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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
108
4 Basic Techniques forFiller Procedures
a
Fig. 4.22 Filler aspiration test with needle. (With kind permission of DAEHAN medbook)
Fig. 4.23 Back ow of
ller
b
4.4 Injection Techniques
There are various methods for injecting llers,
irrespective of the type of cannula or needle used.
Techniques vary based on the amount of ller, the
angle of injection, and the number of insertion
points. These are chosen based on the depth of
the treatment area and the properties of the ller.
There is a signicant difference between injecting large volumes into deep layers and correcting
dynamic wrinkles with small amounts of ller, so
it is essential to be familiar with various
techniques.
• Typically, llers with high viscosity are often
used in volume sandwich techniques and tow-
ering techniques. Both are used to increase
facial volume.
• Mantoux technique, micro-puncture, and
droplet methods are used to correct scars, skin
wrinkles, and dynamic wrinkles.
4.4.1 Types ofInjection Techniques
4.4.1.1 Retrograde andAnterograde
Injection (Fig.4.24)
Anterograde injection involves injecting the ller
as the injection tool (cannula or needle) is
inserted, i.e., injecting while moving forward.
Retrograde injection, on the other hand,
involves injecting as the injection tool is withdrawn, i.e., injecting while pulling back.
Retrograde injection relieves the pressure within
the soft tissue caused by the ller injection. If the
injection tool damages a blood vessel, bleeding
can be easily identied, and the pressure during
4.4 Injection Techniques
a
b
Fig. 4.24 Injection technique depending on direction. (With kind permission of S.THEPHARM)
109
injection decreases even if it enters a vessel,
reducing the risk of vascular complications.
Therefore, most physicians prefer using the retrograde injection method.
4.4.1.2 Fan Technique (Fig.4.25a)
The fan technique is used to uniformly inject
ller across a wide area while minimizing the
number of insertion points. Fundamentally, the
fan technique is very useful not only with cannulas but also with needles.
4.4.1.3 Crosshatching Technique
(Fig.4.25b)
Multiple insertion points are used to inject the
cannula or needle at regular intervals in a parallel
fashion and then re-inserted perpendicularly to
inject several times parallel again. This means the
injection directions cross the previous injection
paths. While it has the advantage of uniform distribution in one area, it has the disadvantage of
potentially causing more bruising due to many
insertion points.
4.4.1.4 Volumizing Injection (Fig.4.26)
Instead of multiple punctures, a large amount of
ller is injected into one layer and molded to create the desired shape. Care must be taken to mold
the ller into the desired shape after injection.
Even if a shape is created, due to the viscoelastic
nature of the ller, it can clump back together.
Therefore, molding the ller by hand does not
always achieve the desired shape.
4.4.1.5 Linear/Continuous Threading
(Fig.4.27a, b)
The linear threading technique involves inserting
a cannula or needle and then injecting ller with
consistent pressure while withdrawing. The continuous threading technique involves not just
injecting linearly but evenly distributing small
dashes of ller.
Both methods reduce the risk of vascular complications by using the retrograde technique
rather than the anterograde technique for ller
injection.
110
4 Basic Techniques forFiller Procedures
a
b
Fig. 4.25 Injection technique for wide area. (With kind permission of S.THEPHARM)
a
b
Fig. 4.26 (a) Bolus Injection technique. (b) Schematic illustration. After perpendicular injection of a large volume of
ller, it is necessary to spread out the ller using pressure. (With kind permission of DAEHAN medbook)
4.4 Injection Techniques
a
b
c
111
d
Fig. 4.27 Injection technique depending on single injection volume. (With kind permission of S.THEPHARM)
112
4 Basic Techniques forFiller Procedures
4.4.1.6 Serial Puncture (Fig.4.27c)
The serial puncture technique involves inserting
the needle, injecting a small amount of ller, and
then moving at regular intervals to inject in the
same manner. This method is primarily used
when injecting into deeper layers.
4.4.1.7 Micro-Puncture/Droplet
(Fig.4.27d)
The micro-puncture/droplet technique is used for
injections into the dermal or subdermal layers.
These methods are utilized to inject very small
amounts of ller into skin wrinkles and ne lines.
