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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
148
Fig. 5.37 3 grooves and 3 segments in old age. A Lid–cheek segment, B Malar segment (malar mound/malar festoon),
C Nasolabial segment (with kind permission of DAEHAN medbook)
5 Filler Procedures Based ontheFacial Area
3 cm. As aging progresses, palpebromalar
grooves appear on the lateral side of the infraorbital area. Later it connects to the tear trough,
which looks like a semicircular curve.
The midcheek groove is a curve that starts at
the midpoint of the tear trough and the
palpebromalar groove and extends inferolaterally. It can appear as a long curve connected to a
tear trough, but most seem to have two lines connected like the shape of a seagull’s wing.
Sometimes it appears as a crease starting in the
middle of the anterior cheek. It is also called an
Indian band.
The three grooves above divide the anterior
cheek into three segments (Fig.5.37).
• Three Grooves
– Tear trough/tear trough deformity
– Palpebromalar groove (orbitomalar groove)
– Midcheek groove (midcheek furrow)
• Three Segments
– Lid-cheek segment
– Malar segment (malar mound/malar
festoon)
– Nasolabial segment
5.2.3.2 Tear Trough andNasojugal
Groove
The denition of a tear trough varies among
authors, making it difcult to dene precisely.
According to the article by Nicholas T. etal., the
area from the medial canthus to the mid-pupillary
line is called the tear trough and from the midpupillary line to the lateral canthus is called the
palpebromalar groove.
A tear trough is formed between the palpebral
and orbital portions of the orbicularis oculi
muscle and is located 2–3mm below the orbital
rim. Previously, it was thought that ligaments
were only present in the lateral part (palpebromalar groove) and not in the medial part (tear
trough). However, recent anatomical studies have
revealed that ligaments do exist in tear troughs.
Therefore, this ligament is called the tear trough
ligament (Fig.5.38).
There are several causes of tear troughs:
1. The presence of the tear trough ligament and
its sagging
2. Thin skin thickness under the eyes
5.2 Midface
Fig. 5.38 Sagittal section of medial infraorbital area
149
3. Difference in the amount of subcutaneous fat
above and below based on the tear trough ligament. (There is more fat in the lower part, and
the skin is thicker.)
4. Bulging of infraorbital fat
5. Resorption of the maxilla bone
The severity of the tear trough varies from
individual to individual.
The nasojugal groove is almost similar inlocation to the tear trough, which can be confusing,
but it differs anatomically from the tear trough.
The tear trough is formed between the palpebral
and orbital portions of the orbicularis oculi muscle (OOm), whereas the nasojugal groove is
formed between the orbital portion of the OOm
and the origin of the levator labii superioris alaeque nasi muscle (LLSAN). In other words, the
tear trough is located above the medial band of
the orbital portion of the OOm, and the nasojugal
groove is located below it. The nasojugal groove
is also less pronounced than the tear trough.
5.2.3.3 Palpebromalar Groove
andOrbital Retaining Ligament
(ORL)
The palpebromalar groove progresses superolaterally from the midpoint of the pupil where the tear
trough terminates and aligns parallel to the infraorbital rim. Typically, the nasojugal grooves appear
rst, followed by the development of the palpebromalar grooves. The orbital retaining ligament
(ORL), a structural component, encapsulates the
border of the infraorbital rim, resembling a septum.
The thickness and length vary across different
regions, not uniformly encircling the orbital area in
a 360° manner (Fig.5.39). Notably, the ORL in the
infraorbital region signicantly varies between its
medial and lateral sections. Therefore, the medial
section is referred to as the tear trough ligament,
while the ORL is conned to the lateral part.
Medial Part (Tear Trough Ligament)
• The tear trough ligament is situated between
the palpebral and orbital portions of the orbi-
150
5 Filler Procedures Based ontheFacial Area
cularis oculi muscle. It is a robust ligament,
short and rmly attached to the bone.
Previously considered a ligamentous attachment (not an actual ligament), it is now classied as a ligament.
• This ligament extends from the medial canthal
tendon to the mid-pupillary line.
• The ligament shows individual variability in
terms of sagging and asymmetry on both sides.
Lateral Part (Orbital Retaining
Ligament,ORL)
• The orbitomalar ligament is a more relaxed
and elongated ligament, not as rmly attached
to the bone, creating a space between the
orbital bone and the orbicularis oculi muscle.
This space facilitates easier ller injection
compared to the medial part.
• It is also easier to create space for ller injection and to relax the ligament for injection in
this area compared to the medial part.
• Lateral hooding often occurs due to the laxity
of the orbitomalar ligament.
