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TheArt and Science ofFiller Injection
Based onClinical Anatomy and thePinch Technique
GiwoongHong SeungminOh YongwooLee JeongmokCho
SecondEdition
123
The Art and Science of Filler Injection
GiwoongHong • SeungminOh YongwooLee • JeongmokCho
The Art and Science of Filler Injection
Based onClinical Anatomy andthePinch Technique
Second Edition
GiwoongHong SAMSKIN Plastic Surgery Seoul, Korea (Republic of)
SeungminOh ON Clinic Seoul, Korea (Republic of)
YongwooLee LIKE Plastic Surgery Seoul, Korea (Republic of)
JeongmokCho Etonne Plastic Surgery Seoul, Korea (Republic of)
ISBN 978-981-96-9214-9 ISBN 978-981-96-9215-6 (eBook)
https://doi.org/10.1007/978-981-96-9215-6
© The Editor(s) (if applicable) and The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2020, 2025
This work is subject to copyright. All rights are solely and exclusively licensed by the Publisher, whether the whole or part of the material is concerned, specically the rights of reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specic statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, expressed or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional afliations.
This Springer imprint is published by the registered company Springer Nature Singapore Pte Ltd. The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore 189721, Singapore
If disposing of this product, please recycle the paper.

Preface

Basically, the pursuit of beauty can be said to be a common need that every­one has, regardless of gender and age, but the standard of beauty differs according to race, culture, and region and changes with the time. So, it is important to analyze these changing trends and guide the patients in the aes­thetic medical eld.
These days, we feel that the trend of aesthetic medical markets is changing in the direction of pursuing natural beauty rather than dramatic effects. Accordingly, among the various cosmetic medical methods to approach beauty, minimally invasive aesthetic procedures are the most important these days.
Among them, ller procedures, along with toxin, are the rst to be encoun­tered by doctors who want to enter the aesthetic medical eld and can be said to be an important basic procedure. Because there are less major side effects compared to plastic surgery, doctors who have not majored in aesthetic medi­cine can also easily try them. However, the results of ller treatment vary greatly depending on the level of aesthetic medical doctors performing the procedures, and in particular, the difference in the probability and severity of side effects can be said to be very large.
The authors have been doing numerous anatomical studies using fresh cadavers at home and abroad, and we have come to feel that ller procedures must be performed based on anatomical knowledge of the human body in order to achieve the best results without side effects after ller procedures. Therefore, the authors wrote this book by analyzing and organizing the knowledge that aesthetic medical doctors who perform ller procedures must know, including anatomical knowledge.
Thank you to everyone around us for supporting this book to be published, and we hope this book will help all doctors in aesthetic medical eld who wish to perform safer and more effective ller procedures.
Seoul, Korea (Republic of) GiwoongHong Seoul, Korea (Republic of) SeungminOh Seoul, Korea (Republic of) YongwooLee Seoul, Korea (Republic of) JeongmokCho
v

