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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_813_Библиотеки_им_академика_М_И_Перельмана.pdf
138 Part V
within these layers are arranged in different directions. Superficial layer arises from the anterior
zygomatic arch and passes posteriorly and inferiorly, inserting onto the masseter tuberosity. The thinner
middle layer arisesfrom the posterior arch and travels downward to the front and inserts into the
masseter tuberosity. The deep layer arises from the posterior arch as well and passes back and
downward to insert on the masseter tuberosity. These three layers fuse together in the lower third of the
muscle. The effective minimal dosage is 20 units and the dosageis increased depending on the strength
of the muscle. Results have shown a decrease in masseter thickness and improved contour of the lower
1,2
face.
Noninvasive and Minimally Invasive Therapy
REFERENCE
1. Xie Y, Zhou J, Li H, et al. Classification of masseter hypertrophy for tailored botulinum toxin type a treatment.
Plast Reconstr Surg 2014;134:209e
2. Rijsdijk BA, van ES RJ, Zonneveld FW, Steenks MH, Koole R. De toepassing van botuline A toxine bij cosmetisch
storende M.-masseterhypertrofie [Botulinum toxin type A treatment of cosmetically disturbing masseteric
hypertrophy]. Ned Tijdschr Geneeskd 1998;142(10):529-532
CLINICAL CONSIDERATIONS
7. When is the typical onset of action of botulinum toxin following injection?
C. 3 to 4 days.
Botulinum toxin usually takes effect within 3 to 4 days and the effect plateaus at 14 days after injection.
Thus, reassessments and touch-ups can be performed at 14 days. Generally, patients are instructed not to
massage the injection sites and to briefly limit activity. Refraining from strenuous activity may be
beneficial by limiting ecchymosis and edema.
1,2
REFERENCES
1. Botox® Cosmetic Package Insert. Allergan, Inc., Irvine, CA. Available at http://www.allergan.com/assets/pdf/
botox_cosmetic_pi.pdf
2. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):
S117
CLINICAL CONSIDERATIONS
8. What is the most commonly reported adverse effect of botulinum
toxin?
E. Transient eyelid ptosis.
Transient lid ptosis is reported in 5% of patients. Injection only above
the orbital rim is recommended to prevent diffusion resulting in
eyelid ptosis. In regard to the glabellar complex, five to seven injection sites are recommended (Fig. 21.2). Starting doses are approximately 20 to 30 U for women and 30 to 40 U for men. Midline
injection should be at the nasal root to treat the procerus muscle.
Injection of the depressor supercilii can raise the static position of
the medial brow, if desired. In regard to the frontalis, injection varies depending on gender. Men generally require larger doses
because they have thicker muscles. The female brow is arched,
whereas the male brow is usually more horizontal. Injection patterns should be tailored with this in mind. Complete paralysis
should be avoided because it can lead to brow ptosis and significantly limits facial expression. This is best
prevented by injecting 2 cm above the eyebrow.Lateralinjections should be high (especially in women) to
prevent drooping of the lateral brow. Starting doses are approximately 10 to 20 U for women and 20 to
30 U for men.
1,2,3
Fig. 21.2 Injection points for bunny
lines. (Source: Injection. In: Janis J, ed.
Essentials of Aesthetic Surgery. 1st
Edition. New York: Thieme; 2018.)
Chapter 21
Botulinum Toxin 139
REFERENCES
1. Rohrich RJ, Janis JE, Fagien S, et al. The cosmetic use of botulinum toxin. Plast Reconstr Surg 2003;112(5 Suppl):
S117
2. Kim EJ, Ramirez AL, Reeck JB, et al. The role of botulinum toxin type B (Myobloc) in the treatment of hyperkinetic
facial lines. Plast Reconstr Surg 2003;112(5 Suppl):S88
3. Carruthers J, Fagien S, Matarasso SL; Botox Consensus Group. Consensus recommendations on the use of botulinum toxin type a in facial aesthetics. Plast Reconstr Surg 2004;114(Suppl 6):S1
22. Soft Tissue Fillers
Nima Khosravani, Anup Patel, Simon Moradian
See Essentials of Aesthetic Surger y, pp. 280–296
ANATOMICAL PRINCIPLES
1. Which of the following is an important consideration with regards to the fat compartments in the malar
region from the lateral zygomaticomaxillary junction to the nasomaxillary region below the tear trough?