5.2.3.4 Midcheek Groove
andZygomatico-cutaneous
Ligament
The midcheek groove initiates where the tear
trough and palpebromalar groove meet, extending
inferolaterally. It appears connected to the tear
trough, but the zygomatico-cutaneous ligament
(Z-C ligament) begins where this connection
seems unnatural. The Z-C ligament is attached
from the maxilla extending to the zygomatic bone,
resulting in a midcheek groove forming a long,
band-like brous region along this ligament within
the anterior cheek (Fig.5.39). The region inated
with malar fat between the midcheek and palpebromalar grooves is known as the “malar mound.”
Both the tear trough and midcheek groove coincide with the superior border of the malar fat pad.
Based on the Z-C ligament, supercial and deep
malar fats are segmented into upper and deeper
sections. As aging progresses, the deep medial
cheek fat (DMCF) beneath the Z-C ligament contracts and depresses, while the supercial fat (such
as nasolabial and medial cheek fat) sags.
Fig. 5.39 Sagittal section of lateral infraorbital area.
Green dotted line: Tear trough ligament, yellow dotted
line: Palpebromalar groove, red dotted line: Midcheek
groove(Indian band). SOOF: Suborbicularis Oculi Fat.
Layers from super cial to deep: ① skin, ② super cial fat
(malar fat), ③ orbicularis oculi muscle, ④ SOOF
(Suborbicularis Oculi Fat)
5.2 Midface
151
Conversely, the supercial and deep malar fat pads
above the Z-C ligament are supported by the ligament, forming a distinct top/bottom boundary
based on the Z-C ligament.
5.2.3.5 Orbital Fat, SOOF
(Suborbicularis Oculi Fat),
andMalar Fat
Orbital Fat
Orbital fat is present in both infraorbital and
supraorbital regions. Both infraorbital and supraorbital fat are enclosed by orbital septa and
extend outward (fat-orbicularis oculi muscleskin). Herniation of infraorbital fat is one of the
causes of the formation of tear troughs and palpebromalar grooves (Fig.5.38).
Suborbicularis Oculi Fat (SOOF)
The deep fat under the orbicularis oculi muscle
(OOm) beneath the eye is called suborbicularis
oculi fat (SOOF), and the deep fat under the
OOm above the eye is termed retro-orbicularis
oculi fat (ROOF). As age progresses, the volume
of SOOF and deep medial cheek fat decreases
(Fig.5.39). This leads to a reduction in the volume of the anterior cheek and the appearance of
infraorbital hollowness.
SOOF provides a suitable space for injecting
llers to correct infraorbital hollowness. Although
the angular vein passes through this SOOF space
before coursing along the medial border of the
orbicularis oculi muscle, it can be safely injected
deep into the prezygomatic space.
The SOOF is divided into medial and lateral
parts. The innermost part of the tear trough has
tight muscles and no SOOF, making it fundamentally impossible to correctly inject ller into the
fat layer below the innermost OOm. A small
amount is injected medially, and sufcient volume is created by injecting enough ller laterally.
If the groove is not adequately corrected on the
inner side, undermine below the skin and inject
the ller with low viscosity to complete the
correction.
Malar Fat
The fat deeper than the orbicularis oculi muscle
(OOm) under the eye is divided into superior and
inferior fat based on the tear trough ligament and
orbitomalar ligament. The fat in the superior (cranial) part is infraorbital fat, and the fat in the inferior (caudal) part is the suborbicularis oculi fat
(SOOF).
The supercial fat over the OOm, which is
inferior (caudal) based on the tear trough ligament, is malar fat. That is, both the tear trough
and palpebromalar grooves coincide with the
superior border of the malar fat pad (Fig.5.39).
The fat more medial than the malar fat is supercial medial cheek fat and nasolabial fat. Malar fat
is divided into superior and inferior parts based
on the zygomatico-cutaneous ligament to form
midcheek grooves. The bulging of malar fat
between the midcheek groove and the palpebromalar groove is termed the malar mound.
5.2.4 Dark Circle (Tear Trough
andPalpebromalar Groove)
Dark circles are primarily caused by three factors: color change, contour change, and skin laxity. Treatment varies depending on the cause.
Various methods such as laser treatment, fat
transfer, llers, transconjunctival blepharoplasty,
HIFU, and radiofrequency are available. One of
the cases that can be resolved by ller injection is
the change of contour under the eye. As aging
progresses, dark circles develop as the infraorbital fat starts to bulge, fat volume decreases, and
bone resorption occurs. Upon close examination
of dark circles, not only changes in color but also
changes in contour or skin laxity can be observed.
