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168
5 Filler Procedures Based ontheFacial Area
higher viscoelasticity than monophasic llers
were recommended. Recently, monophasic llers
with high viscoelasticity and low water retention
capacity have been widely used.
5.2.7.3 Injection Technique
Augmentation of Dorsum and Radix
There are two methods of treatment—using a
needle or cannula.
Firstly, the cannula method starts by creating
an entry point between the nose tip and the columella. Then insert it advancing while feeling it
touching the cartilage or bone in the deep layer.
Proceed from the space between lower lateral
cartilages -> upper lateral cartilages (perichondrium) -> nasal bone (periosteum) -> to radix.
The upper boundary of ller injection is the level
of the upper eyelid crease, and ller is slowly
injected from just below this level with a retrograde linear technique (Fig.5.65).
A 21–23G 5cm cannula is suitable for injection. If the cannula is too long, it is likely to bend
while entering at the supraperiosteum level and
penetrate into the subcutaneous layer, resulting in
vascular accidents.
To prevent this, pinch with the opposite hand,
grab and lift the thick tissue which covers the
deep fat layer, and then advance the cannula in
the supraperiosteal layer.
You can check the depth of the cannula tip by
palpating it with the other hand to see if it is properly positioned in the deep layer or visually check
by lifting the cannula with the syringe-held hand.
If the cannula has entered the supercial layer,
retract the cannula, and then advance it correctly
into the deep layer.
Since a hump exists when correcting a hooked
nose, the cannula cannot enter into the radix from
the tip of the nose in one maneuver. This is because
the cannula enters the supraperiosteal layer initially but penetrates into the subcutaneous layer
while passing the hump. There are three recommended injection methods to solve this problem.
• Make a second entry point just below the
hump for the cannula, insert the cannula, and
inject the ller retrograde from the radix to the
hump.
• Inject with the cannula from the nose tip to the
hump, and inject with a needle from the hump
to the radix.
• Inject with only a needle. A needle is used to
inject approximately three to ve points on the
midline of the nose from the radix to nose tip
(same as the following needle injection
method).
Secondly, inject at the supraperiosteum level
using a needle. In the same way as the cannula
method described above, you can inject it with
the retrograde technique after going straight from
the nose tip to the radix. Or you can inject ller
directly above the supraperiosteum or the perichondrium after inserting the needle vertically or
obliquely and dividing the treatment area into
three to ve points (Fig.5.66).
It is not recommended to use a needle with a
small diameter, such as an insulin syringe, but a
needle about 25G/27G is recommended. Since
the ller is injected under high pressure inside the
needle with a small inner diameter, a change in
the physical properties of the ller may occur,
and the inherent viscoelasticity may not be maintained. If a diameter of the needle is small, the
viscous ller in the needle lumen may result in a
false-negative aspiration test just before ller
injection (see Sect. 6.2.5).
Augmentation of Nose Tip
Similar to the nasal dorsum procedure, llers can
be injected using a cannula or needle. Place the
injection tool between the lower lateral cartilages
and inject deeply over the cartilage.
Unlike the dorsum, the tip has a thick dermis,
and there is no soft subcutaneous fat layer. The
bromuscular layer and dermis are tightly connected, so if a large amount of ller is injected,
skin necrosis is likely to occur due to extravascular compression even if injected into a deep
space. Therefore, it is recommended to inject a
small amount of medium viscosity ller with a
droplet technique.
5.2 Midface
169
a
c
d
b
Fig. 5.65 Injection method using a cannula for nose augmentation. (a) Cannula is inserted on the midline of the
nose. (b) Depth of cannula is supraperichondrium and
supraperiosteum. (c) Location of entry point and direction
of cannula insertion. (d) MRI of the nose (sagittal view).
Filler (high signaling) was placed on the supraperiosteum
level with kind permission of DAEHAN medbook
170
Fig. 5.66 Injection method using a needle for nose aug-
mentation. Serial puncture method is a good option for
needle injection
Augmentation of Columella
The procedure can be performed with both a needle and a cannula, but a cannula is recommended
because the needle is likely to damage the columellar artery in a narrow space.
Insert the cannula to the medial crus of the
lower lateral cartilage and advance it to the anterior nasal spine. Then inject using the retrograde
linear threading technique.
The towing technique is applied to reinforce
the support of the columella, but the support does
not last long. It may be a good option to combine
with a cog lifting thread to reinforce the support
after the ller procedure.
When a small amount of toxin is injected into
the depressor septi nasi muscle, the nose tip is
lifted by releasing the tension of the muscle.
