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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
138
5 Filler Procedures Based ontheFacial Area
The ideal injection plane is the ROOF and the
deep fat connected to the ROOF.The ROOF is
located along the orbital rim, deep to the orbicularis oculi muscle. However, in case of sunken
eye, the deep fat layer of the superior eyelid is
extremely thin. The ller should thus be injected
in the preseptal space supercial to the orbital
space (Fig.5.12).
The procedure should be performed with
extreme caution. The branches of the ophthalmic
arteries such as the supratrochlear and supraorbital arteries that are supply the forehead and glabellar region are located in the medial aspect of
the orbital rim. These terminal branches of the
ophthalmic artery anastomose with the orbital
arteries including the central retinal artery.
Therefore, a cannula should be used to prevent
intra-arterial injections and other situations that
may cause vascular compromise (Fig.5.13).
The entry point for cannula insertion is the
intersection of the vertical line from the lateral
canthus and the orbital rim. After the cannula penetrates the muscle layer, a loose space can be felt.
To be more exact, if the cannula is withdrawn
slightly after touching the bone of the orbital rim,
the cannula tip will be positioned in the space just
deep to the orbicularis oculi muscle (Fig.5.14).
As explained earlier, the layer deeper than the
orbicularis oculi muscle is almost devoid of a fat,
and thus, the injection should be made into the
preseptal space supercial to the orbital septum.
A soft HA ller should be used to ensure that the
injection is made as evenly as possible (Fig.5.15).
While injection, it is important to conrm that
lumps or protruding bulges do not form when the
eyes are closed. The unevenness may occur from
injecting the llers too supercially. On the other
hand, excessive correction may lead to eyes that
appear swollen or inferior migration of the ller
that had been placed in the eyelids. Therefore, it
is always safer to correct conservatively, injecting more while carefully monitoring treatment
outcomes.
If there are partially depressed areas or the
boundary of the injected ller is visible after the
procedure, then a small amount of ller can be
injected into the subdermal layer to create a
smooth surface. Because the skin of the eyelid is
Fig. 5.12 Layers of the supraorbital region
Injection entry point
-V
ca
or
-
und
s
-A
or
-V
- Voluntarily opened eyes
- Retrograde linear tiny injection technique
- Very slow release
e
5.2 Midface
Fig. 5.13 Vessels of the orbital region
ertical line drawn above or outside the lateral
nthus around the lower margin of the superior
bital rim
Mainly medial & mi ddle parts of the periorbital rim
er the brow to avoid the supraorbital &
upratrochlear arteries
bove the supratarsallid crease & belo w the
bicularis retaining ligame nt
139
Injection technique
ertical sitting
Fig. 5.14 Injection entry point and technique for the cannula
Fig. 5.15 Preseptal
space
Green gelatin in the preseptal spac
Intraorbital septal fat
140
Injection planes
- Supraper
ar
septum f
- Subder
to
unnecessar
5 Filler Procedures Based ontheFacial Area
ound the orbital rim over the orbital
even the surface & to remove the
Fig. 5.16 Injection planes
iosteal & submuscular injection
or the filling of the hollowness
mal injection of very soft HA filler
y multiple eyelid lines
very thin and delicate, when injecting intradermally, it is important to exercise caution to prevent beading (Fig.5.16).
It is difcult to achieve favorable results in
patients with ptosis or proptosis. In fact, as the
procedure may exacerbate the symptoms, correction of sunken eyelids in patients with ptosis or
proptosis is contraindicated. In case of presence
of scar tissue from previous surgery or trauma,
even placement and spreading of ller may be
more difcult.
Technique for Flat Eyebrows
Reduced soft tissue volume in the eyebrow region
with subsequent eyebrow ptosis due to aging is
not as severe in Asians, and, thus, not a major
concern among Asians. In contrast, Westerners
believe that the location and volume of the eyes
and eyebrows affect the overall impression they
give.
Typically, the location of brow is considered
to be ideal if the medial end of the eyebrow is
located on the vertical line extending from the
lateral margin of the nasal alae. The lateral end of
the brow should be located on line extending
from the lateral margin of the nasal ala to the lateral canthus. The medial and lateral ends should
be located on the same level, while the peak of
the eyebrow is located in the lateral third of the
Fig. 5.17 Ideal position and shape of the eyebrow
brow at the vertical line from the lateral limbus
(Fig.5.17).
Looking at the ratio of the eye to the eyebrow
considering the size of the eye, when the width
(L) of the eye is 1, the straight length (W) of the
eye is about 1.63, the length (MH) from the
medial canthus to the inner end of the eyebrow
(LH) is 0.60, and the length from the eyelid at the
center of the pupil is about 536 (Fig. 5.18).
Eyebrows tend to change their preferred shape
according to race, culture, and fashion. In Korea,
5.2 Midface
141
eyebrow tattoos are popular these days, and there
are even reports that almost all older women have
eyebrow tattoos, most of which tend to prefer
straight eyebrows. However, since the shape of
the eyebrows that match the shape of the face is
different, let’s look at the basic shape of the eyebrows. There are four main types of eyebrow
shapes common throughout the East and West:
arched, head-up, tail-up, and horizontal types
(Fig.5.19).
