Illustrated Manual of Injectable Fillers: A Technical Guide to the Volumetric Approach to Whole Body...

Illustrated Manual of Injectable Fillers

SERIES IN COSMETIC AND LASER THERAPY

Series Editors

David J. Goldberg, Nicholas J. Lowe, and Gary P. LaskPublished in association with the Journal of Cosmetic and Laser Therapy

David J. Goldberg, Fillers in Cosmetic Dermatology, ISBN 9781841845098Philippe Deprez, Textbook of Chemical Peels, ISBN 9781841842954C. William Hanke, Gerhard Sattler, Boris Sommer, Textbook of Liposuction, ISBN 9781841845326Paul J. Carniol, Neil S. Sadick, Clinical Procedures in Laser Skin Rejuvenation, ISBN 9780415414135David J. Goldberg, Laser Hair Removal, Second Edition, ISBN 9780415414128Benjamin Ascher, Marina Landau, Bernard Rossi, Injection Treatments in Cosmetic Surgery, ISBN 9780415386517Avi Shai, Robert Baran, Howard I. Maibach, Handbook of Cosmetic Skin Care, Second Edition, ISBN 9780415467186Jenny Kim, Gary Lask, Comprehensive Aesthetic Rejuvenation: A Regional Approach, ISBN 9780415458948Paul Carniol, Gary Monheit, Aesthetic Rejuvenation Challenges and Solutions: A Global Perspective, ISBN 9780415475600Neil Sadick, Diane Berson, Mary P. Lupo, Zoe Diana Draelos, Cosmeceutical Science in Clinical Practice, ISBN 9780415471145Anthony Benedetto, Botulinum Toxins in Clinical Aesthetic Practice, Second Edition, ISBN 9780415476362Robert Baran, Howard I. Maibach, Textbook of Cosmetic Dermatology, Fourth Edition, ISBN 9781841847009David J. Goldberg, Alexander L. Berlin, Disorders of Fat and Cellulite, ISBN 9780415477000Kenneth Beer, Mary P. Lupo, Vic A. Narurkar, Cosmetic Bootcamp Primer : Comprehensive Aesthetic Management, ISBN 9781841846989Neil S. Sadick, Paul J. Carniol, Deborshi Roy, Luitgard Wiest, Illustrated Manual of Injectable Fillers: A Technical Guide to the Volumetric Approach to Whole Body Rejuvenation, ISBN 9780415476447

Illustrated Manual of Injectable Fillers

A Technical Guide to the Volumetric Approach to Whole

Body Rejuvenation

Edited by

Neil S. Sadick MD FAAD FAACS FACP FACPhSadick Aesthetic Surgery and Dermatology

New York, New York, USA

Paul J. Carniol MD FACSCosmetic, Laser and Reconstructive Plastic Surgery

and New Jersey Medical SchoolSummit, New Jersey, USA

Deborshi Roy MDFacial Plastic & Reconstructive Surgery

Private Practice, Los Angeles, California, USA

and

Luitgard Wiest MDDermatology

Private Practice AB-Centrum, Munich, Germany

First published in 2011 by Informa Healthcare, Telephone House, 69–77 Paul Street, London EC2A 4LQ, UK.

Simultaneously published in the USA by Informa Healthcare, 52 Vanderbilt Avenue, 7th Floor, New York, NY 10017, USA.

Informa Healthcare is a trading division of Informa UK Ltd. Registered Offi ce: 37–41 Mortimer Street, London W1T 3JH, UK. Registered in England and Wales number 1072954.

© 2011 Informa Healthcare, except as otherwise indicated

No claim to original U.S. Government works

Reprinted material is quoted with permission. Although every effort has been made to ensure that all owners of copyright material have been acknowledged in this publication, we would be glad to acknowledge in subsequent reprints or editions any omissions brought to our attention.

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, unless with the prior written permission of the publisher or in accordance with the provisions of the Copyright, Designs and Patents Act 1988 or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, 90 Tottenham Court Road, London W1P 0LP, UK, or the Copyright Clearance Center, Inc., 222 Rosewood Drive, Danvers, MA 01923, USA (http://www.copyright.com/ or telephone 978-750-8400).

Product or corporate names may be trademarks or registered trademarks, and are used only for identifi cation and explanation without intent to infringe.

This book contains information from reputable sources and although reasonable efforts have been made to publish accurate information, the publisher makes no warranties (either express or implied) as to the accuracy or fi tness for a particular purpose of the information or advice con-tained herein. The publisher wishes to make it clear that any views or opinions expressed in this book by individual authors or contributors are their personal views and opinions and do not necessarily refl ect the views/opinions of the publisher. Any information or guidance contained in this book is intended for use solely by medical professionals strictly as a supplement to the medical professional’s own judgement, knowledge of the patient’s medical history, relevant manufacturer’s instructions and the appropriate best practice guidelines. Because of the rapid advances in medical science, any information or advice on dosages, procedures, or diagnoses should be independently verifi ed. This book does not indicate whether a particular treatment is appropriate or suitable for a particular individual. Ultimately it is the sole responsibility of the medical professional to make his or her own professional judgements, so as appropriately to advise and treat patients. Save for death or personal injury caused by the publisher’s negligence and to the fullest extent otherwise permitted by law, neither the publisher nor any person engaged or employed by the publisher shall be responsible or liable for any loss, injury or damage caused to any person or property arising in any way from the use of this book.

A CIP record for this book is available from the British Library.

ISBN-13: 9780415476447ISSN: (Print) 2158-0286ISSN: (online) 2158-026X

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Library of Congress Cataloging-in-Publication Data

Illustrated manual of injectable fi llers : a technical guide to the volumetric approach to whole body rejuvenation / edited by Neil Sadick ... [et al.]. p. ; cm. — (Series in cosmetic and laser therapy) Includes bibliographical references and index. Summary: “For optimal results from the growing number of fi llers available it is important to understand the use and the limitations of each; it is also important to have an understanding of potential complications, in order to be able to minimize their incidence, and of how to treat any complications if they occur. The growth in other volume replacement procedures has similarly brought new opportunities as well as new problems. This text offers a multidisci-plinary and international perspective on volumetric procedures for the face and neck, as well as therapies for hand rejuvenation and for defects of the torso”--Provided by publisher. ISBN 978-0-415-47644-7 (hardback : alk. paper) 1. Tissue expansion. 2. Surgery, Plastic. 3. Fillers (Materials) I. Sadick, Neil S. II. Series: Series in cosmetic and laser therapy. [DNLM: 1. Cosmetic Techniques. 2. Biopolymers--therapeutic use. 3. Dermatologic Agents--therapeutic use. 4. Injections, Subcutaneous. 5. Tissue Expansion--methods. WO 600] RD119.5.T57I45 2011 617.9’54--dc22 2011001320

Contents

Contributors viiiPreface xAcknowledgments xii

1. Introduction to volumetric enhancement 1Neil S. Sadick

2.1. The approach to volumetric augmentation using injectable fi llers: An overview of the U.S. experience 7Deborshi Roy

2.2. The European experience 12Luitgard Wiest

3.1. Choosing the ideal fi ller 22Cheryl Karcher

3.2. European commentary 33Luitgard Wiest

4. Anatomy of the forehead and periocular region 36Marcelo B. Antunes and Stephen A. Goldstein

5.1. Volumetric approach to the upper face 44Deborshi Roy


6. Anatomy of the midface 52Stephen A. Goldstein and Evan Ransom

7.1. Volumetric approach to midfacial rejuvenation 59Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier


8. Anatomy of the lower face and neck 83Evan Ransom and Stephen A. Goldstein

vi

9.1. Volumetric approach to lower facial rejuvenation 90Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier


10.1. Volumetric approach to the lips 107Mary P. Lupo


11.1. Volumetric approach to rejuvenation of the hands 122Anetta E. Reszko and Neil S. Sadick


12. Complications and their management 139Jason Emer, Heidi Waldorf, and Joel L. Cohen

13. Postliposuction defects 167Misbah H. Khan, Theodore Diktaban, and Neil S. Sadick

Appendix of product names 177Index 185

CONTENTS vii

Marcelo B. Antunes Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Joel L. Cohen AboutSkin Dermatology and DermSurgery P.C., Englewood, Colorado, USA

Theodore Diktaban Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Jason Emer Department of Dermatology, Mount Sinai Medical Center, New York, New York, USA

Mark J. Glasgold Department of Surgery, UMDNJ – Robert Wood Johnson Medical School, Piscataway and Glasgold Group Plastic Surgery, Highland Park, New Jersey, USA

Robert A. Glasgold Department of Surgery, UMDNJ – Robert Wood Johnson Medical School, Piscataway and Glasgold Group Plastic Surgery, Highland Park, New Jersey, USA

Stephen A. Goldstein Department of Surgery, Division of Otolaryngology, The University of Arizona, Tucson, Arizona, USA

Cheryl Karcher Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Misbah H. Khan Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Mary P. Lupo Lupo Center and Clinical Professor of Dermatology, Tulane Medical School, New Orleans, Louisiana, USA

Jason D. Meier Jacksonville, Florida, USA

Evan Ransom Department of Otolaryngology, University of Pennsylvania, Philadelphia, Pennsylvania, USA

Contributors

viii

Anetta E. Reszko Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Deborshi Roy Facial Plastic & Reconstructive Surgery, Private Practice, Los Angeles, California, USA

Neil S. Sadick Sadick Aesthetic Surgery and Dermatology, New York, New York, USA

Heidi Waldorf Department of Dermatology, Mount Sinai Medical Center, New York and Waldorf Dermatology and Laser Associates P.C., Nanuet, New York, USA

Luitgard Wiest Dermatology, Private Practice AB-Centrum, Munich, Germany

CONTRIBUTORS ix

Preface

There are a growing number of fi ller materials available, varying in their composition and optimal usage. In order to obtain the optimal results, it is important to understand each fi ller; this includes not only how to use it but also the limitations of each of these materials. It is also important to have an understanding of potential complications in order to be able to minimize their incidence and of how to treat any complications if they occur.

With the rapid growth in information availability, our patients hear about new techniques and new products, sometimes even before their uses and limitations have been thoroughly evaluated. This rapid spread of “information” makes it more important for medical professionals to have a thorough understanding. Only through detailed analysis, patient education, and precise treatments can we achieve successful results and happy patients.

In addition to facial fi llers, this book includes a volumetric approach to rejuvenation of other parts of the body. Our unique multidisciplinary perspective offers insight into how to diagnose visible aging in the context of volume loss.

Our approach to facial aging takes into account all layers of the face. This book includes detailed techniques for facial analysis and diagnosis of aging conditions. For rejuvenation of the upper face, we discuss advanced techniques involving the forehead, glabella, temple, and lateral brow complex. We introduce some of our new techniques for periorbital rejuvenation, especially for treatment of the nasojugal groove.

The midface is one of the areas most affected by volumetric loss in aging. We illustrate some of our new techniques in this area for treatment of the malar and submalar complex as well as the nasolabial folds.

Volume loss in the lower face occurs primarily around the perioral complex, but changes along the jawline affect the neck as well. Treatment of the lips, perioral rhytides, chin, and jawline are all demonstrated. This area is fraught with possible complications, and preventative techniques are stressed.

One of our exciting new areas is volumetric enhancement of the face. Treatment of the aging hands also requires a multimodality approach, with replacement of lost volume as a key component, and we demonstrate new techniques with several fi llers in the dorsum of the hand. Our treatment technique for post-liposuction and post-traumatic defects of the torso and lower extremities is also shown.

x

This book both acts as an excellent introduction for the novice physician performing volume restoration procedures and also provides new techniques and advanced procedures for experienced physicians. In the past decade, the use of fi llers and volume replacement procedures has been rapidly expanding and now offers many possibilities; we hope that this comprehensive coverage of all aspects from diagnosis to treatment will help practitioners to achieve the safe, reliable, and aesthetic results that patients desire.

Neil S. Sadick Paul J. Carniol Deborshi Roy Luitgard Wiest

PREFACE xi

Acknowledgments

The anatomical drawings in Chapter 4 are the work of Philip Jones from Brian Leatherbarrow’s Oculoplastic Surgery, second edition, Informa Healthcare, London, 2010.

xii

1

1Introduction to volumetric enhancement

Neil S. Sadick

COSMETIC SURGERY TRENDS

The concept of cosmetic surgery and medicine is rapidly changing as it moves from infancy to adolescence. In the past, a youthful appearance was sought through invasive surgical face-lifting techniques. However, there has been a shift in the perception of what consti-tutes a youthful appearance. Physicians and their patients have moved away from the tight, “pulled-back” two-dimensional looks achieved via face-lifts and other surgical procedures. The new movement has been about conservative approaches that deal with the underlying loss of soft tissue to achieve a plumper, less wrinkled, more three-dimensional appearance. This shift in the perception of what constitutes a “youthful visage,” combined with patient demand for minimally invasive procedures, has led to a major expansion in the fi eld of soft tissue augmentation. The “culture” of our civilization has changed dramatically and desires to avail itself of the new science and technology that allow us to look and feel younger as we live longer. The industry of aesthetic medicine and surgery has exploded and is soaring to even greater heights as the next generation becomes the new seniors and seeks to look as young as it feels.

The facial aging process refl ects an interplay of genetic, anatomic, chronologic, and environmental factors. It is characterized by thinning of the epidermis and subcutaneous fat layers and a degree of bone resorption. In addition, a progressive loss of elastic fi bers and collagen and weakening of underlying muscles contribute to the wrinkling process. Age-associated changes can create shadows and hollows where they did not exist before. The aged face has prominent rhytids in the glabella, forehead, nasolabial folds (NLFs), and perioral areas. Today cosmetic surgeons can approach these conditions of atrophic aging with alloplastic implants, autologous fat, or a variety of facial fi llers.

Volumetric fi lling offers an excellent option for the treatment of facial aging, wrinkling, and contour defects. There are viable alternatives to major surgery for patients seeking safe, minimally invasive, and affordable means of maintaining a youthful appearance. It is imperative for the plastic surgeon to have a thorough knowledge of all the available products and their properties. This knowledge will enable optimal pairing of facial fi lling techniques with specifi c concerns and consequent maximal effi cacy and patient satisfaction.

2 ILLUSTRATED MANUAL OF INJECTABLE FILLERS

EVOLUTION OF THE FIELD

Historically, signifi cant volume enhancement has been available through the surgical use of alloplastic implants. The exact origin of maxillofacial prosthetics is diffi cult to identify but major work in the 1930s provided the initiative for maxillofacial, dental, and plastic surgeons to work together for the betterment of focally injured patients. Today, the techni-ques that have evolved from those early trials have become safe and applicable in situations where even minimal deformity is present.

Transferring fat from one area of the body to another has revolutionized the trend of rejuvenation by volume restoration and it can be said that fat was the fi rst available fi ller. There has been interest in fat transfer since the inception of whole fat grafts in the 1890s and injectable fat grafts in the 1920s. From then on, interest waned until the 1980s when interest once again boomed in the plastic surgery community. The rising popularity of this procedure has paralleled the development and popularity of liposuction for body contouring.

Autologous fat is plentiful and readily accessible once the harvesting technique is mastered. The technique is intended to preserve the delicate structure of adipocytes and provide a robust blood supply on which fat cells are extremely dependent. Fat provides excellent volumetric fi lling and the possibility of long-term results exceeding that of resorbable fi llers. Patients’ satisfaction with fat is high and many prefer using their own autologous fat rather than synthetic fi llers. Autologous fat can also offer benefi ts to the skin quality, improving acne, scarring, and providing a healthy luster. Whether this phenome-non is due to nutrients in the fat cells or “stem cell” characteristics as has been proposed is purely theoretical.

Some practitioners believe that fat transfers represent one of the most signifi cant rejuvenation advances of the decade. Volumetric facial rejuvenation is excellent for the forehead, eyes, cheeks, chin, myelolabial lines, lips, marionette lines, and geniomandibular grooves. In the body, large volume fat transfers can be used in the buttocks, breasts, calves, and for posttraumatic or iatrogenic liposuction defects, as detailed in chapter 11.1 of this manual. Ongoing interest in fat transfer and constant reassessment of clinical results will lead to further improvements in the procedure of fat transfer for soft tissue volumization and augmentation.

INJECTABLE FILLERS

The practice of using injectable fi llers for soft tissue augmentation has a long and well-described history. Today it is a crucial tool in the armamentarium of facial volumization.

Over the past decade, the use of injectable products in cosmetic dermatology has increased rapidly to become one of the top three cosmetic procedures performed in a physi-cian’s offi ce. Over the past few years, the search for an ideal fi lling agent has led to a plethora of available materials for facial rejuvenation. The ideal fi ller substance would be nonallergic, noncarcinogenic, nonteratogenic, durable, reproducible, stable, and affordable, and would cause a minimum of adverse events. Arguably, for some the ideal fi ller will be permanent and for others resorbable, depending on the patient’s prior experiences and the physician’s expertise. Although a fi lling material that satisfi es all of the above criteria is yet to be found, there are numerous compounds that fall just short of doing so and are safely and easily administered in the offi ce setting. The choice of fi lling substance depends on the

INTRODUCTION TO VOLUMETRIC ENHANCEMENT 3

depth of the target to be treated as well as various patient factors. It is important for the injector to be judicious, always informing patients of the risks and benefi ts of treat-ment and advocating appropriate test doses, if necessary, to avoid or minimize potential adverse events.

In the 1980s, the use of bovine collagen for cosmetic purposes started a new era of soft tissue augmentation. Over the past fi ve years alone, the number of approved facial fi ll-ers in the United States and abroad has grown rapidly. To date, the most widely used fi llers fall into three major categories: collagens, hyaluronic acid, and biosynthetic fi llers.

In addition to the categorical differences described earlier, facial fi llers can be grouped according to their degree of permanence after injection. Nonpermanent fi llers pro-duce short-lived results and eventually undergo resorption. Fillers of this type will require repeated injections for long-term results. Semipermanent fi llers typically last longer than most nonpermanent fi llers but can be expected to experience some resorptions as well. Only permanent fi llers can be expected to produce long-term results with a single injection.

Short-Term Fillers

Collagens

Collagen is a major component of human connective tissues such as bone, cartilage, skin, and vasculature. The injectable forms consist of varying concentrations of purifi ed bovine, porcine, or human collagen. Bovine collagen was the fi rst Food and Drug Administration (FDA)-approved facial fi ller in 1981 and was harvested from an isolated U.S. herd. One major disadvantage of bovine collagens (Zyderm, Zyplast) is their potential for immuno-genicity and mandatory skin testing. Improving on the issue of allergic reactions are human (CosmoDerm, CosmoPlast) and porcine (Evolence) collagens. At the time of this writing, Evolence has been removed by the manufacturer from the U.S. market; however, the potential remains for a porcine fi ller to be reintroduced. All collagen fi llers are biodegrad-able and resorbable with results lasting under one year. Slowing of collagen resorption (prolonged fi ller effect) is accomplished by cross-linking the collagen with moieties such as glutaraldehyde or ribose. Rapid degradation is not necessarily a drawback to collagen products; indeed, it is an asset under some aesthetic requirements. Collagens are best suited for superfi cial correction and are injected into the dermal plane.

Hyaluronic Acid

Hyaluronic acid (HA) fi llers are particularly popular because they have a low potential for allergic reaction and require no skin testing. Although they are not permanent, most of these agents have a signifi cant length of duration. As of the start of 2010, there are nine U.S. FDA-approved HA fi llers: Restylane, Perlane, Juvederm Ultra, Juvederm Ultra Plus, Elevess, Prevelle Silk, Hylaform, Hylaform Plus, and Captique. A new HA product known as Puragen Plus in Europe is projected to be FDA-approved in spring 2010, and may be approved by the time of this publication.

HA is a naturally occurring glycosaminoglycan that composes the extracellular matrix of connective tissues. In the skin, it provides structure and volume while also main-taining and attracting moisture. As the skin ages, the amount of HA decreases and corre-lates with the formation of rhytids. Clinically, the injection of HA into the skin replenishes


volume and revitalizes the skin’s appearance. Most of the HA on the market are nonanimal-stabilized HAs and are manufactured by the fermentation of Streptococcus equi bacterium. The Hylaform family is animal derived from rooster combs. Most of the products differ in the total HA concentration and degree of cross-linked material. The total HA concentration refers to the measure of insoluble HA and soluble HA in a product. The soluble of liquid form of HA is absorbed very quickly and is added to some products to improve lubrication and fl ow through the needle. The insoluble gel portion that persists in the skin after injec-tion contributes to the clinical effect. All of the currently available HA fi llers are indicated by the FDA for injection into the mid to deep dermis for the correction of moderate to severe facial wrinkles and folds, specifi cally NLFs. However, HA products are routinely used for off-label indications.

Intermediate to Long-Term Fillers

Calcium Hydroxylapatite

Calcium hydroxylapatite (CaH), long used as a bone replacement, lends itself well to soft tissue augmentation. Its high density and low solubility provide a long-term effect with minimal immune sensitivity. Radiesse™ is the only FDA-approved CaH dermal fi ller. It is a viscous gel, composed of carboxymethylcellulose, glycerine, and purifi ed water, within which 25 to 45 µm spherical particles of CaH are suspended. Radiesse is consid-ered a medium- to long-term volumizer with duration of effect being reported to last over 12 months. Additionally this fi ller has been found suitable for diverse locations. In addi-tion to volumizing the cheeks and NLFs, Radiesse is utilized for nose and chin augmenta-tion as a panfacial volumizer and contouring agent. Currently several large prospective studies are underway examining Radiesse usage in the dorsum of the hands and this indi-cation is reviewed in chapter 10 of this manual. In July 2009, Radiesse received FDA approval for lidocaine reconstitution prior to injection, a trend that is expected in other fi llers as well.

Poly- L -lactic Acid

Poly- L -lactic acid (PLLA) is a synthetic material used in resorbable sutures, plates, and screws. PLLA for injection is available as Sculptra, a powered form of PLLA in micro-spheres 40 to 63 µm in diameter, which must be reconstituted with sterile water prior to injection. PLLA is categorized as a bioactive fi ller due to its ability to stimulate neocolla-genesis. PLLA was initially FDA-approved for HIV lipoatrophy correction but was fre-quently used off-label for other cosmetic concerns. In July 2009, Sculptra was approved for aesthetic indications by the FDA. It is primarily utilized for diffuse global correction rather than individual rhytids and often requires multiple sessions for desired results. Correction is not immediate and requires three to six months as fi broblasts are stimulated to produce new collagen and dermal remodeling occurs.

Permanent Fillers

Currently only one fi ller, ArteFill, is FDA-approved for permanent correction. ArteFill is composed of polymethylmethacrylate microspheres in a bovine collagen carrier. The

INTRODUCTION TO VOLUMETRIC ENHANCEMENT 5

nondegradable microspheres serve to stimulate fi broblast activity and connective tissue ingrowth giving ArteFill a biostimulatory property. The end result is a biologically stable matrix that creates a durable, long-lasting cosmetic enhancement. An essential key to suc-cessful ArteFill use is a conservative approach with avoidance of overcorrection. In addi-tion to ArteFill, off-label silicone usage is practiced for wrinkles, scars, and augmentation of the lips. Although aesthetic silicone usage is currently not widely practiced in the United States, the practitioner may encounter patients who have undergone previous volu-mization with this product. It is important to be aware of the complications that may develop in these patients and the risk profi le of performing procedures on patients with implanted silicone.

OTHER CONSIDERATIONS

Although injectable fi llers can offer an effi cacious alternative to surgery, they also have their limitations. It is important for the plastic surgeon to recognize specifi c circumstances which may be best managed with an alternative to fi llers, including superfi cial contour defects too shallow for fi llers; areas with signifi cant skin laxity in which fi ller injection may result in lumpiness; and deep defects or folds in areas of dynamic movement, which may result in fi ller dislodgement or visible fi ller implants.

Appropriate and complete training is critical for success with all fi llers. Indeed train-ing is often a regulatory requirement associated with treatment. Choosing a dermal fi ller for a particular defect is perhaps more an art than science, with few hard and fast rules. Most products have only been studied in the NLFs, but are used in many other applications, thus experience remains the best teacher. Table 1.1 lists some general-use criteria for der-mal fi ller products that are elaborated on in the later chapters. Short-term volumizers such as collagen and HA fi llers are best used for superfi cial, smoothing applications. The longer-lasting stimulatory fi llers are benefi cial for deeper contouring in areas where a more signifi cant tissue response is instrumental in achieving the desired effect.

Dermal fi llers are labeled for injection at specifi c dermal depths. In general, the more viscous and thick the product, the deeper it is to be injected. Care must be taken in thin-skinned areas, such as the glabellar lines, the lips (especially the vermillion border), which may be prone to vascular occlusion and necrosis, or may result in exaggerated protrusion. The literature is full of the trials and wisdom of the pioneers in this fi eld of ever-expanding technology and increasing refi nement of technique. It is imperative to refer to the medi-cal annals and to remain updated on the evolving indications and recommendations of usage.

Table 1.1 Typical Uses of Dermal Fillers

Zyderm/CosmoDerm Superfi cial lines and creasesZyplast/CosmoPlast Lips; short durationHyaluronic acids General use productsRadiesse Deeper folds; deep dermal/supraosteal placementSculptra Deep placement; panfacial volumizerArteFill Permanent in deep to mid dermisSilicone Deeper placement lessens beading and migration


CONCLUSION

The fi eld of aesthetic volumization has grown considerably from the humble beginnings of bovine collagen over 20 years ago. The ease and effectiveness of fi llers has led to great patient acceptance and demand. Today there are many choices driven by powerful market-ing campaigns that have patients clamoring to try the latest fi ller available. The race is on and the search will continue for better and more appropriate injectables that will allow cosmetic surgeons and dermatologists to offer a broad scope of therapeutic combinations. It has been said that a millimeter of improvement on the face is a kilometer in the soul. Although improvement may be transient, patients are very often gratifi ed at turning back the clock, however temporarily. Volume fi lling in the face has moved on to other anatomic locations, such as the hands, décolleté, breasts, and buttocks. The combination approach with neurotoxins and anatomically tailored fi ller placement has allowed for the emergence of the “liquid facelift,” the epitome of noninvasive rejuvenation. Thanks to the success, safety, and ongoing research into dermal fi llers, it is an exciting time for cosmetic surgeons, industry, and most importantly our patients.

7

2.1The approach to volumetric augmentation using injectable fi llers: An overview of the U.S. experience

Deborshi Roy

INTRODUCTION

Our world is changing every day, but the desire to look younger remains the same. Technological advancements coupled with an explosion in the public’s interest in minimally invasive procedures have led to a major increase in the use of injectable fi llers. In this chapter, we will be outlining our multidisciplinary approach for using injectable fi llers for volumetric augmentation throughout the body.

BACKGROUND

The quest for the ideal injectable fi ller continues to this day. The ideal injectable fi ller would be safe, easy to use, and give long-lasting, consistent results.

Liquid silicone was the fi rst fi ller available in the United States to treat contour defects, scars, and rhytides of the face. It was widely used for two decades until concerns about long-term safety caused it to fall out of favor ( 1 , 2 ). Several years ago, a new liquid silicone product was cleared by the Food and Drug Administration (FDA) and has been used in an “off-label” fashion for cosmetic enhancement of the face. Liquid silicone is an example of a permanent fi ller.

Bovine collagen was the second available injectable fi ller and was widely used with a very low incidence of complications ( 3 ). Allergy testing of the skin was necessary with the original formulations—Zyderm and Zyplast. The results from these products lasted for a few months after injection, requiring frequent administration. Over the years, collagen-based products have evolved. CosmoDerm and CosmoPlast (recombinant human collagen) eliminated the need for skin testing. Evolence (porcine collagen) was cross-linked, giving it a longer-lasting quality, and did not require skin testing.

Autologous fat transfer techniques were introduced around the same time as bovine collagen. The safety of using autologous material cannot be matched by any foreign body,


animal or synthetic. However, there is an increased morbidity associated with this more invasive type of procedure that requires a separate harvesting and administration. Consistent, reproducible results have also become an obstacle for some practitioners. Because it is a free graft of live tissue, autologous fat transfer has the potential for lasting over several decades, given the grafts remain viable.

Hyaluronic acid fi llers are among the pack of the latest, most widely used nonsurgi-cal cosmetic treatments. Hyaluronic acid products can be derived from animal sources or from bacterial fermentation ( Table 2.1.1 ). The various preparations currently available in the United States differ in cross-linking and concentration of hyaluronic acid in the carrier vehicle. Although the products are all similar, there are subtle differences that lead each injector to have his or her own preference. Results last from four to six months after injection.

Calcium hydroxylapatite suspended in a matrix composed of water, glycerin, and sodium carboxymethylcellulose is known as Radiesse. This is a bulkier product than those previously mentioned and is injected into a deeper plane. The unique viscosity and elasticity of the material make it possible to mold the implant for several minutes after injection, minimizing irregulari-ties in contour. Unlike the previous products, Radiesse has been shown to stimulate new collagen growth in the injected areas ( 4 ). Results last from 8 to 12 months after injection.

Sculptra is a suspension of poly-L-lactic acid in water. Unlike the previously men-tioned products, it is not used in a single-injection session. In order to obtain optimal results, multiple injection sessions several weeks apart must be utilized. This product can also induce new collagen growth, and has been clinically shown to increase dermal thickness over time, with results lasting for several years ( 5 ).

Artefi ll is a combination of polymethylmethacrylate (PMMA) spheres and bovine collagen. This product requires skin testing, and can last for several years as the bovine collagen is replaced by autologous neocollagen over time, since the PMMA spheres provide a permanent platform.

APPROACH TO INJECTABLE FILLERS

Ours is a multispecialty based approach that involves volumetric assessment and global improvement of all areas of concern. Since most problems are multifactorial, a comprehen-sive analysis is followed by a customized treatment plan that addresses each individual problem as well as overall aging. The most important facets of the aging process that we focus on are sun damage, loss of elasticity, and loss of volume. We will focus on volume loss and its relation to injectable fi llers.

Table 2.1.1 Various Hyaluronic Acid Injectable Filler Preparations

Juvederm UltraJuvederm Ultraplus

Nonanimal stabilized hyaluronic acid (NASHA)

RestylanePerlane

NASHA

Elevess NASHA + lidocaineHylaform Animal hyaluronic acid

AN APPROACH TO VOLUMETRIC AUGMENTATION USING INJECTABLE FILLERS 9

EVALUATION

Careful evaluation and proper diagnosis is critical for a favorable outcome. We analyze the entire anatomic area including the skin, subcutaneous tissue, muscle, fat, and bone. A global appreciation for the proportion and geometry of the area as a whole and the harmony between aesthetic subunits helps to produce the fi nishing touches to volumetric rejuvenation.

When evaluating the face, we break it up into three units: the upper face, from the hairline down to the horizontal axis that goes through the canthi; the midface, from the below the canthi to the upper lip; and the lower face, which starts from the upper lip and ends in the upper neck. Loss of volume can take place in any of the three areas and is usually not confi ned to one. The most common area treated for volume loss is the midface, followed by the lower face.

Off the face, volume loss is most commonly treated in the dorsal part of the hands. Other areas such as the trunk and lower extremities are most commonly treated for scars or postsurgical defi cits.

INJECTION TECHNIQUES

Depending on which fi ller is being used and which area is being treated, there are three choices for the amount of material used. One can decide for a 1:1 correction, overfi lling, or underfi lling. In most cases, one would inject to the point of desired correction. In certain areas (such as the lips) and with certain fi llers (such as collagen), a slight overcorrection is necessary. Undercorrection is most often used with Sculptra, since multiple treatment sessions are employed, with a gradual buildup of product.

There are several injection techniques, and each injector has his or her favorites. There are some situations where one technique is preferred over the other due to anatomic considerations or the depth of injection required. The main techniques are serial puncture, linear threading, cross-hatching, fanning, and depot ( Figs. 2.1.1 – 2.1.4 ). Although most injectors prefer using transcutaneous injection techniques, there are several transoral injection techniques for treatment of the mid and lower face.

Figure 2.1.1 Serial puncture.


Figure 2.1.2 Linear threading.

Figure 2.1.3 Fanning.

Figure 2.1.4 Depot.

AN APPROACH TO VOLUMETRIC AUGMENTATION USING INJECTABLE FILLERS 11

CONCLUSION

There are a myriad of choices when it comes to injectable fi llers. The most important aspect of volumetric enhancement is the clinical evaluation of the patient. Our global approach, considering all aspects of the aging process and the overall picture is a compre-hensive way of assessing the problem and tailoring the treatments accordingly. Fillers can also be combined with surgical and nonsurgical treatment modalities to achieve maximal treatment of multiple factors. Our approach, when combined with excellent injection technique, can produce wonderful results with a high degree of patient satisfaction.

REFERENCES

1. Aronsohn RB. A 22-year experience with the use of silicone injections. Am J Cosmet Surg 1984; 1: 21–8.

2. Pearl RM, Laub DR, Kaplan EN. Complications following silicone injections for augmentation of the contours of the face. Plastic Reconstr Surg 1978; 61: 888–91.

3. Cooperman LS, Mackinnon V, Bechler G, Pharriss B. Injectable collagen: a six-year clinical investigation. Aesthetic Plast Surg 1987; 79: 581–94.

4. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of botulinum toxin A and non-animal sourced hyaluronic acid. Dermatol Surg 2003; 29(8): 802–9.

5. Silvers SL, Eviatar JA, Echavez MI, Pappas AL. Prospective, open-label, 18-month trial of calcium hydroxylapatite (Radiesse) for facial soft-tissue augmentation in patients with human immunodefi ciency virus-associated lipoatrophy: one-year durability. Plastic Reconstr Surg 2006; 118(3 Suppl): 34S–45S.

12

2.2The European experience

Luitgard Wiest

The marketing of bovine collagen preparations began in 1981 and reigned until the mid-1990s, heralding the beginning of the modern era of injectable fi llers for facial rejuvenation. The introduction of the next generation of products, for example, hyaluronic acid (HA) products in the 1990s, started an increase in the number of newly available fi llers ( 1 ), but today the number of available injectable products in Europe has dwindled to almost 200. Why is that?

Until 1993 dermal fi llers were considered drugs, but they are now included in the category of medical devices. Since 1998 injectable fi llers are required to bear a CE ( Conformité Européenne) marking. This marking does not offer any guarantee as to the effi cacy of the product or its safety. The allocation of a CE marking is based on the product’s technical fi le, clinical data, and quality assurance. A CE marking exclusively controls the safety and performance claimed by the manufacturer. A product bearing a CE marking is registered automatically and can be sold in all European countries. These requirements are less stringent than those required for Food and Drug Administration (FDA) approval. The ease in obtaining a CE marking for injectable fi llers has led to an explosion in the number of fi llers especially HA products even resulting in the fi rst CE certifi ed Chinese HA product being marketed as a “Restylane alternative” from Hangzhou Gallop Biological Products, China.

The current situation in Europe is such that the fi ller is produced and marketed and only after extensive use does it undergo random testing to see whether it works and is safe. More often, the new fi ller is introduced in Europe and thereafter FDA approval is adapted by U.S. practitioners. This allows for prior assessment of the newer fi ller products in Europe for their safety and use in cosmetic procedures. These injectable fi llers available to practi-tioners in recent years have different properties, offering different modes of application with different durations of correction.

Currently there are more than 120 different HA products on the market ( Table 2.2.1 ), which are the most commonly used degradable fi llers in Europe ( 2 , 3 ). They are very popular for dermal augmentation and, in the past few years, for soft tissue and facial volume restoration, which have recently become a focus in facial rejuvenation. The vast choice of fi llers is a big challenge for the physician as well as the patient. Among the most

THE EUROPEAN EXPERIENCE 13

popular HA products are various FDA-approved Q-Med products like Restylane ® and Per-lane ® (see chaps. 2.1 and 3), and the FDA-approved HA fi llers from Allergan Juvederm Ultra ® and Juvederm Ultra Plus ® ( 4 ).

Table 2.2.1 Hyaluronic Acid Fillers (June 2010)

Ac-Hyal®

Amalian Balance, Amalian I, II, III, Amalian LipsAlayna Hydro, Light Regular, Repair, Lip VolumeBeauty Gel, Beauty Sphere (HA+Dextranomers)Belotero Basic®

Belotero Soft®

Belotero Intense®

CaptiqueCRM-Dermal Filler, Soft, Dur, Gel, Dex, DXCristal 1,2, Soft, Cristal LipsDethail Coilingel, Dethail Lastingel (HA+Dextran.)Esthelis Basic, Esthelis Soft, Esthelis+GlycerolEsthelis Men®

Fortélis ExtraGlytoneHyacellHyacorp S/Lips/S Face, L, H Hyal 2000 InjectioHyal-System®, Hyalsystem HyalACPHyaluderm®

H. RevitalizeHydrafi ll Grade 1, 2, 3®

Hydrafi ll Softline®

Hydrafi ll Softline MAX®

Hylaform Fine Lines®

Hylaform®

Hylaform Plus®

IAL SytemIsogel 1, 2, 3Juvederm® Ultra SmileJuvederm ™ Voluma ™ Juvederm ™ Hydrate ™ Juvederm Ultra 2,3,4, Juvélift Corneal®

Juveni HA Volumizer, Juveni mesoliftJuveni+Lidocaine 2% mixingLaresse™M-HA18, X-HA, X-HA VolumeNCTF 135, NCTF 135HA®

Mac Dermol S and R®

Mac dermol Bio®

Macrolane®

Matridur®

(Continued )


Table 2.2.1 (Continued ) Hyaluronic Acid Fillers (June 2010)

Matridex® (HA+Dextran)Prevelle Silk™ Prevelle PlusPerlane Lidocaine ™Princess Rich, Filler, Volume®

Pluryal®

Puragen™Puragen Plus Restylane Perlane®

Restylane LidocaineRestylane®

Restylane SubQ®

Restylane Touch®

Restylane Vital®

Restylane Lipp®

Revanesse, PureRevanesse UltraReDexis, Redexis UltraReviderm Intra® (HA+Dextranomers)Revitacare Rofi lan®

SkinFill™ Silver, Gold, DiamondSucceev One, Two, Three®

Surgiderm® 18, 30Surgiderm® 24XPSurgiderm® 30XPSurgilips®

Surgilift® PlusStylage® S, M, L, XL, HydroTeosyal Global action®

Teosyal Deep Lines,Teosyal Ultra DeepTeosyal KissVarioderm ™Varioderm Plus™Varioderm Subdermal™Varioderm FineLine™Viscontour®

Visagel®

Voluma Corneal®

Zetavisc L®

Z Fill® Refresh, Deep,Z Fill Repair+Dextranomers

With the discovery of new technologies, the HA fi llers have been developed into more sophisticated products ( Tables 2.2.2 and 2.2.3 ) and address different aesthetic needs and clinical indications, some of them being combined with lidocaine to decrease the discomfort of the injection.


Table 2.2.2 Products for Lip Augmentation

Amalian LipsAlayna Lip Volume Cristal LipsHYAcorp S/LipsGlytoneJuvederm Ultra SmilePermalipRestylane LippStylage Lip

Table 2.2.3 Increase in the Development of “Volumizers” During Recent Years

Volume enhancing injectablesFat grafts2004: Restylane SubQ® (Q-Med), Redisesse2005: Juvederm Volume® (Allergan)2006: Atlean (TCP), Laresse (CMC + PEO)2007: Fortélis Extra® (Anteis), Teosyal Ultradeep (Teoxane)2008: Belotero Intense (Merz)

Volume (Corneal)GlytoneRedexis UltraRevanesse UltraIsogel (Filorga)CRM DXStylage XLAmalian III

2009: Novabel (Merz) “Shaper” (?)Hyacorp L, HyaCorp H

2010: Succeev Three (Sanofi Aventis)Princess Volume

Flow properties and longevity vary among different HA preparations and are in general determined by

• Molecular weight • Concentration of HA • Degree and technique of cross-linking with different cross-linkers such as BDDE (buta-

diene diepoxide), DVS (divinyl sulfone), and 1,2,7,8-DEO (diepoxyoctane) • More cross-linking—harder gel • Sizing of the gel particles • Relation cross-linked/noncross-linked HA • Hydration level

Today the hyaluronans of the fourth generation are becoming more popular ( Table 2.2.4 ). New technologies such as cohesive polydensifi ed matrix (CPM ® ) have recently led to

the introduction of a monophasic preparation. The CPM technology involves the creation of


a homogenous, totally cohesive, and elastic gel with different densities, thus yielding double cross-linking in areas with the highest density and simple cross-linking in areas with less density. The advantage of these cohesive gels is optimal biointegration of the product injected into the dermis ( 5 , 6 ) by minimizing the risk of nodule formation due to its elasticity.

Lip augmentation has become very popular but demands a special injection technique ( 7 , 8 ). In this region, fi llers tend to form nodules due to the multiple functions with constant movements of the lips while smiling, speaking, and eating. Special preparations ( Table 2.2.2 ) for lip volume augmentation that penetrate homogenously with lower viscosity are available on the market.

HA fi llers prepared using the CPM technology rank among the most popular products in Europe along with those HA products which have already been approved by the FDA in the United States. They seem to provoke the least tissue response two to four weeks after injection in comparison with other HA fi llers ( 4 ).

Belotero ® (Merz Aesthetics, Germany) and Esthélis ® (Anteis SA, Switzerland) ( 5 , 9 ) both prepared using the CPM technology and representing the same product are marketed in different formulations: Belotero Soft ® and Esthélis Soft ® , with a HA content of 20 mg/mL, are designed for more superfi cial wrinkles and are to be injected into the upper dermis; Belotero Basic ® and Esthélis Basic ® , with a HA content of 22.5 mg/mL, are used for deeper wrinkles with a Wrinkle Severity Rating Scale score of 4 and for lip augmentation; Belotero Intense and Fortélis Extra, with double cross-linking and the highest HA content of 25.5 mg/mL, are used for very deep wrinkles, are injected deep into the dermis, and are used for volumizing and lip augmentation. Esthélis Men is the same as Esthélis Basic, but is marketed for male patients.

To facilitate injection of their HA products especially for the novice Anteis has developed the Anteis Injection Pen, which is an automated injection system designed for local injections. The use of this injection pen will alleviate pain for the patient and decreases the amount of adverse effects compared with manual injections (hematomas, redness, bruising). It provides more comfort and ease of use for the practitioner with better control of depth, fl ow, and volume, thereby optimizing clinical results. All that remains is justifying the cost–benefi t of this device.

Since 2007 Macrolane (Q-MED) is the fi rst HA injectable fi ller that has been injected in large volumes subcutaneously or subperiostally into the body; it is available in two forms

Table 2.2.4 Development of Hyaluronic Acid Fillers: Fourth Generation of Hyaluronans

Generation Name Source Cross-linking Technique Form Year

G0 Healon Avian Solution 1966G0 Synvisc Avian DVS Simple Particles 1988G1 Hylaform Avian DVS Simple Particles 1990G2 Restylane Streptogen BDDE Simple Particles 1994G3 Puragen Streptogen 1,2,7,8-DEO Double Particles 2001G4 Belotero Streptogen BDDE CPM Polydense

matrix20042006

Abbreviations: BDDE, butadiene diepoxide; CPM, cohesive polydensifi ed matrix; DEO, diepoxyoctane; DVS, divinyl sulfone.

Source: From Ref. 3.


Macrolane VFR 20 and Macrolane VFR 30. The injection should be performed under local anesthesia with a blunt 0.2 cannula mounted on a 10 mL syringe of Macrolane. With Macrolane, migration has been seen and in a breast pilot study, where amounts of 100 mL of gel were used, microcalcifi cations were observed on radiological examination ( 10 ).

For longer-lasting results in some HA fi llers such as Redexis ® (Prollenium Medical Technologies Inc.), Matridex ® (BioPolymer GmbH, Germany), Beauty Sphere ® (Rofi l Medical International Germany), Dethail Lastingel ® (Phitogen, Italy), Reviderm Intra ® (Rofi l Medical International, The Netherlands), dextranomers (Sephadex)—cross-linked spherical dextran (sugar glucose) beads (size 40–60 µm)—are added, which are positively charged and considered to regenerate new collagen ( 11 ).

It is believed that incorporation of glycerol into an HA fi ller (Esthélis+Glycerol, Anteis), will provide higher resistance to free-radical, enzymatic, and thermal degradation (tests in vitro) of the fi ller. Glycerol is an endogenous natural moisturizing factor which contributes to maintaining the hydration rate of the dermis and reinforces the stratum corneum in its role as a barrier to water loss.

Autologous fat is considered the original fi ller, as it exhibits most of the properties that are expected of an ideal fi ller. It is fully biocompatible, readily available, easily transferred from one area to another, making the procedure for restoring volume in the aging face very cost-effective. All this contributes to its widespread use in Europe since the late 1970s when the procedure of fat grafting, fi rst reported in 1893 by Neuber ( 12 ), was revived by Illouz ( 13 ) and Fournier ( 14 ). Since then the technique of harvesting, preparing, and delivering fat is being refi ned ( 15 ), with acceptable patient satisfaction ( 16 , 17 ). The degree of permanence of autologous fat grafts in the subcutaneous tissue varies. Techniques to add adipose derived stem cells to human autologous fat grafts are now being developed ( 18 ) to extend the longevity of the fat grafts.

In Europe, collagen products no longer play a role since Johnson & Johnson announced in November 2009 their intention to discontinue the manufacturing and marketing of their Evolence ® products, which initially had a very good start in Europe. Much to our regret, Zyderm ® I and II and ZYplast ® are no longer available in Germany. I consider Zyderm I to have the best fl ow capacity for correction of fi ne wrinkles when used in the upper dermis.

Medical grade silicone is available in Europe in form of PMS 350 (Vikomed), which has a kinematic viscosity of 350 cSt. Its use is limited due to negative public opinion and the risk of foreign body granulomas.

Among the biodegradable but slowly absorbable fi llers, poly- L -lactic acid (PLLA) manufactured under the name Sculptra ® (Sanofi -Aventis) has been used the longest in aesthetic medicine in Europe since 1999 (see chap. 3.1). PLLA is a biocompatible, slowly biodegradable synthetic polymer which results in a gradual increase in the facial volume via endogenous production of fi broblasts and subsequent generation of new collagen. Correct reconstitution and administration are considered very important parameters for the optimal use of this fi ller ( 19 , 20 ). The dermal thickening is achieved over the course of several months ( 21 , 22 ). PLLA is slowly degraded into lactic acid microspheres through nonenzymatic hydrolysis ( 23 ). The safety of injectable PLLA has been addressed in several HIV trials; adjustments undertaken in the dilution and injection technique of PLLA and correct placement of the product appear to have improved safety outcomes ( 24 , 25 ).


In earlier experiences with the PLLA product marketed under the name New Fill ® , side effects like nodules and foreign body granulomas were observed in 10% to 30% of subjects ( 26 – 28 ). This experience with a fi ller is an example of a product marketed before a wider series of clinical studies had proved that a greater amount of dilution of the agent and the tunneling technique without overcorrection subcutane-ously would improve the safety parameters. Physicians used the product like a fi ller with injections that were too superfi cial. Since the reappearance of the PLLA product under the name Sculptra (Sanofi -Aventis Laboratories), which is reconstituted with a minimum of 5 mL of apyrogenic water, physicians have changed to a totally different injection technique and compared with the use of other “fi llers” the safety records are excellent ( 29 , 30 ).

Another degradable substance with a long-term effect is Radiesse ® (Merz Pharma-ceuticals) (see chap. 3.1), which was developed in the United States, made its way across the ocean, and was introduced into the European market in 2004. It provides immediate and long-term effects based on its twofold mechanism of action: immediate correction with the carrier gel containing carboxymethylcellulose and long-term correction with the develop-ment of new collagen surrounding the Ca HA microspheres ( 31 ). Only a few studies have been conducted in Europe ( 32 ). The popularity of this fi ller is growing, yet the U.S. experience outgrows by far the European clinical experience ( 33 – 35 ). The clinical use of Radiesse for hand rejuvenation shows encouraging results ( 36 ).