In this chapter, we will discuss ller treatment
for tear troughs and palpebromalar grooves
caused by the anatomical structures mentioned in
the previous chapter.
5.2.4.1 Design
Since the cause of dark circles is due to structural
differences in the submuscular plane, correction
of deeper layers should also be considered.
There are some precautions to be taken in the
design process and while checking results with
the patient. When designing before the procedure, it is advisable to check the area in a mirror
152
5 Filler Procedures Based ontheFacial Area
with the patient. It is important to check exactly
where the patient wants to be corrected: tear
trough, palpebromalar groove, or midcheek
groove. This is because the patient usually wants
to correct the infraorbital hollowness and sometimes claims that the desired area has not been
corrected after the procedure. After correction of
tear trough, the nal assessment should be
checked with the patient gazing straight ahead. In
general, the tear trough looks more severe when
looking upward than gazing ahead and less severe
when looking down. Therefore, it is advisable to
correct the tear trough based on the patient gazing straight ahead. When a patient looks in the
mirror after the procedure, they tend to check by
looking up at the eyes. When the patient looks
upward, the tear trough appears to be more
severe, and the patient tends to think that it is not
corrected. In other words, if the patient looks
upward, the result appears undercorrected. If the
patient looks downward, the result appears overcorrected. Therefore, it is desirable to check the
treatment area by gazing at front in a mirror and
to explain that it may look slightly different
depending on the angle of view and lighting.
5.2.4.2 Anesthesia
Infraorbital nerve block simplies the procedure
execution. Although it’s possible to use local anesthetic creams, cold anesthesia, and lidocaineinfused llers without a nerve block, the patient
may experience pain depending on the depth of the
injection. It’s recommended to perform an infraorbital nerve block rst when injecting into the deep
layer. For supercial injections, the procedure can
be performed using only topical anesthesia.
5.2.4.3 Choice ofFiller
It is advisable to avoid llers with low viscoelasticity when injecting into the deep layer, i.e., the
prezygomatic space. If the skin is thin and the
amount of fat (SOOF/malar fat) is small, the
overall thickness of the soft tissue is thin, so llers with medium viscoelasticity are recommended. In such cases, using a high viscoelastic
ller may cause the shape to appear unnatural
and bulge out. Conversely, if the skin is thick and
the amount of fat is large, the volume increase
may appear too modest after injection with a
medium viscoelastic ller. In this case, it is advisable to use a high viscoelastic ller.
When injecting into supercial layers, llers
with the lowest viscoelasticity and minimal water
retention capacity should be used. Choose a ller
that molds well after the procedure and retains its
shape. Since llers with high water retention
capacity may cause edema post-procedure, special care should be taken not to overcorrect if the
skin is thin. To prevent edema and achieve sufciently corrected results during supercial injection, it is advisable to complete the nal procedure
with a secondary treatment after a certain period
following the rst procedure.
5.2.4.4 Injection Technique
Tear Trough
When correcting the tear trough, the injection
depth can be chosen from (1) deep, (2) supercial, and (3) deep + supercial. The author prefers (3) deep + supercial for primary correction
and (2) supercial for secondary treatments.
Based on the pattern of sagging of the tear
trough, you can choose from the three methods
above. Deep injection is required if there is a lack
of volume in the anterior cheek. Typically, when
the tear trough ligament is tightly attached, causing the skin to be deeply recessed, deep injection
alone does not improve the condition and supercial injection is necessary. It is also essential to
perform ligament release before injecting the ller.
Asymmetry may occasionally be present on
both sides of the tear trough, so it should be
assessed prior to the procedure. This may be due
to differences in the attachment point or length of
the ligament below the orbital rim. Taking these
differences into consideration, varying the volume and depth of ller injection accordingly is
recommended for effective correction.
If the medial border of the orbicularis oculi
muscle (OOm) is band-like on one or both sides,
wrinkles may become visible during smiling or
frowning. Patients may not notice this before
ller treatment, but may discover it days after the
procedure and express dissatisfaction with asymmetry during facial expressions. Therefore, it is
5.2 Midface
153
essential to ask the patient to frown during the
assessment to check for any prominent medial
bands of the OOm and inform the patient in
advance. For correcting the medial band of the
OOm, supercial ller injection alone is not sufcient—combination treatment with botulinum
toxin is necessary.
The entry point is placed along the extension
of the tear trough, approximately 1–2cm away
from the end of the groove to be corrected
(Fig.5.40). The cannula is inserted at a 45–60°
angle through the entry point. After reaching the
bone, it is advanced along the prezygomatic
space of the SOOF layer (Fig.5.41), entering just
beneath the tear trough. Then, ller is injected
slowly using a retrograde technique. Since the
available space for injection in the medial portion
is very limited, only a small amount should be
injected while checking for visible volume elevation at the midpoint (Fig.5.42).
