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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_813_Библиотеки_им_академика_М_И_Перельмана.pdf
148 Part V&Noninvasive and Minimally Invasive Therapy
a
b
cd
Fig. 22.3 (a) Serial puncture. (b) Linear threading. (c) Fanning technique. (d) Cross-radial technique or crosshatching.
Edition. New York: Thieme; 2015.)
(Source: Injection Techniques. In: Pu L, ed. Aesthetic Plastic Surgery in Asians: Principles & Techniques. 1st
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 hyaluronic acid soft-tissue fillers and their relevance to
aesthetic applications. Plast Reconstr Surg 2013;132(4 Suppl):S5
OPERATIVE TECHNIQUE
11. Which injection technique is most appropriate for the commissures?
E. Cross radial technique.
Different locations are best served with different injection techniques. The commissures are best treated
with cross-radial injections. Fig. 22.4 shows the following: (a) serial puncture; (b) linear threading;
(c) fanning technique; (d) cross-radial technique or cross-hatching.
1,2
Chapter 22&Soft Tissue Fillers 149
a
b
cd
Fig. 22.4 (a) Serial puncture. (b) Linear threading. (c) Fanning technique. (d) Cross-radial technique or crosshatching. (Source: Injection Techniques. In: Pu L, ed. Aesthetic Plastic Surgery in Asians: Principles & Techniques. 1st
Edition. New York: Thieme; 2015.)
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 hyaluronic acid soft-tissue fillers and their relevance to
aesthetic applications. Plast Reconstr Surg 2013;132(4 Suppl):S5
OPERATIVE TECHNIQUE
12. Which injection technique is most appropriate when using calcium hydroxyapatite?
D. Fanning technique.
Fanning technique is most useful when using calcium hydroxyapatite because the product is placed
during needle withdrawal. Mindfulness of skin entry and exit sites is essential to prevent inadvertent
superficial deposition of product. Fig. 22.5 shows the following: (a) serial puncture; (b) linear threading; (c) fanning technique; (d) cross-radial technique or cross-hatching.
1,2
150 Part V&Noninvasive and Minimally Invasive Therapy
a
b
cd
Fig. 22.5 (a) Serial puncture. (b) Linear threading. (c) Fanning technique. (d) Cross-radial technique or crosshatching. (Source: Injection Techniques. In: Pu L, ed. Aesthetic Plastic Surgery in Asians: Principles & Techniques. 1st
Edition. New York: Thieme; 2015.)
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 hyaluronic acid soft-tissue fillers and their relevance to
aesthetic applications. Plast Reconstr Surg 2013;132(4 Suppl):S5
PREOPERATIVE PLANNING
13. Which of the following would be a reason to consider the use of calcium hydroxyapatite fillers?
C. Excellent filler for malar and nasolabial fold augmentation.
Maximum volume effect is seen at 4 to 6 weeks, with results clinically lasting up to 9 to 12 months. Ideal
sites are generally in regions with overlying thicker skin (nasolabial folds, malar augmentation, submalar
augmentation, oral commissures, etc.). Meticulous placement of product is most critical with the fanning
technique most useful because product is placed during needle withdrawal. Results are commonly seen up
to 6 to 9 months (Fig. 22.6).
1,2
Chapter 22&Soft Tissue Fillers 151
Fig. 22.6 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
OPERATIVE TECHNIQUE
14. Which of the following must be avoided during malar augmentation with calcium hydroxyapatite?
C. Injecting in region of lower eyelid.
Injection in the region of lower eyelid should be avoided. The injector should hold one finger at the
infraorbital rim to block inadvertent needle passes. The use of the fanning technique from lateral
submalar point and/or medially at upper nasolabial fold, starting deep in the subcutaneous or
preperiosteal level and layer, extension inferiorly along the medial zygoma, and HIV-associated malar
lipoatrophy are all appropriate principles and reasons to use calcium hydroxyapatite filler when
injecting along the malar region.
1
REFERENCE
1. 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
OPERATIVE TECHNIQUE
15. Which technique must be used when injecting prejowl sulcus?
B. Start from lateral to medial and use the fanning technique.
It is important to stay deep, and to start from lateral to medial while using the fanning technique when
correcting the prejowl sulcus. In general, fanning technique is the safest method to use for injections of
the lower third of the face as well as staying deep to not injure superficial neurovascular structures.
