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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
98
4 Basic Techniques forFiller Procedures
cosmetic analysis (Fig.4.2), or a standard design
pen can be used (Fig.4.3).
(a) Forehead Length
If the forehead is relatively short, volume can
be created with forehead llers or adjusting the
hairline using laser hair removal to make the
forehead appear relatively longer. Patients with
unattractive foreheads usually cover them with
hair. Since the forehead is not always visible in
the total length of the face, which can be consid-
ered from the chin to the eyebrows, the face
appears wider in relation to its length/ratio. For
these patients, it is important to create a balanced
forehead that ts the entire face through llers
and hair removal.
(b) Nose Length
If the nose appears short, it can be enhanced
using llers to increase the height of the nasal
bridge or tip to balance the overall nose.
(c) Chin Length
If the chin is short, vertical proportions of the
face can be adjusted through chin augmentation.
If the face shape is round, the entire face appears
larger from the front, so lengthening the chin
slightly can make the jawline appear more
tapered, thus making the face appear smaller.
However, as mentioned above, in today’s Asian
facial standards, it is recommended not to have
the lower facial proportion excessively longer
than the length of the midface.
4.1.2 Frontal View: Heart-Shaped
Midface
Secondly, check from the front if the midface
appears heart-shaped or inverted triangular (refer
Fig. 4.1 Ideal facial proportion
Fig. 4.2 Check the facial proportion using a tool (BEAUTIPHICATION™ Caliper)
to Sect. 1.3).
4.1 Design Guidelines
Fig. 4.3 Check the facial proportion using a design pen
99
• Frontal View of Cheek Volume
The natural volume of the cheeks from the
front is important. While ller treatments were
previously popular for targeting specic areas
like the nose or nasolabial folds, more recently,
using llers to correct the entire facial contour
has become more favored. The cheeks occupy
half of the midface, and a beautiful cheek line
provides a lovely appearance and a good
impression. A design that neglects the concept of
beauty can backre.
The ideal appearance of the front and side
cheeks differs between Westerners and Asians
(refer to Sect. 1.2), due to signicant differences in
bone structure. In Westerners, the line from the
maxilla to the cheekbone naturally forms a curve.
However, in Asians, it appears at from the maxilla and then abruptly bends at the cheekbone arch.
In terms of highlighting the cheekbones,
Westerners differ from Asians. Western cheekbone highlights are oval and located closer to the
tail of the eye. A reverse S-shape, or ogee curve,
is preferred for the side line. In contrast, Asians
prefer the highlight to be more circular than oval,
and located at or inside the eye tail line.
Westerners often enhance cheekbones with
silicone implants, while in East Asians, reducing
the volume of the cheekbones through surgery is
preferred. When correcting nonsurgically with
llers in Asian faces, it is important to design ll-
ing the at volume of the front cheeks more centrally than the eye tail. In Western faces, designing
the cheek highlight closer to the eye tail to create
an ogee curve is crucial.
When the cheekbones are overly protruding,
correcting the adjacent temple concavity and side
cheek concavity can make the face appear narrower horizontally.
When examining the cheeks more closely,
check for the presence of nasojugal groove, palpebromalar groove, and midcheek groove in the
area adjacent to the front cheeks and under the
orbits, and design corrections accordingly. If
there are nasolabial folds or under-eye hollowness, it can give a tired look, so it is advisable to
consider this in the design.
• Frontal View: Side Cheeks and Temple
Concavity
Check for any concavity in the side cheeks
and forehead. If the cheekbone arch is protruding, it may accompany a concavity in the side
cheeks and temples, which can make the face
appear wider and give a negative impression.
While moderately protruding cheekbones can
be attractive in Westerners, it is not preferred in
Asians. In Asian faces with severe concavity in
the temples or side cheeks, it is important to
design the ller treatment to give a softer
impression.
100
4 Basic Techniques forFiller Procedures
• Presence of Nasolabial Folds
Check if there is signicant hollowness in the
nasolabial area. Improving the hollowness in the
nasolabial area is as important as increasing the
volume in the front cheekbone area to achieve a
heart-shaped face (refer to Sect. 1.1).
