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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
Deep t
Stained gelatin
ry
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
Superficial temporal arte
emporal fascia
Superficial temporal fascia
Fig. 3.15 Gelatin in the space between supercial and deep temporal fascia
77
cle. However, targeting deep to the temporalis
muscle is inefcient. In the deeper layer, a larger
amount of ller is needed to create volume so the
treatment effect when compared to volume of
ller used is low. Another problem is that the
movement of the injected ller occurs due to the
strong contraction of the temporalis muscle that
occurs when chewing, and the physical properties of the ller change due to continuous stimulation, so the actual effect is not efcient
compared to the hardness with the amount of the
injected ller.
Generally, with sunken temples, the depression is located in the lower temporal region
immediately above the zygomatic arch. Of the
two temporal fat pads located in this region, the
supercial temporal fat pad located between the
supercial and deep layers of the deep temporal
fascia should be targeted. Compared to injecting
deep to the muscle, efcient volumization of the
sunken area above the zygomatic arch can be
attained with a smaller amount of ller.
Contrary to the belief that it’s technically difcult to inject ller into the supercial temporal
fat pad, over time, physicians will be able to easily
identify the loose sensation of the supercial temporal fat pad. The cannula will penetrate the
supercial temporal fascia, followed by the rmer
supercial layer of the deep temporal fascia
before reaching the supercial temporal fat pad.
Further insertion of the cannula will be eventually
impeded by very rm deep layer of the deep temporal fascia. It is recommended that the physicians have accurately identied the layers of the
temple before attempting to inject this region.
As shown in Fig. 3.16, the cadaveric study
showed that gelatin could be injected accurately
into the desired supercial temporal fat pad.
Within the two layers of the deep temporal
fascia, the middle temporal vein traverses in the
upper portion of the supercial temporal fat pad,
and its course is parallel to the zygomatic arch.
The sentinel vein traverses the temporal region
perpendicularly and joins the middle temporal
vein (Fig.3.15-5, right). Good understanding of
the vascular anatomy of the supercial temporal
fat pad reduces concerns regarding vessel injury
(Fig.3.17).
After conrmation of placement of the gelatin
in the supercial temporal fat pad, the deep layer
of the deep temporal fascia was removed to evaluate the deeper structures. Deep to the supercial
temporal fat pad are the deep temporal fat pad
(also known as the superior lobe or temporal
extension of the buccal fat) and the temporalis
muscle (Fig.3.18).
78
Superficial temporal fat padStained gelatin
of deep temporal fascia
Superf
Middle temporal vein Sentinel vein
3 Anatomical Considerations forFiller Procedures
Superficial temporal fasciaSuperficial layer
Fig. 3.16 Gelatin in supercial temporal fat pad
Fig. 3.17 Middle
temporal vein and
sentinel vein
Superficial layer
of deep temporal fascia
Stained gelatin
icial temporal fat pad
Superficial layer
of deep temporal fascia
Deep la
te
Superficial temporal fat pad
Pr
us space
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
79
yer of deep
mporal fascia
Fig. 3.18 Deep temporal fat pad under deep temporal fascia
Fig. 3.19 Subprocerus
space of the nose
Superficial layer
of deep temporal fascia
ocerus muscle
3.5.3 Subprocerus andSubnasalis
Space
Deep temporal fat pad
Deep layer of deep
temporal fascia
Subprocer
the bromuscular layer, allowing ller procedures for both supercial and deep layers.
However, the distal part, including the tip of the
The soft tissue layer of the nose including the
skin consists of ve layers from above: the skin;
subcutaneous fat layer; bromuscular fat layer,
which is connected to SMAS and includes nasalis muscle in the nasal bridge and procerus muscle in the nasal root area; submuscular fat layer;
and nasal bone and cartilage layer.The proximal
part of the nose, including the nasal root, has
dynamic properties, so there is a space for the
upper and lower layers to move smoothly around
nose, centered on the scroll area, the boundary
between the late nasal cartilage and the alar carti-
lage, has a bromuscular layer attached to the
skin tight because the subcutaneous fat layer con-
sists of dense collagen ber and fat cell.
Therefore, it is recommended to apply ller pro-
cedures to the subprocerus space of Fig.3.19 and
the subnasalis space of Fig. 3.20, which are
spaces under the muscles, when safely trying to
augment the volume.