A. These fat compartments consist of only a superficial region requiring only super ficial volume rejuvenation.
B. These fat compartments consist of both deep and superficial regions requiring multilevel filling.
C. These fat compartments consist of only a deep region requiring only deep volume rejuvenation.
D. Injection should proceed in the deep and superficial fat compartments as well as the lower eyelid region.
E. Injection to these fat compartments is not indicated for large molecule HA fillers and/or hydroxyapatite.
ANATOMICAL PRINCIPLES
2. Youthful characteristics of lips include:
A. Upper lip/lower lip height ratio of 1/3:2/3.
B. Upper lip/lower lip height ratio of 1:1.
C. Flat philtral columns.
D. Poorly defined cupid's bow.
E. Gentle convex sloping lines from nasal base and labiomental groove.
TREATMENT
3. What is considered to be the most effective treatment for crow's feet?
A. Chemodenervation.
B. Fat grafting.
C. Large molecule HA fillers.
D. Hydroxyapatite.
E. Laser.
ANATOMICAL PRINCIPLES/TREATMENT
4. Which of the following should not be injected in the lower lid–cheek junction and tear trough area?
A. Botox.
B. Calcium hydroxyapatite.
C. Small-molecule HA fillers.
D. Poly-L-lactic acid.
E. Fat.
PREOPERATIVE PLANNING
5. A 27-year-old female body builder is interested in lip augmentation and would like a dramatic increase in her
lip size. What strategy should be used for a patient who demands overcorrection of the lips?
A. Soft tissue fillers should be avoided in patients who desire overcorrection of lips.
B. Over-enhanced lips should be achieved by using 2× standard aliquot.
C. Advise the patient that the filler will last between 12 and 18 months.
D. Use a dermal fat graft in addition to filler.
E. An incremental approach should be used, with reevaluation from multiple views during the injection.
Chapter 22&Soft Tissue Fillers 141
PREOPERATIVE PLANNING
6. Which of the following may interfere with healing at the injection site?
A. Family histor y of smoking, diabetes, or lung cancer.
B. Presence of a collagen–vascular disease process.
C. A skin or soft tissue inf lammatory process that completely subsided 1 week before injection.
D. Use of a topical tretinoin.
E. Active viral upper respiratory infection.
PREOPERATIVE PLANNING
7. Which of the following would contraindicate 54-year-old patients from receiving mid face injections with cal-
cium hydroxyapatite?
A. History of smoking.
B. Takes an 81 mg aspirin but stopped taking it 1 week prior to injection.
C. Presence of facial contour irregularities.
D. Received filler 2 weeks ago.
E. Presence of impetigo in the malar region.
PREOPERATIVE PLANNING
8. Which of the following should be discussed with patients during informed consent?
A. Cosmetic outcomes such as lumpiness, overcorrection/undercorrection, and contour irregularities.
B. Hypersensitivity and hyposensitivity are common adverse events.
C. About 12 to 15% of negative skin test patients can produce an allergic reaction to facial injection.
D. Skin necrosis/ulceration can occur in healthy patients.
E. Antibiotics are prescribed prophylactically to reduce chance of cellulitis at injection site.
PREOPERATIVE PLANNING
9. When counseling a patient on the effects of hyaluronic fillers, which of the following are accurate
considerations?