Nasolabial folds accompany sagging of the
cheek skin due to aging of the skin tissues.
Therefore, when designing front cheek corrections, consider this. Since the cause of nasolabial
folds is related to changes in the front cheek fat
layer, injecting too much ller volume is not a
harmonious correction.
4.1.3 45° View: S-Line/Reverse
S-Line/Ogee Curve
Third, from the 45° view, check the silhouette of
the side cheek and the silhouette connecting the
forehead-nasal root-tip of the nose-chin (Fig.4.4).
• Ensure that there is no indentation in the fore-
head and that it is smooth. Check if the silhou-
ette of the forehead’s contour is convex in the
45° view and design any necessary
corrections.
• Check if the line connecting the foreheadglabella- nose (nasal root) forms a natural
S-line curve.
• Design a reverse S-line from the lower lip to
the chin. Designing the lips or chin to protrude
too far forward is not natural.
• Design the ogee curve from the cheekbone to
the side cheek.
It is important to note that Westerners value a
slightly concave ogee curve in the side cheek at a
45° view. However, it should be noted that Asians
generally do not prefer an ogee curve as much.
4.1.4 Lateral View: Ricketts Line
Fourth, in the lateral view, design imagining the
Ricketts line (Fig.4.5).
We already know that the ideal line connect-
ing the tip of the nose, lips, and chin differs
between Asians and Westerners (refer to Sect.
4.1.1). Often, Asians have a shorter chin in the
frontal view, resulting in the chin tip being positioned slightly backward in the lateral view. In
Fig. 4.4 S-line and inverted S-line in the oblique view
(45°)
Fig. 4.5 Ricketts line
4.1 Design Guidelines
101
this case, an ideal silhouette aligning with the
Ricketts line does not emerge.
Using the Ricketts line to create the ideal contour, the following corrections are
recommended:
• Elevate the nasal bridge or project the tip of
the nose forward.
• Design the lips to be positioned inside the line,
not protruding beyond it.
• Project the chin tip forward of the line.
Bringing the chin tip forward in the lateral
view and lengthening a short chin downward in
the frontal view are key elements when performing chin tip ller treatments.
4.1.5 Safe Filler Injection Design:
Marking Hazardous Areas
When designing before a ller treatment, a clear
and thorough understanding of hazardous areas is
crucial, regardless of whether using a cannula or
needle. Understanding and marking the pathways
and depths of vessels and nerves before the procedure helps prevent complications. Besides
marking the vessels, it is also helpful to mark the
areas to be lled with ller and safe lines in
advance.
4.1.5.1 Design Examples forSafe
Procedures
Treatment areas and corresponding hazardous
structures include:
• Anterior cheek/Under-eye hollowness
– Mark the infraorbital foramen where the
infraorbital artery and infraorbital nerve
emerge and the zygomaticofacial foramen where the zygomaticofacial artery
and zygomaticofacial nerve emerge.
Mark the pathway of the traveling artery
(Fig.4.6).
• Nasolabial folds
– Mark the facial artery and its branches.
• Forehead
– Mark veins, the middle forehead vein, and
the supercial temporal artery. Also, mark
the safe areas and entry points for ller
injection (Fig.4.7).
• Forehead
– Mark vessels, treatment areas, and safe
entry points for cannula insertion (Fig.4.8).
Fig. 4.6 Mark of
dangerous areaInfraorbital dark circle.
Blue dotted line: Tear
trough ligament. Red
line: Angular artery. Red
stars: Infraorbital
foramen and
zygomaticofacial
foramen. Green dot:
entry point
102
Fig. 4.7 Mark of
dangerous area-Temple.
Blue dotted line: Middle
temporal vein. Blue
lines: Branches of
sentinel vein. Red dotted
line: Supercial
temporal artery. Green
dot: entry point
Fig. 4.8 Mark of
dangerous areaForehead. Blue dotted
line: Vessels. Red area:
Injection area. Green
dot: entry point
4 Basic Techniques forFiller Procedures
4.2 Anesthesia: Nerve Block
Most ller procedures require anesthesia using
anesthetic cream or lidocaine for nerve blocking.