Among the “permanent” fi llers with the longest clinical experience is Artecoll ® (Rofi l Medical International, Breda, The Netherlands), containing polymethylmethacry-late (PMMA) spheres with a size of 30 to 42 µm suspended in a collagen gel matrix ( 37 – 39 ). At the time of injection, PMMA is effective for the correction of wrinkles and functions as a temporary spacer. When the carrier gel is degraded, the PMMA particles cause endogenous fi broblast activity which leads to a gradual increase of facial volume over time. PMMA Artecoll was introduced into the market in 1992 as a second- generation formulation following the PMMA product Arteplast ® . A third-generation product ArteFill ® ( 40 , 41 ) (see chap. 3.1) was manufactured in the United States (Artes Medical, San Diego) and was the fi rst permanent dermal fi ller to be approved by the FDA in 2008 when the manufacturer went bankrupt. In this third generation, the collagen matrix is optimized with enhanced uniformity of the microspheres and a smaller size and near elimination of nanoparticles compared with the second-generation product Artecoll, , which is still in common use in Europe. It is indicated for glabella frown lines, nasolabial folds, upper lip lines, and marionette lines. It has to be injected very deep into the reticular dermis. My favorite technique with Artecoll is the microdroplet technique using only tiny amounts of the product. This helps to avoid late complications like foreign-body granulomas.

Aquamid ® (Ferrosan, Copenhagen, Denmark) has been marketed in Europe since 2001. It is a polyacrylamide 2.5% gel (PAAG) with a very high water content of 97.5 %; it is kept in place by means of a fi brous capsule (endoprothesis) ( 42 ). These capsules are surrounded by fi broblasts and macrophages ( 43 ). Larger amounts of injected PAAG remain in the tissue for about 20 years, while smaller amounts like 0.1 mL of Aquamid are absorbed in 9 months. PAAG gels are well tolerated ( 44 ), but if injected in larger amounts may cause late complications ( 45 ). Aquamid is indicated for lip augmentation, deep nasolabial folds, and marionette lines, to give volume to cheeks and chin.


Dermalive ® and Dermadeep ® (Dermatech, Paris, France) have been on the European market since 1991 but were withdrawn from the market two years ago. They are composed of an acrylic polymer hydroxyethylmethacrylate and ethylmethacrylate with a water content of 26%. The fi ller is a combination of 40% polygonal hydrogel particles which are suspended in 60% cross-linked HA gel. The hydrogel particles in Dermalive had a diameter of 45 to 60 µm, whereas the hydrogel particles in Dermadeep had a diameter between 80 and 110 µm. The manufacturer claimed biocompatibility and inertness of these fi llers; yet after the initial success ( 46 ) and after a few years of injecting these fi llers, late adverse events increased ( 47 ), and electron microscopic studies demonstrated that these fi llers undergo morphological changes in human dermal tissue ( 48 ) over the years. As a result, these two products were withdrawn from the European market and are no longer in clinical use, yet we do still see the late complications of these acrylic hydrogels in the form of disfi guring foreign body granulomas.

Novabel ® (Merz Aesthetics, Frankfurt, Germany) is a new injectable fi ller made up of biocompatible soft gel spheres of highly purifi ed polysaccharides derived from natural brown algae, which undergo an intensive purifi cation process to build a homogenous orbital matrix (HOM™). The matrix consists of a three-dimensional network of minerally linked polysac-charides, giving fl exibility and stability simultaneously. One milliliter contains 12 mg of Ba cross-linked alginate. The low viscosity of Novabel requires very low injection force and can be injected through a 30 G1/2 needle.

It is used primarily to treat deep nasolabial folds, mentolabial folds, and marionette lines. It can be used for volumization of the cheeks, chin, décolleté, and hands. Marketing of this fi ller began in January 2010 in several European countries. In a phase III study conducted with 154 patients at several locations in France and Germany, clinically relevant improvement after injections of Novabel for correction of nasolabial folds was still noticeable after 12 months in 47% of the patients, and after 18 months in 43% of patients.

CONCLUSION

For the past 30 years, modern injectable fi llers have become increasingly popular and represent a viable alternative to surgical intervention for correction of the aging face. With their different properties, and different modes of administration, they allow the physician to tailor the use these agents for facial rejuvenation as required. Some of these agents have disappeared from the market, but many more have just recently appeared.

In Europe, the procedure to obtain the CE certifi cation for the manufacture of such substances is relatively easy, and most of the injectable fi llers for cosmetic use are brought into the market without suffi cient clinical experience and relevant studies, thus provoking unnecessary complications.

However, many adverse events are related to the procedure, experience, and skill of the injector, rather than to the product. These adverse events can be avoided with experience and training. Many injection techniques in approaching a specifi c problem have been changed or have been newly introduced. The techniques for facial rejuvenation have changed from simply correcting wrinkles to panfacial augmentation and to combining fi llers with other modalities for rejuvenation.

The use of Botulinum toxin for the treatment of expression areas has become gold standard before using fi llers in these areas to optimize their rejuvenating effect ( 49 , 50 ).


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7. Braun M, Braun S, van Eijik T. Lip tenting: a simple technique for better lip enhancement. J Drugs Dermatol 2010; 9: 559–60.

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11. Laeschke K. Biocompatibility of microparticles into soft tissue fi llers. Semin Cutan Med Surg 2004; 23: 214–17.

12. Neuber GA, Fett Transplantation.Verl Dtsch Ges Chir 1893; 22: 66. 13. Illouz YG. The fat cell “graft”: a new technique to fi ll depressions. Plast Reconstr Surg 1986;

78: 122–3. 14. Fournier PF. Microlipoextraction et microlipoinjection. Rev Chir esthet Lang Fr 1985;10: 40. 15. Coleman SR. Structural fat grafting: more than a permanent fi ller. Plast Reconstr Surg 2006;

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at varying concepts and techniques. Facial Plast Surg Clin North Am 2007; 15: 99–111. 18. Hedrick MH, Fraser JK, Hicok HC. The potential role of adipose derived stem calls as

semi-permanent/permanent fi llers in aesthetic surgery. In: Cohen SR, Born TM, eds. Facial Rejuvenation with Fillers. Saunders Elsevier Ltd, 2009: 107–19.

19. Hilinski JM, Cohen SR. Volumetric use of injectable fi llers in the face. In: Cohen, SR, Born TM, eds. Facial Rejuvenation with Fillers. Saunders Elsevier Ltd, 2009: 80.

20. Lam SM, Azizzadeh B, Gravier M. Injectable poly-L-lactic acid (Sculptra): technical considerations in soft-tissue contouring. Plast Reconstr Surg 2006; 118(Suppl): 55–63.

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22. Vleggar D, Bauer U. Facial enhancement and the European experience with Sculptra (poly- L-lactic acid). J Drugs Dermatol 2004; 3: 542–7.

23. Hartmann M. Biopolymers from Renewable Resources. Berlin: Springer Verlag, 1998. 24. Borelli C, Kunte C, Weisenseel P, et al. Deep subcutaneous application of poly-L-lactic acid

as a fi ller for facial lipoatrophy in HIV-infected patients. Skin Pharmacol Physiol 2005; 18: 273–8.

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35. Roy D, Sadick N, Mangat D. Clinical trial of a novel fi ller material for soft tissue augmentation of the face containing synthetic calcium hydroxylapatite microspheres. Dermatol Surg 2006; 32: 1134–9.

36. Busso M, Applebaum D. Hand augmentation with Radiesse® (calcium hydroxylapatite). Dermatol Ther 2007; 20: 315–17.

37. Lemperle G, Gauthier-Hazan N, Lemperle M. PMMA-microspheres (Artecoll) for long-lasting correction of wrinkles: refi nements and statistical results. Aesthetic Plast Surg 1998; 22: 356–65.

38. Lemperle G, Ott H, Charrier U, et al. PMMA microspheres for intradermal implantation. Part I. Animal research. Ann Plast Surg 1991; 26: 57.

39. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10-year history, indications, techniques, and Complications. Dermatol Surg 2003; 29: 573–87.

40. Lemperle G, De Fazio S, Nicolau P. Artefi ll®: a third generation dermal fi ller and tissue stimulator. Clin Plast Surg 2006; 33; 4: 551–65.

41. Cohen SR, Berner CE, Busso M, et al. Five year safety and effi cacy of a novel polymethylmeth-acrylate aesthetic soft tissue fi ller for the correction of nasolabial folds. Dermatol Surg 2007; 33(Suppl): S223–S230.

42. Gogolewski S, Jovanovic M, Perren SM, et al. Tissue response and vivo degradation of selected polyhydroxyacids (PLA, PHB, PHB/VA). J Biomed Mater Res 1993; 27: 1135–48.

43. Christensen L. Normal and pathologic tissue reactions to soft tissue gel fi llers. Dermatol Surg 2007; 33(Suppl 2): S168–72.

44. von Buelow S, von Heimburg D, Pallua N. Effi cacy and safety of polyacrylamide hydrogel for soft tissue augmentation. Plast Reconstr Surg 2005; 116: 1137–46 .

45. Christensen L, Breiting V, Janssen M. Adverse reactions to injectable soft tissue permanent fi llers. Aesthetic Plast Surg 2005; 25: 34–48.

46. Bergeret-Galley C. Comparison of resorbable soft fi llers. Aesth Surg J 2004; 24: 33–46. 47. Zielke H, Wölber L, Wiest L, Rzany B. Risk profi le of different injectable fi llers: results from

the injectable fi ller study (IFS study). Dermatol Surg 2007; 34: 1–10. 48. Wiest LG, Stolz W, Schroeder JA. Electron microscopic documentation of late changes in a

fi ller and clinical management of granulomas in affected patients. Dermatol Surg 2009; 35(Suppl 2): 1688–99.

49. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Chapter 3). In: Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001.

50. Ascher B. Toxine botulique et rides: les associations médicales et chirurgicales. Real Ther Derm Venerol 2004; 138: 7–9.

22

3.1Choosing the ideal fi ller

Cheryl Karcher

HOW TO CHOOSE THE IDEAL FILLER

Over the past decade, the use of injectable products in cosmetic dermatology has increased rapidly to become one of the top three cosmetic procedures performed in a physician’s offi ce. The youthful fullness and skin turgor are altered and reduced as we age with the loss and redistribution of facial fat, collagen, elastin, and bone resorption. These changes in combination with static and dynamic facial rhytids are largely responsible for the rise in soft-tissue augmentation procedures and the quest for the ideal dermal fi ller. The ideal fi ller substance would be nonallergic, noncarcinogenic, nonteratogenic, durable, reproduc-ible, stable, and affordable and would cause a minimum of adverse events. Arguably for some, the ideal fi ller will be permanent and for others resorbable, depending on the patient’s prior experiences and the physician’s expertise. There is no fi ller yet that fulfi lls all these criteria, but a thorough understanding of the differences among the current array of cosmetic fi llers at our disposal is essential for choosing the correct dermal fi ller for optimal cosmetic treatment.

PATIENT SELECTION, FILLER SELECTION—WHERE DO THEY INTERSECT?

The choice of appropriate fi ller agent for each patient begins at the consultation visit. Notable points about the consultation include an in-depth medical history. Patients on aspirin, nonsteroidal antiinfl ammatory drugs, and some potentially blood thinning vitamins need to be warned of the risk of signifi cant bruising and swelling and if possible to discontinue medication seven to ten days prior to treatment. Additional history points include pregnancy or lactation, history of anaphylactic reactions, beef allergy (for bovine collagens), lidocaine allergy (for fi llers already reconstituted with lidocaine), and history of collagen vascular disease (for collagen fi llers). Informed consent needs to be obtained prior to the procedure with all applicable risks outlined. Photographic documentation must be performed. This will allow the physician to effectively manage patient expectations, accurately see improvement post procedure, and document defects present prior to treatment. Only with the aid of photography can an objective evaluation of the patient be

CHOOSING THE IDEAL FILLER 23

made. Therefore, it is a valuable tool to track progress, develop new techniques, and advance the fi eld of volumetric fi lling.

At the consultation, fi ller agents are discussed in relation to their best cosmetic uses, longevity, cost per volume, and potential adverse events. Key questions that must be proposed to the patient are the amount of downtime the patient is able to tolerate post procedure, the necessity of immediate versus delayed results, and the amount of treatments necessary to correct the concern. This enables the patient to decide which fi ller would best suit their cosmetic needs and budget. Some of the points that need to be addressed at the consultation visit include the following choices:

• Passive versus active : This distinction is very important for patients since some choose to globally rejuvenate their face, often opting for several treatments with active fi llers, while others seek instant results in a local problem area and may choose a passive fi ller that will yield an immediate result. Passive fi llers do not infl uence the patient’s produc-tion of collagen and volume replacement is provided by the fi ller agent alone, or by the recruitment of water to the area. In contrast, active fi llers stimulate the infi ltration of fi broblasts into the treatment area and the subsequent secretion of collagen. They provide the initial framework for the fi broblasts but the total fi nal volume replacement results from the patient’s own collagen production. Two examples of Food and Drugs Administration (FDA)-approved active fi llers are Sculptra and ArteFill. These fi llers often require multiple visits to achieve the desired correction and ensure adequate scaffolding for fi broblast infi ltration. To the patient this translates to delayed results. It must be stressed to the patient that active fi llers are not immediate and that the body will take months to rebuild what has been lost over years.

• Resorbable versus permanent fi llers : With the recent availability of ArteFill, the fi rst FDA-approved permanent fi ller in the United States, it is now possible for patients to lastingly alter the contours of their face without the need for repeat visits or what is sometimes known as “wallet fatigue.” Prior to the availability of ArteFill, off-label use of silicone was the only permanent option available. Although there is a large body of data documenting silicone usage via the microdroplet technique for facial augmenta-tion, this use was never sanctioned by the FDA due to large percentage of side effects and granulomas that are associated with this treatment. The option of permanent fi llers should only be explored with patients familiar with the use of fi llers who are seeking to recreate the impact of a resorbable fi ller they have already tried. Permanent fi llers should not be explored with fi rst time clients as results cannot be corrected and misplaced material is very diffi cult to remove. Permanent fi llers are reserved for clinicians with expert technique and considerable experience in soft tissue augmenta-tion. When choosing a resorbable fi ller, it is important to consider the duration of action versus cost to the patient. Many resorbable options are available with the range of action between six months and two years. Longer-lasting fi llers tend to cost more per syringe used and cost to patient may be an important factor in fi ller selection. Addition-ally, it is important to consider whether a reversing agent is available for the fi ller in question. One huge advantage to using hyaluronic acid (HA) fi llers is that the enzyme hyaluronidase may be used to break down fi ller placed incorrectly.


• Dermal versus subdermal placement : Placement of fi ller is an important consideration in the fi nal aesthetic outcome. The choice of the fi ller will generally depend on the depth of the defect to be fi lled in. As a rule, subdermal placement is reserved for more viscous and larger fi ller agents such as Radiesse, Sculptra, and ArteFill. These bulkier fi llers would produce an uneven appearance if placed too superfi cially. Dermal placement is better suited for fi ner particle size fi llers such as collagens and HAs. When restoring volume to fi ne tissue zones, such as a periorbital and temporal areas, subdermal placement is recommended since the tissue is too thin to camoufl age the addition of a foreign substance. Additionally, fi ne rhytids commonly found in the perioral area are treated with dermal placement of fi ller to restore volume in a more superfi cial plane.

BIODEGRADABLE—PASSIVE FILLERS

Collagen

Collagen has been FDA-approved for cosmetic enhancement of the face since 1981. The mechanism of action of collagen fi llers is primarily that of passive volume replacement ( 1 , 2 ). The results are immediate and these fi llers are ideal for patients seeking instant local improvement. Collagen fi llers are biodegradable and resorbable with various duration of action all under one year ( 3 ). Results with collagen are best suited for soft defects with distensible skin and treatment is most effective in fi ne superfi cial rhytids, including the vertical lines above and below the lip, nasolabial folds, glabellar frown lines (with caution due to underlying vasculature), lateral periorbital rhytids, and acne scars. Dermal placement of product is recommended ( Fig. 3.1.1 ) ( 4 ).

Highly purifi ed bovine dermal collagens (Zyderm, Zyplast) were approved by the FDA in 1981 and 1985, respectively as injectable implants for facial aesthetics ( 5 ). The biggest factor related to the decreased use of these bovine collagen products is their risk of causing allergic reactions. To rule out hypersensitivity reactions at least two intradermal skin tests are necessary. Due to the inconvenience of skin testing, these products have been replaced by collagens from other sources ( 5 ).

Improving on the issue of cross-species allergic reactions are human-derived colla-gen fi llers, CosmoDerm and CosmoPlast. The FDA approved the use of these dermal fi llers

Figure 3.1.1 ( A ) Before and ( B ) after rejuvenation with collagen (CosmoPlast) in the nasolabial folds and marionette lines. 1.0 cc syringe was split between the left and right sides.

(A) (B)


in 2003. Dermal fi broblasts are harvested from bioengineered human skin ( 6 ). This dermal tissue is identical to the human dermis but lacks immune cells and therefore pretreatment skin tests are unnecessary. The fi nal product contains type I and type III triple helix collagen that is capable of binding with HA and other molecules to provide structure to the skin ( 6 , 7 ). CosmoDerm and CosmoPlast collagen is dispersed in a phosphate-buffered saline solution and lidocaine to decrease periprocedural pain. During administration, overcorrec-tion of 1.5 to 2 times the initial defect is recommended. As the saline and lidocaine disperse, the correction becomes appropriate. Duration of action is between three and six months. Placement of fi ller is upper papillary dermis for CosmoDerm and deeper reticular dermis for CosmoPlast ( 8 ). Various injection techniques may be utilized, with the serial puncture technique being recommended.

A porcine-derived collagen product, Evolence, attained FDA approval in June 2008. Porcine collagen is more similar to human than bovine collagen and has been used in heart valves, skin grafts, and dental membranes for many years with a minimum of hypersensitivity reactions ( 9 ). Clinical trials with Evolence demonstrate no evidence of adverse immunologic effects ( 10 ). The duration of action for Evolence is longer than for any other collagen product on the market with early clinical experience showing it to be six to nine months ( 11 ). Recommended placement is deep dermal and no overcorrection is necessary. Because of its longer duration of action, Evolence is in competition with HA products for convenience and ease of use. One drawback of this product is reports of nodule formation when injected into the lips; as such, this injection site is not recommended with this particular fi ller ( 12 ).

Additionally, there are other collagen products on the market of cadaveric or autolo-gous human origin. One such fi ller, Isolagen, is prepared from the patient’s own skin ( 13 ). It consists of cultured fi broblasts rather than a suspension of collagen fi brils and is currently in phase III clinical trials for facial rhytids and dermal depressions. As more collagen products gain FDA approval, achieving immediate popularity, natural feeling fi ller with forgiving results will continue to grow.

Hyaluronic Acid

Hyaluronic acid (HA) is a type of glycosoaminoglycan macromolecule. These macromole-cules are chains of repeating disaccharide units of D -glucoronic acid and N -acetylglucosamine and are found throughout the ground substance of the dermis ( 14 ). HAs are passive fi llers acting via their extremely hydrophilic nature; attracting water up to 1000 times its volume and not requiring overcorrection ( 15 ). HAs fall into the class of fi llers that are placed dermally due to their fi ne particle size and are best suited for lips, fi ne lines, nasolabial folds, and the nasojugal groove. HA is identical in all species and therefore has less antige-nicity and does not require a skin test. Currently some HA products are derived from animals while others are nonanimal-derived stabilized hyaluronic acids (NASHAs) derived from bacteria via streptococcal fermentation. Commercially available HA agents have been cross-linked to increase their longevity in the body ( 15 ). Currently HA are the most used injectable fi llers in the United States with the most requested being Restylane, Perlane, and Juvederm. The duration of action of these fi llers is moderate with longevity reaching nine months ( 16 ). On average, HAs last two to four months longer than collagen fi llers. If the HA is injected too superfi cially into the dermis, there may be an apparent “blue” mark caused by the Tyndall effect ( Fig. 3.1.2 ).


Restylane was the fi rst HA to be approved by the FDA (in 2003) and is the most common fi ller in the United States today. It is derived from nonanimal sources and is partially cross-linked. The concentration of HA is 20 mg/mL and longevity is approximately six months ( 8 , 17 ). The Restylane line of products also includes Restylane Fine Lines and Perlane. Perlane was FDA-approved in 2007 for the correction of moderate to severe facial wrinkles and folds. The concentration of product is the same as Restylane at 20 mg/mL but the longevity of Perlane is longer than Restylane, clinically seen to be between six and nine months. Perlane has a higher degree of cross-linking than Restylane, resulting in a thicker consistency. Due to this the recommended placement is the reticular dermis ( 8 , 17 ).

Juvederm was approved by the FDA in 2006 to treat deep facial lines and wrinkles and seems to offer greater longevity than any other HA on the market, touted to last up to one year. Juvederm is nonanimal derived and in contrast to other HA products the Juvederm HA formulation is composed of a homologous gel, while other products have particles of different sizes composing the mixture ( 18 ). In the United States, two different formulations of Juvederm are available: Juvederm Ultra and Juvederm Ultra Plus for deeper folds and rhytids. These products differ between each other in the concentration of HA available with 24 and 30 mg/mL, respectively.

A new HA product, Prevelle Silk, recently attained FDA approval for the treatment of superfi cial to moderate facial lines. Prevelle is unique in that its HAs are double cross-linked to resist degradation in the skin and to further increase their clinical duration ( 19 ). Prevelle is a clear colorless gel that contains 5.5 mg/mL of HA as well as lidocaine for increased comfort upon injection. Prevelle is NASHA-derived product and is therefore contraindicated for anyone allergic to gram positive bacterial products or lidocaine. Prevelle is supplied in

(A) (B)

Figure 3.1.2 ( A ) Before and ( B ) after two syringes of Restylane to the nasolabial folds (NLFs). 1.0 cc to each NLF.


individual treatment 0.9 mL syringes with two 30 gauge needles and is packaged ready for patient use. Injection is into the dermis and duration of product is four to eight months.

Over the past few years, HAs have become the gold standard of facial fi llers for several reasons. HAs provide immediate volume replacement, and the heavy cross-linking of the HA molecules increases their duration within the dermis. Because HA molecules are very hydrophilic, they continue to attract water to sustain volume augmentation after they are injected. An additional advantage of HA fi llers is the availability of a reversing agent. The enzyme hyaluronidase may be used to break down fi ller that is placed incorrectly, that moves, or in rare cases occludes a vessel.


Radiesse is a facial fi ller composed of a suspension of calcium hydroxylapatite, an inert bioceramic that has mineral components similar to those in bones and teeth. As such, patients should be informed that the product may appear on facial x-ray. Radiesse was initially approved by the FDA for the treatment of vocal cord insuffi ciency, oral and maxillofacial defects before being approved for correction of deep to severe facial rhytids in 2006. The particle sizes of the synthetic calcium hydroxylapatite found in Radiesse range from 25 to 45 µm suspended in a 70% gel carrier composed of 1.3% carboxymethylcellulose, 6.4% glycerin, and 36.6% sterile water. The carboxymethylcellulose initially helps to main-tain volume replacement; however, as the carboxymethylcellulose is degraded by the body, the left over calcium hydroxylapatite acts as a scaffold for fi broblast ingrowth ( 20 ). Whether this actively contributes to de novo collagen synthesis is still debated by the dermatologic community. Therefore, Radiesse is classifi ed a passive fi ller ( Figs. 3.1.3 and 3.1.4 ).

Figure 3.1.3 ( A ) Before and ( B ) after calcium hydroxylapatite (Radiesse) to the nasolabial folds (NLFs). 1.3 cc Radiesse was mixed with 0.2 cc lidocaine 1% and split between the left and right NLF.

(A) (B)


Radiesse is used primarily to treat local rhytids such as the nasolabial folds and marionette lines ( 21 ). It can also be used in nose and chin augmentation, cheek augmenta-tion, and diffuse facial contouring such as for HIV-associated lipoatrophy ( 22 ). Currently studies are underway to explore the use of Radiesse for global hand rejuvenation ( 23 ). Injection of Radiesse into the lips is controversial based on the high rate of nodule formation from the compression of the orbicularis muscle during chewing, and is not recommended. Placement is deep dermal/subdermal via a 27 gauge needle and after injection the product may be massaged and molded to fi t the contours of the face.

BIODEGRADABLE—ACTIVE FILLER

Poly- L -Lactic Acid

Poly- L -lactic acid (PLLA) is a synthetic, biocompatible, biodegradable polymer derived from vegetable sources and has been used in synthetic suture material for over 40 years. PLLA is marketed in the United States as Sculptra and in 2004 received FDA approval specifi cally for treatment of HIV-associated lipoatrophy; any uses outside this indication are considered to be off-label ( 24 ).

Sculptra is designed for the global correction of diffuse facial volume loss rather than the correction of a specifi c rhytid. The initial volume response to Sculptra is related to a mechanical volume effect of diluent and may last up to one week. The fi nal correction may not be apparent for a few months. Thus it is ideal for patients seeking natural volume contouring who are comfortable with delayed results and often multiple treatments. Long-term tissue fi lling effects are caused by ingrowth of type I collagen into the areas previously

(A) (B)

Figure 3.1.4 ( A ) Before and ( B ) after Radiesse for the malar creases. 1.5 mL syringe was split between the left and right sides.


occupied by PLLA particles. This type of neocollagenesis is thought to occur through a macrophage and fi broblast response and secretion of tumor necrosis factor-alpha ( 25 ). By contributing to soft tissue augmentation via new collagen synthesis, Sculptra is classifi ed as an active fi ller.

Sculptra is supplied as an anhydrous powder that must be reconstituted 2 to 72 hours prior to injection, therefore same-day procedures are not usually performed unless the product has already been mixed. Reconstitution with lidocaine immediately prior to injec-tion will lessen the discomfort, reduce viscosity, and also potentially decreasing granuloma formation. Sculptra is injected into the subdermal space in a fan-shaped pattern while with-drawing the needle. A small depot or bolus injection can be used in the areas of the upper zygoma or temples. Overcorrection is not needed. Immediately after injection, massage should be done and repeated daily for several days. Repeat injections may be performed every four to six weeks and usually two to three treatments are planned. Effects may last two to four years. Recommended usage includes volumetric fi lling to correct facial fat and bone atrophy, the nasojugal grove, where the product is placed submuscularly, hand rejuvenation, and acne scars ( 25 ).

SYNTHETIC—ACTIVE FILLERS

Polymethylmethacrylate

Polymethylmethacrylate (PMMA) is marketed in the United States as ArteFill, and gained FDA approval in 2006. It is the only nonresorbable dermal fi ller for use in facial lines and rhytids. The effects are classifi ed as permanent, with studies showing the persistence of PMMA spheres up to 10 years postinjection ( 26 ). As such this fi ller should not be the primary choice for fi rst-time patients and is reserved for expert use ( Fig. 3.1.5 ).

ArteFill is a combination fi ller composed of 20% PMMA microspheres evenly suspended in an 80% solution of partly denatured bovine collagen and 0.03% lidocaine ( 27 , 28 ). The PMMA microspheres are permanent, while the bovine collagen is biodegrad-able. The collagen provides instantaneous correction while the PMMA spheres are, in theory, chemically inert and stable for many years. All microspheres have a diameter of 30 to 50 µm

(A) (B)

Figure 3.1.5 ( A ) Before and ( B ) after Artefi ll rejuvenation of the nasolabial folds (NLFs). 0.8 cc to each NLF.


and have a smooth, round surface. The size, smooth surface, and lack of electrical charge enables the microspheres to resist phagocytosis and dislocation as they are encapsulated by the patient’s own collagen ( 27 , 28 ). The bovine collagen in ArteFill is partially denatured and is thought to be less likely to cause an allergic reaction, however a skin test is still required and a 28-day waiting period is observed.

ArteFill is indicated for glabellar frown lines, nasolabial folds, upper lip lines, and mouth corners. It is injected into the reticular dermis, just above the dermal-subcutaneous fat interface, by means of a tunneling technique. ArteFill should be deposited in layered fashion to provide a scaffold for tissue infi ltration. Injection should be followed by gentle massage to evenly distribute the material. Complications can arise from inaccurate depth of injection. An injection that is too deep can lead to ineffective treatment and may require repeat injection. An injection that is too superfi cial can lead to erythema and itching, superfi cial bumps, and may require treatment with topical or intradermal steroids.

Silicone

Medical grade silicone is available in the United States in two forms—Adatosil 5000 and Silikon 1000. Both products are highly purifi ed, injectable, long-chain polydimethylsiloxane oils. The numbers 5000 and 1000 refer to centistokes (cs), which are a measure of viscosity (water has a viscosity of 100 cs). Medical grade silicone is FDA-approved for the treatment of retinal detachment and retinal tamponade. It is used off-label as a soft-tissue fi ller.

The microdroplet technique is used. In this procedure 0.01 to 0.02 ml of silicone is injected subdermally with a tuberculin syringe through a 28 to 30 gauge needle by means of either linear fanning or multiple-stab technique ( 29 ). In time, the implant can harden through ingrowth of connective tissue, and it may form a granuloma or “late siliconoma.” These can generally be treated with steroid injections or antimitotic agents.

Use of silicone in the United States has been limited by lack of FDA approval for aesthetic uses, small margin of error in its injection technique, and negative public opinion about the substance. Currently, high-purifi ed 1000-cs silicone has attained investigative status for the treatment of facial lines and wrinkles and for lipoatrophy related to treatment for HIV infection ( 30 ).

SUMMARY

The use of dermal fi llers for soft tissue augmentation quickly has become the third most popular physician-administered cosmetic procedure in the United States. The development of rhytids, loss of subcutaneous fat, and gravitational changes that accompany the aging face ensure that the demand for soft tissue augmentation and fi llers will only continue to grow. Currently used fi lling agents have different modes of action and different injection techniques, so the dermatologic surgeon must be knowledgeable about the product, its advantages and disadvantages, and its optimal uses. Presently, HA products are the most popular of the dermal fi llers. However, longer-lasting or even permanent fi llers are also available and may be more appealing to the patient and physician. Temporary fi llers should be used as a trial or prelude to permanent or longer-lasting fi llers. This will give the patient an idea of what can be accomplished and determine whether they would like a longer-lasting fi ller, additionally it will give the surgeon a good idea of the amount of fi ller needed to accomplish the patient’s goal.


As newer products are added to the marketplace dermatologists will have more tools to deliver results with fewer allergic events, greater duration, and lesser pain. The ideal facial rejuvenation treatment package will likely utilize combination approaches of der-mal fi llers and various lasers and light sources. Future research evaluating current prod-ucts used alone or in combination will be helpful as treatment of the cosmetic patient is optimized.

REFERENCES

1. Sclafani AP, Romo III T. Collagen, human collagen, and fat: the search for a three-dimensional soft tissue fi ller. Facial Plast Surg 2001; 17: 79–85.

2. Klein AW. Skin fi lling. Collagen and other injectables of the skin. Dermatol Clin 2001; 19: 491–508.

3. Lemperle G, Morhenn V, Charrier U. Human histology and persistence of various injectable fi ller substances for soft-tissue augmentation. Aesthetic Plast Surg 2003; 5: 354–66.

4. Cirillo P, Benci M, Bartoletti E, Bertana C. Proposed guidelines for use of dermal and subdermal fi llers. G Ital Dermatol Venereol 2008; 143: 187–93.

5. Klein AW, Elson ML. The history of substances for soft-tissue augmentation. Dermatol Surg 2000; 26: 1096–105.

6. Bauman L. Cosmoderm/Cosmoplast (human bioengineered collagen) for the aging face. Facial Plast Surg 2004; 20: 125–8.

7. Hotta T. Dermal fi llers. The next generation. Plast Surg Nurs 2004; 24: 14–19. 8. Cohen J, Bar A. Fillers for facial rejuvenation. In: Hirsch R, Sadick N, Cohen J. eds. Aesthetic

Rejuvenation: A Regional Approach. McGraw Hill Medical, 2009. 9. Fernandez EM, Mackley CL. Soft tissue augmentation: a review. J Drugs Dermatol 2006; 5:

630–41. 10. Shoshani D, Markovitz E, Cohen Y, Heremans A, Goldlust A. Skin test hypersensitivity study of

a cross-linked, porcine collagen implant for aesthetic surgery. Dermatol Surg 2007; 33(Suppl 2): S152–8.

11. Narins RS, Brandt FS, Lorenc ZP, et al. Twelve-month persistency of a novel ribose-cross linked collagen dermal fi ller. Dermatol Surg 2008; 34(Suppl 1): S31–9.

12. Braun M, Braun S. Nodule formation following lip augmentation using porcine collagen-derived fi ller. J Drugs Dermatol 2008; 7: 579–81.

13. Boss Jr WK, Usal H, Fodor PB, Chernoff G. Autologous cultured fi broblasts: a protein repair system. Ann Plast Surg 2000; 44: 536–42.

14. Monheit GD. Hyaluronic acid fi ller. Facial Plast Surg Clin North Am 2007; 15: 77–84. 15. Falcone SJ, Berg RA. Cross-linked hyaluronic acid dermal fi llers: a comparison of rheological

properties. J Biomed Mater Res A 2008; 87: 264–71. 16. DeLorenzi C, Weinberg M, Solish N, Swift A. Multicenter study of the effi cacy and safety of

subcutaneous non-animal stabilized hyaluronic acid in aesthetic facial contouring: interim report. Dermatol Surg 2006; 32: 205–11.

17. Brandt FS, Cazzaniga A. Hyaluronic acid fi ller: Restylane and Perlane. Facial Plast Surg Clin North AM 2007; 15: 63–76.

18. Monheit GD, Prather CL. Juvederm: a hyaluronic acid dermal fi ller. J Drugs Dermatol 2007; 6: 1091–5.

19. Sagrillo D. Emerging trends with dermal fi llers. Plastic Surg Nurs 2008; 28: 152–3. 20. Berlin A, Cohen J, Goldberg DJ. Calcium hydroxylapatite for facial rejuvenation. Semin Cutan

Med Surg 2006; 25: 132–7. 21. Alam M, Yoo SS. Technique for calcium hydroxylapatite injection for correction of nasolabial

fold depressions. JAAD 2007; 56: 285–9. 22. Tzikas TL. Evaluation of Radiance FN soft tissue fi ller for facial soft tissue augmentation. Arch

Facial Plast Surg 2004; 6: 234–9.


23. Busso M, Applebaum D. Hand augmentation with Radiesse. Dermatol Ther 2007; 20: 285–7. 24. Vleggaar D. Facial volumetric correction with injectable poly-l-lactic acid. Dermatol Surg 2005;

31: 1511–18. 25. Keni SP, Sidle DM. Sculptra (injectable poly- L -lactic acid). Facial Plast Surg Clin North Am

2007; 15: 91–7. 26. Lemperle G, Romano JJ, Busso M. Soft-tissue augmentation with Artecoll: 10 year history,

indications, techniques, complications. Dermatol Surg 2003; 29: 573–87. 27. Lemperle G, de Fazio S, Nicolau P. Artefi ll: a third generation permanent dermal fi ller and tissue

stimulator. Clin Plast Surg 2006; 33: 551–65. 28. Broder KW, Cohen SR. Artefi ll: a permanent skin fi ller. Expert Rev Med Devices 2006; 3: 281–9. 29. Orentreich DS. Liquid injectable silicone: techniques for soft-tissue augmentation. Clin Plast

Surg 2000; 27: 595–612. 30. Jones DH, Carruthers A, Orentreich DS, et al. Highly purifi ed 1000-cSt silicone oil for treatment

of human immunodefi ciency virus-associated facial lipoatrophy: an open pilot trial. Dermatol Surg 2004; 30: 1279–86.

33

3.2European commentary

Luitgard Wiest

For the most part over the last decade, a great number and a variety of injectable fi llers have evolved in Europe, as shown in the Appendix. Physicians have to select the most appropri-ate fi ller for each specifi c use. Filler properties might differ signifi cantly between the different classes, such as resorbable and permanent, so physicians must have a thorough understanding and knowledge of these properties, the safety considerations, the importance of patient factors, as well as knowledge of facial anatomy and the aging process. Physicians must also have received training in using the best techniques for each individual fi ller to provide the most satisfactory results as explained in chapter 2.2. So it is not only the choice of the fi ller per se that is the key to an optimal result, but also how it is used. In making the right choice of an injectable fi ller for individual use, these issues must be taken into account for a predictable aesthetic result, to optimize the outcome and patient satisfaction. Some of these fi llers such as collagen fi llers, Zyderm, Zyplast, and Evolence have been taken off the market in Europe, new fi llers are being developed, and techniques continue to change and improve.

Key properties of the different types of fi llers have been described in the preceding chapters and the technical aspects of their use will be discussed in the following chapters.

In choosing the best fi ller for the intended correction in a specifi c area, the following factors must be considered:

• Patient’s wishes • Patient’s history ❍ Allergies, previous treatments with fi llers • Physician’s own experience with handling the specifi c fi ller agent • Training of the physician • Area of treatment ❍ Skin quality ❍ Elastosis ❍ Atrophy ❍ Skin type thick/thin ❍ Type of wrinkle superfi cial/deep


❍ Volume defi ciency ❍ Area of expression • Knowledge of the fi lling agent to be injected • Resorbable/permanent • Injection technique • Injection level ❍ Dermis: Superfi cial/deep ❍ Subcutaenuos ❍ Epiperiostal • Flow capacities of the fi lling agent • Volume to be injected • Size of needle • Type of anesthesia • Longevity of the fi lling agent • Necessity of adjunctive treatment

Besides autologous fat, fi ller products range from biologically derived substances to synthetic compounds as well as combinations of both. With regard to their properties, they show differences in terms of indications, application, handling, and durability . As previously discussed, choosing the best fi lling agent is sometimes diffi cult, especially when the choice is among the hyaluronic acid (HA) fi llers that seem to fulfi ll many of the characteristics of a highly satisfactory fi lling agent, but differ considerably among themselves. With over 100 different formulations and multiple manufacturers, the physician has to be very familiar with the different properties (see chap. 2.2) of each of these agents to optimize his choice.

Patients’ foremost interest is the longevity of the achieved correction. Longevity of a fi lling agent is one of the most decisive factors, besides safety issues, for a patient’s wish to be treated with a certain fi ller. Yet with regard to durability it must be remembered that results on longevity as reported in numerous studies do not take into account all the variables encountered in daily practice. The most important factors that might infl uence the permanence of a fi lling agent in the tissue are the technique used and the experience of the physician. A physician might be able to handle one product better than another with which he or she has not yet gained experience. Many side effects are more related to the experience and skill of the physician, rather than the product itself. Other interacting factors that infl u-ence the outcome of treatment and longevity may also be the volume of fi ller injected and the patient’s lifestyle, age, and quality of skin. The negative infl uence of UV radiation and smoking on the skin is well documented.

When used properly, many fi llers can provide satisfactory results. Some facial regions do better with one product than with another, and some facial areas are inappropriate for certain fi llers. The thickness of the dermis of facial skin varies considerably and is the lowest in the periorbital region. This has to be taken into account when choosing a fi ller for this region or using a fi ller in older patients with atrophic skin where longer-lasting or permanent fi llers are not recommended. The choice for this area and for fi ne wrinkles will be a less viscous material, with good fl ow capacities, like the monophasic HA gel fi llers, which can be injected at an upper level and are more forgiving when used in excessive volumes. In general, fi llers with a higher degree of viscosity, particulated fi llers with a higher concentration of HA, the long-lasting fi llers like Radiesse, or the permanent

EUROPEAN COMMENTARY 35

polymethylmethacrylate fi llers like ArteFill have to be injected in deeper levels of the dermis, subcutaneuosly or epiperiostally. They are mostly used for the treatment of deep wrinkles or volume restoration and have to be applied using different techniques. Injectable poly- L -lactic acid remains in a distinct category, as aesthetic results are delayed and the principal goal is to restore volume and not to treat specifi c folds or wrinkles.

When selecting a fi ller, the types of adverse effects have to be considered as any injectable fi ller can result in complications. Permanent fi llers that are not reversible tend to be associated with more serious delayed-onset adverse events like foreign body granulomas. With an experienced physician and a correctly chosen patient and fi lling agent, the use of injectable fi llers for aesthetic correction is a safe, minimally invasive procedure with an overall benefi t to satisfy both the patient and the physician.

36

4Anatomy of the forehead and periocular region

Marcelo B. Antunes and Stephen A. Goldstein

For anyone undertaking even minimally invasive surgery of the face and neck it is vital to understand the vascular, nervous, and muscular anatomical structures ( Figs. 4.1 – 4.3 ).

INTRODUCTION

The upper third of the face is composed of the forehead and eyes. These structures can be said to comprise the fi rst impression of someone’s face. The forehead and eyes together often convey a person’s emotional state or feelings. To this end, an accurate projection of a person’s true state of mind may be misrepresented secondary to the aging process. This is one of the primary reasons for which patients wish to address facial aging. Knowledge of the underlying anatomy of the upper third of the face is pertinent to accurately assess the stages of facial aging. This will allow the surgeon to determine which rejuvenation techniques are most benefi cial for patients with aging of the upper third of the face.

The upper third of the face is the segment between the anterior hairline (trichion) and the superior orbital rims and glabella on frontal view. The periocular area is technically included in the middle third of the face; but secondary to its importance for facial expres-sion and aesthetics, it is usually described separately from the midface. The upper eyelids are most commonly described with the upper third of the face due to their close relationship with forehead and eyebrows.

The eyes are arguably the most important aesthetic feature of the face. They are also often the fi rst area to manifest age-related changes. In youth, the eyelids are taut and have a subtle and gentle fullness. The upper eyelid has a well-defi ned and sharp eyelid crease just above the tarsal plate. The lower eyelid comes down to the orbital rim and gradually blends into cheek creating a single convexity. The periorbital aging process starts with lateral canthal rhytids. Changes in skin texture with laxity and pseudo fat herniation follow. The upper eyelid may also develop excess skin and start to look skeletonized and hollow. The lower eyelid, malar fat, and suborbicularis oculi fat (SOOF) can descend. This can contribute to a tear trough deformity and a double convexity of the lower eyelid and cheek junction.

ANATOMY OF THE FOREHEAD AND PERIOCULAR REGION 37

Orbital branch ofsuperficial temporalartery

Superficial temporalartery

Transverse artery

Supraorbitalartery

Supratrochlearartery

Dorsal nasal arteryMedial palpebral

arteryInfratrochlear artery

Angular artery

Infraorbital artery

Facial artery

Frontal branch

Orbital branch ofsuperficial temporal

arterySupraorbital

artery

Supratrochlearartery

Angular artery

Infraorbital artery

Facial artery

Lacrimal artery

Anterior ethmoidal artery

Posterior ethmoidal artery

Superficial temporalartery

Internal carotid artery

Ophthalmic artery

Maxillary artery

Transverse artery

Zygomaticofacial artery

(A)

(B)

Figure 4.1 ( A , B ) Vascular anatomy of the midface. Source : From Ref. 1, with permission.


Temporal branch

Zygomatic branches

Buccal branches

Marginal mandibularbranch

Carvical branches

Parotid gland

Supraorbitalnerve Zygomaticotemporal nerve

Lacrimal nerve

Zygomaticofacial nerve

Infraorbital nerve

Supratrochlearnerve

Infratrochlear nerve

(A)

(B)

Figure 4.2 ( A ) Branches of the facial nerve. ( B ) Nerves of the orbital region. Source : From Ref. 1, with permission.


Occipitofrontalis

Corrugator supercilii

Procerus

Levator labii superiorisalaeque nasi

Orbicularis oris

Depressor labii inferioris

Mentalis

Depressor superciliiOrbital orbicularis oculi

Preseptal orbicularis oculi

Pretarsal orbicularis oculi

Levator labii superioris

MasseterRisorius

Depressor anguli oris

Platysma

Zygomaticus minorZygomaticus major

Orbital retaining ligament

Zygomatic retaining ligament(McGregor’s patch)

Buccal-maxillary retainingligament

Masseteric ligament

Platysma-auricularligament

Mandibular retaining ligament

(A)

(B)

Figure 4.3 ( A ) The muscles of facial expression. ( B ) The retaining ligaments. (Continued)


The preseptalorbicularis muscle

The orbitalorbicularis muscle The corrugator

supercilii muscle

The frontalis muscle

The depressorsupercilii muscle

The pretarsalorbicularis muscle

The procerusmuscle

Figure 4.3 (Continued ) ( C ) The forehead depressor muscles. Source : From Ref. 1, with permission.

Eyebrow aesthetics differ in female and male patients. A feminine eyebrow arches with the medial and lateral tails resting along the orbital rim. Aesthetically, the apex of the arch is a matter of personal preference. Most women desire the apex of the eyebrow arch at the level of their lateral limbus while others prefer the peak more laterally at the eyelid canthus. The male eyebrow, on the other hand, runs horizontally along the orbital rims and is relatively straight. The male eyebrow creates a T shape with the nasal dorsum. The hair quality and density are also different in men and women. The male eyebrow is thicker and bushier while the female brow is thinner and more refi ned. The remaining upper third of the face is ideally composed of a smooth skin to the level of the hairline.

The anterior hairline is also aesthetically important. The ideal hairline creates a balanced face when it is divided into horizontal thirds. A naturally low hairline will shorten the upper third and is best addressed surgically. A receding and thinning hairline tends to lengthen the forehead and contribute to the perception of aging. An increasing distance between the hairline and eyebrows is a visual sign of aging. The earliest signs of an aging eyebrow include glabellar and horizontal rhytids typically starting in the early thirties. As people age, actinic skin changes in combination with weakening support of the soft tissue of the upper face con-tinue to contribute to the visual signs of aging. Clinically this presents with dermatochalasis of the upper eyelids. The forehead rhytids become more defi ned as the frontalis muscle attempts to compensate for progressive descent of the eyebrows. The eyebrow descent adds to the excess skin and lateral hooding ( 2 ). The orbital fat then breaks through the orbital septum in the upper eyelid causing mechanical eyelid descent and fat pad herniation. The combination of these age-related changes projects a tired and angry appearance.

BONY ANATOMY

The skeletal support for the upper third of the face is composed primarily of the frontal bone and a portion of the temporal bone laterally. The frontal bone has two components, the vertical squama portion and the horizontal orbital portion. The squama corresponds to the forehead and most commonly has a gentle convexity. This portion of the frontal bone is relatively thick, providing strength and protection for the cranial vault. Superiorly there are


two elevated areas named the frontal eminence. These can be asymmetric disturbing the vertical balance of the face. Inferiorly, separated by a slight groove are two more prominent elevations called the superciliary arches. These are joined in the midline by the glabella. These arches are more prominent in males. On the inferior portion of the squama is the supraorbital margin. This is the boundary between the squama portion and the orbital por-tion of the frontal bone. At the junction of the middle and medial thirds of this arch, is the supraorbital foramen (or notch) that caries the supraorbital nerve. A small percentage of people have an accessory foramen 1 to 2 cm above the orbital rim ( 3 ). The orbit is com-posed of seven bones. For the purpose of facial aging and rejuvenation, only the bones creating the orbital rim have relevance. These are the frontal bone superiorly, maxillary bone inferiorly and medially, and the zygomatic bone laterally.

MUSCULATURE AND INNERVATIONS

The muscle function of the upper third of the face enables a person to show surprise, pain, fear, anger, concern, and worry, among many other expressions. The eyebrow has several paired depressor muscles consisting of the corrugators, depressor supercilii, and the orbicularis oculi muscles. The frontal branch of the facial nerve innervates all of these muscles. The procerus muscle, also an eyebrow depressor, lies in the midline between the frontalis muscles. The zygomatic branch of the facial nerve innervates the procerus.

The frontalis muscle serves as the sole brow elevator. It is a paired thin muscle and rhomboidal in form. There are no true bony attachments. It is enveloped by the galea aponeurotica. Inferiorly the frontalis muscle inserts into the forehead skin blending with fi bers from the orbicularis oculi, procerus, and corrugator muscles. Superiorly it continues as the galea aponeurotica transitioning posteriorly into the occipitalis. The frontalis muscle raises the eyebrow and draws the scalp forward giving the expression of surprise. The vertical lift promotes the transverse rhytids in the forehead. These rhytids become well defi ned at rest as elongation of the forehead distance increases. The corrugator is a pyramidal muscle that originates from the medial end of the superciliary arch, travels superiorly and laterally becoming inserted into the subcutaneous tissue close to the pupillary line. The action of the corrugator is to draw the eyebrows medially and inferiorly, creating the oblique and vertical folds in the glabella. The procerus muscle lies medially to the corrugators in the midline of the forehead. Its origin is along the nasal bones. It inserts into the skin of the glabella. The contraction of the procerus muscle draws the eyebrows inferiorly and creates horizontal wrinkles in the glabella.