Contents

1 The Art and Science of Filler Procedures
for a More Attractive Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.1 History of Filler Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . 1
1.2 The Meaning of an Attractive Face . . . . . . . . . . . . . . . . . . . . 2
1.3 Differences Between Asian and Western
Beauty Concepts . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 6
1.4 Medical Reference Values to Create an Attractive Face . . . . 8
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
2 Types of Fillers and Rheological Considerations
for HA (Hyaluronic Acid) Fillers . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1 Classication of Fillers According to Raw Materials . . . . . . 15
2.1.1 HA Fillers. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
2.1.2 Non-HA Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
2.2 Manufacturing Process of HA Fillers . . . . . . . . . . . . . . . . . . 20
2.2.1 Preparation of Raw Materials
of Hyaluronic Acid . . . . . . . . . . . . . . . . . . . . . . . . . . . 20
2.2.2 Dissolution with Strong Base (NaOH) . . . . . . . . . . . 21
2.2.3 Cross-Linking Process . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.4 Dialysis or Washing . . . . . . . . . . . . . . . . . . . . . . . . . . 21
2.2.5 Cutting . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
2.2.6 Filling . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.2.7 Sterilization Process . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3 Rheological Properties of HA Fillers
as Viscoelastic Materials . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23
2.3.1 The Disciplines Underlying the Study
of Viscoelastic Materials . . . . . . . . . . . . . . . . . . . . . . 25
2.3.2 Rheological Indicators Used for Evaluation
of HA Fillers That Are Viscoelastic . . . . . . . . . . . . . . 27
2.4 Relationship Between Cross- Linking of HA Fillers and Degradation in the Human Body After
a Filler Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49
2.4.1 Degradation of HA Filler Materials . . . . . . . . . . . . . . 49
2.4.2 Degree and Efciency of Chemical
Modication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 50
vii
viii
2.5 Changes in the Human Body After an HA
Filler Injection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.5.1 Changes in Histological Human Responses
to HA Fillers . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 53
2.5.2 Relationship Between the Rheological Properties
of HA Fillers and Changes in the Shape
of Filler Treatment Areas . . . . . . . . . . . . . . . . . . . . . . 55
2.6 Considerations for Selecting HA Fillers . . . . . . . . . . . . . . . . 57
2.6.1 Fillers for Intradermal Injection . . . . . . . . . . . . . . . . . 57
2.6.2 Fillers for Subcutaneous Injection . . . . . . . . . . . . . . . 58
2.6.3 Fillers for Supraperiosteal Injection. . . . . . . . . . . . . . 59
2.7 Basic Considerations for the Use of the HA Filler Degrading Enzyme Hyaluronidase
. . . . . . . . . . . . . . . . . . . . 59
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 62
3 Anatomical Considerations for Filler Procedures . . . . . . . . . . . 65
3.1 Vessels and Nerves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65
3.2 Fat Compartments and Muscles . . . . . . . . . . . . . . . . . . . . . . . 69
3.3 Retaining Ligaments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 70
3.4 Layer and Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72
3.5 Identication of SubSMAS Spaces of the Face for Filler Injection: Cadaver Studies
Using Stained Gelatin . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 73
3.5.1 Subgalea-Frontalis Space . . . . . . . . . . . . . . . . . . . . . . 75
3.5.2 Interfascial and Pretemporalis Space . . . . . . . . . . . . . 75
3.5.3 Subprocerus and Subnasalis Space . . . . . . . . . . . . . . 79
3.5.4 Preseptal Space of Upper Eyelid . . . . . . . . . . . . . . . . 80
3.5.5 Suborbicularis Space of Tear Trough . . . . . . . . . . . . . 81
3.5.6 Prezygomatic Space . . . . . . . . . . . . . . . . . . . . . . . . . . 81
3.5.7 Premaxillary and Ristow’s Space . . . . . . . . . . . . . . . . 82
3.5.8 Preparotid and Premasseteric Space . . . . . . . . . . . . . 82
3.5.9 Prebuccal Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84
3.5.10 Subdepressor Anguli Oris Space . . . . . . . . . . . . . . . . 86
3.5.11 Premental Space . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87
3.6 SSRT (Skin and SMAS Layer Remodeling Technique)
for Volumization and Lifting Effect of the Face . . . . . . . . . . 88
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93
Contents
4 Basic Techniques for Filler Procedures . . . . . . . . . . . . . . . . . . . . 97
4.1 Design Guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.1.1 Frontal View: Horizontal/Vertical Proportions
of the Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97
4.1.2 Frontal View: Heart-Shaped Midface . . . . . . . . . . . . 98
4.1.3 45° View: S-Line/Reverse S-Line/Ogee Curve . . . . . 100
4.1.4 Lateral View: Ricketts Line . . . . . . . . . . . . . . . . . . . . 100
4.1.5 Safe Filler Injection Design: Marking
Hazardous Areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101
Contents
ix
4.2 Anesthesia: Nerve Block . . . . . . . . . . . . . . . . . . . . . . . . . . . . 102
4.2.1 Supratrochlear Nerve/Supraorbital Nerve . . . . . . . . . 103
4.2.2 Zygomaticotemporal Nerve . . . . . . . . . . . . . . . . . . . . 103
4.2.3 Zygomaticofacial Nerve . . . . . . . . . . . . . . . . . . . . . . . 104
4.2.4 Lateral Nasal Branch of the Anterior
Ethmoidal Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.2.5 Infraorbital Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104
