprolactone (PCL) particles and 70% carboxy methylcellulose (CMC) gel carriers with a spherical shape and smooth surface (Fig. 2.27).

Both PCL and CMC are totally absorbable substances. After injection, the CMC gel carrier is absorbed by macrophages over several weeks. PCL spheres, on the other hand, are not absorbed by macrophages because of their specific size (25–50 lm) and totally smooth and spherical shape, but are surrounded by a layer of macrophages. As a result, collagen multiplies and occupies the space where the gel carrier around the particle was absorbed (Fig. 2.28).

2.4 Polycaprolactone Filler

35

Fig. 2.27 Polycaprolactone particle (with kind permission of Sinclair company)

Fig. 2.28 Changes after injection of PCL filler (with kind permission of Sinclair company)

Clinicians should understand the natural course of polycaprolactone fillers. Immediately after PCL filler injection, it appears slightly swollen due to edema, but the volume decreases as the swelling is resolved. The gel carrier is then absorbed and replaced with collagen. During this period, the volume seems to decrease further. Over the next few weeks, collagen is stimulated, increasing volume. Patients may complain that the filler seems to be gone at the two to four week period. At this time, if the natural course is not properly understood and additional fillers are

injected through additional procedures, overcorrection may occur. Generally, microspheres less than 15 lm in size are removed by phagocytosis. Microspheres with irregular surfaces larger than 15 lm in size are known to form inflammation and foreign body granulomas. One of the delayed type complications of PCL fillers are foreign body granulomas. As an immune response, chronic inflammation occurs at the filler injection site and the filler material is recognized as a harmful foreign body. However,

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Filler Types and Characteristics

Fig. 2.29 Mixing experiment with PCL filler and saline a. After 1 minute b. 24 hours later

due to the large size of the filler particles, macrophages do not prey on them. Instead, the macrophages forms a giant cell through fusion, then isolate the foreign body by surrounding it. The inflammation is then continued while inducing excessive fibrosis and tissue proliferation. This type of filler is important for making a sphere that has a smooth surface. Some clinicians mix calcium filler or PCL filler with saline or lidocaine to make it softer. However, the homogeneity of the filler components in the mixing process is compromised and there is a concern about the possibility of particle damage. One minute and 24 hours after the mixing of the saline and PCL filler in vitro, changes in the filler were observed (Fig. 2.29). There is also concern about contamination in the mixing process, so I do not recommend this approach.

2.5

Filler Selection

Beginners should use a hyaluronic acid filler that can dissolve. With the exception of some serious side effects caused by intravascular injection, hyaluronidase can be used to treat side effects immediately. After more experience and confidence in safe procedures, calcium or polycaprolactone fillers

can be used gradually. Since these fillers cannot be melted, care must be taken during the procedure. When choosing a filler, we recommend that you choose a product that has been proven safe. As mentioned earlier, newly developed fillers are recommended for use after a minimum of six months of observation. For beginners, when side effects occur, they may not be able to cope. Among other factors of filler side effects, side effects caused by defective products should be minimized. What is more difficult than actually choosing a filler is how to deal with problems after the filler procedure. Commercially available fillers have been proven to be somewhat safe. Nevertheless, even products that have been proven to be safe may cause problems in the manufacturing process at certain times. How to deal with these cases will be discussed in more detail in the complication chapter.

Bibliography 1. Tezel A, Fredrickson G. The science of hyaluronic acid dermal fillers. J Cosmet Laser Therapy. 2008;10:35–42. 2. Park KY, Kim HK, Kim BJ. Comparative study of hyaluronic acid fillers by in vitro and in vivo testing. J Eur Acad Dermatol Venereol. 2014;28(5):565–8.

Bibliography 3. Flynn TC, et al. Comparative histology of intradermal implantation of mono and biphasic hyaluronic acid fillers. Dermtol Surg. 2011;37(5):637–643. 4. Park S, et al. Investigation of the degradationretarding effect caused by the low swelling capacity of a novel hyaluronic acid filler developed by solidphase crosslinking technology. Ann Dermatol. 2014;26(3). 5. Pierre S, et al. Basics of dermal filler Rheology. Dermatol Surg. 2015;41:S120–6. 6. Kablik J, et al. Comparative physical physical properties of hyaluronic acid dermal filler. Dermatol Surg. 2009;35:302–312. 7. Falcone S, et al. Cross-linked hyaluronic acid dermal fillers: a comparison of rheological properties. J Biomed Mater Res. 2008;87A:264–71. 8. Borrell M, et al. Lifting capacities of hyaluronic acid fillers. J Cosmet Laser Ther. 2011;13:21–7. 9. Stern R, et al. Hyaluronan catabolism: a new metabolic pathway. Eur J Cell Biol. 2004;83:317–25. 10. Kim JE, et al. Hyaluronic acid fillers: history and overview. Facial Plast Surg 2011;27:523–8. 11. Fraser JRE, et al. Turn over and metabolism of hyaluronan. The biology of hyaluronan. Ciba Found Symp. 1989;143:41–59. 12. Ramos-e-Silva M, et al. STYLAGE®: a range of hyaluronic acid dermal fillers containing mannitol. Physical properties and review of the literature. Clin, Cosmet Investig Dermatol. 2013;6:257–261.

37 13. Sundaram H, et al. Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plast. Reconstr. Surg. 2013;132:5S. 14. Kho IS, Lee W, Hyaluronic acid filler and hyaluronidase filler complications. Spinger Nature. pp. 27– 40. 15. Oh B, Kim B. Safe filler injection technique demonstration using live imaging tools. DAEHAN 2017. 16. Edsman K, et al. Gel properties of hyaluronic acid dermal fillers. Dermatol Surg. 2012;38:1170–9. 17. Yang B, et al. Determination of medification degree in BDDE-modified hyaluronic acid hydrogel by SEC/MS Carbohydr Polym. 2015;131:233–239. 18. Andre P. Free radical scavenging properties of mannitol and its role as a constituent of hyaluronic acid fillers: a literature review. Int J Cosmet Sci. 27 december 2016. 19. Wende F, et al. Determination of substitution position in hyaluronic acid hydrogels using NMR and MS based methods. Carbohyd Polym. 2016;136:1348–57. 20. Hobar, et al. Porous hydroxyapatite granules for alloplastic enhancement of the facial region. Clin Plast Surg. 2000;27:557–69. 21. Bioform Medical Inc. Regulatory issues. 2007. [online]. Accessed October 25, 2007.

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Anatomical Considerations for Filler Procedures

3.1

Vessels and Nerves

The face contains countless vessels and it is practically impossible to inject fillers without damaging the vessels at all. The reason why we should know the vessel structure and positioning relationship of the arteries is to avoid these complications which can lead to skin necrosis and visual complications. Figure 3.1 shows the facial supraorbital and supratrochlear arteries which most likely to cause such complications. Of course, if the filler is injected into the superficial temporal artery, it can reach the ophthalmic artery via the supraorbital or supratrochlear artery, both able to cause eventually visual complications. The facial artery usually travels upward near the middle of the mandible lower margin and the anterior boundary of the masseter muscle. It is relatively safe to inject filler in the superficial fat layer around the jowl because the vessels are deeply located at the point they pass the mandibular bone (Fig. 3.1). This upward-facing artery can be bent around the corners of the mouth and can be used to drive up and down the facial muscles. In addition, the ascending facial artery, traveling in and out of the nasolabial folds, produces several branches to the nose and lips. The soft tissue of the lip is soft enough that the pressure is low when the filler is injected, and the abundance of blood supply does not easily cause complications. However, in the case of the

© Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_3

nose, the filler injected can increase the pressure in the surrounding tissue, since there is less space to place the filler. Moreover, since the diameter of the facial artery and its branches become narrower as they go up, these vessels can be blocked with less pressure, and the blockage is likely to cause local necrosis around the nose. Although the facial artery sometimes does not extend the dorsal nasal artery branch as it ascends, the dorsal nasal artery and supraorbital artery from the facial artery is clinically important in causing visual complications by its connection to the ophthalmic artery. It is also important to know the depth at which the arteries are located in order to know which depth is safe to inject. It is relatively safe to inject filler directly above the bone in the nasolabial area, as the angular artery runs between the subcutaneous and muscular layers. It can also be safer if the physician presses along the course of the artery distal to the injection site using the opposite hand fingers when doing the filler injection, which can prevent the filler from moving up the vessel. When injecting filler near the eyebrow, one will encounter the supratrochlear artery and supraorbital artery, which originates deep inside the inner part of the orbital rim and rises to the superficial layer. The supratrochlear artery has mainly superficial branches, but the supraorbital artery usually divides into superficial branch and deep branch at a point 1 cm above the orbital rim. Unlike a nasolabial fold procedure, this

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Anatomical Considerations for Filler Procedures

Fig. 3.1 Arteries of the face

artery produces a deep branch, so the deep layer injection is not necessarily safe. Therefore, pressing the superorbital part of the orbital rim with the opposite hand can prevent the movement of the filler. Other vascular structures to be kept in mind are the transcanthal vein between the eyes, angular vein located just below the tear trough, and the middle temporal vein which exists between the superficial and deep layers of the temporal fascia in the temple area (Fig. 3.2). Although visual complications via veins are an unusual event, there is an argument that the risk of vascular complications through the vein may be a problem. However, it is impossible to perform the procedure without causing any vascular damage, so you should first focus much more on avoiding the dangerous arteries and, if possible, then the venous structures. We don’t need to be too concerned about the nerve structures during filler injection. This is because it is rare to have serious side effects such as when a filler enters a blood vessel. A possible nerve injury is a case where the pain persists by

injuring the sensory nerve with the end of a cannula or needle. In such cases, the pain usually disappears within a few days, but in severe cases, the pain can last for more than a month. The sensation of our face is mainly innervated by the fifth cranial nerve(trigeminal) (Fig. 3.3), and the V1 branches of the supratrochlear nerve, supraorbital nerve, emerge from the superomedial border of the orbital rim. Their course is accompanied by an arterial structure of the same name, but not always together. Also, the deep branch of supraorbital nerve proceeds deep near the periosteum in the medial 2 cm area of the superior temporal septum with the remaining nerves emerging from the orbital rim and going upward through the galea layer to the subcutaneous layer (Fig. 3.4). The infraorbital nerve of the V2 branch of the trigeminal nerve, along with the mental nerve of the V3 branch, are important nerves that are responsible for the sensation of the skin surface of the mid- to lower face area and are characterized primarily by the proximity of the midpupillary line (Fig. 3.3). The infraorbital nerve

3.1 Vessels and Nerves

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Fig. 3.2 Vascular structures of the temple

Fig. 3.3 Sensory nerves of the face

usually emerges 1 cm below the orbital rim and is clinically important when treating around the nasolabial fold, upper lip, and tear trough

because it gives off many branches in the inferomedial direction. The mental nerve is associated with lower lip and jaw surgery with a large amount of branches toward superomedial areas. In addition, there is an auriculotemporal nerve which innervates the sensation of the temple or lateral forehead area (Fig. 3.3), and a great auricular nerve for the sensation of the area around the ear and mastoid (Fig. 3.5). It is very unlikely that the motor nerve will be damaged during the filler injection. No matter how sharp a needle used, it is difficult to sever the nerve but, of course, some nerve damage can occur if the cannula or needle is moved too much. The motor nerve of the face is primarily innervated by the facial nerve (VII) and there are 5 branches from top to bottom: temporal, zygomatic, buccal, marginal mandibular, and cervical branches (Fig. 3.6). The other four branches, except the temporal branch of facial nerve, are all located under the deep fascia on the face, but the temporal branch of facial nerve goes up slightly past the area 1 cm above the zygomatic bone and attaches to the bottom of the SMAS. Therefore, if you inject a filler between superficial temporal fascia and deep fascia, you will have to be aware that the nerve is around this area.

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Anatomical Considerations for Filler Procedures

Fig. 3.4 Superficial and deep branch of the supraorbital nerve

Fig. 3.5 Auriculotemporal nerve

3.2

Fat Compartments and Muscles

Our face used to be conceptualized as a big balloon which needs a procedure to fill in (if it is not enough) or to extract (if it is excessive). While there is no significant difference in this concept nowadays, studies of facial anatomy have shown that the fat layers on our faces are not a large mass, but rather a combination of

subdivided fat segments. These local compartments can be thought of in large terms as superficial fat compartments and deep fat compartments. The superficial fat compartment has a relatively large fat cell size, and the overall fat increases as age progresses. In contrast, deep fat compartments are small in size, and the amount of fat decreases as aging progresses. It has also been found that the fat inside all local compartments, regardless of its depth, tends to migrate

3.2 Fat Compartments and Muscles

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Fig. 3.6 Motor nerves of the face

downward over time due to the influence of gravity. Some doctors claim that it is not clinically significant to consider these fat layers as complex and divide them into regional divisions. In fact, it is also true that local compartmentalization cannot be distinguished with the naked eye. It is difficult and meaningless to target the correct local compartment every time a filler procedure is performed. However, in order to plan the amount to inject before the procedure, it is necessary to understand as much as possible the combination of structures such as fat compartments, retaining ligaments and skin. The results of the procedure can be different from those who understand and treat the cause of wrinkles with an analytical perspective, from those who only see the wrinkle itself. Figure 3.7 is a representation of the superficial fat compartments and the right side is a representation of the deep fat compartments. Of course, not all anatomists have a consensus on this classification. Moreover, the layer of fat found during facelift surgery or dissection of cadavers are not as distinct as in the picture. All fat layers are intertwined with surrounding structures such as muscles, nerves, and blood vessels looking like composing structures. However, looking at Fig. 3.8, one can

understand why many consider these local distributions as distinct. Figure 3.8 shows the superficial and deep fat compartments, and pink lines of wrinkles on the surface of the face. The forehead folds and the glabella wrinkles found in the upper face area do not seem to have much connection with the fat compartments. Of course, anatomists like Pessa claim that the fat layer around the glabella is again subdivided into several parts, named and related. However, in a larger context, it may not be that important. If you look closely at other wrinkles, you can see that they have some, if not perfect, relationship to local compartments. In particular, SOOF, deep medial cheek fat and submentalis fat are associated with the midcheek crease, nasolabial fold, and mentolabial sulcus, respectively. Interestingly enough, while the boundaries of the superficial fat compartments correspond to the creases, the deep fat compartments are not confined by these creases, but extend beyond them. In other words, deep layer filler injection in these areas can have the effect of reducing wrinkles. There is labiomandibular fat on the medial aspect of the labiomadibular fold and superior/inferior jowl fat on the lateral aspect of the fold. Anatomy studies have shown that the amount of labiomandibular fat decreases with age, while the jowl fat increases. For this reason,

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Anatomical Considerations for Filler Procedures

Fig. 3.7 Superficial and deep fat compartment

the fat on the outside of the crease is effectively removed or raised by liposuction or lifting procedures, while the depleting fat layer inside the crease is replenished through filler or fat injection. There is buccal fat in areas deeper than the deep fat, which is about 10 cc in volume. There are still differences of opinion on the exact boundary or distinction of the buccal fat, as some describe it as the buccal extension of the buccal fat. This region extends up to the temple, giving a temporal extension called the deep temporal fat pad. It also plays an important role in forming a sunken cheek because it supports all the soft tissue of the surface from deep below the zygomatic arch. The buccal fat also reduces friction during the sucking process (such as suckling in infants and babies) and protects important structures such as nerves and blood vessels by cushioning them. However, its function decreases as it becomes more muscular in nature in the form of the masseter muscle. By about 50 years of age, fat increases slightly, and after 50 years of age, the volume of fat decreases with age, which is similar to the change in deep fat compartments. Sunken cheeks are thought to be the main reason for the decrease in the buccal fat, but direct filler or fat injection in the buccal fat can

be dangerous since blood vessels, nerves, and parotid ducts pass through it.

3.3

Retaining Ligaments

In Fig. 3.9, the areas shown in black are the retaining ligaments of the face, and the pink line indicates the wrinkles and folds on the face. The forehead and the glabella wrinkles are usually less associated with the retaining ligament because they are caused by muscle movements, but the middle face shows a close connection between the retaining ligaments and the surface wrinkles. The retaining ligament can be divided into two main groups: true retaining ligaments which run from bones to skin, and false retaining ligaments which originate from middle layers of connective tissue, such as muscles and fat layers. Traditionally, orbital retaining ligaments, zygomatic ligaments, maxillary ligaments, and mandibular ligaments were regarded as true retaining ligaments, while the rest were regarded as false retaining ligaments. The retaining ligament can be clearly distinct from the surrounding tissue while other times it can be observed as a bundle of rigid soft tissue. The distinction

3.3 Retaining Ligaments

45

Fig. 3.8 Relationship between fat compartments and surface creases

between “true” and “false” is changing gradually. More importantly, which wrinkles on the face are caused by which retaining ligaments and how do we correct them. Not all facial wrinkles are closely related to retaining ligaments, but the midcheek crease and labiomandibular fold (also known as the called the marionette crease) are highly associated with the retaining ligament. There are many causes contributing to a tear trough deformity, such as differences in skin thickness around the eyelid and cheek, changes in the fat compartments, and changes in the boundary of the orbitalis oculi muscle. However, the largest contributing cause can be the tear trough ligament. These ligaments can be thought of as part of an orbital retaining ligament and are connected by a fiber from bone to skin. Similarly, the outer part of the orbitomalar ligament creates

an orbitomalar groove, but this part has thicker soft tissue and a double layer of support, so the frequency and severity of the wrinkle is less than the tear trough. The wrinkle leading to the inferolateral part of the tear trough is called the midcheek crease, which is closely related to the zygomatic ligament. Reading a textbook or journal is likely to cause confusion about the zygomatic ligament, which some describe as the zygomatic cutaneous ligament. In some cases, it may be shown only at the intersection of the T-shape where the zygomatic and the masseteric cutaneous ligaments meet in Fig. 3.9. In some cases, it may be displayed only on the lateral aspect with the zygomatic arch. Recent views have often indicated that all sections extending from the anterior to lateral face are marked as the zygomatic ligament, and that this retaining ligament shows

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Anatomical Considerations for Filler Procedures

Fig. 3.9 Relationship between retaining ligaments and surface creases

great supporting power at the T-intersection where they meet the masseteric cutaneous ligament at the front. The maxillary ligament in Fig. 3.9 on the lateral side of the nasolabial fold is sometimes described by some as a bucomaxillary ligament, which is also divided into two parts: a buccal part and a maxillary part. It has been known that the buccal part is a false retaining ligament and the maxillary part is directly referred to as the skin from the maxilla as the true retaining ligament. The reason for the formation of the nasolabial fold can be explained by the fascial theory and muscular theory. The fascial theory states that wrinkles are caused by retaining ligaments such as the maxillary ligament holding the skin in the nasolabial fold. The muscular theory, on the other hand, is a theory that muscles such as the zygomaticus major/minor muscles and levator labii superioris directly hold the skin layer, which

gives rise to wrinkles. Although there is not a complete consensus as of now, based on the studies near the nasolabial fold, comparing the support force of retaining ligaments, and by histological findings, the muscular theory is slightly more persuasive than the fascial theory. The labiomandibular fold, called the marionette line, originates directly inside the mandibular ligament, separating the inner and outer fat compartments with strong support from the bone to the skin, and blocks the inner movement of the superficial fat to create a jowl. In addition, the presence of a mandibular septum prevents soft tissue on the top of the mandibular border from migrating downwards to create a jowl. On the other hand, the superior temporal and inferior temporal septi create the boundary of the space. The masseteric cutaneous ligament provides a reference boundary for the anterior and lateral face, forms the outer boundary of the

3.3 Retaining Ligaments

pre-massteric space, and creates a jowl if permitting the buccal fat to protrude out.

3.4

Layer and Space

Space is a virtual area surrounded by fat compartments, muscles, and retaining ligaments (such as the fascia or SMAS). In fact, there is no empty space like an airbag, but the meaning of space is as follows. Space is located between superficial and deep fascia allowing muscles to move independently without affecting the movement of other layers of muscles. For example, when the orbicularis oculi muscle or the orbicularis oris muscle are contracting, the zygomaticus major and minor muscles function by raising the corners of the mouth so that they are not affected by each other. Also, blood vessels and nerves pass through the boundaries of

Fig. 3.10 Relationship between retaining ligaments and spaces

47

these spaces, so the area inside the space is only relatively dangerous. This makes it a safe passageway for stripping, needles, and cannulas to pass through when they enter. In addition to the space shown in blue in Fig. 3.10, there are many other spaces on the face. The preseptal space also exists above the orbital retaining ligament and can be easily observed when lower blepharoplasty surgery is performed. Although not called a space, there are upper and lower temporal compartments in the temple area. The upper border of prezygomatic space is the orbital retaining ligament and the lower border is the zygomatic ligament. Suborbiculis oculi fat (SOOF) is the roof of this space. This space is connected to the lower temporal compartment through the temporal tunnel and the inside is blocked by retaining ligaments. Care should be taken when injecting filler at the midcheek crease since the filler is injected into

48

this area. If the filler volumizes the outside and top of this crease, it may bulge, making the crease look deeper. This mistake can also result in similar results if the filler spreads to the lower prezygomatic space when correcting the orbitomalar groove. The premasseteric space is a structure that is formed by the masseteric cutaneous ligament on the front, platysma muscle on the surface, masseter muscle posteriorly, and by a mandibular ligament and septum on the bottom. The space is small in front of the masseter muscle when young, but as one ages, the space’s front, bottom, and surface sagging causes the internal buccal fat to flow medially and inferiorly. This phenomenon makes the jowl worse and contributes to the thickening of labiomandibular fold. Recently, as shown in Fig. 3.10, this space is not one space, but is technically divided into two spaces. The top is called the middle premasseteric space, and the bottom is called the lower pre-masseteric space. Part of the buccal branch of the facial nerve passes between the upper and lower spaces. This pre-masseteric space is clinically meaningful as it can be a space for the filler to move when injecting the filler, and a safe layer when performing facial rejuvenation procedures within the prezygomatic space. Finally, the premaxillary space has not been considered to be very important. This space is located below the SMAS, nasolabial fat, and orbicularis oculi muscle. The upper border is the tear trough ligament and the lower border is the zygomatic ligament. On the outside, they face to prezygomatic space. One interesting point is that unlike normal venous and arterial movements, the angular artery passes through the medial part of the premaxillary space and the angular vein passes through the lateral boundary of the space. The clinical significance of this space is that the filler often migrates over the top of the crease when correcting the nasolabial fold. Therefore, it is important to block with a finger while injecting the filler so that it will not migrate superiorly.

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3.5

Anatomical Considerations for Filler Procedures

Identification of SubSMAS Space for Filler Injection: Cadaver Study Using Stained Gelatin

Based on the latest statistics from around the world, the use of fillers has expanded from dermal fillers and its use as a soft tissue volume filler with the primary purpose of total facial contouring is continuously rising. Moreover, according to a survey on treatments using volume fillers and fat grafting conducted in Asia, the proportion of filler procedures relative to fat grafting to treat not only a localized area of the face, but also for total facial volumization, has grown consistently. Due to the increasing clinical value of fillers, fillers with different components, particle sizes, and strengths are used to enhance the quality of the skin and to treat folds, including those in difficult-to-treat areas such as the periorbital and perioral regions. Moreover, with the development of a wide array of filler types each with its own unique viscoelastic property, total facial volumization approach over partial volumization is possible. Total facial filler injection to create a threedimensional face requires knowledge of the mechanism involved in facial aging and an understanding of the anatomical structures of the face. In the past when dermal fillers were injected into the superficial skin layer, there was a lower risk of serious adverse events. However, with the introduction of firmer fillers for total facial volumization, physicians face numerous safety issues. As fillers are injected into the deep planes of the soft tissue where major vessels course, there is always a risk of vascular injury that could lead to serious complications. Therefore, physicians must understand the locations and pathways of major vessels that course the treatment site. In addition, physicians must be aware of potential complications and appropriate treatment interventions.

3.5 Identification of SubSMAS Space for Filler Injection …

Although the term “wrinkle” is used broadly, they can be classified as lines, wrinkles, rhytids, creases, and folds depending on depth and anatomy. Lines refer to wrinkles that form on the epidermis and when these lines are irregular and sporadically scattered, they are referred to as rhytids. Lines that have become deeper due to various reasons are called wrinkles. Wrinkles are depressions that occur in the skin with uniform depth. While wrinkles form in the skin of the anatomical structure, creases form where two superficial anatomic structures with differing thicknesses meet. For example, a fold within the same page of a book can be viewed as a wrinkle while the binding across spine of an open book can be viewed as a crease. Structural changes that occur in the two regions adjacent to the crease can cause the crease to deepen due to the difference in the thickness. When two adjacent regions divided by the crease are in different planes resembling stairs, this crease is referred to as a fold (Table 3.1). Arteries course underneath the crease/fold to supply blood to the two adjacent areas. The artery course generally aligns with the crease/fold which means that the crease/fold can serve as a surface landmark that predicts the location and direction of the artery coursing below. Such creases could become more prominent due to contraction of facial muscles. Additionally, regardless of crease formation, there is a high chance that a blood vessel courses along the Table 3.1 Categorization of facial crease Line: Line that forms in the epidermis Rhytid: Formed by irregular aggregation of lines Wrinkle: Skin depression of uniform depth Crease: Forms where two superficial structures of differing thicknesses meet. Serves as a surface landmark for artery deep to the crease Fold: Structural changes on the surface adjacent to the fold causes the two regions to have different thicknesses

49

region where two differing anatomical structures or fat layers converge. As vessels in such regions are generally located deep to the subcutaneous fat layer or even deep to the muscles, targeting the superficial planes may be safer. Conversely, beneath wrinkles, vessels course the superficial planes. Thus for wrinkle treatment, superficial injections can cause bleeding or bruising and deeper injections are safer. Skin depressions in the central forehead belong in this category. Therefore, to avoid vascular injury when treating wrinkles, the depth and injection method should be decided based on the type of wrinkle. Clinically, facial creases that form due to differences in the two adjacent fat layers can be classified as follows: corrugator crease, midline forehead crease, forehead-lid crease, supratarsal crease, lid–cheek crease that includes the tear trough deformity and palpebromalar groove, nasojugal crease, nasolabial crease, preauricular creases, cheek–chin crease (crease that forms due to deepening of the commissural line which starts from the mouth corner), labiomental crease that forms horizontally below the lip, oblique lip– chin crease that forms obliquely below the mouth corner, and central chin crease that forms vertically at the tip of the chin. When injecting these areas, it is especially important to be cautious of the underlying vasculature. To improve facial wrinkles and depressions, soft fillers are injected into subdermal tissues, including the subcutaneous fat layer immediately superficial to the skin. However, firmer fillers should be injected into the deeper layers. Thus, it is important to locate the plane deep to the SMAS layer where there is a smaller risk of neurovascular injury. In particular, compared to Caucasians, Asians have thicker and heavier skin and the connective tissue and subcutaneous tissue, such as the SMAS and retinacula cutis that are tougher and firmer. Therefore, efficient facial volumization cannot be achieved by augmenting the subcutaneous fat layer in the subdermal region alone. It is important to accurately identify the spaces in the deeper subSMAS layer and augment the volume in those areas.

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Different regions of the face contain different anatomical structures called subSMAS adipofascial spaces. These structures consist of only fat and soft tissues with boundaries defined by major retaining ligaments and are safe injection zones (Table 3.2). A cadaveric study using a stained gelatin filler was performed to identify the anatomical structures of subSMAS adipofascial spaces. Before dissecting the cadaver, injection points were marked on the face as it is done before performing a filler or fat graft procedure on patients. Subsequently, a cannula was used to inject a small amount of stained gelatin into the subSMAS spaces. After allowing the gelatin to solidify, each injection region was carefully dissected, layer by layer, to check whether the gelatin had been accurately placed in the targeted subSMAS adipofascial spaces. What is important when targeting the subSMAS adipofascial spaces is the thickness of the SMAS as the thickness of the SMAS is not uniform throughout the face. It is thickest in the preauricular region and pro-

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Anatomical Considerations for Filler Procedures

gressively becomes thinner toward the medial facial region (Table 3.3). The varying thicknesses of the SMAS layer by facial region are confirmed in the cadaver photos. The SMAS appears as a white, tough fascia along the side of the face while it appears as a fat layer with no white fascia in the midface region. From such gross findings, it was previously claimed that the formation of the nasolabial fold was due to the presence of a thick and tough SMAS layer in the lateral aspect of the fold and absence of a thick SMAS layer in the medial aspect of the fold. However, actual histological studies have confirmed the presence of the SMAS in the medial aspect of the fold (Fig. 3.11). After the gelatin solidified, cadaveric skin was removed to reveal superficial fat (Fig. 3.12, left). Gelatin that was injected into the subSMAS space below this layer cannot be seen. After the superficial fat layer was removed, the SMAS layer could be observed and green gelatin injected below the SMAS layer became partially visible (Fig. 3.12, right).

Table 3.2 Possible and effective subSMAS adipofascial spaces 1. Subgalea-frontalis space: Under the frontalis muscle 2. Interfascial and pretemporalis space: Compartment between the STF and DTF, STFP between the superficial and deep layer of the DTF 3. Subprocerus space: Area below the procerus muscle 4. Preseptal space: Overlies the orbital septum below the orbital retaining ligament in the upper eyelid 5. Suborbicularis space: Area under the orbicularis oculi muscle (ROOF of the eyebrow, medial part of the SOOF, and lateral portion of deep medial cheek fat) 6. Subnasalis space: Under the nasalis muscle 7. Prezygomatic space including suborbicularis oculi fat: Overlies the body of the zygoma and its floor covers the origin of the zygomaticus muscle and deep fat 8. Premaxillary space including lateral part of deep medial cheek fat: Overlies the maxilla bone and its floor covers the origin of the levator labii superioris muscle and deep fat 9. Ristow’s space (Pyriform space) including medial part of deep medial cheek fat: Overlies the canine fossa under the medial part of the DMCF in the paranasal region and deep fat 10. Preparotid and premasseteric space: Overlies the parotid gland and the lower half of the masseter 11. Prebuccal space: Overlies the capsule of the buccal fat pad medial to the anterior border of the masseter 12. Subdepressor anguli oris space: Fat deposits located under the depressor anguli oris muscle 13. Premental space: Fat deposits under the skin insertion of the mentalis muscle

3.5 Identification of SubSMAS Space for Filler Injection …

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Table 3.3 Change in SMAS thickness by facial region Progressive thinning from the preauricular region to medial facial region (1) Basic structure of the preauricular region – Skin, superficial fat layer with retinacula cutis superficialis, superficial fascia, deep fat layer with retinacula cutis profundus, deep fascia, masticatory muscle (2) Parotid region – Skin, superficial fat layer, SMAS, deep fat layer, parotid fascia, parotid capsule, parotid gland (3) Cheek region – Almost the same as the “Basic structure of preauricular region” (4) Nasolabial fold region – Dim SMAS enveloping the mimetic muscles

Fig. 3.11 Thick SMAS on lateral cheek region

SMAS

(1) Subgalea-Frontalis Space In the forehead area, the subgalea-frontalis space is present below the galeo-frontalis muscle, which is a part of the SMAS in the midface area. The superficial temporal artery, temporal branch of the facial nerve (both enter from the lateral aspect of the forehead), supraorbital artery and nerve, and supratrochlear artery and nerve (course in a superior direction in the central forehead) are present within or above the frontalis muscle. When this area is dissected, the supraorbital artery

and nerve and supratrochlear artery and nerve exiting from the supraorbital foramen and supratrochlear notch can be seen. Therefore, adipofascial space where the gelatin was injected is a safe region where the risk of injuring the major vessels and nerves is minimal (Fig. 3.13). (2) Interfascial and Pretemporalis Space In temporal depression that is not too severe, it is common practice to inject filler or place fat grafts between the superficial temporal fascia (SMAS

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Anatomical Considerations for Filler Procedures

Deep fat compartments

Superficial fat compartments

Fig. 3.12 Superficial and deep fat compartments Fig. 3.13 Gelatin in subgalea-frontalis space

Stained gelatin

Galea-frontalis muscle layer

layer) and the deep temporal fascia. In the temple are the upper and lower temporal spaces. The upper temporal space is bounded by the superior temporal septum (STS), an extension of the temporal ligament adhesion, and inferior temporal septum (ITS). The boundaries of the lower temporal space are the ITS and zygomatic arch. The upper and lower temporal spaces refer to the space formed in between the superficial temporal fascia (SMAS of the midface) and the deeper deep temporal fascia. Important structures do not pass through the upper temporal space. However, the lower temporal space is an anatomically significant triangular-shaped area through which the superficial temporal artery, temporal branch of facial nerve, the medial and lateral branches of the zygomatico-temporal

nerve (ZTN) course. Moreover, the sentinel vein penetrates vertically through the muscle and fascia, while the middle temporal vein runs parallel to and above the zygomatic arch. Therefore, caution must be taken when injecting this area. The risk of neurovascular damage can be minimized by making the entry point at the intersection between the zygomatic arch and lateral orbital rim. Superficial temporal artery and the temporal branch of the facial nerve, the key neurovascular structures of the temporal region, are included in the superficial temporal fascia or they run immediately deep to it. If filler is accurately injected within the plane formed by the two fascia, neurovascular injury can be avoided (Fig. 3.14).

3.5 Identification of SubSMAS Space for Filler Injection …

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Fig. 3.14 Gelatin in space between superficial and deep temporal fascia

For severe depressions requiring significant volumization, many clinicians believe that filler should be injected deep into the temporalis muscle. However, targeting deep to the temporalis muscle is inefficient. In the deeper layer, a larger amount of filler is needed to create volume so the treatment effect when compared to volume of filler used is low. Generally, with sunken temples, the depression is located in the lower temporal region immediately above the zygomatic arch. Of the two temporal fat pads located in this region, the superficial temporal fat pad located between the superficial and deep layers of the deep temporal fascia should be targeted. Compared to injecting deep into the muscle, efficient volumization of the sunken area above the zygomatic arch can be attained with a smaller amount of filler. Contrary to the belief that the superficial temporal fat pad is challenging to locate, over time, physicians will be able to easily identify the loose sensation of the superficial temporal fat

pad. The cannula will penetrate the superficial temporal fascia, followed by the firmer superficial layer of the deep temporal fascia before reaching the superficial temporal fat pad. Further insertion of the cannula will be eventually impeded by very firm deep layer of the deep temporal fascia. It is recommended that the physicians have accurately identified the layers of the temple before attempting to inject this region. As shown in Fig. 3.15 (left), the cadaveric study showed that gelatin could be injected accurately into the desired superficial temporal fat pad. Within the two layers of the deep temporal fascia, the middle temporal vein traverses in the upper portion of the superficial temporal fat pad and its course is parallel to the zygomatic arch. The sentinel vein traverses the temporal region perpendicularly and joins the middle temporal vein (Fig. 3.15, right). Good understanding of the vascular anatomy of the superficial temporal fat pad reduces concerns regarding

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Fig. 3.15 Gelatin in superficial temporal fat pad

vessel injury (Fig. 3.15). After confirmation of placement of the gelatin in the superficial temporal fat pad, the deep layer of the deep temporal fascia was removed to evaluate the deeper structures. Deep to the superficial temporal fat pad are the deep temporal fat pad (also known as

Fig. 3.16 Deep temporal fat pad under deep temporal fascia

the superior lobe or temporal extension of the buccal fat) and the temporalis muscle (Fig. 3.16). (3) Preseptal Space For sunken eyelid correction, filler is injected to replace lost fat volume. Passing through the orbital septum to inject into the septal fat is associated with vascular injury/bleeding and levator muscle injury. The levator muscle passes posterior to the septal fat and is the muscle responsible for opening the eyes. Another potential target is the deep fat layer superior to the septum and is in the same plane as the retro-orbicularis oculi fat (ROOF—deep fat layer deep to the eyebrow). However, in case of sunken eyelid, this deep fat layer has atrophied significantly and may be difficult to locate. The preseptal space is an ideal target. Volumization with minimal risk of injury to the major neurovascular structures such as the supraorbital artery & nerve and the palpebral vascular arcade is possible in this space. The preseptal space is the space in between the orbicularis oculi muscle (SMAS of the midface) and the septal wall (deep to the orbicularis oculi muscle).

