Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
178
Lateral view
5 Filler Procedures Based ontheFacial Area
Frontal view
Fig. 5.80 Before and after combination treatment of the deep and severe nasolabial folds
5.3 Lower Face
sider rejuvenating their lips with this simple
ofce-based procedure rather than surgical
5.3.1 Lip andPhiltrum
Pre-procedural Considerations
Lip morphology is a reection of one’s age.
Although cultural differences in dening “beautiful lips” exist, fuller lips, high tonicity, and
prominent Cupid’s bow are perceived as a sign
of beauty in general. On the other hand, thinner
lips, less tonicity, and obscure Cupid’s bow usually are regarded as aged features in terms of lip
morphology. With increasing age, the smile
becomes elongated and less appealing. Along
with recent advances in ller procedures, despite
its possible complications, many patients con-
manipulations.
Lip rejuvenation with minimally invasive
techniques are gaining popularity.
The upper lip is symmetric to the lower lip, but
the latter is thicker than the former. Even though
an ideal upper to lower lip ratio is different according to Eastern or Western countries and the sex, the
ratio of 1:1.6 is generally considered ideal similar
to a golden rule. From the front view, it is better
when an eversion of the upper lip and the red line
are seen 2~3mm above the upper teeth. On the
lateral view, it is more aesthetically pleasing if the
upper lip is placed 2mm in front of the lower lip.
5.3 Lower Face
Fig. 5.81 Lip anatomy
179
Moreover, a break point on the slightly curved line
above the vermillion border like the supratip break
of nose is considered beautiful (Fig.5.81).
In the sagittal view of the lip, the orbicularis
oris muscle is located more posteriorly than the
center of the lip anatomy. The oribicularis oris
muscle attaches to the vermillion border by forming the oribicularis oris angle at the end of its running (Fig.5.81).
Lips become at and the height of the vermillion decreases as aging. Histologic studies show
that the overall thickness of the skin decreases
with the reduction of collagen and elastic bers
in the epidermis and dermis. Furthermore, the
atrophy of the orbicularis oris muscle and the
widening of the oribicularis oris angle cause lips
to become at and lose their volume. The fat
compartments of the lip consist of the supercial
and deep fat tissues which are divided by the oribicularis oris muscle (Fig.5.82). The volume of
supercial fat tissues increases with the aging
processes, but the suborbicularis oris fat which is
the same as the deep fat tissues is reduced. It is
coincides with changes of other fat tissues in the
face. These studies have shown us evidence to
inject llers into the suborbicularis oris fat layer
that is placed between the mucosa of the vermillion and the orbicularis oris muscle.
Though the volume reduction of the lip is
viewed as a natural process with aging, it is not
Fig. 5.82 Fat compartments of lip and chin
obvious. It is apparent that the volume of muscles
and tissues decreases, but the supercial fat
tissues of the lip increase so that the entire volume of the lip is conserved. As a result, the vermillion (dry mucosa) is not seen in aged lips. It is
more plausible that lips become at by the disappearance of the break point not because of the
reduction of total lip volume but because of internal rolling of lips due to the changes of many elements, such as skin tissues, the orbicularis oris
muscle, and fat tissues.
There are several tips to avoid iatrogenic large
vessel injury with sharp needles. When confronting the vessel wall of the relatively large superior
and inferior labial artery, one can feel slight tension which requires sufcient clinical experience.
So, a most practical tip is to use the mouth corner
area which is located relatively farther away from
major vessels.
The main blood supply of lips is derived from
the SLA (superior labial artery) and the ILA
(inferior labial artery). The SLAs come directly
from the facial artery, and the mean diameter of
the SLA is 1mm. Even though the bilateral SLAs
run symmetrically and anastomose in the midportion of the upper lip with providing the columellar branch superiorly, the SLAs are sometimes
180
Fig. 5.83 Injection techniques of lip augmentation
5 Filler Procedures Based ontheFacial Area
unilateral and asymmetric. The SLAs usually traverse between the mucosa and the orbicularis oris
muscle at the same level with the vermillion border (Fig.5.81). The ILAs, on the other hand, routinely run between the mucosa of the inner aspect
of the lip and the muscle, which means that the
ILAs are more closely positioned to the alveolar
margin than the SLAs.
Therefore, ller injections at the supercial fat
layer are more favorable than at the areas adjacent to the orbicularis oris muscle. If deep ller
injections are needed, at the lower lip, injections
at the suboribicularis oris fat are relatively safe
because the ILAs run outside the lower lip at the
alveolar margin. On the other hand, at the upper
lip, more attentions are needed on ller injections
since the SLAs lie inside the upper lip.