The orbicularis oculi muscles arise medially from the frontal process of the maxilla, lacrimal bone, the medial palpebral ligament, and the nasal process of the frontal bone and extend laterally to insert in the subcutaneous tissue at the lateral part of the orbit. The orbicularis oculi is a sphincter of muscle responsible for eye closure. It is divided into three portions: orbital, palpebral, and tarsal. The orbital portion is the thickest most peripheral portion. The palpebral portion travels from the medial canthal tendon to the lateral canthal tendon immediately underneath the skin of the superior and inferior eyelids. The tarsal portion arises from the posterior lacrimal crest, behind the lacrimal sac and travels laterally, superfi cial to the tarsal plate, to insert into the lateral canthal tendon. The palpebral and tarsal portions act involuntarily. They are responsible for the involuntary closure of the eyelids during blinking or closing of the eyelids. They also form a signifi cant part of the


lacrimal pump system. The orbital portion of the orbicularis is a voluntary muscle. Its contraction causes tight closure of the eyelids, drawing the eyebrows inferiorly and creating rhytids over the lateral portion of the orbit, called crows’ feet. The action of the orbicularis oculi carries a signifi cant importance in facial expression. The orbicularis oculi may be the most important source of nonverbal communication. As we all know “the eyes are the window to the soul.” Through movement of the eyelids, one can express many emotions, such as pain, anger, fear, and surprise.

The tug of war between the eyebrow depressors and elevator muscles help create the signs of periorbital and brow aging. Understanding this interplay is a starting point for surgeons and physicians to apply minimally invasive modifi cations such as neuromodula-tors. Whether the goal is to decrease the action of brow depressors and promote eyebrow elevation, or suppress elevation and contribute to facial symmetry, neuromodulators can be used to provide a more youthful appearance.

Most of the motor innervations of the upper third of the face come from the frontal branch of the facial nerve. The main trunk of the facial nerve divides, at the pes anserinus, typically into two divisions. The two divisions terminate with a total of fi ve branches. The frontal branch originates from the superior division of the facial nerve. A cadaveric study tracing the topographic relationships of the frontal branch to the surrounding fascial layers revealed between one to four identifi able branches. More than one branch is encountered in about 85% of the cases, with two branches being most common at 57.1% ( 4 ). The trajec-tory of the frontal branches is roughly along a line that runs from the attachment of the ear lobe (about 5 mm below the tragus) to a point 1.5 cm above the lateral aspect of the ipsilat-eral brow, also known as Pitanguy’s line ( 5 ). Anatomically, this is a point half the distance between the root of the helix and the lateral canthus. The nerve is found between the super-fi cial temporoparietal fascia and the superfi cial layer of the deep temporal fascia, until they penetrate the undersurface of the frontalis muscle.

The ophthalmic branch of the trigeminal nerve provides the sensorial innervation to the upper third of the face. This nerve has two terminal branches, the supraorbital and the supratrochlear nerves. The supraorbital nerve passes through the supraorbital foramen, innervating the upper eyelid and then ascends on the forehead to innervate the lateral and superior parts of the forehead and the scalp. The supratrochlear nerve passes between the superior oblique muscle in the orbit and the supraorbital foramen and curves superiorly to innervate the skin of the inferior and central portion of the forehead.

FAT PADS AND LIGAMENTS

Even though the upper third of the face does not contain much fat, the periocular region has an intricate anatomy with regard to fat pads. These are divided by the orbital septum into a preseptal and postseptal (orbital) compartment. The preseptal pads are located super-fi cial to the orbital septum and deep to the orbicularis oculi muscle. The preseptal fat pads add contour and fullness, which help frame the eye. Superiorly, beneath the eyebrow rests the retro-orbicularis oculi fat (ROOF) pad, while just below the infraorbital rim is the SOOF pad. The ROOF pad is crescent-shaped and goes along the upper lid, laterally to the supraorbital nerve and extends superiorly over the supraorbital rim. The ROOF pad contributes to a youthful brow by providing fullness and support for the lateral third of the eyebrow. The SOOF pad is located inferiorly below the arcus marginalis and infraorbital


rim ( 6 ). Descent and atrophy of the SOOF is related to the appearance of the nasojugal sulcus or tear trough deformity, which takes place with the aging process. This usually extends from the medial canthal area for about 2 cm inferolaterally most commonly with a slight curvature ( 7 ).

The postseptal fat pads lie deep to the orbital septum. These are the fat pads that pseudoherniate into the eyelid with weakening of the orbital septum periorbital. There are fi ve pockets within each orbit. The upper eyelid has two fat pockets, central and medial with the lacrimal gland sitting laterally. The lower eyelid has three pockets—central, medial, and lateral. These areas of adipose tissue have no relation to body weight. The medial fat pads are lighter in color and more fi brous than the central ones. The upper eyelid fat pads are positioned between the septum and the levator palpebrae aponeurosis. They are separated by the trochlea. The lacrimal gland occupies the lateral area in the superior postseptal space. The lower lid fat pads are also divided by anatomical structures. The inferior oblique muscle separates the medial and central pads, while the arcuate expansion divides the medial and lateral pads.

REFERENCES

1. Leatherbarrow B. Oculoplastic Surgery, 2nd edn. London and New York: Informa Healthcare, 2011.

2. Codner MA, Kikkawa DO, Korn BS, Pacella SJ. Blepharoplasty and brow lift. Plast Reconstr Surg 2010; 126: 1e–17e.

3. Gray H. Anatomy of the human body. II. Osteology, 5.a Cranial bones, 3. Frontal. Philadelphia: Lea & Febiger, 1918; New York: Bartleby, 2000.

4. Babakurban ST, Cakmak O, Kendir S, et al. Temporal branch of the facial nerve and its relation-ship to fascial layers. Arch Facial Plast Surg 2010; 12(1): 16–23.

5. Pitanguy I, Ramos AS. The frontal branch of the facial nerve: the importance of its variations in face lifting. Plast Reconstr Surg 1966; 38: 352–6.

6. Ridgway JM, Larrabee WF. Anatomy for blepharoplasty and brow-lift. Facial Plast Surg 2010; 26: 177–85.

7. Flowers RS, Flowers SS. Precision planning in blepharoplasty: the importance of preoperative mapping. Clin Plast Surg 1993; 20: 303–10.

44

5.1Volumetric approach to the upper face

Deborshi Roy

Volumetric rejuvenation of the upper face is often neglected, since most people tend to focus on the mid- and lower face when it comes to treatment of the aging face. However, ignoring the upper face can lead to a disharmony between the upper and lower face, leaving the patient with a suboptimal overall result.

Aging of the upper face is multifactorial and involves the skin, soft tissue, and bone. Rhytides of the upper face are very common, followed by upper eyelid dermatochalasis and brow ptosis. Rejuvenation of the upper face is usually surgical, most often brought about by blepharoplasty and brow lift (also known as a forehead lift). The most common nonsur-gical treatment of the upper face involves injections of botulinum toxin into the muscles that produce dynamic rhytides of the forehead, glabella, and crow’s feet.

The two most common causes of volume depletion of the upper face are loss of fat, muscle, and bone due to the aging process and fat loss due to lipodystrophy. In general, the most commonly affected areas are the temples and the upper brow. Less commonly, the glabella is affected by volume loss. A subset of patients with HIV-associated lipoatrophy suffer from marked volume loss in the upper face, especially in the temporal area ( 1 ). Volume loss of the lower eyelid is very common, but this topic will be addressed in the chapter related to midfacial volumetric rejuvenation.

The most important aspect of volumetric rejuvenation of the upper face is a proper facial analysis. After diagnosing volume loss in the upper face, the patient needs to be educated about it. Most patients can easily see volume loss in the mid- and lower face on their own, but often do not notice it in the upper face. After careful explanation, we can start the treatment process.

To understand the temporal area, one must be familiar with the anatomy, as explained in detail in the preceding chapter. The most clinically pertinent points are resumed below.

Superomedially, the temple is defi ned by the temporal line—the insertion of the temporalis muscle into the frontal bone. Inferiorly, the temple ends at the zygomatic arch. Within this area is the temporalis muscle, its investing fascia, and fat; volume loss in the temporal area will cause a prominent depression from two key fat pockets deep to the temporalis fascia. Adding volume to this area can have a dramatic effect on the appearance of the upper face, giving a youthful, healthy look.

VOLUMETRIC APPROACH TO THE UPPER FACE 45

Volume loss in the brow area most commonly is a part of the aging process and takes place laterally. The key aspects that defi ne normal brow anatomy are the supraorbital rim, the hair of the eyebrow, and the soft tissue in between. In the aging process, soft tissue and bone loss along the lateral aspect of the brow contribute to the loss of muscle tone causing brow ptosis. While most treatments try to reverse the ptosis, adding volume to this area can help with the rejuvenation process.

The glabella is defi ned as the area between the eyebrows and is comprised of the corrugator supercilii and the procerus muscles and the underlying frontal bone. The most common sign of aging in the glabellar area is hyperkinetic rhytides caused by repeated frowning. Over time, these rhytides can turn into furrows requiring treatment with volume along with paralytic agents ( 2 ).

TREATMENT OF THE TEMPORAL AREA

Almost all of the available fi llers can be used in the treatment of the temporal and lateral brow areas. Prior to treatment, the patient’s photos should be taken in the standard fashion ( Figs. 5.1.1 and 5.1.2 ). Additional photos in the Water’s view are important in order to adequately assess the temporal and brow area. After photos are taken, the patient should be marked in the upright position. The areas to be treated as well as the injection plan should be clearly defi ned with the marking ( Fig. 5.1.3 ). Regardless of the material used, the usual technique is a depot injection followed by massage ( Fig. 5.1.4A , B ). The depth of the injection is the critical part of the treatment—care must be taken to stay in the supraperiostial plane. Postinjection massage is used to spread the product evenly. Superfi cial injections and inadequate massage can lead to palpable and/or visible nodules. Postinjection bruising can occur, but can be minimized by staying away from the

Figure 5.1.1 ( A ) The normal temporal area. Note the boundaries of the temporal line (TL) and the zygomatic arch (ZA). ( B ) A temporal area with severe volume loss. Note the prominent depression

caused by volume loss in two key fat pockets deep to the temporalis fascia (arrow).

(A) (B)

TL

TL

ZAZA


Figure 5.1.3 Preinjection facial markings.

superfi cial venous arcades. Edema is common after injections and can be easily managed with ice packs. Prolonged edema can occur rarely, usually correlating to the use of an excessive injection volume.

Figure 5.1.2 ( A ) The normal brow area. Note the relationship to the supraorbital rim (SOR). ( B ) The aging brow with volume loss and ptosis. Note the change in relationship to the supra-orbital rim (SOR).

(A) (B)

SOR SOR


Prior to any injections, the patient should be kept off any blood thinners, including vitamins, supplements, herbal therapy, and medications. We recommend the use of Arnica Montana pellets starting on the day of treatment and continuing for two weeks. This helps in minimizing any bruising and also decreasing the time it takes to resolve any bruising that does occur. The skin is prepped with alcohol swabs and then marked. Injections usually take place with the patient reclining in a chair. Postinjection massage and ice packs are important to ensure a smooth result and minimal swelling.

Autologous fat transfer techniques have been well described ( 3 , 4 ). Core fat from the abdomen, buttocks, or thighs must be harvested, treated, and then injected into the desired location of the face. Specialized cannulas have been created for harvesting and injecting fat into the face. Typical volumes used for treatment of the temporal area range from 0.5 to 3 cc, depending on the amount of volumetric rejuvenation required. Fat transfer injections in this area are deep into the muscle.

When using hyaluronic acid-based products in the temporal area, the injections must be in the deep dermis. Superfi cial injections can cause nodules to appear or can be visible in the skin due to the Tyndall effect. Approximately 0.8 to 1.6 cc of product is used per side in the average patient.

Calcium hydroxylapatite can also be used in the temporal area. With this product, injections should be subdermal, using approximately 0.5 to 0.8 cc per side in the average patient. Thorough massage is needed to smooth out the distribution of the product after a depot injection.

Repeated treatments with poly- L -lactic acid are necessary to build up an adequate tissue response and obtain proper results. For the temporal area, some injectors use the standard dilution of the product recommended by the manufacturer—that is, 4 cc of sterile water mixed with 2 cc of 1% lidocaine per vial. Others prefer to use a more dilute solution, mixing 6 cc of sterile water with 2 cc of 1% lidocaine. This dilute solution has less clump-ing and therefore a lower incidence of nodules. Injections should be in the supraperiostial plane when treating the temporal area with poly- L -lactic acid. Vigorous postinjection massage is crucial for an even result. With standard dilutions, 1 to 2 cc of product are needed per side. With the more dilute preparation, 2 to 4 cc may be needed per side.

Figure 5.1.4 ( A ) A demonstration of the depot injection technique in the temporal area. The product is placed in the subdermal plane. ( B ) A demonstration of the postinjection massage. Firm, circular

motion is used to even out the product distribution.

(A) (B)


TREATMENT OF THE BROW AREA

The lateral brow area is most often treated as an adjunct to treatment of the temporal area. All of the options available in the temporal area can be used in the brow as well. We prefer to use the “pinch” technique ( Fig. 5.1.5 ). After marking and prepping the skin of the brow, the lateral brow tissue is pinched and tented off the orbital rim. The needle is passed into the skin and deep to the orbicularis oculi muscle. The product is injected into the supraperi-ostial plane and smoothed out with massage. In general, one would tend to use half the volume used to treat the temporal area. Adding too much volume to the lateral brow will give the appearance of worsening ptosis.

TREATMENT OF THE GLABELLA

Due to the nature of the blood supply to the skin of the glabella, injections can cut off the blood supply causing necrosis. This happens due to embolic phenomena or increased pres-sure on local blood fl ow ( 5 ). It is best to keep injections very deep or to use lower density fi llers with no particulate matter in the glabella to minimize the chances of these devastat-ing complications.

Deep (intra- and submuscular) injections of autologous fat using the smallest caliber cannula available can be very successful in the glabella. Small volumes (0.5–0.8 cc) are needed to treat this area.

Hyaluronic acid fi llers in the deep dermal plane can also be used to treat the glabella. Volumes of 0.3 to 0.8 cc are used in the typical patient. As mentioned before, these treat-ments work best when combined with treatment of the dynamic rhytides with botulinum toxin ( Fig. 5.1.6 ).

Figure 5.1.5 A demonstration of the injection technique in the lateral brow area. Note how the skin and soft tissue are pinched and tented up away from the supraorbital rim prior to injection.


CONCLUSION

Isolated upper facial rejuvenation is rare, except when we see patients who have had mid- and lower facial rejuvenation alone. Usually, upper facial volumetric rejuvenation is a facet of full-facial volumetric rejuvenation and should be seen as an integrated part of a thorough approach. Most volumetric treatments of the upper face are adjunctive in nature—usually complementing other treatments of the upper face such as upper eyelid blepharoplasty, brow lifting, or botulinum toxin therapy. Subtle additions of volume can create a more youthful, healthy look. Careful technique coupled with proper patient and product selec-tion will yield very satisfying aesthetic results. The goal in volumetric rejuvenation is to restore the volume lost during the aging process and create an overall harmonious, natural aesthetic.

REFERENCES

1. Yang Y, Sitoh YY, Oo Tha N, Paton NI. Facial fat volume in HIV-infected patients with lipoatrophy. Antivir Ther 2005; 10(4): 575–81.

2. Carruthers J, Carruthers A. A prospective, randomized, parallel group study analyzing the effect of BTX-A (Botox) and nonanimal sourced hyaluronic acid (NASHA, Restylane) in combination compared with NASHA (Restylane) alone in severe glabellar rhytides in adult female subjects: treatment of severe glabellar rhytides with a hyaluronic acid derivative compared with the derivative and BTX-A. Dermatol Surg 2003; 29(8): 802–9.

3. Coleman SR. Facial contouring with lipostructure. Clin Plast Surg 1997; 24(2): 347–67. 4. Shiffman MA, Kaminski MV. Fat transfer to the face: technique and new concepts. Facial Plast

Surg Clin North Am 2001; 9(2): 229–37, viii. Review. 5. Glaich AS, Cohen JL, Goldberg LH. Injection necrosis of the glabella: protocol for prevention

and treatment after use of dermal fi llers. Dermatol Surg 2006; 32(2): 276–81.

Figure 5.1.6 A demonstration of the injection technique in the glabella in the deep dermal plane. The area just below the ryhtide is injected in order to replace the volume lost in the deep furrow.

50


Luitgard Wiest

As the trend for surgical procedures is decreasing, the trend for nonsurgical, minimally invasive procedures is growing, especially in younger and middle-aged patients. Due to their early stages of aging, they are the best candidates for volumetric enhancement in the upper face. With more advanced signs of aging, surgical procedures like blepharoplasty in combination with more extensive volumetric enhancement lead to a more dramatic improvement.

As the author of chapter 5.1 states, the key to success for volumetric enhancement is a thorough analysis of the changes of aging and the determination of volume-defi cient areas, which are mostly the lateral brow and temple areas. After all the necessary preprocedure preparations described in chapter 5.1 are undertaken, we also take photographs of the patient with the marked areas to be treated for documentary reasons. One week prior to treatment patients cease use of any medications that would predispose excessive bleeding and swelling.

For the treatment of the temporal area the autologous fat transfer techniques as described in chapter 5.1 are widely used in addition to the fat autograft muscle injection (FAMI) technique described by Amar in 1999 ( 1 ) preferably with blunt cannulas. Studies have been performed with variations in harvesting, storage techniques, and cell viability ( 2 ). Of the readily available fi llers, the specially designed “volumizers” are among the preferred HA fi llers for volumetric enhancement of the face. The treatment is accomplished by injecting small depots very slowly in the epiperiostal plane with the needle adjusted to the choice of fi ller, followed by a massage to avoid nodule formation.

Best results using fi llers in the periorbital and glabella areas are achieved in combination with botulinum toxin treatment 10 to 14 days prior to the fi ller treatment. After paralysis has taken effect, fi llers are more evenly dispersed and usually less fi ller material is needed for the desired effect ( 3 – 5 ).

To lift the lateral brow end the preferred fi llers are HA fi llers with a high viscosity (Volumizers) are injected with the pinch technique deep below the M. orbicularis oculi.

Use of longer-lasting fi llers in the glabella, which have to be placed into the deep dermis or subcutaneously, increases the risk, as an intravasal injection in this highly vascular region may result in skin necrosis and even blindness. In this region, it is recommended to use resorbable fi llers in small amounts and injecting into the medial part of the glabella.


REFERENCES

1. Amar R. Microinfi ltration adipocytaire (MIA) au niveau de la face, ou restructuration tissulaire par greffe de tissue adipeux. Ann Chir Plast Esthét 1999; 44(6): 593–608.

2. Kaufman MR, Bradley JP, Dickinson B, et al. Autologous fat transfer national consensus survey: trends in techniques for harvest, preparation, and application, and perception of short- and longterm results. Plast Reconst Surg 2007; 119: 323–31.

3. Ascher B. Toxine botulique et rides: les associations médicales et chirurgicales. Real Ther Derm Venerol 2004; 138: 7–9.

4. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Ch 3). In: Sommer B, Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001.

5. Carruthers J, Carruthers A. The adjunctive usage of botulinum toxin. Dermatol Surg 1998; 24: 1244–7.

52

6Anatomy of the midface

Stephen A. Goldstein and Evan Ransom

It is important to understand the underlying structures and the associated anatomy of the midface when planning aesthetic volume restoration procedures. The midface is defi ned as the central third of the face in the anterior projection. Its superior border is a horizontal line drawn through the infraorbital rims to the auricles at the root of the helix. The inferior border is more oblique, and is represented by a line drawn from the oral commissure to the lobule of each auricle. Laterally, the midface border is the masseter muscle. Medially, the nasolabial fold delineates the midface from the nasal and perioral subunit; this area represents the attenuation and fusion of the diverse midfacial layers. The majority of the fullness or bulk of the midface aesthetic unit is provided by the malar fat pad ( 1 ).

Midfacial aging is among the fi rst and most obvious indicators of the aging process as a whole. This follows a predictable course, with progressive exposure of the infraorbital rim and deepening of the nasolabial folds. In addition, rhytids form in typical locations, such as the “crow’s feet” or “smile lines” at the lateral border of the orbit. There is also visible fl attening of the cheek regions. An understanding of the specifi c contributions of different anatomical components to the changes occurring in this complex area is integral to its reju-venation. It is also important to understand the locations of the underlying muscular, osseous, and neurovascular structures to decrease the risk of complications associated with augmenta-tion of this region. Midface anatomy will be described in layers, beginning with the skeletal foundation and moving superfi cially to encompass the pertinent cutaneous features.

THE BONY MIDFACE

Midface aging transitions as the relationships between overlying soft tissues and underlying bony anatomy change. The skeletal foundation of the midface is composed of three bones: the zygomatic arch of the temporal bone, the zygomatic bone, and the maxilla. Only the zygomatic bone and maxilla are seen in the frontal view, while the zygomatic arch becomes

Illustrations of the midfacial anatomy can be found in Chapter 4.

ANATOMY OF THE MIDFACE 53

important in oblique and lateral views. The lateral projection of the zygoma should be the highest point and highlight of the cheek prominence. Strong cheekbones are associated with a certain sense of beauty and this area is often accentuated with makeup by many women.

In youth, there is a smooth eyelid to cheek transition (single convexity). As aging occurs, changes in both adipose tissue position and volume loss expose the infraorbital rim. The infraorbital rim, normally hidden by the malar fat pad in the youthful face, is revealed over time. This bony edge is composed of the zygomatic bone laterally and the ascending process of the maxilla medially. Indeed, an important goal of surgical procedures for midface rejuvenation is largely the repositioning of adipose tissue at the infraorbital rim—either by elevation of the malar fat pad or by repositioning of lower lid or subseptal fat ( 2 ). In the early phases of aging, this goal can be achieved with the aid of volume replacement utilizing any number of fi ller-type agents. Care should be taken to avoid inadvertent injury to the extra ocular muscles or the globe. This will be discussed in separate chapters.

The inferior and medial midface skeleton is formed by the maxilla. As with the orbital rim, aging and descent of soft tissue also result in exposure of the superomedial extent of the maxilla. This causes an apparent deepening of the nasojugal fold (tear trough deformity), which contributes to the appearance of aging in the periocular region and may change the perceived contour of the nasal pyramid in severe cases. Multiple modalities have recently been suggested for rejuvenation of this area, including fat repositioning, fi llers, and free fat grafts ( 3 – 5 ). Even permanent implants have been described ( 6 ).

The maxilla forms the superior alveolus and defi nes the inferior aspect of the midface. This bone holds the roots of the upper teeth providing a platform for the upper lip soft tissues. Over time, there can be a slow progressive volume loss in these regions. This often manifests as fl attening of the upper lip. This is most noticeable in patients who are partially or totally edentulous. The loss of projection that results has implications for restoration especially in perioral rejuvenation. In addition, age-related volume loss within the soft tissue of the lips may be signifi cant. This is amenable to FDA “off label” judicious fi ller placement.

MIDFACE MUSCULATURE AND FACIAL NERVE

The midface musculature is essential to social interaction because of its mimetic function. These muscles are also involved in protecting the eye and contribute to oral competence. Unfortunately, years of repetitive contraction may result in signifi cant lateral canthal and facial rhytids. The midface muscles include the orbicularis oculi, zygomaticus major and minor, levator labii superioris alaeque nasi (levator labii superioris and levator alae nasi), levator anguli oris, risorius, and buccinator. Some muscular anatomic variation is normal, and even the complement of facial muscles may differ between patients ( 7 ). Understanding their location and underlying actions in the face is essential for the use of neuromodulators such as Botulinum toxin. Muscular attachments to the overlying skin may weaken over time, though no age-related changes in muscle position or length have been demonstrated ( 8 ). This fact has been exploited in the fat autograft muscle injection (FAMI) technique, which involves free fat transfer into the mimetic muscles ( 9 ).

The orbicularis oculi is divided functionally into the tarsal, palpebral, and orbital components. The fi rst two allow for gentle unstrained closure of the eye as in blinking or during sleep. The remaining orbital portion surrounds the upper and lower palpebral parts


with its origin at the medial canthal tendon and lacrimal bone and its insertion in the dermis underlying the periocular skin at the orbital margin. Contraction of the orbital part of the orbicularis oculi results in tight closure of the eye, as in a protective maneuver or expressions of pain and anguish. It is this portion where neuromodulators are injected to eradicate lateral canthal rhytids and provide lateral brow lifting.

Contraction of the zygomaticus muscles provides the greatest contribution to the smile. The origin of the zygomaticus major muscle is on the inferolateral part of the zygoma. As the muscle reaches the mouth, it splits to insert on the orbicularis oris superior and inferior to the oral commissure. Contraction thus results in superolateral excursion of the oral commissure and an expression associated with happiness. Some variability exists at the distal end of the zygomaticus major, with microdissections showing different patterns insertion ( 10 , 11 ). Pessa et al. demonstrated a bifi d zygomaticus major in 34% of specimens, with superior and inferior muscle bundles attaching at the upper corner and modiolus below the corner of the mouth, respectively ( 10 ). The authors suggest that this variation in muscle anatomy may explain differences in the presence and depth of cheek “dimples,” with implications for rejuvenation. In a similar study, Shim et al. delineate superfi cial and deep bands of the zygomaticus major in 60% of specimens ( 11 ). Superfi cial bands interlace with the levator anguli oris, while deeper bands blend with the fi bers of the buccinators muscle. This highly varied anatomy attests to the challenge in correcting dimples with injectable fi llers.

The zygomaticus minor muscle may compliment the action of the zygomaticus major and levator labii. Interestingly, this muscle is frequently absent ( 12 ). In a dissection study, Pessa et al. describe seven patterns of midfacial musculature with the most common pattern being a single zygomaticus major with paired upper lip elevators (levator labii superioris and levator alae nasi) ( 10 ). When present, the zygomaticus minor originates medial to the zygomaticus major on the inferomedial aspect of the zygomatic bone and inserts at the lateral most upper lip. Contraction of this muscle raises the upper lip alone, as in a snarl or expression of contempt. The risorius muscle originates at the platysma and masseteric fascia and attaches to the complex of muscles at the angle of the mouth. Like the zygomaticus minor, this muscle is frequently absent ( 7 ). Contraction of the risorius results in lateral excursion of the oral commissure and produces a grinning expression or a toothless smile.

The levator labii superioris alaeque nasi originates on the frontal process of the maxilla. Some texts consider these portions as two separate muscles (levator labii superioris and levator alae nasi). Muscle fi bers are oriented slightly oblique to the vertical axis and divide into two slips distally to insert at the alar rim and in the dermis of the upper lip. Contraction of these divisions results in nostril fl aring and lateral upper lip elevation, respectively. Dissection studies have shown this muscle complex to be present in 100% of specimens, highlighting its importance in mimetic function ( 7 ). Caution is urged with neurotoxin placement in this area, as overzealous injections here can result in nasal valve collapse.

Motor supply to the midface muscles comes from the zygomatic and buccal branches of the facial nerve. The facial nerve emerges from the cranial base at the stylomastoid foramen before traveling anteromedially through the parotid gland. Here it divides into two trunks in about 87% of cases ( 13 ). Most commonly, this results in an upper division containing the frontotemporal and zygomatic contributions and a lower division which contains the buccal, marginal mandibular, and cervical contributions. The buccal branches


form the most intricate and variable arcade, with 70% of specimens having extensive connections with zygomatic branches ( 13 ).

The facial nerve lies deep to the superfi cial musculoaponeurotic system (SMAS) through most of its course, innervating most muscles of facial expression from their undersurface. This creates two safe dissection planes for open approaches: immediately superfi cial to the SMAS (beginning 2–3 cm anterior to the pretragal crease) and subperiosteal. Dissection deep to the SMAS is also possible but entails a higher risk of facial nerve injury. Facial nerve branches move more superfi cially as they approach the nasal pyramid and oral commissure. In addition, motor supply becomes unpredictable and redundant beginning approximately at a plumb line from the lateral canthus. Injuries to these distal branches typically do not necessitate aggressive repair efforts.

ADIPOSE TISSUE, FAT PADS, AND THE SMAS

Perhaps the most important consideration in midface rejuvenation is the malar fat pad. This structure, which lies superfi cial to the SMAS and immediately below the lateral part of the infraorbital rim, provides the bulk of the convexity associated with a youthful midface. The malar fat pad is a thickening (about 6 mm) of the subcutaneous fat in the cheek area overlying the maxilla. Some authors have attempted to subdivide this adipose tissue, but the clinical relevance of this work is limited and beyond the scope of this review ( 14 ). Diffuse attachments to the overlying dermis, along with the lateral orbital thickening and orbicularis retaining ligament (discussed below) help to stabilize the malar fat pad in a superolateral position. No connections to the underlying SMAS, however, have been demonstrated. Thus, gravitational forces and age-related dermal and ligamentous laxity have profound effects on its position.

With age, the dermal attachments of the malar fat pad loosen, resulting in gradual displacement inferiorly and medially. The effect of this movement may be pronounced, leading simultaneously to exposure of the infraorbital rim, a sunken appearance of the eyes, and a signifi cant deepening of the nasolabial folds ( 15 ). In some cases where there is concomitant orbital fat herniation at the lower lids, this gives an unpleasant double convex-ity profi le to the midface. Inferiorly, the weight of the malar fat pad settles at the cheek–lip junction, where the SMAS has an intimate connection to the dermis of the upper and lower lips. The result is an obvious enhancement of the nasolabial folds. This thesis that fat pad descent is the prime mechanism of midface contour changes has been challenged by a study demonstrating increased adipose tissue volume in the medial and lateral parts of the cheek in older subjects and a more even distribution of fat between the superior and middle thirds of the cheek ( 8 ).

At the lateral aspect of the infraorbital rim, deep to the orbicularis oculi muscle but superfi cial to the preperiosteal fat lies a second important fat compartment—the suborbicu-laris oculi fat (SOOF). This adipose tissue is much smaller than the malar fat pad, but its elevation or increased volume can signifi cantly improve results in midface rejuvenation. The ideal single convexity of youth changes to a double convexity over time, and this double convexity reveals an aged appearance with associated lengthening of the lower eyelid ( 2 , 16 ). A single convexity with a short eyelid may be accomplished with repositioning of the malar fat pad, SOOF, and possibly the lower lid fat pockets. Additionally, correction


of the nasojugal fold with medial eyelid fat pad repositioning over the infraorbital rim or an implant can have a powerful effect ( 6 ).

Lying in a plane superfi cial to the mimetic muscles and deep to the fat pads discussed is the SMAS. The SMAS is a diffi cult but critical concept in facial aesthetic surgery, and different descriptions have led to some confusion over time. The most straightforward defi nition of the SMAS is a fi brous connective tissue layer that extends over the cheek from the tragus to the nasolabial fold. It is contiguous with the parotidomasseteric fascia laterally, condenses with the temporoparietal fascia at the zygomatic arch superiorly, and invests the platysma inferiorly. The superfi cial surface of this layer is a starting point for a “ traditional” facelift dissection. Dissection deep to the SMAS and subsequent plication or imbrication of this layer, however, is the hallmark of the modern “deep-plane” facelift. Advocates of this approach attest to a greater lift, longer-lasting results, and a less “operated” look. Currently this is controversial with proponents for each technique. In a recent presentation reporting on a fi ve-year follow-up patient survey as well as comparative photos, Strahan ( 17 ) found that patients who had the SMAS lift reported greater satisfaction with the fi ve-year results of their procedure. Regardless of the type of lift selected, facial plastic surgeons are increasingly aware of the concomitant need for volume replacement, which may be provided by fi llers or structural fat grafting.

LIGAMENTS AND CUTANEOUS ANATOMY

Ligamentous connections between the facial skeleton and the overlying skin, unlike other regions of the body, are a signifi cant source of structural support and functionality. Any discussion of facial anatomy would be incomplete without a detailed description of these connections. In addition, alteration of the osseous, cartilaginous, or muscular components of the face and neck can produce striking results, but failure to address an irregular skin surface or pigmentary abnormalities may lead to an incomplete result and dissatisfi ed patient.

McGregor fi rst described the supporting ligaments of the face. A “patch of fi brous attachment” located anterior to the parotid and connecting to the overlying skin marks the area that bears his name. Furnas further elucidated the facial ligaments essential for mid-face support ( 18 ). There are two types of retaining ligaments anchoring the overlying skin to the osseous foundation: true osteocutaneous ligaments from the zygoma and mandible inserting into the dermis; and coalescence between the deep and superfi cial masseteric fascias ( 18 , 19 ). Release of these ligaments allows repositioning of the midface.

Further anatomical refi nements defi ning the periorbital retaining ligaments have been described in cadaver dissections, including the lateral orbicularis retaining ligament (ORL) and the lateral orbital thickening (LOT) ( 20 – 23 ). The release of the ORL to its junction with the LOT is essential in vertical mobilization of the malar fat pad. As described by Mendelson et al., the prezygomatic space and surrounding ligaments reveal the characteristic age-related changes in this region and explain much about shifts in the infraorbital and malar contours.

Muzaffar et al. have demonstrated the orbitomalar ligament as the anatomic structure responsible for defi ning the palpebromalar groove (i.e., the visible junction between the preseptal part of the lower lid and the cheek). Downward displacement of the lid–cheek junction is associated with a lengthening and attenuation of the preseptal part of the lid as it extends into the area formerly occupied by the upper cheek. For bulging lower lid fat to


extend beyond the orbital rim, the retaining ligament must also undergo distension along with the preseptal segment of the lid ( 22 ). Early in the aging process, support of these structures with the deep placement of a variety of fi llers may recreate a youthful appear-ance, camoufl aging the underlying orbital rim and protruding fat. Once bags and sags prevail, however, surgical intervention remains the gold standard.

Lastly, an appreciation of age-related changes and differences in skin type is extremely important when considering rejuvenation procedures. It is well known that the dermis thins with age, and the relative elasticity of the skin as a whole increases. Recreating the thicker and healthier dermis of youth is the “Holy Grail” of skin rejuvenation. In addition, regardless of age, skin thickness and pigmentation differ between patients. This may have a profound effect on the results achieved with fi llers. Certain areas where the dermis is particularly thin (such as the lower eyelid or dry vermillion border) deserve specifi c consideration when planning injectable-based treatments, in order to avoid palpable raised areas, infl ammation, skin discoloration, and even ulceration. This topic will be explored in depth in later chapters.

The epidermis is a continually renewing keratinizing squamous epithelium, composed of four layers or strata. Beginning at the deepest layer, just above the dermal–epidermal junction, is the stratum germinativum. This basal layer is composed of columnar-shaped keratinocytes which are attached to a basement membrane and which divide and give rise to more superfi cial layers. Interspersed at this level are the melanocytes, which are respon-sible for pigment production. Immediately above lies the stratum spinosum, which is several cells thick and contains keratinocytes that have detached from the basal layer. Next is the thinner stratum granulosum, typically one to four cells thick and darker in appear-ance. The most superfi cial is the stratum corneum, which consists of keratinocytes that have shed their nuclei and fl attened to form keratin plates. As these cells are sloughed they are replaced from below.

The dermis lies between the epidermis and subcutaneous fat, forming the greatest bulk of the skin in youth and progressively thinning with age. The papillary dermis is most superfi cial and interdigitates with the undulating epidermis. Below this lies the thicker reticular dermis, where the bulk of the sebaceous glands and apocrine sweat glands reside. Hair follicles sit at the deep margin of the dermis where it meets the subcutaneous fat and project through the dermis and epidermis to emerge at the skin surface. Along the way, the apocrine sweat glands and erector pili muscles attach to the follicles. Eccrine sweat glands also reside at the deep margin of the reticular dermis. The dermis provides the strength and distensibility of the skin, and is composed of an extracellular matrix of collagen, elastin, and ground substance. The cellular component of this layer is largely fi broblasts, which are more prevalent in the papillary dermis. These cells synthesize the extracellular connective tissue matrix and have a signifi cant role in wound healing and scar formation. Dermal and subdermal fi llers add volume and may promote collagen deposition within this layer. Together, these effects aid in creating a youthful appearance.

REFERENCES

1. Goldstein SA, Goldstein SM. Anatomic and aesthetic considerations in midface rejuvenation. Facial Plast Surg 2006; 22(2): 105–11.

2. Hamra ST. Arcus marginalis release and orbital fat preservation in midface rejuvenation. Plast Reconstr Surg 1995; 96(2): 354–62.


3. Turk JB, Goldman A. SOOF lift and lateral retinacular canthoplasty. Facial Plast Surg 2001; 17(1): 37–48.

4. Kane MA. Treatment of tear trough deformity and lower lid bowing with injectable hyaluronic acid. Aesthetic Plast Surg 2005; 29(5): 363–7.

5. de la Cruz L, Berenguer B, Garcia T. Correction of nasojugal groove with tunneled fat graft. Aesthet Surg J 2009; 29(3): 194–8.

6. Flowers RS. Tear trough implants for correction of tear trough deformity. Clin Plast Surg 1993; 20(2): 403–15.

7. Pessa JE, Zadoo VP, Adrian EK Jr, et al. Variability of the midfacial muscles: analysis of 50 hemifacial cadaver specimens. Plast Reconstr Surg 1998; 102(6): 1888–93.

8. Gosain AK, Klein MH, Sudhakar PV, Prost RW. 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.

9. Butterwick KJ. Fat autograft muscle injection (FAMI): new technique for facial volume restoration. Dermatol Surg 2005; 31(11): 1487–95.

10. Pessa JE, Zadoo VP, Garza PA, et al. Double or bifi d zygomaticus major muscle: anatomy, incidence, and clinical correlation. Clin Anat 1998; 11(5): 310–13.

11. Shim KS, Hu KS, Kwak HH, 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(2): 466–73.

12. Greyling LM, Meiring JH. Morphological study on the convergence of the facial muscles at the angle of the mouth. Acta Anat 1992; 143: 127.

13. Kwak HH, Park HD, Youn KH, et al. Branching patterns of the facial nerve and its communication with the auriculotemporal nerve. Surg Radiol Anat 2004; 26: 494–500.

14. Rohrich RJ, Pessa JE, Ristow B. The youthful cheek and the deep medial fat compartment. Plast Reconstr Surg 2008; 121(6): 2107–12.

15. Gonzalez-Ulloa M. The aging face: elimination of wrinkles and other problems. In: Gonzalez-Ulloa, ed. Aesthetic Plastic Surgery, Vol. 1. St Louis, MO: Mosby, 1988: 13–30.

16. Shorr N, Fallor MK. “Madame Butterfl y” Procedure: combined cheek and lateral canthal ten-don procedure for post blepharoplasty “round eye” and lower eyelid retraction. Ophthal Plast Reconstr Surg 1985; 1: 229–35.

17. Strahan R. Comparison of the fi ve year results of deep plane and SMAS facelifts. Presentation, American Academy of Cosmetic Surgery, Annual Meeting. Scottsdale, Arizona, 2009.

18. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83: 11–16. 19. Stuzin JM, Baker TJ, Gordon HL. The relationship of the superfi cial and deep facial fascias:

relevance to rhytidectomy and aging. Plast Reconstr Surg 1992; 89: 441–9. 20. Lucarelli MJ, Khwarg SI, Lemke BN, et al. The anatomy of midfacial ptosis. Ophthalmic Plast

& Recon Surg 2000; 16: 7–22. 21. Mendelson CB, Muzaffar AR, Adams WP. Surgical anatomy of the mid cheek and malar

mounds. Plast Reconstr Surg 2002; 110: 885–96 22. Muzaffar AR, Mendelson CB, Adams WP. Surgical anatomy of the ligamentous attachments of

the lower lid and lateral canthus. Plast Reconstr Surg 2002; 110: 873–84 23. Gamboa GM, de la Torre JI, Vasconez LO. Surgical anatomy of the midface as applied to facial

rejuvenation. Ann Plast Surg 2004; 52(3): 240–5.

59

7.1Volumetric approach to midfacial rejuvenation

Robert A. Glasgold , Mark J. Glasgold , and Jason D. Meier

INTRODUCTION

For the purposes of this chapter, the midface is defi ned as extending from the lower eyelid superiorly to the oral commissure inferiorly. Midfacial aging is primarily a function of volume loss. A youthful midface has a single convexity spanning from the lower eyelid to nasolabial (NL) fold, without a demarcation between the lower eyelid and cheek. As one ages, a general-ized defl ation of the midface occurs, with more focal volume loss along the inferior orbital rim and anterior cheek ( Fig. 7.1.1A and B ). These changes transform the youthful highlights of the midface convexity to a shadow-fi lled double concavity. Midfacial rejuvenation requires restoration of volume to remove or minimize the shadows of senescence and restore the vibrant highlights of youth ( Fig. 7.1.2A and B ) ( 1 ). The potential options for adding midfacial volume has been greatly enhanced by the newest generation of injectable fi llers.

Traditional volume rejuvenation of the midface relied on preformed alloplastic implants. The benefi ts of alloplastic implants are in their ability to provide long-term predictable volume changes. The placement of implants is inherently limited by the facial anatomy, specifi cally the infraorbital nerve limiting the superior extent. Malar implants add cheek volume but do not address, and may even exaggerate, the volume defi cit at the inferior orbital rim responsible for the shadowed demarcation between lower lid and cheek. Alloplastic implants are also limited in their ability to make very precise surface contour changes. Their subperiosteal placement leaves the retaining ligaments, and their effect on surface contour, intact. Autologous fat transfer has gained increasing popularity as an alternative for midface volume restoration. In our practice, it has become the primary means of surgical midface augmentation and provides a durable result. It has the advantage of creating a more tailored natural augmentation as it can be placed more diffusely, and is not limited by the underlying anatomy. Despite these advantages, fat transfer is a surgical procedure requiring more downtime and, due to variable resorption (average retention rate is 30%), may need multiple treatments to get the ultimate result ( 2 ). The advent of an increasing array of injectable fi llers has opened the door to midface volume restoration with less downtime and performed as a quick offi ce procedure. The presently available injectable fi llers have only been Food and Drug Administration (FDA) approved for


Figure 7.1.2 ( A, B ) Midface rejuvenation is achieved with addition of volume to restore the single convexity, uniting the lower lid and cheek subunits. Lower lid transconjunctival blepharoplast was performed in addition to autologous fat transfer to the inferior orbital rim and cheeks. Source : From Carniol PJ, Sadick NS. Clinical Procedures in Laser Skin Rejuvenation. London: Informa Health-care, 2007.

(A) (B)

(A) (B)

a

b

c

Figure 7.1.1 ( A ) This woman in her mid-twenties displays the characteristics of a youthful midface. There is an absence of shadowing, with smooth transitions between facial zones. ( B ) Midface aging is characterized by inferior orbital rim, anterior and lateral cheek volume loss, all of which create a marked shadowing eliminating the once seamless transition from lower lid to cheek. As in this patient malar mounds (a), defi ned by the orbicularis retaining ligament superiorly (c) and the malar septum inferiorly (b), may become pronounced with age-related volume loss. Source : Adapted from Ref. 1.

VOLUMETRIC APPROACH TO MIDFACIAL REJUVENATION 61

aesthetic improvement of the NL folds. They have been used extensively in an off-label fashion for facial augmentation. In our experience, the newer generation of fi llers provides a great minimally invasive alternative to surgery. There is less associated downtime, they have a relatively good durability, and offer patients the opportunity to see the results of added volume with the comfort that it can be reversed.

In any patient who will be undergoing midfacial volume augmentation with injectable fi llers appropriate informed consent should be obtained with an understanding of it being an off-label use. Pretreatment photographs are especially important for comparison with post-treatment results. Patients often forget their preinjection appearance; both in terms of their baseline volume loss and skin pigmentation, these photographs serve as an integral component of their medical record.

In this chapter, we outline our approach to midface volume rejuvenation with injectable fi llers. We present the techniques and materials that have given us the greatest success rate.

REGION 1: INFRAORBITAL RIM

Patients seeking rejuvenation of the lower eyelid are usually focused on the appearance of lower lid “bags,” “dark circles” under their eyes, or lower lid skin texture (i.e., rhytids). The earliest signs of aging in the lower lid relate primarily to volume loss with development of shadowing under the eyes. This is usually fi rst noted in the tear trough, at the medial aspect of the orbital rim, before progressing to involve the entire inferior orbital rim. Filling the concav-ity along the inferior orbital rim will eliminate shadowing and reestablish the smooth contour at the lid–cheek junction ( Fig. 7.1.3A and B ). Restoring volume does not improve skin pigment or texture. Patients must understand what will and will not be addressed by the procedure in order to optimize their satisfaction. At the pretreatment consultation, patient evaluation includes assessing the degree of pseudoherniated lower eyelid fat, volume loss in the orbital rim, skin pigmentation, and presence (and degree) of redundant lower-lid skin/rhytids.

Figure 7.1.3 ( A ) This patient demonstrates early midface aging with volume loss and shadowing along the inferior orbital rim. ( B ) One month following treatment with Restylane. The entire inferior orbital rim was injected to create an improved contour.

(A) (B)


Patients commonly exhibit a darker pigmentation on the medial lower lid skin. Filling the tear trough eliminates the darkened appearance secondary to shadowing; however, it will not improve the overlying hyperpigmentation. Patients are sometimes not aware of the degree of pigmentation in this location, as it is usually at the depth of the concavity and masked by shadowing. Once the shadow is eliminated they may become more aware of their underlying pigment. This should be reviewed with the patient prior to treatment when counseling them about the benefi ts of fi lling the tear trough ( Fig. 7.1.4A – D ).

Volume added to the inferior orbital rim may expand the skin draped over the concavity between the lower lid and cheek. This may improve minor degrees of skin redun-dancy but in the presence of more signifi cant redundancy will fail to unfold the excess skin ( festoon) ( Fig. 7.1.5 ). In these circumstances, surgical intervention to address the redundant skin is needed to obtain an optimal result.

Assessment of the degree of pseudoherniated lower lid fat is also necessary for selecting potential candidates for a volume fi lling approach. In the presence of very signifi cant pseudoherniated lower lid fat, fi lling the concavity inferior to this at the orbital rim may reduce shadowing but fall short of creating the ideal smooth contour from lid to cheek. In these select patients, the optimal result may require lower lid blepharoplasty to reduce the convexity secondary to pseudoherniated fat, in combination with volume augmentation along the inferior orbital rim. If these patients want to proceed with only a volume fi lling approach, they need to be counseled on the potential for an incomplete result.

Since a primary goal of midface rejuvenation is to reestablish the continuity of the lower lid and cheek, this dictates that evaluation of the lower lid includes assessment of malar volume loss. Any patient who is a candidate for fi lling of the inferior orbital rim should be evaluated to determine the need for additional cheek volume. In patients with more global midface volume defi ciency, fi lling of just the inferior orbital rim may eliminate the original convexity but lead to an exaggeration of anterior cheek volume loss ( Fig. 7.1.6A and B ). If not addressed at initial treatment these patients may return feeling that the orbital rim is overfi lled. In some cases, it may truly be overfi lled yet in others this is a pseudoelevation due to inadequate anterior cheek volume, which can be easily corrected.

The preferred injectable materials for the periorbital region are the nonanimal- stabilized hyaluronic acid (NASHA ) fi llers. The hyaluronic acid (HA) products are less viscous and can be injected with a smaller gauge needle, minimizing patient discomfort. HA fi llers are more malleable than other available products and can be manually contoured after injection. In addition, the reversibility of HA products with hyaluronidase injections provides a great degree of reassurance to both the physician and the patient. Among the available NASHA fi llers, Restylane is our preferred material for periorbital fi lling. Restylane allows for very precise correction and has the lowest potential for problems. In contrast, following periorbital injection with Juvederm, we have observed a signifi cant incidence of a persistent edematous appearance, which had to be corrected with hyaluroni-dase injections ( Fig. 7.1.7A and B ). This has not been a problem with Restylane injection and may be due to an increased hydrophilic property of Juvederm compared with Restylane. This characteristic of Juvederm is benefi cial in certain facial areas, such as the lips, but is undesirable where very precise volume correction is required. If Juvederm is to be used around the eyes, then maintaining a consistently deeper injection plane with signifi cant undercorrection is highly recommended to minimize complications.