3.5 Identification of SubSMAS Space for Filler Injection …

As shown in the left photo in Fig. 3.17, when the cadaveric skin and subcutaneous fat tissue were removed to examine the orbicularis oculi muscle, the gelatin present within the preseptal space was not visible. When the muscle was lifted, as shown in the right photo in Fig. 3.17, the gelatin that had been placed along the ROOF and orbital rim margin below could be identified (Fig. 3.17). Further dissection revealed gelatin

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that was placed accurately into the preseptal space above the septum (Fig. 3.18). (4) Suborbicularis Space The tear trough deformity forms in the medial orbit, along the medial canthus to the midpupillary line. Deep to the orbicularis oculi muscle in the medial orbital region, there is no

Fig. 3.17 ROOF under orbicularis oculi muscle Fig. 3.18 Gelatin in preseptal space over orbital septum

Stained gelatin

Orbital septum wall

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suborbicularis oculi fat tissue. Therefore, the subSMAS space can be viewed as the space between the orbicularis oculi muscle (SMAS) and periosteum. The flat orbicularis oculi muscle band is firmly attached to the orbital bone and sufficient space may not be made. It can be seen that the injected gelatin was found not only deep to the muscle but also within the muscle (Fig. 3.19). (5) Prezygomatic Space including Suborbicularis Oculi Fat For patients with a flat appearance due to sunken anterior cheeks, filler can be injected to create round “apple cheeks.” As Caucasians experience bone volume loss with aging, filler placement in the periosteal layer immediately above the bone is generally recommended. In contrast, excluding patients who congenitally have underdeveloped cheekbones, most Koreans have flat anterior cheeks due to the loss of soft tissue volume above the bone that occurs with age, rather than bone volume loss. Therefore, Koreans require a procedure that augments volume in this soft tissue area. Unlike the forehead or the lower face, the midface has well-developed superficial and deep fat compartments, which are superficial and deep to the SMAS layer, respectively. For mild to moderate volume loss, filler is injected deep to the SMAS into the deep fat layer. For more severe volume loss, filler is injected into the prezygomatic space located between the deep fat layer and the periosteum. There is no important Fig. 3.19 Gelatin under orbicularis oculi muscle in tear trough area

Anatomical Considerations for Filler Procedures

neurovascular structures in the prezygomatic space making it a safe injection zone. The prezygomatic space is usually formed above the body of the zygoma. The floor is the origin of the zygomaticus muscle, the roof is the orbicularis oculi muscle line, the upper border is the orbicularis retaining ligament, and the lower border is the zygomatico-cutaneous ligament. The prezygomatic space is connected to the lower temporal space in the temporal region through the temporal tunnel. This space could be divided into the following seven layers (superficial to deep): skin, subcutaneous fat layer, orbicularis oculi muscle, SOOF, deep fascia origin of zygomaticus muscles, preperiosteal (prezygomatic) fat layer, and periosteum. Cadaver dissections show that the fat in the prezygomatic space appears white and looser than the yellow-colored SOOF (Table 3.4). The prezygomatic space is a preperiosteal space and presence of gelatin within this space in the malar area was confirmed (Fig. 3.20). (6) Ristow’s Space (Pyriform Space) including Medial Part of Deep Medial Cheek Fat The premaxillary space is a space that forms between the zygomatico-cutaneous ligament and the buccal portion of the maxillary ligament or between the angular artery (extension of the facial artery and runs along the side of the nose) and angular vein (extension of the facial vein that runs along the nasojugal groove). Like the prezygomatic space, Ristow’s space is also a

Stained gelatin Orbicularis oculi muscle

3.5 Identification of SubSMAS Space for Filler Injection … Table 3.4 Seven layers of the prezygomatic space 1. Skin 2. Subcutaneous fat layer 3. Orbicularis oculi muscle 4. SOOF 5. Deep fascia origin of zygomatic muscles 6. Preperiosteal (prezygomatic) fat layer 7. Periosteum

space between the deep fat layer and the periosteum. When paranasal depression due to depressed canine fossa is present, the Ristow’s space targeted for the procedure is within the same midface plane and it is created between medial part of the deep medial cheek fat and the periosteum. The presence of gelatin in Ristow’s space in the paranasal region of the nasolabial fold was confirmed (Fig. 3.21). (7) Preparotid and Premasseteric Space The lateral zygomatic bone and zygomatic arch tend to show greater protrusion among Asians than Caucasians, and as a result, the lateral cheek hollow below the zygomatic arch appears more prominent than it actually is. Prominent lateral cheek hollow is due to the zygomatico-cutaneous ligament, which is one of the most powerful retaining ligaments in the face. The hollowness is

Fig. 3.20 Gelatin in prezygomatic space

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not associated with weight loss but due to the zygomatico-cutaneous ligament, parotidmasseteric ligament (below the zygomaticocutaneous ligament), and ligaments that cover the platysma. These structures pull on the skin to make this area look flat and hollow (Fig. 3.22). In such cases, filler injection into the subcutaneous fat will not correct the hollowness. Injection into an incorrect plane may lead to widening of the lateral area or hardening of the region where the filler has been implanted instead of correcting the cheek hollowness. Filler must be injected into the deeper layers of the preparotid and premasseteric space. The preparotid and premasseteric space is the region superior to the parotid gland covering the superior half of the masseter muscle and the lower half of the masseter muscle. Like the upper and lower temporal spaces above the deep fascia of the temporalis, the preparotid and premasseteric spaces are also located above the deep fascia of the masseter muscle (mastication muscle). The preparotid and premasseteric spaces are bounded by the following structures; floor: parotid-masseteric fascia, roof: SMAS and platysma, posterior wall: strong platysma-auricular fascia, anterior wall: masseteric-cutaneous ligament, a false ligament near the anterior edge of the masseter muscle (Table 3.5).

Deep fat layer Orbicularis oculi muscle Stained gelatin

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Deep fat layer

Anatomical Considerations for Filler Procedures

Stained gelatin in Ristow’s space

Fig. 3.21 Gelatin in Ristow’s space on paranasal region Fig. 3.22 Zygomaticocutaneous ligament

Table 3.5 Boundaries of preparotid and premasseteric space 1. Floor: Parotid gland and the lower half of the masseter 2. Roof: SMAS and platysma 3. Posterior border: Anterior edge of the strong PAF 4. Anterior border: Masseteric ligaments near the anterior border of the masseter

The Stenson’s duct exiting from the parotid gland and buccal branch of the facial nerve are located deep to the parotid-masseteric fascia (deep fascia). This space between the superficial and deep fascia is, therefore, a safe layer to perform various procedures. Anterior to the

Zygomatico-cutaneous ligament

boundary between the lateral and anterior face is where the facial nerve beings to descend from the plane close to the SMAS into the deeper layers. Therefore, anterior to this boundary, deep injection requires caution. Just as in correcting the midcheek groove, in lateral cheek hollow treatment, space must be obtained via partial tunneling of the areas between the zygomatico-cutaneous ligaments attached along the zygomatic arch and the masseteric-cutaneous ligament below it to allow the filler to spread through the ligaments. After creating the space, injecting the filler into the preparotid and premasseteric space between the SMAS and parotid-masseteric fascia (Fig. 3.23)

3.5 Identification of SubSMAS Space for Filler Injection …

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SMAS layer

Parotid gland Stained gelatin Fig. 3.23 Gelatin in preparotid and premasseteric space Fig. 3.24 Before and after treatment of lateral cheek hollowness

can result in a smooth and sufficiently volumized cheek area without irregular borders of the implanted filler (Fig. 3.24). (8) Prebuccal Space In the buccal area, filler can be injected in the buccal space (contains buccal fat) and the prebuccal space, which is lateral to the buccal space. The buccal space is one of the deep fascial spaces and like the submandibular space (contains submandibular gland) the buccal space is

deep to the deep fascia. The buccal space and the buccal fat within this space allow smooth movement of the overlying nasolabial segment of the midcheek and serve as a buffer against excessive motions of jaw movement. Buccal fat covers a much wider area than previously believed, spanning from the area above the mandible to the temporal region. It is divided into superior, middle, and inferior lobes, with each lobe separated as capsules. Generally, it is the inferior lobe that is referred to as the buccal fat pad (Fig. 3.25).

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Superior lobe (temporal extension of buccal fat) Middle lobe

Inferior lobe (buccal fat pad) Fig. 3.25 Extensions of buccal fat

The buccal space where the buccal fat pad is Table 3.6 Boundaries of the buccal space located is an anatomically safe zone. The parotid 1. Floor: Buccinator muscle duct runs superficial to the buccal space (between 2. Roof: Mimetic muscles and the SMAS the middle and inferior lobes) and the marginal 3. Superior boundary: Maxillary ligament mandibular branch of facial and nerve runs along the floor of the buccal space, always passing 4. Inferior boundary: Loose adhesion of the platysma muscle across the mandible below the inferior lobe. 5. Anterior boundary: Modiolus When young, the buccal space is located superior to the oral commissure and medial to the anterior 6. Posterior boundary: Facial vein and masseteric ligaments border of the masseter muscle. The space expands with age and the buccal fat prolapses below the level of the oral commissure to the anterior border of the inferior portion of the masseter muscle, concern for major injuries, unless the area is causing exacerbation of marionette line and jowl. penetrated by a large-bore needle. The presence of gelatin in the prebuccal space The buccal space itself is located in the midface, below the medial and lateral part of the deep between the capsule surrounding the buccal fat medial cheek fat in the midface and its boundaries pad and the SMAS was confirmed (Fig. 3.26). are described in Table 3.6. In cases with buccal cheek hollow, volumiz- (9) Premental space ing the thin capsule of the buccal fat pad may result in an undesirable effect of mouth protru- When using a filler injection for chin augmension and not the intended volumization of the tation, filler placement just above the bone at the lateral area. Targeting the following spaces will tip of the chin would require large amounts of result in effective volumization with a smaller filler. Therefore, for volumization using smaller amount of filler: capsule that surrounds the buc- amounts of filler, filler should be injected into the cal fat pad and forms part of the buccal space; premental space. The premental space, which prebuccal space between the SMAS that covers includes the deep fat layer, is between the menthe aforementioned capsule. The buccal branch talis muscle and bone. The presence of gelatin in of the facial nerve that runs above the buccal fat the premental space between the mentalis muscle pad is usually encapsulated, and thus, there is no and the mentum was confirmed (Fig. 3.27).

3.5 Identification of SubSMAS Space for Filler Injection …

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Fig. 3.26 Gelatin in prebuccal space

Buccal fat region

Stained gelatin

Fig. 3.27 Gelatin in premental space

Deep fat on chin

Stained gelatin

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SSRT (Skin and SMAS Layer Remodeling Technique) for Volumization and Lifting Effect

The recent trend in minimally-invasive procedures has shifted from interventions to address wrinkles or appearance of the face when it is in the expressionless, static state. There is greater emphasis on practical treatments that consider dynamic nature of the facial soft tissues and wrinkles formations when making diverse facial expressions involving movement of soft tissue and wrinkle formation when smiling or making facial expressions. Patients seek total facial harmony and balance, including bilateral symmetry from deep to superficial facial layers. Therefore, the goal of filler procedures goes beyond simple volumization in the static, expressionless state. Creating a face that looks natural with facial movement has become a priority. Evaluating facial proportions and harmony in terms of the positions of the skeletal landmarks and age-related changes of the skull is important. However, it is more important to understand anatomical positions, composition, and age-related changes in the soft tissues covering the facial bones. In addition, accurate facial analysis and objective, up to date standards of beauty should be used to identify the individuality of each patient. To go beyond regional volumization or treating just the sunken wrinkles to create a three dimensional, aesthetically pleasing face with a good impression, several conditions must be met. HA fillers, which are currently the most widely used material, can be divided into biphasic fillers with good lifting capacity and monophasic fillers with good cohesive properties. Biphasic fillers consist of particles but monophasic fillers are often considered to be a uniform gel with no particles. However, when viewed under a microscope, all fillers consist of gel particles and monophasic fillers simply feel soft as though there are no particles. Therefore, categorizing fillers according to the presence or absence of particles is not appropriate. The

Anatomical Considerations for Filler Procedures

author classifies fillers based on their consistencies as either soft or firm fillers. Fillers with different viscoelastic properties when used in the right combination can not only volumize the face but can also create a natural vshaped face with a smiling effect by lifting the skin. Fillers are selected based the site of injection, target layer, and treatment goals. Combination treatments with botulinum toxin will produce synergistic effects and the author refers to this filler technique as the “Oval Face” technique. To create an oval face, it is necessary to understand the changes that occur in soft tissues when smiling. When smiling or making facial expressions, the volume in the lower face is reduced and is pushed upward to give the natural appearance of a slim face. The soft tissue in the anterior malar area moves anterosuperiorly and the soft tissues in the paranasal and perioral area move laterosuperiorly. By creating changes in the soft tissues in this pattern, a natural eggshaped face with a smiling impression and elegant image can be created (Fig. 3.28). For successful outcomes, the right combination of fillers with specific rheological properties must be used for different parts of the face to account for the difference in soft tissue density. Generally, the density in the plane below the SMAS layer increases after injection of a firm filler resulting in tissue expansion causing the upward push of the SMAS layer. In response to the tension, there is homeostatic function of the surrounding connective tissue resulting in subsequent stretching of the skin and lifting/tightening effect. In addition, if the skin surface is uneven or wrinkled, injecting soft consistent fillers directly under the skin will make the skin surface smooth and improve wrinkles. This is possible because the vertically oriented fibrous septa in the superficial fat layer between the skin and the SMAS layer extend toward the skin and become retinacular cutis holding the skin firmly. The soft consistent filler injected between the retinacular cutis under this skin will help stretch and harden the skin.

3.6 SSRT (Skin and SMAS Layer Remodeling Technique) … Fig. 3.28 Oval and smiling face

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1. Oval Face Shape Proportion Change for Midface & Lower Face Increase volume for midface Reduce volume for lower face and make lower face look slimmer 2. Smiling Face Soft tissue movement Anterior malar area anterosuperior movement Paranasal & perioral area laterosuperior movement

The author calls this technique of targeting the skin and SMAS layer as the SSRT (Skin and SMAS layer Remodeling Technique). When a relatively firm filler is injected into the subSMAS space, tightening by projection occurs in the SMAS layer overlying the filler and this tightening effect acts as a force that lifts adjacent tissue (Fig. 3.29). Looking around the mouth, tightening of the SMAS with filler placement and subsequent lifting effect in the adjacent region occurs in the following patterns; injection into the anterior malar area with lifting effect in nasolabial area, into nasolabial area with effect in the upper lip area, into anterior cheek area with effect in the lower lip area, into the prejowl area with effect in the mentum, and into side cheek area with effect in the jawline (Fig. 3.30). The reason such a phenomenon occurs is that the entire face is covered by a SMAS layer that has variable thickness and the skin is affected by changes in the SMAS layer as it is attached to this SMAS layer. As demonstrated in the cadaveric study using gelatin, the SMAS separates the soft tissue of the face into superficial and deep fibroadipose connective tissues, each with distinct characteristics and shapes. Appropriate distribution of fillers with different viscoelastic properties into the two layers will result

in adequate volumization with smiling and lifting effect (Fig. 3.31). To achieve volumizing effect with smiling and lifting effect, it is important to understand the fibroadipose layers of the face. The SMAS layer separates the superficial fat layer from the deep fat layer. As these fat layers seemed to be connected to the naked eye, they were thought to be a single, broad layer. However, since the 2000s, it was recognized that the fat layer is actually composed of several compartments by facial region (Fig. 3.32). The fat layer that is comprised of numerous compartments differs by facial region. In the midface, the superficial and deep fat compartments are distinct and distinguishable, while in the upper and lower face, there are differences in the thicknesses and distribution of the two fat layers. Thus, it is necessary to perform filler injections considering such differences in the fat layers in the different parts of the face. Moreover, it is important to consider the location and role of retaining ligaments that support and maintain the shape of soft tissues to ensure effective treatment of sunken areas and volume restoration in the face. Major retaining ligaments in the face were previously categorized as the true or false depending on where they originated. True retaining ligaments originate

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SubSMAS filler injection Filler injection into subSMAS connective tissue Provide support to SMAS layer & create projection

SMAS layer expansion of injected region

Tighten the SMAS layer of injected region by increase of subSMAS tissue density Tightened SMAS make traction effect to adjacent areas lifting effect

adjacent SMAS layer shows tensile &

Skin connected to lifted SMAS layer shows same effect Traction of skin & SMAS layer make compression & smoothness of adjacent bulging loose connective tissue Dermal & subdermal filler injection Dermal & subdermal filling

skin stretching

reduction of skin deformation by the indirect Increase of dermal & subdermal tissue density wrinkle improvement block of the musculocutaneous connection

Fig. 3.29 Mechanism of skin and SMAS layer remodeling technique

Fig. 3.30 Change of lower face by SSRT

3.6 SSRT (Skin and SMAS Layer Remodeling Technique) …

Fig. 3.31 Injection of 2 gels with different properties

Fig. 3.32 Compartment of superficial fat layer

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from bone while false retaining ligaments originate from soft tissue. This type of categorization is outdated and currently, the morphological characteristics and tissue components of retaining ligaments are considered to differentiate true retaining ligaments from tough fibrous structures such as septae, adhesions, or septum. Retaining ligaments do not provide support to just the skin right above them. As seen in cadaveric studies, firm and tough fibrous tissues extending to the face can be seen around the retaining ligaments. These fibrous structures connect the skin tissue to the deeper tissues. Just as atrophy occurs in the fat layer deep to the SMAS layer, the reduction of fat depots near ligamentous tissues weakens the support that holds the retaining ligaments causing them to sag. Typically, sagging of the skin and soft tissues associated with aging is explained by the uniform weakening of the facial retaining ligaments across the face. The author, however, believes that the degree of sagging varies by the type and location of the retaining ligaments. The zygomatico-cutaneous and mandibular ligaments, which are the strongest facial retaining ligaments, do not weaken to a great extent and

Fig. 3.33 Tight zygomatico-cutaneous ligaments

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Anatomical Considerations for Filler Procedures

are better able to hold and retain tissue over time. However, the weaker retaining ligaments and ligamentous fibrous tissues in the adjacent region are more susceptible to drooping with age. The skin and tissue supported by these weaker structures thus would sag more. Thus, the hollows and grooves formed due to strong retaining ligaments become more pronounced with age (Fig. 3.33). Consequently, when establishing a treatment plan, strength of retaining ligaments and consequent clinical manifestation must be taken into account. In areas with a severe groove or hollow due to surface tissue being pinched in by strong retaining ligaments, it is difficult to project the SMAS layer by merely injecting filler into sunken area. In case of strong retaining ligaments, a lifting effect by tightening the SMAS layer can be achieved after first obtaining space by tunneling to release the areas held by these strong ligamentous tissues, followed by injecting a filler that is strong enough to lift and tighten the SMAS layer. This will ensure projection of the sunken area. However, if the retaining ligaments are not retracting the skin and the soft tissues are actually

3.6 SSRT (Skin and SMAS Layer Remodeling Technique) …

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Fig. 3.34 Partial tunneling or supporting according to the tightness of ligament

maintained by these ligamentous structures, then tunneling with a cannula and placing a strong filler is unnecessary. In fact, such ligamentous structures recede into the deep fat layer with age and their strength in supporting the adjacent tissue decreases. Further weakening by aggressive tunneling is actually contraindicated. In areas where slight resistance is felt when inserting the cannula, space just enough for smooth administration of the filler is needed. Tunneling may not be needed and in these cases, procedures may be performed with a needle (Fig. 3.34). The SMAS is a composition of the fibroadipose layer and separates this layer into the superficial and deep layers. It is also the structure that relays the movement of the deep facial muscles to the skin to where it attaches to allow formation of facial expressions. Therefore, for total facial contouring and creation of an oval face with a smiling and lifting effect, a procedure that effectively tightens the SMAS layer is needed. In addition, it is important to understand the role of retaining ligaments. As structures that connect the skin to the deeper tissues, they provide support to the soft tissues to prevent facial skin and soft tissues from sagging. Depending on the part of the face and strength of the retaining ligaments, tunneling for partial release of retaining ligaments and firm fibrous tissue layer may be required to ensure effective filler placement into the desired areas and depths. Conversely, for areas in which sagging is due to

weakened ligamentous tissues, ligamentous tissues should be lifted and reinforced by increasing tissue density using filler injections into nearby ligamentous tissues. Aggressive tunneling, which may actually weaken the tissues, should be avoided. Cytologically, injection of an HA filler comprised of small particles into the dermal layer improves skin elasticity and enhances skin suppleness by inducing the following effects: increases volume of skin, moisturizes the skin through hydration, facilitates collagen production by increasing the number of fibrocytes, and provides antioxidant activity for removal of reactive oxygen species. However, there are claims that stimulation of soft tissue by filler injection causes immediate cell contraction due to changes in the cytoskeleton of fibroblasts, tissue remodeling from adapting to such changes, as well as activation and proliferation of fibroblasts. Moreover, there are theories that the soft tissue HA volume fillers do not induce skin neocollagenesis but instead modifies subcutaneous white adipose tissue (sWAT). Changes in sWAT promote activation and proliferation of adipose-derived stem cells (ADSCs) and expansion of mature adipocytes. In the long run, these changes lead to volumization and tissue tightening by hyperplasia and hypertrophy of ADSCs and mature adipocytes. However, more in-depth studies are needed regarding these mechanisms.

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Bibliography 1. Nakajima, et al. Anatomical study of subcutaneous adipofascial tissue: a concept of the protective adipofascial system (PAFS) and lubricant adipofascial system (LAFS). Scand J Plast Reconstr Surg Hand Surg. 2004; 38(3):261–6. 2. Castro CC, Boehm KA, Codner MA. Midface surgery. Elsevier saunders; 2009. 3. Mendelson BC, et al. Age-related changes of the orbit and midcheek and the implications for facial rejuvenation. Aesthetic Plast Surg. 2007;31:419–23. 4. Kim YS, et al. The anatomical origin and course of the angular artery regarding its clinical implications. Dermatol Surg. 2014;40:1070–6. 5. Yang HM, et al. New anatomical insights on the course and branching patterns of the facial artery: clinical implications of injectable treatments to the nasolabial fold and nasojugal groove. Plast Reconstr Surg. 2014;133:1077–82. 6. Koh KS, et al. Branching patterns and symmetry of the course of the facial artery in Koreans. Int J Oral Maxillofac Surg. 2003;32:414–8. 7. Wong CH, et al. Facial soft-tissue spaces and retaining ligaments of the midcheek: defining the premaxillary space. Plast Reconstr Surg. 2013;132:49–56. 8. Mendelson BC, et al. Surgical anatomy of the middle premasseter space and its application in sub-SMAS face lift surgery. Plast Reconstr Surg. 2013;132:57–64. 9. Gierloff M, et al. Aging changes of the midfacial fat compartments: a computed tomographic study. Plast Reconstr Surg. 2012;129:263–73. 10. Chang H. Arterial anatomy of subdermal plexus of the face. Keio J J Med. 2001;50(1):31–4. 11. Lee JG, et al. Facial arterial depth and relationship with the facial musculature layer. Plast Reconstr Surg. 2015;135:437. 12. Brandt MG, et al. Biomechanical properties of the facial retaining ligaments. Arch Facial Plast Surg. 2012;14(4):289. 13. Scheuer Jack F, et al. Anatomy of the facial danger zones: maximizing safety during soft-tissue filler injections. Plast Reconstr Surg. 2017;139:50e. 14. Ghassemi A, et al. Anatomy of the SMAS revisited. Aesthetic Plast Surg. 2003;27:258–64. 15. Furnas DW, et al. The retaining ligaments of the cheek. Plast Reconstr Surg. 1989;83:11–6. 16. Haddock NT, et al. The tear trough and lid/cheek junction: Anatomy and implications for surgical correction. Plast Reconstr Surg. 2009; 123:1332– 13340. Discussion 1341. 17. Sundine, et al. Analysis of the effects of subcutaneous musculoaponeurotic system facial support on the nasolabial crease. Can J Plast Surg. 2010; 18 (1):11–14.

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18. Lee HJ, et al. Description of a novel anatomic venous structure in the nasoglabellar area. J Craniofac Surg. 2014;25:633–5. 19. Marur T, et al. Facial anatomy. Clin Dermatol. 2014;32:14–23. 20. Loukas M, et al. Gross anatomical, CT and MRI analysis of the buccal fat pad with special emphasis on volumetric variations. Sure Radiol Anat. 2006;28:254. 21. El-Garem YF. Estimation of bony orbit depth for optimal selection of the injection technique to correct the tear trough and palpebromalar groove. Dermatol Surg. 2015;41:94–101. 22. Mendelson BC, et al. Changes in the facial skeleton with aging: Implications and clinical applications in facial rejuvenation. Aesthetic Plast Surg. 2012;36:753–60. 23. Liew S. Ethnic and gender considerations in the use of facial injectables: Asian patients. Plast Reconstr Surg. 2015;136(5):22S–7S. 24. Cotofana S, et al. The anatomy of the aging face: a review. Facial Plast Surg. 2016;32:253–60. 25. Bartlett SP, et al. Age-related changes of the craniofacial skeleton: an anthropometric and histologic analysis. Plast Reconstr Surg. 1992;90:592– 600. 26. Dumont T, et al. Anatomy and imaging of the deep fat of the face. Clin Anat. 2000;13:373–82. 27. Coleman SR, et al. The anatomy of the aging face: volume loss and changes in 3-dimensional topography. Aesthet Surg J. 2006; 26(Suppl):4S–9S. 28. Raskin E, et al. Why do we age in our cheeks? Aesthet Surg J. 2007;27:19–28. 29. Donofrio LM. Fat distribution: a morphologic study of the aging face. Dermatol Surg. 2000;26:1107–12. 30. Wan D, et al. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg Glob Open. 2104; 1:e92. 31. Pessa JE, et al. Double or bifid zygomaticus major muscle: anatomy, incidence, and clinical correlation. Clin Anat. 1998;11:310–3. 32. Macchi V, et al. Histotopographic study of the fibroadipose connective cheek system. Cells Tissues Organs. 2010;191(1):47–56. 33. Pessa JE, et al. Relative maxillary retrusion as a natural consequence of aging: combining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Reconstr Surg. 1998;102 (1):205–12. 34. Allan E Wulc, et al. The anatomic basis of midfacial aging. Hartstein, ME et al., editors. Midfacial rejuvenation, vol. 2. Springer Science + Business Media, LLC; 2012. pp. 15–28. 35. Richard MJ, et al. Analysis of the anatomic changes of the aging facial skeleton using computer-assisted tomography. Ophthal Plast Reconstr Surg. 2009;25 (5):382–6.

Bibliography 36. Khan DM, et al. Aging of the bony orbit: a threedimensional computed tomography study. Aesthet Surg J. 2008;28:258–64. 37. Spiegel JH, et al. The anatomic relationship between the orbicularis oculi muscle and the levator labii superioris and zygomaticus muscles complexes. Plast Reconstr Surg. 2005; 116:1937–1942. 38. Morris DE, et al. Aesthetic facial skeletal contouring in the Asian patients. Clin Plast Surg. 2007;34:547– 56. 39. Gu Y, et al. Comparison of craniofacial characteristics of typical Chinese and Caucasian young adults. Eur J Orthodont. 2011;33:205–11. 40. Arlette JP, et al. Anatomic location of hyaluronic acid filler material injected into nasolabial fold: a histologic study. Dermatol Surg. 2008;34:56S–63S. 41. Niamtu J 3rd. Filler injection with micro-cannula instead of needles. Dermatol Surg. 2009;35 (12):2005–8. 42. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007; 119:2219–2227. Discussion 2228-31. 43. Wu W, et al. Novel administration technique for large-particle stabilized hyaluronic acid-based gel of nonanimal origin in facial tissue augmentation. Aesthetic Plast Surg. 2010;34:88–95. 44. Guyuron B, et al. Factors contributing to the facial aging of identical twins. Plast Reconstr Surg. 2009;123:1321–31. 45. Langevin HM, et al. Subcutaneous tissue fibroblast cytoskeletal remodeling induced by acupuncture: evidence for a mechanotransduction-based mechanism. J Cell Physiol. 2006;207:767–74. 46. Thaller SR, et al. The submuscular aponeurotic system (SMAS): a histologic and comparative anatomy evaluation. Plast Reconstr Surg. 1990;86:690–6. 47. Sundaram H, et al. Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to aesthetic applications. Plast Reconstr Surg. 2013;132:5S–21S. 48. Berros P, et al. Hyalurostructure treatment: superior clinical outcome through a new protocol-a 4-year comparative study of two methods for tear trough treatment. Plast Reconstr Surg. 2013;132:924e–31e. 49. Lee SK, et al. Recent trend in the choice of fillers and injection techniques in Asia: a questionnaire study based on expert opinion. J Drug Dermatol. 2014;13 (1):611. 50. Kim HJ, et al. Clinical anatomy of the face for filler and botulinum toxin injection. Springer, 2016. 51. Shaw RB, et al. Aging of the facial skeleton: aesthetic implications and rejuvenation strategies. Plast Reconstr Surg. 2011;127:374–83. 52. Shaw RB, et al. Aging of the midface bony elements: a three-dimensional computed tomographic study. Plast Reconstr Surg. 2007;119(2):675–81. 53. Edsman KL, et al. Is there a method that can measure cohesivity? Cohesion by sensory evaluation

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compared with other test methods. Dermatol Surg. 2015;41:S365–72. Rohrich RJ, et al. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121:1804–9. Kruglikov IL, et al. Soft tissue fillers as non-specific modulators of adipogenesis: change of the paradigm? Exp Dermatol. 2015;24:912–5. Landau, et al. Science of hyaluronic acid beyond filling: fibroblasts and their response to the extracellular matrix. Plast Reconstr Surg. 2015; 136 (5S):188–195. Stefano, et al. Hyaluronate increases polynucleotides effects on human cultured fibroblasts. J Cosmet Dermatol Sci Appl. 2013; 3:124–128. Shirakabe Y, et al. A new paradigm for the aging Asian face. Aesthetic Plast Surg. 2003;27(5):397– 402. Stuzin JM, et al. The relationship of the superficial and deep facial fascias: relevance to rhytidectomy and aging. Plast Reconstr Surg. 1992;89(3):441–9. Cong L-Y, Phothong W, Lee SH, Wanitphakdeedecha R, Koh I, Tansatit T, Kim HJ. Topographic analysis of the supratrochlear artery and the supraorbital artery. Plast Reconstr Surg. 2017;139 (3):620e–7e. Lee JG, Yang HM, Choi YJ, Favero V, Kim YS, Hu KS, Kim HJ. Facial arterial depth and relationship with the facial musculature layer. Plast Reconstr Surg. 2015;135(2):437–44. Hwang K, Lee GI, Park HJ. Branches of the facial artery. J Craniofac Surg. 2015;26(4):1399–402. Sykes JM, Trevidic P, Suárez GA, CriolloLamilla G. Newer understanding of specific anatomic targets in the aging face as applied to injectables. Plast Reconstr Surg. 2015;136:56S–61S. Lefkowitz T, Hazani R, Chowdhry S, Elston J, Yaremchuk MJ, Wilhelmi BJ. Anatomical landmarks to avoid injury to the great auricular nerve during rhytidectomy. Aesthetic Surg J/Am Soc Aesthetic Plast Surg. 2013;33(1):19–23. Dorafshar AH, Borsuk DE, Bojovic B, Brown EN, Manktelow RT, Zuker RM, et al. Surface anatomy of the middle division of the facial nerve. Plast Reconstr Surg. 2013;131(2):253–7. Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the high-SMAS technique. Plast Reconstr Surg. 2010;125(4):1221–9. Surgical Anatomy of the ligamentous attachments in the temple and periorbital regions. Cosmetic; 2000. pp 1–16. Sullivan PK, Hoy EA, Mehan V, Singer DP. An anatomical evaluation and surgical approach to the perioral mound in facial rejuvenation. Plast Reconstr Surg. 2010;126(4):1333–40. Surek CK, Vargo J, Lamb J. Deep pyriform space. Plast Reconstr Surg. 2016;138(1):59–64.

70 70. Wan D, Amirlak B, Rohrich R, Davis K. The clinical importance of the fat compartments in midfacial aging. Plast Reconstr Surg Glob Open. 2013;1(9):e92–8. 71. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124(1):266–71. 72. Rohrich RJ, Pessa JE. The fat compartments of the face: anatomy and clinical implications for cosmetic surgery. Plast Reconstr Surg. 2007;119(7):2219–27.

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73. Gierloff M, Stöhring C, Buder T, Wiltfang J. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. Br J Plast Surg. 2012;65(10):1292–7. 74. Rohrich RJ, Pessa JE. The retaining system of the face: histologic evaluation of the septal boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2008;121(5):1804–9.

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Basic Technique for Filler Procedure

4.1

Design (Method)

I see many patients who request filler treatments in my clinic. Some patients want filler treatment for a specific region and some want whole face correction with fillers. In this case, I analyze patients’ faces and find regions which need correction step by step. This process is referred to as “Design”. The process which I prefer is as follows. Firstly, check the ratio of length and width of the patient’s face in the frontal view – Length of forehead/nose/chin should be estimated and then determine which region needs correction. Secondly, check the balance of regions around the cheek in the frontal view. – Volume and hollowness of anterior cheek/lateral cheek/temple/nasolabial fold should be estimated. Design the midface to be heart shaped. Thirdly, check the silhouette line of the forehead-radix (nose)-chin in the lateral view. – Lines from forehead to radix and from lips to chin should be a natural curve. The curve of lateral cheek depends on personal preference. Fourthly, check the Ricketts line in the lateral view – Estimate the height of the nose/volume of lips/protrusion of chin and check whether they are located within the Ricketts line.

© Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_4

We will discuss these four steps in detail from now on. Detailed design techniques for each area are covered in the considerations for procedure of each chapter (Chap. 5). This section covers the design of the entire face and design tips that can be naturally connected to adjacent areas.

4.1.1 Frontal View-Horizontal/ Vertical Ratio of the Face First step is to check the horizontal/vertical (longitudinal) ratio of the face in the frontal view. If the vertical length of the face is relatively short, the face looks broad or relatively large. In such cases, designing vertical length longer can balance the ratio of the horizontal/vertical ratio and make the face look smaller. As explained in Sect. 1.3, the ratio of forehead/nose/chin is the most ideal in Westerners with a ratio of 1:1:1, while for Asians, the lower face ratio of 0.8–0.9 is recently the most desirable. In any case, the length of the forehead should be equal to the length of the midface (Fig. 4.1). After checking the length of the forehead/nose/chin on the frontal view, evaluate whether the ratio is balanced or whether one part is short. The ratio can be measured using a measuring tool. Some tools are specifically designed for cosmetic analysis (Fig. 4.2), or a commonly used design pens can be used (Fig. 4.3).

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Fig. 4.1 Ideal facial proportion

• Length of the forehead If the forehead is relatively short, you can make the forehead relatively longer by producing volume with a forehead filler or hairline rearrangement with a laser. Patients who don’t have a pretty forehead usually tend to cover their forehead with hair. Since the forehead is not always visible in the entire length of the face, the length of the face can be considered from the chin to the eyebrows.

4 Basic Technique for Filler Procedure

As a result, the face appears wider in proportion to its width/length ratio. For these patients, it is important to make a balanced forehead suitable for the entire face through filler and hair removal. • Length of the nose If the nose looks short, you can design the entire nose to be balanced by augmentation of the columella or dorsum with a filler. • Length of the chin If the chin is short, you can adjust the vertical ratio of the face by lengthening the chin with chin augmentation. In the case of a round face, the entire face looks larger in the frontal view, so if you make the chin slightly longer, the jawline will be narrow and the face will look smaller. However, as mentioned above, it is recommended that the ratio of the lower face in an Asian face be slightly smaller than the length of the midface these days.

4.1.2 Frontal View—Heart-Shaped Midface Secondly, check that the midface is in the shape of a heart or inverted triangle in the frontal view (See Sect. 1.3).

Fig. 4.2 Check the facial proportion using a tool (BEAUTIPHICATION™ Caliper)

4.1 Design (Method)

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Fig. 4.3 Check the facial proportion using a design pen

• Volume of cheek in the frontal view In the frontal view, the natural volume of the anterior cheek is important. In the past, filler procedures were popular as a replacement for implantation in the nose or nasolabial fold, but recently, trends have been where fillers are used to correct the outline of the whole face. The cheeks make up half of the midface, and the beautiful cheek line gives a lovely look and a good first impression. Neglected design without a concept of beauty can be counterproductive. The ideal view of a beautiful anterior cheek and lateral cheek differs between Westerners and Asians (See Sect. 1.2). This is because the cheekbone structures of Westerners and Asians are markedly different. In the frontal view, the line from maxilla to zygomatic bone naturally curves in Westerners. However, Asians appear to be flat at the maxilla and suddenly bent in the zygomatic arch. Westerners also differ from Asians in the highlight of the cheek. The highlight of a Westerners feature is an oval shape and located more lateral than the lateral canthus. The inverted S-line (ogee curve) is preferred for the lateral line. On the other hand, in Asians, the highlight is similar to a circular shape rather than an oval, and the location is preferred to be on the lateral canthus line or more medial.

Westerners often undergo cheek augmentation with silicone implants, but in the East, they prefer to reduce the volume of the zygoma by cheekbone reduction surgery. When correcting with a nonsurgical filler on an Asian face, it is important to design the volume to fill the flat anterior cheeks, i.e., more medial than the lateral canthus. In western faces, it is important to design the cheek highlights lateral to the lateral canthus and to create an ogee curve with it. When the zygoma is overly prominent, the horizontal width of the face can be perceived as smaller by correcting the temporal hollowness and lateral cheek hollowness adjacent to it. Looking more closely at the cheek, check the presence of nasojugal grooves, palpebromalar grooves, and midcheek grooves in infraorbital areas adjacent to the anterior cheek and design to correct as necessary. The presence of nasolabial folds or infraorbital hollowness on the face can give a tired impression, so it is recommended that you design with this in consideration. • Hollowness of lateral cheek and temple in frontal view Check if there is hollowness in the lateral cheeks and temples. If the zygomatic arch is prominent it may be accompanied by hollowness of lateral cheeks and

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temporal hollowness, which may result in making the face look wider and giving a bad impression. A moderately prominent zygoma may seem attractive in Westerners, but is not preferred in Asians. If there is severe hollowness of the temples or the lateral cheeks in the face of an Asian, it is important to design to give a gentle impression through volume correction? • Presence of nasolabial fold Check if there is a severe depression accompanied in the nasolabial fold area. Volumization of the nasolabial fold area is as important as volumization of the anterior cheek in the midface. The Nasolabial fold needs to be corrected in order to achieve a heart-shaped face (See Sect. 1.1). Nasolabial folds are accompanied by cheek sagging (not wrinkles) due to aging of the skin tissue, so this should be considered when designing for anterior cheek correction. Since the cause of the nasolabial fold is associated with changes in the fat compartment of the malar area, thoughtlessly injecting too much volume of fillers into the nasolabial fold is not a harmonious correction.