Synergistic effect can be obtained by combining
toxin with ller for columella correction.
Precautions for Nose Filler
• Make sure the midline of the nose is preserved
during ller injection.
• The injection plane should be supraperios-
teum/supraperichondrium to reduce the risk of
vascular compression and intravascular
injection.
5 Filler Procedures Based ontheFacial Area
• Do not inject too much volume of ller for
correction of the nasal tip.
– Adjust the amount appropriately for the
second touch-up procedure as well as the
rst procedure.
After a certain period of time, when the
ller is dissolved and the patient visits for
further treatment, the tissue become dense
and mobility of blood vessels are lessened
by collagen formation due to previous procedures. Thus, even the same amount of
injection increases the chance of vascular
compression after repetitive procedures.
Therefore, it is advisable to perform the
procedure with even more caution for correction of the nasal tip.
– In case of a past history of nose surgery,
check the rigidity of the dermis and subcutaneous fat layer by palpation, and if
deemed, do not recommend a ller procedure or inject only a minimal amount.
Patients often hide their history of nose surgery, so careful clinical examination is
needed.
– When simultaneously treating the nasola-
bial fold and the nasal tip, the possibility of
compression of the lateral nasal artery is
increased, so the procedure should be
divided into two sessions with small
amount of injections.
• Thorough communication with patient about
the area to be corrected before the procedure
can reduce postoperative dissatisfaction.
5.2.7.4 Side Eect
Skin Necrosis
The nose is a site where skin necrosis frequently
occurs as a side effect after ller treatment. The
nose has a smaller space in between the bone
(cartilage) and skin than other areas. Also, the
dermis is thicker, so there is even less space for
safe ller injection.
Therefore, ller injection into the nose
increases the possibility of necrosis due to extravascular compression by the ller mass. In par-
5.2 Midface
171
ticular, necrosis is likely to occur in the nasal tip
which has thick skin, so it is better to avoid overinjecting llers with too high lifting capacity.
Injecting ller into the supraperiosteum level,
which is the deepest layer during the procedure,
helps to prevent skin necrosis.
If the skin appears to be blanched after ller
injection, it should be assessed whether it is
caused by vasoconstrictors included in the anesthetics. When there is suspicion of skin discoloration due to blood vessel compression, it is
advisable to dissolve the ller with hyaluronidase
to perform decompression (see Sect 6.2.1 complication—skin necrosis).
Blindness
In the ller procedure for nose augmentation,
blindness occurs when ller product inadvertently is injected into the artery and moves retrograde through the dorsal nasal artery to the
ophthalmic artery and eventually blocking the
retinal artery. To prevent this, it is important to
avoid injection into the dorsal nasal artery during
radix treatment. Lift the soft tissue using a pinching maneuver with the opposite hand, and then
place the injection tool in the supraperiosteum
layer. In addition, when the ller is injected, the
dorsal nasal artery can be compressed with the
opposite hand to prevent the backow of the ller
into the ophthalmic artery.
Hematoma
The radix has intercanthal veins in the subcutaneous layer, which may cause side effects from
intravascular injection. In order to prevent this, it
is preferable to pinch using the thumb and index
nger of the opposite hand to sufciently lift the
subcutaneous fat and blood vessels before injecting ller into the supraperiosteum layer.
5.2.8 Nasolabial Fold
Considerations for Three Types of Nasolabial
Folds
The nasolabial fold refers to lines that appear as
the Chinese character for number 8 (八).
Nasolabial folds are generally seen bilaterally,
starting from border of the ala nasi and bridge of
the nose and extend inferiorly to the cheeks.
Nasolabial folds can be divided into three types
depending on the cause (Fig.5.67).
The rst cause is lack of soft tissue volume in
the paranasal area lateral to the ala nasi. There are
patients who have depression over the maxillary
canine fossa, which is the structure that supports
the paranasal area. In such patients, relative to the
nasolabial fat located superior to the nasolabial
fold, there is barely any supercial fat in the
region inferior to the nasolabial fold. Insufcient
volume of the deep fat and soft tissues of the
deeper layers deepens this depression lateral to
the ala nasi. The soft tissue bulge superior to the
fold and the sunken area resemble stairs. Although
it is not an actual wrinkle, a crease-like boundary
is formed (Fig.5.68).
The second type is caused by difference in
skin characteristics. Relative to the skin superior
to the fold, the skin of the upper lip region adheres
tightly to the underlying orbicularis oculi muscle.