The target nerve for nerve blocking before ller
treatment is the trigeminal nerve (CN5). The trigeminal nerve is divided into three parts: the ophthalmic (V1), maxillary (V2), and mandibular
(V3) branches. The areas covered by each part
and the sensory nerves branching from each area
are shown in the following gures (Figs.4.9 and
4.10). The nerves that can be blocked during ller
treatments depending on the facial area are as follows (Table4.1).
Fig. 4.9 Dermatome distribution of the trigeminal nerve
4.2 Anesthesia: Nerve Block
Fig. 4.10 Branches of
the trigeminal nerve
103
Table 4.1
Facial areas and corresponding nerves
Forehead Supratrochlear nerve/supraorbital
Temple Zygomaticotemporal nerve
Nose External nasal branch of anterior
Nasolabial
fold
Chin Mental nerve
Facial areas and corresponding nerves
nerve
ethmoidal nerve
Infraorbital nerve
4.2.1 Supratrochlear Nerve/ Supraorbital Nerve
The supraorbital nerve emerges from the supraorbital notch, which is located either directly above
or slightly inside the center of the pupil. The
notch can be palpated by pressing with your
hand. Inject about 1 cc of lidocaine near the
notch. The injection should be directed upward
above the eyebrow, and care must be taken not to
inject into the orbital space. In some cases, the
nerve branches emerging above the supraorbital
margin may not be anesthetized. If this occurs,
additional lidocaine can be injected 1cm above
the supraorbital margin (Fig.4.11).
Fig. 4.11 Blocking of supraorbital nerve
4.2.2 Zygomaticotemporal Nerve
(Fig.4.12)
The zygomaticotemporal nerve emerges at the
zygomaticotemporal suture, where the temporal
bone meets the zygomatic bone. This can be felt
as a protruding bone on the outside of the
eyebrow.
The zygomaticotemporal nerve exits from the
side of the bone suture and provides sensation to
the side of the eyebrow and the temple area.
104
Fig. 4.12 Blocking of zygomaticotemporal nerve Fig. 4.13 Blocking of zygomaticofacial nerve
4 Basic Techniques forFiller Procedures
Insert the needle obliquely from top to bottom
(from the skull downwards) and inject lidocaine.
4.2.3 Zygomaticofacial Nerve
(Fig.4.13)
The zygomaticofacial foramen is located near the
zygomatic bone, where the lower orbital margin
intersects with the lateral orbital margin. Insert the
needle toward this intersection point, touch the
bone, and then inject about 0.5cc of lidocaine.
4.2.4 Lateral Nasal Branch
oftheAnterior Ethmoidal
Nerve (Fig.4.14)
The lateral nasal branch emerges at the border
between the nasal bone and the upper lateral cartilage. Palpate this border, insert the needle below
it, and then inject about 0.5cc of lidocaine.
4.2.5 Infraorbital Nerve (Fig.4.15)
Both transcutaneous and intraoral approaches are
possible for accessing the infraorbital nerve. The
infraorbital nerve descends along the central line
of the pupil and emerges from the infraorbital
foramen, located about 1cm below the infraorbital rim. Inject approximately 1cc of lidocaine
at the infraorbital foramen.
Fig. 4.14 Blocking of external nasal branch of anterior
ethmoidal nerve
Fig. 4.15 Blocking of infraorbital nerve
When using the intraoral approach, the needle
is slowly inserted upward from above the second
maxillary premolar.
4.3 Cannula or Needle Selection
Fig. 4.16 Blocking of mental nerve Fig. 4.17 Blocking of greater auricular nerve
105
4.2.6 Mental Nerve (Fig.4.16)
The mental nerve block is similar to the infraorbital nerve block and can be administered via a
transcutaneous or intraoral approach. The mental
nerve emerges from the mental foramen, located
slightly inside from the central line of the pupil
and 2cm below the corner of the mouth. When
using the transcutaneous approach, insert the
needle toward the mental foramen and inject
lidocaine. In the intraoral approach, insert the
needle downward from the second mandibular
premolar.
