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X
- •Preface
- •Contents
- •About the Authors
- •Further Reading
- •2.1.1 HA Fillers
- •2.1.2.4 PLLA (Poly-L-Lactic Acid) Fillers
- •2.1.2.5 PMMA (Polymethyl Methacrylate) Fillers
- •2.1.2.6 PAAG (Polyacrylamide Gel) Fillers
- •2.2.3 Cross-Linking Process
- •2.2.4 Dialysis or Washing
- •2.2.5 Cutting
- •2.2.6 Filling
- •2.2.7 Sterilization Process
- •2.3.1.2 Fluid Mechanics
- •2.1.2 Non-HA Fillers
- •2.1.2.1 Collagen Fillers
- •2.1.2.2 Ca Fillers
- •2.1.2.3 PCL (Polycaprolactone) Fillers
- •2.3.1.3 Rheology
- •2.3.2.1 G′: Elastic Modulus
- •2.3.2.2 G″: Viscous Modulus
- •2.3.2.3 G*: Complex Modulus
- •2.3.2.4 Phase Angle (Tangent δ)
- •2.3.2.5 Cohesion
- •Perceived Cohesion Test
- •Dispersion Test
- •Drop Weight Test
- •Compression Force Test
- •Flexibility Test
- •Further Reading
- •3.3 Retaining Ligaments
- •3.5.1 Subgalea-Frontalis Space
- •3.5.6 Prezygomatic Space
- •3.5.9 Prebuccal Space
- •3.5.11 Premental Space
- •Further Reading
- •4.1 Design Guidelines
- •4.1.4 Lateral View: Ricketts Line
- •4.2 Anesthesia: Nerve Block
- •4.2.1 Supratrochlear Nerve/Supraorbital Nerve
- •4.3 Cannula or Needle Selection
- •4.3.1 Cannula
- •4.4 Injection Techniques
- •4.4.1.8 Mantoux Injection Technique
- •4.4.1.9 Sandwich Technique
- •4.5 Basic Techniques by Area
- •4.6.1.2 Key Methodological Steps
- •4.6.1.3 Study Result
- •4.7.1 Filler Molding
- •4.7.2 Filler Degradation Test
- •Further Reading
- •5.1 Upper Face
- •5.1.2 Temple
- •5.2 Midface
- •5.2.2.1 Terminology
- •5.2.2.4 Injection Skill
- •Needle Injection
- •Cannula Injection
- •5.2.4.1 Design
- •5.2.4.2 Anesthesia
- •5.2.4.4 Injection Technique
- •5.2.5 Midcheek Groove
- •5.2.5.2 Treatment
- •5.2.7 Nose
- •5.2.7.3 Injection Technique
- •5.2.8 Nasolabial Fold
- •5.3 Lower Face
- •5.3.3.2 Injection Technique
- •5.3.4.1 Design
- •5.3.4.2 Anatomy
- •5.4 Skin Booster Procedures
- •5.4.1 Manual Injection Techniques
- •Further Reading
- •6.1.2 Edema
- •6.1.5.2 Granuloma
- •6.1.6 Infection
- •6.2.1.1 Extravascular Compression
- •6.2.1.2 Intravascular Emboli
- •6.2.2 Skin Necrosis
- •Decompression
- •Revascularization
- •Scar Treatment
- •6.2.3 Vascular Complication: Blindness
- •6.3.1.1 Hyaluronic Acid Turnover
- •6.3.2.4 Clinical Implications
- •Further Reading

TheArt and
Science ofFiller
Injection
Based onClinical Anatomy and
thePinch Technique
GiwoongHong
SeungminOh
YongwooLee
JeongmokCho
SecondEdition
123

The Art and Science of Filler Injection

GiwoongHong • SeungminOh
YongwooLee • JeongmokCho
The Art and Science
of Filler Injection
Based onClinical Anatomy
andthePinch Technique
Second Edition

GiwoongHong
SAMSKIN Plastic Surgery
Seoul, Korea (Republic of)
SeungminOh
ON Clinic
Seoul, Korea (Republic of)
YongwooLee
LIKE Plastic Surgery
Seoul, Korea (Republic of)
JeongmokCho
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, specically the rights of reprinting, reuse
of illustrations, recitation, broadcasting, reproduction on microlms or in any other physical
way, and transmission or information storage and retrieval, electronic adaptation, computer
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The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specic statement, that such names are
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The publisher, the authors and the editors are safe to assume that the advice and information in
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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) GiwoongHong
Seoul, Korea (Republic of) SeungminOh
Seoul, Korea (Republic of) YongwooLee
Seoul, Korea (Republic of) JeongmokCho
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 Classication 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 Efciency of Chemical
Modication . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 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 Identication 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-inammatory 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 Classication 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
GiwoongHong, MD, PhD
• Board-certied 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
• Scientic 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
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