4.2.6 Mental Nerve . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.2.7 Greater Auricular Nerve . . . . . . . . . . . . . . . . . . . . . . . 105
4.3 Cannula or Needle Selection . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.3.1 Cannula . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 105
4.3.2 Characteristics of Needles . . . . . . . . . . . . . . . . . . . . . 106
4.4 Injection Techniques . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108
4.4.1 Types of Injection Techniques . . . . . . . . . . . . . . . . . . 108
4.4.2 Techniques for Injection by Area . . . . . . . . . . . . . . . . 113
4.5 Basic Techniques by Area . . . . . . . . . . . . . . . . . . . . . . . . . . . 113
4.6 Considerations for Mechanical Properties
of Filler Injection Process . . . . . . . . . . . . . . . . . . . . . . . . . . . 118
4.6.1 Understanding Injection and Ejection
Pressure for Safety Procedures . . . . . . . . . . . . . . . . . 118
4.6.2 Various Physical Conditions That Determine
Injection and Ejection Force and Pressure . . . . . . . . . 119
4.7 Filler Molding and Filler Degradation Test . . . . . . . . . . . . . . 120
4.7.1 Filler Molding . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120
4.7.2 Filler Degradation Test . . . . . . . . . . . . . . . . . . . . . . . . 123
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 128
5 Filler Procedures Based on the Facial Area . . . . . . . . . . . . . . . . 129
5.1 Upper Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 129
5.1.1 Forehead and Glabella . . . . . . . . . . . . . . . . . . . . . . . . 129
5.1.2 Temple . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 132
5.2 Midface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
5.2.1 Supraorbital Hollowness (Sunken Eyelid)
and Flat Eyebrows . . . . . . . . . . . . . . . . . . . . . . . . . . . 137
5.2.2 Pre-tarsal Roll (Lower Eyelid Charming Roll,
Pre-tarsal Fullness). . . . . . . . . . . . . . . . . . . . . . . . . . . 141
5.2.3 Infraorbital Groove and Hollowness . . . . . . . . . . . . . 146
5.2.4 Dark Circle (Tear Trough and Palpebromalar
Groove) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 151
5.2.5 Midcheek Groove . . . . . . . . . . . . . . . . . . . . . . . . . . . . 156
5.2.6 Anteromedial, Buccal, and Lateral
Cheek Hollow . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 157
5.2.7 Nose . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 163
5.2.8 Nasolabial Fold . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 171
5.3 Lower Face . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
5.3.1 Lip and Philtrum . . . . . . . . . . . . . . . . . . . . . . . . . . . . 178
5.3.2 Marionette Line (Static Labiomandibular Fold) . . . . 181
x
5.3.3 Perioral Wrinkles (Smoker’s Line) . . . . . . . . . . . . . . 186
5.3.4 Chin Augmentation and Jaw Line Contouring . . . . . . 189
5.4 Skin Booster Procedures . . . . . . . . . . . . . . . . . . . . . . . . . . . . 194
5.4.1 Manual Injection Techniques . . . . . . . . . . . . . . . . . . . 195
5.4.2 Automated Injection Techniques . . . . . . . . . . . . . . . . 195
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 196
6 Side Effects and Treatment Methods of Filler Procedures . . . . 199
6.1 Type and Treatment of Complication. . . . . . . . . . . . . . . . . . . 199
6.1.1 Bruising and Hematoma . . . . . . . . . . . . . . . . . . . . . . 199
6.1.2 Edema . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 200
6.1.3 Neovascularization and Erythema . . . . . . . . . . . . . . . 201
6.1.4 PIH (Post-inammatory Hyperpigmentation) . . . . . . 201
6.1.5 Nodule and Granuloma . . . . . . . . . . . . . . . . . . . . . . . 201
6.1.6 Infection . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 202
6.2 Treatment and Prevention of Vascular Complication . . . . . . . 203
6.2.1 Mechanism and Classication of Vascular
Complications . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 203
6.2.2 Skin Necrosis . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 204
6.2.3 Vascular Complication: Blindness . . . . . . . . . . . . . . . 207
6.2.4 Vascular Complication: Pulmonary Embolism . . . . . 208
6.2.5 Prevention of Vascular Complication . . . . . . . . . . . . . 209
6.3 Use of Hyaluronidase for Degeneration of Fillers . . . . . . . . . 212
6.3.1 How to Use Hyaluronidase . . . . . . . . . . . . . . . . . . . . 212
6.3.2 SONO-Guided Techniques for Hyaluronidase
Injections . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 220
Further Reading . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 222
Contents

About the Authors

GiwoongHong, MD, PhD
• Board-certied Plastic Surgeon
• President of SAMSKIN Plastic Surgery Clinic
• Clinical Professor, Department of Plastic Surgery, Chung-Ang University Medical Center
• Member of The Korean Society of Plastic and Reconstructive Surgery
• Member of The Korean Society of Aesthetic Plastic Surgery
• Member of Korean Cleft Palate-Craniofacial Association
• Member of Korean Society for Microsurgery
• Member of Korean Association of Stem Cell Therapy
• Scientic Committee of Korean Association of Minimally Invasive Plastic Surgery
• President of ICALA (International Clinical Aesthetic Leaders Academy)
• Dissertation judge of Archives of Plastic Surgery—Editor-in-Chair of Atlas Aesthetics (AA) Journal
• Advisory Board Member of GALDERMA Korea
• Advisory Board Member of S.THEPHARM
• Advisory Board Member of HEALUX
• Advisory Board Member of JETEMA
• Advisory Board Member of Medytox
• Advisory Board Member of HUGEL
• Advisory Board Member of N-FINDERS
• Advisory Board Member of Thai MNB
• Restylane Filler Global Key Doctor
xi