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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_5214_Библиотеки_им_академика_М_И_Перельмана.pdf
188
Fig. 5.98 Proper layer
of ller injection for
perioral wrinkles
correction is a
supercial layer (deep
dermis or subdermal
layer) / (with kind
permission of
MANIAMIND)
5 Filler Procedures Based ontheFacial Area
lling the volume may look bumpy and awkward,
so care should be taken to ensure the wrinkles are
only slightly attened and made to look natural.
A needle is generally used more than a cannula as an injection tool. Anesthesia before needle injection is sufcient with topical anesthesia.
Inject a soft ller with low viscosity into the subdermal layer or deep dermis (Fig.5.98).
There are several techniques for the injection
method such as the retrograde serial threading
technique, retrograde fanning technique,
Mantoux test injection technique, and droplet
technique (see Sect. 4.4.1 injection technique).
Treatment of Smoker’s Line
In the treatment of smoker’s lines, the injection
depth is subdermal or intradermal. Inject a soft
HA ller with low viscosity using 30G/31G needles along the vermillion border of the upper and
lower lip. Unlike lip augmentation, this does not
require a large amount of ller. Conversely, a
large amount injected along the vermillion border
can lead to irregularities.
Treatment of smoker’s line requires combination with toxin. Toxin can be used to weaken
orbicularis oris muscles so that the skin is less
folded and wrinkles less obvious, and the effect
of ller treatment can be maximized. Toxin is
injected 0.5units at approximately 1cm intervals
along the vermillion border. If toxin injection is
too much, orbicularis oris muscles may be exces-
sively relaxed, making it difcult to close the
mouth, and saliva may leak out when brushing
the teeth.
5.3.3.3 Precautions/Side Eects
Vascular Complication: Bruising
Bruising is caused by subdermal plexus injury
when a subdermal needle is injected to treat wrinkles around the mouth. Bleeding or bruising from
capillary injury may occur, but there is little
chance of injury to the facial artery and facial
vein. However, there is a supercial course of the
facial artery between the zygomaticus major and
the risorius muscle outside the orbicularis oris
muscle. In other words, the facial artery may
reach the tissue below the skin at the area 1.5cm
lateral of the oral commissure where the facial
artery gives off the superior labial artery branch.
If you palpate this area, you will feel an arterial
pulse, and sometimes the pulsation is visible to
the naked eye. Therefore, when injecting ller
into the wrinkles around the oral commissure, the
artery must be checked, and it is better to avoid
the procedure in the subcutaneous fat layer
(Fig.5.99).
Lump/Irregularity
Care should be taken when injecting too supercially into the dermis, as a lump may occur. After
injecting the ller, use a teaspoon or roller to
massage sufciently to prevent lumps. In
addition, it is helpful to prevent a lump or irregu-
5.3 Lower Face
a
b
Fig. 5.99 Cautions for vascular complication during
perioral wrinkles correction. (a) Blue dotted circle: supercial winding of the facial artery (with kind permission of
MANIAMIND). (b) Rea dotted circle: pulsation of the
facial artery is sometimes visible without palpation
larity by dividing the procedure into multiple sessions with small amounts injected rather than
completing the procedure in one single session.
189
Fig. 5.100 Inverted S-line from lower lip to chin
to the chin look beautiful as an inverted-S line
(Fig.5.100). In the lateral view, the chin should
look beautiful just on the Ricketts line. The
Ricketts line is the line from the nasal tip to the
chin tip in the lateral view. In Korea, it is considered that the upper and lower lip margins should
be located on this line or 1–2mm behind the line
to look harmonious. Correcting the chin with a
ller to coincide with this line can harmonize the
overall lateral contour (see Sect. 4.4.1).
• When correction is needed in the frontal view
5.3.4 Chin Augmentation andJaw
Line Contouring
If the chin is not fully developed or if the teeth are
protruding, chin augmentation can produce
excellent results. In the past, silicone implants
were widely used, but nowadays, the ller has
become a substitute for this. Since the chin is not
complicated in structure, side effects are rare and
even beginners can easily try.
5.3.4.1 Design
Western patients prefer treatments to make the
mandibular angle and jaw lines look more distinct
or to smoothen an uneven jawline. On the other
hand, many Koreans (Asians) have short chins or
retracted chins and prefer to correct them.