Because deep-layer injection alone may not
sufciently correct the medial portion of the tear
trough ligament, the cannula should be repositioned to a more supercial plane above the orbicularis oculi muscle, and then ller should again
be injected slowly using the retrograde technique
(Fig. 5.43). Low-viscosity llers are injected
with a 25G cannula. Before injecting into the
supercial layer, it is important to rst tunnel the
area beneath the skin. Slightly wider tunneling
than the actual injection area is key. This allows
the ller to spread into the adjacent area rather
than bulging under the thin skin, resulting in a
more natural contour. If the medial tear trough is
sufciently long or relatively loose, deep layer
injection alone may be sufcient for correction.
Palpebromalar Groove
The palpebromalar groove can be partially
improved by the volume effect after correcting
the tear trough or midcheek groove rst. This is
because during the tear trough correction, the
volume is somewhat lled by deep injection.
However, if the volume decreases and additional
deep injection is needed in this area, inject ller
into the submuscular plane.
Special attention should be given to vascular
damage when treating this area. Since visible
supercial veins (especially the inferior palpebral
vein) are more developed on the lateral than the
medial aspect of the infraorbital area, it is advisable to visually check the veins and avoid them
before making the entry point.
a
Fig. 5.40 Location of entry point and injection space for tear trough correction. (a) Cannula at the entry point. (b)
Cannula is located under the tear trough while injecting ller into deep layer
b
154
Fig. 5.41 Deep injection
and supercial injection for
tear trough correction
(transverse view). (a) Blue
area – deep injection. (b)
Pink area – supercial
injection
5 Filler Procedures Based ontheFacial Area
5.2.4.5 Side Eects andPrecautions
• Combination Treatments for Dark Circles: If
llers alone cannot resolve dark circles, it’s
crucial to thoroughly explain to the patient
that additional combination treatments may be
necessary. Surgical intervention might be
required in cases of severe infraorbital fat protrusion. Surgical treatments may prove more
effective than ller injections, particularly for
patients aged 50–60 and older. For those with
pigmentation under the eyes, a combination
with laser therapy is necessary.
• Vessels to Avoid During Injection: Over 30%
of Koreans have an infraorbital branch of the
duplex type facial artery, known as the
“detoured branch of the facial artery.” The
angular vein has a large diameter, especially
when dilated in the supine position. Both these
vessels (infraorbital branch of the duplex type
facial artery and angular vein) pass through
the SOOF and DMCF and then ascend along
the medial border of the orbicularis oculi muscle (Fig.5.44). Injection with a needle has a
higher likelihood of causing vascular damage,
hence the strong recommendation to use a
cannula. Even with cannula use, careful handling is required to avoid damage to the
vessels.
• Nodularity: Injecting more supercially than
the orbicularis oculi muscle can cause problems in the following situations: (1) uneven
injection of ller, (2) excessive volume of
injection, (3) injection of high viscoelastic llers, and (4) injection of llers with high water
retention capacity.
5.2 Midface
155
a
b
c
Fig. 5.42 Deep injection for tear trough correction. (a)
Insert cannula under the tear trough. (b) Check if the cannula is located in a deep layer not a supercial layer.
a
Fig. 5.43 Comparison of depth of cannula during deep
injection and supercial injection for tear trough correction. (a) Deep injection – cannula is placed under the
(c) Inject ller and feel the resistance over the treatment
area with ngertips on the opposite hand
b
muscle so that skin is not inuenced by its movement. (b)
Supercial injection – skin is lifted and motion of cannula
is visible when cannula is lifted and moved
156
Fig. 5.44 Running of
detoured branch of facial
artery and angular vein
(deep fat layer) / (with
kind permission of
MANIAMIND)
5 Filler Procedures Based ontheFacial Area
• Overcorrection: Injecting too much volume
into both deep and supercial layers can
appear unnatural and blur the boundaries with
the pre-tarsal fullness. Since the tear trough is
dense tissue on the medial side and is not sufciently released, injecting large amounts into
deep layers can make dark circles appear more
pronounced. Therefore, it is advisable to use
the sandwich technique, where a small amount
is injected into the deep layer of the tear
trough, followed by a supercial injection.
5.2.5 Midcheek Groove
5.2.5.1 Causes andAnatomy
The midcheek groove can develop due to several
factors.