4.4.1.8 Mantoux Injection Technique
The Mantoux technique involves injecting into
the dermis or just below it until the skin blanches
as it does in the dermis. This method, using soft
llers, is used to correct scars, skin wrinkles, and
dynamic wrinkles.
a
4.4.1.9 Sandwich Technique
The sandwich technique involves inserting a needle or cannula horizontally into the deep layers
and then injecting a small amount of ller there.
Subsequently, the angle is adjusted to enter the
mid or supercial layers and inject another small
amount of ller. Unlike the towering technique,
which stacks layers by inserting the needle vertically, the sandwich technique uses horizontal
injections to build layers.
4.4.1.10 Towering Technique (Fig.4.28)
The procedure for the towering technique is as
follows: First, position the needle tip just above
the periosteum. Then, slightly withdraw the needle to create negative pressure before injecting
the ller. Continue this process intermittently
across multiple layers. When negative pressure is
created, spaces form between layers, allowing the
ller to stack up like a tower.
b
c
Fig. 4.28 Tower technique. It is a variation of the perpendicular pulling method and involves injecting the ller into
different layers in a noncontinuous manner. (With kind permission of DAEHAN medbook)
d
4.5 Basic Techniques by Area
113
4.4.2 Techniques forInjection
byArea
4.5 Basic Techniques by Area
Selection of cannulas and needles by area:
A. Forehead
(i) Cannula
(a) The use of a cannula is recom-
mended for even distribution of llers without bruising. This method
takes more time and is harder to
learn. Avoiding major vessels can
result in a bruise-free procedure, but
damage to large vessels can cause
more extensive bruising.
(b) Choose 2–3 entry points and broadly
dissect the supraperiosteal area
(Fig.4.29).
(c) Extra care is needed in the upper part
of the eyebrows where the supraorbital artery and supratrochlear artery
are located deeper. Press below the
supraorbital rim with your ngers to
prevent ller from owing into the
orbital area. Ensure the cannula
opening faces away from the eye during injection (Figs.4.30 and 4.31).
(ii) Needle
(a) Needles are used for quicker and
easier application of forehead llers.
Keep in mind that there is a relatively
higher chance of bruising.
(b) Mark injection points at 1cm inter-
vals on the forehead. Inject vertically
at the marked spots and inject the
ller as the needle touches the bone.
Use an aspiration test before injecting to check for intravascular
injection.
B. Temporal Area
(i) Cannula
(a) Cannulas facilitate the injection of
ller into the subcutaneous fat layer.
(b) The supercial temporal vein is
clearly visible, and the pulse of the
supercial temporal artery can be
palpated. These vessels are located
at the bottom of the subcutaneous fat
layer and are surrounded by the
supercial temporal fascia. Pinching
the soft tissue gently elevates the
Fig. 4.29 Forehead dissection for ller injection with
cannula
Fig. 4.30 Press the upper orbital rim over eye with cannula opening faces upper area
Fig. 4.31 Press the upper orbital rim over eye with cannula opening faces upper area
114
4 Basic Techniques forFiller Procedures
deeper parts of the subcutaneous fat
without raising the vessels encased
in the supercial temporal fascia. If
the cannula is carefully advanced
into the swollen-looking subcutaneous fat layer, the procedure can be
performed without damaging the
vessels (Fig.4.32). Additionally, the
space between the supercial temporal fascia and the deep temporal fascia can be utilized. Only slight
resistance is felt when the cannula
passes through the supercial temporal fascia, while the deep temporal
fascia is very tough and requires
signicant force to penetrate. When
the cannula is located within the subcutaneous fat layer, moving it left
and right shows the movement on the
surface. However, if the cannula has
passed beneath the supercial temporal fascia, it does not move easily
left and right, and the movement is
not clearly visible on the surface.
Using this layer allows for treatments without creating a lumpy surface in patients with thin
subcutaneous fat.
(ii) Needle
(a) Needles are more convenient for
deeper injections.
(b) Mark the supercial temporal vein
and artery and identify areas believed
Fig. 4.32 Soft pinch at temple area
to be free of vessels. Perform an
aspiration test to ensure there is no
bleeding and then perform vertical
volumizing injections (Fig.4.33).