1
REFERENCE
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
152 Part V&Noninvasive and Minimally Invasive Therapy
PERIOPERATIVE CONSIDERATIONS
16. Which of the following applies to the use of poly-L-lactic Acid (PLLA)?
E. The initial, robust appearance of PLLA is from edema and inflammation, which will diminish and
return at approximately 8 to 12 weeks as collagen replacement is under way.
PLLA may last up to 2 years and may require 3 to 6 treatments. It must be reconstituted prior to injection
with sterile water, which will allow for easier injection as viscosity is lowered. Initial effects results from an
inflammatory process between the soft tissue and PLLA. Macrophages and fibroblasts form a capsule
around the microspheres. PLLA is eventually all degraded and replaced with collagen; therefore, the initial
robust appearance of the product is from edema and inflammation, which will diminish and return at
approximately 8 to 12 weeks as collagen replacement occurs. It is FDA approved for the use of HIV-associated lipoatrophy of the face.
1,2,3
REFERENCES
1. Woerle B, Hanke CW, Sattler G. Poly-L-lactic acid: a temporary filler for soft tissue augmentation. J Drugs
Dermatol 2004;3:385
2. Sterling JB, Hanke CW. Poly-L-lactic acid as a facial filler. Skin Therapy Lett 2005;10:9
3. Borelli C, Kunte C, Weisenseel P, et al. Deep subcutaneous application of poly-L-lactic acid as a filler for facial
lipoatrophy in HIV-infected patients. Skin Pharmacol Physiol 2005;18:273
PERIOPERATIVE CONSIDERATIONS
17. Which of the following products is FDA approved for HIV lipoatrophy of the face?
B. Poly-L-lactic acid.
Poly-L-lactic acid (PLLA) is FDA approved for HIV lipoatrophy of the face. PLLA is a synthetic polymer. It
is biodegradable, biocompatible, immunologically inert, and no skin test required. PLLA is delivered as
microparticles that are broken down by nonenzymatic hydrolysis into lactic acid monomers. Lactic acid
polymers are then broken down to CO
The initial effect results from an inflammatory process between the soft tissue and PLLA whereby macrophages and fibroblasts form a capsule around the microspheres and PLLA is eventually all degraded and
replaced with collagen.
1
or glucose.
2
REFERENCE
1. Borelli C, Kunte C, Weisenseel P, et al. Deep subcutaneous application of poly-L-lactic acid as a filler for facial
lipoatrophy in HIV-infected patients. Skin Pharmacol Physiol 2005;18:273
PREOPERATIVE PLANNING
18. Which of the following applies to the use of polymethylmethacrylate (PMMA)?
A. Skin testing is required.
Skin testing is required when using PMMA. PMMA is considered a permanent filler; however, more filler
may be required at 1.5 years, and initial results may not be seen for 6 to 8 months. PMMA is not safe for
superficial rhytids or locations prone to skin ulceration/atrophy as product becomes more visible with
time as soft tissue and skin atrophy with age. For depressed scars, release scar first (18 gauge or pickle
fork instrument), and fill the scar gradually using serial injection over several weeks to months.
1,2
REFERENCES
1. Lemperle G, Romano JJ, Busso M. Soft tissue augmentation with Artecoll: 10-year history, indications, techniques, and complications. Dermatol Surg 2003;29:573
2. Alcalay J, Alkalay R, Gat A, et al. Late onset granuloma to reaction to Artecoll. Dermatol Surg 2003;29:859
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.
There will be edema, erythema, and bruising for up to 2 weeks, and therefore a patient getting married
in 2 days should be aware of the presence of edema and erythema. The remaining scenarios would all
be considered appropriate patients to augment using filler.
1
Chapter 22&Soft Tissue Fillers 153
REFERENCE
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
POSTOPERATIVE CARE
20. Which of the following is the most appropriate postinjection care for fillers?
B. Initial ice application may help to reduce facial edema and can be applied for 20 minutes on and 20
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. Application of heat packs would not be beneficial after filler injection, nor
would it assist in filler dispersion. Additionally, manipulation of the filler would not be recommended to be
performed by the patient. Filler volume and shape should be optimal before the patient leaves the office
precluding the need for manipulation or shaping of the product at home. Patients are instructed to limit
activity that increases heart rate for 3 to 7 days. Patients can resume previous diet as tolerated but limiting
salt intake may help decrease edema slightly.