A. They are animal based and less likely to cause inflammatory reaction.
B. Skin testing is required as these fillers have immunologic activity.
C. They are hydrophilic in nature accounting for initial swollen/overcorrected appearance.
D. Contraindicated in lower lid–cheek junction and tear trough area.
E. Degree of cross linking and weight is consistent between products.
OPERATIVE TECHNIQUE
10. Which injection technique is most appropriate for the white roll of the vermilion?
A. Serial puncture.
B. Linear threading.
C. Fanning technique.
D. Cross radial technique.
E. Intradermal microdroplet techniques.
OPERATIVE TECHNIQUE
11. Which injection technique is most appropriate for the commissures?
A. Serial puncture.
B. Linear threading.
C. Lip tenting technique.
D. Fanning technique.
E. Cross radial technique.
OPERATIVE TECHNIQUE
12. Which injection technique is most appropriate when using calcium hydroxyapatite?
A. Serial puncture.
B. Linear threading.
C. Lip tenting technique.
D. Fanning technique.
E. Cross radial technique.
142 Part V&Noninvasive and Minimally Invasive Therapy
PREOPERATIVE PLANNING
13. Which of the following would be a reason to consider the use of calcium hydroxyapatite fillers?
A. Maximum volume effect seen immediately.
B. FDA approved for HIV lipoatrophy of the face.
C. Excellent filler for malar and nasolabial fold augmentation.
D. Meticulous product placement is not crucial as massaging of product is extremely effective.
E. Results commonly seen up to 3 to 6 months.
OPERATIVE TECHNIQUE
14. Which of the following must be avoided during malar augmentation with calcium hydroxyapatite?
A. Fanning technique from lateral submalar point and/or medially at upper nasolabial fold.
B. Starting deep in subcutaneous or preperiosteal level and layer.
C. Injecting in region of lower eyelid.
D. Extending inferiorly along medial zygoma.
E. Serial puncture technique from lateral submalar point and/or medially at upper nasolabial fold.
OPERATIVE TECHNIQUE
15. Which technique must be used when injecting prejowl sulcus?
A. It is important to remain superficial to avoid neurovascular structures.
B. Start from lateral to medial and use the fanning technique.
C. Start from lateral to medial and use serial puncture technique.
D. Start from medial to lateral and use a combination of serial puncture and linear threading technique.
E. It is important to overcorrect in this region.
PERIOPERATIVE CONSIDERATIONS
16. Which of the following applies to the use of poly-L-lactic Acid (PLLA)?
A. May require 3 to 6 treatments that may last up to 2 years.
B. Glycosaminoglycan biopolymer of repeating disaccharide units of N-acetylglucosamine and glucuronic acid.
C. Reconstitution with 3 to 5 mL of sterile water is not necessary as with other injectables.
D. It is not FDA approved for correction of HIV-associated lipoatrophy of the face.
E. The initial, robust appearance of PLLA is from edema and inf lammation, which will diminish and return at
approximately 8 to 12 weeks as collagen replacement is under way.
PERIOPERATIVE CONSIDERATIONS
17. Which of the following products is FDA approved for HIV lipoatrophy of the face?
A. Calcium hydroxyapatite.
B. Poly-L-lactic acid.
C. Large particle hyaluronic acid fillers.
D. Small particle hyaluronic acid fillers.
E. Autologous fat injections.
PREOPERATIVE PLANNING
18. Which of the following applies to the use of polymethylmethacrylate (PMMA)?
A. Skin testing is required.
B. Indicated for superficial rhytids and other locations prone to skin ulceration/atrophy.
C. It is considered a temporary filler.
D. Postinjection irregular ities are uncommon; however, they should be treated with gentle massage.
E. For depressed scars, large aliquot is injected into scar and defect is corrected during one session.
PREOPERATIVE PLANNING
19. Which scenario would make injectables an inappropriate treatment in a 31-year-old female patient?
A. She is getting married in 2 days and desires dermal fillers to enhance her nasolabial folds.
B. She is getting married in 2 months and desires dermal fillers to enhance her nasolabial folds.
C. She is an actress who takes a daily aspirin and desires augmentation of her malar region.
D. She has lipoatrophy of the face due to extreme body fat loss secondary to body building and dieting.
E. She has lipoatrophy of the face and is HIV/AIDS posit ive.
Chapter 22&Soft Tissue Fillers 143
POSTOPERATIVE CARE
20. Which of the following is the most appropriate postinjection care for fillers?
A. At home manipulation or “shaping” of product when injected properly should be performed every 6 hours
for the first 72 hours post injection.
B. Initial ice application may help to reduce facial edema and can be applied for 20 minutes on and 20 minutes
off during the first 12 to 24 hours.
C. Initial application of warm packs to help with dispersion of the filler.
D. Patients can resume normal activity that increases heart rate immediately.
E. Patients are encouraged to increase salt intake as this may help decrease edema and erythema.
PERIOPERATIVE CONSIDERATIONS
21. Which of the following applies to the appearance of lumpiness following injection of fillers?
A. It is more likely with malleable products.
B. Should be treated within 48 to 72 hours of being seen, with massage to smooth out the lump.
C. This is a normal immediate effect of filler and will resolve on its own within 2 to 3 days.
D. It is often related to improper technique, fast injection, and placement of disproportionate filler material in
one spot.
E. Gentle massage is usually ineffective in smoothing out lumps immediately following injection.
144 Part V&Noninvasive and Minimally Invasive Therapy
Answers
ANATOMICAL PRINCIPLES
1. Which of the following is an important consideration with regards to the fat compartments in the malar
region from the lateral zygomaticomaxillary junction to the nasomaxillary region below the tear trough?
B. These fat compartments consist of both deep and superficial regions requiring multilevel filling.
Fat compartments in the malar region from lateral zygomaticomaxillary junction to the nasomaxillary
region below the tear trough consist of both deep and superficial compartments requiring multilevel filling.