• When correction is needed in the lateral view
When the contour of the forehead-nose-chin is
viewed in oblique views, the curves from the lips
On the frontal view, if the chin looks short or
wide, one can make the chin slightly sharper or
longer to make the jawline look slimmer.
Make the length from philtrum to chin about
1/3 of the total face length. In the West, the ratio
of forehead to nose to chin is preferably 1:1:1,
and in the East, the ratio 1:1:0.8 is preferred.
To summarize, to make a beautiful chin, the
retracted chin is augmented to project slightly
anteriorly and a short chin is augmented to elongate slightly downward (Fig.5.101).
However, in actual clinical practice, there are
more important design principles to consider.
Even if llers are injected into the chin to create
an ideal prole based on the Ricketts line, the
result must also be aesthetically pleasing from the
frontal view. For individuals with smaller chins,
particularly among Asians, elongating the chin to
align with the Ricketts line can result in an overly
prominent appearance when viewed from the
front, leading to a very unnatural look. This type
of unnatural appearance is quite common with
190
5 Filler Procedures Based ontheFacial Area
ller procedures. Therefore, the Ricketts line
should be regarded merely as a reference, not an
absolute guideline. It is more crucial to create a
natural chin line when viewed from the front. If
there is a discrepancy between the natural appearance of the chin line from the front and the ideal
chin line according to the Ricketts line from the
side, achieving a natural appearance from the
frontal view is far more desirable.
5.3.4.2 Anatomy
The layers around the chin and jaw are divided
into skin-subcutaneous tissue (supercial fat) and
muscle-deep fat-bone (mental protuberance and
mandibular body). At the tip of the chin, there is
thin layer of deep fat under the muscle layer. In
chin augmentation and jaw contouring, the injection layer should be the supraperiosteum and
subcutaneous fat.
Mentalis Muscle (Fig.5.102)
Asians tend to have a “cobble-stone” appearance
due to the development of the mentalis muscles
due to their oral structure. Fillers may not be sufcient to correct the volume in an aesthetically
pleasing manner. Combining with toxin treatment into the mentalis muscles has the advantage
of smoothening the skin dimples and maintaining
the corrected shape longer.
In addition to the chin shape, the mentalis
muscle asymmetry must be checked before the
procedure. When ller correction is satisfactory,
but asymmetric muscle correction is not done
properly, the physician may encounter complaints after the procedure.
Vasculature/Artery
Blood vessels around the chin include the mental
artery from the mental foramen and the inferior
labial artery. For midline injections, the blood
vessels are located outside the treatment area,
making the procedure relatively safe. The central
branch of the submental artery can sometimes
run into the midline, but due to its small diameter,
the injection tool is unlikely to be inserted into
the vessel. Also, since supercial fat is abundant,
there is less risk of skin necrosis by extravascular
compression.
5.3.4.3 Choice ofFiller
Chin augmentation and jaw line contouring can
Fig. 5.101 Aesthetic lines—Ricketts line
a
Fig. 5.102 Injection layer for chin augmentation. (a) Filler is injected into the supraperiosteum level. (b) Filler can be
additionally injected in the subcutaneous layer
be injected at two different depths and using dif-
b
5.3 Lower Face
ferent llers selected accordingly. Use HA or
CaHA llers which have high viscoelasticity and
good shape when injected into the deep layer.
Inject a medium viscosity ller into the supercial layer.
5.3.4.4 Injection Technique forChin
Augmentation
Check with the patient whether to project the jaw
forward or elongate downward before the
procedure.
In addition, the hypertrophy of mentalis muscle needs to be checked along with the asymmetry of the chin.
In the case of chin augmentation, most of the
procedure can be performed without any major
discomfort by just applying topical anesthetic
agent or inject local anesthesia at the entry point.
However, pain-sensitive patients need to be anesthetized through a mental nerve block.
Needle Injection (Fig.5.103a)
In general, needles are more frequently used than
cannulas for chin augmentation. Use a needle
with 25/27G to inject high viscoelastic llers.