1,2
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. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr
Surg 2007;120(6 Suppl):S98
PERIOPERATIVE CONSIDERATIONS
21. Which of the following applies to the appearance of lumpiness following injection of fillers?
D. It is often related to improper technique, fast injection, and placement of disproportionate filler
material in one spot.
#Lumps are often related to improper technique, fast injection, and placement of disproportionate filler
material in one spot. Injection is performed with an even flow to prevent lumpiness and irregularities.
If lumpiness is seen or felt, the area needs to be massaged immediately to smooth the product, not days
later. Lumpiness is more likely with less malleable products or semipermanent compared to fully
permanent products.
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. Alam M, Dover JS. Management of complications and sequelae with temporary injectable fillers. Plast Reconstr
Surg 2007;120(6 Suppl):S98
3. Lombardi T, Samson J, Plantier F, et al. Orofacial granulomas after injection of cosmetic fillers. Histopathological
and clinical study of 11 cases. J Oral Pathol Med 2004;33:115
23. Fat Grafting
Stelios C. Wilson
See Essentials of Aesthetic Surger y, first edition, pp. 297–312
HARVEST SITE
1. Which harvest site has been shown to have the best fat longevity?
A. Abdomen.
B. Flanks.
C. Medial thigh.
D. Lateral thigh.
E. There is no difference based on donor site.
FAT PROCESSING
2. According to the Coleman technique of fat preparation, how long the fat should be centrifuged?
A. 3 minutes at 3000 rpm.
B. 5 minutes at 5000 rpm.
C. 8 minutes at 8000 rpm.
D. 10 minutes at 10,000 rpm.
E. 12 minutes at 15,000 rpm.
FAT PROCESSING
3. Following centrifugation, the lipoaspirate separates into three layers. Which layer contains potentially viable
parcels of fat?
A. Upper level.
B. Middle level.
C. Lower level.
D. Upper and middle layers only.
E. All three layers.
FAT PLACEMENT
4. To strengthen soft tissue projection over bony prominences, fat should be placed in which of the following
levels?
A. Subperiosteal.
B. Supraperiosteal.
C. In the subcutaneous fat.
D. Immediately subdermal.
E. Intradermal.
EDEMA
5. According to the Coleman technique description, when is the patient allowed to start massaging the recipient
site after the procedure?
A. Immediately after surgery.
B. 1 week after surgery.
C. 2 weeks after surgery.
D. 4 weeks after surgery.
E. 6 weeks after surgery.
Chapter 23&Fat Grafting 155
EDEMA
6. According to the Coleman technique, when is the patient allowed to start massaging the donor site after the
procedure?
A. Immediately after surgery.
B. 1 week after surgery.
C. 2 weeks after surgery.
D. 4 weeks after surgery.
E. 6 weeks after surgery.
EDEMA
7. How long should you tell a patient to expect postoperative edema of the face following fat grafting?
A. 1 week after surgery.
B. 1 month after surgery.
C. 2 months after surgery.
D. Greater than 4 months after surgery.
E. Up to 8 to 12 months after surgery.
TREATMENT OF SELECT AREAS
8. When treating the lips, what layer is the preferred layer for fat injection?
A. Into the vermilion and white roll.
B. Immediately deep to the mucosa or vermilion.
C. Immediately deep to the mucosa only.
D. Intramuscular.
E. Deep to the muscle.
COMPLICATIONS
9. Which of the following is the most common potential complication in fat grafting to the face?
A. Hematoma.
B. Infection.
C. Blindness.
D. Skin necrosis.
E. Inaccurate volume.
COMPLICATIONS
10. Although rare, blindness is the most feared potential complication in fat grafting to the face. This complica-
tion generally occurs from induction of fat (or filler) around which artery?
A. Lateral nasal artery.
B. Infraorbital artery.
C. Supratrochlear arter y.
D. Superior labial artery.
E. Transverse facial artery.
COMPLICATIONS
11. Which of the following potential complications is more likely to be associated with direct trauma rather
than intraarterial fat injection?