4.1.3 Oblique View—S-Line/Inverted S-Line/Ogee Curve Thirdly, check the silhouette of the lateral cheek and the silhouette from the forehead-radix-nose tip-to chin in the oblique view (45°) (Fig. 4.4). • Check that the volume of the forehead is smooth without depression. In the oblique view, check that the silhouette of the forehead contour is a convex line and design the part that needs correction. • Check if the line from the forehead-glabellato nose (radix) is a natural curve with a S-line. • Design an inverted S-line from lower lip to chin It is unnatural to design the lips or chin to protrude too far forward. • Design the ogee curve from zygoma to lateral cheek

Fig. 4.4 S-line and inverted S-line in the oblique view (45°)

Westerners value the ogee curve with a slight depression in the lateral cheeks on the oblique view. However, it should be noted that Asians tend to be reluctant to have the ogee curve.

4.1.4 Lateral View-Ricketts Line Fourthly, design with an imaginary “Ricketts line” in the lateral view (Fig. 4.5). We have already seen that the ideal line from nose tip-lips-to chin is different between Asians and Westerners (see Sect. 4.1.1). Asians often have short chins in the frontal view and retracted chins in the lateral view. In this case, the ideal silhouette does not come out in the lateral view. To create an ideal contour using the Ricketts line, the following correction is recommended. • Make the columella high or the nose tip protrude. • Lips are designed to go inside the line. • Make the chin protrude over the line.

4.1 Design (Method)

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whether a cannula or needle is used. Understanding the route and depth of blood vessels and nerves, and marking them prior to the procedure will help prevent complications. In addition to marking the blood vessels, it is helpful to mark the area to be filled with the filler and the safety line in advance.

Tip of nose

Lower lip Tip of chin

Fig. 4.5 Ricketts line

Making the retracted chin protrude forward in the lateral view and making the short chin elongate downward in the frontal view is the key when augmenting the chin.

4.1.5 Design for Safe Filler Injection —Mark of Dangerous Area When designing before the filler procedure, it is important to have a clear and in-depth understanding of the danger areas, regardless of Fig. 4.6 Mark of dangerous area-Infraorbital dark circle. Blue dotted line: Tear trough ligament. Red line: Angular artery. Red stars: Infraorbital foramen and zygomaticofacial foramen. Green dot: entry point

4.1.5.1 Design Examples for Safe Procedures The treatment area and corresponding dangerous structures are as follows. • Anterior cheek/infraorbital hollowness – Mark the infraorbital foremen from which the infraorbital artery and the infraorbital nerve come from; and the zygomaticofacial foramen from which the zygomaticofacial artery and zygomaticofacial nerve come from. Mark the route of the angular artery (Fig. 4.6). • Nasolabial fold – Mark the facial artery and its branches. • Temple – Mark the sentinel vein, mid-temporal vein, and superficial temporal artery. Then, mark the safe area and entry point where filler is to be injected (Fig. 4.7). • Forehead – Mark blood vessels, treatment area and the safe entry point for the cannula to enter (Fig. 4.8).

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Fig. 4.7 Mark of dangerous area-Temple. Blue dotted line: Middle temporal vein. Blue lines: Branches of sentinel vein. Red dotted line: Superficial temporal artery. Green dot: entry point

Superficial temporal artery

Branches of sentinel vein Middle temporal vein

4.2

4.2.1 Supratrochlear/Supraorbital Nerve

Anesthesia—Nerve Block

Most filler procedures require anesthetic ointment or a nerve block using lidocaine. The nerve that can be targeted for the nerve block before the filler procedure is the CN5 trigeminal nerve. It is divided into three divisions; ophthalmic division (V1), maxillary division (V2), and mandibular division (V3). The areas covered by the three divisions and the sensory nerves branched from each area are shown in the following figure (Figs. 4.9 and 4.10). The nerves that can be blocked according to the facial area during the filler procedure are as follows (Table 4.1).

Supraorbital nerves come from supraorbital notch. The supraorbital notch almost coincides with the mid-pupillary line or slightly medial to the line. The notch can be confirmed by palpating it with one’s hand. Inject approximately 1 cc of lidocaine near the notch. The direction of injection should be above the eyebrows and you should be careful not to inject into the orbital cavity. In some case, the lateral branch comes from the foramen above the supraorbital margin, which may not be anesthetized. In this case, additional lidocaine can be injected 1 cm above the supraorbital margin (Fig. 4.11).

Injection area(red) Vessels

Fig. 4.8 Mark of dangerous area-Forehead. Blue dotted line: Vessels. Red area: Injection area. Green dot: entry point

4.2 Anesthesia—Nerve Block

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Ophthalmic division (V1)

Maxillary division (V2)

Fig. 4.11 Blocking of supraorbital nerve

Mandibular division (V3) Fig. 4.9 Dermatome distribution of the trigeminal nerve

Supratrochlear nerves come from supratrochlear notch around the medial border of the eyebrows. In the same way as anesthesia for the supraorbital nerve, first touch the notch with one’s hand and inject about 0.5 cc near the notch (Fig. 4.12). When anesthetizing these nerves, a needle is inserted into each area in a direction perpendicular to the skin, but a single injection of the needle may be used to anesthetize the supraorbital/supratrochlear nerve. Using a needle

longer than 1 inch, insert at the lateral 2/3 point of the supraorbital margin and advance inward to the supratrochlear foramen. Then, anesthetize the supratrochlear nerve and anesthetize the supraorbital nerve as it comes out (Fig. 4.13).

4.2.2 Zygomaticotemporal Nerve (Fig. 4.14) There is a zygomaticofrontal suture where the frontal bone and zygomatic bone meet and can be palpated as the protruding bone on the outside of the eyebrow. The zygomaticotemporal nerve emerges from the lateral aspect of the suture and is responsible

Fig. 4.10 Branches of the trigeminal nerve

infratrochlear nerve zygomaticofacial nerve infraorbital nerve

supraorbital nerve supratrochlear nerve External nasal branch of anterior ethmoidal nerve

mental nerve

78 Table 4.1 Facial areas and corresponding nerves

4 Basic Technique for Filler Procedure

Facial areas and corresponding nerves Forehead

Supratrochlear nerve/supraorbital nerve

Temple

Zygomaticotemporal nerve

Nose

External nasal branch of anterior ethmoidal nerve

Nasolabial fold

Infraorbital nerve

Chin

Mental nerve

Fig. 4.12 Blocking of supratrochlear nerve

Fig. 4.13 Blocking of supratrochlear nerve and supraorbital nerve

Fig. 4.14 Blocking of zygomaticotemporal nerve

Fig. 4.15 Blocking of zygomaticofacial nerve

4.2.3 Zygomaticofacial Nerve (Fig. 4.15) for the sensation of the lateral eyebrow and temple area. After inserting the needle obliquely from the top down (from cranial to caudal), lidocaine is injected in a retrograde fashion.

The zygomaticofacial foramen is near the intersection of the infraorbital margin and the lateral orbital margin in the zygomatic bone. After

4.2 Anesthesia—Nerve Block

Fig. 4.16 Blocking of external nasal branch of anterior ethmoidal nerve

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Fig. 4.17 Blocking of infraorbital nerve

inserting a needle toward this intersection and touching the bone, inject approximately 0.5 cc of lidocaine.

4.2.4 External Nasal Branch of Anterior Ethmoidal Nerve (Fig. 4.16) An external nasal branch emerges from the boundary between the nasal bone and the upper lateral cartilage. After checking the boundary by palpating with one’s hand and inserting a needle below it, inject approximately 0.5 cc of lidocaine.

4.2.5 Infraorbital Nerve (Fig. 4.17) Both transcutaneous and intraoral approaches are possible. The infraorbital nerve emerges from the infraorbital foramen, located about 1 cm below the infraorbital margin of the mid-pupillary line. Inject approximately 1 cc of lidocaine near the foramen. During an intraoral approach, the needle is slowly inserted upward from the upper second premolar tooth.

4.2.6 Mental Nerve (Fig. 4.18) The mental nerve block is the same as the infraorbital nerve block and can be percutaneously

Fig. 4.18 Blocking of mental nerve

or intraorally administered. The mental nerve comes from the mental foramen, located slightly medial of the mid-pupillary line and 2 cm below the mouth corner. For a percutaneous approach, the needle is inserted from the outside toward the mental foramen and injected. In the intraoral approach, slowly insert the needle downward from the lower second premolar tooth.

4.2.7 Greater Auricular Nerve (Fig. 4.19) The greater auricular nerve is not the trigeminal nerve, but branches from C2 and C3, covering the front of the sternocleidomastoid muscle (SCM) and travels up. With the patient supine, turn the head laterally to one side to reveal the SCM, and mark the anterior and posterior

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Fig. 4.19 Blocking of greater auricular nerve

margins with a pen. The target point is about 6.5 cm from the external auditory canal on the centerline of the two margins. After inserting the needle, the lidocaine is injected onto the fascia, not the SCM itself, making a wheal on the skin. At this time, 6.5 cm can be easily measured using the operator’s finger. Usually, the distance from the metacarpophalangeal joint of the thumb to the tip is about 6.5 cm.

4.3

Selection of Cannula or Needle

4.3.1 Cannula A. The tip of cannula is blunt and causes less tissue damage. The procedure can be performed with gentle manipulation to reduce nerve and blood vessel damage (Fig. 4.20).

Fig. 4.20 Cannulas

B. Long cannulas can be bent during progression. C. If you encounter a strong ligament during the treatment you will feel resistance. This can be confirmed through the resistance of the cannula without seeing anatomical structures. Before the procedure, it is necessary to be aware of the major structures present on the path of the cannula. D. The patient will complain of pain if the cannula causes irritation of blood vessels or nerves during the procedure. Even without direct damage, the patient can complain of pain even when stimulating blood vessels or nerves. E. It is not always possible to check intravascular injection through aspiration tests. Even though the cannula might have actually entered the vessel, negative findings can be shown on aspiration tests (Fig. 4.21). F. In the cannula, the exit hole from which the filler is ejected is on the side, not at the end of the cannula. Therefore, the filler is not injected at the end of the cannula but on the side. In order to inject the filler precisely into the designed area, it is necessary to accurately orientate the position of the hole to area to be injected as well as accurately positioning the end of the cannula. G. If the injection force is too high, the connection between the cannula and the syringe may burst. When joining the cannula and the filler syringe, it should be locked tightly. If

4.3 Selection of Cannula or Needle

Fig. 4.21 Filler aspiration test with cannula

81

injected and the separation site may be squeezed by hand to remove the blood. If blood does not leak out of the entry point, it is evidence that the separation was made without vascular damage. e. If you see bleeding during squeezing, you can check the bleeding spot by the following method. Press on the entire path through which the cannula has passed. If bleeding begins immediately after the hand is removed from the puncture area, the bleeding area is between the puncture area and the compressing area. On the other hand, if there is no additional bleeding when the bleeding area is wiped off under pressure, the point of bleeding is in one of the areas of compression. You can find areas of bleeding by gradually reducing the area you are compressing. f. After injecting the filler, create the desired contour through the molding process.

the syringe bursts repeatedly when you connect a specific product to a specific cannula, you should choose a cannula with a larger internal diameter. H. When using large diameter cannulas, the possibility of vascular injury is thought to be smaller. I. The end of the cannula is blunt, but the exit hole where the filler product actually comes out is often sharp depending on the precision of the manufacturing process (Fig. 4.22). In the process of moving the cannula forward and backward, sharp edges at the opening 4.3.2 Characteristics of Needles may cause blood vessel or nerve damage. J. DPS injection method (filler injection after A. Since the tip is sharp, it is easy to advance deep puncture and separation) while injuring/tearing tissue. One technique that the authors use is a tech- B. The likelihood of blood vessel or nerve nique called DPS injection. This is done damage is relatively high compared to through the following steps. cannula. C. The end of the needle is made in a diagonal a. Decide which layer you want to inject the form. The area where the filler is actually filler into. injected is not the end of the oblique line, but b. Insert the cannula tip into the desired layer the portion nearer to the syringe at the oblique by using the PINCH technique, press line (Fig. 4.23). technique and the feeling of bone touch. D. The procedure should be performed after Then advance the cannula in the same confirming the safe filler injection depth for layer. each treatment site. c. Move the cannula back and forth within E. Can be injected into the dermal layer, but in the same layer similar to the fan techthe case of cannulas, dermal layer injection is nique. The filler is not injected at this very difficult. time. F. You can check for intravascular injection d. If it is determined that the fibrous conthrough aspiration before injecting the filler nective tissue in the space to be injected is (Fig. 4.24). In most cases, the aspiration test loosened, inject a small amount of filler is significant when using the needle included while reversing the cannula. The cannula with the syringe. A positive aspiration test (+) may be removed before the filler is does not necessarily mean that the needle tip

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4 Basic Technique for Filler Procedure

Fig. 4.22 Sharp opening hole of cannula (with kind permission of Wook Oh M.D. Ph.D. Samsung Feel Clinic)

the outer wall of the needle toward the tract from where the needle has advanced (Fig. 4.25). The features are summarized as follows (Table 4.2).

4.4 Fig. 4.23 The point where the filler actually comes out

is inside the vessel. False positive findings may occur if blood is spread in tissues after partial injury to vessels during the procedure. G. If the physician unnecessarily increases the injection force, the filler may flow back along

Injection Technique

There are many different methods to inject fillers. Regardless of the type of cannula and needle, there are various techniques depending on the injection amount, the injection angle, and the number of insertion points. This can be selected depending on the depth of the treatment area and the properties of the filler. There is a significant difference between injecting large volumes into

4.4 Injection Technique

83

Fig. 4.24 Filler aspiration test with needle (with kind permission of DAEHAN medbook) Fig. 4.25 Back flow of filler

Table 4.2 Cannula verses needle summary Cannula

Needle

Tissue damage

Less than needle

More than cannula

Injection technique

Fan technique and retrograde injection

Vertical injection

Entry point

Make separately

No need to make separately

Injection depth

Layers except the dermis

All layer including dermis

Aspiration test

Useless

Useful

Safety

There is no absolutely safe procedure

the deep layer and correcting dynamic wrinkles with a small amount of filler, so we need to be familiar with various techniques.

• Mantoux technique, Micropuncture, and droplet methods are used to correct scars, skin creases, and dynamic wrinkles.

• In general, fillers with high viscoelasticity are often used in the methods of bolus Sandwich technique and towering technique. They are both used for augmenting facial volume.

Selection and basic injection techniques of cannula and needle according to facial areas are introduced in Sect. 4.5.

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4 Basic Technique for Filler Procedure

4.4.1 Types of Injection Techniques 4.4.1.1 Retrograde Injection and Anterograde Injection (Fig. 4.26) Anterograde injection is injecting the filler as the injection tool (cannula or needle) enters, i.e., when moving forward. Injecting as the injection tool comes out (i.e., as it withdraws) after entering, it is called retrograde technique. Retrograde injection releases pressure by pulling the injection tool back after injection. If the injection tool damages the blood vessels, bleeding is easy to identify, and even when it enters the blood vessels, the pressure decreases during injection. This minimizes the risk of vascular complications. Therefore, most doctors use the retrograde injection method. 4.4.1.2 Fanning (Fig. 4.27a) The fanning technique is used to uniformly inject fillers over a wide area while minimizing the number of insertion points. Basically, the fanning technique is very useful when using a cannula as well as a needle. It is also a skill that underlies

the DPS technique, which is an important injection method mentioned below.

4.4.1.3 Cross Hatching (Fig. 4.27b) After the cannula or needle is injected in parallel at regular intervals through several insertion points, it is inserted again in the vertical direction and injected several times in a parallel fashion. That is, the injection direction is to cross the previous injection routes. Although it has the advantage of uniformly injecting in one area, there are disadvantages in that many insertion points are generated which can cause bruises. 4.4.1.4 Bolus (Fig. 4.28) Instead of puncturing multiple sites, a large amount of filler is injected into one layer and molded to create the desired shape. After injecting the filler, one needs to be careful to mold it into the desired shape. Even if the shape is made, there is a possibility that lumps may form again due to viscoelasticity, which is a unique property of fillers. Therefore, it should be noted that molding the filler by hand does not always produce the desired shape.

(a) Retrograde injection

(b) Anterograde injection Fig. 4.26 Injection technique depending on direction (with kind permission of S. THEPHARM)

4.4 Injection Technique

85

(a) Fanning

(b) Cross hatching Fig. 4.27 Injection technique for wide area (with kind permission of S. THEPHARM)

(a)

(b)

Superficial fat Muscle layer Deep fat Bone Fig. 4.28 a Bolus Injection technique. b Schematic illustration. After perpendicular injection of a large volume of filler, it is necessary to spread out the filler using pressure (with kind permission of DAEHAN medbook)

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4.4.1.5 Linear/Serial Threading (Fig. 4.29a, b) The linear threading technique injects the filler at a uniform pressure as it withdraws after inserting the cannula or needle. The serial threading technique is not to inject linearly, but to inject uniformly in small dotted lines. Both can reduce the risk of vascular complications by injecting filler using the retrograde technique rather than the anterograde technique. 4.4.1.6 Serial Puncture (Fig. 4.29c) The serial puncture technique involves inserting a needle and then injecting a small amount of filler, moving it at regular intervals and injecting it in the same way. This is mainly used when injecting into the deeper layers. 4.4.1.7 Micropuncture/Droplet (Fig. 4.29d) The micropuncture/droplet method is used to inject into the dermis or subdermal layer. They are used to inject a very small amount of filler into a skin crease or wrinkle. 4.4.1.8 Mantoux Test Injection Technique Mantoux technique is a method of injecting into the dermis or subdermal plane so that the skin color changes white like skin test on the dermis. This is the method used to correct scars, skin creases, and dynamic wrinkles using soft fillers. 4.4.1.9 Sandwich Technique The sandwich technique inserts a needle or cannula horizontally into a deep layer, then injects a small amount of filler into the layer. Next, the angle is changed and enters into the intermediate or superficial layer and injects a small amount of filler. Compared to the tower technique where the needle is injected vertically to build up the layers, this is a method that uses horizontal injection to build up the layers. 4.4.1.10 Tower Technique (Fig. 4.30) The procedure of the tower technique is as follows. First place the needle tip at the

4 Basic Technique for Filler Procedure

supraperiosteal level. Next, the needle is pulled back slightly to produce negative pressure, and then filler is injected. In the same way, fillers are injected intermittently in different layers. When the negative pressure is formed, a space is formed between the layers so that the filler is stacked in several layers like a tower.

4.4.1.11 DPS Technique: Deep Puncture and Separation (Fig. 4.31) The DPS method is slightly different from the method of injecting filler by the retrograde injection method. Although the method is similar to the fanning technique, the purpose of the procedure is different. In the case of the fanning technique, fillers are injected in various directions with the minimum number of insertion points. However, in the DPS method, similar to the fanning technique, the fan is moved forward and backward in the shape of a fan, but the filler is not injected in various directions. The DPS method first separates the tissue layer to form a space for filler injection. In other words, the procedure is performed with the purpose of creating one larger space by connecting all the smaller spaces made by the fanning technique. Using the DPS method, make a space in the deep layer, remove the cannula, and squeeze the area to check for bleeding. Bleeding is visible if there is vascular damage. If blood is not seen when squeezed, inject the filler. If a small amount of blood is seen, inject the filler after hemostasis. If blood leaks through the insertion point even though it is not squeezed, the area where the cannula has passed must be compressed to stop the bleeding. After enough compression, inject filler or change the position of insertion point and inject filler.

4.4.2 Injection Techniques for Each Area Recommended techniques for each part of the face are as follows (Table 4.3).

4.4 Injection Technique

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(a) Linear threading

(b) Serial threading

(c) Serial puncture

(d) Micropuncture/Droplet Fig. 4.29 Injection technique depending on single injection volume (with kind permission of S. THEPHARM)

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4 Basic Technique for Filler Procedure

Fig. 4.30 Tower technique. It is a variation of the perpendicular pulling method and involves injecting the filler into different layers in a noncontinuous manner (with kind permission of DAEHAN medbook)

Fig. 4.31 Schematic illustration of DPS technique. a Traditional bolus injection method. b DPS (Deep Puncture and Separation) technique (with kind permission of DAEHAN medbook)

4.5

Basic Techniques by Region

Selection of cannula and needle by site A. Forehead i. Cannula a. Cannula is recommended when you want to distribute filler evenly without

bruising. It takes more time and more difficult to learn the techniques. If the main blood vessels are avoided, the procedure can be done without bruising, but if there is damage to large blood vessels, the bruise may spread more widely. b. Select an entry point of 2–3 sites and dissect the supraperiosteal plane area widely (Fig. 4.32).

4.5 Basic Techniques by Region

Fig. 4.32 Forehead dissection for filler injection with cannula

c. Care should be taken in the upper part of the eyebrows because the supraorbital artery and supratrochlear artery run deeper. Press the upper orbital rim over the eye with your hand to prevent the filler from flowing into the eye. Make sure the cannula hole faces away from the eye when injecting (Fig. 4.33) (Fig. 4.34). ii. Needle a. If you want to apply forehead filler more easily and quickly, use a needle. Keep in mind the probability of bruising is relatively high. b. Mark the points to inject 1 cm apart on the forehead. Inject the needle vertically at the marked position and inject

Table 4.3 Recommended injection technique

89

the filler with the bone touch. Prior to injection, aspiration tests are used to determine whether one is intravascular or not. B. Temple i. Cannula a. Cannula is easy to inject filler into the subcutaneous fat layer. b. The superficial temporal vein is clearly visible and the physician can palpate the pulse of the superficial temporal artery. The two vessels are located at the bottom of the subcutaneous fat layer and are enclosed in the superficial temporal fascia. When the operator performs a soft pinch manipulation, the deep portion of the subcutaneous fat is stretched and pulled up. At this time, the blood vessels are enclosed in the superficial temporal fascia and cannot be pulled up. Careful progression of the cannula to the superficial fat layer, which is felt to be a raised portion, allows the procedure to be performed without vascular damage (Fig. 4.35). ii. Needle a. It is easier to use needles for deeper injection.

Location

Recommended injection technique

Forehead/Glabella

Retrograde linear threading/retrograde fanning Serial puncture/vertical bolus

Temple

Retrograde fanning/vertical bolus

Infraorbital hollowness

Retrograde linear threading/retrograde fanning

Cheek

Retrograde linear threading/retrograde fanning/vertical bolus

Nose

Retrograde linear threading/vertical bolus

Nasolabial fold

Retrograde linear threading/vertical bolus

Lip

Retrograde linear threading/vertical bolus

Marionette line

Retrograde linear threading/vertical bolus

Chin

Retrograde fanning Vertical bolus/layering

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4 Basic Technique for Filler Procedure

no bleeding and vertically inject filler into the same route (Fig. 4.36).

Press point

Fig. 4.33 Press the upper orbital rim over eye with cannula opening faces upper area

Press point

Fig. 4.34 Press the upper orbital rim over eye with cannula opening faces upper area

Fig. 4.35 Soft pinch at temple area

b. Mark the superficial temporal vein and artery and areas where blood vessels are thought to be absent. The anesthesia is then performed with vertical injection of lidocaine. Confirm there is

C. Nose i. Cannula a. After anesthesia is administered, puncture the nasal tip and proceed to the nasal dorsum with a cannula. Then use the retrograde injection technique while withdrawing the cannula backward (Fig. 4.37). b. It is also possible to inject the nasal column using the same entry point. ii. Needle a. For a more simple and convenient procedure, mark the position where injection is needed at 3–4 mm intervals and then perform vertical injections using a needle. An aspiration test must be performed before each injection. b. It is safer to inject deeper than the muscles (Fig. 4.38) so it is useful to use the pinch manipulation. D. Nasolabial fold (NLF) i. Cannula a. Cannula alone is useful when there is a nasolabial fold depression but no skin crease. There is a method of creating an entry point on the nasolabial fold extension outside the oral commissure and injecting into the NLF (Fig. 4.39). This method inserts the cannula in the same direction the angular artery travels so therefore, there is a risk of vascular accident if the cannula enters the angular artery. Some practitioners have used cannulas perpendicular to the nasolabial fold (Fig. 4.40). b. When injecting into nasolabial fold, it is safe to inject into the Ristow’s Space under the deep medial cheek fat pad (Fig. 4.41).

4.5 Basic Techniques by Region

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Fig. 4.36 Temple area vertical injection with needle (with kind permission of MANIAMIND)

Fig. 4.37 Cannula injection (with kind permission of DAEHAN medbook)

Fig. 4.39 Entry point on the nasolabial fold extension line with cannula

Fig. 4.38 Needle injection with pinch technique

c. In dual plane injection, it is possible to separate and inject just below the dermis. However, intradermal layer injection is impossible. ii. Needle a. In cases of nasolabial fold depression accompanied by a skin crease, it is recommended to use the needle injection method

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4 Basic Technique for Filler Procedure

Fig. 4.42 Fern type dermal injection

feel the angular artery pulse, you need to be very cautious when treating the area.

Fig. 4.40 Entry point perpendicular to nasolabial fold

Ristow’s space

Fig. 4.41 Ristow’s space

simultaneously. This is because correction of the dermal skin crease is only possible with a needle. Some dermal injections can be made linear along the skin crease and some perpendicular to the crease using the fern type dermal injection method in an intersecting direction (Fig. 4.42). b. An understanding of a safe injection layer without blood vessels is needed. c. Place a finger on the expected path of the angular artery to identify the pulse. If one can

E. Indian wrinkles under the eyes. i. Cannula a. It is useful when there are wide and deep depressions in Indian wrinkles under the eyes. b. Proceed with the cannula to the supraperiosteal plane through the entry point and proceed with the cannula in close contact with the bone (Fig. 4.43). c. Take care not to damage the infraorbital nerves and vessels as they pass through the infraorbital foramen (Figs. 4.44 and 4.45). d. Since the zygomatico-cutaneous ligament is hard tissue, the physician may occasionally feel strong resistance when using the cannula. The path should be changed from side to side to find looser tissue and then advance the cannula. e. If the cannula proceeds close to the nose, the patient may complain of pain due to the angular artery being irritated (Fig. 4.46). ii. Needle 1. It is useful when the recessed area of the Indian wrinkle is not wide. 2. When you want to emphasize the zygoma area, the skill to inject filler after bone touch through vertical injection is useful. 3. In the front of the face, the deep fat area is relatively safe. After checking the vascular

4.5 Basic Techniques by Region

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Fig. 4.43 Safe injection depth of infraorbital Indian fold area with cannula (with kind permission of DAEHAN medbook)

Fig. 4.44 Infraorbital foramen area and filler injection

Fig. 4.45 Infraorbital foramen area and filler injection (with kind permission of MANIAMIND)

path and depth, mark the area of danger. Then after inserting the needle into the deep layer, be sure to check whether the blood flows back through aspiration before injecting the filler.

Fig. 4.46 Pain from angular artery irritation (with kind permission of MANIAMIND)

F. Chin filler i. Cannula a. It is useful when the chin is low in volume and needs to be injected over a large area. b. Create an entry point on the side of the chin line, insert the cannula deeply, and advance after bone touch (Fig. 4.47). c. The deep layer is a safe area free of dangerous blood vessels, and less bruising during the chin filler procedure. However, due to vascular variations in some cases, large vessels may pass through the center of the chin. Although it is a relatively safe area, gentle manipulations must be used to minimize vascular damage. ii. Needle a. It is used when there is a recess in the center or side of the chin and not so wide.

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4 Basic Technique for Filler Procedure

Fig. 4.47 Entry point of chin filler with cannula

b. It is relatively safe to do deep layer injection. c. Do an aspiration test before injecting.

4.6

Filler Molding and Filler Degradation Test

4.6.1 Filler Molding A. Fillers are semisolid materials with fluidity. Due to this characteristic, injection is possible through thin tubes such as needles or cannula. After injection into the tissue, it is restored to its original form and functions as an implant. The physical properties of the filler are determined by the aforementioned rheology values. In particular, these figures relate to elasticity and viscosity, expressed in terms of G’, G”, and G*. B. There are two main uses of fillers. The first is depression correction of the dermis and the second is increasing volume of the face. Clinically, there are many more cases and types of fillers to increase the volume of the face. C. When filler is used to increase the volume of a facial area, it is mainly injected in the deep layers. The filler must not only resist the pressure exerted on the face, but also the pressures exerted by the facial muscles. From a clinical point of view, fillers with low elasticity have low resistance to external forces. The shape of the first injection is not well maintained and changes easily. Low elastic and

soft fillers are easily made into the desired shape after filler injection. However, the shape created is not well maintained and changes or migrates easily. On the other hand, elastic and hard fillers are difficult to inject and require more force to produce the desired shape. However, once you mold the shape, deformation is not easy and thus the shape is well maintained. D. Highly elastic fillers are generally preferred for the purpose of increasing volume by injecting into deeper layers. When injecting a filler into the nose, a filler that can maintain a good shape and resistance to external forces is suitable. However, the greater the elasticity of the filler, the greater the possibility of vascular compression by the product. This in turn increases the risk of developing ischemic side effects. Depending on the skill or preference of the physician, the filler with the appropriate rheology should be selected. On the other hand, if the filler is to be injected into a shallow layer and then evenly spread out, a less elastic filler is preferred. A representative indication would be for infraorbital dark circles. This is because it should be injected just below the skin and then spread evenly. However, well spreading fillers are easily changed by external forces. Due to the high probability of ruggedness after the procedure, patients who have undergone the procedure should be thoroughly trained in postoperative care. E. Each filler company produces a variety of fillers by adjusting the cross-linking ratio or by adjusting the concentration of hyaluronic acid. (Figure 4.48, Picture of the difference in the shape of the aggregates by type of the same brand of filler). Therefore, relatively high elastic fillers are recommended for volumizing through deep layer injection and low elastic fillers for wrinkle correction through shallow layer injection. F. The following points should be considered before the filler procedure.

4.6 Filler Molding and Filler Degradation Test

Fig. 4.48 Entry point of chin filler with cannula (with kind permission of MANIAMIND)

i. Is the area to be treated an area that requires a molding process? ii. Is it exposed to pressure from external forces or facial expressions after the procedure? iii. How will the change in volume of the filler itself after the procedure affect the outcome of the procedure?

95

Even when the tissue pressure of the area to be injected is high, it is difficult to maintain the appearance immediately after the procedure due to the compressing phenomenon after the procedure. For example, if you are performing a procedure to correct the depression of the nose, it is a good idea to evaluate the tissue pressure in the area before the procedure. It is possible to estimate the pressure through a pinch maneuver. If the operator feels that the pressure at the site to be treated is high, the filler shape is not likely to remain after the procedure and the area is likely to sink again. One should decide whether to use a harder filler or just accept a mild correction. Some monophasic fillers contain mannitol. Mannitol acts as an antioxidant, draws water as a polymer and acts as a diuretic. The physician must understand and select the characteristics of each product. This will produce better results and will eliminate the need for unnecessary additional procedures. Even if the same procedure is performed using the same technique, the result may vary depending on the characteristics of the product. When treating with antioxidant fillers containing mannitol, the scope of the procedure should be well designed and planned.

For example, in the case of nasal dorsum, asymmetry is likely to occur when injecting without considering symmetry sufficiently during the procedure. If asymmetry occurs, the molding process should be used to correct it after the procedure. From the initial start of injection, it is good practice to perform molding concurrently G. Molding process while watching for asymmetry. i. Molding of pre-tarsal roll The nasal dorsum area tends to be deformed The pre-tarsal roll area is a difficult area to due to facial expressions of the eyebrows and mold. When molding, it is good practice nose itself, and wearing glasses/sunglasses after to aim for the hard tissue to hold the the procedure. The patient’s facial expression product inside. However, during the preshould be carefully observed during the design tarsal roll area procedure, there is a risk of and consultation before the procedure, along with pressure (and product) passing to the eye predicting the possible change in the shape of the when molding. Therefore, it is necessary filler after the procedure. During the examination to mold using special equipment of the patient, if the patient has high utilization of (Figs. 4.49 and 4.50). glabella or nasal muscles, pretreatment with ii Molding of the lateral cheek area botulinum toxin is necessary. When injecting filler into the lateral cheek It must also be noted that fillers changes in area, the operator should inject at the volume after being injected into the body. In the correct depth. The fibrous connective tiscase of biphasic fillers, the free HA component is sue in the sub-SMAS layer must be disabsorbed between 2–3 days, leaving less than the sected using the cannula. This will prevent volume actually injected. After the procedure, the the lateral cheeks from becoming bumpy result is satisfactory, but a patient may complain after filler injection. The pinch maneuver that the filler disappeared after 1–2 weeks.

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4 Basic Technique for Filler Procedure

Fig. 4.49 Special equipment used for molding pre-tarsal roll

Fig. 4.50 How to use a guider. (with kind permission of DAEHAN medbook)

is used to determine the depth of the SMAS and the location of the parotid gland, assisting the dissection of the subSMAS layer. The physician should not completely dissect the entire site to be injected. Instead, it should be partially

dissected to just weaken the connective tissue. The dissection area should be the entire area designed to inject filler. After dissection, filler is injected and molding is performed. Specially designed equipment may be used (Figs. 4.51 and 4.52).

4.6 Filler Molding and Filler Degradation Test

97

Fig. 4.51 Equipment for lateral cheek area molding

Fig. 4.52 Lateral cheek molding

4.6.2 Filler Degradation Test A. Hyaluronic acid filler and hyaluronidase i. The physician can solve side effects or unsatisfactory procedures of hyaluronic acid filler injection by dissolving the filler. In particular, hyaluronidase can be used for side effects caused by intravascular filler injection. The use of hyaluronidase in the event of adverse events will be discussed in detail later. ii. There are two types of hyaluronic acid filler. The first is a biphasic type and the second is a monophasic type. Whether these two types of fillers differ in their dissolution is worth investigating. The situation in which the filler must be dissolved is often an

emergency. Therefore, understanding the characteristics of the dissolution process according to hyaluronic acid filler type is meaningful in that it helps physicians effectively treat side effects. The authors tested how biphasic and monophasic fillers respond to hyaluronidase. In addition, we tested how polycaprolactone fillers respond to hyaluronidase. B. Organization of the Experiment i. The hyaluronidase used in the experiment consisted of 1,500 units in 1 vial. Generally, hyaluronidase used in the United States or Europe is 150–200 units per vial. The hyaluronidase used in this experiment is higher in dosage than the product used in the United States or Europe. ii. It was mixed with 2 cc of saline solution and prepared at a concentration of 75 units/0.1 cc. iii. After placing 1 cc of filler in a Petri dish, we mixed invarious concentrations of hyaluronidase or saline solution. C. Biphasic filler dissolution experiment. i. Different concentrations of hyaluronidase and saline were mixed with 1 cc of biphasic filler. a. Biphasic filler 1 cc + hyaluronidase 0.1 cc (75 units) (Fig. 4.53) 0.1 cc 75 units of hyaluronidase hardly dissolve 1 cc of biphasic filler.