This is an excellent indication for large-molecule HA fillers and/or hydroxyapatite. Injection should be
AVOIDED in the lower eyelid region, and one finger should be held at infraorbital rim to block inadvertent
needle passes. Malar augmentation is important and complementary to lower lid–tear trough treatments
with HA agents. This allows comprehensive and natural blending of the periorbital with malar subcutaneous
compartments.
1,2
Fig. 22.1 depicts the injection of the nasolabial folds and malar mounds with Radiesse.
Fig. 22.1 Injection technique. Injection of the nasolabial folds and malar mounds with Radiesse. (Source: From
Tonnard PL, Verpaele AM, Bensimon RH, eds. Centrofacial Rejuvenation. New York: Thieme Publishers, 2018.)
REFERENCES
1. Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic, and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther 2004;6:223
2. Graivier MH, Bass, Lawrence S, et al. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower
face: consensus recommendations. Plast Reconstr Surg 2007;120(6 Suppl):S55
Chapter 22&Soft Tissue Fillers 145
ANATOMICAL PRINCIPLES
2. Youthful characteristics of lips include:
A. Upper lip/lower lip height ratio of 1/3:2/3.
Youthful characteristics of lips include upper lip/lower lip height ratio of 1/3:2/3. Cupid's bow should be
sharp and well defined. Philtral columns are full. There is a gentle concave sloping from nasal base and
labiomental groove. Oral commissures should be slightly upward in orientation with full medial tubercle
accompanied by sharp white rolls (vermilion–cutaneous junction) (Fig. 22.2).
1,2
1/3
2/3
abc
de
Fig. 22.2 (a–e) Youthful lip characteristics. (Source: Lips. In: Janis J, ed. Essentials of Aesthetic Surgery. 1st Edition. New
York: Thieme; 2018.)
REFERENCES
1. Born TM. Soft tissue fillers in aesthetic facial surgery. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles &
Techniques. New York: Thieme Publishers; 2007
2. Fagien S, Klein AW. A brief overview and history of temporary fillers: evolution, advantages, and limitations.
Plast Reconstr Surg 2007;120(6 Suppl):S8
TREATMENT
3. What is considered to be the most effective treatment for crow's feet?
A. Chemodenervation.
Chemodenervation is considered the best treatment for crow's feet. Fat and fillers are rarely effective in
this area where the skin is thick and well adherent to the underlying orbicularis. Laser treatment is
somewhat unpredictable in the periorbital area given the thinness of the skin and therefore caution
should be taken.
1,2,3
146 Part V&Noninvasive and Minimally Invasive Therapy
REFERENCES
1. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery:
review and technical considerations. Plast Reconstr Surg 2007;120(6 Suppl):S41
2. Born TM. Soft tissue fillers in aesthetic facial surgery. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles &
Techniques. New York: Thieme Publishers; 2007
3. Fagien S, Klein AW. A brief overview and history of temporary fillers: evolution, advantages, and limitations.
Plast Reconstr Surg 2007;120(6 Suppl):S8
ANATOMICAL PRINCIPLES/TREATMENT
4. Which of the following should not be injected in the lower lid–cheek junction and tear trough area?
B. Calcium hydroxyapatite.
Calcium hydroxyapatite should not be injected in the lower lid–cheek junction and tear trough area. Ideal
sites are generally in regions with overlying thicker skin: nasolabial folds, malar augmentation, submalar
augmentation, oral commissures, marionette lines, labiomental crease, jawline, prejowl/premental
depression, and chin augmentation.
1,2
REFERENCES
1. Marmur ES, Phelps R, Goldberg DJ. Clinical, histologic, and electron microscopic findings after injection of a calcium hydroxylapatite filler. J Cosmet Laser Ther 2004;6:223
2. Graivier MH, Bass LS, et al. Calcium hydroxylapatite (Radiesse) for correction of the mid- and lower face: consensus recommendations. Plast Reconstr Surg 2007;120(6 Suppl):S55
PREOPERATIVE PLANNING
5. A 27-year-old female body builder is interested in lip augmentation and would like a dramatic increase in her
lip size. What strategy should be used for a patient who demands overcorrection of the lips?
E. An incremental approach should be used, with reevaluation from multiple views during the injection.
The lips are a vital and central portion of the face that evoke emotion, sensuality, youth, and vitality.An incremental approach should always be used with reevaluation from multiple views during injection. Hyaluronic
acid–based fillers are absorbed by the body over time and generally will last between 6 and 12 months.
Although a dermal fat graft could be considered, it may not be the best option for patients if they have
an extremely low body fat, as in this body builder. Additionally, the concomitant use of a dermal fat graft
in addition to filler should be avoided and would be unpredictable.