Technique
Generally, there have been two different methods
in rejuvenating lips. Most physicians prefer to
inject from the skin side along the vermilion border (Fig. 5.83). Others choose to inject at the
mucosal side of the lip. The former technique
makes it possible to rejuvenate the lips with relatively lesser volume compared to latter one. In
addition, injecting llers from the skin side is
benecial to patients without any prominent
break points of the lips.
However, this technique is not appropriate to
the patient with well-dened break points.
Rather, ller injections in these patients disrupt
the originally well-dened lip contour. Therefore,
injecting llers from the mucosal sides is very
critical in these patients in terms of achieving
maximal vermilion eversion effect and preservation of their original break points. Keep in mind,
more volume is required and foreign body sensation can be present but rare.
A topical anesthetic (EMLA cream) lidocaine
and prilocaine cream can be applied for 30minutes to the area to be treated. Then, perform a
single injection of ller in the upper and lower
lips using the retrograde technique, with almost
1cm distance between entry points (and in the
lower one if it was necessary). Fillers should be
injected into the inner side of the lips to avoid any
visualization of injected llers. When patients
want to accentuate their central tubercle of upper
lip area, one can augment this special area with
small amounts of llers (0.1~0.2cc).
Immediately after the injections, to minimize
the potential ecchymosis and edema in the injection sites, apply direct pressure with ice compresses until there are no signs of bleeding.
Massaging of the injected area can also be performed when it was considered necessary to
spread out the injected ller material more evenly
(Fig.5.84).
Total dose for lip augmentation should be
determined by the degree of asymmetry. In case
of asymmetry, more ller should be added to
decient area and overall dose should be
increased accordingly. In general, 0.3~0.4cc of
ller can be used on each lip and add more volume when required for better aesthetic outcomes.
Maximal dose per lip (upper or lower lip) in a
Modiolus
5.3 Lower Face
Fig. 5.84 Lip augmentation using ller
patient should not exceed 1.5cc because when
that volume is exceeded, it makes the treated lip
look too swollen and “puffy.” This excess ller
just makes lips thicker rather than rotating them
appropriately. Therefore, caution should be taken
not to overly inject llers.
Injection of the central tubercle of the upper
lip area is dependent on the patient’s opinion. In
general, Asians want to augment their central
tubercle, while Westerns do not want their central
upper lip to be augmented.
Post-procedural management is very simple.
Physicians should alert patients that they can feel
a foreign body sensation with their tongue initially, which spontaneously resolves over time.
Also inform the patient that 10–20% of the initial
volume can be lost after 1week.
181
5.3.2 Marionette Line (Static
Labiomandibular Fold)
Types and Denition of Marionette Line
In medical literature, numerous terms have been
used to refer to the creases that form around the
mouth corner. The author has used the most frequently used terminology to discuss these creases.
In Caucasians, the modiolus, the small and
thick muscular nodule formed by the chiasma of
muscles near the mouth corner, is located mostly
at level of or above mouth corner. In contrast, the
Fig. 5.85 Location of Asian modiolus
modiolus in Koreans is mostly located approximately 11mm lateral and 9mm inferior to the
mouth corner. Therefore, compared to
Caucasians, Asians are more prone to develop
downturned corners of the mouth, ptosis of the
mouth corner, and creases in the area (Fig.5.85).
182
Nasolabial
compar
Medial cheek
compar
Both lat
lip compar
C
compar
5 Filler Procedures Based ontheFacial Area
Commissural lines, which are the vertical
depressions at the mouth corner, are caused by
the difference in depths of the depressor anguli
muscle bers (supercial layer) and the orbicularis oris muscle bers (intermediate layer) converging at the modiolus. These lines are more
visible in Asians than in Caucasians due to the
anatomic location of modiolus.
If the lateral lower lip fat compartment (one of
the three lateral and central supercial fat compartments located inferior to the lips) atrophies,
the commissural line that forms at the junction
between the cheek and the lips and degree of
tment
tment
eral lower
tment
mouth corner drooping becomes more severe
(Fig.5.86).
The supercial anatomic boundary between
the cheek and chin that worsens with the difference in tissue thicknesses is called the cheek-chin
crease. As the line also gives the impression of
sadness/depression, it is also called the melolabial fold (Fig.5.87).
If volume loss of the lower lateral lip compartment, the primary cause of this fold, is corrected
by volume augmentation, then both an improvement in the sunken area/crease and a lifting effect
of the mouth corner could be attained (Fig.5.88).
Inferior orbital
compartment
Middle cheek
compartment
Buccal extension
of buccal fat
entral lower lip
tment
Jowl fat above
the commisural line
Superficial fat below
the commisural line
Fig. 5.86 Difference of tissue thickness around the mouth corner
Inferior jowl
compartment
Superior jowl
compartment
Jowling Marionette line Prejowlsulcus
5.3 Lower Face
Fig. 5.87 Types of the mouth corner line
183
Fig. 5.88 Before and after treatment of the melolabial fold with loss of deep fat volume
shows, it is unclear as to when this term was used
for the rst time and by whom. As a static,
oblique fold that extends from the mouth corner
to the jawline, it is also referred to as static labiomandibular fold (Fig.5.87).