Straight eyebrows are popular these days, so
Koreans’ preferred shape is likely to be straight
eyebrows, but according to the actual poll results,
more than half of Koreans prefer naturally bent
arched shapes. Therefore, the shape of the ideal
eyebrow should vary depending on the shape of
the face. Typically, shorter brows positioned high
above the eyes suit round faces, while curved
eyebrows suit rectangular faces. Horizontal eyebrows are more ideal for rectangular faces.
With age, the ROOF, the deep fat layer deep to
the orbicularis oculi muscle in the eyebrow area,
atrophies. The shape of the eyebrow and lid complex changes with the volume loss in brow region,
which gives the appearance of sagging eyebrows.
By tenting the eyebrow region with llers, the
original volume of the ROOF can be restored.
Moreover, llers act a supporting structure to the
eyebrows, providing a lifting effect on the lateral
end of the eyebrow (Fig.5.20).
Medial to the midpupillary line, rm skin tissue is connected to the underlying muscles, and
thus, sagging or volume reduction in this area is
not as severe. Therefore, volume should be augmented in the region lateral to the midpupillary
line. After puncturing the lateral end of the brow,
insert the cannula into the ROOF deep to the
orbicularis oculi muscle. Inject a moderatestrength HA ller to create volume. Subsequently,
a soft ller could be injected into the dermal and
subdermal layers to create a smooth surface
(Fig.5.21).
5.2.2 Pre-tarsal Roll (Lower Eyelid
5.2.2.1 Terminology
Pre-tarsal fullness refers to the inferior aspect of
Fig. 5.18 Ratio difference according to the size of eye
and eyebrow
Fig. 5.19 The common classication of the eyebrows around the world
the lower brow which protrudes in a banana
shape.
Charming Roll, Pre-tarsal
Fullness)
142
Injection planes
- Submuscular injection into ROOF
(Retro-Orbicularis Oculi Fat) for the
eyebrow augmentation
- Subdermal injection of very soft filler to
even out the surface & to remove the
unnecessary multiple eyelid lines
Fig. 5.20 ROOF on the eyebrow region
5 Filler Procedures Based ontheFacial Area
Fig. 5.21 Injection planes for the cannula
Fig. 5.22 Pre-tarsal fullness in the absence of
expression
This is manifested when the tarsal portion of
the orbicularis oculi muscle in front of the tarsal
plate is thickened and is more pronounced by the
contraction of the muscle when smiling
(Figs.5.22 and 5.23).
Fig. 5.23 Pre-tarsal fullness when smiling
5.2.2.2 Beauty ofPre-tarsal Fullness
Beautiful pre-tarsal fullness is characterized by
several specic conditions: it must be symmetrical, avoiding any sagging downward, and should
present as a single, continuous volume rather
5.2 Midface
143
than being divided into multiple parts. This
fullness should extend naturally from the beginning to the end of the lower eyelid, maintaining a
seamless connection along the length of the eyelid. Additionally, it should be positioned as close
to the margin of the lower eyelid as possible to
achieve the desired aesthetic effect.
The following patients are expected to have
good results after a pre-tarsal roll procedure.
Good results can be expected for patients who
do not see the pre-tarsal roll when they are
expressionless, but clearly visible when
laughing.
Patients whose natural pre-tarsal rolls are able
to be simulated when the physician pushes the
lower eyelid area upward by hand. Patients with
good skin elasticity under the eyes and without
severe sagging are ideal candidates for pre-tarsal
roll ller injection procedures.
Pre-tarsal roll ller injection is considered one
of the most challenging treatments due to several
factors: bruising is common, the surface often
appears bumpy, excessive thickness can result in
an unnatural facial appearance, and there may be
interruptions in the continuity of the roll. While
many of these issues can be mitigated by using a
cannula, the procedure itself is technically
demanding with this instrument. Consequently,
clinicians generally prefer using a needle for the
pre-tarsal roll procedure despite the potential
complications.
5.2.2.3 Lower Eyelid Anatomy
(Figs.5.24, 5.25, 5.26, 5.27,
5.28, and5.29)
The inferior palpebral artery is the most important anatomical structure to consider during the
pre-tarsal roll procedure. These vessels branch
off the ipsilateral supratrochlear artery and extend
deeper than the orbicularis oculi muscle.
Inject directly into the orbicularis oculi muscle or in a more supercial layer. It is also safer to
inject ller as close to the lower eyelid margin as
possible.
As mentioned, the inferior palpebral artery is
a branched vessel from the supratrochlear artery,
and the supratrochlear artery is a branched vessel
from the internal carotid artery. Therefore, there
is a risk of blindness if the ller is injected into
the inferior palpebral artery during the pre-tarsal
roll procedure.
5.2.2.4 Injection Skill
Anesthesia is an important aspect to consider.
