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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_537_Библиотеки_им_академика_М_И_Перельмана
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the pharmacological effect was established and expressed decreased
satisfaction after reoccurrence of fine lines and wrinkles. Decreased
duration of aesthetic augmentation is directly correlated with lower doses
[148]. Additional research is indicated to determine the maximal value at
which dosage increase no longer impacts the duration of wrinkle reduction
[147] (Figs. 19 and 20).
Fig. 19 The posttreatment results are shown in a patient who received botulism toxin injections for
correction of platysmal banding [150]
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Fig. 20 Before (left) and after (right) photos of two patients who received neuromodulator therapy
for masseteric hypertrophy. Improved facial contour is noted in the right images after treatment [149]
6 Injectable Fillers
Dermal fillers are well utilized in the improvement of skin contour and
texture, reducing the appearance of fine lines and wrinkles while replacing
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lost volume. There are various compositions of facial fillers with unique
indications. Hyaluronic acid fillers are most frequently utilized in cosmetic
augmentation, although other formulations include poly-Lactic acid,
polymethyl-methacrylate microspheres (PMMA), polyalkymide, and
calcium hydroxylapatite.
Depending on the composition, the results may disappear after 6months
or last as long as 2–3years. Most people tolerate injectable fillers well with
minimal side effects related to the normal physiological response, although
complications have been well documented in the literature. As a rule of
thumb, filler-related adverse effects tend to resolve once the filler is
dissolved and processed [151, 152].
6.1 Filler Formulations
Various types of fillers are used for nonsurgical facial contouring and/or
volume replacement, often characterized by their elastic modulus (G’).
Fillers with a higher G’ tend to have increased cross-linking, allowing them
to resist deformation (from applied pressure) and dynamic forces (from
facial muscle use) with the additional advantages of increased volumizing
and tissue support [153, 154].
Water absorption and cohesivity are additional factors to be considered
when identifying the best formulation. Fillers with higher molecular crosslinking tend to have increased water absorption and are more cohesive after
placement, allowing for improved tissue hydration and increased projection
with volume replacement respectively. These characteristics can help
injectors choose the best formulation, as the more water-absorbent fillers
are well utilized in the lips but contraindicated in the tear trough [155].
Hyaluronic acid (HA) fillers are reversible and well utilized for many
different injection sites, and as such are generally the most popular choice
for both patients and injectors. Formulations with higher concentrations of
HA allow for increased molecular cross-linking, thus increasing the G’
[156, 157]. Overall, the hydrating properties of HA, limited
immunogenicity, and longer mechanism of action allow for tissue hydration
in aging patients, improved safety, and maintenance of results even in
mobile areas impacted by dynamic movement [158, 159].
Currently, the FDA-approved HA fillers include Juvéderm formulations
(XC, VOLUMA, VOLBELLA, VOLLURE), Belotero Balance, Revanesse
Versa, and the RHA collection (RHA 2, 3, and 4). Restylane was the first to
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gain FDA approval in the United States and has incorporated XpresHAn
technology into the newer Refyne and Defyne lines (2016), which allows
for improved filler stability with dynamic facial expressions. Currently,
FDA approval exists for Restylane Silk, Lyft, Refyne, Defyne, Kysse, and
Contour formulations [160]. Juvederm has been approved since 2006
(Juvederm Ultra and Ultra Plus), well known for its high-water absorption
and HA concentration (24mg/mL). Their new line updated the patented
Hylacross technology with Vycross cross-linking, lending to reduced water
absorption and cohesivity. Juvéderm VOLUMA is the second-line
formulation with the highest G’ and well utilized in deeper injections, while
the low cohesivity of VOLLURE is better suited to superficial filler
placement [161, 162].
Belotero Balance (Merz Aesthetics, Greensboro, N.C.) fillers use crosslinked HA in addition to unlinked molecules, as part of their Cohesive
Polydensified Matrix technology. The result is a smooth filler with
increased cohesivity and low G’, and as such is best used for more
superficial filler placement (intradermal or subdermal) [163–165].
6.2 Indications and Contraindications
The underlying indication for most patients is facial rejuvenation, although
the variable manifestations of aging impact some facial components more
than others. These manifestations are listed in Table 4, along with the
recommended injection site [166–171].