The causes of melolabial folds include maxillary and mandibular resorption, inferior displacement due to gravitational pull, loss of deep
fat layer below the depressor anguli oris muscle,
compression of the depressor anguli oris muscle,
Fig. 5.89 Marionette line with the prejowl sulcus and
jowling
a tethering effect of the mandibular ligament,
sagging of redundant skin and connective tissue,
and sagging of jowl and buccal fat. Depending
When the melolabial fold extends to the mandibular border and the prejowl sulcus is observed
in the jawline anterior to the fold, it is called the
marionette line (Fig.5.89).
Although the term marionette line is known to
have originated from its similar appearance to the
mouths of marionettes used in European puppet
on the cause, combination treatment may be
needed. In addition to llers for correcting the
mandibular border line including the prejowl
sulcus and sunken area anterior to the marionette
line and mouth corner, toxin injections for
improving the mouth corner depression caused
by contraction of the depressor anguli oris mus-
184
5 Filler Procedures Based ontheFacial Area
Table 5.2
line
1. Causes of the deepening melolabial fold
(marionette line)
Resorption of the maxillary & mandibular bone
Gravitational downward displacement
Depressed labiomandibular fat with the sagging of
Tethering effect of the mandibular ligament
Compression of the depressor anguli oris muscle
Tight lower lip compartment with redundant skin &
2. Combination procedures
1. Botulinum toxin injection to improve the mouth
2. Removal of the jowl fat
3. Thread lifting
4. Filler injection for the mandible border line &
Considerations for the treatment of marionette
jowl & buccal fat
connective tissue above the marionette line
corner depression caused by the depressor anguli
oris muscle action
mouth corner
cle, jowl fat removal, or tissue lifting using
threads are typically performed together
(Table5.2).
The marionette line (static labiomandibular
fold) is present even in the expressionless state. It
usually starts from the mouth corner and extends
obliquely along the posterior border of the
depressor anguli oris muscle. In contrast,
dynamic labiomandibular fold occurs due to contraction of the lip elevators and depressors that
insert at the modiolus to lift or lower the mouth
corner. It refers to the fold that starts from the
area near the mouth corner extending obliquely
along the anterior border of the depressor anguli
oris muscle (Fig.5.87).
In older people with more severe wrinkles, the
marionette line is present in the static state, and
the line may even be one long continuous line
with the nasolabial fold extending from the side
of the nose to the jawline. Even in young adults,
it can be present as a dynamic wrinkle that is
more noticeable when forming facial
expressions.
Dynamic labiomandibular folds can be exacerbated by the lateral pulling effect of the platysma and zygomaticus major muscles. The
superior 1/3–1/2 of the depressor anguli oris
muscle consists of only myobers, while the
Fig. 5.90 Bowing effect of the depressor anguli oris
muscle by the lateral pulling
inferior boundary is rmly anchored by the mandibular ligament, a true retaining ligament that
extends to the bone. When lateral pulling occurs
due to smiling of making facial expressions, the
retaining ligament acts as a xation point that
rmly holds the inferior aspect of the muscle to
the bone. Consequently, the area attached to skin
shows a bowing effect, where the area bends like
a bow (Fig.5.90).
Therefore, when treating dynamic labiomandibular folds, it is important to determine the
underlying anatomic issue and distinguish them
from the static labiomandibular fold or marionette
line. The treatment principle is same as that for
dynamic perioral wrinkles that worsen with aging,
as explained in the section on perioral wrinkles.
Procedure for Commissural Line and
Melolabial Fold
Inject ller along the crease. Sunken area anterior
to the crease can be augmented simultaneously.
Typically, a needle is used for injection into fat
layer above the muscle by linear threading and
retrograde fanning (Fig.5.91).
As the injected ller lls the sunken area, it
effaces the fold and lifts the mouth corners.
Caution should be exercised during the procedure
to avoid injuring the branches of the facial and
inferior labial arteries.