80
Nasalis muscle
Subnasalis space
Orbicularis oculi muscle
Orbicularis ocli muscle
Fig. 3.20 Subnasalis
space of the nose
3 Anatomical Considerations forFiller Procedures
Fig. 3.21 ROOF under
orbicularis oculi muscle
During the procedure, we should hold and lift
the skin thickly so that procerus muscle or nasalis
muscle under the subcutaneous tissue layer is
sufciently included and then inject the ller
deeply under the muscle.
3.5.4 Preseptal Space ofUpper
For sunken eyelid correction, ller is injected to
replace lost fat volume. Passing through the
orbital septum to inject into the septal fat is associated with vascular injury/bleeding and levator
muscle injury. The levator muscle passes posterior to the septal fat and is the muscle responsible
for opening the eyes.
Eyelid
Stained elatin over
orbital septum
ROOF under eyebrow region
Another potential target is the deep fat layer
superior to the septum and is in the same plane as
the retro-orbicularis oculi fat (ROOF, deep fat
layer deep to the eyebrow). However, in case of
sunken eyelid, this deep fat layer has atrophied
signicantly and may be difcult to inject ller.
The preseptal space is an ideal target.
Volumization with minimal risk of injury to the
major neurovascular structures such as the supraorbital artery and nerve and the palpebral vascular arcade is possible in this space. The preseptal
space is the space in between the orbicularis oculi
muscle (SMAS of the midface) and the septal
wall (deep to the orbicularis oculi muscle).
As shown in the left photo in Fig.3.21, when
the cadaveric skin and subcutaneous fat tissue
were removed to examine the orbicularis oculi
under orbicularis oculi muscle
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
81
muscle, the gelatin present within the preseptal
space was not visible. When the muscle was
lifted, as shown in the right photo in Fig.3.21, the
gelatin that had been placed along the ROOF and
orbital rim margin below could be identied.
Further dissection revealed gelatin that was
placed accurately into the preseptal space above
the septum.
3.5.5 Suborbicularis Space ofTear
Trough
The tear trough deformity forms in the medial
orbit, along the medial canthus to the midpupillary line. Deep to the orbicularis oculi muscle in
the medial orbital region, there is no suborbicularis oculi fat tissue. Therefore, the subSMAS
space can be viewed as the space between the
orbicularis oculi muscle (SMAS) and periosteum. The at orbicularis oculi muscle band is
rmly attached to the orbital bone, and sufcient
space may not be made. It can be seen that the
injected gelatin was found not only deep to the
muscle but also within the muscle.
The left picture of Fig.3.22 shows only the
muscles, and the gelatin injected under the muscles is not well visible, but as shown in the right
picture of Fig.3.22, the dyed gelatin is clearly
visible.
3.5.6 Prezygomatic Space
For patients with a at appearance due to sunken
anterior cheeks, ller can be injected to create
round “apple cheeks.” As Caucasians experience
bone volume loss with aging, ller injection in
the periosteal layer immediately above the bone
is generally recommended. In contrast, excluding
patients who congenitally have underdeveloped
cheekbones, most Koreans have at anterior
cheeks due to the loss of soft tissue volume above
the bone that occurs with age, rather than bone
volume loss. Therefore, Koreans require a procedure that augments volume in this soft tissue
area.
Unlike the forehead or the lower face, the midface has well-developed supercial and deep fat
compartments, which are supercial and deep to
the SMAS layer, respectively. For mild to moderate volume loss, ller is injected deep to the
SMAS into the deep fat layer. For more severe
volume loss, ller is injected into the prezygomatic space located between the deep fat layer
and the periosteum. There are no importance
neurovascular structures in the prezygomatic
space making it a safe injection zone.
The prezygomatic space is usually formed
above the body of the zygoma. The oor is the
origin of the zygomaticus muscle, the roof is the
orbicularis oculi muscle line, the upper border is
Orbicularis oculi muscle
Fig. 3.22 Gelatin under orbicularis oculi muscle in tear trough region
Stained gelatin
82
Orbicular
Deep fat layer
Stained gelatin
premaxillary space
3 Anatomical Considerations forFiller Procedures
the orbicularis retaining ligament, and the lower
border is the zygomatico-cutaneous ligament.
The prezygomatic space is connected to the lower
temporal space in the temporal region through
the temporal tunnel.