Since there is little risk of vascular accident, it
can be performed relatively safely. Inject the needle vertically in the midline, touch the bone,
retract slightly, and inject the ller. In other
words, inject into the supraperiosteum level
below the muscle layer. Inject using the bolus
technique and adjust the bevel direction of the
needle in the cephalic direction when projecting
and in the caudal direction when elongating. If
deep injection alone does not provide satisfactory
correction, additional medium viscoelastic ller
can be injected into the supercial fat layer over
the muscle layer.
Cannula Injection (Fig.5.103b)
It is better to use a cannula for evenly spreading
over a wider range. Using retrograde fanning
techniques, a cannula with 21/23G can be used to
inject into the supraperiosteum layers and subcutaneous layers.
The entry point can be made on the midline or
on both sides of the midline.
191
Fig. 5.103 Entry point for chin augmentation. (a) Entry
point for needle injection, (b) entry point for cannula
injection
Fig. 5.104 Toxin injection points in the mentalis muscle
Inject the cannula deep until it touches the
bone, retract slightly, and inject it into the supraperiosteum layer below the muscle.
Immediately after the chin augmentation procedure, it may appear to be uniformly injected
due to the edema, but if you carefully palpate,
you may feel the uneven areas. In such a case,
massage with your hands and inject additional
llers into areas with irregularities or depressions
so that you can maintain a smooth shape without
bumps after edema is resolved.
Botulinum Toxin Injection into the Mentalis
Muscle (Fig.5.104)
Many patients undergoing chin augmentation
due to their micrognathia have mentalis muscle
hypertrophy resulting in skin dimpling. Injecting
192
5 Filler Procedures Based ontheFacial Area
toxin in the mentalis muscle not only eliminates
dimples but also relaxes the tension of the muscles so that the corrected shape maintains longer
after ller injection below the muscles.
Inject into the muscle at points 0.5cm lateral
of the midline of the chin, two-third the distance
between the vermillion border of lower lip and the
end of the chin. The proper injection layer is when
the needle is slightly retracted after it touches the
bone. Inject botulinum toxin 2–4U per side.
Patients with severe cobble stone appearance
can obtain satisfactory results with botulinum
toxin pretreatment.
If the left and right muscles are not symmetrically corrected after the rst procedure, a second
touch-up procedure will be needed.
5.3.4.5 Injection Technique forJaw
Line Contouring
Jaw line contouring can be performed for both
old and young patients. In older patients, sagging
produces a pre-jowl sulcus, and the jaw line is not
smooth, so ller correction is necessary. In young
patients, the jawline may be depressed on both
sides of the chin after chin augmentation. It
occurs at the boundary of the chin (mental protuberance) and mandible body, which requires
additional jaw line contouring after chin
augmentation.
Needle Injection (Fig.5.105)
Insert a 25/27G needle vertically or obliquely
into the boundary of the chin and mandible body.
Penetrate into the depressor anguli oris muscle
and platysma muscle, an then inject into the
supraperiosteum level.
Cannula Injection (Fig.5.106)
When injecting with a cannula, two entry points can
be created. The rst is to make an entry point medial
to the boundary of the chin and mandible body and
then insert the cannula toward the mandible body.
The second is to make an entry point below the
anterior border of the masseter muscle and then
insert the cannula toward the chin. At this time, special care is needed not to damage the facial artery
when creating the entry point with the needle.
A 5cm cannula with 21/23G can be injected
into both the supraperiosteum level and subcutaneous fat layer. Subcutaneous fat of the mandibular
body is thinner than that of the chin. The mandibular ligament is attached to the skin and holds the
skin rmly, so it may not be smooth when entering
with the cannula. Slowly insert the cannula while
touching the bone and inject ller using the retrograde linear technique. When injecting into the
subcutaneous layer, retract the tool without removing from the entry point then advance it into the
subcutaneous layer for injection.
a
Fig. 5.105 Jawline contouring—needle injection. (a) Needle penetrate into the depressor anguli oris muscle and pla-
tysma muscle. (b) Filler is injected into the supraperiosteum level
b
5.3 Lower Face
193
a
Fig. 5.106 Jawline contouring—cannula injection. (a)
Two entry points for cannula insertion. The rst entry
point is made medial to the boundary of the chin and mandible body, and then the cannula is inserted toward the
mandible body. The second entry point is made below the
b
c
anterior border of the masseter muscle, and then the cannula is inserted toward the chin. (b) Filler is injected into
the supraperiosteum level. (c) Filler can be additionally
injected in the subcutaneous layer
Combination with Toxin (Jaw Line
Lifting- Nefertiti Lift) (Fig.5.107)
By paralyzing and releasing the platysma muscle
along the jaw line, it can improve the sagging
jaw.