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4 Basic Technique for Filler Procedure

Fig. 4.53 Before mix versus after 5 min of mix

Fig. 4.54 Before mixing versus after 5 min of mix

dissolved, but not in actuality. This shows b. Biphasic filler 1 cc + hyaluronidase that the dose of hyaluronidase is important 0.5 cc (375 units) (Fig. 4.54) in dissolving the filler (especially in the case Hyaluronidase 0.5 cc (375 units) is insufof biphasic filler), but the amount of saline ficient to dissolve 1 cc of biphasic filler. mixed together is also important. This c. Biphasic filler 1 cc + Hyaluronidase 1 cc experiment shows two functions of saline. (750 units) (Fig. 4.55) The first is the dilution effect of the filler For dissolving 1 cc of biphasic filler, a component, and the second is the effect of dose of hyaluronidase 750 unit (1 cc) can lowering the viscoelasticity of the filler. be considered sufficient. Of course, the experimental results in vitro and in vivo D. Monophasic filler dissolution test are known to be different. This is because i. Various concentrations of hyaluronidase and the degree of degradation by hyalursaline were mixed with 1 cc of monophasic onidase will vary in vivo and in vitro. filler. d. Biphasic filler 1 cc + Saline 1 cc (Fig. 4.56) a. Monophasic filler 1 cc + hyaluronidase When biphasic filler is mixed with saline, it 0.1 cc (75 units) (Fig. 4.57) is mixed homogeneously and reaches a new The amount of hyaluronidase is insuffiequilibrium. At first glance it appears to be cient to dissolve the filler. It is different

4.6 Filler Molding and Filler Degradation Test

Fig. 4.55 Before mixing versus after 5 min of mix

Fig. 4.56 Before mix versus after 5 min of mix

Fig. 4.57 Before mix versus after 5 min

99

100

Fig. 4.58 Before mix versus after 5 min

Fig. 4.59 Before mix versus after 5 min vs after mix 1 h

Fig. 4.5.60 Before mix versus after 24 h of mix

4 Basic Technique for Filler Procedure

4.6 Filler Molding and Filler Degradation Test

from when dissolving the biphasic filler. It is observed that hyaluronidase does not mix uniformly with the filler and is present in a separate state. b. Monophasic filler 1 cc + hyaluronidase 0.5 cc (375 units) (Fig. 4.58) It can be seen that 0.5 cc 375 units of hyaluronidase cannot completely dissolve 1 cc of monophasic filler. Since the action time of the hyaluronidase in the body lasts more than 5 min, the actual dissolution in vivo will proceed further. However, assuming an emergency, the 375 units of hyaluronidase were insufficient to dissolve 1 cc filler immediately. c. Monophasic filler 1 cc + hyaluronidase 1 cc (750 units) (Fig. 4.59) The results are quite different from the dissolution of the biphasic filler shown above. Biphasic fillers become homogeneously mixed with the hyaluronidase solution, whereas monophasic fillers separate from the hyaluronidase solution. At five minutes, there were no significant effects, and after 1 h of observation, dissolution proceeded further. In emergencies it is necessary to use a sufficient amount of hyaluronidase. F. Dissolution of polycaprolactone filler i. It is known as an insoluble filler and often used for collagen stimulation in a mixed state with saline solution. ii. Polycaprolactone filler 1 cc + Hyaluronidase 1 cc (750 units) (Fig. 4.60) After 24 h, the polycaprolactone filler hardly responds to hyaluronidase.

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Dissolution test conclusions 1. Use hyaluronidase in sufficient amount. 2. Mix with saline in sufficient amount. 3. For monophasic fillers, consider massaging more aggressively. 4. Polycaprolactone fillers are insoluble by hyaluronidase.

Bibliography 1. Kho I-S, Lee W. Filler complication Springer Nature; 2019. 2. Oh S, Kim B. Safe filler injection technique using live imaging tools. DAEHAN Medboolk. 3. Niamtu J. III DMD* Filler injection with microcannula instead of needles. Dermatologic surgery: December 2009, vol. 35, Issue 12, p. 2005– 2008. 4. DeJoseph LM. MD cannulas for facial filler placement facial plastic surgery clinics May 2012, vol. 20, Issue 2, p. 215–220. 5. Jani A, van Loghem J et al. cannul; a versus sharp needle for placement of soft tissue fillers: an observational cadaver study. Aesthet Surg J. 2018; 38 (1):73–88. 6. Hexel D et al. Double‐Blind, randomized, controlled clinical trial to compare safety and efficacy of a metallic cannula with that of a standard needle for soft tissue augmentation of the nasolabial folds dermatologic surgery vol. 38, Issue 2, p. 207–214. 7. Casabona G. Blood aspiration test for cosmetic fillers to prevent accidental intravascular injection in the face dermatologic surgery July 2015, vol. 41, Issue 7, p. 841–847. 8. Pavicic T et al. Precision in dermal filling: a comparison between needle and cannula when using soft tissue fillers. J Drugs Dermatol. 2017;16(9):866–827. 9. Phillipp-Dormston et al. Intracranial penetration during temporal soft tissue filler injection—is it possible? Dermatologic surgery Jan 2018, vol. 44, Issue 1, p. 84–91.

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Filler Procedures Based on the Facial Area

5.1

Upper Face

5.1.1 Forehead and Glabella Pre-procedural Considerations Asians view an evenly rounded forehead without angular protrusions as beautiful, although the preferred forehead shapes may differ across different cultures. Unfortunately, bilateral frontal eminence exists in the frontal bone from birth. The supraorbital rim projects forward which can create a hollowness between the frontal eminence and supraorbital rim. Therefore, the key area of the forehead augmentation procedure is the cross shape between two frontal eminences and two supraorbital ridges (Fig. 5.1). Frontalis Muscle The frontalis muscle lies above the frontal bone. This muscle is attached to the eyebrow and is an antagonist to the procerus, corrugator supercilii, depressor supercilii, and orbicularis oculi muscles. The galea aponeurotica that includes the frontalis muscle is posteriorly connected to the occipitalis muscle and forms the superior temporal septum (STS) at the border with superficial temporal fascia. In the past, Spiegel et al. reported that the frontalis muscle bifurcates at about 3.5 cm above

© Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_5

the superior orbital rim. Based on this, the uppermid portion of the forehead was thought to lack muscle and botulinum neurotoxin was useless in this area. However, such findings were based on gross examination. Costin et al. found cases where the bifurcation of the frontalis muscle occurred higher and those where the frontalis muscle continued without bifurcation. Histological examination of the upper-mid forehead confirmed existence of muscle and disproved the previous reports based on gross examination. This indicated that botulinum neurotoxin may be necessary in the upper-mid portion as well. The depth of the frontalis muscle is around 3–5 mm below the skin surface and the horizontal width varied among individuals. Corrugator Supercilii Muscle Among muscles that pull the eyebrows down, the corrugator supercilii muscle lies the deepest under the skin. The muscle is sometimes divided into the transverse head and oblique head, however, such categorization has little clinical significance. This muscle originates from the bone 2.9 mm lateral to the midline and 9.8 mm superior to the nasion. It rises superficially as it courses to the right and upward to insert into skin. Although the courses of the muscle and insertion vary between individuals, have the patient furrow the eyebrows to create glabella lines and find skin dimpling to closely observe the area of

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Fig. 5.1 Forehead and Frontalis muscle (STS: Superior Temporal Septum)

Fig. 5.2 Corrugator supercilii muscle and Procerus muscle

muscle insertion, area lying lateral to this dimpling is the actual site of skin insertion and the muscle stretches more laterally than we expect. This muscle is the thickest between the medial canthal line and midpupil line measuring about 2–3 mm (Fig. 5.2). Procerus Muscle The corrugator supercilii muscle creates vertical lines in the glabella, whereas the procerus muscle forms horizontal lines. The procerus muscle originates from the nasal SMAS near the nasal

bone and reaches the skin of the eyebrow. This muscle stretches up to the supraorbital rim and down to the medial canthal line or nasion level. The frontalis muscle, corrugator supercilii muscle, and procerus muscle discussed above have particular clinical importance as they are the main targets of botulinum neurotoxin injection of the forehead. The frontalis muscle is the single muscle in charge of lifting the eyebrow and excessive injection of botulinum neurotoxin can cause eyebrow ptosis. Currently, the preferred

5.1 Upper Face

injection method is lower dose injection of botulinum neurotoxin followed by additional injection if necessary. Injection into the corrugator supercilii muscle and procerus muscle, two relatively smaller muscles, require correct knowledge of the level and location of the muscle. Supratrochlear Artery and supraorbital artery The most serious complication of injectable dermal fillers is visual loss, which is most common with injections in the glabella. Data on the frequency of visual loss at this site are consistent in domestic and foreign literature. The supratrochlear artery is often involved and we need to be clearly aware of the course of the supratrochlear artery to avoid it during injection. However, controversy still exists over exactly where the supratrochlear artery perforates the frontalis muscle for its superficial emergence or which structures it lies above. Pessa named the crease in the lateral glabella as “corrugator crease” and argued that this crease coincides with the course of the supratrochlear artery. He also argued that the artery passes below the frontalis muscle and corrugator supercilii muscle. On the other hand, Ugur et al. reported that the supratrochlear artery courses around the medial canthal line, which lies lateral to the glabellar frown line (corrugator crease) in his doppler imaging and cadaver study (Fig. 5.3). Reece et al. argued that the supratrochlear artery passes along the periosteum to exit the medial orbit and divides into a superficial and deep

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branch. The deep branch rises along the periosteum but the superficial branch perforates the frontalis muscle 1.5 mm above the supraorbital rim and runs in the subcutaneous layer. The course of the supraorbital artery is slightly lateral to the supratrochlear artery. They usually have anastomosis but it is hard to distinguish each other. The supraorbital artery passes underneath the orbital foramen and separates into superficial and deep branches (Fig. 5.3). Based on these various reports, I have concluded that the course of the supratrochlear artery mostly coincides with the corrugator crease, the deep branch does exist, and that the superficial branch is a thicker main branch. I believe the superficial branch perforates the frontalis muscle slightly above the supraorbital rim. However, there are variations to the location of these structures among patients and glabella injections should be carried out with great caution. Forehead Fat Compartments The fat compartment of the forehead only has superficial fat above the frontalis muscle and lacks deep fat. The forehead is divided into the central compartment in the middle and two lateral forehead compartments on both sides. The middle forehead compartment connects with the lateral temporal cheek fat compartment at the temple area. Injecting a filler immediately above the periosteum would not affect the septum between these compartments, but if the filler is injected into the subcutaneous layer, the needle or cannula may face resistance by the septum.

Fig. 5.3 Supratrochlear artery (left) and Supraorbital artery (right)

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Fig. 5.4 Forehead Fat compartments (CTS: Central temporal septum, STS: Superior Temporal Septum)

This may cause difficulty in molding the injected filler as it may not be able to be moved to other compartments (Fig. 5.4). Technique One must consider both frontal bossing and supraorbital elevation. Mark the sunken area and injection point at the eyebrow apex via which one can reach the center of the forehead using a 5 cm cannula (Fig. 5.5). Perform a nerve block of the supratrochlear nerve (medial canthal line) and supraorbital nerve (medial pupillary line) using lidocaine. Make an entry for cannula insertion using a 23G needle and inject filler at the supraperiosteal level using a 23G cannula (bolus technique). Block the dangerous arteries by applying pressure on the superomedial orbital rim. Usually, three entry points are used and filler is injected between the base of the galea and periosteum. Less viscous fillers have the advantage of not creating bumps after injection, but are

not preferred because they can easily migrate by the action of surrounding facial expression muscles. If possible, all the fillers should be connected and creating a bolus mass may have a more ideal result (Fig. 5.6). Massage with your fingers and wet gauze. Care should be taken when injecting filler into a patient who has previously performed a forehead lift or a forehead shortening operation. It is difficult to evenly insert the filler because of adhesion between the galea and the periosteum layer.

5.1.2 Temple Pre-procedural Considerations The temporal hollowing that occurs with aging or excessive dieting is an indication for injectable filler or autologous fat graft. Temporal hypertrophy may be corrected by botulinum neurotoxin injection. The interest in the aesthetics of

5.1 Upper Face

Fig. 5.5 Entry points of the forehead augmentation

Fig. 5.6 Forehead augmentation using filler

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the temple area is increasing with the rising frequency of anchored-type thread lifting. Serious complications such as necrosis or vision loss are less common in this area, however, the risk of bleeding or neural damage still exists. As the thread is commonly fixed onto the temple area during anchored-type thread lift, accurate anatomical knowledge is necessary. Terminology The temple is one of the most anatomically complicated areas of the face. In this area, blood vessels, nerves, muscles, and fat exist in many layers and scholars have not agreed on the nomenclature of different structures, frequently leading to confusion. The temporal region refers to the concave area inferior to the superior temporal line where the temporalis muscle originates from. Mendelson divides the face into five layers and as shown in (Table 5.1), various terms are used to refer to the same structure. Superficial temporal fascia (STF) is called galea aponeurotica superomedial to the temple and its name changes to temporoparietal fascia or mesotemporalis after passing the superior temporal septum (STS, also known as the zone of adhesion or zone of fixation). The fourth layer, loose areolar tissue, is also called subgaleal fascia at the temple and is divided into

Filler Procedures Based on the Facial Area

upper temporal compartment (UTC) cephalically, and lower temporal compartment (LTC) caudally, based on the inferior temporal septum (ITS, also known as the orbicularis temporal ligament). The fifth layer, the periosteum, passes through STS and is divided into deep temporal fascia (DTF) inferiorly and periosteum that actually attaches to the bone. The DTF is also known as the temporalis fascia or temporal aponeurosis, etc. In this section, I will use numbers and acronyms 1– Skin, 2-SubQ, 3-STF, 4-UTC and LTC, or 5-DTF to avoid confusion (Table 5.1, Fig. 5.7). Anatomy of the Temple As shown in the right image in (Fig. 5.7), the lateral temporal cheek fat is the 2-subcutaneous tissue under the 1-skin of the temple and stretches to the midface. The fat in this area can be very scant and not readily distinguishable from other structures in some cases. The 3-STF lies under the lateral temporal cheek and connects to the SMAS caudally. The STF is the first layer of mild resistance against the subcutaneously injected needle or cannula tip. The STF forms a roof over the 4-UTC and 4-LTC. The 5 DTF descends from the periosteum to form the floor of the UTC and LTC. The DTF splits into the superficial layer and deep layer which surround

Table 5.1 Nomenclature of the temple region Layer

Terms at temple area

①

Skin

Skin

Same Terms

Subdivision

②

Subcutaneous tissue

Lateral temporal cheek fat

③

Musculoapneurotic layer

Superficial Temporal Fascia (STF)

Temporoparietal Fascia (TPF)

④

Loose Areolar Tissue (LAT)

Subgaleal fascia

Upper Temporal Compartment (UTC) = lnnominate fascia

⑤

Periosteum

Deep Temporal Fascia (DTF)

Temporalis fascia (TF)

Lower Temporal Compartment (LTC) = Parotid Temporal Fascia (PTF) = Fibrofatty extension Superficial layer Deep layer

5.1 Upper Face

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Fig. 5.7 Anatomy of temple (TT-temporal tunnel, SI-superior interval)

the superficial temporal fat pad in the middle. The superficial and deep layers of the DFT joins again near the zygomatic arch. In the past, the superficial layer of the DFT was thought to attach laterally to the zygomatic arch and the deep layer attached medially to the zygomatic arch. However, Ramirez reported that the superficial and deep layers join together 1 cm superior to the zygomatic arch. Moreover, Hwang et al. found that 56% of the fusion of the superficial and deep layers of the DTF attaches to the zygomatic arch’s superior margin and 44% of it attaches to the superolateral margin. They also described that the attachment between the zygomatic arch and fused DTF is within 2 mm.

many causal factors of temporal hollowing. Aging-related temporalis muscle thinning may be one or volume loss of the DTFP due to sagging and thinning of the buccal fat pad could be another. Temporal hollowing is also caused by STFP thinning. Matic et al. reported that the STFP covers 4
5 cm of area cephalic to the zygomatic arch. Temporal hollowing is reported to deteriorate with lower body mass index (BMI) related to weight loss. The STFP volume loss was also observed after surgical trauma such as incision in the area. During coronary incision, suprafascial dissection of the DTF rather than that of the superficial layer was shown to reduce temporal hollowing.

Superficial Temporal Fat Pad

Upper Temporal Compartment (UTC) and Lower Temporal Compartment (LTC)

The superficial temporal fat pad (STFP) is commonly also called the temporal fat pad (TFP). However, the deep temporal fat pad (DTFP), an extension of the buccal fat pad, lies inferior to the STFP. Therefore, the term TFP may cause confusion with this structure (Fig. 5.7). There are

The UTC and LTC are not as extensively discussed in textbooks of anatomy. These two compartments may be thought of as spaces between layers but are also argued to be a separate layer such as fascia. The UTC is colored purple on (Fig. 5.7) and is separated by the roof of the STF

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Fig. 5.8 Position of temporal branch of facial nerve

(the third layer) and the floor of the DTF (the fifth layer). The STS and ITS form superior and inferior borders, respectively, and are blocked anteriorly by the hard structure of temporal ligamentous adhesion. The UTC lacks major blood vessels or nerves and is often used as a safe area to fix the anchored-type thread (Figs. 5.7 and 5.8). The LTC has different characteristics from the UTC. First, whereas the UTC has a hard anterior blockage, the LTC has two anterior openings. It forms a superior interval and temporal tunnel underneath. The temporal tunnel is connected to the prezygomatic space. The second difference is that unlike the UTC that lacks fat, the LTC has more fat tissues with caudal progression. Third, the ITS at the superior border of the LTC is a blocked sheet form, whereas the LTC has no inferior border and is sparsely bordered by the zygomatic ligament. Blood vessels and nerves pass through the openings and caution is needed during surgery to avoid damaging important structures in this area (Fig. 5.7). Moreover, the ITS is significant that it serves as a border blocking superior progression of the facial nerve temporal branch (Fig. 5.8).

Superficial Temporal Artery (STA) The superficial temporal artery proceeds anteriorly and bifurcates into the anterior frontal branch and posterior parietal branch. As shown in (Fig. 5.8), the STA sprouts from the horizontal line of the superior orbital rim in most cases. The bifurcation is above the superior orbital rim in 64% and below the superior orbital rim in 36%. The frontal branch of the STA has superomedial progression at a 60.8° angle toward the lateral margin of the frontalis muscle. The STA is still within the third layer at this point but rises superficially toward the skin surface at the superolateral quadrant of the intersection between the eyebrow upper margin and lateral canthus line (Fig. 5.8). That is, small STA branches may exist in the subcutaneous level, medial to this area. Facial Nerve To locate the temporal branch of the facial nerve, the 2D course and depth of the nerve along skin landmarks need to be understood. Two methods are largely used to predict the course of the facial nerve’s temporal branch from the skin surface.

5.1 Upper Face

First method is to use the frontal branch of STA described above and second is to use Pitanguy’s line. Many scholars have shown that the temporal branch of the facial nerve lies inferomedially to the STA’s frontal branch. However, a low bifurcation of the STA causes a unique variation where a few distal strands of the temporal branch rise above the STA. In the second method of using Pitanguy’s line, the facial nerve’s temporal branch passes along the imaginary line connecting the points 0.5 cm inferior to tragus and 1.5 cm superior to the eyebrow lateral margin (Fig. 5.8). Next, the depth also needs to be assessed. Among the five branches of the facial nerve, the temporal or frontal branch has a unique course. The other four branches pass the parotid gland to progress under the deep facial fascia and insert into the mimetic muscle. However, the temporal branch penetrates the deep fascia (the DTF at the temple) to rise toward the surface. Agarwal et al. explained that the temporal branch travels through the fourth layer of LTC and rises superficially to the floor of the STF at 1.5–3.0 cm above the zygomatic arch’s upper border and 0.9–1.4 cm posterior to the lateral orbital rim (marked with a star in Fig. 5.8).

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the DTF. Level C is at the LTC level and the needle comfortably reaches this level with cannula or needle injection in cadaver. Great caution is needed as the facial nerve temporal branch and superficial temporal artery pass this area. Lastly, level D is the subcutaneous layer that lacks major nerves or blood vessels and is a safe layer for injection. However, caution is still required as uneven spread of the injected filler may result in bumpy appearance. As this layer has little subcutaneous fat, the doctor may inject in layer C mistaking it for D (Fig. 5.7). Make the entry point for cannula insertion using a 23G needle. Insert a 23G cannula until the tip touches the deep temporal fascia. Inject the filler between the superficial temporal fascia (STF) and deep temporal fascia (DTF) (Fig. 5.9). Move the cannula tip gently to prevent sentinel vein injury. The sentinel vein is located at the anterior part of the temporal compartment. At the hairline, inject filler between the superficial thermal fascia and the deep thermal fascia using a 5 cm 23G cannula (Fig. 5.10). Inject the filler with a bolus technique and massage it well to connect the boluses.

Technique The target layers for filler injection include A–D in the right image of Fig. 5.7. At level A, the filler is injected above the bone inferior to the temporalis muscle and may not show change despite a large amount of injection. However, as the tip of the needle touches the bone, this level is less susceptible to nerve or vascular damage. At level B, the filler is injected between the superficial and deep layers of the DTF. The DTF deep layer is hard and one can feel the resistance at the tip of the cannula or needle to identify the injection depth. However, a lot of experience is required to be able to feel the deep layer after puncturing the DTF superficial layer. The risk of bleeding exists as the 5 mm thick middle temporal vein passes 2 cm superior to the zygomatic arch between the superficial and deep layers of

5.2

Midface

5.2.1 Supraorbital Hollowness (Sunken Eyelid) and Flat Eyebrow Pre-procedural Considerations Supraorbital hollowness or sunken eyelid is a congenital or acquired tissue atrophy that occurs in the upper eyelid. This may cause the individual to appear older, fatigued, or sleepy. The causes of sunken eyelid include genetic factors, reduced eyelid fat due to aging, and excessive removal of orbital fat during blepharoplasty. Asians have an especially weak levator palpebrae superioris muscle, which, attached to the tarsal plate is responsible for eye opening.

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Fig. 5.9 Filler between the superficial temporal fascia (STF) and deep temporal fascia (DTF)

Furthermore, this muscle does not insert into dermal tissue in many Asians. Therefore, double eyelid does not form and the upper eyelid does not roll upward while opening the eye. This causes skin of the upper eyelid to look relatively thicker and droopier. Furthermore, compared to Caucasians, Asians have more subcutaneous fat in the upper eyelid area, including the eyebrows. Due to the sagging of the subcutaneous fat, the eyelid appears to be swollen. In contrast to the swollen orbital margin, with aging there is atrophy of the fat within the orbital septum causing a sunken furrow. The strength to lift the eyelid weakens and the skin begins to sag. These factors lead to the formation of the sunken eyelid. A person with sunken eyelids may look tired or sleepy. The shape of the eye is not defined, giving the appearance of eyelid ptosis. A thick supratarsal lid crease may form between the eyelid and

eyebrow. Moreover, even if the person has double eyelids, the lids may not fully roll upward, causing only partial formation of the double eyelid fold. In such cases, filling the hollow area just inferior to the orbital rim may improve the overall appearance. Making the lid creases fainter will make the double eyelid folds look more distinct, adding more definition to the eyes (Fig. 5.11). Technique for Supraorbital Hollowness Request the patient to sit in an upright position with eyes open. Using the retrograde linear threading tiny injection technique, slowly inject a soft HA filler that is easily moldable. Intramuscular injection into the orbicularis oculi muscle is associated with a high risk of bleeding. Targeting the atrophied orbital fat deep to the orbital layer may also result in bleeding that is more difficult to control than bleeding in the subcutaneous layer. Moreover, there are spaces deep to the

5.2 Midface

Fig. 5.10 Entry points of the temple augmentation

Fig. 5.11 Before and after treatment of supraorbital hollowness

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Fig. 5.12 Layers of the supraorbital area

septum where hematomas may form, and the septum, which acts as a lubricating layer when opening and closing the eye, may get injured. The ideal injection plane is the ROOF and the deep fat connected to the ROOF. The ROOF is located along the orbital rim, deep to the orbicularis oculi muscle. However, in case of sunken eye, the deep fat layer of the superior eyelid is extremely thin. The filler should thus be injected in the preseptal space superficial to the orbital space (Fig. 5.12). The procedure should be performed with extreme caution. The branches of the ophthalmic arteries such as the supratrochlear and supraorbital arteries that are supply the forehead and glabellar region are located in the medial aspect of the orbital rim. These terminal branches of the ophthalmic artery anastomose with the orbital arteries including the central retinal artery. Therefore, a cannula should be used to prevent intra-arterial injections and other situations that may cause vascular compromise (Fig. 5.13).

The entry point for cannula insertion is the intersection of the vertical line from the lateral canthus and the orbital rim. After the cannula penetrates the muscle layer, a loose space can be felt. To be more exact, if the cannula is withdrawn slightly after touching the bone of the orbital rim, the cannula tip will be positioned in the space just deep to the orbicularis oculi muscle (Fig. 5.14). As explained earlier, the layer deeper than the orbicularis oculi muscle is almost devoid of a fat, and thus, the injection should be made into the preseptal space superficial to the orbital septum. A soft HA filler should be used to ensure that the injection is made as evenly as possible (Fig. 5.15). While injection, it is important to confirm that lumps or protruding bulges do not form when the eyes are closed. The unevenness may occur from injecting the fillers too superficially. On the other hand, excessive correction may lead to eyes that appear swollen or inferior migration of the filler that had been placed in the eyelids. Therefore, it is always safer to correct conservatively,

5.2 Midface

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Fig. 5.13 Vessels of the orbital area

Injection entry point - Vertical line on lateral canthus around the lower margin of superior orbital rim Injection techniques - Vertical sitting position - Voluntarily opened eyes - Retrograde linear tiny injection - Very slow release

Fig. 5.14 Supraorbital hollowness: Injection technique (cannula)

injecting more while carefully monitoring treatment outcomes. If there are partially depressed areas or the boundary of the injected filler is visible after the procedure, then a small amount of filler can be injected into the subdermal layer to create a smooth surface. Because the skin of the eyelid is very thin and delicate, when injecting intradermally, it is important to exercise caution to prevent beading (Fig. 5.16). It is difficult to achieve favorable results in patients with ptosis or proptosis. In fact, as the

procedure may exacerbate the symptoms, correction of sunken eyelids in patients with ptosis or proptosis is contraindicated. In case of the presence of scar tissue from previous surgery or trauma, even placement and spreading of filler may be more difficult. Technique for Flat Eyebrows Reduced soft tissue volume in the eyebrow region with subsequent eyebrow ptosis due to aging is not as severe in Asians, and thus, not a major concern among Asians. In contrast,

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Orbital septum Orbital fat

Fig. 5.15 Preseptal space

Injection plane - Preseptal space under the orbicularis oculi muscle for filling of hollowness - Injection around the orbital rim over the orbital septum - Subdermal injection of very soft filler to even out the surface and to remove the unnecessary multiple eyelid lines

Fig. 5.16 Supraorbital hollowness: Injection plane

Westerners believe that the location and volume of the eyes and eyebrows affect the overall impression they give. Typically, the location of brow is considered to be ideal if the medial end of the eyebrow is located on the vertical line extending from the lateral margin of the nasal alae. The lateral end of the brow should be located on line extending from the lateral margin of the nasal ala to the lateral canthus. The

medial and lateral ends should be located on the same level, while the peak of the eyebrow is located in the lateral third of the brow at the vertical line from the lateral limbus (Fig. 5.17). With the increase in popularity of eyebrow tattoos, there has been a tendency to create straight eyebrows without the arch. However, the ideal eyebrow shape varies by facial type. Typically, shorter brows positioned high above the

5.2 Midface

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Fig. 5.17 Ideal position and shape of the eyebrow

eyes suit round faces, while curved eyebrows suit rectangular faces. Horizontal eyebrows are more ideal for rectangular faces (Fig. 5.18). With age, the ROOF, the deep fat layer deep to the orbicularis oculi muscle in the eyebrow area, atrophies. The shape of the eyebrow and lid complex changes with the volume loss in brow region, which gives the appearance of sagging eyebrows. By tenting the eyebrow region with

Tail-up

Arched

fillers, the original volume of the ROOF can be restored. Moreover, fillers act a supporting structure to the eyebrows, providing a lifting effect on the lateral end of the eyebrow (Fig. 5.19). Medial to the mid-pupillary line, firm skin tissue is connected to the underlying muscles, and thus, sagging or volume reduction in this area is not as severe. Therefore, volume should be augmented in the region lateral to the mid-pupillary line. After

Horizontal

Fig. 5.18 The common classification of eyebrows around the world

Fig. 5.19 ROOF on the eyebrow area

Head-up

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Injection plane - Submuscular injection into suborbicularis oculi fat (ROOF) for the brow augmentation - Subdermal injection of very soft filler to even out the surface and to remove the unnecessary multiple eyelid lines

Fig. 5.20 Flat eyebrow: Injection plane

puncturing the lateral end of the brow, insert the cannula into the ROOF deep to the orbicularis oculi muscle. Inject a moderate-strength HA filler to create volume. Subsequently, a soft filler could be injected into the dermal and subdermal layers to create a smooth surface (Fig. 5.20).

5.2.2 Pre-tarsal Roll (=Lower Eyelid Charming Roll, Pre-tarsal Fullness)

contraction of the muscle when smiling Figs. 5.21 and 5.22. B. Beauty of pre-tarsal fullness Beautiful pre-tarsal fullness is when the following conditions are met: – Must be symmetrical. – Not sagging downward. – It should not be divided into several parts, but rather a single continuous volume. – Extends from the beginning to the end of the lower eyelid, and the connection should be natural. – Should be as close to the margin of lower eyelid as possible.

A. Terminology Pre-tarsal fullness refers to the inferior aspect of the lower brow which protrudes in a banana shape. This is manifested when the tarsal portion of the orbicularis oculi muscle in front of the tarsal plate is thickened and is more pronounced by the

The following patients are expected to have good results after a pre-tarsal roll procedure.

Fig. 5.21 Pre-tarsal fullness in the absence of expression

Fig. 5.22 Shows the pre-tarsal fullness when smiling

5.2 Midface

Good results can be expected for patients who do not see the pre-tarsal roll when they are expressionless, but clearly visible when laughing. Patients whose natural pre-tarsal rolls are able to be simulated when the physician pushes the lower eyelid area upward by hand. – Patients with elastic skin under the eyes and not severe sagging.

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D. Injection skill (1) Anesthesia a. The pre-tarsal roll procedure is painful. b. Anesthetic ointment is applied to the lower eyelid and sealed with a plastic wrap for 10–20 min. c. Infra orbital nerve block may be done. (2) Injection volume

Pre-tarsal roll creation is one of the most difficult treatments. The reasons are as follows: – Bruising is common. – It is common to have a bumpy surface. – If it is made too thick, the face will not look natural. – It may not be continuous, but have a break in the middle. – Most of these problems can be solved by using a cannula. The pre-tarsal roll making procedure with a cannula is a technically difficult. So, in general, clinicians are more likely to use the needle. C. Lower Eyelid anatomy (Figs. 5.23, 5.24, 5.25, 5.26, 5.27, 5.28, 5.29). The inferior palpebral artery is the most important anatomical structure to consider during the pre-tarsal roll procedure. These vessels branch off the ipsilateral supratrochlear artery and extend deeper than the orbicularis oculi muscle. Inject directly into the orbicularis oculi muscle or in a more superficial layer. It is also safer to inject filler as close to the lower eyelid margin as possible. As mentioned, the inferior palpebral artery is a branched vessel from the supratrochlear artery, and the supratrochlear artery is a branched vessel from the internal carotid artery. Therefore, there is a risk of blindness if the filler is injected into the inferior palpebral artery during the pre-tarsal roll procedure.

a. Use up to 0.2–0.4 cc per side. b. After checking the difference of appearance between having no expression and when smiling. Calculate which part needs more product. (3) Injection a. Needle injection Needle injection has the advantage of being convenient. If the injection is divided into three sections, it can cover the whole area. Afterward, it is possible to inject small amounts to areas needed. Caution should be taken when performing the procedure with a needle. Even if the injection is divided into several sections, the injection depth must always be constant (Fig. 5.29). The injection position should be as close to the lower eyelid margin as possible. The depth of injection is preferably within the orbicularis oculi muscle or the superficial layer above it. This is due to the fact that the inferior palpebral artery travels deeper than the orbicularis oculi muscle and below the eyelid margin (Figs. 5.30 and 5.31). Be careful not to inject too superficially, as this can lead to the Tyndall effect, which makes the filler appear bluish. Tyndall effects may be present throughout the pre-tarsal roll, or only in some of the front or midsections. In this case, it is recommended to dissolve the filler and to perform the procedure again. It is very difficult to calibrate through molding in this area.

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Margin of Lower eyelid

Pre-tarsal roll

Lower eyelid crease

Nasojugal groove Fig. 5.23 Lower Eyelid surface anatomy Fig. 5.24 Lower eyelid anatomy

Fig. 5.25 Vascular anatomy around the eyelid

Inferior palpebral artery

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Skin is removed. Orbicularis oculi muscle visible, inferior palpebral artery not visible (Fig. 5.27). Skin, superficial fat, orbicularis oculi muscle removed. Inferior palpebral artery visible (Fig. 5.28). a. Cannula injection

Fig. 5.26 The picture of pre-tarsal roll area (skin)

Fig. 5.27 The picture of pre-tarsal roll area (skin and superficial fat removed) / (with kind permission of MANIAMIND)

Create an entry point on the lateral side of the planned lower eyelid charming roll area (Fig. 5.32). It is recommended to create an entry point close to the lower lashes. The closer the pre-tarsal roll is to the inferior eyelid margin, the more beautiful it will appear. If the roll is located lower, the patient’s satisfaction decreases. Keep the cannula as close to the eyelid margin as possible through the superficial fat or intramuscular muscles (Fig. 5.33). Then, retrograde injection is performed while maintaining the injection pressure uniformly. It is helpful to use all your tactile senses as you perform the retrograde injection (Fig. 5.34). If the physician can inject the filler in a uniform shape using retrograde injection technique with the eyes closed, he/she is an experienced physician. The first picture is when the filler is injected without moving the position of the cannula. The second picture shows a slow retrograde injection while maintaining a constant force, and the third picture shows a rapid retrograde injection. Sufficient practice is required until a uniform injection is possible.

5.2.3 Infraorbital Groove and Hollowness

Fig. 5.28 The picture of pre-tarsal roll area (muscle removed)

As a person ages and the skin sags, wrinkles or grooves appear in the lower part of the eye, which makes him or her look tired. If the indication is appropriate, correcting with a filler can produce satisfactory results without surgery. The depression of the skin around the inferior orbital bone is usually called an “infraorbital groove”. There are many different names for each anatomical site under the eye. In this book, various forms of depression of the skin under the eye are collectively called “infraorbital hollowness” and will be discussed in detail.

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Fig. 5.29 Needle injection with kind permission of DAEHAN medbook

Fig. 5.30 Depth of inferior palpebral artery (deeper than orbicularis oculi muscle) / (with kind permission of MANIAMIND)

5.2.3.1 Definition and Classification of Terms The space from the bottom of the eye to the anterior cheeks is an oval shape (or apple cheek) at a young age, which has no depression.

Fig. 5.31 Depth of inferior palpebral artery (deeper than orbicularis oculi muscle) / (with kind permission of MANIAMIND)

However, as aging progresses, depressions, or grooves appear (Fig. 5.35). The terms associated with infraorbital depression has recently been somewhat unified. The most commonly used terms can be explained as follows:

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Fig. 5.32 Entry point for pre-tarsal roll injection with cannula

Fig. 5.33 Pre-tarsal roll filler injection with cannula

First of all, a tear trough occurs. The palpebromalar groove or midcheek groove is then visible. As aging progresses, all three of these lines appear. A tear trough deformity refers to the groove on the medial side of infraorbital area, starting from the medial canthus and down to the mid-

pupillary line, with a gentle curve of about 3 cm. As aging progresses, palpebromalar grooves appear on the lateral side of infraorbital area. Later it is connected to the tear trough, which looks like a semicircular curve. The midcheek groove is a curve that starts at the midpoint of the tear trough and the

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Fig. 5.34 Retrograde injection training

Fig. 5.35 Changes of infraorbital area in old age with kind permission of DAEHAN medbook

palpebromal groove and extends inferolaterally. It can be seen as a long curve connected to a tear trough, but most seem to have two lines connected like the shape of a seagull wing. Sometimes it looks like a crease starting in the middle of the anterior cheek. It is also called an Indian band. The three grooves above divide the anterior cheek into three segments (Fig. 5.36).

▶ 3 grooves • Tear trough/tear trough deformity • Palpebromalar groove (orbitomalar groove) • Midcheek groove (Midcheek furrow) ▶ 3 segments • Lid–cheek segment

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Fig. 5.36 3 grooves and 3 segments in old age. A Lid–cheek segment, B Malar segment (malar mound/malar festoon), C Nasolabial segment (with kind permission of DAEHAN medbook)

• Malar segment (malar mound/malar festoon) • Nasolabial segment

5.2.3.2 Tear Trough and Nasojugal Groove The definition of a tear trough is different from author to author, making it difficult to define it correctly. According to the article of Nicholas T. et al., the medial canthus to mid-pupillary line was called the tear trough and the mid-pupillary line to lateral canthus was called the palpebromalar groove. It is also known as a tear trough deformity when the groove becomes more depressed. A tear trough is formed between the palpebral portion and the orbital portion of the orbicularis oculi muscle and is located 2–3 mm below the orbital rim. In the past, the ligament was thought to be present only in the lateral part (palpebromalar groove), but not in the medial part (tear trough). The structure of a tear trough was

considered not to be fully ligament. However, recent anatomical studies have revealed that a ligament exists in tear troughs. The ligament is therefore called the tear trough ligament (Fig. 5.37). There are many causes of tear troughs: (1) The presence of the tear trough ligament and its sagging (2) Thin skin thickness under the eyes (3) Difference in the amount of subcutaneous fat in the upper and lower parts based on the tear trough ligament. (There are more fat in the lower part and the skin is thicker) (4) Bulging of infraorbital fat (5) Absorption of maxilla bone The severity of the tear trough varies from individual to individual. The nasojugal groove is almost similar in location to the tear trough, which can be

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Fig. 5.37 Sagittal section of medial infraorbital area

confusing, but it differs anatomically from the tear trough. The tear trough is formed between the palpebral and orbital portions of the orbicularis oculi muscle (OOm), whereas the nasojugal groove is formed between the orbital portion of the OOm and the origin of the levator labii superioris alaeque nasi muscle (LLSAN). In other words, the tear trough is located above the medial band of the orbital portion of the OOm, and the nasojugal groove is located below it. The nasojugal groove is also less pronounced than the tear trough.

