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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
158
Western people
Asian people
5 Filler Procedures Based ontheFacial Area
Fig. 5.46 Difference of the apple cheek location between Western and Asian people
The tissue layers in the cheek area can be
divided as follows: skin, supercial malar fat
pad, orbicularis oculi muscle, deep malar fat pad
including the suborbicularis oculi fat (SOOF),
the facial expression muscle layer where the
For the malar area or cheek treatments that
require deep injections, hygiene before and after
the procedure is especially important, and
patients must be instructed not to wear makeup
for at least 6hours after the procedure.
upper lip levators such as the zygomaticus muscles originate, preperiosteal fat, and periosteum.
For apple cheek procedure that is performed to
volumize central region of the cheeks, ller
should be injected into the prezygomatic space,
which is located supercial to the periosteal layer
and contains preperiosteal fat.
When augmenting the anterior malar region of
the maxilla, more medial to the apple cheek, the
ideal injection plane is the deep malar fat pad
located under the SMAS and above the facial
expression muscles such as the zygomaticus
muscles. To ensure natural outcomes with
Technique by Facial Area
To correct anteromedial cheek (midcheek) hollow for Koreans, the central point of the cheekbone should be located based on the shape of the
apple cheek (refer to previous section for
method). After treatment design, enter from the
inferolateral aspect of the treatment area and treat
using either a needle or cannula. When a needle
is used, caution should be taken not to injure the
zygomaticofacial artery and nerve and infraorbital artery and nerve that emerge from within the
infraorbital bone (Fig.5.47).
implanted ller adjusting to facial movement
associated with expression formation and smiling, bolus injections should be avoided and ller
should be spread evenly throughout the fat layer.
Moreover, when treating the medial aspect of the
anterior malar area, any potential injury to the facial
vein that runs along the nasojugal groove, which is
5.2 Midface
Fig. 5.47 Infraorbital artery and zygomaticofacial artery
159
Fig. 5.48 Pathway of the facial vein
important during the infraorbital groove treatment
(Fig.5.48), and to the infraorbital trunk of duplex
type facial artery present in approximately 30% of
Koreans, should be kept in mind (Fig.5.49).
Facial vein is branched from external jugular
vein and initially goes up along a path similar to
facial array, but it always exists on the outside of
the face and is located deeper than the deep fat
layer that runs near the nasolabial fold after passing near the mouth (Fig.5.50).
When using a cannula, the entry point should
be located using the same method for the midcheek groove. The entry point is at the intersec-
Fig. 5.49 Infraorbital trunk of duplex type facial artery
tion between the lateral orbital rim line and the
mid-alar groove line. By doing so, the risk of vascular injury can be minimized (Fig.5.51).
Procedure layer depends on bone structure. If
there is signicant bone resorption in the malar
area necessitating volume restoration with a rm
ller from the periosteal layer, the target plane is
the prezygomatic space. However, as most
Koreans do not have severely atrophied cheekbones, the deep malar fat pad that includes the
SOOF should be targeted. This fat pad is located
supercial to the upper lip levator muscles. Use
the retrograde, fanning, cross-hatching, and layering technique. Use the non-injecting hand to
160
old
T
- Line fr
- Line fr
Injection entry points f
- Lat
- Lat
lat
Injection
- R
-
Fig. 5.50 Comparison
of location and depth of
the facial artery and vein
5 Filler Procedures Based ontheFacial Area
Facial artery on the nasolabial f
Facial vein on the cheek region
op of the apple cheek mound
om the lateral canthus to the mouth commissure
om the root of helix to the nasal alar base
eral & inferior to the area requiring volume
eral part of the midcheek on the vertical line of the
eral orbital rim & the horizontal line of the mid-alar groove
techniques for the midcheek hollow
etrograde fanning & cross hatching technique
Ver tical bolus & layering technique
Fig. 5.51 Injection techniques for the apple cheek and the midcheek hollow
hold the cheek fat pad and add volume focusing
on the apex of the mound. Add adequate volume
radially from the center as needed.
If there are minor depressions even after ller
placement or visible boundaries between the augmented and non-augmented areas, a soft ller
could be injected supercially into the subdermal
layer using the tenting technique to smoothen out
the surface (Fig.5.52).
The buccal area, which is commonly called the
anterior cheek, is composed of the following
or the midcheek hollow
planes: the skin, subcutaneous fat layer, supercially coursing facial expression muscles and
SMAS/buccal fat pad, deep muscle layer, and oral
mucosa. The ideal procedure layers are the subcutaneous fat layer or the prebuccal space located in
between the SMAS and buccal fat pad. Direct
injection into the buccal fat pad may result in
using excessive amounts of ller. Since the tissue
in this area is not very dense, a lump may be felt
inside the mouth, or the injected ller may migrate
downward; caution should be taken (Fig.5.53).
Injection planes
space
2.
supe
3.
superf
4.