(A) (B)

(C) (D)

Figure 7.1.4 In the presence of signifi cant hyperpigmentation, correction of volume defi cits will improve shadowing under the eyes but will not improve the pigment. Patients may even become more aware of the pigment now that the skin is elevated from the depth of the fold and the shadowing eliminated. Pre ( A ) and post ( B ) injection photographs of this patient do not demonstrate any signifi cant improvement in the appearance of “dark circles” due to the degree of hyperpigmentation. The Vectra 3D contour (Canfi eld Scientifi c, Fairfi eld, NJ) pre ( C ) and post ( D ) images of the same patient demonstrate signifi cant improvement in contour with a smooth transition from the lower lid to the cheek.


Figure 7.1.5 In the presence of signifi cant skin redundancy, whereupon the fold of skin (festoon) is draping across the tear trough, the mere addition of volume will not be adequate to create the optimal result. This patient demonstrates a situation where the demarcation at the lid–cheek junction is primarily a function of the skin fold, and not volume loss.

Figure 7.1.6 ( A ) Vectra 3-D contour image prior to treatment demonstrates shadowing primarily in the tear trough (arrow). This patient subsequently underwent Restylane injection of the tear trough without augmentation of the cheek. ( B ) One month following treatment, the original tear trough is eliminated but the previously mild shadow (arrow) inferior to this from anterior cheek hollowing is now exaggerated. This creates the illusion of the tear trough being overfi lled, when in actuality the anterior cheek volume needs to be restored to recreate the desired convexity spanning from lower lid to nasolabial fold.

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Before proceeding with injections the planned area for fi lling is marked out. Topical anesthetic ointment alone provides almost complete anesthesia in the periorbital region. As bruising and swelling tend to be more extensive in this region, efforts are aimed at minimizing these sequelae, both to facilitate the injector’s assessment during treatment and to hasten the recovery period. All patients are instructed to be off aspirin containing products for 10 days, and nonsteroidal anti-infl ammatory drugs (NSAIDs) for 2 days, prior to periorbital injection. Ice packs are applied for several minutes prior to injection for vasoconstriction to minimize bruising. Good lighting will aid in visualization and avoidance of superfi cial vessels while injecting, potentially reducing ecchymosis. The order of injections in the lower lid are planned to minimize the impact of bruising and swelling on intraprocedure judgment. The injector’s judgment is also aided by completing injections in an area before moving on to the next area. Proceeding from areas least likely to most likely to bruise, injections are begun medially, continuing across the tear trough in an inferolat-eral direction. Injections are stopped at the central infraorbital rim. Vessel injury in the central infraorbital rim, medial to the malar mound, is more likely and leads to more signifi cant bruising and swelling. Therefore, upon completing the tear trough, injections are then initiated at the lateral orbital rim and progress medially. The remaining central defi cit is fi lled last to complete the infraorbital rim correction ( Fig. 7.1.8 ).

Injections are performed using a serial puncture technique, with placement of material deep to the orbicularis oculi muscle. Although injection can be done at any level, deeper injection will reduce the chance of contour irregularities. In the tear trough and lateral inferior orbital rim, where there is a thin plane between muscle and bone, the needle can be advanced till the bony orbital rim is hit and injection done just superfi cial to the periosteum. In the central inferior orbital rim, which is addressed last, injection should be

Figure 7.1.7 ( A ) Pretreatment Vectra 3-D contour image of a patient requesting treatment for shadowing under her eyes. ( B ) Post-treatment image of this patient two months after Juvederm ultrainjections along the inferior orbital rim. The image demonstrates the appearance of persistent edema (arrow). These patients more commonly have a boggy edema in the region with a greater incidence of a bluish hue in the tear trough.

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just below the orbicularis oculi muscle ( Fig. 7.1.8 ). Advancing the needle down to the bone, which is deeper in this area, is associated with a much greater incidence of piercing blood vessels and exacerbating bruising and swelling. Additionally injection on bone in this location places material far from the surface which is to be treated, thus reducing precision of correction. Restylane is injected until full or slight undercorrection is obtained. Less experienced injectors should err on the side of undercorrection as more product can be easily injected at the follow-up visit. Approximately 0.2 to 0.3 mL of Restylane is generally needed to correct each tear-trough and another 0.3 to 0.4 mL is used to correct the remaining infraorbital rim concavity.

After completing the orbital rim injections, the area is gently massaged to ensure an even contour using a gauze and petrolatum-based ointment. Broad, even pressure, not vigorous massage, is recommended. Patients are instructed to use ice intermittently on the day of injections. In contrast to recovery times in other areas of the face, patients undergoing periorbital injections are advised that ecchymosis may last up to a week. Patients with thicker skin types and more isolated medial hollowing tend to have less bruising. All patients are instructed to follow up at four weeks after injections to assess the result and possible need for touch up.

The duration of effect of HA fi llers in the inferior orbital rim is routinely about 18 months, and not uncommonly patients still have some residual benefi t at 2 years following treatment ( 3 ). Initially this was noted anecdotally in patients, but since the availability of 3-D photography, we have been able to demonstrate the actual degree of volume augmentation persisting over this time frame ( Fig. 7.1.9A – C ).

Figure 7.1.8 Injection technique for the inferior orbital rim. Recommended order for injections: fi ll tear trough from medial to lateral (yellow), fi ll lateral inferior orbital rim from lateral to medial (red), and fi ll central rim defi cit (blue) last. Recommended depth of injection: suborbicularis oculi muscle and supraperiosteal in the tear trough (yellow) and lateral rim (red); immediately deep to the orbicularis oculi muscle (not down to bone) at the central rim (blue).


Other injectable products are available and have been used in the periorbital region. Radiesse was used in our practice for infraorbital rim volume augmentation initially, with relatively good results. However, persistent erythema in the skin at the medial inferior orbital rim, lasting three to four months, occurred in approximately 5% of the patients. In the periorbital region, Radiesse is usually palpable and patients would require counseling prior to treatment to ignore this. Periorbital injections with Radiesse were generally associated with a greater degree of bruising and swelling, which was at least in part due to the need for a larger gauge needle. These issues, in combination with the fact that there is no quick reversibility of the effect, have made Radiesse a less than ideal choice for the periorbital region.

Figure 7.1.9 Long-term results of Restylane injections in the tear trough demonstrated using the Vectra 3-D camera. ( A ) Vectra 3-D contour photo prior to fi lling the tear trough. ( B ) Result at 10 months after injections. ( C ) Persistence of result in the tear trough at 26 months following treatment.

(A) (B)

(C)


REGION 2: CHEEK

Aging in the cheek manifests as overall volume loss with fl attening of the anterior cheek and skeletonization of the zygoma. A particularly challenging aspect of midface rejuvena-tion is in management of malar mounds, when present. For the purposes of this chapter, we defi ne the anterior cheek as spanning from infraorbital rim to NL fold and from the nasofacial junction to medial aspect of the malar mound. The lateral cheek overlies the zygoma, lateral to the malar mound, and is often addressed in conjunction with the submalar region. The malar mound is addressed as a separate subunit. Anterior and lateral cheek rejuvenation is primarily, and more simply, addressed with adding volume. The malar mound is more complicated due to its uneven surface contours created by adjacent osteocutaneous ligaments, and the frequent dynamic nature of its prominence due to swelling. Strategies for rejuvenating the midface, and cheek in particular, need to reestablish the union of the lower lid and cheek subunits, restore volume loss, and create a smooth full cheek convexity (minimizing the visibility of malar mounds) ( Fig. 7.1.10A and B ).

Until recently, cheek augmentation with alloplastic implants has been the mainstay of treatment for this area. Although implants do create malar volume, they cannot create a precise correction of surface contour due to their deep subperiosteal placement. A further limitation with alloplastic implants is that with advancing age and midfacial volume loss the implants may become more visible, creating a severe and overly angular appearance. Autologous fat transfer has provided an excellent alternative for cheek augmentation creating a more individualized result and is particularly advantageous for larger-volume augmentation. Fillers also offer an excellent alternative to implants. They provide the

(A) (B)

Figure 7.1.10 ( A ) Pretreatment photo demonstrates loss of volume in inferior orbital rim and anterior cheek. ( B ) Following inferior orbital rim and anterior cheek augmentation with Restylane the full convex contour is reestablished from lid to cheek.


ability to create very precise changes and tailoring of the result to the individual patient’s needs. HA fi llers, Radiesse, and Sculptra, have all been used in this region with varying degrees of success.

Evaluating candidates for cheek augmentation with fi llers must include an under-standing of the patient’s goals and assessment of overall volume loss in the cheek and adjacent areas. In patients with signifi cant global volume defi ciency, injectable fi llers may not be a cost- effective option for patients. Potential patients must understand the limitations in terms of volume that can be achieved. The presence and severity of malar mounds must also be evaluated prior to treatment. The malar mounds present an obstacle to midface rejuvenation that sometimes cannot be overcome; again this emphasizes the need for counseling patients on realistic goals.

The malar mound is a discrete soft tissue convexity that protrudes from the lateral aspect of the malar eminence. It is defi ned by the orbicularis retaining ligament superiorly, which is responsible for the tethered depression at the lateral inferior orbital rim. Infero-medially, the malar mound is defi ned by the malar septum, an osteocutaneous ligament creating a cutaneous crease running in an inferolateral direction across the anterior cheek ( 4 ). There is variability in the presence and degree of malar mounds. At a minimum, patients may just have a visible anterior cheek depression that corresponds at its deepest aspect with the malar septum. The prominence of the malar mound can be progressively delineated. Furthermore, patients may note fl uctuating edema of the malar mound. The more defi ned the malar mound, and the greater the degree of variable edema, the harder they are to manage. The primary goal is to camoufl age the malar mound by adding vol-ume around it ( Fig. 7.1.11A and B ). Volume placed at deeper planes in the cheek will create an overall increase in malar fullness but will not address the ligamentous attach-ments, leaving the malar mound intact. During fat transfer to the cheek in the presence of less severe malar mounds, the cannula is used to release the septum and place fat along the depressed area. When malar septal tethering is more signifi cant, fat transfer improves, but tends to incompletely correct the malar septal depression. Dermal fi llers provide an advantage in correcting the malar septal depression. The malar septum is an osteocutane-ous ligament adherent superfi cially to the dermis. By injecting in and expanding the der-mis, superfi cial to the ligamentous attachment, the depression may be effaced. There is a limit to the degree of dermal expansion, such that if the mound is too high relative to the septal depression, the depression will be improved but not fully effaced ( Fig. 7.1.12A and B ). Injection must be done very carefully at the malar septum, if done below the dermis the material may track into the malar mound, causing augmentation of the malar mound. Additionally, in patients with very volatile malar mounds, even when injected properly in the dermis, there is a propensity for prolonged malar edema which may, if occurs, will resolve spontaneously.

The goal of midface rejuvenation is also affected by the sex of the patient. In general, volume loss in the lateral and anterior cheek makes the face appear more masculine and square-shaped. The goal of midface volume replacement in the female patient is to restore the natural feminine heart shape of the face. For male patients, a lesser degree of volume augmentation (particularly in the anterior cheek) is desirable. Too much roundness to cheeks is feminizing and a more angular sculpted appearance is preferable in a man. In addition, most male patients are focused not on overall volume augmentation but more frequently are looking to address specifi c contour abnormalities and their associated shadows, as seen with malar mounds.


Figure 7.1.12 ( A ) The effect of a tethered malar septum delineating the inferior aspect of the malar mound is demonstrated on this Vectra 3-D contour photograph. ( B ) Vectra 3-D photograph following Restylane injection in the anterior cheek, placed intradermally along the malar septum. The malar mound is less apparent with overall improvement in cheek contour. But as is common with a more tethered malar septum, the effect of the malar septum cannot be completely overcome in this patient.

(A) (B)

Figure 7.1.11 ( A ) Malar mounds are delineated by the orbicularis retaining ligament superiorly and the malar septum inferomedially (also see Fig. 7.1.1B ). ( B ) Depending on the severity of the malar mounds, they can be camoufl aged by fi lling around it as demonstrated in this photo.

(A) (B)


In the cheek, there is greater fl exibility in terms of which injectable fi llers can be used. Several factors should be weighed when choosing the appropriate material, including whether adjacent areas are being addressed concurrently, how much augmentation is needed, and the presence of and desire to correct malar mounds.

Any of the HA products (Restylane, Perlane, Juvederm Ultra, or Juvederm Ultra Plus) can be used for malar augmentation. Patients who need volume added in the inferior orbital rim, where Restylane is preferred, as well as the cheek will frequently use the same product in both areas. All of the HA fi llers, due to their dermal placement, are more effective for making precise contour changes in the cheek especially in the presence of malar mounds. When using NASHA fi llers to add overall cheek volume the more cross-linked products (Perlane or Juvederm Ultra Plus) are recommended.

Pretreatment markings are performed to outline the area to be fi lled. If a well-defi ned malar crease needs to be addressed this is marked out. Our preference is for topical anesthetic, but in contrast to the thin lid skin, the anesthesia from topical alone is less effective on the cheek. Using the HA products, a serial puncture technique is preferred to create a more uniform fi lling. The one location where a linear threading technique may be used is at the malar septal crease. Depth of injection for the anterior and lateral cheek is in the deep dermis except along the malar septum where more superfi cial placement is more effective to efface the septal crease. Deeper injection in a subdermal plane not only lowers the chance of surface irregularities but also diminishes the volume obtained.

The amount of HA material needed for the cheek ranges from 1 to 3 mL per side depending on patient’s degree of volume loss and whether or not the entire cheek is being volumized or just focal regions (i.e., anterior, lateral, or just camoufl age of malar mound). In our experience, HA fi llers last up to nine months, and sometimes longer, in the cheek ( Fig. 7.1.13A and B ). The duration of effect is generally longer than that observed in the NL fold, but not as persistent as in the periorbital region, where an 18-month result is routine. In patients needing larger volume correction, reliance on HA fi llers can become cost-prohibitive for patients due to the material cost and the fi nite duration of benefi t from the procedure. In these patients, autologous fat transfer becomes a much better option and their primary reason to start with fi llers instead of going directly to fat is to due to limited downtime or to test whether or not they will be pleased with the restored volume. (The role of fat in cheek augmentation will be further detailed later.)

Other materials that can be used for malar augmentation include Radiesse and Sculptra. Radiesse, consisting of calcium hydroxylapatite, is more dense/viscous than the HA products. It is effective in providing a general volume augmentation of the cheek and may be advantageous for larger volume augmentation, based on the larger quantity of material per syringe and the thicker quality of the product. Radiesse needs to be placed in the immediate subdermal plane or deeper, not intradermal. As a result, it is not effective for making the precise changes in surface contour that can be achieved with the dermal fi llers, which is particularly important in patients with visible malar mounds. In our experience, there has been no signifi cant advantage in duration of the result in comparison to NASHA products.

Sculptra consists of poly- L -lactic acid which is diluted into a water suspension prior to injecting. It provides a delayed effect requiring up to two months before the ultimate result from a treatment is realized and requires multiple treatment sessions. To obtain any signifi cant volume change of the entire cheek region, an average of three to four sessions


(two vials per session) is needed. Depending on the desired end result, in patients with signifi cant volume loss, the procedure may be cost-prohibitive. A linear threading injection technique in a subcutaneous plane is recommended. A fanning technique of injection over a small region can be performed through each needle stick to minimize the number of injec-tion sites, each of which is a potential site of nodule formation in areas with thinner skin. Care should be taken so as not to have material on the tip of the needle when entering or exiting the skin as superfi cial placement is a potential cause of nodule formation. With proper technique, Sculptra provides a useful option in anterior and lateral cheek volume replacement with results lasting up to two years through an increase in dermal thickness secondary to collagen deposition. The main limitations of Sculptra are the limited volume change with each treatment, diffi culty in getting large volume changes, variability in result, making it a poor choice when precise correction is needed (i.e., camoufl aging malar mounds), and the relatively high material cost. Although some injectors use it as a fi rst line for cheek augmentation, we primarily use it in patients who want a diffuse softening through added volume without undergoing surgery and patients who would otherwise be ideal can-didates for fat transfer, but who do not have adequate donor fat.

REGION 3: BUCCAL

The buccal region is located just lateral to the inferior extent of the NL fold and below the cheek/submalar region. There exist two primary subsets of patients who show aging effects secondary to buccal volume loss. The very physically active individual in their late thirties and into their forties who have signifi cant global facial volume loss, and the older patient

(A) (B)

Figure 7.1.13 ( A ) Pretreatment photo demonstrates anterior malar and inferior orbital rim volume loss. ( B ) Post-treatment photograph 12 months after malar and inferior orbital rim augmentation using a total of 1 mL of Restylane for the bilateral treatment.


in their late fi fties and beyond who develop more isolated buccal volume loss, creating a more skeletal appearance ( Fig. 7.1.14A – D ). In general, the early effects of buccal volume loss create a more angular and sculpted facial appearance (i.e., loss of baby fat). Most women and men are pleased with this early change in appearance. Progressive buccal volume loss, whether it be in the younger active individual or the older individual, contributes to the loss off the soft, less shadowed youthful appearance, resulting in a more harsh and “gaunt” appearance. Unique to the very gaunt athletic individual is the complaint of a fold of skin posterior to the NL crease. These patients often come in requesting fi lling

Figure 7.1.14 ( A , B ) Pre- and post-treatment photographs of buccal volume replacement with Perlane in a younger patient with global facial volume loss. One milliliter of Perlane was used to fi ll the buccal and submalar region on each side. ( C , D ) Pre- and post-treatment photographs of buccal volume replacement with Juvederm Ultra (0.8 mL) in an older patient with more focal volume loss.

(A) (B)

(C) (D)


of the NL fold; however, in our experience, they are usually dissatisfi ed with the result of doing just this as they still see the fold. To truly address this complaint, fi lling of the buccal region is required to eliminate the shadow posterior to this fold ( Fig. 7.1.15A and B ).

Filling the buccal region does not require a large volume change over a focal area, but a small buildup of volume over a diffused region. Pretreatment marking is important as the fi lled area needs to be gently tapered out into all of the surrounding regions. Because this area does not need a large volume, nor does it require very precise volume addition, any of the previously mentioned fi llers will do. A topical anesthetic is preferred here to minimize swelling which will otherwise impair intratreatment assessment. Our preference is to use one of the HA products as they are more malleable, can be injected with a fi ne gauge needle, give a quick predictable result, and can be reversed if necessary. The results from the HA products in this area again tend to be longer than that seen in the NL fold, frequently lasting at least one year. Technically, serial injections in the deep dermis are preferred, moving broadly across the delineated area. An average 0.5 to 1 mL of an HA material will be required to fi ll each side. Although complications are rare, the primary potential issues relate to contour irregularities either from inadequate taper at the periphery into adjacent regions, or overfi lling centrally. If inadequate tapering at the periphery is noted at follow-up, this is very easily corrected with addition of more material. In our experience, overfi lling has only occurred with Juvederm and is likely related to the proposed more hydrophilic nature of the product. In contrast to the periorbital region, simply underfi lling the buccal area will avoid problems in this region.

REGION 4: NASOLABIAL FOLD

The NL fold occurs at the transition between the anterior cheek and the upper perioral region and is a normal facial feature. As patients perceive that there is a progressive aging

(A) (B)

Figure 7.1.15 ( A ) In the presence of signifi cant global facial volume loss patients not uncommonly complain of both visibility of the nasolabial fold and the prominence (arrow) or pouch of skin, just posterior to it. ( B ) To address these concerns and soften the appearance of the fullness posterior to the nasolabial fold, volume is added into the buccal region in addition to fi lling the nasolabial fold.


appearance to their face, they often become focused on the NL fold because it is the facial feature most easily seen in a mirror. The global loss in facial volume is diffi cult to see even though this is the underlying cause of deepening in the NL fold. The relative position of the NL fold on the face is fi xed by the suspensory strut of the zygomatic musculature, which inserts into the skin at the fold. As the face defl ates and the maxilla rotates posterior cephalad the foundation of the tissues surrounding the NL fold is lost and this tissue hangs tethered only by the suspension of the muscular strut (5).

Correction of the NL fold should be focused on minimizing any harsh shadow in order to make a softer transition from cheek to upper lip. In evaluating the NL fold, the nature of the fold should be appreciated; is it a deep concavity creating shadowing or is it fi ner creasing that is seen in the skin particularly toward the inferolateral aspect; further, it is also important to elicit what aspect is bothersome to the patient. Despite some patient’s insistence, the goal is not and should not be to completely obliterate any hint of indentation along the fold; to do so is to create an unnatural appearance. The superomedial concavity is corrected by adding volume in the triangular region outlined by the nasal ala medially and the NL fold superolaterally. A deep injection of fi ller in this region will often complete any defi cits that superfi cial injection is unable to achieve. Correction of a deep skin crease, which is usually present inferolaterally if not along the entire fold, can be improved but not completely effaced ( Fig. 7.1.16A and B ). This crease is due to the dynamic muscular forces pulling on the dermis of the skin. Patient should be informed that there is a limit to improvement that can be obtained in this fi ne-etched crease.

Any of the HA fi llers, collagen materials, or Radiesse are effective for fi lling the NL fold. The dermal fi llers, specifi cally HA materials, have the advantage of allowing for more plumping out of the fold and are more effective in softening the fi ner creases at the

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Figure 7.1.16 ( A ) Pretreatment photograph of a patient desiring improvement of his nasolabial folds. ( B ) Photograph taken one month following fi lling of nasolabial and labiomandibular folds using a total of 2 mL of Restylane.


inferolateral aspect. Patients are counseled that the HA fi llers typically provide a result in the range of six to nine months, but we have commonly seen patients get at least nine-month results. Regardless of the HA material used, patients will need one to two vials of material. For very minimal folds, one vial will do, but as the depth increases and the patient wants greater degrees of effacement, the likelihood of needing two vials is more likely. For anesthesia, depending on the particular patient, either topical anesthesia, mini-mal infi ltration of lidocaine immediately subcutaneous at the planned injection site, or an infraorbital nerve block can be performed. Our preference is for topical, otherwise we will infi ltrate approximately 0.3 mL of 1% lidocaine with epinephrine (1:100,000) immedi-ately deep to the planned treatment site. This type of local injection is very well tolerated by patients and does not give them the prolonged discomfort of a regional block. Techni-cally, a serial puncture injection into the deeper dermis is preferred in the superomedial triangle as this reduces the chance of surface irregularity yet provides good effacement. Inferolaterally, when there is a fi ne crease, a linear threading technique is used with more superfi cial placement in the dermis. If the initial pass does not efface the fi ne crease, additional passes more superfi cially with minimal material deposition can be done. This should be done cautiously; although this superfi cial placement is more effective at elimi-nating fi ne creases, it comes at the risk of a greater incidence of a prolonged erythema or bluish hue (Tyndall effect). In terms of the different HA materials, Juvederm has the advantage of spreading out more smoothly, which reduces chance of visible lumps, par-ticularly superomedially. With good technique, any of the HA materials will give a very good result. One of the more likely reasons for patient dissatisfaction is incomplete correction with an inadequate amount of material. This is avoided with proper explanation of the expected result and a realistic understanding of the amount of material that needs to be used in a particular patient.

Radiesse can also provide very good results in fi lling the NL fold. Before the availability of the HA products, this was our preferred material for the NL fold. The disadvantage of Radiesse is that it needs to be placed deeper, so that it does not plump out the area as well. In particular, this makes it less effective for fi ne skin creases along the NL fold which are best approached with dermal fi llers. A secondary issue is the noticeable volume loss from the carrier gel dissolving over the fi rst three months, which led to a higher incidence of patients complaining that the result did not last. This can be minimized by explaining to patients that a touch-up procedure is commonly required. One potential advantage of Radiesse is that a larger amount is provided in a single vial, making treatment with one vial realistic in many patients; although it can be argued that a larger portion of the volume will be resorbed in the fi rst few months diminishing this advantage. In terms of actual duration of time before patients return for retreatment, we have not found Radiesse to be advantageous over the HA fi llers.

POSTINJECTION CARE AND MANAGEMENT OF COMPLICATIONS

If markings were made to delineate the injection site, this should be removed with alcohol, not hydrogen peroxide. The area injected is then massaged, using a cotton gauze and Aquaphor, gently with a broad sweeping motion across the injection site in order to ensure a relatively smooth distribution of material. Patients are counseled that contour irregulari-ties are commonly present due to swelling and thus should not massage the area at least for


the fi rst week. Ice packs should be applied to decrease swelling and bruising. This is more important for periorbital injections; these patients are instructed to ice intermittently for the fi rst 48 hours. Ecchymosis is very variable and patients may appear fi ne within a couple of days, but may take up to a week for complete resolution of bruising. Makeup can be applied in two hours after treatment, but if very bruised, will be of limited benefi t.

All patients having cheek or periorbital injections are scheduled for follow-up appointment in three to four weeks. It is generally recommended that the fi rst time a patient has the NL folds fi lled that a follow-up be scheduled to ensure the result is appropriate; on subsequent treatment of the NL fold, this short-term follow-up is not necessary. At the follow-up visit, the result is evaluated to ensure there are no irregularities. If additional fi lling is required, it is performed at this time. If mild visible irregularities are present at follow-up, massage may smooth out the appearance. Should irregularities persist, hyaluronidase can be injected to fl atten out any elevation. The hyaluronidase is used at a concentration of 15 units/mL, with between 1 and 3 units being injected at a time.

Immediately following injections the skin tends to appear erythematous. This lessens signifi cantly within 24 hours, but may persist up to one week. In rare circumstances, a mild degree of redness can persist beyond this time, particularly with very superfi cial injection. The severity of erythema and the patience of the patient will determine intervention. Interventions that have been successful in reducing persistent erythema include intense pulsed light treatment of the area or, if necessary, hyaluronidase injections will break down material and improve the appearance.

Infection is very rare with injectable treatments. In one instance, we have observed delayed onset of erythema, induration, and infl ammation at six weeks following injections (Fig. 7.1.17A, B). This occurred bilaterally in the NL folds; but the labiomandibular folds, which were treated simultaneously, were unaffected. There was no associated pain in the

Figure 7.1.17 ( A ) Six weeks after Restylane injections into her nasolabial and labiomandibular folds this patient presented with erythema and infl ammation isolated to the nasolabial folds that began one month after her injections. ( B ) Once a course of Azithromycin was started to treat atypical mycobacteria she had resolution of the erythema and infl ammation. The patient is shown at four months after initial injections with resolution of infection.

(A) (B)


involved region. This presentation is consistent with atypical mycobacterial infection. This can be easily confused as a type IV (delayed hypersensitivity) infl ammatory reaction but does not respond to topical corticosteroids. Treatment with oral macrolide antibiotics such as Azithromycin is recommended for one to two weeks and has led to complete resolution of the infection in these cases ( 6 ).

AUTOLOGOUS FAT TRANSFER

Autologous fat transfer is primarily used to provide larger volume augmentation in midfacial rejuvenation. It has proven effi cacy in midfacial rejuvenation with quantitative measured volume of around 30% retention of initial volume injected at nearly 1.5 years follow-up with clinical results lasting up to 10 years or longer ( 4 ). It can be used in conjunction with other surgical procedures with excellent results (Fig. 7.1.12A,B). How-ever, autologous fat grafting does have limitations including some variability in the retained amount, which may require touch-up procedures.

One of the main limitations of fat grafting is in obtaining precise small-volume augmentation. Dermal fi llers can efface fi ne rhytids and hollows with the small volumes and precise technique described earlier. Injectable fi llers also have the advantage in overcoming and effacing depressions corresponding to osteocutaneous ligaments such as the malar septum and mandibular ligaments. This cannot be obtained with fat due to the deeper injection required. Also, fi llers have signifi cantly less downtime and most patients can go back to work within the same day as makeup can be applied to the region within hours after treatment.

CONCLUSION

In midfacial rejuvenation, a paradigm shift in both the public’s expectations and physician practices has occurred. Soft-tissue volume augmentation is now an essential component in treating the aging face. Although surgical procedures such as rhytidectomy continue to have a major role, it is no longer acceptable to only address skin and soft tissue laxity and descent.

Soft-tissue volume augmentation plays an integral and complementary role when addressing the facial signs of aging including signifi cant volume loss from soft tissue atrophy and rhytids. The primary goal of midfacial volume contouring is to produce a natural appearance of beauty and youth by enhancing structure and creating the smooth facial contour that tends to be lost with age. Patients are increasingly in search of minimally invasive techniques with little downtime that provide natural results.

With the enormous success of Botox as a minimally invasive treatment, there has been a market explosion of numerous injectables fi llers for soft-tissue augmentation in recent years. Fillers have the advantage of less downtime with increased patient comfort. They also can be used as a “trial-run” before a more invasive surgical procedure is performed. Soft tissue fi llers are an excellent option for midfacial rejuvenation. Each specifi c midface region has specifi c techniques and products which have demonstrated long-lasting and good results. With appropriate expectations, patients can have a high degree of satisfaction in correcting there volume defi cits. These minimally invasive treatments are an excellent alternative to surgical treatment.


REFERENCES

1. Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Philadelphia: Lippincott, Williams & Wilkins, 2007.

2. Meier JD, Glasgold RA, Glasgold MJ. Autologous fat grafting: long term evidence of its effi cacy in midfacial rejuvenation. Arch Facial Plastic Surg 2009; 11(1): 24–8.

3. Donath AS, Glasgold MJ, Glasgold RA. Quantitative evaluation of volume augmentation of nasojugal groove with hyaluronic acid-based fi ller: a 3-dimensional analysis. American Academy of Facial Plastic and Reconstructive Surgery. Fall Meeting. Washington DC, September 2007.

4. Mendelson BC, Muzaffar AR, Adams WP. Surgical anatomy of the midcheek and malar mounds. Plast Reconstr Surg 2002; 110(3): 885–96.

5. Pessa JE, Zadoo VP, et al. Relative maxillary retrusion as a natural consequence of aging: com-bining skeletal and soft-tissue changes into an integrated model of midfacial aging. Plast Recon-str Surg 1998; 102(1): 205–12.

6. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fi llers: focal necrosis and angry red bumps. Dermatol Surg 2006; 32(3): 426–34.

80


Luitgard Wiest

During recent years, dermal fi llers have demonstrated both new techniques and dimensions in facial contouring through revolumization of the aging face when volume defi cits become increasingly apparent. There has been a change in the approach of correcting signs of facial aging; it is now known that patients profi t more from facial enhancement when these fi llers are not only used to fi ll up wrinkles but also to correct volume defi cits below the dermal plane.

Popular indications for injectable fi ller use in the midface are the regional volume defi ciencies in areas like the tear trough/malar region, the buccal region, and the nasolabial fold, as already outlined by the authors of chapter 7.1.

Volumetric enhancement of the periorbital region by restoring an uninterrupted convexity is achieved by blending the lower eyelid and malar region, which results in a greater degree of rejuvenated appearance effacing the tired look that dark circles below the eye imprints on the face. Rejuvenating this area, especially fi lling the tear trough has recently become very popular, as results are often dramatic and fi lling seems so simple to perform. Yet the periorbital region including the lateral regions of the upper and lower eyelids is a very sensitive area. Wu introduced a zone concept of the periorbital and midface area, which he called the lower eyelid midface hollow zones ( 1 ).

Injections in this region have numerous pitfalls and assessment of this region is an absolutely necessary prior to the use of fi llers as already outlined in chapter 11.1. Good candidates for fi lling are patients with modest eye bags and a more prominent tear trough due to midface sagging.

The wrong choice of fi ller material and the wrong technique in this delicate area can lead to possible side effects. An increasing number of nodule formation has been referred to us recently, all of which had been treated with particulated HA fi llers for treatment of the tear trough, and which did not respond to repeated injections of hyaluronidase. In one case, the nodules above the infraorbital rim persisted over two years and the patient insisted on surgical removal. All of these cases had a history of lower blepharoplasty in common. A previous surgical intervention in the periorbital region like a lower blepharo-plasty might increase the risk of persistent swelling, lymphedema, formation of nodules, and granulomas.


The choice of fi ller for this region would be a monophasic fi ller with good viscoelastic properties ( 2 ). With the use of longer-lasting fi llers like Radiesse and Sculptra, the risk of nodule formation rises ( 3 ). As explained in chapter 7.1, the material is injected deeply and epiperiostally at the medial and lateral part of the infraorbital rim. At the medium part of the infraorbital rim we inject just below the orbicularis muscle according to the individual situation, skeletonization, and skin thickness. After using the push-ahead technique for several years, we changed to another technique where the needle is introduced into the skin at an angle of about 45º to 60º deep into the periosteum. The material is then injected in small boluses depositing the majority of the fi ller at the base and gradually injecting less while withdrawing the needle. This gives more volume to the deep levels where most of the volume defi ciency has taken place. The boluses are placed side by side, spaced apart up to 5 mm depending on the area to treat and the volume that is injected. We gently massage the material immediately after the deposition of each bolus for even distribution.

CHEEK

Augmentation of the malar region by fi llers is one of the most popular sites of volume augmentation in exchange for an alloplastic fi ller and is often done in combination with tear-trough augmentation. For the defi nition of the different anatomical regions in this area, for example, anterior cheek, malar mound, and other regions, see chapter 7.1.

Very good results have been obtained in this area over the years with autologous fat transfer ( 4 – 6 ), harvested from the patient and processed with fi ltration plus cleansing or simply reinjected. A debate continues as to the effi cacy of these different methods of fat replacement injections. One problem is variable duration of the obtained result. It has been suggested that this is site-specifi c, with the cheek area having the best retention of injectable fat ( 7 ).

There are multiple techniques for injecting in the malar region reported in the literature and via personal communication with experienced injectors, like the retrograde injection with a linear, fanning, and/or crosshatching technique.

We use the technique of injection of a bolus side by side with a massage or molding of the fi ller to attain the desired effect and to prevent palpable nodules as described earlier. Our fi rst choice is blunt cannulas gauge 25 (e.g., “magic needle”) to avoid fatal compli-cations ( 8 ). We use HA fi llers that are specially designed for giving more volume (Table 2.2.3 ), the so-called volumizers. They usually contain a higher concentration of HA, are double-crossed with a higher degree and are more viscous. The high viscosity neces-sitates utilization of 26- to 27-gauge needle for injection with injection depth in the subcu-taneous space superior to the periosteum. Additional use of lidocaine with the fi ller immediately prior to injecting has added to a more comfortable patient experience.

NASOLABIAL FOLD

As previously discussed in this chapter, the nature of this fold should be taken into consideration and the technique of injection should be chosen accordingly. Enhancement of the minimal and medium nasolabial fold is done primarily with the linear threading or serial puncture technique in the middermis with an HA fi ller whose viscosity is chosen according to the thickness of the skin; for thin skin, an HA fi ller with less viscosity like a monophasic fi ller is preferred.


A special challenge for enhancement is the very deep nasolabial folds often encountered together with thick skin or in male patients. These folds require a layered injection because of more volume defi ciency. Good results in plumping up these folds, when greater volumes of fi ller material is needed, have been reported by Nerwayhid ( 9 ) using the “ fi shbone” technique. This technique is based on a geometric approach of fi lling up the volume defi ciency in this area by placing a long strand in the mid dermis along the fold. Transversally and vertically from lateral to medial short beams are placed below the longitudinal strand spaced 8 to 10 mm apart. These beams lift the longitudinal strand and unfold the crease at the same time. In a study with 31 patients longer results of the HA fi ller (Belotero basic) and less volume was needed with this geometric technique building up a structured scaffold of HA fi ller ( 7 ).

Longer-lasting fi llers like Radiesse ( 10 ), Sculptra (3), and permanent fi llers ( 11 , 12 ) give excellent results when used to enhance deep nasolabial folds. Cohen et al. ( 11 ) demonstrated the safety of ArteFill relative to collagen control and a longer duration than collagen for correction of the nasolabial folds. After fi ve years, the results looked better than they did during the three months to one-year period after injecting ArteFill. The longer-lasting materials are mostly more viscous and are placed with larger bore needles in the deep dermis or subcutaneously medial to the fold in order to avoid spreading of the material laterally to the nasolabial fold and further deepening it upon injection.

As adjunctive measurement, treatment of the alar fi bers of the levator labii superioris alaeque nasi muscle with Botulinum toxin will decrease the dynamic forces pulling up the superomedial concavity of the nasolabial fold. In order to optimize the result and patient satisfaction a subscision of the nasolabial fold with a wire scalpel can be considered to detach subcutaneously the muscular fi bers that insert into the skin before fi lling up the cavity with a fi ller material.

REFERENCES

1. Wu WTL. Facial rejuvenation without facelifts: personal strategies. Presented at the regional Conference in Dermatological Laser and Facial Cosmetic Surgery, Hon Kong, 13–15 Septem-ber 2002.

2. Reinmüller J. Auf der Suche nach dem ultimativen Filler. J Ästhet Chir 2009; 2: 9–14. 3. Vleggaar D. Soft-tissue augmentation and the role of poly- L -lactic acid. Plast Reconstr Surg

2006; 118(3S): 46S–54S. 4. Coleman S. Facial recontouring with lipostructure. Clin Plast Surg 1997; 24: 347–67. 5. Amar R. Adipocyte microinfi ltration in the face or tissue restructuration with fat tissue graft.

Ann Chir Plast Esthet 1999; 44: 593–608. 6. Illouz YG. Adipoaspiration and “fi lling” in the face. Facial Plast Surg 1992; 8: 59–71. 7. Donofrio LM. Panfacial volume restoration with fat. Dermatol Surg 2005; 31: 1496–505. 8. Gleeson CM, Lucas S, Langrish CJ, Barlow RJ. Acute fatal fat tissue embolism after auto-

logous fat transfer in a patient with lupus profundus. Dermatol Surg 2011; 37: 111–15. 9. Nerwayhid M. Fishbone: Eine neue Unterspritzungstechnik zur Behandlung tiefer Nasolabial-

falten mit Hyaluronsäure. Plast Chir 2007; 3: 173–7. 10. Busso M, Karlsberg PL. Cheek augmentation and rejuvenation using injectable hydroxylapatite

(Radiesse®). Cosmetic Dermatol 2006; 19(9): 538–88. 11. Cohen SR, Berner CF, Busso M, et al. Artefi ll: a long-lasting injectable wrinkle fi ller material:

Summary of the U.S. Food and Drug Administration trials and a progress report on 4- to 5–year outcomes. Plast Reconstr Surg 2006; 118(3S): 64S–76S.

12. von Buelow S, von Heimburg D, Pallua N. Effi cacy and safety of polyacrylamide hydrogel for soft tissue augmentation. Plast Reconstr Surg 2005; 116: 1137–46.

83

8 Anatomy of the lower face and neck

Evan Ransom and Stephen A. Goldstein

An understanding of the underlying anatomy of the lower face and neck is important in the clinical practice of facial aesthetics. The lower face is defi ned as the inferior third of the face in the anterior projection. The superior border of the lower face is determined by an oblique line drawn from the oral commissure to the lobule of each auricle. The inferior border is formed by the mandible and its overlying soft tissues. Laterally, the lower face border is the angle and ascending ramus of the mandible. Medially, the left and right lower face aesthetic units meet at the chin, excluding the lower lip and its subunit. Although anatomically distinct, the anterior neck contributes signifi cantly to the appearance of the lower face, particularly in the region between the two sternocleidomastoid muscles.

Lower face and neck aging may contribute signifi cantly to the appearance of aging in the face. In addition, failure to address the lower face and neck, especially in conjunction with midface rejuvenation, may lead to an uneven or incomplete result resulting in an unsatisfi ed patient. The process of lower face aging follows a less defi ned course than the midface, but some events are common. Decent of the adipose tissues of the midface paired with loss of skin turgor may produce an obvious jowl or marionette lines in some cases. Similarly, accumulation of subcutaneous fat and excess lax skin in the submental area diminishes the aesthetic contour of the cervicofacial angle. An understanding of the specifi c contributions of different anatomical components to the changes occurring in this complex area is integral to its rejuvenation. Lower face and anterior neck should be considered in layers, beginning with the skeletal framework and moving superfi cially.

THE OSSEOUS LOWER FACE AND NECK

The single most dominant structure in the lower face is the mandible, which provides both support and contour for the overlying soft tissues. The mandible is generally larger in men, approximately 5 mm greater in height at the body and ramus, and approximately 5 mm thicker at the body. In the female face, the jaw line is typically softer, with a smoother

Illustrations of the lower facial anatomy can be found in Chapter 4 .


transition from the face to the upper cervical structures and has a less pronounced shadow effect than in males. Males have a greater mental protuberance, a prominent elevation of bone inferior to the symphysis. Two important anthropometric points are determined by the size and position of the mandible: the pogonion and the menton. The pogonion is the most anterior point of the mandible in the midline, while the menton is the lowest point of the mandible. A cleft chin occurs when there is incomplete inferior fusion of the right and left hemimandible during embryogenesis and fetal development. This is a heritable trait with varying penetrance. In the past, there have been varying individual and cultural preferences relating to chin clefts.

With advancing age, the bone loss in the mandible may become signifi cant and can adversely affect the shape of the lower face. As the overlying skin volume does not dimin-ish, this creates an aesthetically noticeable change. Furthermore, loss of mandibular height can have a negative aesthetic effect on the jaw line, giving an appearance of excess soft tissue, augmenting any existing laxity or age-related descent, and exposing the contours of the submandibular glands ( 1 ).

In some individuals, a relatively small mandible or inadequate projection can limit the effi cacy of other cosmetic efforts. This should be considered when planning rhinoplasty procedures and is also important in nonsurgical perioral and lip rejuvenation. Superiorly, the mandible forms the inferior alveolus. This bone holds the roots of the lower teeth and provides contour to the lower lip soft tissues. In older patients, particularly those who are partially or totally edentulous, the lower alveolus may suffer signifi cant resorption. This creates a visible change with diminishing fullness of the lips and adjacent structures. We have all seen the edentulous patient whose lips appear to be sinking in toward their mouth.

Some authors specifi cally highlight the importance of addressing bony changes in rejuvenation ( 1 ). Implants and fi llers may be used in this area, particularly in patients with pronounced bone loss in the mandible proper, such as at the chin (symphysis) and prejowl (parasymphysis) ( 2 ). The loss of mandibular projection also creates signifi cant challenges for reconstruction.

Lastly, though it is easily overlooked, the hyoid bone contributes signifi cantly to the appearance of the lower face and neck. Deposition of fatty or loose tissue in the submental area naturally blunts the contour of the mandible and distorts the relationship between the chin and the neck. It is critical to remember, however, that the position of the hyoid determines the cervicomental angle in the youthful face (90°–105°), particularly in profi le but also in oblique views. This is important to consider when planning lower face and neck rejuvenation procedures, such as submental or cervical liposuction and a variety of lifts. Removal of excess adipose tissue or redundant skin may tighten this area, but a malpositioned hyoid can dramatically limit the overall success of these efforts. Surgical procedures to reposition the hyoid are outside of the scope of this review, but are an important adjunct to consider in a small subset of patients ( 1 , 3 ).

MUSCULATURE AND INNERVATION OF THE LOWER FACE AND NECK

The musculature of the lower face and neck is somewhat less complex than the midface but contributes signifi cantly to the appearance of aging and may provide some excellent opportunities for neurotoxin and fi ller-based rejuvenation. Beginning laterally, the lower face muscles include the masseter, platysma, buccinator, orbicularis oris, depressor anguli

ANATOMY OF THE LOWER FACE AND NECK 85

oris, depressor labii inferioris, and mentalis. The masseter provides the greatest bulk of any facial muscle and may have a pronounced effect on the lower face contour in the frontal view in some patients. The other lower face muscles play an important role in mimetic function and are largely responsible for oral competence. Even minute asymmetry at this level, from uneven or improperly placed neurotoxins for example, is easily noticed and can have profound consequences on patients’ perceived beauty.

The masseter muscle originates as superfi cial and deep components. The superfi cial part originates on the zygomatic bone and anterior-most zygomatic arch as a broad aponeu-rosis and inserts at the angle and inferior ramus of the mandible. The deep part is smaller and arises from the posterior border and entire medial surface of the zygomatic arch and inserts more superiorly on the ramus and at the coronoid process. This muscle is responsible for chewing and is among the strongest in the body. As such, masseter hypertrophy may occur, giving the lower face a “square” appearance. Though the exact etiology of masseter hypertrophy is not understood, it appears to be more common in persons of East Asian descent ( 4 ). Multiple aggressive treatment strategies for reduction in masseter volume have been tested, including open surgical reduction and radiofrequency ablation ( 5 – 7 ). A less invasive, fi rst-line therapy involves targeted Botulinum toxin. Relaxation of the masseter with neurotoxin can dramatically soften the jawline in women with a more masculine or “square” jaw ( 4 , 8 ). As the masseter is an important muscle for mastication, injection of any neurotoxin into this muscle should be performed judiciously.

Downward and lateral excursions of the angle of the mouth are performed by two overlapping muscles: the depressor anguli oris superfi cially, and the depressor labii inferi-oris below. The depressor anguli oris originates at the modiolus and inserts on the mandible, pulling the angle of the mouth down with contraction. It responds very well to neurotoxin injections. The depressor labii inferioris interlaces with the orbicularis oris fi bers as they encircle the upper lip and meets its contralateral partner before attaching to the parasym-physeal region of the mandible. Medial to these muscles are the paired mentalis, small quadrangular muscles arising from the symphysis and inserting into the dermis of the chin below the lower lip border. The mentalis elevate the chin skin, as in an expression of doubt, and contribute to pouting and puckering of the lower lip. The orbicularis oris provides the tonic sphincter action of oral competence and also plays a role in articulation and expres-sion. Perioral rhytids may result from repeated orbicularis contraction, particularly in cigarette and pipe smokers. Fine rhytids in this area may be treated quite well with laser resurfacing or chemical peels, while deeper rhytids may necessitate fi ller placement.

Providing tone to the cheek and assisting in mastication, the buccinator muscle sweeps posterior to anterior before curving onto the superior part of the mandibular symphysis. Detailed investigation of the buccinator anatomy has shown that contralateral muscles may converge in the deepest muscle layer of the chin. Some authors have suggested that an inferior band of the buccinator contributes functionally to a “deep unit” along with the inner ring of the orbicularis oris ( 9 ). This is distinct from a “superfi cial unit” composed of the depressor anguli oris, zygomaticus, risorius, and outer ring of the orbicularis, which is anchored more superiorly at the modiolus ( 9 ).

The role of the platysma in facial rejuvenation may be easily overlooked. Along with hyoid position, as discussed above, platysmal banding or laxity can have a detrimental effect on the lower face–neck transition and compromise the cervicofacial angle. The platysma is unique in that it is the only subcutaneous muscle in the head and neck. It arises


from the fascia of the superior parts of the deltoid and pectoralis major muscles at the level of the second rib and sweeps superomedially over the clavicle, soft tissues of the neck, and inferior border of the mandible, before terminating in a fascial plane of the face. Recent investigation has shown that the superior extent of the platysma is variable ( 10 ). The paired platysma muscles are dehiscent in the midline neck up to the level of the submental triangle, where their fi bers begin to decussate. This leaves a point of relative weakness between the chin and the hyoid, where increases in adipose tissue may become obvious.

Contraction of the platysma pulls the angle of the mouth inferiorly and tightens the skin of the neck. Over time in association with associated soft tissue and skin changes, contraction of this muscle creates visible cervical banding.

Furthermore, although excessively increased platysma activity is uncommon, it occurs in synkinesis patients who may be compensating for paralysis/paresis of other facial nerve branches. This can give an uneven appearance to the lower face and is an indication for neurotoxin injection ( 11 ).

In some individuals, in association with aging, there can be progressive platysma weakness and skin laxity leading to a “turkey gobbler” deformity. This presents with a loose wattle of tissue suspended from the chin.