Firstly, changes in fat around the zygomatic-
cutaneous ligament (Z-C ligament) are the primary cause. As discussed in Sect. 5.2.3, with
aging, the volume of the deep medial cheek fat
(DMCF) beneath the Z-C ligament decreases
more compared to the deep fat above the Z-C
ligament, creating a top/bottom boundary based
on the Z-C ligament.
Secondly, bone resorption of the maxilla
results in volume loss of the anterior cheek.
Thirdly, sagging of the Z-C ligament leads to
the prominence of the malar mound.
The treatment method varies depending on the
causes. Anatomical causes are rst examined,
followed by the appropriate treatment. Among
these treatments, there are two methods to treat
with llers, and the choice of anesthesia, injection method, and ller varies depending on the
depth of injection.
5.2.5.2 Treatment
Supercial Injection
Before injecting the ller, it is benecial to rst
use a cannula to tunnel the brous tissue at the
reticular dermis level of the zygomatic-cutaneous
ligament (Z-C ligament). While holding the skin
still with the other hand, move the cannula.
Repeat this process about 10 times using a 23G
cannula and inject the ller once the movement
of the cannula has softened. Too much damage to
the tissue during the tunneling process can
increase the risk of bruising and swelling, so gentle handling is necessary to minimize tissue
injury. A medium viscoelastic ller is typically
injected in this area. In patients with sufcient
volume in the anterior cheek, supercial injection
alone may be sufcient for correction.
Deep Injection
If there is insufcient volume in the anterior
cheek, supercial injection alone will not resolve
the issue. In such cases, deep injection alone can
have an excellent correction effect and high
patient satisfaction. There are two methods for
deep injection—using either a cannula or a
needle.
First, use medium to high viscoelastic llers.
Inject the ller using a needle at the supraperios-
5.2 Midface
Fig. 5.45 Deep injection and supercial injection for
midcheek groove correction. (a) Blue area – deep injec-
tion. (b) Pink area – supercial injection
teal level, and move up to the middle layer using
the towering technique. The injection position of
the needle is crucial, and make sure to inject
directly beneath the Z-C ligament. As aging progresses, the volume of the SOOF and DMCF
located directly below the Z-C ligament decreases.
Filling the volume loss by injecting ller results
in lifting of the sagging Z-C ligament and improving the midcheek groove (Fig.5.45).
The second method involves using a cannula.
For deep injections, it is recommended to rst
ll the volume under the tear trough with a cannula and then correct underneath the Z-C ligament. In the treatment of the midcheek groove,
deep injection alone provides excellent correction, but if the patient desires detailed correction,
additional injection to the supercial layer is
recommended.
Reduction of Malar Fat
When the midcheek groove is caused by malar fat
bulging, or patients who refuse llers need treatment, a different approach should be taken. As
explained in the rst part of the chapter, the
DMCF below the Z-C ligament decreases more
in volume compared to the deep fat above the ZC
ligament. Reduction of the fat above the Z-C ligament decreases the difference in fat volume
157
above and below the Z-C ligament, improving
the midcheek groove. A lipolytic agent and HIFU
can be used to reduce the malar mound volume
above the Z-C ligament. However, since the correction is not as detailed as with llers, it should
only be applied to patients who are not keen on
llers, and the physician must explain in advance
that it will not be an ideal correction.
5.2.6 Anteromedial, Buccal,
andLateral Cheek Hollow
Pre-procedural Considerations
When referring to sunken cheeks, there are ethnic
differences based on differences in facial bone
structure. Typically, Koreans dene sunken
cheeks as either lateral cheek hollow (hollowness
in the area inferior to the zygomatic arch) or buccal cheek hollow (hollowness in the perioral
region). In contrast, Caucasians refer to hollowness in the maxillary region across the anteromedial cheek (midcheek) and zygoma or volume
loss needing malar augmentation as sunken
cheeks.
When creating “apple cheeks” by augmentation of the malar eminence, the preferred locations and shapes of the apple cheek differ among
Caucasians and Asians. Caucasians prefer to have
the apex of the cheek to be lateral to or above the
cheekbone, whereas Asians, who have wider midfaces with more prominent cheekbones, prefer the
apex to be located more medially.
Prior to ller administration, the central point
of the cheekbone should be located. In Asians,
this point can be located by drawing a horizontal
line from the lower portion of the alar groove to
the root of the helix and a vertical line from the
lateral canthus to the lateral commissure. The
apex should be located close to the intersection of
the two lines or slightly medial to this point.
Unlike in Westerners who request prominent
augmentation of the cheeks, the anterior malar
area should be injected just enough to observe a
smooth mound that occurs when the smiling
action elevates the cheek fat pad (Fig.5.46).