5.2 Midface
Fig. 5.52 Before and after treatment of the anteromedial cheek hollow
1. Apple cheek augmentation : Into the prezygomatic
Midcheek hollow & groove : Into the deep cheek fat pads
rior to the deep facial muscles
Buccal & lateral cheek hollow : SubSMAS space or
icial fat layer
Subdermal injection to smooth out the surface
161
Fig. 5.53 Injection planes for the apple cheek and the cheek hollows
In cases of mild to moderate degree of cheek
hollowness, ller is injected into the subcutaneous
layer or the fat layer deep to the subcutaneous layer.
Mark the area with buccal cheek hollow rst and
make the entry point inferior to the region to be
volumized. To enhance volume, use the retrograde
fanning/cross-hatching technique to inject ller
from an inferior to superior direction (Fig.5.54).
Either a needle or cannula can be used. After,
a soft ller can be injected into the dermal and
subdermal layers to smoothen out the surface
(Fig.5.55).
If the buccal cheek hollowness is severe and
requires more pronounced volume augmentation,
then ller must be placed deep to the SMAS.The
procedure will involve penetration of the SMAS
layer and placement of ller to the deeper layer.
Cannula should be used to avoid vascular or
facial nerve injury. For the entry point, the needle
puncture is performed approximately 4cm anterior to the tragus and 2cm below the inferior border of the zygomatic arch. After the cannula is
introduced via the entry point, it is used to penetrate the rm SMAS layer and inserted toward
162
Injection entry point f
lat
- Inf
f
Injection
lat
- R
Injection entry point f
cheek hollo
- 4cm ant
belo
zy
injection
Injection
cheek hollo
- R
Fig. 5.54 Supercial
injection for the buccal
and the lateral cheek
hollow
5 Filler Procedures Based ontheFacial Area
or the buccal &
eral cheek hollow
erior to the buccal & submalar region
or the superficial fat layer injection
technique for the buccal &
eral cheek hollow
etrograde horizontal fanning technique
Fig. 5.55 Before and after treatment of the buccal cheek hollow
Fig. 5.56 Deep
injection for the buccal
cheek hollow
or the buccal
w
erior to the tragal line & 2cm
w the lower margin of the
gomatic arch for the subSMAS layer
technique for the buccal
w
etrograde horizontal fanning technique
5.2 Midface
Fig. 5.57 Before and after treatment of the buccal cheek hollow
163
the deeper layer of the buccal fat pad. By doing
so, the prebuccal space, the loose space supercial
to the capsule that wraps the buccal fat pad, can
be felt (Fig.5.56).
After injecting an appropriate amount of ller
into the prebuccal space, the volume in the subcutaneous layer above is augmented to complete
the procedure (Fig.5.57).
If the area inferior to the zygomatic arch,
referred to as the posterior or lateral cheek, is
sunken, the cheekbone may appear to protrude
even more. The facial contours may appear
uneven and thus require correction. If the hollowness is not severe, the boundary of the region to
be augmented is marked rst. Then with a needle
or cannula, ller is injected into the fat layer
below the skin, lling from the inferior end and
gradually working upward. If there are uneven
areas, a soft ller is injected into the dermal and
subdermal layers to complete the procedure
(Fig.5.54).
Severe hollowness usually involves development of the zygomatico-cutaneous ligament, a
true retaining ligament that originates from the
inferior border of the zygomatic arch and attaches
to the skin; the masseteric cutaneous ligament, a
false retaining ligament that extends from the
parotid-masseteric fascia to the skin; and the platysma auricular fascia. The developed ligaments
cause tight adhesions of the deeper tissues in the
subzygomatic area to the skin surface.
Consequently, even when ller is injected into
the sunken area, it may be difcult to adequately
augment the area. Forcing ller into the area may
cause the ller to spread to the side and cause the
surrounding area to appear swollen and uneven.
In such cases, a cannula should be used for tunneling through the ligaments that are pulling on
the skin. This will weaken the pulling force of the
ligaments and create a space for the ller to enter
(similar to the midcheek groove treatment), and
sunken area could be augmented smoothly
(Fig.5.58).
The ideal entry point for the cannula is located
at the intersection of the lateral orbital rim line
and the line drawn from the mouth commissure
to the tragus. After using the cannula to release
the ligamentous adhesions, retrograde fanning
and layering techniques should be used to inject
an appropriate amount of ller into the preparotidmasseteric space to ll the sunken area. Just as
with other areas, if there are uneven areas or areas
where boundaries are visible, a soft ller is
injected in the subdermal layers (Fig.5.59).
5.2.7 Nose
Nose augmentation with llers is a simple procedure that can produce dramatic results. When
learning how to do llers, it is often the rst area
to try, and it is also the most popular ller site.
Indications for nose augmentation using ller or
surgical treatment are as follows.
164
Injection entry point
cheek hollo
- Cr
commissur
line of the lat
the subSMA
Injection
cheek hollo
- R
Fig. 5.58 Before and after treatment of the deep lateral cheek hollow
Fig. 5.59 Deep
injection for the lateral
cheek hollow
w
oss of the line from the mouth
e to the tragus & the vertical
eral orbital rim for
S layer injection
for the lateral
5 Filler Procedures Based ontheFacial Area
Indications for nose augmentation using llers
include patients who prefer nonsurgical options.