Injecting too shallowly will not be effective.
Therefore, it should be injected deeper than the
subcutaneous layer. Intradermal and subdermal
injections are all possible. The dose is about
10–15U per side, divided into multiple points on
the jawline at 1.0–1.5cm intervals.
5.3.4.6 Precaution/Side Eect
Vascular Complication
• Chin augmentation procedures are relatively
safe from vascular complications.
• Be careful not to damage the facial artery
when injecting into the subcutaneous layer
during jaw line contouring.
Fig. 5.107 Jawline lifting using botulinum toxinNefertiti lift. Blue dots, toxin injection points
Nodule/Depression
• When the amount of subcutaneous fat is too
small or the skin is thin during chin augmentation, a nodule may occur after subcutaneous
194
5 Filler Procedures Based ontheFacial Area
injection. Therefore, it is recommended to rst
inject at the supraperiosteum level if possible
and to inject into the subcutaneous layer in
small amounts only when necessary.
• After the chin augmentation, the jawline may
be depressed at the boundary of the chin and
the mandible body. Additional ller injection
for the jawline contouring can be performed to
create a harmonious jawline.
Migration
• During chin augmentation, special attention is
needed as it may enter the oral cavity rather
than the mental protuberance when the injection is too close to the lower lip.
• When elongating the chin downward, if the
injection direction is too downward or amount
is too much, the ller may migrate toward the
platysma muscle. Since the ller can move
downward along the plane of the platysma
muscle, direct the injection tool above the tip
of the chin, and use your thumb and index nger of the opposite hand to prevent the ller
from migrating.
5.4 Skin Booster Procedures
Rather than aiming to add volume to a specic
area, skin booster procedures are primarily
intended to introduce llers throughout the facial
skin to improve overall skin quality. Unlike traditional llers that focus on volumization, skin
boosters are designed to rejuvenate the skin by
delivering various substances through microinjections. These substances may include PDRN
(polydeoxyribonucleotide), PRP, EGF, and other
growth factors, all of which serve as skin boosters. In this chapter, we will focus specically on
the llers used for skin boosters.
Skin boosters are commonly injected into the
dermal layer, where they are slowly absorbed and
effectively hydrate the skin over time, enhancing
its texture and elasticity. By retaining moisture,
the skin appears rmer and more luminous.
Recent advancements in drug delivery techniques
have allowed for more effective and even distribution of these substances, leading to sustained
skin improvement.
There are various forms of skin boosters,
some of which use a polymer matrix to gradually
release active ingredients over time. For example,
free hyaluronic acid (HA) can be used to deeply
hydrate and improve skin tone. However, due to
its fast absorption, HA may not provide
long- lasting effects, necessitating repeated treatments. To address this, more advanced products
have been developed that release HA gradually or
combine it with other substances for sustained
results. This technique is particularly useful for
patients with early signs of aging who seek minimal downtime.
For rmer, longer-lasting results, other biostimulatory materials like PLA (poly L-lactic
acid) are often used. PLA, introduced under the
brand name Sculptra in 2004 and approved by the
FDA, has gained popularity as a ller for collagen stimulation. By triggering the body’s natural
collagen production, PLA treatments provide
gradual and long-lasting improvements in skin
texture and elasticity.
PLA may be mixed with other components to
further enhance its effectiveness. Some formulations include additives such as H2O2, which
enhance the efcacy of the treatment by facilitating deeper penetration and reducing inammation. In recent years, other biocompatible and
biostimulatory materials like PLLA (poly L-lactic
acid) and PCL (polycaprolactone) have been
introduced. These substances not only stimulate
collagen production but also provide long-lasting
volumization and are used frequently in modern
skin booster procedures.
These advancements in skin booster treatments have made them a popular choice for
patients looking to improve skin quality without
signicant downtime. The gradual, naturallooking results have broadened the appeal of
these procedures among patients seeking subtle
and effective skin rejuvenation.