Injection entry point
Slightl
melolabial f
ri
Injection of sof
mar
Injection
1.
t
2.
walk technique
Injection entry points
along the line when using the needle
the subcutaneous injection of sof
mar
2.
position fr
the mandib
cannula f
Injection
2.
layering technique for the cannula
5.3 Lower Face
y medial to the commissural line or
old along the line or with
ght angles along the line for subdermal
t filler to smooth out the
gin of the line
185
Retrograde fanning & linear threading
echnique
Superficial multiple fern leaf or duck
Fig. 5.91 Injection techniques for the commisural line and melolabial fold
1. Slightly medial to the marionette line
to smooth out the surface including
gin of the line
Medial to depressed area on lower 2/3
om the oral commissure to
le border when using the
or the volume replacement
for
t filler
techniques
1. Linear threading, retrograde fanning &
cross hatching technique for the needle
Retrograde fanning, cross hatching &
Fig. 5.92 Injection techniques for the marionette line
techniques
Procedure for the Marionette Line (Static
Labiomandibular Fold)
For lines with mild to moderate severity, a needle
is typically used to add volume into subcutaneous
fat layer above the muscle layer. Volume is
enhanced using the linear threading technique
along the linear region slightly medial to the marionette line, while the sunken area anterior to the
line is augmented using the retrograde fanning or
cross-hatching techniques (Fig.5.92).
By carefully considering the direction of
branches of the facial, inferior labial, labiomental, and submental arteries, vascular injuries may
be avoided (Fig.5.93).
In cases with deep creases and severe hollowness, the submuscular fat layer is usually augmented. To avoid neurovascular injury, it is better
to use a cannula (Fig.5.94).
The entry point for cannula is located in the
inferior third of the line that connects the mouth
corner and mandibular border line. To smoothen
the deep lines and uneven jawline caused by the
prejowl sulcus, use the retrograde fanning and
layering techniques to inject ller into the fat layers deep and supercial to the muscles (Fig.5.92).
Caution should be taken to avoid injuring the
mental artery and nerve exiting the mental foramen and facial artery near the jawline (Fig.5.95).
The pressure should be applied against the
bulge superior to the line with the non-dominant,
non-injecting hand to ensure the ller does not
spread to this area. After adequate volumization,
soft llers may be injected into the subdermal
and dermal layers, to smoothen out the surface.
The depressor anguli oris muscle originates
broadly from the mandibular border and narrows
into a triangular shape, inserting to the risorius
186
Right & left superior labial arteries
Right submental ar
ry
Right in
Right & left ascending mental arteries
muscle that’s pulled up
Right & left mental nerves from the mental foramens
Fig. 5.93 Main vessels
near the marionette line
5 Filler Procedures Based ontheFacial Area
tery Left submental arte
ferior labial artery Left inferior labial artery
Fig. 5.94 Supercial and deep fat medial to the marionette line
Fig. 5.95 Location of the mental foramen
Depressor anguli oris muscle
Superficial fat above the muscle
Deep fat under the muscle
Depressor anguli oris
and orbicularis oris muscles near the mouth corner. Excessive contraction of this muscle causes
downturned mouth corners. In such cases, toxin
injection could be used to weaken the depressor
anguli oris muscles (Fig.5.96).
5.3.3 Perioral Wrinkles (Smoker’s
Line)
5.3.3.1 Denition ofPerioral Wrinkles
As people age, wrinkles appear around the
mouth. Dynamic wrinkles are visible when peo-
Orbicularis oris muscle
Depressor anguli oris muscle
Modiolus
5.3 Lower Face
187
ple smile. As people age, the dermal layer also
ages and fat volume decreases, causing static
wrinkles to appear. Treatment with llers is necessary to improve these wrinkles.
Perioral wrinkles vary in appearance and
name due to the various movements of surrounding muscles (zygomaticus major, risorius, platysma, depressor anguli oris muscle). Although
individual differences exist, the most common
types of wrinkles around the mouth are as follows (Fig.5.97):
• Smoker’s line (vertical wrinkles of the upper
and lower lips): Fine wrinkles that extend per-
pendicularly from the vermillion border of the
lips due to contraction of the orbicularis oris
muscle.
Fig. 5.96 Location of the depressor anguli oris
muscle
• Oblique lip-chin creases: Wrinkles that occur
obliquely under the corners of the mouth.
• Labiomental crease: Wrinkles that appear horizontally in the center between the lower lip
and the chin.
• Extended type of nasolabial fold: The nasolabial fold extends to the lower level of the
mouth and is not connected to the oral
commissure.
• Static labiomandibular fold (marionette line):
Wrinkles that extend outward from the oral
commissure to the mandible.
• Dynamic labiomandibular fold: Wrinkles that
occur when smiling or making facial expressions, caused by the contraction of the muscles around the mouth, pulling the skin to the
lateral side.
5.3.3.2 Injection Technique
Before the procedure, it is recommended that the
physician checks the patient’s jawline symmetry,
the location of the perioral wrinkles, and any sagging of the cheeks and conrms the treatment
area by looking in a mirror together with the
patient.
Treatment of most perioral wrinkles differs
from that of the marionette line (static labiomandibular fold). In the treatment of the marionette
line, both deep and supercial injections are
required if the fold accompanies a volume loss of
the fat. Perioral dynamic wrinkles become static
as they age. Attempting to treat the wrinkles by
Fig. 5.97 Types of perioral wrinkles