5.2.3.3 Palpebromalar Groove and Orbital Retaining Ligament (ORL) The palpebromalar groove runs superolaterally from the mid-pupillary line where the tear trough ends and it runs parallel to the infraorbital rim. Usually, nasojugal grooves are formed first, followed by palpebromalar grooves. There is a structure called the orbital retaining ligament (ORL) that surrounds the perimeter of the infraorbital rim like a septum. There are some

differences in thickness and length in each area, not surrounding the 360° angle of the eye in exactly the same shape (Fig. 5.38). In particular, the ORL of the infraorbital area is significantly different in the medial and lateral parts. Therefore, the medial part is called tear tough ligament, and the orbital retaining ligament(ORL) is limited to the lateral part. Medial Part (Tear Trough Ligament) • The tear trough ligament is present between the palpebral portion and orbital portion of the orbicularis oculi muscle (OOm). It is a tight ligament that is short and firmly attached to bone. In the past, it was called a ligamentous attachment (not a true ligament), but recently it is being called a ligament. • The ligament begins at the insertion level of the medial canthal tendon up to the midpupillary line. • The ligament has individual differences in regards to sagging and asymmetry on both sides.

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Fig. 5.38 Sagittal section of lateral infraorbital area. Green dotted line: Tear trough ligament, yellow dotted line: Palpebromalar groove, red dotted line: Midcheek groove(Indian band). SOOF: Suborbicularis Oculi Fat.

Layers from superficial to deep: ① skin, ② superficial fat (malar fat), ③ orbicularis oculi muscle, ④ SOOF (Suborbicularis Oculi Fat)

Lateral Part (ORL, Orbitomalar Ligament)

5.2.3.4 Midcheek Furrow (Groove) and ZygomaticoCutaneous Ligament The midcheek groove runs inferolaterally, starting where the tear trough meets the palpebromalar groove. The groove appears to be connected to the tear trough, but the zygomatico-cutaneous ligament (Z-C ligament) begins at the point where the connection appears unnatural. The Z-C ligament is attached to the maxilla bone extending to the zygomatic bone. This results in a midcheek groove which is a long, band-like fibrous area that is in the anterior cheek along the Z-C ligament (Fig. 5.38). The area bulging with malar fat between the midcheek groove and palpebromalar groove is

• The orbitomalar ligament is a loose ligament that is relatively long and not firmly attached to the bone. This creates space between the orbital bone and the orbicularis oculi muscle. Thus, injecting filler into this area is easier than injecting into the medial part. • It is easier to undermine the skin here than the media part which makes more space for filler injection. • It is also easier to release the ligament here for filler injection. • Lateral hooding often occurs due to a loose orbitomalar ligament.

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called the “malar mound”. Both tear trough and midcheek groove match the superior border of the malar fat pad. Based on the Z-C ligament, superficial and deep malar fat is divided into superior and deep parts. As aging progresses, the deep medial cheek fat (DMCF) under the Z-C ligament is contracted and depressed and the superficial fat (nasolabial fat, medial cheek fat) sags. In contrast, the superficial and deep malar fat pads above the Z-C ligament are supported by the ligament, resulting in a top/bottom boundary based on the Z-C ligament.

5.2.3.5 Orbital Fat and SOOF (Suborbicularis Oculi Fat) and Malar Fat Orbital Fat Orbital fat exists in both infraorbital and supraorbital areas. Both infraorbital and supraorbital fat are surrounded by orbital septa and extend outward (fat-orbicularis oculi muscleskin). Herniation of infraorbital fat is one of the causes of tear trough and palpebromalar grooves (Fig. 5.37). Suborbicularis Oculi Fat (SOOF) The deep fat under the orbicularis oculi muscle (OOm) under the eye is called suborbicularis oculi fat (SOOF), and the deep fat under the OOm above the eye is called retor-orbicularis oculi fat (ROOF). As age progresses, the volume of SOOF and deep medial cheek fat decrease (Fig. 5.38). This causes a decrease in the volume of anterior cheek and infraorbital hollowness. SOOF is an easy space to inject fillers to correct Infraorbital hollowness. Although the angular vein passes through this SOOF space before driving along the medial border of the orbicularis oculi muscle, it can be injected safely in deep prezygomatic spaces. The SOOF is divided into medial part and lateral part. The innermost part of the tear trough has tight muscles and no SOOF. So it is fundamentally impossible to inject filler correctly into the fat layer below the innermost OOm. Inject a small amount in the medial side and create volume by

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injecting enough filler in the lateral side. If the groove is not sufficiently corrected on the inner side, undermine below the skin and inject the filler with low viscosity to complete the correction. Malar Fat The fat deeper than the orbicularis oculi muscle (OOm) under the eye is divided into superior and inferior fat on the basis of tear trough ligament and orbitomalar ligament. The fat in the superior (cranial) part is infraorbital fat, and the fat in the inferior (caudal) part is the suborbicularis oculi fat (SOOF). The superficial fat on the OOm, which is inferior (caudal) based on the tear trough ligament, is the malar fat. That is, both the tear trough and palpebromalar grooves coincide with the superior border of the malar fat pad (Fig. 5.38). The fat more medial than the malar fat are superficial medial cheek fat and nasolabial fat. Malar fat is divided into superior and inferior parts on the basis of zygomatico-cutaneous ligament to form midcheek grooves. The bulging of malar fat between the midcheek groove and the palpebromalar groove is called the malar mound.

5.2.4 Dark Circle (Tear Trough and Palpebromalar Groove) There are three main causes of dark circles: color change, contour change, and skin laxity. Treatment depends completely on the cause. There are various methods such as laser treatment, fat transplant, filler, transconjunctival fat removal, lifting surgery, HIFU, and radiofrequency. One of the cases that can be solved by filler injection is the change of contour under the eye. As aging progresses, dark circles develop as the infraorbital fat start to bulge, fat volume decreases, and bone reabsorption occurs. If we look closely at dark circles, we can see not only changes in color, but also changes in contour or skin laxity. In this chapter, we will discuss filler treatment for tear troughs and palpebromalar grooves caused by the anatomical structures mentioned in the previous chapter.

5.2 Midface

5.2.4.1 Design Tear trough or palpebromalar groove under the eye refers to the areas that are seen superficially. Since the cause is due to structural differences in the submuscular plane, correction of deeper layers should be considered together. There are some precautions to be taken in the design process and while checking results with the patient. When designing before the procedure, it is advisable to check the area in a mirror with the patient. It is important to check exactly where the patient wants to be corrected: tear trough, palpebromalar groove, or midcheek groove. This is because the patient usually wants to correct the infraorbital hollowness, and sometimes claims that the desired area has not been corrected after the procedure. After correction of tear trough, the final assessment should be checked with the patient gazing straight ahead. In general, the tear trough looks more severe when looking upward than gazing ahead, and less severe when looking down. Therefore, it is advisable to correct the tear trough based on the patient gazing straight ahead. When a patient looks in the mirror after the procedure, they tend to check by looking up at the eyes. When the patient looks upward, the tear trough appears to be more severe and the patient tends to think that it is not corrected. In other words, if the patient looks upward, the result appears undercorrected. If the patient looks downward, the result appears overcorrected. Therefore, it is desirable to check the treatment area by gazing at front in a mirror and to explain that it may look slightly different depending on the angle of view and lighting. 5.2.4.2 Anesthesia Infraorbital nerve block makes it easier to perform the procedure. Local anesthetic ointment, cold anesthesia, and lidocaine-contained fillers can be used without nerve blocks, but the patient may feel pain depending on the depth of injection. It is recommended to perform an infraorbital nerve block first when injecting into the deep layer. When injecting into the superficial layer, the procedure can be performed by only topical anesthesia.

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5.2.4.3 Choice of Filler It is advisable to avoid fillers with low viscoelasticity when injecting filler into the deep layer, i.e., prezygomatic space. If the skin is thin and the amount of fat (SOOF/Malar fat) is small, the entire thickness is thin so medium viscoelastic fillers are recommended. In this case, the use of a high viscoelastic filler may cause the shape to look unnatural and bulge out. On the contrary, if the skin is thick and the amount of fat is large, the volume increase may seem too modest after injection using a medium viscoelastic filler. In this case, it is advisable to use a high viscoelastic filler. When fillers are injected into superficial layers, fillers with the lowest viscoelasticity and minimal water retention capacity should be used. Use a filler that stretches well when molded and retains its shape after the procedure. Since fillers with high water retention capacity may cause edema after the procedure, special precaution should be taken not to overcorrect if the skin is thin. In order to prevent edema and produce sufficiently corrected results during superficial injection, it is desirable to complete the final procedure with secondary treatment after a certain period of time after the first procedure. 5.2.4.4 Injection Technique Tear Trough When correcting the tear trough, the injection depth can be selected from: (1) deep, (2) superficial, (3) deep + superficial. The author prefers (3) deep + superficial for primary correction and (2) superficial for secondary treatment. Depending on the pattern of tear trough sagging, you can choose from the three methods above. Deep injection is required if the anterior cheek is depressed or there is a lack of volume. Deep injection is required if the volume of anterior cheek is insufficient. Usually, when the tear trough ligament is firmly attached causing the skin to be deeply recessed, deep injection alone does not improve and superficial injection is required. Also, it is important to inject filler after performing ligament release.

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Occasionally there may be asymmetry on both sides of the tear trough, so it is necessary to check before the procedure. This is caused by the difference in the position where the ligament is attached below the orbital rim, or the difference in the length of the ligament. It is advisable to check them both and make corrections considering the difference in the filler injection amounts and the injection depth. If the medial border of the orbicularis oculi muscle (OOm) develops on one or both sides as a band, it becomes visible when laughing or frowning. Patients may not know it before the filler procedure, but they may find it a few days after the procedure and complain about asymmetry when they smile after the treatment. Therefore, it is necessary to check the development of the medial band of the OOm by making a frowning expression before the procedure and let the patient know. For correction of the medial band of the OOm, superficial injection of the filler alone is not sufficient and combination treatment with botulinum toxin is required. The entry point is made at the tear trough extension, about 1 to 2 cm from the end of the groove to be corrected (Fig. 5.39). Insert the cannula at an angle of 45–60° through the entry

(a)

Filler Procedures Based on the Facial Area

point. After bone touch, advance along the prezygomatic space of the suborbicularis oculi fat (SOOF) layer (Fig. 5.40). Enter just below the tear trough. Then inject fillers with medium to high viscoelasticity slowly with the retrograde linear technique. Use a cannula of approximately 23 gauge diameter. Since the space to inject is very small from the medial side, inject only a small amount and confirm that the volume rises while injecting from the middle point (Fig. 5.41). Since the inner side of the tear trough ligament is not sufficiently corrected by injection into the submuscular layer, change the cannula insertion to a more superficial layer than the orbicularis oculi m. and then inject filler slowly again with the retrograde linear technique (Fig. 5.42). The filler with the lowest viscoelasticity is injected with a 25/27G cannula. Before injecting filler into the superficial layer, it is important to first undermine the area below the skin to be injected and then inject. Undermining a little wider than the range to be injected is an important point. This ensures that the water retention of the filler does not cause the thin skin to bulge out, but rather spreads to the adjacent space thus creating a natural shape. If the inner side of the tear trough is sufficiently long or relatively loose, the skin should not be severely

(b)

tear trough angular artery

infraorbital foramen cannula inserƟon

Entry point Fig. 5.39 Location of entry point and injection space for tear trough correction. a Cannula at the entry point. b Cannula is located under the tear trough while injecting filler into deep layer

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Fig. 5.40 Deep injection and superficial injection for tear trough correction (transverse view). a Blue area—deep injection. b Pink area— superficial injection

(b)

(a) recessed and deep layer injection alone is enough to correct it. Nasojugal grooves can also be corrected according to the superficial injection method for the tear trough. Palpebromalar groove Palpebromalar groove is improved to a certain extent by volume effect after correcting the tear trough or midcheek groove first. This is because during the tear trough correction, the volume is filled to some extent by deep injection. However, if the volume decreases and additional deep injection is needed in this area, inject filler into the submuscular plane. Precaution should be taken in the treatment of this area in respect to vascular damage. Since visible superficial veins (especially the inferior palpebral vein) are more developed on the lateral than the medial aspect of the infraorbital area, it

is advisable to visually check the veins and avoid them before making the entry point.

5.2.4.5 Side Effect/Precaution • If the filler alone cannot resolve the dark circle, it is advisable to fully explain to the patient that other combination treatments may be necessary. Surgery may be necessary in cases of severe infraorbital fat bulging. Surgical treatment may be more effective than filler injection, especially if patients are 50–60 years of age or older. A combination with laser therapy is necessary for those with pigmentation under the eye. • Vessel to avoid during injection More than 30% of Koreans have an infraorbital branch of duplex type facial artery called “detoured branch of facial artery”. The angular vein

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Fig. 5.41 Deep injection for tear trough correction. a Insert cannula under the tear trough. b Check if the cannula is located in a deep layer not a superficial layer.

c Inject filler and feel the resistance over the treatment area with fingertips on the opposite hand

Fig. 5.42 Comparison of depth of cannula during deep injection and superficial injection for tear trough correction. a Deep injection–cannula is placed under the muscle

so that skin is not influenced by its movement. b Superficial injection–skin is lifted and motion of cannula is visible when cannula is lifted and moved

5.2 Midface Fig. 5.43 Running of detoured branch of facial artery and angular vein (deep fat layer) / (with kind permission of MANIAMIND)

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Angular vein

SOOF Detoured branch of facial artery

DMCF Facial artery

has a large diameter, especially when the vessel is dilatated in the supine position. Both of these vessels (infraorbital branch of duplex type facial artery and angular vein) pass through the SOOF and DMCF and then up through the medial border of the orbicularis oculi muscle (Fig. 5.43). Injecting with a needle is more likely to damage blood vessels. Therefore, it is highly recommended to use a cannula. Careful handling is required to avoid damage to the vessels even with the cannula. • Nodularity Injecting more superficially than the orbicularis oculi muscle may cause problems in the following situations: (1) injecting filler unevenly, (2) injecting too much volume, (3) injecting high viscoelastic fillers, (4) injecting fillers with high water retention capacity. • Over correction Injecting too much volume into deep and superficial layers not only looks unnatural, but also blurs the boundaries with the pre-tarsal fullness. Tear troughs are dense tissues on the medial side and are not released sufficiently, so dark circles may appear more prominent when injecting large amounts into deep layers. Therefore, it is advisable to use a sandwich technique in which a small amount is injected into the deep layer of the tear trough, followed by superficial injection.

5.2.5 Midcheek Groove 5.2.5.1 Causes and Anatomy Midcheek grooves can be caused by various factors. Firstly, volume change of the fat around the zygomatico-cutaneous ligament (Z-C ligament) is the main cause. As explained in Sect. 5.2.3., as aging progresses, the DMCF below the Z-C ligament decreases more in volume compared to the deep fat above the Z-C ligament, resulting in a top/bottom boundary based on the Z-C ligament. Secondly, absorption of the maxilla bone causes volume loss of the anterior cheek. Thirdly, the malar mound becomes prominent due to the sagging of the Z-C ligament. The treatment method varies depending on the causes. The anatomical cause is examined first and then perform the appropriate treatment. Among these treatments, there are two ways to treat with filler, and the choice of anesthesia/injection method/filler depends on the depth of injection. 5.2.5.2 Treatment Superficial Injection Before injecting the filler, the cannula is first used to undermine the fibrous tissue at the reticular cutis level of the zygomatico-cutaneous ligament (Z-C ligament). At this step, it is a key

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to undermine the tissue sufficiently. Move the cannula while holding the skin still with the other hand. Repeat this process approximately 10 times using the 23G cannula and inject the filler after the movement of the cannula has softened. The more damage is done to the tissue when undermining, the more likely it is to result in bruises and swelling, so gentle care should be taken to minimize injury. If there is bleeding during this step, apply sufficient pressure to stop the bleeding. Then, after confirming that blood does not flow out when pressed, inject a filler with medium viscoelasticity. In patients with sufficient volume in the anterior cheek with midcheek grooves, such as creases in the Z-C ligament area, superficial injection alone is sufficient for correction. Deep Injection If there is insufficient volume in the anterior cheek, superficial injection alone will not resolve the problem. In this case, deep injection alone

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Filler Procedures Based on the Facial Area

has excellent correction effect and the patient’s satisfaction level is high. There are two methods of deep injection—using either a cannula or needle. Firstly, Use medium to high viscoelastic fillers. Inject the filler using a needle in the supraperiosteal level, move up to the middle layer using the powering technique. The injection position of the needle is important and make sure to inject directly under the Z-C ligament. As aging progresses, there is volume loss of the SOOF and DMCF, which are located directly below the Z-C ligament. Filling the volume loss by injecting filler results in lifting of the sagging Z-C ligament and improving the MC groove (Fig. 5.44). The second method is using a cannula. For deep injections, it is recommended to first fill the volume under the tear trough with a cannula and then correct underneath the Z-C ligament. In the treatment of the midcheek groove, deep injection alone provides excellent correction, but if the patient wants detailed

Fig. 5.44 Deep injection and superficial injection for midcheek groove correction. a Blue area—deep injection. b Pink area—superficial injection

(a)

(b)

5.2 Midface

correction, additional injection to the superficial layer is recommended. Reduction of Malar Fat When the midcheek groove is caused by malar fat bulging, or patients who refuse fillers need treatment, a different approach should be taken. As explained in the first part of the chapter, the DMCF below the Z-C ligament decreases more in volume compared to the deep fat above the ZC ligament. Reduction of the fat above the Z-C ligament decreases the difference in fat volume above and below the Z-C ligament, improving the midcheek groove. A lipolytic agent and HIFU can be used to reduce the malar mound volume above the Z-C ligament. However, since the correction is not as detailed as the filler, it is necessary to apply it only to the patient who is not keen for fillers and the physician must explain in advance that it will not be an ideal correction.

5.2.6 Anteromedial, Buccal, and Lateral Cheek Hollow Pre-procedural Considerations When referring to sunken cheeks, there are ethnic differences based on differences in facial bone structure. Typically, Koreans define sunken cheeks as either lateral cheek hollow (hollowness in the area inferior to the zygomatic arch) or buccal cheek hollow (hollowness in the perioral region). In contrast, Caucasians refer to hollowness in the maxillary region across the anteromedial cheek (midcheek) and zygoma or volume loss needing malar augmentation as sunken cheeks. When creating “apple cheeks” by augmentation of the malar eminence, the preferred locations and shapes of the apple cheek differ among Caucasians and Asians. Caucasians prefer to have the apex of the cheek to be lateral to or above the cheekbone, whereas Asians, who have wider midfaces with more prominent cheekbones, prefer the apex to be located more medially.

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Prior to filler administration, the central point of the cheekbone should be located. In Asians, this point can be located by drawing a horizontal line from the lower portion of the alar groove to the root of the helix and a vertical line from the lateral canthus to the lateral commissure. The apex is should be located close to the intersection of the two lines or slightly medial to this point. Unlike in Westerners who request prominent augmentation of the cheeks, the anterior malar area should be injected just enough to observe a smooth mound that occurs when the smiling action elevates the cheek fat pad (Fig. 5.45). The tissue layers in the cheek area can be divided as follows: skin, superficial malar fat pad, orbicularis oculi muscle, deep malar fat pad including the suborbicularis oculi fat (SOOF), the facial expression muscle layer where the upper lip levators such as the zygomaticus muscles originate, preperiosteal fat, and periosteum. For apple cheek procedure that is performed to volumize central region of the cheeks, filler should be injected into the prezygomatic space, which is located superficial to the periosteal layer and contains preperiosteal fat. When augmenting the anterior malar region of the maxilla, more medial to the apple cheek, the ideal injection plane is the deep malar fat pad located under the SMAS and above the facial expression muscles such as the zygomaticus muscles. To ensure natural outcomes with implanted filler adjusting to facial movement associated with expression formation and smiling, bolus injections should be avoided and filler should be spread evenly throughout the fat layer. For the malar area or cheek treatments that require deep injections, hygiene before and after the procedure is especially important and patients must be instructed not to wear makeup for at least 6 h after the procedure. Technique by Facial Area To correct anteromedial cheek (midcheek) hollow for Koreans, the central point of the cheekbone should be located based on the shape of the apple cheek (refer to previous section for method). After treatment design, enter from the

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Western people

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Asian people

Fig. 5.45 Difference of apple cheek location between Western and Asian people

Fig. 5.46 Infraorbital artery and zygomaticofacial artery

inferolateral aspect of the treatment area and treat using either a needle or cannula. When a needle is used, caution should be taken not to injure the zygomaticofacial artery and nerve and

infraorbital artery and nerve that emerge from within the infraorbital bone (Fig. 5.46). Moreover, when treating the medial aspect of the anterior malar area, any potential injury to the

5.2 Midface

facial vein that runs along the nasojugal groove, which is important during the infraorbital groove treatment (Fig. 5.47), and to the infraorbital trunk of duplex type facial artery present in approximately 30% of Koreans, should be kept in mind (Fig. 5.48). When using a cannula, the entry point should be located using the same method for the midcheek groove. The entry point is at the

Fig. 5.47 Pathway of facial vein

Fig. 5.48 Infraorbital trunk of duplex type facial artery

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intersection between the lateral orbital rim line and the mid-alar groove line. By doing so, the risk of vascular injury can be minimized (Fig. 5.49). Procedure layer depends on bone structure. If there is significant bone resorption in the malar area necessitating volume restoration with a firm filler from the periosteal layer, the target plane is the prezygomatic space. However, as most

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Top of apple cheek mound - Line from lateral canthus to mouth commissure - Line from root of helix to nasal alar base Midcheek hollow injection entry point - Lateral and inferior to area requiring volume - Lateral part of midcheek on the vertical line of the lateral orbital rim and horizontal line of mid-alar groove Midcheek hollow injection technique - Retrograde fanning & crossing technique - Vertical bolus and layering technique

Fig. 5.49 Midcheek hollow and apple cheek: Injection techniques

Koreans do not have severely atrophied cheekbones, the deep malar fat pad that includes the SOOF should be targeted. This fat pad is located superficial to the upper lip levator muscles. Use the retrograde, fanning, cross-hatching, layering technique. Use the non-injecting hand to hold the cheek fat pad and add volume focusing on the apex of the mound. Add adequate volume radially from the center as needed (Fig. 5.50). If there are minor depressions even after filler placement or visible boundaries between the augmented and non-augmented areas, a soft filler could be injected superficially into the subdermal layer using the tenting technique to smoothen out the surface. The buccal area, which is commonly called the anterior cheek, is composed of the following planes; skin, subcutaneous fat layer, superficially coursing facial expression muscles and SMAS/buccal fat pad, deep muscle layer and oral mucosa. The ideal procedure layers are the subcutaneous fat layer or the prebuccal space located in between the SMAS and buccal fat pad. Direct injection into the buccal fat pad may result in using excessive amounts of filler. Since the tissue in this area is not very dense, a lump may be felt inside the mouth or the injected filler may migrate downward, caution should be taken (Fig. 5.51).

In cases of mild to moderate degree of cheek hollowness, filler is injected into the subcutaneous layer or the fat layer deep to the subcutaneous layer. Mark the area with buccal cheek hollow first and make the entry point inferior to the region to be volumized. To enhance volume, use the retrograde fanning/cross-hatching technique to inject filler from an inferior to superior direction. Either a needle or cannula can be used. After, a soft filler can be injected into the dermal and subdermal layers to smoothen out the surface (Figs. 5.52 and 5.53). If the buccal cheek hollowness is severe and requires more pronounced volume augmentation, then filler must be placed deep to the SMAS. The procedure will involve penetration of the SMAS layer and placement of filler to the deeper layer. Cannula should be used to avoid vascular or facial nerve injury. For the entry point, the needle puncture is performed approximately 4 cm anterior to the tragus and 2 cm below the inferior border of the zygomatic arch. After, the cannula is introduced via the entry point, it is used to penetrate the firm SMAS layer and inserted toward the deeper layer of the buccal fat pad. By doing so, the prebuccal space, the loose space superficial to the capsule that wraps the buccal fat pad, can be felt. After injecting an appropriate amount of filler into the prebuccal space, the volume in the

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Fig. 5.50 Before and after treatment of anteromedial cheek hollow

Injection plane - Midcheek hollow and Midcheek groove : Into the deep cheek fat pads superior to deep facial muscles - Apple cheek augmentation : Into the prezygomatic space - Buccal and lateral cheek hollow : subSMAS layer or superficial fat layer - Subdermal injection to smooth out the surface

Fig. 5.51 Cheek hollow: Injection plane

subcutaneous layer above is augmented to complete the procedure (Figs. 5.54 and 5.55). If the area inferior to the zygomatic arch, referred to as the posterior or lateral cheek, is the sunken, the cheekbone may appear to protrude even more. The facial contours may appear uneven and thus require correction. If the hollowness is not severe, the boundary of the region to be augmented is marked first. Then with a needle or cannula, filler is injected into the fat layer below the skin, filling from the inferior end and gradually working upward. If there are uneven areas, a soft filler is injected into the dermal and subdermal layers to complete the procedure (Fig. 5.52).

Severe hollowness usually involves development of the zygomatico-cutaneous ligament, a true retaining ligament that originates from the inferior border of the zygomatic arch and attaches to the skin; the masseteric cutaneous ligament, a false retaining ligament that extends from the parotid-masseteric fascia to the skin; and the platysma auricular fascia. The developed ligaments cause tight adhesions of the deeper tissues in the subzygomatic area to the skin surface. Consequently, even when filler is injected into the sunken area, it may be difficult to adequately augment the area. Forcing filler into the area may cause the filler to spread to the side and cause the surrounding area to appear swollen and uneven.

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Buccal and lateral cheek hollow injection entry point - Inferior to buccal and submalar area for superficial fat layer injection Buccal and lateral cheek hollow injection technique - Retrograde horizontal fanning

Fig. 5.52 Buccal and lateral cheek hollow: superficial injection technique

Fig. 5.53 Before and after treatment of buccal cheek hollow

In such cases, a cannula should be used for tunneling through the ligaments that are pulling on the skin. This will to weaken the pulling force of the ligaments and create a space for the filler to enter (similar to the midcheek groove treatment) (Fig. 5.56) and sunken area could be augmented smoothly (Fig. 5.57). The ideal entry point for the cannula is located at the intersection of the lateral orbital rim line

and the line drawn from the mouth commissure to the tragus. After using the cannula to release the ligamentous adhesions, retrograde fanning and layering techniques should be used inject an appropriate amount of filler into the preparotidmasseteric space to fill the sunken area. Just as with other areas, if there are uneven areas or areas where boundaries are visible, a soft filler is injected in the subdermal layers (Fig. 5.58).

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Buccal cheek hollow injection entry point - 4cm anterior to tragal line and 2cm below from lower margin of the zygomatic arch for subSMAS layer injection Buccal cheek hollow injection technique - Retrograde horizontal fanning

Fig. 5.54 Buccal cheek hollow: deep injection technique

Fig. 5.55 Before and after treatment of buccal cheek hollow

5.2.7 Nose

When Surgical Treatment Is Recommended

Nose augmentation with fillers is a simple procedure that can produce dramatic results. When learning how to do fillers, it is often the first area to try, and it is also the most popular filler site. Indications for nose augmentation using filler or surgical treatment are as follows:

• A hard-to-correct nose with filler: wide nose, severe hooked nose, wide nasal ala. • If the patients want a very high and slender nose. • If the patients have high expectations for outcome after filler procedure.

Indications for Nose Augmentation Using Filler

During the filler procedure, the nasal area is also a site of fatal complications such as skin necrosis due to excessive augmentation and blindness due to filler injection into the blood vessel. Therefore, it is essential the physicians understand the anatomical structure and proceed with care during the filler procedure.

• Patients who don’t want surgery. • If the patients want natural and slight changes. • If the patients want augmentation without down time.

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Fig. 5.56 Sub-SMAS space on lateral cheek region

Fig. 5.57 Before and after treatment of lateral cheek hollow

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Lateral cheek hollow injection entry point Cross of the line from the mouth commissure to tragus and the vertical line of lateral orbital rim for subSMAS layer injection Lateral cheek hollow injection technique Retrograde horizontal fanning

Fig. 5.58 Lateral cheek hollow: deep injection technique

5.2.7.1 Design and Anatomy The nose is located at the very center of the face, so it is important for the balance and harmony of the entire face. Different races have different preferences for beautiful noses, but ideal nose conditions are as follows (Fig. 5.59):

• Nose length is 1/3 of total face length (equivalent to forehead height) • The width of the nose is 1/5 of the width of the face • Nasofrontal angles range from 115 to 135° • Nasolabial angles range from 90 to 95° for men and 95 to 100° for women • Naso-facial angles range from 30 to 45° The names of the parts of the nose are as follows. (5 divisions of the nose) (Fig. 5.60).

135°

30~45°

90~100°

Fig. 5.59 Criteria for an ideal nose

• • • • •

radix dorsum nasal tip collumella nasolabial angle

As described above, there are various parts of the nose that can be corrected during the filler procedure. Before the procedure, it is essential to check the treatment area with the patient by pointing with your finger while looking in the mirror. It is not advisable for the physician to make arbitrary judgments or determine the location of correction at the request of the patient with “Please make my nose pretty”. For example, the patient who wants to correct the columella and nasolabial angles tends to say, “Please make

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nose tip pretty.” If the physician mistakenly performs augmentation of the nasal tip, the patient may complain that the desired area has not been treated. Radix Dorsum Nasal tip Columella Nasolabial angle Fig. 5.60 Five divisions of the nose

Arteries of the Nose The layers from the surface of the nose to the deep layer are as follows: skin, superficial fat, fibromuscular layer (connected with SMAS), deep fat, periosteum, and perichondrium. Arteries of the nose are present in the fibromuscular layer or between the fibromuscular layer and the deep fatty layer (Figs. 5.61 and 5.62). In the distribution of the arteries, the lateral nasal artery branching from the facial artery is responsible for blood circulation to the tip of the nose. Blood flow of the dorsum is supplied by the dorsal nasal artery branching from the ophthalmic artery. The columellar artery branching

Fig. 5.61 Cross section of the nose skin (with kind permission of DAEHAN medbook)

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Fig. 5.62 Structure of nasal bone and cartilage (with kind permission of DAEHAN medbook)

from the superior labial artery supplies the columella with blood flow (Fig. 5.63). Most branches of the nasal arteries originate from the side of the nose. This does not mean that the arteries are not distributed in the midline. The arteries can be distributed in the middle of the nose, or they can cross and connect to the opposite vessel. In other cases, the blood vessels exist only on one side and the blood vessels do not exist on the other side. In this situation, if the blood vessel on one side is blocked by the filler procedure, the blood flow of the other side is not supplied, so the possibility of necrosis is very high. When the filler is injected, one should never assume that you are treating an area where blood vessels are not distributed. It is advisable to use the opposite hand to pull up the soft tissue and blood vessels as much as possible before injecting into the deep layer. Intercanthal Vein The intercanthal vein is located in the subcutaneous layer above the procerus muscle, a vein that connects both angular veins like a bridge. It

mainly is located in the intercanthal space but also can be commonly found cranial or caudal to the intercanthal line. If filler is accidentally injected into this vessel during the procedure, the flow will travel in one of two ways: • Supratrochlear vein ! supraophthalmic vein ! cavernous sinus ! internal jugular vein • Angular vein ! facial vein ! external jugular vein Both of these can cause pulmonary embolism through venous drainage. To prevent this side effect, it is helpful to use a technique that pinches with the opposite finger, lifts the vessel and injects filler deeper during the procedure.

5.2.7.2 Choice of Filler Generally, physicians prefer a HA filler that can easily dissolve if side effects occur after filler procedure. Suitable fillers for augmentation of the nose are those with low water retention capacity while keeping the volume well maintained.

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Dorsal nasal artery Angular artery Lateral nasal artery Columellar artery

Superior labial artery Facial artery

Fig. 5.63 Arterial supply of the nose. Pink colored arteries are branched from internal carotid artery and red those are from external carotid artery. Dorsal nasal artery is branched from internal carotid artery (with kind permission of MANIAMIND)

Patients are reluctant to have their dorsum or radix become overcorrected or appear too wide from excessive water retention after treatment. In the past, biphasic fillers with larger particles and higher viscoelasticity than monophasic fillers were recommended. Recently, monophasic fillers with high viscoelasticity and low water retention capacity have been widely used.

5.2.7.3 Injection Technique Augmentation of Dorsum and Radix There are two methods of treatment—using a needle or cannula. Firstly, the cannula method starts by creating an entry point between the nose tip and the columella. Then insert it advancing while feeling it touching the cartilage or bone in the deep layer; proceed from the space between lower lateral cartilages- > upper lateral cartilages (perichondrium)- > nasal bone (periosteum)- > to radix. The upper boundary of filler injection is the level of the upper eyelid crease, and filler is slowly

injected from just below this level with a retrograde linear technique (Fig. 5.64). A 21-23G 5 cm cannula is suitable for injection. If the cannula is too long, it is likely to bend while entering the supraperiosteum level and penetrate into the subcutaneous layer, resulting in vascular accidents. To prevent this, pinch with the opposite hand, grab, and lift the thick tissue which covers the deep fat layer and then advance the cannula in the supraperiosteal layer. You can check the depth of the cannula tip by palpating it with the other hand to see if it is properly positioned in the deep layer, or visually check by lifting the cannula with the syringe held hand. If the cannula has entered the superficial layer, retract the cannula then advance it correctly into the deep layer. Since a hump exists when correcting a hooked nose, the cannula cannot enter into the radix from the tip of the nose in one maneuver. This is because the cannula enters the supraperiosteal layer initially but penetrates into the

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Fig. 5.64 Injection method (a) using a cannula for nose augmentation. a Cannula is inserted on the midline of the nose. b Depth of cannula is supraperichondrium and supraperiosteum. c Location of entry point and direction of cannula insertion. d MRI of the nose (sagittal view). Filler (high signaling) was placed on the supraperiosteum level (with kind permission of DAEHAN medbook)

(c)

(b)

(d)

Entry point

subcutaneous layer while passing the hump. There are three recommended injection methods to solve this problem. • Make a second entry point just below the hump for the cannula, insert the cannula and inject the filler retrograde from the radix to the hump. • Inject with the cannula from the nose tip to the hump, and inject with a needle from the hump to the radix. • Inject with only a needle. A needle is used to inject approximately 3 to 5 points on the midline of the nose from the radix to nose tip (Same as the following needle injection method).

Secondly, inject at the supraperiosteum level using a needle. In the same way as the cannula method described above, you can inject it with the retrograde technique after going straight from the nose tip to the radix. Or you can inject filler directly above the supraperiosteum or the perichondrium after inserting the needle vertically or obliquely and dividing the treatment area into 3– 5 points (Fig. 5.65). It is not recommended to use a needle with a small diameter, such as an insulin syringe, but a needle about 25G/27G is recommended. Since the filler is injected under high pressure inside the needle with a small inner diameter, a change

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Insert the cannula to the medial crus of the lower lateral cartilage and advance it to the anterior nasal spine. Then inject using the retrograde linear threading technique. The towing technique is applied to reinforce the support of the columella, but the support does not last long. It may be a good option to combine with a cog lifting thread to reinforce the support after the filler procedure. When a small amount of toxin is injected into the depressor septi nasi muscle, the nose tip is lifted by releasing the tension of the muscle. Synergistic effect can be obtained by combining toxin with filler for columella correction. Fig. 5.65 Injection method using a needle for nose augmentation. Serial puncture method is a good option for needle injection

in the physical properties of the filler may occur, and the inherent viscoelasticity may not be maintained. If a diameter of the needle is small, the viscous filler in the needle lumen may result in a false negative aspiration test just before filler injection (See Sect. 6.2.5 Prevention of vascular complication). Augmentation of Nose Tip Similar to the nasal dorsum procedure, fillers can be injected using a cannula or needle. Place the injection tool between the lower lateral cartilages and inject deeply over the cartilage. Unlike the dorsum, the tip has a thick dermis and there is no soft subcutaneous fat layer. The fibromuscular layer and dermis are tightly connected, so if a large amount of filler is injected, skin necrosis is likely to occur due to extravascular compression even if injected into a deep space. Therefore, it is recommended to inject a small amount of medium viscosity filler with a droplet technique. Augmentation of Columella The procedure can be performed with both a needle and a cannula, but a cannula is recommended because the needle is likely to damage the columellar artery in a narrow space.

Precautions for Nose Filler • Make sure the midline of the nose is preserved during filler injection. • The injection plane should be supraperiosteum/supraperichondrium to reduce the risk of vascular compression and intravascular injection. • Do not inject too much volume of filler for correction of the nasal tip • Adjust the amount appropriately for the second touch-up procedure as well as the first procedure. After a certain period of time, when the filler is dissolved and the patient visits for further treatment, the tissue becomes dense and mobility of blood vessels is lessened by collagen formation due to previous procedures. Thus, even the same amount of injection increases the chance of vascular compression after repetitive procedures. Therefore, it is advisable to perform the procedure with even more caution for correction of the nasal tip. – In case of a past history of nose surgery, check the rigidity of the dermis and subcutaneous fat layer by palpation and if deemed, do not recommend a filler procedure or inject only a minimal amount. Patients often hide their history of nose surgery, so careful clinical examination is needed.