Treatment of these changes associated with aging varies. Platysmal bands may be injected with neurotoxins, providing both relaxation and lifting of the cervicomental angle. Multiple surgical techniques to address cervical rejuvenation have been described for more signifi cant laxity, including platysma Z-plasty, imbrication, resection, and suturing ( 1 , 12 , 13 ).

Innervation of the muscles of the lower face and neck is provided by two nerves, the facial nerve and the motor branch of mandibular division of the trigeminal nerve (V3). Facial nerve supply to the lower face and neck comes from the marginal mandibular and cervical branches, with variable connections to the buccal branch and its arcade ( 14 ). These nerves are generally very small and can easily be injured inadvertently when dissecting soft tissue planes. The cervical branch follows a steep descent after separating from the lower trunk, passing posterior to the mandibular ramus into the neck before angling more anteriorly to broadly innervate the platysma. Injury of the cervical branch has signifi cantly less effects on facial symmetry than comparable injury of other branches, though complete transection can produce subtle asymmetries.

The marginal mandibular branch follows a curvilinear course from the lower division of the facial nerve, dipping below the platysma insertion and the edge of the mandible into the upper neck, superfi cial to the submandibular gland, before ascending beneath the lower face muscles. Unlike those found in the midface, connections between the marginal branch and other facial nerve branches are found in only about 15% of dissection specimens ( 15 ). Section of the marginal branch may be signifi cant to a patient, resulting in signifi cant lower face asymmetry, which is made even more obvious with facial expression. Facial nerve injury has been reported between 0.3% and 2.6% of rhytidectomy procedures, with the temporal and marginal nerves at greatest risk ( 16 ).

Temporary paralysis resulting from neuropraxia, stretch, or electrocautery is more common than permanent injury. This is likely due to the intimate relationship of the nerve to the mandibular retaining ligament, which may be cut in open procedures, in order to increase the amount of soft tissue lift in the lower face ( 15 ). A subtle lower face asymmetry is also seen in some cases of cervical branch injury, though lower lip curling and inferior


excursion remain possible because of an intact marginal branch. In a large case series, Daane and Owsley reported a 1.7% incidence of “pseudo-paralysis” due to cervical branch injury, though 100% of these patients fully recovered ( 17 ).

The masseter and the anterior belly of the digastric muscle are innervated by the mandibular division of the trigeminal nerve (V3). This nerve exits the skull base at the foramen ovale, descends in the parapharyngeal space, and then forms multiple distal branches with motor, sensory, and parasympathetic components. The motor branch to the masseter innervates the muscle fi bers from the deep surface and is generally not at risk during facial rejuvenation procedures. More anteriorly, the mandibular branch provides the motor innervation of the anterior belly of the digastric muscle, making rotation of this portion an excellent option in repair of a permanent marginal branch injury with lower face asymmetry ( 18 ). The posterior belly of the digastric muscle is innervated by a short branch off the proximal facial nerve.

SMAS, LIGAMENTS, AND ADIPOSE TISSUE

The superfi cial musculoaponeurotic system (SMAS) is the tissue layer continuous with the platysma, which invests the mimetic muscles in the lower face. Laterally, the platysma muscle fi bers reach the parotid tail before dissipating and becoming the parotid fascia. In the middle of the platysma, muscle fi bers cross over the mandibular body loosely, account-ing for the relative mobility of the facial skin in this area. More anteriorly, overlying the parasymphysis, the platysma is attached to the mandible at a band of tissue called the mandibular septum or mandibular retaining ligament ( 19 , 20 ).

Similar to the malar fat pad in the midface, the jowl and submental fat in the lower face and neck play a critical role in rejuvenation. Descent of adipose tissue compartments along the mandibular border, lateral to the chin, is one of the factors that create the jowl effect. This is seen in the profi le view as a double contour, though some authors have described this as three curves ( 20 ). The exact composition of the jowl area fat has been debated for years, but recent detailed cadaver dissections have led to some important conclusions. First, the jowl is independent from the buccal fat pad anatomically and functionally ( 20 ). Second, the jowl is not a single fat pad; rather, in a majority of patients, it is composed of three separate compartments. This includes the inferior and superior jowl areas, along with a submental fat pad ( 20 ).

Anteriorly, jowl descent is limited by the mandibular ligament, where the labioman-dibular fold reaches the inferior border of the mandible ( 21 ). Posteriorly, overlying the masseter and in the preauricular area, the SMAS is thicker and densely attached to the parotid fascia ( 19 ). This provides the posterior limit of jowl compartment descent, thus confi ning this process roughly to the middle third of the lower cheek ( 21 ). Jowl area rejuvenation includes traditional lifting procedures as well as using a predominantly upward vector. Targeted, judicious volume replacement, however, may also play an impor-tant role in lower face rejuvenation. This is especially true of patients with minimal jowl decent but an obvious prejowl sulcus. Loss of midface volume creates skin laxity in the cheeks, which affects both the mid and lower face.

In contrast, treatment of the submental fat compartment frequently requires lipectomy or liposuction, though some excellent results with neurotoxins are possible and may delay the need for a surgical procedure.


Relative to the forehead and midface, rhytids and pronounced soft tissue folds are less prominent in the lower face. For example, perioral rhytids are frequently fi ner than in the glabellar region. An exception to this is marionette lines. In some individuals, a deep sulcus following the labiomandibular fold forms with age. This is not an anatomical continuation of the nasolabial fold, but rather represents a distinct fold, generally following the arc of the depressor anguli oris inferolaterally from the modiolus.

Marionette lines may be aligned with or positioned somewhat more toward the mid-line than nasolabial folds in patients with prominence in both areas. These folds are very diffi cult to address with SMAS lift and deeper plane procedures. Treatment of these folds frequently necessitates volume replacement strategies.

This area is an ideal place for fi ller injection, with some dramatic results reported ( 22 ). Indeed, treatment of deep marionette lines and nasolabial folds in lower face and midface rejuvenation highlights the complementary nature of nonsurgical volume replacement with surgical “lifting” procedures. Combining these modalities, either concurrently or over time as the patient ages, allows the aesthetic physician to provide a three- dimensional contour improvement.

As was true of the midface, an appreciation of the anatomy of the skin is important in lower face and neck rejuvenation. This is particularly important when treating issues of skin laxity and pigmentation abnormality. A complex treatment regimen employing neuro-modulators, fi llers, and resurfacing for example, may adequately address these concerns in the lower face. If the neck is not addressed concurrently, however, an uneven or artifi cial appearance may result. For further review of cutaneous anatomy, please see chapter 6 on midface anatomy.

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2. Romo T, Yalamanchili H, Sclafani AP. Chin & Prejowl Augmentation in the management of the aging Jawline. Facial Plast Surg 2005; 21(1): 38–46.

3. Sykes JM. Rejuvenation of the aging neck. Facial Plast Surg 2001; 17(2): 99–107. 4. Liew S, Dart A. Nonsurgical reshaping of the lower face. Aesthetic Surg J 2008; 28(3): 251–7. 5. Roncevic R. Masseter muscle hypertrophy: aetiology and therapy. J Maxillofac Surg 1986;

14(6): 344–8. 6. Ham JW. Masseter reduction procedure with radiofrequency coagulation. J Oral Maxillofac

Surg 2009; 67(2): 457–63. 7. Jin Park Y, Woo Jo Y, Bang SI, et al. Radiofrequency volumetric reduction for masseteric

hypertrophy. Aesthetic Plast Surg 2007; 31(1): 42–52. 8. Castro WH, Gomez RS, Oliveira J, et al. Botulinum toxin type A treatment for contouring of the

lower face. J Oral Maxillofac Surg 2005; 63(1): 20–4. 9. D’Andrea E, Barbaix E. Anatomic research on the perioral muscles, functional matrix of

maxillary and mandibular bones. Surg Radiol Anat 2006; 28(3): 261–6. 10. Shah AR, Rosenberg D. Defi ning the facial extent of the platysma muscle. Arch Facial Plast

Surg 2009; 11(6): 405–8. 11. Husseman J, Mehta RP. Management of synkinesis. Facial Plast Surg 2008; 24(2): 242–9. 12. Gentile RD. Purse-string platysmaplasty: the third dimension for neck contouring. Facial Plast

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13. Giampapa V, Bitzos I, Ramirez O, Granick M. Suture suspension platysmaplasty for neck rejuvenation revisited: technical fi ne points for improving outcomes. Aesth Plast Surg 2005; 29(5): 341–50.

14. Kwak HH, Park HD, Youn KH, et al. Branching patterns of the facial nerve and its communica-tion with the auriculotemporal nerve. Surg Radiol Anat 2004; 26: 494–500.

15. Gosain AK. Surgical anatomy of the facial nerve. Clin Plast Surg 1995; 22(2): 241–51. 16. Baker DC, Conley J. Avoiding facial nerve injury in rhytidectomy: anatomical variations and

pitfalls. Plast Reconstr Surg 1979; 64(6): 781–95. 17. Daane SP, Owsley JQ. Incidence of cervical branch injury with “Marginal mandibular nerve

pseudo-paralysis” in patients undergoing face lift. Plast Reconstr Surg 2003; 111(7): 2414–18. 18. Conley J, Baker DC. Paralysis of the mandibular branch of the facial nerve. Plast Reconstr Surg

1982; 70: 569–77. 19. Furnas DW. The retaining ligaments of the cheek. Plast Reconstr Surg 1989; 83: 11–16. 20. Reece EM, Pessa JE, Rohrich RJ. The mandibular septum: anatomical observations of the jowls

in aging: implications for facial rejuvenation. Plast Reconstr Surg 2008; 121: 1414–20. 21. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the

premasseter space, the jowl, and the labiomandibular fold. Aesth Plast Surg 2008; 32: 185–95. 22. Gravier MH, Bass LS, Busso M, et al. Calcium hydroxylapatite (Radiesse) for correction of the

mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007; 120(6 Suppl): 55S–66S.

90

9.1 Volumetric approach to lower facial rejuvenation

Robert A. Glasgold, Mark J. Glasgold, and Jason D. Meier

The aging process that occurs in the lower face has been well documented ( 1 , 2 ). Skin laxity coupled with the gradual descent of the soft tissues including facial fat, superfi cial musculoaponeurotic system (SMAS), and musculature result in the development of the labiomental fold, platysmal banding, and ptotic jowls that are the stigmata of the aging lower face. This process can be exacerbated by genetics, smoking, and ultraviolet light exposure. Poor bone defi nition of the mandible can accentuate the soft tissue descent of the face, thereby creating an accelerated impression of aging. Similar to midfacial rejuvenation, a volumetric approach to the lower face and neck plays an integral and complementary role in rejuvenation procedures. The lower face and neck has been primarily addressed with surgical techniques including rhytidectomy and mentoplasty. However, patients are increasingly looking for minimally invasive procedures that provide lasting results. With the advent of nonanimal-stabilized hyaluronic acid (NASHA) injectable fi llers and the off-label expansion of their use in treating the aging lower face, patients have a variety of options to address their concerns.

The lower face, defi ned for the purposes of this chapter, begins at the level of the oral commissure and continues inferiorly into the neck. Volume restoration for facial rejuvena-tion is frequently discussed in the context of midfacial rejuvenation. Traditionally there has been less focus on the role of volume in rejuvenating the lower face, outside the role of chin implants. Volume loss has a very real effect on lower face aging, and as in the midface often accounts for the initial signs of aging in younger patients ( 3 ). This chapter will review the techniques and fi lling materials used for jawline and lower perioral rejuvenation in our practice. Volume by no means can replace the role of surgery in jawline and neck rejuvena-tion but in the appropriate patient can be a very effective substitute, or even complement, for surgery ( Fig. 9.1.1A and B ).

This chapter focuses on injectable fi llers that have been used in our practice with proven success and high patient satisfaction. As in the previous chapter, this chapter will focus on anatomically defi ning a region and describing the specialized techniques and products recommended for that region. In addition, complications and pitfalls of various products and techniques based on our experience will be addressed.

VOLUMETRIC APPROACH TO LOWER FACIAL REJUVENATION 91

JAWLINE

The most common jawline complaint is development of jowls. This is manifest by the loss of the crisp uniform shadow that runs from mentum to angle of the mandible. Under-lying this change is soft tissue ptosis at the jowl resulting in fullness inferior to the mandibular border. The mandibular ligament, an osteocutaneous attachment, demarcates the anterior limit of the jowl. Volume loss, both bone and soft tissue occurs at the mandibular ligament resulting in the prejowl sulcus. To a lesser degree, posterior to the jowl at the angle of the mandible, volume defi ciency (age related or congenital) will further emphasize the presence of a jowl. The sum of these changes turns the youthful crisp “hockey-stick”-shaped shadow defi ning the jawline into an irregular “W”-shaped aged jawline ( Fig. 9.1.2A and B ).

Jawline rejuvenation requires addressing the volume loss, anterior and posterior to the jowl, and/or lifting the jowl itself. The chosen treatment depends on a particular patient’s anatomy and their desired result. This chapter is primarily focused on volume rejuvenation of the jawline. In younger patients with minimal jowl ptosis, addition of prejowl volume can create excellent jawline restoration, possibly exceeding the result a surgical facelift would obtain ( Fig. 9.1.3A and B ). With more progressive jowl ptosis and prejowl sulcus defi ciencies, several issues need to be assessed in order to optimize the result and patient satisfaction. A more ptotic jowl will require a greater degree of volume in order to camoufl age its presence. If very signifi cant, it may not be possible to camoufl age the jowl with volume alone. This may be in part due to overly extensive jowl ptosis, but is also

Figure 9.1.1 ( A ) Prior to treatment this patient demonstrates characteristic changes of the aging jawline including prejowl sulcus volume loss, jowl ptosis, and loss of mandibular angle volume/ defi nition. ( B ) Photograph of the same patient one month after volume rejuvenation of the jawline, with fi lling of the prejowl sulcus and lateral (angle) jawline. A total of two and a half vials of Juvederm were used in this patient. Two vials of Juvederm Ultra were used in the prejowl sulcus and to delineate the mandibular angle. Juvederm Ultra Plus (0.4 mL/side) was used to add bulk in the remaining area of the mandibular angle.

(A) (B)


Figure 9.1.2 ( A ) This woman in her mid twenties demonstrates the characteristic youthful jawline defi ned by a “hockey stick”-shaped shadow. ( B ) In the aging jawline the defi ning shadow transitions from the “hockey stick” shape into an irregular “W”-shape, secondary to prejowl sulcus volume loss, jowl descent and loss of lateral jawline defi nition. (Figure 9.1.2A is reprinted with permission from Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Lippincott Williams & Wilkins. Philadelphia, 2007.)

(A) (B)

(A) (B)

Figure 9.1.3 ( A ) Early aging changes in the jawline are primarily related to volume loss in the prejowl sulcus and may be accompanied by lateral jawline volume loss. ( B ) Volume rejuvenation of the jawline with placement of Restylane in the prejowl sulcus and lateral jawline. A total of 2 mL of Restylane were used for the entire bilateral treatment.

related to the adherence of the mandibular ligament. The mandibular ligament attaches from the underside of the dermis to the mandible and delineates the prejowl sulcus. The degree of mandibular ligament adherence limits the extent to which the prejowl sulcus can be effaced. If very adherent, no amount of volume will adequately infl ate it to the point of completely masking the jowl ( Fig. 9.1.4A and B ). If it is less adherent, the prejowl sulcus


is more amenable to a volume fi lling approach. Dermal fi llers (hyaluronic acid (HA) fi llers) offer an advantage in patients with more adherent mandibular ligaments. Filling and infl ating the dermis, which is superfi cial to the mandibular ligament, improves the ability to overcome the ligament’s tethering effect. Mandibular ligament adherence can be assessed simply by pulling inferolaterally on the skin at the depth of the prejowl sulcus. If the skin is easily pulled down to the level of the jowl, then the ligament’s adherence should not inhibit full correction with injection alone. If it is more tethered and will not pull down to the level of the jowl easily, fi lling of the prejowl sulcus, and thus camoufl age of the jowl, will likely be incomplete.

Volume defi ciency of the lateral jawline, or angle of mandible, may be due to a congenital defi cit of bone or soft tissue ( Fig. 9.1.5A and B ) or may be a relative loss in comparison to the adjacent jowl ptosis. In most patients adding lateral jawline volume is of secondary importance relative to the benefi t from volume added to the prejowl sulcus. People generally view themselves front on, or obliquely, in a mirror. From these perspec-tives they will appreciate the improvement of prejowl volume more readily than improve-ments in lateral jawline volume. Explaining to patients the role of lateral jawline volume is best done by reviewing their profi le photos with them, and those of patients with similar fi ndings who have undergone these procedures. Deciding whether or not to recommend addition of lateral jawline volume depends on the shape of the jawline shadow posterior to the jowl. If fi lling in the prejowl sulcus accomplishes the full “hockey-stick” shadow then the lateral jawline does not need to be addressed ( Fig. 9.1.6A and B ). As the degree of jowling increases the appropriate angle defi nition is lost and full camoufl age of the jowl will require lateral jawline volume ( Fig. 9.1.7A and B ).

Figure 9.1.4 ( A ) This patient demonstrates both jowl descent and prejowl sulcus contraction in the presence of a very adherent mandibular ligament. ( B ) Jawline defi nition was improved with prejowl sulcus and lateral jawline volume, using a total of 3 mL of Restylane. The appearance of persistent jowling is from the inability to fully overcome the tethering effect of the mandibular ligament. In this patient the optimal result would require facelift combined with release of the mandibular ligament and fi lling of the prejowl sulcus.

(A) (B)


(A) (B)

Figure 9.1.5 ( A ) Prior to treatment this patient demonstrates congenitally defi cient mandibular angle defi nition. ( B ) Angle defi nition was improved by fi lling the lateral jawline with 0.4 mL of Juvederm Ultra Plus on each side.

The technique for jawline rejuvenation using HA fi llers begins with marking of the planned injection sites. Conceptually the jowl is the lowest point along the jawline and the goal is to bring the adjacent areas (prejowl sulcus and lateral jawline) down to the level of the jowl. The prejowl sulcus marking is basically a triangle, tapering into the chin anteri-orly and the jowl posteriorly ( Fig. 9.1.8A and B ). The angle marking is also a triangle with its lateral inferior corner rounded off, and its anterior corner tapering into the posterior border of the jowl. A topical anesthetic is generally used; if needed for patient comfort, a minimal (less than 1 mL) amount of 1% lidocaine with epinephrine (1:100,000) is injected subcutaneously at the planned injection sites. HA fi ller injections can be done either with a linear threading or serial puncture technique. Depth of injection is in the mid to deep

Figure 9.1.6 ( A ) This patient demonstrates jawline aging primarily due to prejowl volume loss. ( B ) In this circumstance excellent rejuvenation of the jawline was obtained by adding volume to just the prejowl sulcus. A total of 1.2 mL of Radiesse was used for bilateral treatment.

(A) (B)


dermis, staying more superfi cial to overcome the most adherent part of the mandibular ligament as well as for defi ning the lateral jawline ( Fig. 9.1.8C and D ). The more superfi -cial injections in these locations are usually done with a linear threading technique. The area is massaged with some degree of molding to ensure a smooth and appropriate contour. Bruising is less common than that which occurs in the midface. Patients are instructed to follow up in three to four weeks to evaluate the result and for a touch up injection, if needed. Filling of the prejowl sulcus will require between 0.5 and 1 mL of HA product per side, depending on the severity of the defi cit. The amount of material needed for the lateral jawline is much more variable. At a minimum 0.5 cc of volume needs to be placed. As the jowl increases, in fullness and degree of descent, the amount of volume required can increase to 1 or 2 mL per side. In general, 3 to 4 mL of material will be required to complete bilateral prejowl sulcus and angle defi nition. Since most patients can better appreciate the prejowl result, they will usually opt to underdo the lateral jawline to reduce the total amount of material needed.

In contrast to the inferior orbital rim, there is much more fl exibility for the type of product that can be used here. Our early experiences were with Radiesse, prior to availability of HA fi llers, with which we generally got a 10-month result before patients noted diminishing volume. One potential advantage of Radiesse is the larger amount of volume in the syringe, reducing the material costs ( Fig. 9.1.9A and B ). The limitation with Radiesse in the prejowl sulcus and lateral jawline is based on its requiring a deeper subdermal placement. Patients with a less adherent mandibular ligament can get a good result, but when the ligament is more adherent the result is improved by more superfi cial dermal placement using an HA fi ller. Additionally, following Radiesse injection, there was typically thickening or fi brosis that was present even after the result receded, making subsequent injection with Radiesse very diffi cult. In the lateral jawline, our original

Figure 9.1.7 ( A ) Demonstration of an aging jawline with more progressive prejowl and angle volume loss combined with jowl ptosis. ( B ) Prejowl sulcus fi lling with Restylane improved the anterior jawline contour, but the posterior aspect of the jowl is left uncamoufl aged. An optimal result would be obtained through the addition of volume at the angle of mandible to complete the ideal “hockey stick” contour.

(A) (B)


thinking was that the thicker material would be benefi cial for the bulk required to address this area. In practice, more important than just bulk is creation of a well-defi ned shadow that delineates the angle. Again, dermal injection can create the type of ridge that is necessary to optimize jawline defi nition in this area. For these reasons, the HA fi llers have become our primary choice for jawline rejuvenation.

Figure 9.1.8 ( A ) Appearance immediately prior to volume rejuvenation of the jawline. ( B ) The injection plan is marked out. The prejowl sulcus is fi lled inferiorly, dropping it down to the level of the jowl and mentum to create a straight jawline. The angle is defi ned by fi lling out the delineated triangular region, carefully tapering the added volume into the posterior border of the jowl. ( C ) Technique and depth of injections. The green indicates where more superfi cial dermal injection is performed; including at the mandibular ligament (at the apex of the prejowl sulcus) and to outline the angle defi nition. A linear injection technique is often used in these areas. The blue indicates where deeper dermal injection is used for fi lling the remainder of the prejowl sulcus and the lateral jawline. This is usually performed with a serial puncture injection technique. ( D ) The patient is shown immediately following Restylane (using a total of 3mL) injections in the prejowl sulcus and lateral jawline with recreation of the uniform “hockey stick”-shaped jawline.

(A) (B)

(C) (D)


Figure 9.1.9 ( A , B ) Pre and posttreatment photographs showing the result obtained from isolated fi lling of the prejowl sulcus. One vial of Radiesse was adequate for bilateral treatment. Evaluation revealed very little resistance to fi lling from the mandibular ligament allowing for adequate correction with Radiesse. This result also demonstrates how lowering the height of the jawline at the prejowl sulcus hides submental fullness giving the appearance of an improved submental contour.

(A) (B)

In terms of which HA fi ller to use, we have used with good success Restylane, Perlane, Juvederm Ultra, and Juvederm Ultra Plus. We have noted some benefi ts of the individual products that can infl uence which one to use. In areas where material is placed more super-fi cially in the dermis (i.e. mandibular ligament and angle defi nition) a less viscous material, such as Restylane or Juvederm, is preferred. In distinguishing between Restylane and Juvederm family of products we have found that Juvederm spreads out over an area more readily and seems to be more hydrophilic, giving a more infl ated appearance (which is the very reason we do not use it in the periorbital region). In contrast, Restylane does not seem to spread over the area as readily and is therefore better at creating very defi ned elevations. Clinically this has led to a preference for Restylane in thicker skin types where it is more diffi cult to create the “ridge” or defi nition of the jawline, and a preference for Juvederm in thinner more crepe-paper like skin where Restylane may be more visible and the “infl ating” effect of Juvederm gives a nice full appearance to the skin ( Fig. 9.1.10A – D ). Jawline correction with injectable HA fi llers can be expected to last around nine months to a year.

LABIOMANDIBULAR FOLD (MARIONETTE LINES)

The labiomandibular folds (LMF), often referred to as “marionette lines,” begin at the oral commissure and run in an inferolateral direction toward the jawline. This region is of particular concern to patients, who note that the corners of their mouth turn down. The labiomandibular fold defi nes the anterior border of the jowl. As one ages, the labioman-dibular fold deepens, accentuating the appearance of the jowl. The volume loss in this fold is often accompanied by volume loss in the lateral superior aspect of the chin, lateral to the labiomental sulcus. Results from fi lling of LMF are often optimized by placing material both at the depth of the fold and anterior to it, creating a smooth contour from jowl to lateral


Figure 9.1.10 ( A , B ) Restylane (2 mL) and Perlane (1 mL) were used for volume rejuvenation of the jawline by fi lling the prejowl sulcus and lateral jawline. This patient demonstrates the type of result obtained with thicker skin types where Restylane is often preferred for creating jawline defi nition. ( C , D ) Juvederm Ultra (2 syringe) and Ultra Plus (1 syringe) were used for volume reju-venation of jawline by fi lling the prejowl sulcus and lateral jawline. The nasolabial folds and perioral rhytids were also fi lled with Juvederm. This patient demonstrates the thinner more crepe-paper like skin that often obtains a nicer result with Juvederm.

(A) (B)

(C) (D)

chin ( Fig. 9.1.11A and B ). HA fi llers are our preferred material for this area as they can provide excellent and precise correction of the volume loss. As in other areas, dermal placement facilitates effacement of the fold ( Fig. 9.1.12A and B ).

The injection technique begins with marking the planned injection area along the labiomandibular fold along with the triangular shaped region of volume loss just medial to the fold ( Fig. 9.1.11 ). Topical anesthetic is applied. A serial puncture injection technique is preferred in this area. Injection should remain in the mid to deep dermis, particularly in the


superomedial aspect of the fold, where too superfi cial injection is more likely to result in prolonged erythema or a bluish hue (Tyndall effect). On average, 0.3 to 0.5 mL of HA product per side is typically required to correct this region. It is important to inject only at or medial to the fold as injection lateral to it will worsen the appearance of the jowl and LMF. After correction, gentle massage of the area is performed with petrolatum-based oint-ment to ensure a smooth contour. The result can be expected to last between six and nine months. For patients who are very focused on the downward turn at the oral commissure,

(A) (B)

Figure 9.1.11 ( A ) The labiomandibular fold delineates the anterior border of the jowl. Volume loss at the fold itself should be restored, in addition to the lateral chin depression anteromedially, to create a smooth contour. ( B ) The planned injection site is marked in the diagram.

Figure 9.1.12 ( A , B ) Pre- and posttreatment photograph demonstrates the effect of fi lling the labiomandibular fold to create a uniform contour from the jowl into chin.

(A) (B)


ancillary use of Botulinum toxin injection of the depressor anguli oris (DAO) muscles, 2 to 4 units/side, can enhance the resulting of LMF fi lling. These injections are done into the inferior portion of the DAO muscle, at the anterior face of the mandible, so as to prevent inadvertent weakening of the orbicularis oris muscle. Patients are asked to show their bottom teeth, activating the DAO muscle for identifi cation of its location prior to injection with Botulinum toxin.

CHIN

The primary patient concerns related to the chin involve projection and contour. Microgenia (under projection) is not an uncommon complaint even in the younger patient; but age-related volume loss of bone and soft tissue may unmask or exaggerate a long-standing microgenia. The contour changes in the chin are secondary to soft tissue volume loss over the highly dynamic mentalis muscle in combination with decreased skin elasticity. The resulting change in the chin surface contour, commonly referred to as “peau d’orange,” has a very aging effect on the lower face.

Injectable fi llers have a limited role in correction of chin projection. Alloplastic implants remain our gold standard for chin augmentation. These implants have a long history of use with proven effi cacy, providing predictable and safe long-term results. The limitations of injectable fi llers for chin augmentation relate to their fi nite duration of effect and the diffi culty in obtaining signifi cant projection without using very large volumes. The advantages offered by injectable fi llers include the ability to demonstrate the result of chin augmentation in patients who are considering an implant or do not want to undergo surgery, and the ability to precisely contour chin irregularities or asymmetries ( Fig. 9.1.13A and B ).

Figure 9.1.13 ( A ) This patient demonstrates signifi cant microgenia and is an ideal candidate for an alloplastic implant. The patient wanted a nonsurgical solution and only a mild increase in chin projection. ( B ) Result at two months following treatment with a total of 2 mL of Perlane and 1 mL of Restylane used to fi ll the anterior chin, labiomandibular fold, lateral chin depressions, and prejowl sulcus.

(A) (B)


Due to the limited projection that can be achieved with injections this treatment is usually reserved for patients with smaller degrees of microgenia.

Treatment begins with marking the planned area for injection. If projection is the central goal, the central mentum is marked out with plan for lateral extension into the prejowl sulcus to mimic the effect of an extended anatomical implant. The injections may also be tapered into the adjacent lateral chin depressions that span from the labiomandibular fold to the labiomental sulcus. When correcting “peau d’orange” skin texture the involved area, generally the central mentum, is outlined. Anesthesia is obtained using small amounts (1 mL) of 1% lidocaine with epinephrine 1:100.000 layered subcutaneously in the chin, as topical anesthetics are generally insuffi cient for analgesia of the chin.

Chin projection can be accomplished with any of the HA fi llers or with Radiesse. The main advantage of Radiesse is the larger volume per syringe. In contrast, despite smaller volume, the ability to place HA fi llers in both the dermis and subdermis actually helps to increase the amount of obtainable projection. Additionally, since most aging patients have some degree of contour irregularity in the chin, this will be simultaneously addressed with dermal (HA) fi llers. Perlane or Juvederm Ultra Plus is generally used when trying to increase projection. Regardless of the goal, injection of the HA fi llers can be done with either a serial puncture or linear threading technique. For correction of “peau d’orange,” the HA fi ller is distributed evenly throughout the involved dermis. Clinically this effect on surface contour was an incidental benefi t realized in a patient undergoing injectable chin augmentation ( Fig. 9.1.14A and B ). Prior to this, the primary treatment for the surface irregularity was Botulinum toxin injection (2–4 units) into the mentalis muscle. To maxi-mize contour results, Botulinum toxin and fi ller treatment can be combined and a result lasting nine months or longer can be obtained. Further, patients can get a longer and still very good result even with use of an HA fi ller alone.

Figure 9.1.14 ( A ) The patient (also seen in fi gure 9.1.13A and B on profi le) demonstrates signifi -cant “peau d’orange” changes to the chin. ( B ) Dermal injection across the involved area improved the skin texture. This result was obtained without using Botulinum toxin in the mentalis muscle, but can be further improved with its addition.

(A) (B)


LOWER LIP VERTICAL RHYTIDS

Lower lip vertical rhytids are particularly bothersome for many patients. In addition to genetic and general aging factors, smoking and solar damage play an important role in the genesis of perioral vertical rhytids. Smoking causes repeated mimetic motion of the orbicularis oris musculature, which usually defi nes and worsens the vertical lines. These rhytids usually begin at the vermillion border and have varying depth and length. Vertical rhytids in the lower lip are usually less prominent than those present in the upper lip; however, if present both regions should be addressed in the same session.

HA fi llers are the mainstay of treatment for correction of vertical rhytids and vol-ume loss. Marking out each deep vertical rhytid with a fi ne-tipped marker is benefi cial prior to application of topical anesthetic. Superfi cial injection of HA fi ller in a linear threading technique is recommended for treatment of the individual deep vertical rhytid. The needle should be visible with only a thin tissue layer between it and the skin surface. In addition, injection of the vermillion border provides for some effacement of the verti-cal rhytids along the entire length of the lower lip and a linear threading technique is preferred.

Juvederm Ultra or Restylane are preferred for direct injection into the deep vertical lip rhytid and for the vermillion border. If volume augmentation of the body of the lip is being performed, then Juvederm is preferred as it provides a smoother augmentation with more of a plumping effect. Longevity of the result in the perioral region tends to be less than other facial regions, but still can frequently last up to nine months.

LABIOMENTAL SULCUS

The labiomental sulcus is the depression that divides the lower lip from the chin. It has a hyperbolic shape and usually terminates in the lateral chin area. Deepening of the labiomental sulcus occurs with age and can be of concern to some patients.

Correction and effacement of this sulcus can be obtained with a variety of injectable fi llers. If a deep well-demarcated crease is present, then superfi cial injection with a HA fi ller is preferred. Either Restylane or Juvederm works well using a linear threading deep dermal injection to “unfold” the crease. A broad depression in the labiomental sulcus can be corrected with thicker formulations of HA such as Juvederm Ultra Plus or Perlane or can be corrected with Radiesse. Less than 0.5 mL of an HA fi ller is usually all that is required for correction of this region.

POSTINJECTION CARE AND MANAGEMENT OF COMPLICATIONS

After injection of HA fi llers, the skin markings should be removed with alcohol. After superfi cial injections, especially when there is even minimal blanching of the skin, hydrogen peroxide should never be used to clean the skin. We have seen two instances of minimal focal superfi cial skin necrosis that occurred immediately after cleaning the site with hydrogen peroxide. Both cases healed without complication, but with the avoidance of hydrogen peroxide, focal superfi cial skin necrosis has not been seen. Application of Aquaphor ointment and a gentle but fi rm massage is recommended to smooth out any pal-pable or visible lumps. Ice packs are applied to decrease swelling and bruising. Bruising, if


it occurs, may take up to fi ve to seven days to completely resolve. Makeup can be applied within two hours after treatment.

Immediately following injections the skin appears erythematous. This lessens signifi cantly within 24 hours, but may persist up to one week. In rare circumstances, a mild degree of redness can persist, particularly with very superfi cial injection. The severity of erythema and the patience of the patient will determine intervention. Interventions that have been successful in reducing persistent erythema include intense pulsed light treatment of the area or, if necessary, hyaluronidase injections will break down material and improve the appearance.

Patients are instructed not to massage the area treated. If visible irregularities are still present after one week from the time of injection, the patient can gently massage the area if they are very concerned. Palpability of the material is normal and expected, this will soften with time; but the degree of palpability does not correlate with persistence of result. Patients are scheduled for a follow-up visit in approximately three to four weeks after injections to assess the result and determine any need for a touch-up procedure. This also allows for photographic documentation of the patient’s result. If mild visible irregularities are present at follow-up, massage may smooth out the appearance. Should irregularities persist, hyaluronidase can be injected to fl atten out any elevation. The hyaluronidase is used at a concentration of 15 units/mL, with 1 to 3 units being injected at a time.

Infection is very rare with injectable treatments. In one instance we have observed delayed onset of erythema, induration, and infl ammation at six weeks following injections (Fig. 7.1.17A and B ). This was not associated with any signifi cant pain. This presentation is consistent with atypical mycobacterial infection. This can be easily confused as a type IV (delayed hypersensitivity) infl ammatory reaction but does not respond to topical cortico-steroids. Treatment with oral macrolide antibiotics such as Azithromycin is recommended for one to two weeks and will lead to complete resolution of the infection ( 4 ).

AUTOLOGOUS FAT TRANSFER

Our experience with autologous fat transfer in the lower face has demonstrated good results in specifi c regions. It is very useful for jawline correction of both prejowl sulcus and angle of mandible. It is an appealing option for patients with signifi cant lateral jawline defi cien-cies where larger volumes of material are required. Autologous fat offers a very long-term result, but does require more downtime following treatment due to bruising and swelling. Autologous fat augmentation of the chin is useful for smaller augmentations, but, as with fi llers, the results from alloplastic implants are usually superior and provide predictable long-term results. In other areas of the lower face, such as the labiomandibular fold, improvements can be made with fat but where very precise and complete effacement is desired the HA fi llers are often a better alternative ( 5 ).

CONCLUSION

Utilizing a volumetric approach for lower facial rejuvenation, soft tissue fi llers provide long-lasting excellent results with minimal downtime. Each lower facial region has specifi c techniques and products, which have demonstrated long-lasting and good results. With appropriate expectations, patients can have a high degree of satisfaction with soft tissue


fi llers. These minimally invasive procedures are an excellent alternative or can be used in conjunction with surgical treatment.

REFERENCES

1. Mendelson BC, Freeman ME, Wu W, Huggins RJ. Surgical anatomy of the lower face: the premasseter space, the jowl, and the labiomandibular fold. Aesthetic Plast Surg 2008; 32(2): 185–95.

2. Reece EM, Rohrich RJ. The aesthetic jawline: management of the aging jowl. Aesthet Surg J 2008; 28(6): 668–74.

3. Lam SM, Glasgold MJ, Glasgold RA. Complementary Fat Grafting. Philadelphia: Lippincott, Williams & Wilkins, 2007.

4. Narins RS, Jewell M, Rubin M, et al. Clinical conference: management of rare events following dermal fi llers: focal necrosis and angry red bumps. Dermatol Surg 2006; 32(3): 426–34.

5. Glasgold MJ, Lam SM, Glasgold RA. Autologous fat grafting for cosmetic enhancement of the perioral region. Facial Plast Surg Clin North Am 2007; 15: 461–70.

105

9.2 European commentary

Luitgard Wiest

The authors of chapter 9.1, which focuses on the lower face, have described the challenges encountered in using injectable fi llers in the lower face. If jawline ptosis is not too progressive and rejuvenation of the jawline can be restored with an injectable fi ller, then assessment of the anatomical situation and the adherence of the mandibular ligament are necessary before enhancement with fi llers. Although the jowl compartment is clearly demarcated from adjacent compartments, Pilsl and Anderhuber ( 1 ) have demonstrated in a study with 30 anatomic specimens that the retaining ligaments have different origins and are differently formed. At sites where the ligaments of the skin do not reach skeletal structures (false ligaments), the skin is not effectively anchored, and age-related changes are more prominent. These anatomic variations might contribute to variable results when using fi llers.

In our practice we have abandoned the use of more viscous materials like Radiesse for rejuvenation of the jawline and obtained good results with hyaluronic acid (HA) volumizing agents (Table 2.2.3 ) that are more viscous and have a higher degree of cross-linking. In areas where the material has to be placed more superfi cially and intradermally and in thinner skin our preference is a monophasic HA fi ller gel that has greater fl ow capacity. Most of the HA fi ller manufacturers have recently introduced a variety of their preparations, which are bioengineered materials that can be used interchangeably for many different applications and which allow a choice of fi ller from the same family that is specially designed for different indications, different areas, and levels to be injected.

Vleggar ( 2 ) showed excellent results with poly- L -lactic acid in recontouring the mid- and lower face, particularly around the jowls after three to four treatment sessions.

In the lower face enhancement of marionette lines, the chin, and labiomental sulcus with injectable fi llers should, if possible, include the relaxation with Botulinum toxin of the facial muscles that contribute to the formation of wrinkles or defi ciencies in the lower face. The highly dynamic muscles of the lower face are responsible for speech, eating, and communication and thus are much more active than the facial muscles in the upper face. The depressor anguli oris m., the mentalis m. and the orbicularis m., even the platysma play a great role in contributing to the formation of marionette lines, the vertical lines of the lower lip, and the labomental sulcus, which contribute to giving the patients a sad and


dissatisfi ed look. Several authors ( 3 – 5 ) demonstrated that the outcome of wrinkle treat-ment with injectable fi llers is clearly improved when Botulinum toxin was injected before-hand. They were able to achieve longer durability of the fi ller material and better results on the wrinkle score. The muscular relaxation provided by the Botulinum toxin may act to promote longevity of the fi ller by preventing deformation of the hyaluronic acid residing in the dermis ( 6 ).

Various techniques can be used for volume enhancement of the marionette lines. If more volume is needed the cross-hatching technique can be used along with the linear threading or serial puncture technique.

In older patients and in thicker skin, more viscous material like volumizing agents (Table 2.2.3) or fi llers with a longer benefi t like Radiesse are required.

The limitations of injectable fi llers for chin augmentation have been described in chapter 9.1. We fi nd it also extremely diffi cult to enhance the “peau d’orange” skin texture of the chin or the labiomental sulcus with injectable fi llers in the presence of a very dynamic mentalis muscle. Other modalities like skin resurfacing give better results in combination with Botulinum toxin than with injectable fi llers.

REFERENCES

1. Pilsl U, Anderhuber F. The chin and adjacent fat compartments. Dermatol Surg 2010; 36: 214–18. 2. Vleggar D. Soft-tissue augmentation and the role of Poly- L -Lactic Acid. Plast Reconstr Surg

2006; 118(3S): 46S–54S. 3. Carruthers J, Carruthers A. The adjunctive usage of botulinum toxin. Dermatol Surg 1998; 24:

1244–7. 4. Sommer B, Sattler G. Cosmetic indications according to anatomic region (Ch 3). In: Sommer B,

Sattler G, eds. Botulinum Toxin in Aesthetic Medicine. Berlin: Blackwell Science, 2001. 5. Ascher B, Wibault-Collange C. Botulinum toxin (Dysport ® ) and hyaluronic acid (Hylaform ® )

association in the treatment of lines. A preliminary evaluation. Inamed Aesthet News 2002: 1. 6. Tierney EP, Hanke CW. Recent advances in combination treatments for photoaging. Review of

the literature. Dermatol Surg 2010; 36: 829–40.

107

10.1 Volumetric approach to the lips

Mary P. Lupo

INTRODUCTION

A youthful face has several notable features: smooth skin with no wrinkles or discolorations, central facial volume that prevents sagging of the lower face, and full, well- demarcated lips ( Fig. 10.1.1 ). As we age, loss of dermal volume, loss of bone mass, realignment and/or loss of fat pockets, and changes in dentition result in changes of the lips and the surrounding perioral unit. The distance from the nose to the upper lip lengthens due to volumetric loss of bone and dermis in the nasolabial area and canine fossa, while the distance from the lower lip to the tip of the chin shortens from loss of bone and dentition. This will result in a forward pivoting of the chin and a relative involution of the entire mouth that would be especially prominent in the edentulous.

Aging lips have a loss of volume that results in a shrinking of the visible pink “show” of the lips, making the lips pencil thin on anterior view. Additionally, decreased prominence and defi nition of the philtral columns and Cupid’s bow over time fl attens the lips in profi le. Photoaging and repeated life-long purse-string movement of the orbicularis oris muscle results in perioral rhytids known as “lipstick” lines ( Fig. 10.1.2 ). All these factors must be assessed and corrected for rejuvenation of the lower face and lips. This chapter will address the author’s methods to revolumize, reshape, and rejuvenate the lips.

INJECTION METHODS

For purposes of this discussion, we must fi rst describe and discuss the nomenclature and anatomy of the lips. The wet–dry border is where the mucosa inside the mouth meets the externally visible lip ( Fig. 10.1.3 ) . This area is the most important for revolumizing the lips as proper technique will externally rotate the visible lip “show” and make the lips look fuller. Placing the needle’s bevel up and slightly bending the needle to push the material more toward the surface can project the lips out more—with less material. The injection level for optimal revolumizing is the muscle layer. Immediate massage will insure a smooth result ( Figs. 10.1.4 and 10.1.5 ). But increasing size alone is not rejuvenating. A naturally youthful lip has undulations and prominences called tubercles ( Fig. 10.1.6 ). Typically the


Figure 10.1.1 Lips in a 24-year-old, showing fullness, shape, and youthful perioral unit.

Figure 10.1.2 Aged lips in 72-year-old, showing loss of lip volume and shape, surrounding dermal atrophy and resulting fi ne rhytids, and loss of bone causing involution of the lips, deep folds, and forward pivot of the chin.

Figure 10.1.3 Needle placement into the wet–dry border to achieve volume. Injection is in the muscular layer.

VOLUMETRIC APPROACH TO THE LIPS 109

upper lip has three: the center and two lateral. The lower lip has one on each side. This anatomy should be maintained to prevent the unattractive “sausage” lips ( Fig. 10.1.7 ). Well-balanced lips also have the lower lip slightly larger than the upper.

In addition to a youthful shape, attractive lips have a well-defi ned border. The vermillion border or “white roll” is where the pink mucosa meets the cornifi ed epithelium of facial skin ( Fig. 10.1.8 ). This area must be defi ned, not volumized. If the vermillion alone is injected, it can actually roll the lip inward and decrease the pink show that our patients desire. Even worse, overcorrection of the vermillion alone without some volumization of the body of the lips can result in “duck” lips. This is more likely if the upper lip platform has dermal atrophy and fl attening of philtral columns. This emphasizes again the importance of looking at the entire perioral unit rather than just lip size ( Figs. 10.1.9 and 10.1.10 ). Ideally, for vermillion correction, the dermal fi ller is injected into the potential space just beneath the dermis. When injected in this plane, the material dissects along the border, does not lump, and requires fewer sticks of the needle.

Figure 10.1.4 Before injection photograph of 32-year-old female with moderate photoaging.

Figure 10.1.5 After reshaping and revolumizing the lips, fi lling the nasolabial fold and correcting the perioral scar using 0.8 cc of hyaluronic acid gel fi ller.


The lateral corners of the lips often require dermal fi ller to turn the mouth corner up. In addition, dermal injections of fi ller inferior and just lateral to the mouth corner will support and “buttress” the lateral mouth and diminish the marionette or “puppet” lines ( Fig. 10.1.11 ).

Figure 10.1.6 Injection into lower lip tubercle for shape.

Figure 10.1.7 Overinjected lips showing loss of lip landmarks and an artifi cial look.

Figure 10.1.8 Injection into the white roll for defi nition.


Figure 10.1.9 Side view of lip fl attening and lengthening and fl attening of upper lip platform.

Figure 10.1.10 After 0.5 cc HA fi ller into lip, nasolabial fold, and into cupid’s bow to project lips and shorten distance from nose to upper lip.

Figure 10.1.11 Injection into the lateral support of mouth corner to buttress and lift mouth corner.

This correction is better achieved with the complementing benefi ts of neurotoxin injection into the depressor angularis oris as well as injection of fi ller into the prejowl sulcus as needed ( Figs. 10.1.12 and 10.1.13 ) ( 1 ).


Figure 10.1.12 Before treatment: 44-year old showing shadowing of the chin area that ages the perioral unit.

Figure 10.1.13 After injection with 0.8 cc of HA fi ller into lips, nasolabial fold, and marionette; 4 units into each DAO; and 4 units into mentalis to relax and reshape the oral unit and complement fi ller.

Lipstick lines are often stretched out and improved when the body of the lips is revolumized. Older patients, those with profound photoaging, smokers, whistlers, lip pursers, and musicians will often require additional fi lling directly into these radial perioral “lipstick” lines. The level of these injections here is into the dermis ( Figs. 10.1.14 – 10.1.17 ). The addition of neurotoxin in small quantities will dramatically improve the result and its duration ( 1 ). Care must be taken to make the injections symmetrical and they should be omitted in those for whom mouth movement is critical such as television personnel, singers, and musicians.

MATERIALS FOR INJECTION

Hyaluronic acid (HA) fi llers, as of writing, are the safest, most versatile, and most durable products for injecting into the lips. It has great patient acceptance and popularity ( 2 ).


Figure 10.1.14 A 55-year-old female with full lips but profound solar elastosis resulting in signifi cant lipstick lines.

Figure 10.1.15 After 0.8 cc HA fi ller into perioral lines only.

HA fi llers can be injected into all planes: dermal, subcutaneous, and muscular ( Figs. 10.1.18 and 10.1.19 ). Care must be taken with the dermal injections to prevent lumping and the blue hue or Tyndall effect from superfi cial dermal placement. This can be easily corrected by nicking the skin and extruding the material. It is noteworthy that although lip augmenta-tion and rejuvenation is very popular, there is technically no FDA-approved product for injections into the lips. Practicing physicians do lip injections “off-label” and as such, it is accepted as effective and safe based on years of experience using bovine and human collagen as well as HA fi llers ( 3 , 4 ).

For many years, bovine collagen was injected into and around the lips with very nice results but the duration was not acceptable. In 2003, human collagen became available, but its only advantage was that allergy testing was not necessary. HA fi llers became the


workhorse for lip injections and remain so to this day. HA can be reversed with hyaluroni-dase if there is a problem ( 5 ). Newer fi llers such as porcine collagen, calcium hydroxyl-apatite, and poly- L -lactic acid are contraindicated in the lips because of the high incidence of nodules and lumps ( Fig. 10.1.20 ).

COMPLICATIONS

Bruising is the most common complication of lip augmentation ( Fig. 10.1.21 ). It can be reduced by having patients discontinue blood thinners and anticoagulants (as appropriate to the patient’s medical history). Aspirin, vitamin E, fi sh oil, and many herbal remedies are known to increase bruising. If bruises occur, they can often be easily hidden by lipstick,

Figure 10.1.17 After correction of lipstick lines using 0.8 cc HA.