5.4 Skin Booster Procedures
195
5.4.1 Manual Injection Techniques
When injecting hyaluronic acid llers manually,
a ne needle (typically 30–34G) is used to introduce the ller into the supercial dermis. To
apply llers across the entire face, injections are
typically administered at intervals of approximately 1.5–2cm. Cannulas, such as those used
for procedures requiring deeper injection (e.g.,
mesotherapy), are generally avoided in favor of
needles, which allow for greater control and precision. This method utilizes the smallest possible
amount of ller in each entry point, which facilitates even distribution across the facial area.
For areas that require delicate handling, needles no longer than 5 mm are recommended.
Shorter needles are preferable, especially when
injecting into the supercial dermal layer, as they
minimize the risk of tissue trauma and allow for
precise ller placement. Injectors should employ
a variety of techniques, including adjusting the
angle of entry and needle depth based on the
patient’s specic skin condition. For instance,
needles may be inserted at a 45° angle in certain
areas to avoid vascular complications and achieve
uniform distribution of the ller.
Due to the manual nature of this procedure,
there are multiple injection techniques available,
each suited to specic areas of the face and levels
of patient sensitivity. Each injector has a preferred technique, though the ultimate goal is to
achieve an even and natural appearance across
the treated area. For certain procedures that
require high precision, injecting in a multilayered
or fan-like pattern ensures that the ller disperses
evenly without creating lumps or irregularities.
One major consideration is the patient’s facial
symmetry. While llers should be injected evenly,
injectors must also account for each patient’s
unique anatomical structure. Special attention
should be paid to areas that are more prone to
asymmetry or volume loss to achieve a balanced
appearance. Furthermore, due to the risk of overcorrection in some areas, injectors should gradually build up volume, especially in sensitive or
delicate zones, to avoid an unnatural result.
Fillers not based on hyaluronic acid, such as
those containing PLLA (poly L-lactic acid),
require a different approach. Due to PLLA’s
unique biostimulatory properties, they should be
injected at a deeper level, targeting areas with
substantial collagen loss. Additionally, PLLA
llers may cause transient swelling, so patients
should be informed about the expected recovery
process.
By tailoring the injection technique to the specic ller type and treatment area, practitioners
can provide patients with more natural, longlasting results and reduce the risk of adverse
effects.
5.4.2 Automated Injection
Techniques
Automated injection devices typically use a
method where a needle tip is placed close to the
skin, and the device rhythmically injects the ller
into the dermis. Among the most commonly used
devices for automated injection is the dermal
injector. This device allows for consistent, controlled doses in multiple points across the skin.
Some devices are equipped with multiple needles, allowing for several tiny punctures in a single application, thereby enabling a broad
distribution of the ller. Automated devices typically use a 34G needle, which is small enough to
minimize discomfort while ensuring precise ller
placement.
These devices can deliver up to 720 injections
per minute, making them highly efcient for skin
booster procedures. The fast, repetitive injections
effectively enhance skin hydration and elasticity,
producing an overall rejuvenating effect. While
these devices provide reliable results for skin
boosters and similar treatments, care must be
taken when using automated devices on patients
with sensitive skin or specic needs.
The use of automated injectors also requires a
thorough understanding of skin anatomy to avoid
potential risks. For instance, if the needle penetrates too deeply or at an incorrect angle, there is
196
5 Filler Procedures Based ontheFacial Area
a risk of tissue trauma or irregular ller distribution. Furthermore, automated devices should
only be handled by trained professionals, as
incorrect usage can lead to overcorrection or
inadequate results. It is especially important to
avoid areas where ller accumulation could lead
to lumps or unevenness.
In addition to standard dermal injectors,
devices such as mesotherapy guns with pneumatic gas systems are also frequently used. These
tools are advantageous for treatments requiring
rapid, uniform application across a wide area.
They are often employed with substances like
PDLA (poly D, L-lactic acid) or PDRN (polydeoxyribonucleotide) in rejuvenating procedures,
allowing for enhanced control and precision.
By selecting the appropriate device and technique, practitioners can achieve consistent, safe,
and effective outcomes, even with automated
ller injections.
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