A. Severe pain.
B. Skin loss.
C. Blindness.
D. Petechia.
E. Numbness.
FATE OF TRANSPLANTED ADIPOCYTES
12. How long can adipose-derived stromal cells remain viable in vitro?
A. 4 hours.
B. 1 day.
C. 3 days.
D. 7 days.
E. 12 days.
156 Part V&Noninvasive and Minimally Invasive Therapy
Answers
HARVEST SITE
1. Which harvest site has been shown to have the best fat longevity?
E. There is no difference based on donor site.
There is no difference of grafted fat longevity based on donor site. Thus, fat should be harvested from sites
that enhance body contour and are easily accessible in the supine position. The most common sites used are
the abdomen and medial thigh. Other sites include the flanks, knees, lateral thighs, and anterior thighs.
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19:421
FAT PROCESSING
2. According to the Coleman technique of fat preparation, how long the fat should be centrifuged?
A. 3 minutes at 3000 rpm.
Using the Coleman technique of fat preparation, a syringe is filled, the cannula is removed, and a dualfunction Luer-Lok plug is used to cap the syringe. This is then tightly capped, the plunger is removed, and
the syringe is placed in a centrifuge for 3 minutes at 3000 rpm. After centr ifugation, the harvested fat
will separate into three layers.
1,2,3,4
1,2,3
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19:421
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
FAT PROCESSING
3. Following centrifugation, the lipoaspirate separates into three layers. Which layer contains potentially viable
parcels of fat?
B. Middle level.
After centrifugation, the harvested fat will separate into three layers (Fig. 23.1). The upper level contains oil
from ruptured fat cells, the middle level contains potentially viable parcels of t issue, and the lowest level
contacts blood, water, and lidocaine.
1,2,3,4
Upper level
• Least dense layer
• Oil from ruptured fat cells
Middle level (30% to 70%)
• Potentially viable parcels of tissue
Lowest level
• Most dense layer
• Blood, water, lidocaine
Fig. 23.1 Three different layers of harvested fat after centrifugation. (Source: Centrifugation. In: Coleman S, Mazzola
R, Pu L, ed. Fat Injection: From Filling to Regeneration. 2nd Edition. New York: Thieme; 2017.)
Chapter 23&Fat Grafting 157
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Facial recontouring with lipostructure. Clin Plast Surg 1997;24:347
3. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg 1995;19:421
4. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
FAT PLACEMENT
4. To strengthen soft tissue projection over bony prominences, fat should be placed in which of the following levels?
B. Supraperiosteal.
The level of fat placement is important and dictated by the goal. To strengthen soft tissue projection over
bony prominences, fat should be injected deep against the bone or cartilage in a supraperiosteal location.
1,2,3
REFERENCES
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
2. Coleman SR. Long-term survival of fat transplants: controlled demonstrations. Aesthetic Plast Surg
1995;19:421
3. Coleman SR. Structural fat grafts: the ideal filler? Clin Plast Surg 2001;28:111
EDEMA
5. According to the Coleman technique description, when is the patient allowed to start massaging the recipient
site after the procedure?
C. 2 weeks after surgery.
Edema is one of the most common problems after fat grafting to the face. In addition to elevation and
cold therapy that should be performed in the first 48 hours, patients are encouraged to massage the
recipient site. That being said, this is not recommended until 2 weeks after the procedure. Further, fat
placed in folds or grooves should not be massaged.
1
REFERENCE
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
EDEMA
6. According to the Coleman technique, when is the patient allowed to start massaging the donor site after the
procedure?
A. Immediately after surgery.
In comparison to the recipient site, which should not be massaged until 2 weeks after surgery, Dr. Coleman
encourages massage of the donor site as soon as tenderness in the area permits it. Thus, the patients can start
immediately after surgery to help with edema.
1
REFERENCE
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004
EDEMA
7. How long should you tell a patient to expect postoperative edema of the face following fat grafting?
D. Greater than 4 months after surgery.
As previously mentioned, edema is one of the most common problems. Patients should be informed preoperatively about what to expect. Patients will have the worst swelling on postoperative day 3 but will continue to have some varying degrees of swelling even at the 4-month period. Thus, patients should be
prepared for prolonged swelling following fat grafting to the face.
1
REFERENCE
1. Coleman SR. Structural Fat Grafting. New York: Thieme Publishers; 2004