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– When simultaneously treating the nasolabial fold and the nasal tip, the possibility of compression of the lateral nasal artery is increased, so the procedure should be divided into two sessions with small amount of injections. – Thorough communication with patient about the area to be corrected before the procedure can reduce postoperative dissatisfaction.

5.2.7.4 Side Effect Skin Necrosis The nose is a site where skin necrosis frequently occurs as a side effect after filler treatment. The nose has a smaller space in between the bone (cartilage) and skin than other areas. Also, the dermis is thicker, so there is even less space for safe filler injection. Therefore, filler injection into the nose increases the possibility of necrosis due to extravascular compression by the filler mass. In particular, necrosis is likely to occur in the nasal tip which has thick skin, so it is better to avoid over injecting fillers with too high lifting capacity. Injecting filler into the supraperiosteum level, which is the deepest layer during the procedure, helps to prevent skin necrosis. If the skin appears to be blanched after filler injection, it should be assessed whether it is caused by vasoconstrictors included in the anesthetics. When there is suspicion of skin discoloration due to blood vessel compression, it is advisable to dissolve the filler with hyaluronidase to perform decompression. (See Sect. 6. 2.1 Complication—skin necrosis). Blindness In the filler procedure for nose augmentation, blindness occurs when filler product inadvertently is injected into the artery and moves retrograde through the dorsal nasal artery to the ophthalmic artery and eventually blocking the retinal artery. To prevent this, it is important to avoid injection into the dorsal nasal artery during radix treatment. Lift the soft tissue using a pinching maneuver with the opposite hand, then place the injection tool in the supraperiosteum layer. In addition, when the filler is injected, the dorsal nasal artery can be

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compressed with the opposite hand to prevent the backflow of the filler into the ophthalmic artery. Hematoma The radix has intercanthal veins in the subcutaneous layer, which may cause side effects from intravascular injection. In order to prevent this, it is preferable to pinch using the thumb and index finger of the opposite hand to sufficiently lift the subcutaneous fat and blood vessels before injecting filler into the supraperiosteum layer.

5.2.8 Nasolabial Fold Considerations for Three Types of Nasolabial Folds The nasolabial fold refers to lines that appear as the Chinese character for number 8 (八). Nasolabial folds are generally seen bilaterally, starting from border of the ala nasi and bridge of the nose and extend inferiorly to the cheeks. Nasolabial folds can be divided into three types depending on the cause (Fig. 5.66). The first cause is lack of soft tissue volume in the paranasal area lateral to the ala nasi. There are patients who have depression over the maxillary canine fossa, which is the structure that supports the paranasal area. In such patients, relative to the nasolabial fat located superior to the nasolabial fold, there is barely any superficial fat in the region inferior to the nasolabial fold. Insufficient volume of the deep fat and soft tissues of the deeper layers deepens this depression lateral to the ala nasi. The soft tissue bulge superior to the fold and the sunken area resemble stairs. Although it is not an actual wrinkle, a crease-like boundary is formed (Fig. 5.67). The second type is caused by difference in skin characteristics. Relative to the skin superior to the fold, the skin of the upper lip region adheres tightly to the underlying orbicularis oculi muscle. With the aging process, the skin superior to the fold along with the buccal fat sags (Fig. 5.68). Over time, the nasolabial fat superior to the fold becomes more hypertrophic, while the paranasal area inferior the fold and lateral to the ala nasi atrophies. These age related changes

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Fig. 5.66 Three types of nasolabial fold

Fig. 5.67 Superficial fat layer around nasolabial fold

Fig. 5.68 Subcutaneous layer around nasolabial fold

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Fig. 5.69 Upper lip elevator muscles on nasolabial fold

Fig. 5.70 Relationship of facial muscles to other facial structures in the nasolabial fold area

further deepens the fold and the difference in depths between the fold and surrounding skin becomes more pronounced. The third type is not caused by differences in volume or sagging due to aging. Instead, the nasolabial fold is formed due to upper lip elevator muscles, levator labii superioris alaeque nasi, levator labii superioris, and zygomaticus minor and major muscles. These muscles insert to skin where the nasolabial fold forms, lateral to the nose before finally inserting to the upper lip and the orbicularis oris muscle (Fig. 5.69). Insertions of the upper lip elevator muscles form a boundary that prevents the superficial fat from descending further. Muscle movement during smiling pulls on musculocutaneous area, causing the area inferior to the fold to appear deeper and the line more noticeable.

Although classified into three types by cause, the cause of nasolabial folds is multifactorial and may be associated with 2–3 of the aforementioned factors. Unlike in other parts of the cheek, this area contains a musculocutaneous attachment area and facial muscles course superficially. In addition, as the structure of tissue layers is different (Fig. 5.70) and the facial artery runs parallel to the nasolabial fold, caution is required when injecting this region (Fig. 5.71). Technique for the Nasolabial Crease Cases presenting only a slight depression in the paranasal area will require correction of the mild crease only. The linear region slightly medial to the crease is targeted and a needle is used to inject the filler along the crease into the subcutaneous layer above the orbicularis oris muscle

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Fig. 5.71 Facial artery on nasolabial fold

Facial artery

Facial vein

using the retrograde linear threading and fanning techniques (Figs. 5.72 and 5.73). In over 50% of Koreans, the facial artery along the nasolabial fold and the region where it branches into the superior labial artery course superficially, exposed above the orbicularis oris muscle. Vessel injury can be avoided by inserting the needle in the superficial subdermal layer (Fig. 5.74). Uneven surfaces that form after the injection can be smoothened out by injecting a softer filler into the dermal and subdermal layers. Technique for Nasolabial Fold and Paranasal Depression In cases involving both a paranasal depression and a deep nasolabial fold, the filler is typically placed in two layers. In the superficial layer, a soft filler is injected along the crease into the superficial subcutaneous tissue and subdermal layer with the inferior portion of dermis. Lateral to the ala nasi, a deeper plane is targeted with a firmer filler. Fat layer deep to the muscle or Ristow’s space, a loose space superficial to the periosteum is targeted (Fig. 5.75). In the triangular paranasal depression located between the alar groove and the crease, a needle can be inserted perpendicularly to the skin in the center

of the triangle. This is a relatively safe zone with no major vascular structures. However, it is important to aspirate to ensure there has been no vessel injury before injecting (Fig. 5.76). The injection layer is adjusted according to the severity of the depression. With moderate depression, the ideal injection plane is the deep fat compartment deep to the muscles. Severe depressions require larger volumes of filler. However, injecting large amounts of filler into the subcutaneous fat layer encompassing the deep fat will not create projection but rather cause lateral expansion. In severe cases, it is better to inject into Ristow’s space (Fig. 5.77). To locate Ristow’s space, slightly withdraw the needle after contact with bone of the canine fossa. A loose space can be felt above the preperitoneal fat overlying the periosteum. With experience, the loose space could be felt immediately after penetrating the deep fat layer without actually having to touch the bone and withdrawing the needle. After the needle has been positioned in the deep fat compartment or Ristow’s space, add volume by using the towering and layering techniques. During the procedure, use the fingers of the non-injecting, non-dominant hand to apply pressure on the bulging tissue superior to the

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Injection techniques 1. Injection into slightly medial to nasolabial crease 2. Subdermal layer 3. Superficial injections for lines and to even out the surface (fern leaf or duck walk technique)

Fig. 5.72 Nasolabial crease injection technique

Fig. 5.73 Before and after treatment of nasolabial crease

crease. This will ensure that the filler does not ascend to the area superior to the crease. After the depression has been corrected, the skin surface may be uneven from the demarcations formed between the augmented and nonaugmented areas of the triangular region in the paranasal region, the alar groove, and crease. A soft filler should be injected into the subdermal and dermal layers to smoothen the area

(Fig. 5.78). The long oblique creases external to the triangular region extending inferolaterally can be treated using the aforementioned technique for nasolabial crease (Fig. 5.76). Technique Using a Cannula Anatomically, over 70% of Koreans have facial artery that courses medially to the nasolabial fold. It has been reported that even in cases

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Angular artery Infraorbital trunk of duplex type facial artery Facial artery on antegonial notch

Fig. 5.74 Position of facial artery around nasolabial fold

Injection into two layers for deep nasolabial folds Top layer : use soft consistent filler to inject into superficial subcutaneous or subdermal layer Bottom layer (Paranasal space) : use firm consistent filler to inject into paranasal deep fat compartment or Ristow’s space Fig. 5.75 Nasolabial folds injection plane

where the facial artery courses lateral to the fold, it runs within 5 mm from the fold in more than half of the cases. Therefore, safe entry point that minimizes the risk of vascular injury for cannula treatment can be located with the following method. Draw a line from the alar base to the mouth corner and divide the line into thirds. At the inferior third of this line, make the entry point 5 mm lateral to the crease. Move the cannula within the subcutaneous layer to reach the triangular region lateral to ala nasi. The injection layer and techniques are similar to that when using a needle to augment the paranasal area. The

layering and fanning techniques are used (Fig. 5.79). After augmenting the paranasal area, the cannula can be withdrawn along the crease and the retrograde linear threading and fanning techniques could be used to inject the filler into the superficial subcutaneous layer to smoothen the crease. Subsequently, if it is necessary to smoothen out the uneven surface of the injected area, a needle can be used to inject a very soft filler into the subdermal and dermal layers of the sunken region. Nasolabial creases that become prominent when smiling, can be treated botulinum toxin.

5.2 Midface

Injection techniques 1. Center of triangular spaces requiring volume 2. Bolus with layering and fanning injection into depressed paranasal space 3. Superficial injections for lines and to even the surface of the alar base and nasolabial fold mound Fig. 5.76 Paranasal depression injection technique Fig. 5.77 Ristow’s space for paranasal depression injection

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Fig. 5.78 Before and after treatment of deep nasolabial fold with paranasal depression

Injection entry point and techniques 1. Slightly lateral (5mm) to lower 1/3 point of nasolabial fold line from nasal alae to mouth corner 2. layering and fanning injection into depressed paranasal space for volume augmentation 3. Retrograde linear threading and fanning for superficial injections for lines and to even out the surface of the alar base and nasolabial fold mound

Fig. 5.79 Cannula injection for nasolabial fold

Weakening the upper lip elevator muscles where they insert to the skin will reduce the severity of the crease. Nasolabial fat superior to the nasolabial crease does not atrophy with age. In fact, it is a fat layer that hypertrophies over time. The difference in soft tissue volume between the region inferior to the fold and the bulging of the nasolabial fat superior to the

fold becomes marked over time, further deepening the crease. This difference in volume can be addressed by treating the fat layer with a lipolytic agent. Moreover, synergistic effects can be obtained when filler is combined with threads. Thread will elevate sagging tissue superior to the nasolabial crease and smoothen the skin surface, thus maximizing the effects of the injected filler (Fig. 5.80).

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Fig. 5.80 Before and after combination treatment of deep nasolabial fold

5.3

Lower Face

5.3.1 Lip and Philtrum Pre-procedural Considerations Lip morphology is a reflection of one’s age. Although cultural differences in defining “beautiful lips” exist, fuller lips, high tonicity, and prominent Cupid’s bow are perceived as a sign of beauty in general. On the other hand, thinner lips, less tonicity, and obscure Cupid’s bow usually are regarded as aged features in terms of lip morphology. With increasing age, the smile becomes elongated and less appealing. Along with recent advances in filler procedures, despite its possible complications, many patients consider rejuvenating their lips with this simple office-based procedure rather than surgical manipulations. Lip rejuvenation with minimally invasive techniques is gaining popularity. The upper lip is symmetric to the lower lip, but the latter is thicker than the former. Even though an ideal upper to lower lip ratio is different according to eastern or western countries and the sex, the ratio of 1:1.6 is generally

considered ideal similar to a golden rule. From the front view, it is better when an eversion of the upper lip and the red line are seen 2–3 mm above the upper teeth. On the lateral view, it is more aesthetically pleasing if the upper lip is placed 2 mm in front of the lower lip. Moreover, a breakpoint on the slightly curved line above the vermillion border like the supratip break of nose is considered beautiful (Fig. 5.81). In the sagittal view of the lip, the orbicularis oris muscle is located more posteriorly than the center of the lip anatomy. The oribicularis oris muscle attaches to the vermillion border by forming the oribicularis oris angle at the end of its running (Fig. 5.81). Lips become flat and the height of the vermillion decreases as aging. Histologic studies show that the overall thickness of skin decreases with the reduction of collagen and elastic fibers in the epidermis and dermis. Furthermore, the atrophy of the orbicularis oris muscle and the widening of the oribicularis oris angle cause lips to become flat and lose their volume. The fat compartments of the lip consist of the superficial and deep fat tissues which are divided by the oribicularis oris muscle (Fig. 5.82). The volume of superficial fat tissues increases with the aging

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Fig. 5.81 Lip anatomy

processes, but the suborbicularis oris fat which is the same as the deep fat tissues is reduced. It coincides with changes of other fat tissues in the face. These studies have shown us evidence to inject fillers into the suborbicularis oris fat layer that is placed between the mucosa of the vermillion and the orbicularis oris muscle. Though the volume reduction of the lip is viewed as a natural process with aging, it is not obvious. It is apparent that the volume of muscles and tissues decreases, but the superficial fat tissues of the lip increase so that the entire volume of the lip is conserved. As a result, the vermillion (dry mucosa) is not seen in aged lips. It is more plausible that lips become flat by the disappearance of the breakpoint not because of the reduction of total lip volume, but because of internal rolling of lips due to the changes of many elements, such as skin tissues, the orbicularis oris muscle, and fat tissues.

There are several tips to avoid iatrogenic large vessel injury with sharp needles. When confronting the vessel wall of the relatively large superior and inferior labial artery, one can feel slight tension which requires sufficient clinical experience. So, a most practical tip is to use the mouth corner area which is located relatively farther away from major vessels. The main blood supply of lips is derived from the superior labial artery (SLA) and the inferior labial artery (ILA). The SLAs come directly from the facial artery and the mean diameter of the SLA is 1 mm. Even though the bilateral SLAs run symmetrically and anastomose in the midportion of the upper lip with providing the columellar branch superiorly, the SLAs are sometimes unilateral and asymmetric. The SLAs usually traverse between the mucosa and the orbicularis oris muscle at the same level with the vermillion border (Fig. 5.81). The ILAs, on the

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Fig. 5.82 Fat compartments of lip and chin

other hand, routinely run between the mucosa of the inner aspect of the lip and the muscle, which means that the ILAs are more closely positioned to the alveolar margin than the SLAs. Therefore, filler injections at the superficial fat layer are more favorable than at the areas adjacent to the orbicularis oris muscle. If deep filler injections are needed, at the lower lip, injections at the suboribicularis oris fat are relatively safe because the ILAs run outside the lower lip at the alveolar margin. On the other hand, at the upper lip, more attention are needed on filler injections since the SLAs lie inside the upper lip. Technique Generally, there have been two different methods in rejuvenating lips. Most physicians prefer to inject

from the skin side along the vermilion border (Fig. 5.83). Others choose to inject at the mucosal side of the lip. The former technique makes it possible to rejuvenate the lips with relatively lesser volume compared to latter one. In addition, injecting fillers from the skin side is beneficial to patients without any prominent breakpoints of the lips. However, this technique is not appropriate to the patient with well-defined breakpoints. Rather, filler injections in these patients disrupt the originally well-defined lip contour. Therefore, injecting fillers from the mucosal sides is very critical in these patients in terms of achieving maximal vermilion eversion effect and preservation of their original breakpoints. Keep in mind, more volume is required and foreign body sensation can be present but rare.

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Fig. 5.83 Injection techniques of lip augmentation

A topical anesthetic (EMLA cream) lidocaine and prilocaine cream can be applied, for 30 min to the area to be treated. Then, perform a single injection of filler in the upper and lower lips using the retrograde technique, with almost 1 cm distance between entry points (and in the lower one if it was necessary). Fillers should be injected into the inner side of the lips to avoid any visualization of injected fillers. When patients want to accentuate their central tubercle of upper lip area, one can augment this special area with small amounts of fillers (0.1–0.2 cc). Immediately after the injections, to minimize the potential ecchymosis and edema in the injection sites, apply direct pressure with ice compresses until there are no signs of bleeding. Massaging of the injected area can also be

Fig. 5.84 Lip augmentation using filler

performed when it was considered necessary to spread out the injected filler material more evenly (Fig. 5.84). Total dose for lip augmentation should be determined by the degree of asymmetry. In case of asymmetry, more filler should be added to deficient area and overall dose should be increased accordingly. In general, 0.3–0.4 cc of filler can be used on each lip and add more volume when required for better aesthetic outcomes. Maximal dose per lip (upper or lower lip) in a patient should not exceed 1.5 cc because when that volume is exceeded, it makes the treated lip look too swollen and “puffy”. This excess filler just makes lips thicker rather than rotating them appropriately. Therefore, caution should be taken not to overly inject fillers.

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Injection of the central tubercle of the upper lip area is dependent on the patient’s opinion. In general, Asians want to augment their central tubercle, while westerns do not want their central upper lip to be augmented. Post-procedural management is very simple. Physicians should alert patients that they can feel a foreign body sensation with their tongue initially, which spontaneously resolves over time. Also inform the patient that 10–20% of the initial volume can be lost after one week.

5.3.2 Marionette Line (Static Labiomandibular Fold) Types and Definition of Marionette Line In medical literature, numerous terms have been used to refer to the creases that form around the mouth corner. The author has used the most frequently used terminology to discuss these creases. In Caucasians, the modiolus, the small and thick muscular nodule formed by the chiasma of muscles near the mouth corner, is located mostly at level of or above mouth corner. In contrast, the modiolus in Koreans is mostly located approximately 11 mm lateral and 9 mm inferior to the mouth corner. Therefore, compared to Caucasians, Asians are more prone to develop downturned corners of the mouth, ptosis of the mouth corner, and creases in the area. Commissural lines, which are the vertical depressions at the mouth corner, are caused by the difference in depths of the depressor anguli muscle fibers (superficial layer) and the orbicularis oris muscle fibers (intermediate layer) converging at the modiolus. These lines are more visible in Asians than in Caucasians due to the anatomic location of modiolus (Fig. 5.85). If the lateral lower lip fat compartment (one of the three lateral and central superficial fat compartments located inferior to the lips) atrophies, the commissural line that forms at the junction between the cheek and the lips and degree of mouth corner drooping becomes more severe. The superficial anatomic boundary between the cheek and chin that worsens with the

Modiolus Fig. 5.85 Position of Asian modiolus

difference in tissue thicknesses is called the cheek–chin crease. As the line also gives the impression of sadness/depression, it is also called the melolabial fold. If volume loss of the lower lateral lip compartment, the primary cause of this fold, is corrected by volume augmentation, then both an improvement in the sunken area/crease and a lifting effect of the mouth corner could be attained (Fig. 5.86). When the melolabial fold extends to the mandibular border and the prejowl sulcus is observed in the jawline anterior to the fold, it is called the marionette line. Although the term marionette line is known to have originated from its similar appearance to the mouths of marionettes used in European puppet shows, it is unclear as to when this term was used for the first time and by whom. As a static, oblique fold that extends from the mouth corner to the jawline, it is also referred to as static labiomandibular fold (Fig. 5.87). The causes of melolabial folds include maxillary and mandibular resorption, inferior displacement due to gravitational pull, loss of deep fat layer below the depressor anguli oris muscle, compression of the depressor anguli oris muscle,

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Fig. 5.86 Before and after treatment of marionette line

Fig. 5.87 Type of mouth corner line

a tethering effect of the mandibular ligament, sagging of redundant skin and connective tissue, and sagging of jowl and buccal fat. Depending on the cause, combination treatment may be needed. In addition to fillers for correcting the mandibular borderline including the prejowl sulcus and sunken area anterior to the marionette line and mouth corner, toxin injections for improving the mouth corner depression caused by contraction of the depressor anguli oris muscle, jowl fat removal, or tissue lifting using threads are typically performed together (Table 5.2). The marionette line (static labiomandibular fold) is present even in the expressionless state. It usually starts from the mouth corner and extends obliquely along the posterior border of the depressor anguli oris muscle. In contrast, dynamic labiomandibular fold occurs due to contraction of the lip elevators and depressors that insert at the modiolus to lift or lower the mouth corner. It refers to the fold that starts from

the area near the mouth corner extending obliquely along the anterior border of the depressor anguli oris muscle. In older people with more severe wrinkles, the marionette line is present in the static state and the line may even be one long continuous line with the nasolabial fold extending from the side of the nose to the jawline. Even in young adults, it can be present as a dynamic wrinkle that is more noticeable when forming facial expressions (Fig. 5.87). Dynamic labiomandibular folds can be exacerbated by the lateral pulling effect of the platysma and zygomaticus major muscles. The superior 1/3 to 1/2 of the depressor anguli oris muscle consists of only myofibers, while the inferior boundary is firmly anchored by the mandibular ligament, a true retaining ligament that extends to bone. When lateral pulling occurs due to smiling of making facial expressions, the retaining ligament acts as a fixation point that firmly holds the inferior aspect of the muscle to

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Table 5.2 Considerations for the treatment of marionette line ▷ Causes of Deepening Melolabial Fold (Marionette Line) – Resorption of maxillary and mandibular bone – Gravitational pull downward displacement – Depressed labiomandibular fat with sagging of jowl and buccal fat – Tethering effect of mandibular ligament – Compression of depressor anguli oris muscle – Tight lower lip compartment with redundant skin and connective tissue above the marionette line ▷ Verify the location of the mental foramen ▷ Perform combination procedure ① Botulinum toxin injection to improve mouth corner depression by depressor anguli oris muscle action ② Removal of jowl fat ③ Thread lifting ④ Mandible borderline and mouth corner filler

the bone. Consequently, the area attached to skin shows a bowing effect, where the area bends like a bow (Fig. 5.88). Therefore, when treating dynamic labiomandibular folds, it is important to determine the underlying anatomic issue and distinguish them from the static labiomandibular fold or marionette line. The treatment principle is same as that for Fig. 5.88 Bowing effect of depressor anguli oris by lateral pulling

dynamic perioral wrinkles that worsen with aging, as explained in the section on perioral wrinkles. Procedure for Commissural Line and Melolabial Fold Inject filler along the crease. Sunken area anterior to the crease can be augmented simultaneously. Typically, a needle is used for injection

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into fat layer above the muscle by linear threading and retrograde fanning techniques (Fig. 5.89). As the injected filler fills the sunken area, it effaces the fold and lifts the mouth corners. Caution should be exercised during the procedure to avoid injuring the branches of the facial and inferior labial arteries. Procedure for the Marionette Line (Static Labiomandibular Fold) For lines with mild to moderate severity, a needle is typically used to add volume into subcutaneous fat layer above the muscle layer. Volume is enhanced using the linear threading technique along the linear region slightly medial to the marionette line, while the sunken area anterior to the line is augmented using the retrograde fanning or cross-hatching techniques (Fig. 5.90). By carefully considering the direction of branches of the facial, inferior labial, and submental arteries, vascular injuries may be avoided. In cases with deep creases and severe hollowness, the submuscular fat layer is usually augmented. To avoid neurovascular injury, it is

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better to use a cannula (Fig. 5.91). The entry point for cannula is located in the inferior third of the line that connects the mouth corner and mandibular borderline. To smoothen the deep lines and uneven jawline caused by the prejowl sulcus, use the retrograde fanning and layering techniques to inject filler into the fat layers deep and superficial to the muscles (Fig. 5.90). Caution should be taken to avoid injuring the mental artery and nerve exiting the mental foramen and facial artery near the jawline. The pressure should be applied against the bulge superior to the line with the non-dominant, noninjecting hand to ensure the filler does not spread to this area. After adequate volumization, soft fillers may be injected into the subdermal and dermal layers, to smoothen out the surface. The depressor anguli oris muscle originates broadly from the mandibular border and narrows into a triangular shape, inserting to the risorius and orbicularis oris muscles near the mouth corner. Excessive contraction of this muscle causes downturned mouth corners. In such cases, toxin injection could be used to weaken the depressor anguli oris muscles (Fig. 5.92).

Injection Entry Point Slightly medial to commissural line or melolabial fold along the line or with right angles along the line for subdermal injection of soft filler to smooth out the margin of the line Injection Techniques 1. Retrograde fanning and linear threading 2. Superficial multiple fern leaf or duck walk technique

Fig. 5.89 Injection technique for commisural line and melolabial fold

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Injection Entry Point 1. Slightly medial to marionette line along the line when using the needle for subcutaneous injection of soft filler to smooth out the surface including margin of the line 2. Medial to depressed area on lower 2/3 position from oral commissure to mandible border when using the cannula for volume replacement Injection techniques 1. Linear threading, retrograde fanning and cross hatching for needle 2. Retrograde fanning, cross hatching and layering for cannula

Fig. 5.90 Injection techniques for marionette line Fig. 5.91 Superficial and deep fat medial to marionette line

Fig. 5.92 Depressor anguli oris muscle

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5.3.3 Perioral Wrinkles (Smoker’s Line) 5.3.3.1 Definition of Perioral Wrinkles As people get older, wrinkles appear on the sides of the mouth. Dynamic wrinkles are visible when people smile. As people age, the dermal layer also ages and fat volume decreases, static wrinkles appear. To improve those wrinkles, treatment with filler is needed. Wrinkles around the mouth vary in appearance and name due to various movements of the surrounding muscles (zygomaticus major, risorius, platysma, depressor anguli oris muscle). Although there are individual differences, the most common types of wrinkles around the mouth are as follows (Fig. 5.93): • Smoker’s line (vertical wrinkles of upper and lower lips): fine wrinkles that extend perpendicularly from the vermillion border of the upper and lower lips due to contraction of the orbicularis oris muscle. • Oblique lip–chin creases: wrinkles that occur obliquely under the corners of the mouth • Labiomental crease: wrinkles that appear horizontally in the center between the lower lip and the chin. • Extended type of nasolabial fold: the nasolabial fold extends to the lower level of the mouth and is not connected to the oral commissure.

Filler Procedures Based on the Facial Area

• Static labiomandibular fold (Marionette line): wrinkles that extend outward from the oral commissure to the mandible. • Dynamic labiomandibular fold: wrinkles that occur when smiling or making facial expressions, caused by the contraction of the zygomaticus major muscle and platysma muscle pulling the skin to the lateral side.

5.3.3.2 Injection Technique It is recommended that the physician check the patient’s jawline symmetry, the location of the peripheral wrinkles, sagging of the jowl before the treatment, and confirm the treatment area by looking in a mirror together with the patient. Treatment of most of the perioral wrinkles is different from that of the Marionette line (static labiomandibular fold). In the treatment of the Marionette line, it requires both deep and superficial injections if the fold accompanies a volume loss of the fat. Perioral dynamic wrinkles become static wrinkles as they age. Attempting to treat the wrinkles by filling the volume may look bumpy and rather awkward, so make sure that the wrinkles should only be slightly flattened and made to look natural. A needle is generally used as an injection tool more than a cannula. Anesthesia before needle injection is sufficient with topical anesthesia. Inject a soft filler with a low viscosity into the subdermal layer or deep dermis (Fig. 5.94).

Perioral cheek wrinkles (extended type of nasolabial fold )

Lip vertical wrinkles (smoker’s line)

Oblique lip-chin crease

Marionette line (Static labiomandibular fold) Labiomental crease Fig. 5.93 Types of perioral wrinkles

Central chin crease

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Fig. 5.94 Proper layer of filler injection for perioral wrinkles correction is a superficial layer (deep dermis or subdermal layer) / (with kind permission of MANIAMIND)

Needle Needle There are several techniques for the injection method such as the retrograde serial threading technique, retrograde fanning technique, Mantoux Test injection technique, and droplet technique (see Sect. 4.4.1 injection technique). Treatment of Smoker’s Line In the treatment of smoker’s lines, the injection depth is subdermal or intradermal. Inject a soft HA filler with low viscosity using 30G/31G needles along the vermillion border of the upper and lower lip. Unlike lip augmentation, this does Fig. 5.95 Cautions for (a) Vascular complication during perioral wrinkles correction. a Blue dotted circle: superficial winding of the facial artery (with kind permission of MANIAMIND). b Rea dotted circle: Pulsation of the facial artery is sometimes visible without palpation

not require a large amount of filler. Conversely, a large amount injected along the vermillion border can lead to irregularities. Treatment of smoker’s line requires combination with toxin. Toxin can be used to weaken orbicularis oris muscle muscles so that the skin is less folded, wrinkles less obvious and the effect of filler treatment can be maximized. Toxin is injected 0.5 units at approximately 1 cm intervals along the vermillion border. If toxin injection is too much, orbicularis oris muscles may be excessively relaxed, making it difficult to close

Facial artery

(b)

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the mouth and saliva may leak out when brushing the teeth.

5.3.4 Chin Augmentation and Jaw Line Contouring

5.3.3.3 Precaution/Side Effect Vascular Complication—Bruise

If the chin is not fully developed or if the teeth are protruding, chin augmentation can produce excellent results. In the past, silicone implants were widely used, but nowadays, the filler has become a substitute for this. Since the chin is not complicated in structure, side effects are rare and even beginners can easily try.

Bruising is caused by subdermal plexus injury when a subdermal needle is injected to treat wrinkles around the mouth. Bleeding or bruising from capillary injury may occur, but there is little chance of injury to the facial artery and facial vein. However, there is a superficial course of the facial artery between the zygomaticus major and the risorius muscle outside the orbicularis oris muscle. In other words, the facial artery may reach the tissue below the skin at the area 1.5 cm lateral of the oral commissure where the facial artery gives off the superior labial artery branch. If you palpate this area, you will feel an arterial pulse, and sometimes the pulsation is visible to the naked eye. Therefore, when injecting filler into the wrinkles around the oral commissure, the artery must be checked and it is better to avoid the procedure in the subcutaneous fat layer (Fig. 5.95). Lump/Irregularity Care should be taken when injecting too superficially into the dermis, as a lump may occur. After injecting the filler, use a teaspoon or roller to massage sufficiently to prevent lumps. In addition, it is helpful to prevent a lump or irregularity by dividing the procedure into multiple sessions with small amounts injected rather than completing the procedure in one single session.

Inverted - S line

Fig. 5.96 Inverted S-line from lower lip to chin

5.3.4.1 Design Western patients prefer treatments to make the mandibular angle and jaw lines look more distinct or to smoothen an uneven jawline. On the other hand, many Koreans (Asians) have short chins or retracted chins and prefer to correct them. • When correction is needed in the lateral view When the contour of the forehead–nose–chin is viewed in oblique views, the curves from the lips to the chin look beautiful as an inverted S-line (Fig. 5.96). In the lateral view, the chin should look beautiful just on the Ricketts line. The Ricketts line is the line from the nasal tip to the chin tip in the lateral view. In Korea, it is considered that the upper and lower lip margins should be located on this line or 1–2 mm behind the line to look harmonious. Correcting the chin with a filler to coincide with this line can harmonize the overall lateral contour (see Sect. 4.1.4). • When correction is needed in the frontal view On the frontal view, if the chin looks short or wide, one can make the chin slightly sharper or longer to make the jawline look slimmer. Make the length from philtrum to chin about 1/3 of the total face length. In the West, the ratio of forehead to nose to chin is preferably 1:1:1, and in the East, the ratio 1:1:0.8 is preferred. To summarize, to make a beautiful chin, the retracted chin is augmented to project slightly anteriorly and a short chin is augmented to elongate slightly downward (Fig. 5.97).

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of smoothening the skin dimples and maintaining the corrected shape longer. In addition to the chin shape, the mentalis muscle asymmetry must be checked before the procedure. When filler correction is satisfactory, but asymmetric muscle correction is not done properly, the physician may encounter complaints after the procedure.

Tip of nose

Lower lip

Vasculature/Artery

Tip of chin Fig. 5.97 Aesthetic Lines–Ricketts line

5.3.4.2 Anatomy The layers around the chin and jaw are divided into skin-subcutaneous tissue (superficial fat) and muscle-deep fat-bone (mental protuberance and mandibular body). At the tip of the chin, there is a thin layer of deep fat under the muscle layer. In chin augmentation and jaw contouring, the injection layer should be the supraperiosteum and subcutaneous fat. Mentalis Muscle Asians tend to have a “cobble-stone” appearance due to the development of the mentalis muscles due to their oral structure. Fillers may not be sufficient to correct the volume in an aesthetically pleasing manner. Combining with toxin treatment into the mentalis muscles has the advantage

(a)

Blood vessels around the chin include the mental artery from the mental foramen and the inferior labial artery. For midline injections, the blood vessels are located outside the treatment area, making the procedure relatively safe. The central branch of the submental artery can sometimes run into the midline, but due to its small diameter, the injection tool is unlikely to be inserted into the vessel. Also, since superficial fat is abundant, there is less risk of skin necrosis by extravascular compression.

5.3.4.3 Choice of Filler Chin augmentation and jawline contouring can be injected at two different depths and using different fillers selected accordingly. Use HA or CaHA fillers which have high viscoelasticity and good shape when injected into the deep layer (Fig. 5.98a). Inject s medium viscosity filler into the superficial layer (Fig. 5.98b).

(b)

Injected filler

Injected filler

Fig. 5.98 Injection layer for chin augmentation. a Filler is injected into the supraperiosteum level. b Filler can be additionally injected in the superficial fat layer above the mentalis muscle (with kind permission of MANIAMIND)

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5.3.4.4 Injection Technique for Chin Augmentation Check with the patient whether to project the jaw forward or elongate downward before the procedure. In addition, the hypertrophy of mentalis muscle needs to be checked along with the asymmetry of the chin. In the case of chin augmentation, most of the procedure can be performed without any major discomfort by just applying topical anesthetic agent or inject local anesthesia at the entry point. However, pain-sensitive patients need to be anesthetized through a mental nerve block. Needle Injection (Fig. 5.99a) In general, needles are more frequently used than cannulas for chin augmentation. Use a needle with 25/27G to inject high viscoelastic fillers. Since there is little risk of vascular accident, it can be performed relatively safely. Inject the needle vertically in the midline, touch the bone, retract slightly, and inject the filler. In other words, inject into the supraperiosteum level below the muscle layer. Inject using the bolus technique and adjust the bevel direction of the needle in the cephalic direction when projecting and in the caudal direction when elongating. If deep injection alone does not provide satisfactory correction, additional medium viscoelastic filler can be injected into the superficial fat layer over the muscle layer.

Filler Procedures Based on the Facial Area

Cannula Injection (Fig. 5.99b) It is better to use a cannula for evenly spreading over a wider range. Using retrograde fanning techniques, a cannula with 21/23G can be used to inject into the supraperiosteum layers and subcutaneous layers. The entry point can be made on the midline or on both sides of the midline. Inject the cannula deep until it touches the bone, retract slightly and inject it into the supraperiosteum layer below the muscle. Immediately after the chin augmentation procedure, it may appear to be uniformly injected due to the edema, but if you carefully palpate, you may feel the uneven areas. In such a case, massage with your hands and inject additional fillers into areas with irregularities or depressions so that you can maintain a smooth shape without bumps after edema is resolved. Botulinum Toxin Injection into the Mentalis Muscle (Fig. 5.100) Many patients undergoing chin augmentation due to their micrognathia have mentalis muscle hypertrophy resulting in skin dimpling. Injecting toxin in the mentalis muscle not only eliminates dimples, but also relaxes the tension of the muscles so that the corrected shape maintains longer after filler injection below the muscles. Inject into the muscle at points 0.5 cm lateral of the midline of the chin, two-third the distance between the vermillion border of lower lip and the end of the chin. The proper injection layer is

Cannula

b

a

b

Needle

Toxin injection points Fig. 5.99 Entry points for chin augmentation. a Entry point for needle injection. b Entry points for cannula injection

Fig. 5.100 Toxin injection points in the mentalis muscle (with kind permission of MANIAMIND)

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when the needle is slightly retracted after it touches the bone. Inject botulinum toxin 2–4 U per side. Patients with severe cobble-stone appearance can obtain satisfactory results with botulinum toxin pretreatment. If the left and right muscles are not symmetrically corrected after the first procedure, a second touch-up procedure will be needed.

5.3.4.5 Injection Technique for Jawline Contouring Jawline contouring can be performed for both old and young patients. In older patients, sagging produces a prejowl sulcus, and the jawline is not smooth, so filler correction is necessary. In young patients, the jawline may be depressed on both sides of the chin after chin augmentation. It occurs at the boundary of the chin (mental protuberance) and mandible body, which requires additional jawline contouring after chin augmentation. Needle Injection (Fig. 5.101) Insert a 25/27G needle vertically or obliquely into the boundary of the chin and mandible body. Penetrate into the depressor anguli oris muscle and platysma muscle, then inject into the supraperiosteum level. Cannula Injection (Fig. 5.102) When injecting with a cannula, two entry points can be created. The first is to make an entry point medial

(a)

to the boundary of the chin and mandible body then insert the cannula toward the mandible body. The second is to make an entry point below the anterior border of the masseter muscle then insert the cannula toward the chin. At this time, special care is needed not to damage the facial artery when creating the entry point with the needle. A 5 cm cannula with 21/23G can be injected into both the supraperiosteum level and subcutaneous fat layer. Subcutaneous fat of the mandibular body is thinner than that of the chin. The mandibular ligament is attached to the skin and holds the skin firmly, so it may not be smooth when entering with the cannula. Slowly insert the cannula while touching the bone and inject filler using the retrograde linear technique. When injecting into the subcutaneous layer, retract the tool without removing from the entry point then advance it into the subcutaneous layer for injection. Combination with Toxin (Jawline LiftingNefertiti Lift) (Fig. 5.103) By paralyzing and releasing the platysma muscle along the jawline, it can improve the sagging jaw. Injecting too shallowly will not be effective. Therefore, it should be injected deeper than the subcutaneous layer. Intradermal and subdermal injections are all possible. The dose is about 10– 15U per side, divided into multiple points on the jawline at 1.0–1.5 cm intervals.