This approach is ideal for those desiring natural
and slight changes to their nose. Additionally,
llers are suitable for patients looking for augmentation without the need for downtime.
On the other hand, surgical treatment is recommended for noses that are challenging to correct with llers, such as those with a wide nose,
severe hooked nose, or wide nasal ala. Surgery is
also preferable for patients who desire a very
high and slender nose. Furthermore, patients with
high expectations for the outcome after a ller
procedure may nd surgical options more
satisfactory.
During the ller procedure, the nasal area is
also a site of fatal complications such as skin
necrosis due to excessive augmentation and
blindness due to ller injection into the blood
technique for the lateral
w
etrograde horizontal fanning technique
vessel. Therefore, it is essential the physicians
understand the anatomical structure and proceed
with care during the ller procedure.
5.2.7.1 Design andAnatomy
The nose is located at the very center of the face,
so it is important for the balance and harmony of
the entire face. Different races have different
preferences for beautiful noses, but ideal nose
conditions are as follows (Fig.5.60).
• Nose length is one-third of total face length
(equivalent to forehead height).
• The width of the nose is one-fth of the width
of the face.
• Nasofrontal angles range from 115° to 130°.
• Nasolabial angles range from 90° to 95° for
men and 95–105° for women.
• Naso-facial angles range from 35° to 40°.
5.2 Midface
Fig. 5.60 Criteria for ideal nose
165
Fig. 5.61 Five divisions of the nose
The names of the parts of the nose are as fol-
lows (ve divisions of the nose) (Fig.5.61):
• Radix
• Dorsum
• Nasal tip
• Columella
• Nasolabial angle
As described above, there are various parts of
the nose that can be corrected during the ller
procedure. Before the procedure, it is essential to
check the treatment area with the patient by
pointing with your nger while looking in the
mirror. It is not advisable for the physician to
make arbitrary judgments or determine the location of correction at the request of the patient
with “Please make my nose pretty.” For example,
the patient who wants to correct the columella
and nasolabial angles tends to say, “Please make
nose tip pretty.” If the physician mistakenly performs augmentation of the nasal tip, the patient
may complain that the desired area has not been
treated.
Arteries of the Nose
The layers from the surface of the nose to the
deep layer are as follows: skin-supercial fatbromuscular layer (connected with SMAS)deep fat-periosteum and perichondrium. Arteries
of the nose are present in the bromuscular layer
or between the bromuscular layer and the deep
fatty layer (Figs.5.62 and 5.63).
In the distribution of the arteries, the lateral
nasal artery branching from the facial artery is
responsible for blood circulation to the tip of the
nose. Blood ow of the dorsum is supplied by the
dorsal nasal artery branching from the ophthalmic artery. The columellar artery branching from
the superior labial artery supplies the columella
with blood ow (Fig.5.64).
Most branches of the nasal arteries originate
from the side of the nose. This does not mean that
the arteries are not distributed in the midline. The
arteries can be distributed in the middle of the
nose, or they can cross and connect to the opposite vessel. In other cases, the blood vessels exist
only on one side, and the blood vessels do not
166
Superficial falty layer
5 Filler Procedures Based ontheFacial Area
Skin
Fibromuscular layer
Deep fatty layer
Periosteum
(Perichondrium)
Fig. 5.62 Cross section of the nose skin with kind permission of DAEHAN medbook
exist on the other side. In this situation, if the
blood vessel on one side is blocked by the ller
procedure, the blood ow of the other side is not
supplied, so the possibility of necrosis is very
high.
When the ller is injected, one should never
assume that you are treating an area where blood
vessels are not distributed. It is advisable to use
the opposite hand to pull up the soft tissue and
blood vessels as much as possible before inject-
Bone
(Cartilage)
• Supratrochlear vein → supra-ophthalmic vein
→ cavernous sinus → internal jugular vein
• Angular vein → facial vein → external
jugular vein
Both of these can cause pulmonary embolism
through venous drainage. To prevent this side
effect, it is helpful to use a technique that pinches
with the opposite nger, lifts the vessel, and
injects ller deeper during the procedure.
ing into the deep layer.
5.2.7.2 Choice ofFiller
Intercanthal vein
The intercanthal vein is located in the subcutaneous layer above the procerus muscle, a vein that
connects both angular veins like a bridge. It
mainly is located in the intercanthal space but
also can be commonly found cranial or caudal to
the intercanthal line. If ller is accidentally
injected into this vessel during the procedure, the
ow will travel in one of two ways:
Generally, physicians prefer a HA ller that can
easily dissolve if side effects occur after ller
procedure. Suitable llers for augmentation of
the nose are those with low water retention capacity while keeping the volume well maintained.
Patients are reluctant to have their dorsum or
radix become overcorrected or appear too wide
from excessive water retention after treatment. In
the past, biphasic llers with larger particles and
5.2 Midface
Fig. 5.63 Structure of nasal bone and cartilage with kind permission of DAEHAN medbook
167
Fig. 5.64 Arterial supply of the nose. Pink-colored arteries are branched from internal carotid artery, and those red are
from external carotid artery. Dorsal nasal artery is branched from internal carotid artery