C. Nose
(i) Cannula
(a) After administering local anesthe-
sia, puncture the nasal tip and pro-
ceed to the nasal dorsum using a
cannula. Then use the retrograde
injection technique while with-
drawing the cannula backward
(Fig.4.34).
(b) It is also possible to inject the nasal
column using the same entry point.
(ii) Needle
(a) For a simpler and more convenient
procedure, mark the positions where
injection is needed at 3–4mm inter-
vals and then perform vertical injec-
tions using a needle. An aspiration
test must be performed before each
injection.
(b) It is safer to inject deeper than the
muscles (Fig. 4.35), so using the
pinch technique is benecial.
D. Nasolabial Folds
(i) Cannula
(a) Using a cannula is useful when there
are depressions in the nasolabial area
but no skin creases. An entry point is
created on the extension line outside
the commissure of the mouth, and
the cannula is advanced into the area
(Fig. 4.36). This method involves
inserting the cannula in the same
direction as the facial artery, which
poses a risk of vascular accident if
the cannula enters a vessel. Some
practitioners use the cannula perpen-
dicular to the direction of the nasola-
bial folds (Fig.4.37).
(b) When injecting into the nasolabial
folds, it is safe to inject into Ristow’s
space beneath the deep medial cheek
fat pad (Fig.4.38).
(c) In dual-plane injections, it is possi-
ble to separate and inject just below
4.5 Basic Techniques by Area
Fig. 4.33 Temple area vertical injection with needle. (With kind permission of MANIAMIND)
115
Fig. 4.34 Cannula injection. (With kind permission of
DAEHAN medbook)
Fig. 4.35 Needle injection with pinch technique
Fig. 4.36 Entry point on the nasolabial fold extension
line with cannula
116
Fig. 4.37 Entry point perpendicular to nasolabial fold
Fig. 4.38 Ristow’s space
the dermis. However, injections
within the dermal layer are not
possible.
(ii) Needle
(a) In cases of nasolabial fold depres-
sions accompanied by skin creases,
simultaneous use of the needle injec-
4 Basic Techniques forFiller Procedures
Fig. 4.39 Fern type dermal injection
tion method is recommended. This is
because correction of the dermal
skin crease is only possible with a
needle. Dermal injections can be
made linearly along the skin crease
or some perpendicular to the crease
using the fern-type dermal injection
method in an intersecting direction
(Fig.4.39).
(b) An understanding of a safe injection
layer without blood vessels is
needed.
(c) Place a nger on the expected path of
the facial artery to identify the pulse.
If one can feel the pulse of the facial
artery, you need to be very cautious
when treating the area.
E. Indian Wrinkles Under the Eyes
(i) Cannula
(a) Useful when there are wide and deep
depressions in Indian wrinkles under
the eyes.
(b) Proceed with the cannula to the
supraperiosteal plane through the
entry point and proceed with the can-
nula in close contact with the bone
(Fig.4.40).
(c) Take care not to damage the infraor-
bital nerves and vessels as they pass
through the infraorbital foramen
(Figs.4.41 and 4.42).
(d) Since the zygomatico-cutaneous lig-
ament is hard tissue, the physician
4.5 Basic Techniques by Area
Fig. 4.40 Safe injection
depth of infraorbital
Indian fold area with
cannula. (With kind
permission of DAEHAN
medbook)
117
may occasionally feel strong resis-
tance when using the cannula. The
path should be changed from side to
side to nd looser tissue and then
Fig. 4.41 Infraorbital foramen area and ller injection
Fig. 4.42 Infraorbital foramen area and ller injection.
(With kind permission of MANIAMIND)
(e) If the cannula proceeds close to the
nose, the patient may complain of
pain due to the angular artery being
irritated (Fig.4.43).
(ii) Needle
1. Useful when the recessed area of the
Indian wrinkle is not wide.
2. When you want to emphasize the
zygoma area, the skill to inject ller
after bone touch through vertical
injection is useful.
3. In the front of the face, the deep fat
area is relatively safe. After checking
the vascular path and depth, mark the
area of danger. Then after inserting
the needle into the deep layer, be sure
to check whether the blood ows back
through aspiration before injecting
the ller.