(b)

Needle Injection point

depressor anguli oris muscle

Injected filler

Fig. 5.101 Jawline contouring—needle injection. a Needle penetrate into the depressor anguli oris muscle and platysma muscle. b Filler is injected into the supraperiosteum level (with kind permission of MANIAMIND)

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(b)

(a)

2nd entry point

1st entry point

Injected filler

Boundary of the chin(mental protuberance) and mandible body

(c)

Injected filler Fig. 5.102 Jawline contouring—cannula injection. a 2 entry points for cannula insertion. The first entry point is made medial to the boundary of the chin and mandible body then the cannula is inserted toward the mandible body. The second entry point is made below the anterior border of the

masseter muscle then the cannula is inserted toward the chin. b Filler is injected into the supraperiosteum level. c Filler can be additionally injected in the subcutaneous layer (with kind permission of MANIAMIND)

5.3.4.6 Precaution/Side Effect Vascular Complication • Chin augmentation procedures are relatively safe from vascular complications. • Be careful not to damage the facial artery when injecting into the subcutaneous layer during jawline contouring. Nodule/Depression

Fig. 5.103 Jawline lifting using botulinum toxin–Nefertiti lift. Blue dots: toxin injection points

• When the amount of subcutaneous fat is too small or the skin is thin during chin augmentation, a nodule may occur after

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subcutaneous injection. Therefore, it is recommended to first inject at the supraperiosteum level if possible and to inject into the subcutaneous layer in small amounts only when necessary. • After the chin augmentation, the jawline may be depressed at the boundary of the chin and the mandible body. Additional filler injection for the jawline contouring can be performed to create a harmonious jawline.

12.

Migration

13.

• During chin augmentation, special attention is needed as it may enter the oral cavity rather than the mental protuberance when the injection is too close to the lower lip, • When elongating the chin downward, if the injection direction is too downward or amount is too much, the filler may migrate toward the platysma muscle. Since the filler can move downward along the plane of the platysma muscle, direct the injection tool above the tip of the chin and use your thumb and index finger of the opposite hand to prevent the filler from migrating.

8.

9. 10. 11.

14.

15.

16. 17.

18.

19.

20.

Bibliography 1. Webster RC, et al. Supraorbital and supratrochlear notches and foramina: anatomical variations and surgical relevance. Laryngoscope. 1986;96:311–5. 2. Sykes Jonathan M, et al. Upper face: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136:204S. 3. Hetzler L, et al. The brow and forehead in periocular rejuvenation. Facial Plast Surg Clin North Am. 2010;18:375–84. 4. Kornstein AN. Soft-tissue reconstruction of the brow with Restylane. Plast Reconstr Surg. 2005;116:2017– 20. 5. Griepentrog GJ, et al. Anatomical position of hyaluronic acid gel following injection to the eyebrow. Ophthal Plast Reconstr Surg. 2013;29:364–6. 6. Yoo DB, et al. Effacing the orbitoglabellar groove with transposed upper eyelid fat. Ophthal Plast Reconstr Surg. 2013;29:220–4. 7. Goldberg RA, et al. Eyelid anatomy revisited. Dynamic high-resolution magnetic resonance images of Whitnall’s ligament and upper eyelid structures

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24. 25.

26.

27.

with the use of a surface coil. Arch Ophthalmol. 1992;110:1598–600. Morley AM, et al. Use of hyaluronic acid gel for upper eyelid filling and contouring. Ophthal Plast Reconstr Surg. 2009;25:440–4. Lambros V. Volumizing the brow with hyaluronic acid fillers. Aesthet Surg J. 2009;29:174–9. Collar RM, et al. Adjunctive fat grafting to the upper lid and brow. Clin Plast Surg. 2013;40:191–9. Lam VB, et al. The brow-eyelid continuum: An anatomic perspective. Clin Plast Surg. 2013;40:1–19. Pottier Francoise, et al. Aging of orbicularis oculi: anatomophysiologic consideration in upper blepharoplasty. Arch Facial Plast Surg. 2008;10(5):346–9. Erdogmus Senem, et al. Anatomy of the supraorbital region and the evaluation of it for the reconstruction of facial defects. J Craniofac Surg. 2007;18:104–12. Ugur MB, et al. A reliable surface landmark for localizing supratrochlear artery: Medial canthus. Otolaryngol Head Neck Surg. 2008;138:162–5. Goldberg RA. The three periorbital hollows: a paradigm for periorbital rejuvenation. Plast Reconstr Surg. 2005;116:1796–804. Putterman AM. Facial anatomy of the eyelids (Letter). Plast Reconstr Surg. 2004;113:1871–2. Doubt G, et al. Surgical anatomy relevant to the transpalpebral subperiosteal elevation of the midface. Aesthet Surg J. 2015;35(4):353. Mendelson BC, et al. Surgical anatomy of the midcheek: facial layers, spaces, and the mid cheek segments. Clin Plastic Surg. 2008;35:395. Kpodzo DS, et al. Malar mounds and festoons: review of current management. Aesthet Surg J. 2014;34(2):235. Yousuf S, et al. A review of the gross anatomy, functions, pathology, and clinical uses of the buccal fat pad. Surg Radiol Anat. 2013;32:427–36. Zhang HM, et al. Anatomical structure of the buccal fat pad and its clinical adaptations. Plast Reconstr Surg. 2002;109:2509–18:discussion 2519. Pessa JE, Rohrich RJ. The cheek in: facial topography: clinical anatomy of the face. St. Louis: Quality Medical Publishing;2012. p. 47–93. Pessa JE, et al. Concertina effect and facial aging: nonlinear aspects of youthfulness and skeletal remodeling, and why, perhaps, infants have jowls. Plast Reconstr Surg. 1999;103:635–44. Pilsl U, et al. Anatomy of the cheek: implications for soft tissue augmentation. Dermatol Surg. 2012;38:1254–62. Swanson E. Malar augmentation assessed by magnetic resonance imaging in patients after face lift and fat injection. Plast Reconstr Surg. 2011;127:2057–65. Gosain AK, et al. A volumetric analysis of soft-tissue changes in the aging midface using high-resolution MRI: implications for facial rejuvenation. Plast Reconstr Surg. 2005;115:1143–52. (discussion 1153–5). Mendelson BC, et al. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885–96. (discussion 897).

174 28. Wang Wenjin, et al. Facial contouring by targeted restoration of facial fat compartment volume: The midface. Plast Reconstr Surg. 2017;139:563. 29. Wan D, et al. The differing adipocyte morphologies of deep versus superficial midfacial compartments: a cadaveric study. Plast Reconstr Surg. 2013;133:615e–25e. 30. Schaverien MV, et al. Vascularized membranes determine the anatomical boundaries of the subcutaneous fat compartments. Plast Reconstr Surg. 2009;123:695–700. 31. Pessa JE, et al. The malar septum: the anatomic basis of malar mounds and malar edema. Aesthet Surg J. 1997;17:11–7. 32. Lin TM, et al. Application of microautologous fat transplantation in the correction of sunken upper eyelid. Plast Reconstr Surg Glob Open. 2014;2:e259. 33. Liew S. Nonsurgical volumetric upper periorbital rejuvenation: a plastic surgeon’s perspective. Aesthetic Plast Surg. 2011;35:319. 34. Park SK, et al. Correction of superior sulcus deformity with orbital fat anatomic repositioning and fat graft applied to retro-orbicularis oculi fat for Asian eyelids. Aesthetic Plast Surg. 2011;35:162. 35. Lambros V. Observations on periorbital and midface aging. Plast Reconstr Surg. 2007;120:1367–76. (discussion 1377). 36. Mendelson BC, et al. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg. 2002;110:885. 37. Rohrich RJ, et al. The anatomy of suborbicularis fat: implications for periorbital rejuvenation. Plast Reconstr Surg. 2009;124:946–51. 38. Surek Christopher K, et al. Deep pyriform space: anatomical clarifications and clinical implications. Plast Reconstr Surg. 2016;138:59–64. 39. Zufferey J. Anatomic variations of the nasolabial fold. Plast Reconstr Surg. 1992;89:225–31. 40. Gardetto A, et al. Does a superficial musculoaponeurotic system exist in the face and neck? An anatomical study by the tissue plastination technique. Plast Reconstr Surg. 2003;111(2):664–72. 41. Gosain AK, et al. Surgical anatomy of the SMAS: a reinvestigation. Plast Reconstr Surg. 1993;92:1254–63. 42. Lucarelli MJ, et al. The anatomy of midfacial ptosis. Ophthal Plast Reconstr Surg. 2000;16:7–22. 43. Zadoo VP, et al. Biological arches and changes to the curvilinear form of the aging maxilla. Plast Reconstr Surg. 2000;106:460–6. 44. Pessa JE, et al. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver dissections. Plast Reconstr Surg. 1998;102:1888–93. 45. Hastein ME, et al. Midfacial rejuvenation. Springer;2012. 46. Beer GM, et al. The causes of the nasolabial crease: a histomorphological study. Clin Anat. 2013;26:196– 203. 47. Ezure T, et al. Involvement of upper cheek sagging in nasolabial fold formation. Skin Res Technol. 2012;18:259–64.

5

Filler Procedures Based on the Facial Area

48. Park SH, et al. Sudden unilateral visual loss after autologous fat injection into the nasolabial fold. Clin Ophthalmol. 2008;2:679–83. 49. Cohen JL, et al. Anatomic considerations for soft tissue augmentation of the face. J Drugs Dermatol. 2009;8:13–6. 50. Mitz V, Peyronie M. The superficial musculoaponeurotic system (SMAS) in the parotid and cheek area. Plast Reconstr Surg. 1976;77:17–24. 51. Cotofana Sabastian, et al. Midface: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136:219S. 52. Rohrich RJ, et al. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg. 2008;121:2107–12. 53. Gierloff M, et al. The subcutaneous fat compartments in relation to aesthetically important facial folds and rhytides. J Plast Reconstr Aesthet Surg. 2012;65:1292–7. 54. Yousif NJ, et al. The nasolabial fold: an anatomic and histologic reappraisal. Plast Reconstr Surg. 1994;93:60. 55. Rubin LR, et al. Anatomy of the nasolabial fold: the keystone of the smiling mechanism. Plast Reconstr Surg. 1989;83:1. 56. Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with hyaluronic acid-filler complications. J Plastic Reconstr Aesthet Surg JPRAS. 2011;64 (7):892–6. 57. Geronemus RG, Bank DE, Hardas B, Shamban A, Weichman BM, Murphy DK. Safety and effectiveness of VYC-15L, a hyaluronic acid filler for lip and perioral enhancement: one-year results from a randomized, controlled study. Dermatol Surg. 2017;43 (3):396–404 Official publication for American Society for Dermatologic Surgery [et al]. 58. Pascali M, Quarato D, Carinci F. Filling procedures for lip and perioral rejuvenation: a systematic review. Rejuvenation Res. 2018. 59. Sahan A, Funda T. Four-point injection technique for lip augmentation. Acta dermatovenerologica Alpina, Pannonica, et Adriatica. 2018;27(2):71–73. 60. Yazdanparast T, Samadi A, Hasanzadeh H, Nasrollahi SA, Firooz A, Kashani MN. Assessment of the efficacy and safety of hyaluronic acid gel injection in the restoration of fullness of the upper lips. J Cutan Aesthet Surg. 2017;10(2):101–5. 61. Park TH. Comment on Grippaudo et al.: Radiolabelled white blood cell scintigraphy in the work-up of dermal filler complications. Eur J Nucl Med Mol Imaging. 2013;40(5):790–791. 62. Park TH, Seo SW, Kim JK, Chang CH. Clinical experience with polymethylmethacrylate microsphere filler complications. Aesthet Plast Surg. 2012;36(2):421–6. 63. Park TH, Seo SW, Kim JK, Chang CH. Clinical outcome in a series of 173 cases of foreign body granuloma: improved outcomes with a novel surgical technique. J Plastic Reconstr Aesthet Surg JPRAS. 2012;65(1):29–34.

Bibliography 64. Park TH, Yeo KK, Seo SW, et al. Clinical experience with complications of hand rejuvenation. J Plastic Reconstr Aesthet Surg JPRAS. 2012;65(12):1627–31. 65. Pinar YA, et al. Anatomic study of the blood supply of perioral region. Clin Anat. 2005;18:330–9. 66. Mendelson BC, et al. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthet Plast Surg. 2008;32:185–95. 67. Braz Andre, et al. Lower face: clinical anatomy and regional approaches with injectable fillers. Plast Reconstr Surg. 2015;136:235S. 68. Pessa JE, Rohrich RJ. The lips and chin. in: facial topography: clinical anatomy of the face. St. Louis: Quality Medical Publishing; 2012. p. 251–91. 69. Reece EM, et al. The aesthetic jaw line: management of the aging jowl. Aesthet Surg J. 2008;28:668–74. 70. Hazani R, et al. Bony anatomic landmarks to avoid injury to the marginal mandibular nerve. Aesthet Surg J. 2011;31:286–9. 71. Rohrich RJ, Pessa JE. The anatomy and clinical implications of perioral submuscular fat. Plast Reconstr Surg. 2009;124:266–71. 72. Hur MS, et al. Morphology of the mentalis muscle and its relationship with the orbicularis oris and incisivus labii inferioris muscles. J Craniofac Surg. 2013;24:602–4. 73. Reece EM, et al. The mandibular septum: Anatomical observations of the jowls in aging-implications for facial rejuvenation. Plast Reconstr Surg. 2008;121:1414–20. 74. Romo T, et al. Chin and prejowl augmentation in the management of the aging jawline. Facial Plast Surg. 2005;21:38–46. 75. Dallara JM, et al. Calcium hydroxylapatite for jawline rejuvenation: Consensus recommendations. J Cosmet Dermatol. 2014;13:3–14. 76. Pezeshk RA, et al. Role of autologous fat transfer to the superficial fat compartments for perioral rejuvenation. Plast Reconstr Surg. 2015;136:301e–9e. 77. Iblher N, et al. The aging perioral region: Do we really know what is happening? J Nutr Health Aging. 2012;16:581–5. 78. Cacou C, et al. Patterns of coordinated lower facial muscle function and their importance in facial reanimation. Br J Plast Surg. 1996;49:274. 79. Shim KS, et al. An anatomical study of the insertion of the zygomaticus major muscle in humans focused on the muscle arrangement at the corner of the mouth. Plast Reconstr Surg. 2008;121:466–73. 80. Cotofana S, Mian A, Sykes JM, Redka-Swoboda W, Ladinger A, Pavicic T, et al. An update on the anatomy of the forehead compartments. Plast Reconstr Surg. 2017;139(4):864e–72e. 81. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. Anatomy of the corrugator supercilii muscle: part I. Corrugator topography. Plastic Reconstr Surg. 2007;120(6):1647–53.

175 82. Hwang K. Surgical anatomy of the facial nerve relating to facial rejuvenation surgery. J Craniofacial Surg. 2014;25(4):1476–81. 83. Ugur M, Savranlar A, Uzun L, Kucuker H, Cinar F. A reliable surface landmark for localizing supratrochlear artery: medial canthus. Otolaryngol Head Neck Surg. 2008;138(2):162–5. 84. Costin BR, Plesec TP, Sakolsatayadorn N, Rubinstein TJ, McBride JM, Perry JD. Anatomy and histology of the frontalis muscle. Ophthalmic Plast Reconstr Surg. 2015;31(1):66–72. 85. Janis JE, Ghavami A, Lemmon JA, Leedy JE, Guyuron B. The anatomy of the corrugator supercilii muscle: part II. Supraorbital nerve branching patterns. Plastic Reconstr Surg. 2008;121(1), 233–40. 86. Anatomy of the Supraorbital Region and the Evaluation of it for the Reconstructionof Facial Defects. Anatomy of the Supraorbital Region andthe Evaluation of it for the Reconstructionof Facial Defects, 2007. p. 1–9. 87. Huang R-L, Xie Y, Wang W, Herrler T, Zhou J, Zhao P, et al. Anatomical study of temporal fat compartments and its clinical application for temporal fat grafting. Aesthet Surg J. 2017;37 (8):855–62. 88. Trussler AP, Stephan P, Hatef D, Schaverien M, Meade R, Barton FE. The frontal branch of the facial nerve across the zygomatic arch: anatomical relevance of the High-SMAS technique. Plast Reconstr Surg. 2010;125(4):1221–9. 89. Agarwal CA, Mendenhall SD III, Foreman KB, Owsley JQ. The course of the frontal branch of the facial nerve in relation to fascial planes: an anatomic study. Plast Reconstr Surg. 2010;125 (2):532–7. 90. CosmeticSurgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions. CosmeticSurgical Anatomy of the Ligamentous Attachments in the Temple and Periorbital Regions, 2000. p. 1–16. 91. Clinical Implications of the Middle Temporal Vein With Regard to Temporal Fossa Augmentation. Clinical Implications of the Middle Temporal Vein With Regard to Temporal Fossa Augmentation, 2014. p. 1–6. 92. Matic DB, Kim S. Temporal hollowing following coronal incision: a prospective, randomize, controlled triald. Plastic Reconstr Surg. 2008;121 (6):379e–85e. 93. O ʼ Brien JX, Ashton MW, Rozen WM, Ross R, Mendelson BC. New perspectives on the surgical anatomy and nomenclature of the temporal region. Plastic Reconstr Surg. 2013;131(3):510–22. 94. Anatomic Studies The Anatomy of Temporal Hollowing: The Superficial Temporal Fat Pad. Anatomic Studies The Anatomy of Temporal Hollowing: The Superficial Temporal Fat Pad, 2005. p. 1–4.

6

Complication of Filler Procedures

6.1

Type and Treatment of Complication

As filler procedures become more popular, the frequency and types of side effects are increasing and becoming more diverse. Prior to the popularization of filler procedures, foreign body reactions and cases of granulomas caused by illegal procedures were reported as side effects. Since filler procedures have become more popular, skin necrosis and more recently, blindness has become issue due to vascular complications. In addition to the above fatal side effects, there are minor side effects such as bruising, erythema, edema, soft tissue infection, pigmentation, overcorrection, nodule, and migration. Most of the vascular side effects after a filler are caused by the physicians. Therefore, in order to prevent these side effects, it is essential to understand the properties of fillers, precautions for various injection methods and facial anatomy (especially vasculature). Side effects of fillers can be categorized according to when they occur—as early or late complications (Table 6.1). Preventing side effects is a priority, but it is important to detect and treat them early when they occur. In addition, it is desirable to understand possible side effects depending on the timing and to know the appropriate treatment method. Among these, vascular complications will be discussed in Sect. 6.2.

© Springer Nature Singapore Pte Ltd. 2020 G. Hong et al., The Art and Science of Filler Injection, https://doi.org/10.1007/978-981-13-0611-2_6

6.1.1 Bruising and Hematoma Bruising and hematoma are the most common side effects after a filler procedure. It occurs immediately after the procedure or within a few days and can occur regardless of the type of filler. If the blood vessels are injured during the injection into the subdermal layer, the bruise is visible immediately after the procedure. Injecting into the supraperiosteum level reduces the likelihood of bruising, but is not 100% preventable. If the blood vessels are injured by injection into the deep or intermediate layer (subcutaneous supraperiosteum level), the bruise is not visible immediately after the procedure, so intervention by compression is usually not performed. Therefore, it should be noted that hematoma can develop slowly after injection and may be detected later. Proper compression even when a slight amount of bleeding is seen immediately after the procedure will reduce the size of a larger bruise or hematoma. If patients are taking medication that can aggravate bleeding, avoid taking it for several days to a week before the procedure. Factors Associated with Bruising/Hematoma • Needle gauge • Depth of injection plane • Patient-related factors (age, medication, liver disease)

177

178 Table 6.1 Timing and presentation of filler complications

6

Complication of Filler Procedures

Early onset (< 1–2 weeks)

Late onset (>2 weeks*1 year)

Bruise, hematoma

Neovascularization

Edema

PIH (Post-inflammatory hyperpigmentation

Pain

Nodule

Erythema

Granuloma

Lump

Migration

Infection

Chronic infection

• medications (aspirin, warfarin, NSAIDs, Vit E, fish oil, etc.) How to reduce bruising/hematoma during the procedure • Apply ice packs before and after the procedure to constrict the blood vessels. • Use lidocaine mixed with epinephrine for anesthesia. • Perform the procedure slowly and gently. • During the procedure, the skin may swell after undermining of the space using a cannula. If the area swells before filler injection, a hematoma may be suspected due to vascular damage. In this case, immediately remove the cannula and apply sufficient pressure. Even if the area is no longer swollen after pressing for at least 5 min, it is advisable to postpone the procedure.

6.1.2 Edema Transient edema immediately after the filler procedure is normal, usually disappearing within two to three days. Some fillers may cause unpleasant edema due to its high water retention capacity, so it is advisable to inform the patient before the procedure about the possibility of edema. Hematoma caused by vascular injury during the procedure and edema due to water retention after the procedure needs to be differentiated. Hematoma is usually unilateral and occurs within minutes or hours after the procedure.

In case of excessive undermining of the treatment area with a cannula, severe edema can be accompanied. To prevent this, it is helpful to refrain from excessive undermining and apply pressure after the procedure. For example, in case of filler treatment with severe dissection of the subgaleal space during forehead treatment, using an elastic bandage after treatment may minimize edema. Water retention of filler Depending on the filler product, some may cause more severe edema than others. Therefore, it is advisable to know the properties of the filler used in advance and explain the possibilities of swelling to the patient. Delayed hypersensitivity reaction Delayed hypersensitivity reactions occur days to months after filler procedures. Severe edema with erythema sometimes accompanies itching and pain. It may occur in the areas where the filler was injected or in the areas where the filler was dissolved. • Treatment – Oral steroids (It does not respond to antihistamines) – In case of a HA filler, dissolve with hyaluronidase. Symptoms resolve only when the filler is completely gone (see Sect. 4.6.2. Hyaluronic acid filler degradation test and Sect. 6.3.2 Use of hyaluronidase) – For non-HA fillers, remove the filler surgically. – If a hard nodule is palpated, inject triamcinolone by diluting it or inject 5-FU.

6.1 Type and Treatment of Complication

6.1.3 Neovascularization and Erythema It is common for mild erythema to develop at the treatment area immediately after the filler procedure and resolve after a few days. A few days or weeks after the filler is injected, diffuse erythema may develop in a circular or elliptical manner. This type of delayed diffuse erythema is more likely to occur in the superficial layer than in the deep layer, or in areas where there is not enough space from the skin to the periosteum. This is due to the formation of new capillaries by the pressure increase in the tissue as a compensating mechanism. In this case, a vascular laser can be used for treatment. Long-term use of steroid ointments is contraindicated as it causes capillary dilation and makes symptoms worse. Differential diagnosis • Impending necrosis It is very important to recognize erythema by impending necrosis, which appears one to three days after the procedure. In case of impending necrosis, it is red or light purple with a reticular pattern. In this case, immediate treatment is needed (See Sect. 6.2.2 Treatment of skin necrosis) • Soft tissue infection Skin infections due to filler treatment appear 2 to 3 days after the procedure. The center of the erythema is dark red and softens in a gradation pattern toward the periphery. It usually appears unilateral and is accompanied by burning sensation and edema. Antibiotic treatment is needed (see Sect. 6.1.6 Infection).

6.1.4 PIH (Post-inflammatory Hyperpigmentation) After filler injection, sometimes postinflammatory hyperpigmentation can occur at the entry point.

179

In particular, it is more likely to occur with Fitzpatrick Skin Type IV–VI. To prevent this, reduce the number of entry points. When puncturing the skin, it is recommended to use a small needle. Treatment • Whitening agent (hydroquinone) • Laser treatment: Q-switched 1,064 nm laser, Pico-second 1,064 nm laser.

Nd:Yag Nd:Yag

6.1.5 Nodule and Granuloma In the past, nodule and granuloma were understood as different categories. Nodule is a filler tissue that is touched by the dermis and has a small size, no inflammation and a lesion caused by technical error. Granuloma is a large, inflammation-associated lesion that was thought to be a side effect of the filler itself or infection. However, nodule is a clinical finding, but granuloma is histologic finding. So I think the above classification is not appropriate. Therefore, the authors define the palpable mass of late or delayed onset after filler injection as nodule. There are several causes for nodule. It may be caused by problems with the filler product itself, and it may be associated with an infection or biofilm. In some severe cases, the tissue inflammatory response is severe, with histological findings of granuloma caused by multinucleated giant cells. These cases are called foreign body granuloma separately. The mechanism of foreign body granuloma formation is as follows. When a human body's immune system recognizes a foreign body as a dangerous substance, macrophage predation begins. However, when the size of the foreign body is so large that the macrophage cannot feed on its own, the macrophage fuses to form a multinucleated giant cell. These multinucleated giant cells isolate the foreign body from the human tissues by surrounding it. When the

180

inflamed tissue surrounded by multinucleated giant cells is observed on the biopsy, it is called foreign body granuloma. Hyaluronic acid is a substance present in the human body. Not only humans, but also animals and bacteria have no difference in molecular structure. So even if the raw material is made from bacteria, not humans, to produce hyaluronic acid filler, no immune rejection reaction occurs. Foreign body reactions after filler injection may be due to the manufacturing process itself, not just hyaluronic acid. Severe immune reactions can occur when using poor quality ingredients, high residual BDDE or protein residues, or high levels of endotoxin. Even products that have been used on the market for a long time and are considered safe have a low rate but can produce a delayed immune reaction.

6.1.6 Infection

6

Complication of Filler Procedures

• Once diagnosed, it is advisable to refrain from massaging to prevent spread to surrounding tissues. • An abscess may be suspected if after the first oral antibiotics the condition does not improve and persists for a longer time. After incision and drainage, pus should be cultured and administer susceptible antibiotics. If you suspect an inflammatory nodule but not abscess, administer empiric antibiotics. Recommended empiric antibiotics therapy – Clarithromycin 500 mg + moxifloxacin 400 mg twice daily for 10 days or – Ciproflaxacin 500 to 750 mg twice daily for 2 to 4 weeks or – Minocycline 100 mg once daily for 6 months. * Differential diagnosis with Herpes infection

• Thorough disinfection of the treatment site • Wear sterilized gloves during the procedure • Prescribe oral antibiotics after the procedure.

If a patient with poor immunity receives a filler procedure on the face, there is a possibility of herpes virus recurring. Lesions begin with tingling and develop into vesicles and crusts. Vesicle patterns need to be differentiated from skin necrosis. In cases of skin necrosis, the skin color change in a reticular pattern is accompanied first. If there is a history of herpes infection or frequent relapses, prophylactic antiviral therapy may be considered.

Treatment

Prophylactic treatment

• Oral antibiotics

• Valacyclovir 500 mg twice a day for 3 days

Recommended empiric antibiotics therapy

Antiviral treatment

– Amoxicillin + Clavulanate or – Cephalexin or – Ciproflaxacin 750 mg twice daily for 1 week (if has penicillin allergy)

• Valacyclovir 2,000 mg twice a day for 1 day

An infection may be suspected when accompanied by edema, burning sensation and erythema in the affected area within 2–3 days after the filler procedure. Prevention

* Differential diagnosis with Delayed hypersensitivity reaction

6.1 Type and Treatment of Complication

181

Delayed hypersensitivity reactions are accompanied by itching, edema, diffuse erythema, but no burning sensation.

occur. If a branch of the cerebral artery is blocked, it causes a cerebral infarction. If injected into a vein, it may cause pulmonary embolism through venous drainage.

6.2

6.2.1.3 Commonly Affected Areas Skin necrosis cases have been reported before fillers became more common as in recent years. In the early years, skin necrosis was reported mainly in the nose and the nasolabial fold, as filler procedures were performed mainly in these two areas. However, recently, as fillers are being applied to the whole face, skin necrosis is being reported in additional areas such as the forehead and glabella. Blindness has been reported more recently being caused by inadvertent injection of filler into the supratrochlear artery, supraorbital artery, or dorsal nasal artery which are all associated with the central retinal artery (during forehead or glabella injection—see Sect. 6.2.3 Blindness). It can also occur by injection into other vessels connected to the vessels mentioned above. Pulmonary embolism is rarely reported, and it is most likely to occur during injection in the temple region which has the sentinel vein and middle temporal vein, which are the largest veins in the facial region (see Sect. 6.2.4 Pulmonary embolism). Since the facial vessels are connected to each other, skin necrosis, blindness, and pulmonary embolism can occur in any part of the facial region and care should be taken at all times.

Treatment and Prevention of Vascular Complication

6.2.1 Mechanism and Classification of Vascular Complications There is an increasing trend in vascular complications due to filler procedures. There are two main causes of vascular complications: intravascular emboli and extravascular compression (Table 6.2).

6.2.1.1 Extravascular Compression If the injected filler mass is pressed against an adjacent artery, ischemia may progress slowly and skin necrosis may occur. When the filler mass compresses a vein, venous congestion occurs, and this can lead to the oxygen supply from the arteries connected to it to decrease. This can eventually cause skin necrosis to progress slowly. 6.2.1.2 Intravascular Emboli If the blood vessel is blocked by an embolus which is inadvertently formed in a vessel due to a filler procedure, oxygen may not be supplied to the tissue, which may cause fatal side effects. Blocking the branches of the external carotid artery can lead to skin necrosis due to insufficient blood supply even if the vessels are anastomosed with surrounding arteries. If the terminal artery is blocked, symptoms of embolism appear within a few minutes after the procedure, and irreversible injury can occur if immediate treatment is not taken. If the filler material blocks the retinal artery or its branches, blindness or eye movement dysfunction may Table 6.2 Types of vascular complications

Artery

6.2.2 Skin Necrosis 6.2.2.1 Predisposing Factors of Skin Necrosis • Skin thickness Areas with thick skin are more likely to cause necrosis by extravascular compression than thinner

Intravascular emboli

Extravascular compression

Skin necrosis

Skin necrosis

Blindness Cerebral infarct Vein

Pulmonary embolism

Skin necrosis

182

skin areas. If the space between the dermis and the periosteum is thin, it is more likely that the blood vessels will be compressed by the filler mass. For example, in the tip of the nose, the space between the skin and the cartilage is small. If a large amount of filler product is injected, the arteries can be compressed and skin necrosis more likely to occur. In particular, if the artery is not anastomosed with peripheral blood vessels, the likelihood is even higher. • Injection technique Over-injecting filler in one space can cause the filler mass to compress blood vessels. • Injection plane Injecting into the subcutaneous fat layer which has more vascularity rather than the supraperiosteum level, there is a higher risk of compressing or damaging blood vessel. • History of filler/fat injection If there is a history of fat transplantation, fillers, or surgery, the affected area undergoes a fibrotic change, resulting in less tissue flexibility and less mobility of blood vessels. This increases the likelihood of extravascular compression and vessel damage, so care must be taken.

6.2.2.2 Influencing Factors with Prognosis of Skin Necrosis • Degree of blockage of blood vessels The area of skin necrosis caused by an intravascular embolus is much broader than the area caused by extravascular compression. • Diameter of blood vessel The extent of skin necrosis due to complete obstruction by an embolus in the main artery is wider than that of a peripheral artery obstruction.

6

Complication of Filler Procedures

• Anastomosis with adjacent arteries In the case of an intravascular embolus or extravascular compression, the possibility of recovery depends on the anastomosis with adjacent vessels. The skin necrosis may be reversible by blood flow from adjacent blood vessels. However, in the absence of adjacent blood vessels, blood supply failure causes more severe side effects and makes recovery difficult.

6.2.2.3 Symptoms of Skin Necrosis Symptoms of skin necrosis vary and the treatment of skin necrosis varies depending on the stage it is discovered and intervention implemented. Therefore, it is important to exactly know the symptoms at each phase so it can be treated properly. The symptoms of each phase are as follows. Impending necrosis This is the stage before an eschar occurs on the skin. When the blood vessels are partially obstructed, it progresses slowly. About 2–3 days after the procedure, the symptoms develop and the skin color changes to purple with a reticular pattern and is accompanied by pain and edema. In mild cases, impending necrosis does not progress to the next stage and may recover without sequelae. If it progresses to the next stage, it will develop an infection with pustules, which will result in a mild eschar. However in the case of complete obstruction (severe necrosis), the impending necrosis stage passes briefly. The range of infection is more widespread and large eschars develop. After the eschar is removed, atrophic scars usually follow. If the impending necrosis stage is present within one day and the skin color change is widespread, intensive treatment should be administered as soon as possible. Skin necrosis If the ischemic state persists during the period of impending necrosis, the skin barrier is broken which leads to weakening of bactericidal action. Pustules appear on the skin accompanied by pain and edema.

6.2 Treatment and Prevention of Vascular Complication

As the wound healing process progresses further, the pustules burst and eschars are developed. Scar formation Once the infection has recovered and the large eschar disappears, skin defects may develop and can be accompanied by erythematous scars.

6.2.2.4 Treatment of Skin Necrosis (Table 6.3) • Decompression Skin necrosis varies in terms of symptoms depending on its extent and severity. Patients usually complain of symptoms within 1 to 2 days if the area of necrosis is wide and after 2 to 3 days if the area is small. Decompression that can eliminate the cause of vascular compression should be performed first, since the blood vessels are compressed by filler masses or edema and oxygen is not supplied to tissues by ischemia. If initial symptoms of necrosis are suspected with skin color change immediately after the procedure, blood flow can be improved by attempting to spread the filler via massage to disperse the pressure applied in the corresponding space. In the case of hyaluronic acid fillers, attempt to dissolve it by injecting hyaluronidase and subsequent massage.

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– Puncture and drainage In the case of injection into superficial to medium planes rather than deeper planes, the most obvious decompression method is to incise the skin and drain the filler. Non-HA fillers do not have a dissolving agent, so decompression is done using this method. This can be done immediately after the procedure or during the early stage of necrosis. It is not recommended to use this method if there are eschars on the skin after several days. Excessive manipulation of the affected area with a damaged skin barrier can harm the skin. If the filler was injected into a deep plane, suction may be attempted with negative pressure of a syringe using a large bore needle. – Warm massage If the vessel suspected of being pressed by the filler mass is in a confined space, it may be helpful to attempt decompression by pressing and rolling over the filler mass with massage. Massage with a wet gauze (warm water or saline solution) can also be helpful in vasodilation of the vessels. CaHA fillers that do not respond to hyaluronidase may be broken up by massage after infusion of lidocaine or saline.

Table 6.3 Symptoms and treatments depending on the timing of necrosis Impending necrosis

Skin necrosis

Scar formation

– Ischemic state

– Infection

– Skin defect

– Wound healing state Symptoms

–Reticular pattern

–Pustule

–Redness

–Purple color

–Eschar

–Depressed scar

• Infection control – PO antibiotics – Remove pustule • Dressing – Antibiotics gauze • Growth factor – EGF/PDRN/PRP/stem cell

• Scar Treatment – Vascular laser – Fractional laser • Skin graft

–Pain, swelling Treatments

• Decompression – Hyaluronidase – Puncture & Drainage (if possible) – Warm massage • Revascularization – PGE1 IV (vasodilator) – Hyperbaric O2 – Aspirin

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Massage should be done with caution as it can cause harm to vulnerable vasculature. This method is not helpful when there is a severe skin infection or eschar.

the progression to ischemia. The use of aspirin may help to inhibit ischemia progression.

– Hyaluronidase

– Infection control

In cases of HA filler, decompression can be done by dissolving it with hyaluronidase. Massage must be performed together since hyaluronidase is a polymer and it does not penetrate into the filler mass. Massage the filler mass to increase the surface area for hyaluronidase to function properly. According to an article, hyaluronidase can penetrate the vessel wall to dissolve the hyaluronic acid in the vessel. Therefore, even if there is suspected vascular occlusion, hyaluronidase should be actively administered to the filler injection site (see 6.3.2 Use of Hyaluronidase).

If impending necrosis occurs after the filler procedure and only skin color changes appear, it can be treated with oral antibiotics. However, if pustules appear with skin color change, they should be removed aseptically. After removal of the pustules, wet dressing with antibiotic gauze must be followed. This minimizes the occurrence of an eschar. If the infected skin is left dry, not only will an eschar develop, but later scarring will also occur.

• Revascularization

Applying or injecting growth factors during wound healing after skin necrosis may help in recovery. Growth factors such as EFG, PDRN, and stem cells are commonly used. Care should be taken to avoid bleeding during needle injection. If there is an eschar or difficulty injecting it directly into the lesion, you can attempt injecting it at the margin.