With the aging process, the skin superior to the
Fig. 5.67 Three types of the nasolabial folds
172
gion
Loose subcutaneous la
on the cheek r
er
Fig. 5.68 Volume
deciency of the canine
fossa
5 Filler Procedures Based ontheFacial Area
Tr iangular depression of the paranasal re
Fig. 5.69 Tightness difference of subcutaneous tissue around the nasolabial fold
fold along with the buccal fat sags. Over time, the
nasolabial fat superior to the fold becomes more
hypertrophic, while the paranasal area inferior
the fold and lateral to the ala nasi atrophies.
These age-related changes further deepen the
fold, and the difference in depths between the
fold and surrounding skin becomes more pronounced (Fig.5.69).
The third type is not caused by differences in
volume or sagging due to aging. Instead, the
nasolabial fold is formed due to upper lip elevator
muscles, levator labii superioris alaeque nasi,
levator labii superioris, and zygomaticus minor
egion
yer
Tight subcutaneous lay
on the upper lip region
and major muscles. These muscles insert to the
skin where the nasolabial fold forms, lateral to
the nose before nally inserting to the upper lip
and the orbicularis oris muscle (Fig.5.70).
Insertions of the upper lip elevator muscles
form a boundary that prevents the supercial fat
from descending further. Muscle movement during smiling pulls on musculocutaneous area,
causing the area inferior to the fold to appear
deeper and the line more noticeable.
Although classied into three types by cause,
the cause of nasolabial folds is multifactorial and
may be associated with 2–3 of the aforemen-
LL
LLS muscle
e
Orbicularis oris muscle
5.2 Midface
173
Orbicularis oculi muscle
SAN muscle
Fig. 5.70 Upper lip elevator muscles on the nasolabial fold
Zygomaticus minor muscle
Zygomaticus major muscl
Fig. 5.71 Relationship
of facial muscles to
other facial structures in
the nasolabial fold
region—
musculocutaneous
attachment
tioned factors. Unlike in other parts of the cheek,
this area contains a musculocutaneous attachment area and facial muscles course supercially.
In addition, as the structure of tissue layers is different Fig.5.71 and the facial artery runs parallel
to the nasolabial fold, caution is required when
injecting this region (Fig.5.72).
Technique for the Nasolabial Crease
Cases presenting only a slight depression in the
paranasal area will require correction of the mild
crease only. The linear region slightly medial to
the crease is targeted, and a needle is used to
inject the ller along the crease into the subcutaneous layer above the orbicularis oris muscle
using the retrograde linear threading and fanning
techniques (Fig.5.73).
In over 50% of Koreans, the facial artery along
the nasolabial fold and the region where it
branches into the superior labial artery course
supercially, exposed above the orbicularis oris
174
duple
old line
Facial artery on the antegonial notch
Injection la
1.
nasolabial cr
2.
3.
Infraorbital trunk of
x type facial artery
Fig. 5.72 Position of the facial artery around the nasolabial fold
Fig. 5.73 Injection
layer and technique for
the nasolabial crease
Injection into slightly medial side to the
Subdermal layer
Superficial injection for the lines & to
even out the surface (Fern leaf or Duck
walk technique)
yer & technique
ease
5 Filler Procedures Based ontheFacial Area
Facial artery on the nasolabial f
muscle. Vessel injury can be avoided by inserting
the needle in the supercial subdermal layer.
Uneven surfaces that form after the injection can
be smoothened out by injecting a softer ller into
the dermal and subdermal layers (Fig.5.74).
Technique for Nasolabial Fold and Paranasal
Depression
In cases involving both a paranasal depression
and a deep nasolabial fold, the ller is typically
placed in two layers. In the supercial layer, a
soft ller is injected along the crease into the
supercial subcutaneous tissue and subdermal
layer with the inferior portion of dermis. Lateral
to the ala nasi, a deeper plane is targeted with a
rmer ller. Fat layer deep to the muscle or
Ristow’s space, a loose space supercial to the
periosteum, is targeted (Fig.5.75).
In the triangular paranasal depression located
between the alar groove and the crease, a needle
can be inserted perpendicularly to the skin in the
center of the triangle. This is a relatively safe
zone with no major vascular structures. However,
it is important to aspirate to ensure there has been
no vessel injury before injecting (Fig.5.76).