Table 4 Various indications for filler augmentation are listed, along with the respective facial
subunits which would benefit from injection with these indications
Presentation Injection site
Forehead rhytids Glabellar region
Loss of contour and/or sunken appearance of
periorbital area and eyebrows
Periorbital region (upper and lower eyelids,
infraorbital groove, root of nose-glabellar junction)
Tired appearance due to tear trough deformity
and/or herniated orbital fat pads
Tear trough
Marionette lines and/or prejowl sulcus Lower jaw and lateral chin (below the lips)
Patients desiring correction of dorsal contour
and/or increased nasal tip projection
Nasal dorsum (areas of concavity), nasal tip
Younger patients desiring improved lip
volume
Central lips, cupid’s bow augmentation
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Presentation Injection site
Older patients desiring improved lip volume
and projection, vertical lip rhytids
Entire length of lips, increased volume laterally
(displace vertical rhytids)
Bony resorption of the maxilla, concavity,
and deep rhytids (nose to mouth corners)
Nasolabial folds
Less common indications include aesthetic correction of atrophic acne
scars using HA, poly-L lactic acid, or collagen fillers, as well as
improvement of chin contour after implant placement (when used
concurrently with botulism toxin) [172–174].
Contraindications are detailed below, with additional considerations for
formulations, brands, and patient factors [175]:
Active infection at the injection site.
Allergy/hypersensitivity to filler ingredient or lidocaine.
– Collagen and HA fillers with incorporated lidocaine are
contraindicated.
Current/previous history of glabellar necrosis.
Immunosuppressive disease.
– May contraindicate use of poly-L-lactic acid.
6.3 Injection Technique
While there are specific indications for each target location, it is important
to understand the general injection techniques. Isolated wrinkles or folds
(e.g., nasolabial folds) are corrected with linear tunneling injection, in
which the needle is inserted along the length of the wrinkle and filler is
released carefully as the needle is withdrawn. Radial fanning uses multiple
adjacent linear tunnels in a fan-like pattern when volume augmentation
(e.g., malar augmentation) is indicated. Crosshatching is well suited for the
marionette lines and prejowl sulcus and uses a grid of perpendicular and
parallel filler tunnels. Serial puncture injection involves injection at
multiple points in close proximity along the length of the wrinkle and can
also be used to correct individual rhytids or folds [166].
For each specific region, there are indicated injection techniques,
general recommended guidelines for filler formulation, and special
considerations relevant to the local anatomy (Fig. 21).
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Fig. 21 The image demonstrates the various injection depth for filler placement, which will be
discussed in further detail in reference to specific areas of the face [176]
6.3.1 Temple
Hollowing of the temples may occur with aging, and the resulting concavity
can be recontoured with fillers to produce a more youthful appearance.
Injectors can inject superficially and subdermally to avoid the middle
temporal vein and superficial temporal artery, which are, respectively,
located in the temporal fat pad and temporoparietal fascia. While some
providers prefer to avoid the underlying vasculature and remain superficial,
others perform deeper injections keeping 2.5 cm above the zygomatic arch.
Juvéderm VOLLURE is recommended for superficial injections such as
temporal fillers, as well as blended Restylane-L (lidocaine) [177–180].
6.3.2 Glabella
The superficial vasculature in the glabellar region, specifically
supratrochlear and supraorbital vessels, are often a cause of complications
in filler complications. The glabella is known as the riskiest injection site in
regard to visual changes/loss. Filler injection is well suited to correct the
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area just superior to the eyebrows where botulism toxin is contraindicated.
In addition, formation of deep static wrinkles in this region can only be
corrected with filler injection [181, 182].
The supratrochlear artery originates from the inner former of the
eyebrow and branches up superficially to the anterior forehead, and the
supraorbital artery is located a few centimeters laterally. Recently, surgeons
have discussed use of the crest technique, which is performed by pinching
the glabellar rhytids while the patient is frowning. Superficial projection of
the rhytid allows for more precise superficial injection into the subreticular
dermis while the vasculature is temporarily occluded. Superficial filler
formulations are used, such as Belotero, Restalyne Refyne/Silk, and
blended Juvederm (1:1 lidocaine composition), with a combined serial
puncture and crosshatching technique [183, 184].
6.3.3 Cheek
Volume augmentation in the malar region is accomplished with radial
fanning injections, placed deeply anterograde and retrograde just above the
periosteum. Generally, fillers with a higher G’ value are chosen for this area
due to the deep injection plane, including Juvéderm VOLUMA/VOLLURA
or Restylane Defyne/Lyft. The lateral, medial, and anterior cheek should be
targeted, while avoiding the infraorbital bundle (located about 1
fingerbreadth below the orbital rim) [182, 185].