1,2,3
REFERENCES
1. Born TM. Soft tissue fillers in aesthetic facial surgery. In: Nahai F, ed. The Art of Aesthetic Surgery: Principles &
Techniques. New York: Thieme Publishers; 2007
2. Sundaram H, Cassuto D. Biophysical characteristics of hylauronic acid soft-tissue fillers and their relevance to
aesthetic applications. Plast Reconstr Surg 2013;132(4 Suppl):S5
3. Fagien S, Klein AW. A brief overview and history of temporary fillers: evolution, advantages, and limitations.
Plast Reconstr Surg 2007;120(6 Suppl):S8
PREOPERATIVE PLANNING
6. Which of the following may interfere with healing at the injection site?
B. Presence of a collagen–vascular disease process.
The presence of collagen–vascular disease process may interfere with healing at the injection site and compromise skin blood supply. Any active skin or soft tissue inflammatory infectious process should completely
subside before injections. Smoking may delay or interfere with healing and longevity of the product , especially if a collagen response is necessary for results. The use of a topical tretinoin will not affect the use of
filler as the filler is used for augmentation in tissues deep to the dermis/epidermis.
1
REFERENCE
1. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr
Surg 2007;120(6 Suppl):S98
Chapter 22&Soft Tissue Fillers 147
PREOPERATIVE PLANNING
7. Which of the following would contraindicate 54-year-old patients from receiving mid face injections with cal-
cium hydroxyapatite?
E. Presence of impetigo in the malar region.
Any active skin or soft tissue inflammatory process should completely subside before injections. Patients
should not take aspirin, NSAIDs, and other blood thinning medications for at least 1 week prior to injection.
Patients should understand that smoking may delay or interfere with healing and longevity of the product.
Maximum volume effect is seen at 4 to 6 weeks post injection; therefore, it would not be advisable to
inject at 2 weeks after a prior injection as the final aesthetic outcome would be overcorrected.
1,2
REFERENCES
1. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr
Surg 2007;120(6 Suppl):S98
2. Fagien S, Klein AW. A brief overview and history of temporary fillers: evolution, advantages, and limitations.
Plast Reconstr Surg 2007;120(6 Suppl):S8
PREOPERATIVE PLANNING
8. Which of the following should be discussed with patients during informed consent?
A. Cosmetic outcomes such as lumpiness, overcorrection/undercorrection, and contour irregularities.
Cosmetic outcomes such as lumpiness, overcorrection and undercorrection, and contour irregularities
should be explained during informed consent. Rarely hypersensitivity/hyposensitivity has been reported
with all types of fillers. In fact, 1 to 5% of negative skin test patients can produce an allergic reaction to facial
injection. Skin necrosis ulcerations are rare but are more likely in poorly selected patients.
1
REFERENCE
1. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr
Surg 2007;120(6 Suppl):S98
PREOPERATIVE PLANNING
9. When counseling a patient on the effects of hyaluronic fillers, which of the following are accurate
considerations?
C. They are hydrophilic in nature accounting for initial swollen/overcorrected appearance.
Hyaluronic acid fillers are not animal based. They do not require skin testing, and do not have
immunologic activity. They are hydrophilic which accounts for the initial swollen/overcorrected appearance.
Calcium hydroxyapatite is contraindicated in lower lid–cheek junction and tear trough area. Hyaluronic
acid is a normal ground substance that is found in many tissues such as bone, skin, cartilage, and synovial
fluid which decreases with age. The degree of cross linking and weight differs between products.
1,2,3
REFERENCES
1. Rohrich RJ, Ghavami A, Crosby MA. The role of hyaluronic acid fillers (Restylane) in facial cosmetic surgery:
review and technical considerations. Plast Reconstr Surg 2007;120(6 Suppl):S41
2. Sundaram H, Cassuto D. Biophysical characteristics of hyaluronic acid soft-tissue fillers and their relevance to
aesthetic applications. Plast Reconstr Surg 2013;132(4 Suppl):S5
3. Flynn TC, Thompson DH, Hyun SH. Molecular weight analysis and enzymatic degradation profiles of the softtissue fillers Belotero Balance, Restylane, and Juvéderm Ultra. Plast Reconstr Surg 2013;132(4 Suppl):S22
OPERATIVE TECHNIQUE
10. Which injection technique is most appropriate for the white roll of the vermilion?
B. Linear threading.
Different locations are best served with different injection techniques. The white roll of the vermilion
necessitates linear threading. Fig. 22.3 shows the following: (a) serial puncture; (b) linear threading;
(c) fanning technique; (d) cross-radial technique or cross-hatching.
1,2