Figure 10.1.16 A 59-year-old female with more intrinsic aging but profound lipstick lines.


Figure 10.1.18 Before injection of 1.0 cc HA fi ller into lips.

Figure 10.1.19 After, showing overall natural correction.

Figure 10.1.20 Two years after calcium hydroxylapatite injection for lip augmentation. Nodules eventually dissipated after three years.


especially when the injection approach is through the mucosa rather than the skin. Posttreatment ice, and pressure as well as the use of bruise reduction creams or arnica might be of value ( 6 ). The technique coined by Dr Jean Carruthers as the “push ahead” technique can reduce tissue trauma and bruise by using the fi ller to push small vessels out of the way of the needle ( 7 ). The author also “primes” the needle to place HA at the beveled edge to further reduce tissue tear and trauma. Finally, using a slow injection rate and lower product volume has been found to decrease bruising ( 8 ). Hematoma is possible if an artery is nicked ( Fig. 10.1.22 ). If severe, evacuation may be necessary, but they usually resolve without sequelae.

As mentioned earlier, superfi cial placement of HA fi ller will result in lumping and/or Tyndall effect. Nick and extrusion is the optimal treatment for this. Hyaluronidase is for deeper lumps, excess correction, and asymmetry. Asymmetry is usually the result of injection by nonphysician injectors and is often amenable to correction with more fi ller

Figure 10.1.21 Mild bruise after injection from percutaneous approach into lips.

Figure 10.1.22 Severe hematoma two hours after injection, likely the result of an arterial nick.


( Figs. 10.1.23 and 10.1.24 ). Swelling can occur within hours to a day after injection. Idiosyncratic angioedema has also been reported ( 9 ). Avoidance of salt and sleeping on the back on two to three pillows might be benefi cial, but the best way to avoid swelling is to not overcorrect or over massage. The use of oral or intramuscular corticosteroids might also be benefi cial ( 10 , 11 ). Prophylaxis against herpes simplex is always a good idea when doing procedures around the mouth ( 10 ). There have been reports of granulomatous nodules from HA injections for lip augmentation ( 12 , 13 ). The treatment of choice to reverse this type of reaction would be hyaluronidase ( 5 ).

Finally, techniques to reduce pain are critical to patient happiness and continued injections in the future. One of the best ways to retain patients and to have them refer their friends for treatment is to improve the patients’ experience. Ice, nerve blocks, vibration distraction, topical anesthetics, and mixing the fi ller directly with lidocaine can all reduce the patient’s discomfort ( 7 , 11 , 14 ). A good cosmetic result, little or no complications, and good pain management are the keys to success ( Figs. 10.1.25 – 10.1.27 ).

Figure 10.1.23 Asymmetrical result from HA injection by nonphysician provider.

Figure 10.1.24 After correction with 0.8 cc HA fi ller.


Figure 10.1.25 Before picture of patient shown getting injections in Figures 10.1.3, 10.1.6, 10.1.8, and 10.1.11.

Figure 10.1.26 Immediately after injection of 0.8 cc HA.

Figure 10.1.27 Eight months after the treatment.


SUMMARY

The lips are an important facial landmark for a youthful face. The use of dermal fi llers such as the HA family can restore volume, defi nition, and shape. When combined with fi ller into the upper lip platform, perioral rhytids and the chin to lift and support the mouth, as well as careful placement of complementing Botulinum toxin, an overall youthful appearance to the entire lower face can be restored.

REFERENCES

1. Carruthers J, Glogau R, Blitzer A, et al. Advances in facial rejuvenation: botulinum toxin type A, hyaluronic acid dermal fi llers, and combination therapies: consensus recommendations. Plast Reconstruct Surg 2008; 121(Suppl): 5S–30S.

2. Bosniak S, Cantisano-Zilkha M, Glavas I. Non-stabilized hyaluronic acid for lip augmentation and facial rhytid ablation. Arch Facial Plast Surg 2004; 6: 379–83.

3. Lupo MP. Hyaluronic acid fi llers in facial rejuvenation. Semin Cutan Med Surg 2006; 25: 122–6.

4. Sarnoff DS, Saini R, Gotkin RH. Comparison of fi lling agents for lip augmentation. Aesthetic Surg J 2008; 28: 556–63.

5. Brody HJ. Use of hyaluronidase in the treatment of granulomatous hyaluronic acid reactions or unwanted hyaluronic acid placement. Dermatol Surg 2005; 31: 893–7.

6. Lupo MP. A double-blinded, randomized, placebo-controlled split faced within subject evaluation of a bruise reduction serum. Poster Exhibit, Cosmetic Boot Camp, Aspen Co., 2009.

7. Carruthers J, Carruthers A. Hyaluronic acid gel in skin rejuvenation. J Drugs Dermatol 2006; 5: 959–64.

8. Glogau R, Kane M. Effect of injection techniques on the rate of local adverse events in patients implanted with nonanimal hyaluronic acid gel dermal fi llers. Dermatol Surg 2008; 34: S105–S109.

9. Leonhardt J, Lawrence N, Narins R. Angioedema acute hypersensitivity reaction to injectable hyaluronic acid. Dermatol Surg 2005; 31: 577.

10. Carruthers A, Carruthers J. Non-animal-based hyaluronic acid fi llers: scientifi c and technical considerations. Plast Reconstruc Surg 2007; 120(Suppl): 33S–40S.

11. Dover J, Carruthers A, Carruthers J, et al. Clinical use of Restylane. Skin Ther Lett 2005; 10: 5–7.

12. Fernandez-Acenero M, Zamora E, Borbujo J. Granulomatous foreign body reaction against hyaluronic acid: report of a case after lip augmentation. Dermatol Surg 2003; 29: 1225.

13. Saylan Z. Facial fi llers and their complications. Aesthetic Surg J 2003; 23: 221. 14. Swetman G, Lupo MP, Waller W. Comparison of the effi cacy and tolerability of non-animal

stabilized hyaluronic acid fi ller with and without lidocaine hydrochloride 2% for the correction of nasolabial folds. Poster Exhibit, Cosmetic Boot Camp, Aspen Co, 2009.

120

10.2 European commentary

Luitgard Wiest

The author of chapter 10.1 emphasizes the importance of looking at the entire perioral unit, when restoring volume to the lips. Except for the younger patient group who require lip augmentation only, older patients with aging lips will benefi t from other modalities for rejuvenation of the entire perioral unit. It should be remembered that a “nonexisting lip” or a very small lip cannot be restored by dermal fi llers and should be approached with surgical techniques.

An understanding of the embryology of lips serves as a foundation for lip augmentation and for choosing the best technique to obtain a natural fullness of the lip. During embryo-nal development the lateral maxillary swellings fuse with the paired medial nasal swellings to form the upper lip. The union of these different structures is refl ected by the character-istic undulations of the philtral ridge and Cupid’s bow. The lower lip is a simpler and less defi ned structure, it forms from the merger of the paired mandibular swellings. The difference between upper and lower lip has to be considered in the volumetric approach to lips. The correction especially of aging lips has to address the whole perioral unit like perioral rhytids, the drooping angles of the mouth, as well as restoring the fl attened philtral ridges and the Cupid’s bow. Other defi ciencies like dentition should be restored. Photoaged skin is best rejuvenated with different laser methods or chemical peel.

Regarding the technique of restoring the vermillion border it should be defi ned, not volumized as already mentioned earlier in chapter 10.1. In order to get a better defi nition we pinch the border between the thumb and forefi nger of the nondominant hand while injecting and withdrawing the needle. To volumize the lips it is best not to use a permanent fi ller that might result in nodule formation, which is diffi cult to treat. A much better option is to use a resorbable fi ller that can be corrected in the case of overcorrection or if nodules occur. We have found that pretreatment with small amounts of Botulinum toxin distributed evenly in four injection points along the vermillion boarder prior to fi ller treatment helps to prevent nodule formation in this area with constant movement of the M. orbicularis oris.

In addition to relaxing the pars marginalis of the orbicularis muscle that forms the red lip, it adds a very natural pseudo-volume to the lip of about 1 mm, it improves the ease of injection into the relaxed muscle and the injected fi ller material is dispersed easier without


forming lumps. There is a wide range of HA fi llers available in Europe especially designed for the use of volumizing lips (Table 2.2.2) ( 1 ).

Many techniques have been described to prevent the “sausage look” of the lips after augmentation ( 2 , 3 ). Injecting the fi ller above the muscle will result in outward rotation of the lip, injecting under the muscle at the wet border will result in projection of the lip. Considering the embryologic features and respecting the anatomy of the lip “sausage lips” can be prevented and an individual approach can be performed.

Most patients require volume enhancement only along the central three-fi fth of the lip. We prefer vertical injections starting at the vermillion border of the lip until the wet–dry border of the lip proceeding from medial to lateral. Upon withdrawing the fi ller is injected, depositing volume in the muscular part of the lip, if necessary in an additional layer. The vertical injections are repeated every few millimeters as needed to reach the desired volume.

The perioral unit, especially the upper lip, is one of the most sensitive areas of the face and excellent anesthetist an absolute requirement.

We prefer an infraorbital and/or mental nerve block for more comfort for the patient during the procedure as topical agents are not as effective in this area.

CONCLUSION

In Europe quite a few HA-fi llers are specially designed for lip enhancement, the choice lies between monophasic HA-gels and biphasic particulated fi llers with different viscosities proving dermal fi llers are important tools in this area and in the whole perioral unit. This is especially effective in older patients combined with the treatment of Botulinum toxin to relax the depressor muscles resulting in a lift of the perioral area. Several newer techniques of lip augmentation have been introduced recently, leading away from those techniques that were applied in a horizontal fashion across the entire lip, resulting in the so-called “sausage lip”.

For more comfort for the patient nerve blocks are preferred.

REFERENCES

1. Sanoff DS, Saini R, Gotkin RH. Comparison of fi lling agents for lip augmentation. Aesthet Surg J 2008; 28(5): 556–63.

2. Braun M, Braun S, van Eijik T. Lip tenting: a simple technique for better lip enhancement. J Drugs Dermatol 2010; 9: 559–60.

3. Klein AW. In search of the perfect lip. Dermatol Surg 2005; 31: 1599–603.

122

11.1Volumetric approach to rejuvenation of the hands

Anetta E. Reszko and Neil S. Sadick

INTRODUCTION

The aging process is commonly accelerated in the hands due to their intense and continuous usage and constant exposure to environmental pressures. After the face, hands are the most visible body part and as such are of major aesthetic importance. Increasing numbers of patients are seeking treatments that would restore a more youthful appearance to their hands based on a common belief that hands’ appearance can be used to determine a true chronological age ( 1 ).

COMPONENTS OF THE AGING HAND

The principles of hand aesthetics are based on normal anatomy, adequate proportions, even skin pigmentation, suffi cient subcutaneous tissue volume, adequate elasticity, and minimal skin wrinkling.

The aging process of hands has extrinsic and intrinsic bases. Extrinsic aging encom-passes superfi cial epidermal changes such as actinic and seborrheic keratoses, dyschromia, solar lentigines, solar purpura, and perceived skin roughness. Skin roughness may be the result of irregular epidermal contours and aberrations of cell proliferation and turnover.

Intrinsic aging involves deep soft-tissue planes and comprises skin textual changes such as dermal atrophy and wrinkling, and muscular, bone, and fat atrophy ( 1 ) . Clinically visible manifestations of intrinsic aging are skin laxity, loss of skin elasticity, volume loss with concomitant protuberant tendons, bones, and hand veins.

Overall, intrinsic and extrinsic aging processes of the hands can be divided into three broad categories ( Fig. 11.1.1 ).

Type I—epidermal and superfi cial dermal; clinically apparent as pigmentary skin alterations such as lentigines, postinfl ammatory dyschromia, skin roughness, and vascular aberrations (telangiectasias, purpura).

Type II—dermal; results from architectural changes involving collagen, elastin, and glycosaminoglycans. Type II aging is clinically characterized by formation of rhytids.

VOLUMETRIC APPROACH TO REJUVENATION OF THE HANDS 123

Type III—subcutaneous involving bone, muscle, and fat atrophy. This type of aging is clinically visible as skin laxity, loss of elasticity, volume loss due to osteoporosis of carpal bones and subsequently to clinically widened and deepened interosseous sulci that may be further exacerbated by atrophy of interossei and lumbrical muscles.

To restore and refi ne a youthful hand appearance, the clinical type of aging must be matched to an appropriate rejuvenation program, with both intrinsic and extrinsic factors being taken into account.

This chapter provides a review of current literature and data from our clinical prac-tice on the use of soft-tissue fi llers for treatment as an outpatient, which are minimally invasive and an effi cacious procedure for type III hands rejuvenation.

The ideal soft-tissue fi ller/semipermanent soft-tissue volumizer for type III hands rejuvenation should have several basic properties. It should be safe, completely nonaller-genic, produce a smooth and natural looking effect, should be easy to inject, easy to store, readily prepared, affordable, and have a long duration of effects, but not permanent so that potential errors could be corrected.

Currently available soft-tissue fi llers are: harvested autologous fat, collagen, hyal-uronic acid (HA), poly- L -lactic acid (PLLA ), and calcium hydroxylapatite (CaHA).

Few general principles apply for volumetric rejuvenation with various fi ller materials. First, preoperative evaluation for all soft-tissue injectables should include a prior his-

tory of injectables, medical history, review of current medications, and a coagulopathy history. Medications that lessen blood coagulation, such as aspirin, ibuprofen, and platelet inhibitors, are contraindicated for fi ve to seven days before treatment to minimize intra- and perioperative bruising. Bruising may be further reduced by supplementation with arnica and Bromelain for one to two days perioperatively ( 2 – 4 ).

Second, sterile technique should be followed at all times.

Figure 11.1.1 Aging hand demonstrating Type I (epidermal), Type II (dermal), and Type III ( subcutaneous) changes. Appropriate Type III rejuvenation protocol with fi llers would target loss of volume and resulting skin laxity as well as deepened interosseous sulci.


Third, topical anesthetics and/or regional nerve blocks may be used for the anesthesia of the hands prior to fi ller injection. Other methods such as distraction, vibration, and cool-ing might be used.

Fourth, patient may be placed in Trendelenburg position to reduce dorsal hand venous pressure and possibly minimize the risk of venous puncture.

AUTOLOGOUS FAT

Autologous fat augmentation has been performed for facial rejuvenation and reconstruc-tion for over 100 years. Fournier was the fi rst to describe the use of autologous fat for the dorsal hand rejuvenation ( 5 ). Fournier’s technique centered on the injection of the bolus of fat though a single incision in the dorsum of the hand and subsequent digital manipulation over entire dorsum of the hand and, in special cases, into the fi ngers.

In 2001, Coleman introduced the idea of “structural fat grafting” to describe the process in which small amounts of intact fat are placed in a structured method into the subcutaneous dorsal hand ( 6 ).

Autologous fat transfer comprises of several steps: fat harvesting, fat preparation/refi nement, fat transfer, and fi nally structural fat placement. Strictly sterile technique is required for all aforementioned steps.

AUTOLOGOUS FAT HARVESTING

Fat harvesting involves aspiration of fat from a donor site (hips, inner and outer thighs, medial knees) infi ltrated with tumescent anesthesia with a blunt-tipped cannula or a blunt Lamis infi ltrator (Byron Medical Inc., Tucson, AZ, U.S.) attached to a 10 mL Luer-Lok syringe. On an average, 1 mL of tumescent anesthetic is required per 1 mL of the fat to be harvested. Commonly employed harvesting cannulas have a diameter of 3 mm and a length between 15 and 23 cm; commercially available harvesting cannulas have a blunt tip in the shape of a bucket handle for harvesting very small fragments of fat.

During the harvesting process, as the light negative pressure is applied to the plunger, the cannula is advanced and retracted through the harvested tissue. Alternatively, high-vacuum suction systems used for liposuction may be employed for tissue harvesting, although the risk of marked damage to the delicate fatty tissue is markedly increased with higher pressure systems.

Extracted fat is centrifuged at 3000 rpm for three minutes in harvesting syringes after securing the Luer-Lok end and removing the plunger. The centrifugation process separates the harvested material into three separate layers. The top layer (lowest density) is comprised primarily of oils and ruptured adipocytes. The mid portion (mid density) and lower portion (highest density) consist of a viable adipocytes/fat particles and mixture of blood, lidocaine, and water, respectively. After decanting the top layer (cotton surgical strips (Codman & Shurtleff, Rayham, MA, U.S.) may be used to wick oil remaining after initial decanting), and draining the aqueous (bottom) portion, the midportion is ready for harvesting ( 7 ). In an alternative protocol, harvested fat may be subjected to gravitational separation for up to 15 minutes in the harvesting syringe in the upright position, with infra-natant fl uid discarded and the remaining supernatant centrifuged at 3600 rpm for three minutes ( 8 ).


Generally, approximately 30 to 40 mL of centrifuged fat must be harvested per hand to ensure adequate treatment volume.

Exposure to atmospheric air should be minimized during the harvesting process to avoid cytoplasmic lysis of adipocytes. Histological analysis of the harvested fat demon-strates cytoplasmic lysis of up to 50% of the adipocytes exposed to air for a period of 15 minutes ( 6 ).

Centrifuged fat is then transferred to 1 mL syringes for injection. Compared with larger volume syringe, a 1 mL syringe confers more control and delivers smaller particles of fat with less pressure. Care should be taken to minimize trauma to the harvested fat and the introduction of air bubbles.

AUTOLOGOUS FAT GRAFTING

Topical anesthetics and/or regional nerve blocks may be used for the anesthesia of the hands prior to structural fat grafting. In addition, tumescent anesthesia (3–5 mL) is injected in the dorsal wrist crease (and more proximally as required).

An injection needle (#10 Amay, Byron) or a microcannula is inserted into the area to be treated through small incisions or an 18-gauge needle-entry port in the dorsal crease. Any sharp instruments such as needles should be avoided to minimize potential damage to the hand vasculature and nerves. The level of fat placement for rejuvenation of the hand is in the immediate subdermal plane superfi cial to the veins and tendons. Fat is then injected in the retrograde fashion with approximately 0.02 to 0.3 mL deposited as the cannula is withdrawn. To cover the entire dorsum of the hand, the cannula is redirected in the fanning fashion. To ensure uniform fi nal effect, continued passes are made in a weaving crisscross pattern and 10 to 20 mL of centrifuged fat is deposited. Accuracy of the initial placement is essential since the manual molding of the placed material is rather diffi cult without creating surface irregularities.

The size of the area of grafting should be adjusted based on the physical appearance and patient’s expectations. Care must be taken to uniformly fi ll the intercarpal spaces, both sides of the hand, and the proximal web spaces. Coleman proposed six cannula entry points spaced around the periphery of the hand for optimal fi nal cosmetic effect ( 6 ). These include: ulnar and radial wrist, the metacarpophalangeal joint of the 5th digit, the web space between the 3rd and 4th digit, radial 2nd fi nger and the radial thumb.

Structural fat grafting should not be performed directly over the metacarpophalan-geal or proximal interphalangeal joints to decrease the likelihood of the clinical appear-ance of an enlarged joint. If reconstitution of volume around the metacarpophalangeal joints is desired, transplanted fat should be feathered to at the proximal half of the proximal phalanx.

For optimal long-lasting cosmetic result, the hand should appear slightly overfi lled upon completion of the fat transplant. Fair estimate of the amount of the fat placed can be determined four months after the procedure with even more accurate estimate at six to eight months.

Systemic antibiotics prophylaxis is recommended a day before and up to 10 days postprocedure ( 8 ).

Postoperative care includes application of ice/cold compresses, the elevation of hands for 24 hours, and slight compression to minimize postprocedure edema. Patients


should avoid touching dorsal hand and limit manual activity for approximately one week. Edema is the most frequently encountered side effect and its extent is proportional to the volume of the autologous fat transplanted. Edema is self-limited and usually resolves within one to two weeks postprocedure. Rare complications of autologous fat transfer are infection (including Mycobacterium abscessus ( 9 )), cyst formation, and temporary dysthesia. Bruising is minimal with the use of a blunt tip cannula. Technique-related com-plications include small lumps secondary to uneven deposition of the fat or fat migration.

Several factors contribute to adipocyte survival and long-term cosmetic improve-ment. These include harvesting method, recipient site, manipulations and exposure of harvested adipocytes to blood, anesthetic and air, centrifugation of fat, diameter of the injec-tion device (needle or cannula), volume of the injected fat, and the degree of overcorrection.

Butterwick showed better patient-assessed clinical outcomes with centrifuged versus noncentrifuged fat at three and fi ve months posttreatment ( 8 ). In a pilot study of 10 patients, frozen autologous fat had improved results with respect to longevity and aesthetic appear-ance versus fresh fat at one, three, and fi ve months. In an extensive review comparing various reported harvesting techniques, Sommer and Sattler concluded that, in most cases, good results are reported regardless of technique if small transplant volumes were used ( 10 ). Lower injection volumes were shown to be associated with more effi cient neo-vascularization and better graft survival. Only 40% of grafted tissue is viable 1 mm from the edge of the graft at 60 days ( 11 ).

In most current reports, an average of 5 to 12 mL of fat is implanted per hand per ses-sion. In some reports, up to 20 to 30 mL of centrifuged fat was used per hand per session ( 6 ). A noted complication of large injection volume is persistent (up to 16 weeks) edema.

Longevity of the injected fat remains a subject of literary debate. Effects are reported to last from six to eight months ( 12 ) to up to one to fi ve years ( 6 , 13 ) although studies specifi cally designed to study longevity of autologous fat for hand rejuvenation are lacking. Generally, autologous fat was observed to absorb slower when placed in the hand compared with fat placed in facial areas presumably due to relative immobility of the dorsal hand.

Autologous fat transfer is generally well tolerated with high patient satisfaction rates reported. Aboudib et al. reported a 98% satisfaction in 72 patients ( 14 ).

The benefi ts of autologous fat transfer relate to the fact that the fi ller material is accessible, autologous, natural, and nonantigenic. Albeit, autologous fat requires donor harvesting, an invasive surgical procedure with a risk of morbidity and infection. The limitations are unpredictable longevity and relatively complex preparation protocol. However, when used properly fat may restore a long-lasting youthful fullness to the dorsum of the hand.

INJECTABLE FILLERS

Injectable synthetic, biocompatible fi llers discussed in this section include: collagen, HA, CaHA, and PLLA. Depending on the material injected, injection needle might vary from 25- to 32-gauge and from 0.5 to 1.25 inches in length.

Due to the signifi cant pain associated with injection of viscous fi ller materials, it is recommended that the patient should undergo some form of anesthesia (topical, nerve block, other) prior to the product placement.


Collagen

Bovine-derived collagen was the fi rst Food and Drug Administration (FDA)-approved prepackaged injectable soft-tissue augmentation material. Two major drawbacks of bovine-derived collagen were a short duration of action and the risk of allergy, requiring preimplantation testing. In 2003, human-derived (neonatal foreskin) collagen preparations gained FDA approval. One major advantage of human-derived collagen was lower potential for an allergic reaction and therefore no need for preinjection testing.

Human-derived injectable collagen preparations for aesthetic use are CosmoPlast and CosmoDerm (Inamed Aesthetics, Santa Barbara, CA, U.S.). Equivalent bovine-derived collagen preparations are Zyplast, Zyderm I, and Zyderm II.

Injectable human collagen is approved for correction of facial wrinkles, lip augmen-tation, acne scars, and other soft-tissue defects. CosmoDerm and Zyderm are approved for the correction of papillary dermal rhytids and defects such as scars, and CosmoPlast and Zyplast for mid- to deep-dermal lesions.

Collagen is a short-acting fi ller, with most of the cosmetic effect lasting two to three months. Due to the presence of the aqueous component, slight overcorrection is desired.

Prepackaged material must be stored in the refrigerator, but not frozen. Usually a 30-gauge needle with the bevel pointing downwards is used to deliver material into the superfi cial dermis (CosmoDerm and Zyderm) or mid- to deep-dermis (CosmoPlast and Zyplast).

Minimal postprocedure erythema and edema usually fully subsides within one to two days. Postprocedure application of ice may decrease edema and bruising.

Clinical Data

In a double-blind comparative study of nonanimal stabilized HA (see below) (Restylane; total injection volume of 1.4 mL per hand) versus human collagen (CosmoPlast; total injec-tion volume of 2 mL per hand) for soft-tissue augmentation of the dorsal hands, HA was found to be signifi cantly superior to collagen in general clearance of rhytids, veins, bony prominence, dermal and subcutaneous atrophy, and patient satisfaction.

Compared with collagen, HA injection was associated with overall higher patient discomfort although discomfort score did not reach statistical signifi cance ( 15 ). Lower patient discomfort rates associated with collagen injection likely relates to the presence of 0.3% lidocaine in collagen preparation ( 16 ).

Hyaluronic Acid

Hyaluronic acid (HA) is highly biocompatible dermal fi ller used successfully for several decades for volume restoration. The common sources of the substrate for HA preparations are vitreous humor, rooster combs, umbilical cord, tendons, and more recently bacterial cultures.

HA is approved by the FDA for facial soft-tissue augmentation of the nasolabial folds. Off-label use is well documented when used for the lips, glabellar lines, cheeks, tear troughs, chin and jaw lines, depressed scars, marionette lines, oral commissures, and HIV-associated lipoatrophy. Injected HA is hydrophilic and undergoes isovolumetric degrada-tion over the period of fi ve to nine months depending on the treated site ( 15 ). Various HA


products differ in viscosity, gel hardness, particle size, swelling (the gel’s ability to resist dilution), concentration, and the ratio of soluble to insoluble HA (particulate vs. fl uid component) ( 17 ). HAs should be stored at room temperature, out of direct sunlight.

The fi rst HA derivative that gained FDA approval in the United States for cosmetic indications was Restylane. Because current HA preparations do not contain anesthetic, other forms of dorsal hand anesthesia might be required. HA for the hand rejuvenation is placed at the level of the mid- to deep-dermis.

Four techniques for the injection of HA are: serial puncture, fanning, linear/serial threading, and cross-hatching. Compared with other injection methods, the serial puncture technique may increase the risk of bruising. Once the needle is placed into a desired plane (mid- to deep-dermal), even pressure is applied onto the plunger while the syringe is with-drawn. Injection should be terminated before the needle is completely withdrawn to avoid injection into superfi cial dermal planes. The goal of the treatment is to correct the rhytid without signifi cant overfi lling. Treated area may be manually massaged with or without a lubricant (Aquaphor, Petrolatum, and others) to smooth out and uniformly distribute the HA. In instances where blanching occurs the injection should be stopped and the area should be massaged until blanching is resolved. Clinically apparent blanching signifi es inadvertent injection into superfi cial vasculature, vascular compromise, and possibly tissue necrosis.

The amount of HA injected depends on the amount of correction desired. In the authors’ experience, one to two syringes of HA can be implanted into both hands, depend-ing on the degree of volume required. When injected in dorsal hands, HA’s cosmetic effects last between six and nine months ( 13 ).

Posttreatment care instructions should include application of ice to reduce bruising, swelling and pain, avoidance of heavy exercise for few hours after injection to further pre-vent soft-tissue swelling, and systemic acetaminophen for associated discomfort. Use of non steroidal antiinfl ammatory drugs (NSAIDs) and acetylsalicylic acid (aspirin) is contraindicated.

Touch-up treatments, if needed, can be done at two weeks following the initial procedure. Common side effects of HA injection include edema, erythema, bruising and pain. Rare complications include nodule formation, allergic reactions, vascular occlusion, infection, over- or undercorrection, and blue-gray discoloration.


A semipermanent fi ller CaHA (Radiesse; Bioform, San Mateo, CA, U.S.) has been used off-label in facial aesthetics since 2002. In 2006, Radiesse gained FDA approval for use in facial aesthetics for the correction of moderate to severe facial wrinkles and folds, such as nasolabial folds and in treating HIV-associated lipoatrophy ( 18 , 19 ).

Radiesse consists of 25 to 45 µm microspheres of CaHA in a carrier gel comprised of glycerin, sterile water, and sodium carboxymethylcellulose. The carrier solution undergoes resorption over a period of 4 to 12 weeks, leaving a scaffolding of CaHA microspheres for fi broblast-mediated soft-tissue in-growth. Matrix deposition provides long-lasting fi lling effect.

CaHA microspheres are biodegradable. In an aqueous environment, the particles break down into submicron subparticles that subsequently undergo phagocytosis by tissue macrophages.


Synthetic CaHA shares the same biocompatibility profi le as the naturally occurring CaHA. Use of Radiesse does not require prior skin testing, does not show evidence of migration, calcifi cation, or ossifi cation when placed subdermally. No severe adverse events such as delayed granulomas, allergic reactions, or tissue necrosis have been reported ( 18 ).

In theory the duration of cosmetic correction after Radiesse injection depends on three main factors:

1. Rate of dissolution of CaHA microspheres 2. Degree of soft-tissue in-growth 3. Presence or absence of microparticle dislocation

Therefore, different anatomical locations and individual patient variation will result in different degrees of tissue persistence.

In a clinical trial of Radiesse for nasolabial fold correction, adequate correction was maintained at six months follow-up. Long-lasting results (18–24 months) are seen in the areas of relative stasis, such as those overlying bony prominences (zygomatic arch, infra-orbital rim, mentum, dorsal aspect of the nose and jaw). Studies on longevity of CaHA in dorsal hands are lacking.

Procedure Protocol

CaHA is supplied in 1.3 and 0.3 mL prefi lled syringes. The material may be stored at room temperature.

To increase patient comfort levels, 0.8 mL of Radiesse may be combined with 0.2 mL of 1% plain lidocaine.

Injection Technique and Clinical Results

A 25- to 27-gauge, 1.25-inch needle is preferred for smooth correction. Multiple linear threads are placed in three-dimensional, double-fanning motion

across the dorsum of the hand the fi fth metacarpal, medially by the second metacarpal, proximally by the dorsal wrist crease, and distally by the metacarpophalangeal joints. Cross-hatching of material in multiple planes is essential to provide optimal structural sup-port. The targeted placement depth is subcutis. Only small volumes of CaHA are required during each thread deposition, typically, 50 µL or 0.05 mL per pass. Following injection, the implanted material can be easily massaged and molded to provide the desired end result.

Therapy with CaHA does not require overcorrection. Alternatively, skin tenting (bolus) technique might be employed. Skin tenting is used

to separate skin from vascular and tendinous structures by lifting the skin with thumb and forefi nger over the dorsal aspect of the hand being treated. Filler–lidocaine mixture is injected as a bolus in the superfi cial subcutaneous plane. Immediately following injection, the entire injection area should be gently massaged to ensure even distribution. Skin tent-ing results in high patient satisfaction rates ( 20 ).

For optimal cosmetic result, 1.3 mL of Radiesse is required per treatment per hand ( Fig. 11.1.2 ).


Poly- L -Lactic Acid PLLA is an immunologically inert aliphatic polymer of L -lactic acid with a molecular weight of 170 kDa. It is a biodegradable and resorbable synthetic material that has been used for over 25 years in resorbable sutures, plates and screws, soft tissue, bone implants, and in drug delivery devices ( 21 ). In 1999, injectable PLLA (NewFill, Medifi ll, London, U.K.; Biotech Industrie SA, Luxembourg) gained approval in Europe for treatment of scars and rhytides. In 2004, PLLA (Sculptra, Dermik Laboratories, Berwyn, PA, U.S.) was approved by the FDA for the treatment of HIV-associated facial lipoatrophy ( 22 ). PLLA is currently widely used off-label for a number of other cosmetic interventions, including hand rejuvenation.

When injected into the subcutaneous plane, PLLA causes immediate tissue expan-sion due to volume expansion by the carrier solution (mannitol/carbomethoxycellulose). The long-term volumetric improvement, however, results from the PLLA microsphere-induced fi broblast proliferation and subsequent stimulation of de novo collagen I synthesis ( 22 , 23 ). The resulting dermal fi broplasia leads ultimately to dermal thickening.

The resorption of the PLLA microspheres when used for facial lipoatrophy is esti-mated to occur between seven months and two years with a mean of 10 to 12 months ( 24 ). PLLA for hand rejuvenation has demonstrated both versatility and durability for up to two years ( 25 , 26 ).

When injected correctly, PLLA is associated with a very favorable risk/benefi t profi le ( 26 ). Short-term adverse reactions to PLLA injections reported in the literature include pain, edema, bleeding, ecchymosis, dyschromia, overcorrection, embolism, and localized cellulites ( 27 , 28 ). These side effects usually occur within days following injection and resolve spontaneously within one to two weeks. Localized cellulites require treatment with systemic antibiotics.

Figure 11.1.2 Hand rejuvenation with Radiesse: ( A ) 1.95 mL of Radiesse was injected in the left dorsum; 1.95 mL of Radiesse was injected into the right dorsum. ( B ) Follow-up at two months.

(A)

(B)


Techniques Used for Injecting PLLA in a Clinical Setting

PLLA Reconstitution

Injectable PLLA is supplied in a glass vial as a lyophilized powder that must be reconsti-tuted prior to use. Per manufactures guidelines, the dry material must be reconstituted with sterile water for injection (SWFI) for at least two hours prior to injection and the material should be used within 72 hours following reconstitution. Dilution techniques reported in the literature range from 5 mL SWFI plus 5 mL of 1% lidocaine for a fi nal volume of 10 to 6 mL SWFI plus 2 mL of 1% lidocaine for a fi nal volume of 8 mL per vial per hand ( Fig. 11.1.3 ). Prior to injection, the material must be vigorously shaken to ensure a uniform and translucent suspension.

Injection

Two injection techniques discussed in the literature for PLLA hand rejuvenation are linear treading and bolus techniques. When using a linear treading technique, the skin of the dor-sal hand is tented and PLLA is injected proximally from the metacarpophalangeal joint subcutaneously above the fascial plane, using a 25-gauge, 1.5-inch needle, 1 and 3 mL syringe size. The needle is guided into the subcutaneous space, between the tendons and muscle bundles of the hand. Care must be taken to avoid deposition of the PLLA more superfi cially (mid- and superfi cial-dermal) to prevent early- and late-onset papule and nod-ule formation. The snuff box region between the thumb and index fi nger is to be avoided so that undue compression does not cause any neurovascular compromise. In the midhand, the skin is tented, but the needle is inserted into the middorsal intertendinous region of the hand and a depot of 0.3 to 0.5 mL is injected into the three to four regions in the mid-hand ( Fig. 11.1.4 ).

Alternatively, a bolus technique can be utilized. Utilizing 1 cc syringes and 27-gauge 1-1/2 inch needles, 4 to 12 boluses are implanted subcutaneously in the dorsum of the hand ( Fig. 11.1.5 ).

Figure 11.1.3 Sculptra reconstitution process.


After implantation the treatment area is gently massaged with or without lubricant (Aquaphor or Biafi ne) until a uniform distribution of material is achieved. It is crucial for the material to be uniformly distributed from the wrist to include proximal digits as well as the interosseous spaces.

Avoidance of the cursive dorsal arch veins will minimize procedure-related bruising. In the case of intrinsic muscle wasting (interossei and lumbricals) the approach is to

inject the product into the interosseous spaces of the hand in a “fi st” maneuver. Material is injected into the muscle belly with a 25-gauge, 1.5-inch needle, 1 and 3 mL syringe size. The treated area is subsequently massaged prior to application of ice packs. For optimal fi nal result, all patients are advised to massage the treated area for fi ve minutes, fi ve times a day for fi ve days.

Two to three treatment sessions are usually carried out at four to eight weeks inter-vals, affording the patient and the physician the opportunity to assess the effects of each

Figure 11.1.4 Hand rejuvenation with PLLA: ( A ) tenting of the dorsal skin and ( B ) bolus injection.

(A) (B)

Figure 11.1.5 Hand rejuvenation with PLLA—immediate postinjection bolus in interosseous space.


treatment. Using the aforementioned protocol, the duration of clinical effect is 18 to 36 months ( Fig. 11.1.6 ).

Optimizing the injection technique for PLLA, that is, correct depth of the fi ller placement, appropriate dilution, and thorough postinjection massage by the physician is crucial for optimal outcome and low risk of potential side effects such as early- and late-onset papules and nodules.

Clinical Data

In a recent review of our clinical experience of 26 patients, an average of 2.38 treatments was administered, with an average of 3.06 vials per patient ( 29 ). The majority of patients reported high rates of satisfaction with clinical results. Bruising and swelling were the most commonly reported adverse events (30.8%), followed by pain (15.4%), pruritus (3.8%), and an arterial spasm (3.8%). No subcutaneous papules or nodules were reported. All side effects listed above were injection-related, transient, and resolved within a few days of treatment.

In an Italian case series of 27 patients, Redaelli found a measurable decrease in the tortuosity of veins and decreased visibility of the extensor tendons using a defi nite gradu-ated score with repeated PLLA injections ( 30 ). The clinical improvement was greatest at the maximal follow-up period of 15 months. The average number of injections for a fi nal desired cosmetic outcome was four per patient, with an average injection volume of 2 mL

Figure 11.1.6 Hand rejuvenation with PLLA: ( A ) 8 mL of PLLA was injected into the dorsum of the hand in two sessions. ( B ) Follow-up at 10 months.

(A) (B)


of 5 mL per hand dilution for the fi rst treatment session, followed by 1.5 to 2 mL per hand of 6 to 8 mL dilution for subsequent treatments spaced one-month apart ( 30 ). PLLA was injected using a linear treading technique with 0.05 mL PLLA deposited per injection parallel to and perpendicular to metacarpal bones.

Side effects profi led in the study were minimal and largely injection related. Visually nondetectable, fi ne subcutaneous nodules without any associated signs of infl ammation were detected in one of 27 patients ( Fig. 11.1.7 ).

Overall, PLLA is well-tolerated soft-tissue fi ller; patients reported high-satisfaction rates with cosmetic outcome and experienced mainly minor and short-term largely injection-related adverse events.

CONCLUSION

Visible aging of the hands are a signifi cant visual marker of the chronological aging process and correction is often sought by patients who wish to restore a more youthful appearance. Understanding and matching patient concerns and treatment requirements with specifi c therapies yields optimal patient satisfaction rates. A combination approach using multiple modalities targeting dyschromia, rhytids, skin laxity, and volume loss is often necessary in order to achieve optimal results. In cases of volume loss and secondary prominence of hand veins, tendons, and bones, volumetric restoration alone with soft-tissue augmentation using autologous fat, PLLA, or CaHA may offer synergistic benefi t and translate into high rates of patient satisfaction.

REFERENCES

1. Jakubietz RG, Jakubietz MG, Kloss D, Gruenert JG. Defi ning the basic aesthetics of the hand. Aesthetic Plast Surg 2005; 29: 546–51.

2. Seeley BM, Denton AB, Ahn MS, Maas CS. Effect of homeopathic Arnica montana on bruising in face-lifts: results of a randomized, double-blind, placebo-controlled clinical trial. Arch Facial Plast Surg 2006; 8: 54–9.

3. Totonchi A, Guyuron B. A randomized, controlled comparison between arnica and steroids in the management of postrhinoplasty ecchymosis and edema. Plast Reconstr Surg 2007; 120: 271–4.

Figure 11.1.7 ( A, B ) Complications post hand rejuvenation with PLLA demonstrating fi ne subcu-taneous nodules.

(A) (B)


4. Orsini RA. Bromelain. Plast Reconstr Surg 2006; 118: 1640–4. 5. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000; 26: 1117–28. 6. Coleman SR. Hand rejuvenation with structural fat grafting. Plast Reconstr Surg 2002; 110:

1731–44. 7. Carraway JH, Mellow CG. Syringe aspiration and fat concentration: a simple technique for

autologous fat injection. Ann Plast Surg 1990; 24: 293–6. 8. Butterwick KJ. Lipoaugmentation for aging hands: a comparison of the longevity and aesthetic

results of centrifuged versus noncentrifuged fat. Dermatol Surg 2002; 28: 987–91. 9. Galea LA, Nicklin S. Mycobacterium abscessus infection complicating hand rejuvenation with

structural fat grafting. J Plast Reconstr Aesthet Surg 2009: 62(2): e15–6. Epub 2008 May 9 . 10. Sommer B, Sattler G. Current concepts of fat graft survival: histology of aspirated adipose tis-

sue and review of the literature. Dermatol Surg 2000; 26: 1159–66. 11. Carpaneda CA, Ribeiro MT. Percentage of graft viability versus injected volume in adipose

autotransplants. Aesthetic Plast Surg 1994; 18: 17–19. 12. Coleman III WP. Fat transplantation. Dermatol Clin 1999; 17: 891–8, viii. 13. Werschler WP, Weinkle S. Longevity of effects of injectable products for soft-tissue augmenta-

tion. J Drugs Dermatol 2005; 4: 20–7. 14. Boudib Jr JH, de Castro CC, Gradel J. Hand rejuvenescence by fat fi lling. Ann Plast Surg 1992;

28: 559–64. 15. Man J, Rao J, Goldman M. A double-blind, comparative study of nonanimal-stabilized hyal-

uronic acid versus human collagen for tissue augmentation of the dorsal hands. Dermatol Surg 2008; 34: 1026–31.

16. Baumann L. Dermal fi llers. J Cosmet Dermatol 2004; 3: 249–50. 17. Monheit GD, Coleman KM. Hyaluronic acid fi llers. Dermatol Ther 2006; 19: 141–50. 18. Ahn MS. Calcium hydroxylapatite: Radiesse. Facial Plast Surg Clin North Am 2007; 15:

85–90, vii. 19. Jansen DA, Graivier MH. Evaluation of a calcium hydroxylapatite-based implant (Radiesse) for

facial soft-tissue augmentation. Plast Reconstr Surg 2006; 118: 22S–30S; discussion. 20. Busso M, Applebaum D. Hand augmentation with Radiesse (calcium hydroxylapatite). Derma-

tol Ther 2007; 20: 385–7. 21. Broder KW, Cohen SR. An overview of permanent and semipermanent fi llers. Plast Reconstr

Surg 2006; 118: 7S–14S. 22. Burgess CM, Quiroga RM. Assessment of the safety and effi cacy of poly-L-lactic acid for the

treatment of HIV-associated facial lipoatrophy. J Am Acad Dermatol 2005; 52: 233–9. 23. Vert M, Li SM, Garreau H. Attempts to map the structure and degradation characteristics of

aliphatic polyesters derived from lactic and glycolic acids. J Biomater Sci Polym Ed 1994; 6: 639–49.

24. Lombardi T, Samson J, Plantier F, Husson C, Kuffer R. Orofacial granulomas after injection of cosmetic fi llers. Histopathologic and clinical study of 11 cases. J Oral Pathol Med 2004; 33: 115–20.

25. Vleggaar D. Facial volumetric correction with injectable poly-L-lactic acid. Dermatol Surg 2005; 31: 1511–17.

26. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary fi ller for soft tissue augmenta-tion. J Drugs Dermatol 2004; 3: 385–9.

27. Moyle GJ, Brown S, Lysakova L, Barton SE. Long-term safety and effi cacy of poly-L-lactic acid in the treatment of HIV-related facial lipoatrophy. HIV Med 2006; 7: 181–5.

28. Lemperle G, Morhenn V, Charrier U. Human histology and persistence of various injectable fi ller substances for soft tissue augmentation. Aesthetic Plast Surg 2003; 27: 354–66.

29. Sadick NS. Poly-L-lactic acid: a perspective from my practice. J Cosmet Dermatol 2008; 7: 55–60.

30. Redaelli A. Cosmetic use of polylactic acid for hand rejuvenation: report on 27 patients. J Cosmet Dermatol 2006; 5: 233–8.

136


Luitgard Wiest

In recent years, rejuvenation that was traditionally focused on the face has now been recognized to be just as important for aging hands. Most patients seek treatments for their aging hands when the aging process appears visible caused by epidermal changes, loss of elasticity, appearance of solar lentigines, and loss of volume with protuberant tendons and veins. One has to take into consideration that these two main processes in aging hands: change in skin texture and loss of volume have to be addressed by different modalities. In the face deep chemical peels or laser peels give excellent results in restoring skin elasticity and in reducing solar lentigines. The possibilities on the dorsum of the hands are limited and risk of scar formation is increased due to the very sparse distribution of hair follicles from which the regeneration of the epidermis arises after an ablative procedure. Best results are obtained when the aging processes are addressed in a combined procedure. In chapter 11.1, the authors have focused on the age-induced volume loss in hands classifi ed as type III ( Fig. 11.1.1 ).

Since the beginning of the 1990s autologous fat grafting was also used for the hands ( 1 ).With the Fournier’s technique good results were obtained when fat graft was placed through a single small incision above the lateral wrist crease in one bolus just above the superfi cial dorsal fascia The bolus of fat, which is placed right above the fascia dorsalis manus, has to be massaged and can be easily spread and distributed along the entire dor-sum of the hand. With Fourniers method, as well as with Coleman’s structural fat grafting (see chapter 11.1), the hands have to be overcorrected and immediately after the procedure have a clinical appearance of puffy hands, which generally takes three to four weeks to dissolve.

The fat injection procedures require fat harvesting from a donor site. The adipocyte survival rate and the longevity of the result is dependent on the skills of the physician, the harvesting method, manipulation of harvested fat, and several other factors (see chapter 11.1). Since the autologous fat transfer is generally well tolerated, with variable long- lasting effects reported it is a very popular rejuvenation method for hands in Europe, due to the low cost for the larger volumes needed. Interestingly a much larger volume of fat grafts is needed to achieve a satisfactory result in fi lling up the volume loss of the hands as with semipermanent fi llers (see chapter 11.1).


In search for a readily available fi ller studies with HA fi llers versus human collagen (chapter 11.1) fi llers have been performed in hand rejuvenation. Despite the long-lasting effect described by Werschler and Weinkle for six to nine months, our own clinical experi-ence with the earlier HA fi llers, either monophasic or particulated did not yield long-lasting effects, even when 2 to 3 mL of HA fi llers were injected per hand. Better results are noted with the HA volumizers (Table 2.2.3 ) that were put on the market recently, although exten-sive studies have not yet been published for the use of volumizers in the dorsum of the hands.

The most satisfying results in addressing the process of volume loss of the dorsum of the hand in terms of effi cacy and safety have been recently reported with the semiperma-nent fi ller Radiesse® (see chapter 11.1) ( 2 , 3 ). Busso (4) in a multicenter, randomized study in the United States and Germany reported on the effectiveness up to 12 months. Various techniques have been described ( 2 , 5 , 6 ) (see chapter 11.1). Placing a small lidocaine bleb between the metacarpophalangeal joints and mixing each CaHA syringe 1.3 mL with 0.2 mL of lidocaine leads to an almost painless procedure and to maximum patient comfort. After tenting the skin, the material is injected very conservatively and very slowly subcu-taneously above the fascia dorsalis manus using a 26-gauge, 1.5 inch needle by the push-ahead technique in order to avoid hematomas. The volume required per hand depends on the volume loss and varies between 1.5 and 2.5 mL Radiesse per hand.

Poly- L -lactic acid (PLLA ), marketed as Sculptra® has been safely used for more than 30 years in a variety of medical devices. PLLA (see chapter 11.1) elicits increased collagen production from the fi broblasts when injected into the deep dermis, leading to dermal thickening. Various injection techniques have been described. With the appropriate recon-stitution injected into the correct plane, it addresses several processes of the aging hands. PLLA can improve both, the skin texture and the loss of volume. Usually two to three treat-ments ( 7 ) spaced apart six to eight weeks are necessary for optimal results lasting up to two years. Although PLLA injections have been associated with the manifestation of subcuta-neous papules in hand rejuvenation [( 8 ), and Becker-Wegerich, personal communication] it has been demonstrated that thorough massage signifi cantly reduces the incidence of sub-cutaneous nodules and papules. The main limitations of Sculptra are variability in result and diffi culty in getting large volume changes with each treatment.

CONCLUSION

More data about longevity of dermal fi llers for rejuvenation of the aging hand with loss of volume will be available in the future. With the already existing semipermanent fi llers and with the newer HA fi llers designed as “Volumizers” that are used to augment larger areas, volume replacement of the dorsum of the hand will become an attractive option.