The injection layer is adjusted according to
the severity of the depression. With moderate
depression, the ideal injection plane is the deep
fat compartment deep to the muscles. Severe
Injection into two layers for the deep
nasolabial f
1.
int
the subder
2.
the paranasal deep f
or Rist
base & the nasolabial fold mound
5.2 Midface
Fig. 5.74 Before and after treatment of the nasolabial crease
olds
Top layer
: Soft consistent filler injection
o the superficial subcutaneous or
mal layer
Bottom layer (Paranasal space)
: Firm consistent filler injection into
at compartment
ow’s space
175
Fig. 5.75 Injection planes for the nasolabial folds
Injection techniques
Fig. 5.76 Injection techniques for the paranasal depression
1. Center of triangular spaces requiring volumization
2. Bolus with layering & fanning injection into the depressed paranasal
space
3. Supercial injections for the lines & to even the surface of the alar
176
Ristow’s space of the
5 Filler Procedures Based ontheFacial Area
depressions require larger volumes of ller.
However, injecting large amounts of ller into
the subcutaneous fat layer encompassing the
deep fat will not create projection but rather
cause lateral expansion. In severe cases, it is better to inject into Ristow’s space (Fig.5.77).
To locate Ristow’s space, slightly withdraw
the needle after contact with the bone of the
canine fossa. A loose space can be felt above the
preperitoneal fat overlying the periosteum. With
experience, the loose space could be felt immediately after penetrating the deep fat layer without
actually having to touch the bone and withdrawing the needle.
After the needle has been positioned in the
deep fat compartment or Ristow’s space, add vol-
Deep fat tissue
Fig. 5.77 Ristow’s space for the injection of paranasal
depression
paranasal region
ume by using the towering and layering techniques. During the procedure, use the ngers of
the non-injecting, non-dominant hand to apply
pressure on the bulging tissue superior to the
crease. This will ensure that the ller does not
ascend to the area superior to the crease.
After the depression has been corrected, the
skin surface may be uneven from the demarcations formed between the augmented and nonaugmented areas of the triangular region in the
paranasal region, the alar groove, and crease. A
soft ller should be injected into the subdermal
and dermal layers to smoothen the area (Fig.5.78).
The long oblique creases external to the triangular region extending inferolaterally can be
treated using the aforementioned technique for
nasolabial crease (Fig.5.73).
Technique Using a Cannula
Anatomically, over 70% of Koreans have facial
artery that courses medially to the nasolabial
fold. It has been reported that even in cases where
the facial artery courses lateral to the fold, it runs
within 5mm from the fold in more than half of
the cases. Therefore, safe entry point that minimizes the risk of vascular injury for cannula
treatment can be located with the following
method. Draw a line from the alar base to the
mouth corner and divide the line into thirds. At
the inferior third of this line, make the entry point
5 mm lateral to the crease. Move the cannula
within the subcutaneous layer to reach the triangular region lateral to ala nasi. The injection layer
and techniques are similar to that when using a
Fig. 5.78 Before and after treatment of the deep nasolabial folds with the paranasal depression
Injection entry point &
1.
of nasolabial f
alae
2.
depr
v
3.
t
of the alar base & the nasolabial f
mound
5.2 Midface
Fig. 5.79 Cannula
injection for the
nasolabial folds
177
techniques
Slightly lateral(5mm) to lower 1/3 point
old line from the nasal
to the mouth corner
Layering & fanning injection into the
essed paranasal space for the
olume augmentation
Retrograde linear threading & fanning
echnique for the superficial injections
for the lines & to even out the surface
needle to augment the paranasal area. The layering and fanning techniques are used (Fig.5.79).
After augmenting the paranasal area, the cannula can be withdrawn along the crease, and the
retrograde linear threading and fanning techniques could be used to inject the ller into the
supercial subcutaneous layer to smoothen the
crease. Subsequently, if it is necessary to
smoothen out the uneven surface of the injected
area, a needle can be used to inject a very soft
ller into the subdermal and dermal layers of the
sunken region.
Nasolabial creases that become prominent
when smiling can be treated botulinum toxin.
Weakening the upper lip elevator muscles where
old
they insert to the skin will reduce the severity of
the crease.
Nasolabial fat superior to the nasolabial crease
does not atrophy with age. In fact, it is a fat layer
that hypertrophies over time. The difference in
soft tissue volume between the region inferior to
the fold and the bulging of the nasolabial fat
superior to the fold becomes marked over time,
further deepening the crease. This difference in
volume can be addressed by treating the fat layer
with a lipolytic agent. Moreover, synergistic
effects can be obtained when ller is combined
with threads. Thread will elevate sagging tissue
superior to the nasolabial crease and smoothen
the skin surface, thus maximizing the effects of
the injected ller (Fig.5.80).