6.3.4 Tear Trough
Thinner skin and racial variation make the tear through a complicated and
unforgiving injection site, as any contour abnormalities will be highly
visible. Injections are placed beneath the lower eyelid above the periosteum
in a deeper plane, using a filler with lower G’ and minimal hydrophilic
properties (Restylane Silk, Belotero, Juvéderm VOLLURE).
Smaller cannulae (30-guage) are used to place the filler, allowing for
slower distribution of small aliquots. The linear threading technique can be
utilized in which the needle is inserted towards the medial aspect, allowing
for careful filler release upon lateral withdrawal. Undercorrection of the
lateral tear trough should be avoided, while ensuring conservative medial or
central augmentation [185–187] (Fig. 22).
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Fig. 22 The before (a) and after (b) images of a patient who received autologous fibroblast fillers
for correction of an exaggerated tear trough [188]
6.3.5 Lips
Lip filler injections are commonly performed, and most injectors will refer
to the ideal facial proportions when considering placement and volume.
Generally, the vertical height from upper vermilion to lower vermilion can
be divided into thirds, with the upper lip comprising the first and the lower
lip contributing to the lower two-thirds. As shown in Fig. 24 (left), the
inferior and superior labial arteries course horizontally through the deeper
mucosa, indicating a maximal injection depth of 3 mm superficial to the
vasculature [185, 189].
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Rohrich et al. detail a five-step approach to lip augmentation, although
the technique varies between injectors. The stepwise augmentation uses
linear filling in the lateral upper and lower lips for primary oral commissure
support and subsequent definition of the lip-skin junction and Cupid’s bow.
Lateral aliquots of filler can then be placed superficially in the lower lip to
add additional volume. Smaller, parenthesis-shaped areas of filler are placed
from the height of the Cupid’s bow to the columella, allowing for philtral
column definition [185].
6.3.6 Nasolabial Fold
Filler augmentation of the nasolabial fold is riskier than other sites, due to
the superficial course of the facial artery in the upper fold and its
anastomoses to inferior alar and lateral nasal arteries. Keeping this
vasculature in mind, deeper injections are placed medial to the fold in the
subdermal plane. The use of high G’ fillers such as Juvéderm VOLLURE,
VOLUMA, or Restylane Lyft is documented in the literature [189–191].
Similar improvements in the aesthetic appearance of nasolabial folds are
observed with mid- to lateral cheek placement when compared with direct
fold placement, highlighting the success of variable approaches [192] (Fig.
23).
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Fig. 23 The yellow dots indicate lip filler placement, the orange dots highlight the placement of
nasolabial filler injections, and the green dots indicate correct filler placement for treatment of
marionette lines [193]
6.3.7 Nose (Liquid Rhinoplasty)
Liquid rhinoplasty is a temporary solution for the correction of a drooping
nasal tip, dorsal hump, or minor nasal asymmetry. In some cases, liquid
rhinoplasty is successful in aesthetic corrections post rhinoplasty and may
be useful for correction when surgery is not an option [194].
There are multiple approaches to nasal contouring with fillers, although
the increased vascularity along the side of the external lateral nasal walls
limit the degree of injection-based augmentation. The angular arteries are
located just lateral to the nose, with a vertical trajectory upward from the
lips along the medial cheeks. Dorsal nasal arteries are vertically oriented
along the sides of the dorsum, anastomosing with the horizontally oriented
lateral nasal artery above the tip of the nose. Nasal vasculature is
encountered between the SMAS (superficial musculoaponeurotic system)
and cutaneous tissues, indicating deeper injection techniques to minimize
damage or compression [190, 195].
Prior to injection, the skin should be carefully inspected for scarring and
discoloration, which is a potential indicator of prior trauma and impaired
vascular integrity. Hydrophilic fillers are generally contraindicated at the
dorsum, and the use of Restylane-L (and other minimally hydrophilic
formulations) prevents excess water absorption in the tissues. The needle is
inserted at the dorsal midline in the deeper preperichondrial or preperiosteal
planes to avoid the superficial vasculature, and filler is added as needed in
regions of concavity to camouflage a nasal hump [185, 196] (Figs. 24 and
25).
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