After decompression as an initial treatment, improvement of blood flow is needed. – PGE1 (vasodilator) Intravenous infusion of vasodilators has been widely used to treat pressure ulcers and necrotic tissue. It can also be used to treat skin necrosis after a filler procedure. Mix PGE1 (alprostadil 5 lg) in 500 cc normal saline and infuse it slowly over approximately 2 h. If you administer it over too short a period, the vasodilation effect often causes headaches. Use it for 3–5 days until clinical improvement is seen. – Aspirin Aspirin lowers the viscosity of the blood, which helps increase blood flow in narrowed blood vessels. When filler is injected into a blood vessel, blood clots along with filler emboli play a role in

• Infection control and Growth factor

– Growth factor

• Scar treatment Proper treatment at the skin necrosis stage can reduce eschar and minimize scarring. However, if the extent of infection is large or if it is not treated properly, permanent scarring can be left over a wide area. If a scar remains, it is very disheartening for the doctor as well as the patient. Depression of the skin seen immediately after resolution of the eschar is still in the process of wound healing, so use growth factors to help the skin regenerate. Multiple fractional laser treatments can also be helpful. In severe cases, skin grafts may be necessary.

6.2 Treatment and Prevention of Vascular Complication

6.2.2.5 Tips for Early Detection and Immediate Treatment If both the doctor and patient have never experienced skin necrosis before, they might not have adequate knowledge of how to detect, diagnose, and treat the condition. The day after the filler procedure, the clinic staff must call the patient to check on the condition. If the obstruction of blood vessels is severe, the symptoms appear the next day. If the obstruction is present but not severe, the next day may only be accompanied by slight pain or edema and no change in skin color. In this case, differential diagnosis with skin infection is necessary, and it is advisable to check whether there is a change in skin color with a reticular pattern after 2–3 days. If the patient complains of a change in skin color or an uncomfortable symptom the next day, the clinic should receive a photograph of the lesion and decide whether to examine the patient in the clinic. An emergency kit containing hyaluronidase and vasodilators should be prepared for necrosis treatment. If you have no experience with skin necrosis or do not prepare an emergency kit, it is advisable to have an emergency contact network available to ask for advice or to refer a patient. The most important point in the treatment of necrosis is early detection and immediate treatment. If you experience necrosis case for the first time, the symptoms appearing 1–2 days after the procedure tend to be overlooked and considered a simple infection or a minor symptom. Care must be taken to differentiate these scenarios (see Sect. 6.1.3).

6.2.3 Vascular Complication— Blindness The most fatal complication of intra-arterial filler injection is blindness. Blindness is caused by occlusion of the central retinal artery and can be caused by almost all injections used for cosmetic purposes such as fat transplantation, hyaluronic acid, PLLA, and CaHA.

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Mechanism The ophthalmic artery has several branches, one of which is can be blocked due to backflow of filler material that has been incorrectly injected into a blood vessel, leading to blindness. Filler material refluxed mainly from the supratrochlear/supraorbital artery ! migrates to the ophthalmic artery (derived from the internal carotid artery) ! causes the occlusion of the branches, such as central retinal artery and posterior ciliary artery. This occurs when injected in the opposite direction to the blood flow at a pressure stronger than the arterial blood pressure. When continuously injected, the filler material is more likely to occlude the terminal artery. Immediately after the procedure, diplopia and visual field defects appear. If these symptoms occur, you should call an ophthalmologist immediately. Even if the patient receives professional treatment in an eye hospital after the event, recovery may vary depending on the extent of the blood vessel’s occlusion. In severe cases, complete bilateral blindness or cerebral infarction may result. Emergency treatment First aid may be attempted to dissolve the filler in the retinal artery before transferring the patient to an eye hospital. Hyaluronidase is injected into the retrobulbar space using a cannula, which is absorbed into the retinal artery by diffusion to dissolve the filler and recirculate blood flow. See Sect. 6.4 retrobulbar injection technique. Prevention In order to prevent intra-arterial filler injections, it is recommended to inject at the supraperiosteum level where there is the least amount of blood vessels. Using a cannula can never guarantee safety. According to literature, a large number of blindness accidents occurred after filler or fat transplantation using cannula, and even reported when a 2 mm diameter cannula was used. HA fillers also do not guarantee safety. In addition to HA fillers, ocular complications have been reported by various fillers such as

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corticosteroids, paraffin, silicone oil, and bovine collagen. In cases of blindness caused by HA filler, hyaluronidase can be injected by the retrobulbar injection technique to dissolve emboli in the central retinal artery. This has been proven effective in animal experiments. Location Ocular complications are more likely to occur in the eyebrow, forehead, and nose areas where the branches of the ophthalmic artery are distributed. Since ICA and ECA are anastomosed, it may also be caused by arteries in other parts of the face (temple, nasolabial fold, anterior cheeks, perioral area, etc.).

6.2.4 Vascular Complication— Pulmonary Embolism Recently, blindness and cerebral infarction have been emphasized as fatal complications after filler injection. This is caused by filler material or autologous fat injected into the arteries. Another fatal side effect caused by intravenous injection is pulmonary embolism. According to the literature, pulmonary embolism occurs after the injection of autologous fat or filler in the facial region, and some have resulted in death. In addition, there are reports of pulmonary embolism by injection of the vulva and vaginal fillers for perineal rejuvenation. Mechanism Pulmonary embolization after the filler procedure mainly occurs in the temporal region because of the relatively large diameter of the sentinel vein and middle temporal vein in the temple. The sentinel vein is about 2 mm in diameter and the middle temporal vein is about 5 mm in diameter. When filler is injected into these veins, the emboli may move from the superficial temporal vein -> external jugular vein -> heart -> pulmonary artery, eventually causing pulmonary embolism (see Sect. 5.1.2 temple). Prevention In order to prevent the occurrence of pulmonary embolism by filler injection in the temple, it is

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Complication of Filler Procedures

necessary to be aware of the depth and movement of the sentinel vein and middle temporal vein. The sentinel vein is more superficial than the TPF (Temporoparietal fascia), that is, it travels in the subcutaneous layer and penetrates the TPF and deep temporal fascia (DTF). It is then connected to the middle temporal vein in the layer between the superficial and deep layers of the DTF. To prevent filler injection into these large veins, two other methods are recommended besides subcutaneous layer injection. The first method is injection into the superficial layer. It is injected into the space between TPF and DTF, which has the least distribution of large veins. Filler with a medium viscoelasticity is injected using a cannula. A small amount of filler is effective and is the safest way to inject (see Sect. 5.1.2 temple). The second method is to inject into the deep layer. Inject into the space between the temporalis muscle and the supraperiosteum. Use a filler with high viscosity and inject with a needle. Many practitioners often prefer to inject into the subcutaneous fat layer. This is because there is anxiety about deep injections and having little confidence in the injection layer. Since the sentinel vein runs for a distance in the subcutaneous fat layer, it is likely for a physician to damage the sentinel vein and cause bleeding while injecting in the subcutaneous fat layer using a needle or cannula. Therefore, it is necessary to know the location and pathway of the sentinel vein before injecting it carefully.

6.2.5 Prevention of Vascular Complication 6.2.5.1 Procedural Tips to Reduce Vascular Complications Vascular complications after a filler procedure can result in fatal sequelae, so utmost care must be taken when treating facial areas. There are several tips to reduce vascular complications: • Choose proper tools (filler, cannula/needle) • Visualize the anatomical structure

syringe,

6.2 Treatment and Prevention of Vascular Complication

• Inject gently and in small volumes (4R) Remove and Reinsert injection tools -> Recheck with an aspiration test -> Retrograde injection • Feel the injection force and volumizing resistance • Check the patient’s response (sharp pain, neurologic symptom) Choose proper cannula/needle)

tools

(filler,

syringe,

Fillers that can be dissolved in the case of side effects are limited to hyaluronic acid fillers, so beginners should start with hyaluronic acid fillers to be safe. The viscosity of the filler affects the force of injection as well as the degree of correction, so the choice of viscosity is important. If the injection force needed by a beginner is too strong, the beginner tends to shake while injecting. If this is the case, it is advisable to use a filler which is one level lower than the viscosity recommended for the treatment site to prevent it from being injected incorrectly into another space. The larger the diameter of the syringe barrel, the stronger the injection force. Beginners are advised to use a smaller diameter syringe to inject. Smaller diameters and longer lengths of the cannula will also increase ejection pressure, so using a shorter injection tool with a proper diameter can lower the injection force needed. Since the cannula and needle are structurally different, it is recommended to use them appropriately according to the treatment area and depth of injection (see Sect. 4.3 selection of cannula or needle). The preference between a cannula and needle and which one is more helpful in preventing vascular complications is controversial. This will be covered later in this chapter. Visualize the anatomical structure Unlike open surgery, filler procedures are performed blindly without any field of view.

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Therefore, there is a higher probability of tissue or blood vessel damage. Therefore, one needs to be aware of the structures under the skin. The anatomical structures most often associated with complications are blood vessels (See Sect. 3.1 Vessels). It should be understood that the routes of blood vessels are not two-dimensional but three-dimensional. In other words, one must not only find the path of blood vessels, but the depth of the blood vessels at a specific location must be considered also. Arterial vessels in the facial area consist of the ECA origin group and the ICA origin group. Blindness which is the most lethal side effect of vascular complications, occur when fillers are injected into the central retinal artery which is a branch of the ICA. However, these two groups of blood vessels are not completely separated but are connected to each other. Even if intravascular filler injection occurs in the ECA, the emboli may reach the central retinal artery (a branch of the ICA) resulting in blindness. Therefore, it is important to know the location of the ICA and its associated arteries. Avoiding the location of the associated blood vessels that cause vascular complications within the treatment site, and then injecting filler into the vascular-free layer is a shortcut to prevent complications. With the least distribution of blood vessels, the generally recommended injection layer is the supraperiosteum level. However, there are always anatomical variations, so one must be sure to familiarize oneself with anatomical knowledge and safe procedural skills. Inject gently and in small volumes (4R) Remove and Reinsert -> Recheck with aspiration test -> Retrograde injection The author has a series of steps to prevent side effects when treating areas with high possibility of blood vessel damage. After inserting the injection tool, the filler is not injected immediately. Remove the injection tool and confirm that there is no bleeding. -> Next, reinsert the injection tool through the passage. For example, in the correction of the temple, if a thick, short needle (23G–25G) is inserted first for local anesthesia,

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the passage is already formed and the filler needle can be safely inserted through the same passage. -> Then recheck by an aspiration test whether it is inserted into the vessel or not. -> Inject a small amount of filler slowly with a retrograde technique. Feel the injection force and volumizing resistance This is a method to check if the filler is properly injected into the area to obtain a volumizing effect. When injecting filler into the tissue, the feeling of injection force is stronger than that of injection in vitro. Feel it with your hands while injecting filler. Then use your fingertips on the opposite hand to feel the resistance over the treatment area while injecting. You can also see the volume increase with your eyes. If the injection tool is located somewhere other than where you planned, you will not feel the resistance of volume filling with your opposite hand. This is often the case when using a long flexible cannula. In such cases, stop the injection and remove the injection tool. Insert it again into the correct area. Check the patient’s response (sharp pain, neurologic symptoms) If the treatment site is sufficiently localized for anesthesia, pain will not be felt during the procedure. In a locally anesthetized state, if the patient feels sharp pain while the injection tool is passing through, a vessel or nerve might have been damaged and the injection direction should be changed. If neurological symptoms occur during or immediately after injection, it should be suspected that the filler was injected into a branch of the ICA. After stopping the injection, one should check for any additional symptoms (See Sect. 6.2.3 vascular complicationBlindness). If the treatment area turns pale within a few minutes after the procedure, consider the possibility of vasoconstriction caused by both epinephrine and filler emboli. If it is caused by anesthesia, the anesthetized area feels more bloated than the other areas. If filler is injected into a blood vessel, the pain can be severe when

6

Complication of Filler Procedures

penetrating the vessel walls, accompanied by neurological symptoms or pale skin within minutes. In this case, follow up under bed rest for about 30 min after the procedure. If skin discoloration is getting wider, consider intravascular complications. However, if the discoloration is improving and no additional symptoms occur, one can conclude that the vasoconstriction was caused by epinephrine. The tips above are generally well known. However, further discussion of controversial issues is needed. • Is the aspiration test useful just before filler injection? • Which is more safe, cannula or needle? • Does the diameter of the needle help to reduce vascular complications?

6.2.5.2 Prevention of Vascular Complications— Aspiration Test (Fig. 6.1) An aspiration test prior to filler injection is a widely used method, yet there is a lack of proof of effectiveness. There are several factors to consider. • What is the appropriate diameter of the needle for the blood to be aspirated? The larger the diameter of the needle, the easier blood is aspirated and vice versa. When a needle with a small diameter is used, the blood aspiration test may be false negative. When this needle is located in a blood vessel, the backflow of blood may not occur. If filler already exists in the middle of the needle lumen, blood aspiration may not occur in the needle lumen due to the viscosity of the filler. Thus, the smaller the needle diameter and the higher the viscosity of the filler, the higher the probability of a false negative aspiration test. • Even if the needle is located in the blood vessel, the wall of the blood vessel may adhere(occlude) to the needle tip due to negative pressure of suction and thus blood may not be aspirated.

6.2 Treatment and Prevention of Vascular Complication

(a)

189

(b)

Fig. 6.1 Aspiration test—in vitro. a Plunger was withdrawn under negative pressure (Restylane Perlain syringe connected with 27 G/13 mm needle). Blood was aspirated in 1 second. b Plunger was withdrawn under negative

pressure (Restylane Perlain syringe connected with 25 G/40 mm cannula). Blood was not aspirated even after 10 s. This means the probability of a false negative aspiration test during procedure

• Even if the needle is not actually inside a blood vessel, it may cause false positives if blood is at the end of the needle due to damage of a vessel while reaching the layer to be injected. • After the aspiration test, the needle is moved due to error or shaking leading to improper positioning. This may cause damage to blood vessels, even if the test is actually negative.

6.2.5.3 Prevention of Vascular Complications—Needle Versus Cannula In the past, there has been a tendency to think that cannulas are less at risk to cause vascular damage compared to needles. However, according to the papers that reported vascular complications, the number of vascular complications caused by needles are not more than by cannula, and sometimes even caused more often by cannulas. This is controversial to date and requires continued research. Needles and cannulas are structurally different. Needles are pointed and rigid. A cannula is blunt and flexible. The cannula is theoretically blunt and therefore may be less likely to penetrate blood vessels, but unlike rigid needles, it can be bent so the cannula tip can be located in an unwanted layer or position. For example, if you inject into the periosteum, it is easy to place the needle exactly on the periosteum. However, in the case of a cannula, because it is flexible, the filler can be injected in a layer other than the periosteum, i.e., in a blood

Despite these reasons, many doctors routinely perform aspiration tests during the procedure and sometimes experience backflow of blood. The literature reported to date points out the limitations of the effectiveness of the aspiration test. A closer look at the research mentioned in the articles showed some effectiveness in aspiration tests when it is performed using shorter needles with a large diameter rather than with cannulas. Nevertheless, it is recommended to conduct an aspiration test first when treating areas where large vessels exist. It is also advisable to stop the injection and reinject at another location if blood aspiration is positive regardless of false positives.

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vessel-rich layer. Also, due to the preconception that cannulas are safer than needles, there is a possibility of being more aggressive and careless than injecting with a needle. Nevertheless, the cannula is recommended for beginners, and advanced practitioners are advised to use a needle and cannula appropriately. When using a cannula, it is recommended to inject using one as short and rigid as possible (See Sect. 4.3 selection of cannula or needle).

6.2.5.4 Prevention of Vascular Complications—Diameter of Injection Tool Large diameter injection tools are less likely to penetrate blood vessels and be placed in the vessels, while smaller diameter injection tools are more likely to be placed in the vessels. For example, it is more likely that a 30G cannula may penetrate a 1 mm diameter vessel and place it inside compared to a 23G cannula. The author prefers a 23G cannula when injecting filler into the deep layer, and uses a 25G–27G cannula when injecting into dermal wrinkles where only relatively small blood vessels are present. 23–25G is preferred when injecting a large amount of filler using a needle, and 30G is used when injecting dermal wrinkles. Some claim that since a thin cannula is flexible, it is more likely to proceed without penetration of blood vessels. This means that a thick cannula is rigid enough to penetrate the vessels. This is controversial. In cases where the injection tool is located inside a vessel, the claim that a smaller diameter tool produces a higher ejection pressure leading to faster movement of the filler to the central retinal artery causing blindness has not been demonstrated to date. The theory that the filler mass does not travel at high speed in the blood vessels like a bullet under ejection pressure, but rather moves inside the vessels toward the eyeball in a single file line is more prevalent. The difference in the possibility of ocular complications according to the diameter of the injection tool and injection pressure needs to be verified through further studies.

6

6.3

Complication of Filler Procedures

Hyaluronidase Usage

6.3.1 Hyaluronic Acid Turnover The proper use of hyaluronidase requires an understanding of the turnover process of hyaluronic acid. The turn over of hyaluronic acid has a half-life of 24–48 h. Hyaluronic acid fillers are products that have a longer duration due to the cross-linking process. However, empirically, we can see that the duration of the filler is different for each facial area and injection depth. The halflife of hyaluronic acid filler is shortened in the dermis of the face, which is known to be higher in hyaluronidase. On the other hand, the half-life of hyaluronic acid filler is longer at low hyaluronidase concentrations in deeper layers. Clinicians have been empirically aware that the duration of hyaluronic acid filler injected into the deep facial area is much longer than when administered in the dermis level. We hope to do more research about filler duration according to injection depth and the injection site in the near future. Hyaluronidase is widely distributed in animal testes and skin, and a total of six kinds are known. Hyaluronidase in the anterior head of sperm is known to play an important role in the passage of hyaluronic acid-rich ovary ECM. Therefore, hyaluronidase extracted from bovine testes is widely used in research. The most active human hyaluronidases are HYAL1 and HYAL2. HYAL2 breaks down large molecular weight hyaluronic acid into 20 KDa size fragments. HYAL1 additionally degrades hyaluronic acid to the size of its tetra-saccharide. It is then further broken down into monosaccharides and removed from the body by the function of the hyaluronidase families (b-glucuronidase, b-Nacetylglucosaminidase). The pharmacokinetics and pharmacodynamics of hyaluronidase are not well known. The halflife of hyaluonidase in the blood is 2 min, and it quickly loses its activity. However, it is known to work much longer in tissue. The process of inactivation of hyaluronidase is also not well known. Empirically, it is a common opinion

6.3 Hyaluronidase Usage

among clinicians that the ability to decompose hyaluronic acid fillers seems to last for several hours or more. H.J. Kim et al. studied the action time of hyaluronidase by injecting hyaluronidase into rats to dissolve the hyaluronic acid filler. In other words, after using hyaluronidase, it was investigated how much time interval is needed to reinject hyaluronic acid filler into the same site. In an experiment with a rat, 0.2 cc of hyaluronic acid filler was injected per site and 600 IU of hyaluronidase was injected per site to dissolve the filler. Then, the filler was reinjected at 30 min, 1 h, 3 h, 6 h, 12 h, 24 h, 2 days, 4 days, 7 days, and 14 days, respectively. In each experimental group, histological examination of the site was performed 1 h after each secondary injection. In this experiment, the enzyme activity of hyaluronidase was found to have disappeared 6 h after hyaluronidase injection. From this study, we can see that the guidelines may have to differ between using hyaluronidase to dissolve hyaluronic acid in blood vessels and using it to dissolve hyaluronic acid in other tissues. This is because hyaluronidase quickly loses its activity when it encounters blood. When using hyaluronidase for filler side effects such as intravascular filler injection, hyaluronidase should be administered frequently at short intervals, taking into account that the activity of hyaluronidase quickly disappears upon contact with blood. Hyaluronic acid is decomposed by hyaluronidase into small fragments (Fig. 6.2). Hydrolyzation of the hexosamidic b (1–4) link in the disaccharide structure (Fig. 6.3). Hyaluronic acid fragmentation is observed. Several months after the injection of hyaluronic acid filler, an immune response appears as a delayed type. The fact that it takes several months to decompose the cross-linked hyaluronic acid filler and that fragments of various sizes are produced during the decomposition process may suggest that the delayed type immune response may be related to the hyaluronic acid filler fragment. Further research is required in this area. The fact that high molecular weight hyaluronic acid has a better effect does not mean that it would be better as a material for fillers.

191

Attempts have been made to develop products using hyaluronic acid with a molecular weight much greater than that commonly used in filler manufacturing. However, some new fillers that have attempted to do so have caused many problems and have been withdrawn from the market. Generally, hyaluronic acid of 1.5  106 Da to 2.5  106 Da is used to produce the filler. Since filler manufacturing involves the crosslinking process using a cross-linker, we cannot apply the results studied with the molecular weight using free hyaluronic acid without crosslinking to all situations. Be sure to keep this in mind.

6.3.2 Use of Hyaluronidase The use of hyaluronidase as a dissolving treatment in cases of adverse events after hyaluronic acid filler is currently off label. There have been various discussions on how to use hyaluronidase in the most effective way. Recently, a diverse group of doctors created a consensus on this topic. Based on various experimental results, the use of evidence-based hyaluronidase has been summarized. There are dozens of hyaluronidases on the market today. It is interesting to note that 150– 200 USP is used mainly in the US, while 1,500 IU is used in Korea. international unit (IU) = 1 USP unit. In the previous studies on the use of hyaluronidase, we recommended about 3–15 units for 0.1 cc of filler volume. Of course, there is a difference in recommendation dosage depending on whether it is a simple nodule, an impending necrosis, or a vascular accident. Later consensus recommended high doses of hyaluronidase—approximately 200–300 IU per day. If needed to use hyaluronidase repeatedly, some doctors recommend a 1 day interval for the procedure, while some doctors recommend a 1 h interval. The authors present an evidence-based guideline on the use of hyaluronidase. Based

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Fig. 6.2 Action of hyaluronidase

Fig. 6.3 Site where hyaluronidase acts

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Complication of Filler Procedures

6.3 Hyaluronidase Usage

on the experience of clinicians and scientific experiments. The principles of proper use of hyaluronidase can be summarized as follows. Method of using hyaluronidase (1)

Prepare for the possibility of hypersensitivity to hyaluronidase

(2)

Use a sufficient amount of hyaluronidase

(3)

Inject widely in all areas where ischemia is suspected

(4)

Inject at 1 cm intervals over all the suspected ischemia area

(5)

Repeat every 15 min

(6)

Massage the area after injection

(7)

When injecting into a nodule or granuloma, make sure to penetrate the capsule and inject into the center of the mass

The following is the summary of the rationale for each guideline. – Theoretical Basis of the Guidelines (1) Prepare for the possibility of hypersensitivity to hyaluronidase. Some guidelines recommend a skin test. However, in the clinical field, skin test is practically easy to do. It is possible to treat the

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hypersensitivity reaction or use antihistamines and steroid injections prophylactically. (2) Use a sufficient amount of hyaluronidase. The authors performed a hyaluronic acid filler degradation test. Different concentrations of hyaluronidase were used to degrade the filler. The temperature was maintained at 36 °C to create an environment similar to that of a in vivo environment. In order to observe the difference in concentration only, the hyaluronidase was mixed into a 1 cc volume (Figs. 6.4, 6.5, 6.6 and 6.7). In the past, the recommended hyaluronidase dosage for dissolving fillers or filler nodules were 3–15 units/0.1 cc. This is assuming that hyaluronidase is correctly injected into the center of the nodule. However, the same amount of hyaluronidase should not be recommended for impending necrosis by intravascular filler injection. This is because the filler is expected to dissolve due to the diffusion of hyaluronidase under the assumption of trans-arterial penetration, rather than the direct injection of hyaluronidase into the filler bolus center. In addition, hyaluronidase is rapidly deactivated in contact with blood. Therefore, the recommended amount of hyaluronidase for dissolving filler/filler nodules and the amount for impending necrosis by

Fig. 6.4 Filler dissolution test. Filler 1 cc + HU 75 units (1 cc), a 5 min, b 1 h, c 24 h

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Fig. 6.5 Filler dissolution test. Filler 1 cc + HU 300 units (1 cc) a 5 min, b 1 h, c 24 h

Fig. 6.6 Filler dissolution test. Filler 1 cc + HU 750 units (1 cc) a 5 min, b 1 h, c 24 h

Fig. 6.7 Filler dissolution test. Filler 1 cc + HU 1500 units (1 cc) a 5 min, b 1 h, c 24 h

intravascular filler injection should be different. Naturally, higher doses of hyaluronidase would be required in the latter.

(3) Inject widely in all areas where ischemia is suspected.

6.3 Hyaluronidase Usage

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progress is poor. One can improve the clinical course by injecting hyaluronidase in all areas suspected of skin compromise caused by ischemia. (4) Inject at 1 cm intervals over all suspected ischemia areas.

Fig. 6.8 Schematic diagram of endovascular filler injection case

This is when the ischemia occurs in a wide area from intravascular injection, not for nodule or granuloma cases. The filler injected into the vessels are not formed into an embolus, but advance into the vessels forming columns (Fig. 6.8). Therefore, the filler may spread through the vessels in all parts of the ischemic area that appear in the intravascular filler injection case. Therefore, in intravascular filler injection cases, the hyaluronidase should be injected into all areas showing signs of ischemia. Hyaluronidase degrades hyaluronic acid by acting directly on the filler surface. Therefore, direct contact is necessary. In case of vascular accident by intravascular injection, ischemia signs appear according to the route of the facial artery (Fig. 6.9). In cases of impending necrosis by intravascular filler injection, if the hyaluronidase is injected only into the filler injection site, the Fig. 6.9 Facial artery variation—The route of the left and right facial artery is different (with kind permission of MANIAMIND)

This is also applicable for cases of impending necrosis by intravascular injection. Hyaluronidase not only dissolves hyaluronic acid at the injection site, but also diffuses to the periphery. In practice, hyaluronidase is used to increase the spread of drugs in ophthalmology and dermatology. This is because dissolving hyaluronic acid in tissue ECM eliminates the barrier to drug diffusion. However, due to the limited diffusion range, injection of hyaluronidase at appropriate intervals is required in Fig. 6.10. In previous studies, hyaluronidase proved to have trans-arterial penetration (Fig. 6.11). In other words, in cases of filler side effects via intravascular injection, the hyaluronic acid filler can be dissolved by injecting hyaluronidase into the periphery of the vessel instead of directly injecting it directly into the blood vessel. (5) Repeat every 15 min When dissolving hyaluronic acid filler with hyaluronidase, one procedure may not be enough

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Fig. 6.10 Interval distance of hyaluronidase injection

Fig. 6.11 Degradation of hyaluronic acid filler in blood vessel by infiltration of hyaluronidase

to dissolve all the fillers. Therefore, it is necessary to clarify what intervals are most effective when performing repetitive procedures. Especially in serious complication cases such as intravascular filler injection. As mentioned earlier, hyaluronidase activity in tissues is known to last for several hours. However, in an emergency case, the duration of maximal effect will be more

important than the total duration of hyaluronidase activity. Won Lee et al. studied the proper hyaluronidase injection interval after intravascular filler injection using a rabbit model. Flaps were made in rabbit ears to block blood vessel anastomosis, and then fillers were injected into the auricular artery. Necrosis of the ear was induced after which hyaluronidase was injected at various intervals. The results of the experiment were as follows (Table 6.4). The hyaluronidase usage guidelines have changed over time. In the past, it was recommended to repeat the procedure every day. Recently, re-evaluation and re-administration at 1 h intervals are recommended. This study found that in emergency situations such as intravascular injections, frequent administrations at 15 min intervals are more desirable. Based on these findings, we expect that new evidence-based guidelines will be coming soon. To compare the difference between in vivo and in vitro experiments, the authors conducted a similar experiment for the use of hyaluronidase in the laboratory. Unlike in vivo experiments, the filler degradation effect of hyaluronidase was related to the total amount of hyaluronidase used.

6.3 Hyaluronidase Usage

In summary, there was no difference between the group administered 750 units at once and the group administered 250 units divided into 3 injections at 15 min intervals. Repeated administration did not show better results. This is thought to be associated with the inactivation of hyaluronidase in vivo (Fig. 6.12).

197 Table 6.4 Hyaluronidase usage recommendations Repeated hyaluronidase treatment is effective The interval should be as short as 15–30 min It is effective to use high doses of hyaluronidase

(6) Massage the area after injection Borders and Raftery (1968) reported that the molecular weight of hyaluronidase is 61,000 Da. Khorlin et al. (1973) report four subunits of 14,000 Da each and a total molecular weight of 55,000 Da. hyaluronidase has a large molecular weight, it dissolves on the outer surface of the filler material when it encounters hyaluronic acid filler. Naturally, the contact surface must be large for effective enzymatic degradation. After hyaluronidase injection, the area of contact should be widened through massage. As mentioned earlier, because hyaluronidase activity decreases in the body, it is recommended to massage after injection to effectively facilitate contact between the filler and hyaluronidase. The authors performed hyaluronic acid filler degradation test and observed the difference of solubility according to massage (Fig. 6.13). Experimental condition a. It was performed at 36.5 °C to match the enzyme activity.

b. The authors performed a seal after hyaluronidase mixing to prevent evaporation of water during the experiment. c. A monophasic filler was used. d. The group without massage was compared with the group which received the massage at the same time. (7) When injecting into a nodule or granuloma, make sure to penetrate the capsule and inject into the center of the mass. Nodules or granulomas are caused by a variety of factors. Thick fibrous capsules form around the filler when it is due to the poor quality of the filler itself or by abnormal immune responses. Even when nodules or granulomas are present, hyaluronidase is recommended for primary treatment. When the fibrous capsule around the nodule or granuloma is not thick, it is adequate to inject a sufficient amount of hyaluronidase into the area around the lesion and massage it. However, in cases where the capsule is very thick

Fig. 6.12 Comparison of hyaluronidase usage in vitro test. a 750 unit at once + 1cc HA filler. b 250 unit 3 times 15min interval (with kind permission of S.THEPHARM)

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Fig. 6.13 Degradation difference between the non-massage and massage group after 24 h of mixing 750 units of hyaluronidase. a Massage group. b Non-massage group (with kind permission of S.THEPHARM)

Fig. 6.15 Hyaluronidase is injected and dissolved in the center of the mass. Hyaluronidase is injected directly through the fibrous capsule via a needle and then directly inside

Fig. 6.14 When injected outside the mass: hyaluronidase cannot pass through the thick fibrous capsule of the nodule and thus cannot remove the mass

and severely inflamed with calcification, injection, and massage of hyaluronidase around the mass cannot effectively dissolve it. Only hyaluronic acid fillers in connective tissues along the periphery of normal tissues can be dissolved, but the mass will not disappear. Although surgical removal may be considered, surgical removal often leaves scars on the face. Therefore, efforts to dissolve using hyaluronidase should not be easily abandoned.

When treating a hard nodule or granuloma with hyaluronidase, the hyaluronidase must be injected into the center of the mass to dissolve it from the inside (Figs. 6.14 and 6.15). It is important to know whether hyaluronidase is properly injected into the center of the mass during the procedure. If it is not injected in the right place, not only does the mass not dissolve, it can cause unwanted side effects. There is a way to determine if the needle tip is properly positioned in the center of mass. It is one of the most important details in treating filler side effects (Table 6.5). Retrobulbar hyaluronidase injection

6.3 Hyaluronidase Usage Table 6.5 How to make sure hyaluronidase is correctly injected into the center of mass 1. If the needle tip is located at the center of mass correctly, it is difficult to inject hyaluronidase due to the higher injection force than when the needle tip is located at the surrounding normal tissue 2. When the injection is successful, you can feel that the size of the mass has increased immediately after the injection. If the central injection fails, swelling simply occurs in the periphery 3. You can feel the mass swell and burst while the injection is successful. Fibrous capsules are inflated due to hyaluronidase injected into the body and can not withstand pressure and burst 4. If it is properly injected and then promoted again after several minutes, it can be seen that the rigidity of the mass is reduced and the size is reduced. If you feel the capsule pops out, you can see that the mass itself is gone

Fig. 6.16 Arterial supply of eyeball (with kind permission of DAEHAN medbook)

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The most serious complication of a facial filler is blindness. The mechanism by which blindness occurs can be explained graphically (Fig. 6.16). When blindness occurs, there is controversy as to whether it can be reversed. To date, no officially recognized cases of blindness have been treated by retrobulbar injection in blindness from filler cases. Some cases have been reported to have been successful, but there is no definite evidence that the blindness actually occurred. Won Lee et al. demonstrated that blindness can be treated by retrobulbar injection using a rabbit model. The points of the retrobulbar injection technique are as follows (Figs. 6.17, 6.18, 6.19, 6.20, 6.21, and 6.22).

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Fig. 6.17 Retro-bulbar injection point (with kind permission of MANIAMIND)

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Complication of Filler Procedures

Fig. 6.18 Retro-bulbar injection point (with kind permission of MANIAMIND)

Fig. 6.20 Retro-bulbar injection point

Fig. 6.19 Retro-bulbar injection point Entry point: Lower lateral margin of the orbit (with kind permission of MANIAMIND)

6.3 Hyaluronidase Usage

Fig. 6.21 Retro-bulbar injection point (with kind permission of MANIAMIND)

When side effects from intravascular filler injection occur, it is necessary to remove not only the filler material but also the thrombus arising from blood coagulation. Compared with hyaluronidase treatment alone, studies have shown better results with simultaneous administration of hyaluronidase and thrombolytic agents.

6.4

Retrobulbar Injection Technique

Retrobulbar hyaluronidase injection is the only method that has been almost proven to be effective in the event of visual complications caused by filler. Hyaluronidase is known to be permeable in vessels that are less than 1 mm thick, so it can be effective even if no injections are placed into the vessels. It is important to inject hyaluronidase at the point where these vessels are located because the branches around the ophthalmic artery or ophthalmic artery are

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Fig. 6.22 Retro-bulbar injection point Entry point: Lower lateral margin of the orbit (with kind permission of MANIAMIND)

clogged and cause symptoms. It is recommended that the needle’s direction be directed toward the optical foramen and that the fluid should be spread properly in the space from the optical foramen to the back of the eyeball (Fig. 6.23). Opinions vary on the concentration of the hyaluronidase, but usually inject a hyaluronidase + saline solution mixed with 150– 300 IU/cc. It is recommended to inject several times with 15 to 30 minutes interval because the filler may not dissolve at once or the injection may not have entered the correct position. It is recommended to use a 5 cm 23G cannula on the inferolateral side of the orbital rim and reach the end of the cannula sufficiently near the optic foramen. It is easier to enter through the inner wall and a cannula is more suitable than a needle to prevent unnecessary bleeding (Fig. 6.24). When injecting hyaluronidase, you may be worried about penetrating the eyeball or blood vessels, but any situation would be better than

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Fig. 6.23 Ophthalmic artery & branchs of ophthalmic artery

blindness. Therefore, if you suspect visual complications, it is recommended that you actively inject hyaluronidase without worrying about these other complications (Fig. 6.25). Some argue that it is preferable to find and inject inside the facial artery so that a hyaluronidase injection can enter the ophthalmic artery. However, such a method is more likely to push the filler deeper into the ophthalmic artery, which is not recommended because it makes it more difficult to treat the emergency.

According to a recent study, after artificially blocking the rabbit's ophthalmic artery to create a visual complication, reperfusion by retrobulbar hyaluronidase injection was successfully performed. This is the basis that most strongly supports the effectiveness of the retrobulbar hyaluronidase injection, and need to be more familiar with this injection more than any other treatment, and should be able to be conducted immediately in the event of an emergency.

6.4 Retrobulbar Injection Technique

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Fig. 6.24 Retrobulbar injection technique & Retrobulbar target site

Fig. 6.25 Retrobulbar injection (greenish area)

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3. Kho I-S, Lee W. Hyaluronic acid filler and hyaluronidase Filler Complications Spingernature, pp 27–40. 4. Narins, et al. Clinical conference: management of rare events following dermal fillers-focal necrosis and angry red bumps. Dermatol Surg. 2006;32 (3):426–34. 5. Hanke CW, et al. abscess formation and local necrosis after treatment with Zyderm or Zyplast collagen implants. J Am Acad Dermatol. 1991;25(2 pt 1):319–26. 6. Hirsh et al. Successful management of an unusual presentation of impending necrosis following a hyaluronic acid injection embolus and proposed algorithm for management with hyaluronidase. Dermatol Surg 2007;33(3):357–360. 7. Glaish AS. Injection necrosis of the glabella: protocol for prevention and treatment after use of dermal fillers. Dermatol Surg. 2006;32:276–81. 8. kim et al. Vascular complications of hyaluronic acid fillers and the role of hyaluronidase in management. J Plastic Reconstr Aesthet Surg 2011;64:1590–1595. 9. Joel L, et al. treatment of hyaluronic acid fillerinduced impending necrosis with hyaluronidase: consensus recommendation. Aesthetic Surg J. 2015;35(7):844–9. 10. Stern R. Hyaluronan catabolism: a new metabolic pathway. Eur J Cell Biol. 2004;83:317–25. 11. Stern R, Kogan G, Jedrzejas M, _Solt_es L. The many ways to cleave hyaluronan. Biotechnol Adv 2007;25:537–57. 12. Fraser JRE, Laurent TE. Turnover and metabolism of hyaluronan. In: Evered D, Wheelan J (eds) The Biology of hyaluronan. Ciba Found Symp; 1989;143: 41–59. 13. Kim HJ et al. The duration of hyaluronidase and optimal timing of hyaluronic acid (HA) filler

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