REFERENCES

1. Fournier PF. Fat grafting: my technique. Dermatol Surg 2000; 26: 1117–28. 2. Marmur ES, Al Quran H, de SA Earp AP, Yoo JY. A fi ve-patient satisfaction pilot study of calcium

hydroxylapatite injection for the treatment of aging hands. Dermatol Surg 2009; 35: 1978–84. 3. Lizzul PF, Narurkar VA. The role of calcium hydroxylapatite (Radiesse) in nonsurgical aesthetic

rejuvenation. J Derm Drug 2010; 9: 446–50.


4. Busso M, Moers-Carpi M, Storck R, Ogilvie P, Ogilvie A. Multicenter, randomized trial assess-ing the effectiveness and safety of calcium hydroxylapatite for hand rejuvenation. Dermatol Surg 2010; 36(Suppl 1): 790–7.

5. Bank D. A novel approach to treatment of the aging hand with Radiesse. J Dermatol Ther 2009; 8: 1122–6.

6. Edelson K. Hand recontouring with calcium hydroxylapatite (Radiesse®). J Cosmet Dermatol 2009; 8: 44–51.

7. Vleggar D. Soft-tissue augmentation and the role of poly-L-lactic acid. Plast Reconstr Surg 2006; 118(Suppl 3): 46S–54S.

8. Palm MD, Woodhall KW, Butterwick KJ, Goldman MP. Cosmetic use of poly-L-lactic acid: a retrospective study of 130 patients. Dermatol Surg 2010; 36: 161–70.

139

12 Complications and their management

Jason Emer , Heidi Waldorf , and Joel L. Cohen

INTRODUCTION

Cosmetic procedures, specifi cally those that are minimally invasive, have become increasingly more popular in the past decade. There were close to 10 million cosmetic procedures performed in the United States in 2009 alone, which is an increase of over 147% in the total number of cosmetic procedures performed in 1997 ( 1 ). In this time frame, surgical procedures have increased by almost 50% and nonsurgical procedures have increased by over 231%. According to statistics published by the American Society for Aesthetic Plastic Surgery (ASAPS), of the top fi ve nonsurgical procedures performed in 2009, dermal fi llers ranked second to Botulinum toxin injections with over 1 million injections ( 1 ). Soft tissue augmentation is a noninvasive procedure that is particularly attractive to patients wanting a quick and satisfying aesthetic result with fairly predict-able longevity. Increased public interest, multiple product options, diminished social stigma, affordability, and increased effectiveness and versatility are the major factors that have infl uenced their rapid popularity. Most clinicians regard soft tissue fi llers as having an impressive safety profi le, with the majority of reported side effects being mild and transitory such as local injection-site reactions (redness, swelling, bruising, and pain) or abnormal skin tightness/sensation ( 2 – 5 ). Unfortunately, in the minority of cases more severe adverse outcomes and unforeseen events can occur and have been reported in the literature ( 6 – 20 ). One study asked dermatologists, plastic surgeons, and maxillofacial surgeons in Berlin to report patients with adverse reactions by using a standardized ques-tionnaire to collect all data. Fifty-six patients who had been treated with nine different fi llers were assessed and symptoms such as continuing pain, swelling, nodules, pigmen-tation, abscess formation, and erythema were discovered as adverse reactions ( 21 ). Nevertheless, with proper patient selection and expectations, injection techniques, and product selection, clinicians can prevent complications and/or treat issues appropriately if the situation arises ( 22 – 24 ). This chapter will focus on the prevention, recognition, and treatment of complications associated with soft tissue fi lling agents with emphasis on the key characteristics to consider before, during, and after procedure completion.


PRIOR TO THE PROCEDURE

Patient Selection and Expectations

A proper initial evaluation is essential when performing elective cosmetic procedures. During the aesthetic evaluation, it is important that the patient’s satisfaction is priority, thus photographs should be taken and asymmetries identifi ed to document the patient’s initial appearance and to facilitate a clear and frank discussion addressing the concerns, desires, and/or wants of the patient in order to help devise a realistic treatment plan to achieve these goals. During this discussion a distinction should be made between lines of expression, static and dynamic wrinkling, and volume loss that may or may not be augmented by fi lling agents ( 25 ). Once clear and practical treatment goals have been discussed and agreed upon, the practitioner should determine which fi lling agent is best for the cosmetic concerns of the patient and discuss the potential limitations and expectations. In general, fi llers can fi ll defects such as folds, scars, and/or depressions, or augment existing facial structures or contour abnormalities. These procedures are not meant to take the place of surgical proce-dures, but may help to postpone or complement them ( 26 – 29 ). Common postoperative side effects such as bruising, swelling, pain, nodularities, redness, and abnormal sensation/feel-ing should be discussed and patients should be advised to avoid these procedures immedi-ately prior to any signifi cant social or professional event. Rare, potentially serious adverse side effects should be discussed if indicated, particularly in patients who have previously had adverse events, who have undergone facial surgeries or facial trauma that may have changed typical anatomy, or those undergoing treatment for off-label indications. Lastly, the clinician should discuss the fi nancial commitment involved in order to achieve the patient’s overall aesthetic goal.

Skin Testing

After choosing the appropriate fi ller, the potential for allergy or reactivity should at very least be discussed. Given that all fi llers (with the exception of autologous fat) are com-posed of foreign-body material, varying degrees of immune system reactivity can poten-tially occur and have important aesthetic implications ( 9 , 23 ). Historically, bovine collagen (Zyderm I, Zyderm II, Zyplast; Allergan Inc., Santa Barbara, CA, U.S.) was the most frequently used packaged fi ller because it was relatively inexpensive, easy to inject, and versatile; however, signifi cant disadvantages included the potential for allergic reactions that necessitated two separate skin tests and limited cosmetic satisfaction due to its short-term persistence ( 25 ). These specifi c bovine collagen products are no longer being manu-factured, but the skin test for bovine collagen used to be performed with an intradermal injection of 0.1 mL of product into the antecubital area and 30 days later injecting a separate area (such as the scalp line). Approximately 3.5% of patients did have a positive fi rst reaction (local wheal and fl are reaction), with 70% of these reactions manifesting in the fi rst 48 to 72 hours ( 30 , 31 ). A negative second test lowered the risk of a subsequent collagen hypersensitivity reaction to less than 0.5%. Granulomatous foreign body reac-tions against animal-derived bovine collagens are well documented, with incidence reach-ing as high as 1.3% in some series ( 32 ). Overall, bovine collagen has an incidence of acute hypersensitivity of 3.5% and delayed hypersensitivity rates ranging from 3% to 10% ( 31 , 33 ).

COMPLICATIONS AND THEIR MANAGEMENT 141

Not all collagen fi llers require a skin test. Human-derived collagen (CosmoDerm, CosmoPlast; Allergan Inc., Santa Barbara, CA, U.S.) was approved without skin testing because it carried a very low risk of reactivity, but had a similar relatively short duration (2–6 months) as compared with bovine collagen ( 26 , 34 – 36 ). These human collagen prod-ucts are also no longer being produced. In June 2008, a porcine-derived collagen product (Evolence and Evolence Breeze; Colbar LifeScience Ltd., Herzliya, Israel and OrthoNeu-trogena, Louisville, KY, U.S.) comprised of 3.5% purifi ed porcine type I collagen was also approved by the Food and Drug Administration (FDA) without skin testing because removal of the primary antigenic components of the product during processing signifi -cantly reduced collagen-sensitivity reactions ( 37 ). A 2007 study by Shoshani et al indicated the hypersensitivity of Evolence had a calculated risk equal to 0.58% and was lower than estimated for both bovine and human collagen. Interestingly, the hypersensitivity after injecting Evolence was also lower than what was observed with nonanimal hyaluronic acid (HA), which had a calculated risk equal to 0.74% ( 38 , 39 ). Unlike the human collagen prod-ucts, this porcine collagen offered more duration with 6 to 12 months of aesthetic effect due to a unique cross-linking with D -ribose using a Glymatrix technology. At this time, produc-tion has also ceased on porcine collagen products as well, and all remaining bovine, human and porcine collagen product has expired.

Among the products currently available in the United States, only polymethylmeth-acrylate (PMMA; ArteFill; Suneva Medical, San Diego, CA, U.S.) contains collagen (the exact composition is 20% nonbiodegradable PMMA microspheres and 80% purifi ed bovine collagen) and requires skin testing ( 40 ). The collagen carrier of this product is of bovine origin and thus carries the same potential allergenicity of 1% to 5% reported in the literature for bovine collagen ( 33 , 41 ) Product sensitivity in the form of delayed granulo-mas, although rare, have been reported with the precursor to this product (Artecoll) as 0.01% (15/200,000) from 1995 to 2000 ( 42 ). These granulomas have generally occurred 6 to 24 months posttreatment and frequently after multiple procedures (second to third trans-plantation of product), although one report has documented granulomas or nodules up to six years after gel injection ( 43 ). No acute sensitivity reactions have been documented to date ( 44 – 46 ). Skin testing consists of the patient receiving a 0.1 mL intradermal injection of collagen into the volar forearm four weeks prior to treatment. A positive response con-sists of erythema to any degree, induration, tenderness, and swelling, with or without pru-ritus. An equivocal response is where no localized skin reaction occurs but the patient develops a systemic reaction such as a rash, arthralgia, or myalgia any time during the four-week observation period. Patients demonstrating a positive skin test or two equivocal skin tests should not receive treatment.

In the 1990s, published articles suggested a causal relationship between collagen dermal implants and autoimmune disease, in particular, polymyositis ( 47 – 49 ). Epidemio-logic review of the literature, reports to the manufacturer, and litigation refuted this alleged link ( 50 ). However, collagen-containing products are contraindicated in patients with a known history of collagen-reactive autoimmune disorders such as systemic lupus erythe-matosus and scleroderma. These patients can safely be treated with noncollagen fi lling agents. Consultation with the patient’s rheumatologist is often recommended before use ( 51 – 54 ).

HA fi llers are still the most popular injectable fi ller in the United States ( 55 – 57 ). Signi-fi cant hypersensitivity has been reported only rarely with HA products. Whether bacterial or


avian in origin, these products are extremely purifi ed and the rate of severe immunologic reactions is low ( 58 – 64 ). The avian product itself is actually no longer being manufactured for aesthetic use, but is still available for orthopedic use in joints. A severe angioedema-type hypersensitivity reaction was documented following injection with nonanimal stabilized HA gel (Restylane; Medicis Aesthetics Inc., Scottsdale, AZ, U.S.) into the upper lip ( 13 ). Another case reported persistent discrete nodules in the form of a granulomatous foreign-body reac-tion in a female who received a HA agent in the lips for the purposes of augmentation ( 65 ). In a retrospective study from 1997 to 2001 evaluating the safety of nonanimal-stabilized HA in European countries, the incidence of hypersensitivity reaction was found to be 0.3% to 0.6%. Half of these reactions were immediate and resolved within three weeks ( 2 , 66 ). One HA fi ller containing both lidocaine and sulfi tes (Elevess; Anika Therapeutics Inc., Bedford, MA, U.S.) has a higher reported incidence of reactivity and is typically avoided in patients with a history of multiple hypersensitivities or allergy to these components ( 67 ).

Prevention of Local Common Reactions

Local injection site reactions are the most common adverse event associated with soft tissue augmentation since injection requires skin piercing and implantation of a foreign substance. The potential to bruise can be affected by needle size, location, technique, and speed of injection, as well as fi ller choice ( 67 ). The most commonly seen complications are swelling, redness, tenderness, pain, bruising, and itchiness ( Fig. 12.1 ). In a randomized, double-blind, multicenter comparison of HA (Restylane) versus collagen (Zyplast) for the treatment of nasolabial folds in contralateral sides of each patient ( n = 138), injection-site reactions occurred at 93.5% (129/138) and 90.6% (125/138) of the HA- and collagen-treated sites, respectively ( 68 ). These reactions were less than seven days in duration, were mild to moderate, and were similar between treatments. Thus, it is important patients be aware of the likelihood of injection-site reactions most specifi cally ecchymoses (bruising) and edema (swelling) that may persist for up to one week posttreatment or longer especially in patients on anticoagulant therapy.

Figure 12.1 Large ecchymosis on the superior aspect of the left cutaneous lip three days after HA fi ller placement.


The majority of edema and ecchymoses is due to injection technique and can be minimized with slow, precise injections. It is important to note that as hydrophilic sugar molecules, HA-based fi lling agents intrinsically cause more swelling than other classes of fi llers. While certainly apples-to-apples comparisons with studies being performed by dif-ferent injectors on different patients with different needle sizes, some juxtaposition of piv-otal FDA data on products is something commonly seen amid commercial banter. One HA fi ller (Juvederm Ultra; Allergan, Santa Barbara, CA, U.S.) has a reported 86% incidence of swelling and 59% incidence of bruising on their package insert compared with 4% to 7% incidence of swelling and 6% to 38% incidence of bruising on the package insert for poly- L -lactic acid (PLLA; Sculptra; Dermik Laboratories, Bridgewater, NJ, U.S.) and 69.2% incidence of swelling and 63.2% incidence of bruising on the package insert for calcium hydroxylapatite (CaHA; Radiesse; Bioform Medical Inc., Franksville, WI, U.S.) ( 69 – 71 ). Fortunately, regardless of the product injected the swelling and bruising are typically local-ized, minor, and self-limiting. Some of these problems can be reduced with proper patient selection and detailed preoperative instructions. Patients who do not have a history of heart attack, stroke, blood clots, or other medical indication for aspirin therapy should discon-tinue aspirin 7 to 10 days prior to the procedure. Patients on warfarin or clopidogrel should be warned of the potential for more serious bruising, swelling, and potential for unsatisfac-tory correction. However, these anticoagulant patients and those taking aspirin or any other blood thinner for medical indication should not stop treatment prior to a fi lling procedure. Generally, if the international normalized ratio (INR) is between two and three for patients taking warfarin, the risk of hematoma or excessive bruising from injection is relatively low, and most practitioners would feel comfortable performing injections judiciously. Other aspirin-containing products, nonsteroidal antiinfl ammatory drugs (NSAIDs), and vitamin/herbal supplements associated with anticoagulation (vitamin E, ginseng, ginger, ginkgo, garlic, kava kava, celery root, fi sh oils, St. John’s Wart) should be discontinued 7 to 10 days prior to treatment as well, to reduce the risk of bruising and unanticipated events ( 72 – 74 ). Alcohol may be discontinued about fi ve days prior to treatment as the potential for vasodilation and alteration in liver coagulation factors is diminished after this time.

When assessing patients with cardiovascular stents and/or patients who are on anti-coagulation (warfarin, clopidogrel, enoxaparin), it is important to consider the time frame the patient will be taking the medication and their risk of suffering if the medication is stopped ( 75 ). One study reviewed all the patients ( n = 16) who maintained warfarin therapy during excisional and Mohs surgeries in a practice from 1999 to 2000 ( 76 ). Perioperative complications such as bleeding and cosmetic outcomes were evaluated and it was con-cluded that warfarin treatment (INR 2–3.5) should be continued in patients undergoing cutaneous surgery to reduce the risk of thromboembolic events while still maintaining adequate wound healing without any complications. In general, it is not recommended that patients taking therapeutic anticoagulation alter their regimens for elective cutaneous soft tissue augmentation as clearly this risk outweighs the benefi ts ( 77 – 81 ). If the medication usage is for a limited time period, it may be prudent to wait until the medications can be discontinued—for example, in the case of anticoagulation for initial attack of venous thromboembolism. The recent guidelines from the American College of Chest Physicians (ACCP) recommends, for minor dermatological/cutaneous procedures with low risk for bleeding, the continuance of anticoagulation through the procedure as these patients are at a signifi cantly higher risk of adverse events from thrombosis as high as 50% ( 82 ).


An advantage of soft tissue augmentation using fi lling agents over more invasive cosmetic procedures is that anticoagulants are not an absolute contraindication to use. In clinical practice, patients often accept the risk of increased transient local complications for the convenience of continuing their medications. Successful treatment of patients who either cannot or will not discontinue anticoagulants may be facilitated by the use of local anesthetics containing epinephrine, liberal use of ice packs, slow and precise technique that limits the number of skin punctures and minimizes the need for aggressive posttreatment manipulation. Opaque makeup is useful to conceal discoloration and there are several excellent commercially available products (CoverFx, Toronto, Ontario, Canada; Derm-ablend Professional, New York, NY, U.S.; Physician’s Formula, Azusa, CA, U.S.) appropri-ate for a range of skin colors. Treatment with the 595-nm pulsed dye laser can expedite resolution of postoperative ecchymoses by several days with high patient satisfaction ( 83 ). Perioperative use of oral homeopathic medications containing Arnica montana and Brome-lain (plant family Bromeliaceae, which includes pineapple) have been advocated to reduce bruising, but further investigation is needed to substantiate their effect and patients with cardiovascular disease and/or on anticoagulation therapy should consult their primary physician before starting ( 84 , 85 ).

Prevention of Infection

Infection following the use of soft tissue fi llers is low. Antimicrobial preparations to the fi eld, prior to injections, helps limit these issues. It is unclear if the incidence of infection correlates to the degree of skin penetration and implantation of foreign material into the skin. Two infections have been associated with dermal fi llers: herpes simplex virus and Mycobacterium abscessus ( 10 , 23 ) ( Fig. 12.2 ). In patients with a strong history of perioral herpes simplex virus, prophylactic treatment with antiviral treatment (valacyclovir, famci-clovir, and acyclovir) is often recommended before and after lip augmentation. Injection in the presence of active infection is contraindicated. Product contamination is a concern, especially if the products are non-FDA approved as reported by Toy and Frank in 2002

Figure 12.2 Herpes labials infection on the upper cutaneous lip and small ecchymosis on the lower cutaneous lip seven days after HA fi ller placement.


where an outbreak of Mycobacterium abscessus originated in New York city following soft tissue augmentation with an unapproved HA product called Hyacell illegally brought into the United States from South America and injected illicitly ( 10 ).

Another infectious risk that has attracted a lot of recent attention is a biofi lm reaction, a complex aggregation of microorganisms marked by the excretion of an extracellular protective adhesive matrix that allow for the development of a community of antibiotic-resistant microorganisms ( 86 , 87 ). Clinically, biofi lms present as late-onset deeply erythem-atous nodules ( Fig. 12.3 ). These lesions were previously assumed to be foreign body granulomas or allergic reactions (so-called sterile abscesses) on the basis of negative bacte-rial cultures and were treated incorrectly with intralesional corticosteroid injections instead of antibiotics ( 88 – 90 ). Biofi lms have complex chemical communications that can shift aggregates from active to dormant depending on exogenous threats and when cell metabo-lism is halted, the communities are antibiotic resistant and quite often impossible to culture as well as treat. The clinical presentation is that of a local infection such as abscess, cellulitis, granulomatous foreign body reaction, allergic reactions, or, if the biofi lm covers a large implant or prosthetic joint or heart valve, systemic infection with sepsis ( 17 ). Asymptomatic nodules seen or felt shortly after treatment can be followed or massaged out. However, acutely painful nodules or late-onset nodules are most likely due to infection and subsequent biofi lm formation, and must be treated immediately with oral antibiotics (quinolone and a third-general macrolide and/or minocycline). A biopsy and/or aspiration may be necessary if initial treatment is unsuccessful ( 91 ) ( Fig. 12.3 ). The length of treatment with systemic antibiotics depends on the severity of the infection, typically four to eight weeks but may

Figure 12.3 ( A ) Late-onset painful erythematous fl uctuant nodule over the right nasolabial fold following treatment with human collagen. ( B ) Purulent discharge revealed after incision and drainage.

(A) (B)


require signifi cantly longer treatment in severe cases. Local injection of hyaluronidase can reduce the quantity of fi ller and therefore reduce the nidus of infection in cases when the fi lling agent used was a HA. Incision and drainage can be used for both therapeutic (product removal, disruption of biofi lm) and diagnostic (culture with special techniques for biofi lm detection) reasons for lesions that are fl uctuant ( 92 , 93 ). Intradermal injection of corticoste-roid is becoming much less commonly used, and really should only be considered in this type of infection scenario if the patient is already on an antibiotic regimen ( 94 ).

Measures to prevent infection and potential biofi lm formation include taking a full history including any previous treatments, bleeding disorders, an immunocompromised state, and previous infections. Skin preparation is essential in preventing soft tissue infec-tions; a number of antiseptics are available. Currently, no specifi c guidelines are available on the appropriate method to prepare the skin prior to a procedure. Data are limited to that published regarding clinical experiences with central lines and other implantable devices. Calfee et al. compared the effi cacies of 10% providone-iodine, 70% isopropyl alcohol, tincture of iodine, or providone-iodine with 70% ethyl alcohol in the prevention of blood culture contamination and detected no signifi cant differences although some evidence sug-gested greater effi cacy with alcohol-containing products ( 95 , 96 ). Chlorhexidine has the ability to treat resistant strains of the gram-positive bacteria Staphylococcus aureus and some gram-negative, viral, and fungal microbes. Chlorhexidine-based agents have become popular due to their longer durability and effi cacy, but should be avoided in the periocular area due to the potential risk of keratitis and ocular injury ( 97 – 101 ). Chlorhexidine can also induce skin sensitivity reactions, including skin breakdown. For this reason, one of the book editors (P.J.C.) does not use chlorhexidine for this.

In addition to following proper technique, prophylactic antibiotics are sometimes prescribed to patients when semipermanent or permanent fi llers are used, although this has not been validated. Other measures to limit infectious complications include: maintaining injection depths appropriate for the given fi lling agent and anatomic location, limiting the placement of multiple fi ller types overlying each other (“fi ller stacking”) at an individual treatment, avoiding large-volume injections, and avoiding injections into active infections or infl ammatory acne lesions ( 102 ).

Once the skin has been prepared, it is essential to avoid contamination of the syringe and needle. Filling agents can become contaminated in fi ve ways: (i) during manufacture, (ii) during reconstitution/packaging, (iii) during dilution with lidocaine, (iv) during injec-tion by surface bacteria, or (v) by topical contamination immediately postprocedure through needle puncture sites (such as via contact with a patient’s unclean fi nger tips during makeup application). Needle size may play a role; smaller needles (30- or 32-gauge) may reduce the risk of injection by providing a smaller conduit for skin bacteria to penetrate. However, higher viscosity fi llers require larger needle sizes (27-gauge for CaHA and 25-gauge for PLLA) to avoid high extrusion forces that predispose to clumping or clogging, increase bruising and swelling, and may infl uence incorrect placement or amount deposited ( 103 , 104 ). General recommendations for the prevention of short- and long-term infectious complications include (i) washing hands thoroughly before applying gloves, (ii) maintaining proper contact precautions, (iii) ensuring removal of all makeup and other skin contami-nants, (iv) cleansing the skin using prior to injection, (v) maintaining a clean injection tray, (vi) avoiding injection during an active skin infection, and (vii) and using the smallest gauge needle appropriate during injection.


DURING THE PROCEDURE

The key to optimizing results starts with the initial evaluation, but the major step in decreasing the chance for problems is proper placement of product. Appropriate placement of product requires detailed knowledge of anatomy, injection techniques, and the unique characteristics of individual fi lling agents.

Placement of Product

Too superfi cial placement of dermal fi llers is a common error associated with visible product, nodule formation, and sometimes scarring ( 42 , 94 , 105 ). Many of these compli-cations can be avoided with proper depth of injection, although this is often imprecise. A study comparing perceived versus actual depth of injection of HA fi llers into the nasolabial fold skin revealed that the majority did not match. The results suggested however that the exact location of HA product was not required for excellent cosmetic results ( 106 ). Another study of histology of excised tissue samples injected with HA fi llers in vivo (Restylane, Perlane, or layered Restylane/Perlane; Medicis Aesthetics Inc., Scottsdale, AZ, U.S.) found the exogenous HA primarily in the lower reticular dermis and subcutis and clinically appeared similar regardless of the HA product used ( 107 ). Most injectors are actually placing product deeper than they believe, including below the dermis.

Visible signs of depth during injection include the appearance of the color and shape of the needle as well as the response of the skin. In the more superfi cial plane (intradermal) the “gray” of the needle can be seen and the skin may blanch focally, especially if the needle is lifted slightly once situated ( 94 , 105 , 106 , 108 ). Although this plane is typically too superfi cial for most fi ller indications, it may be necessary for acne scarring and fi ne lines. Thin particle fi llers such as CosmoDerm, Zyderm, and Evolence Breeze were useful for these situations, but are no longer available. A new superfi cial HA fi ller is expected to gain FDA clearance in late 2010 (Belotero; Merz Pharmaceuticals, Greensboro, NC, U.S.). Alternatively, using small-gauge needles (such as a 32-gauge needle with some HA fi llers prepackaged with a 30 gauge including Juvederm Ultra and Restylane) to “thin” out the fi ller during extrusion may decrease the risks associated with superfi cial placement, but still allowing for treatment in these locations. One of the editors (P.J.C.) does not place fi llers not designed for superfi cial placement superfi cially even using a fi ne needle for injection.

Most fi lling agents are indicated for mid-to-deep dermal placement, but placement subdermally or periosteally is frequently done to improve longevity and reduce the risk of seeing the product through the skin. Clues to confi rm placement into the deep dermal or subdermal levels are: (i) “gray” of the needle is not visible, (ii) the location and shape of the needle is apparent, and (iii) the fat should be able to be pressed down by pointing the tip of the needle down ( 105 , 108 ). Dermal fi lling agents should never be placed intramuscu-larly due to the potential for nodule formation from uncontrolled displacement of the fi ller during routine muscle movement. CaHA has been reported in one case to cause a nodule distant from the injection site. Because of frequent nodule formation after direct injection into the orbicularis oris, CaHA is no longer recommended for lip augmentation ( 109 , 110 ).

Periosteal placement of fi ller substances involves a strong knowledge of anatomy as the needle must be inserted through the skin, subcutaneous tissue, and musculature until


the periosteum is felt with the tip of the needle. Careful localization of the preperiosteal plane is essential as the periosteum can be disrupted leading to hemorrhage and pain ( 111 ). Proper placement directly onto bone and beneath the overlying musculature can be obtained by slightly pulling back on the needle once the periosteum is felt. Repetitive contact with the periosteum will result in dulling of the needle and patient discomfort. Periosteal place-ment is not for novice injectors. Deep injection into high-risk locations (temple, lateral brow, suprabrow, angle of the mandible, base of nasal alae, tear trough, glabella) where nerves and vessels can be easily compromised should also be avoided until a thorough understanding of facial anatomy and injection techniques is mastered.

Manifestation of Superfi cial Filler Placement

Superfi cial placement is avoidable with the proper knowledge and technique. Caution should be maintained when injecting any fi ller superfi cially; however, areas that are par-ticularly high-risk for product visibility (lower eyelids, tear trough, periorbital, lips, nose) should only be performed by those experienced and with a complete understanding of fi ller anatomy ( 91 , 112 – 114 ).

Hyaluronic Acid

The currently available HAs are indicated for injection into mid-to-deep dermis or subdermal planes, as superfi cial placement can result impalpable and/or visible nodules. In general, the formation of bumps under the skin occurs due to the consistency of the fi ller itself when placed superfi cially with poor technique, but can also far less commonly occur with reaction to the product ( 67 ). Most injectors massage the material upon placement to ensure the smooth nature of the clear gel and mold it to facial contours. If superfi cial, HA bumps will sometimes appear blue and may be confused with postinjection edema or ecchymoses. The bluish-gray appearance, called the Tyndall effect, is a result of scattered light of various wavelengths through the chamber of clear gel it encounters in the dermis ( 115 , 116 ). Common areas to see this effect include the central face (nasojugal fold, nasal dorsum, lip), periorbital area including tear troughs, and fi ne superfi cial lines such as peri-orbital and perioral rhytides (“crow’s feet” and “pucker lines”) ( 117 , 118 ) ( Fig. 12.4 ). If caught early, the gel can be fi rmly massaged to fl atten and disperse excessive material and distribute more evenly ( 119 ). If massage is not effective, the superfi cial HA product can often be expressed after nicking the skin with a #11 blade or 18-gauge needle. In addition, inappropriately placed HA fi ller product can be dissolved with hyaluronidase enzyme, making it an ideal fi ller for novice injectors and patients who are unsure if they will be pleased with the results.

The treatment of choice for persistent unwanted HA is hyaluronidase (commercially available as Amphadase, Hydase, Hylenex, or Vitrase) ( 93 , 120 ). Hyaluronidase is a soluble protein enzyme that acts locally to break down and hydrolyze HA. The enzyme hydrolyzes HA by splitting the glucosaminidic bond between C1 of the glucosamine moiety and the C4 of the glucuronic acid in the ground substance ( 117 ). The fi rst successful report of hyal-uronidase used to reverse the effects of HA fi ller excess used 75 units mixed with 1.5 cc of 0.5% lidocaine (with or without epinephrine). Ninety percent of the lumpiness caused by the gel resolved in 24 hours ( 92 ). In another report, 15 units caused complete resolution of a nodule in 24 hours ( 121 ). Most preparations are animal based (except Hylenex) and carry the


risk of hypersensitivity reaction so skin testing is recommended. An intradermal injection of three units should be placed in the volar forearm while the patient is monitored for a minimum period of 20 minutes ( 23 ). A positive reaction is when a wheal or fl are occurs at the testing site and may be due to the animal protein or the ingredient thimerisol. Bee venom contains hyaluronidase and patients with beesting allergies may be highly sensitive. Some authors have reported cases of HA nodules resistant to hyaluronidase ( Fig. 12.5 ), therefore incision and drainage with an 18-gauge needle or #11 blade is still a common and

Figure 12.4 Superfi cial placement of HA fi ller under the right eye with visible material in a linear thread.

Figure 12.5 This is the histologic image of a 65-year-old female who presented with a nodule two years after injection of a biphasic HA preparation into the lower periorbital region. Amorphous deposits of various sizes are surrounded by multinucleated giant cells in the dermis. The team con-tributing this image has had eight cases resistant to hyaluronidase referred to them after injection of various preparations of HA in the lower periorbital region. All the patients have had previous lower blepharoplasty, which might be speculated to have increased the risk of nodule formation in this area. Source : Courtesy of Prof. Dr. W. Stolz, Ludwig-Maximilians-University, Munich, Germany.


cost-effective method to extrude unwanted HA product from the dermis and avoid the potential risk of hypersensitivity to the hyaluronidase enzyme ( 17 , 121 ). Finally, 1064-nm Q-switched Nd:YAG laser has also been reported as a treatment modality of HA product placed quite superfi cially, but may have more effi cacy for associated postinfl ammatory hyperpigmentation than for primary reduction of HA ( 116 ). The potential risks of 1064-nm laser treatment should be considered before initiating treatment.


CaHA is indicated for placement into the deep dermis or subdermis. Superfi cial placement is contraindicated because of the risk visible and/or palpable white nodules. As described previously, the tear troughs, malar eminence, lateral zygoma, and mental crease are par-ticularly vulnerable to fi ller visibility. In order to avoid this some physicians have per-formed treatment of these areas with CaHA subperiosteal placement. One of the editors (P.J.C.) will not place this fi ller in the subperiosteal plane in the tear trough, or in the men-tal crease regions. The risks of injecting into the tear-trough region should be considered before placing fi llers in this region.

Also as discussed, nodule formation may occur if CaHA is injected in areas that are frequently mobile such as the lips due to the “pumping action” of orbicularis oris muscle coalescing product so this area should be avoided ( 109 , 110 , 122 ). Increasing the volume of lidocaine that is mixed in standard to CaHA, before treatment, may also reduce the risk of nodule formation by reducing viscosity. The decreased viscosity translates into reduced extrusion force and more malleable product for massage ( 123 ). This may be particularly helpful in areas such as the hands and around the mouth, where nodule formation is more common with localized accumulation of fi ller.

After injection, aggressive immediate massage may help to ensure adequate dispersion and prevent clumping of product. When they occur, nodules may be punctured with an 18-gauge needle or a #11 blade to facilitate extrusion of the material. Unfortunately, unlike hyaluronidase for HA agents, there is no “antidote” available to dissolve unwanted CaHA. The use of intralesional saline injection followed by massage in order to mechani-cally break up the product has been described. Intralesional corticosteroids have also been used; however, they carry a risk of atrophy peripheral to the retained fi ller making it more, rather than less visible. Finally, injecting additional fi ller, for example an HA, around the nodule to blend the surface with the surrounding skin contours can reduce the appearance of the nodule until it resolves over time.


The PMMA (ArteFill) available in the United States differs from that available in Europe (Artecoll) as it derived from a closed U.S. bovine herd, has a more consistent particle size, and has a larger particle size ( 40 ). The larger particle size helps carry a lower risk of immunogenicity and digestion by macrophages. This fi ller is preferentially placed deeper, into the deep dermis since superfi cial placement can be associated with long-lasting pruri-tus, redness, and hypertrophic scarring in association with delayed-onset infl ammatory nodules or hypersensitivity reactions. Fortunately, localized pruritus and redness can be treated with topical or injectable corticosteroids and/or topical calcineurin inhibitors.


Hypertrophic scarring can sometimes be softened by topical or injectable corticosteroids, topical silicone, topical 5-fl uorouracil, topical imiquimod, cryotherapy, or various laser technologies such as pulsed dye, fractional, or ablative resurfacing ( 124 – 126 ). It is impor-tant to avoid a big, localized accumulation of product, especially with fi ller products that are particulate or more permanent. Skin testing four weeks prior to the planned procedure as well as using cautious and conservative treatment sessions with appropriate injection techniques, can give optimal results with high patient satisfaction because of its durability. If nodules arise, the only option is surgical removal.

Injection Patterns and Injection Technique

Appropriate injection technique can help ensure successful outcome and limit the risk of contour irregularities and subsequent patient dissatisfaction. Many patterns are recognized such as fanning, serial puncture, cross-hatching, linear threading, and the choice of pattern is based on the location to be injected and the product utilized. The proper use of these pat-terns can help the injector more uniformly treat the desired areas. Glogau et al. found in a prospective, blinded, randomized, controlled study of 283 patients, having midface volume correction of the nasolabial folds and oral commissures with HA-fi lling agents (Restylane or Perlane) that local adverse events following injection were related to investigator tech-nique and not to differences in the intrinsic properties of the fi ller or needle size ( 127 ). The elements that were found to be associated with an increased risk of adverse events included injection techniques that increased the dissection of the subepidermal plane such as a fan-like projection, rapid injection, rapid fl ow rates, and higher volumes. Interestingly, injec-tion techniques that increased epidermal damage or subcutaneous contact such as serial puncture or deep depot injections had no effect on adverse events. Thus, proper technique is essential to successful outcomes.

The nasolabial folds, glabella, philtral columns, fi ne perioral and periocular rhytides, lips, and forehead lines do well with serial puncture or linear threading techniques. With serial puncture, multiple small depot injections are made along a wrinkle or crease, this allows for accurate material placement. Care must be taken to ensure each injection is of equal volume and sequential so the overall picture is that of a smooth, continuous line that lifts or fi lls out the fold. Molding and massaging can help to ensure gaps are fi lled in and soften minor irregularities posttreatment.

Linear threading works well for the lips (along the “white roll”), nasolabial folds, lateral zygoma, angle of the mandible, and preauricular areas. The correct technique involves inserting the full length of the needle in the middle of the wrinkle or area to be enhanced and creating a tunnel that will be fi lled with the product by either an anterograde (while needle is advanced) or retrograde injection (while need is withdrawn). Both tech-niques are acceptable and give excellent cosmetic results. Some may feel the anterograde method is safer as it allows the material being injected to “push away” small cutaneous vessels and nerves and may decrease complications, most notably bruising and swelling. However, in areas that are highly vascular such as the glabella or lip, a retrograde method may be a better choice as it decreases the likelihood of an intraarterial injection. The ver-million boarder (“white roll”), philtral columns, and lateral eyebrow are great places for an anterograde approach as the potential spaces in these locations may allow easy product fl ow and placement.


For very large areas such as the cheek, midface, and marionette lines, the cross-hatching or fanning technique may be very effective. Cross-hatching works by creating a series of linear threads evenly spaced in a progressive grid similar to a scaffold that works to ensure a large space is supported and fi lled. Several levels may be needed to help fi ll and lift the area of treatment, especially in the midface where there is no osseous backing of facial support. Fanning is similar in fashion to linear threading except that the needle is not completely withdrawn and is advanced in a different location (clockwise or counterclockwise) allowing for the same injection site to be used to fi ll a particular area. This method limits the amount of skin punctures needed and may decrease the risk of surface bruising and swelling ( 128 , 129 ). However, the process of fanning the needle hori-zontally through the skin increases the change of encountering small vessels and therefore deeper bruising. Alternatively, use of the depot method, where larger volumes of low- viscosity product are injected and then massaged or molded to facial contours limits both surface and deeper needle movement.

Special Considerations: Expectations, High-Risk Areas, Skin of Color

Ultimately, patient satisfaction is the primary goal of any cosmetic therapy. Thorough patient counseling regarding realistic patient expectations is essential. This discussion should include expected perioperative side effects as well as possible adverse effects. In addition, an overall short and long-term rejuvenation plan should be outlined at the fi rst visit. Many patients will require multiple treatments with numerous syringes or vials of fi ller, often in combination with other noninvasive cosmetic procedures. Filler longevity is also a common patient concern and the need for return visits at intervals discussed. Patients need to understand what physical and fi nancial undertaking is entailed prior to starting therapy to avoid frustration and animosity toward the physician. Pre- and posttreatment photographs are important to document results for both the patient and the physician.

As explained previously, certain anatomical regions are more sensitive to injury either due to the nature of the skin at that location (thickness) or the structures that lie beneath (vessels or nerves). The major anatomic vessels of concern for soft tissue aug-mentation of the face includes (i) supratrochlear artery, (ii) superior and inferior labial arteries, (iii) angular artery, and (iv) the parotid duct ( 130 ). With the recent popularity of fi lling temple concavities as well as correcting nasal contour irregularities, clearly the superfi cial temporal artery and the dorsal nasal artery are also areas of concern and caution ( Fig. 12.6 ).

The periocular area and tear trough, temple and lateral brow, and angle of the man-dible, may be more diffi cult to treat and challenging to a novice injector. Strict adherence to proper technique can help limit serious side effects in these locations, but sometimes minor side effects may be unavoidable and should be explained completely prior to treat-ment. For example, the periorbital area is surrounded by several major vessels and nerves that can be injured during careless injection or simple bad luck, and this type of injury could potentially result in visual impairment or blindness ( 130 – 132 ). Injections above the bony border of the orbit can result in septal damage and possibly injury to the globe that may be irreversible.

The supratrochlear artery is particularly at high risk of injury from injection in the glabellar region and/or superior medial bony orbit. The superfi cial temporal artery is


particularly vulnerable in the preauricular, lateral zygoma, and temporal locations. Vessel damage here can potentially lead to the devastating complication of unilateral scalp necro-sis. The superior and inferior labial arteries are at particular risk of injury with augmenta-tion of the perioral area and lips, as these arteries supply the upper lip including some of the nasal ala and the lower lip and superior part of the chin, respectively. The angular artery (continuation of the facial artery) provides blood to the medial cheek, nasal ala, nasal side-wall, and dorsum of the nose. Care should be exercised when injecting near the alar groove, as excessive compression with large volumes of fi ller or frank injection directly into the vessel at this point can lead to nasal ala, nasal tip, nasolabial fold, and upper lip necrosis.

Clinicians should take every precaution to avoid vascular compromise. If possible, aspirating prior to injection in anatomic danger zones can be helpful but proves quite dif-fi cult with viscous fi llers and may only be more reliable in circumstances like when using Sculptra. Intravascular injection may lead to immediate blanching followed by ischemia and necrosis. When using local anesthesia separately or mixed into a fi lling agent, it is important to know if it contains epinephrine so that the cause of blanching can be deter-mined quickly. This is one reason that some clinicians prefer to use lidocaine without epinephrine during tissue augmentation.

Other structures can also be at risk. Like the artery, the superfi cial temporal nerve is vulnerable in the preauricular, lateral zygoma, and temporal locations. The temporal branch of the facial nerve is at risk over the lateral brow and the zygomatic branch of the facial nerve is at risk over the zygoma. Injury to the nerves in this location can lead to the inabil-ity to move the unilateral eyebrow or close the unilateral eye completely. Injections near the angle of the mandible put the marginal mandibular branch of the facial nerve at risk, and injury to this nerve causes denervation of the depressors of the lip/mouth, which in turn can cause chronic drooling or the inability to chew/eat correctly. Finally, the parotid duct (Stenson’s duct) enters the mouth at the level of the second molar and is vulnerable to trauma during midface and cheek augmentation, especially in patients with more signifi cant

Figure 12.6 Caution is required in areas with vessels, such as in the temporal area as well as the glabella, alar groove, and lips.


degree of aging, extreme weight loss, and HIV lipoatrophy. Less subcutaneous volume makes the duct more susceptible to injury.

Recently, there has been more awareness of complications specifi c to the use of fi lling agents in patients with skin of color (Fitzpatrick skin types IV–VI). Darker skin types have increased melanin content and their fi broblasts are larger and more numerous, which may predispose them to dyspigmentation, hypersensitivity reactions, keloids, or hypertrophic scar formation ( 133 ). Published data on the safety and effi cacy of soft tissue fi llers in ethnic skin is limited due to an underrepresentation of darker skin types in clin-ical trials. However a recent, multicenter, open-label, nonrandomized, prospective trial evaluated the use of CaHA in the nasolabial folds of dark skin individuals (Fitzpatrick skin types IV–VI) and found no signifi cant increase in keloid formation, hypertrophic scarring, or dyspigmentation ( 134 ).

Other studies have validated these fi ndings with the use of HA and collagen prod-ucts ( 135 – 138 ). Thus, a theoretical concern of increased adverse events in patients with darker skin has not been demonstrated, and patients with skin of color should be treated with the same precision as any other patient without these concerns of scar abnormalities or dyspigmentation until more data is available.

EARLY POSTPROCEDURE

Allergic Reactions and other Hypersensitivity Reactions

As discussed above, any fi lling agent composed of foreign materials can theoretically trigger immune activity to a variable degree from mild irritation and redness to extremely rare anaphylaxis. Despite adequate skin testing (bovine collagen and PMMA) and using fi llers with low-reactivity profi le (HA, CaHA, PLLA), reactions can occur albeit rarely. Stolman and Nijhawan have reported cases of allergic reactions to human collagen prod-ucts presenting with erythema, induration, burning, and nonerythematous subcutaneous lumps ( 139 , 140 ). These reactions have been treated with topical calcineurin inhibitors, intralesional corticosteroid injections, systemic corticosteroids, and/or antihistamines. A rare case of angioedema-type hypersensitivity reaction has been reported after HA injection (Restylane) into the lips and resolved after treatment with intramuscular dexamethasone and with an oral prednisone taper ( 13 ).

Skin Necrosis

Typically, necrosis is a rare occurrence, especially with proper education and injection technique ( 7 ). Vascular occlusion can occur either by external compression of the blood supply by surrounding fi ller material or swelling, by direct intraarterial injection of prod-uct, or by vascular injury. Arterial occlusion is characterized by extreme pain and blanch-ing, but it may present as a painless patchy cutaneous erythema or an expanding violaceous reticulated patch; if these symptoms do occur they should not be ignored. The area most regarded as high risk is the glabella as the vessels are of small caliber and do not have a good source of collateral circulation ( 7 , 8 ). The skin of the alar region of the nose is sup-plied by small branches of the facial artery (dorsal nasal, angular, lateral nasal) and is also at risk ( 141 , 142 ). Injection necrosis of the glabella can theoretically best be prevented by (i) knowledge of local anatomy, (ii) utilizing lower volumes and use of serial injections,


(iii) injecting in a more medial and superfi cial plane, (iv) utilizing less viscous fi lling agents by choosing a “thinner” or low-concentration fi ller or improving viscosity of fi llers with extra plain lidocaine, (v) treating one side at a time and the other side done at a different session (to decrease the likelihood of large volumes plus or minus signifi cant swelling superseding arteriole local pressure), (vi) pinching/tenting the skin to provide more space to the superfi cial branches of the main arteries and to move away the underlying vascula-ture, (vii) manual occlusion of the origin of the supratrochlear vessels with the nondomi-nant fi nger, (viii) using the smallest gauge needle possible, (ix) avoiding anesthesia near a vascular bundle that may induce vascular spasm, such as those containing epinephrine, and (x) attempting to aspirate some products prior to injecting ( 23 , 130 ). It is also generally recommended to limit treatment of the glabellar area to an HA product, as it can at least be attempted to be removed with hyaluronidase enzyme should necrosis be imminent.

Although the incidence of actual skin necrosis is low, all injectors should be familiar with the signs of skin necrosis and the appropriate therapy, as the time to treatment and type of treatment are good determinants of morbidity in these devastating situations ( 17 ). The goal of treatment is to promote increased blood fl ow to the affected area and this can be accomplished by applying warm gauze (avoiding ice), tapping or massaging the area to facilitate vasodilation and dispersion of material, applying 2% nitroglycerin paste (Nitro-Bid; Fougera, Melville, NY, U.S.), and taking oral aspirin ( 19 ). Hyaluronidase injection is recommended in cases of impending necrosis after HA use, and there are cases document-ing careful injection along the distribution of the underlying vessel showing improvement by likely decompressing the vessel. In some of these circumstances, a Doppler device may be helpful in pinpointing proximal placement into the suspected compromised vessel. For extreme cases of unresponsive necrosis, subcutaneous injections of low molecular weight heparin may be useful ( 143 ). If necrosis ensues, as demonstrated by an ulceration and/or eschar formation at the site of injection, diligent wound care management with hydrocol-loidal dressings (Duoderm Ultra Thin Sheets; Convatec, NJ, U.S.), emollients, and topical antibiotics are the primary treatment and if necessary surgical debridement or possibly hyperbaric oxygen therapy. “Watchful waiting” is all that can be done once treatments have been initiated and the utmost importance is to minimize scarring. Once healed, the resultant scar can be treated with silicone pads and/or dermabrasion, excision, pulse dye laser, 1450-nm diode laser, or laser resurfacing depending upon the severity, texture, and color ( 7 ).

LATE POSTPROCEDURE

Nodule Formation and Granulomatous Reactions

As previously discussed, delayed-onset nodule and granulomatous reactions have been reported with several fi lling agents.

Hyaluronic Acid

Nodule formation following injection of HA fi llers is most commonly due to superfi cial placement ( Fig. 12.7 ). Granulomatous reactions or infl ammatory nodules are of a different nature and have been reported in the literature as persistent nodules and/or delayed-onset erythematous nodules (“angry red bumps”). These bumps may or may not be tender and are


regarded as possible allergic reactions, foreign body reactions, infections, and/or sterile abscesses ( Fig. 12.8 ). A granuloma can sometimes be differentiated from a fi brotic foreign body reaction by its later onset, tenderness, swelling, and suppuration ( 144 ). Biofi lms (chronic indolent infections) may play a role in the presentation of delayed-onset nodule formation and as noted previously are often resistant to treatment ( 145 – 148 ). Case reports describe some that fail to improve with standard measures such as topical, oral, or inject-able corticosteroids. Others have reported success with injection of hyaluronidase. Overall, the management of “angry red bumps” has been well outlined with the use of empiric antibiotics, incision and drainage with culture, and close observation ( 17 ).

Figure 12.7 Nodule formation 10 days after HA fi ller placement for lip rejuvenation. Product is more palpable than visible and most likely due to improper placement or too large an aliquot of material without adequate manipulation postprocedure.

Figure 12.8 Six months after injection with Varioderm (HA) for correction of tear troughs, an oval hard nodule about 1 cm in length developed, slowly increasing in size. Several attempts with treatment of hyaluronidase were without results. The patient wanted to have the nodule removed. Source : Courtesy of Prof. Dr. W. Stolz, Ludwig-Maximilians-University, Munich, Germany.