The pre-tarsal roll procedure is known to be painful. To alleviate this, an anesthetic ointment is
Fig. 5.24 Lower eyelid surface anatomy
Margin of Lower eyelid
Pre-tarsal Roll
Lower eyelid crease
Naso-Jugal groove
144
Fig. 5.25 Lower eyelid anatomy
5 Filler Procedures Based ontheFacial Area
Fig. 5.26 Vascular anatomy around the eyelid
Fig. 5.27 Pre-tarsal roll area (skin)
Fig. 5.28 Pre-tarsal roll area (the skin and supercial fat
removed)
5.2 Midface
Fig. 5.29 Pre-tarsal roll area (muscle removed)
145
applied to the lower eyelid and sealed with a plastic wrap for 10–20 minutes. Additionally, an
infraorbital nerve block may be performed to further reduce discomfort.
When it comes to the injection volume, it is
recommended to use up to 0.2–0.4cc per side.
After administering the injection, it is crucial to
check the difference in appearance between having no expression and when smiling. This helps
in calculating which part may need more volume
to achieve the desired outcome.
Needle Injection
Needle injection has the advantage of being convenient. If the injection is divided into three sections, it can cover the whole area. Afterward, it is
possible to inject small amounts to areas needed.
Caution should be taken when performing the
procedure with a needle. Even if the injection is
divided into several sections, the injection depth
must always be constant (Fig.5.30).
The injection position should be as close to
the lower eyelid margin as possible. The depth of
injection is preferably within the orbicularis oculi
muscle or the supercial layer above it. This is
due to fact that the inferior palpebral artery travels deeper than the orbicularis oculi muscle and
below the eyelid margin (Figs.5.31 and 5.32).
Fig. 5.30 Needle injection
Fig. 5.31 Depth of inferior palpebral artery
Be careful not to inject too supercially, as
this can lead to the Tyndall effect, which makes
the ller appear bluish. Tyndall effects may be
present throughout the pre-tarsal roll or only in
some of the front or mid-sections. In this case, it
is recommended to dissolve the ller and to perform the procedure again. It is very difcult to
calibrate through molding in this area.
146
Fig. 5.32 Depth of inferior palpebral artery
Fig. 5.33 Entry point for pre-tarsal roll injection with
cannula
The skin is removed. Orbicularis oculi muscle
is visible and inferior palpebral artery not
visible.
The skin, supercial fat, and orbicularis oculi
muscle are removed. Inferior palpebral artery is
visible.
Cannula Injection
Create an entry point on the lateral side of the
planned lower eyelid charming roll area
(Fig.5.33). It is recommended to create an entry
point close to the lower lashes. The closer the
pre-tarsal roll is to the inferior eyelid margin, the
more beautiful it will appear. If the roll is located
lower, the patient’s satisfaction decreases.
5 Filler Procedures Based ontheFacial Area
Fig. 5.34 Pre-tarsal roll ller injection with cannula
Keep the cannula as close to the eyelid margin
as possible through the supercial fat or
intramuscular muscles (Fig. 5.34). Then, retrograde injection is performed while maintaining
the injection pressure uniformly. It is helpful to
use all your tactile senses as you perform the retrograde injection (Fig.5.35). If the physician can
inject the ller in a uniform shape with the eyes
closed, he/she is an experienced physician.
The rst picture is when the ller is injected
without moving the position of the cannula. The
second picture shows a slow retrograde injection
while maintaining a constant force, and the third
picture shows a rapid retrograde injection.
Sufcient practice is required until a uniform
injection is possible.
One of the advantages of using a cannula for
pre-tarsal roll ller injection is the ability to perform molding. Since the ller resides within a
single pathway during cannula procedures, if a
particular area has an excessive amount of ller,
molding can be employed to distribute the ller
uniformly. Additionally, for the rst 2–3 days
post-procedure, patients can benet from selfmolding by gently pushing the ller upwards
using a cotton swab or similar tool.
5.2.3 Infraorbital Groove
andHollowness
As people age and the skin sags, wrinkles or
grooves appear in the lower part of the eye, mak-
5.2 Midface
147
1 Shooting TnJ.
Fig. 5.35 Retrograde injection training
2 Rectrograde Tnj
1
3 Retrograde Tnj.
2
Fig. 5.36 Changes of infraorbital area in old age with kind permission of DAEHAN medbook
ing them look tired. If the indication is appropriate, correcting with a ller can produce
satisfactory results without surgery. The depression around the inferior orbital bone is usually
called an “infraorbital groove.” Various names
exist for each anatomical site under the eye. In
this book, various forms of depression under the
eye are collectively referred to as “infraorbital
hollowness” and will be discussed in detail.
young age, which has no depression. However, as
aging progresses, depressions or grooves appear
(Fig. 5.36). The terms associated with infraorbital depression have recently become somewhat
unied. The most commonly used terms can be
explained as follows:
First of all, a tear trough occurs. The palpebromalar groove or midcheek groove then becomes
visible. As aging progresses, all three of these
lines appear.
5.2.3.1 Denition andClassication
ofTerms
The space from the bottom of the eye to the anterior cheeks is oval-shaped (or apple cheek) at a
A tear trough deformity refers to the groove
on the medial side of the infraorbital area, starting from the medial canthus and extending to the
midpupillary line with a gentle curve of about