This space could be divided into the seven lay-
ers (supercial to deep) (Table3.3).
In the cadaver picture, as described above,
dyed gelatin in the prezygomatic space of the
malar region corresponding to the preperiosteal
space present on the bone can be seen that the fat
in this space is whiter and more loose, unlike the
yellow SOOF at the top (Fig.3.23).
3.5.7 Premaxillary andRistow’s
Space
The premaxillary space is a space that forms
between the zygomatico-cutaneous ligament and
the buccal portion of the maxillary ligament or
between the angular artery (extension of the
facial artery and runs along the side of the nose)
and angular vein (extension of the facial vein that
runs along the nasojugal groove). Like the prezy-
gomatic space, Ristow’s space is also a space
between the deep fat layer and the periosteum
(Fig.3.24).
When paranasal depression due to depressed
canine fossa is present, Ristow’s space targeted
for the procedure is within the same midface
plane, and it is created between medial part of the
deep medial cheek fat and the periosteum. The
presence of gelatin in Ristow’s space in the paranasal region of the nasolabial fold was conrmed
(Fig.3.25).
Since the premaxillary space and Ristow’s
space are on the same plane, the ller placed
under the wrinkle line to correct the nasolabial
fold can move across the wrinkle line to the top
of the wrinkle line. Therefore, when performing a
ller procedure on a paransasal region, it is necessary to press the upper part of the nasolabial
crease with a non-treatment nger to prevent the
ller from moving to the upper part of the wrinkle line.
3.5.8 Preparotid andPremasseteric
Space
Table 3.3 Seven layers of prezygomatic space
1. Skin
2. Subcutaneous fat layer
3. Orbicularis oculi muscle
4. SOOF (Sub-Orbicularis Oculi Fat)
5. Deep fascia origin of zygomatic muscles
6. Preperiosteal (prezygomatic) fat layer
7. Periosteum
is oculi muscle
Fig. 3.23 Gelatin in prezygomatic space
The lateral zygomatic bone and zygomatic arch
tend to show greater protrusion among Asians
than Caucasians, and as a result, the lateral cheek
hollow below the zygomatic arch appears more
prominent than it actually is. Prominent lateral
Stained gelatin in
Fig. 3.24 Gelatin in premaxillary space
Deep fat layer
Deep fat layer
ligaments
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
Fig. 3.25 Gelatin in
Ristow’s space on
paranasal region
Stained gelatin in Ristow’s space
Fig. 3.26 Zygomatic
ligaments on lateral
cheek and zygomaticocutaneous ligaments on
anterior malar region
83
cheek hollow is due to the zygomatic ligament,
which is one of the most powerful retaining ligaments in the face. The hollowness is not associated with weight loss but due to the zygomatic
ligament, parotid-masseteric ligament (below
the zygomatic ligament), and ligaments that
cover the platysma. These structures pull on the
skin to make this area look at and hollow
(Fig.3.26).
In such cases, ller injection into the subcutaneous fat will not correct the hollowness.
Injection into an incorrect plane may lead to widening of the lateral area or hardening of the region
Zygomatic ligaments Zygomatico-cutaneous
where the ller has been implanted instead of
correcting the cheek hollowness. Filler must be
injected into the deeper layers of the preparotid
and premasseteric space. The preparotid and premasseteric space is the region superior to the
parotid gland covering the superior half of the
masseter muscle and the lower half of the masseter muscle.
Like the upper and lower temporal spaces
above the deep fascia of the temporalis, the preparotid and premasseteric spaces are also located
above the deep fascia of the masseter muscle
which is mastication muscle.
84
3 Anatomical Considerations forFiller Procedures
The preparotid and premasseteric spaces are
bounded by the following structures (Table3.4).
The Stenson’s duct exiting from the parotid
gland and buccal branch of the facial nerve are
located deep to the parotid-masseteric fascia
(deep fascia). This space between the supercial
and deep fascia is therefore a safe layer to perform various procedures. Anterior to the boundary between the lateral and anterior face is where
the facial nerve beings to descend from the plane
close to the SMAS into the deeper layers.
Therefore, anterior to this boundary, deep injection requires caution (Fig.3.27).