4.2.7 Greater Auricular Nerve
(Fig.4.17)
The greater auricular nerve is not a branch of the
trigeminal nerve but branches from C2 and C3,
covering the anterior surface of the sternocleidomastoid muscle (SCM). With the patient lying
down and the head turned to expose the SCM,
mark the anterior and posterior edges with a pen.
The target point is about 6.5cm away from the
external auditory canal along the midpoint of the
two edges. Insert the needle and inject lidocaine
not into the SCM itself but above the fascia, causing the skin to puff up. The 6.5cm measurement
can easily be determined using the practitioner’s
ngers; typically, the distance from the metacarpophalangeal joint to the end of the thumb is
about 6.5cm.
4.3 Cannula or Needle Selection
4.3.1 Cannula
A. The tip of the cannula is blunt, which causes
less tissue damage. Smooth manipulation
during the procedure can reduce the risk of
damaging nerves and vessels (Fig.4.18).
B. Long cannulas can bend during progression.
C. When encountering strong ligaments during
the procedure, resistance can be felt. This
allows for the identication of anatomical
structures without visual conrmation through
the resistance of the cannula. It is necessary to
be aware of major structures present in the
path of the cannula before the procedure.
D. If the cannula stimulates a vessel or nerve
during the procedure, the patient may experi-
ence pain. Pain can occur even without direct
damage if vessels or nerves are stimulated.
E. Aspiration tests do not always conrm intra-
vascular injection. Even if the cannula has
entered a vessel, blood may not be aspirated
during the test (Fig.4.19).
F. The outlet from which the ller is expelled is
not at the end of the cannula but on the side.
Therefore, the ller is discharged from the
side, not the end of the cannula. To precisely
inject ller into the designed area, it is neces-
sary to align the position of the outlet with the
injection area and accurately place the end of
the cannula.
106
Fig. 4.18 Cannulas
Fig. 4.19 Filler aspiration test with cannula
G. If the injection force is too strong, the con-
nection between the cannula and the syringe
can burst. When connecting the cannula to
the ller syringe, it should be securely fastened. If the syringe bursts repeatedly during
the procedure after connecting a specic
product to a specic cannula, choose a cannula with a larger inner diameter to reduce
the pressure inside the syringe and cannula.
H. Using a cannula with a larger diameter
decreases the likelihood of accidental intravascular injection.
I. While the tip of the cannula is blunt, the
actual outlet where the ller product is
expelled can often be sharp due to manufacturing precision (Fig.4.20).
During the process of moving the cannula
back and forth, the sharp edges of the outlet can
cause damage to vessels or nerves.
4 Basic Techniques forFiller Procedures
4.3.2 Characteristics ofNeedles
A. The tip is sharp, allowing easy progression
through tissue while potentially causing cuts
or tears.
B. Compared to a cannula, there is a relatively
higher risk of damaging blood vessels or
nerves.
C. The tip of the needle is made in a beveled
shape. The actual point of ller injection is
not at the beveled tip but closer to the side of
the syringe that is aligned with the bevel
(Fig.4.21).
D. Before proceeding with the treatment, it is
crucial to verify the safe injection depth for
each treatment area.
E. While it is very difcult to inject into the der-
mal layer with a cannula, using a needle
makes it easier to inject directly into the
dermis.
F. Before injecting the ller, aspiration can be
performed to check if the needle has penetrated a blood vessel (Fig.4.22). Not seeing
blood in the syringe during an aspiration test
does not guarantee complete safety.
G. If too much force is applied during ller
injection, the ller can reux along the path
created by the needle’s outer wall
(Fig.4.23).
4.3 Cannula or Needle Selection
107
Fig. 4.20 Sharp opening hole of cannula. (With kind permission of Wook Oh M.D.Ph.D.Samsung Feel Clinic)
These characteristics are summarized in
Table4.2.
Table 4.2 Cannula verses needle summary
Category Cannula Needle
Fig. 4.21 The point where the ller actually comes out
Soft tissue
damage
Injection
technique
Injection
location
Injection
depth
Aspiration
test
Relatively less Relatively
Fan technique,
retrograde injection
Away from the
treatment area
All layers except the
dermal layer
Less useful Useful
more
Vertical
injection
Near the
treatment area
All layers