Poly- L -Lactic Acid

Nodule formation with PLLA was quite common initially with a rate of 31% to 52% in early European studies of patients with HIV lipodystrophy ( 70 , 149 ). Lower instances have been reported by several U.S. authors and ranged between 6% and 13% ( 23 , 150 , 151 ). Treatment protocols incorporating higher dilution volumes (8–12 mL total; 5–10 mL of sterile water plus 1–2 mL of 1% lidocaine with epinephrine), precise injection into a deeper plane (subcutaneous plane avoiding dermal and intramuscular placement), fewer vials used at each session with adequate reconstitution times (12–24 hours or more), adequate time between injection sessions (six to eight weeks), and aggressive postinjection patient mas-sage should decrease the risks and avoid the potential complications associated with PLLA injection ( 90 , 104 , 152 ). Butterwick et al. recommend a dilution of 5 mL or more of sterile water with additional 1 mL of lidocaine prior to injection with reconstitution time to at least overnight ( 153 ). The periorbital area is a particularly sensitive area to the formation of nodules and foreign body granulomas and it is suggested that only experienced injectors use PLLA in this area ( Fig. 12.9 ). Similarly, due to thin skin and meager subcutaneous tis-sue, the dorsal hands should only be approached with caution and by experienced injectors ( 20 , 154 ). In addition, in the hands, PLLA should be injected in a “depot” method below the muscle at a signifi cantly diluted volume to avoid complications ( 155 ). A retrospective, single-center study of 130 HIV-negative patients treated with PLLA from 2003 to 2008 found that the highest incidence of posttreatment nodules were located in the hands (12.5%) and cheeks (7.2%), but the majority of patients (68%) were satisfi ed and would repeat the procedure again despite the possibilities of further complications ( 156 ). A review of the literature suggests that the use of appropriate injection technique (subcutaneous plane injection with even distribution of product and no more than 0.1–0.2 mL of product per pass of the needle), increased dilution volumes, and posttreatment massage are the most helpful in reducing nodule formation ( 157 – 163 ). Fortunately most nodules are palpable but not visible; however, if nodules are visible or symptomatic in any way, treatment of proves very diffi cult, for example, PLLA nodules ( Fig. 12.10 ). Intralesional corticosteroid or

Figure 12.9 Nodule formations after treatment with PLLA over the lateral zygoma, most likely from improper superfi cial placement of product or low dilution volume.


saline injections in combination with topical 5% imiquimod cream and/or 5-fl uorouracil cream may be helpful. Surgical excision is an option in long-lasting cases, but may yield a poor cosmetic result.

Most PLLA nodules encountered are noninfl ammatory, but one case series of 10 patients reported delayed infl ammatory nodules marked by edema, induration, and tender-ness, with or without pus or fi ller material with the use of PLLA ( 164 ). Previous thinking was that PLLA injections did not have infl ammatory-related side effects, and to date no additional infl ammatory PLLA reports have been published.


Nodule formation with CaHA has also been reported with most noted cases occurring during lip and perioral injection. Thus, lip injection has been abandoned and many injectors take caution when using this product in the perioral area. In other areas of the face, CaHA is very safe and effective especially for the nasolabial folds, oral commissures, and cheeks. Some experienced injectors use CaHA to augment the mandible, lateral brow, and temples as well, with excellent results ( 24 , 165 ). Thus far, serious complications reported have been minimal especially if injected into the deep dermis or above the periosteum ( 166 ). One recent study has shown excellent six-month safety results in patients with skin of color (Fitzpatrick skin types IV–VI) without any increase in keloid formation, hypertrophic scarring, dyspigmentation, or other complications ( 134 ). There is one report of a CaHA nodule appearing 2 cm distal to the site of injection ( 109 ). As outlined previously, if nod-ules do occur, they can be treated in part with intralesional injection and/or surgical excision. Theoretical concerns of bone stimulation following CaHA injection have been raised, but to date no studies have shown this theory to be true ( 167 ). Nonetheless, it is still recommended that this fi ller not come in direct contact with bone when injecting into the preperiosteal plane ( 5 ).

Figure 12.10 PLLA nodules visible from inside the mouth as a result of abnormal placement during cheek injections.



Delayed granuloma formation has been associated with PMMA mainly in the form commercially available in Europe (Artecoll). The rate is quite low (0.1%), but can be trou-blesome because of its delayed appearance (6–24 months following injection) ( 44 , 168 , 169 ). Generally, treatment includes repeated intralesional corticosteroid injections at increasing concentrations every three to four weeks ( 23 , 42 ). It is important to distinguish this type of nodule formation versus superfi cial beading and ridging representing a hypertrophic scar due to superfi cial placement of PMMA, as the latter may require more aggressive therapies such as laser or excision ( 129 ).

CONCLUSION

As soft tissue augmentation with fi lling agents becomes more popular, there is need for practitioners to have proper training in order to provide a safe means of facial rejuvenation. Understanding and knowledge of regional anatomy, product characteristics, and injection techniques can help give optimal results with the least complications. Nonetheless, circum-stances may arise and the practitioner needs a thorough understanding of the correct means to diagnose a complication in order to quickly initiate the proper treatment algorithm. The goal of all facial rejuvenation procedures should be patient satisfaction with minimal sequelae. Proper patient selection and counseling will provide realistic expectations that will lead to lasting fulfi llment. Practitioners of all levels should be familiar with the most commonly available fi lling agents and their characteristics in order to successfully avoid adverse effects and accurately diagnose and effectively manage complications if they do occur.

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167

13 Postliposuction defects

Misbah H. Khan, Theodore Diktaban, and Neil S. Sadick

INTRODUCTION

Adipose tissue is deposited in human subcutaneous tissue as an energy reservoir and serves to provide the body with temperature and vibratory insulation. It is deposited and reab-sorbed as part of normal homeostasis and its sites of deposition are in large part genetically predetermined. Two body shapes are known to exist: gynecoid, seen more commonly in females, and android generally seen in males. There are certainly exceptions to both, as well as substantial crossover in fat distribution patterns between men and women. However, an individual may be near his or her ideal body weight, yet have disproportionate, localized adipose deposition. It is for such a patient that liposuction is an ideal procedure.

Liposuction is an aesthetic removal of undesirable localized collections of subcutaneous adipose tissues (1). Liposuction is the most common advanced cosmetic procedure in the world. Dermatologic surgeons have played a major role in advancing its safety and reducing the complications associated with this surgery overall. Long-term experience has shown that complications are very low with tumescent liposuction performed only with local anesthesia or with added intravenous or general anesthesia. Nevertheless, complications do occur.

Most postoperative complications associated with tumescent liposuction are minor and resolve on their own. These include bruising, swelling, soreness, infl amed incision sites, and fatigue. Rather serious complications such as large seromas, skin necrosis, infection, and even death have been reported from general anesthesia (2). This chapter will focus on treatment of surface irregularities that can be seen after tumescent liposuction and how certain fi llers can be utilized to correct these.

The goal of liposuction is to improve the shape, proportion, and size of the body and to produce a smooth and pleasing appearance. The outcome of the surgery is infl uenced by many variables. These variables include the skin condition, age of the patient, extractability of fat, equipment used (e.g., traditional liposuction, ultrasound-assisted lipoplasty, and power-assisted device), infi ltration of wetting solution, anesthetic technique, artistic planning, surgical execution, and postoperative care. The impact and interaction of these variables may result in a certain degree of unpredictability in the outcome of the operation (3).


PREVENTION OF POSTLIPOSUCTION SURFACE IRREGULARITIES

In order to avoid or reduce these complications during liposuction, there are three phases that need to be considered: the preoperative, intraoperative, and postoperative periods.

Preoperative Patient Evaluation

One can predict who will develop surface imperfections after liposuction. Patients seeking liposuction of rather larger body surface areas and with poor skin elasticity, aged older than 60 generally do not benefi t to a great extent from this procedure. Preexisting scars, abdom-inal hernias, poor muscle tone, and signifi cant muscle atrophy as seen on extremities, deep indentations, and the presence of coexisting cellulite predict poorer outcome (4). A detailed cardiovascular and pertinent medical history is also of paramount importance and should be obtained at length especially in patients greater than 60 years of age. Special attention should be directed at medications that the patient consumes, particularly nonprescription over-the-counter and holistic medications, as some of these medications can cause signifi cant intraoperative and postoperative bleeding, which makes it very diffi cult for the surgeon to perform adequate liposuction.

Patients who are at risk of getting postoperative surface irregularities should be warned ahead of time especially in areas of poor skin elasticity; they will be more accepting of the end result. Informed consent should be reviewed with emphasis that liposuction is, foremost, a body contouring procedure, with the goal to achieve better lines, both in and out of clothing.

Intraoperative Considerations

A set of preoperative photographs should be taken from at least two different angles of the areas being treated. Marking of the areas being treated should be done with special attention to the areas with greater versus lesser protuberance. This is especially true for areas that have a higher incidence of surface irregularities such as posterolateral and medial thighs. Adequate tumescent anesthesia should be employed. For patients seeking correction for larger body surface areas, liposuction should be performed in more than one setting in order to avoid over and/or under-correction of the treated site. The choice of liposuction equipment, traditional versus powered largely depends on the surgeon’s choice. However, the use of internal ultrasonic cannulas can lead to an increased incidence of seromas, skin necrosis, and necrotizing fasciitis (5). Choice of an appropriate cannula is very essential in achieving better cosmetic outcomes ( Table 13.1 ). As a general rule, large-bore cannulas are mostly used for larger and deeper adiposities and if used for superfi cial liposuction for too long can cause signifi cant adverse effects such as skin necrosis, track marks, skin dimpling and atrophy, and reticulated mottling. Cannulas with smaller diameter and fewer holes are preferred for rather superfi cial liposuction and for fi ne tuning ( Fig. 13.1 ). Newer technologies such as the powered reciprocating instruments and laser-like devices seem to be associated with much lower rates of complications. It remains controversial whether they signifi cantly improve the fi nal aesthetic result.

Postoperative Considerations

Compression garments worn after liposuction will enhance even skin contraction. Endermologie, external ultrasound, and/or lymphatic drainage massage may assist in rapid

POSTLIPOSUCTION DEFECTS 169

Table 13.1 Commonly used Cannulas for Traditional Liposuction

Aggressive: large diameter numerous holes, holes at the tip of cannulaKeel Cobra 3–3.7 mmCapistriano 10–12 gaugeMercedes 10–12 gaugePinto 10–12 gaugeToledo 10–12 gauge

Intermediate: medium diameter, distal holes oriented away from dermisAccelerator/Triport 3 mm3-port radial or Standard 3 mmPyramid 3 mmKlein (dual port) 12 gaugeCapistriano 14 gaugeKeel Cobra 2.5 mmTexas 2.5 mmDual port Standard 2.5 mmFourneir 2.5 mmSattler 2 mm

Least aggressive: small diameter, distal holes away from the dermisCapistriano 16 gaugeKlein (dual port) 14–16 gaugeSpatula 2–3 mm1-Hole Standard 2 mm

Figure 13.1 Orientation and placement of liposuction cannula tunnels. Smaller cannula diameters are often used to remove superfi cial fat after deeper fat is suctioned with larger-diameter cannulas.

removal of swelling and fl uid accumulation and enhance skin elasticity. Minor irregularities usually improve as the edema improves. Reassurance and reevaluation of the treated areas in three months is advised. Skin dimpling can be caused by damage to the reticular dermis, overzealous suctioning of the deep fat, or poor skin tone.


ANALYSIS OF POSTLIPOSUCTION SURFACE IRREGULARITIES

Postprocedure surface irregularities can vary from relatively smaller areas of localized lipoatrophy to signifi cant larger contour and bodyline asymmetry. It is important to have a close follow-up with the patient and to examine the treated areas three to six months postprocedure and compare the preoperative and postoperative pictures of the treated areas.

Approximately 5% to 10% of the cases require touch-ups. The degree and extent of the surface contour change must be discussed with the patient in-depth. The location of surface irregularities is also important as a small area of surface dimpling on the anterior neck might be more noticeable and concerning to the patient as opposed to the dimpling on lower abdomen or thighs.

Postoperative surface irregularities can be largely subdivided into the following categories: (i) isolated smaller areas with approximately 1 to 2 mL of volume loss; (ii) single cosmetic unit with multiple smaller areas of surface irregularities such as neck; (iii) larger cosmetic units with areas of dimpling and/or track marks, or lumpiness such as lower or upper abdomen; larger cosmetic units with well-defi ned contour irregularities as seen on posterolateral thighs. Of note is the fact that most of these aforementioned surface irregularities can coexist in the same patient and at times within the same cosmetic unit. Although there is a signifi cant degree of overlap in the presentation of these post-procedure complications, management of each of these complications will be discussed separately in this chapter.

CORRECTION OF POSTLIPOSUCTION DEFECTS WITH FILLERS

Isolated Well-defi ned Smaller Areas

Isolated and rather smaller postliposuction defects with well-defi ned borders can be corrected with temporary or semipermanent injectable fi llers. Dermal fi llers are increasingly being used for multiple cosmetic dermatologic indications (6) . The rapid worldwide expansion of injectable fi lling materials for facial rejuvenation has given rise to long- lasting and perma-nent fi llers. Two principal and different gel fi llers are used today. The most common type is a homogenous polymer, called a volumizer, because of its fi lling effects, such as hyaluronic acid gel (Juvederm, Allergan Inc., Irvine, CA, U.S.) (7). The other gel type is a combination of microparticles dissolved in a transient degradable polymer gel, also called a stimulator as the fi lling effect partly or completely relies on the host foreign body response to the mic-roparticles. Belonging to this group are poly- L -lactic acid (PLLA) microparticles suspended in sodium carboxymethylcellulose, mannitol, and water (NewFill, Sculptra, Sanofi -Aventis, Paris, France) and calcium hydroxyapatite microspheres suspended in glycerin and carboxymethylcellulose (Radiesse, Bioform Medical Inc., San Mateo, CA, U.S.).

Augmentation of the surface dimpling or depressions can be performed to enhance the entire volume loss and to achieve a rather smoother surface contour (8) ( Fig. 13.2 ). The microparticles are slowly degraded and some disappear with time. Others are nondegrad-able. They stay in the tissue forever and contribute to the permanent fi lling effect (9). Although there is limited data available regarding the use of gel fi llers for correction of postliposuction defects, the authors have used these fi llers to correct smaller well-defi ned depressions. The advantage to the use of fi llers is their safety profi le and minimal down time. Long-term effi cacy of the fi llers remains to be investigated.


Single Cosmetic Unit with Multiple Surface Irregularities

Multiple surface irregularities in a single cosmetic unit are commonly seen after liposuc-tion especially in areas with rather superfi cial distribution of fat such as neck, or after aggressive superfi cial liposuction on rounder surface areas such as lower abdomen and buttocks. Minor contour irregularities can be treated by limited additional liposuction, often performed in the offi ce under local anesthesia. Other invasive treatment modalities include laser-assisted lipolysis (10) that has been successfully employed for corrections of localized adiposities.

Fillers have recently gained popularity as one of the minimally invasive procedures that can be used to correct postliposuction surface irregularities. Fillers commonly employed for this purpose include longer-lasting fi llers such as PLLA. PLLA is a biode-gradable, nontoxic, synthetic, inactive material derived from corn starch. It has been used in suture material, stents, and other biomedical implants (11). The Food and Drug Admin-istration (FDA) approved Sculptra (Sanofi -Aventis, Bridgewater, NJ, U.S.) in 2004 for Human Immunodefi ciency Virus (HIV)-related lipoatrophy. PLLA is metabolized to carbon dioxide and glucose after injection. Growth of type I collagen into the areas of accumulated PLLA microspheres causes soft tissue augmentation. The clinical effects can be seen for up to two years (12).

Although there is limited experience of treating postliposuction defects with semipermanent fi llers such as PLLA, the authors would like to present the case of a 43- year-old female who underwent liposuction of buttocks and love handles. The patient developed signifi cantly noticeable dimpling and contour irregularities of the medial buttocks, which were unresponsive to several noninvasive treatments with SmoothShapes device. The patient was subsequently treated with three sessions of PLLA over a period of fi ve months resulting in a substantial improvement ( Fig. 13.3 ). The longevity of the effects as seen in our patient can be attributed to the host foreign-body response that ends up as a permanent de novo fi brous scar tissue, which might contribute to a rather smooth contour of the surface irregularity. It is postulated that some microparticles slowly degrade over years by disintegration. Since PLLA particles continuously evoke a foreign-body response,

Figure 13.2 Localized, well-defi ned 2.5 × 3 cm sized defect on the lateral knee seen before ( A ) and three weeks after ( B ) 1.5 mL of hyaluronic acid gel fi ller injection with signifi cant improvement in surface contour.

(A) (B)


they also carry a higher risk of granuloma formation (13). Although this adverse effect was not seen in our patient, long-term follow-up is necessary in order to better identify and manage the formation of granulomas.

Larger Cosmetic Units with Well-defi ned Contour Irregularities

The central premise in treating challenging areas such as lateral and medial thighs and lower abdomen is conservative fat removal. If the surgeon undertreats slightly, then it is possible to go back for a touch-up procedure and remove additional fat to enhance the results. If the surgeon overtreats, then there is a need to either replace fat with fat transplan-tation, or elevate the skin and improve contours with alternate methods. Clearly, the method of removing more fat is preferable if a touch-up is to be performed. This point cannot be emphasized enough.

If the area of concern is largely volume defi cient fat transplantation or fi ller injections are good options. Fat transplantation is the gold standard for these conditions. Fat offers several advantages with minimal complications. First of all, it is nonantigenic, does not require pretesting, readily available, and provides secondary gain to the patient by contouring a protuberant or fuller donor site. The technique, however, is tedious and rather technically challenging. Various steps are involved in the process of fat harvesting and injection.

(A) (B)

Figure 13.3 Multiple surface irregularities on a single cosmetic unit (buttock) as seen before ( A ) and after three serial injections of PLLA over fi ve months ( B ).


Donor Site and Fat Preparation

The patient must be assessed for suitable donor sites. Visual inspection is usually suffi cient in choosing areas for fat harvesting. The potential donor site should also be palpated to determine the amount of fat that can be obtained. There is not one particular donor site associated with greater cell viability for transfer. The area(s) is marked out and anesthe-tized. Different types of fat harvesting cannulas are chosen and connected to a hand syringe. Klein and Coleman cannulas are quite popular for this purpose. Cannula size may vary from 14 to 18 gauge or 2 to 3 mm. The authors utilize a 12-gauge Klein cannula to harvest and implant the fat from a 10-mL syringe. It is important to realize that fat will be less likely to maintain permanence in areas of high mobility, such as lateral thighs. Also, some fat is likely to be absorbed during the healing phase, so it is advisable to harvest more fat than is needed and freeze some in the event a fat transplantation touch-up is indicated (3,14). The syringe instrumentation is used most commonly because the negative pressure created is less traumatizing to the fat than using standard liposuction aspirators. Once the fat is harvested then there is one of three ways in which to handle it prior to injection. Some physicians will prepare the fat with serial saline rinses. Others will centrifuge it at 3000 rpm in order to separate the aspirate into three layers. The superfi cial oily and the deepest saline/bloody layers are discarded. This leaves the remaining middle fatty layer for grafting.

Recipient Site Preparation

The recipient site needs to be assessed in terms of the site’s condition. Assessment of the volume that needs to be replaced is essential when performing fat transplantation. Some patients have limited loss of 10 to 20 mL. Others might have a signifi cant volume loss in the order of 100 mL. They cannot be corrected in one session unless they are willing to endure weeks to months of edema and downtime. In general, the degree of edema is proportional to the volume injected. If one injects more than 40 mL the swelling can persist for two weeks or even longer. The volume restoration should preferably be performed in multiple sessions (15,16).

The amount of soft tissue adherence to the deeper fascial layers will determine whether or not a release of this adherence is necessary to create space for the fat grafts. A V-shaped notch at the tip of a cannula can be used for release over a broad arc. For smaller areas that require a release, a Nokor needle works quite well. Small amounts of local anesthesia are used so as to not distort the recipient site. Various blunt tip infi ltration cannulas are used to inject the fat. Cannula diameters (14–18 gauge), lengths and curves will be determined by the bodily site, the volume needed, and surgeon preference. The fat is injected as the cannula is withdrawn. Fat is placed in different planes with multiple thread-ing passes. Crisscrossing the fat placement will lend itself to a smoother meshed effect. The endpoint varies from full correction to overcorrection depending on the amount of scarring and the anatomical area. Fat grafting should be performed using sterile technique in order to avoid infections and other related complications. Postprocedure care although very simple is essential for survival of the transferred fat. Compression and relative immobilization of the treated area to prevent fat displacement and to decrease edema can be helpful tips. Additionally, patients are often placed in fi tted elastic garments that will be worn for two to four weeks. Antibiotics and analgesics can be prescribed as needed or indicated.


There are several reasons touch-up procedures should be performed. With the use of smaller volumes for fat grafting versus overcorrection, one treatment session may not be adequate to achieve optimal aesthetic outcome. Adequately placed fat can provide a smooth contour for up to six months. Fat transplantation can be combined with touch-up liposuction for better cosmesis ( Fig. 13.4 ). Postliposuction defects can also be corrected by a combination of fat transfer and other treatment modalities such as mesotherapy ( Fig. 13.5 ).

An alternative or complimentary solution to fat transplantation is subdermal undermining. This is done with the 12-gauge Klein cannula and can be performed alone or in combination with fat transplantation. The cannula is inserted in a piston-like motion similar to liposuction and is directed to bound-down or fi brous areas that are in need for elevation. Release of the tissue improves the surface contours. The body’s natural response to injury will likely produce a fi brous reaction, which develops into a form of soft tissue augmentation.

(A) (B)

Figure 13.4 Postliposuction defects seen on lower abdomen before ( A ) and after 10 mL of fat trans-fer resulting in signifi cant improvement in surface contour ( B ) four months after the procedure.

(A) (B)

Figure 13.5 Postliposuction defect on posterolateral thigh with signifi cant localized dimpling seen before ( A ) and after two sessions of fat transfer with a total of 30 mL of fat injected into the area followed by mesotherapy treatments ( B ).


CONCLUSIONS

Liposuction is a challenging surgical procedure that can produce superb aesthetic results when performed properly. Careful suctioning, use of smart hand, triangulation, and fl uid management are all important parts of liposuction procedure. Due to ever increasing demand and popularity of liposuction procedures being performed every day, the need to correct some of the undesirable outcomes such as surface irregularities is also increasing. Fillers have revolutionized how volume and body contour is restored or corrected and have certainly found its place in the correction of postliposuction defects. It is a safe, minimally invasive, well-studied aesthetic procedure with rather predictable outcomes. Although not much is published regarding their use in postliposuction surface irregularities, they can be safely used with essentially no downtime.

Another exciting development relates to stem cell research. Subcutaneous fat may be the most ideal source for adult stem cells. It is simple, safe, inexpensive to procure, and is present in abundant quantities (17–19). Laser assisted lipoplasty can also be used to correct postprocedure contour irregularities (20). Although there are several ways to correct postliposuction surface defects, it is beyond the scope of this chapter to discuss all of them. Instead the use of fi llers and other minimally invasive techniques have been presented in detail. The authors hope that the reader will benefi t from their personal experiences, as presented in this chapter and they would like to thank Dr. Karchar for sharing her experience of using fi llers to treat postprocedure complications.

REFERENCES

1. Coldiron B, Coleman III WP, Cox SE, et al. ASDS Guidelines of care for tumescent liposuction. Dermatol Surg 2006; 32: 709–16.

2. Beeson WH, Slama TG, Beeler RT, et al. Group A Streptoccal fasciitis after submental tumescent liposuction. Archives of Facial Plast Surg 2001; 3: 277–9.

3. Chang KN. Long-term results of surgical correction of postliposuction contour irregularities. Plast Recon Surg 2002; 109(6): 2141–5.

4. Lanzer D. Safety of large volume liposuction. Int J Cos Surg Aesth Dermatol 2002; 4: 173–7.

5. Igra H, Lanzer D. Avoiding complications. In: Hanke W, Sattler G, eds Liposuction. Elsevier Saunders, 2005: 131–40.

6. Cox SE. Clinical experience with fi ller complications. Dermatol Surg 2009; 35: 1661–6. 7. Taylor SC, Burgess CM, Callender VD. Safety of nonanimal stabilized hyaluronic acid dermal

fi llers in patients with skin of color: a randomized, evaluator-blinded comparative trial. Dermatol Surg 2009; 35: 1653–60.

8. Distante F, Pagani V, Bonfi gli A. Stabilized hyaluronic acid of non-animal origin for rejuvenat-ing the skin of the upper arm. Dermatol Surg 2009; 35: 389–94.

9. Christensen LH. Host tissue interaction, fate and risks of degradable and nondegradable gel fi llers. Dermatol Surg 2009; 35: 1612–19.

10. Goldman A, Gotkin RH. Laser assisted liposuction. Clin Plast Surg 2009; 36(2): 241–53. 11. Rohrich JR, Nguyen TA, Kenkel JM. Lexicon for soft tissue implants. Derm Surg 2009; 35:

1605–11. 12. Broder KW, Cohen SR. An overview of permanent and semipermanent fi llers. Plast Reconstr

Surg 2006; 118: 7S–14S. 13. Valantin MA, Auborn-Olivier C, Ghosn J, et al. Ploy-L-lactic acid implants to correct facial

lipoatrophy in HIV infected patients: results of an open label study VEGA, AIDS 2003; 17: 2471–7.


14. Pereira LH, Sterodimas A. Correction of iatrogenic form of banana fold and sensuous triangle deformity. Aesth Plast Surg 2008; 32: 923–7.

15. Fulton JE, Suarez M, Silverton K et al. Small volume fat transfer. Dermatol Surg 1998; 24: 857–65.

16. Markey AC, Glogau RG. Autologous fat grafting: comparison of techniques. Dermatol Surg 2000; 26: 1135–44.

17. Fodor P, Fraser JK, Hedrick MH. Banking on stem cells. Plast Surg Prod 2002: 16–17. 18. Fodor PB. Initial clinical experience with fat recycling: stem cells and autologous matrix.

Presented at the American Society for Aesthetic Plastic Surgery 35th Anniversary Meeting, Las Vegas, NV. May 2002.

19. Fodor PB. Refl ections on lipoplasty: history and personal experience. Aesth Surg J 2009; 29(3): 226–31.

20. DiBernardo BE, Reyes J. Evaluation of skin tightening after laser-assisted liposuction. Aesth

Surg J 2009; 29(5): 400–7.

177

Appendix of product names

I HYALURONIC ACID PREPARATIONS

Note : the following list is included as a helpful ready reference. It is not intended to be complete in all aspects; in particular, practitioners should check independently the current status of any product they plan to use and the exact indication that has been FDA-approved. Products should not be assumed to be FDA-approved unless this is specifi cally noted.

Product name Manufacturer Status

AcHyal® CE markedAlayna Hydro Beauty Science CenterAlayna LightAlayna RegularAlayna RepairAlayna Lip VolumeAmalian Balance SBV Technologies CE markedAmalian IAmalian IIAmalian IIIAmalian LipsBeauty Gel (Estherase/Coilingel)

Rofi l

Beauty Sphere (Lastingel)Belotero Basic® Merz CE marked/FDA pendingBelotero Soft®

Belotero Intense®

Captique Inamed/Genzyme FDA approvedCRM® Soft BioPolymer GmbHCRM® DurCRM® GelCRM® DexCRM® DXCristal 1 Parpas GroupCristal 2Cristal Soft

(Continued)

178 APPENDIX

(Continued)


Cristal LipsCytocare 532 Revitacare CE markedCytocare 516Cytocare 502Emervel® Touch Galderma CE markedEmervel® ClassicEmervel® LipsEmervel® DeepEmervel® VolumeEsthélis Anteis S.A. CE marked/FDA pendingFortélis Extra Anteis S.A.Glytone Pierre FabreHyacell® KuhraVitalHyacorp® BioPolymer GmbH CE markedHyacorp® HHyacorp® LHyacorp® S FaceHyacorp® S LipsHyal 2000 InjectionHyal-System® MerzHyalACPHyaluderm® LCA Pharmaceutical CE markedHyaluderm Revitalize LCA Pharmaceutical CE markedHyaluronica® Soft Vital Esthetique CE markedHyaluronica® StyleHyaluronica® UltraHydrafi ll Grade 1® Allergan CE markedHydrafi ll Grade 2® CE markedHydrafi ll Grade 3® CE markedHydrafi ll Softline® CE markedHydrafi ll Softline Max® CE markedHylaform Fine Lines® InamedHylaform® FDA approvedHylaform Plus® FDA approvedISOGel 1 Euromedical SystemsISOGel 2ISOGel 3Juvederm® 18 Allergan CE markedJuvederm® 24Juvederm® 30Juvederm® 24 HVJuvederm® 30 HVJuvederm® Ultra FDA approvedJuvederm® Ultra 2Juvederm® Ultra 3Juvederm® Ultra Plus FDA approvedJuvederm® Ultra SmileJuvederm® VolumaJuvederm® Hydrate

(Continued)

APPENDIX 179

(Continued)


Juvélift Corneal® Sanofi Juveni HA Volumizer Feratti Global BrandsJuveni MesoliftJuveni HA Volumizer + Lidocaine 2% mixing

M-HA 18 Filorga CE markedMacDermol S® ORGéV CE markedMacDermol R®

MacDermol Bio®

Macrolane® Q-Med FDA approvedMatridur® BioPolymer GmbH CE markedMatridex®

NCTF 135 FilorgaNCTF 135HA®

Pluryal®

Prevelle Silk Mentor/Genzyme FDA approvedPrevelle PlusPerlane Lidocaine Q-Med FDA approvedPrincess® Rich Croma-Pharma GmbH CE markedPrincess® FillerPrincess® VolumePuragen Mentor/Genzyme CE marked/FDA pendingPuragen Plus CE marked/FDA pendingRadiesse BioForm Medical FDA approvedRestylane Perlane® Medicis/Q-Med Worldwide except Japan,

United StatesRestylane LidocaineRestylane® Worldwide except JapanRestylane SubQ®

Restylane Touch® Worldwide except JapanRestylane Vital®

Restylane Lipp® CE approvedRevanesse® Prollenium CE marked/Health CanadaRevanesse® PureRevanesse® UltraReDexis® Prollenium Medical

Technologies Inc.CE marked

ReDexis UltraReviderm® Intra Rofi lReviderm® FineReviderm® ForteRofi lan® Forte Philoderm Aesthetics CE approved in Europe,

elsewhereRofi lan® TouchRofi lan® LipsRofi lan® BasicSkinFill Silver Pharma Marketing & Services Not FDA approvedSkinFill GoldSkinFill Diamond

(Continued)

180 APPENDIX

(Continued)


Succeev® One CE marked

Succeev® TwoSucceev® ThreeSurgiderm® 18 Allergan CE markedSurgiderm® 30Surgiderm® 24XPSurgiderm® 30XPSurgilips®

Surgilift® Plus Corneal Group/Allergan Not FDA approved; CE marked

Stylage® S Energy Control CE marked/Not FDA approvedStylage® MStylage® LStylage® XLStylage® HydroTeosyal Global action® Teoxane CE marked/FDA pendingTeosyal Deep LinesTeosyal Ultra DeepTeosyal KissVarioderm Adoderm/Pacifi c Trading Marketed in Europe, elsewhereVarioderm PlusVarioderm SubdermalVarioderm FineLineVisagel® Surgical-Concepts GmbH CE markedViscontour® Q-MedVoluma Corneal® Corneal Group/Allergan Not in United States, Asia

Pacifi c, Canada; CE markedX-HA Filorga CE markedX-HA VolumeZetavisc L® Rofi l Medical/Philoderm

AestheticsCE approved in Canada, elsewhere

ZetadermZFill refresh Zimmer Aesthetic Division CE markedZFill DeepZFill Repair

APPENDIX 181

II COLLAGEN PREPARATIONS


Product Name Manufacturer Status

AlloDerm® LifeCell Corporation FDA approved?Autologen® (processed from own skin)

Collagenesis FDA-classifi ed as tissue product without limitation on use?

CosmoDerm 1, 2® Inamed FDA approvedCosmoPlast® FDA approvedCosmeta Life® Gel-Del® Technologies Not yet FDA approvedCosmeta CorpCymetra® LifeCell Corporation FDA approved?Dermalogen® Human Tissue Matrix

Collagenesis Withdrawn?

Endoplast® Filorga Not FDA approvedEvolence® Johnson & Johnson Withdrawn?Evolence® Breeze CE markedFascian® FDA-classifi ed as tissue

product without limitation on use?

Fibroquel Aspid S.A. Not FDA approvedFibrel®

Isolagen Isolagen Inc. Not yet FDA approved?Koken® Atelocollagen Implant Koken Co. Not yet FDA approvedPermacol Covidien A.G. FDA-classifi ed as tissue

product without limitation on use?

Resoplast® Rofi lZyderm I® Inamed FDA approvedZyderm II® CE markedZyplast®

182 APPENDIX

III RESORBABLE SYNTHETIC FILLERS



Atléan®βTCP (tricalcium phosphate suspended in HA)

Stiefel CE marked

Bioinblue “deep blue” (polyvinyl alcohol)

Polymekon CE marked

Bioinblue “lips” (polyvinyl alcohol) CE markedEvolution® PolyCytech CE markedHyaldex®

Laresse (carboxymethylcellulose + polyethylene)

FzioMed Inc.

Novabel® (alginate) Merz Aesthetics CE markedProfi ll®

Radiesse (calcium hydroxylapatite) Merz Aesthetics FDA approved, CE markedSculptra® (poly-L-lactic acid) Sanofi -Aventis FDA approved, CE marked

APPENDIX 183

IV PERMANENT FILLERS



AdatoSil-OL 5000 (PDMS) Bausch & Lomb FDA approved (retinal uses only)

Amazing Gel (PAAG) FuHua High Molecular Matter Company Ltd, China

Argiform® (PAAG) Bioform Medical, RussiaAquamid (PAAG) Ferrosan SA, Denmark CE markedArteFill (PMMA + collagen) Artes Medical, USA FDA approvedArtecoll® (PMMA + collagen) Rofi l, The Netherlands CE markedArteplast® (PMMA + collagen) Suneva Medical Inc. Discontinued?ArteSense (PMMA + collagen) Canderm Pharma Inc.Bio-Alcamid (polyalkylimide) Polymekon, ItalyBiopolymere (PDMS) Biocell Ultravital, SwitzerlandBioformacryl® (polyacrylamide) Polymekon, ItalyBioplastique (methylpolysiloxane + polyvinylpyrrolidone)

Uroplasty BV, Netherlands CE marked

Dermabiol® (PMMA + collagen) Dermabiol Institute of Kuhra Vital GmbH, Switzerland

Derma Collagen GeriGene Med. Corp., USADermaLive® (HEMA + EMA + HA) Dermatech, France CE markedDermaDeep® (HEMA + EMA + HA) CE markedDermagen (PDMS) Radiant Skin Sciences, USAEvolution (polyvinyl + polyacrylamide)

ProCytech, France CE marked

Formacryl (polyacrylamide) Bioform, RussiaKopolymer 4E (polioxyethlene + elastin copolymer)

Dermabiol Institute of Kuhra Vital GmbH, Switzerland

Juveni PMMA DX (PMMA + HA) Feratti Global BrandsJuveni PMMA Confort (w/Lidocaine)Medical grade polydimethylsiloxane oil

MetaCrill (PMMA + carboxygluco-natehydrolactic of magnesium)

Metrex® (acrylate and methacrylate + polyethylenglycol)


Outline® Fine, Original, Ultra(PAAG) ProCytech, France CE markedProcell (elastine, polyoxyethylene, HA + methacrylate)


PMS 350® Vikomed, Germany CE markedRhegecoll® (methacrylate + copolymer 4-G + collagen + 5% stemcells)


Silicex 350Silikon 1000 (PDMS) Alcon Laboratories Inc.

185

Active fi llers, 23Adatosil 5000, 30Adipose tissue, 167

in lower face and neck, 87midface, 55

Aging, 40extrinsic, 122intrinsic, 122lips, 107lower face, 83neck, 83of upper face, 44

Albeit, 126Allergy testing of skin, 7Alloplastic implants, 59

chin augmentation, 100The American College of Chest

Physicians (ACCP), 143The American Society for Aesthetic Plastic

Surgery (ASAPS), 139Aquamid®, 18Artecoll®, 18ArteFill, 8, 18

in dermal fi llers, 5in permanent fi llers, 4in synthetic active fi llers, 29–30

Arterial occlusion, 154Autologous fat, 2, 17Autologous fat transfer technique, 7

hand rejuvenationgrafting, 125–126harvesting, 124–125

lower facial rejuvenation, 103midfacial rejuvenation, 78in temporal area treatment, 47

Beauty Sphere®, 17Belotero®, 16Biodegradable active fi ller, 28–29

Biodegradable passive fi llerscalcium hydroxylapatite, 27–28collagen, 24–25hyaluronic acid, 25–27

Bovine collagen, 3, 7, 127Brow area

in upper facial volumetric rejuvenation, 48volume loss, 45

Bruising, 114–118Buccinator muscle, 85

Calcium hydroxylapatite (CaH), 4, 8biodegradable passive fi llers, 27–28cosmetic procedures

late postprocedure, 158during treatment, 150

rejuvenation of hands, 128–130in temporal area treatment, 47

Cheek augmentation, midfacial rejuvenation, 67–72, 81

Chin augmentation, lower facial rejuvenation, 100–101

Cleft chin, 84Cohesive polydensifi ed matrix

(CPM®), 15–16Collagens, 3

biodegradable passive fi llers, 24–25

product names, 181rejuvenation of hands, 127

Corrugator, 41Cosmetic procedures

early postproceduresallergic reactions, 154hypersensitivity reactions, 154skin necrosis, 154–155

initial treatmentlocal common reactions, 142–144patient selection and expectations, 140

Index

186 INDEX

Cosmetic procedures (Continued)prevention of infection, 144–146skin testing, 140–142

late postprocedurecalcium hydroxylapatite, 158granulomatous reactions, 155HA fi llers, 155–156poly-L-lactic acid, 157–158polymethylmethacrylate, 159

during treatmentcalcium hydroxylapatite, 150high risk areas, 152–153hyaluronic acid, 148–150injection patterns and techniques, 151–152patient expectations, 152polymethylmethacrylate, 150–151product placement, 147–148skin of color, 154superfi cial fi ller placement, 148

CosmoDerm, 5, 7, 25CosmoPlast, 5, 7, 25CPM®. See Cohesive polydensifi ed matrixCrow’s feet, 52

Depot injection technique, 10in temporal area treatment, 45, 47

Depressor anguli oris (DAO), 85muscles, 100

Depressor labii inferioris, 85Dermadeep®, 19Dermal fi broblasts, 25Dermal fi llers, 78

jawline rejuvenation, 93uses of, 5

Dermalive®, 19Dermal placement fi llers, 24Dethail Lastingel®, 17Digastric muscle, 87Duck lips, 109

Ecchymosis, 77Edema, 46Esthélis®, 16Evolence, 8, 25Extrinsic aging, 122Eyebrow

aesthetics, 40depressor, 41

Eyelids, 36

Face, upper thirdbony anatomy, 40–43fat pads, 42–43innervations, 42

ligaments, 42–43muscle function of, 41–42

Facial aging process, 1Facial expression muscles, 39Facial nerve

branches of, 38midface, 54–55

Fanning injection technique, 10Fat pads

midface, 55–56postseptal, 43preseptal, 42–43

Fat transplantation, 172Feminine eyebrow, 40Fillers

active, 23dermal, 78factors for, 33–34longevity, 152passive, 23permanent, 4–5resorbable, 23selection of, 35semipermanent, 3soft tissue, 123

Fishbone technique, 82Food and Drug Administration (FDA), 3, 7, 12,

23, 59, 127, 141, 171Forehead, 36

depressor muscles, 40rhytids, 40

Fournier’s technique, 124, 136Frontal bone, 40–41Frontalis muscle, 41

Glabelladefi nition, 45injection necrosis, 154–155longer-lasting fi llers, 50in upper facial rejuvenation

treatment, 48–49Glycerol, 17

Hairline, anterior, 40Hands rejuvenation

autologous fat transfergrafting, 125–126harvesting, 124–125

injectable fi llerscalcium hydroxylapatite, 128–130collagen, 127hyaluronic acid, 127–128poly-L-lactic acid, 130

PLLA injectionbolus technique, 131–132

INDEX 187

clinical data, 133–134linear treading technique, 131reconstitution, 131

Homogenous orbital matrix (HOM™), 19Human-derived collagen fi llers, 24–25Hyaluronans, fourth generation, 16Hyaluronic acid (HA) fi llers, 3–4, 8, 112, 113

biodegradable passive fi llers, 25–27chin projection, 101cosmetic procedures

late postprocedure, 155–156during treatment, 148–150

development of, 16glabella treatment, 48–49inferior orbital rim, 62, 66jawline rejuvenation, 93labiomental sulcus, 102lip augmentation products, 15for lips, 112–114lower lip vertical rhytids, 102preparation properties, 15product names, 177–180products on market, 13–14rejuvenation of hands, 127–128

Hyaluronidase, 116Hypertrophic scarring, 151

Ideal fi ller, 2defi nition, 22patient selection, 22–23

Inferior orbital rimHA fi llers, 62, 66midfacial volumetric rejuvenation, 61–67serial puncture technique, 65–66

Injection techniquesdepot, 10fanning, 10linear threading, 10serial puncture, 9

Intrinsic aging, 122Isolagen, 25

Jawline rejuvenation, 91–97Juvederm, 26, 62Juvederm Ultra, 26Juvederm Ultra Plus, 26

Labiomandibular folds (LMF), lower facial rejuvenation, 97–100

Labiomental sulcus, lower facial rejuvenation, 102

Laser assisted lipoplasty, 175Lateral orbital thickening (LOT), 56Levator labii superioris alaeque nasi, 54

Ligamentsin lower face and neck, 87–88midface, 55–56

Linear threading injection technique, 10Lip augmentation

aging, 107complications, 114–118injection materials, 112–114injection methods, 107–112products for, 15

Liposuctioncomplications

intraoperative considerations, 168postoperative considerations, 168–169preoperative patient

evaluation, 168defects with fi llers

donor site, 173fat preparation, 173isolated well-defi ned areas, 170–171multiple surface irregularities, 171–172recipient site preparation, 173–174well-defi ned contour

irregularities, 172defi nition, 167goal of, 167postoperative surface

irregularities, 170traditional, 169

Lipstick lines, 112Liquid silicone, 7LMF. See Labiomandibular foldsLong-term fi llers

calcium hydroxylapatite, 4poly-L-lactic acid, 4

LOT. See Lateral orbital thickeningLower face

adipose tissue, 87defi nition, 83innervation of muscles, 86–87ligaments, 87–88musculature of, 84–86superfi cial musculoaponeurotic

system, 87Lower facial rejuvenation

autologous fat transfer, 103chin, 100–101complications management, 102–103jawline rejuvenation, 91–97labiomandibular folds, 97–100labiomental sulcus, 102lower lip vertical rhytids, 102postinjection care, 102–103

Lower lip vertical rhytids, 102

188 INDEX

Macrolane (Q-MED), 16–17Malar implants, 59Malar mounds, 68–70Male eyebrow, 40Mandibular ligament, jawline rejuvenation,

92–93Mandibular retaining ligament, 87–88Marionette lines, 88. See also

Labiomandibular folds (LMF)Masseter muscle, 85Matridex®, 17Medical grade silicone, 17, 30Mentalis, 85Microgenia, 100Midface

adipose tissue, 55aging, 52, 60facial nerve, 54–55fat pads, 55–56ligaments, 55–56musculature, 53–54skeletal foundation of, 52–53superfi cial musculoaponeurotic system,

55–56vascular anatomy, 37youthful, 59–60

Midfacial volumetric rejuvenationalloplastic implants, 59autologous fat transfer, 78buccal region, 72–74cheek, 67–72goal of, 69infraorbital rim, 61–67management complications, 76–78nasolabial fold, 74–76postinjection care, 76–78

Muscle fi bers, 54

Nasolabial folds (NLFs)Artefi ll rejuvenation of, 29midfacial volumetric rejuvenation, 74–76,

81–82Radiesse, 76

Neckadipose tissue, 87aging, 83innervation of muscles, 86–87ligaments, 87–88musculature of, 84–86superfi cial musculoaponeurotic

system, 87Nerve, orbital region, 38NewFill®, 18

Nonanimal-stabilized hyaluronic acid (NASHA) fi llers, 62

Nonpermanent fi llers, 3Novabel®, 19

Orbicularis oculi, 53–54Orbicularis oculi muscles, 41Orbicularis oris, 85Orbicularis retaining ligament

(ORT), 56Orbitomalar ligament, 56

Passive fi llers, 23Perioral rhytids, 85Perlane, 26Permanent fi llers, 4–5, 23, 183Pinch technique, 48Pitanguy’s line, 42PLA rejuvenation of hands

bolus technique, 131–132clinical data, 133–134linear treading technique, 131reconstitution, 131

Platysma, 85–86PMS 350 (Vikomed), 17Poly-L-lactic acid (PLLA), 4, 17

biodegradable active fi ller, 28–29cosmetic procedures

late postprocedure, 157–158in multiple surface irregularities, 171rejuvenation of hands, 130

Polymethylmethacrylate (PMMA), 18cosmetic procedures

late postprocedure, 159during treatment, 150–151

synthetic active fi ller, 29–30Porcine collagen, 25. See also EvolencePostinjection massage, 45, 47Postseptal fat pad, 43Preseptal fat pad, 42–43Prevelle, 26–27Procerus muscle, 41Pseudoherniated lower lid fat, 62Puppet lines, 110–111Push ahead technique, 116

Radiesse™, 4, 18, 27–28nasolabial fold, 76

Redexis®, 17Resorbable fi llers, 23Resorbable synthetic fi llers, 182Restylane, 26Retro-orbicularis oculi fat

(ROOF) pad, 42

INDEX 189

Reviderm Intra®, 17Risorius muscle, 54

Sausage lips, 109–110, 121Sculptra, 8

biodegradable active fi ller, 28–29in dermal fi llers, 5in long-term fi llers, 4

Semipermanent fi llers, 3. See also Calcium hydroxylapatite (CaH)

Semipermanent soft-tissue volumizer, 123

Serial puncture injection technique, 9inferior orbital rim, 65–66labiomandibular fold, 98–99

Short-term fi llerscollagens, 3hyaluronic acid, 3–4

Short-term volumizers. See Short-term fi llersSilicone, synthetic active fi ller, 30Silikon 1000, 30Skin dimpling, 169Skin necrosis, 154–155Skin roughness, 122Skin tenting technique, 129Skin testing, 140–142Smile lines, 52Soft-tissue fi llers, 123Soft-tissue volume augmentation, 78Structural fat grafting, 125Subdermal placement fi llers, 24Suborbicularis oculi fat (SOOF) pad, 42Superciliary arches, 41Superfi cial fi ller placement, 148Superfi cial injections, 47Superfi cial musculoaponeurotic

system (SMAS)in lower face, 87midface, 55–56in neck, 87

Superfi cial temporal artery, 152–153Superfi cial temporal nerve, 153Supraorbital nerve, 42Supratrochlear artery, 152Supratrochlear nerve, 42Synthetic active fi ller

polymethylmethacrylate, 29–30silicone, 30

Traditional liposuction, 169Trigeminal nerve, 42Tubercles, 107Type I aging hand, 122Type II aging hand, 122Type III aging hand, 123

Upper facial volumetric rejuvenationglabella treatment, 48–49lateral brow area treatment, 48temporal area treatment

autologous fat transfer techniques, 47

depot injection technique, 45, 47preinjection facial markings, 46

U.S. FDA-approved HA fi llers, 3

Vascular occlusion, 154Volumetric augmentation

clinical evaluation, 9injection techniques, 9–10multispecialty based approach, 8

Volumetric facial rejuvenation, 2Volumetric fi lling, 1

Youthful jawline, 92Youthful midface, 59–60

Zygomaticus major muscle, 54Zygomaticus minor muscle, 54Zygomaticus muscles, 54

Illustrated Manual of Injectable Fillers: A Technical Guide to the Volumetric Approach to Whole Body...

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