Table 3.4 Boundary of preparotid and premasseteric
space
1. The oor—Parotid gland and the lower half of
masseter muscle
2. The roof—SMAS and platysma muscle
3. The posterior border—The anterior edge of strong
platysma—auricular ligament
4. The anterior border—The masseteric ligaments
near the anterior edge of masseter muscle
Just as in correcting the midcheek groove, in
lateral cheek hollow treatment, space must be
obtained via partial tunneling of the areas
between the zygomatic ligaments attached along
the zygomatic arch and the masseteric-cutaneous
ligament below it to allow the ller to spread
through the ligaments. After creating the space,
injecting the ller into the preparotid and premasseteric space between the SMAS and parotidmasseteric fascia Fig.3.28 can result in a smooth
and sufciently volumized cheek area without
irregular borders of the implanted ller
(Fig.3.29).
3.5.9 Prebuccal Space
In the buccal area, ller can be injected in the
buccal space (contains buccal fat) and the prebuccal space, which is lateral to the buccal space.
The buccal space is one of the deep fascial
spaces, and like the submandibular space (contains submandibular gland), the buccal space is
Fig. 3.27 Anatomical
structures between the
compartments of
preparotid and
premasseteric space
SMAS layer
Parotid gland
Stained gelatin
3.5 Identication ofSubSMAS Spaces oftheFace forFiller Injection: Cadaver Studies Using Stained Gelatin
Fig. 3.28 Gelatin in preparotid and premasseteric space
Fig. 3.29 Before and
after treatment of lateral
cheek hollowness
85
deep to the deep fascia. The buccal space and the
buccal fat within this space allow smooth movement of the overlying nasolabial segment of the
midcheek and serve as a buffer against excessive
motions of jaw movement. Buccal fat covers a
much wider area than previously believed, spanning from the area above the mandible to the temporal region. It is divided into superior, middle,
and inferior lobes, with each lobe separated as
capsules. Generally, it is the inferior lobe that is
referred to as the buccal fat pad (Fig.3.30).
The buccal space where the buccal fat pad is
located is an anatomically safe zone. The parotid
duct runs supercial to the buccal space (between
the middle and inferior lobes), and the marginal
mandibular branch of facial and nerve runs along
the oor of the buccal space, always passing
across the mandible below the inferior lobe.
When young, the buccal space is located superior
to the oral commissure and medial to the anterior
border of the masseter muscle. The space expands
with age and the buccal fat prolapses below the
86
Stained gelatin
Fig. 3.30 Extensions of buccal fat
3 Anatomical Considerations forFiller Procedures
Superior lobe
(Temporal extension of buccal fat)
Middle lobe
Inferior lobe
(Buccal fat pad)
Table 3.5 Boundary of buccal space
1. The oor—The buccinator muscle
2. The roof—Mimetic muscles and the SMAS
3. The superior boundary—The maxillary ligament
4. The inferior boundary—Loose adhesion of the
platysma muscle
5. The anterior boundary—The modiolus
6. The posterior boundary—The facial vein and the
masseteric ligaments
level of the oral commissure to the anterior border of the inferior portion of the masseter muscle,
causing exacerbation of marionette line and jowl.
The buccal space itself is located in the midface,
below the medial and lateral part of the deep
medial cheek fat in the midface, and its boundaries are described in Table3.5.
In cases with buccal cheek hollow, volumizing
the thin capsule of the buccal fat pad may result
in an undesirable effect of mouth protrusion and
not the intended volumization of the lateral area.
Targeting the following spaces will result in
effective volumization with a smaller amount of
ller: capsule that surrounds the buccal fat pad
and forms part of the buccal space and prebuccal
space between the SMAS that covers the aforementioned capsule. The buccal branch of the
facial nerve that runs above the buccal fat pad is
usually encapsulated, and thus, there is no con-
Buccal fat region
Fig. 3.31 Gelatin in prebuccal space
cern for major injuries, unless the area is penetrated by a large bore needle.
The presence of gelatin in the prebuccal space
between the capsule surrounding the buccal fat
pad and the SMAS was conrmed (Fig.3.31).
3.5.10 Subdepressor Anguli Oris
Space
If the supercial brous layers of the orbicularis
oris muscle and depressor anguli oris muscle,
which are the most supercial of the muscles
forming Modiolus, have a wide height difference
from the deep brous layer of orbicularis oris
muscle, a commissural line made vertically